Every finding on record at Randolph County Care Center

Based on interview and record review, the facility failed to provide enough CNAS (Certified Nurse Assistants) to ensure residents receive assistance with care including toileting in a timely manner. These failures have the potential to affect all 53 residents residing in the facility. Findings Include:1.R1's admission Record, print date of 10/27/25, documented R1 has diagnoses including malignant neoplasm of female breast, neoplasm of brain, epilepsy, cerebral infarction, and dysphagia.R1's MDS (Minimum Data Set), dated 8/29/25, documented R1 is cognitively intact although at time of interview R1 was lethargic and confused. R1's Care Plan Report, undated, documented R1 has a terminal diagnosis related to metastatic breast cancer. This care plan also documented R1 is at risk for falls with interventions including low bed at all times, 15-minute checks to ensure proper bed positioning, and floor mat with an initiation date of 10/18/25. On 10/23/25 at 12:20 PM R1 was observed resting on a low bed, no mat was observed on the floor next to the bed as care planned. R1's father V8 was present. Surveyor asked V8, R1's father, if facility staff have ever brought a floor mat into R1's room to place besides her bed. V8 stated no and that a staff person mentioned it but R1 has never been given one. V8 stated R1 fell twice yesterday, and he feels he cannot leave her room due to her having falls. V8 stated he went into the hospice sitting area for a break because the chairs are more comfortable and when he came back to R1's room he found her on the floor. V8 stated he has been staying with R1 around the clock because of her condition and fall risk. V8 stated there is never enough staff in nursing homes and it usually takes more than 15 minutes for someone to answer R1's call light. Surveyor asked V8 if facility staff have been checking on R1 at least every 15 minutes as documented in her care plan and V8 stated no.2.R4's admission Record, print date of 10/27/25, documented R4 has diagnoses including unspecified dementia, hypothyroidism, parkinsonism, hypotension, and benign prostatic hyperplasia. R4's MDS, dated [DATE], documented R4 is severely cognitively impaired although at time of interview R4 appeared alert and oriented. This MDS also documented R4 requires substantial to maximal assistance with toileting hygiene. R4's Care Plan Report, undated, documented R4 has an ADL (activities of daily living) self-care performance deficit related to aggressive behavior and impaired balance. R4 has limited physical mobility related to Parkinson's disease and requires assist of 1 with ambulation. R4's care plan also documented R4 has functional bladder incontinence related to activity intolerance, dementia, and impaired mobility with interventions including assist to the bathroom every 2 hours while awake. On 10/23/25 at 12:07 PM R4 and his wife V7 were interviewed regarding facility staffing. V7 stated evening shift has been bad and she complained again about staffing at the care plan meeting last week. Day shift staffing is okay. V7 stated R4 doesn't get toileted timely and sometimes she just takes him to the bathroom herself, so he doesn't have an accident. V7 stated 2 CNAS on the evening shift for the first floor is not enough. V7 stated sometimes it takes almost an hour to get R4's call light answered. R4 stated the facility does not have enough CNAS and it takes a long time to get his call light answered.The facility Grievance Form for R4, dated 8/5/25, documented issue: call lights, description: waited over 20 minutes for someone to answer light she took her husband to the bathroom herself. (Adult diaper) was soaked, once in the bathroom no one came to help, when returned to room staff came in with a terrible attitude. Investigation: wife took resident to restroom after being told staff was assisting other. Nurse paged over intercom for aid. Upon entering room wife stated, there is never any help around here. 3.R5's admission Record, print date of 10/27/25, documented R5 has diagnoses including unspecified fracture of left humerus, hypothyroidism, anxiety disorder, essential hypertension, atherosclerotic heart disease, nontraumatic intracerebral hemorrhage in hemisphere, and COPD (Chronic Obstructive Pulmonary Disease). R5's MDS, dated [DATE], documented R5 is cognitively intact and requires partial to moderate assistance with toileting and substantial to maximal assistance with donning footwear. R5's Care Plan Report, undated, documented R5 uses a wheelchair, needs assistance in transfers, and R5 is on oxygen per nasal cannula. On 10/23/25 at 12:25 PM R5 stated there's never enough staff in a facility. The staff try as hard as they can to answer the call lights, but it takes quite a while on all shifts. R5 stated we need more staff.4.R6's admission Record, print date of 10/27/25, documented R6 has diagnoses including atherosclerotic heart disease, urine retention, hypertension, obesity, osteoarthritis, abnormalities of gait and mobility, cerebral infarction, paroxysmal atrial fibrillation, and dizziness. R6's MDS, dated [DATE], documented R6 is cognitively intact and requires substantial to maximal assistance with transfers. On 10/27/25 at 9:08 AM R6 stated he is the President of the Resident Council and that he does not think the facility has enough CNAS. Surveyor asked R6 what shifts need more CNAS and R6 replied all of the shifts need more. R6 stated residents complain about lack of CNAS at every Resident Council meeting.On 10/27/25 at 1:22 PM R6 stopped Surveyor and stated another thing, people aren't getting walked like they are supposed to. I am supposed to be walked every day and it has been over 2 weeks since they have walked me. Surveyor asked R6 if the facility has a Restorative CNA and R6 replied I don't know but they just don't have the staff to walk us like they are supposed to.R6's Care Plan, undated, documented nursing rehab/restorative: walking program - staff to ambulate to or from all meals. On 10/23/25 at 11:58 AM V5 CNA stated the new administrator said we can run 6 CNAS on day shift and that is not enough because most of the residents are 2 assists for transfers plus there are too many tasks, they want us to complete on top of all our other duties. We used to have 2 shower CNAS and they cut 1 so now we have to do showers also. When we had 2 shower CNAS they would help float.On 10/23/25 at 12:03 PM V6 CNA stated, the new administrator cut staff, there has been an increase in resident falls, residents don't always get showers as scheduled, and residents are complaining about lack of staff.On 10/23/25 at 2:22 PM V10 CNA stated the facility has frequently been staffed with 2 CNAS on the first floor and 2 CNAS on the second floor on evening shift. V10 stated it is not always possible to complete all the tasks and residents are complaining about not getting showers. V10 stated the facility no longer has a shower CNA. V10 stated staff have complained to management and they said it's enough staff with the census.On 10/23/25 at 2:30 PM V11 CNA stated the facility often has just 2 CNAS on each floor during the evening shift and it is not always possible to get showers completed plus it takes a while to get the call lights answered when there are only 2 CNAS on a floor.On 10/23/25 at 2:37 PM V12 CNA stated the days she works they only have 2 CNAS on each floor on evening shift. V11 stated what management expects the CNAS to do is not doable with 4 CNAS in the building. V11 stated we're getting more residents, but the staffing has decreased. V12 stated most of the residents on the second floor have to be transported downstairs via the elevator to the dining room for dinner and it is very difficult to get the residents transported back and forth when there are just 2 CNAS on each floor.On 10/27/25 at 12:05 PM V2 DON (Director of Nursing) stated they staff the facility based on census. V2 stated around the second week of October the census got high enough that they increased the CNA staffing to 3 CNAS on each floor on the evening shift.On 10/27/25 at 1:17 PM Surveyor reviewed the daily staff schedules with V2 DON. V2 confirmed that the facility was staffed with 2 CNAS on the first floor and 2 CNAS on the second floor on 10/1/25, 10/2/25, 10/3/25, 10/11/25, 10/13/25, and 10/19/25. The facility's Detailed Census Report for October 2025, dated 10/27/25, documented the census was 49 on 10/1/25, 10/2/25, and 10/3/25. This form documented the facility census was 52 on 10/11/25, 10/13/25, and on 10/19/25.On 10/27/25 at 11:53 AM V1 Administrator stated the facility does not have a staffing policy and they follow the state guidelines. V1 stated when she started working at the facility, they were running 8 CNAS on the day shift for 43 residents, that's craziness, we can't survive with that staffing ratio. V1 stated she took down 1 shower aid position and they now run 6 CNAS on the day shift plus a shower aid and 6 CNAS on the evening shift.The facility's Daily Census report, dated 10/27/25, documented there are 53 residents residing at the facility with 28 residents residing on the first floor and 25 residing on the second floor.

Based on interview, observation, and record review the facility failed to implement care plan fall interventions as documented for 2 of 3 residents (R1, R2) reviewed for falls in the sample of 6. Findings Include:1.R1's admission Record, print date of 10/27/25, documented R1 has diagnoses including malignant neoplasm of female breast, neoplasm of brain, epilepsy, cerebral infarction, and dysphagia.R1's MDS (Minimum Data Set), dated 8/29/25, documented R1 is cognitively intact although at time of interview R1 was lethargic and confused. R1's Care Plan Report, undated, documented R1 has a terminal diagnosis related to metastatic breast cancer. This care plan also documented R1 is at risk for falls with interventions including low bed at all times, 15-minute checks to ensure proper bed positioning, and floor mat with an initiation date of 10/18/25. R1's Incident Report, date 10/18/25, documented CNA (Certified Nurse Assistant) came to this nurse, resident's father was in her room and said resident climbed out of her bed and fell/sat on her floor. R1's Incident Report, dated 10/22/25 at 11:30 AM, documented CNA reported to nurse that resident was sitting on the floor in front of her bed. Father was in the room with resident, reported that she was sitting on the side of the bed and slid out onto the floor. R1's Incident Report, dated 10/22/25 at 9:50 PM, documented CNA reported to this nurse at this time that resident was found sitting on the floor. This nurse immediately went to resident's room and observed resident sitting on the floor with her back resting against her bed, this nurse ask resident how the incident occurred, resident stated she was trying to get out of bed. It continues, plan of care ongoing. Immediate action: with increased confusion family states they will remain at bedside. On 10/23/25 at 12:20 PM R1 was observed resting on a low bed, no mat was observed on the floor next to the bed as care planned. R1's father V8 was present. Surveyor asked V8, R1's father, if facility staff have ever brought a floor mat into R1's room to place beside her bed. V8 stated no and that a staff person mentioned it but R1 has never been given one. V8 stated R1 fell twice yesterday, and he feels he cannot leave her room due to her having falls. V8 stated he went into the hospice sitting area for a break because the chairs are more comfortable and when he came back to R1's room he found her on the floor. V8 stated he has been staying with R1 around the clock because of her condition and fall risk. V8 stated there is never enough staff in nursing homes and it usually takes more than 15 minutes for someone to answer R1's call light. Surveyor asked V8 if facility staff have been checking on R1 at least every 15 minutes as documented in her care plan and V8 stated no.On 10/23/25 at 1:45 PM surveyor requested to review the 15-minute check logs for residents on the 2nd floor. CNA V4 handed the stack of stapled 15 minutes checks to surveyor and surveyor did not observe any 15-minute checks for R1. Surveyor asked V4 if staff have been completing 15-minute checks on R1 and V4 stated the nurse gives us these 15-minute checks and she is not listed. V4 then looked at R1's care plan and stated, it does say 15-minute checks and she is supposed to have a mat on the floor. Surveyor asked V4 if she knew R1 was supposed to have a mat next to her bed and V4 replied we get report information from the nurse, we don't have time to go through the care plans. She (R1) has not had a mat nor been on 15-minute checks.2.R2's admission Record, print date of 10/23/25, documented R2 has diagnoses including disorientation, osteoarthritis, hyperlipidemia, anxiety disorder, hypertension, and depression. R2's MDS, dated [DATE], documented R2 is moderately cognitively impaired although at time of interview R2 was severely cognitively impaired. This MDS also documented R2 requires substantial to maximal assistance with transfers. R2's Care Plan Report, undated, documented R2 is high risk for falls related to gait/balance problems, incontinence, and unaware of safety needs. Interventions include ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair.R2's Incident Report, dated 10/20/25, documented this nurse was notified by CNA that this resident was on the floor in her room. Upon entering resident's room noted resident lying on her left side against the wall in front of her WC (wheelchair). Immediate action taken: Assessed for injuries. Noted hematoma to center of forehead and to the left side of her forehead. Scant bleeding from her left cheek. Very small scrape to left cheek. Cleansed with NS (normal saline) and LOTA (left open to air). Sat resident up on her buttocks. No c/o pain other than a headache. Assisted resident off the floor x2 assist and into her WC. Noted that resident's glasses were broken on the left side. VS (vital signs) obtained. Noted elevation in resident's BPs. On call doctor notified. Order given to sent to ER for evaluation to rule out a brain bleed. On 10/23/25 at 12:13 PM R2 was observed in the dining room in her wheelchair. R2 was observed with bilateral black eyes and R2 was wearing plain white socks. No non-skid material was on the bottom of R2's socks.On 10/27/25 at 12:08 PM V2 DON (Director of Nursing) stated she expects fall interventions to be in place per the care plan. V2 stated (R2) is supposed to have non-skid socks or shoes on at all times when she is up in her wheelchair. V2 stated she was not aware (R1) did not have her interventions in place on 10/23/25.The facility's Fall Policy, review date of 6/14/23, documented Mission Statement - to identify residents at risk for falls and provide guidelines for prevention and treatment post fall. All residents upon admission shall be assessed by the licensed nurse using the Fall Risk Assessment Form. This form will be updated quarterly, annual, significant change, or post fall episode. It continues, Post Fall - resident is assessed by the licensed nurse for potential injury and obtain treatment as necessary with MD guidance, responsible party is also notified. All falls are investigated to determine cause (avoidable or unavoidable), correction and prevention. Vital signs and condition are monitored by licensed nurse, care plan adjusted as needed to prevent additional falls. Care plan interventions reviewed with POA (Power of Attorney) and residents as needed.

Based on observation, interview, and record review the facility failed to supervise residents to prevent elopement for one of 9 residents (R2) reviewed for supervision to prevent elopements in the sample of 11. This failure resulted in an Immediate Jeopardy when on 4/11/25, R2, a resident with dementia, left without staff knowledge and was found 1 mile away from the facility. The Immediate Jeopardy began on 4/11/25 at 4:45 PM when the facility staff noticed the wander guard alarm was sounding at the front door. R2, with diagnosis with dementia and elopement risk, eloped from the facility and was found in a ditch along a busy road by a passerby at 5:22 PM per the police report. R2 admitted ly removed his (resident monitoring device) bracelet by filing it off with an emery board. R2 then left the facility by entering the front door code which is directly posted above the keypad on a red sign with bold white numbers. R2 continues to state he will attempt to leave the facility again. V1, Administrator, was notified of the Immediate Jeopardy on 4/17/25 at 9:05 AM. Based on observation, interview, and record review, the surveyor team could not validate the facility's abatement plan and the immediacy was not removed at the time of the exit on 4/22/25. Findings Include: R2's Diagnosis Report, dated 4/17/25, documented R2 has diagnoses including senile degeneration of the brain, dementia, anxiety disorder, depression, atherosclerotic heart disease, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, diabetic polyneuropathy, hypertension, heart failure, hyperlipidemia, hypothyroidism, and Parkinson's disease. R2's Care Plan, undated, documented R2 uses a wheelchair for mobility, requires assistance with ADLS (Activities of Daily Living) due to his impaired balance and occasional forgetfulness secondary to diagnosis of Parkinson's disease. This care plan also documented R2 is an elopement risk related to impaired safety awareness with interventions to check (resident monitoring device) function daily and placement every shift, monitor location every 15 minutes, document wandering behavior and attempted diversional interventions. R2's care plan also documented R2 has impaired cognitive function related to forgetfulness with interventions including R2's needs assistance with all decision making. R2's Progress Note, dated 4/9/25 at 11:21 PM documented pt (patient) found without (resident monitoring device). Reapplied to RLE (right lower extremity). Explained to pt it is important to wear. Pt remains in bed watching tv. Call light within reach. Room checked no (resident monitoring device) found in pt room or pt trash can. Removed 4 butter knives and 1 metal nail file for safety reasons. R2's Progress Note, dated 4/11/25 at 8:00 PM documented Staff noticed (resident monitoring) alarm at front door going off at 1645 (4:45 PM). This nurse and staff did a head count in the facility and noticed resident not in room. Room checks complete by staff to locate resident without success. (resident monitoring device) located in trash can by front door. ADON (Assistant Director of Nursing) notified immediately, Administrator notified. Code yellow called. Resident's wife (POA) and daughter (emergency contact) contacted. 911 call placed at 1650 (4:50 PM). On call Dr notified. Call received from local PD (Police Department) stating resident located at 1735 (5:35 PM). Resident returned to facility by local PD with resident. Wife at facility with resident. EMS (Emergency Medical Services) refused by resident. Order for 0.5 mg Ativan IM (intramuscular) once with order to give second dose if needed after 15 minutes. Both doses of Ativan administered and effective. Resident currently in room with wife eating dinner. Continuing to monitor at this time. The facility's incident report of R2's elopement, dated 4/11/25, documented Nursing Description: staff noticed (resident monitoring) alarm at front door going off at 1645 (4:45 PM). This nurse and staff did a head count in the facility and noticed resident not in room. Room checks complete by staff to locate resident without success. (Resident monitoring device) located in trash can by front door. ADON notified immediately, Administrator notified. Code yellow called. Resident's wife and daughter contacted. 911 call placed at 1650 (4:50 PM). On call Dr. notified. Call received from (local) PD stating resident located at 1735 (5:35 PM). Resident returned to facility by (local) PD with resident. Wife at facility with resident. EMS refused by resident. Resident Description: Resident stated he was 'going home and had enough of this place.' The local Police Department Incident Report, dated 4/11/25, documented missing person, reported 4/11/25 at 17:18 (5:18 PM) by walk in, occurred at (facility address). 911 call from V20 LPN (Licensed Practical Nurse) reporting R2 has been missing for approximately 20 minutes, we found his tracking bracelet in the trash. 911 call from V21, individual who found R2, reporting I'm on (name of road) Rd, just south of the ball diamond, I just found my ex-father-in-law walking in the ditch. Officers are in route, he walked away from the facility approximately 20 minutes. I'll stay with him til they arrive. It continues, Public Narrative: Located (R2) walking along (name of road) Road and transported him back to facility. EMS received a refusal and R2 was released back to the facility staff. On 4/15/25 at 11:30 AM R2 stated he took an emery board to his (resident monitoring device) band and filed it until it came off. R2 stated he just punched in the door code that is posted directly above the keypad and started walking to his home which is located about 6 miles from the facility. R2 stated he made it about 2 miles until his legs gave out, sat down on an embankment, saw his ex-daughter in law drive by, she turned around and came back, 3 cop cars then showed up and the police helped him to stand up and then took him back to the facility. R2 stated he did not tell any facility staff he was leaving. R2 then stated If I want to get out of here, I'll get out of here. I'll take the full blame if I get caught again. R2 stated he had been running the idea of leaving around in his head for a while and had been planning how he would leave. On 4/15/25 at 1:17 PM V7 Certified Nurse Assistant, CNA, stated she was told R2 eloped from the facility, but she was not on duty when it happened because it occurred on the evening shift. V7 stated she is assigned to R2's hall today and she does not know if any interventions have been put into place for R2 to prevent him from eloping again. On 4/15/25 at 1:21 PM V8, Housekeeper, stated facility staff check on the residents who are high risk for elopement often and those residents have (resident wandering device) bracelets on the make the doors lock when they go near it. V8 stated she is unaware of any added precautions for R2 since he eloped last week. On 4/15/25 at 1:25 PM V9, Licensed Practical Nurse, stated she is R2's nurse today and she was not on duty when R2 eloped, but she heard about it in report. V9 stated the facility has not implemented any new interventions since the elopement including for R2 and the facility has not changed the front door code since it happened. V9 stated she was told in report R2 sustained a laceration of his arm during the elopement. V9 stated the nurses now check and chart R2's wander guard bracelet is intact once a shift. V9 stated she is not aware of the facility doing any additional checks/monitoring nor documentation for R2 since the elopement other than the once a shift charting by his assigned nurse. On 4/15/25 at 1:32 PM V10, Activity Assistant, stated the activity staff are trying to keep R2 busy since he eloped, and she is not sure of what interventions are in place to try and prevent him from further elopement other than the (resident monitoring device) and she thought someone said they were going to put him on 15-minute checks. V10 stated R2 talks about going home all the time and this morning in activities R2 stated he is getting out of here one way or another. On 4/15/25 at 1:40 PM V5, wife of R2, stated after the elopement on 4/11/25 she came to the facility and R2's nurse stated to her the facility does not have enough help and they cannot watch him 24/7. V5 stated she replied to the nurse should I get someone else to come in and watch him and the nurse replied, we can't, we don't have the help. V5 stated she was even more upset about the facility not calling her when they noticed R2 was missing. V5 stated she had her phone on, and she did not have any missed calls from the facility but then received a call from her daughter who informed her R2 was missing. V5 stated the facility called her daughter about R2 missing but did not call her. V5 stated she immediately drove to town once her daughter informed her about R2 missing. V5 stated she believes R2 was gone from the facility for at least 50 minutes, that their ex-daughter in law (V21) was driving down the road, a busy road that goes to the high school ball diamonds, and (V21) thought she saw an animal in the ditch, that she turned around and realized it was R2. V5 stated R2's pants were grass stained and wet, and he had a cut on his arm, so she believes he fell at some point during the elopement. V5 stated the facility never did notify her of the elopement nor did they have a meeting with her to discuss the event. V5 stated the facility has not implemented any new precautions to keep R2 from eloping again and the facility still has the door code posted above the keypad. V5 stated R2 is usually not confused in the AM but by evening he gets confused, and he is not the same person she married [AGE] years ago due to the dementia. V5 stated R2 was very confused by the time she got to him after he eloped on 4/11/25. V5 stated she placed R2 at the facility for his safety because last fall he backed her car down to the creek, hit a tree, and totaled it due to his dementia. V5 stated she told the facility staff when he was admitted that they needed to keep a close eye on R2 because of the issues with him being forgetful. V5 stated she felt pressured to take R2 home last weekend (4/12/25 and 4/13/25) because the facility nurse stated they did not have enough staff to do 1 on 1 with him nor watch him closely. V5 stated R2 did display confusion over the weekend when he was at home. V5 stated the facility is very short staffed, even worse on the evening shift and weekends, the front office staff leave by 3:30 or 4 PM during the week and no staff are in the front to observe the front door in the evenings nor on weekends. V5 stated the facility has not changed the door code nor have they removed the sign with the door code exit since R2 eloped. On 4/15/25 at 2:12 PM V11 LPN stated she heard about R2's elopement and she does not know of any new interventions that have been put into place to prevent it from happening again. On 4/15/25 at 2:12 PM V12 CNA stated she was working the evening R2 eloped, the front door wander guard alarm was going off, and the staff realized R2 was missing. V12 stated R2 had a scratch on his arm once he was returned to the facility and she is not aware of any new interventions that have been added to R2's care plan to prevent him from further elopement. On 4/15/25 at 2:55 PM V1, Administrator, stated she called the Ombudsman on Monday to ask about where the facility stands with R2 wanting to leave the building and his resident rights. V1 stated R2 took his (resident monitoring device) off and threw it in the trash by the front door. V1 stated I don't consider it an elopement; we weren't going to keep him here come hell or high water. Surveyor asked what interventions have been added to R2's care plan since he eloped and V1 replied the facility is continuing to do frequent checks of R2, offering R2 distractions, and R2 has his wander guard back on. V1 stated R2 got out on 4/11/25 around 5 PM, a CNA tried to come back from lunch through the front door and it was locked so she realized something was wrong, and R2's (resident monitoring device) locked the front door since it was in the trash by the front door. V1 stated R2 obtained a small skin tear on his arm during the elopement. V1 stated R2 was found by the police sitting near the road. On 4/16/25 at 12:15 PM V7 CNA stated R2 has been talking about leaving today. V7 stated the facility management, nor anyone has told her of any new interventions to keep R2 from leaving again. On 4/16/25 at 12:18 PM R2 was observed sitting in his recliner in his room. V9, LPN was present, and surveyor witnessed R2 state to V9 I'm not going to keep doing this, I'm going to get out of here. I'm building up my strength. R2 stated, watch this and he quickly stood up from his recliner. R2 then stated my buddy drives a truck to California, and I might try and get a ride with him. My word is gold, I don't lie, if I tell you I'm going to do something then I'll do it. On 4/16/25 at 12:22 PM V14 CNA stated she is not aware of any new interventions that have been put into place to prevent R2 from eloping again. On 4/16/25 at 12:25 PM V3 Assistant Director of Nursing/Care Plan Coordinator, ADON/CPC stated she updated R2's care plan on 4/15/25 after he eloped on 4/11/25. V3 provided surveyor with a copy of R2's updated care plan that documented the added interventions of provide snacks, offer to turn on channel of a show he likes, ask if he would like a magazine to look at, or to color. On 4/16/25 at 1:20 PM Surveyor observed the red sign with white bold letters announcing PLEASE ENTER CODE BEFORE OPENING 1379* STAR still posted directly above the front door keypad. On 4/16/25 at 1:56 PM V15 CNA stated she did hear about R2's elopement, she has not been informed of any new interventions to try and prevent R2 from having another elopement. V15 stated we are keeping an eye on him. V15 stated she has worked at the facility for [AGE] years and she cannot remember the door code ever being changed, office staff leave between 3 - 4 PM and there is no staff in the front lobby to monitor the front door. V15 stated staff cannot view the front door because the double doors to the East Hall are always closed and, in her opinion, Management keeps the doors closed to prevent odors from going to the front lobby. V15 stated R2 was frequently attempting to go through the double doors to the front entrance prior to R2 eloping on 4/11/25 and the double doors are not alarmed. V2 stated R2 packed a bag today and said he is getting out of here. V15 stated sometimes she works over on evening shift, and she can see a change in R2's cognition from day shift to evening shift as he does have some sundowner's syndrome and was confused in the evenings when she stayed over. On 4/16/25 at 1:58 PM V7 CNA stated she does not know why the double doors are always closed on the East Hall, the floor staff cannot closely monitor the front door with them closed, and she assumes they are kept closed to keep the offices separated from the hall. V7 stated she has noticed a change in R2's cognition from AM to PM when she has worked day shift and stayed over on evening shift, and R2 has symptoms of sundowner's syndrome. V7 stated she observed R2 attempting to go through the double doors to the front lobby several times before his elopement this past Friday evening and R2 continues to state he is getting out of here. On 4/16/25 at 2:00 PM V14 CNA stated she has observed sundowner's symptoms in R2, he is alert and oriented in the morning but the times she has stayed over on evening shift she has noticed R2 to become confused, unsure of where he is at, and once thought he was at a grocery store. V14 stated the double doors are always closed, floor staff are not able to see the front door with it closed, and no office staff are in the front of the facility after 4 pm nor weekends. V14 stated R2 had attempted to go through the double doors multiple times prior to him getting out and he is still talking about leaving today. On 4/16/25 at 2:12 PM V13 CNA stated she was working the evening R2 eloped from the building. V13 stated she did see R2 in his room just before she went to break at approximately 3:45 PM, when she returned from break around 4:15 PM she attempted to enter the front door but could not because it was locked, and the alarm was going off. V13 stated she looked around and did not see a resident, then she called her coworker to let her in the building, coworker then let her in, and she went to the front lobby to shut the door alarm off. V13 stated as she was attempting to shut the alarm off, she saw the agency nurse for her and R2's unit trying to enter the front door as she was coming back from break. V13 stated she let the nurse in the door, and she thought she had deactivated the alarm, but it kept going off, so she said to the nurse that is strange, the alarm is still going off. V13 stated she went and told the other CNAS about the door alarm sounding and they checked the first floor 2 times then realized R2 wasn't in the building. V13 stated she went to the nurse who is an agency nurse and reported to her R2 was missing. V13 stated the agency nurse asked her who do I call and V13 then showed the nurse the list of numbers for the managers. V13 stated the front door alarm was still sounding and she noticed a wander guard in the trash can by the front entrance. V13 stated she was able to deactivate the door alarm once she removed the wander guard from the front lobby. V13 stated she does not know how long R2 was missing however she did see him shortly before she went on her break. V13 stated the staff cannot monitor the front door from the hall due to the double door always being closed. V13 stated once R2 was returned to the facility after he eloped, R2 stated to her that he was fighting with the cops, that he walked about 2 miles, he had walked through some brush, that he got himself out by putting in the 1379 door code that was posted by the keypad, and that he was only going to be at the facility for a couple more days. V13 stated as of yet no one has informed me of what we are doing to try and prevent R2 from eloping again. V13 stated she was initially working with just 1 other CNA and the agency nurse for the entire first floor until another CNA arrived later in the shift. V13 stated the shift was difficult because one of their assigned residents had fallen twice that day and her coworker was trying to keep that resident with her to prevent the resident from having anymore falls. V13 stated she nor her coworker were able to complete R2's 15-minute checks that day because there was no way to get everything done with only 2 CNAs. V13 stated it is even difficult to get everything done for the residents when they have 3 CNAS but they usually just have 2 CNAs on the first-floor unit for the evening shift. V13 stated the third CNA (V23) who was assigned to float between the first and second floors came on duty at approximately 3:30 PM and when she went on break it left 2 CNAs on the unit since the nurse was on break at about the same time as her. V13 stated R2 was not in the building when she came to work the next evening and she was told R2's wife took him home for the weekend because V16, LPN, told R2's wife V5 she had to take him home for the weekend because the facility did not have enough staff to do one on ones with R2. On 4/16/25 at 2:25 PM V3, ADON/CPC (Assistant Director of Nursing/Care Plan Coordinator), stated R2's last wandering assessment was completed on 4/4/25 and R2 was assessed as low risk for elopement. V3 stated the facility does not complete a separate elopement assessment for the residents. V3 stated the front office staff work until 4 PM and after that there is no staff in the front to monitor the door, the door is alarmed, and has a wander guard alarm. V3 stated R2's new interventions after R2 eloped is to monitor R2 one on one when he is agitated and to offer R2 diversional activities. On 4/16/25 at 2:32 PM V16, LPN, stated she was the nurse on day shift last weekend on 4/12/25 and that R2 went home with his wife at about 1:45 PM on that Saturday. V16 stated she asked his wife, V5, to come to the facility because R2 stated to her if I get a chance I am getting out of here. V16 stated she parked her med cart by R2's door during the morning medication pass so she could monitor him and that he napped most of the morning then around lunch he said he was going home today. R2 then took his (resident monitoring device) off right before lunch and stated he was leaving so she then called V5 and updated her. V5 stated she would come and talk to R2 and stay for a while. V16 stated she then asked V5 what about when you leave, the Administrator wants to know if you can have a friend who can sit with him if you can't do it. V16 stated more or less I told her we didn't have the staff to monitor him 1 on 1. V16 stated she usually works weekends and we don't keep an eye on the front door because the double doors are closed. V16 stated she does not know why the double doors are always closed. Surveyor asked V16 what interventions have been implemented since R2 eloped and V16 replied nothing really new, I remind him his son is working on a plan for him to return home. On 4/17/25 at 11:25 AM V17, LPN, stated she was told the intervention to prevent R2 from eloping again is make sure his (resident monitoring device) is on and make sure the staff know where he is. V17 stated she works weekends, there is no staff in the front of the building on the weekends, and she does not know who monitors the front door when there is no office staff working. V17 stated staff do not have a view of the front door because the double doors are always closed between the front lobby and the hall. V17 stated she has noticed R2 does become confused later in the day. On 4/17/25 at 12:13 PM R2 stated when he walked away from the facility, he made it about 2 miles then his legs gave out, so he put his feet in the ditch, it was dry, and sat down by it. R2 stated he has 3 plans for when he leaves the facility next time and he about has his alarm band off by using his dentures. R2 then showed surveyors the band which was half separated in one section. R2 stated if they don't let me out of here in 2 weeks, I have plans of how to get out. R2 then stated his plans: 1. follow the creek, 2. take the south and east road down to the stop sign to (name of road) Road then east about 3 miles and his home is the first one on the right, 3. take the same route as last time but not when there are 2 ball games with 100 people driving by like there was when he left last time and plan 4. is on a route on property he is not familiar with so he is scared he might get lost if he goes that route. R2 stated he did not tell anyone he was leaving last time; he did not want to be found, and he has been exercising so he can make it home next time. R2 stated he hates being treated like a 3-year-old, he is depressed, he has marital problems after [AGE] years of marriage and he thinks his marriage is going to end. R2 stated he has a buddy who drives a truck to California every week so he has been thinking about getting a ride with him out there and getting a job, it might be hard at [AGE] years old to get a job, but he can get a job sweeping sidewalks. R2 stated the next time he tries to get out of the facility it will be after dark. On 4/21/25 V21, R2's ex-daughter-in-law/witness to elopement provided a written statement on 4/21/25 that documented 04/11/2025 at approximately 5:00 p.m. while on my way home from work, I was traveling north into (town) on (name of road) Road. From a distance, I noticed something ahead in the ditch that I believed may be an animal. As I drove closer, I realized it was a person. I slowed to nearly an idle as I veered slightly into the opposite lane and looked over to discover it was, in fact, a man sitting in the ditch. He turned his head slightly and I immediately recognized him to be (R2). I quickly turned around on a field road less than 20 feet ahead and drove back. I rolled my window down and yelled (R2's) name. He finally looked up at me and I asked if he was okay. He stated, I am trying to get up. I told him to stay still, and I would be right there. He seemed worried and asked where I was going. I told him I needed to pull my car off the road. Before exiting my vehicle, I called the (local) Police Department as I was aware this was not a good situation. I told the dispatcher my name, gave my location on (name of road) Road south of the ball diamonds, and stated there was a man in the ditch and I knew him to be (R2). She asked me to hold, and I heard her repeat the information I had given prior to returning to speak with me. She stated officers were on their way and I told her I did not need her to stay on the phone with me until they arrived. I exited my vehicle and began to walk across the road. (R2) looked up at me and asked, (V21?) Are you (V21)? I told him I was and began to help him from the ditch. He had mud on his pants, and I could tell they were damp from being in the ditch. Once he was up and on the side of the road, I helped him cross the road, so we were safely behind my vehicle as it is a frequently traveled road and the speed limit at that location is near the change from 55 mph to, I believe, 35 mph as it enters the city limits. Once I helped him lean against my car, I asked him, Did you go out for a stroll and wander off the beaten path? He responded he knew where he was going and asked if I would give him a ride up to the cut-off road to (name of road) Road. I told him I could not do that, and someone was on their way to help. R2 became very angry and stated, F_ _ _. You called the cops on me? I explained to him that I was afraid I would need help getting him out of the ditch and I knew they were strong guys that could help. He calmed slightly and said that was okay. He was holding a branch he had fashioned into a walking stick to remain steady and began to tap it hard on the road as he became very agitated telling me that he was not going back to that meat locker. I presumed he was talking about (the facility) as I was aware he was a resident. His tone was furious as he shared with me, they were going to take his driver's license away. I asked him where his driver's license was, and he told me it was in his wallet. While I was fully aware from observing his physical and mental condition that he should not drive, I told him that if it was in his wallet they couldn't take it unless he gave it to them and to just hang on to it in an attempt to validate his feelings. Once again, he agreed and seemed to calm down. I add these details from some of our conversation to confirm that his mood was not constant; he moved through emotions quickly. It was easy to calm him when he became agitated; however, it did not last, and he returned to discontent moments later. When the officers arrived, I observed more change in his mental status. The officers were very respectful when asking information about him such as his name. He responded confidently, My name is (R2), but everyone calls me (R2). When they asked if him and I knew each other, he stated I was his daughter-in-law. To that point, I am his former daughter-in-law, we have not interacted in over [AGE] years, and (R2) spoke as if no time had passed. When asked by the officers where he lived, (R2) responded that he lived right up at (address) Street as he pointed toward (town). I followed up talking directly to (R2) and said, I remember you and your dad built that house on (R2's prior address) Street before you built your house at (address) Road. I then looked to the officer and nodded so they were aware that was his most recent address, and they nodded back in acknowledgment. At one point, (R2) started speaking about places in (town) like where he was born, and I was able to engage in this conversation with him as I am aware of some of his history because I have known him for nearly [AGE] years. In the more than 30 minutes we were on the side of the road, the only time I noticed him speak about the present was when he spoke about his displeasure of being in (the facility). He had a fair memory of his younger past but seemed to have little recollection of the last [AGE] years, give, or take, if I were to put it on a timeline. Additionally, he was bleeding from what I observed to be a puncture wound on his right wrist. I held tissues on it firmly to stop the bleeding. A young woman arrived at some point from (the facility). I am not aware of her name. My observation of her interaction with him was not favorable. Most of the time, she referred to him as man. For example, she said, Man, we already have your tray in your room. Let's just go back so you can eat your dinner. R2 said something about it not even being real food and the eggs are cardboard. She responded, It's not that bad, man. To say this bothered me is an understatement; I cared for my mother who suffered from significant mental changes due to brain cancer up and till she passed and the disrespect of not calling him by name is something that quite honestly hurt my heart. Additionally, I am a certified crisis negotiator with the State (name of employer), and I am also certified in Critical Incident Stress Management. I am greatly aware that bringing yourself to the same level as a person in crisis is paramount; this most simply begins with calling them by name. By no means am I saying that I know more than anyone else, but I share this to confirm I do have personal experience as well as professional training with those in crisis which I feel was greatly accurate for (R2) on the side of the road that day. Again, I feel it is imperative to note that I have not interacted with (R2) in over [AGE] years since his son and I divorced and there has been a great deal of animosity in the last ten years. This seemed to be unknown to (R2); something he was not aware of whatsoever at the time. This fact alone confirmed to me that his memory changes are significant. In terms of his physical condition, I observed a very broken old man who showed little resemblance of the man I once knew. He was unsteady, frail, and thinner than I have ever known him to be. He needed the assistance of both me and the officer to walk to and get in the police car. Please also understand my account is in no way biased as I have no interaction with (R2) or anyone in his family. My ex-sister-in-law contacted me to thank me for stopping to help and that was the first time I had spoken with her in at least [AGE] years, as well. My hope from sharing what I witnessed is that additional protocols are put in place for the residents at the (facility) so this may not happen to someone else. I am thankful I was driving home from work at the time and able to help him. This certainly could have had a worse outcome. The facility's final investigation of R2's elopement, dated 4/17/25, documented R2 was admitted to (the facility) on 9/27/24. He is an [AGE] year-old gentleman with diagnosis of DM (diabetes mellitus), senile degeneration of the brain, Parkinson's disease, and COPD. It continues, on 4/11/25 at 4:45 PM facility front door alarm sounded. Facility staff responded immediately to the alarm and began code yellow procedures with head counts. R2 was not in his room. A (resident monitoring device) bracelet was found in the trash by the front door. 911 was notified at 4:50 PM. His wife was also notified. R2 was located at 5:35 PM by (local) PD (Police Department) badge #12 and brought back to facility. He sustained a small skin tear on his right wrist. R2 stated he was going home with his wife. He had shown no signs of exit seeking hours prior to this. After return to facility his (resident monitoring device) bracelet was placed, and he was comprehensively assessed and found to have no other injuries and was in good spirits. His wife took him home for an overnight visit on 4/12/25 and he returned to facility on 4/15/25 at 6:15 AM. His (resident monitoring device) bracelet was replaced, and 15-minute checks are in place. His care plan has been reviewed and updated. SSD (Social Service Director) has met with resident and his wife about alternate placement or safe discharge ho[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure and implement an individualized plan of care for a resident experiencing psychosocial adjustment difficulty for one of one resident (R2) reviewed for psychosocial adjustment difficulties in the sample of 11. This failure resulted in harm as evidence by R2 expressing feelings of self-harm, displaying tearfulness, and wanting to leave the facility. Findings includes: R2's Face Sheet, print date of 04/16/25, documented R2 had diagnoses of depression and dementia. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and required supervision/touching assistance with ambulation. He wears a wander/elopement alarm daily. Section D of the MDS documented under the symptom's presence R2 was having feelings of feeling down, depressed, or feeling hopeless. Under the symptoms frequency documented he was having these feelings 12-14 days (nearly every day). R2's Care Plan, with admitted [DATE], was reviewed and had no documentation regarding R2 having a diagnosis of depression. R2's Physician's Orders were reviewed and had no documentation of a psychiatric evaluation being ordered. R2's Local Psychiatric Consultants report, dated 01/31/25, documented chief complaint: Routine visit for chronic care management for Parkinson's, dementia, and anxiety. R2's Physician Notification for Routine Orders, dated 04/10/25, sent at 12:00 PM, documented the following: Explain: Today during a conversation with (R2), he said he's upset about having to stay here and just stare at the same 4 walls. He stated, If I have to stay much longer, I will shoot myself or kill myself. While he doesn't have the means to do this, I wanted you to be aware. The document was then signed by V3, Assistant Director of Nursing (ADON). This document has a section labeled Physician's Response (if appropriate) which was blank. R2's Progress Notes were reviewed and documented the following: On 4/9/2025 at 11:21 PM, Behavior Note: Patient (pt) found without (resident monitoring device). Reapplied to right lower extremity (RLE). Explained to pt it is important to wear. Pt remains in bed watching television (tv). Call light within reach, room checked no (resident monitoring device) found in pt room or pt trash can. Removed 4 butter knives and 1 metal nail file for safety reasons. R2's Progress Notes had no documentation regarding R2 having thoughts of self-harm on 04/10/25 and no documentation the doctor was notified, or any orders were received. On 4/11/2025 at 10:03 PM, documented Behavior Note: Pt in bed at this time. (Resident monitoring device) placed on left lower extremity (LLE), pt asleep, respirations even and unlabored, and no distress noted. Dressing to right forearm (FA) dry and intact. Call light within reach. Removed 1 nail file and 2 razors from room. On 4/16/2025 at 1:39 PM, documented Behavior Note: Resident noted to be up walking around with or without assistive devices this shift. No attempts to leave out of facility as of this entry. Resident stated, I'm just building up my strength. Upon checks resident noted to be sitting in room crying. This nurse sat down with resident to console him, and he just kept saying I've had it with this place, looking at the same 4 walls, I can't do it anymore. Resident reminded of the importance of not eloping again for his safety. Resident noted with ideations of leaving again, stating, When I figure it out, I will leave again. Care is ongoing. On 4/19/2025 at 1:33 PM, documented Behavior Note: Behavioral charting continues related to (r/t) increase in antipsychotic medication at bedtime (HS). Resident noted with self-harm ideals this morning, stating I'd rather be gone, then live here any longer, I don't want to be a burden to anyone, I don't know how yet, but I'm thinking of it. That Doctor yesterday told me that I cannot do anything on my own, or be by myself, all bad news. This nurse redirected resident to think positive thoughts, resident stated, thank you for being so kind! On 4/19/2025 at 9:15 PM, documented Behavior Note: Resident redirected twice after stating he's leaving this place Resident was educated on the risks of leaving and educated on safety. This nurse had a long talk with resident while wife was present about different things that upset him and make him want to leave. Resident seems to be troubled with some family issues from years ago. Resident did mention while wife was present if/when I get out of here, I'll be dead the same day because I'll kill myself. On 4/20/2025 at 3:13 PM, documented Behavior Note: Behavior monitoring continues. Resident stated, I just have to get out of here. If it didn't hurt my boy and girl, then I'd kill myself. I just can't do it here anymore, I was supposed to be here for a week, and it's been 5 months. Resident educated on the risks of suicide and the pain that it would cause his family and friends. Resident redirected to focus on the positive aspects in life. Resident currently roaming through the halls, talking to other residents at this time. (Resident monitoring device) in place on left ankle (LA), working properly. Care is ongoing. On 04/15/25 at 10:45 AM, R2 was sitting up in his wheelchair in his room, (resident monitoring device) noted to his left ankle. He said he had only been out of the facility three times in the last 5 months, and he was tired of looking at the walls. He said he took the (resident monitoring device) off his ankle and through it in the trash. R2 said he put the code in and then went out. He said the code is by the door on a sign. R2 said he had taken his wander guard off twice now. R2 said his doctor and his wife have taken his driver's license away and he isn't able to drive anymore. He said being here in the facility is like being in prison. R2 thinks he was railroaded in to coming here to the facility and he wants to go home. He stated he had a lawn to [NAME] and things to take care of. R2 said he wants to go home. On 04/17/25 at 10:23 AM, R2 is sitting up in his wheelchair in his room. When this surveyor talked with him, he said he had refused his shower twice today. He said he doesn't like to take a shower here the bathrooms are nasty. R2 said he will go home and take a shower at home this weekend then come back. He said he was depressed just by being here at the facility. He said he feels like he doesn't have any freedom anymore. He said he isn't happy here. R2 said he could just set here right now and cry. While talking with R2 he became tearful at times. R2 said you know what the bible says GOD doesn't give you any more than you can handle and I'm at the top of the list. He said I feel like they have me backed into the corner and you know the only thing you can do is go forward. R2 said he hasn't had an appetite lately and he thinks his wife might be running around on him. On 04/17/25 at 12:04 PM, V3, Assistant Director of Nursing, ADON said when someone voice self-harm they will have the social worker come and talk with them to determine if they have a plan and if they are able to carry out that plan. Then they will notify the doctor about what is going on with the resident. V3 said on the day R2 voiced self-harm she had the social worker (V19) come and talk with R2. V19 then advised V3 the doctor should be notified and so she then notified the doctor. She said she typically wouldn't make a note in the progress notes the social worker would make the note. She said she sent a fax to the doctor at the time of the incident with R2 and he didn't have access to a gun the doctor didn't give any new orders it just said noted on the fax. On 04/17/25 at 12:12 PM, V19, Social Worker said the nurse will notify her when a resident makes a statement about wanting to hurt themselves and she will go down and interview the resident and ask them what statement they made. She said she would make to a point to ask them what they intended to do and what they were going to use. She would notify the doctor of the resident's behaviors and the means the resident had to anything to hurt themselves and if the doctor wasn't the resident sent out to the emergency room (ER) for evaluation. V19 said she didn't interview the resident the day of the incident due to her being out of the facility at a funeral. She said the nursing staff can interview the resident also they know what to do. She said she would also notify the family of what was happening. V19 said she didn't make a note that day because she didn't talk with R2 due to her being out of the facility. On 04/21/25 at 10:15 AM, V7, Certified Nursing Assistant (CNA) said the residents have a section in their chart where you can document their behaviors. She said R2 doesn't have a specific behavior they monitor for. V7 said some of the residents do have specific behaviors they monitor for like if a resident is combative, they will monitor for that behavior. V7 said R2 doesn't have any unless it's changed. On 04/21/25 at 10:15 AM, V17, Licensed Practical Nurse (LPN) said they are doing behavior monitoring right now on R2 due to his increase in his antipsychotic medication. She said they are also doing 15-minute checks on R2 as well. On 04/21/25 at 1:49 PM, V6, Primary Care Physician said the facility did contact him regarding R2 wanting to harm his self. He said he faxed back an order for them to get a psychiatric (psych) evaluation on R2. V6 said he doesn't believe he has a copy of what his office faxed back. V6 said he would expect the nursing staff to follow his orders and would expect the psych eval. to happen. On 04/22/25 at 11:01 V1, Administrator stated she was not aware V6, Medical Director had sent an order back regarding R2 and obtaining a psychiatric evaluation. V1 said it isn't in his chart. This surveyor explained to V1, V6 was called, and he stated he fax an order back for R2 to have a psych eval. V1 said she would expect the nurses to follow the doctor's orders. V1 stated when a resident is having self-harm thoughts, she would expect the nurses to do close supervision, make sure they talk with the resident, and redirection/distraction. The facility's treatment/services for mental/psychosocial concerns, dated 02/05/2019, documented Intent: It is the policy of (facility) to provide Behavioral Health Services in accordance with State and Federal regulations. 1. (Facility) will ensure that, a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and /or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. 2. (Facility) will ensure that, a resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post-traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the residents clinical condition demonstrates that development of such a pattern was unavoidable. 3. A resident, who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review the facility failed to ensure and implement an individualized plan of care for a resident experiencing psychosocial adjustment difficulty for one of one resident (R2) reviewed for psychosocial adjustment difficulties in the sample of 11. This failure resulted in harm as evidence by R2 expressing feelings of self-harm, displaying tearfulness, and wanting to leave the facility. Findings includes: R2's Face Sheet, print date of 04/16/25, documented R2 had diagnoses of depression and dementia. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and required supervision/touching assistance with ambulation. He wears a wander/elopement alarm daily. Section D of the MDS documented under the symptom's presence R2 was having feelings of feeling down, depressed, or feeling hopeless. Under the symptoms frequency documented he was having these feelings 12-14 days (nearly every day). R2's Care Plan, with admission date of 09/27/24, was reviewed and had no documentation regarding R2 having a diagnosis of depression. R2's Physician's Orders were reviewed and had no documentation of a psychiatric evaluation being ordered. R2's Local Psychiatric Consultants report, dated 01/31/25, documented chief complaint: Routine visit for chronic care management for Parkinson's, dementia, and anxiety. R2's Physician Notification for Routine Orders, dated 04/10/25, sent at 12:00 PM, documented the following: Explain: Today during a conversation with (R2), he said he's upset about having to stay here and just stare at the same 4 walls. He stated, If I have to stay much longer, I will shoot myself or kill myself. While he doesn't have the means to do this, I wanted you to be aware. The document was then signed by V3, Assistant Director of Nursing (ADON). This document has a section labeled Physician's Response (if appropriate) which was blank. R2's Progress Notes were reviewed and documented the following: On 4/9/2025 at 11:21 PM, Behavior Note: Patient (pt) found without (resident monitoring device). Reapplied to right lower extremity (RLE). Explained to pt it is important to wear. Pt remains in bed watching television (tv). Call light within reach, room checked no (resident monitoring device) found in pt room or pt trash can. Removed 4 butter knives and 1 metal nail file for safety reasons. R2's Progress Notes had no documentation regarding R2 having thoughts of self-harm on 04/10/25 and no documentation the doctor was notified, or any orders were received. On 4/11/2025 at 10:03 PM, documented Behavior Note: Pt in bed at this time. (Resident monitoring device) placed on left lower extremity (LLE), pt asleep, respirations even and unlabored, and no distress noted. Dressing to right forearm (FA) dry and intact. Call light within reach. Removed 1 nail file and 2 razors from room. On 4/16/2025 at 1:39 PM, documented Behavior Note: Resident noted to be up walking around with or without assistive devices this shift. No attempts to leave out of facility as of this entry. Resident stated, I'm just building up my strength. Upon checks resident noted to be sitting in room crying. This nurse sat down with resident to console him, and he just kept saying I've had it with this place, looking at the same 4 walls, I can't do it anymore. Resident reminded of the importance of not eloping again for his safety. Resident noted with ideations of leaving again, stating, When I figure it out, I will leave again. Care is ongoing. On 4/19/2025 at 1:33 PM, documented Behavior Note: Behavioral charting continues related to (r/t) increase in antipsychotic medication at bedtime (HS). Resident noted with self-harm ideals this morning, stating I'd rather be gone, then live here any longer, I don't want to be a burden to anyone, I don't know how yet, but I'm thinking of it. That Doctor yesterday told me that I cannot do anything on my own, or be by myself, all bad news. This nurse redirected resident to think positive thoughts, resident stated, thank you for being so kind! On 4/19/2025 at 9:15 PM, documented Behavior Note: Resident redirected twice after stating he's leaving this place Resident was educated on the risks of leaving and educated on safety. This nurse had a long talk with resident while wife was present about different things that upset him and make him want to leave. Resident seems to be troubled with some family issues from years ago. Resident did mention while wife was present if/when I get out of here, I'll be dead the same day because I'll kill myself. On 4/20/2025 at 3:13 PM, documented Behavior Note: Behavior monitoring continues. Resident stated, I just have to get out of here. If it didn't hurt my boy and girl, then I'd kill myself. I just can't do it here anymore, I was supposed to be here for a week, and it's been 5 months. Resident educated on the risks of suicide and the pain that it would cause his family and friends. Resident redirected to focus on the positive aspects in life. Resident currently roaming through the halls, talking to other residents at this time. (Resident monitoring device) in place on left ankle (LA), working properly. Care is ongoing. On 04/15/25 at 10:45 AM, R2 was sitting up in his wheelchair in his room, (resident monitoring device) noted to his left ankle. He said he had only been out of the facility three times in the last 5 months, and he was tired of looking at the walls. He said he took the (resident monitoring device) off his ankle and through it in the trash. R2 said he put the code in and then went out. He said the code is by the door on a sign. R2 said he had taken his wander guard off twice now. R2 said his doctor and his wife have taken his driver's license away and he isn't able to drive anymore. He said being here in the facility is like being in prison. R2 thinks he was railroaded in to coming here to the facility and he wants to go home. He stated he had a lawn to [NAME] and things to take care of. R2 said he wants to go home. On 04/17/25 at 10:23 AM, R2 is sitting up in his wheelchair in his room. When this surveyor talked with him, he said he had refused his shower twice today. He said he doesn't like to take a shower here the bathrooms are nasty. R2 said he will go home and take a shower at home this weekend then come back. He said he was depressed just by being here at the facility. He said he feels like he doesn't have any freedom anymore. He said he isn't happy here. R2 said he could just set here right now and cry. While talking with R2 he became tearful at times. R2 said you know what the bible says GOD doesn't give you any more than you can handle and I'm at the top of the list. He said I feel like they have me backed into the corner and you know the only thing you can do is go forward. R2 said he hasn't had an appetite lately and he thinks his wife might be running around on him. On 04/17/25 at 12:04 PM, V3, Assistant Director of Nursing, ADON said when someone voice self-harm they will have the social worker come and talk with them to determine if they have a plan and if they are able to carry out that plan. Then they will notify the doctor about what is going on with the resident. V3 said on the day R2 voiced self-harm she had the social worker (V19) come and talk with R2. V19 then advised V3 the doctor should be notified and so she then notified the doctor. She said she typically wouldn't make a note in the progress notes the social worker would make the note. She said she sent a fax to the doctor at the time of the incident with R2 and he didn't have access to a gun the doctor didn't give any new orders it just said noted on the fax. On 04/17/25 at 12:12 PM, V19, Social Worker said the nurse will notify her when a resident makes a statement about wanting to hurt themselves and she will go down and interview the resident and ask them what statement they made. She said she would make to a point to ask them what they intended to do and what they were going to use. She would notify the doctor of the resident's behaviors and the means the resident had to anything to hurt themselves and if the doctor wasn't the resident sent out to the emergency room (ER) for evaluation. V19 said she didn't interview the resident the day of the incident due to her being out of the facility at a funeral. She said the nursing staff can interview the resident also they know what to do. She said she would also notify the family of what was happening. V19 said she didn't make a note that day because she didn't talk with R2 due to her being out of the facility. On 04/21/25 at 10:15 AM, V7, Certified Nursing Assistant (CNA) said the residents have a section in their chart where you can document their behaviors. She said R2 doesn't have a specific behavior they monitor for. V7 said some of the residents do have specific behaviors they monitor for like if a resident is combative, they will monitor for that behavior. V7 said R2 doesn't have any unless it's changed. On 04/21/25 at 10:15 AM, V17, Licensed Practical Nurse (LPN) said they are doing behavior monitoring right now on R2 due to his increase in his antipsychotic medication. She said they are also doing 15-minute checks on R2 as well. On 04/21/25 at 1:49 PM, V6, Primary Care Physician said the facility did contact him regarding R2 wanting to harm his self. He said he faxed back an order for them to get a psychiatric (psych) evaluation on R2. V6 said he doesn't believe he has a copy of what his office faxed back. V6 said he would expect the nursing staff to follow his orders and would expect the psych eval. to happen. On 04/22/25 at 11:01 V1, Administrator stated she was not aware V6, Medical Director had sent an order back regarding R2 and obtaining a psychiatric evaluation. V1 said it isn't in his chart. This surveyor explained to V1, V6 was called, and he stated he fax an order back for R2 to have a psych eval. V1 said she would expect the nurses to follow the doctor's orders. V1 stated when a resident is having self-harm thoughts, she would expect the nurses to do close supervision, make sure they talk with the resident, and redirection/distraction. The facility's treatment/services for mental/psychosocial concerns, dated 02/05/2019, documented Intent: It is the policy of (facility) to provide Behavioral Health Services in accordance with State and Federal regulations. 1. (Facility) will ensure that, a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and /or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. 2. (Facility) will ensure that, a resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post-traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the residents clinical condition demonstrates that development of such a pattern was unavoidable. 3. A resident, who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being.

Based on interview and record review the facility failed to ensure the Director of Nursing was part of the Quality Assessment and Assurance Committee. This failure has the potential to affect all 46 residents residing in the facility. Findings Include: The Quality Assessment and Assurance Committee attendance sheet dated 03/05/25 documented the last QAA meeting had in attendance V1, Administrator, V6, Medical Director, V40, Pharmacist, V41, Medical Records consultant, and V3, Assistant Director of Nursing (ADON). There was no Director of Nursing (DON) in attendance. On 04/29/2025 at 12:11 PM, V1, Administrator, stated the facility currently doesn't have a DON. The Quality Assurance and Performance Improvement (QAPI) policy, not dated, documented It is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. It further documented 5. The Quality Assessment and Assurance Committee Consists at a minimum of: A. The director of nursing services; B. The Medical Director or his/her designee; C. At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and D. The infection Preventionist- effective November 28, 2019. On 04/29/2025 at 1:07 PM, V1, Administrator stated the facility's current census is 46.

Based on interview and record review the facility failed to ensure the Director of Nursing was part of the Quality Assessment and Assurance Committee. This failure has the potential to affect all 46 residents residing in the facility. Findings Include: The Quality Assessment and Assurance Committee attendance sheet dated 03/05/25 documented the last QAA meeting had in attendance V1, Administrator, V6, Medical Director, V40, Pharmacist, V41, Medical Records consultant, and V3, Assistant Director of Nursing (ADON). There was no Director of Nursing (DON) in attendance. On 04/29/2025 at 12:11 PM, V1, Administrator, stated the facility currently doesn't have a DON. The Quality Assurance and Performance Improvement (QAPI) policy, not dated, documented It is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. It further documented 5. The Quality Assessment and Assurance Committee Consists at a minimum of: A. The director of nursing services; B. The Medical Director or his/her designee; C. At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and D. The infection Preventionist- effective November 28, 2019. On 04/29/2025 at 1:07 PM, V1, Administrator stated the facility's current census is 46.

Based on interview and record review the facility failed to ensure nurse aides completed the required 12 hours of education per year. This has the potential to affect all 46 residents residing in the facility. Findings include: On 4/29/25 at 11:33 AM V1, Administrator, stated the facility provides education to the facility staff including Certified Nurse Assistants, CNAs, in person and the facility does not provide any online education. V1 stated she or any of the managers keep the in-service records with hours of education in one location and she will have to get the records from the department managers who did the in-services. On 4/29/25 at 11:53 AM V1 stated the facility did not provide any dementia care training for any of the CNAs in the past year, and the facility only has documentation for 3 in-services provided to CNAs in the last 12 months and those in-services were for sexual harassment, resident rights, abuse, and emergency preparedness. V1 stated the records do not have the amount of time each in-service lasted, just the dates the in-services were conducted. V1 stated the facility does not track the CNA in-service hours to ensure the CNAs receive at least 12 hours of education a year nor does the facility track what education/in-services the CNAS receive to ensure they receive the required trainings. V1 then confirmed V15 CNA, V27 CNA, V28 CNA and V38 did not received 12 hours of continuing education including dementia care within the last 12 months. V1 provided facility in-service records for the last 12 months and they document an in-service on sexual harassment was held at the facility on 11/11/24, resident rights and abuse in-service was conducted on 11/20/24, and an in-service on emergency preparedness was conducted on 4/2/25. V15, CNA, hire date of 6/26/08, documented V15 attended the 3 in-services provided by the facility in the past year. The facility in-service records do not document V15 received dementia care education nor the required 12 hours of education. V27, CNA, hire date of 5/1/23, documented V27 attended the 3 in-services provided by the facility in the past year. The facility in-service records do not document V28 received the required dementia care training nor the required 12 hours of education. V28, CNA, hire date of 3/27/23, documented V28 attended the 3 in-services provided by the facility in the past year. The facility in-service records do not document V28 received the required dementia care training nor the required 12 hours of education. V38, CNA, hire date of 10/3/23, documented V38 attended the 3 in-services provided by the facility in the past year. The facility in-service records do not document V28 received the required dementia care training nor the required 12 hours of education. On 4/29/25 at 1:07 PM V1 stated the facility does not have a policy on CNA required trainings. V1 stated the facility currently has 46 residents living at the facility.

Based on interview and record review the facility failed to ensure nurse aides completed the required 12 hours of education per year. This has the potential to affect all 46 residents residing in the facility. Findings include: On 4/29/25 at 11:33 AM V1, Administrator, stated the facility provides education to the facility staff including Certified Nurse Assistants, CNAs, in person and the facility does not provide any online education. V1 stated she or any of the managers keep the in-service records with hours of education in one location and she will have to get the records from the department managers who did the in-services. On 4/29/25 at 11:53 AM V1 stated the facility did not provide any dementia care training for any of the CNAs in the past year, and the facility only has documentation for 3 in-services provided to CNAs in the last 12 months and those in-services were for sexual harassment, resident rights, abuse, and emergency preparedness. V1 stated the records do not have the amount of time each in-service lasted, just the dates the in-services were conducted. V1 stated the facility does not track the CNA in-service hours to ensure the CNAs receive at least 12 hours of education a year nor does the facility track what education/in-services the CNAS receive to ensure they receive the required trainings. V1 then confirmed V15 CNA, V27 CNA, V28 CNA and V38 did not received 12 hours of continuing education including dementia care within the last 12 months. V1 provided facility in-service records for the last 12 months and they document an in-service on sexual harassment was held at the facility on 11/11/24, resident rights and abuse in-service was conducted on 11/20/24, and an in-service on emergency preparedness was conducted on 4/2/25. V15, CNA, hire date of 6/26/08, documented V15 attended the 3 in-services provided by the facility in the past year. The facility in-service records do not document V15 received dementia care education nor the required 12 hours of education. V27, CNA, hire date of 5/1/23, documented V27 attended the 3 in-services provided by the facility in the past year. The facility in-service records do not document V28 received the required dementia care training nor the required 12 hours of education. V28, CNA, hire date of 3/27/23, documented V28 attended the 3 in-services provided by the facility in the past year. The facility in-service records do not document V28 received the required dementia care training nor the required 12 hours of education. V38, CNA, hire date of 10/3/23, documented V38 attended the 3 in-services provided by the facility in the past year. The facility in-service records do not document V28 received the required dementia care training nor the required 12 hours of education. On 4/29/25 at 1:07 PM V1 stated the facility does not have a policy on CNA required trainings. V1 stated the facility currently has 46 residents living at the facility.

Based on interview and record review the facility failed to notify the Power of Attorney (POA)/family of a resident who was experiencing self-harm thoughts for 1 of 3 residents (R2) reviewed for self-harm in a sample of 11. Findings Include: R2's Face Sheet, print date of 04/16/25, documented R2 had diagnoses of depression and dementia. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and required supervision/touching assistance with ambulation. He wears a wander/elopement alarm daily. Section D of the MDS documented under the symptom's presence R2 was having feelings of feeling down, depressed, or feeling hopeless. Under the symptoms frequency documented he was having these feelings 12-14 days (nearly every day). R2's Care Plan, with admitted [DATE], was reviewed and had no documentation regarding R2 having a diagnosis of depression. R2's Physician Notification for Routine Orders, dated 04/10/25, sent at 12:00 PM, documented the following: Explain: Today during a conversation with (R2), he said he's upset about having to stay here and just stare at the same 4 walls. He stated, If I have to stay much longer, I will shoot myself or kill myself. While he doesn't have the means to do this, I wanted you to be aware. The document was then signed by V3, Assistant Director of Nursing (ADON). This document has a section labeled Physician's Response (if appropriate) which was blank. R2's Progress Notes were reviewed and had no documentation regarding R2 having thoughts of self-harm on 04/10/25 and no documentation the POA/family was notified. On 04/15/25 at 1:40 PM, V5, R2's POA/wife said she wasn't made aware R2 had made statements of him wanting to hurt his self. She said when she did find out later, she had to have family come over and remove all the guns from the house. On 04/17/25 at 12:04 PM, V3, ADON said when someone voices self-harm they will have the social worker come and talk with them to determine if they have a plan and if they are able to carry out that plan. Then they will notify the doctor about what is going on with the resident. V3 said on the day R2 voiced self-harm she had the social worker (V19) come and talk with R2. V19 then advised V3 the doctor should be notified and so she then notified the doctor. She said she typically wouldn't make a note in the progress notes the social worker would make the note. She said she sent a fax to the doctor at the time of the incident with R2 and he didn't have access to a gun the doctor didn't give any new orders it just said noted on the fax. On 04/17/25 at 12:12 PM, V19, Social Worker said the nurse will notify her when a resident makes a statement about wanting to hurt themselves and she will go down and interview the resident and ask them what statement they made. She said she would make to a point to ask them what they intended to do and what they were going to use. She would notify the doctor of the resident's behaviors and the means the resident had to anything to hurt themselves and if the doctor wasn't the resident sent out to the ER for evaluation. V19 said she didn't interview the resident the day of the incident due to her being out of the facility at a funeral. She said the nursing staff can interview the resident also they know what to do. She said she would also notify the family of what was happening. V19 said she didn't make a note that day because she didn't talk with R2 due to her being out of the facility. On 04/17/25 at 12:24 PM, Follow up interview with V3, ADON she said V19 was here on the day of the incident. She said V19 was standing next to her (V3's) desk when they discussed what was going on with R2. She said she would expect the social worker to notify the family about the incident with R2, but she guesses she didn't. On 04/22/25 at 11:01 V1, Administrator stated she was not aware V6, Medical Director had sent an order back regarding R2 and obtaining a psychiatric evaluation. V1 said it isn't in his chart. This surveyor explained to V1 V6 was called, and he stated he fax an order back for R2 to have a psych eval. V1 said she would expect the nurses to follow the doctor's orders. V1 stated when a resident is having self-harm thoughts, she would expect the nurses to do close supervision, make sure they talk with the resident, and redirection/distraction. On 04/22/25 at 11:22 AM, during a follow-up interview with V1, V1 said the nurses are expected to call and notify the families/POA when a resident is having thoughts of self-harm. The facility's physician Notification for routine orders policy, note dated, documented L. You must always notify family/guardian/POA/representative of any incident by telephone immediately (document each attempt in nurse's notes). You must also notify above parties of any significant change in resident's condition.

Based on interview and record review the facility failed to notify the Power of Attorney (POA)/family of a resident who was experiencing self-harm thoughts for 1 of 3 residents (R2) reviewed for self-harm in a sample of 11. Findings Include: R2's Face Sheet, print date of 04/16/25, documented R2 had diagnoses of depression and dementia. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and required supervision/touching assistance with ambulation. He wears a wander/elopement alarm daily. Section D of the MDS documented under the symptom's presence R2 was having feelings of feeling down, depressed, or feeling hopeless. Under the symptoms frequency documented he was having these feelings 12-14 days (nearly every day). R2's Care Plan, with admission date of 09/27/24, was reviewed and had no documentation regarding R2 having a diagnosis of depression. R2's Physician Notification for Routine Orders, dated 04/10/25, sent at 12:00 PM, documented the following: Explain: Today during a conversation with (R2), he said he's upset about having to stay here and just stare at the same 4 walls. He stated, If I have to stay much longer, I will shoot myself or kill myself. While he doesn't have the means to do this, I wanted you to be aware. The document was then signed by V3, Assistant Director of Nursing (ADON). This document has a section labeled Physician's Response (if appropriate) which was blank. R2's Progress Notes were reviewed and had no documentation regarding R2 having thoughts of self-harm on 04/10/25 and no documentation the POA/family was notified. On 04/15/25 at 1:40 PM, V5, R2's POA/wife said she wasn't made aware R2 had made statements of him wanting to hurt his self. She said when she did find out later, she had to have family come over and remove all the guns from the house. On 04/17/25 at 12:04 PM, V3, ADON said when someone voices self-harm they will have the social worker come and talk with them to determine if they have a plan and if they are able to carry out that plan. Then they will notify the doctor about what is going on with the resident. V3 said on the day R2 voiced self-harm she had the social worker (V19) come and talk with R2. V19 then advised V3 the doctor should be notified and so she then notified the doctor. She said she typically wouldn't make a note in the progress notes the social worker would make the note. She said she sent a fax to the doctor at the time of the incident with R2 and he didn't have access to a gun the doctor didn't give any new orders it just said noted on the fax. On 04/17/25 at 12:12 PM, V19, Social Worker said the nurse will notify her when a resident makes a statement about wanting to hurt themselves and she will go down and interview the resident and ask them what statement they made. She said she would make to a point to ask them what they intended to do and what they were going to use. She would notify the doctor of the resident's behaviors and the means the resident had to anything to hurt themselves and if the doctor wasn't the resident sent out to the ER for evaluation. V19 said she didn't interview the resident the day of the incident due to her being out of the facility at a funeral. She said the nursing staff can interview the resident also they know what to do. She said she would also notify the family of what was happening. V19 said she didn't make a note that day because she didn't talk with R2 due to her being out of the facility. On 04/17/25 at 12:24 PM, Follow up interview with V3, ADON she said V19 was here on the day of the incident. She said V19 was standing next to her (V3's) desk when they discussed what was going on with R2. She said she would expect the social worker to notify the family about the incident with R2, but she guesses she didn't. On 04/22/25 at 11:01 V1, Administrator stated she was not aware V6, Medical Director had sent an order back regarding R2 and obtaining a psychiatric evaluation. V1 said it isn't in his chart. This surveyor explained to V1 V6 was called, and he stated he fax an order back for R2 to have a psych eval. V1 said she would expect the nurses to follow the doctor's orders. V1 stated when a resident is having self-harm thoughts, she would expect the nurses to do close supervision, make sure they talk with the resident, and redirection/distraction. On 04/22/25 at 11:22 AM, during a follow-up interview with V1, V1 said the nurses are expected to call and notify the families/POA when a resident is having thoughts of self-harm. The facility's physician Notification for routine orders policy, note dated, documented L. You must always notify family/guardian/POA/representative of any incident by telephone immediately (document each attempt in nurse's notes). You must also notify above parties of any significant change in resident's condition.

Based on interview and record review, the facility failed to provide adequate staffing to provide supervision for 1 of 4 residents (R2) reviewed for sufficient staffing in a sample of 11. Findings include: The facility's daily assignment sheet, dated 4/11/25, documented 1 nurse, Agency Licensed Practical Nurse, LPN) and 2 Certified Nurse Assistants, CNAs, (V12, V13) were assigned to the first floor of the facility from 2:00 PM to 10:00 PM and a CNA (V28) assigned as floater for the first and second floor from 3:30 PM to 10 PM. On 4/11/25 between 4 PM and 5 PM R2, with Alzheimer's dementia eloped from the facility and was found approximately a mile away from the facility in a ditch along a busy road. It was determined that on 4/11/25 only 1 CNA (V12) was present on the first floor of the facility at times between 4 PM and 5 PM due to a CNA (V13) being on her lunch break, nurse (V20) being on break outside of the facility, and V23 float CNA working on the 2nd floor. The facility's incident report of R2's elopement, dated 4/11/25, documented Nursing Description: staff noticed wander guard alarm at front door going off at 1645 (4:45 PM). This nurse and staff did a head count in the facility and noticed resident not in room. Room checks complete by staff to locate resident without success. (resident monitoring device) located in trash can by front door. ADON (Assistant Director of Nursing) notified immediately, Administrator notified. Code yellow called. Resident's wife and daughter contacted. 911 call placed at 1650 (4:50 PM). On call Dr. notified. Call received from (local) PD (Police Department) stating resident located at 1735 (5:35 PM). Resident returned to facility by (local) PD with resident. Wife at facility with resident. On 4/15/25 at 1:40 PM V5, wife of R2, stated after the elopement on 4/11/25 she came to the facility and R2's nurse stated to her the facility does not have enough help and they cannot watch him 24/7. V5 stated she replied to the nurse should I get someone else to come in and watch him and the nurse replied, we can't, we don't have the help. V5 stated she believes R2 was gone from the facility for at least 50 minutes, that their ex-daughter in law (V21) was driving down the road, a busy road that goes to the high school ball diamonds, and (V21) thought she saw an animal in the ditch, that she turned around and realized it was R2. V5 stated R2's pants were grass stained and wet, and he had a cut on his arm, so she believes he fell at some point during the elopement. V5 stated she felt pressured to take R2 home last weekend (4/12/25 and 4/13/25) because the facility nurse stated they did not have enough staff to do 1 on 1 with him nor watch him closely. V5 stated R2 did display confusion over the weekend when he was at home. V5 stated the facility is very short staffed, even worse on the evening shift and weekends, the front office staff leave by 3:30 or 4 PM during the week and no staff are in the front to observe the front door in the evenings nor on weekends. On 4/16/25 at 2:12 PM V13 CNA stated she was working the evening R2 eloped from the building. V13 stated she did see R2 in his room just before she went to break at approximately 3:45 PM, when she returned from break around 4:15 PM she attempted to enter the front door but could not because it was locked, and the alarm was going off. V13 stated she looked around and did not see a resident, then she called her coworker to let her in the building, coworker then let her in, and she went to the front lobby to shut the door alarm off. V13 stated as she was attempting to shut the alarm off, she saw the agency nurse (V20) for her and R2's unit trying to enter the front door as she was coming back from break. V13 stated she let the nurse in the door, and she thought she had deactivated the alarm, but it kept going off, so she said to the nurse that is strange, the alarm is still going off. V13 stated she went and told the other CNAS about the door alarm sounding and they checked the first floor 2 times then realized R2 wasn't in the building. V13 stated she does not know how long R2 was missing however she did see him shortly before she went on her break. V13 stated once R2 was returned to the facility after he eloped, R2 stated to her that he was fighting with the cops, that he walked about 2 miles, he had walked through some brush, that he got himself out by putting in the 1379 door code that was posted by the keypad, and that he was only going to be at the facility for a couple more days. V13 stated she was initially working with just 1 other CNA and the agency nurse for the entire first floor until another CNA arrived later in the shift. V13 stated the shift was difficult because one of their assigned residents had fallen twice that day and her coworker was trying to keep that resident with her to prevent the resident from having anymore falls. V13 stated she nor her coworker were able to complete R2's 15-minute checks that day because there was no way to get everything done with only 2 CNAS. V13 stated it is even difficult to get everything done for the residents when they have 3 CNAS but they usually just have 2 CNAS on the first-floor unit for the evening shift. V13 stated the third CNA (V23) who was assigned to float between the first and second floors came on duty at approximately 3:30 PM and when she went on break it left 2 CNAS on the unit since the nurse was on break at about the same time as her. V13 stated R2 was not in the building when she came to work the next evening and she was told R2's wife took him home for the weekend because V16, LPN, told R2's wife V5 she had to take him home for the weekend because the facility did not have enough staff to do one on ones with R2. On 4/16/25 at 2:32 PM V16, LPN, stated she was the nurse on day shift last weekend on 4/12/25 and that R2 went home with his wife at about 1:45 PM on that Saturday. V16 stated she asked his wife, V5, to come to the facility because R2 stated to her if I get a chance I am getting out of here. V16 stated she parked her med cart by R2's door during the morning medication pass so she could monitor him and that he napped most of the morning then around lunch he said he was going home today. R2 then took his wander guard off right before lunch and stated he was leaving so she then called V5 and updated her. V5 stated she would come and talk to R2 and stay for a while. V16 stated she then asked V5 what about when you leave, the Administrator wants to know if you can have a friend who can sit with him if you can't do it. V16 stated more or less I told her we didn't have the staff to monitor him 1 on 1. The facility's investigation included a witness statement, dated 4/11/25, by V12 CNA that documented (R2) in his room when I got here. Then around 4:00 PM getting busy helping residents to get ready for dinner. Nurse told me she is going to break. I answered room [ROOM NUMBER], my co-CNA went to break too then after 3 minutes the alarm is off, get up to check it and I see my co-CNA in the back door asking me to open. The facility's investigation included a witness statement, dated 4/11/25, by V23 CNA that documented I clocked in shortly after 3:35 PM and I saw (R2) in his room wearing a long-sleeved dark shirt and dark colored pants. About 30 minutes after being at work an older gentleman walked into R2's room and visited. At about 4:50 PM, V12 came upstairs and asked for my help looking for (R2). At about 5:20 PM after searching the building I got in my car and started to drive up and down the nearby streets. At 5:30 a man said he thinks (R2) would be headed back home towards (name of road) road. As I headed that way, I saw a cop car coming towards my direction, so I flagged him down and asked if he had seen (R2). He told me they had him and to go straight about 1/4 mile. As I pulled up, I saw (R2) leaned up against a woman's car, and a cop car behind them. I got out to check on him and he was wearing 2 button down shirts, pants, and running shoes. He was carrying a long stick which he had used to walk down the street. He was holding a blood soiled napkin against his right wrist and being very adamant that he was never stepping foot into this building again. The police officer made the decision to bring him back to (the facility) and wait for (EMS) to check him out here. I followed them back here, got the nurse, and returned to work. On 4/22/25 at 9:14 AM V20, Agency LPN, stated she went outside to her car for a few minutes on 4/11/25 when R2 eloped from the facility. V20 stated when she attempted to go back into the facility after her break, but the front door was locked, and the alarm was sounding so she called the facility and asked for staff to let her in. V20 stated V13 let her in, and a visitor stated to them he thought he set the alarm off however when they tried to deactivate the alarm it would not shut off, and they discovered a wander guard was in the trash can by the front door therefore the alarm could not be deactivated until the (resident monitoring device) was removed from the area. V20 stated when she was on a short break, the float CNA (V23) was on the second-floor unit, V13 CNA was on break, and V12 CNA was working the floor but primarily keeping an eye on a resident who had fallen twice on day shift that day. 04/17/25 at 10:10 AM, V7, CNA, stated she feels like the facility does not have enough staff working daily to properly supervise the residents. She said with all of the residents who need to be 1:1 due to being a fall risk. She said sometimes it can get chaotic. On 4/22/25 at 10:54 AM V1, Administrator, stated the facility does not have a staffing policy and follows state guidelines. V1 stated they assign breaks, but they may fluctuate depending on what is going on that day, and she expects there to be at least 2 nursing department staff members to be on each floor at all times. V1 stated she was not aware that the agency nurse (V20) and CNA (V13) went on break and out of the building at the same time on the evening shift of 4/11/25 when R2 eloped from the building. On 4/22/25 at 11:03 AM V28 CNA stated the facility normally has 3 CNAs on the day shift and she feels that is sufficient. V28 then stated, I've worked the floor by myself before and that is not enough.

Based on interview and record review, the facility failed to provide adequate staffing to provide supervision for 1 of 4 residents (R2) reviewed for sufficient staffing in a sample of 11. Findings include: The facility's daily assignment sheet, dated 4/11/25, documented 1 nurse, Agency Licensed Practical Nurse, LPN) and 2 Certified Nurse Assistants, CNAs, (V12, V13) were assigned to the first floor of the facility from 2:00 PM to 10:00 PM and a CNA (V28) assigned as floater for the first and second floor from 3:30 PM to 10 PM. On 4/11/25 between 4 PM and 5 PM R2, with Alzheimer's dementia eloped from the facility and was found approximately a mile away from the facility in a ditch along a busy road. It was determined that on 4/11/25 only 1 CNA (V12) was present on the first floor of the facility at times between 4 PM and 5 PM due to a CNA (V13) being on her lunch break, nurse (V20) being on break outside of the facility, and V23 float CNA working on the 2nd floor. The facility's incident report of R2's elopement, dated 4/11/25, documented Nursing Description: staff noticed wander guard alarm at front door going off at 1645 (4:45 PM). This nurse and staff did a head count in the facility and noticed resident not in room. Room checks complete by staff to locate resident without success. (resident monitoring device) located in trash can by front door. ADON (Assistant Director of Nursing) notified immediately, Administrator notified. Code yellow called. Resident's wife and daughter contacted. 911 call placed at 1650 (4:50 PM). On call Dr. notified. Call received from (local) PD (Police Department) stating resident located at 1735 (5:35 PM). Resident returned to facility by (local) PD with resident. Wife at facility with resident. On 4/15/25 at 1:40 PM V5, wife of R2, stated after the elopement on 4/11/25 she came to the facility and R2's nurse stated to her the facility does not have enough help and they cannot watch him 24/7. V5 stated she replied to the nurse should I get someone else to come in and watch him and the nurse replied, we can't, we don't have the help. V5 stated she believes R2 was gone from the facility for at least 50 minutes, that their ex-daughter in law (V21) was driving down the road, a busy road that goes to the high school ball diamonds, and (V21) thought she saw an animal in the ditch, that she turned around and realized it was R2. V5 stated R2's pants were grass stained and wet, and he had a cut on his arm, so she believes he fell at some point during the elopement. V5 stated she felt pressured to take R2 home last weekend (4/12/25 and 4/13/25) because the facility nurse stated they did not have enough staff to do 1 on 1 with him nor watch him closely. V5 stated R2 did display confusion over the weekend when he was at home. V5 stated the facility is very short staffed, even worse on the evening shift and weekends, the front office staff leave by 3:30 or 4 PM during the week and no staff are in the front to observe the front door in the evenings nor on weekends. On 4/16/25 at 2:12 PM V13 CNA stated she was working the evening R2 eloped from the building. V13 stated she did see R2 in his room just before she went to break at approximately 3:45 PM, when she returned from break around 4:15 PM she attempted to enter the front door but could not because it was locked, and the alarm was going off. V13 stated she looked around and did not see a resident, then she called her coworker to let her in the building, coworker then let her in, and she went to the front lobby to shut the door alarm off. V13 stated as she was attempting to shut the alarm off, she saw the agency nurse (V20) for her and R2's unit trying to enter the front door as she was coming back from break. V13 stated she let the nurse in the door, and she thought she had deactivated the alarm, but it kept going off, so she said to the nurse that is strange, the alarm is still going off. V13 stated she went and told the other CNAS about the door alarm sounding and they checked the first floor 2 times then realized R2 wasn't in the building. V13 stated she does not know how long R2 was missing however she did see him shortly before she went on her break. V13 stated once R2 was returned to the facility after he eloped, R2 stated to her that he was fighting with the cops, that he walked about 2 miles, he had walked through some brush, that he got himself out by putting in the 1379 door code that was posted by the keypad, and that he was only going to be at the facility for a couple more days. V13 stated she was initially working with just 1 other CNA and the agency nurse for the entire first floor until another CNA arrived later in the shift. V13 stated the shift was difficult because one of their assigned residents had fallen twice that day and her coworker was trying to keep that resident with her to prevent the resident from having anymore falls. V13 stated she nor her coworker were able to complete R2's 15-minute checks that day because there was no way to get everything done with only 2 CNAS. V13 stated it is even difficult to get everything done for the residents when they have 3 CNAS but they usually just have 2 CNAS on the first-floor unit for the evening shift. V13 stated the third CNA (V23) who was assigned to float between the first and second floors came on duty at approximately 3:30 PM and when she went on break it left 2 CNAS on the unit since the nurse was on break at about the same time as her. V13 stated R2 was not in the building when she came to work the next evening and she was told R2's wife took him home for the weekend because V16, LPN, told R2's wife V5 she had to take him home for the weekend because the facility did not have enough staff to do one on ones with R2. On 4/16/25 at 2:32 PM V16, LPN, stated she was the nurse on day shift last weekend on 4/12/25 and that R2 went home with his wife at about 1:45 PM on that Saturday. V16 stated she asked his wife, V5, to come to the facility because R2 stated to her if I get a chance I am getting out of here. V16 stated she parked her med cart by R2's door during the morning medication pass so she could monitor him and that he napped most of the morning then around lunch he said he was going home today. R2 then took his wander guard off right before lunch and stated he was leaving so she then called V5 and updated her. V5 stated she would come and talk to R2 and stay for a while. V16 stated she then asked V5 what about when you leave, the Administrator wants to know if you can have a friend who can sit with him if you can't do it. V16 stated more or less I told her we didn't have the staff to monitor him 1 on 1. The facility's investigation included a witness statement, dated 4/11/25, by V12 CNA that documented (R2) in his room when I got here. Then around 4:00 PM getting busy helping residents to get ready for dinner. Nurse told me she is going to break. I answered room [ROOM NUMBER], my co-CNA went to break too then after 3 minutes the alarm is off, get up to check it and I see my co-CNA in the back door asking me to open. The facility's investigation included a witness statement, dated 4/11/25, by V23 CNA that documented I clocked in shortly after 3:35 PM and I saw (R2) in his room wearing a long-sleeved dark shirt and dark colored pants. About 30 minutes after being at work an older gentleman walked into R2's room and visited. At about 4:50 PM, V12 came upstairs and asked for my help looking for (R2). At about 5:20 PM after searching the building I got in my car and started to drive up and down the nearby streets. At 5:30 a man said he thinks (R2) would be headed back home towards (name of road) road. As I headed that way, I saw a cop car coming towards my direction, so I flagged him down and asked if he had seen (R2). He told me they had him and to go straight about ¼ mile. As I pulled up, I saw (R2) leaned up against a woman's car, and a cop car behind them. I got out to check on him and he was wearing 2 button down shirts, pants, and running shoes. He was carrying a long stick which he had used to walk down the street. He was holding a blood soiled napkin against his right wrist and being very adamant that he was never stepping foot into this building again. The police officer made the decision to bring him back to (the facility) and wait for (EMS) to check him out here. I followed them back here, got the nurse, and returned to work. On 4/22/25 at 9:14 AM V20, Agency LPN, stated she went outside to her car for a few minutes on 4/11/25 when R2 eloped from the facility. V20 stated when she attempted to go back into the facility after her break, but the front door was locked, and the alarm was sounding so she called the facility and asked for staff to let her in. V20 stated V13 let her in, and a visitor stated to them he thought he set the alarm off however when they tried to deactivate the alarm it would not shut off, and they discovered a wander guard was in the trash can by the front door therefore the alarm could not be deactivated until the (resident monitoring device) was removed from the area. V20 stated when she was on a short break, the float CNA (V23) was on the second-floor unit, V13 CNA was on break, and V12 CNA was working the floor but primarily keeping an eye on a resident who had fallen twice on day shift that day. 04/17/25 at 10:10 AM, V7, CNA, stated she feels like the facility does not have enough staff working daily to properly supervise the residents. She said with all of the residents who need to be 1:1 due to being a fall risk. She said sometimes it can get chaotic. On 4/22/25 at 10:54 AM V1, Administrator, stated the facility does not have a staffing policy and follows state guidelines. V1 stated they assign breaks, but they may fluctuate depending on what is going on that day, and she expects there to be at least 2 nursing department staff members to be on each floor at all times. V1 stated she was not aware that the agency nurse (V20) and CNA (V13) went on break and out of the building at the same time on the evening shift of 4/11/25 when R2 eloped from the building. On 4/22/25 at 11:03 AM V28 CNA stated the facility normally has 3 CNAs on the day shift and she feels that is sufficient. V28 then stated, I've worked the floor by myself before and that is not enough.

Based on observation, interview, and record review, the facility failed to ensure resident's coffee was served at safe temperatures to prevent burns/injury. This failure resulted in an Immediate Jeopardy when R21 sustained a second degree burn from spilling hot coffee on himself on 2/8/2024 and the facility continued to provide all residents' coffee at unsafe temperatures. Findings include: The Immediate Jeopardy began on 2/8/2024 when R21 sustained a second degree burn from spilling hot coffee on himself. On 4/26/2024 at 1:50 PM, V1 (Administrator), V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) were notified of the Immediate Jeopardy. The surveyor confirmed by observations, record review and interview, that the Immediate Jeopardy was removed on 4/30/2024 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. 1. R21's Physicians Order Sheet (POS) dated April 2024, documented a diagnoses of multiple sclerosis (MS), pneumonia, unspecified organism, bacteremia, urinary tract infection, sepsis, unspecified organism, colostomy status, presence of urogenital implant, stiffness of right knee, not elsewhere classified, stiffness of left knee, not elsewhere, weakness, other reduced mobility, problem related to care providers dependency, unspecified, Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere an a pressure ulcer of sacral region. R21's Minimum Data Set (MDS) dated [DATE] documented that R21 was cognitively intact for decision making. R21's Care Plan 4/13/2024 documented, The resident has limited physical mobility related to Multiple sclerosis (MS) dated initiated 4/13/2022. It continues, Resident uses an electric wheelchair, resident is on a regular diet, resident has multiple sclerosis. The resident has limited physical mobility related to MS. 2/8/2024 spilled coffee on thigh, blister healed 2/12/2024. R21's Progress Note, dated 2/8/2024 at 1:01 PM, documented, Note Text: MD (Medical Doctor) notification received regarding treatment to open area to right thigh r/t (related to) popped blister from resident's spilled coffee. (V4) APRN (Advanced Practice Registered Nurse) agree with treatment to cleanse right thigh with NS (Normal Saline). Applied xeroform, cover with DD (dried dressing) and secure with tape. Change daily and prn (As needed). POA and resident aware of new order. R21's Skin Assessment, dated 2/13/2024 at 12: 50 PM, Right front thigh scabbed, 1 length x 0.4 width; front thigh scabbed length 0.5 x width 0.3. Referral to (Wound Company) x 2 scabs right front thigh. No new skin issues. On 4/25/2024 at 12:02 PM, R21 stated, I was going to get a cup of coffee off of the table, there are cups and everything available and I was helping myself to a cup of coffee and my nerves got the best of me and I accidentally dumped the coffee on my lap. I got blisters on my thigh, but I am okay now. On 4/30/2024 at 10:32 PM, V25 (Certified Nursing Assistant/CNA) stated, When I was assisting (R21) to bed I noticed he had a quarter size burn on his top thigh. When I asked him what happened he stated he got burned with the coffee. Normally, we have the coffee available in the dining room with cups available to residents to have coffee. 2. On 4/25/2024 at 11:11 AM, V19 (Dietary Manager) stated I have received complaint about the coffee being hot, but I am not aware of any resident being injured from the hot liquid. On 4/25/2024 at 12:06 PM in the main dining room the lunch service was taking place and there are thermal cups available for use and a machine with coffee in it on a table. The plastic thermal cups do not have lids. The coffee machine has a lever that you pull down and fill the coffee cup with. A cup of coffee water temperature was taken with a calibrated metal thermometer and documents a temperature of 160.5 degrees Fahrenheit (F). On 4/25/2024 at 12:07 PM, V5 (CNA), stated, We have coffee available for our residents all day. Anytime they want a drink they can go to the window and ask, and we always have coffee available. On 4/25/2024 at 12:11 PM during lunch coffee was available to all residents and R150 and were observed getting up and getting her own cup of coffee. The coffee was steaming from the cup. On 4/25/2024 at 12:14 PM, R150 stated, Yes, the coffee is really hot, look at that steam. 04/25/2024 2:06 PM R42 went into the dining room and got herself a cup of coffee. On 4/25/2024 at 2:06 PM, in the main dining room there is a group activity going on and there are thermal cups available to use. A cup of coffee temperature was taken with a calibrated metal digital thermometer and documents a temperature of 160.5 degrees F. On 4/25/2024 at 2:08 PM, R42 stated that she always gets her own coffee here and there is always coffee sitting there on the table with cups. She continued to state, The coffee is really hot you can see the steam coming out of it. I usually put my silverware in my coffee to cool it off. I love coffee. On 4/25/2024 at 2:59 PM, in the main dining room there are residents inside watching a movie on the projector screen. The coffee is still available and coffee temperatures were taken with a calibrated metal digital thermometer and documents a temperature of 159.5 degrees F. On 4/25/2024 at 3:13 PM, V7 (Dietary Cook) stated, We always try and have hot coffee always available for residents. On 4/25/2024 at 4:10 PM, the coffee temperature was taken with a metal, digital thermometer and documents a temperature of 158.5 degrees F. On 4/26/2024 at 12:47 PM, V19 (Dietary Manager) stated I just took the temperatures on the coffee, and they were 180 degrees Fahrenheit, and the holding temperature was 165 degrees. I talked with Folgers manufacture, and they recommended the temperature to be 195 degrees to 205 degrees Fahrenheit. On 4/25/2024 at 2:26 PM, V21 (Nurse Practitioner) stated, If a resident had a burn and there was a blister, I would expect it was a second- or third-degree burn. If the coffee or hot liquid was extremely hot it could easily cause a second- or third-degree burn. (R21) was treated for a blister/burn. On 4/25/2024 at 2:29 PM, V22 (Medical Director) stated, If a resident gets a blister from a burn, I would consider it to be a second degree burn. Ideally, we would not want the liquid to be that hot so if a resident did spill the drink, and with this population they are some high-risk groups, there would not be any injury from spilling the beverage. The Precautions for Hot Beverages Policy, dated 2022, documented, The temperature for brewing and serving hot beverages will be based on the manufacture recommendations for the beverage equipment utilized in each community. Although, the recommended setting for proper brewing will vary based on community equipment, it is recommended that the temperature of the equipment be set at the lowest possible temperature for adequate brewing, anticipated to be in the range of 160 F to 170 degrees F. The serving temperature should be approximately 10 to 15 degrees less that the brewing temperature. Additional precautions may be implemented based on the needs of each resident and may include Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. Ensure staff monitors the identified high-risk residents during mealtimes, and/or when hot beverages are served. Utilizing spill proof lids and cups for those individuals identified as high risk for spillage and potential for burning. Assessing those individuals who request beverages served hotter than the guidelines outline above for the ability to consume hot beverages independently and safely. The Long -Term Care Facility Application for Medicare and Medicaid form dated 4/23/2024 documented the facility had a census of 51 residents. The Immediate Jeopardy that began on 2/8/24 was removed on 4/30/24 when the facility took the following actions to remove the immediacy: 1. On 4/26/2024 at 4:00 PM, the coffee maker machine in the dining room was removed by V19 (Dietary Manager) and is no longer in use for meals or activities. 2. Safe hot liquid temperature range identified by Manufacturer recommendations for the beverage equipment utilized. A. It is recommended that the temperature of the equipment be set at the lowest possible temperature brewing anticipated to be in the range of 160 degrees to 170 degrees Fahrenheit. 3.On 4/30/2024 at 8:00 AM, V19 (Dietary Manger) will ensure coffee temperatures are brewed at recommended levels and temperatures will be monitored until the coffee reaches a safe temperature (between 135 to 145 degrees) and the temperature is documented on temperature logbook by dietary cooks and overseen by the dietary manager. A-Once the coffee is at an acceptable safe temperature range documented on the logbook the coffee will be available for resident consummation. B-All coffee will be handed out of the kitchen by dietary staff and no longer be available to self- serve. No coffee will be available for use unless it has reached the safe temperature level recorded by staff. 4. On 4/30/2024 Kitchen staff will be in serviced by V19 (Dietary Manager) on coffee temperatures logging coffee temperatures and ensuring coffee has been cooled to the safe temperature before residents are served any coffee. 5. On 4/30/2024 Certified Nursing Assistants and nursing staff will be in-serviced by V2 (Director of Nursing) and V3 (Assistant Director of Nursing) regarding getting coffee from the kitchen and not serving coffee that has not been cooled, residents' capabilities of handling hot coffee/hot beverages, and watching for steam and potential for burns. No staff (kitchen, CNAs, nursing) will begin shift prior to getting this Inservice. This is to ensure that anyone who is taking time off will be in-serviced prior to starting their shift. 6. Hot Liquid beverage policy was reviewed/revised by V1(Administrator) on 4/30/24. A.V19 (Dietary Manager) in-service all kitchen personal on Hot Liquid policy on 04/30/24. B.V2 and V3 in-serviced Nursing and CNAs on the new policy for Hot Beverages on 4/30/24. 7. QAPI Plan: A. On 4/30/2024 at 8:00 AM, V19 (Dietary Manger) will ensure coffee temperatures are brewed at recommended levels and temperatures will be monitored until the coffee reaches a safe temperature (between 135 to 145 degrees) and the temperature is documented on temperature logbook by dietary cooks and overseen by the dietary manager and all kitchen staff are aware and taking temperatures and documenting temperatures in the log. Staff will be in serviced on watching for steam and taking temperatures before serving residents.

Based on interview and record review the facility failed to ensure abuse did not occur for 2 of 3 residents (R9 and R149) reviewed for abuse in the sample of 31. Findings include: 1.) R149 Physician Order Sheet for September 2023 documents, a diagnosis of acute cholecystitis, pneumonia, arthropathies in other specified diseases, type 2 diabetes mellites with diabetic neuropathy, major depression, hypertension, acute ischemic heart disease, typical atrial flutter, peripheral vascular disease, asthma, acute and chronic respiratory failure with hypercapnia, respiratory failure unspecified with hypoxia, Gerd, heart failure. R149's Care Plan with a revision date of 1/25/2023 documents, The resident has a communication problem, related to minimal hearing deficit. Intervention: Allow adequate time to respond. Repeat as necessary, do not rush. Request clarification from the resident to ensure understanding. Face when speaking, make eye contact. Turn off TV/radio reduce environmental noise. R149's Minimum Data Set, dated dated dated [DATE] documents, R149 was severely impaired for cognition. R149's MDS also documents he is deaf. R149's Initial Investigation Report Sent 9/18/2023 at 10:59 AM, documents, To whom it may concern: Resident's family member brought to my attention this morning a picture from 9/16/2023 of his white board with a handwritten message stating to Stop abusing the call light, last warning. MD (Medical Doctor) notified. DON (Director of Nursing) interviewed resident. He has no recollection of seeing the message. Investigation to continue. (Author V1- Administrator). On 4/25/2024 at 4:14 PM, V1 (Administrator) stated, I cannot find the final report for this investigation. I am not sure who the staff member was and/or what the outcome was regarding this allegation. (R149) is no longer in the facility. On 4/25/2024 at 4:22 PM, V2 (Director of Nursing) stated, I was not working here, that was a different DON. I am not familiar with anything regarding (R149). On 4/25/2024 at 4:32 PM, V3 (Assistant Director of Nursing) stated, I was here at the time, but I cannot tell you anything. I do not know anything about the investigation and/or staff member related to (R149). On 4/25/2025 at 5:33 PM, V6 (Family of R149) stated, My dad was deaf, and we were using a white board to communicate. When my dad was at the nursing home, he was completely helpless and at the mercy of the facility. When I went to visit him, I saw this message written on the white board and took a picture of it because it said to 'stop abusing the call light, this is your last warning. It gave me goosebumps because it was not right. We met with the administrator, and I showed her the photo and she said she would address it. My dad passed away a few weeks later. When I was picking up his stuff, I asked whatever happened with the message left on the whiteboard and staff said they had done an investigation. When I asked more questions, nobody could tell me anything. Nobody knew who wrote the message they said they did not know. I asked if they still worked there, and nobody knew anything, and it did not set right with me. I just hope they really investigated this and found out who would write such a message and hope he or she does not still work in the nursing home. To me it was unsettling that anyone would threaten my poor helpless dad. No final report or investigation was provided by the facility for this allegation of abuse for R149 on 9/18/2023. 44953 2.) R9's Face Sheet undated documents, pertinent medical diagnosis as Unspecified Diastolic (Congestive) Heart Failure, Major Depressive Disorder, Suicidal Ideation, Cervical Disc Disorder with Myelopathy, High Cervical Region, Fusion of Spine, Cervical Region, Spinal Stenosis, Cervical Region, Unsteadiness on Feet and Weakness. The Facility Reported Incident (FRI) dated 3/27/24 documents a staff member reported that another staff member raised her voice and used a curse word, while in R9's room providing care. Alleged staff member has not been on duty since allegation was made. Administrator, MD and POA were notified of the allegation, V31 (police officer) was also notified. Upon resident interview he stated that the staff member did raise her voice at him but would not quote anything that was said. Interview with reporting staff member who was in the room alleged that co-worker raised her voice and used a curse word in the presence of the resident. Alleged staff member denies that she used a curse word but did state she was tired and may have sounded rude. She also stated she did not intend to cause the resident any distress. Multiple other residents were interviewed and denied any issues with staff yelling and all stated, they felt safe at the facility. (R9) states that he feels safe and has no adverse effects from interaction with this staff member. No other staff members report negative interactions with the alleged staff member. Due to the employee's interaction with the resident facility administration terminated employee. On 4/26/24 at 10:22 AM R9 stated, all I said to the Certified Nursing Assistant/CNA was that I did not want to be left on the bed pan for 35-45 minutes. Since it was the changing of shift, I asked her to pass it on to the next shift. That's when she (V24) began yelling at me. I yelled back at her because I don't have to take it from anybody. On 4/26/24 at 10:26 AM V10 (R9's spouse) stated, she can verify R9's statement because sometimes when she come in to visit her husband is not in the room. He is in the bathroom and that he has been in the bathroom over 35-minutes. When she questioned the staff, they dismiss her stating he has not been in the bathroom that long. On 4/30/24 at 9:38 AM V26 (CNA) stated she reported the incident to the Administrator the next morning after the incident because V24 (CNA) was telling the other staff that the resident (R9) had cursed at her. V26 stated she witnessed V24 yelling and cursing at (R9). V24 did not initially hear what R9 said, but when R9 repeated that he just wanted V24 to alert the on-coming shift that he (R9) was on the bedpan, V24 became upset and started yelling and screaming at V9 calling him (R9) a f*****g drunk. (R9) did stand up for himself and kept repeating that he was not accusing her (V24) of anything. He (R9) was really quiet afterwards and offered to apologize to V24 if he offended her. V24 was suspended and did not return to the facility afterwards. On 4/30/24 at 10:30 AM, V25 (Registered Nurse/RN) stated she did not witness the incident between V24 (CNA) and R9. The CNA (V26) reported to her that V24 was being rude and abrasive with resident (R9). V25 stated she did not interview either V24 or R9. V24 was suspended and did not return to the facility. R9 did not exhibit any changes in behaviors. Police report dated 3/29/24 at 7:12PM, documents, that V1 (Administrator) contacted the area Police Department to report a verbal confrontation that took place between V24 and R9. V1 reported that V24 the staff member later identified as V24 yelled and used foul language towards (R9). V1 reported that nothing physical took place during the incident. Also, that action taken against the staff member was that she was suspended from work. (State Agency for Aging) was being contacted due to a prior report of an incident with staff. On 4/30/24 at 10:42 AM V1 (Administrator) stated the report was referring to the prior incident with another resident (R6). No one from (State Agency for Aging) had been out to investigate. On 4/02/24 a typed statement of the interview with V24 (CNA) documents V24 admits she might have gotten a little loud with the resident, but it was getting to be at the end of her shift, and she might have been tired. She did not recall cussing or pointing in residents' face. The interview was witnessed by the V3 (Assistant Director of Nursing). V24's termination letter dated 4/01/24 documents, V24's employment was being terminated at the facility, due to the following violation of the Care Centers' work rules: Speaking loudly at and cursing at the resident. V24's (CNA) timecard dated 3/26/24- 4/08/24, do not document, any days worked after 3/27/24 at 10:01 PM. The facility's Policy Subject: Abuse Neglect Exploitation ADN Misappropriation of Property Prevention. dated 4/22/19 documents, Verbal/Written Abuse- is defined as the use of oral/written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his /her family again.

Based on interview and record review the Facility failed to ensure all abuse allegations were investigated thoroughly and completed for 1 of 4 residents (R149) reviewed for abuse in the sample of 31. Findings include: R149's Initial Investigation Report sent 9/18/2023 at 10:59 AM, documents, To whom it may concern: Resident's family member brought to my attention this morning a picture from 9/16/2023 of his white board with a handwritten message stating to Stop abusing the call light, last warning. MD (Medical Doctor) notified. DON (Director of Nursing) interviewed resident. He has no recollection of seeing the message. Investigation to continue. (Author V1- Administrator). On 4/25/2024 at 4:14 PM, V1 (Administrator) stated, I cannot find the final report for this investigation. I am not sure who the staff member was and/or what the outcome was regarding this allegation. (R149) is no longer in the facility. I have no interviews from other residents and or staff regarding this allegation. On 4/25/2024 at 4:22 PM, V2 (Director of Nursing) stated, I was not working here, that was a different DON. I am not familiar with anything regarding (R149). On 4/25/2024 at 4:32 PM, V3 (Assistant Director of Nursing) stated, I was here at the time, but I cannot tell you anything. I do not know anything about the investigation and/or staff member related to (R149). On 4/25/2025 at 5:33 PM, V6 (family of R149) stated, My dad was deaf, and we were using a white board to communicate. When my dad was at the nursing home, he was completely helpless and at the mercy of the facility. When I went to visit him, I saw this message written on the white board and took a picture of it because it said to 'stop abusing the call light, this is your last warning.' It gave me goosebumps because, it was not right. We met with the Administrator, and I showed her the photo and she said, she would address it. My dad passed away a few weeks later. When I was picking up his stuff, I asked whatever happened with the message left on the whiteboard and staff said they had done an investigation and when I asked more questions, nobody could tell me anything. I asked who wrote the message. They said they did not know. I asked if they still worked there, and nobody knew anything, and it did not set right with me. I just hope they really investigated this and found out who would write such a message and hope he or she does not still work in the Nursing Home. To me it was unsettling that anyone would threaten my poor helpless dad. On 4/30/2024 at 1:02 PM, no abuse investigation was provided by the facility, documenting any observations, interactions, interviews, witnesses, or record review regarding this allegation. The Abuse Policy dated 4/22/2019 documents, (Facility) will develop and operationalize policies and procedures for screening training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within control to prevent occurrences. Investigation: Investigate different types of incidents and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities.

Based on interview and record review, the facility failed to have a Registered Nurse (RN) at least 8 consecutive hours, 7 days a week. This has the potential to affect all 49 residents who reside at this facility. This past non-compliance occurred between 7/2/22 and 9/20/22. Findings include: On 2/7/2023 at 2:00 p.m., V2 (Director of Nursing/DON), stated that for the following dates in July 2022 (7/2, 7/3, 7/4, 7/10, 7/22, 7/26, & 7/30), August 2022 (8/5, 8/10, 8/17, & 8/20), and September 2022, (9/3, 9/4, 9/8, & 9/20) there was no Registered Nurse (RN) coverage for those days. V2 provided handwritten documentation regarding the facility's nursing schedule for July, August and September 2022 to clarify the missing RN staffing hours. This documentation showed there were no RN coverage hours on the following dates: 7/02, 7/03, 7/04, 7/10, 7/22, 7/26, 7/30, 8/05, 8/10, 8/17, 8/20, 9/03, 9/04, 9/08 & 9/20/2022. A facility document titled Resident Census and Condition documented the facility had 49 residents on 2/06/2023. Prior to the survey date, the facility implemented the following actions to correct the deficient practice: 1. The facility currently has one full time RN, one part time RN, and the DON. 2. A Quality Assurance Performance Improvement Meeting was held on 8/16/22 to discuss the reason the facility had days of no RN coverage, which included the full time RN being out for maternity leave and V2 being out for approximately 10 of the non-covered days with Covid. It was determined at this time to utilize an agency RN to help with coverage. Since the last date of 9/20/22 without RN coverage, the full time RN has returned from maternity leave. 3. The facility schedules the part-time RN to be here on the full time RN's days off. To cover any extra vacation or sick days, V2 adjusts her time to be at the facility and if that is not possible, an agency RN is utilized.

Based on interview and record review the facility failed to perform an accurate respiratory and circulatory assessment regarding an end of life hospice resident experiencing periods of not breathing, facility staff in error reported a resident had expired to family error and failed to document the assessment in the medical record for 1 resident of 3 residents (R2) reviewed for end of life care in a sample of 6 residents. This past noncompliance occurred from [DATE] to [DATE]. Findings include: 1. R2's Admission Record documented in part, original admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan documented in part, On [DATE] (R2) is now hospice-all care is dependent and is bed ridden. R2's Progress Notes were reviewed and there were no entries made by V4 (Licensed Practical Nurse/LPN) between the hours of 2:00 AM to 6:00 AM on [DATE] during the time she was responsible for (R2)'s care. On [DATE] at 6:15 AM, V2 (Director of Nursing/DON) stated V10 (R2's daughter) has been very upset with one issue that occurred during the hospice care on [DATE] because V4 (LPN) declared R2 had passed away prematurely and called the family to notify them, then immediately after the call a Certified Nursing Assistant (CNA) found R2 was still breathing. V2 stated, V4 had to call V10 back and let her know R2 was not expired and still breathing. V2 stated, V10 made a formal complaint to herself, V1 (Administrator), and the County Commissioner requesting V4 be fired for the incompetence. V2 stated, she followed up with V4 immediately to discuss the incident and educated her on the assessment for death. V2 stated, V4 was a good competent nurse with no prior issues. V2 stated, upon her investigation V4 reported she visually assessed R2 had no respirations, felt for a radial pulse for about a minute and there was no pulse and she determined R2 had passed. V2 stated, V4 told her she did not use a stethoscope to verify respirations or a heartbeat for over 2 minutes. V2 stated, she expected nursing to observe resident upon death and listen with a stethoscope for over 2 minutes and get a second nurse to verify with them if possible and if there is only one nurse to be sure observations for over a 2 minute period of time. V2 stated, she educated V4 individually at the time and the entire nursing staff at a nurses meeting held on [DATE]th, 2022. On [DATE] at 1:45 PM, V4 (LPN) stated, she was the only nurse on duty [DATE] from 2:00 AM to 6:00 AM and responsible R2's care during these hours. V4 stated, on the same date she checked R2 at 2:30 AM and 4:00 AM and R2 was comfortable and breathing. V4 stated, at about 5:45 AM she checked R2 and saw R2 was lifeless, not breathing, and did not have a radial pulse for about a minute. V4 stated, she determined R2 had passed away at that time and she instructed CNA staff V11 and V12 to clean up R2, then called V10 (family) to notify them. V4 stated, immediately after making the call V11 came and reported R2 was still breathing. V4 stated, she felt bad and had to call V10 back and report her mistake. V4 stated, V3 (Assistant Director of Nursing/ADON) came up to the unit and talked to her about the error and checked on R2. V4 stated, she did not use a stethoscope when assessing R2 at 5:45 AM check and did not realize she had not documented any of the assessment in R2's chart. V4 stated, she was educated immediately the same day by V2 regarding how to determine death by always listening with a stethoscope for the apical heart rate and respirations for over 2 minutes, and that she should get another nurse or CNA to check with her to verify death. On [DATE] at 10:30 AM, V3 (Assistant Director of Nursing/ADON) stated, on [DATE] at about 6:00 AM she went to the 2nd floor, and V4 had just got off the phone with V10 reporting her mistake that R2 was still breathing and had not actually expired. V3 stated, V4 was visibly upset and nervous about her mistake. V3 stated, the incident transpired in a very short amount of time between V4 calls to V10 and V10 was very angry with V4. V3 stated, at around 6:00 AM she checked on R2 who was having periods of slow breaths. V3 stated, when a resident expires the nurse should take sufficient time and use a stethoscope to check breathing and apical pulse for at least 2 minutes. V3 stated, nurses are expected to chart assessments completed in the medical record and V4 should have charted the events on her shift [DATE]. On [DATE] at 1:00 PM V2 (DON) stated, there was no written facility policy or procedure for determining a resident's death. V2 stated, she would have expected V4 to document the [DATE] nursing assessment and family notifications in R2's chart. V2 stated, she was unaware that V4 did not document the event. V2 stated, she researched and did not find any good procedures to pull for the nursing meeting on determining death of a resident, and she utilized her years of experience to instruct the nurses on the use of a stethoscope to listen for respirations, and apical heartbeat for over 2 minutes, and if possible, have another nurse verify the death as well. The facility did not have any written policies regarding determining a resident death. Prior to the survey date, the facility took the following actions to correct the noncompliance: Facility document, entitled Training Sign in Sheet, dated on [DATE] at 6:30 AM and [DATE] at 1:30 PM. Attached Nursing Meeting Agenda with a topic listed, Verification of Death. The sign in sheets document 24 employees which included RNs, LPNs and CNAs were trained. On [DATE] at 1:00 PM V2 stated, on [DATE] she educated V4 LPN, and the other nursing staff on duty that in the event of a resident's death nurses should use a stethoscope to listen for respirations, apical heartbeat over 2 minute period, and obtain another nurse to verify if available. V2 stated, she reviewed the same information with nursing staff again at the [DATE] nurses meeting. On [DATE] at 5:00 AM, V5 (LPN) stated, was recently re-educated to check residents who expire with a stethoscope listening for respirations and apical heart rate for over 2 minutes and have a second nurse, if possible, to verify the death before notifications are made. On [DATE] at 7:00 AM, V6 (LPN) also stated, she was recently re-educated to check residents who expire with a stethoscope listening for respirations and apical heart rate for over 2 minutes and have a second nurse, if possible, to verify the death before notifications are made. On [DATE] at 1:45 PM, V4 (LPN) stated, she was individually educated on determining death by V2 (DON) immediately after the incident with R2 on [DATE]. On [DATE] at 10:30 AM, V3 stated, she attended the nurses meeting held on [DATE] and V2 discussed how procedure for determining resident death by use of a stethoscope for listening to respirations and pulse for at least 2 minutes and have another nurse verify if possible. R2's Progress Notes dated on [DATE] at 6:15 PM documented in part, Checked on resident noted no breathing, no blood pressure, no heartbeat. Confirmed death with other nurse. signed by V6 (LPN.)

Based on interview, observation, and record review, the facility failed to ensure narcotic medication was securely stored, failed to accurately document narcotic medication administration, failed to consistently and accurately reconcile narcotic medication counts in accordance with professional standards of practice; and failed to administer narcotic medication as prescribed for 4 (R1, R2, R3, R5) of 5 residents reviewed for narcotic medication in a sample of 5. This failure resulted in R3 missing four consecutive doses of her narcotic pain medication to treat her diagnosis of chronic pain. A reasonable person would experience symptoms of mild to moderate pain and express feelings of discomfort due to not receiving their scheduled dose of pain medication. Findings Include: On 04/04/2022, IDPH (Illinois Department of Public Health) received a facility reported initial incident summary as follows - To Whom It May Concern, On Thursday 03/31/2022 it was brought to the attention of the nursing department that 60 [MEDICATION(S)] pills could not be found. All nurses and CNAs (Certified Nursing Assistant) who have worked on the second floor have been interviewed over the course of three days without findings. (V16/Police Officer) was notified along with the State Police. Investigation to continue. V1 (Administrator) . 1. R3's Admission Record documents admission to this facility on 09/30/19 with diagnoses to include [CONDITION(S)]/[CONDITION(S)] following cerebral infarction affecting right dominant side, dementia, major depressive disorder, abnormal posture, cognitive communication disorder, and chronic pain. R3's Minimum Data set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. R3's cumulative Physician Order Sheet (POS) documents an order for [MEDICATION(S)] 50 mg HCL ([MEDICATION(S)]) give 1 tablet by mouth four times daily with a start date of 10/13/20. A pharmacy packing slip dated 01/17/22 documents R3 received 121 [MEDICATION(S)] pills from pharmacy. R3's narc sheet dated this same day on1/17/22 includes - Rx#: (prescription number) 91; Date Dispensed: 01/21/22; Resident Name: (R3); Doctor: (V29); Drug/Name/Strength: [MEDICATION(S)] HCL tab 50mg (milligrams); Directions: Take one tablet by mouth four times daily; Pharmacy: (out of town pharmacy); Quantity Dispensed: 121.00; Quantity Received: #31 (already on hand)/#121 (152 pill total) as of 1/17/22. An unnumbered narc sheet for R3 dated 01/17/22 documents a 31-pill [MEDICATION(S)] count on 01/19/22 through 01/26/22 with 0 pills remaining in the bubble pack card as of 1/26/22. Another unnumbered narc sheet for R3 dated 01/17/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 01/27/22 through 02/03/22 with 0 pills remaining in the bubble pack card as of 2/03/22. A third unnumbered narc sheet for R3 dated 01/17/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/03/22 through 02/10/22 with 0 pills remaining in the bubble pack card as of 2/10/22. A fourth unnumbered narc sheet for R3 dated 01/17/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/11/22 through 02/18/22 with 0 pills remaining in the bubble pack card as of 2/18/22. According to this facility documentation, 121 of 121 [MEDICATION(S)] pills had been given to R3 from 1/19/22 - 2/18/22, with 31 [MEDICATION(S)] pills remaining as of 2/18/22. A pharmacy packing slip dated 02/17/22 documents R3 received 120 [MEDICATION(S)] pills from pharmacy. With 31 pills remaining as noted above, per facility documentation, R3 should now have 151 [MEDICATION(S)] pills on hand. An unnumbered narc sheet for R3 dated 02/20/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/18/22 through 02/25/22 with 0 pills remaining in the bubble pack card as of 2/25/22. A second unnumbered narc sheet for R3 dated 02/20/22 documents a 30-pill [MEDICATION(S)] count with administration beginning 02/26/22 through 03/05/22 with 0 pills remaining in the bubble pack card as of 3/05/22. A third unnumbered narc sheet for R3 dated 02/20/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/05/22 through 03/12/22 with 0 pills remaining in the bubble pack card as of 3/12/22. R3's record indicates 90 out of 120 [MEDICATION(S)] pills received on 02/17/22 have been given to her. R3's January and February 2022 MAR document she received [MEDICATION(S)] four times daily as prescribed. According to facility documentation, R3 should have had 61 [MEDICATION(S)] pills available as of 03/13/22. However, R3's narc sheet dated 03/13/22 documents 6 pills were taken from the facility emergency kit for administration of [MEDICATION(S)] on 03/13/22 at 8:00AM, 12:00PM, 4:00PM, and 8:00PM, and 03/14/22 at 8:00AM and 4:00PM. There is no sign out on this narc sheet documenting [MEDICATION(S)] being given on 03/14/22 at 12:00PM, even though R3's March 2022 MAR indicated it was given at that time by V8 (Licensed Practical Nurse/LPN). A pharmacy packing slip dated 03/14/22 documents delivery of 6 [MEDICATION(S)] pills to replace floor stock and an additional 120 [MEDICATION(S)] pills for R3. Per review of the above facility records, R3 should now have 181 [MEDICATION(S)] pills on hand as of 03/14/22. An unnumbered narc sheet for R3 dated 03/14/22 (120.00 quantity dispensed on 03/14/22) documents a 30-pill [MEDICATION(S)] count with administration beginning 03/14/22 through 03/22/22 with 0 pills remaining in the bubble pack card as of 3/22/22. Another unnumbered narc sheet for R3 dated 03/14/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/22/22 through 03/29/22 at 4:00 PM with 0 pills remaining in the bubble pack card as of 3/29/22. R3's March 2022 MAR documents R3 was given [MEDICATION(S)] on 03/29/22 at 8:00 PM and 03/31/22 at 4:00 PM but are not documented on the narc sheet on these dates or times. R3's March 2022 MAR also documents 2 [MEDICATION(S)] pills were pulled from the facility emergency kit on 03/30/22 at 8:00 AM and 12:00 PM. R3 did not receive any [MEDICATION(S)] for four consecutive doses on 03/30/22 at 4:00PM or 8:00PM or on 03/31/22 at 8:00AM and 12:00PM (4 pills). According to facility documentation reviewed above, R3 should have had 121 [MEDICATION(S)] pills available on 03/30/22 when the facility emergency kit was utilized. On 05/11/22 at 11:00 AM, when asked why R3 would have been given 6 [MEDICATION(S)] from the facility emergency kit on 03/13/22 and 03/14/22, and 2 [MEDICATION(S)] from the facility kit on 03/30/22, V3 (Assistant Director of Nursing/ADON) stated this would have been because R3 was out of her [MEDICATION(S)] from pharmacy. When this surveyor noted that according to facility records, R3 should have had 61 pills available when the 6 pills from the facility emergency kit were pulled, and 121 [MEDICATION(S)] pills available when the 2 pills from the facility emergency kit were pulled, V3 stated she was not aware of any missing pills or discrepancy with R3's [MEDICATION(S)] until it was reported to her on 03/31/22. V3 stated she was under the impression that only 60 [MEDICATION(S)] pills were missing from R3's 03/14/22 pharmacy delivery. On 05/06/22 at 9:20 AM, V15 (LPN) stated the day she discovered the [MEDICATION(S)] was not there for R3 was on 03/30/22. V15 stated she went to look for R3's next card and discovered it was not there. V15 stated she called the pharmacy, pharmacy checked and verified they sent 120 pills on 03/14/22, and it was too soon to fill. The prescription number they gave me on 03/30/22 matched the one empty card I had for R3. V15 stated she did not speak to any of the other nurses but reported this to V3, who told her it would be taken care of. V15 stated that V3 interviewed her and (V6) on the morning of 03/31/22 and asked if they did across shift med counts. V6 said they told (V3) that they did not always do this. V6 said I did not recognize any discrepancies until the card was empty and I knew she should have more. A pharmacy packing slip dated 03/31/22 documents R3 received 60 [MEDICATION(S)] pills from pharmacy, at which time R3 should have had a total of 181 [MEDICATION(S)] pills available in the facility. R3's narc sheet marked as 1 of 2 dated 03/31/22 (60.00 quantity dispensed on 03/31/22) documents a 30-pill count with administration beginning on 03/31/22 at 8:00 PM through 04/08/22 at 8:00 AM with 0 available on 04/08/22. R3's narc sheet marked as 2 of 2 dated 03/31/22 documents a 30-pill count with administration beginning on 04/08/22 through 4:15 PM with 0 available on 04/08/22 for a total of 60 [MEDICATION(S)] pills being given since pharmacy delivery of 60 pills on 03/31/22. According to facility documentation, R3 should have had 121 [MEDICATION(S)] pills remaining on 03/31/22. A pharmacy packing slip dated 04/11/22 documents R3 received 120 [MEDICATION(S)] pills for a total of 241 [MEDICATION(S)] pills on hand as of 04/11/22. R3's narc sheet marked as 1 of 4 dated 04/11/22 (120.00 quantity dispensed on 04/11/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/15/22 through 04/23/22 with 0 pills remaining in the bubble pack card as of 4/23/22. R3's narc sheet marked as 2 of 4 dated 04/11/22 (120.00 quantity dispensed on 04/11/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/23/22 through 04/30/22 with 0 pills remaining in the bubble pack card as of 4/30/22. R3's narc sheet marked as 3 of 4 dated 04/11/22 (120.00 quantity dispensed on 04/11/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/30/22 through 05/08/22 with 0 pills remaining in the bubble pack card, indicating R3 should have 151 [MEDICATION(S)] pills as of 05/08/22. A pharmacy packing slip dated 05/06/22 documents R3 received an additional 120 [MEDICATION(S)] pills, indicating R3 should have had a total of 271 [MEDICATION(S)] pills available to her on 05/08/22. R3's narc sheet marked as 4 of 4 dated 04/11/22 (120.00 quantity dispensed on 04/11/22) documents a 30-pill count with administration beginning on 05/08/22 through 05/11/22 at 12:00 PM (13 pills administered) with 17 out of 30 pills available in the bubble pack card on 5/11/22 at 12:00PM. This leaves 258 [MEDICATION(S)] pills that should have been available to R3 in the facility on at that same time. R3's April and May 2022 MAR document [MEDICATION(S)] was administered as prescribed. On 05/12/22 at 10:20 AM, a narcotic count of R3's [MEDICATION(S)] was conducted with V13 (Registered Nurse/RN) in the 2nd nursing station/medication room. V13 confirmed R3 had been given 3 more scheduled doses of [MEDICATION(S)] since 05/11/22 at 12:00 PM (14 out of 120 pills remaining in the bubble pack card from the 04/11/22 pharmacy delivery - V13's narc sheet reflected this indicating 255 pills should be available for this count). After count was concluded, only 134 [MEDICATION(S)] pills were on hand for R3. When asked to re-check her med cart for R3's [MEDICATION(S)], V3 confirmed, That's all the [MEDICATION(S)] I got. After review of all facility documentation noted above, a discrepancy of 121 [MEDICATION(S)] pills was noted from 1/19/22 to 5/12/22. On 05/05/22 at 11:05 AM, V5 (LPN) stated she works at the facility part time every other weekend. In reference to 3/14/22, V5 stated she was off work at the time R3's [MEDICATION(S)] was alleged to have gone missing, but V3 (ADON) had sent a multi-message to all nursing staff asking if anyone knew anything about the missing pills. V5 stated the nursing stations in this facility are in a room and not at a station on the floor. The doors to the nursing station must be closed and locked at all times when we are out of the office. V5 stated as far as she knew, V7 (RN) on the 1st floor received the R3's [MEDICATION(S)] when the pharmacy technician delivered them (on 3/14/22) and then brought them to the 2nd floor nurse on shift, who was V8 (LPN). V5 stated she understood V7 supposedly left them on the counter in the nursing station and went back to the 1st floor without making sure V8 knew they were there. V5 stated V8 retired on 04/30/22. When asked what the procedure was when narcotics are received from the pharmacy (or any med), V5 stated - the 1st floor nurse usually meets pharmacy in the lobby and signs for the medications. Narcotics are counted with the pharmacy at that time, the nurse signs a paper and gives it back to the pharmacy to confirm receipt of delivery and quantity received of each med. V5 stated the 1st floor nurse usually brings meds belonging to residents residing on the 2nd floor up after delivery. V5 stated if she is the nurse on shift, she and the 1st floor nurse count all the medications and check them off on the pharmacy sheet and circles the number of pills. If it's a narcotic, V5 stated she gets with another nurse, they count, they sign, and fill in the received paper that goes in the facility narc books. V5 stated she watches the card go in the narc box and get locked before she walks away. V5 stated they are supposed to count narcs across shift and both nurses sign off. When asked how meds are destroyed, V5 stated the RN pops the pills out of the card, crushes them, puts the crushed med in a cup and puts water on top, then we dump in our container of kitty litter. We then scoop that out and put in the biohazard sharps container on the side of our med cart. Another nurse has to verify and witness, and both sign the Continuous Drug Receipt/Record/Disposition Form. On 05/05/22 at 11:51 AM, V6 (LPN) stated she first became aware of R3's missing [MEDICATION(S)] by rumor. She stated she spoke with an investigator from the State Police (V26) a few weeks ago regarding the incident. V6 stated she heard that 2 or 3, 30-count cards of [MEDICATION(S)] were missing along with the pharmacy reconciliation sheets. On 05/05/22 at 2:20 PM, V7 (RN) stated every night around 7:00 or 8:00 PM the pharmacy calls the 1st floor nurse to let them know they are on the way or in the building. V7 stated, I receive the meds for both floors. On 03/14/22 we had narcotics. The pharmacy technician and I always count the narcs together to verify everything they are bringing is there. We have the manifest sheet that tells you strength and number of pills. They take their signed copy, and we keep our copy. I would then take all the meds back to my nursing station on 1st floor. I would go through and count all mine and put them away. I would do that with the 2nd floor meds and take them to the 2nd floor nursing station. The manifest sheet then goes in my basket after counting and then someone comes each morning and picks them up. I think that is (V3). On 03/14/22 when I took the meds to the second floor, I can't remember exactly what happened on that date, but I would always run them up and more often than not, the nurse would be sitting in the office. I do the same thing every night. If she was not in there, I would usually set them in the back of the nursing room on the counter back by the sink. I can't say with certainty that V8 (LPN on shift) was there or not on 03/14/22. I can't remember. V8 is since retired. I remember I came in early one day, I was working 10A to 10P. I don't remember the exact date, but V15 (LPN) was working the second floor and she relayed to me that R3 was out of her [MEDICATION(S)]. I guess (V15) was calling to the pharmacy to see if it was ordered or coming in. The pharmacy told her no, because 120 pills were delivered on 03/14/22. At that time, we did not know what happened, if they were misplaced or what happened. When I interviewed with the state police last month it was fresher in my mind. I was not a part of when they were physically searching for the missing pills. V2 (Director of Nursing/DON) and V3 were searching everywhere initially. To my knowledge the [MEDICATION(S)] was never found. The DON or ADON never asked staff to take a drug test. They never asked me, at least. Honestly, I did not get to talk with V8 about the incident. She could not remember exactly what happened that night. R3 was completely out of the [MEDICATION(S)], so V8 would have had to pull a pill immediately. Almost always, R3 would get 120 pills of [MEDICATION(S)] at a time. She is one that gets the most at a time. She got four cards that night. V7 stated she wished this was fresher in her mind, but it had been a while since it happened. On 05/06/22 at 9:42 AM, V19 (LPN) via cell phone stated she was not working on 03/14/22. V19 confirmed she heard later two cards of R3's [MEDICATION(S)] was missing, and no one knows what happened to it. V19 stated also when she came to work on 03/31/22, she and V8 were asked by V3 if they had any knowledge of what happened to R3's missing [MEDICATION(S)] and if we knew anything about it to tell the truth. V19 stated she had no idea what happened, and V8 asked for a drug test. V19 stated she always reconciles her medication across shifts and to her knowledge never had a count that was incorrect. 2. R5's Admission Record documents admission to this facility on 02/19/15 with diagnoses to include [CONDITION(S)], Diabetes Mellitus II, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and Overactive Bladder. R5's quarterly MDS dated [DATE] documents a BIMS score of 7, indicating he is moderately cognitively impaired. R5's cumulative POS documents an order for [MEDICATION(S)] HCI ([MEDICATION(S)]) 50mg tablet, give 1 tablet by mouth three times a day. A pharmacy packing slip dated 01/13/22 documents 30 [MEDICATION(S)] pills were delivered for R5. A pharmacy packing slip dated 01/14/22 documents an additional delivery of 90 [MEDICATION(S)] pills were delivered for a total of 120 pills remaining in the bubble pack card. An unnumbered narc sheet for R5 dated 01/14/22 includes - Rx#: (prescription number) 31; Date Dispensed: 01/19/22; Resident Name: (R5); Doctor: V29; Drug/Name/Strength: [MEDICATION(S)] HCL tab 50mg; Directions: Take one tablet by mouth three times daily; Pharmacy: (out of town pharmacy); Quantity Dispensed: 90.00. An unnumbered narc sheet for R5 dated 01/14/22 (90.00 quantity dispensed on 01/19/22) documents administration began with a 30-pill [MEDICATION(S)] count on 01/15/22 through 01/24/22 with 0 pills remaining in the bubble pack card as of 1/24/22. Another unnumbered narc sheet for R5 dated 01/14/22 (90.00 quantity dispensed on 01/19/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 01/25/22 through 02/03/22 with 0 pills remaining in the bubble pack card as of 2/03/22. Yet another unnumbered narc sheet for R5 dated 01/14/22 (90.00 quantity dispensed on 01/19/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/04/22 through 02/13/22 with 0 pills remaining in the bubble pack card as of 2/13/22. After review of the facility documentation above, it is noted that R5 should have 30 out of 120 [MEDICATION(S)] pills on hand at this same time. A pharmacy packing slip dated 02/09/22 documents delivery of 90 [MEDICATION(S)] pills for R5, indicating per facility records R5 should have available a total of 120 [MEDICATION(S)] pills on 02/09/22. R5's unnumbered narc sheet dated 02/09/22 (90.00 quantity dispensed on 02/09/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/14/22 through 02/23/22 with 0 pills remaining in the bubble pack card as of 2/23/22. R5's unnumbered narc sheet dated 02/09/22 (90.00 quantity dispensed on 02/09/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/24/22 through 03/02/22 with 0 pills remaining in the bubble pack card as of 03/02/22, indicating R5 should have 60 out of 120 pills on hand at this same time. A pharmacy packing slip dated 03/03/22 documents delivery of 90 [MEDICATION(S)] pills for R5, indicating per facility records R5 should have a total of 150 [MEDICATION(S)] pills as of 03/03/22. R5's unnumbered narc sheet dated 03/03/22 (90.00 quantity dispensed on 03/03/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/06/22 through 03/15/22 with 0 pills remaining in the bubble pack card as of 03/15/22. R5's unnumbered narc sheet dated 03/03/22 (90.00 quantity dispensed on 03/03/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/16/22 through 03/25/22 with 0 pills remaining in the bubble pack card as of 03/25/22. A pharmacy packing slip dated 03/23/22 documents delivery of 30 [MEDICATION(S)] pills, indicating per facility records R5 should have 120 pills available as of this same date. R5's unnumbered narc sheet dated 03/23/22 (30.00 quantity dispensed on 03/23/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/26/22 through 04/04/22 with 0 pills remaining in the bubble pack card as of 04/04/22. A pharmacy packing slip dated 03/29/22 documents delivery of 90 [MEDICATION(S)] pills, indicating per facility records R5 should now have 180 [MEDICATION(S)] pills available on 03/29/22. R5's unnumbered narc sheet dated 03/29/22 (90.00 quantity dispensed on 03/29/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/05/22 through 04/16/22 with 0 pills remaining in the bubble pack card as of 04/16/22. R5's unnumbered narc sheet dated 03/29/22 (90.00 quantity dispensed on 03/29/22) documents a 30-pill count with administration beginning on 04/17/22 through 04/26/22 with 0 pills remaining in the bubble pack card as of 04/26/22. R5's unnumbered narc sheet dated 03/29/22 (90.00 quantity dispensed on 03/29/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/27/22 through 05/06/22 with 0 pills remaining in the bubble pack card as of 05/06/22, indicating R5 should have 90 out of 180 pills on hand at this same time. A pharmacy packing slip dated 04/27/22 documents delivery of 90 [MEDICATION(S)] pills, indicating R5 should have 180 pills available as of 04/27/22. R5's narc sheet dated 04/27/22 (90.00 quantity dispensed on 04/27/22) marked 1 of 3 documents a 30-pill [MEDICATION(S)] count with administration beginning on 05/07/22 through 05/11/22 at 8:00 PM with 15 out of 30 pills remaining in the bubble pack card. R5 has two more narc sheets dated 04/27/22, each with a starting count of 30, marked 2 of 3, and 3 of 3 that have not yet been used. R5 should have available 165 [MEDICATION(S)] pills per facility documentation as of 5/11/22 at 8:00 PM. On 05/12/22 at 1:20 PM, a narcotic count was conducted for R5 in the 1st floor nursing station and medication room with V6 (LPN). V6 stated since 05/11/22 at 8:00 PM, an additional 2 [MEDICATION(S)] pills had been given to R5 as scheduled on 05/12/22 at 8:00 AM and 12:00 PM. Documentation by V6 on R5's narc sheet dated 04/27/22 shows 13 out of 30 pills remain, indicating R5 should have 163 pills at this time. Upon completion, R5's narcotic count confirmed one card with 13 pills remaining, and 2 full, unused cards of 30 pills each for a total of 73 pills available at this time. Per the above review and facility documentation showing R5 should have 163 pills available at this time but only has 73, this indicates a 90-pill discrepancy. 3. R1's Admission Record documents admission to this facility on 09/02/21 with diagnoses to include [CONDITION(S)], hypertension, heart failure, unspecified [CONDITION(S)]. R1's cumulative POS documents an order for [MEDICATION(S)] HCI 50 mg give 1 tablet by mouth every 8 hours as needed for pain. Start date: 09/25/21. A revision to this medication dated 01/17/22 documents - [MEDICATION(S)] 50 mg HCI give 1 tablet by mouth at bedtime for back pain. R1's order for as needed [MEDICATION(S)] remains active, as well. R1's most recent quarterly MDS dated [DATE] documents a BIMS score of 9, indicating he is moderately cognitively impaired. A Pharmacy packing Slip from an out-of-town pharmacy documents 30 [MEDICATION(S)] pills were delivered to the facility for R1 on 12/03/21 at 8:00 PM, signed for by V19 (LPN). R1's Controlled Drug Receipt/Record/Disposition Form (commonly referred to as a narc sheet) dated 12/03/21 documents 30 [MEDICATION(S)] pills were received from the pharmacy, dispensed on 12/03/21, and contains the following instructions in part - [MEDICATION(S)] HCL tab 50 mg take one tablet by mouth every 8 hours as needed .Every dose must be accounted for and requires charting on the Medication Administration Record (MAR). On 01/01/22, R1's unnumbered narc sheet documents 18 out of 30 pills remain from the 12/03/21 delivery. According to this narc sheet, R1 was given [MEDICATION(S)] on 01/01/22 through 01/23/22 with 0 (zero) [MEDICATION(S)] pills remaining in the bubble pack card on 01/23/22. R1's narc sheet documents [MEDICATION(S)] was administered on 01/01 at 9:00PM; 01/02 at 5:15 AM; 01/03 at 4:30AM; 01/04 at 8:00AM; 01/05 at 1:00AM; 01/15 at 8:00PM, and 01/16 at 8:00PM. R1's January 2022 MAR is blank for these dates and times indicating a 7-pill discrepancy. A Pharmacy packing Slip from an out-of-town pharmacy documents 30 [MEDICATION(S)] pills were delivered to the facility for R1 on 01/06/22. R1's unnumbered narc sheet dated 01/06/22 documents 30 [MEDICATION(S)] 50 mg pills (take one tablet by mouth every 8 hours as needed) were received from the pharmacy, dispensed on 01/06/22, with administration from this delivery beginning on 01/24/22 through 02/22/22 with 0 pills remaining in the bubble pack card on 02/22/22. On 05/12/22 at 10:00 AM, V3 (Assistant Director of Nursing - ADON) stated R1's pharmacy packing slip dated 01/06/22 would be the last one that came from pharmacy supply. After that R1's insurance changed and V20 (Family Member/POA - Power of Attorney) would bring in a home supply of [MEDICATION(S)] from the local pharmacy that would come in a brown bottle of 90 pills at a time. V3 also confirmed R1's [MEDICATION(S)] was ordered as routine on 01/17/22 in addition to his PRN (as needed) prescription. R1's unnumbered narc sheet dated 02/05/22 documents 90 [MEDICATION(S)] 50 mg pills were received from home supply (per V3) with no pharmacy dispense date. Hand-written instructions document - [MEDICATION(S)] HCL 50 mg take 1 tablet as needed every 8 hours and 1 tab night at HS (hour of sleep). This form documents administration from this 90-pill supply began on 02/23/22 through 03/23/22 at 8:00 PM with 59 pills remaining in the bubble pack card, documented by V8 (former LPN). R1's unnumbered narc sheet dated 03/24/22 at 8:00 PM documents 49 pills were on hand, indicating a 10-pill discrepancy from last dose on 03/23/22 at 8:00 PM as documented on the 02/05/22 narc sheet by V8 (LPN). According to R1's March 2022 MAR, no [MEDICATION(S)] was administered between 03/23/22 at 8:00 PM and 03/24/22 at 8:00 PM. Administration began on 03/24/22 at 8:00 PM through 05/06/22 at 8:00 PM, with 0 pills remaining in the bubble pack card as of 05/06/22. R1's unnumbered narc sheet dated 3/24/22 also documents that on 03/30/22 at 5:15 AM, R1 was given a PRN [MEDICATION(S)]; and on 04/28/22 at 4:00 AM, R1 was given a PRN [MEDICATION(S)]. There is no documentation on the March 2022 or April 2022 MAR to show that [MEDICATION(S)] was administered to R1 on 03/30/22 at 5:15 AM or on 04/28/22 at 4:00 AM, indicating an additional discrepancy of 2 [MEDICATION(S)] pills. R1's unnumbered narc sheet dated 05/02/22 documents a 90-pill home supply was provided by V20. Administration began on 05/07/22 at 7:00 AM through 05/10/22 at 8:00 PM. At this date/time of 5/10/22 at 8:00 PM, 85 pills are documented to remain. On 05/12/22 at 12:10 PM, a narcotic count of R1's [MEDICATION(S)] was conducted with V13 (RN) with no further discrepancies since last administered on 05/10/22 at 8:00 PM. On 05/05/22 at 11:38 AM, V20 was visiting R1 in his room. When asked if V20 ever had an issue with R1 not receiving his [MEDICATION(S)] or the facility reporting [MEDICATION(S)] pills missing, she stated there was an instance when a bottle she had brought from home was misplaced by the facility, but staff found it in a drawer, and to her knowledge there were no pills missing. On 05/06/22 at 2:00 PM, R1 stated he is not aware he had any missing [MEDICATION(S)]. He stated he usually hurts at night and gets his pain pill before bedtime. On 05/06/22 at 12:00 PM, V2 (DON) stated she did investigate R1's missing [MEDICATION(S)] on 03/24/22 when V19 (LPN) called to report R1's [MEDICATION(S)] count was off when she went to give him a dose. V2 stated R1 gets his [MEDICATION(S)] from a home pharmacy that V20 brings to the facility. V2 stated there were 9 pills in the bottle and the rest of the pills had been split in quantities of 10 and placed in pill crusher pouches, stapled shut, then put inside a specimen bag. V2 stated she and V19 both searched the medication cart. V2 stated she thought maybe some got thrown away by accident, and to her knowledge were never found. An undated typed statement by V2 documents the following - I was called to the 2nd floor nurse's station by (V19) on 03/24/22. Nurse stated her narcotic count for (R1's) [MEDICATION(S)] was short by 10 pills. According to the count sheet there should have been 59 [MEDICATION(S)] but there was only 49 [MEDICATION(S)] present and accounted for. (V19) and I searched the cart and lock box. I noted the medication for this resident was in a large pill bottle that was originally brought from home. The pills were separated into 4 small packs of 10 each with 9 loose pills in the bottle. The packs were not stored in the bottle but in a specimen bag. Upon further investigation of the bag, the outer sleeve of the bag was open on both ends. Some of the packs were in the part of the bag and some, in addition to the large bottle, were in the inner sleeve which was closed on one end and had a zip lock on the other end. I noted that the night nurse had given a prn dose at 4:30 AM this same day (3/24/22). When re-enacting taking the bag out of the lockbox and placing on top of med cart, several times some of the loose small packs landed in the trash can attached on the right side of the med cart at same level as the top of the cart. A new narcotic count sheet was started with correct count. On 05/06/22 at 12:00 PM, when V2 was shown R1's March 2022 MAR that documents the PRN dose of [MEDICATION(S)] she referred to in her investigation (noted above) was given on 03/21/22 at 4:30 AM and not on 03/24/22 at 4:30 AM, V2 stated she must have looked at it wrong and the count must have been off prior to 03/24/22. From 12/03/21 through 5/12/22, R1's record contains a 19-pill total discrepancy related to [MEDICATION(S)] administration and missing pills. 4. R2's Admission Record documents admission to this facility on 04/04/22 with diagnoses to include [CONDITION(S)], stiffness in left and right knee, and other reduced mobility. R2's cumulative POS documents an order for [MEDICATION(S)] HCI tablet 50 mg give 1 tablet by mouth every 6 hours as needed for pain, start date 04/04/22, end date 04/23/22; [MEDICATION(S)]-Acetaminophen tablet 5/325 mg give 1 tablet by mouth every 6 hours as needed for pain, start date 04/21/22. R2's Admission MDS documents a BIMS of 15 indicating he is cognitively intact. A pharmacy packing slip dated 04/04/22 documents 30 [MEDICATION(S)] pills were delivered from the pharmacy. R2's unnumbered narc sheet dated 04/04/22 (30.00 dispensed on 04/04/22) documents a 30-pill count with administration beginning on 04/09/22 through 04/21/22 with 0 pills remaining. This narc sheet documents [MEDICATION(S)] was signed out as administered on: 04/09/22 at 7:00 PM; 04/10/22 at 4:00 AM; 04/10/22 at 6:00 PM; 04/11/22 at 1:15 AM; 04/13/22 at 6:00 PM; 04/17/22 at 2:00 PM; and 04/18/22 at 8:00 PM. However, upon review of R2's April 2022 MAR these dates and times are blank, indicating a 7-pill discrepancy. On 05/06/22 at 1:55 PM, R2 stated he used to take [MEDICATION(S)], but it didn't really help with his pain and due to his insurance, had issues getting it. The facility changed his prescription at his request to [MEDICATION(S)] on 04/21/22. On 05/05/22 at 11:00 AM,

Based on interview, observation, and record review, the facility failed to ensure residents were free from misappropriation of controlled substance medication for 3 (R1, R3 and R5) of 5 residents reviewed for abuse in a sample of 5. The findings include: On 04/04/2022, IDPH (Illinois Department of Public Health) received a facility reported initial incident summary as follows - To Whom It May Concern, On Thursday 03/31/2022 it was brought to the attention of the nursing department that 60 [MEDICATION(S)] pills could not be found. All nurses and CNAs (Certified Nursing Assistant) who have worked on the second floor have been interviewed over the course of three days without findings. (V16/Police Officer) was notified along with the State Police. Investigation to continue. V1 (Administrator) . 1. R3's Admission Record documents admission to this facility on 09/30/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. R3's cumulative Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A pharmacy packing slip dated 01/17/22 documents R3 received 121 [MEDICATION(S)] pills from pharmacy. R3's narc sheet dated this same day on1/17/22 includes - Rx#: (prescription number) 91; Date Dispensed: 01/21/22; Resident Name: (R3); Doctor: (V29); Drug/Name/Strength: [MEDICATION(S)] HCL tab 50mg; Directions: Take one tablet by mouth four times daily; Pharmacy: (out of town pharmacy); Quantity Dispensed: 121.00; Quantity Received: #31 (already on hand)/#121 (152 pill total) as of 1/17/22. An unnumbered narc sheet for R3 dated 01/17/22 documents a 31-pill [MEDICATION(S)] count on 01/19/22 through 01/26/22 with 0 pills remaining in the bubble pack card as of 1/26/22. Another unnumbered narc sheet for R3 dated 01/17/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 01/27/22 through 02/03/22 with 0 pills remaining in the bubble pack card as of 2/03/22. A third unnumbered narc sheet for R3 dated 01/17/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/03/22 through 02/10/22 with 0 pills remaining in the bubble pack card as of 2/10/22. A fourth unnumbered narc sheet for R3 dated 01/17/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/11/22 through 02/18/22 with 0 pills remaining in the bubble pack card as of 2/18/22. According to this facility documentation, 121 of 121 [MEDICATION(S)] pills had been given to R3 from 1/19/22 - 2/18/22, with 31 [MEDICATION(S)] pills remaining as of 2/18/22. A pharmacy packing slip dated 02/17/22 documents R3 received 120 [MEDICATION(S)] pills from pharmacy. With 31 pills remaining as noted above, per facility documentation, R3 should now have 151 [MEDICATION(S)] pills on hand. An unnumbered narc sheet for R3 dated 02/20/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/18/22 through 02/25/22 with 0 pills remaining in the bubble pack card as of 2/25/22. A second unnumbered narc sheet for R3 dated 02/20/22 documents a 30-pill [MEDICATION(S)] count with administration beginning 02/26/22 through 03/05/22 with 0 pills remaining in the bubble pack card as of 3/05/22. A third unnumbered narc sheet for R3 dated 02/20/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/05/22 through 03/12/22 with 0 pills remaining in the bubble pack card as of 3/12/22. R3's record indicates 90 out of 120 [MEDICATION(S)] pills received on 02/17/22 have been given to her. R3's January and February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to facility documentation, R3 should have had 61 [MEDICATION(S)] pills available as of 03/13/22. However, R3's narc sheet dated 03/13/22 documents 6 pills were taken from the facility emergency kit for administration of [MEDICATION(S)] on 03/13/22 at 8:00AM, 12:00PM, 4:00PM, and 8:00PM, and 03/14/22 at 8:00AM and 4:00PM. There is no sign out on this narc sheet documenting [MEDICATION(S)] being given on 03/14/22 at 12:00PM, even though R3's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A pharmacy packing slip dated 03/14/22 documents delivery of 6 [MEDICATION(S)] pills to replace floor stock and an additional 120 [MEDICATION(S)] pills for R3. Per review of the above facility records, R3 should now have 181 [MEDICATION(S)] pills on hand as of 03/14/22. An unnumbered narc sheet for R3 dated 03/14/22 (120.00 quantity dispensed on 03/14/22) documents a 30-pill [MEDICATION(S)] count with administration beginning 03/14/22 through 03/22/22 with 0 pills remaining in the bubble pack card as of 3/22/22. Another unnumbered narc sheet for R3 dated 03/14/22 documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/22/22 through 03/29/22 at 4:00 PM with 0 pills remaining in the bubble pack card as of 3/29/22. R3's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 did not receive any [MEDICATION(S)] for four consecutive doses on 03/30/22 at 4:00PM or 8:00PM or on 03/31/22 at 8:00AM and 12:00PM (4 pills). According to facility documentation reviewed above, R3 should have had 121 [MEDICATION(S)] pills available on 03/30/22 when the facility emergency kit was utilized. On 05/11/22 at 11:00 AM, when asked why R3 would have been given 6 [MEDICATION(S)] from the facility emergency kit on 03/13/22 and 03/14/22, and 2 [MEDICATION(S)] from the facility kit on 03/30/22, V3 (Assistant Director of Nursing/ADON) stated this would have been because R3 was out of her [MEDICATION(S)] from pharmacy. When this surveyor noted that according to facility records, R3 should have had 61 pills available when the 6 pills from the facility emergency kit were pulled, and 121 [MEDICATION(S)] pills available when the 2 pills from the facility emergency kit were pulled, V3 stated she was not aware of any missing pills or discrepancy with R3's [MEDICATION(S)] until it was reported to her on 03/31/22. V3 stated she was under the impression that only 60 [MEDICATION(S)] pills were missing from R3's 03/14/22 pharmacy delivery. On 05/06/22 at 9:20 AM, V15 (LPN) stated the day she discovered the [MEDICATION(S)] was not there for R3 was on 03/30/22. V15 stated she went to look for R3's next card and discovered it was not there. V15 stated she called the pharmacy, pharmacy checked and verified they sent 120 pills on 03/14/22, and it was too soon to fill. The prescription number they gave me on 03/30/22 matched the one empty card I had for R3. V15 stated she did not speak to any of the other nurses but reported this to V3, who told her it would be taken care of. V15 stated that V3 interviewed her and (V6) on the morning of 03/31/22 and asked if they did across shift med counts. V6 said they told (V3) that they did not always do this. V6 said I did not recognize any discrepancies until the card was empty and I knew she should have more. A pharmacy packing slip dated 03/31/22 documents R3 received 60 [MEDICATION(S)] pills from pharmacy, at which time R3 should have had a total of 181 [MEDICATION(S)] pills available in the facility. R3's narc sheet marked as 1 of 2 dated 03/31/22 (60.00 quantity dispensed on 03/31/22) documents a 30-pill count with administration beginning on 03/31/22 at 8:00 PM through 04/08/22 at 8:00 AM with 0 available on 04/08/22. R3's narc sheet marked as 2 of 2 dated 03/31/22 documents a 30-pill count with administration beginning on 04/08/22 through 4:15 PM with 0 available on 04/08/22 for a total of 60 [MEDICATION(S)] pills being given since pharmacy delivery of 60 pills on 03/31/22. According to facility documentation, R3 should have had 121 [MEDICATION(S)] pills remaining on 03/31/22. A pharmacy packing slip dated 04/11/22 documents R3 received 120 [MEDICATION(S)] pills for a total of 241 [MEDICATION(S)] pills on hand as of 04/11/22. R3's narc sheet marked as 1 of 4 dated 04/11/22 (120.00 quantity dispensed on 04/11/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/15/22 through 04/23/22 with 0 pills remaining in the bubble pack card as of 4/23/22. R3's narc sheet marked as 2 of 4 dated 04/11/22 (120.00 quantity dispensed on 04/11/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/23/22 through 04/30/22 with 0 pills remaining in the bubble pack card as of 4/30/22. R3's narc sheet marked as 3 of 4 dated 04/11/22 (120.00 quantity dispensed on 04/11/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/30/22 through 05/08/22 with 0 pills remaining in the bubble pack card, indicating R3 should have 151 [MEDICATION(S)] pills as of 05/08/22. A pharmacy packing slip dated 05/06/22 documents R3 received an additional 120 [MEDICATION(S)] pills, indicating R3 should have had a total of 271 [MEDICATION(S)] pills available to her on 05/08/22. R3's narc sheet marked as 4 of 4 dated 04/11/22 (120.00 quantity dispensed on 04/11/22) documents a 30-pill count with administration beginning on 05/08/22 through 05/11/22 at 12:00 PM (13 pills administered) with 17 out of 30 pills available in the bubble pack card on 5/11/22 at 12:00PM. This leaves 258 [MEDICATION(S)] pills that should have been available to R3 in the facility on at that same time. R3's April and May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/12/22 at 10:20 AM, a narcotic count of R3's [MEDICATION(S)] was conducted with V13 (Registered Nurse/RN) in the 2nd nursing station/medication room. V13 confirmed R3 had been given 3 more scheduled doses of [MEDICATION(S)] since 05/11/22 at 12:00 PM (14 out of 120 pills remaining in the bubble pack card from the 04/11/22 pharmacy delivery - V13's narc sheet reflected this indicating 255 pills should be available for this count). After count was concluded, only 134 [MEDICATION(S)] pills were on hand for R3. When asked to re-check her med cart for R3's [MEDICATION(S)], V3 confirmed, That's all the [MEDICATION(S)] I got. After review of all facility documentation noted above, a discrepancy of 121 [MEDICATION(S)] pills was noted from 1/19/22 to 5/12/22. On 05/05/22 at 11:05 AM, V5 (LPN) stated she works at the facility part time every other weekend. In reference to 3/14/22, V5 stated she was off work at the time R3's [MEDICATION(S)] was alleged to have gone missing, but V3 (ADON) had sent a multi-message to all nursing staff asking if anyone knew anything about the missing pills. V5 stated the nursing stations in this facility are in a room and not at a station on the floor. The doors to the nursing station must be closed and locked at all times when we are out of the office. V5 stated as far as she knew, V7 (RN) on the 1st floor received the R3's [MEDICATION(S)] when the pharmacy technician delivered them (on 3/14/22) and then brought them to the 2nd floor nurse on shift, who was V8 (LPN). V5 stated she understood V7 supposedly left them on the counter in the nursing station and went back to the 1st floor without making sure V8 knew they were there. V5 stated V8 retired on 04/30/22. When asked what the procedure was when narcotics are received from the pharmacy (or any med), V5 stated - the 1st floor nurse usually meets pharmacy in the lobby and signs for the medications. Narcotics are counted with the pharmacy at that time, the nurse signs a paper and gives it back to the pharmacy to confirm receipt of delivery and quantity received of each med. V5 stated the 1st floor nurse usually brings meds belonging to residents residing on the 2nd floor up after delivery. V5 stated if she is the nurse on shift, she and the 1st floor nurse count all the medications and check them off on the pharmacy sheet and circles the number of pills. If it's a narcotic, V5 stated she gets with another nurse, they count, they sign, and fill in the received paper that goes in the facility narc books. V5 stated she watches the card go in the narc box and get locked before she walks away. V5 stated they are supposed to count narcs across shift and both nurses sign off. When asked how meds are destroyed, V5 stated the RN pops the pills out of the card, crushes them, puts the crushed med in a cup and puts water on top, then we dump in our container of kitty litter. We then scoop that out and put in the biohazard sharps container on the side of our med cart. Another nurse has to verify and witness, and both sign the Continuous Drug Receipt/Record/Disposition Form. On 05/05/22 at 11:51 AM, V6 (LPN) stated she first became aware of R3's missing [MEDICATION(S)] by rumor. She stated she spoke with an investigator from the State Police (V26) a few weeks ago regarding the incident. V6 stated she heard that 2 or 3, 30-count cards of [MEDICATION(S)] were missing along with the pharmacy reconciliation sheets. On 05/05/22 at 2:20 PM, V7 (RN) stated every night around 7:00 or 8:00 PM the pharmacy calls the 1st floor nurse to let them know they are on the way or in the building. V7 stated, I receive the meds for both floors. On 03/14/22 we had narcotics. The pharmacy technician and I always count the narcs together to verify everything they are bringing is there. We have the manifest sheet that tells you strength and number of pills. They take their signed copy, and we keep our copy. I would then take all the meds back to my nursing station on 1st floor. I would go through and count all mine and put them away. I would do that with the 2nd floor meds and take them to the 2nd floor nursing station. The manifest sheet then goes in my basket after counting and then someone comes each morning and picks them up. I think that is (V3). On 03/14/22 when I took the meds to the second floor, I can't remember exactly what happened on that date, but I would always run them up and more often than not, the nurse would be sitting in the office. I do the same thing every night. If she was not in there, I would usually set them in the back of the nursing room on the counter back by the sink. I can't say with certainty that V8 (LPN on shift) was there or not on 03/14/22. I can't remember. V8 is since retired. I remember I came in early one day, I was working 10A to 10P. I don't remember the exact date, but V15 (LPN) was working the second floor and she relayed to me that R3 was out of her [MEDICATION(S)]. I guess (V15) was calling to the pharmacy to see if it was ordered or coming in. The pharmacy told her no, because 120 pills were delivered on 03/14/22. At that time, we did not know what happened, if they were misplaced or what happened. When I interviewed with the state police last month it was fresher in my mind. I was not a part of when they were physically searching for the missing pills. V2 (Director of Nursing/DON) and V3 were searching everywhere initially. To my knowledge the [MEDICATION(S)] was never found. The DON or ADON never asked staff to take a drug test. They never asked me, at least. Honestly, I did not get to talk with V8 about the incident. She could not remember exactly what happened that night. R3 was completely out of the [MEDICATION(S)], so V8 would have had to pull a pill immediately. Almost always, R3 would get 120 pills of [MEDICATION(S)] at a time. She is one that gets the most at a time. She got four cards that night. V7 stated she wished this was fresher in her mind, but it had been a while since it happened. On 05/06/22 at 9:42 AM, V19 (LPN) via cell phone stated she was not working on 03/14/22. V19 confirmed she heard later two cards of R3's [MEDICATION(S)] was missing, and no one knows what happened to it. V19 stated also when she came to work on 03/31/22, she and V8 were asked by V3 if they had any knowledge of what happened to R3's missing [MEDICATION(S)] and if we knew anything about it to tell the truth. V19 stated she had no idea what happened, and V8 asked for a drug test. V19 stated she always reconciles her medication across shifts and to her knowledge never had a count that was incorrect. 2. R5's Admission Record documents admission to this facility on 02/19/15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's quarterly MDS dated [DATE] documents a BIMS score of 7, indicating he is moderately cognitively impaired. R5's cumulative POS documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A pharmacy packing slip dated 01/13/22 documents 30 [MEDICATION(S)] pills were delivered for R5. A pharmacy packing slip dated 01/14/22 documents an additional delivery of 90 [MEDICATION(S)] pills were delivered for a total of 120 pills remaining in the bubble pack card. An unnumbered narc sheet for R5 dated 01/14/22 includes - Rx#: (prescription number) 31; Date Dispensed: 01/19/22; Resident Name: (R5); Doctor: V29; Drug/Name/Strength: [MEDICATION(S)] HCL tab 50mg; Directions: Take one tablet by mouth three times daily; Pharmacy: (out of town pharmacy); Quantity Dispensed: 90.00. An unnumbered narc sheet for R5 dated 01/14/22 (90.00 quantity dispensed on 01/19/22) documents administration began with a 30-pill [MEDICATION(S)] count on 01/15/22 through 01/24/22 with 0 pills remaining in the bubble pack card as of 1/24/22. Another unnumbered narc sheet for R5 dated 01/14/22 (90.00 quantity dispensed on 01/19/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 01/25/22 through 02/03/22 with 0 pills remaining in the bubble pack card as of 2/03/22. Yet another unnumbered narc sheet for R5 dated 01/14/22 (90.00 quantity dispensed on 01/19/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/04/22 through 02/13/22 with 0 pills remaining in the bubble pack card as of 2/13/22. After review of the facility documentation above, it is noted that R5 should have 30 out of 120 [MEDICATION(S)] pills on hand at this same time. A pharmacy packing slip dated 02/09/22 documents delivery of 90 [MEDICATION(S)] pills for R5, indicating per facility records R5 should have available a total of 120 [MEDICATION(S)] pills on 02/09/22. R5's unnumbered narc sheet dated 02/09/22 (90.00 quantity dispensed on 02/09/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/14/22 through 02/23/22 with 0 pills remaining in the bubble pack card as of 2/23/22. R5's unnumbered narc sheet dated 02/09/22 (90.00 quantity dispensed on 02/09/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 02/24/22 through 03/02/22 with 0 pills remaining in the bubble pack card as of 03/02/22, indicating R5 should have 60 out of 120 pills on hand at this same time. A pharmacy packing slip dated 03/03/22 documents delivery of 90 [MEDICATION(S)] pills for R5, indicating per facility records R5 should have a total of 150 [MEDICATION(S)] pills as of 03/03/22. R5's unnumbered narc sheet dated 03/03/22 (90.00 quantity dispensed on 03/03/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/06/22 through 03/15/22 with 0 pills remaining in the bubble pack card as of 03/15/22. R5's unnumbered narc sheet dated 03/03/22 (90.00 quantity dispensed on 03/03/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/16/22 through 03/25/22 with 0 pills remaining in the bubble pack card as of 03/25/22. A pharmacy packing slip dated 03/23/22 documents delivery of 30 [MEDICATION(S)] pills, indicating per facility records R5 should have 120 pills available as of this same date. R5's unnumbered narc sheet dated 03/23/22 (30.00 quantity dispensed on 03/23/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 03/26/22 through 04/04/22 with 0 pills remaining in the bubble pack card as of 04/04/22. A pharmacy packing slip dated 03/29/22 documents delivery of 90 [MEDICATION(S)] pills, indicating per facility records R5 should now have 180 [MEDICATION(S)] pills available on 03/29/22. R5's unnumbered narc sheet dated 03/29/22 (90.00 quantity dispensed on 03/29/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/05/22 through 04/16/22 with 0 pills remaining in the bubble pack card as of 04/16/22. R5's unnumbered narc sheet dated 03/29/22 (90.00 quantity dispensed on 03/29/22) documents a 30-pill count with administration beginning on 04/17/22 through 04/26/22 with 0 pills remaining in the bubble pack card as of 04/26/22. R5's unnumbered narc sheet dated 03/29/22 (90.00 quantity dispensed on 03/29/22) documents a 30-pill [MEDICATION(S)] count with administration beginning on 04/27/22 through 05/06/22 with 0 pills remaining in the bubble pack card as of 05/06/22, indicating R5 should have 90 out of 180 pills on hand at this same time. A pharmacy packing slip dated 04/27/22 documents delivery of 90 [MEDICATION(S)] pills, indicating R5 should have 180 pills available as of 04/27/22. R5's narc sheet dated 04/27/22 (90.00 quantity dispensed on 04/27/22) marked 1 of 3 documents a 30-pill [MEDICATION(S)] count with administration beginning on 05/07/22 through 05/11/22 at 8:00 PM with 15 out of 30 pills remaining in the bubble pack card. R5 has two more narc sheets dated 04/27/22, each with a starting count of 30, marked 2 of 3, and 3 of 3 that have not yet been used. R5 should have available 165 [MEDICATION(S)] pills per facility documentation as of 5/11/22 at 8:00 PM. On 05/12/22 at 1:20 PM, a narcotic count was conducted for R5 in the 1st floor nursing station and medication room with V6 (LPN). V6 stated since 05/11/22 at 8:00 PM, an additional 2 [MEDICATION(S)] pills had been given to R5 as scheduled on 05/12/22 at 8:00 AM and 12:00 PM. Documentation by V6 on R5's narc sheet dated 04/27/22 shows 13 out of 30 pills remain, indicating R5 should have 163 pills at this time. Upon completion, R5's narcotic count confirmed one card with 13 pills remaining, and 2 full, unused cards of 30 pills each for a total of 73 pills available at this time. Per the above review and facility documentation showing R5 should have 163 pills available at this time but only has 73, this indicates a 90-pill discrepancy. 3. R1's Admission Record documents admission to this facility on 09/02/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's cumulative POS documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date: 09/25/21. A revision to this medication dated 01/17/22 documents - [MEDICATION(S)] 50 mg HCI give 1 tablet by mouth at bedtime for back pain. R1's order for as needed [MEDICATION(S)] remains active, as well. R1's most recent quarterly MDS dated [DATE] documents a BIMS score of 9, indicating he is moderately cognitively impaired. A Pharmacy packing Slip from an out-of-town pharmacy documents 30 [MEDICATION(S)] pills were delivered to the facility for R1 on 12/03/21 at 8:00 PM, signed for by V19 (LPN). R1's Controlled Drug Receipt/Record/Disposition Form (commonly referred to as a narc sheet) dated 12/03/21 documents 30 [MEDICATION(S)] pills were received from the pharmacy, dispensed on 12/03/21, and contains the following instructions in part - [MEDICATION(S)] HCL tab 50 mg take one tablet by mouth every 8 hours as needed .Every dose must be accounted for and requires charting on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 01/01/22, R1's unnumbered narc sheet documents 18 out of 30 pills remain from the 12/03/21 delivery. According to this narc sheet, R1 was given [MEDICATION(S)] on 01/01/22 through 01/23/22 with 0 (zero) [MEDICATION(S)] pills remaining in the bubble pack card on 01/23/22. R1's narc sheet documents [MEDICATION(S)] was administered on 01/01 at 9:00PM; 01/02 at 5:15 AM; 01/03 at 4:30AM; 01/04 at 8:00AM; 01/05 at 1:00AM; 01/15 at 8:00PM, and 01/16 at 8:00PM. R1's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pharmacy packing Slip from an out-of-town pharmacy documents 30 [MEDICATION(S)] pills were delivered to the facility for R1 on 01/06/22. R1's unnumbered narc sheet dated 01/06/22 documents 30 [MEDICATION(S)] 50 mg pills (take one tablet by mouth every 8 hours as needed) were received from the pharmacy, dispensed on 01/06/22, with administration from this delivery beginning on 01/24/22 through 02/22/22 with 0 pills remaining in the bubble pack card on 02/22/22. On 05/12/22 at 10:00 AM, V3 (Assistant Director of Nursing - ADON) stated R1's pharmacy packing slip dated 01/06/22 would be the last one that came from pharmacy supply. After that R1's insurance changed and V20 (Family Member/POA - Power of Attorney) would bring in a home supply of [MEDICATION(S)] from the local pharmacy that would come in a brown bottle of 90 pills at a time. V3 also confirmed R1's [MEDICATION(S)] was ordered as routine on 01/17/22 in addition to his PRN (as needed) prescription. R1's unnumbered narc sheet dated 02/05/22 documents 90 [MEDICATION(S)] 50 mg pills were received from home supply (per V3) with no pharmacy dispense date. Hand-written instructions document - [MEDICATION(S)] HCL 50 mg take 1 tablet as needed every 8 hours and 1 tab night at HS (hour of sleep). This form documents administration from this 90-pill supply began on 02/23/22 through 03/23/22 at 8:00 PM with 59 pills remaining in the bubble pack card, documented by V8 (former LPN). R1's unnumbered narc sheet dated 03/24/22 at 8:00 PM documents 49 pills were on hand, indicating a 10-pill discrepancy from last dose on 03/23/22 at 8:00 PM as documented on the 02/05/22 narc sheet by V8 (LPN). According to R1's March 2022 MAR, no [MEDICATION(S)] was administered between 03/23/22 at 8:00 PM and 03/24/22 at 8:00 PM. Administration began on 03/24/22 at 8:00 PM through 05/06/22 at 8:00 PM, with 0 pills remaining in the bubble pack card as of 05/06/22. R1's unnumbered narc sheet dated 3/24/22 also documents that on 03/30/22 at 5:15 AM, R1 was given a PRN [MEDICATION(S)]; and on 04/28/22 at 4:00 AM, R1 was given a PRN [MEDICATION(S)]. There is no documentation on the March 2022 or April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's unnumbered narc sheet dated 05/02/22 documents a 90-pill home supply was provided by V20. Administration began on 05/07/22 at 7:00 AM through 05/10/22 at 8:00 PM. At this date/time of 5/10/22 at 8:00 PM, 85 pills are documented to remain. On 05/12/22 at 12:10 PM, a narcotic count of R1's [MEDICATION(S)] was conducted with V13 (RN) with no further discrepancies since last administered on 05/10/22 at 8:00 PM. On 05/05/22 at 11:38 AM, V20 was visiting R1 in his room. When asked if V20 ever had an issue with R1 not receiving his [MEDICATION(S)] or the facility reporting [MEDICATION(S)] pills missing, she stated there was an instance when a bottle she had brought from home was misplaced by the facility, but staff found it in a drawer, and to her knowledge there were no pills missing. On 05/06/22 at 2:00 PM, R1 stated he is not aware he had any missing [MEDICATION(S)]. He stated he usually hurts at night and gets his pain pill before bedtime. On 05/06/22 at 12:00 PM, V2 (DON) stated she did investigate R1's missing [MEDICATION(S)] on 03/24/22 when V19 (LPN) called to report R1's [MEDICATION(S)] count was off when she went to give him a dose. V2 stated R1 gets his [MEDICATION(S)] from a home pharmacy that V20 brings to the facility. V2 stated there were 9 pills in the bottle and the rest of the pills had been split in quantities of 10 and placed in pill crusher pouches, stapled shut, then put inside a specimen bag. V2 stated she and V19 both searched the medication cart. V2 stated she thought maybe some got thrown away by accident, and to her knowledge were never found. An undated typed statement by V2 documents the following - I was called to the 2nd floor nurse's station by (V19) on 03/24/22. Nurse stated her narcotic count for (R1's) [MEDICATION(S)] was short by 10 pills. According to the count sheet there should have been 59 [MEDICATION(S)] but there was only 49 [MEDICATION(S)] present and accounted for. (V19) and I searched the cart and lock box. I noted the medication for this resident was in a large pill bottle that was originally brought from home. The pills were separated into 4 small packs of 10 each with 9 loose pills in the bottle. The packs were not stored in the bottle but in a specimen bag. Upon further investigation of the bag, the outer sleeve of the bag was open on both ends. Some of the packs were in the part of the bag and some, in addition to the large bottle, were in the inner sleeve which was closed on one end and had a zip lock on the other end. I noted that the night nurse had given a prn dose at 4:30 AM this same day (3/24/22). When re-enacting taking the bag out of the lockbox and placing on top of med cart, several times some of the loose small packs landed in the trash can attached on the right side of the med cart at same level as the top of the cart. A new narcotic count sheet was started with correct count. On 05/06/22 at 12:00 PM, when V2 was shown R1's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . From 12/03/21 through 5/12/22, R1's record contains a 19-pill total discrepancy related to [MEDICATION(S)] administration and missing pills. On 05/05/22 at 11:00 AM, V4 (CNA) stated she only heard rumors from nursing that some narcotics were missing but had no other information. She stated since the missing [MEDICATION(S)] incident, the facility had implemented no one except the nurses are allowed in the nursing station unattended. The nursing station is in a room behind closed doors and is kept locked if the nurse has to step out for any reason. V4 stated she did not see the narcotics when the pharmacy delivered them on 03/14/22 nor did she see them on the 2nd floor med cart or counter when the nurse from the 1st floor brought them up that evening. On 05/05/22 at 12:31 PM, V2 (DON) stated that through the facility's investigation process regarding the missing [MEDICATION(S)], it was determined there was no procedure in place regarding medication. We are implementing new procedures and a policy is being written on how to handle medications including narcotic medication when we receive them from the pharmacy and how they are delivered to the respective nursing station. V2 stated she would have V3 (ADON) come and talk with this surveyor because (V3) handled the investigation and remedies. The facility schedule was reviewed and noted the following staff working the 2:00 PM to 10:00 PM shift on 3/14/22: V7 (RN), V8 (LPN), V22 (CNA), V23 (CNA), V24 (CNA) and V25 (CNA). On 05/06/22, the following attempts were made to contact the following staff members via cell phone for interviews: V8 at 9:00 AM, V22 at 10:39 AM, V23 at 10:48 AM, V24 at 10:50 AM and V25 at 10:52 AM. Messages were left with no return phone calls. On 05/06/22 at 9:44 AM, via cell phone interview, V21 (CNA) confirmed she did not see V7 bring any medication to the 2nd floor the evening of 03/14/22 whe

Based on observation, interview, and record review the facility failed to implement fall interventions for 1 of 4 residents (R33) reviewed for accidents in the sample of 25. This failure resulted in R33 suffering a fall resulting in a subdural hematoma requiring hospitalization for monitoring and treatment. Findings Include: R33's Admission Record documents R33's original admitted to facility as 1/3/22. R33's Minimum Data Set (MDS) dated [DATE] documents a BIMS score of 09, indicating cognitive impairment. This same MDS documents in Section G0110 that R33 requires limited assistance from 1-person physical assist for transfers, walking in room, and walking in corridor. R33's Morse Fall Scale dated 1/3/22 documents a score of 75, indicating R33 is at high risk for falls. R33's Plan of Care documents a focus area that states, The resident is high risk for falls r/t (related to) Confusion, Gait/balance problems, unaware of safety needs. An intervention listed for this focus area documents a date initiated as 1/10/22 which states, The resident uses chair/bed electronic alarm. Ensure the device is in place as needed. Facility Final Report incident dated 1/24/22 documents a fall with major injury for R33. The report states, Upon further investigation of fall from 1/17/22, per nurse's notes and staff interviews, resident had been sitting at the table outside of the nurse's station where (R33) ate (R33's) evening meal. The nurse was with R33 and had left the area to take medications to another resident. Nurse states she was gone for no longer than 5 minutes. Upon her return, nurse found Resident laying on R33's back on the opposite side of the table. Resident had (R33's) walker with (R33), no objects noted on the floor which is carpeted. Resident was admitted [DATE]. Diagnosis of dementia with a BIMS (Brief Interview for Mental Status) score of 9. Requires SBA (stand by assistance) - A (assist)x1 for locomotion. Resident is forgetful and attempts to ambulate without assistance. admitted for rehab after frequently falling at home, last fall resulting in left femoral neck fracture requiring a pinning and acute subdural hematoma according to CT (computed tomography) scans from 12/28/21. CT scans from 1/17/22 show acute on subacute subdural hematoma. Resident continues to be admitted to (Name) out of town hospital at this time with an expected return to our facility tomorrow 1/25/22. On 2/17/22 at 9:59 am, V2 (Director of Nursing) states that she completed the fall investigation for R33 regarding the 1/17/22 fall. V2 states it was determined R33's chair alarm had been left on a chair in R33's room, while R33 fell from a chair located in the lounge area outside of the nurses' station. V2 states R33 had a history of falls and staff were educated on ensuring R33's chair alarm was moved to whatever chair R33 was utilizing. V2 confirms R33's Plan of Care indicated R33 was to have a chair alarm in place. V2 states R33 received hospital evaluation and treatment for a subdural hematoma as a result of the fall. V2 states that R33 had a smaller subdural hematoma from a fall prior to R33's admission to the facility, but after the fall on 1/17/22, reports show it had now grown in size. On 2/17/22 at 10:25 am, V4 (Certified Nurse Assistant) states that she was working with R33 on 1/17/22 when she fell . V4 states that she did not witness R33's fall but arrived later after the fall had occurred and V5 (Licensed Practical Nurse) was tending to R33. V4 states that R33 utilized a bed and chair alarm. V4 states that R33 did not have R33's chair alarm in place at the time R33 fell . V4 states that R33 had been with visitors who had brought R33 to the lounge area at the end of the visit. V4 states the chair alarm was not put back in place after the visitors left. V4 confirms education was provided on ensuring R33's alarm is present and working wherever R33 is sitting. On 2/17/22 at 1:58 am, V5 (Licensed Practical Nurse) states that she was working the night R33 fell . V5 states that R33's baseline status is confused. V5 states that R33 utilizes a chair alarm and confirms it was not in place at the time of the fall. V5 states that R33 was sent to the local emergency room for evaluation and treatment. R33's Clinical Record documents a nursing note made on 1/17/22 with an effective time of 5:45 pm which documents R33's blood pressure and pulse were elevated post fall. The same note documents a 3.0 cc hematoma was present to the back, upper, left portion of R33's head. R33's pupils were differing in size, with the right measuring 4 mm (millimeter) and left measuring 2 mm. V18 (physician) was contacted with orders to send R33 to the local hospital for evaluation a treatment. R33's local hospital Emergency Department Clinical Report documents R33 arrived by ambulance and was seen on 1/17/22 at 7:08 pm. Review of the Radiology Report located in this same document dated 1/17/22 documents a CT Scan of the Brain was complete without contract. The Impression listed on this report documents, 1. Acute on subacute subdural hematoma in the left cerebral fossa measuring up to 17 mm with associated mass effect on the left hemisphere and approximately 6 mm of left-to-right midline shift. 2. There appears to be a small volume of left subarachnoid hemorrhage This report documents under Progress and Procedures that the case has been discussed with trauma service and R33 will be transferred to an out-of-town hospital for a Medium sized, chronic, traumatic left subdural hematoma. R33's Neurosurgery Consult Note from the out-of-town hospital dated 1/17/22 made by V6 (Physician) documents an Assessment stating, [AGE] year old female with prior fall and small SDH (subdural hematoma) presents s/p (status post) fall tonight with increasing size to SDH to 17 mm with 5 mm midline shift. Neurologically intact but confused. Concern for acute deterioration, so recommend ICU (Intensive Care Unit) care. Will discuss possible surgical intervention with patient and family. R33's out of town hospital Summary of Care documents R33 was admitted to the hospital from 1/17/22 - 1/25/22 with a primary diagnosis of Subdural hematoma. This report documents repeated CT scans of the Brain were complete along with neurological referral and treatment of the subdural bleed. Imaging Results for a CT of head without contract complete on 1/20/22 documents in Findings that R33 Is now status post left frontal approach subdural drain placement. There is a mild interval decrease in the size of the left cerebral convexity subdural collection. The maximum depth of this residual collection is approximately 0.8 cm (previously 1.2 cm). The collection is predominately hypodense with minimal hyperdense blood products. The mass effect on the left cerebral hemisphere and ventricles is significantly decreased. There is residual bowing of the septum pellucidum with near complete resolution of the midline shift. R33 was discharge back to the facility on [DATE] with orders to follow up with R33's Primary Care Provider in two weeks. R33's Subdural Drain Procedure Note documents on 1/18/22, R33 had a subdural drain placed. The note documents a 2 (centimeter) incision was made. Subcutaneous tissue and the [NAME] were dissected until the skull was identified. A handheld twist drill was used to create a burr hole. The burr hole was undermined with a straight bone [NAME]. The dura was incised in a cruciate fashion with a #11 scalpel blade. A trauma catheter was inserted and directed frontally and tunneled away from the incision site. Dark brown crank case fluid consisted with a chronic subdural hematoma was visualized upon [NAME] incision and within the collection system. The drain was secured to the skin with nylon suture. The catheter was serilly connected to the distal collection system with confirmation of spontaneous flow of fluid through to the collection system. After appropriate hemostasis was obtained, the wound was closed with running nylon suture. On 2/15/22 at 10:36 AM, R33 was observed residing in the facility, sitting in R33's wheelchair, with a functioning chair alarm in place. R33 was alert to person only. The facility's undated policy titled, Fall Policy states the mission statement is, to identify residents at risk for falls and provide guidelines for prevention and treatment post fall.

Based on observation, interview, and record review, the facility failed to a) implement, monitor, and modify interventions to prevent and/or promote healing of pressure ulcers, b) accurately and thoroughly identify areas and assess and/or document assessments of pressure areas, c) timely identify and treat an area of compromised skin and/or pressure ulcer, and d) follow the facility pressure ulcer policy/procedures for 3 of 3 (R1-R3) residents investigated for pressure ulcers in the sample of 9. These failures resulted in R2 being hospitalized on [DATE] and diagnosed with [CONDITION(S)] and gangrene and subsequently having bilateral heel debridement after R2 refused amputations. Findings Include: 1. R2's facility admission record dated 4/15/2021 documents an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Braden Scale for Predicting Pressure Sore risk dated 9/4/2020 and 11/30/2020 documents a score of 19, which indicates R2 is not at risk for skin breakdown. R2's facility care plan documents a focus area of potential for skin impairment related to immobility and documents ulcers to bilateral heels and top of right foot with an initiation date of 7/9/2020. The interventions documented include; administer medications as ordered, administer treatments and monitor for effectiveness as ordered, assess monitor and record wound healing weekly and as needed, measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed, and healing process, report improvements and decline to the physician, educate the family/resident/caregivers as to causes of skin breakdown: including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow policies and procedures for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/23/2021 at 11:05 AM V2 (Director of Nurses) clarified R2 did not have ulcers to bilateral heels on 7/9/2020. V2 stated R2 was admitted to the facility with a diabetic ulcer on his toe and the area resolved. On 4/8/2021 11:15 AM R2 was observed in bed with V15 (Certified Nursing Assistant/CNA) and V16 (Licensed Practical Nurse/LPN) present. R2's right heel was covered with eschar and R2's left heel and part of his foot was covered with black eschar, both with what appeared to be yellow slough under the eschar and the wound edges were separated from the surrounding tissue. The entire area of both feet were observed to shift position as V16 wipes the area with normal saline covered gauze. The area surrounding the eschar on the left foot is red and inflamed and the left foot is edematous. On 4/15/2021 at 10:45 AM R2 was observed in bed, with V10 (CNA) and V16 (LPN) present. R2's coccyx was observed to have an open area with yellow slough in the center of the area. The surrounding tissue did not appear inflamed. 1a) R2's facility nursing progress notes dated 11/30/2020 documents R2 was transferred to the local hospital for blister et (and) DTI (deep tissue injury) noted to R (right) heel et (and) [CONDITION(S)] noted to RLE (right lower extremity), dx (diagnosis) Rt (right) foot [CONDITION(S)]. R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Recently was tested for COVID due to the same. Per nursing he has had a blister to right heel for some time however she reports today that it deroofed and looked infected. Under physical exam the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Medial aspect of the heel has a large partially deroofed blister. There is surrounding [CONDITION(S)] and warmth with swelling of the right foot. The right foot is severely tender to touch. The left heel is red, mushy, with non-blanchable [CONDITION(S)] to lateral aspect. Under assessment the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Under plan the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unable to provide reproducible evidence of assessment, treatment, and/or interventions implemented for R2's left heel other than the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's local hospital records with an admitted [DATE] documents R2 was sent to the hospital and per report of the facility had a blister to the right heel for some time however on admission it deroofed and looked infected so R2 was sent to the emergency room for evaluation. The record documents under hospital course that dressing changes were done daily, complete pressure relief was provided to bilateral heels and intravenous antibiotics were administered. R2's hospital record documents under the skin assessment on 11/22/2020 a stage 1 decubitus ulcer left lateral heel. The left heel is described as being red, mushy, with non-blanchable [CONDITION(S)] to lateral aspect. R2's hospital records document on 11/27/2020 R2 is still having pain to his left heel but the skin assessment documents it as being normal. R2's hospital assessment and plan document the Stage 1 decubitus ulcer to R2's left lateral heel as resolved prior to discharge. R2's facility nursing admission screening history dated 11/30/2020 documents R2 returned to the facility after a stay at the local hospital for decubitus. The assessment documents a decubitus on R2's right heel with no specific assessment of R2's left heel documented. R2's medical record does not document an assessment of R2's left heel from 11/22/2020 until 12/29/2020. R2's facility care plan documents R2 has a history of skin breakdown on his heels beginning on 7/7/2020. R2's care plan documents an intervention to float R2's heels while in bed beginning on 1/1/2021. There is no documentation in R2's care plan of an intervention to protect R2's heels while up in the wheelchair and no intervention for any heel protection prior to 1/1/2021. R2's 11/2020 and 12/2020 facility progress notes do not document protection to R2's heels until 12/16/2020 when the progress notes document float heels while in bed every evening and night shift for wound. R2's facility clinical physician orders document an order to float heels while in bed with a start date of 1/1/2021. On 4/14/2021 at 2:49 PM when asked why R2's heels had not been protected prior to 11/30/2020 (when a skin and wound evaluation of R2's right heel documented the intervention). V2 (Director of Nurses) stated, heel protectors are a nursing measure and were implemented on 11/03/2020. V2 stated R2's heels were floated while he was in bed prior to 11/03/2020. The facility was unable to provide reproducible evidence R2's heels were protected prior to 11/30/2020. R2's facility wound evaluation dated 12/29/2020 documents a blister to R2's left heel acquired in house with an unknown age measuring 6.02 cm x 4.28 cm. The assessment documents the surrounding tissue as [CONDITION(S)] and the practitioner was notified and awaiting physician orders. On 4/16/2021 at 3:21 PM V2 stated she was unable to locate an assessment of R2's left heel from 11/22/2020 until 12/29/2020 when the facility documented a blister to R2's left heel. V2 stated after R2's physician assessment on 11/22/2020 R2 was sent to the local hospital for evaluation and was admitted . V2 stated R2 returned to the facility on [DATE] and the nurse did an admission assessment. V2 stated R2's left heel is not specifically addressed on the assessment, but she is sure the nurse would have assessed it and documented if there were any issues. V2 stated she believes the area healed during R2's hospital stay. R2's facility skin observation tool dated 1/5/2021 documents a suspected deep tissue injury/pressure to left heel with no other description or assessment documented. V14's (wound specialist) note dated 1/6/2021 documents blister intact to R2's left heel, measures 4.0 cm x 7.0 cm, interventions include heel float boot, specialty mattress, elevate legs when in wheelchair. The treatment orders are documented as clean left heel with normal saline, paint with [MEDICATION(S)], gauze, kling, change daily and as needed. V14's (wound specialist) notes dated 1/13/21 and 1/19/2021 document the area increases in size from 4.0 cm x 7.0 cm to 6.5 cm x 7.0 cm. The treatment orders change to xeroform instead of [MEDICATION(S)] and the area is documented as 100% necrotic on 1/19/2021. R2's facility skin and wound evaluation dated 1/20/2021 documents a blister to R2's left heel acquired in house measuring 5.5 cm x 4.1 cm with unknown duration, and the progress is documented as stalled. No other assessment or description of the area is documented on this evaluation. The picture attached to the report is difficult to see but appears to show an area of eschar with uneven wound edges. There is no facility assessment (only (V14) wound specialist notes) of this area from 12/29/2020 through 1/20/2021. V14's wound specialist note dated one day prior to this assessment documents the area is 6.5 cm 7.0 cm which indicates the area is larger than the facility assessment documents. V14's (wound specialist) notes dated 1/29/2021 through 3/17/2021 document the area increases in size from 6.5 cm x 7.0 cm to 7.0 cm x 7.0 cm. The notes document the treatment is changed to add crushed [MEDICATION(S)] to the xeroform with no other significant changes documented on these notes. There are no facility assessments of the pressure ulcer to R2's left heel from 1/20/2021 until 3/17/2021. R2's facility skin and wound evaluation dated 3/17/2021 identifies the area to R2's left heel as an arterial wound measuring 7.4 cm x 7.0 cm, with no other assessment of the area documented. The picture attached to this report appears to show an area of eschar with wound edges slightly separated. V14's (wound specialist) note dated 3/17/2021 documents R2 saw a vascular physician yesterday and treatment was changed to [MEDICATION(S)], gauze, kling, and ace wraps change and CT (computerized tomography) is pending. There is no change to the size or description of the area to R2's left heel documented on this assessment. V14's (wound specialist) notes dated 3/24/2021 to 4/7/2021 document the unstageable pressure area to R2's left heel increased in size from 7.0 cm x 7.0 cm to 7.5 cm x 10.0 cm with no other significant changes documented. R2's facility skin and wound evaluations dated 3/24/2021 to 4/7/2021 document the wound measurements ranging from 1.6 cm x 1.2 cm to 7.0 cm x 6.3 cm. This indicates a significant difference in measurements from V14's (wound specialist) measurements of the area during the same time. The facility skin and wound evaluations document the area as stable and/or deteriorating with no other assessment of the area. R2's radiology report dated 4/5/2021 documents a computed tomography angiogram (CTA) was done on 4/5/21 with impression documented as There appears to be worsening [CONDITION(S)] and [CONDITION(S)] involving the right and left calcaneus . The patients known [CONDITION(S)] is suspect is worsening. MRI recommended .There is a small focal narrowing of the right femoral artery in the mid-thigh with an approximately 50% diameter stenosis. There is a small focal narrowing of the right popliteal artery just proximal to the trifurcation. There is occlusion of the right anterior tibial artery just below the trifurcation. There subsequent high-grade stenosis or occlusion of the posterior tibial artery on the right inferior to the trifurcation Some of these findings could relate to slow or no perfusion of these vessels as bolus injection was reduced due to only having a 20-gauge venous access present. If intervention is contemplated follow-up examination prior to intervention would be recommended with a larger gauge intravenous access at higher injection rate. An additional slightly delayed phased second acquisition may also be of use in evaluation of trickle flow through the altered vessel in the lower legs. (This indicates further testing needs to be done to ensure the accuracy of the results). R2's hospital record dated 4/8/2021 documents R2 presented with bilateral heel ulcers. R2's physical exam documents redness, warmth, wet, swelling, no tenderness with a black eschar present on both heels. R2's hospital records document x-ray of left foot to have the following under impression, Abnormal a few soft tissue swelling, as well as multifocal areas of permeative bone change concerning for possible [CONDITION(S)]. R2's hospital records document an X-ray of the right foot with the following impression, calcaneal findings consistent with [CONDITION(S)]. R2's hospital record with a vascular report dated 4/9/2021 documents under history of present illness, .With past medical history significant for PVD ([CONDITION(S)]) and significant deconditioning presents w/ (with) worsening B (bilateral) heel ulcers. The left heel ulcer started to develop malodor. He has no fevers or chills. He has confirmed osteo ([CONDITION(S)]) by CT scan. He was in the process of undergoing w/u (workup) to assess for PVD that might be amenable to intervention. The patient developed the ulcers spontaneously as his dementia has worsened over time. He is completely non-ambulatory .the patient has expressed that he does not want a leg amputation. Under physical exam the vascular report documents, R (right) heel gangrenous eschar w/malodor and maceration at the edges, L (left) heel dry gangrenous eschar, B (bilateral) LE (lower extremity) [CONDITION(S)], no [CONDITION(S)]. Under assessment and plan the vascular report documents, Infected B heel ulcers, no significant PVD, after long discussion w/ POA (power of attorney) it was decided to proceed w/ excisional debridement, wound care, wound c/s (culture and sensitivity), prevalon boots . Report signed by V12 (vascular surgeon). R2's hospital record documents an operative note dated 4/13/2021 under description of procedure the report documents there was gross purulence obtained on the right and left and wound dimensions were 6 x 7 cm on the right and 8 x 9 cm on the left. The report documents the curette was used to remove some of the calcaneal bone that was soft and osteomyelitic. 1b) R2's facility skin observation tool dated 11/17/2020 documents a blister and a pressure ulcer/suspected deep tissue injury to right heel with no assessment, measurements and/or physician notification for treatment orders documented on this assessment. R2's facility wound evaluation and the facility skin and wound evaluation dated 11/18/2020 documents the blister on R2's right heel measures 4.42 cm x 3.67 cm and 4.4 cm x 3.7 cm. The area is identified to be new and acquired in house with no further description/assessment of the area and no physician and/or family notification of the area documented on these assessments. R2's facility skin and wound evaluation dated 11/18/2020 documents the pressure ulcer (deep tissue injury) was identified to be new, acquired in house, and measures 2.2 cm x 1.9 cm. There is no further description or assessment documented and no physician notification for treatment orders documented on this assessment. R2's facility clinical physician orders document an order was started on 11/19/2020 to apply [MEDICATION(S)] to right heel topically. This indicates there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Recently was tested for COVID due to the same. Per nursing he has had a blister to right heel for some time however she reports today that it deroofed and looked infected. Under physical exam the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Medial aspect of the heel has a large partially deroofed blister. There is surrounding [CONDITION(S)] and warmth with swelling of the right foot. The right foot is severely tender to touch. The left heel is red, mushy, with non-blanchable [CONDITION(S)] to lateral aspect. Under assessment the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .: R2's progress notes document R2 was sent to the local hospital for evaluation of symptoms and returned to the facility (on 11/30/2020) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's facility progress notes do not document further assessment of R2's heels in November of 2020. R2's local hospital record documents with an admitted [DATE] documents under history of present illness: .Per nursing had episode of nausea and vomiting this am with a fingerstick glucose over 400. Call to on call physician with orders for insulin. Per nursing the patient (R2) has had intermittent fevers, chills, nausea and vomiting for a few days . Per nursing he has had a blister to right heel for some time however she reports today that it deroofed and looked infected. Under physical examination the hospital record documents, skin: Right heel is mushy, dark discoloration from medial to lateral heel including posterior heel. Medial aspect of the heel has a large partially deroofed blister. There is surrounding [CONDITION(S)] and warmth with swelling to the right foot. The right foot is severely tender to touch . Under assessment/plan the hospital record documents 1. Decubitus ulcer right calcaneous with surrounding [CONDITION(S)] and possible [CONDITION(S)]: blood culture, wound culture, IV (intravenous) vanc ([MEDICATION(S)]) and [MEDICATION(S)] Patient will need complete relieve (sic) of pressure from both heels at all times with BID (twice daily) wound care .Under hospital course the record documents, R2 was started on [MEDICATION(S)] and [MEDICATION(S)], wound and blood cultures were obtained. Dressing changes were done daily with a dry dressing and complete relief of pressure was provided to bilateral heels Wound culture was reported as MRSA (methicillin resistant staphylococcus aureus), therefore [MEDICATION(S)] was stopped and he was continued on [MEDICATION(S)]. R2's hospital swing bed history and physical dated 11/27/2020 documents R2's chief complaint as right pressure ulcer with [CONDITION(S)]. Under history of present illness, the record documents R2's wound was showing improvements throughout his inpatient stay but R2 will be admitted to a swing bed for more IV antibiotics. Under skin assessment the history and physical documents, right heel with pressure wound to right medial and posterior heel .medial aspect is open with central necrosis noted, no odor, the posterior heel is also open with central discoloration, improvement of surrounding [CONDITION(S)], [CONDITION(S)], and tenderness . Under assessment and plan the history and physical documents, 1. Decubitus ulcer right calcaneous with surrounding [CONDITION(S)] and possible [CONDITION(S)], improving . R2's facility nursing admission screening history dated 11/30/2020 documents R2 returned to the facility after a stay at the local hospital for decubitus. The assessment documents a decubitus on R2's right heel. R2's facility skin and wound evaluations dated 11/30/2020 document two areas on R2's right heel. One area is documented a pressure/ulcer deep tissue injury that measures 4.8 cm x 3.2 cm and is described as 40% eschar with a light amount of seropurulent exudate and the surrounding tissue is described as calloused, blanching, dark reddish brown with no [CONDITION(S)]. The second area is documented as a blister that measures 4.9 cm x 4.7 cm scabbed with no evidence of infection. Interventions are listed on the assessments to include heel suspension and protection device. R2's facility care plan documents an intervention for R2 to be evaluated and treated by a wound specialist with a start date of 12/01/2020. V14's (wound specialist) note dated 12/04/2020 documents R2 presents for an initial evaluation of wound to R2's right heel. The note documents R2 was recently in the hospital due to [CONDITION(S)] and right heel infection. CT (computerized tomography) 11/22 (2020) on right foot showed diffused heterogeneous likely from [CONDITION(S)] and [CONDITION(S)]. Wound cx (culture) showed MRSA (methicillin resistant staphylococcus aureus) and (R2) is currently on [MEDICATION(S)] 100 mg BID (twice daily). Under assessment the wound specialist note documents an unstageable pressure ulcer/injury to R2's right heel measuring 4.7 cm x 5.5 cm, with interventions listed as float heels, prostat daily, and xeroform double layer change daily and as needed. R2's wound specialist note documents the two areas previously identified as a blister and pressure ulcer to R2's right heel as one area. R2's facility skin and wound evaluation dated 12/09/2020 documents the deep tissue injury to right heel to measure 5.3 cm x 4.3 cm. The area is documented as stable with no other assessment/description documented. On 4/15/2021 at 3:00 PM V2 (Director of Nurses) stated this area was previously identified as a blister. V14's (wound specialist) note dated 12/10/2021 documents the area to R2's right heel has increased in size from 4.7 cm x 5.5 cm to 7.0 cm x 6.0 cm. The area is documented as being 40% granulated and 60% necrotic with the periwound area as macerated, a moderate amount of serosanguineous drainage with no changes documented to the treatment orders and an intervention of elevate legs when up in wheelchair added. There is no documentation of facility assessments of the area identified as a pressure/DTI on R2's right heel from 12/10/2020 until 1/1/2021 and of the area originally identified as a blister on R2's right heel from 12/09/2020 until 1/5/2021. V14's (wound specialist) note dated 12/15/2020 documents the visit was cancelled due to Covid-19. This indicates the pressure ulcers to R2's right heel was not assessed by the wound specialist from 12/10/2020 until 1/6/2020, which indicates no assessment of the areas to R2's right heel was documented by the facility and/or wound specialist from 12/10/2020 until 1/1/2020. R2's facility progress notes document treatments and antibiotics given for [CONDITION(S)] of right foot through the month of December 2020 with no assessments of the area documented. R2's facility skin and wound evaluation dated 1/1/2021 documents the pressure ulcer to R2's right heel to measure 3.2 cm x 2.9 cm with no other assessment of the area documented on this evaluation. R2's skin and wound evaluation dated the same date also documents a separate area to R2's right heel previously identified as the blister to measure 3.7 cm x 3.4 cm with no other assessment/description of the area documented. R2's facility skin observation tool dated 1/5/2021 documents an unstageable pressure ulcer to the right heel with no other assessment or description of the area documented. R2's facility progress notes document on 1/6/2021 upon providing wound care to res (resident) heels foul odor noted, redness noted to peri wound pharm (pharmacy-sic) aware. V14's (wound specialist) notes dated 1/6/2021 and 1/13/2021 documents the unstageable pressure ulcer to R2's right heel has an odor per nurse and R2 is started on [MEDICATION(S)] with the odor showing some improvement. The area is documented as 100% necrotic and increases in size from 7.0 cm x 6.0 cm to 7.0 cm x 9.0 cm. V14's (wound specialist) note dated 1/19/2021 documents R2 completed the [MEDICATION(S)] but is still having some odor in the unstageable pressure ulcer to R2's right heel. The note documents R2 is scheduled for a doppler and has had an overall decline in his condition. The assessment documents the wound edges are pulling away slightly with measurements remaining unchanged. Interventions are documented as including doppler, low air loss mattress, ESTEM (electrical stimulation), and a wound culture with the treatment remaining unchanged. R2's facility skin and wound evaluations dated 1/20/2021 documents the areas as stable with the area measured as two separate areas (2.5 cm x 1.7 cm and 4.5 cm x 4.0 cm) with no other assessment and/or description of the area documented. R2's facility clinical physician orders document an order to start [MEDICATION(S)] one gram intramuscularly on 1/22/2021. V14's (wound specialist) notes dated 1/29/2021 to 3/10/2021 document the area remained unchanged in size and goes from 100% necrotic to 90% slough/eschar and 10% granulated with a moderate amount of exudate. The notes document a culture was obtained and crushed [MEDICATION(S)] was added to the treatment on 2/17/2021. There were no other significant changes documented on these notes. V14's (wound specialist) notes dated 3/17/2021 and 3/24/2021 document R2 was evaluated by a vascular physician on 3/16/2021 and the treatment orders were changed to clean area with normal saline, apply [MEDICATION(S)], gauze, kling, and ace wraps, change daily and as needed. The notes document a pending CT (computerized tomography) and the area is documented as decreasing in size from 7.0 cm x 9.0 cm to 6.5 cm x 7.5 cm, with no other significant changes documented. R2's facility skin and wound evaluations 3/17/2021, 3/24/2021, and 3/31/2021 begin documenting the two areas as one merged area and describe the area as an arterial wound, with measurements documented as ranging from 5.0 cm x 4.4 cm to 5.9 cm x 5.0 cm, which indicates a discrepancy in size and type of wound from V14's (wound specialist) assessments. The facility evaluation documents the area as improving on 3/24/2021 with no other assessment/description documented. R2's wound specialist note dated 3/31/2021 documents the CT report un-officially showed gangrene to the right heel. The note documents the area decreased in size to 5.8 cm x 6.0 cm with no other significant changes documented. R2's wound specialist note dated 4/7/2021 documents R2 had an appointment with a vascular specialist that was cancelled (by vascular office) and rescheduled for 4/8/21. The note documents the unstageable pressure to R2's right heel is unchanged. R2's facility skin and wound evaluation dated 4/7/21 identifies the area to R2's right heel as arterial and measures 4.5 cm x 3.9 cm. The area is documented as improving with no other assessment/description documented. The picture attached to this assessment is difficult to see but shows what appears to be an eschar covered area with wound edges that appear to be separated and pulling away, with what appears to be sloughing under the eschar and dressings with what appears to be drainage covering approximately 70 percent of the dressing laying under the raised heel. The facility assessment documents the area as improving and measures smaller than V14's assessment. This indicates a discrepancy in size and condition of the wound from the facility assessment and V14's assessment on 3/31/2021 that documents the CT scan showed gangrene. R2's hospital records dated 4/8/2021 document R2 presented to the hospital with bilateral heel ulcers. The heels are described as being infected, gangrenous, with an odor, and to have [CONDITION(S)]. The hospital records document x-rays of both heels with findings consistent with [CONDITION(S)]. The record documents R2 expressed he did not want leg amputations so excisional debridement was performed on bilateral heels. On 4/9/2021 at 11:30 AM V10 (CNA) stated the facility used heel protection for R2 prior to the Covid-19 outbreak in December. V10 stated he had been wearing them for a while but was unable to remember when they started. V10 stated interventions that were implemented when R2 had Covid-19 were to turn and position, elevate the head of his bed, and heel protectors. R2's progress notes document R2 was diagnosed with Covid-19 on 12/16/2021. On 4/9/2021 at 11:45 AM V3 (Assistant Director of Nurses) stated R2 had the intervention of heel protectors implemented on 12/01/2020. V3 stated the initial blister was identified on R2's right heel on 11/17/2020. When asked why they didn't implement heel protection at that time or prior to the skin breakdown since R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if R2 used a wheelchair for locomotion at that time V3 stated he did. When asked what protection was provided to R2's heel when he was up in a wheelchair V3 stated he did not wear shoes after they identified the blister. V3 then stated they began floating R2's heels on admission to the facility in July of 2020. On 4/15/2021 at 1:54 PM V14 (wound specialist/Nurse Practitioner) stated the pressure ulcers to R2's heels were not preventable due to his severe arterial disease. When asked if the facility should have implemented heel protection prior to the breakdown V14 stated, Yes. When asked why the hospital records document no significant [CONDITION(S)] and her report documents severe arterial disease V14 stated she wasn't aware of the hospital report saying that. When asked if there was anything, she felt the facility should have done differently to prevent the areas from developing on R2's bilateral heels V14 stated, I always though he needed a longer bed. He is a bigger guy. On 4/16/2021 at 8:04 AM V13 (Physician) stated he did not recall what the findings were on R2's doppler and angiograms and that he is sure R2 has some vascular/arterial disease. V13 stated heel ulcers are generally pressure related. When asked if heel protection should have been implemented prior to the skin breakdown V13 stated, Yes. On 4/15/2021 at 6:30 PM V12 (vascular surgeon) stated R2 has some [CONDITION(S)] but it is not significant or causative for the pressure ulcers on R2's bilateral heels. Reviewed with V12, R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if the areas could have been prevented/unavoidable if the facility had implemented preventative measures V12 stated, Potentially, R2 has relatively advanced dementia and can't tell when he is putting pressure on his heels for long periods of time and he has other health issues. But yes, they could have potentially been prevented. V12 stated the ulcers on R2's heels were strictly pressure related. V12 stated These wounds are really, really bad. They are never going to heal. When asked about his notation in R2's hospital record regarding amputation. V12 stated although R2 had dementia he had expressed not wanting to have an amputation and his family honored his wishes. V12 stated amputation would have been reasonable treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V12 stated there is a reasonable chance of them staying ok for the rest of R2's life as long as he stays in a steady state and they are treated appropriately. 1c) R2's facility progress notes document on 1/2/2021 Noted pressure ulcer to coccyx 4.9 cm x 6.2 cm x 2.4 cm. Cleaned with NS (normal saline) et (and) covered with foam dressing. Resident will be repositioned every two hours et (and) as needed. MD (V13) notified, awaiting response. R2's facility sk

Based on interview and record review, the facility failed to provide required supervision during toileting for 1 (R3) of 3 residents reviewed for falls in the sample of 3. This failure resulted in R3 falling from the toilet and sustaining an acute fracture to the left trochanter. Findings Include: R3's face sheet documents R3 was admitted to the facility on [DATE]. R3's history and physical from a local discharging hospital dated 10/23/19 documents that R3 presented to the emergency room from home after experiencing a fall. This document further states R3 has a history of dementia and is more confused per family. R3's family have been thinking about long term placement due to altered mental status and unsafe living condition (living alone). During hospital stay, R3 was found to have sustained a compression deformity of L1 from fall at home. R3 was discharged to a Long Term Care Facility on 10/24/19. R3's face sheet documents, among other diagnoses, [DIAGNOSES REDACTED]. R3's Morse Fall Scale was completed 10/24/19 and documents a score of 90. A score of 45 or more indicates a resident is fall risk. R3's initial Care Plan has a focus area with a date initiated on 11/19/19 of ADL self-care performance deficit related to weakness and unsteady gait. The intervention for toileting was as follows: resident can assist with pivot transfers with toileting needs with assist of staff. The intervention under this same focus area for transfer status is the resident is able to pivot transfer with staff assist only. A focus area of high risk for falls related to dementia, weakness, unsteady and history of falls at home with initiation date of 11/19/19 has the following intervention: Follow facility fall protocol. R3's admission MDS (Minimum Data Set) dated 10/31/19 documents R3 is cognitively impaired with a Brief Interview for Mental Status score of 7. R3's functional status for toilet use, which includes the defined area of how the resident uses the toilet room, and transfers on/off toilet is scored as 3 (Extensive assistance), 2 (One person physical assist). The same MDS documents in all sections of G0300 which identifies R3's Balance during transitions and walking including moving on and off toilet, as a 2 (Not Steady, only able to stabilize with staff assistance. An untitled document with a subject line of: Free of Accident and Hazards/Supervision/Devices dated 1/14/19 was provided by V1 and verified on 1/28/19 at 1:19 PM, that this was the facility's 'fall protocol' referred to in R3's care plan. The document lists that it is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care, and professional standards of practice that will meet each resident's physical, mental and psychological needs. Listed under the 'Procedure was that the facility must ensure that: 1. The resident environment remains as free of accident hazards as possible. 2. Each resident receives adequate supervision and assistance devices to prevent accidents. An injury incident report submitted on 1/6/20 to the state regulatory agency documents on 1/4/2020, R3 was found by staff in the male resident's bathroom, laying on his left side, on the floor. R3 had a skin tear to his right hand and could not bear weight on the left leg due to pain. R3 was sent to the local hospital for evaluation and treatment. This report also documented R3 had x-rays that showing an acute fracture through the base of the greater trochanter with mild displacement and soft tissue swelling. A final investigation report dated 1/8/20 concluded that R3 was assisted to the toilet, the CNA (Certified Nurse Assistant) determined to be V8, stepped out of the bathroom area where R3 was, and went to the linen closet right across the hall. R3 fell from the toilet, resulting in a skin tear on the right hand and pain in left lower extremity. R3 was transported to the local ED (emergency department) for evaluation and treatment via ambulance. R3's Progress Notes dated 1/4/20 documents as reported in the serious injury report submitted to the state regulation agency that R3 sustained a fall on 1/4/20 at 9:25AM from the toilet. The note made by V6, LPN (Licensed Practical Nurse) at 10:43 AM, documents left lower extremity pain non weight bearing. On call doctor notified. New orders to send resident to local community hospital for evaluation and treatment. V6 documents the local ambulance service was notified of need to transfer and R3 left the facility at 10:30AM on a stretcher. R3's Emergency Department note dated 1/4/20 documents R3 presented to the emergency department to be evaluated for the following condition: Closed displaced [MEDICATION NAME] trochanter of the left femur. Discharge instructions were: only bed to chair at the nursing home. Follow up with primary care physician on 1/8/20 and may use Tylenol 650mg by mouth every 8 hours as needed for pain. An incident report dated 1/4/20 regarding R3's fall documents under nursing description that R3 was noted lying on the bathroom floor. Resident Description documents that the resident stated, these damn shoes tripped me up. Description of Action Taken documents that resident was assessed, and vital signs taken. On this same report the predisposing physiological items checked off were gait imbalance, impaired memory, confused, and weakness/fainted. On 1/28/19 at 1:15PM, V6 (Licensed Practical Nurse) stated that she was the nurse on duty when R3's fall occurred. V6 was in the nurses' room' charting when V8 (CNA) came and said, I need you in the bathroom. V6 found R3 lying beside the toilet on his left side, somewhat up against the wall. When V6 and V8 asked R3 what happened,all he could state was 'he fell .' V6 and V8 were unsure if R3 tried to transfer himself or lost his balance. V6 stated that V8 (Certified Nurse Assistant) left him alone to run across the hall to the linen closet. V6 confirmed that R3 needed staff assistance at all times when he was up ambulating or in the shower/restroom for safety awareness and added that R3 was a high fall risk and was confused. 0n 1/28/20 at 10:04 AM, R3 stated that he did not remember the fall on 1/4/20. He stated he was really busy at the moment, looking for his lost towel,and thanked the surveyor for her concern. R3 was observed self propelling himself in his wheelchair around the facility sitting room. On 1/28/20 at 11:55 AM, V1 (Administrator) stated that it would be her expectation that residents who are a high fall risk not be left unattended in the restroom for safety. 0n 1/29/20 at 9:12 AM, V7 (Certified Nurse Assistant) stated that as long as R3 has lived here, in the facility, he has been considered a high fall risk. V7 would never leave R3 alone in the shower or bathroom due to his confusion and safety awareness. The only times he is left unattended is when he is in his chair, recliner or bed and has a chair alarm on. This has been the case since R3 has lived here. On 1/29/20 at 1:45PM, V9 (Licensed Practical Nurse) stated that she is the nurse that typically works days shift on the lower floor. V9 stated that R3 is a high fall risk due to his confusion and previous fall history and should have supervision when he is not in his chair or bed with an alarm on. V4 (Director of Nursing/DON) stated on 1/29/19 at 1:58 PM, R3 probably should have had someone with him in the bathroom. While V8 was only gone a couple seconds, that was when R3 had the fall and sustained the injury.

Based on record review and interview, the facility failed to follow the plan of care related to ambulation for one of four residents (R1) reviewed for falls in the sample of four. R1 was not being ambulated properly by staff and fell sustaining a hematoma above the eye and two abraisons across the nose . Findings include: 1. R1's Minimum Data Set ((MDS) dated [DATE] documents R1is extensively dependent on two or more staff for transfers, ambulation, dressing, and tolieting. The MDS further documents R1's balance during transitions and walking as "not steady, only able to stabilize with staff assistance." R1's Brief Interview of Mental Status (BIMS) score was not addressed. R1's Care Plan dated 2/10/12 documents R1's goal is to transfer safely with moderate/HHA (hand held assist) x 2 staff members and to walk 150 plus feet with HHA x 2 staff members. The Care Plan further documents R1 had a low bed, mat on floor, personal alarm, and one to one when resident is restless. R1's Care Plan documents falls on 6/23/13, 11/6/14, 11/27/13, and 1/4/14. No progressive interventions for prevention of falls were found in R1's Care Plan. R1's Fall Risk Assessment with an initial date of 8/03/13 and a re-assessment date of 4/30/14 documents R1's fall risk score a 14 with a score of 10 or above representing high risk for falls. R1's Functional Area of Needs Assessment with an initial date of 1/28/14 documents R1 ambulates with staff of two. Assessment further documents on 4/30/14 no changes for R1's initial assessment. Accident/Incident report dated 6/23/13 documents R1 fell in Dining room when R1 stood up and stumbled in chair legs causing R1 to fall and hit head on the floor. R1 sustained a 6 x 7 centimenter (cm) hematoma to the occipital area. Prevention for Reoccurrence: Observe at all times while in Dining room. External Risk Factors: Position alarm in place? NO- Alarm activated? NO. Conclusion: Personal alarm on Dining room Chair Accident/Incident report dated 11/6/13 documents R1 fell in beauty shop when R1 grabbed the door frame and pulled herself (R1) forward and chair rolled out from under causing R1 to fall and land on her left hip. Personal alarm was sounding, no apparent injuries. Conclusion: Beautician instructed to make sure there is nothing in reach for R1 to assist her up. Accident/Incident report dated 11/27/13 documents R1 fell in Dining room when R1 removed personal alarm and stood up. Prevention for Reoccurrence: pin personal alarm at mid back so R1 cannot reach to remove, one to one when resident is restless. Accident/Incident report dated 1/4/14 documents R1 was found lying on floor in Dining Room and noted to have a 5cm hematoma to back of head. Prevention for Reoccurrence: not to be left alone in Dining room. External Risk Factors: Position alarm in place- YES-Alarm activated? YES. Accident/Incident report dated 4/3/14 documents in part, as follows: Description of Incident and Treatment Administered: "R1 was ambulating with SBA (stand by assist) of one staff member and lost balance falling to floor landing on right side hitting head. Noted bleeding from face and a 5 x 3.5 cm hematoma above right eye and 0.3 cm abrasion to center with 2 abrasions 0.1 cm and 0.2 cm to bridge of nose. Residents account of what happened: staff ambulated R1 alone. Area Accident Occurred: East Hallway. Primary Injuries: head involved, hematoma and abrasion." Incident Questionnaire documents E4, Certified Nurse Aid (CNA)and E5, CNA stood R1 up out of recliner and noticed R1 was incontinent. E5 left R1 with E4 to go get dry clothes and E4 started ambulating R1 to the bathroom when R1 stumbled and fell . On 5/20/14 at 10:15 AM, E3 (Director of Nursing) DON, stated that E4 and E5 were walking R1 when E5 left to get R1 dry clothes and left E4 walking alone with R1. E3 stated "there should have been two staff to ambulate R1, she has had previous falls and staff must stay with her. That's where the breakdown was right there, you need to send a third person for undergarments." On 5/20/14 at 11:42 AM, during an interview, E4 stated "E4 had went to get dry clothes for R1 and I asked R1 to walk to the bathroom, R1 stumbled, and I tried to hold her but couldn't and that's when R1 fell and hit her head on the floor." E4 further stated that R1 had previous falls and required assistance from 2 staff members at all times and that another CNA could have went to get R1's clothes. On 5/20/14 at 11:50 AM, during an interview, E5 stated "I went to get clothes for R1 while E4 walked R1, I was was coming up hall and saw R1 on the floor." On 5/21/14 at 10:36 AM, during an interview with E6, (Care Plan Registered Nurse) RN, stated that there were no further progressive interventions to prevent R1's falls except to talk with staff and look at R1's environment when falls occurred. On 5/21/14 at 10:40 AM, E2 stated that R1 had a personal alarm in place and it was ineffective and did not sound at times and the facility's progressive interventions to prevent R1 from falling was to place R1's personal alarm in a different area on R1's body. On 5/21/14 at 2:00 PM, E2 stated the Facility did not have a fall policy/procedure and staff followed residents Care Plan.

A. Based on observation and interview the facility failed to ensure hot water temperatures are maintained at safe levels in areas accessible to residents. Water temperatures measured 130 degrees Fahrenheit (F) and above in four of four employee use areas which are accessible to residents . None of the doors to these these rooms were provided with a locking device. This failure resulted in an Immediate Jeopardy. While the immediacy was removed, the facility remains out of compliance at Severity Level 2 as the facility continues to monitor the utility rooms to ensure these doors remain locked,and the areas are inaccessible to residents. On 2/23/11, water temperatures were as follows using a digital thermometer that was recently checked for accuracy using the ice bath method by the surveyor. -At 10:12 AM, the hot water temperature was taken at the sink in the 2nd floor unlocked soiled utility room. The temperature was 130.5 degrees F. Steam was visible as the hot water came out of the faucet. There was an alarm on this door which had been turned off. -At 10:16 AM, the hot water temperature was taken at the sink in the 2nd floor unlocked clean utility room. The temperature was 132.2 degrees F. At 10:33 AM, the hot water temperature was 132.4 degrees F. Steam was visible as the hot water came out of the faucet. There was an alarm on the this door which had been turned off. -At 10:40 AM, the hot water temperature was taken at the sink in the 1st floor unlocked soiled utility room. The temperature was 130.2 degrees F. Steam was visible as the hot water came out of the facet. There was an alarm on this door which had been turned off. -At 10:43 AM, the hot water temperature as taken at the sink in the 1st floor unlocked clean utility room. The temperature was 133.2 degrees F. Steam was visible as the hot water came out of the faucet. There was an alarm on this door which had been turned off. On 2/23/11, at 12:00 PM, E4, Maintenance Director, indicated the soiled and clean utility areas on both floors had water temperature levels that were set above 140 degrees F. He indicated it had always been set that high as the staff sanitized the bed pans in these areas. On 2/25/11, at 10:20 AM, the facility 's water temperature logs were reviewed. The log indicated that maintenance checks the water temperatures in the clean and soiled utility areas one time weekly. The Immediate Jeopardy situation was identified on 2/23/11, at 10:12 AM, due to the hot water temperatures being above 130 degrees F in areas accessible to residents. E1, Administrator, was informed of the Immediate Jeopardy on 2/23/11, at 11:20 AM. The facility took the following actions to remove the immediacy: 1. On 2/23/11, the alarms were immediately replaced on all utility doors and checked for function. 2. On 2/23/11, staff were stationed on the 1st and 2nd floor utility doors until door locks could be installed. 3. On 2/23/11, locks were installed on all utility doors with keys hung at the top of door. 4. Floor supervisors will monitor doors to ensure that they are locked when no employee is in the utility rooms. B. Based on observation, record review, and interview the facility failed to assess, and provide for safe use of an air mattress overlay for one (R6) of seven residents at risk for falls. Findings include: R6 was admitted to the facility on [DATE] after sustaining a fractured right femur at home. R6 was admitted with a pressure ulcer and had an air mattress overlay on her mattress. On 2/23/11 at 9:50 AM, E7, Licensed Practical Nurse, LPN, and E8, Certified Nursing Assistant, CNA, were in the room to care for R6. R6 was on the bed, the air mattress overlay was unsecured to the mattress under her. As R6 was turned onto her left side, the air overlay mattress slid on the mattress. There were no siderails in place to prevent R6 from sliding out of bed. R6 called out, stating, "I almost fell out of bed. It makes me scared of falling. I can see the floor, need something to hang on to. Usually I'll grab the girls legs so I don't feel like I'm falling." E7, LPN, stated the facility "usually doesn't use siderails unless requested by the family". There were 1/2 siderails on the bed next to R6. E7, LPN, stated "She must have requested them and signed a release." On 2/23/11 at 11:45 AM, E2, Director of Nursing, stated she had checked the air mattress overlay, and had "made sure the flaps are tucked in and the air pump is at the foot of the bed." E2 provided the Operating Instructions for the Alternating Pressure Pad and Pump System. There were no safety instructions included, just set-up instructions. Z1, Account Manager for the equipment was interviewed by telephone on 3/1/11 at 9:15 AM. Z1 acknowledged he did not have specific safety instructions for the use of the air mattress overlay but stated, "I personally always suggest use of a siderail."