Every finding on record at Shady Grove Nursing and Rehabilitation Center

Based on complaint, reviews of a closed clinical record and all other pertinent administrative documents, and interviews with a resident and the facility staff, it was determined that the facility staff failed to notify the resident of a proposed room change in writing before the staff moved the resident's belongings to a new room without his/her knowledge. This was evident for 1 (Resident #4) of 5 residents reviewed during a complaint survey. The findings include: On 6/18/26 at 10:46 am the Office of Health Care Quality received a complaint (3048023) from another State agency that indicated Resident #4 was inappropriately discharge from the facility. A review of Resident #4's closed medical records on 08/27/26 revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that include but are not limited to diabetes and significant ambulatory dysfunction. Resident #4 required assistance for many aspects of his/her care upon admission. The facility staff conducted a BIMS assessment and determined that Resident #4 had a BIMS score of 14/15 on 02/16/26. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. In a telephone interview with Resident #4 on 08/28/26 at 12:10 pm, Resident #4 stated that his/her belongings in the room s/he was residing in were moved to a different room without his/her knowledge when s/he was participating in therapy. Resident #4 stated that s/he was in a private room that was quiet before the staff changed his/her room to a semi-private room. In an interview with the nursing unit manager (RN#1) on 08/31/26 at 1:14 pm, RN#1 stated that Resident #4 was moved to a different room on a different nursing unit on 03/13/26. RN#1 stated that Resident #4's room was changed because management told me to move Resident #4 in a new room. RN#1 also stated that the facility ran out dually certified beds in the facility. RN#1 stated that s/he could not recall who instructed him/her to move Resident #4 to a new room. RN#1 also stated that social services usually provide copies of the room change to the residents when a room change is discussed. RN#1 stated that s/he had been give written notification of Resident #4's room change but s/he did not provide Resident #4 with a copy of the written notification of the room change. RN#1 stated that s/he only spoke to Resident #4 about a facility-initiated room change.

Based on complaint, reviews of a closed clinical record and all pertinent administrative records, and resident and staff interviews, it was determined that the facility failed to implement an effective discharge planning process before discharging Resident #4 home. This was evident for 1 (Resident #4) of 5 resident reviewed during a complaint survey. The findings include: The discharge care plan is part of the comprehensive care plan and must: Be developed by the interdisciplinary team and involve direct communication with the resident and if applicable, the resident's representative; Address the resident's goals for care and treatment preferences; Identify needs that must be addresses before the resident can be discharged , such as resident education, rehabilitation, and caregiver support and education; Be re-evaluated regularly and updated when the resident's needs or goals change; Document the resident's interest in, and any referrals made to local contact afency; and identify post-discharge needs such as nursing and therapy services, medical equipment or modifications to the home, or ADL assistance. On 6/18/26 at 10:46 am the Office of Health Care Quality received a complaint (3048023) from another State agency that indicated Resident #4 was inappropriately discharge from the facility. A review of Resident #4's admission social work admission progress note dated 02/12/26 at 11:29 am, Social worker #2 (SW#2) documented an interview with Resident #4 from 8:45 am to 10 am regarding his/her reason for admission. Resident #4 informed SW#2 that S/he was involved in suspected elder abuse. The perpetrator was allegedly Resident #4's personal aide at home. Resident #4 stated that the alleged perpetrator pulled out his/her telephone land line, taken the keys to his/her home, destroyed telephone number logs by ripping out the pages, and had thrown out some of his/her medical records, and thrown away some of her personal number logs from a notebook by ripping out some of the pages. Resident #4 detailed how the alleged perpetrator left him/her on the floor until being found by a neighbor who notified the local police.A review of Resident #4's closed medical record review was conducted on 08/27/26 at 12:30 pm which revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that include but are not limited to diabetes and significant ambulatory dysfunction. Resident #4 required assistance for many aspects of his/her care upon admission. The facility staff conducted a BIMS assessment and determined that Resident #4 had a BIMS score of 14/15 on 02/16/26. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. A review of Resident #4's admission care plans revealed a discharge care plan, dated 02/14/26, that indicated Resident #4 was going to be admitted on a short term and return to the community. The goal indicated Resident #4 will return to the community successfully when ready through the review period. Interventions included; coordinate with physician regarding discharge plan as indicated; refer for community resources as indicated and per resident/resident representative preference; review and update discharge plans with the resident when needed. There were no other updates to Resident #4's discharge care plan prior to him/her being discharged on 05/22/26. A review of Resident #4's business office progress notes that were provided to the surveyor on 08/28/26 at 12:50 pm, the business office manager documented that in an interview with Resident #4 on 05/15/26 at 10:43 am the business office manager informed Resident #4 that s/he will have had exhausted his/her 100 Medicare A days on 05/21/26. The business office manager informed Resident #4 that s/he would be responsible for cost out of pocket from 05/22/26. Resident #4 state s/he understood but that s/he would need help assistance getting home. The business office manager informed Resident #4 that the facility will not pay for his/her transportation home for patients. After discussions with the facility administrator, the facility stated they would pay for a local UBER taxi home for Resident #4. Resident #4 informed the business office manager that his/her former personal care giver had his/her keys to his/her home. A review of SW#1's 05/15/26 3:46 pm discharge planning progress note indicated Resident #4 received a NOMNC (Notice of Medical Non-Coverage) on 05/15/26 with a last day of services being 05/21/26 with a proposed discharge date of 05/22/26. The SW#1 progress note also noted Resident #4 did not want to appeal the discharge but disclosed the former personal care aide s/he had was in possession of Resident #4's house keys and that s/he does not have access into his/her home. A review of SW#1's discharge planning progress note dated 05/21/26 at 12:17 pm, Resident #4 informed SW#1 that s/he was concerned about not being able to enter his/her home and that s/he had not been able to contact a locksmith to open the house door. On 05/22/26, Resident #4's physician wrote an order to discharge Resident #4 to home with home health services. A review of Resident #4's 05/22/26 4:17 pm discharge instructions/post discharge plan of care on 08/28/26 revealed a nursing documentation that; 1) Resident #4 was being discharged home under the care of organized home health services organization and that a referral was sent to the local home health agency, 2) Resident #4 is to arrange transportation home, 3) Resident #4 will access to home caregivers and will restart upon resident discretion. No DME was provided to Resident #4 because s/he stated they had a wheelchair and walker at home. In an interview with facility the Occupation Therapist (OT#1) and the director of therapy (COTA#1) on 08/31/26 at 1 pm, OT#1 stated that at the end of Resident #4's therapy, Resident #4 requires should have been discharged with durable medical equipment (DME) that included; grab bars for the shower and toilet, a 3 in 1 commode (has an elevated seat, can be placed over the toilet or used as a bed side commode, and has arm rests). OT#1 stated that s/he provided education and a copy of the home exercise program documents to Resident #4 prior to being discharged home. OT#1 indicated that the facility social workers are that staff members that obtain DME for residents being discharged . In an interview with the Nurse Manager (RN#1) overseeing the care of Resident #4's 05/22/26 on 08/31/26 at 1:14 pm, RN#1 stated that on the day Resident #4 was to be discharged home 05/22/26, there was an issue with Resident #4 not having a set of keys to get into his/her house. On the day of discharge, Resident #4 had to call fire and rescue to gain access inside his/her house. RN#1 stated that s/he helped Resident #4 into the UBER taxi after having discussions with the UBER taxi driver. RN#1 stated the UBER taxi driver ended up calling for 911/police assistance because there was no way for Resident #4 to get into his/her house. RN#1 stated that s/he could not recall if Resident #4 was discharged home with a walker. RN#1 stated that s/he did not update Resident #4's discharge plan of care prior to Resident #4 being discharged home. In an interview with the facility physical therapist (PT#1) and director of therapy (COTA#1) on 08/31/26 at 1:47 pm, during the review of Resident #4's physical therapy documents, PT#1 stated that upon admission Resident #4 was assessed to be a high risk for falls and that it took Resident #4 greater than 2 minutes to get up and go. The physical therapy notes indicated Resident #4 had physical and environmental barriers (steps and stairs) at home before being admitted . The goal for Resident #4's therapy was to return to a prior level of functioning and a safe discharge. A review of Resident #4's discharge physical therapy summary indicated that upon discharge, Resident #4 required the assistance of one person for toileting transfers, assistance from sitting to standing, and assistance from a chair or bed to chair transfers. Resident #4 did not receive any car transfer education or therapy nor any therapy or education on walking 10 feet on uneven surfaces due to safety concerns. Further review of Resident #4's therapy progress documentation, there was documentation that a discharge house assessment was conducted at Resident #4' residence prior to discharge. In an interview with the director of social work (SW#1) on 08/31/26 at 2:54 pm, SW#1 stated that s/he was the staff member in charge of discharge planning for Resident #4. SW#1 stated that s/he emailed the home health agency (HHA#1) on 05/18/26 but did not receive a reply phone call or email regarding the 05/21/26 discharge of Resident #4. SW#1 stated that s/he was next contacted by a second home health agency (HHA#2) on 06/03/26 who indicated they could not provide home health services for Resident #4. On 06/04/26, SW#1 stated that s/he was next contacted by a third home health agency (HH#3) who called regarding Resident #4. SW#1 stated that she was unaware of when (HH#3) would be able to start home health therapy services for Resident #4. SW#1 stated that s/he updates discharge care plans for residents but was unsure if s/he had updated Resident #4's discharge care plan before Resident #4 was discharged home. SW#1 stated that the facility was contacted by Adult Protective Services the day of Resident #4's discharge.

Based on complaint, reviews of a closed clinical record and all other pertinent administrative documents, and interviews with the resident and facility staff, it was determined that the facility staff failed to maintain transfer to the local eyeglass store as indicated in the ophthalmology consultant's discharge/consult note. This was evident for 1 (Resident #4) of 5 residents reviewed during a complaint survey. The findings include: On 6/18/26 at 10:46 am the Office of Health Care Quality received a complaint (3048023) from another State agency that indicated Resident #4 was inappropriately discharge from the facility. A review of Resident #4's closed medical records on 08/27/26 revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that include but are not limited to diabetes and significant ambulatory dysfunction. Resident #4 required assistance for many aspects of his/her care upon admission. The facility staff conducted a BIMS assessment and determined that Resident #4 had a BIMS score of 14/15 on 02/16/26. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. Resident #4 was discharged from the facility on 05/22/26.In a telephone interview with Resident #4 on 08/28/26 at 12:10 pm, Resident #4 stated that s/he was seen and assessed for new eyeglasses by the facility ophthalmologist shortly after admission. Resident #4 stated that the eyeglasses s/he had with him/her were broken. After the ophthalmologist's visit, Resident #4 stated that the ophthalmologist informed him/her that a new prescription for a new set of eyeglasses the order was written in the discharge/consult note. The facility ophthalmologist also informed Resident #4 that the Resident's Medicare payor source would be able to pay for the new set of glasses. Resident #4 stated that s/he refused to obtain a new set of glasses from the ophthalmologist but wanted to go to a local eyeglass store s/he had used in the past. Resident #4 stated that the facility staff told him/her that they would not be able to drive her to the eyeglass store. A review of Resident #4's closed medical record failed to reveal a copy of the ophthalmologist's consult note nor any nursing documentation indicating that Resident #4 was seen by the facility ophthalmologist. A telephone call to the facility ophthalmologist on 08/31/26 at 4:30 pm was unsuccessful. In an interview with the facility director of nurses (DON) on 08/31/26 at 4:45 pm, the DON was able to produce the third page of the facility ophthalmologist consult noted dated 03/13/26 which indicated the referral process was reviewed with Resident #4 and that Resident #4 confirmed that s/he did not want to purchase eyeglasses from the ophthalmologist but the eyeglass store in the community that was previously discussed on 02/13/26 during the initial consultation. The DON confirmed that the facility does provide transportation to eye care providers. In an telephone call with the eye consultant's office manager, the office manager confirmed that Resident #4 was seen by the ophthalmologist twice during his/her stay in the facility (02/13/26 and 03/13/26). A review of Resident #4's ophthalmologist 02/13/26 consult note revealed that Resident #4 was diagnosed with Blepharitis, Blepharitis is a common condition that causes inflammation, swelling, and irritation along the edges of the eyelids, and an order to wipe both of Resident #4's eyes with an eye wipe twice daily. Resident #4 was also ordered to be seen by an ophthalmologist to obtain a set of new eye glasses. Further review of Resident #4's closed record revealed a physician's order dated 02/11/26 instructing the nursing staff to obtain an ophthalmologist consult as needed.

Based on complaint, reviews of a closed clinical record and all other pertinent administrative documents, and interviews with staff, it was determined that the facility staff failed to maintain a medical record in the most accurate. This was evident for 1 (Resident #4) of 5 residents reviewed during a complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.resident records. On 6/18/26 at 10:46 am the Office of Health Care Quality received a complaint (3048023) from another State agency that indicated Resident #4 was inappropriately discharge from the facility. A review of Resident #4's closed medical records on 08/27/26 revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that include but are not limited to diabetes and significant ambulatory dysfunction. Resident #4 required assistance for many aspects of his/her care upon admission. The facility staff conducted a BIMS assessment and determined that Resident #4 had a BIMS score of 14/15 on 02/16/26. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. In a telephone interview with Resident #4 on 08/28/26 at 12:10 pm, Resident #4 stated that s/he was seen and assessed for new eyeglasses by the facility ophthalmologist shortly after admission. Resident #4 stated that the eyeglasses s/he had with him/her were broken. After the ophthalmologist's visit, Resident #4 stated that the ophthalmologist informed him/her that a new prescription for a new set of eyeglasses the order was written in the discharge/consult note. The facility ophthalmologist also informed Resident #4 that the Resident's Medicare payor source would be able to pay for the new set of glasses. Resident #4 stated that s/he refused to obtain a new set of glasses from the ophthalmologist but wanted to go to a local eyeglass store s/he had used in the past. Resident #4 stated that the facility staff told him/her that they would not be able to drive her to the eyeglass store. A review of Resident #4's closed medical record failed to reveal a copy of the ophthalmologist's consult note nor any nursing documentation indicating that Resident #4 was seen by the facility ophthalmologist. A telephone call to the facility ophthalmologist on 08/31/26 at 4:30 pm was unsuccessful. In an interview with the facility director of nurses (DON) on 08/31/26 at 4:45 pm, the DON was able to produce the third page of the facility ophthalmologist consult noted dated 03/13/26 which indicated the referral process was reviewed with Resident #4 and that Resident #4 confirmed that s/he did not want to purchase eyeglasses from the ophthalmologist but the eyeglass store in the community that was previously discussed on 02/13/26 during the initial consultation. The DON confirmed that the facility does provide transportation to eye care providers.

Based on reviews of a closed clinical record, all pertinent facility administrative records, and interviews with the facility staff, it was determined that the facility nursing staff failed to 1) follow the physician's specific pulse and blood pressure parameters before administering cardiac medications to residents, and 2) failed to document an associated blood pressure before administering the cardiac medication. This was evident for 1 (Resident #1) of 4 residents reviewed during a complaint survey. The findings include: A) A review of Resident #1's closed clinical record on 06/12/26 revealed that Resident #1 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation, hypertension, hypotension, and end stage renal disease. Resident #1 was also receiving hemodialysis 3 times a week. Further review of Resident #1's closed clinical record revealed a physician's order dated 05/20/26 instructing the nursing staff to administer the medication, Metoprolol Succinate ER Oral Tablet, Extended Release 24 Hour, give 12.5 MG tablet, by mouth, one time a day for hypertension. Hold the medication if the systolic blood pressure (SBP) is greater than (>) than 110 or the heart rate (HR) is less than 55. Metoprolol succinate (extended release) is a beta-blocker taken once daily to manage high blood pressure, treat chest pain (angina), and lower the risk of heart failure complications. It works by slowing your heart rate and reducing the strain on your heart and blood vessels. Further review of Resident #1's May 2026 medication administration records (MAR) on 06/12/26 revealed the nursing staff failed to withhold the dose of Metoprolol on the following dates and times: 05/20/26, 9 am dose, documented blood pressure: 120/75.05/21/26, 9 am dose, documented blood pressure: 117/68.05/22/26, 9 am dose, documented blood pressure: 137/72.05/23/26, 9 am dose, documented blood pressure: 126/72.05/24/26, 9 am dose, documented blood pressure: 126/70.05/25/26, 9 am dose, documented blood pressure: 128/77.05/26/26, 9 am dose, documented blood pressure: 118/80.05/28/26, 9 am dose, documented blood pressure: 138/84.05/29/26, 9 am dose, documented blood pressure: 138/76.05/30/26, 9 am dose, documented blood pressure: 149/84. B) Further review of Resident #1's closed clinical record revealed a physician's order dated 05/17/26 instructing the nursing staff to administer the medication, Midodrine HCL, 5 mg tablet, given by mouth every 8 hours as needed for hypotension. Hold the medication if the systolic blood pressure (SBP) is greater than 140 mm/Hg. Midodrine is a prescription medication used to treat severe orthostatic hypotension (low blood pressure when standing) by constricting blood vessels, raising blood pressure, and reducing dizziness or fainting. Further review of Resident #1's May 2026 medication administration records (MAR) on 06/12/26 revealed that the nursing staff failed to obtain and document Resident #1's blood pressure, every 8 hours for 14 days, to determine if Resident #1 required a dose of Midodrine for hypotension per physician order.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.The findings include.A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.A review of Resident #3's clinical record on 06/12/26 revealed Resident #3 was admitted to the facility on [DATE]. Resident #3 and their physician in the hospital completed a MOLST form on 05/07/2026 that traveled to the nursing home with the resident.Further review of Resident #3's medical record on 06/12/26 revealed a different Resident MOLST form (Residents #4) had been scanned into Resident #3 electronic medical record. This could pose a problem if Resident #4's MOLST form was sent with Resident #3 to the hospital or doctor's appointment.The facility administrator and director of nurses were made aware of the findings during the exit conference on 06/15/226 at 4 PM.

Based on observations and interviews, it was determined that the facility failed to maintain food storage and food service equipment in a safe and sanitary manner to help prevent potential foodborne illness. This deficient practice was evident for 1 of 1 resident food storage refrigerator reviewed, and during the kitchen tour conducted during the annual survey. The findings include1. On 5/4/2026 at 8:10 AM, the surveyor observed a refrigerator in a dining area on the Ambassador unit. Dried tan and red spills covered one-third of the refrigerator's bottom, which also contained crumbs. A container with lacking a name or date sat on the top shelf of the refrigerator. On 5/8/2026 at 11:30 AM, the surveyor showed the Administrator the refrigerator's location and a picture taken during the 05/04/2026 observation. The Administrator acknowledged the concern, stated the spills happened over the weekend, and confirmed that they subsequently cleaned the refrigerator. Based on observation, and interview with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the kitchen tour of the annual survey. 2. A food-contact surface refers to any surface of equipment and utensils that typically comes into contact with food; or from which food may drain, drip, or splash onto food; or a surface that is usually in contact with food. On 05/07/2026 at 9:00 AM, the surveyor conducted a tour of the kitchen alongside the Healthcare Services Group Regional Manager and identified the following deficient practices: The hand sink near the ware washing station was not dispensing cold water. Multiple cove base tiles were missing throughout the kitchen areas, which created gaps/holes on the wall for possible pests and bacterial harborage. There were multiple gaps/holes in the drywalls, measuring about 12-inch by 24-inch throughout the kitchen and within the kitchen manager's office. The drain lines for the two food prep sinks were leaking grey water directly onto the kitchen floor. The two wall-mounted faucets of the 3-compartment sink were not securely attached to the wall. The two faucets were falling off the wall. The surveyor observed steam, vapor, and heat were escaping from the high temperature conveyor dish machine. In addition, the walls and caulked edges showed significant buildup of mold-like substances. At 2:05 PM, a follow-up tour of the kitchen was conducted with the Administrator, Maintenance Director and the Regional Manager to go over the findings listed above.

Based on complaint investigation, record reviews, and interviews, it was determined that the facility staff failed to ensure a resident was able to exercise the rights to leave the facility against medical advice without interference. This deficient practice was evident for one (Resident # 154) resident reviewed for resident rights during the annual survey. The findings include:On 05/04/2026, the surveyor reviewed complaint intake and medical records for Residents #154.A review of complaint #2807564 revealed the resident reported facility staff physically blocked the door, preventing the resident and the resident's family member from leaving the facility against medical advice (AMA) on 03/05/26. The resident further reported that staff informed the resident, they could not leave the facility because the resident had a peripherally inserted central catheter (PICC) line in place. The resident's family member contacted local law enforcement.On 05/07/2026, a review of progress note written by the Assistant Director of Nursing (ADON) #26 on 03/05/26 revealed the resident was admitted to the facility on [DATE]. During a follow up, the resident expressed dissatisfaction with the care provided and stated a desire to leave the facility and return home. Nursing staff educated the resident on the importance of remaining in the facility to complete prescribed intravenous therapy and explained the risk associated with leaving. Staff also informed the resident that it was unsafe to leave the facility with a PICC line in place due to safety and infection risks. The resident acknowledged understanding of the information provided but continued to insist on leaving the facility. An individual arrived to pick up the resident, which resulted in a disagreement and local law enforcement was contacted. Following the law enforcements assessment, the resident was cleared to leave the facility. During an interview with the ADON # 26 on 05/07/2026 at 12:35 PM, she recalled the incident involving Resident #154 on 03/05/26. The ADON #26 stated an individual who was not listed as the resident's emergency contact arrived at the facility. The ADON reported that the facility was not comfortable allowing the resident to leave with a PICC line while being escorted by an individual unfamiliar to the facility. The ADON further stated that the facility did not physically force the resident to remain in the facility but asked the resident to remain in the facility until local law enforcement arrived.

Based on observation, medical record review, and interviews it was determined the facility failed to document the interdisciplinary team assessed and deemed appropriate for a resident to self-administer medication. This was evidenced in 1 (#70) of 1 resident reviewed for self-administering medication during the survey. The findings include: On 5/7/26 at 8:49 AM, the surveyor conducted an interview with Resident #70. During the interview Resident #70 reported that after the survey team came into the building the staff removed Resident #70's inhaler that was kept at the bedside. On 5/7/26 at 9:04 AM, the surveyor observed Licensed Practical Nurse (LPN) #9 along with Unit Manager (UM) #3 bring Resident #70's his/her inhaler for administration and leave the room with the inhaler. On 5/7/26 9:20 AM, the surveyor conducted an interview, UM #3. The surveyor asked if residents could have inhalers left at the bedside. UM #3 stated that it was allowed and that she was not aware that Resident #70 desired to do so. On 5/7/26 at 9:33 AM, the surveyor conducted an interview with the Director or Nursing (DON). During the interview the DON explained the process before a resident would be able to self-administer medications and keep the medication at their bedside. She stated that an interdisciplinary team would complete an assessment and if appropriate an order would be in place for the resident to self administer the medications. The DON stated she was not aware of any medications kept at the bedside or taken away from Resident #70. Next the surveyor reviewed Resident #70's inhaler orders. On 10/20/25 an order was written for Resident #70 to have Fluticasone Propionate one puff twice a day for wheezing. The order stated may keep at resident's bedside. Additionally, an order placed on 9/16/25 for Ventolin (albuterol) 2 puffs every 8 hours as needed for shortness of breath was written with the same instructions, may keep at resident's bedside. No care plan or assessment was noted for Resident #70 to self medicate and/or keep medications at the bedside. On 5/7/26 at 9:33 at 12:49 PM, the surveyor conducted a follow-up interview with the DON. The DON confirmed that the facility did not complete the process for a Resident to self administer medications and that she had started the process for Resident #70.

Based on observation and interviews, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment with adequate lighting. This was evident for 6 (200, 300, 608, 701, 805 and 908) out of 27 rooms observed during the initial tour and throughout the recertification survey.The findings include:1. On 05/04/26 at 7:50 AM, room [ROOM NUMBER]'s bathroom had a running toilet, a rusted sink, a bucket of fluid beneath the sink, an overflowing trashcan, and a tied bag of trash with rags lying on the floor. On 05/04/26 at 8:20 AM, room [ROOM NUMBER] (Bed A) had stained privacy curtains and water stains located on the ceiling tiles. On 05/04/26 at 9:07 AM, room [ROOM NUMBER] had a large dent located behind the head of Bed A. On 05/04/26 at 9:26 AM, room [ROOM NUMBER] had a flickering light in the bathroom. On 05/04/26 at 11:59 AM, the Administrator and Maintenance Director acknowledged the concern. 2. On 05/06/2026 at 10:50 AM, the surveyor observed that the windowsill in Resident #14 was in a state of disrepair. The bottom right corner of windowsill had detached from the wall and about one inch of the nail was protruding from it. An interview with the Maintenance Director confirmed that the windowsill would be repaired, and the nail would be either removed or secured flushed to the surface to prevent any hazards. At 10:55 AM, the surveyor noted there were two one-door armoire closets in Resident #6's room. However, one of the armoire closet door was missing, while the other armoire closet door was falling off the hinges. In addition, an interview with the resident indicated that the toilet seat was missing from the toilet. The surveyor verified that the toilet seat was missing and observed multiple speckles on the bathroom wall. An interview with the Maintenance Director confirmed that the armoire closet would be removed and/or replaced, a new toilet seat would be provided, and the wall speckles would be sanded down.

Based on interviews and record reviews, it was determined that the facility failed to ensure residents receive written bed hold notice upon hospital transfer. This deficient practice was evident for 2 (Resident #126 and Resident # 1) of 4 resident's reviewed for discharge process during the annual survey.The findings include:1.) During an interview with Resident #126 on 05/04/26 at 4:01 PM, the resident stated they were transferred to the hospital in April 2026 due to a gastrointestinal bleed. The resident further reported that they did not receive bed hold notice information at the time of transfer.A review of Resident #126's electronic health records (EHR) on 05/05/2026, revealed the resident was admitted to the facility in April 2026 to a bed on the 2nd floor of Lifeworks unit. Further review of the records indicated the resident was transferred to the hospital in April 2026, however, the EHR failed to show evidence that the resident was provided with written bed hold information at the time of transfer. Records revealed the resident had decision making capacity at the time of transfer. The resident later returned to the facility in April 2026 and was admitted to a bed on the1st floor of Lifeworks unit. The surveyor reviewed the bed hold concern with the Director of Nursing (DON) #2 and requested evidence supporting that the resident received bed hold information upon hospital transfer.On 05/05/2026 at 12:01 PM, the DON #2 provided a copy of an unsigned, undated bed hold form that was reportedly transported to the hospital with the resident. The DON also provided a copy of a bed hold information email sent by the Discharge Planner #5 to the residents' emergency contact only.During an interview with the Discharge Planner #5 on 05/05/2026 at 12:07 PM, she explained that the resident's emergency contact is identified at the time of admission and this information is used to determine who receives the bed hold information at the time of hospital transfer. She further acknowledged that even when a resident has decision making capacity, the facility's process is to provide the bed hold information to the resident's emergency contact.2.) A review of Resident #1's EHR on 05/06/2026, revealed the resident was transferred from the facility to the hospital in April 2026. At the time of transfer, the resident was identified as their own responsible party. Further review of the records failed to show evidence that written bed hold information was provided to the resident upon hospital transfer.On 05/06/2026 the surveyor requested documentation from the DON indicating Resident #1 was provided with written bed hold information upon hospital transfer in April 2026. The DON provided the surveyor with a Social Worker Assistant progress note dated 05/06/26, documenting that the Social Worker contacted the resident on 05/05/2026, regarding the facility's bed hold policy.

Based on interviews and record reviews, it was determined that the facility failed to provide the resident and/or the resident's representative with a summary of the baseline care plan. This deficient practice was evident for 2 (Resident #1, Resident #23) of 5 residents reviewed for baseline care plans during the annual survey. The findings include:1.) During an interview with the Director of Nursing (DON) #2 on 05/05/2026 at 12:56 PM, the surveyor inquired about the facility's baseline care plan process. The DON #2 stated that the admitting nurse will initiate the baseline care plan at bedside with the resident and/or the resident's representative. She further stated that the resident and/or representative are provided a summary of the baseline care plan. The DON #2 explained that the unit manager is responsible for ensuring baseline care plans are completed and uploaded into the resident's electronic health record (EHR).A review of Resident #1's EHR on 05/06/2026, revealed the resident was admitted to the facility in March 2026. Further review of the records failed to show evidence a summary of the resident's baseline care plan was provided to the resident and/or representative.The surveyor informed the DON #2 that Resident #1's EHR failed to show evidence a summary of the resident's baseline care plan was provided to the resident and/or representative. The DON later followed up with the surveyor and provided a copy of the sign-in sheet for attendees of the baseline care plan meeting. The sign-in sheet contained signatures from a Registered Nurse (RN) supervisor, and an RN; however, there was no signature from the resident and/or the resident's representative. The document failed to show the resident and/or the resident's representative received a summary of the resident's baseline care plan.2.) A review of Resident #23's EHR on 05/07/2026 at 2:52PM, revealed the resident was admitted to the facility in October 2024. Further review of the record failed to show evidence that a summary of the resident's baseline care plan was provided to the resident and/or the resident's representative. The surveyor reviewed the findings with the DON #2 and Discharge Planner #5. Both acknowledged that a summary of the resident's baseline care plan was not provided to the resident and/or the resident's representative.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings composed of an interdisciplinary team after the completion of the Minimum Data Set assessment. This was evident for 3 (Resident #10, #11 and #55) of 3 residents reviewed for care planning during the survey. Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team. The findings include: On 5/6/26 at 11:06 AM the surveyor reviewed Resident #10, #11, & #55's care plan attendance sheets dated 2/20/26, 3/24/26 and 3/10/26 respectively, and noted that in all three care plan meetings only two people were in attendance. One person from the social service department and the other was the resident and/or the Responsible Party (RP). On 5/6/26 at 1:23 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that multiple resident's care plan meetings were conducted with only the social services staff in attendance. The DON confirmed that a care plan meeting should be conducted with an interdisciplinary team and just having the social service staff there was not the expectation.

Based on interviews and record review, it was determined that the facility failed to provide treatments to assure proper care was provided for residents with documented skin issues. This was evident in 2 (Resident #10 and Resident #83) out of 14 residents reviewed for skin integrity during the recertification and complaint surveys. The findings include:1. On 05/04/2026 at 8:15 AM, Resident #83 reported a medical history of herpes and the presence of blisters in the private and buttocks regions that caused discomfort during urination. Resident #83 further indicated that although a request for medication was made to the physician in February 2026 to alleviate the symptoms, the request was not successfully addressed. On 05/06/2026 at 8:30 AM, a record review determined that the resident is immunocompromised. In addition, a progress note revealed that Resident #83 was seen by a Nurse Practitioner (NP) for a comprehensive skin exam on 04/28/2026. The NP's summary stated Patient was seen today for a comprehensive skin exam, patient reports sores present since February. Reported sores cause discomfort with urination. Does not know any current treatment. Reports history of herpes. The comprehensive exam identified two new wounds (private area and buttocks) and their treatments were to be determined but treatment recommendations were listed. The assessment/plan noted: Comprehensive skin assessment performed during skin sweep, initiate treatment as above and further treatment may require testing and/or referral. The orders for Resident #83 were not entered until a week after (05/06/2026) seeing the NP. On 05/06/26 at 10:00 AM, the Director of Nursing acknowledged the concern. 2. On 5/7/26 at 11:49 AM, the surveyor Reviewed Resident #10's medical record. The review revealed a care plan that stated Resident #10 was at risk for worsening pressure ulcers related to frequent incontinence, immobility and inability to turn and repositions independently. Next the surveyor reviewed a weekly wound care note written after a treatment on 5/4/26. The provider documented that Resident #10 was at high risk for sin breakdown related to decreased mobility and comorbidities. Next it was recommended that ongoing pressure reduction and turning/repositioning precautions were provided per protocol. In the assessment plan section the providers wrote, continue carefully off-loading elbow off the edge of the bed. The surveyor did not find documentation that these cares were provided. On 5/8/26 at 6 AM, the surveyor conducted an interview with the Director of Nursing (DON). The surveyor requested documentation that the turning and offloading recommendations for Resident #10 were completed. On 5/8/26 at 7:35 AM the surveyor conducted a follow-up interview with the DON. During the interview the DON stated that on Resident #10's Kardex it was noted that he/she needed to be turned and repositioned often, however, she was not able to provide documentation that these cares were signed off on and/or provided.

Based on review of medical records and interviews it was determined that the facility failed to adequately assist a dependent resident during Activity of Daily Living (ADL) cares. This was found evident for 1 (Resident #80) out of 6 residents reviewed for abuse. The findings include: On 5/4/26 at 8:30 AM, the surveyor conducted an interview with Resident #80. During the interview Resident #80 stated that over the weekend one of the Certified Nursing Assistants (CNA) woke him/her up in the early morning and was rough while providing cares. The surveyor reported the concern to the Director of Nursing (DON). On 5/6/26 at 9:50 AM, the surveyor reviewed Resident #80's medical record. The review revealed that on 4/14/26 a Physical Therapy (PT) evaluation was ordered along with therapy services for 4 weeks. Next the surveyor reviewed the PT notes. A note dated 5/4/26 wrote, Resident #80 provided bed mobility training for rolling with moderate to maximum assistance of 2 to roll to the left and moderate assistance of 2 to roll to the right. Following the PT note the surveyor reviewed a provider note dated 5/1/26 that documented, Resident #10's bed mobility self-performance (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep) as totally dependent - requiring full staff performance. If further stated the Resident #10's ability to roll left to right and the ability from lying on the back to left and right and return to lying on the back was also dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. On 5/8/26 at 11:14 AM, the surveyor reviewed the facility's investigation into the incident. The review revealed that the abuse was unsubstantiated and that Certified Nursing Assistant (CNA) #11 assisted Resident #10 by herself. On 5/8/26 at 11:55 AM, the surveyor conducted an interview with the DON and reviewed the concern that Resident #80 was not assisted with 2 staff members as determined he/she needed in the plan of care during the cares provided by CNA #11.

Number of residents sampled: Number of residents cited: Based on interviews, observations, and record reviews, it was determined that the facility failed to ensure central line dressings were changed according to the physicians' orders. This deficient practice was evident for one (Resident #117) resident review for intravenous therapy during the annual survey. Intravenous (IV) therapy is the administration of parenteral fluids or medications through an IV catheter to treat a condition.A central line (also known as a central venous catheter) is a catheter (tube) that healthcare providers often place in a large vein in the neck, chest or groin.The findings include:On 05/04/2026 at 12:01 PM, during an interview, Resident #117 reported having a central line that was placed while hospitalized . The resident stated the central line dressing had not been changed since admission to facility. The surveyor observed a loose, cloudy dressing covering the central line site. The date on the dressing was 04/07/2026. On 05/05/2026 a review of Resident #117's electronic health records (EHR) revealed the resident was admitted to the facility on [DATE]. Further review revealed physician orders directing staff to change the needless device weekly and as needed, measure the external portion of the central line catheter weekly during dressing changes, and change the transparent dressing weekly during the evening shift. The order further directed staff to initial and label the dressing after each dressing change.During an interview with the Director of Nursing (DON) #2 on 05/05/2026 at 2:05 PM, she explained the facility's process of managing central lines. She stated that central line dressings are changed within 24 hours of admission. The following changes are according to the physician's orders. The surveyor informed the DON #2 of the observation made regarding Resident #117s central line dressing. The DON later followed up with the surveyor and acknowledged that staff failed to change the resident's central line dressing as ordered.

Based on interview and record review it was determined that the facility failed to administer pain medications consistent with professional standards. This was found evident of 1 (Resident #5) out of 4 Residents reviewed for pain management during the survey. The findings include: On 5/7/26 at 7:06 AM, the surveyor reviewed Resident #5's medical record. The review revealed a care plan that was revised on 3/5/26 that stated, Resident #5 was at risk for pain related to a history of falls and abdominal pain. One of the interventions was to administer medication as ordered. Next the surveyor reviewed Resident #5's medications. The review revealed that Resident #5 had morphine sulfate 15mg tables ordered to be given by mouth every 6 hours as needed for severe pain 7-10 as well as tramadol 50mg tablet to be given every 6 hours as needed for pain. Following the medication review the surveyor reviewed Resident #5's May Medication Administration Record (MAR). The review revealed that on May 3rd 2026 at 7:27 PM, Resident #5 rated their pain a 5 out of 10. A dose of morphine sulfate was given even though the instructions stated to give for severe pain 7-10. Additionally, a dose of tramadol was given one minute later at 7:28 PM. On 5/8/26 at 6:00 AM, the surveyor conducted an interview with the Director of Nursing (DON) and during the interview the surveyor reviewed the concern the two pain medications were given at the same time and one of the medications was given out of the pain scale range in the instructions.

Based on record review and interviews with staff, it was determined that the medical provider failed to review the total program of care for 2 (Resident #8 and #5) out of 55 residents reviewed during the survey. The findings include: On 5/6/26 at 12:45 PM, the surveyor reviewed Resident #8's medical record. The review revealed that on 9/29/25 a care plan was created for Resident #8 that stated he/she was experiencing acute signs and symptoms of delirium as well as, Resident #8 was at risk for adverse reactions related to the use of antipsychotic medications. One of the interventions was to have psychiatric services as needed. Next the surveyor reviewed the psychiatric medications ordered for Resident #8 in September of 2025. The medications included Mirtazapine (Remeron) 7.5mg (an antidepressant) to be given nightly and Olanzapine (Zyprexa) 2.5 mg (an antipsychotic) also to be given nightly. On further review on 11/19/25 Zyprexa was decreased by half and was ordered to be given a half a tablet (1.25mg) nightly. Following the medication review the surveyor reviewed Resident #8's psychiatric notes. Psych services saw Resident #8 on 12/14/25 and documented that Resident #8 was on Zyprexa 1.25mg, however, documented the dose was twice a day. Additionally there was no mention of the Remeron that was ordered for Resident #8. On 2/21/26, 3/22/26 and 4/15/26 the psych note documented the Resident #8 was on Remeron, however, continued to document that Zyprexa 1.25mg was given twice a day. Next the surveyor reviewed Resident #8's medical care provider note dated 5/1/26. The note listed all Resident #8's prescribed medications, however, Zyprexa was listed as a full tablet of 2.5mg nightly. This dose had not been given since November 2025 when it was decreased to half. On 5/8/26 at 6:00 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that both the psychiatric and medical providers were not accurately reviewing and/or documenting Resident #8's prescribed medications regimen. 2) On 5/7/26 at 7:06 AM, the surveyor reviewed Resident #5's medical record. The review revealed a care plan that was revised on 3/5/26 that stated, Resident #5 was at risk for pain related to a history of falls and abdominal pain. One of the interventions was to administer medication as ordered. Next the surveyor reviewed Resident #5's medications. The review revealed that Resident #5 had an order of morphine sulfate 15mg tablet to be given by mouth every 6 hours as needed for severe pain 7-10 as well as tramadol 50mg tablet to be given every 6 hours as needed for pain. Following the medication review the surveyor reviewed Resident #5's provider progress note dated 4/29/26. The provider documented that there was no change in Resident #5's reported pain. The note listed Resident #8's medications, however, Resident #5's morphine and tramadol were not part of the list. The list also had a lidocaine patch written to be applied every 12 hours as needed for left shoulder pain even though there was no active order for this medication for Resident #5. Further in the note the plan for pain stated lidocaine patches. On 5/8/26 at 6:00 AM, the surveyor conducted an interview with Director of Nursing (DON) and during the interview the surveyor reviewed the concern the provider's notes were not accurate in documenting the plan of care for Resident #5.

Based on interview and observation, it was determined the facility failed to provide sufficient staff to respond to the call system promptly. This was found to be evident for 1 (#14) out of 2 residents observed for call system response.The findings include:On 05/04/2026 at 7:44 AM Resident #14 told the surveyor, I'm thirsty, I need water. No water was observed at the bedside. Resident #14 was encouraged to use the call bell to request water. The surveyor heard the call bell activate and observed the light go on in the room and above the room door in the hall. Certified Nursing Assistant (CNA) #8 was observed sitting at the nurse's station outside the room and Licensed Practical Nurse (LPN) #9 was observed at the medication cart in the hall near the room. On 05/04/2026 at 8:04 AM, when no one had responded to the call light, the surveyor approached CNA #8 who was sitting at the nurses station. When asked why she did not respond to the ringing call bell, she replied, I saw the call light hanging off the wall. It is broken, that's why I didn't go into the room.LPN #9 was asked why she did not respond to the call bell on 05/04/2026 at 8:05 AM. LPN #9 responded that she was passing medications.On 05/04/2026 at 8:13 AM, the Director of Nursing (DON) stated she expected call bell to be answered in a maximum 15 minutes. When asked if the call system was functioning properly, she stated she would look into it. At 8:28 AM the DON stated the call system was functional and someone should have responded.

Based on observations, record reviews, and interviews, the facility failed to obtain, document and administer medications according to procedures that ensure accurate, safe dispensing of medications. This was evident for 4 residents (#57, #70, #98 and #141) out of 10 reviewed for medications.The findings included:1. On 05/04/2026 at 9:35 AM, the surveyor observed Resident #57 taking pills while no nurse was in the room. Resident #57 stated, They don't always leave my pills but this time they did. At 9:40 AM on 05/04/2026, RN #15 entered the room to check if Resident #57 had taken their medications. RN #15 stated, Resident #57 is good to take medications alone. 2. On 05/04/2026 at 11:40 AM, the surveyor observed Resident #141 sitting on the side of the bed pouring liquid into the nebulizer. No staff member was present. Resident #141's family member stated, My parent administers albuterol so it can be taken immediately when needed. The facility evaluated and assessed the resident as independent to administer albuterol. A record review at 9:32 AM on 05/06/2026 revealed no documentation that the facility evaluated Residents #57 or #141 for self-administration of medications. The surveyor requested that the Director of Nursing (DON) provide documentation showing the facility evaluated the residents for self-medication. On 05/07/2026 at 9:29 AM, the DON stated that they could not provide documentation of assessment to self-administer medications for Residents #57 and #141. 3. On 5/4/26 at 9:29 AM, the surveyor conducted an interview with Resident #98 and during the interview Resident #98 stated that the facility often ran out of his/her medications. Next the surveyor reviewed Resident #98's Medication Administration Record (MAR) from January 2026. The review revealed that Resident #98 was ordered to have lamotrigine 25mg in the morning for bipolar. On 1/20/26 a (9) was coded see progress notes, on 1/21/26 the administration was left blank, on 1/22/26 (2) was coded for refusal and on 1/21/26 administration was left blank again. On review of Resident #89's April 2026 MAR hydroxyzine was marked (9) see progress notes on 4/7/26 with an administration time of 7 PM, and again on 4/8/26 but the administration time was 9 PM. On 5/5/26 at 1:59 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that in January there was three days in which Resident #98 was not given lamotrigine as ordered and in April, two days where Resident #98 was not given hydroxyzine as ordered. The DON stated that when the facility changed their pharmacy automatic renewals were not always prompted when a medication ran out but recently the facility reviewed medication order and believed they fixed the system. She stated she would look into the lamotrigine. On 5/6/26 at 9:51 AM, the surveyor conducted a follow-up interview with DON. The DON stated that Resident #98 had been refusing the medication and the medications time was adjusted shortly after. The surveyor reviewed with the DON that on 1/22/26 the staff documented refused however there was no documentation on the other day as to the reason the medication was not given, even with the code see progress note. The surveyor asked if there was no documentation, was the medications given? The DON confirmed if there was no documentation she would assume the medication was not given. 4. On 5/7/26 at 9:04 AM, the surveyor observed Licensed Practical Nurse (LPN) #9 prepare and administer a stool softener, probiotic, oral pain mediation and an inhaler to Resident #70. Following the observation the surveyor reviewed Resident #70's Medication Administration Record (MAR). The review revealed that voltaren external gel was also signed out in the 9 AM time slot, however, the application to the medication was not observed with the other 9 AM medications. On 5/8/26 at 6 AM, the surveyor requested Resident #70's Medications Administration Audit Report. On review of the report the surveyor noted that the medications observed given at 9:04 AM, were documented as given at 9:51 AM, along with the vollaren external gel. On 5/8/26 at 8:04 AM, the surveyor conducted an interview the LPN #9 and Unit Manager (UM) #3. During the interview the surveyor reviewed the concerns that the documented administration of medications was not consistent with the time they were observed administered. LPN #9 confirmed that she had gone into Resident #70's room multiple times to administer medications, however signed them all out at the same time once they were all given. UM #3 then stated that it was the expectation that staff document medications at the time of administration and confirmed this expectation with LPN #9.

Based on observation, interview, record review, facility policy review, and review of manufacturer's guidelines for mechanical lifts and for mechanical lift slings, the facility failed to follow the guidelines for operation of the mechanical lift for 1 (Resident #2) of 2 residents observed that were transferred with a sling. The failure to follow the facility policy and guidelines supplied by the manufacturer contributed to Resident #2 sustaining a severely comminuted (a fracture of a bone into three or more pieces usually from high impact trauma or a fall from heights) fracture. Findings included: A facility policy titled, Mechanical Lift, dated 01/29/2024, revealed the section titled, Procedure, included, 2. Two trained staff must assist with mechanical lift and transfer. The policy revealed, 4. Follow manufacturer's guidelines for use. An admission Record revealed the facility admitted Resident #2 on 12/17/2015. According to the admission Record, Resident #2 had a medical history that included anoxic brain damage not elsewhere classified, unspecified hemiplegia (partial paralysis on one side of the body) affecting the right dominant side, and right-hand and left-hand contractures. The admission Record did not include a diagnosis of osteoporosis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2025, revealed Resident #2 had severe impairment in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). The MDS revealed Resident #2 had no speech. The MDS revealed the resident rarely/never understood others and rarely/never made themself understood. The MDS revealed the resident's vision was highly impaired, and no corrective lenses were used. The MDS indicated Resident #2 had functional limitations in range of motion (ROM) of bilateral upper extremities and bilateral lower extremities. The MDS revealed Resident #2 was dependent upon staff for all activities of daily living and mobility. The MDS indicated Resident #2 had not sustained any falls during the assessment's lookback period. Resident #2's Care Plan Report, included a focus area revised on 01/24/2023, that indicated the resident had an activities of daily living self-care performance deficit. Interventions directed staff to transfer the resident with a mechanical lift (revised 09/26/2022). The Care Plan Report included a focus area revised on 01/24/2023, that indicated Resident #2 was at risk for falls. Interventions indicated staff should be educated to use the mechanical device, and the resident was a total lift for all transfers, using two staff to assist with the lift (revised on 09/26/2022). Resident #2's Weight Summary revealed that on 05/25/2025 Resident #2 weighed 160 pounds and had a height of 66 inches. An undated Proactive (name of a brand of medical equipment) Patient Sling Reference Guide, indicated, It is very important to use the correct sized sling and make sure it is fitted properly prior to lifting. The guide indicated, - The position achieved by adjusting the loops will depend upon the height and build of the patient. The guide included a Size &(and) Weight Range Guide that indicated Please note the following sling guide is a recommendation only. A full risk assessment must be done prior to any sling being selected. This will ensure safety for the patient and caregiver. The guide revealed that a medium size sling should be used for a resident that was 125 to 200 pounds and 63 to 68 inches tall. An Invacare Reliant 450/600 (a type of mechanical lift) user manual, dated 2022, indicated BEFORE using this product, this manual MUST be read and saved for future reference. The manual revealed the section titled, 2.2 Operating Information, indicated, -Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of the Invacare patient lift system. The manual revealed the section titled, 2.2.4, Lift Operations, indicated, -Although Invacare recommends that two assistants be used for all lifting preparation and transferring-from and transferring-to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case. Resident #2's Progress Notes, dated 05/08/2025 at 9:22 PM, revealed a Situation, Background, Assessment, and Recommendation (SBAR) form was completed, which indicated Resident #2 had an other change in condition. The SBAR indicated Resident #2 experienced pain, and the resident's right leg was swollen, warm to touch, and had discoloration. The SBAR revealed the provider was notified, and staff were waiting to hear from the provider. Resident #2's Pain Assessment, dated 05/08/2025 at 9:37 PM, revealed the section titled, E. Indicators of Pain or Possible Pain, revealed the box for Facial expressions was checked. The assessment revealed Registered Nurse (RN) #4 gave the resident Tylenol (a mild pain reliever). Resident #2's Progress Notes, dated 05/08/2025 at 10:40 PM, revealed Resident #2's power of attorney (POA) was notified about the resident's change in condition and the resident's hospital transfer. Resident #2's Progress Notes, dated 05/09/2025 at 4:15 AM, revealed that Resident #2 remained in the emergency room (ER). Resident #2's Progress Notes, dated 05/09/2025 at 2:51 PM, revealed Resident #2 had been admitted to the hospital with a right femoral displaced fracture (a break in the upper bone of the leg with the bones not in alignment) and had received a blood transfusion. A SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated 05/08/2025 at 9:52 PM, indicated the reason for Resident #2's transfer was a suspected fracture. The form indicated the resident was alert, disoriented, but could follow simple instructions. Resident #2's ED [emergency department] Note-Physician, dated 05/08/2025, indicated Resident #2 had been transferred due to swelling of the right knee and generalized pain. The note indicated that the resident had normocytic anemia due to blood loss and a complex, right distal femur fracture with an associated hematoma. The note indicated Resident #2's right leg was diffusely edematous with distal pulses well-preserved. The note indicated the source of the normocytic anemia was unclear although the anemia may be associated with the hematoma that developed from the fracture. A hospital History and Physical, dated 05/09/2025, revealed Resident #2's findings from a computed tomography (CT) scan (a type of X-ray technique used to create detailed images), included diagnoses of a severely comminuted and displaced rapture of the distal femoral metaphysis with marked external rotation of the distal fragment and moderate hemorrhage between the fracture fragments. During a telephone interview on 06/10/2025 at 10:26 AM, Resident Representative (RR) #5, Resident #2's representative, stated Resident #2 was able to move their arm or leg but was unable to turn in bed independently, and was dependent upon staff for everything. RR #5 stated staff reported to them that Resident #2's fracture must have occurred during care. RR #5 stated Resident #2's roommate, Resident #24, reported that they had told the nurse that they did not like the staff person putting Resident #2 in the lift alone. RR #5 stated Resident #24 reported to them that when the staff member swung Resident #2 around in the lift, Resident #2 yelled out. RR #5 stated she had relayed what Resident #24 had reported to the two Social Workers. During an interview on 06/10/2025 at 11:15 AM, Resident #24 confirmed they had been the roommate of Resident #2 on 05/08/2025. Resident #24 stated a female, day shift, certified nursing assistant (CNA) had transferred Resident #2 alone, but Resident #24 would not divulge the staff member's name. Resident #24 stated Resident #2 was unable to speak, but they were able to tell Resident #2 was in pain by the grimace on their face. Resident #24 stated they had given a statement to RN #6 about what they had witnessed and how Resident #2 sustained the fracture, but they were unsure what RN #6 had put in the statement. A quarterly MDS, with an ARD of 05/24/2025, revealed Resident #24 had a BIMS score of 15, which indicated the resident had intact cognition. During an interview on 06/10/2025 at 11:31 AM, CNA #7 stated she had been assigned to care for Resident #2 on 05/07/2025 during the 7:00 AM to 3:00 PM shift. CNA #7 stated Resident #2 had no purposeful movement but did have jerking movements. CNA #7 stated she had cared for Resident #2 for over a year and felt she knew the resident. She described Resident #2 as making noises but had no sounds or facial grimaces that indicated pain. CNA #7 stated that during the care of the resident she had checked the resident's skin and had not seen any bruising or anything out of the ordinary. CNA #7 stated Resident #2 was care planned to get out of bed on Mondays, Wednesdays, and Fridays and stated she had transferred the resident out of bed on Wednesday, 05/07/2025, by herself, although she knew it was the facility policy to have two staff members when using the mechanical lift. CNA #7 stated she had not asked other CNAs to help her because it was a hectic day and stated she had not asked the assigned nurse or the Director of Nursing (DON) to help because she knew they were busy. CNA #7 stated the room was small and not suitable for transferring the resident with both the mechanical lift and the geriatric (geri) chair in the room, so she left Resident #2's chair in the hallway. CNA #7 stated that as she moved Resident #2 out of the room, she was also trying to move any items out of the way, noting she had to angle the chair and the bed to make sure the lift fit between the wall and the roommate's bed. CNA #7 stated Resident #2 had jerking movements as the resident was moved from the bed to the chair but had not been severe enough to fall out of the lift. CNA #7 stated that during the resident's jerking movements, she had made sure the resident's arms and legs had not touched any items in the room. CNA #7 demonstrated how she had moved the foot of Resident #2's bed over, angled the lift, placed Resident #2 on the sling for the lift, backed the resident out of the room, and placed the resident in the chair in the hallway. CNA #7 stated she held the sling to try to keep Resident #2 from jerking uncontrollably. During an interview on 06/10/2025 at 1:50 PM, Licensed Practical Nurse (LPN) #8 stated she had been assigned to Resident #2 on 05/07/2025 and 05/08/2025. LPN #8 stated the facility policy indicated two staff members were needed to transfer a resident with the mechanical lift, and if there were no other staff available, she expected the CNA to ask her for assistance. LPN #8 stated CNA #7 had not requested her assistance with Resident #2's transfer. LPN #8 stated Resident #2 had both purposeful and spastic movements. LPN #8 stated that when she would give the resident their tube feeding, Resident #2 would try to push her arm out of the way. LPN #8 stated the resident smiled when spoken to and would grind teeth or moan when they were in pain. During an interview on 06/10/2025 at 2:27 PM, CNA #7 stated she chose the sling that was used with the mechanical lift by the size of the resident and the length and width of the sling. CNA #7 stated the facility used different types of slings and used three different types of mechanical lifts. CNA #7 identified the Invacare Reliant as the mechanical lift she had used to transfer Resident #2. CNA #7 stated she measured the sling against the resident's body to keep the resident's head and body safe. CNA #7 stated she remembered the type of sling she had used and got the sling that was labeled Proactive. CNA #7 stated all the slings in the building could be used on all the lifts in the building. An observation of the sling that CNA #7 stated she had used on Resident #2 revealed a tag that indicated the sling had a maximum weight of 600 pounds; the sling had three tabs on each side that were purple, green, and blue in color. CNA #7 stated she was hired on 03/05/2024, and since then no one had observed her skills using a mechanical lift. CNA #7 stated the only time she had not had someone helping her transfer a resident was when she had transferred Resident #2. During an interview on 06/10/2025 at 3:16 PM, RN #4 stated he had been assigned to Resident #2 on 05/08/2025 during the 3:00 PM to 11:00 PM shift. He stated that on that night around 10:00 PM, CNA #9 had reported there was something wrong with Resident #2's leg. RN #4 stated that when he assessed the resident, he found the resident's right leg was shorter than the left leg (a shorter leg is one sign of a fracture) and was swollen. He stated the resident's leg was pink in color and warmer to touch than the other leg. RN #4 stated Resident #2 grimaced when moved. RN #4 stated he called RN #10, the nurse supervisor, and RN #10 told him Resident #2's leg looked fractured. RN #4 stated that RN #10 made calls to the primary care provider (PCP) and made arrangements to transfer the resident. RN #4 stated Resident #2 was transferred to the hospital. RN #4 stated he did not find out until 05/09/2025 that Resident #2's leg was fractured. During an interview on 06/10/2025 at 3:43 PM, CNA #9 stated that when she cared for Resident #2 on 05/08/2025 during the 3:00 PM to 11:00 PM shift, she noticed the resident's leg was big and warm. CNA #9 stated she notified RN #4. CNA #9 stated that when she turned Resident #2, the resident made a face she described as not a happy face. During an interview on 06/10/2025 at 4:02 PM, RN #10 stated that on 05/08/2025 during the 3:00 PM to 11:00 PM shift, RN #4 notified him that Resident #2's leg was swollen and warm and the resident was in pain. RN #10 stated Resident #2's leg was paler and slightly bent, but he had not noticed any bruising. He stated he called the PCP, and the resident was transferred to the hospital. During an interview on 06/10/2025 at 4:09 PM, the Central Supply Coordinator (CSC) stated the slings for the lifts were not interchangeable and that a sling with a weight limit of 600 pounds was for a bariatric resident. He stated the lift sling used was based on the size of the resident. He stated he was unable to find a posted sizing chart for the slings, and added staff usually looked at the resident and chose a sling that was appropriate. During an interview on 06/11/2025 at 8:30 AM, RN #6 stated he was the unit manager during the day, but his hours of work varied. RN #6 stated he assisted with interviewing staff and residents after the incident with Resident #2. He stated he had interviewed Resident #24, who had been Resident #2's roommate. RN #6 stated Resident #24 had been confused about when the incident happened, and he was unsure what Resident #24 had seen. RN #6 stated Resident #24 told him Resident #2 had been transferred with only one staff member using the mechanical lift. RN #6 stated he knew the policy indicated two staff members were to use the mechanical lift. RN #6 stated he wrote Resident #24's statement and handed the entire stack of statements to the DON During an interview on 06/11/2025 at 10:01 AM, the CSC stated there were three mechanical lifts currently in service and added that all the lifts were different. He stated the lift slings could be interchanged between all three lifts since they were all connected to the lifts in the same way. He stated the slings could be interchanged since each sling had four differently colored loops that correlated to the weight of the resident. On review of the sizing chart for the Proactive chart, the CSC noted that the colors on the chart did not match the color of the loops on the sling. The DON entered the room with a sizing chart that was from a different manufacturer. The colors on the sizing chart did not correlate to the loop colors on the sling. The DON stated if the staff chose the wrong size sling the resident would be constricted or could fall. A representative from Invacare customer support was interviewed by telephone on 06/11/2025 at 10:30 AM and stated he suggested facilities only use the sling sold by the Invacare company since that was the only sling that had been tested by the company with the identified lift. He stated if facilities used another brand of sling with the Invacare mechanical lift there was a possibility it could cause harm to the residents. A member of Proactive customer support was interviewed by telephone on 06/11/2025 at 10:40 AM. The Proactive customer support member stated the weight capacity was the same for all the lifts slings sold by the company, with a maximum of 600 pounds. She stated the loops were color coded for positioning and not weight, and the full body sling could be used for any sized resident. She stated there should be no issues encountered when using a different brand mechanical lift with the Proactive sling. During an interview on 06/11/2025 at 2:02 PM, the Director of Rehabilitation (DOR) stated the rehabilitation department was not involved in choosing the sling used by residents for mechanical lift transfers. During an interview on 06/12/2025 at 8:03 AM, the Assistant Director of Nursing (ADON) stated mechanical lift training was done on the floor with the CNA preceptor (another CNA), and she did not observe those. The ADON stated staff were taught there always had to be two staff members present when transferring a resident with a mechanical lift to provide safety for the resident, and only one person would not be able to safely maneuver the mechanical lift. During an interview on 06/12/2025 at 8:41 AM, the DON stated that after she found out about Resident #2's fracture, she initiated training on abuse and mechanical lift transfers for the nursing department. She stated she had read Resident #24's statement but had doubted Resident #24's statement since the resident had a history of not being truthful. She stated that now she felt she should have investigated the resident's statement more. The DON stated that she had not known CNA #7 had transferred Resident #2 alone and added CNA #7 had stated previously that someone had helped her transfer the resident. The DON stated staff had been trained to choose a sling for the lift based on the resident's height and weight, and until yesterday when she called the Proactive company, she had been unaware one sling size fit all. The DON reviewed the Proactive color graph listing weights and heights with colored codes and stated she had called the company again since the two sets of information on one instruction sheet was confusing. She stated she had not received a return call. The DON stated she had not requested a return demonstration from the CNAs that had transferred Resident #2 on 05/07/2025 but did not think the use of the available sling had anything to do with the fracture. The DON stated it may be possible that when CNA #7 moved the resident alone that could have contributed to the fracture. The DON stated Resident #2 had co-morbidities such as long-term use of anticoagulants and being bed bound, and the resident's Vitamin D level was low. During a telephone interview on 06/12/2025 at 9:33 AM, the Medical Director stated he had reviewed Resident #2's chart and the fracture was due to undiagnosed and untreated osteoporosis secondary to the resident's bed bound status and a low Vitamin D along with hormonal changes. He stated there were residents that incurred fractures with minimal trauma. During an interview on 06/12/2025 at 3:59 PM, the ADON stated she used a video provided by the therapy department for mechanical lift training. The ADON stated that other than knowing the video concentrated on body mechanics, she did not know what was included in the video. At that time, the video was reviewed, and it was noted that the lift and the slings used in the video were different from the lifts and slings used by the facility. The ADON stated she told staff it was not the same lift and showed the staff the ones used by the facility. She stated she had seen the manuals but had not read them. The ADON stated the loops on the slings were for balance only, and weight, height, and girth were secondary. The ADON stated the therapy department only supplied the video for lift training and did not have a role in deciding which loop or sling residents required. The ADON stated no one was responsible for making sure the loops used for individual residents by the CNAs were correct. During an interview on 06/13/2025 at 11:12 AM, the DON stated she had been unaware that the manufacturer's instructions included using the slings made by the same company to avoid injury. The DON stated she was unaware the video for lift training had not used the lifts or slings used by the facility and thought the video was more about teaching techniques to lift transfers. She stated in hindsight that the ADON should have reviewed the material she taught. The DON stated not following the manufacturer's recommendations when using the lift and sling may cause harm and added the only time the therapy department had input into residents' transfers with lifts was when the staff from the department assisted with the transfers. During a telephone interview on 06/16/2025 at 10:41 AM, PCP #38, Resident #2's PCP, stated the resident was bedbound, which placed Resident #2 at a higher risk of developing osteoporosis and fragile bones that could fracture with turning the resident during care. He stated he was unsure how much force would be needed to result in a comminuted fracture.

Based on staff interviews, and the review of clinical and administrative records, it was determined that the facility failed to maintain a safe environment for a cognitively impaired resident with a history of exit seeking behavior. This finding was evident for 1 of 14 residents (Resident #4) reviewed for elopement during a complaint survey. The finding was identified during the investigation of complaint MD 154. The review of the facility's plan of correction implemented after the facility gained knowledge of the incident resulted in the deficiency being cited as past non-compliance. The findings include: A wander alert system is an alarm system used to alert staff if a resident, who has been determined at risk for elopement, tries to leave the facility or wander into a restricted area. A transmitter is placed on the at-risk resident (typically by a band around the wrist or the ankle of the resident). When the resident approaches the doorway or area equipped with a wander guard sensor, an alarm will sound to notify the staff that the resident may be attempting to exit the area. The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. On 08-31-2020 a review of Resident #4's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) admission assessment revealed the resident had the ability to self-propel when in a wheelchair and required a minimum assistance of two persons for transfers. Further review of Resident #4's record revealed a cognitive assessment was completed on the day of admission to the facility. The resident's Brief Interview of Mental Status (BIMS) score was noted as seven (7) on a scale of 15. A BIMS score between zero (0) and seven (7) indicates severe cognitive impairment. The continued review of Resident #4's clinical record revealed a wander risk assessment, dated 07-08-2020. According to the assessment, Resident #4 was identified as high risk for wandering. The assessment notes state, Resident (#4) tries to go out and per spouse the resident always escapes the house. Today the resident wanted to go by uber. Wander guard was placed on the resident's right arm for safety precaution. According to Resident #4's clinical record, on 07-08-2020 the facility initiated an elopement risk care plan that included a clinical intervention to monitor the resident's whereabouts every two (2) hours. The elopement risk care plan also included an intervention to put a wander guard alert in place. On 08-31-2020 a review of facility self-reported incident (FRI) MD 154 revealed that on 07-11-2020 at 2:15 PM the Assistant Plant Operations Manage (APOM) saw Resident #4 in the parking lot near the back of the facility. The APOM observed Resident #4 being assisted back into a wheelchair by a civilian in the community. The FRI did not indicate that staff were aware that Resident #4 had eloped prior to APOM seeing the resident outside. On 09-01-2020, a review of Resident #4's clinical record revealed that the resident did not complain of pain upon returning to the facility on [DATE] and there was no swelling noted. A change in condition follow up dated 07-12-2020 revealed Resident #4 complained of left hip pain and swelling. The physician ordered an x-ray, which showed dislocation of left hip prosthesis. Resident #4 was sent to the hospital via emergency services. Review of the acute hospital records dated on 07/12/2020 revealed the resident presented to the emergency room with complaint of left hip pain. A left hip x-ray was performed, which showed dislocation of the left hip prosthesis. Review of emergency department records on 07/13/2020 revealed the hospital staff performed a reduction of the left hip dislocation and discharged the resident back to the facility. A closed reduction is a procedure for treating a hip dislocation without surgery, using manipulation of thigh bone (femur) to put the hip back in place. On 09-01-2020 a review of Staff #1's written statement (dated 07-14-2020) revealed that Resident #4 displayed exit seeking behavior on 07-11-2020. Prior to Resident #4's successful elopement, the resident left the nursing unit and was found on the Kingshire unit (an area of the building dedicated to Assisted Living). Staff #1 wrote, On Saturday, July 11, (2020), I was at the nursing station when I saw a resident self-propelling in their wheelchair. The Resident told me that they were waiting for a cab to pick them up. The Resident was redirected back to the Ambassador unit after a brief exchange. This was before lunch time. On 09-01-2020 a review of Staff #3's written statement (dated 07-13-2020) revealed the staff's account of the events on 07-11-2020. Staff #3 wrote, On Saturday came to work did all my rounds. (Resident #4) was in his room. Later I came out and (the resident) was sitting in front of the nursing station. I continued to do my care and was there was very busy doing patient care from one to another. Later after 2:00 PM I decided to take a break cuz the (illegible) days I work did not take a break until my time was over to head home. Staff #3 was no longer employed at the facility and was unavailable for interview. On 09-01-2020, a review the facility's bihourly documentation of Resident #4's whereabouts, revealed that on 07-11-2020 at 1:23 PM Staff #3 signed the 8:00 AM, 10:00 AM, and 12:00 PM location checks for Resident #4 as completed. At 1:24 PM Staff #3 signed the 2:00 PM location check time slot for Resident #4 as completed. There was no documentation to indicate that Resident #4 was missing from the facility at 1:23 p.m. There was no indication that facility staff were aware that Resident #4 was missing from the building, searched for the resident or initiated their elopement response procedures prior to the resident being discovered outside by the APOM. In an interview, completed on 08-31-2020 at 12:00 PM, the Administrator stated on 07-11-2020 Resident #4's wander guard bracelet did not trigger the roam alert security system (the facility's wander alert system). The facility's review of their security camera footage showed Resident #4 leaving the building through the main Kingshire entrance on 07-11-2020 at 12:10 PM. In an interview, conducted on 08-31-2020 at 12:30 PM, the Director of Plants Operations (DOP) stated the facility's roam alert service company inspected the facility's wander guard system 07-12-2020 and attributed the failure of the system's audible alarm to a possible electrical interference which caused the wander guard bracelet to malfunction. In an interview, conducted on 09-01-2020 at 1:00 PM, the Director of Nursing was unable to explain why Staff #3 signed the 2:00 PM location check time slot for Resident #4 at 1:24 PM as completed, when Resident #4 was not in the building. On 09-01-2020 at 1:30 PM, the surveyor interviewed the APOM. The APOM stated on 07-11-2020 he was outside fixing an air conditioning unit in the back of the building. He saw a lady helping someone get back into a wheelchair. He then realized that the person being assisted was Resident #4. The APOM asked the women to stay with the Resident while he went to get help. He returned with the manager on duty and they brought the Resident back into the facility through the back-patio door that has a roam alert alarm. The APOM noted the roam alert system did not trigger. On 09-01-2020 at 2:00 PM, an interview with the Director of Social Services, revealed that on 07-11-2020 she was the manager on duty. She confirmed that she and the APOM assisted Resident #4 back into the building. The resident was wearing a wander guard bracelet at the time. She noticed that the alarm to the back door did not sound when they brought the resident back into the building. After the resident was assessed for injuries, she took Resident #4 to the front door in their wheelchair to test the alarm system. The alarm did not work. She then asked the nurse to replace the Resident's roam alert bracelet. Surveyor interview on 09-03-2020 at 1:30 PM with the Director of Nursing revealed no additional information. A review of the facility corrective action following Resident #4's elopement revealed the following: On 07-12-2020 a quick census was conducted and all residents on the units were accounted for. Resident #4's wander bracelet was replaced by the maintenance director and confirmed to be functioning properly. On 07-12-2020 the wander alert system was inspected by a commercial contractor and deemed to be functioning properly. The contractor stated there was a possible malfunction of the wander bracelet due to electrical interference. On 07-13-2020 an AD-HOC Quality Assurance and Performance Improvement (QAPI) meeting was held to determine and review root cause analysis and corrective actions were implemented on following 2-hour checks for residents that have a wander guard and/or score 9 or greater on the wander guard assessment. On 07-13-2020 an elopement assessment audit was completed by the clinical team managers to ensure accurate identification of residents at risk for elopement. Red bracelets were placed on residents who were identified as high risk for elopement. On 07-14-2020, the commercial contractor installed a numbered keypad on the main Kingshire entrance that requires staff to enter a code to allow visitors or residents to exit. On 07-14-2020 all staff were provided in-service education by the nursing educator regarding the facility's elopement policy. On 07/14-2020 the facility implemented a new process to review residents with wander guards. The Director of Nursing/Administrator and Medical Director will review residents, who have a wander guard and/or score 9 or greater on the wander guard assessment for the past 60 days, to ensure residents are being checked on following 2-hour checks for residents that have a wander guard and/or score 9 or greater on the wander guard assessment. The facility's compliance date is 07-14-2020.

Based on staff interviews, surveyor observations, and review of clinical and administrative records and policies, it was determined that the facility failed to: 1. initiate appropriate interventions, review and revise care plans for Residents #6, #7, & #8 when they were identified as at risk for elopement to address previously identified elopement risks, 2. identify the elopement of Resident #6 for 4 hours resulting in missed blood glucose monitoring for this resident with Type I diabetes mellitus, and 3. implement processes to ensure that residents at risk for elopement could not exit the facility through a smoking patio door (Resident #7). These findings were evident for 3 of 3 residents (#6, #7, & #8) reviewed for elopement and were related to facility reported incidents #MD 467 & MD 809. These failures resulted in an immediate jeopardy (IJ) being identified on 11-06-19 at 12:10 PM related to the facility not implementing interventions to prevent the elopements of Residents #6, #7, & #8. On 11-06-19 at 8:20AM, the facility submitted an IJ removal plan, which was accepted. The IJ was removed on 11-08-19 at 12:30 PM after confirmation that the accepted plan had been fully executed. After removal of the immediacy, the deficient practice remained at a scope and severity of D. The findings included: A wander alert system is an alarm system used to alert staff if a resident who has been determined at risk for elopement is trying to leave the facility or wander into a restricted area. A transmitter is placed on the at-risk resident (typically on a band around the wrist or the ankle) and when the resident approaches the door-way or area equipped with a wander guard sensor, an alarm sounds to notify the staffcx. 1. On 11-04-19, surveyor review of Resident #6's clinical record revealed that he/she was admitted to the facility in (MONTH) 2019 with the [DIAGNOSES REDACTED]. Resident #6 was assessed on 06-16-19 by the facility staff to be at risk for wandering. Further review of the clinical record revealed a nurses' note written as late entry for 06-22-19 at 5:30 PM that documented Resident #6 allowed Registered Nurse #13 to perform a blood sugar check and administer long acting insulin. In addition, the resident insisted to Registered Nurse #13 that he/she did not belong in the facility and was just visiting a friend. The resident then refused to take his/her medications and sat at the nurses' station for approximately 2 hours then walked down the hall to the TV lounge near the front entrance. In addition, Registered Nurse #13 wrote a note for 06-22-19 at 11:35 PM that documented that the he gave report to the oncoming shift and had informed the oncoming nurse that Resident #6 had refused medications and was agitated by the nurse's repeated attempts to get the resident to take the medications. Registered Nurse #13 documented that the oncoming nurse would follow up with the resident about taking the medications. On 06-22-19 at 11:50 PM, a nurse's note was written stating the Director of Nursing was notified that Resident #6 was missing from the facility and a search was started. On 06-23-19 at 2 AM, a nurse's note was written stating the resident was found by the police on a local 4 lane highway and brought back to the facility. The resident was transferred to the acute hospital for evaluation. Surveyor review of the nurse's note written on 06-23-19 at 11 PM revealed the resident was admitted to the acute hospital for low blood sugar secondary to the resident's [DIAGNOSES REDACTED]. Further review of the clinical record revealed there was no evidence that a care plan was developed to address the resident's risk for wandering and no interventions were initiated prior to the resident's elopement on 06-22-19. On 11-05-19, surveyor review of the facility investigation revealed Resident #6 walked out of the facility on 06-22-19 at 7:38PM through the main entrance. Review of facility video footage confirmed that the resident exited the main entrance at the same time the evening receptionist was locking the door for the night. As the evening receptionist was placing a sign at the door, Resident #6 walked past him through the door. Nursing staff did not find out that Resident #6 was missing from the building until 11:30 PM on 06-22-19. The resident was scheduled for blood glucose monitoring at 9:00 PM which was not performed as the resident was not in the building. A search was initiated and the police were contacted at 12:30 AM on 06-23-19. Resident #6 was found by the police on 06-23-19 at 2 AM approximately 2 miles from the facility walking along a highway. Resident #6 was returned to the facility where he/she was subsequently transferred to an acute hospital. The resident was admitted to the hospital for low blood sugar. On 11-05-19 at 07:45 AM, surveyor interview with the daytime Receptionist #04 revealed the main entrance was accessible from 8:30 AM to 8 PM Monday through Friday and 9 AM to 8 PM on the weekends. There was a receptionist at the front desk facing the main entrance during those times that monitored residents and visitors entering and exiting the building. The main entrance was locked at night and no one could enter or exit. On 11-05-19 at 10 AM, surveyor interview with the Director of Nursing (DON) revealed there was a wander alert alarm at the main entrance that locked the door and activated a loud alarm if a wander alert transmitter was near. Residents who were assessed to be at risk for wandering were given a wander alert transmitter. Resident #6 did not have a wander alert transmitter when he/she eloped from the facility on 06-22-19 despite being assessed as at risk for wandering. The DON further stated that the nursing staff are expected to check on their assigned residents every 2 hours. On 11-07-19 at 12:50 PM, phone interview with evening Receptionist #05 revealed he/she was working on the front desk on the evening of 06-22-19 and did not remember seeing Resident #6 exit the building. The evening receptionist further stated that many senior citizens come and go from the facility and it is hard to distinguish who is a resident and who is a visitor. 2. On 11-04-19, surveyor review of Resident #7's clinical record revealed he/she was admitted to the facility in (MONTH) 2019 with the [DIAGNOSES REDACTED]. Resident #7 was assessed on 10-03-19 by the facility staff to be at high risk for wandering. A wander alert bracelet was placed on Resident #7 on 10-04-19 and a care plan for at risk for wandering was initiated on 10-06-19. On 10-08-19 at 12:10 PM, surveyor review of a late entry nurse's note revealed the resident left the building without speaking with the nursing staff and went home and called their community case worker. The case worker went to the resident's home and escorted Resident #7 back to the facility. On 11-04-19, surveyor review of facility reported incident #MD 467 received on 10-09-19 revealed that Resident #7 left the faciity on [DATE] at 12 PM via taxicab to return to his/her previous residence without staff knowledge. On 10-08-19 at 1:40 PM, Resident #7 was returned to the facility by their care manager and informed the staff that the Resident had left. Further review of the facility's written investigation revealed Resident #7 informed the staff on 10-07-19 that he/she was scheduled to discharge home. After 10-07-19 had passed, the resident stated he/she decided to go back home on 10-08-19 via taxicab. Resident #7 exited the large activities room door through the smoking patio. On 11-04-19 at 12 PM, surveyor observation revealed a resident was exiting the large activities room door to the smoking patio. The door opened when the resident placed his/her badge near the door. There was no staff directly monitoring the smoking patio or door. In addition, the smoking patio had 2 unlocked gates that lead to the outside parking lot. On 11-04-19 at 3 PM, surveyor interview with the Administrator revealed Resident #7 verbalized to the staff on 10-07-19 that he/she was going home that day. However, the staff redirected the resident and informed him/her that they were not scheduled to be discharged yet. On 10-08-19, Resident #7 exited the building through the activities room door that leads to the smoking patio. The Administrator stated the facility believes Resident #7 followed a resident smoker to the smoking patio and out to the parking lot through a gate. Furthermore, the staff were unaware that Resident #7 had left the building until he/she was returned to the facility by their community case manager. On 11-05-19, surveyor review of the facility smoking policy revealed residents assessed as independent smokers may be given a badge that allows unsupervised access to the smoking patio from the hours of 07:30 AM to 10:30 PM. On 11-05-19 at 12:40 PM, follow up interview with the Administrator revealed the activities room door that leads to the smoking patio is equipped with a wander alert alarm that locks the door if a wander alert transmitter is near. However, if a resident smoker attempts to open the door with a badge, it will unlock the door. On 11-06-19 at 09:45 AM, surveyor observation with the Administrator, Assistant Administrator, and maintenance staff #6 revealed that if a wander alert transmitter is near the smoking patio door, the door would lock and a low sounding alarm was activated. However, the alarm was only audible in the activity room and stops after 30 seconds. Furthermore, if a smoking patio door badge was near the door, it will override the door lock and allow someone to exit. The facility failed to monitor Resident #7's whereabouts after being assessed as at risk for elopement. Furthermore, the facility failed to implement interventions to prevent Resident #7 from eloping through the smoking patio. Cross reference F926 3. On 11-04-19, surveyor review of Resident #8's clinical record revealed he/she was admitted to the facility in (MONTH) 2012 with [DIAGNOSES REDACTED]. Resident #8 was assessed on 07-02-19 and 10-02-19 by the facility staff to be at risk for wandering. On 10-19-19 at 21:00, the nurse documented that they received a call from the front desk receptionist stating that the resident was found in a nearby building by a police officer. The resident was then brought back by a police officer. Further review of Resident #8's clinical record revealed there was no evidence that a care plan was developed to address the resident's risk for wandering and no interventions were initiated prior to the resident's elopement from the facility on 10-19-19. On 10-20-19, Resident #8's clinical record was updated with a care plan for elopement and interventions to prevent elopement were initiated. Resident #8 was given a wander alert transmitter on 10-21-19. On 11-04-19, surveyor review of facility reported incident #MD 809 revealed on 10-19-19 at 05:28 PM, Resident #8 walked out of the facility through the front door and was located by the police in an adjacent parking lot at 7 PM on 10-19-19. An assessment was performed by staff, which revealed no injuries. Video footage confirmed that the resident left the building through the main entrance. On 11-05-19 at 07:45 AM, surveyor interview with the daytime Receptionist #04 revealed the main entrance is accessible from 8:30 AM to 8 PM on Monday through Friday and 9 AM to 8 PM on the weekends. There is a receptionist at the front desk facing the main entrance during those times that monitors residents and visitors entering and exiting the building. On 11-05-19 at 09:55 AM, surveyor interview with the Director of Nursing (DON) revealed there is a wander alert alarm at the main entrance that locks the door and activates a loud alarm if a wander alert transmitter is near. Residents who are assessed to be at risk for wandering are given a wander alert transmitter. Resident #8 did not have a wander alert transmitter when he/she eloped from the facility on 10-19-19 despite being assessed as at risk for wandering. Resident #8 was given a wander alert transmitter on 10-19-19 after he/she returned to the facility and a care plan for wandering was initiated. On 11-07-19 at 12:50 PM, phone interview with evening Receptionist #05 revealed he/she was working on the front desk on 10-19-19 and did not remember seeing Resident #8 exit the building. The evening receptionist further stated that many senior citizens come and go from the facility and it is hard to distinguish who is a resident and who is a visitor. Furthermore, the evening receptionist recommended to the administration that residents who are not allowed to go out independently should wear a fluorescent bracelet that easily identifies them. On 11-06-19 at 12:10 PM, an immediate jeopardy (IJ) was determined due to the facility's failure to: 1. initiate appropriate interventions, review and revise care plans for Residents #6, #7, when they were identified as at risk for elopement to address previously identified elopement risks, 2. identify the elopement of resident #6 for 4 hours resulting in missed blood glucose monitoring for this resident with Type I diabetes mellitus, and 3. implement processes to ensure that residents at risk for elopement could not exit the facility through a smoking patio door (resident #7). On 11-06-19 at 8:20 PM, the facility staff submitted the IJ removal plan which included the following: -Residents #6 & #7 no longer reside in the facility -On 10-20-19, resident #8's medical record was updated with an elopement care plan and interventions were implemented to prevent further elopements by the facility staff -On 10-21-19, a wander alert transmitter was placed on resident #8's right ankle by the facility staff -On 11-05-19, badges that grant access to the smoking patio were taken from 9 of 9 independent smokers and a staff member was placed at the door 24 hours a day to monitor residents that enter and exit the door and allow authorized residents to go out to the smoking patio -On 11-06-19, all persons entering and exiting the main entrance of the building will be required to sign in and out with the receptionist. Furthermore, an elopement binder kept at the front desk and nurses' stations to identify residents who are elopement or wandering risks with pictures was updated. Residents who are identified as elopement risks were given bright red armbands for quick identification. The resident risk level was added to the shift-to-shift report. In addition, all residents assessed 'at risk' and 'high risk' were added to the behavior monitoring sheet for nurses and in the point of care system for the geriatric nursing assistants to monitor every 2 hours. -On 11-06-19, the facility staff audited 11 of 11 residents who were evaluated for 'at risk to wander' and 'high risk to wander' to ensure that a care plan for elopement risk with appropriate interventions were implemented and a wander alert transmitter was placed on the resident unless otherwise specified in the clinical record. -On 11-06-19 at 04:15PM, an outside contractor adjusted the volume of the wander alert alarm on the smoking patio door so that it is audible from the 2 closest nursing stations (Embassy and Capitol). -On 11-06-19 at 08:15PM, a doorbell was installed on the outside of the smoking patio door, which is audible from the 2 closest nursing stations. -On 11-08-19, review of administrative documents and staff interviews revealed the facility achieved 100% compliance on 11-08-19 with staff in-service education regarding the facility elopement policy and additional interventions of bright red armbands and increased location monitoring for residents identified as at risk. -The facility will arrange for an outside contractor to install a gate 'Maglock System' on the smoking patio gates on 11-15-19, which will automatically lock the 2 outside gates if a wander alert transmitter activates the alarm on the door leading to the smoking patio. Until the Maglock System is installed, the facility will not allow independent smokers outside to the smoking patio without a staff member granting them access. -Finally, the removal plan stated the DON will conduct on-going weekly audits of residents identified as 'at risk' for elopement on admission to ensure wandering interventions have been put in place. This will include the newly added interventions of increased location monitoring (i.e. every 2 hours) and placement of wander alert alarm bracelets unless otherwise specified. Findings of these audit results will be reviewed in the QAPI (Quality Assurance Performance Improvement) meeting monthly for 6 months to ensure compliance. On 11-08-19 at 12:30PM, the Administrator and DON were notified that the surveyors had verified that the removal plan had been fully implemented as of 11-08-19 at 11AM, and the immediacy was removed.

Based on surveyor review of the clinical record, review of facility administrative documents and interview of facility staff, it was determined that the facility failed to ensure that resident #106 was free from abuse. This finding was evident for 1 of 32 residents reviewed during the survey. This finding is related to facility reported incident #MD 964 and is valid. The findings include: On 03-14-18 at 4:30 PM, surveyor interview with resident #106 revealed that the resident was tearful and upset and stated he/she was roommates with resident #82 for 20 days without incident. On 03-09-18 the roommate (resident #82) was sitting on the edge of his/her bed looking out the window in the afternoon when suddenly resident #82 came over and wrapped his/her arms around my head and neck and I cried out for help. A staff member was passing by and came in to help but this person had to call for additional assistance to get my roommate off me. The staff called the police and my family and then sent me to the hospital to be looked over. I didn't want to go back and I told the hospital staff that the only humane thing to do was ask their supervisor not to send me back. The hospital staff said they spoke with the facility and that I would have a private room and someone to be with me that night when I returned to the facility. On 03-19-18, surveyor review of the facility reported incident revealed that, on 03-09-18 at 5:25 PM, resident #106 was yelling for help. When staff responded, resident #82 was on top of resident #106 with their left hand close to resident #106's neck. The staff member called for additional help to remove resident #82 from the room. Resident #106 was noted with lacerations and swelling to the left side of the face, and scratches around his/her neck. The police were called and both residents were sent to the hospital. On 03-19-18, surveyor review of the clinical record for resident #82 revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed that, on 03-02-18, a nurse's note was written that stated acute changes in mental status exhibited by profanity, non-redirectable, agitation. In addition, on 03-04-18, a change of condition note revealed resident #82 was observed to be verbally aggressive towards staff this shift. The on call physician was notified and a one time order was given for an antipsychotic to be administered via injection for agitation and combativeness, and to obtain a urine sample via catheter. On 03-05-18, the attending physician wrote the following: Weekend events noted. Was verbally and physically abusive to weekend staff yesterday. After a one time dose of an antipsychotic, Resident #82 is more calm today but when asked questions {resident} is tangential, talking about how {he/she} is in control of conflict and non-conflict. Does not make eye contact and looks away frequently. Labs reviewed, urine is normal. Discussed with unit manager and Director of Nursing. On 03-06-18, the attending physician wrote that resident #82 is more calm today but still not making eye contact and tangential, not answering questions. Unclear what caused behavioral exacerbation as he has been stable for some time on current medication regimen. Further review of the clinical record for resident #82 revealed that the psychiatrist evaluated the resident on 03-06-18. The progress note revealed that the resident was seen for follow up after the resident got agitated, hit a staff member per report and required an as needed dose of an antipsychotic medication by injection. The note also stated that the resident was delusional, angry and stated people are after him and there is drug dealing going on here. In addition, the psychiatrist documented Thought content: suspicious and delusional thought disorder Risk to self/others-no. The plan was to start an antipsychotic medication by mouth three times a day, to be given in the morning, at noon. and at bedtime. In addition, the resident's behavior was to be monitored and the physician called with any changes. Further review of the clinical record for resident #82 revealed that, on 03-06-18, a care plan was initiated for potential to demonstrate verbal and physical behaviors related to: psychiatric disorder. The interventions included monitoring conditions that may contribute to verbal behaviors, and monitoring medications, especially new/changed/discontinued, for side effects and resident's response contributing to verbal behaviors. On 03-08-18, the attending physician noted that resident #82 seemed to be tolerating the medication change, continued to have some agitation but appears more calm than Tuesday. In addition, the physician noted continue to monitor for worsening aggression especially with new medication change. However, the physician failed to clearly state what the plan of care was to monitor resident 82's behavior. Additionally, there was no plan for the level of supervision required or frequency of monitoring. Interview of the Administrator and Director of Nursing on 03-19-18 at 3 PM revealed that the first dose of the injectable antipsychotic was administered because resident #82 had thrown a pen at staff who was trying to obtain a urine sample. Resident #82 was described as quiet and didn't bother anyone and that this behavior was not typical for this resident. Resident # 82 wheels around in his wheelchair outside of his room frequently and this is how staff monitors the resident. Interview of the psychiatrist, on 03-19-18 at 7 PM, revealed that resident #82 was not displaying any behavior that would predict the resident would strike out at another resident. The psychiatrist stated that the behavior may have been caused by an underlying medical condition. The psychiatrist was not concerned about resident #82 having increased behaviors due to changing the medication. The antipsychotic was ordered three times a day initially due to its immediate calming effect. Review of the facility report revealed that an interview was conducted with resident #106 on 03-09-18 at 5:25 PM. Resident #106 stated that resident #82 came over scratched his/her face and neck and started choking him/her. Resident #106 stated that he/she was afraid of resident #82 and did not want to be in the same room. Surveyor review of the clinical record for resident #106 revealed discharge paper work from the emergency room visit on 03-09-18. The physician's assistant note revealed that resident #106 had abrasions to left face and neck and dried blood around the mouth and that the injury was from an assault and the type of injury was laceration and direct blow. In addition, follow up instructions revealed that resident #106 had been examined due to an assault and that someone attacked and tried to harm the resident. The instructions stated that the resident may feel shock, embarrassment, fear and sadness as well as blame, guilt, shame, and anger. It was noted that crisis support and counseling can help. The instructions included following up with a healthcare provider, not isolating the resident, and talking with people about how the resident is feeling. Further review of the clinical record revealed a nurse's note written on 03-09-18 at 11:53 PM that stated I received a call at about 2200 from the hospital ER that {resident #106} is coming back because {he/she} is medically stable, but {he/she} needs to be in a private room with a sitter. {He/she} is in shock because of the incident. {He/she} is in a post traumatic stress disorder at this time. After 15 minutes, the family came into the facility and demanded someone stay with {resident #106} overnight. I requested for one of the night {nursing assistant} staff to stay with {resident} overnight. The family was very pleased of the decision. The facility failed to maintain a safe environment when Resident #82 began displaying new and aggressive behavior. The physician called for increased monitoring, which was not defined, and the level of supervision needed was neither ordered nor planned.