Every finding on record at Savoy Care Center

Based on observation, interview, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of activities based on comprehensive assessments, care plans and preferences for 3 (Resident #15, Resident #43, and Resident #70) of 33 sampled residents. This deficient practice has the potential to affect all 83 residents currently residing in the facility. Findings:Review of the facility's undated policy titled, Activities , read in part . The facility will provide an ongoing program of actives that support the interest and enhances the quality of life of each resident. Activities will be individualized based in resident assessments, preferences, and functional abilities. Procedure: 3. Implementations:Activities will be scheduled daily, including afternoon and weekendsPrograms will include group and individual activitiesResidents will be encouraged but not forced to participate Review of the facility's March 2026 activities calendar revealed the following scheduled activities in part . 03/23/2026 - 9:00 a.m. Coffee & Friends03/23/2026 - 9:30 a.m. Music Hour03/23/2026 - 10:00 a.m. Room Visits 03/23/2026 - 2:00 p.m. Hot Dollar/ Pretty Nails03/23/2026 - Serving Chips & Dip - National Chip & Dip Day!03/24/2026 - 9:00 a.m. Coffee & Friends03/24/2026 - 9:20 a.m. Music Hour03/24/2026 - 10:00 a.m. Body in Motion03/24/2026 - 2:00 p.m. Activity with Hospice03/24/2026 - 6:00 p.m. Bingo 03/25/2026 - 9:00 a.m. Coffee & Friends03/25/2026 - 9:30 a.m. Music Hour03/25/2026 - 10:00 a.m. Room Visits03/25/2026 - 2:00 p.m. Coffee & Cards on the Patio Resident #15 Review of Resident #15's medical record revealed an admission date of 04/12/2023 with diagnoses that included Chronic Obstructive Pulmonary Disease, Anemia, Morbid (Severe) Obesity Due To Excess Calories, Pulmonary Hypertension, Heart Failure, and Obstructive Sleep Apnea. Review of Resident #15's 01/21/2026 Quarterly MDS revealed a BIMS score of 15, indicative of intact cognition. Further review of MDS revealed Resident #15's reported Activity Preferences were very important to him. Review of Resident #15's Care plan revealed in part. Cognition: Cognitively intact per BIMS score. Interventions included in part. Encourage to participate in activities. In an interview on 03/23/2026 at 10:38 a.m., Resident #15 stated the activity director was never around. Resident #15 stated he likes to go to bingo but they only have it about once per week and he doesn't attend due to the inconsistent activity schedule In an interview on 03/24/2026 at 9:16 a.m., Resident #15 observed sitting in recliner. Observed March 2026 activities posted on wall in room, Resident stated You may see the activity director for 20 minutes. Resident #15 stated I use to go, but I got tired of sitting and waiting for activities to begin. Resident #43 Review of Resident #43's medical record revealed an admission date of 07/15/2023 with diagnoses that include Type 2 DM, Edema, HTN, Acute Embolism of Deep Veins of LUE, Pain, Primary Insomnia, Unspecified Psychosis, Bipolar disorder, Current Episode Manic Severe with Psychotic Features and Major Depressive Disorder, Recurrent Mild Review of Annual MDS Assessment with ARD 02/19/2026 revealed a BIMS score of 15 indicative of intact cognition. Further review of MDS revealed Resident #43's Activity Preferences were very important. Review of Resident #43's Care plan with a review date of 05/20/2026 revealed in part. Cognition: Cognitively intact per BIMS score with goal resident will follow orders per MD daily. Interventions included in part. Encourage to participate in activities. Focus of Activities: Involved in some activities with goal for Resident will continue to be involved in activities of choice. Interventions include in part. Beanbag /ring toss board games. ( Bingo, pokeno, checkers, etc.), determine feasibility of offering activities of interest to resident that are not currently offered, encourage resident to attend facility activities, post calendar in room and remind resident of activities by announcement prior to beginning. Resident #70 Review of Resident #70's medical record revealed an admission date of 08/04/2025 with diagnosis that include COPD, Chronic Atrial Fibrillation, Hyperlipidemia, MDD, recurrent, severe with psychotic symptoms, Bipolar disorder, HIV, Viral Hepatitis C, Extrapyramidal and movement disorder, Vitamin D deficiency, Thyroid disorder, Pain, Liver transplant status, GERD, Enlarged prostate, Insomnia, Dementia and Hypertensive Heart Disease.Review of Resident #70's Quarterly MDS with ARD revealed a BIMS score of 11 indicating moderate cognitive impairment. Review of Resident #70's admission Comprehensive MDS Assessment with ARD 08/13/2025 revealed a BIMS score of 12, indicative of moderate cognitive impairment. Further review of Resident #70's MDS revealed Resident #70's Activity Preferences were very important. Interview on 03/24/2026 at 3:00 p.m. with Resident #70 revealed no activities for the mornings. Resident #70 revealed we have been waiting for a body building exercise activities in the morning but have not had it yet. Interview on 03/23/2026 at 3:21 p.m. with Resident #43 revealed staff did not have morning activities scheduled. Resident #43 revealed would like to be have more activities offered. Observation on 03/24/2026 at 9:25 a.m. of Resident #43 awake sitting in his recliner in his bedroom. Interview at this time with Resident #43 revealed a volunteer from hospice played bingo yesterday afternoon on the north dining area. Resident #43 revealed he likes playing Bingo but would like to play more often. 03/24/2026 09:30 am Observation of North dining area where activities are held revealed no activities occurring, no residents or staff noted in area Interview on 03/24/2026 at 9:50 a.m. with S15 CNA revealed she used to be the Activity Director. S15 CNA stated she now usually works as CNA on the North hall on the 2-10 p.m. shift but filling in today for S9 Activity Director. S15 CNA revealed S9 Activity Director left early yesterday and out again today. S15 CNA revealed she had not received any instructions and did not know about the activity 'body in motion' on the activity schedule. Interview on 03/24/2026 at 9:55 a.m. with S16 CNA Transportation revealed she recalls the last outing was around Christmas for lights in Church Point and ice cream at Wendy's. S16 CNA Transportation revealed S9 Activity Director does meal of the month. S16 CNA Transportation revealed that sometimes S9 Activity Director does bingo but it is mostly led by volunteer hospice staff. Telephone interview on 03/24/2026 at 10:06 a.m. with S9 Activity Director accompanied by S15 CNA's cell phone revealed the 'body in motion' activity had not been done yet. S9 Activity Director hung up abruptly and ended the telephone call. Interview on 03/24/2026 at 10:08 a.m. with S15 CNA revealed she did not do activity, 'music hour' this am at 9:30 a.m. because she was doing pretty nails on north hall. She stated she did 5 resident's nails this morning. Observation on 03/24/2026 at 10:15 a.m. of utility cart in the activity room revealed with 6 bags of chips and 4 jars of assorted dips unopened. Interview at this time with S16 CNA Transportation revealed she shares the activity office with S9 Activity Director. S16 CNA Transportation revealed the chips and dips were supposed to be served yesterday for the residents for the activity Chips and Dips as noted on the activity schedule, but was not done. Interview on 03/24/2026 at 10:20 a.m. with S14 CNA Supervisor revealed she was not aware of an activity called 'body in motion' and had not seen the activity provided for the residents. S14 CNA Supervisor further revealed the volunteers of hospice usually do the Bingo activities. Interview on 03/24/2026 at 11:15 a.m. with S8 Administrator revealed she is aware of the ongoing issues with S9 Activity Director and the residents' complaints in reference to activities. S8 Administrator revealed she had initiated a Plan of Improvement for S9 Activity Director who had to leave early yesterday and was not here today to review it with her. S8 Administrator reported S9 Activity Director had to leave yesterday due to a family emergency. S8 Administrator revealed the activities posted on the board and schedule state that activities are subject to change. In an interview on 03/25/2026 at 8:53 a.m., S14 CNA Supervisor stated, That's not my job; She was not here, she is never here, she is the DON's daughter referring to S9 Activity Director; That is her sister (S15 CNA walking down the hall), she is a night CNA but they have her filling in because S9 Activity Director is not here. Observation on 03/25/2026 at 9:28 a.m. of residents in the south dining area drinking coffee and listening to music. Interview at this time with S15 CNA revealed she was filling in for and working as the Resident Activity Director again today due to S9 Activity Director called in again today. S15 CNA revealed this is the first time doing this activity 'Coffee & friends' and confirmed it was not done yesterday, but should have been. Interview on 03/26/2026 at 11:30 a.m. with S8 Administrator revealed S9 Activity Director had not been here this week, called in again this morning, and she was unable to counsel her in regard to her Improvement Plan. S8 Administrator revealed that S9 Activity Director would be terminated. S8 Administrator confirmed that activities should have been provided for the residents, but was not.

Based on interviews and record review, the facility failed to ensure a resident's medical record was complete and accurate by failing to ensure administration of narcotics were properly documented on the narcotic record for 2 (Cart A & Cart B) of 2 medication carts reviewed during the medication storage facility task. Findings:Review of the Controlled Substances facility policy dated 01/15/2026 revealed the following in part: Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances. 7. The charge nurse who administers the prescribed narcotic will immediately document it on the medication administration record and the controlled drug administration record.Medication Carts A and B were observed and narcotics were counted and compared to narcotic records for both carts with S5 LPN present on 03/25/2026 at 2:15 p.m. The following discrepancies were found:Record Review revealed Medication Administration Record (MAR) for March 2026 for Resident #36 dated March 25, 2026 revealed in part-----Hydrocodone/APAP 10-325 mg given at 08:48 a.m. by S5LPN. Medication administration was not signed by nurse on the narcotic record when reviewed at 02:20 p.m. on 03/25/2026. Review of Resident #36 Hydrocodone/APAP 10-325 mg tab 1 PO q 4 hours prn pain breakthrough Narcotic records revealed in part . amount received/remaining 19, but there were 18 tablets remaining on the medication card.2. Review of Resident #67 Gabapentin 600 mg tab 1 PO TID Narcotic records on 03/25/2026 at 2:21 p.m. revealed in part . amount received/remaining 38, but there were 39 tablets remaining on the medication card.3. Review of Resident #79 Lorazepam 1 mg 1 PO q 6 hours. Narcotic records revealed in part . amount received/remaining 30, but there were 29 tablets remaining on the medication card (S5 LPN documented on the narcotic record at 2:25 p.m., given at 11 a.m.)4. Review of Resident #30 Gabapentin 300 mg cap 1 PO TID Narcotic records revealed in part . amount received/remaining 30, but there were 29 capsules remaining on the medication card.5. Record Review revealed Medication Administration Record (MAR) for March 2026 for Resident #4 dated March 25, 2026 revealed in part Oxycodone w/ Acetaminophen Tab 10-325 MG Give 1 tablet by mouth four times a day related to pain, unspecified given at 11:00 a.m. by S5 LPN. Medication was not signed out by nurse at narcotic record review at 02:20 p.m. Resident #4 Oxycodone APAP 10/325 mg 1 PO every 6 hours Narcotic records revealed in part . amount received/remaining 21, but there were 20 tablets remaining on the medication card.6. Resident #25 Gabapentin 800 mg take 1 tab PO TID Narcotic records revealed in part . amount received/remaining 7, but there were 6 tablets remaining on the medication card.7. Resident #46 Lacosamide 100 mg take 1 tab PO BID Narcotic records revealed in part . amount received/remaining 17, but there were 16 tablets remaining on the medication card.8. Resident #56 Clonazepam 0.5 mg tab 1 per tube TID Narcotic records revealed in part . amount received/remaining 12, but there were 11 tablets remaining on the medication card.In an interview on 03/25/2026 at 2:15 p.m., S5 LPN stated she gave the medications, but did not document it on the Narcotic Record.In an interview on 03/25/2026 at 2:24 p.m., S1 DON confirmed nurses should document narcotics on the Narcotic record at the time they are administered.

Based on observation, interview and record review, the facility failed to ensure the comprehensive plan of care was reviewed and revised to include nursing interventions implemented for a client with behaviors that required increased supervision and monitoring of behaviors for 1 resident (Resident #61) of 33 sampled residents. Findings:Review of the facility's revised policy dated March 2022 titled, Care Plans, Comprehensive Person-Centered read in part. Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident #61's medical record revealed an admission date of 01/15/2025 with diagnoses that include Unspecified Dementia, Unspecified Severity with other Behavioral Disturbances, Insomnia, Depression, Alcohol Abuse, in Remission, General Anxiety Disorder and Schizophrenia. Review of Resident #61's Annual MDS with an ARD of 01/14/2026 revealed a BIMS score of 00, indicating severe cognitive impairment. Further review of Resident #61's MDS Behaviors section revealed Resident #61 did not exhibit behaviors in reference to pacing and wandering. Review of Care plan with review date of 04/15/2026 in part .I have cognitive impairment: Diagnosis of Dementia with other behavioral disturbances, Impaired ability to understand others; episodes of disorganized thinking, episodes of inattention impaired judgement/ Impaired Safety awareness. Goal for Resident's needs will be anticipated/met by staff and dignity maintained. Interventions included in part. Assess cognitive deficits or behaviors that interfere with forming relationships with others, avoid an over-stimulating environment, and redirect the resident when behaviors become socially unacceptable. Further review of Resident #61's Care plan revealed no documentation of interventions initiated on 02/14/2026 that included to increase supervision to 1:1 related to resident's behaviors and required close monitoring. Review of Resident #61's Incident Report dated 2/14/2026 at 5 p.m. by S2ADON read in part. Noticed resident wandering into other resident's room down hallway. Redirected twice. Notified DON. Initiated q1hour checks on resident. Daughter aware. Redirection frequently needed. Review of Resident #61's Close Monitoring: Every 15 Minutes documentation dated 02/14/2026 at 5:00 p.m. and Close Monitoring: Every 1 Hour dated 02/17/2025 at 5:00 p.m. through current date and ongoing. Observation on 03/24/2026 at 8:50 a.m. of Resident #61 lying in bed with eyes closed and S11CNA sitting at bedside table in bedroom. Interview at this time with S11CNA revealed she is expected to monitor and document on Resident #61 every hour because started combative behaviors and going into other resident's rooms. Interview on 03/25/2026 at 8:55 a.m. with S10MDS revealed Resident #61 had an incident where he was wandering in other residents' rooms on Valentine's Day. S10MDS revealed she was out on vacation during this time. S10MDS revealed Resident #61 was then placed on 1:1 supervision/ Q1Hour Checks as a nursing intervention. S10MDS confirmed she had not updated or revised his care plan because the order for Resident #61 to place on 1:1 supervision/ Q1Hour Checks was not a physician's order. Interview on 03/25/2026 at 2:30 PM with S1DON revealed she and the MDS nurse were responsible for updating or revising residents' care plans. S1DON revealed Resident #61 did not have a physician's order for increasing monitoring to 1:1 supervision/ Q1Hour Checks after the incident that occurred on 02/14/2026. S1DON revealed it was initiated as a nursing intervention for his behaviors and safety and did not have a physician's order. S1DON confirmed she did not update Resident #61's care plan to include interventions of resident being placed on 1:1 supervision due to his behaviors and wandering in other resident's rooms.

Based on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #59 & Resident #60) of 33 sampled residents, by failing to:1. Promote resident dignity by providing a bedpan per the resident request for Resident #60.2. Promote resident dignity by providing disposable dishware for Resident #59 in the dining room. Findings: Resident #60 Record review of facility policy Resident Rights reads in part . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. On 03/25/2026 at 8:59 a.m. observation revealed Resident #60 lying in bed requesting bed pan. Surveyor assisted resident with pressing call light, per resident request. S6 CNA entered room shortly and stated resident has on a diaper and is not able to get up at this time due to left side weakness due to stroke; S6 CNA said she can go in her diaper. On 03/25/2026 at 10:48 a.m. an interview with S7 COTA revealed on 03/24/2026 therapy recommended Resident #60 use a bedpan and removed the bedside commode from her room. S7 COTA stated Resident #60's left arm is flaccid and requires maximum assistance of 2 people. S7 COTA stated Resident #60 does not want to use a diaper and I don't blame her. S7 COTA stated she told the wound care nurse on 03/24/2026 the resident was able to use bedpan. An interview on 03/25/2026 at 11:02 a.m. with S1 DON, S2 ADON, and S8 Administrator confirmed the CNA should have offered Resident #60 the bedpan. S2 ADON stated, We will in-service staff. Resident #59 Review of Resident #59's medical record revealed an admit date of 12/12/2024 with diagnoses that included in part: Vascular Dementia, Entercolitis due to Clostridium Difficile, Hyperlipidemia, Heart Failure, and Depression. Review of Resident #59's quarterly MDS with an ARD of 02/19/2026 revealed Resident #59 had a BIMS score of 9, indicating moderately impaired cognition. Review of a Physician Order for single room isolation with contact precautions was discontinued on 02/17/2026. On 03/23/2026 at 11:20 a.m., Observation revealed Resident #59 received her lunch meal tray on disposable dishware while seated in the dining room. On 03/23/2026 at 11:22 a.m., interview with S2ADON revealed Resident #59 had previously been placed on contact & isolation precautions and received meals on disposable dishware. S2ADON confirmed Resident #59 was no longer on contact precautions and should not have received meals on disposable dishware.

Based on observation, interview, and record review, the facility failed to ensure a resident received a reasonable accommodation of their needs by failing to ensure the call light was accessible to a resident for 1 (Resident #3) of 33 sampled residents.Review of a facility policy dated 01/16/2026, titled Answering the Call Light revealed in part. The purpose of this procedure is to respond to the residents needs and request. 5. When the resident is in bed or confined to a chair be sure the call light is within easy each of the resident.Review of Resident #3's medical record revealed an admission date of 12/07/2023, with diagnoses that included, in part, Moneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease. Review of Resident #3's Quarterly MDS with an ARD 03/03/2026 revealed Resident #3 had a BIMS of 6, indicating severe cognitive impairment. Resident required set up assistance with eating, dependent for toileting hygiene and personal hygiene, and required substantial/maximal assistance to roll left to right.An observation on 03/24/2026 at 10:12 a.m. revealed Resident #3 lying in his bed, resting with his eyes closed. Resident #3's call bell was observed on the floor on the right side of the bed, not within reach of the resident.An observation/interview on 03/24/2026 at 12:24 p.m. revealed that Resident #3 was sitting up in bed, awake and alert. Resident #3's call bell was observed on the floor on the right side of the bed and not within reach of the resident. Resident #3 revealed he could not reach his call bell.An interview on 03/24/2026 at 12:45 p.m. with S4CNA revealed she was familiar with Resident #3 and the care he required. S4CNA stated Resident #3 can express his wants and needs with short responses and utilizes his call bell.On 03/24/2026 at 12:48 p.m., an observation was made of Resident #3 in his room with S4CNA. Observation revealed Resident #3's call bell was on the floor on the right side of the bed and not within reach of the resident. S4CNA confirmed Resident #3's call bell was not within reach for the resident and should have been. An observation on 03/24/2026 at 1:41 p.m. revealed that Resident #3 was in his room, awake and alert, in a reclined position in his Geri chair. Resident #3's call bell was observed hanging on the side of the bed, out of reach for the resident.An observation on 03/24/2026 at 3:00 p.m. revealed Resident #3 in his room, awake and alert, in a reclined position in his Geri chair. Resident #3's call bell was observed hanging on the side of the bed, not within reach for the resident. S1DON present in Resident #3's room at this time. S1DON confirmed the call bell was not within reach for Resident #3, and should have been.

Based on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #84) of 33 sampled residents. Findings:Review of Resident #84's electronic health record revealed an admission date of 10/06/2023 with diagnoses which included: Dementia, Depressive Disorder, Anxiety, Polyneuropathy, Peripheral Vascular Disease, Repeated Falls, and Mild Cognitive Impairment. Review of Resident #84's Quarterly MDS with an ARD of 12/25/2025 revealed a BIMS score of 6, indicating moderate cognitive impairment. Resident #84 required substantial to maximal assistance with transfers. Review of a task in Resident #84's electronic medical record, initiated on 02/15/2026, revealed Resident #84 required transfer using a Hoyer lift with two-person assist. Review of Resident #84's comprehensive care plan dated 02/04/2026 revealed Resident #84 required transfer using a Hoyer lift with two-person assist. On 03/23/2026 at 1:35 p.m., observation of S12CNA and S13CNA revealed staff exited Resident #84's room without a Hoyer lift. Interview with S12CNA confirmed that staff were providing incontinent care and did not utilize a lift for the transfer. S12CNA confirmed Resident #84 should have been transferred utilizing a Hoyer lift, but was not. On 03/23/2026 at 1:52 p.m., interview with S13CNA confirmed she assisted S12CNA in providing incontinent care to Resident #84. S13CNA confirmed Resident #84 should have been transferred back to bed utilizing a Hoyer lift, but was not. On 03/25/26 at 1:54 PM, interview with S1DON confirmed Resident #84's care plan read in part. Resident #84 required transfers utilizing a Hoyer lift with a two-person assist. S1DON acknowledged that S12CNA and S13CNA did not utilize a Hoyer lift when transferring Resident #84, but should have.

Based on record review and interview the facility failed to obtain laboratory services as ordered by a physician to meet the needs of its residents for 1 (#2) of 5 (#1, #2, #7,#10, and #11 ) residents reviewed for unnecessary medications.Findings: Review of the Facility's undated policy titled Lab and Diagnostic Test Results- Clinical Protocol read in part.1. Thy physician will identify and order diagnostic and lab testing based on the residents diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for the test. Review of Resident #2's medical record revealed an admission to the facility on [DATE] with the following Diagnoses: Cerebral infarction, Dysarthria, Type 2 Diabetes, Congestive Heart Failure, Hypothyroidism, Hypertensive Heart Disease, and Cirrhosis of Liver. Review of Resident #2's medical record revealed a TSH lab completed 01/22/2026 with a hand written order at the bottom of the page that read in part . repeat TSH in 4 weeks. Review of Resident #'2 03/2026 Physician Orders revealed in part.01/26/2026-Repeat TSH (Thyroid Stimulating Hormone) level in 4 weeks. Review of Resident #2's medical record revealed no TSH lab draw was collected since 01/21/2026. An interview on 03/26/2026 at 9:15 a.m., S17 Unit Secretary stated that she manages most of the labs not given an order for Resident # 2's TSH to be drawn in 02/2026 and confirmed with the lab that the TSH was not drawn or collected in 02/2026. An interview on 03/26/2026 at 9:28 a.m., S1 DON confirmed that Resident #2's TSH lab had been overlooked and had not been collected in 02/2026, but should have been.

Based on observation, interview, and record, the facility failed to ensure that the mattress was compatible with the bedframe for 1 (Resident #3) of 33 sampled residents.Review of Resident #3's medical record revealed an admission date of 12/07/2023, with diagnoses that included, in part, Myoneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease.Review of Resident #3's Quarterly MDS with ARD 03/03/2026 revealed Resident #3 had a BIMS of 6, indicating severe cognitive impairment.On 03/23/2026 at 11:39 a.m., observation revealed Resident #3 lying in bed with his feet hanging off of his mattress. Resident #3's mattress appeared to be too small for the bed frame.On 03/24/2026 at 10:12 a.m., an observation revealed Resident #3 lying in bed, positioned on his back with his head elevated. The resident's air mattress was observed not to fit the bed frame properly. There was approximately a 1-foot gap between the top of the bedframe and the head of Resident #3's mattress. Resident #3's head was partially above the mattress.On 03/24/2026 at 12:48 p.m., S4CNA was present at Resident #3's bedside. S4CNA confirmed that Resident #3's air mattress in place did not fit the bed frame properly. There was approximately a 1-foot gap between the top of the bedframe and the head of Resident #3's mattress. Resident #3's head was partially above the mattress. S4CNA revealed that if she pulled the resident and the mattress up in the bed, there would be a gap at the foot of the resident's bed between the air mattress and the footboard.On 03/24/2026 at 1:00 p.m., S2ADON was present at Resident #3's bedside. S2ADON confirmed Resident #3's mattress was not accommodating to Resident #3's height and should be.On 03/24/2026 at 3:00 p.m., observation of Resident #3 at this time with S1DON revealed Resident #3 in his room, reclined in a Geri chair. Observation of the resident's bed with S1DON at this time revealed that the air mattress on the bed was approximately 1 foot smaller than the bedframe. S1DON confirmed the resident's bed is not accommodating the resident and should be. S1DON confirmed that Resident #3's mattress does not fit the bedframe properly, but should.

Based on record review, observation, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure:1. A fall mat was in place as ordered and care planned for Resident #1, and2. Physician's orders for increasing water flush for Resident #3, who received feeding and hydration via PEG (Percutaneous Endoscopic Gastrostomy), was followed. Findings:Resident #1Review of Resident #1's electronic medical record revealed an admit date of 06/06/2025 with diagnoses that included in part: Encephalopathy, Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Generalized Anxiety Disorder, Alcohol Abuse Uncomplicated, and Major Depressive Disorder Recurrent with Psychotic Symptoms. Review of Resident #1's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/18/2025 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3, which indicated Severe Cognitive Impairment. Resident #1 was dependent on staff for all self-care and transfers. Review of Resident #1's Active Physician Orders revealed an order initiated 07/22/2025 for Fall Mat every shift. Review of Resident #1's Care Plan revealed the resident was at risk for falls related to impaired mobility with an intervention that read in part. 07/18/2025 resident found on floor by bed. Fall Mat initiated. On 07/28/2025 at 11:25 a.m., observation revealed that a fall mat was not in place in Resident #1's room.On 07/28/2025 at 11:45 a.m., S3ADON acknowledged Resident #1 did not have a fall mat at his bedside and confirmed he should have. Resident #3Record Review revealed Resident #3 was admitted to the facility on [DATE], and had the following diagnoses in part. Aphasia following Cerebral Infarction, Unspecified Protein-Calorie Malnutrition, and Encounter for Attention to Gastrostomy.Record Review of Resident #3's annual MDS with ARD of 07/16/2025 BIMS score was not assessed due to resident condition. Resident #3 was dependent on staff for Eating, and all ADL (Activities for Daily Living) care. Resident #3 had a feeding tube. Record Review of Resident #3's Departmental Progress Notes read in part.07/29/2025 1:36 p.m. S1DON documented: RD (Registered Dietician) seen Resident #3 yesterday (07/28/2025) and made recommendations for increasing free water flush to 40ml/hr.07/29/2025 11:00 p.m. S4LPN documented: Peg tube placement verified, patent and intact. No residual noted. Has formula isosource at 35ml/hour and Water at 30ml/hour in progress to peg per pump.Record Review of Resident #3's 07/2025 active physician orders read in part.Enteral Feed every shift isosource at 35ml/hr with 40ml/hr water flushes per e-pump. Start date: 07/29/2025Observation on 07/30/2025 at 8:35 a.m. of Resident #3 revealed she received feeding and hydration per PEG tube via pump. The tube feeding bag was labeled isosource and was programmed at 35ml/hr. The water flush was programmed at 30ml/hr. Observation on 07/30/2025 at 11:11 a.m. Resident #3 revealed she received feeding and hydration per PEG tube via pump. The tube feeding bag was labeled isosource programmed at 35ml/hr. The water flush was programmed at 30ml/hr. Observation on 07/30/2025 at 12:25 p.m. of Resident #3 and Interview with S2LPN confirmed Resident #3's water flush should be set at 40ml/hr, but was set at 30ml/hr. S2LPN stated the RD recommended an increase for Resident #3's water flush and confirmed the settings should have been changed when the order was put in on 07/29/2025, but had not. Interview on 07/30/2025 at 12:30 p.m. with S1DON revealed the facility had a standing order from the Medical Director to follow RD recommendations for all Residents who receive tube feedings. S1DON stated on 07/29/2025 the RD increased Resident #3's water flush to 40ml/hr from 30/hr, and confirmed that when the order was put in, nursing staff should have increased the water flush settings. S1DON confirmed nursing staff should have checked pump settings on 07/29/2025 night shift, and 07/30/2025 morning shift to ensure Resident #3 received the correct feeding and water flushes, but had not.

Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice by failing to ensure a resident's Medical Director was notified of Registered Dietician recommendation in a timely manner for 1 (#2) of 6 (#1, #2,#3, #4,#5, and #6) sampled residents. Findings: Review of the facility's undated policy titled Weights read in part The Registered Dietician will complete the dietician recommendations and or/dietician noted at her discretion. The notes will be given to the DON for nursing staff to send to the physician for review and follow-up. Review of Resident #2's medical record revealed an admit date of 02/06/2025 with diagnoses that included in part .Supraventricular Tachycardia, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Cardiac Pacemaker, Aphasia following Cerebrovascular Disease and Chronic Atrial Fibrillation. Review of Resident #2's 03/2025 Physician Orders read in part . 02/06/2025 -Isosource hn at 50cc/hr per pump with water flushes at 30 cc/hr per feeding pump. Review of Registered Dietician note dated 02/18/2025 read in part Recommendations: 1. Change tube feeding to Jevity 1.2 @50cc/hr with 47cc/hr of free H20. This will provide 1440 kcal, 2096cc free H2o and 67 grams of protein. 2. To meet protein goals: 30 cc liquid protein per peg twice daily. Interview on 06/11/2025 at 2:55 p.m. with S1 ADON revealed that once the registered dietician makes recommendations they are sent to the MD for approval via fax or phone. S1 ADON stated the recommendations are kept in a box in the nurses' station and a follow up fax/calls are made until the MD responds. S1 ADON stated the facility did not get a response in regards to the Registered Dietician recommendations for Resident #2 until 03/05/2025, after Resident #2 had passed away in the hospital. Interview on 06/11/2025 at 1:33 p.m. with Resident #2's medical director stated that he could not recall receiving the registered dietician recommendation for Resident #2, but that didn't mean he didn't receive them. Interview on 06/11/2025 at 3:46 p.m. with S1 ADON confirmed that the registered dietician's recommendation to change tube feeding from Isosource hn at 50cc/hr with 30cc/hr H2o flush to Jevity 1.2 at 50cc/hr with 47cc/hr of free H2O dated 02/18/2025 and add 30 cc liquid protein per peg twice daily were faxed over to Resident #2's medical director's office on 02/18/2025. S1 ADON confirmed the facility failed to follow up via telephone after not receiving correspondence from the medical director until 03/05/2025, but should have.

Based on interview and record review the facility failed to ensure that all alleged violations involving verbal, sexual, physical,and/or mental abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse, or not later than 24 hours if the events that cause the allegation do not involve abuse in accordance with State law through established procedures, for 3 (#6, # 15, and #51) of 3 (#6, # 15, #51) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/16/2025, when S4 CNA yelled and cursed Resident #15, and made her go to bed; on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies; and on 03/08/2025 at approximately 4:20 p.m., when Resident #25 pulled Resident #6's hair. The facility failed to report the above staff to resident verbal abuse, and resident to resident abuse, to the State Agency. The deficient practice has the likelihood to affect all other residents who reside in the facility. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 03/27/2025 at 5:56 p.m. Findings: Resident #15 Review of Resident #15's medical record revealed she was admitted to the facility on [DATE]. Resident #15 had diagnoses that included in part . Chronic Pain Syndrome, Major Depressive Disorder, Anxiety Disorder, Parkinson's Disease, Spinal Stenosis, and Other Lack of Coordination. Review of Resident #15's Quarterly MDS with ARD of 01/08/2025, revealed a BIMS score of 15 (cognition intact). Resident #15 had range of motion impairment on both sides, and was dependent on staff for toileting, showering/bathing, and dressing. Review of Resident #15's care plan with an initiation date of 12/18/2024, revealed Resident #15 had a problem of impaired physical mobility related to Parkinson's disease. Interventions included in part . 2 person assist, transfer with mechanical lift. Interview of Resident #37 during the Resident Council meeting on 03/24/2025 at 1:32 p.m., revealed. Resident # 37 stated that S4 CNA made Resident #15 stay in bed and refused to get Resident #15 up, per Resident #15's request. S4 CNA then yelled at Resident #15. Interview on 03/24/2025 at 3:05 p.m. with Resident #15, revealed on 02/16/2025 she was seated in her wheelchair in her room, and S4 CNA came into her room to put her to bed. Resident #15 said she stated to S4 CNA that she did not want to go to bed, and that S4 CNA then became upset. Resident #15 stated S4 CNA came at me, and I saw her pull a girl's hair once, so I was afraid of her. Resident #15 stated S4 CNA used an ugly tone with her. Resident #15 stated she directly reported the incident, and how she was afraid of S4 CNA to S1 Administrator on 02/17/2025. Resident #15 reported S1 Administrator asked her if she was afraid of S4 CNA, to which she replied yes. Resident #15 revealed S1 Administrator stated she would take care of the situation, and that S4 CNA would not provide care to her anymore. Resident #15 stated S1 Administrator moved S4 CNA from Hall Y to Hall Z, and S4 CNA had not provided care to her since. Review of Resident #15's medical record revealed no evidence that the alleged staff to resident abuse of Resident #15 by S4 CNA had been reported to the State Agency. Interview on 03/25/2025 at 11:30 a.m. with S1 Administrator, revealed last month Resident #15 reported that she was upset that S4 CNA put her back to bed when she (Resident# 15) did not want to go to bed. S1 Administrator stated Resident #15 reported this as a grievance to S2 DON. S1 Administrator revealed Resident #15 had never at any point in time informed her that she was afraid of S4 CNA, and denied Resident #15 reporting any abuse allegations to her. S1 Administrator revealed S2 DON moved S4 CNA to another hall due to Resident #15 not wanting S4 CNA to care for her again. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed there was no SIMS or facility incident report related to the allegations. S1 Administrator stated that the facility had completed a written grievance; however, S1 Administrator was unable to state how the facility addressed Resident #15's grievance. Telephone interview on 03/25/2025 at 3:56 p.m. with S4 CNA, revealed she was paged to the nurses station by S13 LPN on 02/16/2025, and S13 LPN asked her to put Resident #15 to bed, because Resident #15 was not feeling well. S4 CNA stated Resident #15 stated she did not want to go to bed, but she and S15 CNA convinced Resident #15, and they transferred her 2 person assist with a mechanical lift to bed. Interview on 03/26/2025 at 3:10 p.m. with Resident #37 (BIMS score of 15-indicating cognition intact), revealed she was fearful of S4 CNA. Resident #37 began to cry and revealed she was fearful because S4 CNA screamed and cursed at Resident #15. Resident #37 revealed on 02/16/2025, she heard S4 CNA screaming at Resident #15 from the nursing station, so she went down the hall to Resident #15's room, and witnessed S4 CNA yelling and cursing at Resident #15. Observation and Interview on 03/26/2025 at 3:20 p.m. with Resident #15 and Resident #37 revealed Resident #15 stated S4 CNA yelled at her on 02/16/2025, and said You stupid piece of sh*t, you're going to do what I say, and you're going to get in that bed! Resident #37 stated at that time that she heard S4 CNA yell at Resident #15 and say, You stupid piece of sh*t, you're going do what I say, and you're going to get in that bed! Resident #15 began to cry during the interview, and stated yes that is exactly what S4 CNA said to me! I don't like to use profanity, she hurt my feelings. Interview on 03/27/2025 at 8:43 a.m. with Resident #15, revealed she informed S1 Administrator of her exact concerns with S4 CNA, and reported to S1 Administrator that S4 CNA yelled and used profanity at her, made her go to bed, and grabbed her ankle and arm. Resident #15 stated S1 Administrator revealed she would take care of things. Resident #15 stated S4 CNA made me afraid and I just want to forget the whole incident, because it made me question if I made the right choice in moving here. Resident #15 stated she has often thought about going home since the incident with S4 CNA. Resident #25 Review of Resident #25's medical record revealed Resident #25 was admitted to the facility on [DATE]. Resident #25 had diagnoses that included in part . Traumatic Subarachnoid Hemorrhage, General Anxiety Disorder, Bipolar Disorder, Weakness, Generalized Muscle Weakness, Depression, and Anxiety. Review of Resident #25's Quarterly MDS with an ARD 02/20/2025, revealed Resident #25 had a BIMS score of 00 (severe cognitive impairment). Review of Resident #25's Care Plan with a problem initiation date of 12/24/2024, revealed in part . Potential for verbally aggressive behaviors due to a history of delusions and verbal aggression secondary to Bipolar disorder; Depressed Severe, with psychotic features; Depression; Anxiety Disorder. Interventions: 02/21/2025, Resident got into an altercation with another resident. S2 DON contacted psychiatrist, a medication review was done, and medication adjustment was ordered. Psychiatrist made aware of resident being manic. Review of Resident #25's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:37 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Interview on 03/25/2025 at 10:30 a.m. with S5 CNA Supervisor, revealed there was an incident between Resident #25 and Resident #6 one day last month (date unknown). Resident #25 became mad and aggressive, and pulled Resident #6's hair. S5 CNA Supervisor stated Resident #6 became very upset and told Resident #25 What's the matter with you? Don't do that! and went to her room crying. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON, confirmed last month Resident #25 pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, and confirmed the facility had not reported the resident to resident abuse to the State Agency. Resident #51 Review of Resident #51's medical record, revealed Resident #51 was admitted to facility on 03/27/2024. Resident #51 had diagnoses that included in part . Bipolar Disorder, Paranoid Schizophrenia, Chronic Kidney Disease, Pain, and Major Depressive Disorder. Review of Resident #51's Annual MDS with an ARD of 12/18/2024 revealed a BIMS score of 15 (cognition intact). Review of Resident #51's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:28 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. Interview on 03/27/2025 at 8:32 a.m. with Resident #51, revealed sometime last month (unknown date), Resident #25 came into the dining room acting mad, and hit her in the face with a box of cookies. Resident #51 stated that made me mad and upset me, but she did not hurt me. She's just mean! Telephone interview on 03/28/2025 at 11:53 a.m. with Resident #51's RP confirmed the facility had called him last month to inform him another Resident had hit Resident #51 with a box of cookies. S16 LPN was unavailable for interview at time of survey. Interview on 03/27/2025 at 11:00 a.m. with S2 DON, revealed the incident was not reported to the State Agency because she was not aware of the resident to resident altercation between Resident #25 and Resident #51 on 02/21/2025. Resident #6 Review of Resident #6's medical record, revealed Resident #6 was admitted to facility on 10/14/2024. Resident #6 had diagnoses that included in part . Depression, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #6's Quarterly MDS with an ARD of 01/22/2025, revealed a BIMS score of 6 (severe cognitive impairment). Review of Resident #6's Departmental Progress Notes revealed in part . On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Telephone interview on 03/26/2025 at 12:31 p.m. with S14 CNA, revealed she worked the 2:00 p.m. - 10:00 p.m. shift on 03/08/2025 on Hall Y. S14 CNA stated she was working in another resident's room, and Resident #46's RP came to the room to tell her that Resident #25 and Resident #6 were fighting. S14 CNA stated that she did not witness the incident, but Resident #46's RP did, and she immediately reported the incident to S12 LPN. Interview on 03/24/2025 at 1:04 p.m. with S1 Administrator confirmed the facility had no reportable incidents, and no submission to the State Agency since last survey on 06/12/2024. The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. as confirmed by onsite verification through observations, interviews and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to survey exit that included the following: The facility identified 4 instances of abuse/neglect in the facility: 1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15; 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51; 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6; and These instances have the ability to affect all residents that reside in the facility. The facility implemented the following actions to remove the immediacy: On 03/27/2025 at 5:56 p.m. all current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained. On 03/28/2025 at 6:00 a.m. all on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift. The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months. Facility completion date 03/28/2025.

Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 (Resident #6, Resident # 15, Resident #25, Resident #51, and Resident #68) of 34 Sampled Residents. The facility failed to: 1. Protect and ensure Resident #15 was free from verbal abuse and psychosocial harm by S4 CNA; 2. Ensure Resident #51 and Resident #6 were free from resident to resident physical abuse by Resident #25; 3. Ensure Resident #68 was free from neglect by S6 CNA; 4. Have an effective system in place to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made for Resident #6, Resident # 15, and Resident #51; and 5. Have an effective system in place to ensure allegations of abuse and neglect were thoroughly investigated for Resident #6, Resident # 15, Resident #51, and Resident #68. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. Resident #51 stated this made her mad. The Immediate Jeopardy continued on 03/08/2025 at approximately 4:20 p.m., when Resident #25 (who exhibited aggressive and angry behavior on day of the incident), pulled Resident #6's hair. The Immediate Jeopardy continued on 03/25/2025 at 2:25 p.m., when S6 CNA was observed to willfully transfer Resident #68 without the required 2 person physical assist with mechanical lift; although she was knowledgeable that 2 person assist with mechanical lift was required of Care. The deficient practice has the likelihood to affect all other residents who reside in the facility. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 03/27/2025 at 5:56 p.m. Findings: Cross reference F600, F609, and F610. Review of a facility policy on 03/26/2025 at 12:39 p.m., titled Abuse Prevention, with revision date of 03/21/2012, read in part . Each resident shall remain free from harm. Abuse - the ill treatment or disregard of an individual, whether purposeful, or due to carelessness, inattentiveness or omission of the perpetrator Emotional Abuse - any threatening behavior or statement directed to a person including, but not limited to ridicule, gestures that subject the person to humiliation or degradation, threatening motions or noises intended to startle or frighten the person. Physical Injury - an act that physically hurts or damages an individual's body where damage is inflicted by external force. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An intentional act of omission by an employee which denies the standard of care and treatment due to an individual as required by law, rules, regulations, policies, procedures, guidelines or care plans. Physical Abuse - any physical motion of action, e.g. hitting, spitting, slapping, punching, kicking, pinching, directed toward the individual . Threat- any condition or situation that could cause or result in severe, temporary or permanent injury or harm to the mental or physical condition of individuals or their death. Verbal Abuse - use of oral, written, or gestured language by which abuse occurs. Includes: Name calling, swearing., taunting, and using derogatory terms to describe persons with disabilities. Psychological Abuse - includes: humiliation, harassment, threats of punishment or deprivation, sexual coercion, and intimidation. If alleged abuse occurs staff will: Take immediate action to protect the individual(s) involved including removal of the alleged abuser. Ensure that any health or psychological needs of the resident are provided for. Notify the DON immediately. Review of a facility policy on 03/25/2025 at 4:16 p.m., titled Abuse and Neglect-Clinical Protocol, with revision date of 01/01/2025, read in part . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, misappropriation of property or financial abuse, involuntary seclusion, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of a facility policy on 03/26/2025 at 1:30 p.m. titled Resident Rights with revision date of 12/2021, read in part . Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; and to be free from abuse and neglect. Interview on 03/24/2025 at 1:04 p.m. with S1 Administrator confirmed the facility had no reportable incidents, and no submission to the State Agency since last survey on 06/12/2024. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed the facility had not investigated staff to resident verbal and emotional abuse that occurred for Resident #15 by S4 CNA on 02/16/2025, because they did not consider the incident as an abuse allegation, and so they did not investigate it as such. S2 DON confirmed the facility had not performed monitoring of S4 CNA, and had not interviewed any other resident following Resident #15's allegations of verbal abuse by S4 CNA. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON, confirmed last month (02/2025), Resident #25 pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, and confirmed the facility had not reported the resident to resident abuse to the State Agency. Interview on 03/25/2025 at 2:57 p.m. with S3 ADON, revealed Resident #68's transfer status is 2-person lift according to his care plan. S3 ADON revealed that all staff should access a resident's transfer status prior to transfer by looking at the residents' POC in the kiosk on the hall. S3 ADON confirmed mechanical lift was documented in Resident #68's POC for transfer status. Interview on 03/26/2025 at 5:10 p.m. with S2 DON, revealed that when a resident's POC was entered into the electronic system, it then fired to the kiosk located on the halls for the CNAs to view. S2 DON stated that staff were to look at the kiosk prior to caring for residents to determine their transfer status. S2 DON confirmed that Resident #68 was care planned as a 2-person lift, and should not have been transferred without another staff member present and without the use of a lift. Interview on 03/27/2025 at 11:00 a.m. with S2 DON revealed she was aware of an incident between Resident #25 and Resident #51 that occurred sometime last month. S2 DON stated she was told by staff that Resident #25 and Resident #51 was arguing over a cookie, but was not informed of Resident #25 hitting Resident #51. S2 DON confirmed she did not further investigate the documented resident to resident abuse on 02/21/2025 when Resident #25 hit Resident #51 in the face with a box of cookies, but should have. S2 DON revealed the incident was not reported to the State Agency because she was not aware of the resident to resident altercation between Resident #25 and Resident #51 on 02/21/2025. The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that included the following: The facility identified 4 instances of abuse/neglect in the facility: 1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15; 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51; 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6; and 4. Neglect, when S6 CNA neglected Resident #68. These instances have the ability to affect all residents that reside in the facility. The facility implemented the following actions to remove the immediacy: On 03/27/2025 in-service was completed with all current staff on shift for abuse and neglect policy and procedure, lifting protocol, and what constitutes abuse and neglect. On 03/27/2025 S4 CNA was placed on administrative leave pending thorough investigation. On 03/27/2025 S6 CNA was in services on proper lifting techniques with proper return demonstration completed. On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained. On 03/27/2025 Administrative oversight was provided to S1 Administrator and S2 DON by the regional administrator. The regional administrator shall thoroughly investigate all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Regional administrator will monitor S1 Administrator weekly by direct observation and onsite oversight weekly for 30 days. On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting to discuss Abuse and Neglect Policy and procedure, reportable incidents, lifting protocols, and use of lifters. In-service also included monitoring for and reporting resident to resident abuse, staff to resident abuse, and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Any staff member not in serviced will be in serviced prior to the beginning of their shift. On 03/28/2025 a monitoring tool was initiated for nurse's notes to be reviewed daily for any alleged cases of abuse and neglect to be investigated as necessary. All alleged cases will be brought to S2 DON and S1 Administrator's attention and investigation and reporting are to be done immediately. On 03/28/2025 the above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months. Facility completion date 03/28/2025.

Based on interview and record review the facility failed to ensure allegations of verbal, physical, and/or mental abuse, were thoroughly investigated for 3 (Resident #6, Resident # 15, and Resident #51) of 3 (Resident #6, Resident # 15, and Resident #51) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. Resident #51 stated this made her mad. The Immediate Jeopardy continued on 03/08/2025 at approximately 4:20 p.m., when Resident #25 (who exhibited aggressive and angry behavior on day of incident), pulled Resident #6's hair. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 03/27/2025 at 5:56 p.m. Findings: Review of a facility policy on 03/26/2025 at 12:39 p.m. titled Abuse Prevention with revision date of 03/21/2012 read in part . Each resident shall remain free from harm. Should an employee and/or resident report suspected abuse the following should occur: The incident will be immediately reported to the charge nurse. The charge nurse will immediately contact the Director of Nursing. The charge nurse will then complete an incident report. The DON and/or Administrator will conduct an investigation per policy and federal/state guidelines. Investigation: The Administrator with the assistance of the DON and in their absence the ADON, and Social Services will begin the investigation process for all incidents that require investigation as soon as the following situations are identified: Abuse - the ill treatment or disregard of an individual, whether purposeful, or due to carelessness, inattentiveness or omission of the perpetrator. May also include domestic, institutional, self-abuse and self-neglect. Emotional Abuse - any threatening behavior or statement directed to a person including, but not limited to ridicule, gestures that subject the person to humiliation or degradation, threatening motions or noises intended to startle or frighten the person. Physical Injury - an act that physically hurts or damages an individual's body where damage is inflicted by external force. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An intentional act of omission by an employee which denies the standard of care and treatment due to an individual as required by law, rules, regulations, policies, procedures, guidelines or care plans. Physical Abuse - any physical motion of action, e.g. hitting, spitting, slapping, punching, kicking, pinching, directed toward the individual. It included use of corporal punishment as well as the use of restrictive, intrusive procedure to control inappropriate behavior for purposes of punishment or correction. Threat- any condition or situation that could cause or result in severe, temporary or permanent injury or harm to the mental or physical condition of individuals or their death. Verbal Abuse - use of oral, written, or gestured language by which abuse occurs. Includes: Name calling, swearing., taunting, and using derogatory terms to describe persons with disabilities. Psychological Abuse - includes: humiliation, harassment, threats of punishment or deprivation, sexual coercion, and intimidation. If alleged abuse occurs staff will: Take immediate action to protect the individual(s) involved including removal of the alleged abuser. Ensure that any health or psychological needs of the resident are provided for. Notify the DON immediately. Resident #15 Review of Resident #15's medical record revealed she was admitted to the facility on [DATE]. Resident #15 had diagnoses that included in part . Chronic Pain Syndrome, Major Depressive Disorder, Anxiety Disorder, Parkinson's Disease, Spinal Stenosis, and Other Lack of Coordination. Review of Resident #15's Quarterly MDS with ARD of 01/08/2025, revealed a BIMS score of 15 (cognition intact). Resident #15 had range of motion impairment on both sides, and was dependent on staff for toileting, showering/bathing, and dressing. Review of Resident #15's care plan with an initiation date of 12/18/2024, revealed Resident #15 had a problem of impaired physical mobility related to Parkinson's disease. Interventions included in part . 2 person assist, transfer with mechanical lift. Interview on 03/24/2025 at 3:05 p.m. with Resident #15, revealed on 02/16/2025 she was seated in her wheelchair in her room, and S4 CNA came into her room to put her to bed. Resident #15 said she stated to S4 CNA that she did not want to go to bed, and that S4 CNA then became upset. Resident #15 stated S4 CNA came at me, and I saw her pull a girl's hair once, so I was afraid of her. Resident #15 stated S4 CNA used an ugly tone with her, and she directly reported the incident and how she was afraid of S4 CNA to S1 Administrator on 02/17/2025. Resident #15 reported S1 Administrator asked her if she was afraid of S4 CNA, to which she replied yes. Resident #15 revealed S1 Administrator stated she would take care of the situation, and that S4 CNA would not provide care to her anymore. Resident #15 stated S1 Administrator moved S4 CNA from Hall Y to Hall Z, and had not provided care to her since. Interview on 03/25/2025 at 11:30 a.m. with S1 Administrator, revealed last month (02/2025), Resident #15 reported that she was upset that S4 CNA put her back to bed when she (Resident# 15) did not want to go to bed. S1 Administrator stated Resident #15 reported this as a grievance to S2 DON. S1 Administrator revealed Resident #15 had never at any point in time informed her that she was afraid of S4 CNA, and denied Resident #15 reporting any abuse allegations to her. S1 Administrator revealed S2 DON moved S4 CNA's halls due to Resident #15 not wanting S4 CNA to care for her again. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed the facility had not investigated staff to resident verbal and emotional abuse that occurred for Resident #15 by S4 CNA on 02/16/2025, because they did not consider the incident as an abuse allegation, and so they did not investigate it as such. S2 DON confirmed the facility had not performed monitoring of S4 CNA, and had not interviewed any other resident following Resident #15's allegations of verbal abuse by S4 CNA. Telephone interview on 03/25/2025 at 3:56 p.m. with S4 CNA revealed on 02/16/2025, she was paged to the nurses station by S13 LPN, and S13 LPN asked her to put Resident #15 to bed, because Resident #15 was not feeling well. S4 CNA stated Resident #15 stated she did not want to go to bed, but she and S15 CNA convinced Resident #15, and they transferred her 2 person assist with mechanical lift to bed. Observation and Interview on 03/26/2025 at 3:20 p.m. with Resident #15 and Resident #37 revealed Resident #15 stated S4 CNA yelled at her on 02/16/2025, and said You stupid piece of sh*t, you're going to do what I say, and you're going to get in that bed! Resident #37 stated at that time that she heard S4 CNA yell at Resident #15 and say, You stupid piece of sh*t, you're going do what I say, and you're going to get in that bed! Resident #15 began to cry during the interview, and stated yes that is exactly what S4 CNA said to me! I don't like to use profanity, she hurt my feelings. Interview on 03/27/2025 at 8:43 a.m. with Resident #15 revealed she informed S1 Administrator of her exact concerns with S4 CNA, and reported to S1 Administrator that S4 CNA yelled and used profanity at her, made her go to bed, and grabbed her ankle and arm. Resident #15 stated S1 Administrator revealed she would take care of things. Resident #15 stated S4 CNA made me afraid and I just want to forget the whole incident, because it made me question if I made the right choice in moving here. Resident #15 stated she has often thought about going home since the incident with S4 CNA. Resident #51 Review of Resident #51's medical record, revealed Resident #51 was admitted to facility on 03/27/2024. Resident #51 had diagnoses that included in part . Bipolar Disorder, Paranoid Schizophrenia, Chronic Kidney Disease, Pain, and Major Depressive Disorder. Review of Resident #51's Annual MDS with an ARD of 12/18/2024 revealed a BIMS score of 15 (cognition intact). Review of Resident #51's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:28 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. Interview on 03/27/2025 at 8:32 a.m. with Resident #51, revealed sometime last month (unknown date), Resident #25 came into the dining room acting mad, and hit her in the face with a box of cookies. Resident #51 stated that made me mad and upset me, but she did not hurt me. She's just mean! Telephone interview on 03/28/2025 at 11:53 a.m. with Resident #51's RP, confirmed the facility had called him last month to inform him another Resident had hit Resident #51 with a box of cookies. Interview on 03/27/2025 at 11:00 a.m. with S2 DON revealed she was aware of an incident between Resident #25 and Resident #51 that occurred sometime last month. S2 DON stated she was told by staff that Resident #25 and Resident #51 was arguing over a cookie, but was not informed of Resident #25 hitting Resident #51. S2 DON confirmed she did not further investigate the resident to resident abuse on 02/21/2025 when Resident #25 hit Resident #51 in the face with a box of cookies, but should have. Resident #6 Review of Resident #6's medical record, revealed Resident #6 was admitted to facility on 10/14/2024. Resident #6 had diagnoses that included in part . Depression, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #6's Quarterly MDS with an ARD of 01/22/2025, revealed a BIMS score of 6 (severe cognitive impairment). Review of Resident #6's Departmental Progress Notes revealed in part . On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed last month (02/2025), Resident #25 pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, so the facility had not performed an abuse investigation. Telephone interview on 03/26/2025 at 12:31 p.m. with S14 CNA, revealed she worked the 2:00 p.m. - 10:00 p.m. shift on 03/08/2025 on Hall Y. S14 CNA stated she was working in another resident's room, and Resident #46's RP came to the room to tell her that Resident #25 and Resident #6 were fighting. S14 CNA stated that she did not witness the incident, but Resident #46's RP did, and she immediately reported the incident to S12 LPN. Interview on 03/26/2025 at 12:53 p.m. with S2 DON revealed on 03/08/2025 she spoke to S12 LPN about the documented disagreement between Resident #25 and Resident #6. S2 DON stated S12 LPN informed her that she observed the two residents playing in each other's hair. S2 DON confirmed she did not interview any other staff, and that no one had reported a physical altercation between Resident #25 and Resident #6 to her, so she did not investigate further, but should have. The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that included the following: The facility identified 3 instances of abuse/neglect in the facility: 1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15; 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51; 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6. These instances have the ability to affect all residents that reside in the facility. The facility implemented the following actions to remove the immediacy: On 03/27/2025 at 5:56 p.m. all current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained. On 03/27/2025 monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately. On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting to discuss Abuse and Neglect Policy and Procedure, Lifting protocols, and the facility's Use of Mechanical Lift. In-service included monitoring for a reporting resident to resident abuse, staff to resident abuse, and neglect. In addition, reporting and investigation requirements of all alleged incidents of abuse and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse and neglect. The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months. Facility completion date 03/28/2025.

Based on interview, observation, and record review the facility failed to ensure residents' rights to be free from verbal abuse and psychosocial harm by staff (Resident #15), resident to resident physical abuse (Resident #51 and #6); and protect a resident's right to be free from neglect (Resident #68), for 4 (Residents #6, #15, #51, and #68) of 4 residents (#6, #15, #51, and #68) reviewed for abuse and neglect. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. Resident #51 stated this made her mad. The Immediate Jeopardy continued on 03/08/2025 at approximately 4:20 p.m., when Resident #25 (who exhibited aggressive and angry behavior on day of the incident), pulled Resident #6's hair. The Immediate Jeopardy continued on 03/25/2025 at 2:25 p.m., when S6 CNA was observed to willfully transfer Resident #68 without the required 2 person physical assist with mechanical lift; although she was knowledgeable that 2 person assist with mechanical lift was required of Care. The deficient practice has the likelihood to affect all other residents who reside in the facility. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 03/27/2025 at 5:56 p.m. Findings: Review of a facility policy on 03/26/2025 at 12:39 p.m., titled Abuse Prevention, with revision date of 03/21/2012, read in part . Each resident shall remain free from harm. Abuse - the ill treatment or disregard of an individual, whether purposeful, or due to carelessness, inattentiveness or omission of the perpetrator Emotional Abuse - any threatening behavior or statement directed to a person including, but not limited to ridicule, gestures that subject the person to humiliation or degradation, threatening motions or noises intended to startle or frighten the person. Physical Injury - an act that physically hurts or damages an individual's body where damage is inflicted by external force. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An intentional act of omission by an employee which denies the standard of care and treatment due to an individual as required by law, rules, regulations, policies, procedures, guidelines or care plans. Physical Abuse - any physical motion of action, e.g. hitting, spitting, slapping, punching, kicking, pinching, directed toward the individual . Threat- any condition or situation that could cause or result in severe, temporary or permanent injury or harm to the mental or physical condition of individuals or their death. Verbal Abuse - use of oral, written, or gestured language by which abuse occurs. Includes: Name calling, swearing., taunting, and using derogatory terms to describe persons with disabilities. Psychological Abuse - includes: humiliation, harassment, threats of punishment or deprivation, sexual coercion, and intimidation. If alleged abuse occurs staff will: Take immediate action to protect the individual(s) involved including removal of the alleged abuser. Ensure that any health or psychological needs of the resident are provided for. Notify the DON immediately. Review of a facility policy on 03/25/2025 at 4:16 p.m., titled Abuse and Neglect-Clinical Protocol, with revision date of 01/01/2025, read in part . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, misappropriation of property or financial abuse, involuntary seclusion, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of a facility policy on 03/26/2025 at 1:30 p.m. titled Resident Rights with revision date of 12/2021, read in part . Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; and to be free from abuse and neglect. Resident #15 Review of Resident #15's medical record revealed she was admitted to the facility on [DATE]. Resident #15 had diagnoses that included in part . Chronic Pain Syndrome, Major Depressive Disorder, Anxiety Disorder, Parkinson's Disease, Spinal Stenosis, and Other Lack of Coordination. Review of Resident #15's Quarterly MDS with ARD of 01/08/2025, revealed a BIMS score of 15 (cognition intact). Resident #15 had range of motion impairment on both sides, and was dependent on staff for toileting, showering/bathing, and dressing. Review of Resident #15's care plan with an initiation date of 12/18/2024, revealed Resident #15 had a problem of impaired physical mobility related to Parkinson's disease. Interventions included in part . 2 person assist, transfer with mechanical lift. Interview of Resident #37 during the Resident Council meeting on 03/24/2025 at 1:32 p.m., revealed Resident # 37 stated that S4 CNA made Resident #15 stay in bed, and refused to get Resident #15 up, per Resident #15's request. S4 CNA then yelled at Resident #15. Interview on 03/24/2025 at 3:05 p.m. with Resident #15, revealed on 02/16/2025 she was seated in her wheelchair in her room, and S4 CNA came into her room to put her to bed. Resident #15 said she stated to S4 CNA that she did not want to go to bed, and that S4 CNA then became upset. Resident #15 stated S4 CNA came at me, and I saw her pull a girl's hair once, so I was afraid of her. Resident #15 stated S4 CNA used an ugly tone with her, and she directly reported the incident and how she was afraid of S4 CNA to S1 Administrator on 02/17/2025. Resident #15 reported S1 Administrator asked her if she was afraid of S4 CNA, to which she replied yes. Resident #15 revealed S1 Administrator stated she would take care of the situation, and that S4 CNA would not provide care to her anymore. Resident #15 stated S1 Administrator moved S4 CNA from Hall Y to Hall Z, and S4 CNA had not provided care to her since. Interview on 03/25/2025 at 10:30 a.m. with S5 CNA Supervisor, revealed S2 DON moved S4 CNA from Hall Y to Hall Z last month, but she was unsure why. S5 CNA Supervisor revealed she was unaware of any incident between S4 CNA and Resident #15. S5 CNA Supervisor revealed she was aware that Resident #37 had informed S2 DON that she did not like the way S4 CNA spoke to residents, so she assumed that was why S2 DON moved S4 CNA to a different hall. Interview on 03/25/2025 at 11:30 a.m. with S1 Administrator revealed last month (02/2025), Resident #15 had reported that she was upset that S4 CNA put her back to bed when she (Resident# 15) did not want to go to bed. S1 Administrator stated Resident #15 reported this as a grievance to S2 DON. S1 Administrator revealed Resident #15 had never at any point in time informed her that she was afraid of S4 CNA, and denied Resident #15 reporting any abuse allegations to her. S1 Administrator revealed S2 DON moved S4 CNA's halls due to Resident #15 not wanting S4 CNA to care for her again. Review of a grievance form dated 02/17/2025, revealed Resident #15 filed a written grievance with S2 DON that read in part . Resident #15 stated S4 CNA put her to bed yesterday, although she was not ready to go to bed. She stated she did not care for S4 CNA due to her loud tone of voice. Action taken to resolve concern: In-service done. Statements received. S4 CNA reassigned to accommodate Resident #15 preference. Telephone interview on 03/25/2025 at 3:56 p.m. with S4 CNA revealed on 02/16/2025, she was paged to the nurses station by S13 LPN, and S13 LPN asked her to put Resident #15 to bed, because Resident #15 was not feeling well. S4 CNA stated Resident #15 stated she did not want to go to bed, but she and S15 CNA convinced Resident #15, and they transferred her 2 person assist with mechanical lift to bed. Interview on 03/26/2025 at 3:10 p.m. with Resident #37 (BIMS score of 15-indicating cognition intact), revealed she was fearful of S4 CNA. Resident #37 began to cry and revealed she was fearful because S4 CNA screamed and cursed at Resident #15. Resident #37 revealed on 02/16/2025, she could hear S4 CNA screaming at Resident #15 from the nursing station, so she went down the hall to Resident #15's room and witnessed S4 CNA yelling and cursing at Resident #15. Observation and Interview on 03/26/2025 at 3:20 p.m. with Resident #15 revealed, Resident #37 and a visitor were in the room Resident #15 stated S4 CNA yelled at her and said You stupid piece of sh*t, you're going to do what I say, and you're going to get in that bed! Resident #37 stated at that time that she heard S4 CNA yell at Resident #15 and say, You stupid piece of sh*t, you're going do what I say, and you're going to get in that bed! Resident #15 began to cry during the interview, and stated yes that is exactly what S4 CNA said to me! I don't like to use profanity, she hurt my feelings. The visitor stated that he has heard S4 CNA tell other residents on several occasions to Shut up and get in your room! Interview on 03/27/2025 at 8:43 a.m. with Resident #15 revealed she informed S1 Administrator of her exact concerns with S4 CNA, and reported to S1 Administrator that S4 CNA yelled and used profanity at her, made her go to bed, and grabbed her ankle and arm. Resident #15 stated S1 Administrator revealed she would take care of things. Resident #15 stated S4 CNA made me afraid and I just want to forget the whole incident, because it made me question if I made the right choice in moving here. Resident #15 stated she has often thought about going home since the incident with S4 CNA. Resident #51 Review of Resident #51's medical record, revealed Resident #51 was admitted to facility on 03/27/2024. Resident #51 had diagnoses that included in part . Bipolar Disorder, Paranoid Schizophrenia, Chronic Kidney Disease, Pain, and Major Depressive Disorder. Review of Resident #51's Annual MDS with an ARD of 12/18/2024 revealed a BIMS score of 15 (cognition intact). Review of Resident #51's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:28 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Neuro started, and Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. Interview on 03/27/2025 at 8:32 a.m. with Resident #51, revealed sometime last month (unknown date), Resident #25 came into the dining room acting mad, and hit her in the face with a box of cookies. Resident #51 stated that made me mad and upset me, but she did not hurt me. She's just mean! Telephone interview on 03/28/2025 at 11:53 a.m. with Resident #51's RP confirmed the facility had called him last month to inform him another Resident had hit Resident #51 with a box of cookies. Interview with S16 LPN was unsuccessful. Interview on 03/27/2025 at 11:00 a.m. with S2 DON, revealed she was not aware of the resident to resident altercation between Resident #25 and Resident #51 on 02/21/2025. Resident #6 Review of Resident #6's medical record, revealed Resident #6 was admitted to facility on 10/14/2024. Resident #6 had diagnoses that included in part . Depression, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #6's Quarterly MDS with an ARD of 01/22/2025, revealed a BIMS score of 6 (severe cognitive impairment). Review of Resident #6's Departmental Progress Notes revealed in part . On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Telephone interview on 03/26/2025 at 12:31 p.m. with S14 CNA, revealed she worked the 2:00 p.m. - 10:00 p.m. shift on 03/08/2025 on Hall Y. S14 CNA stated she was working in another resident's room, and Resident #46's RP came to the room to tell her that Resident #25 and Resident #6 were fighting. S14 CNA stated that she did not witness the incident, but Resident #46's RP did, and she immediately reported the incident to S12 LPN. Resident #25 Review of Resident #25's medical record revealed Resident #25 was admitted to the facility on [DATE]. Resident #25 had diagnoses that included in part . Traumatic Subarachnoid Hemorrhage, General Anxiety Disorder, Bipolar Disorder, Depression, and Anxiety. Review of Resident #25's Quarterly MDS with an ARD 02/20/2025, revealed a BIMS score of 00 (severe cognitive impairment). Review of Resident #25's Care Plan with a problem initiation date of 12/24/2024, revealed in part . Potential for verbally aggressive behaviors due to a history of delusions and verbal aggression secondary to Bipolar disorder; Depressed Severe, with psychotic features; Depression; Anxiety Disorder. Interventions: 02/21/2025, Resident got into an altercation with another resident. S2 DON contacted psychiatrist, a medication review was done, and medication adjustment was ordered. Psychiatrist made aware of resident being manic. Review of Resident #25's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:37 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Interview on 03/25/2025 at 10:30 a.m. with S5 CNA Supervisor, revealed last month Resident #25 had aggressive behaviors. S5 CNA Supervisor stated there was an incident between Resident #25 and Resident #6 one day last month (date unknown). Resident #25 became mad and aggressive, and pulled her best friend's hair (Resident #6). S5 CNA Supervisor stated Resident #6 became very upset and told Resident #25 What's the matter with you? Don't do that! and went to her room crying. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON, confirmed last month Resident #25 had pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, so the facility had not performed an abuse investigation. S1 Administrator confirmed the facility had not reported the resident to resident abuse to SIMS. S1 Administrator stated she was not aware of the details of situation, so she would have to look into it. Interview on 03/26/2025 at 3:50 p.m. revealed Resident #50 (BIMS score of 15 indicating cognition intact), stated on 03/08/2025, Resident #25 attempted to hit him right before she hit Resident #6. Resident #50 stated he told Resident #25 Don't hit me, and she left him alone and he went to his room. During interview Resident #46's RP revealed he visited daily, and stated on 03/08/2025 he saw Resident #25 hit Resident #6 in the head, and he went and told a CNA what was going on. 46773 Resident #68 Review of Resident #68's medical records revealed an admitted [DATE], with diagnoses that included: Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's Care plan with review date of 06/04/2025 revealed Resident #68's transfer status required a lift with 2-person physical assist, and extensive assistance with bed mobility. Review of Resident #68's Quarterly MDS with an ARD of 03/05/2025, revealed a BIMS of 14, indicating intact cognition, and the resident's chair/bed-to-chair transfer status as dependent on staff to complete the activity. Observation on 03/25/2025 at 2:25 p.m., revealed S6 CNA transferred Resident #68 from the bed to his wheelchair, without another staff member present, and without the use of a mechanical lift. Interview on 03/25/2025 at 2:57 p.m. with S3 ADON, revealed Resident #68's transfer status is 2-person lift according to his care plan. S3 ADON revealed that all staff should access a resident's transfer status prior to transfer by looking at the residents' POC in the kiosk on the hall. S3 ADON confirmed mechanical lift was documented in Resident #68's POC for transfer status. Interview on 03/25/2025 at 3:02 p.m. with S9 CNA revealed she was able to determine a resident's transfer status by the presence of a leaf on his or her door, and if there was a lifter pad underneath the resident. S9 CNA stated that she transferred Resident #68 by herself, and did not use a lift when she transferred Resident #68 by herself. S9 CNA stated she had transferred other residents with a lift, by herself at times, if she was unable to find staff to help. Interview on 03/25/2025 at 3:08 p.m. with Resident #68 revealed he was transferred by 1 staff member, without a lift, from the bed to the wheelchair. Resident #68 was unable to tell the surveyor which CNAs transferred him without the lift. He stated that when he was first admitted , a lift was used during transfers; however 2 person assistance with a lift had not been used in a while. Resident #68 was unable to say exactly how long the lift and 2 person assist had not been used for transfers. Interview on 03/26/2025 at 9:25 a.m. with S7 CNA revealed she has been trained to look in the kiosk for transfer status, but stated she was unaware that Resident #68 was a 2-person assist with lift. S7 CNA revealed if she were to call a nurse to come assist her, they would come help, but she does not always call for help. Interview on 03/26/2025 at 9:30 a.m. with S8 CNA revealed she had been trained to look in the kiosk to determine a resident's transfer status. S8 CNA stated she did not believe Resident #68 was a 2-person assist. S8 CNA stated there are times that she had to get residents up alone with the lifts, because there was no one else on the halls. Interview on 03/26/2025 at 9:40 a.m. with S6 CNA revealed she transferred Resident #68 by herself without a lift because she was unaware that he required a lift. S6 CNA stated she could find the residents transfer status on the kiosk located on the hall to determine transfer status, but did not look at the Kiosk for Resident #68's transfer status. Interview on 03/26/2025 at 5:10 p.m. with S2 DON, revealed that when a resident's POC was entered into the electronic system, it then fired to the kiosk located on the halls for the CNAs to view. S2 DON stated that staff were to look at the kiosk prior to caring for residents to determine their transfer status. S2 DON confirmed that Resident #68 was care planned as a 2-person lift, and should not have been transferred without another staff member present and without the use of a lift. An interview on 03/27/2025 at 3:06 p.m. with S20 CNA, revealed she has been trained by the facility that all residents who require a bed lift for transfers should always have 2 CNAs operating the lift. S20 CNA stated she has transferred lift residents by herself often because other CNAs were busy, and residents were ready to go to bed and don't want to wait. S20 CNA stated she recently transferred Resident #11 on 03/25/2025 by herself on Hall Y on the 2:00 p.m. to 10:00 p.m. shift. The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. as confirmed by onsite verification through observations, interviews and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to survey exit that included the following: The facility identified 4 instances of abuse/neglect in the facility: 1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15; 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51; 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6; and 4. Neglect, when S6 CNA neglected Resident #68. These instances have the ability to affect all residents that reside in the facility. The facility implemented the following actions to remove the immediacy: On 03/27/2025 S4 CNA was placed on administrative leave pending thorough investigation. On 03/27/2025 at 5:56 p.m. all current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/27/2025 Monitoring tool initiated for S5 CNA Supervisor or designee to complete the lift protocol monitoring tool 4 times a week for 4 weeks, then twice per week for 2 weeks to ensure compliance with lift protocol and mechanical lifts for residents who require 2 person transfer. On 03/27/2025 Monitoring tool initiated for every 15 minute and every 30 minute checks for Resident #6, Resident #15, Resident #25, and Resident #51, and shall be turned into S2 DON daily for review. On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained. On 03/27/2025 monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately. On 03/28/2025 at 6:00 a.m. all on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift. On 03/28/2025 S6 CNA was in serviced on the policy and procedure for patients requiring mechanical lift. Return demonstration for S6 CNA was required. Visual return demonstration was observed by S2 DON. Resident #68 was discharged home on 03/27/2025 at 2:30p.m. On 03/28/2025 Interviews were conducted with Resident #15, Resident #6, Resident #25, and Resident #51 to ensure freedom of abuse/neglect. Resident #15 shall continue to be on every 30 minute checks indefinitely. Resident #6 was placed on every 30 minute checks indefinitely. Resident #25 had every 15 minutes checks for 24 hours, then every 30 minute checks indefinitely. Resident #51 was placed on every 30 minute checks for two weeks. Resident #68 was discharged from the facility on 03/27/2025 at 2:30 p.m. On 03/28/2025 Resident #25's psychiatrist was informed of resident's behaviors. No new orders were given. The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months. Facility completion date 03/28/2025.

Based on observations and interviews, the facility failed to provide drinks consistent with resident preferences. The facility failed to ensure staff, in Hall X dining room, provided water to 10 residents with their meal during lunchtime. Findings: Observation on 03/24/2025 at 11:11 a.m. revealed staff serving resident lunch trays in Hall X dining room with only juice observed on the lunch tray. No water was observed on the lunch trays or offered to the 10 residents prior to receiving their lunch trays. Interview on 03/24/2025 at 11:12 a.m. with S5 CNA Supervisor revealed that the residents were given juice and milk with their lunch tray, but were not served/offered water with their meal. Observation on 03/25/2025 11:30 a.m. in Hall X dining room revealed the 10 residents were served only milk and juice with their lunch tray and were not offered or provided water. Interview on 03/25/2025 at 2:32 p.m. S5 CNA Supervisor revealed the kitchen does not send water on resident's meal trays and only send juice and Kool-Aid. S5 CNA Supervisor stated only if a resident were to request water with their meal, staff would go get it for them.

Based on record review, observation, and interviews, the facility failed to administer a resident's enteral flush per the physician orders for 1(Resident #68) of 1 residents investigated for enteral feedings. Findings: Review of the facility's policy titled, Enteral Nutritional Therapy dated 04/05/2012, read in part Purpose: to provide hydration through a tube inserted into the stomach. If a feeding pump had been ordered .d. Adjust flow rate as prescribed. Review of Resident #68 medical records revealed an admitted [DATE] with diagnoses that include: Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's 03/2025 physician orders revealed an order was started on 02/18/2025 for Glucerna 1.5 cal at 60cc/hour with 35cc/hour H2O flushes, per pump. Review of Resident #68's care plan with the next review date of 06/02/2025 read in part I require tube feeding related to Dysphagia secondary to Cerebrovascular Accident. Interventions: Glucerna 1.5 cal at 60cc/hour/pump with 35cc/hour/pump water flush. Observation on 03/24/2025 at 1:25 p.m. revealed Resident #68's tube feeding of Glucerna 1.5 cal at 60cc/hour with 30cc/hour water flush. Observation on 03/25/2025 at 2:15 p.m. revealed Resident #68's tube feeding of Glucerna 1.5 cal at 60cc/hour with 30cc/hour water flush. Interview on 03/25/2025 at 2:30 p.m. with S3 ADON revealed Resident #68's water flush was set incorrectly at 30 cc/hour and should have been set as ordered at 35cc/hour, but was not.

Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan to meet the needs of 3 ( #34, #36, and #37) residents of 34 sampled residents. The facility failed to ensure Resident #34's and Resident #36's fall interventions were implemented, and failed to ensure 2 person physical assistance was used for bed mobility and toileting for Resident #37. Findings: Review of an undated facility policy titled, Care Plans Comprehensive read the following part .1. The interdisciplinary team will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, dietary and psychosocial needs and maximize the resident's highest level of functioning. Resident #34 Review of Resident #34's medical record revealed an admitted [DATE], with diagnoses that included in part .Chronic Kidney Disease, Stage 4 (Severe), Atrial Fibrillation, Pulmonary Fibrosis, and History of Falling. Review of Resident #34's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/16/2024 revealed a BIMS (Brief Interview of Mental Status) score of 13, which indicated intact cognition. Resident #34 had a history of falls in the last month and required limited assistance with one person physical assistance for bed mobility, transfers, and toilet use. Review of Resident #34's physician orders revealed an order for a fall mat on the floor next to her bed per the family's request every 12 hours with a start date of 12/04/2024. Review of Resident #34's care plan revealed in part .Focus: Risk for falls related to history of falls. Interventions: fall mat on the floor next to bed per the family's request with an initial date of 12/05/2024. On 03/24/2025 at 9:39 a.m., observed Resident #34 in the bed with the right side of the bed against the wall. No fall mat observed on the left side of the bed. On 03/25/2025 at 9:05 a.m., observed Resident #34 asleep in the bed with no fall mat on the bedside floor. On 03/26/2025 at 8:54 a.m., observed Resident #34 in the bed with no fall mat on the bedside floor. In an interview and record review on 03/26/2025 at 2:31 p.m., S12 LPN revealed that Resident #34 should have had a fall mat at the bedside per the physician's orders. S12 LPN confirmed that Resident #34 did not have a fall mat on the floor at her bedside and should have. In an interview and record review on 03/26/2025 at 2:58 p.m., S2 DON revealed that Resident #34 had active physician's orders started on 12/04/2024 for a fall mat next to her bed. S2 DON revealed Resident #34's fall risk care plan had a fall intervention to place a fall mat at the resident's bedside. S2 DON confirmed Resident #34 should have had a fall mat on the floor next to her bed, but did not. Resident #36 Review of Resident #36's medical record revealed an admitted [DATE], with diagnoses that included in part .Paroxysmal Atrial Fibrillation, Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction Without Residual Deficits, and Seizures. Review of Resident #36's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/20/2025 revealed a BIMS (Brief Interview of Mental Status) score of 14, which indicated intact cognition. Resident #36 had two or more falls since admission to the facility and required total dependence with two person physical assistance for bed mobility, transfers, and toilet use. Review of Resident #36's care plan revealed in part .Focus: Risk for falls characterized by history of fall/injury, and multiple risk factors related to unsteady gait. Interventions: Fall mat to the resident's bedside with an initial date of 02/18/2025. On 03/24/2025 at 10:55 a.m., observed Resident #36 in the bed with a black fall mat propped up against the wall, which was located behind the resident's bed. On 03/25/2025 at 2:14 p.m., observed Resident #36 asleep in the bed with a black fall mat propped up against the wall, which was located behind the resident's bed. On 03/26/2025 at 8:40 a.m., observed Resident #36 sitting on the side of her bed with a black fall mat propped up against the wall, which was located behind the resident's bed. In an interview and record review on 03/26/2025 at 10:04 a.m., S2 DON revealed Resident #36 had a fall on 02/16/2025 and the fall risk intervention was to place a fall mat at the resident's bedside. S2 DON confirmed that Resident #36's fall mat should not be propped up against the wall located behind the resident's bed. S2 DON confirmed Resident #36's fall mat should be placed on the left of the bedside floor, but was not. Resident #37 Review of Resident 37's's medical records revealed an admitted [DATE] with diagnoses that included: Malignant Neoplasm of Upper Lobe, Left Bronchus or Lung; Neoplastic (Malignant) related Fatigue, Spinal Stenosis, Chronic Systolic (Congestive) Heart Failure, and Chronic Pain. Review of Resident #37's care plan with a revision date of 12/5/2024 revealed Resident #37 required extensive assistance with bed mobility and toileting and requires 2-person physical assist using a lift with transfers. Review of Resident #37's Quarterly MDS with ARD of 10/16/2024 revealed a BIMS of 14, which indicated intact cognition. Resident #37 was dependent on staff with bed mobility and required 2 person physical assist. Review of a facility report dated 10/19/2024 revealed in part Resident #37 rolled on her side to be cleaned and rolled out of the bed. No injuries observed. Interview on 03/27/2025 at 12:05 p.m. with Resident #37 revealed 1 one CNA staff rolled her over in bed to provide incontinent care and the resident fell /rolled out of the bed. Several unsuccessful attempts to contact S10 CNA. Interview on 03/27/2025 at 12:19 p.m. with S2 DON, revealed that on 10/19/2024, S10 CNA reported that Resident #37 fell /rolled out of bed when she provided incontinent care alone. Interview on 03/27/2025 at 1:50 p.m. with S2 DON revealed that Resident #37's current care plan required 2 person physical assistance with bed mobility and toileting. S2 DON confirmed S10 CNA provided bed mobility and toileting on 10/19/2024 alone and confirmed S10 CNA failed to follow Resident #37's plan of care at the time of her fall.

Based on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review) Level I and/or Level II for 1(#23) resident of 2(#23 and #26) residents reviewed for PASARR screening. Findings: Review of the facility's undated policy titled, PASARR Policy read in part .If during the residents stay, their condition warrants having an inpatient psychiatric hospitalization or becomes diagnosed with a serious mental illness, a Level 2 screening should be done. Review of Resident #23's medical record revealed an admitted [DATE] with diagnoses read in part Benign Neoplasm of Stomach , Chronic Kidney Disease, and Bipolar Disorder, Current Episode Severe with Psychotic Features (01/19/2023). Review of Resident #23's medical record revealed a Level 1 pre-screening was provided for Resident #23 prior to admission on 12/01/2022, which indicated a Level 2 screening is not necessary due to no diagnoses of mental illness. Review of Resident #23's medical record revealed a psychiatric evaluation completed on 01/03/2023, which indicated Resident #23 has persistent symptoms of depression and delusions with diagnostic impression of Bipolar Disorder. Review of Resident #23's electronic record revealed a diagnosis of Bipolar disorder with a start date of 01/19/2023. Interview on 03/26/2025 at 09:50 a.m. with S2 DON revealed if a resident is admitted to the facility with a Level 1 PASARR and they received a new serious mental illness that a Level 2 screening would be required. S2 DON revealed Resident #23 was admitted with a Level 1 without any mental condition and received a diagnosis of Bipolar Disorder after being admitted to the facility. S2 DON confirmed that a Level 2 screening should have been completed for Resident #23 after the mental illness diagnosis, but had not been done.

Based on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#38) of 1 resident reviewed for advance directives. The facility failed to ensure all medical records consistently reflected the resident's wishes to be a DNR (Do Not Resuscitate) code status. Findings: Review of the facility's policy dated 01/15/2025 titled, Advance Directives read in part . Policy statement: Advance Directives will be respected in accordance with state law and facility policy. 8. The plan of care for each resident will be consistent with his or her documented treatment preference and/or advance directives. Review of Resident #68's medical record revealed an admitted [DATE] with diagnoses that included: Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's electronic record dashboard/orders revealed the resident was a Full Code status. Review of Resident #68's 03/2025 physician's orders revealed the code status as DNR. Review for Resident #68's care plan with the next review date of 06/24/2025 revealed the code status as DNR. Interview on 03/26/2025 at 10:40 a.m., with S11 LPN revealed she would look at the resident's dashboard/orders in their electronic record to determine their advance directive during a code. Interview on 03/26/2025 at 11:00 a.m., with S2 DON revealed the staff should look at the dashboard/orders of the resident's chart and determine their code status. S2 DON confirmed that Resident #68's electronic record and care plan had inconsistent data regarding advance directives and should be updated to reflect the corrected code status of DNR, but was not.

Based on observation, record review, and interview, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 (#68) of 1 resident reviewed for pressure ulcers. The facility failed to ensure: 1. gloves used during wound care were not contaminated by the bedside table; and 2. gloves were removed and hands were sanitized after cleaning Resident #68's wound. Findings: Review of the facility's undated policy titled Wound Treatment Management read in part .Policy: To promote wound healing of various types of wounds . to provide evidence based treatments in accordance with current standards of practice and physicians orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Review of Resident #68's medical records revealed an admitted [DATE] with diagnoses that include: Pressure Ulcer of Sacral Region, Stage 3, Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's 03/2025 Physician Orders read in part . 03/25/2025 -Stage 3 Pressure ulcer to sacrum - Clean with wound cleanser, apply Santyl and apply collagen dressing, cover with silicone bordered foam dressing, change daily and as needed due to soiling or dislodgment. Observation of wound care for Resident #68 on 03/25/2025 at 9:16 a.m. revealed S17 Treatment nurse removing the gloves from her clean field and placing them on Resident #68's beside table on top of a banana and his belongings. S17 Treatment nurse was observed removing the gloves from the bedside table, donning the gloves, and providing wound care to Resident #68's sacrum pressure ulcer. S17 Treatment Nurse was observed cleaning the wound with a 4x4, discarded soiled 4x4, obtained a new 4x4 from the clean field and cleansed the wound with soiled gloves without discarding gloves and cleansing hands. Interview on 03/25/2025 at 3:35 p.m., S17 Treatment Nurse was notified by this surveyor that she placed clean gloves on the unclean bedside table on top of Resident #68's belongings prior to using them for wound care, and failed to remove soiled gloves and sanitize hands prior to obtaining supplies from the clean field and cleansing the wound. S17 Treatment Nurse confirmed the above findings.

Based on observation, record review and interview the facility failed to ensure each resident receives adequate supervision to prevent accidents by staff not responding when the facility's ProtecPoint door monitor system sounded allowing 1 (#2) of 5 (#1, 3, 4, and 5) residents at risk for wandering to exit the building, unaware to staff. This failed practice resulted in an Immediate Jeopardy situation for resident #2. On 1/29/17 between 4:50 p.m. and 5:00 p.m., staff failed to respond when the facility's alarm system sounded, and they were aware that the front door did not lock upon activation of the alarm system. Resident #2 exited the front door of the facility unsupervised and got into a vehicle with strangers. According to interview of the person who drove the vehicle, the resident was returned to the facility when he realized the resident was confused, and asked a CNA who was outside if they were missing a resident, and the CNA responded yes. S1 Administrator was informed of the Immediate Jeopardy situation on 2/3/17 at 3:34 p.m. The Immediately Jeopardy was removed on 2/6/17 at 3:00 p.m., when an acceptable plan of removal was received from the Administrator on the above date and time. The plan of removal included the following: 1. Ensure safety of all residents at risk for elopement. Action: as soon as resident #2 returned inside facility, she was placed on close monitoring for every 15 minutes x 48 hours, then every 30 minutes for 24 hours. However, since she wears a wander guard, she was always on every 30 minute monitoring, therefore every 30 minute monitoring will continue indefinitely until further notice. Increased monitoring of resident was initiated. 2. A notice was placed in the sign in/out book that states anytime resident #2 signs in/out, facility was to notify the daughter and all staff was notified. Monitoring tool was placed in sign in/out book. It will be checked weekly times 60 days, then monthly times 2 months. 3. Agency binder was updated at each nurses station to state what agency nurses need to do in case of a major incident occurring such as elopement along with the fact that they need to familiarize themselves with all residents at risk for elopement and those wearing a wander guard. It states that any time a major incident occurs, the nurse needs to notify the DON/ADON immediately. Also, the binder states for the agency nurses to look at each station and know the residents that are at risk for elopement and those wearing wander guard. Resident was given extra activities in the afternoon to help prevent any future incident such as this one. 4. The nursing home facility identified all residents at risk for elopement and wearing wander guard and informed entire staff per in-service that these residents are to be checked when seen going out on pass with both the person taking them out on pass and the proper family member. When the alarms go off, staff must physically go check outside the doors and make sure a resident did not get outside. Make sure they are signed out. Once staff knows who rigged the alarm, they will then announce All clear north/all clear south. 5. Elopement policy was updated to state the above information which was anytime a resident at risk for elopement or wearing wander guard was walking outside with someone or towards outside, the staff member was to ask that person if resident was signed out and then go physically check to see if resident was signed out. 6. LPNs have a form for verification of random check nurses' station cover to ensure someone is at all times. An RN will check the pages on a weekly basis for 1 month. 7. Walking rounds to ensure all staff are aware of new procedure to follow when elopement risks or wander guard residents go out on pass. After 30 days of compliance, it will be checked quarterly until removed from QA. Agency, binder was updated at each nurses station to state what agency nurses needed to do in case of a major incident occurring such as elopement along with the fact that they need to familiarize themselves with all residents at risk for elopement and those wearing a wander guard. In-service was done with all staff on 1/30/2017, stating that if any staff sees a resident that was at risk for elopement or wearing a wander guard walking outside or towards outside with another person, staff was to ask that person if resident was signed out, the staff member needs to go physically check to see if resident was signed out. Elopement policy was updated to state the above information, which is anytime a resident at risk for elopement or wearing wander guard was walking outside with someone or towards outside, the staff member was to ask that person if resident was signed out and then go physically check to see if the resident was signed out. Elopement binders are at each nurses' station and had a list all residents at risk for elopement and wearing wander guards along with pictures if these residents. Staff was in serviced to physically check outside the doors before clearing the alarm and announcing north or south all clear. On weekends, unit secretaries will now work until 6:00 p.m. instead of 4:00 p.m. 8. In-Service was done with all staff on 1/30/2017, stating that if any staff sees a resident that was at risk for elopement or wearing a wander guard walking outside or towards outside with another person, staff was to ask that person if resident was signed out, then the staff member needed to go physically check to see if resident was signed out. Elopement policy was updated to state the above information, which was anytime a resident at risk for elopement or wearing wander guard was walking outside with someone or towards outside, the staff member was to ask that person if the resident was signed out. The elopement binders are at each nurses' station and had a list of all residents at risk for elopement and wearing wander guards along with pictures of these residents . Monitoring tool was placed in the residents sign in/out binder to ensure the daughter (resident #2) was notified every time resident #2 signs in/out. ADON/CNA Supervisor would monitor the sign in/out sheet weekly times 60 days, then monthly times 2 months and she would survey all employees on knowledge of procedure weekly times 60 days, then monthly times 2 months. All procedures and forms would be QA'd first quarter of 2018. 9. This issue would be added to QA process. Resident left the facility without signing out. See above numbers 1-8 for interventions. Evaluation was ongoing. 10. All these measures were completed on 1/30/2017 This deficient practice continued at a potential for more than minimal harm for the facility's remaining 4 residents (#1, 3, 4, and 5) in the sample. Findings: Observation on 2/2/17 at 10:20 a.m. revealed resident #2 sitting in front of the north nurses' station watching television. She was observed to have a wander guard bracelet on her right wrist. The resident was ambulatory and walked to the front entrance door with S2 DON and surveyor. As the resident approached the door, the alarm system sounded behind the north nurses' station. The staff was observed to reset the alarm. Observation on 2/2/17 at 10:41 a.m. revealed S4 Maintenance Supervisor and resident #2 approached the front entrance door again and the alarm system sounded. S4 Maintenance Supervisor and resident #2 were observed to walk 48 steps to the curve, at which time the alarm system was noted to reset (stop alarming). According to an Internet Steps to Foot and Steps to Yard calculator, 48 steps is equal to 120 feet or 40 yards. Interview on 2/3/17 at 2:30 p.m. with S4 Maintenance Supervisor confirmed it was 48 steps from the entrance front door to the curve. He stated that once a resident gets out of range of the ProtecPoint monitor (alarm system), the monitor resets automatically. Review of resident #2's Face Sheet revealed [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS with an ARD of 1/19/17 revealed the resident had a BIMS score of 4 (Severe Impairment). The MDS further revealed the resident was ambulatory with supervision. Review of resident #2's Quarterly Elopement Risk Evaluation dated 1/19/17 revealed she was occasionally disoriented, ambulatory, and had not wandered or attempted to leave the facility. The above dated evaluation read that the resident scored 10, and a score greater than 10 indicated the resident was a risk for elopement. However, interview of the S2 DON on 2/6/17 at 2:00 p.m. revealed the resident wandered the facility with little assistance, and should have been scored as being at high risk for elopement. Review of the resident's Comprehensive Plan of Care with an onset date of 1/27/15 and a target date of 4/19/17 revealed the resident was High Risk for elopement. The goal read: Will remain safe within facility unless accompanied by staff other authorized persons through review 4/19/17. Care plan approaches included: Complete elopement risk assessment per facility protocol; assess/record/report to MD risk factors for potential elopement such as wandering, repeated requests to leave facility, statements such as I'm leaving, I'm going home; attempts from previous facility or hospital; supervise closely and make regular compliance rounds whenever resident is in the room; discuss with resident/family risks of elopement and wandering; if resident is wandering in potentially unsafe area or situation, redirect to safer area, and reassess regularly; take photograph of resident to maintain on file for identification purposes, with family or resident consent; if resident is missing from facility, follow elopement protocol, notify MD and family immediately/document;wander guard as directed; and every 30 minutes monitoring. Review of Client Incident Report (CIR) written by S3 ADON revealed it was reported to her around 9:00 p.m. on 1/29/17 that resident #2 had left the facility around 5:30 p.m. with another resident's family. Further review of the CIR revealed the couple realized resident #2 was confused so they brought her back to the facility. Interview on 2/2/17 at 12:00 p.m. with S3 ADON revealed S7 LPN Agency Nurse notified her around 9:30 p.m. of the incident. S3 ADON stated S7 LPN Agency Nurse should have immediately reported the incident to administration. Review of a Grievance/Complaint Report dated 1/30/17 revealed resident #2's daughter was concerned about the incident from the weekend. Further review of the Grievance/Complaint Report revealed the daughter received a phone call from the charge nurse on 1/29/17 stating that another resident's family member had left with her mother in a vehicle. Interview on 2/2/17 at 10:20 a.m. with S2 DON revealed the resident was not on the list for High Risk for Elopement. She stated resident #2 had Dementia with sundowners and every evening between 4:30 p.m. and 5:00 p.m. the resident would grab her purse and she would state I want to go home! Interview on 2/2/17 at 12:15 p.m. with S3 ADON revealed it was the responsibility of the person sitting at the nurses' station to monitor the alarm system and observe the door for residents' safety. However, she stated they did not have a Ward Clark on duty on Saturday (1/28/17) or Sunday (1/29/17) after 4:00 p.m. to sit at the nurses' station. Interview on 2/2/17 at 12:25 p.m. with S1 Administrator revealed it was the responsibility of the person sitting at the nurses' station to monitor the alarm system and observe the door for residents' safety. S1 Administrator stated after 4:00 p.m. it was the responsibility of the floor nurse and the CNAs to monitor the alarm system and observe the door for safety. Further interview with S1 Administrator on the above date and time revealed resident #2 left the facility with another resident's family. He also stated that S5 CNA was outside on a break and watched resident #2 get into the vehicle with another resident's family. S1 Administrator stated S5 CNA thought resident #2 was with her family. Interview on 2/2/2017 at 1:44 p.m. with S2 DON revealed the Ward Clerk worked until 4:00 p.m. on the weekends. She stated that once the Ward Clerk left, a CNA or a nurse would be responsible for sitting at or near the nurses' station to monitor the alarm system and observe the door entrance. Interview on 2/3/17 at 9:16 a.m. with S7 LPN Agency Nurse revealed on 1/29/17, she administered resident #2's evening medications around 5:00 p.m. and then the resident went and sat down across from the north nurses' station. Further interview with S7 LPN Agency Nurse revealed she continued her evening medication pass down the middle hall (out of view of the front entrance door). She confirmed the middle hall did not allow her to observe the front door for safety. S7 LPN Agency Nurse stated S5 CNA and S6 CNA were passing supper trays in the dining room and on the hall out of view of the facility's front entrance door. Further interview with S7 LPN Agency Nurse revealed after passing her medications she returned to the north nurses' station and she observed S5 CNA walking resident #2 back into the building. S5 CNA reported resident #2 had left out of the building and got into a vehicle with another resident's family members. S7 LPN Agency Nurse confirmed there was no staff sitting at the nurses' station when resident #2 exited the front door, and she had not been informed to leave a CNA at the nursing station after the Ward Clerk went home. Continued interview with S7 LPN Agency Nurse revealed the door alarm would sound all the time, but she observed that there were no residents trying to leave out of the door. S7 LPN Agency Nurse stated if a resident was wearing a wander guard bracelet and passed in front of the door, the alarm would sound. She revealed if a resident with wander guard was taking a shower on the north long hall, the alarm would sound. Interview on 2/3/17 at 9:51 a.m. with S5 CNA revealed she was passing supper trays in the dining room and on the north hall on 1/29/17 around 4:50 p.m. when resident #2 walked out of the facility. She stated resident #2 complained of stomach pains and she did not want to eat supper. S5 CNA revealed resident #2 was sitting across from the north nurses' station when she (S5 CNA) went into another resident's room to set up the other resident's meal tray. S5 CNA stated while in the other resident's room, she heard the alarm sounding; however, she continued to set up the other resident's meal tray. She stated she did not stop to observe if a resident was at the front door. S5 CNA revealed the alarm stopped sounding before she left the other resident's room. Further interview with S5 CNA revealed around 5:05 p.m. she went outside for a 10 minute break and she observed resident #2 getting into a vehicle. S5 CNA stated she thought resident #2 was getting into the vehicle with her family. She revealed the vehicle made a loop around the facility's parking lot and returned around 5:05 p.m. She further stated a man got out of the vehicle and asked Are you missing a resident? and S5 CNA stated Yes. Interview on 2/3/17 at 10:41 a.m. with the man resident #2 got into the vehicle with, revealed on Sunday 1/29/17, around 4:30 p.m. or 5:00 p.m. he drove his vehicle to the curve where his girlfriend was standing along with resident #2. His girlfriend asked him if they could give resident #2 a ride to her daughter's house. The man stated resident #2 appeared to be normal and was dressed appropriately with her purse in her hand. The man stated resident #2 got into his vehicle, but could not explain where her daughter lived. They then realized resident #2 was very confused, so he made a loop around the facility's parking lot and drove her back to the curve. The man stated as he pulled up to the curve, he saw staff outside and they appeared to be looking for someone. The man stated he asked staff Are you missing a resident and they replied Yes. The man revealed staff stated resident #2 would get very confused at times and they had to keep a close watch on her at all times. Interview on 2/6/17 at 2:00 p.m. with S2 DON revealed resident #2 was not identified on her last Quarterly Elopement Risk Evaluation dated 1/19/2017 as High Risk for elopement; however, resident #2 had Dementia and would get very confused in the evening. S2 DON stated resident #2 was ambulatory and wandered the facility with little assistance, and maybe her last Quarterly Elopement Risk Evaluation was not accurate. She confirmed resident #2 should have been coded as High Risk for elopement.

Based on interview and record review the facility failed to ensure staff adequately supervised 1 (#1) of 3 (#1, #3 and #5) sampled residents assessed by the facility as being at high risk of eloping from the facility and taking resident #5 (a wheelchair bound resident) with her. The facility failed to: 1. Have a system in place to ensure Resident #1, diagnosed with [REDACTED].#5, a wheelchair bound resident, diagnosed with [REDACTED]. 2. Increase monitoring and supervision for Resident #1 who had a history of [REDACTED]. This resulted in an Immediate Jeopardy situation on 10/02/15 at 6:00 p.m. when Resident #5 (who was wheelchair bound), was taken out of the facility by Resident #1 and left in the drive thru at a local bank. Resident #1 returned to the facility without Resident #5. Interview with facility staff revealed that they were unaware that Resident #1 left the facility with Resident #5. S14 ADM, S2 DON and S4 ADON were notified of the Immediate Jeopardy situation on 11/09/15 at 3:34 p.m. A plan of removal was submitted by S1 DON and S4 ADON on 11/10/15 at 10:47 a.m. and Included: 1. All residents who require the wander guard (decision made per DON/ADON) will have a wander guard in place. If they have a wander guard on and get hospitalized , the wander guard is to be placed back on the day that they get back from the hospital. If they go inpatient psych due to elopement or elopement attempts, they are to be on 72 hour close monitoring upon return from psychiatric hospital. Our close monitoring system will now be every 15 minutes x 48 hours, then every 30 minutes x 24 hours. New continued monitoring forms were created. The care plan will show evidence for those residents having a wander guard. All residents who are at risk for elopement will be monitored every 30 minutes. 2. All residents who are identified as having the need to have wander guard due to wandering or attempted/actual elopement will have a wander guard in place on them and it will be monitored on the treatment record. Our close monitoring system will now be every 15 minutes x 48 hours, then every 30 minutes x 24 hours. New continuing monitoring forms were created. The care plan will show evidence for those residents having a wander guard. All residents who are at risk for elopement will be monitored every 30 minutes. 3. In-service of staff beginning 11/09/15 to make sure to know where a resident is at when door alarms go off, edit out elopement policy to ensure a wander guard is put on upon return from hospital, if they had one prior to hospitalization . When door alarms go off, employees are to page, Roam Alert - Doors. Employees will page Clear Roam Alert. All residents who are at risk for elopement will be monitored every 30 minutes. 4. ADON will start a QA monitoring form weekly x 2 months, twice monthly x 2 months, and monthly x 4 months. Monitoring form will verify that all residents having a wander guard will have the wander guard on them, will have it care planned, and will be monitored on daily treatment record. 5. QA process will begin on 11/09/15. New measures will be put into effect on 11/09/15. The Immediate Jeopardy was removed on 11/10/15 at 10:47 a.m. The deficient practice continues as a potential for more than minimal harm. According the Resident Census and Condition of Residents Form the facility had a census of 70. Findings: A review of the facility's Elopement Policy revealed the following: 1. All residents will be assessed upon admission, then quarterly via the MDS process to identify residents at risk of elopement. 3. Residents at risk of elopement will be monitored every 2 hours. Documentation of such will be on the Certified Nursing Assistant Flow Sheets. 4. The residents care plan will reflect elopement risk and interventions. 6. If a resident wanders, become disruptive or intrusive to other residents a monitoring system will be put in place to ensure residents safety and privacy. RESIDENT #1 Observation of resident #1 on 11/06/15 at 10:00 a.m. revealed her sitting in her room. The resident was noted to have a wander guard in place to her right ankle. Interview of the resident at that time revealed she was able to state her name, but did not know the time or place. The resident was not able to recall any incidents of leaving the facility without the staff's knowledge. Review of the October 2015 physician's orders [REDACTED]. Review of the resident's Quarterly Elopement Risk Evaluation revealed the following: 2/23/15 - the resident was oriented not determined/disoriented occasionally, was complacent, ambulatory, mobility was slightly limited, and had not wandered or attempted to leave facility. The Elopement Risk Evaluation revealed a score of 9; and according to the Elopement Risk Evaluation, a score of less than 10 revealed the resident was not at risk for elopement. Review of the 14 Day Medicare assessment dated [DATE] revealed the resident as coded to have a BIMS of 9 which indicated the resident was moderately impaired cognitively; required supervision for transfers, dressing, eating, toilet use, personal hygiene and walk in room; required limited assistance of 1 person for walk in corridor and locomotion on unit; and extensive assistance of 1 person for locomotion off unit. The resident was also coded to have no ROM limitations for upper and lower extremities. Review of the March 2015 Nursing Notes revealed the following: 3/25/15 at 9:15 a.m. - resident returned to facility per an apartment staff member, who stated the resident was found visiting there and returned her to the nursing home. 3/25/15 at 11:00 a.m. - resident wandering, constantly moving, does not stay still, and constantly worrying about her son. 3/25/15 at 2:02 p.m. - resident found in parking lot on north side, pushing son in wheelchair. Resident returned to the facility in stable condition. 3/25/15 at 2:20 p.m. - Doctor aware of resident's behavior, will refer to day program. 3/26/15 at 2:30 p.m. - Resident's wander guard in place, and resident is requesting scissors to cut bracelet off. Resident became angry when told she could not remove the bracelet. 3/26/15 at 3:45 p.m. - Resident noted to not have wander guard bracelet on. When resident was asked about the bracelet she stated, I threw it in the trash. Close monitoring in progress. 3/27/15 at 3:42 p.m.- Left in stable condition to a senior care psych facility. Review of the Resident Care Record for Risk of Elopement revealed the resident was monitored every 2 hours according to the facility's elopement policy, on 03/26/15 and 3/27/15, and from 04/15/15 to 04/30/15 for elopement. There was no documentation to reveal that increased monitoring of the resident was initiated and implemented after the resident's return to the facility from the behavioral hospital on [DATE]. Review on a H&P from the senior care hospital dated 3/27/15 revealed the resident with fairly severe dementia. She had been trying to wander off and elope on two occasions. She tries to care for her son in the NH and interferes with nursing's ability to care for him. She feeds him although he is NPO and dumps his Foley which interferes with accurate I&O tracking. Review of the resident's MDS Quarterly assessment dated [DATE] revealed a BIMS score of 6, which indicated severe cognitive impairment. Further review revealed the resident wandered 1-3 days, required supervision with walk in room/corridor, locomotion on unit, dressing, eating, toilet use, and personal hygiene, and required extensive one person assistance with locomotion off unit. Review of the resident's Quarterly Elopement Risk Evaluation revealed the following: 8/21/15 - the resident was oriented not determined/disoriented occasionally, was complacent, ambulatory, full mobility, and wanders the facility but does not try to leave. Review of the Elopement Risk Evaluation revealed a total score was 15, and according to the evaluation, a score greater than 10 indicated a high risk for elopement. Review of the Nursing Notes dated 10/02/15 - 10/05/15 revealed the following: 10/02/15 at 6:00 p.m. - Resident pushed another resident in her w/c to the bank and left her there, and returned to the nursing home. No injuries noted. 10/03/15 at 10:00 a.m. - Close monitoring in place. 10/03/15 at 8:00 p.m. - Close monitoring in place. 10/04/15 at 10:00 a.m. - Close monitoring continues. 10/04/15 at 8:00 p.m. - Close monitoring in progress. 10/05/15 at 10:45 a.m. - Resident left in stable condition for admission to senior care psych facility. Review of the Admit Note from the senior care hospital dated 10/05/15 revealed the resident had a history of [REDACTED]. She was starting to become a bit more agitated, paranoid, and resistant to redirection. She had extremely poor boundaries with trying to help out. Impression: Alzheimer's with Behavioral Psychosis, Depression with moderate psychosis. Plan: Add a low dose of antipsychotic, primarily Seroquel, consider adding a mood stabilizer and see how she does in a structured environment. Discuss with the NH possible use of wander guards. She will be at a high risk for elopement. Interview on 11/06/15 at 10:50 a.m. with S9 LPN revealed she was the nurse for the resident. She stated the resident had to be watched very closely, because she wandered around the facility. She stated the CNAs monitored her often, but was not sure how often. She stated she was not working on 10/02/15 when the resident eloped and did not know how it happened. She stated the resident was always making comments that her family was coming to get her. Interview on 11/06/15 at 11:10 a.m. with S12 CNA revealed she took care of the resident and she usually worked 6:00 a.m. to 2:00 p.m. She stated the resident was a high risk for elopement and she monitored her every 20-30 minutes. She stated she was not present on 10/02/15, the day the resident eloped from the facility. She stated the resident often goes to the other end of facility to visit her son. She stated whenever the resident is not in her room or in the hall she immediately goes to the other hall to check on her. S12 CNA stated she was not sure if the resident had a wander guard, but there is a list at the nursing station of residents with wander guards. She stated she just monitors the resident more often because of her behaviors. She stated the resident is often found pushing the other residents around the facility to their rooms, the bathroom, the dining room, etc. She stated the resident does not respond well to redirect, and becomes angry. She stated the resident initially resided on the other hall near her son when she came in the facility, but was moved approximately 5 months ago, to her current hall after interfering with her son's care. She stated since the resident was moved to her current hall her wandering behavior has increased, and she is often found packing her bags to go home. Interview on 11/06/15 at 11:20 a.m. with S1 DON revealed the resident had a wander guard placed on her on 3/26/15 after she eloped, but was cutting it off. She stated the staff should have replaced the wander guard after each incident of cutting it off. She stated she was not able to confirm if the resident was wearing a wander guard when she eloped on 10/02/15. S1 DON stated after the resident eloped on 3/25/15, she was admitted to a behavioral hospital on [DATE] and discharged to the nursing home on 4/15/15. The surveyor requested documentation to ascertain resident #1 had a wander guard placed on her after she returned to the nursing facility from the behavioral hospital on [DATE]. A telephone interview with S3 LPN on 11/06/15 at 12:20 p.m. revealed she cared for resident #1 from 6:00 a.m. to 6:00 p.m. on 10/02/15. She stated the resident eloped that day, but was back in the facility before staff became aware of the incident. She stated resident #1 wheeled another resident out of the facility and left her at another location and returned to the facility. She stated when the other resident was returned to the facility she pointed to resident #1 and stated that resident #1 had wheeled her out. She stated resident #1 said, Well, I'm never doing that again. She stated resident #1 did not have a wander guard in place at the time because she kept cutting off wander guards. She stated staff tried to replace the wander guards, but the resident destroyed 2-3 wander guards. She stated the resident did not have a wander guard for a long time. She estimated that in the month of September 2015 and early October 2015, the resident had no wander guard in place. Interview with S1 DON on 11/06/15 at 12:45 p.m. revealed there was no documentation of resident #1 having a wander guard in place once she returned from the behavioral hospital on [DATE]. She confirmed that the resident was placed on every 15 minute monitoring after eloping on 10/02/15 at 6:00 p.m. until 10/05/15 at 6:00 a.m. She further stated the resident was then transferred to a behavioral hospital on [DATE] at 10:45 a.m. Interview on 11/09/15 at 11:00 a.m. with S1 DON and S4 ADON revealed any resident who scored at high risk for elopement was reviewed by ADON and SW to decide about wander guard placement. S1 DON and S4 ADON stated after determining that a resident required a wander guard, the treatment nurse was then notified to place the wander guard on the resident, and to monitor the resident's wander guard every day for placement and function. Interview on 11/09/15 at 11:20 a.m. with a local pharmacy employee revealed on 10/02/15 at approximately 5:00 p.m. while going to the bank, she noted resident #5 sitting in her wheelchair in the drive thru at the bank. She stated she asked the resident how she got there, and the resident replied, a lady in the nursing home was coming to the bank and brought me. I told her to go back to the nursing home because I was close to my house. The pharmacy employee stated that the resident was only a couple of houses down from her home, and was trying to get to her home. She stated she called the residents' daughter, then wheeled the resident back to the nursing home through the hospital ER entrance. She stated when she arrived at the nurse's station, the residents' daughter was on the phone with the nurse inquiring about her mother. The pharmacy employee and the surveyor walked to the local bank where the resident was found. The pharmacy employee stated that there were two possible routes from the nursing home to the bank. The pharmacy employee stated the first route involved taking the main road to the bank, and due to the absence of sidewalks the resident would have had to be wheeled on street (which is a high traffic street) to get to the bank. The second route involved going across the hospital parking lot and crossing a side street (that had frequent traffic) to get to the bank. A telephone interview with S13 CNA on 11/09/15 at 11:50 a.m. revealed he cared for the resident on the 2:00 p.m. to 10:00 p.m. shift on the evening of 10/02/15. When asked if he was aware of the resident having a wander guard in place at any time he stated, I started working around August 2015 and never knew her to have a wander guard. He stated he knew she was at risk for elopement and observed her every 2 hours for elopement. An interview on 11/09/15 at 12:05 a.m. with S4 ADON revealed that resident #1 was identified per her assessment on 5/22/15 as requiring a wander guard, based on her wandering, disruptive, and intrusive behavior. She stated the resident was also identified after an elopement on 3/25/15 as being at high risk for elopement, and a wander guard was placed on the resident at that time. She stated that the resident cut the wander guard off and was sent to the behavioral hospital on [DATE], and returned to the nursing facility on 4/15/15. She confirmed that there was no documentation in the resident's clinical record from 4/15/15 when she returned from the behavioral hospital until her second elopement on 10/02/15, of the resident being monitored daily for wander guard placement and function. She further confirmed there was no care plan initiated for the resident refusing, resisting, or removing her wander guard. An interview on 11/09/15 at 12:15 p.m. with S8 Treatment Nurse revealed she remembered the resident being resistant to the wander guard placement after her elopement on 3/25/15, but was unable to remember dates. She stated she could not recall being directed by either the S1 DON or the S4 ADON to place a wander guard on the resident after her return from the hospital on [DATE]. She stated she did receive a directive to place a wander guard on the resident on her return from the hospital on [DATE], and that she had been monitoring the wander guard daily for placement and function since then. Interview on 11/09/15 at 12:30 p.m. with S6 MDS revealed the facility only completed elopement evaluations every quarter and not after an incident of elopement. She stated to her knowledge a wander guard was automatically placed on a resident after an elopement incident. She stated she recalled that resident #1 had cut off her wander guard. She stated she could not remember if the resident's wander guard was placed back on her when she returned from the hospital on [DATE]. She stated when the resident was identified on her 5/22/15 elopement assessment as high risk, the S1 DON received the report, and this should have triggered use of the wander guard. She stated the care plan should have been changed to reflect interventions for high risk for elopement and her behavior of cutting off the wander guard. Interview on 11/09/15 at 12:45 p.m. with S7 MDS revealed when asked if the resident had problems with the wander guard, or if she had a wander guard on her return from the hospital, She replied, I have no knowledge if she had a wander guard at that time, or if she was removing her wander guard. Interview on 11/09/15 at 12:50 p.m. with S1 DON revealed that she usually would tell the staff to put a wander guard on a resident requiring one, but did not remember what happened with resident #1's wander guard not being replaced on return from the hospital, or any other interventions after being assessed on 5/22/15 for high risk for elopement. She stated, I guess it was a system failure. Interview on 11/09/15 at 2:14 p.m. with S11 CNA Supervisor revealed she received directives from the S4 ADON to place a resident on every 2 hour monitoring after being assessed as being at high risk for elopement. She stated once they were identified as high risk, she placed a sticker on the Resident Care Record to alert the CNAs to monitor every two hours, and activate the Code Silver immediately if unable to locate a resident. Observation of the resident on 11/09/15 at 1:15 p.m. revealed her going through the front door with a nursing home employee and her wander guard alarmed at that time. RESIDENT #5 Review of resident #5's physician's orders [REDACTED]. Review the Resident Elopement Attempts form dated 10/02/15 revealed an incident form was completed, notified on call nurse/administrator, implemented close monitoring form and placed in MAR, family notified, and documented in nurses notes. Review of the Quarterly Elopement Risk Evaluation dated 9/9/15 revealed the resident was not disoriented, was complacent, was ambulatory with 2 person assist, mobility was slightly limited, and had not wandered or attempted to leave facility. The resident scored a 4, a score of greater than 10 represents a resident is an elopement risk. Observation of the resident on 11/05/15 at 1:10 p.m. revealed her sitting in wheelchair at her room door. The wheelchair was noted to have an alarm system attached to the back. The resident was noted to have a wander guard bracelet to her right wrist. Interview of resident #5 at that time revealed she was oriented to her first name only, and was confused. Interview with resident #5's daughter on 11/4/15 at 1:40 p.m. revealed she received a call from her cousin on 10/02/15 stating that her mother was kidnapped. She stated her cousin worked at a pharmacy near the nursing home and she saw her mother strapped in a w/c in the drive through window at the bank. She stated her mother had Alzheimer's and had been in the nursing home approximately one month. Resident #5's daughter stated her cousin asked her mother what she was doing there and she stated, Isn't my house around the corner? She stated her mother told her a lady brought her to the bank because she was going to give her a ride to her house, but she told the lady she could make it from there to home. Resident #5's daughter stated her mother was confused about the operation of the w/c and had difficulty maneuvering the w/c, she also stated the w/c had an alarm on the seat. She stated her cousin then returned the resident to the nursing home. Resident #5's daughter stated she called the nursing home, and as she was talking to the nurse her mother was being returned to the facility. She stated she visited her mother every day and since the incident the nursing home had placed an alarm on her wrist that signals if she leaves out the door. Review of the Daily Skilled Nurse's Note dated 10/02/15 at 6:00 p.m. and documented by S10 LPN revealed the following: the resident was found by the pharmacy personnel at the bank in her w/c. The pharmacy personnel pushed the resident back to the nursing home in stable condition, resident stated a lady in red pushed her to the bank and left her there. Family member was aware. The doctor was made aware in a fax, and the S1 DON aware. Review the Resident Elopement Attempts form dated 10/02/15 revealed an incident form was completed, notified on call nurse/administrator, implemented close monitoring form and placed in MAR, family notified, and documented in nurses notes. A telephone interview with S3 LPN on 11/05/15 at 12:05 p.m. revealed she was working the day the resident eloped from the facility. S3 LPN stated she received a phone call from the residents ' daughter asking where her mother was. S3 LPN stated she told the daughter to hold on she would check. S3 LPN stated when she went to check she met the pharmacy personnel walking up to the nursing station pushing the resident in her wheelchair. She stated she checked the resident for injuries, took her v/s, contacted the MD per fax, and started every 15 minute monitoring of the resident. S3 LPN stated she was in the dining room with the resident until 5:00 p.m. or 5:30 p.m. prior to the incident. S3 LPN stated she received the resident from the pharmacy personnel at 6:00 p.m.