Every finding on record at Springdale Healthcare Center

F600 Free from Abuse and Neglect - related to sexual abuseBased on observation, interview, and record review, the facility failed to ensure Resident (R)6 remained free from sexual abuse. The facility failed to protect R6, a cognitively impaired female who lacked the capacity to consent, from sexual contact initiated by R119. On 1/17/26, the Administrator was notified that R119 was engaged in inappropriate sexual interactions with R6, when R119 had his hand around R6's wrist, using R6's hand to masturbate R119's p****.Due to the cognitive impairment of R6, the Reasonable Person Approach was utilized to determine the negative effects of this non-compliance. A reasonable person in this same situation would feel serious adverse outcomes of psychosocial harm.On 01/23/26 at 1:36 PM, it was determined that the facility's non-compliance with one or more federal health, safety, and or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 01/23/26 at 1:36 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 01/15/26 when the facility failed to report an elopement to the State Agency. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 01/23/26, the facility provided an acceptable IJ Removal Plan. On 01/23/26 the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D.Review of the facility policy, Abuse, Neglect, Exploitation, or Mistreatment with a complete revision date of 11/01/17, revealed, Policy: The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse . ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and reported immediately. Component: Identification: 2. Types of abuse include BUT ARE NOT LIMITED TO: C. Rape, molestation or other inappropriate sexual behavior against a resident, such as: 4. Inappropriate sexual behaviors displayed by and/or toward an incapable resident.Review of R6's Face Sheet revealed she was admitted on [DATE], with diagnoses of vascular dementia, Parkinsons, and bipolar disorder. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. The resident requires partial/moderate assistance to substantial to max assistance with Activities of Daily Living (ADLs).Review of R119's Face Sheet revealed he had a diagnosis of bipolar disorder. Review of R119's Annual MDS with an ARD of 10/25/25 revealed a BIMS Score of 13, indicating he is cognitively intact. The resident requires set-up or cleanup assistance to supervision assistance with ADLs.Review of the facility's Five Day Report indicated, During an interview on 01/17/26 at 7:39 PM, Licensed Practical Nurse (LPN)2 revealed she had walked over to a dining table where R6 was seated in a Geri chair, and R119 was seated in a wheelchair. R119 was observed with unzipped pants exposing his genitals while holding R6's wrist/hand in his lap. R6 did not appear confused or frightened as reported by LPN2.Review of R6's medical record revealed the resident has difficulty with decision-making at times and requires redirection and daily structured programs.Review of R6's psychiatric progress note dated 12/29/25 revealed, She has been reported to the social worker for exhibiting intrusive behaviors, including recently snatching a peer's coloring book, taking items that do not belong to her, etc . Although her speech is clear and normal in rate and tone, she demonstrates impaired judgement and concrete thinking.Review of R119's medical record revealed resident has a history of periods of inappropriate behavior and inappropriate gestures towards staff during his shower in the shower room.Review of R119's Care Plan revealed R119 had a history of inappropriate behavior and inappropriate gestures. Approach directed staff to decrease inappropriate behaviors and gestures include communication.Review of R119's progress notes dated 01/17/26 revealed, Resident involved in sexual encounter and inappropriate touching with another resident. During an interview on 01/22/26 at approximately 3:16 PM, R6 stated, H*** no, I didn't do that.During an interview on 01/22/26 at approximately 4:09 PM, LPN2 revealed she observed R119 sitting in his wheelchair close to R6 in the dayroom/dining room on Unit 300. R119 had a blanket over his lap. LPN2 stated she observed R119 holding R6's wrist under the blanket. LPN2 removed the blanket and observed R119's genitals exposed. LPN2 stated she immediately told R119 to put his genitals back in his pants and zip up his pants. R119 rolled the wheelchair away from the table. LPN2 revealed R119 had previously been reported for inappropriate behaviors in the shower. LPN2 reported she immediately contacted Provider, RP [responsible party], On-call nurse, Psych, Director of Nursing (DON), and the Administrator.During an interview on 01/22/26 at approximately 4:30 PM, R119 stated, [R6] told me she had 15 orgasms. She dropped her crayons, and I tried to help her pick them up, but I couldn't. I did have a blue blanket; I put it over me. She's not to blame; she didn't touch me, she's not the one to blame. We all make mistakes. I don't want to get her in trouble.During an interview on 01/23/26 at approximately 10:50 AM, the DON revealed the incident was reported to her by LPN2 and the on-call supervisor. The DON stated she was told that it appeared R119 had his penis out and R6 had her hand on his penis. In her follow-up to the incident, R6 stated she wanted to masturbate and play with his balls. The DON stated she immediately had R119 moved to hall 100, did bed audits on all nonverbal females, took verbal statements from verbal female residents and staff, called 911 to report it, and psych was made aware. R119 was placed on 1:1 until the provider discontinued. The DON stated her expectations for staff are to immediately separate residents, ensure safety, notify the abuse coordinator, and immediately launch an investigation, dependent on the type of Reportable event, place the resident on 1:1. During an interview on 01/23/26 at approximately 10:57 AM, the Administrator revealed she was called by LPN2, who reported R119 and R6 were sitting closely to each other. R119 had a blanket over his lap. R6's hand was touching R119's genitals, and they were immediately separated. R119 was placed on 1:1, room change, authorities notified, providers contacted, statements were taken from staff, body audits on all female residents, verbal interviews with residents, and body audit on R6. Reports she is unaware of R119 having inappropriate behaviors. Expectations for staff is to separate residents immediately, contact the Abuse Coordinator (Administrator), and follow abuse policy. Removal Plan Included:Springdale F600 1/23/26 Resident #6 had a head to toe assessment completed on 1/17/26 by a licensed nurse. No injuries identified. A psychosocial evaluation was completed on Resident #6 by the Social Services Director on 1/19/26, 1/20/26, and 1/21/26 without negative effect. Resident #6 seen by psychiatrist on 1/21/26 with no negative effects identified. Resident # 119 was placed on 1: 1 supervision beginning 1/17 /26 until seen by medical provider and assessed to be safe to remove from 1: 1 supervision on 1/19/26. Resident #119 has psychosocial follow up by Social Services Director on 1/19/26, 1/20/26 and 1/21/26 without negative effects. Administrator/Designee interviewed alert and orientated residents to identify possible allegations of abuse on 01/17/2026. The Director ofNursing/Designee assessed cognitively impaired residents for signs and symptoms of abuse on O 1/17/2026. No additional residents identified. The facility staff were re-educated by the Administrator/Designee by O 1/17/2026 on the Abuse, Neglect and Misappropriation policy including: Identification of abuse or neglect, by observable and objective evidence, witness eports of unusual occurrence or patterns or trends of potential abuse or neglect Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse Inappropriate sexual behavior displays by and/or toward an incapable resident Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim Implementation of protective measures to maintain physical and psychological safety for alleged victims This reeducation began immediately on 1/17/26. Any staff not receiving this education will receive prior to their next scheduled shift. This education will be presented to agency staff and new hires. The Administrator and Director of Nursing review incident reports and grievance reports completed from the prior day in morning meeting daily Monday through Friday for identification of possible allegations of abuse. The weekend supervisor will review the incident reports and grievances on the weekends to identify possible allegations of abuse. The weekend supervisor will notify the Administrator and the Director of Nursing if any identified for further direction. Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held on 1/23/26 to discuss the Immediate Jeopardy Template and the contents of this plan The Medical Director was notified of the Immediate Jeopardy and the contents of this plan on 01/23/2026.

Based on review of facility policy, interview, observation, and record review, the facility failed to ensure Resident (R)13 was adequately supervised to prevent him from eloping from the facility on 01/15/26, for 1 of 1 resident reviewed for elopement. Specifically, on 01/15/26 at approximately 2:30 PM, R13 had a successful, unwitnessed elopement from the facility. R13 was found by staff members on a gravel road leading to the main street approximately 200 feet from the door he exited from. Review of R13's medical record showed no clinical notes were written and no clinical assessments were conducted related to the elopement. On 01/22/26 at 11:57 AM, it was determined that the facility's non-compliance with one or more federal health, safety, and or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 01/22/26 at 11:57 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 01/15/26 when a resident successfully eloped from the facility. The IJ was related to 42 CFR 483.25 - Quality of Care, F689.On 01/22/26 at 2:30 PM, the facility provided an acceptable IJ Removal Plan. On 01/22/26 the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F689 at a lower scope and severity of D. Findings include:Review of the facility policy titled Elopement with a complete revision date of 11/01/17, documented, Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Procedures documented, . 7. When the Patient/Resident is located, the Charge Nurse completes a head-to-toe assessment. The Social Service Designee assesses the patient/resident for emotional distress. Review of R13's Face Sheet revealed R13 was originally admitted to the facility on [DATE], with a re-entry date of 09/12/25. R13 was admitted with diagnoses included, but not limited to, heart disease, heart failure, Type 2 diabetes, dizziness and giddiness, right below-the-knee amputation, anxiety disorder, major depressive disorder, and post-traumatic stress disorder. Review of R13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/25, revealed R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R13 had no cognitive deficits. Further review of the MDS revealed R13 used a manual wheelchair independently and needed partial assistance from others for personal care. Review of R13's Care Plan revealed R13 was at risk for elopement and wandered throughout the facility. Approaches to prevent elopement included identifying R13 to staff as an elopement risk, ensuring R13's physical needs were met, and assessing R13 for activities of interest. Review of R13's Elopement Risk Observation dated 09/12/25 revealed R13 had a history of attempting to leave the health care center, had expressed discontent with the health care center, and had a diagnosis that required supervision. Review of R13's Progress Notes dated 01/15/26, revealed no nursing notes regarding the elopement. Additionally, no notes were found showing the facility notified R13's medical provider or Responsible Person (RP) of the elopement. Review of R13's Assessments revealed no clinical assessments were documented post-elopement. Review of the daily temperatures on Weather.com revealed the daytime high for the area on 01/15/26 was 43 degrees Fahrenheit. During an interview on 01/21/26 at 3:10 PM, R13 revealed, Yes, I just rolled right out. It was Friday, no wait, it was last Thursday. I left through the exit the employees use. I got the code from a Certified Nurse Assistant (CNA) who used to work here. I just fiddled with the keypad and got it open. I wanted out of here. I got past the dumpsters on the side and onto the area with the white sand. I was almost to the street. I did this in the afternoon after lunch that day, probably about 3. A bunch of them found me: The Unit Manager, the Housekeeper/Activities person, and the Social Worker. I was going to go next door and get myself a Greyhound ticket. I want out of here. During an interview and observation on 01/21/26 at 3:44 PM, the Medical Social Worker (MSW) revealed, Yes, [R13] sneaked out. It was the day his room was changed. It was on 01/15/26. He left through the staff exit on the side. I can show you which one. He went all the way past the dumpsters on the dirt road heading towards Battleship Road - the street out front. He left out the side door. It is a door the staff go in and out of. I asked him how he got the code for the door. He said a CNA gave it to him. We had changed the code, I think, so I don't know if that was how he did it. If you push the door long enough, it will open. Once we got to him, we redirected and talked to him. He was mad and upset. We then got him situated in his room. The protocol when this happens is I follow up with the Resident to do a psychosocial note, follow up with psych services, and notify the administrator. Surveyor informed the MSW that there were no notes, the MSW replied, What? There are no notes about him leaving? I would have thought someone would have written something. I mean so many people were there - The Unit Manager, the Director of Nursing, a Medical Records staff member, and even a housekeeping person. During an observation, the MSW showed the Surveyors the door R13 eloped through and pointed to the area R13 was found. The door to the hallway leading to the exit door had a sign on it stating, Staff Only and was located on the 100 Hall next to the Meeting Room. While looking through the exit door window, the MSW revealed, See the dumpsters there? He was way past them. He was on the dirt road beyond the dumpsters. He was going towards the main street, Battleship Road, outside the building. I would say he was at least 200 feet away from the door. During an interview on 01/21/26 at 3:15 PM, the Director of Nursing (DON) stated, [R13] was upset about a room change. He exited through the employee side door. He said that a staff member gave him the code. He was near the kitchen area, behind the dumpster on the gravel going toward the gravel road. The Unit Manager [(UM)1] saw [R13] from a distance and someone from the kitchen saw [R13] leaving the facility. During an interview on 01/21/26 at approximately 4:34 PM, the Administrator stated, [R13] was upset about his room change with his roommate. He told staff that he was going to leave the facility. He was located by the trash dump. [UM1] and a dietary staff member had [R13] in the line of sight leaving the facility. [UM1] was on break or clocking out. I'm not sure how he got out. He exited out the door by the conference room.During an interview on 01/21/26 at approximately 4:45 PM, R13 stated, No, I did not sign myself out when I left. During an interview on 01/22/26 at 8:25 AM, UM1 stated, I pulled up on Thursday at the employee door getting ready to clock out. I went in, clocked out, and he (R13) was at the road with the kitchen staff. He said he wanted to leave. Not sure what went on after that. I didn't see him leave the building. When I pulled up, he was already outside the door. I don't know the name of the kitchen staff that found him. During an interview on 01/22/26 at 8:30 AM, the Kitchen Manager (KM)1 revealed, I wasn't aware my staff found him outside. We had a meeting about this last night. I'll ask my staff. During an interview on 01/22/26 at 8:49 AM, Dietary Aide (DA)1 stated, I was going home. I clocked out and went outside. I saw him, and he was in his wheelchair. He was stuck in a hole near the road. I went to go talk to him, and he told me he was getting the h*** out of here. More staff came out to help, and I stepped back and let them take care of it. I don't remember what he was wearing. On 01/22/26 at approximately 1:10 PM, the Administrator informed the survey team of a discrepancy in the IJ Template related to the 200 feet distance that was revealed during an interview with the MSW. The Administrator stated Maintenance measured the distance to where the resident was found, which measured 82 feet. The Administrator also stated the resident was found on the sidewalk where the sidewalk meets the dirt road. At this time the Administrator also revealed there was video footage of the incident and a copy was requested, however the video footage was never received. On 01/22/26 at 2:30 PM, the facility provided an acceptable IJ Removal Plan which included the following:1. Resident #1 was identified outside of the facility on 1-15-2026 at approximately 3:15 pm. Resident #1 exited through the staff door on Unit 100. Staff members observed Resident #1 on facility premises and resident was resistant to return to the facility despite staff redirection. Resident #1 declined for a body audit to be obtained at this time. Resident #1 verbalized no injury.2. Resident #1's elopement risk evaluation repeated on 1-21-2026. Any resident identified has high risk for elopement had interventions validated and care plans updated. No new were identified.3. Grievances reviewed from 10-01-2026-1-21-2026 regarding resident exit seeking behaviors- no concerns identified.4. Progress notes were reviewed from 1-15-2026 through 1-21-2026- no concerns identified.5. Maintenance Director immediately performed an audit on 01-21-2026 to validate facility exits alarms were functioning properly and code for doors was changed. No concerns identified with exit doors.6. Residents at risk of elopement have the potential to be affected.7. The Facility Staff were re-education on 1-21-2026 by the Director of Nursing/Designee regarding the Policy including:a. Re-educate facility staff the expectation that if a door is noticed to be non-functioning to report to management immediately and post an employee at the door until otherwise indicated and redirected by a member of management.b Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified.c. Facility to safely and timely redirect patients/residents to safe environmentd. A prompt investigation and search will be conducted if a patient/resident is considered missing.e.The Facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/residentf. When the Patient/Resident is located, the Charge Nurse completes a head-to-toe assessment. The Social Service Designee assesses the patient/resident for emotional distress. The Charge Nurse reports any findings to the Director of Nursing or designee. The Director of Nursing or designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician and patient's/resident's legal representative.g. Implementation of protective measures to maintain physical and psychological safety for alleged victims.o When a resident expresses a desire to leave the facility and is alert and responsive, reeducate the resident on the process of signing out utilizing the leave of absence form and document understanding from the resident.o Do not share door codes with residents or family members.o When residents verbalize wanting to leave the facility and/or exit seeking behavior staff should immediately notify DON and Administrator.Re-education will be completed by 1-21-2026Any member of target audience not receiving this by this date will receive prior to next scheduled shift, as education has been added to agency staff prior to the start of the next shift.8. Social Services Director and Social Services Assistant re-educated on 1-21-2026 on Elopement and exit seeking behaviors including notifications to Administrator and Director of Nursing.9. Administrator and Director of Nursing re-educated 1-21-2026 by the Clinical Nursing Consultant on the Elopement policy and Investigation process including:Root cause analysisa) Validating interventions in place to protect the resident Facility to safely and timely redirect patients/residents to safe environment.b) A prompt investigation and search will be conducted if a patient/resident is considered missing.c) The Facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident.d) When the Patient/Resident is located, the Charge Nurse completes a head to toe assessment. The Social Service Designee assesses the patient/resident for emotional distress. The Charge Nurse reports any findings to the Director of Nursing or designee. The Director of Nursing or designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician and patient's/resident's legal representative.e) Implementation of protective measures to maintain physical and psychological safety for alleged victims.f)When a resident expresses a desire to leave the facility and is alert and responsive, reeducate the resident on the process of signing out utilizing the leave of absence form and document understanding from the resident.Do not share door codes with residents or family members.When residents verbalize wanting to leave the facility and/or exit seeking behavior staff should immediately notify DON and Administrator.10. New admissions elopement risk assessments will be reviewed in morning meeting daily Monday thru Friday as part of the clinical morning meeting process for accuracy and to validate interventions if indicated. Quarterly elopement risk assessments will be reviewed for accuracy and to validate interventions are in place if indicated as part of the MDS/Care planning process.11. The Director of Nursing will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy.12. The Maintenance director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months.13. The Facility Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with maintenance director to validate that door are functioning properly.Ad hoc QAPI held on 01-21-2026Medical Director, Dr. Binyue [NAME] was notified of the incident and plan for improvement on 01-21-2026This process will be reviewed in QAPI for a minimum of 3 monthsAllegation of Compliance 1-21-2026

Based on review of facility policy, interview, observation, and record review, the facility failed to report the elopement of Resident (R)13 to the required community agencies. Specifically, on 01/15/26 at approximately 2:30 PM, R13 had a successful, unwitnessed elopement from the facility. The facility failed to report the elopement to the State Survey Agency as required. On 01/22/26 at 11:57 AM, it was determined that the facility's non-compliance with one or more federal health, safety, and or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 01/22/26 at 11:57 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 01/15/26 when the facility failed to report an elopement to the State Agency. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 01/22/26 at 2:30 PM, the facility provided an acceptable IJ Removal Plan. On 01/22/26 the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F609 at a lower scope and severity of D. Findings include: Review of the facility policy titled Elopement, with a complete revision date of 11/01/17, documented, Policy . A prompt investigation and search will be conducted if a patient/resident is considered missing. Procedures included, . 7. The Director of Nursing or designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician, and patient's/resident's legal representative.Review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment with a complete revision date of 11/01/17 documented, Policy: . 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including State Survey Agency and adult protective services . 3. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect, or exploitation or mistreatment and will implement immediate action to safeguard resident. 4. The facility's Leadership will provide notification to the proper authorities .Review of R13's Face Sheet revealed R13 was originally admitted to the facility on [DATE], with a re-entry date of 09/12/25. R13's diagnoses included, but were not limited to, heart disease, heart failure, Type 2 diabetes, dizziness and giddiness, right below-the-knee amputation, anxiety disorder, major depressive disorder, and post-traumatic stress disorder.Review of R13's Progress Notes for 01/15/26 revealed no nursing notes regarding the elopement. Additionally, no notes were found showing the facility notified R13's medical provider or Responsible Person (RP).During an interview on 01/21/26 at 3:10 PM, R13 stated, Yes, I just rolled right out. It was Friday, no wait, it was last Thursday. I left through the exit the employees use. I got the code from a Certified Nurse Assistant (CNA) who used to work here. I just fiddled with the keypad and got it open. I wanted out of here. I got past the dumpsters on the side and onto the area with the white sand. I was almost to the street. I did this in the afternoon after lunch that day, probably about 3. A bunch of them found me: The Unit Manager, the Housekeeper/Activities person, and the Social Worker. I was going to go next door and get myself a Greyhound ticket. I want out of here.During an interview on 01/21/26 at 3:44 PM, the Medical Social Worker (MSW) stated, What? There are no notes about him leaving? I would have thought someone would have written something. I mean so many people were there - The Unit Manager, the Director of Nursing, a Medical Records staff member, and even a housekeeping person, I think. When asked about reporting the incident, the MSW responded, Yes, I did notify the Administrator right after it happened. That is why we changed his room. On the 300 Hall, we felt he would be safer because the exit doors there are right next to the Nurse's Station.During an interview on 01/21/26 at 3:15 PM, the Director of Nursing (DON) revealed, No, I didn't report it. I called the Ombudsman about the room change because he was so upset about the room change.During an interview on 01/21/26 at approximately 4:34 PM, the Administrator stated, No, I didn't report it. I didn't think this incident rose to the level of elopement and needed to be reported since the resident was in line of sight by an employee. On 01/22/26 at 2:30 PM, the facility provided an acceptable IJ Removal Plan, which included the following: 1. Resident #1 was identified outside of the facility on 1-15-2026 at approximately 3:15 pm. Resident #1 exited through the staff door on Unit 100. Staff members observed Resident #1 on facility premises and resident was resistant to return to the facility despite staff redirection. Resident #1 declined for a body audit to be obtained at this time. Resident #1 verbalized no injury. 2. Incident reported to the State Survey Agency and Ombudsman on 1-21-2026. 3. Progress notes from 1/15/2026-1/21/2026 were reviewed for exit seeking behaviors by the Director of Nursing/Designee. None identified.4. Administrator and Director of Nursing re-educated on Elopement and Investigation process by the Clinical Consultant on 1/21/2026 including:a. Root cause analysisb. Validating interventions in place to protect the residentc. Timely reporting per State Agency guidelinesd. Facility to safely and timely redirect patients/residents to safe environmente. A prompt investigation and search will be conducted if a patient/resident is considered missing.f. The Facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/residentg. When the Patient/Resident is located, the Charge Nurse completes a head to toe assessment. The Social Service Designee assesses the patient/resident for emotional distress. The Charge Nurse reports any findings to the Director of Nursing or designee.The Director of Nursing or designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician and patient's/resident's legal representative.h. Implementation of protective measures to maintain physical and psychological safety for alleged victimsi. The Facility leadership contacts their Regional [NAME] President of Operations and their Clinical Services Director for recommendations at the time of the elopement.j. The Facility will report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the State Survey agency and other in accordance with state lawk. Conducting a prompt, thorough investigation of any allegation of abuse or neglect and grievances and appropriate actions taken to protect the residentl. Investigations should be prompt, comprehensive and responsive to the situation and contain founded conclusions 5. Social Services Director and Social Services Assistant were re-educated on 1-21-2026 by the Clinical Consultant on Elopement and exit seeking behaviors including notifications to Administrator and Director of Nursing. 6. A review of grievance and Incident reports from 10/01/2025-1/21/2026 has been completed by 1/21/2026 by the Director of Nursing or Administrator to identify any exit seeking behavior. None identified. 7. The Facility Staff will be re-educated by the Administrator/Designee by 1/21/2026 on the Elopement policy including:Facility to safely and timely redirect patients/residents to safe environmentA prompt investigation and search will be conducted if a patient/resident is considered missing.The Facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/residentWhen the Patient/Resident is located, the Charge Nurse completes a head to toe assessment. The Social Service Designee assesses the patient/resident for emotional distress. The Charge Nurse reports any findings to the Director of Nursing or designee. The Director of Nursing or designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician and patient's/resident's legal representative.Re-educating facility staff the expectation that if a door is noticed to be non-functioning to report to management immediately and post an employee at the door until otherwise indicated and redirected by a member of management.Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identifiedWhen a resident expresses a desire to leave the facility and is alert and responsive, reeducate the resident on the process of signing out utilizing the leave of absence form and document understanding from the resident.Do not share door codes with residents or family membersWhen residents verbalize wanting to leave the facility and/or exit seeking behavior staff should immediately notify DON and Administrator This reeducation began immediately and will be completed by 1/22/2026. Any, including PRN, staff not receiving this education prior to this date will receive prior to next scheduled shift. This education will be presented in Agency and New Hire orientation. 8. Administrator and Director of Nursing will review incident reports and grievance reports completed from the prior day in morning meeting daily beginning 1/22/2026 for 7 days then Monday - Friday ongoing for identification of residents with possible exit seeking behaviors. The weekend supervisor will review the incident reports and grievances on the weekends to identify residents with possible exit seeking behaviors. The weekend supervisor will notify the Administrator and Director of Nursing if any identified for further direction. 9. Human Resources will interview 3 random employees daily beginning 1/22/2026 for one week to validate transfer of knowledge of education provided, then 3 employees weekly for 4 weeks.10. Ad Hoc QAPI was held on 1/21/2026 with Administrator, Director of Nursing, Unit Managers x2, Social Services Director, Social Services Assistant, Activity Director, Business Office Manager, Scheduler, Dietary Manager, Maintenance Director, Therapy Director, Staff Development Coordinator and Medical Director in which the Immediate Jeopardy Templates and the contents of this plan were discussed. The Medical Director was notified of the Immediate Jeopardy and the contents of this plan on 1/21/2026.Allegations of compliance 1/21/2026.

Based on review of facility policy, record review and interview, the facility failed to update and revise Resident (R)25's Care Plan to reflect the resident's election for Do Not Resuscitate (DNR) status for 1 of 3 residents reviewed.Findings include: Review of the facility policy titled Care Plan Process, Person-Centered Care with a complete revision date of [DATE], documented, The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident . Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices . The services provided or arranged by the facility, as outlined by the comprehensive person-centered care plan, will meet professional standards of quality. Procedures: 6. The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each assessment . 9. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change off condition dictates the need . Review of the facility policy titled Advance Directives with a complete revision date of [DATE] documented, Policy: The facility recognizes the resident's right to formulate an advance directive. Intent: this policy and procedure provide instruction to Facility staff for obtaining, honoring, and implementing advance directives to the fullest extent of the law. Review of R25's Face Sheet revealed R25 was admitted to the facility on [DATE], with diagnoses including but not limited to: aphasia, Hypokalemia, Hypomagnesemia, lump in the right breast, unspecified quadrant, other specified disorders of bone density and structure, and vascular dementia. Review of R25's Physician Orders revealed an order, Admit to Pathway Hospice and Palliative Care, . Admitting Diagnosis: Vascular Dementia with a start date of [DATE]. Further review of the Orders revealed an order for, CODE STATUS: DNR with a start date of [DATE]. Review of a Telephone Order for R25 dated [DATE] and signed by a physician, revealed under section Medication/Order - DNR. Review of R25's South Carolina Physician Orders for Scope of Treatment (POST), signed on [DATE], revealed under Section A Cardiopulmonary Resuscitation (CPR): Unresponsive, pulseless, & not breathing, the selection Attempt Resuscitation/CPR. Review of R25's South Carolina Physician Orders for Scope of Treatment (POST), signed on [DATE], revealed under Section A Cardiopulmonary Resuscitation (CPR): Unresponsive, pulseless, & not breathing, the selection Do Not Attempt Resuscitation/DNR (Allow Natural Death) was selected.Review of R25's Care Plan with a start date of [DATE] revealed, [R25's] family has chosen to utilize hospice services due to terminal DX of vascular dementia. She is at risk for increased physical needs and psychosocial needs with end of life. The approach directed staff to, Ensure [R25's] care wishes are aligned with written advanced directives or spoken and documented request of care directives. Further review of R25's Care Plan revealed, Problem: Advance Care Planning: Code Status is Full Code with a start date of [DATE]. The approach directed staff to, Advanced directives of [R25's] choice completed and placed on medical record under advanced directive tab or in documents in Matrix , [R25] has completed the following advanced directives and copies are in the medical record ( X) Full Code and [R25] will be informed of her right to complete advanced directives to direct her medical care and make his/her values and treatment goals known. Ms. [NAME] Bowles's RP stated desires will be honored.During an interview on [DATE] at 12:04 PM, the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator stated, On that usually when code status is changed, social services is supposed to change the code status. They would update that.During an interview on [DATE] at 12:09 PM, Social Services Assistant (SS1) and Social Services Director (SSD) stated SS1 and SSD are responsible for updating code status. SSD did the paperwork for DNR on [DATE], it was scanned in. SS1 defers to SSD when asked about the code status in the R25's Care Plan. The SSD states she was Full code and the family switched her to DNR. It was signed on [DATE]. It could have been a mistake. I will update that right now.During an interview on [DATE] at 12:15 PM, the Administrator stated the expectation is to update them as changes are made.

Based on review of facility policy, observation, record review and interview, the facility failed to ensure the facility were free of pests in 3 resident rooms on 2 different units.Review of the facility policy titled Pest Control with a complete revision date of 06/20/23, documented, Facility will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. Review of a Service Report from Ecolab with a service date of 01/22/26, revealed, Inspected selected areas. Inspected and treated selected areas. Rooms serviced today: 113 331. Rooms maybe returned to service after sitting one hour and a thorough deep clean. PEST ACTIVITY FOUND. Further review of the Service Report revealed, AREA Patient/Guest Rooms - Interior - Interior FINDINGS Bed Bugs noted during treatment 311 ACTION NEEDED/TAKEN This area was inspected and serviced. The last section of the Service Report revealed, MATERIAL MATERIAL APPLIED: Finito QTY USED: 92.0 OZ REGULATORY NUMBER 25B APPLICATION TARGET PEST: Bedbugs APPLICATION METHOD: Crack & Crevice. During an observation and interview on 01/21/26 at 2:25 PM, of room [ROOM NUMBER] revealed what appeared to be roaches crawling in the sanitizer station near the resident's bathroom. The resident stated, There are always bugs in here, they are in the lights, the sanitizer container and on the ceilings. They came in to spray for the bugs 2 days ago. During an observation on 01/22/26 at approximately 4:30 PM, of room [ROOM NUMBER] revealed the residents' belongings were packed in trash bags and placed on top of the residents' bed.During an observation on 01/23/26 at 10:23 AM, of room [ROOM NUMBER] revealed the residents' belongings were placed in the hallway, in front of the room, on a rack. The belongings included bags of clothes, a walker, and plastic bins.During an interview on 01/23/26 at 10:26 AM, R56, who lives across the hall in room [ROOM NUMBER], stated he doesn't like all this junk in front of his room. R56 further stated he thinks there are rats or water bugs in the room and they are cleaning it out.During an interview on 01/23/26 at 10:29 AM, the Floor Tech stated we pulled everything out to deep clean that room. The Floor Tech further stated, I was not aware of any pest control issues in that room. During an interview on 01/23/26 at 10:31 AM, Housekeeper 1 stated they might be doing a deep clean or stripping the floor. Housekeep 1 further stated, I've worked over there and knew nothing about bed bugs or pest. During an interview on 01/23/26 at 10:38 AM, the Maintenance Director (MD) stated we sprayed the room (room [ROOM NUMBER]) cause the resident stated he saw a roach in the room, so we removed his belongings and sprayed the room. The MD further stated, I haven't seen any roaches even after the spray treatment. During an interview on 01/23/26 at 11:30 AM, the Administrator stated in full transparency we had an issue with bed bugs in room [ROOM NUMBER]. The Administrator further stated the room has been treated and is now under control. It was isolated to room [ROOM NUMBER]. During an interview on 01/23/26 at 11:42 AM, R87 stated they have roaches sometimes but not a whole lot of them. They are the little roaches not the big ones. People come out to spray. During an interview on 01/23/26 at 11:46 AM, R120, who lives in room [ROOM NUMBER], stated, I've noticed bugs in here. Roaches that's about it. I see them crawling through the day room. I don't know where it came from. This was sometime last year. During an interview on 01/23/26 at 11:47 AM, R60, who lives in room [ROOM NUMBER], stated, We got little black bugs about the size of rice. They came out the ceiling. I caught one, one night and it got a hard shell. If you leave food out, it comes down and lands on the food, even if you leave water out. To me that's nasty. I see them every night. During a follow up interview on 01/23/26 at 12:39 PM, the MD stated, They spotted a couple bed bugs in room [ROOM NUMBER], they notified me on Wednesday. I had a guy come from Ecolab to spray yesterday. I am not aware of any other issues with bed bugs throughout the facility. During an observation on 01/23/26 at 2:50 PM, while the survey team was conducting a team meeting in the meeting room, a roach was observed crawling across the meeting room table. This was observed by multiple surveyors.

Based on review of the facility policy, observation and interview, the facility failed to ensure Resident (R)85 and R11 were free from significant medication errors related to insulin administration via a Kwik Pen, for 2 of 2 residents observed receiving insulin by Licensed Practical Nurse (LPN)1.Findings include:Review of the facility policy titled Medication Administration - Insulin Pen under Preparing the Pen states, . 2. Removes the external pen cover and inspects the excessive air in the cylinder and that the internal screw mechanism is attached to the internal plunger. 3. Wipes the rubber stopper on the end of the pen with an alcohol pad. 4. Removes the tabbed paper seal from the outer cap of a new single-use safety insulin pen needle. 5. Screws the needle into the rubber stopper unit it stops . Priming the Pen: 1. Removes the outer needle cap and dials 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. 3. Repeats these steps as needed until a drop of stream of insulin appears at the needle tip.Review of R11's Face Sheet revealed the facility admitted R11 with diagnoses including but not limited to, Diabetes Mellitus.During an observation on 01/22/26 at 8:18 AM, LPN1 failed to prime the insulin pen for R11, who received 5 units of Aspart Insulin (Novolog) via a kwik pen.During an interview on 01/22/26 at 8:20 AM, LPN1 confirmed that she had not primed the insulin pen, prior to administering the 5 units of insulin.Review of R85's Face Sheet revealed the facility admitted R85 with a diagnoses including, but not limited to Diabetes Mellitus. During an observation and interview on 01/22/26 at an unspecified time, of the administration of Lantus Insulin 24 units for R85 by LPN1, LPN1 failed to prime that insulin pen, even after an interview earlier when she (LPN1) administered the insulin for R11 and had not primed the pen. LPN1 confirmed that she failed to prime the insulin pen for R85.During both interview with LPN1, she could not confirm that R85 and R11 had received the correct dosage of insulin due to failing to prime the insulin pens.

Based on review of the facility policy, observation, record review and interview, the facility failed to ensure a medication administration rate of less than 5 percent for 3 out of 29 opportunities for error. The medication administration error rate was 10.34 percent. Findings include:Review of the facility policy titled Medication Administration - Insulin Pen under Preparing the Pen documented, . 2. Removes the external pen cover and inspects the excessive air in the cylinder and that the internal screw mechanism is attached to the internal plunger. 3. Wipes the rubber stopper on the end of the pen with an alcohol pad. 4. Removes the tabbed paper seal from the outer cap of a new single-use safety insulin pen needle. 5. Screws the needle into the rubber stopper unit it stops . Priming the Pen: 1. Removes the outer needle cap and dials 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. 3. Repeats these steps as needed until a drop of stream of insulin appears at the needle tip.Review of the facility policy titled Medication Administration, Liquids documented, 5. Measures dosage precisely using a medicine cup or syringe. 6. Dilutes medication according to pharmacy and or manufacturer's specification.Review of Resident (R)11's Face Sheet revealed the facility admitted R11 with diagnoses including but not limited to, Diabetes Mellitus.During an observation on 01/22/26 at 8:18 AM, Licensed Practical Nurse (LPN)1 failed to prime the insulin pen for R11, receiving 5 units of Aspart Insulin (Novolog) via a kwik pen.During an interview on 01/22/26 at 8:20 AM, LPN1 confirmed that she had not primed the insulin pen, prior to administering the 5 units of insulin.During an observation and interview on 01/22/26 at 8:18 AM, of the oral medications for R11, LPN1 administered Miralax 17 grams. LPN1 mixed the medication in 3 ounces of water instead of the 6 - 8 ounces required to promote the efficacy of the medication. LPN1 confirmed that she had not used the 6 to 8 ounces of liquid to promote the desired results from the Miralax for R11. Review of R85's Face Sheet revealed the facility admitted R85 with diagnoses including, but not limited to, Diabetes Mellitus. During a second observation of the administration of Lantus Insulin 24 units for R85 by LPN1, LPN1 failed to prime that insulin pen, LPN1 confirmed that she failed to prime the insulin pen for R85.

Based on facility policy review, observation, record review, and interview, the facility failed to maintain accurate narcotic medication records for 2 of 6 medication carts reviewed for medication storage. Findings include:Review of the facility policy titled Medication Management Program with a complete revision date of 05/05/23, revealed, Preparing for the Medication Pass: . 8. Documentation of medications administered is completed according to State and Federal requirements. The initials and verifying signature are generally required . Security and Safety Guidelines: . 9. Controlled substances are accounted for each patient/resident on a Controlled Substance Record (obtained from the contract pharmacy) . Administering the Medication Pass: . 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR.During a count of the narcotic medications in one medication cart on the 100 Hall, revealed seven instances of the count of Residents' narcotic medications not matching the number on the Residents' narcotic count sheets.During a count of the narcotic medications in one medication cart on the 200 Hall, revealed two instances of the count of Residents' narcotic medication not matching the number on the Residents' narcotic count sheets.During an interview on 01/22/26 at 1:00 PM, Licensed Practical Nurse (LPN)4 stated, I'm so sorry. I'm so sorry. I don't want to give the medications late, so I go back to document on the narcotic count sheets after I'm all done with my medication pass. I guess I forgot today.During an interview on 01/22/26 at 1:10 PM, Unit Manager (UM)2 stated, The narcotics should be signed out on the sheet as soon as they are given. I think she (LPN4) got nervous with you here.During an interview on 01/22/26 at 2:10 PM, UM3 revealed, The narcotics should be signed out when they are given to the resident.During an interview on 01/22/26 at 2:20 PM, UM3 revealed, If [LPN3] was an employee, I would start the Performance Management process and corrective action. She is from an agency. I haven't worked with her before. She usually works nights. I will have to ask the Director of Nursing about what to do in this case.During an interview on 01/22/26 at 2:45 PM, LPN3 stated, I was distracted. [R99] was asking for BioFreeze. So much was going on. I normally sign the narcotic sheets as soon as I give the medications.During an interview on 01/22/26 at an unspecified time, the Director of Nursing (DON) revealed, I just want to show you that [LPN4] had already received verbal counseling about not documenting on the narcotic count sheets. I have given her a final warning based on the findings today of her not documenting those seven instances of giving narcotic medications.During an interview on 01/23/26 at 11:00 AM, the DON stated, My expectation is the nurses document giving narcotics as soon as they are given. That involves documenting on the narcotic sheets and in the electronic record. I expect at change of shift, the nurses verify the counts and sign the sign out/sign in sheets. They need to look at the narcotic medication cards and the narcotic count sheets to verify the counts are the same. Yes, I am aware of the second nurse who didn't document on the narcotic sheets. I had walked up when it was discovered when you were doing the counts with the Unit Manager. She is an agency nurse. I provided education to her yesterday regarding the situation.

Based on review of facility policy, record review and interview, the facility failed to ensure Resident (R)5 was free from significant medication errors. Specifically, R5 was discharged from the hospital and admitted to the facility on [DATE], with physicians orders for seizure medications, the facility failed to administer the medication as ordered resulting in the resident experiencing seizure activity and being sent to the hospital, for 1 of 1 resident reviewed for significant medication errors. On 05/21/25 at 10:35 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/06/25. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On 05/21/25 at 11:32 AM, the facility presented an acceptable plan of removal. On 05/21/25 at 1:30 PM, the survey team validated the facility's corrective actions and determined that the facility showed due diligence in addressing the noncompliance. The SA is considering this IJ at Past Non-compliance effective 05/08/25. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care. Findings include: Review of the facility policy titled, Medication Management Program (email revision 01/15/2025), states, B. The facility will ensure the schedules for administering medications: 1. Maximize the effectiveness of the medications. 4. Authorized staff must understand: A. Indications or reason for therapy. B. Effectiveness for drug, achieving the therapeutic goal. C. Drug actions. D. The 8 rights for administering medication: 2. The right drug, 3. The right dose, 4. The right time. Review of R5's Face Sheet revealed the facility admitted R5 on 05/06/25, with diagnoses including, but not limited to: metabolic encephalopathy, seizure disorder and status epilepticus. R5 was discharged to the hospital on [DATE] at 8:40 PM due to seizure activity. Review of R5's Physician's Orders revealed the following orders: Keppra 500 milligrams per 5 milliliters (mls) and R5 is to receive 10 mls 2 times daily at 06:00 AM and 06:00 PM. Lacosamide (Vimpat) 100 milligrams (mgs) 1 tablet 2 times daily at 06:00 AM and 06:00 PM. Zonisade 100 mgs per 5 mls and R5 is to receive 15 mls at 10:00 PM. Review of R5's Medication Administration Record (MAR) for May 2025, revealed that R5 did not receive one dose of Keppra, three doses of Vimpat and two doses of Zonisade. Review of the admission Baseline Care Plan for R5 revealed, Services and treatments to be administered by the facility will be identified, Target date of 05/14/2025. Review of R5's Progress Note dated 05/07/25 at approximately 8:40 PM, revealed, At approximately 8:40 PM. This nurse was notified by family member that resident was having a seizure. Upon entering the room resident was lying in bed in supine position having unresponsive with seizure like activity. She was repositioned to right side. Vital signs obtained was Bp -179/76, P- 130, RR-22, SPO2 -98% on room air. Supervisor notified and 911 was called. Resident had a total of 6 seizures with duration of 1-3 minutes. Onset was between of 3-4 minutes. She was transported by EMS via stretcher to [local hospital]. Accompanied by her brother. During an interview on 05/20/25 at 1:22 PM, Licensed Practical Nurse (LPN) Unit Manager stated, there was no order from the hospital, so she had to get a hard script and call the provider to let them know they do not have the medication here at the facility. LPN Unit Manager further stated that was on 05/06/25. A call was placed to the Medical Director to see if she wanted to change the medication, discontinue the medication, or give something else. LPN Unit Manager stated, The resident missed maybe 3 doses. Her expectation was, the nurses should have called the physician. During an interview on 05/20/25 at 6:20 PM, LPN2, the night shift supervisor, stated that the Vimpat was not delivered by the pharmacy and no hard script was sent from the hospital. LPN2 stated the Zonisade was not delivered and the pharmacy did not contact us and let us know this medication was on backorder. LPN2 continued that the Keppra was delivered but the pharmacy does not deliver until 9:00 PM or 9:30 PM. LPN2 concluded that the resident was fine on 05/06/25. I reported to work at 8:00 PM on 05/07/25 and the resident started seizing shortly after I reported to work. During an interview on 05/20/25 at 6:30 PM, the Director of Nursing (DON) stated the nurses should go by the discharge summary from the hospital. They should put the orders into Matrix Care. The DON stated that the Vimpat was not in the emergency box, the hospital did not send a hard script and the resident did not receive Vimpat, but did receive Keppra and the Zonisade. The DON further stated that the floor nurse does the assessments and observations and the Unit Manager does the admissions by putting the orders in the computer. The facility realized there was no hard script for the Vimpat the evening of 05/06/25, and no one notified the physician until 05/07/25 in the AM. The resident was discharged to the hospital with seizure activity at 8:40 PM on 05/07/25. The DON further stated the resident had missed the morning dose and the evening dose of Vimpat. After reviewing the Medication Administration Record (MAR) on 05/20/25 at 7:15 PM, the DON confirmed that the resident did not receive 1 dose of Keppra, 3 doses of Vimpat and 2 doses of Zonisade. The DON concluded that she was not aware that the resident missed that many doses of her antiseizure medications. During an interview on 05/21/25 at 8:30 AM, the Nurse Practitioner (NP) revealed she was in the facility in the AM on 05/07/25, she is on call from 6:00 AM until 6:00 PM and after 6:00 PM, calls go to an on-call service. The NP stated, I received no calls and the on-call service received no calls from the facility pertaining to hard scripts or R5 not receiving her seizure medications. I was told by the Unit Manager on 05/07/25 between 8:00 AM and 9:00 AM, that the resident needed a hard script for Vimpat. The Unit Manager apologized and stated that with everything going on, she had forgotten to call me the previous day. I E'scribed the script at that time. The NP stated she expects the nurse to notify her if they do not have a medication that the resident needs. She stated there were no triage notes from the on-call to let her know the resident was sent out to the hospital. The NP stated that she was not aware that R5 did not receive the Vimpat nor the Zonisade, Missing several medication doses for seizures could have been detrimental to this resident. She ended up on life support. On 05/21/25 at 11:32 AM, the facility presented an acceptable plan of removal, which included the following: The following measures were immediately implemented upon notification of the facility: 1. Corrective action for residents found to have been affected by the deficiency: a. R5 was found to be affected by the alleged deficient practice. b. On 05/08/2025 a review of all residents admitted on seizure medications since 05/05.2025 was completed to validate orders for seizure medications and that medicatios were available. No discrepancies were identified. c. On 05/08/2025, the Director of Nursing was re-educated by the Clinical Consultant on the following: Medication Management policy specifically medications that are unavailable. Validate the Medication Reconciliation is completed at admission with providers. Medications that are unavailable, specifically seizure medications-process for notifying the provider for scripts, and utilization of the in house stat box. The below process regarding admission medication reconciliation. The following process will be implemented: 1. Director of Nursing or designee will review new admission medication reconciliation for completion Monday through Friday for four weeks. Concerns to be addressed at time of discovery. 2. Director of Nursing and or designee will review medication administration report for unavailable medication and interventions. Monday through Friday for four weeks. Concerns to be addressed at the time of discovery. 3. Licensed nurses will complete medication reconciliation upon admission and communicated to the provider for additional orders if indicated. Any unavailable medications (those not available in stat safe/emergency box) will require a call to the pharmacy to have the medication delivered. The after-hours pharmacy may be need to be contacted to have a medication delivered quickly. If the medication that will be delivered, will result in a late medication administration, the provider must be notified for further orders. d. Licensed nurse in the facility will be re-educated by 05/08/2025. Staff not re-educated by 05/08/2025 will be educated prior to next scheduled shift. New hires will receive education during new hire orientation. Licensed nurses will be educated on the following: Medication Management policy specifically medications that are unavailable. Validate the Medication Reconciliation is completed at admission with providers. Medications that are unavailable, specifically seizure medications- process for notifying the provider for scripts, and utilization of the in house stat box. The below process regarding admission medication reconciliation. The following process will be implemented: 1. Director of Nursing or designee will review new admission medication reconciliation for completion Monday through Friday for four weeks. Concerns to be addressed at time of discovery. 2. Director of Nursing and or designee will review medication administration report for unavailable medication and interventions. Monday through Friday for four weeks. Concerns to be addressed at the time of discovery. 3. Licensed nurses will complete medication reconciliation upon admission and communicated to the provider for additional orders if indicated. Any unavailable medications (those not available in stat safe/emergency box) will require a call to the pharmacy to have the medication delivered. The after-hours pharmacy may be need to be contacted to have a medication delivered quickly. If the medication that will be delivered, will result in a late medication administration, the provider must be notified for further orders. e. Ad hoc QAPI held on 05/08/2025. f. Medical Director was notified of the incident and plan for improvement on 05/08/2025. g. The process will be reviewed in QAPI for a minimum of 3 months. 2. Corrective action for residents that may be affected by the deficiency: a. The Medical Director was notified of the IJ on 05/08/2025. b. All residents on antiseizure medications have the potential to be affected by the alleged deficient practice. Compliance Date: 05/08/2025

Based on observations, interviews, kitchen cleaning schedule review, and facility policy review, the facility failed to ensure the kitchen floor was free of debris and kept clean in a sanitary condition and failed to ensure the kitchen deep fryer was kept clean in 1 of 1 kitchen. The deficient practice had the potential to affect all 143 residents in the facility who receive meals prepared in and served from the facility's kitchen. Findings include: Review of the facility's policy titled, Nutrition Policies and Procedures Sanitation & Food Safety in Food and Nutrition Services, dated 06/20/23, revealed The Certified Dietary Manager (CDM) will assume responsibility for the food safety and sanitation . The policy indicated, The CDM develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals. Cleaning tasks are initialed as they are completed .The CDM provides a cleaning schedule for each area and piece of equipment in the kitchen. During the initial kitchen observation on 02/25/25 at 6:00 PM, the entire kitchen floor was observed to be sticky and dirty. The floor directly located under the food prep area was observed to be dirty with crumbs of food on the floor. The flooring where the kitchen deep fryer machine was observed to be very dirty, littered with splatters of grease and food crumbs. During this observation, the deep fryer machine was observed to be very dirty and littered with splatters of grease on the front, bottom, sides, top, inside of the top with thick yellow/brownish pieces of caked dried grease inside and on the front covering. The top inside of the deep fryer was observed to have a very large thick buildup of dried clumps of yellow/brown grease pieces on it. The bottom front wheels of the deep fryer were also observed to have a heavy buildup of grease on them. The flooring on the bottom of the deep fryer was dirty, greasy, and had food crumbs near the wheels. During an interview on 02/25/25 at 6:15 PM, the Dietary Assistant (DA) indicated the staff were just completing dinner being served and acknowledged the floor to be dirty and sticky. During an observation made on 02/27/25 at 11:30 AM, the lunch meal was observed as prepared, and food was placed on the tray line. At this time, the entire kitchen floor was again observed to be sticky and dirty. The flooring where the kitchen deep fryer machine was, was observed again to be very dirty littered with splatters of grease and food crumbs. The deep fryer machine was again observed to be very dirty with the same splatters of caked grease on the front, bottom, sides, top as before. The same splatters of thick yellow/brownish pieces of caked dried grease were again observed to be on the front covering and the top inside of the deep fryer was observed to have the same thick buildup of dried clumps of yellow/brown grease pieces on it. The bottom front wheels of the deep fryer were also observed with the heavy buildup of grease on them. The flooring on the bottom of the deep fryer was also observed to be dirty and greasy. During an interview on 02/27/25 at 11:45 AM, the Dietary Manager (DM) was asked how often the deep fryer and flooring were cleaned. She stated, Every week. The DM indicated she had only been the DM at the facility for three weeks. During an observation of the kitchen deep fryer and interview on 02/27/25 at 11:47 AM, the Dietary Assistant (DA) confirmed the heavy buildup of grease splatters on the deep fryer machine top, sides, inside, wheels and stated, It's been like this for a while. The DA then stated, We just need a new one. We have a brush to clean it out. It could use good cleaning. During an observation of the kitchen deep fryer and interview on 02/27/25 at 11:49 AM, the DM confirmed the heavy buildup of grease splatters on the deep fryer machine top, heavy buildup of the clumps of yellow/brown dried grease on the inside and front of the machine, sides, and grease splatters on the wheels and dirty floor. The DM stated, I will have to see when the last time it was cleaned. I see it could use some tender love and care. It could use some cleaning. Yes. When the DM was asked how often the kitchen floors were cleaned, she stated, Every night. At this time, the cleaning schedules were requested. Review of the facility's February 17, 2025 - February 23, 2025, and February 24, 2025 - March 2, 2025, Nutrition Policies and Procedures Cleaning Schedules, labeled Aides revealed sweep and mop was to be completed daily Monday through Friday by the PM [evening] cook. There was no documentation of it being completed daily Monday through Friday for the week of February 17, 2025 - February 23, 2025, and initialed only once as being completed on 02/25/25. The Nutrition Policies and Procedures Cleaning Schedules also revealed the cleaning of the Deep Fryer was to be completed on Sundays by the PM cook. There was no documentation on the cleaning schedule as being completed by the aides on February 17, 2025 - February 23, 2025, cleaning schedule and only once as being completed by the PM cook. During an observation of the kitchen floors and cleanliness of the deep fryer machine and interview on 02/27/25 at 1:00 PM, the Administrator observed the heavy buildup of splatters of grease on the deep fryer top, bottom, sides, wheels and inside still with the same heavy buildup of dried yellow/brown grease and stated, I would not consider this to be clean. No. I would expect the staff to be cleaning it [referring to the deep fryer] and the floors as well.

Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure: 1. staff used proper personal protective equipment (PPE) and/or performed hand hygiene with residents who required enhanced barrier precautions (EBP) for 2 residents (Resident (R)65 and R93), 2. proper sanitization of patient care equipment between uses for 2 (R35 and R1) residents, 3. Housekeeping staff used appropriated PPE and performed hand hygiene while cleaning rooms under EBP, and 4. immunization and education regarding the risks and benefits of the COVID-19 immunization was offered to 3 of 5 residents (Resident (R)62, R65, and R93) reviewed for COVID-19 immunizations out of a total sample of 33 residents. Failure to perform adequate infection control practices increased the risk of cross contamination and spread of infection. Findings include: 1. The facility staff failed to wear all required PPE and/or perform hand hygiene when caring for residents under EBP. Review of the facility's policy titled Infection Prevention and Control last revised 05/15/23 indicated 1. Enhanced Barrier Precautions expend the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistance organisms) to staff hands and clothing. A. EBP will be implemented for all residents with the following: 1) Infection or colonization with an MDRO when contact precautions do not otherwise apply 2) Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. B. EBP will be implemented during the following high-contact resident care activities: .4) Providing hygiene. a. Review of R65's Face sheet located in the electronic medical record (EMR) under the Face sheet tab revealed R65 was admitted on [DATE] with diagnoses including but not limited to obstructive and reflux uropathy. Review of R65's Orders found in the EMR under the Orders tab revealed an order dated 02/26/25 for Enhanced barrier precaution r/t foley catheter. Review of R65's Care Plan located in the EMR under the Care Plan tab revealed a focus area for enhanced barrier precaution d/t foley catheter with an intervention that Staff to wear appropriate PPE when providing personal care. Observation on 02/26/25 at 11:06 AM revealed Certified Nurse Aide (CNA)3 provided personal hygiene to R65 including a brief change wearing only gloves and no gown. Observation revealed signage on R65's door which indicated that gowns and gloves were required for direct care including dressing, bathing, changing linens, transferring, providing hygiene, changing briefs, device care, toileting, wound care for any open wounds. Hanging on R65's door were gowns, gloves, and masks. During an interview on 02/26/25 at 11:10 AM, CNA3 was observed to exit R65's room with a bag of trash from toileting and stated she did not know which resident required EBP (R65 or roommate) and stated she was wearing gloves. CNA3 confirmed she did not wear a gown while providing care to R65. During an interview on 02/26/25 at 11:45 AM Unit Manager (UM)1 stated staff know which residents required EBP based on information in the Point of Care system located on the wall down each hall. She stated R65 had a catheter and required EBP, and staff should wear a gown and gloves for direct care. She stated staff received EBP training, and EBP signage was provided on resident doors for guidance. During an interview on 03/01/25 at 9:42 AM the Director of Nursing (DON) stated for a resident with a catheter she expected staff to wear gloves and a gown for direct care. During an interview on 03/01/25 at 1:20 PM the Infection Preventionist (IP) stated staff should wear gowns and gloves for EBP. b. Review of R93's face sheet, found in EMR revealed an admitted [DATE], with multiple diagnosis including but not limited to end stage renal disease. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/29/24 revealed R93 was on dialysis (a treatment requiring a shunt to access the blood circulatory system for kidney failure) and had a gastrostomy tube (a tube placed in the abdomen for delivering nutritional supplements into the stomach.) During an observation on 02/26/25 at 10:30 AM, revealed R93 in his room seated on the edge of the bed dressed. The right foot did not have a sock in place (the left foot did), and a wound with blood was observed on the base of the nail bed along the cuticle on the right great toe. R93 stated he was getting ready for an appointment outside the facility and stated the nurse was going to put a dressing on the toe wound. Further observation on 02/26/25 at 10:35 AM, Unit Manager (UM)2 entered the room to complete the dressing on the wound on R93's right toe. UM2 applied a gown, and mask, and obtained a pair of gloves and applied them but did not complete hand hygiene prior to putting on the gloves. When asked about the reason for the Enhanced Barrier Precaution's (EBP) posting outside the room UM2, explained R93 was on dialysis, and then approached the resident to provide wound care. When asked if hand hygiene was completed prior to placing the gloves UM2 discarded the gloves and went to the bathroom sink and washed her hands. After applying new gloves, the UM2 sprayed a wound cleaner on the area, wiped the area with a gauze pad, and discarded it. UM 2 then applied antibiotic cream to the area then began to bandage the toe. After the dressing was placed, UM2 washed her hands, obtained a new pair of gloves, and explained that another dressing would be applied to the gastrostomy tube. UM2 did not complete hand hygiene or change gloves after handling the soiled gauze used to clean the wound. During an observation on 02/26/25 at 10:40 AM, revealed Certified Nursing Assistant (CNA)4 entered R93's room to assist. UM2 asked CNA4 to obtain R93's blood pressure (BP). CNA4 exited and then reentered the room with a cart containing testing equipment. CNA4 began to apply the BP cuff but was only wearing gloves, no gown or mask, which according to the notice posted on the door were needed when providing care for R93. UM2 then asked CNA4 to assist with reposition R93, and directed CNA4 to place a gown, new gloves, and a mask. On 02/26/25 at 11:15 AM, during a follow up interview UM2 verified the failure to complete hand hygiene as needed and CNA4 not wearing a gown and mask required for EBP. 2. The facility failed to sanitize resident equipment between residents. The facility did not provide a policy related to sanitizing patient care equipment. Review of R35's Face sheet located in the EMR under the Face sheet tab revealed R35 was admitted on [DATE] with diagnosis including but not limited to essential (primary) hypertension. Review of R35's Orders located in the EMR under the Orders tab revealed an order dated 10/07/24 for Vital signs twice a day. Review of R1's Face sheet located in the EMR under the Face sheet tab revealed R1 was admitted on [DATE] with a diagnosis including but not limited to essential (primary) hypertension. Review of R1's Orders located in the EMR under the Orders tab revealed an order dated 09/24/24 for midodrine tablet 5 mg (milligram) 1 tablet oral three times a day. Hold for SBP (systolic blood pressure) > 130. Task to record: Blood Pressure. Observations on 02/27/25 at 9:21 AM during medication administration for R35 revealed Registered Nurse (RN)2 measured R35's blood pressure using a blood pressure (BP) machine. RN2 then removed the BP machine out of R35's room and parked it next to the medication cart on 100 hall without sanitizing it and then documented R35's medication and BP reading. Licensed Practical Nurse (LPN)4 walked up from the other side of 100 hall and took the BP machine. This writer asked RN2 if she had sanitized the machine. RN2 said she had not. RN2 then realized she did not have sanitizing wipes or spray on her medication cart, so she took the machine down towards the nurses' station to get cleaning supplies. RN2 then took wipes from LPN4's medication cart and sanitizing spray from the nurses' station and took the machine to LPN4 and began to clean the machine and BP cuffs. At this same time, R1 was observed waiting in the hall to have his BP checked so RN2 proceeded to measure R1's BP, first using the small cuff and then changing it to the larger cuff. RN2 gave the BP measurement to LPN4, then walked back to her medication cart, leaving the BP machine with LPN4 without sanitizing the machine again. RN2 confirmed that she had not sanitized the BP machine. During an interview on 02/27/25 at 9:41 AM UM1 stated staff should sanitize the BP machine and cuffs between each resident use and make sure the medication cart had wipes. During an interview on 03/01/25 at 9:42 AM the DON stated staff should sanitize patient care equipment such as BP cuffs before and after each use. During an interview on 03/01/25 at 1:20 PM the IP stated staff should sanitize BP equipment between uses. 3. Housekeeping staff failed to wear PPE and/or perform hand hygiene between cleaning resident rooms. Observation on 02/26/25 at 10:20 AM, revealed Housekeeper (HK)1 was exiting a room in the 300 hall, that had EBP posted outside the door. HK1 completed cleaning the room and had a wet floor mop in her hand and placed it on the cart. Removed and discarded their gloves. The staff then placed one glove on the right hand and stripped a soiled cloth from the head of the mop, which was discarded in a bag of soiled laundry and the glove on the right hand was discarded. The staff then picked up key to the cart and locked it. HK did not complete hand hygiene after discarding the soiled mop head. When asked about the observation, HK1 stated she should have washed her hands after handling the soiled mop head but did not. Observation on 02/27/25 at 9:45 AM, revealed HK2 cleaning rooms in the 300 hallway. HK2 was cleaning room [ROOM NUMBER] which housed a resident on EBP, was first observed with a broom and dustpan sweeping, the staff member approached the cart and emptied the dustpan, however he was not observed wearing any gloves. HK2 repeatedly entered and exited the room for supplies, to clean different areas in the room. The last task completed was using a wet mop to clean the floor. The staff member was not wearing gloves and did not complete hand hygiene after exiting the room. EBP precautions were posted outside the door of room [ROOM NUMBER]. Further observation revealed HK2 going directly to room [ROOM NUMBER] across the hallway and began cleaning without any hand hygiene or changing the wet mop head. During an interview on 02/27/25 at 10:03 AM, when asked about the use of gloves HK2 stated that the facility did not have gloves that fit him. When asked when hand hygiene should be completed, he stated after completing each room. On 02/28/25 at 5:05 PM, the Maintenance Director (MD) (who was also the HK supervisor) was interviewed about expectations for handwashing and glove use. The MD stated gloves should be worn when cleaning rooms and stated they should be washing and/or sanitizing hands between resident rooms. 4. The facility failed to offer education of risk and benefits and immunization with COVID-19 vaccine. Review of the facility's policy titled, Infection Prevention and Control Policies subject Immunization recommendations for patients, residents and health care workers (HCWs) revised 08/02/23 stated, .The facility will track all staff and resident vaccination status for the COVID-19 vaccine. Resident vaccination status will be documented in their medical record and include: 1) Education provided to the resident or resident representative regarding the benefits and potential risks associated with the COVID-19 vaccine (including date and name of representative) AND 2) Each dose of the COVID-19 vaccine administered to the resident 3) If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal . a. Review of R62's Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed she was admitted to the facility on [DATE] with a primary diagnosis of acute kidney failure. Review of R62's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/25 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact. Review of R62's undated Preventive Health Care report located in the EMR under the Preventive Health tab did not include any information related to COVID-19 immunization. During an interview with R62 on 02/26/25 at 11:44 AM stated, I do not want to talk. b. Review of R65's Face Sheet located in the EMR under the Resident tab revealed he was admitted to the facility on [DATE] with a primary diagnosis of dementia without behavioral disturbance. Review of R65's Quarterly MDS with an ARD of 01/31/25, R65 had a BIMS score of 4 out of 15, which indicated the resident was severely cognitively impaired. Review of R65's undated Preventive Health Care report located in the EMR under the Preventive Health tab did not include any information related to COVID-19 immunization. Resident R65 was not interviewed related to COVID-19 immunization due to severe cognitive impairment. Review of R93's Face Sheet located in the EMR under the Resident tab revealed he was admitted to the facility on [DATE] with a primary diagnosis of end stage renal disease. Review of R93's Quarterly MDS with an ARD of 11/29/24 had a BIMS score of 3 out of 15, which indicated the resident was severely cognitively impaired. Review of R93's undated Preventive Health Care report located in the EMR under the Preventive Health tab did not include any information related to COVID-19 immunization. Resident R93 was not interviewed related to COVID-19 immunization due to severe cognitive impairment. During an interview on 03/01/25 at 2:38 PM, the Infection Prevention Nurse (IP) stated that she did not have documentation of COVID-19 immunizations being offered to R62, R65, or R93 or their representatives. The IP confirmed that all residents should be offered the COVID-19 immunization and be offered education on the risks and benefits of the immunization. The IP stated that she was not aware that she did not have documentation on their COVID-19 immunization status but should have. During an interview on 03/01/25 at 3:23 PM, the Director of Nurses (DON) stated that it was her expectation that all residents be offered the COVID-19 immunization and offered education. If the resident was not cognitively intact, then their responsible party (RP) should be contacted to obtain immunization consent or declination. The DON confirmed that if the resident or RP declined the immunization it should be entered in the EMR under the Preventive Health tab and indicate offered and declined.

Based on interview, record review, and facility policy review, the facility failed to ensure residents received their medications in a timely manner according to physician's orders for 6 residents (Resident (R)34, R46, R72, R97, R102, and R107). This failure had the potential to lead to unwarranted medication side effects or improperly treated medical conditions. Findings include: Review of the facility policy titled Medication Management Policy last revised 01/15/25 revealed Preparing for the Medication Pass .7. Medications are administered no more than one (1) hour before to one (1) hour after the designated the medication pass time . 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. If a medication is not administered, the authorized staff or licensed nurse must explain why it was not given. During an observation on 02/27/25 at 5:54 PM, revealed Registered Nurse (RN)1 on the 200-hall medication cart preparing to administer medications. Observation of RN1's computer screen revealed nine resident profiles in red. During an interview on 02/27/25 at 5:54 PM, RN1 stated the red resident profiles indicated those residents' medications were late. RN1 stated she had been behind on medication administration all day. During an interview on 02/27/25 at 5:58 PM, Licensed Practical Nurse (LPN)2 and Unit Manager (UM)1 stated RN1 was late on medication administration and had been late with medication administration that morning as well so LPN2 had helped RN1 late morning to navigate the electronic medication administration system to catch her up. Review of the electronic Medication Administration Records (MAR) located in the Electronic Medical Record (EMR) under the Orders tab for 02/27/25 revealed RN1 administered the following late medications: 1. R34: Gabapentin (antiepileptic for pain) 400 milligrams (mg) ordered for 3:00 PM and administered at 7:05 PM. Carvedilol (antihypertensive) 6.25 mg ordered for 5:00 PM and administered at 7:05 PM. Acetaminophen (analgesic) 325 mg give two tablets ordered for 6:00 PM and administered at 7:05 PM. 2. R46: Hiprex (urinary anti-infective) 1 gram ordered for 5:00 PM and administered at 6:55 PM. Metoprolol tartrate (antihypertensive) 25 mg ordered for 5:00 PM and administered at 6:55 PM. Calcium 600 + Vitamin D3 tablet (vitamin) ordered for 5:00 PM and administered at 6:55 PM. House supplement (nutritional supplement) 120 mL ordered for 3:00 PM and administered at 6:55 PM. 3. R 64: Gabapentin (antiepileptic for pain) 400 mg ordered for 3:00 PM and administered at 6:51 PM. 4. R72: Hydralazine (antihistamine for itching)100 mg ordered for 5:00 PM and administered at 7:03 PM. 5. R102: Tizanidine (muscle relaxant) 6 mg ordered for 3:00 PM and administered at 6:57 PM. 6. R107: Alprazolam (antianxiety/hypnotic) 0.5 mg ordered for 5:00 PM and administered at 7:02 PM. Creon (lipase-protease-amylase digestive enzymes) capsule ordered for 5:00 PM and administered at 7:02 PM. Gabapentin 100 mg administer 2 tablets ordered for 3:00 PM and administered at 7:02 PM. Sodium bicarbonate (antacid) 650 mg ordered for 3:00 PM and administered at 7:02 PM. During a follow up interview on 03/01/25 at 9:42 AM, the Director of Nursing (DON) stated staff have one hour before and after to administer timely; if a medication was late staff should notify physician to verify if the late medication can be given, and make family aware of the late medication, and monitor resident for medication response after administration.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure that care conferences were held for 2 of 4 residents (Resident (R)72, and R86) reviewed for care conferences of 33 sampled residents. The failure increased the risk of the resident's preferences and concerns not being included in the plan of care. Findings include: Review of the facility policy titled Care Plan Process, Person-Centered Care revised 05/05/23 indicated, .Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and understanding the resident's life before coming to reside in the nursing home .The IDT [Interdisciplinary Team] will invite participation from the resident and the resident's legal representative (if applicable). The IDT will document an explanation in the resident's medical record of the invitation, participation, or lack of participation of the resident and their representative . 1. Review of R72's undated Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed an original admitted [DATE] and re-admission on 12/26/24. Review of R72's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/24 revealed R72 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Review of R72's Quarterly MDS with an ARD of 11/30/24 revealed R72 had a BIMS score of 11 out of 15 indicating she had moderate cognitive impairment. Review of R72's undated Care Conference Report located in the EMR under the Care Plan tab did not include any care conferences. Review of Social Services progress notes and documents did not indicate that any care conferences were scheduled, no invitations were sent, and the resident/family did not attend any care conferences. Review of R72's Documents located in the EMR under the Documents tab did not include any Social Services care conference documentation. Review of R72's Social Services Progress Notes located in the EMR under the Progress Notes did not include documentation of care conferences being held or offered. During an interview on 02/27/25 at 6:14 PM, R72 stated that she was recently hospitalized and would like to speak with the team regarding her care. R72 stated that she had not been invited or attended any care conferences but would like to attend so she could be more aware of her care regarding gastroenterology consult. 2. Review of R86's undated Face Sheet located in the EMR under the Resident tab, revealed an original admitted [DATE] and re-admission on 09/28/24 with a primary diagnosis of congestive heart failure. Review of R86's quarterly MDS with an ARD of 01/26/25 revealed R86 had a BIMS score of 15 out of 15 indicating that he was cognitively intact. Review of R86's Care Conference Report located in the EMR under the Care Plan tab did not include any care conferences after the quarterly MDS assessment on 01/26/25. Review of R86's Documents located in the EMR under the Documents tab did not include any Social Services care conference related documentation since 10/25/24 which was to invite the resident/responsible party to the care conference to be held on 11/07/24. Review of R86's Social Services Progress Notes located in the EMR under the Progress Notes did not include documentation of care conferences being held or offered since 11/07/24. During an interview on 02/26/25 at 10:22 AM with R86 he stated that he would like to attend his care conference meetings due to concerns he had with his room placement at the facility. During an interview on 02/27/25 at 4:07 PM, the Social Services Director (SSD) confirmed that it was the expectation that long term residents have quarterly care conferences in coordination with their MDS assessments. SSD was not aware that R72 had not had any care conferences since she was admitted and confirmed that he was not able to locate any documentation that would indicate that a care conference had been held. SSD confirmed that R86's most recent MDS assessment was 01/26/25 and that the care conference should have been held by 02/16/25. SSD stated that from 12/27/24 - 02/17/25 he was the only SW and was behind on care conferences. The expectation was for care conferences to be held per the Resident Assessment Instrument (RAI) Manual. During an interview on 03/01/25 at 3:51 PM, the Director of Nursing (DON) and Administrator stated that the Social Services department sends out invitations to care conferences. It was their expectation that care conferences be held in coordination with the MDS assessment schedule. The DON and Administrator were not aware that R72 did not having any care conferences since she was admitted to the facility or that R86's care conference had not been held for his last MDS assessment.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to implement care plans for 2 residents (Resident (R)80 and R93) out of a sample of 33 residents. This failure placed the residents to be at risk for unmet care needs. Findings include: Review of the facility's policy titled, Care Plan Process, Person-Centered Care revised 05/05/23 and provided by the facility stated, .The services provided or arranged by the facility, as outlined by the comprehensive person- centered care plan, will meet professional standards of quality .Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls . Review of the facility's policy titled, Person-Centered Care Plan revised 06/09/23 and provided by the facility stated, .The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care, and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible . Review of R80's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab indicated R80 was admitted to the facility on [DATE], with a primary diagnosis of dysphagia and dementia. Review of R80's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/24, and a Brief Interview for Mental Status (BIMS) score of 99 which indicated R80 had severe cognitive impairment and was unable to participate in the assessment. Review of R80's Care Plan located in the EMR under the Care Plan tab revised 01/28/25 included medical review for neurology consult and referrals for memory care. Review of R80's Fall Investigation provided by the facility indicated R80 sustained a fall on 01/22/25, resulting in a laceration to the forehead. Review of R80's Social Services Progress Notes located in the EMR under the Progress Notes tab and dated 01/23/25, 01/27/25, 02/12/25, and 02/27/25, did not include any documentation related to a referral to a memory care unit. Review of R80's Five-Day Follow-Up Report dated 01/28/25, included, Interventions by facility to prevent future injury/alleged abuse: Referrals to be sent to facilities with memory care unit and additional services for severely cognitively impaired. Fall intervention updated on care plan. Medical review and neurology consult added for follow up . During an interview on 03/01/25 at 10:24 AM, the Director of Nursing (DON) stated that after R80 fell and hit his head, the Interdisciplinary Team (IDT) put in a request for a neurology consultation. The DON confirmed that she was not able to locate the order for a neurology consultation and that the provider would have written the order for the referral. The medical records department would be responsible for scheduling the appointment once the referral was received. Additionally, the referral to a memory care unit was also to be made due to wandering behaviors. The DON stated that it was the Social Services department's responsibility to make these referrals. It was her expectation that the IDT follow up to ensure that consultations and referrals are made. During an interview on 03/01/25 at 11:09 AM, the Social Services Director (SSD) stated that if a neurology consultation had been received there would be an order in the EMR. The SSD was unable to locate the order and confirmed that the facility should have followed up on the neurology consultation request. Additionally, the SSD confirmed that the IDT had agreed to submit a referral to a facility with a memory care unit due to R80's wandering behaviors. The SSD stated that he thought that he had sent a referral to [name of facility] at the end of January 2025, or the beginning of February 2025 but was unable to locate documentation confirming the referral had been sent. The SSD confirmed that he had not followed up on the referral but should have. 2. Review of the EMR Face Sheet revealed R93's admitted [DATE], with multiple diagnosis including but not limited to end stage renal disease. Review of the EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/29/25, under the Resident Assessment Instrument (RAI) tab, revealed R93 required dialysis (a treatment provided through a surgically placed tube into the circulatory system). Review the Care Plan (CP) to address dialysis, initiated on 08/24/24, in the EMR under the tab for the Resident Assessment Instrument (RAI) revealed a directive dated 11/18/24, stating Do not take BP on the arm of dialysis fistula (LUA Left Upper Arm). Observation on 02/26/25 at 10:30 AM, revealed R93 in his room seated on the edge of the bed and dressed. R93 stated he was getting ready for an appointment outside the facility and stated the nurse was coming back to finish a treatment. On 02/26/25 at 10:35 AM, Unit Manager (UM) 2 entered the room to complete a wound dressing. On 02/26/25 at 10:40 AM, Certified Nursing Assistant (CNA)4 entered R93's room to assist. UM2 asked CNA4 to obtain R93's blood pressure. CNA4 began to apply the BP cuff to the left arm. When asked where the dialysis site was located, CNA4 did not respond. UM2 checked for the site and found it was located on the left interior side of the upper arm (the same location CNA4 was applying the BP cuff.) UM2 then directed CNA4 to test the BP on right arm. Prior to leaving the room on 02/26/25 at 10:50 AM, a sign was observed, posted to the right of the head of the bed. It stated, do not take blood pressure or complete blood draws on the left arm.

Based on interviews, record reviews, and facility policy review, the facility failed to notify the physician for 1 resident's (Resident (R) 134) change in condition out of a sample of 33 residents. This failure delayed the physician in treating pressure ulcers. Findings include: Review of the facility's policy titled Documentation- Licensed Nursing revised 05/05/23 and provided by the facility indicated, . The initial evaluation of the patient/resident will be completed as soon as possible, but no later than 24 hours following admission or re-admission. Review of the facility's policy titled Wound care policies and procedures revised 06/01/15, and provided by the facility indicated, . Licensed Nurse performs a head to toe check of the patient's/resident's skin, . 2. Any significant abnormal findings are reported to the patient's/resident's physician . Review of the facility's policy titled Wound care policies and procedures reference revised 09/07/17, provided by the facility stated . Staff should remain alert to potential changes in the skin condition and should evaluate, report and document changes as soon as identified . Review of R134's undated Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed an admitted [DATE], with diagnoses including but not limited to: protein-calorie malnutrition, dysuria, localized edema, and an unspecified open wound to left lower leg. Review of the Hospital Discharge summary packet dated 01/26/25, did not include orders for wound care to the buttocks/sacrum. Review of R134's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/11/25, revealed R134 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated she was cognitively intact. The MDS also included two unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar and both were present upon admission/reentry. Review of R134's Baseline Care Plan dated 02/04/25, located in the EMR under the Care Plan tab did not identify the pressure ulcers to the sacrum with no interventions for prevention. Review of R134's Care Plan located in the EMR under the Care Plan tab revised 02/10/25, indicated that R134 was admitted to the facility with cellulitis to bilateral legs and pressure area to buttocks. Interventions included wound care to buttocks as ordered and wound team to evaluate wound(s), treatments, and healing status weekly. Review of R134's Focused Observation located in the EMR under the Observations tab and dated 02/04/25, by Licensed Practical Nurse (LPN)4 indicated upon admission R134 had a wound to the sacrum measuring four centimeters (cm) by five cm. Review of R134's Progress Note dated 02/04/25 indicated she was admitted to the facility with excoriated areas to the sacrum and a barrier cream was applied. Review of R134's Orders located in the EMR under the Orders tab revealed the facility did not obtain physician orders for wounds to the sacrum/buttocks until 02/10/25 (clean area to bilateral buttocks with wound cleanser, apply collagen powder and apply bordered gauze daily and as needed). During an interview on 02/04/25 at 10:05 AM, the Director of Nursing (DON) confirmed that LPN4 assessed R134 upon admission and noted excoriation to her bottom, applied barrier cream, however, did not notify the physician, and did not obtain any orders for wound care treatment to the buttocks/sacral area. The DON stated that it was her expectation that the admitting nurse would notify the physician immediately of any abnormal skin condition and obtain orders for treatment, as necessary.

Based on observation, interview, record review, and policy review, the facility failed to complete a thorough investigation of an altercation for 2 of 7 residents (Resident (R)59 and R0) reviewed for abuse out of a total sample of 33 residents. Findings include: The Leadership Policies and Procedures addressing the Subject: Abuse, Neglect, Exploitation or Mistreatment, revised [DATE]. Under the subheading Component V: Reporting/ Response 2.) An analysis is completed to determine what changes are needed if appropriate, to prevent further occurrences. Component VI: Investigation, states The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc Are thoroughly investigated and appropriate actions are taken. Under 4.) Investigations are prompt, comprehensive, and responsive to the situation and contain founded conclusions. Review of R59's Face Sheet located in the electronic medical record (EMR) revealed R59 was admitted to the facility on [DATE], with multiple diagnoses including but not limited to: dementia and bipolar disease. Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], under the Resident Assessment Instrument (RAI) tab revealed R59 had displayed behaviors which were not directed towards others and would wander in the living unit. R59 used a wheelchair and could independently move throughout the unit for short distances. Review of R0's Face Sheet EMR, revealed an admitted [DATE], with multiple diagnosis including schizoaffective disorder and dementia with agitation. Review of the Admission MDS, with an ARD date of [DATE], under the RAI tab in the EMR revealed a discharge notification, dated [DATE], that reported R0 died at the facility. Review of an Investigation Worksheet (IW), dated [DATE], documented R59 was approached in the dining room by R0 and after yelling at R59 not to take off her shoes. R59 responded by kicking her shoes off towards R0. R0 got angry and responded by slapping R59 across the left cheek. The IW, dated [DATE], documented the two residents involved were separated and were checked for injury. The facility reported the incident as required within two hours and initiated an investigation of the incident. Statements from the staff who observed, heard, or responded to the altercation were completed. However, there was no evidence any one interviewed residents seated in the dining room, to determine if other residents were negatively impacted by the incident and/or had been abused by R0. The facilities investigation concluded that the incident was abuse and documented that the staff could not reach R0 to prevent him from slapping R59. On [DATE] at 9:30 AM, the Administrator was asked if interviews were completed to ensure residents who observed the incident felt safe in the facility or if the incident had an impact on their psycho-social wellbeing and/or had been abused by R0. The Administrator stated the Social Services Director (SSD) should have completed interviews. On [DATE] at 11:00 AM, SSD reported he had not completed any safety check interviews with residents on the 300 unit after the altercation between R59 and R0 which occurred in the dining room.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to assess and monitor the nutritional status of 1 of 4 residents (Resident (R)46) reviewed for weight loss in a total sample of 33 residents. Findings include: Review of the facility policy titled Weighing the resident, revised on 02/26/24 stated .If the month-to-month weight shows more than a five-percent gain or loss, the patient/resident is reweighed in the presence of licensed personnel. 3. Record all weights per facility protocol. 4. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Registered Dietician. Document this notification per facility protocol .9. Unplanned and undesired weight variance will be evaluated for significance utilizing the following guidelines: 3% in one week, 5% in 30 days, 7.5% in 90 days, and 10% in 180 days . Review of R46's undated Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed an admitted [DATE] with a primary diagnosis of heart failure. Review of R46's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/24 revealed R46 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated he was severely cognitively impaired. The MDS assessment indicated R46 had weight loss and was not on a physician-prescribed weight-loss regimen, as well as received a mechanically altered diet. Review of R46's Care Plan located in the EMR under the Care Plan tab and revised on 01/31/24, indicated he was at risk nutritionally related to multiple comorbidities. Interventions included obtaining weights per protocol, giving diet as ordered, registered dietitian to evaluate nutritional needs, offer snacks, and notifying medical doctor of significant weight change. Additionally, R46 required feeding assistance by staff during all meals. Review of R46's Care Conference Report located in the EMR under the Care Plan tab indicated that a meeting was held on 12/31/24 discussing a dietary texture of pureed food, nectar thick liquids, double portions with super potatoes, and meal consumptions of 75-100%. No mention of ongoing weight loss was included in the discussion. Review of R46's Orders located in the EMR under the Orders tab, included orders for house supplement 120 milliliters (ml) three times daily (TID) (01/23/25), eating with assistance of resident by staff (03/04/24), monthly weights (09/02/24), and nectar thick liquids/pureed/double portions/super potatoes at lunch/dinner (08/01/24). Review of weight monitoring located in the EMR under the Vitals tab, revealed R46 weighed 117 lbs. (pounds) on 02/27/25, 126.8lbs. on 01/06/25, 133.8lbs. on 12/05/24, 140.2lbs. on 10/02/24, and 141.2lbs on 07/08/24. Weight loss from July to January was 10.2%. Review of R46's dietary Progress Notes located in the EMR under the Progress Notes tab, revealed a dietary note dated 01/23/25 indicating R46 had a weight loss of five percent in one month, weight loss of 10% in the past three and six months. The Dietitian (RD) noted request of further weight to validate changes and an increase in house supplement administration. Weekly weights were recommended, along with house supplements 120 ml TID. Review of orders included an increase in the house supplements which the resident consumed 25-75%, but weekly weights were not performed. Review of R46's Progress Note provided by the facility and written by the Medical Director dated 02/17/25, did not address weight loss. Review of R46's Progress Note written by the Nurse Practitioner (NP1) provided by the facility, and dated 12/04/24, 02/07/25, and 02/14/25 did not include mention of weight loss. Review of R46's Meal Intake located in the EMR under the Vitals tab revealed he ate at least 25% of all documented meals and snacks. Review of R46's Supplement consumption located in the EMR under the Reports tab indicated he consumed 75% most of the time. During an interview on 02/27/25 at 10:22 AM the Registered Dietitian (RD) stated that on 01/23/25 she reviewed his records and noted that he had varying appetite, eating greater than 50% of most meals, was on supplements, staff assist with meals, and she had increased the supplements to three times per day. Further weights were requested but not provided to her so she could validate the weight changes/loss. The RD stated that she did not attend weight meetings. During an interview on 02/27/25 at 3:13 PM, the Unit Manager (UM)3 stated that either the nurse or a Certified Nursing Aide (CNA) does the weights monthly and as prescribed. UM3 was not aware of R46's weight loss and was not aware of the need for weekly weights as of 01/23/25. During an interview on 03/01/25 at 9:28 AM, the Director of Nurses (DON) stated that on 02/27/25 the RD recommended PEG (percutaneous endoscopic gastrostomy) tube placement. Additionally, the DON stated that the RD sends out a Medical Nutrition Therapy Log addressing residents with weight gain/loss, the RD assessment, and a provider signed off for any RD recommendations. The DON stated that a while back the facility had concerns about weight variances. No in-services were located to indicate re-education of staff on weight monitoring. During an interview on 03/01/25 at 12:33 PM the DON confirmed that no Medical Physician or Nurse Practitioner had initiated frequent weight monitoring, and no in-services were located on re-weighing residents. Additionally, the DON confirmed that she was unable to locate documentation of either nursing staff or RD notifying the MD of identified weight loss.

Based on the facility policy, record reviews and interviews, the facility failed to ensure 2 topical medications for wounds, were not left unattended in a dementia resident's room. Specifically, Dakin's Solution full strength and Remedy Barrier Creme were left in Resident (R)1's room unattended for an unknown amount of time for 1 of 2 residents reviewed for neglect. Findings include: Review of the facility policy titled, Medication Storage, General Guidelines for Storage of Medication and Biological's, states: Policy: 1. Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biological's in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. 2. The Medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members. The facility admitted R1 on 12/11/2024 and readmitted on [DATE], with diagnoses including, but not limited to metabolic encephalopathy, vascular dementia, cognitive communication deficit and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed for a Brief Interview for Mental Status (BIMS) was not scored. The facility was not able to conduct the interview due to R1's mental capacity. Review on 01/02/2025 at 10:45 AM of the physician order report dated 01/01/2025 through 01/02/2025 included the medication Quetiapine (Seroquel) ordered 12/11/2024 for 25 milligrams to be administered orally at bedtime. R1 is not currently receiving any other antipsychotic medications or any other psychotropic medications. During an interview on 01/02/2025 at 11:32 AM, the facility Administrator stated that she received a call from the night nurse on 12/27/2024 at around 06:50 PM. The nurse stated that R1's roommate alleged that R1 had ingested Dakin's Solution. At that time, the nurse did not mention the Remedy barrier creme. No one knows why or who left the medications, belonging to R1's roommate in the room and unattended. She stated that it could not be confirmed if the bottle of Dakin's or the barrier creme containers were empty or not. During an interview on 01/02/2025 with Licensed Practical Nurse (LPN)1, she stated she was an agency nurse and was at the nurses station charting when a Certified Nursing Assistant (CNA) happened to pass by the resident's room and said that the resident's roommate stated that R1 had drank the bottle of Dakin's Solution. LPN1 stated, I immediately went to the resident's room and I actually saw white barrier creme in the corners of R1's mouth. There was no Dakin's Solution left in the bottle, so I cannot say whether or not that there was any in the bottle at all. She stated, The Dakin's Solution for wound care and the Remedy barrier creme were for R1's roommate and not for R1 himself. LPN1 stated that she took the resident's vitals and assessed him and call the physician and obtained an order to send him to the emergency room for evaluation. During an interview on 01/02/2025 at 12:07 with LPN2, she stated that she was not working the evening shift and that she had worked the day shift. She stated that she had gone in and out of R1's room many times during the day, and the Dakin's Solution and the Remedy barrier creme were not in the room. She stated that the nurses only take into the room exactly what they are going to use, and this particular day (12/27/2024), R1's roommate had refused wound care and the barrier creme. She stated the wound care supplies had not been taken into R1's room during the day shift. During an interview on 01/02/2025 at 12:15 PM with CNA1, she stated, She was walking by the room just checking on residents, that the CNA taking care of the group of residents that R1 and his roommate were in, had gone to break and she was just checking to make sure they were alright or if they needed anything. I had started passing out dinner trays and I saw R1 with the tube of barrier creme and I saw the white creme on his tongue and around his mouth, I took the creme and attempted to clean any that I saw in his mouth out and at the same time I called for the nurse. The Dakin's Solution bottle was empty and I have no idea if it had any in it before I got there or not. During an interview on 01/02/2025 at 12:45 PM, the Director of Nursing stated that the roommate for R1 will fabricate stories at times and he is care planned for it. She said, We do not know who left the medications at the bedside, or even if there was any of the Dakin's Solution in the bottle. So we sent R1 out to the emergency room for evaluation. Review of the documentation from the emergency room , did not indicate that R1 could have drank the Dakin's Solution. All tests performed in the emergency room were within normal limits and R1 had no ill side effects from the alleged incident.

Based on interviews, record reviews, document reviews, and facility policy review, the facility failed to protect the residents' right to be free from physical and verbal abuse perpetrated by staff for 2 (Resident (R)1 and R3) of 3 sampled residents reviewed for abuse. Findings included: A review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised on 10/23/2019, revealed, 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. The policy specified, 1. Abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. A review of R1's Resident Face Sheet revealed the facility admitted the resident on 06/27/2023, with diagnoses that included diabetes mellitus, neuropathy, and paraplegia. A review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/04/2024, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the Five-Day Follow-Up Report dated 01/26/2024, revealed R1 alleged that during the night shift on 01/21/2024, Certified Nursing Assistant (CNA)3 made offensive and inappropriate comments to them and began to curse and yell at them after they requested their coffee to be heated up. Per the Five-Day Follow-Up Report, the resident's allegation of verbal abuse was substantiated as Licensed Practical Nurse (LPN)2 stated she did witness CNA3 yell and argue back and forth with the resident but did not recall what was said by CNA3. The Five-Day Follow-Up Report revealed the facility terminated the employment of CNA3. During an interview on 04/08/2024 at 8:33 AM, R1 stated there had been a CNA that worked in the facility in January 2024, and they felt the CNA was just a mean individual. R1 stated they could not really state why the altercation occurred, but acknowledged they shouted at each other. R1 stated the facility resolved the issue when they got rid of (terminated the employment of) the CNA. During a telephone interview on 04/08/2024 at 2:29 PM, LPN2 stated R1 and CNA3 had a verbal disagreement as she could hear both the resident and CNA3. LPN2 stated she did not hear what was being said, but both were loud. LPN2 stated she pulled CNA3 from the resident's room and asked the resident to calm down. According to LPN2, the resident was upset over a cup of coffee. During a telephone interview on 04/08/2024 at 4:28 PM, CNA3 stated she usually fixed the resident two cups of coffee and that night she was orienting another CNA. CNA3 stated R1 yelled and screamed that they wanted their coffee, so she informed the resident that it would be a minute because she was orienting a new employee. CNA3 stated the nurse, LPN2, came down to the room because she heard the yelling, and she left the room. According to CNA3, the resident cursed at her. CNA3 stated she did not curse at the resident and the facility terminated her employment due to unprofessionalism. During an interview on 04/08/2024 at 11:45 AM, the Administrator stated CNA3 had a bad attitude and was terminated for being unprofessional. During an interview on 04/08/2024 at 2:03 PM, R1's roommate, R4, stated they recalled R1 hollering, but they could not tell what any of it was about or who said what. R4 stated R1 and the CNA were both loud. R4's quarterly MDS with an ARD of 01/13/2024, revealed the resident had a BIMS score of 13, which indicated the resident was cognitively intact. 2. A review of R3's Resident Face Sheet revealed the facility admitted the resident on 01/10/2022, with diagnoses that included chronic pain syndrome, osteoarthritis, and anxiety disorder. A review of R3's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2024, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. A review of an undated Patient/Resident Incident/Accident Investigation Worksheet, completed by Registered Nurse (RN)12, revealed on 02/06/2024, R3 reported Certified Nursing Assistant (CNA)10 had been rough during care on 02/02/2024. Per the document, the resident sustained a skin tear to their left arm. The document revealed the CNA stated when the resident tried to swing at her, she put her arm up to keep her from being hit. The document revealed the resident acknowledged they swung at the CNA because the CNA tossed them during incontinence care. A review of the Five-Day Follow-Up Report, dated 02/09/2024, revealed upon investigation, the facility found that the CNA did grab the resident by their arm to stop the resident from hitting her and did not willfully inflict injury to the resident. The Five-Day Follow-Up Report revealed, the resident had evidence of discoloration to their left forearm as related to the incident. Per the Five-Day Follow-Up Report, the CNA would not return to the facility. During an interview on 04/08/2024 at 1:57 PM, R3 stated when the CNA turned them over during incontinence care, they felt the CNA was rough when they turned them in bed. R3 acknowledged the CNA grabbed their forearm as they swung their arm back at the CNA. According to R3, the nurse applied some cream on their arm, the CNA did not work anymore that evening, and had not provided care to them since. R3 stated they were fine, and the incident did not make them feel bad or anything. The surveyor attempted to interview CNA10 on 04/08/2024 at 12:59 PM, 04/08/2024 at 2:38 PM, and 04/08/2024 at 4:12 PM. Each time there was a fast busy signal and no voicemail. During a telephone interview on 04/08/2024 at 4:13 PM, RN12 stated she did not witness the event, but it occurred on 02/02/2024. She stated R3 informed her that the CNA scratched them. Per RN12, the CNA stated that she went in to provide incontinence care and when she rolled R3 over, the resident swung at them, and they put up their arm to block the swing. RN12 stated she removed the CNA from the room and assigned another aide to work with R3. RN12 stated she cleaned the skin tear and applied ointment and a covering. She stated there was no bruising to the area when assessed, only the skin tear. During an interview on 04/08/2024 at 12:12 PM, the Administrator stated she would expect residents to be protected from any type of abuse. During an interview on 04/08/2024 at 1:06 PM, the previous Director of Nursing (DON) stated once the incident was reported an investigation was started. The previous DON stated the CNA was removed from direct resident care, placed on suspension pending the investigation, and once the investigation was completed, the CNA was not allowed back in the facility.

Based on interviews, record review, document review, and facility policy review, the facility failed to timely report an allegation of physical abuse to the state survey agency for 1 (Resident (R)3) of 3 sampled residents reviewed for abuse. Findings include: The facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised on 10/23/19, revealed, 2. The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. A review of R3's Resident Face Sheet revealed the facility admitted the resident on 01/10/22, with diagnoses that included chronic pain syndrome, osteoarthritis, and anxiety disorder. A review of R3's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/24, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. A review of an undated Patient/Resident Incident/Accident Investigation Worksheet, completed by Registered Nurse (RN)12, revealed on 02/02/24, R3 reported Certified Nursing Assistant (CNA)10 had been rough during care on 02/02/24. Per the document, the resident sustained a skin tear to their left arm. The document revealed the CNA stated when the resident tried to swing at her, she put her arm up to keep her from being hit. The document revealed the resident acknowledged they swung at the CNA because the CNA tossed them during incontinence care. A review of the Initial Report, revealed R3 alleged a staff member exerted excessive force during incontinence care. Per the Initial Report, the state survey agency was notified of the abuse allegation on 02/06/24 at 5:07 PM, which was not submitted to the state survey agency timely. During a telephone interview on 04/08/24 at 4:13 PM, RN12 stated she did not witness the event, but it occurred on 02/02/24. She stated R3 informed her that the CNA scratched them. Per RN12, the CNA stated that she went in to provide incontinence care and when she rolled R3 over, the resident swung at them, and they put up their arm to block the swing. RN12 stated she removed the CNA from the room and assigned another aide to work with R3. RN12 stated she cleaned the skin tear and applied ointment and a covering. She stated there was no bruising to the area when assessed, only the skin tear. During an interview on 04/08/24 at 12:12 PM, the Administrator stated RN12 did not report the incident that occurred on 02/02/24 until 02/06/24 because she felt it was more resident behavior than abuse. The Administrator stated once she became aware, the allegation was reported to the state agency. The Administrator acknowledged the allegation of abuse should have been reported to the state agency 02/02/24. think the incident was abuse, but more of a resident behavior. During an interview on 04/08/24 at 1:06 PM, the previous Director of Nursing stated the allegation of abuse should have been reported to the state agency on 02/02/24.

Based on observation, interview, record review, facility document and policy review, the facility failed to protect seven (Resident (R)230, R44, R70, R91, R26, R37, and R39) of ten residents reviewed for abuse, from physical and/or psychosocial abuse perpetrated by another resident and/or staff member. Specifically, residents were not free from resident-to-resident physical abuse. Residents were slapped, hit, and/or pushed to the ground, with one resident (R91) being transported to the hospital for facial abrasions and chest wall tenderness, after being physically abused by another resident, who had previously physically abused two other residents. In addition, residents were not free from psychosocial abuse perpetrated by a Licensed Practical Nurse (LPN) who used a telephone to film and share images of cognitively impaired residents who could not give consent. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised [DATE], revealed, The facility leadership prohibits neglect, mental, physical and/or verbal abuse, use of physical and/or chemical restraints .involuntary seclusion, corporal punishment, and misappropriation of resident's property. Further review of the policy included definitions per CMS [Centers for Medicaid and Medicare Services], section 483.5: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. 1. Review of R379's undated Face Sheet located in the Electronic Medical Record (EMR), under the Profile tab, revealed that R379 was admitted to the facility on [DATE] with diagnoses of psychotic disorder, bipolar, and schizophrenia. Review of R379's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview of Mental Status (BIMS) score of ,d+[DATE], indicating R379 was cognitively intact. Further review of the MDS revealed a history of substance abuse with borderline/antisocial personality disorder. a. Review of R44's undated Face Sheet located in the EMR, under the Profile revealed that R44 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, diabetes, and depression. Review of R44's Admission MDS with an ARD of [DATE], located in the EMR under the MDS tab, R44 had a BIMS score of ,d+[DATE], indicating R44 was cognitively intact. Review of the Facility Reported Incident (FRI) dated [DATE], provided by the facility, revealed a resident-to-resident altercation occurred between R379 and R44. R44 was in her room when R379 entered and sat on the opposite bed while a resident was sleeping in the bed and tried to wake them up. R44 told R379 to leave the room, and that they should not be in there. R379 got up off the bed and began striking R44 several times in the head. R379 was removed from the room by staff and moved to another room on the opposite side of the facility with one-on-one supervision. No injuries were noted to R44 after a body audit was completed. The Medical Director was notified, and the Sheriff's Department issued a report. Interview on [DATE] at 10:04 AM with R44 revealed that they did not want to discuss the incident. Interview on [DATE] at 09:45 AM with Certified Nursing Assistant (CNA)3 revealed I heard R44 screaming get off of me and when I entered the room, R379 was beating R44 in the head. R379 was pulled off R44 and moved out of the room. b. Review of R70's undated Face Sheet located in the EMR, under the Profile tab revealed R70 was admitted to the facility on [DATE] with diagnoses including acute respiratory distress, psychotic disorder with hallucinations, schizoaffective disorder, and bipolar. Review of R70's quarterly MDS, with an ARD dated [DATE], located in the EMR under the MDS tab, revealed R70 had a BIMS score of ,d+[DATE], indicating R70's cognition was moderately impaired. Review of the FRI dated [DATE], provided by the facility, revealed a resident-to-resident altercation occurred between R379 and R70. R70 was in her wheelchair and was wheeling past the couch where R379 was sitting with her one-on-one sitter. R379 suddenly lunged at R70 and grabbed her hair. The residents were separated and R379 continued to show aggression against other residents nearby. R379 laid on the floor in an attempt to not go back to her room. When R379 finally calmed down, the sitter took her back to her room. R70 was not injured, and a body audit was completed. The Medical Director was notified of the incident, along with the Sheriff's Department, and a report was issued. Interview on [DATE] at 2:30 PM with R70 revealed that R70 did not recall the incident. Interview on [DATE] at 2:45 PM with Licensed Practical Nurse (LPN)3 stated I was at the nurse's desk and R379 was sitting on the couch with her sitter and without warning, jumped up and grabbed R70's hair as she was wheeling past the couch. The sitter jumped up and immediately separated the two residents. c. Review of R91's undated Face Sheet located in the EMR, under the Profile tab, revealed R91 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance and anxiety. Review of R91's admission MDS with an ARD of [DATE] revealed a BIMS score of ,d+[DATE], indicating severe cognitive impairment. Review of the FRI dated [DATE], provided by the facility, revealed R379 assaulted R91 as the resident was walking out of their room into the hall. R91 was pushed to the ground and hit several times. R379 was pulled off R91, and R91 was transported to the emergency room with facial abrasions, and chest wall tenderness. R91 returned to the facility with a black scab over the left eyebrow, and redness and scab to the left nares. R379 was transported to the emergency room , and then taken to jail by the Sheriff's Department and discharged from the facility. Per R379's hospital history and physical indicated that since admission, R379 has struggled with behavioral/mental health issues. Alternative living situations and inpatient psychiatric care was aggressively pursued without avail .behaviors to include hypersexuality, aggression towards staff, and residents, yelling out and making animal noises, and having delusions of being pregnant . seen extensively by psychiatry who was able to titrate medications resulting in improved behavior. Interview on [DATE] at 11:02 AM with the Activities Assistant (AA) stated I had walked out of the activity office and heard yelling. Staff were pulling R379 off R91 who was on the floor. R379 was yelling I don't care if I go to jail. R91 had blood on his face and was taken to his room. R379 was on her way back to her room when she attempted to go back to R91's room and hurt him again. R379 had to be carried to her room. 2.Review of an undated Face Sheet, found in the profile tab of R79's EMR, revealed R79 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, bipolar disorder with psychotic features, and schizophrenia. Review of R79's quarterly MDS, with an ARD of [DATE], located in R79's EMR under the MDS tab, revealed the resident a had a BIMS score of ,d+[DATE] which indicated R79 had moderate cognitive impairment. The resident was ambulatory and required minimal staff assistance and supervision for physical activities and Activities of Daily Living (ADLs). Observations of R79 on [DATE] at 3:30 PM, and on [DATE] at 8:30 AM and 2:15 PM, revealed the resident was in her room in bed. R79 looked up when spoken to but did not respond verbally and pulled her blanket over her head. Review of Facility Reported Incident, dated [DATE], revealed on [DATE] at 7:30 AM, R79 walked out of her room and towards the nurse's station on the 100-hall. She told CNA1 that she slapped her roommate (R230) because she would not stop yelling out last night. CNA1 alerted the Unit Manager (UM)1 who responded and removed R79 from the area. CNA1 went to assist R230 and noted redness on the right side of her face. At that time R230 stated She hit me. The victim in this incident was R230, who was admitted on [DATE] with diagnoses including unspecified dementia and aftercare of a fractured left hip. R230 was severely cognitively impaired with a BIMS of 99 indicating she was unable to participate in mental status assessment. R230 expired in the facility on [DATE] while under hospice care and could not be interviewed. Review of the witness/staff statements, rendered during the facility's investigation, initiated immediately following the incident on [DATE], revealed R230 remained in her room, and R79 was moved immediately. R230 was upset initially and had confirmed she was slapped when asked by staff. R230 did not remember the abusive act in subsequent staff interviews/follow-ups with her by nursing and social services the following day. R79 was moved to another room with no roommate, and R230 remained in the room. The appropriate notifications were made, and no new orders were received at that time. Further review of the witness statements and interviews conducted at the time of the incident revealed no-one saw R79 strike R230, but there was no reason not to believe them when they both reported the same thing immediately following the abuse. In an interview on [DATE], at 12:15 PM, with UM1, who was in the hall as R79 stormed by immediately following the 'slap,' revealed CNA1 was the first to respond to the incident when R79 stormed out of her room and said she slapped her (R230) in the face for screaming all night. CNA1 went to R230's aid, assured her safety, and called out for help. The UM responded, initiated the facility investigation, and all employees present on that shift were questioned and provided written statements on [DATE] as per the facility's investigation. These were reviewed with UM1, who confirmed the events as described. CNA1 was interviewed on [DATE] at 1:00 PM, and confirmed she remembered the incident, and she responded first to ensure R230 was safe. CNA1 said R230 knew she had been slapped immediately after it happened, but not later. R230 did have redness on the right side of her face but that faded quickly. During a follow-up interview with the Unit Manager (UM)1 on [DATE] at 1:05 PM, the UM1 stated that she was aware of R79's history and stated, [R79's name] had been sent out for a gero-psych exam hoping to stabilize her in some way, but they changed her meds and that was it - then sent her back here the same night - where she refuses to take her medications and treatments. UM1 stated they discontinued R79's meds last week because she would not take them, and they get spit out or wasted by R79. R79's Care Plan revised [DATE], includes poor safety awareness and poor impulse control and the potential to act impulsively and abusively towards other residents and staff. The comprehensive EMR review, Nursing and CNA Progress Notes located under the Progress Notes tab of the EMR, and lookback period of [DATE] to present revealed R79 is ambulatory, and noncompliant with medications, treatments, and ADL care, making her unstable, unpredictable and an elevated abuse risk to other residents if her behaviors are triggered. 3. Review of the Facility Reported Incident (FRI) dated [DATE], provided by the facility, revealed an Agency Licensed Practical Nurse (LPN), was observed by staff members on the 300 unit during the day shift, to enter in and out of resident's rooms while on Facetime (via cellphone) with an unknown person, unrelated to the facility, or the resident. The Agency LPN was investigated and asked questions by the previous Administrator, who completed the investigation. The Agency LPN denied all allegations. However, staff members were interviewed and provided written statements verifying the Agency LPN was observed to be showing the residents to the person on the Facetime call. The staff members could not confirm who the Agency LPN was on the phone with but did confirm the Agency LPN was on the phone with a friend of hers. Other residents throughout the facility were interviewed and denied any staff members recording them or having a phone around them. Responsible Parties (RP) for R26, R37, and R39 were called and notified of the incident. The allegation of abuse was substantiated by the facility's Administrator, employed during the time of the incident. Per interviews with DON and CNA2 these were the only three residents voiced by staff to be impacted. a. Review of R26's Face Sheet located in the EMR under the Profile tab, revealed an admitted [DATE], with diagnoses including cognitive communication deficit, Alzheimer's disease with late onset, and need for assistance with personal care. Review of R26's Care Plan dated [DATE], located in the EMR under the Care Plan tab indicated R26 is at risk for alteration in psychosocial well-being related to allegation of abuse. Review of the R26's quarterly MDS located the EMR under the MDS tab, with an ARD date of [DATE], revealed R26 had a BIMS) of 99 indicating resident's cognition assessment could not be completed. R26 is assessed as being dependent on staff with one person assistance, dressing is extensive assistance, and one-person physical assist. b. Review of R37's Face Sheet located in the EMR under the Profile tab, revealed an admitted [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and Alzheimer's disease. Review of R37's Care Plan dated [DATE], located in the EMR under the Care Plan tab included is at risk for alteration in psychosocial well-being related to allegation of abuse. Review of R37's quarterly MDS located in the EMR under the MDS tab, with an ARD date of [DATE] revealed R37 had a BIMS score of ,d+[DATE] indicating the resident is severely cognitively impaired. Further review of the MDS for R37 revealed the resident is limited assistance with one-person physical assist for bed mobility, transfer, locomotion on unit. Extensive Assistance with one person assists for dressing and personal hygiene, total dependence one-person physical assist and supervision for eating. c. Review of R39's Face Sheet located in the EMR under the Profile tab revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, unspecified sequelae of cerebral infarction. Review of R39's Care Plan dated [DATE], located in the EMR under the Care Plan tab indicated R39 is at risk for alteration in psychosocial well-being related to allegation of abuse. Review of R39's quarterly MDS located in the EMR under the MDS tab, with an ARD date of [DATE], revealed R39 had a BIMS score of 99, indicating resident's cognition assessment could not be completed. Further review of R39's MDS revealed resident is limited assistance one-person physical assist for bed mobility, transfer, dressing, eating and toilet use. Extensive assistance with two people for personal hygiene. Interview on [DATE] at 1:08 PM with the Social Services Director (SSD1) confirmed the perpetrator was an Agency LPN. Interview on [DATE] 11:44 AM with Director of Nursing 1 (DON 1), DON1 stated the perpetrator was asked to complete a written statement and is now on the facility's do not come back list. She confirmed the allegation was substantiated after it was investigated and a follow up with the police was completed. Interview on [DATE] at 4:44 PM with CNA2 revealed he observed the alleged perpetrator go in and out of R26's, R37's, and R39's rooms with her cell phone on facetime. On [DATE] from 09:00 AM - 02:00 PM, attempts to call additional witnesses no answer and no return phone call.

Based on review of the facility policy, interview and record review, the facility failed to protect 1 of 5 residents reviewed for sexual abuse. Resident (R)2 was discovered by staff in R1's bed in room [ROOM NUMBER] on 11/09/22 at approximately 8:25 PM. R2's hand was on R1's breast, and his leg was over her. R2 was clothed, but R1's gown was lifted. Her brief was intact. The incident caused R1 significant emotional distress, as she did not consent to sexual contact and was unable to call for help. On 11/17/22 at approximately 2:30 PM, the facility was notified of an Immediate Jeopardy (IJ) at past noncompliance was identified related to F600-Sexual Abuse. At this time, the facility presented a credible plan of action after identifying their own deficiency. Review of this plan revealed the facility had taken the proper steps prior to the survey date to remove the immediacy, effective 11/11/22. The facility's failure to protect R1 constituted substandard quality of care, warranting the completion of an extended survey, which was completed on 11/17/22. Findings Include: Review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment with a revision date of 10/01/20 revealed, The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds. Under the section titled, Definitions, the policy states, Sexual abuse is non-consensual sexual contact of any type with a resident. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral infarction, hemiplegia, and generalized anxiety disorder. Review of an unspecified Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/07/22 revealed R1 had a brief interview for mental status (BIMS) score of 99/15, indicating she was unable to complete the assessment. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2, vascular dementia, schizophrenia, and major depressive disorder. Review of an unspecified MDS with an ARD of 10/06/22 revealed R2 had a BIMS score of 15/15, indicating he was cognitely intact. Review of facility witness statements on 11/17/22 revealed, On 11/09/22 at 8:25 PM, Certified Nursing Aide (CNA)1 entered room [ROOM NUMBER] to find R2 lying with his leg across R1. Her gown was up, and his hand was on her left breast with his face over her face. R2 asked the CNA What are you doing? and rolled to the right side of the bed. He removed his hand from the breast. CNA1 asked R1 if she was okay, to which she replied, I'm so glad you came; I couldn't talk because he had his tongue down my throat. R1 stated she was frightened and did not want to stay in her room. CNA1 and the nurse removed the resident's gown and put on pants and a shirt. She was moved to the nursing station where she could be observed. Review of facility witness statements on 11/17/22 revealed that on 11/9/22, Licensed Practical Nurse (LPN)1 was called to room [ROOM NUMBER] where R2 was lying beside R1 with her gown up. R2 exited without saying anything. R1 was moved to the desk where she expressed, I'm scared to staff. Three attempts were made to contact both CNA1 and LPN1 via telephone, with no success. Review of the Post Traumatic Stress Disorder (PTSD) screening tool for R1 dated 11/10/22 revealed, R1 displayed tearfulness and increased anxiety. She was unable to answer questions related to the incident, but repeated I'm scared, He scared me, and I don't want to be here to staff. During an interview with R1 on 11/17/22 at approximately 12:20 PM, R1 stated she wished to leave the facility. She was unable or refused to answer questions regarding the incident of sexual assault. Review of the discharge note dated 11/11/22 for R2 revealed a psychiatry evaluation indicating he was competent and understood the decisions he was making. Review of an email, with an unspecified date, from Licensed Independent Social Worker (LISW)1 revealed she interviewed R2 after the incident. R2 described the incident as totally two consenting adults. When asked if it would happen again, he replied, Can't say right now what will make me approach someone. He then continued, I have been here a while and have needs. He further clarified that he had no relationship with the lady from last night. An interview with the Director of Nursing and Administrator on 11/11/22 at approximately 5:15 PM revealed R2 was emergency discharged , as he was a sexual predator. Review of facility in-services revealed the facility provided ongoing abuse and neglect education on 11/10/22 and 11/11/22. Review of R1's chart revealed a laser alarm was placed in R1's room on 11/11/22. Observation revealed R1's room was alarmed so that visitors could not enter or exit without the resident's and staff's awareness. Review of the facility's timeline/removal plan revealed: On November 9, 2022 at approximately 8:25 PM, CNA1 noted male R2 lying on the right side of female R1's bed with his left leg over her right leg. R2 was clothed, but R1's gown was raised with her brief intact. CNA1 called LPN1 to the room. LPN1 entered and R2 went back to his room. Body audit of R1 showed no abnormal findings. At 8:39 PM, the Administrator, Director of Nursing (DON), and Social Services Director (SSD) were notified of the incident. At approximately 8:45 PM, R1 was changed into a shirt and pants and placed at the nurse's station for direct supervision. She was made comfortable by the staff. At approximately 9:40 PM, the facility initiated investigation. On November 10, 2022 at approximately 12:30 AM the police arrived at the facility. At 11:30 AM, SSD conducted PTSD screenings for R1. Facility provided ongoing education regarding abuse and neglect throughout November 10, 2022 and November 11, 2022. The facility also placed a Laser alarm in the room of R1 to alert her when someone entered or exited her room, providing safety reassurance to the resident. On November 10, 2022 at approximately 2:30 PM, Psych evaluations were completed by CHE Services for both residents. On November 11, 2022 at approximately 10 AM, R1 was sent to the ER for evaluation. On November 11, 2022 at approximately 7:30 PM, R2 was discharged from the facility. On November 11, 2022 at approximately 9:30 PM, R1 returned from the ER. There were no negative findings from her evaluation.

Based on record reviews and interviews, the facility failed to ensure that a resident was free from abuse for 1 of 3 sampled residents reviewed. Resident (R) #1 was observed being forcibly removed from the nursing station by a Licensed Practical Nurse (LPN) in which the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] The findings included: The facility admitted R #1 on 4/06/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record on 5/19/21 at approximately 9:09 AM revealed a Nurse Practitioner (NP) #1's written report dated 4/30/21 that indicated R #1 had bruise to left side of neck (thumb size) and bruise to left upper arm. An SBAR (Situation-Background-Assessment-Recommendation) Communication Form dated 4/30/21 indicated R #1 had bruising to arm, neck and areas to back. A review of the facility's investigation on 5/19/21 at approximately 10:00 AM revealed witness statements of the abuse and a Police Report that indicated the LPN was arrested and removed from the facility on 4/30/21. An interview on 5/19/21 at approximately 10:08 AM with Certified Nurse Aide (CNA) #1 revealed he/she was in the day/dining area when he/she observed a LPN holding R #1 by the neck with one hand and one hand on his/her upper arm and guiding him/her backward from out of the nursing station. CNA #1 further stated that the LPN had R #1's back pinned to the wall outside of the nursing station. CNA #1 reported that another staff member was present and observed the incident. An interview on 5/19/21 at approximately 10:30 AM with NP #1 confirmed his/her medical reported and indicated bruises were observed on the resident. A telephone interview on 5/19/21 at approximately 11:02 AM with LPN #1 revealed he/she observed the accused LPN, grab R #1 by his/her wrist and told the resident was not suppose be behind the nurse station. Then the LPN was observed with one hand on back of the resident's neck and one hand on the resident's arm shoving her/him out of the nursing station. The accused LPN shoved the resident against the wall outside of the nursing station.

Based on record review and interview, the facility failed to report to ensure residents were free from resident to resident abuse for 1 of 9 sample residents reviewed for abuse (Resident #103). The findings included: Record review revealed Resident #103 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the facility statement by Licensed Practical Nurse (LPN) #4 revealed that on 06/24/2019 LPN #4 who was assigned to Resident #103 reported that Resident #103 had slid out of his/her wheelchair. LPN #4 heard something pop and stated Resident #103 needed to go to the hospital. LPN #4 documented that he/she attempted to notify the Director of Nursing of the incident at 5:30 AM, but did not receive an answer. LPN #4 also documented that he/she attempted to notify the Unit manager at 6:00 AM with no answer. LPN #4 reported that he/she did not call further at the time of the incident because he/she was busy doing paperwork. Review of the facility statement by LPN #1 revealed that on 06/24/2019 at 5:30 AM Resident #103 got out of bed and decided to sit in Resident #33's wheelchair. Resident #33 started yelling at Resident #103, This my wheelchair. Get out. Resident #33 then lifted the back of the wheelchair causing Resident #103 to slide to the floor. Both were separated and evaluated. Resident #103 complained of right hip discomfort and was admitted to the hospital with [REDACTED].#33 was placed on 30 minute checks and had a psychiatry consult on 06/29/2019. Room changes were made to relocate Resident #103 to another room. Review of facility statement by Resident #33 revealed he/she stated, I heard some noise when I woke up. I saw that man/woman in my stuff. He/she took my wheelchair. I told him/her to get out of my things. He/she get out. He/she was sitting in my wheelchair outside my door. I got up and walked to my chair and grabbed the handles and dumped him/her on the floor. Further review of the facility reported incident revealed the incident was not reported to Administration on 06/24/2019 until approximately 8:30 AM. The MD and responsible representatives for both residents were notified of the incident and Resident #103 was readmitted to the facility on [DATE]. Interview with Resident #33 on 08/13/2019 at approximately 11:10 AM revealed he/she did not remember the incident. Resident #33 stated he/she feels safe and that the staff were great. Interview with Resident #103 on 08/13/2019 at approximately 12:05 PM revealed that he/she did not remember the incident. Resident#103 stated that he/she was having problems with Resident #33 because he/she was noisy and loud. Resident #103 stated,That is why I was moved to a private room. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment Policy revealed it prohibits abuse and neglect, and stated abuse is the willful infliction of injury, unreasonable confinement, and mental anguish, as hereafter defined, and will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members, or legal guardians, friends, visitors or any other individual in this center.

Based on record review, interview, and review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment Policy, the facility failed to prevent abuse when Resident #33 pushed Resident #103 out of the wheelchair causing Resident #103 to sustain a hip injury (1 of 9 sample residents reviewed for abuse). The findings included: Record review revealed Resident #103 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the facility statement by Licensed Practical Nurse (LPN) #4 revealed that on 06/24/2019 LPN #4 who was assigned to Resident #103 reported that Resident #103 had slid out of his/her wheelchair. LPN #4 heard something pop and stated Resident #103 needed to go to the hospital. LPN #4 documented that he/she attempted to notify the Director of Nursing of the incident at 5:30 AM, but did not receive an answer. LPN #4 also documented that he/she attempted to notify the Unit manager at 6:00 AM with no answer. LPN #4 reported that he/she did not call further at the time of the incident because he/she was busy doing paperwork. Review of the facility statement by LPN #1 revealed that on 06/24/2019 at 5:30 AM Resident #103 got out of bed and decided to sit in Resident #33's wheelchair. Resident #33 started yelling at Resident #103, This my wheelchair. Get out. Resident #33 then lifted the back of the wheelchair causing Resident #103 to slide to the floor. Both were separated and evaluated. Resident #103 complained of right hip discomfort and was admitted to the hospital with [REDACTED].#33 was placed on 30 minute checks and had a psychiatry consult on 06/29/2019. Room changes were made to relocate Resident #103 to another room. Review of facility statement by Resident #33 revealed he/she stated, I heard some noise when I woke up. I saw that man/woman in my stuff. He/she took my wheelchair. I told him/her to get out of my things. He/she get out. He/she was sitting in my wheelchair outside my door. I got up and walked to my chair and grabbed the handles and dumped him/her on the floor. Further review of the facility reported incident revealed the incident was not reported to Administration on 06/24/2019 until approximately 8:30 AM. The MD and responsible representatives for both residents were notified of the incident and Resident #103 was readmitted to the facility on [DATE]. Interview with Resident #33 on 08/13/2019 at approximately 11:10 AM revealed he/she did not remember the incident. Resident #33 stated he/she feels safe and that the staff were great. Interview with Resident #103 on 08/13/2019 at approximately 12:05 PM revealed that he/she did not remember the incident. Resident#103 stated that he/she was having problems with Resident #33 because he/she was noisy and loud. Resident #103 stated,That is why I was moved to a private room. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment Policy revealed it prohibits abuse and neglect, and stated abuse is the willful infliction of injury, unreasonable confinement, and mental anguish, as hereafter defined, and will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members, or legal guardians, friends, visitors or any other individual in this center.

On the day of the survey, based on record review, observations, interviews, and review of the facility's investigative file concerning a resident's fall, the facility failed to ensure that residents received adequate supervision and assistance to prevent falls for 1 of 1 resident who fell on her way to an outdoor activity (Resident #1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the resident assessment of 1/16/12 revealed the resident had severe cognitive impairment. Her vision, hearing, and communication ability was intact. The resident needed extensive assistance of one person for transfer, dressing, hygiene, and bathing. She was not ambulatory but did propel herself about the facility in her wheelchair. Review of the medical record revealed that on 4/7/12, at approximately 2:45 PM, the resident attempted to propel herself along the sidewalk from the long term care facility to the courtyard of the apartments next door to attend an Easter egg hunt. Her wheelchair rolled off the curbing causing her to fall to the ground. She sustained a laceration to the left elbow and a fractured left hip. Review of the facility's investigation results revealed two Activity Assistants failed to employ the usual precautions used by the facility when taking residents out of their building to another location. The facility's protocol was for residents to wait in one supervised area while staff transported them individually to another supervised area. On 4/7/12, residents were taken out of the facility and lined up on the sidewalk to wait for staff transport. Resident #1 began propelling herself. The sidewalk first veered to the right, then make a sharp turn to the right. Shortly after negotiating the sharp right turn, the wheelchair fell off the side walk and the resident fell to her left side. The two Activity Assistants reported to the Administrator verbally and in writing, that they did follow protocol. However, another staff member saw residents outside unattended and witnessed Resident #1's fall. The Administrator reviewed video of the outdoor area and was able to confirm that residents were left outside unattended while waiting to be transported to the activity. The facility was asked to produce a copy of their protocol for transporting residents to activities outside their residence. Per the Administrator, the facility did not have a written policy. An interview with the Activity Director revealed that this protocol was taught to both Activity Assistants on duty 4/7/12, and taught to all other Activity Department staff when hired. As a result of the incident, all current staff were inserviced on the facility's protocol for taking residents outside the facility, but there was no plan in place to ensure future staff were taught the correct procedure.

On the day of the Complaint Inspection, based on limited record review and interviews, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents that had a fall with injuries. Resident # 4 had a fall and a laceration. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Poor safety awareness... Wanderguard placed in left lower extremity for safety. Therapy notified, alarms placed on bed for safety. Daughter stated resident wandered at home and fell several times." Review of the nurse's note from 4/21/2011 through 4/22/2011 revealed the following: 4/21/2011 at 4:00 AM stated, "...12:30 AM Started yelling and crawled OOB (out of bed). When CNA (Certified Nursing Assistant) got to room, resident was standing by bed. CNA had to call for A (assistance) from other staff members just to get her in w/c (wheelchair) to bring her to nurses station... 8:00 PM ...Sitting in w/c @ nurses station. Chair alarm on & functioning properly. Res continues to try to get up without assistance. Requires frequent reminding not to get up without assistance... 9:50 PM ...Paged Dr (Doctor)... on call for Dr... . Res is very agitated-will not stay in bed, continues to get out of w/c. Received N.O. (new order) to increase Seroquel to 50 mg (milligrams) BID (twice a day), Ativan 1 mgm IM (intra muscular)/ po (by mouth) then q (every) 6 hours prn (as needed) agitation." 4/22/2011 at 3:45 AM stated, "Resident attempting to get OOB continuously, put in w/c and would not sit down. Very agitated and uncooperative... 6:30 AM At 5:45 AM, ... observed resident on floor. She had a gash above R (right) bloody nose and a small bruise on R groin area... 11:10 AM Returned from ER (emergency room )... Laceration above OD (right eye) 4 staples placed by ER..." An Elopement Risk Review was performed by the facility on 4/20/2011. The review included behaviors of, "wandering with no purpose, oblivious to needs or safety, searching behavior and increased confusion/ anxiety/disorientation". A Fall Risk Assessment completed on 4/20/2011 scored Resident #4 a 16. The rating scale stated a score of 10 or greater represented high risk. Review of the facility investigation included an Unusual Occurrence Incident Report that description the incident dated 4/22/2011 that stated, "... Resident leaned forward in w/c and fell to floor as CNA (#1) ... tried to catch her. " CNA #1 in a facility obtained statement dated 4/22/2011 at 5:45 AM stated, "While doing my rounds, I headed back to the nurses station and saw Ms... (Resident #4) bending over to grab something off the floor, that wasn't there. I told her to sit back and at that time ... (CNA #2) came out of room 215. We both ran to grab her but she hit the floor headfirst... She was bleeding from her head above the right eye, and her nose. She also had a bruise on her right hip... Ms... (Resident #4) had been sitting up since 3:30 a (AM) in her chair. She was violent and very agitated so...(RN) gave her a shot of Ativan, this did not take affect. We were taking her from room to room with us doing rounds. CNA #2 in a facility obtained statement dated 4/22/2011 at 5:45 AM stated, "... I was coming out of room 215 from doing my rounds and saw ... (Resident #4) falling forward from her chair. I help ... (CNA #1) assist her after the fall. She hit the floor headfirst, she have a gash on her forehead. her nose is bruised and swollen and a bruise on her right hip. ... (CNA #1) got her up at 3:30 am because she would not stay in bed. She kept getting (sic) up all night. Me and ... (CNA #1) was taking turns watching her as we were doing our last rounds." Registered Nurse (RN) #1 in a facility obtained statement dated 4/22/2011 at 5:45 AM, on duty at the time of the incident gave a statement that said CNA #1 was one on one with the resident. The resident leaned forward to pick something off the floor that wasn't there and ... CNA #1 tried to grab her, but was unable to catch her. A Post Fall Rehab Screen was conducted on 4/23/2011 by the Physical Therapist. The Post Fall Screen under Previous/Current Fall Prevention had Safety Alarm checked. Written in, by the alarm, was "Bed to bed & w/c. It indicated the resident had a bed and wheelchair alarm. A phone interview was conducted with CNA #1 on 10/31/2011. CNA #1 stated the resident had been hallucinating all night. "We did one on one with her all night." One of us would do rounds and the other would watch her. (CNA #2) had her outside of room 215. (Resident #4) was leaning over. I was running to her and (CNA #2) was coming out of the room 215. We both could not get to her before she fell ." The Administrator was interviewed on 11/1/2011 regarding one on one observation. The Administrator stated the facility did not have a policy for one on one. She stated that one on one was in close proximity. If they had been actual one on one, the staffing would have been adjusted and a CNA would have been assigned to the resident and nothing else. Resident #4 had been admitted with a history of falls and no safety awareness. The facility assessed the resident to be at high risk for falls. There was repeated documentation of the resident climbing out of bed and standing up from wheelchair. The facility was aware of the resident's behaviors and safety risks and did not provide adequate supervision to prevent the resident from a fall with injuries.