Every finding on record at Staunton Post Acute & Rehabilitation

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of seven residents (Resident #107) followed protocols for safe smoking.The findings include:Resident #107 was observed smoking without supervision and with a cigarette that had not been provided or lit by facility staff.Resident #107 (R107) was admitted to the facility with diagnoses that included major depressive disorder, COPD (chronic obstructive pulmonary disease), anemia, dementia, anxiety, insomnia and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed R107 with moderately impaired cognitive skills.On 4/27/26 at 2:40 p.m., R107 was observed seated in the corner of the outdoor courtyard that was designated as the smoking area for residents. R107 was actively smoking holding a lighted cigarette. R107 was interviewed at this time about smoking. R107 stated a staff member had been in the courtyard and just went back inside. R107 put out the cigarette on the concrete surface and stated that smoking in the facility was usually supervised. R107 demonstrated no unsafe behavior while smoking and the resident's clothes had no indication of burns/dropped ashes. The courtyard area was posted with smoking times listed as 10:30 a.m., 2:30 p.m. and 7:30 p.m.R107's clinical record documented a smoking assessment dated [DATE] listing the resident as low risk for safety concerns with smoking and included a requirement for supervision with smoking. The assessment documented that the resident had no visual impairment, no range of motion or balance issues, no fine motor skill difficulty, no lethargy during tasks, did not drop ashes, had no history of burns to clothing/skin, and as able to light, hold and extinguish a cigarette safely. The assessment documented the resident required no adaptive or protective equipment (apron) and that the resident was able to follow facility smoking protocols for safety. This assessment documented the resident as safe to smoke with supervision.R107's plan of care (revised 3/13/26) documented the resident was deemed to be a safe smoker with staff supervision. Interventions to ensure smoking safety included supervision with smoking, education to the resident on the facility's smoking policy that included location, times and safety precautions and smoking assessments performed as needed.On 4/28/26 at 8:10 a.m., R107 was interviewed about smoking on 4/27/26 without supervision. R107 stated that staff members supervised smoking each day at the designated times (10:30 a.m., 2:30 p.m. and 7:30 p.m.). R107 stated yesterday (4/27/26) that she was finishing up my last cigarette. R107 stated the staff person supervising allowed her to finish the last couple of puffs and that was when the surveyors walked up. R107 stated she did not require an apron or device for smoking and that she had never had any safety issues during smoking. R107 denied having cigarettes or lighter on her person or in her room. R107 stated residents were not allowed to keep smoking materials in their room and that nursing kept supplies locked in the medication room. R107 stated she did not remember the name of the staff person supervising smoking yesterday afternoon (4/27/26).On 4/28/26 at 8:20 a.m., accompanied by licensed practical nurse (LPN #1), resident smoking materials were observed locked in the second-floor medication room. The box contained 3 packs of cigarettes with a lighter and was secured in the locked room. LPN #1 stated at this time that all the current smokers in the facility were supervised by staff at the designated times and that no residents were allowed to keep smoking materials in their possession. LPN #1 stated two certified nurses' aides (CNAs) from 3rd floor provided smoking supervision on the afternoon of 4/27/26.On 4/28/26 at 8:25 a.m., CNA #1 that supervised resident smoking on the afternoon of 4/27/26 was interviewed. CNA #1 stated she was passing out ice on 3rd floor and was a little late going out with the smokers on 4/27/26. CNA #1 stated she and CNA #2 did not go out with the smokers on 4/27/26 until approximately 2:45 p.m. CNA #1 stated there were three other smokers in the courtyard during the session in addition to R107. CNA #1 stated R107 was not smoking when she arrived in the courtyard, and she did not see the resident with any smoking materials. CNA #1 stated, We hand out cigarettes individually, one at a time, and light them. CNA #1 stated R107 smoked two cigarettes during the session and consumed both prior to ending the smoking session. CNA #1 stated if R107 was smoking prior to 2:45 p.m., she had no idea where she got the cigarette or lighter as the smoking supplies stayed locked in the medication room. CNA #1 stated regarding the observation of R107 actively smoking at 2:40 p.m., We were not down there yet [in the courtyard]. CNA #1 stated none of the residents were smoking when she arrived in the courtyard with the smoking supplies. CNA #1 stated R107 had never demonstrated any safety issues during smoking and did not require an apron or adaptive equipment.On 4/28/26 at 8:35 a.m. CNA #2 that supervised smoking on the afternoon of 4/27/26 was interviewed. CNA #2 stated she was with CNA #1 supervising smoking on the afternoon of 4/27/26. CNA #2 state she and CNA #1 were not out with residents at 2:30 p.m. as scheduled but were late taking the smokers out. CNA #2 stated she and CNA # 1got the smoking box from the medication room and took it to the courtyard. CNA #2 stated R107 was already in the courtyard and there was no smoking going on by any residents when they arrived in the courtyard. CNA #2 stated she and CNA #1 watched R107 smoke two cigarettes during the session with both cigarettes consumed and extinguished/discarded in the receptacle prior to the end of the session. CNA #2 stated R107 was given two cigarettes, one at a time and that staff always lighted the cigarettes for residents. CNA #2 stated she was not aware R107 had been smoking and she did not know how the resident got a cigarette or lighter. CNA #2 stated R107 was always a safe smoker, never dropping ashes or cigarettes and that the resident did not require an apron or device. CNA #2 stated R107 smoked two cigarettes in front of us and that all cigarettes and the lighter were returned and locked in the medication room after the session.On 4/28/26 at 9:10 a.m., the administrator and director of nursing (DON) were interviewed about R107 observed actively smoking unsupervised. The administrator stated all resident smoking required supervision and that he was unsure where R107 got the cigarette and/or lighter. The administrator stated that residents that smoked were required to follow facility policies to ensure safe smoking.The facility's policy titled Smoking Permitted (revised 10/20/22) documented, .The facility will implement processes to respect the resident's right to smoke and will provide an environment for safe smoking in a manner that does not infringe on any resident's rights.Residents who desire to smoke will be educated on the facility policy and practices for safe smoking.The resident will verbalize understanding of the facility policy and practices and will sign acknowledgement of receipt of the policy.Resident who desire to smoke may not keep smoking related materials [i.e. cigarettes, electronic smoking devices (e-cigarettes), refill cartridges/fluid, cigars, pipes, tobacco, lighter, lighter fluid, match, etc.] on their person when not smoking or in their room.Resident who are determined by the interdisciplinary team as needing supervision will be within eyesight of staff, family, or designated volunteer during the time that the resident is smoking.Non-compliance with smoking safety requirements is taken very seriously.The facility may initiate discharge planning for a violation of any part of this policy and for any unsafe smoking practice that poses risk to residents or for repeated non-compliance with the facility safe smoking policy/practices.This finding was reviewed with the administrator and DON on 4/28/26 at 3:00 p.m. with no further information presented prior to the end of the survey.

Based on resident interviews, staff interviews, clinical record review, and facility document review the facility failed to protect the residents' rights to be free from abuse, including physical and verbal abuse for four of eleven residents in the survey sample, (resident #'s 2, 3, 4, 5) resulting in immediate jeopardy (IJ) and substandard quality of care. After accepting the plan for removal of Immediate Jeopardy from the Administrator, and determining that the Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity level of level 2, pattern. The Findings Include:For Resident #1 (R1) who had repeated aggressive behaviors towards multiple residents including R2, R3, R4, and R5, the facility staff failed to implement interventions to respond to and intervene in R1's continued abuse towards others. Diagnoses for R1 included heart failure, diabetes, dementia, hemiplegia, and seizure disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/16/2025. R1 was assessed with a cognitive score of 5 out of 15, which indicated severe cognitive impairment. R1's behavior notes were reviewed and documented the following: Effective Date: 12/19/2025 09:03 Type: *Behavior Note Please describe the behavior demonstrated: a resident from the upstairs unit [identified as R2] came down to say hello to his friends, [name, R1] started yelling, he's a [expletive]!! Leave! you can't be here, you {expletive]! Effective Date: 12/20/2025 19:00 Type: *Behavior Note Please describe the behavior demonstrated: another resident [identified as R2] was sitting across the dividing wall of the dining room, speaking to another resident who asked him to come see her. [resident name, R1] began staring at said resident and grinding his teeth. He then yelled, NO! very loud frightening 2 female residents [identified as R3 and R4]. One yelled out STOP IT as the other female was trying to get out of the dining room. [R1] then rammed the w/c of the resident [identified as R3] trying to leave. He then went toward female resident [identified as R4] who was standing with her walker, he jumped toward the resident standing swinging his arms attempting to hit her, however male nurse was able to intervene, and [R1[ made no contact with standing female resident. both nurses, removed [R1] from dining area to his room. [R1] came back out of his room yelling NO. Male nurse and this nurse attempted to speak with [R1], explaining we would go to the dining area after he is better able to control himself. [R1] stated, I'll move you! [R1] then kicked this nurse in the right shin and punched in center of chest, leaving bruising and a knot on the shin and bruising on the chest. This nurse fell against the wall, and male nurse stepped in to help. How often did this behavior occur/last: >6-7 times a week Describe any Interventions attempted: separate [name R1] to quiet location Effectiveness of Interventions: not effective he continued to curse and yell at others Effective Date: 12/25/2025 10:20 Type: *Behavior Note Please describe the behavior demonstrated: [R1] was going to get a Dr. Pepper. When the elevator opened on the first floor, another resident who he does not like was awaiting [SIC] the elevator to go back upstairs. As soon as [R1] saw the other resident he began screaming, [repeated expletive]![R1] then started kicking the other resident [identified as R2] and swinging to hit [R2]. The other resident [R2] back up into the wall and started yelling. [expletive] other resident was told to go upstairs and he did, this resident came back to the unit and began yelling at whoever he came into contact with, including the nurse who was on the phone. Male nurse separated [R1] away from other as he was scaring the other residents. How often did this behavior occur/last: daily Describe any Interventions attempted: separated from other residents Effectiveness of Interventions: ineffective [name of nurse]. Effective Date: 02/10/2026 18:38 Type: *Behavior Note Please describe the behavior demonstrated: : [R1] started yelling out NO! in repetition another resident [identified as R5] stated , please stop and at that time [name, R1] went toward the female attempting to attack her, male nurse arrived standing in front of [residents name] who began yelling, move ma'am move to get to female resident he was moved back to his table, where he became increasingly angry grinding his teeth and glaring those around him shaking with anger How often did this behavior occur/last : >5x's a week Describe any Interventions attempted: : separate him from others Effectiveness of Interventions : a female staff member he will continue and attack that female, when it is a male, he will not. Effective Date: 03/10/2026 19:09 Type: *Behavior Note Please describe the behavior demonstrated: [R1] was in his room watching TV. When another resident [identified as R2] came off the elevator and he heard them talking, he came out of his room and began yelling garbled word, was shaking and grinding his teeth. The other resident was socializing with one of his friends. [R1] continued to yell as he started coming down the hallway towards the other resident who was still socializing. This nurse stepped in front of him so he could not attack the two residents socializing. He started yelling at this nurse NO! another staff member took the other two residents away from the elevator, as soon as they were out of [R1] sight he went directly back to watching TV. Review of psychiatric notes indicated causes of aggressive behavior was possibly related to underlying vascular dementia and unspecific mood disorder. The notes' indicated medications were being adjusted, and laboratory tests were being performed. The treatment plan included observations and assessments of triggers that may cause aggression, redirection, one-to-one staffing ratio, reinforce positive behaviors and psychosocial sensory interventions. Review of the care plan also included these interventions. On 3/17/26 at 1:05 p.m. certified nursing assistant (CNA #1, assigned to R1) was interviewed. CNA #1 verbalized R1 has a temper and when he wants something, it must be done right away or he becomes aggressive. CNA #1 said that when R1 becomes aggressive, the staff will remove R1 from the area and try to do activities or place R1 on one-to-one. CNA #1 said that R2 was a trigger for R1 and R2 was moved upstairs and felt like it has helped the situation, but R1 will still exhibit aggression towards other residents and staff. On 3/17/26 at 1:15 p.m. license practical nurse (LPN #2, assigned to R1) was interviewed. LPN #2 verbalized taking care of R1 for several years and R1's behaviors can be sporadic and can be directed at any one at any time. LPN #2 said that R1 and R2 used to be roommates and got along fine, but then R1 was getting increasingly aggressive with R2, and a room change occurred, the aggressive actions continued and R2 was then moved to another unit which seemed to have helped along with medication changes. LPN #2 said that when R1 does become aggressive the staff try to redirect, put R1 on one-to-one and offer snacks and sodas. On 3/17/26 at 1:45 p.m. a contracted mental health therapist (other staff, OS #1) was interviewed. OS #1 said she was hired to provide talk therapy, and R1 was offered the therapy but declined and is currently being followed by the psychiatric nurse practitioner. On 3/17/26 at 2:00 p.m. the psychiatric nurse practitioner (OS #2) was interviewed. OS #2 verbalized only being in the facility for the past two weeks and R1 has been on the list of residents to see but has not been seen yet. OS #2 verbalized awareness that R1 had been seen by the previous nurse practitioner. OS#2 said R4 and R5 had been seen and did not feel there were any concerns regarding fearfulness. Diagnoses for R4 included cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/15/2025. R4 was assessed with a cognitive score of 15 indicating cognitively intact. On 3/17/26 at 3:00 p.m. R4 and R5 (roommates) were interviewed. R4 verbalized there has not been any physical contact by R1, but R1 is a bully, loud, rude and begins yelling when he wants something and yells at residents, which can be startling. Diagnoses for R5 include asthma, bipolar, alcohol induced dementia, attention deficit disorder. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/1/2026. R5 was assessed with a cognitive score of 9 indicating moderately cognitively impaired. R5 said that R1 thinks he's God and should get everything he wants, R1 is hateful and loud. R5 said that R1 had not attacked her but had come toward her aggressively and was stopped. R5 then mouthed the words He's tried it with her. Pointing towards R4 (the privacy curtain was pulled between the beds). R4 and R5 both verbalized feeling safe. Diagnoses for R3 include heart failure, kidney disease, dysphagia, and cognitive communication deficit. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/28/2026. R3 was assessed with a cognitive score of 12 indicating moderately impaired. On 3/17/26 at 3:20 p.m. R3 was interviewed. R3 verbalized R1 has been aggressive with R3, is loud, hateful, and is a bully. R3 verbalized trying to stay to herself and felt safe and was not afraid of R1. Diagnoses for R2 include intracerebral hemorrhage, hemiplegia, and dysphagia. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 3/5/2026. R2 was assessed with a cognitive score of 12 indicating moderately impaired. On 3/18/26 at 9:00 a.m. R2 was interviewed. R2 verbalized that R1 had a verbal confrontation and that R1 can be a bully and always wants his way. R2 was asked about R1 kicking him in the elevator, R2 said yes that happened and did not have injuries from it. R2 said that he felt safe, and both residents now ignore each other. On 3/18/26 at 10:15 a.m. registered nurse (RN #2, nurse that wrote behavior note on 12/20/25 and 12/25/25) was interviewed. RN #2 said that the residents involved were separated and R1 had kicked and punched RN #2. The director of nursing (DON) was notified and instructed RN #2 to call the police. The police came and took a report and R1 remained at the facility. The DON was told about R3 and R4 being involved in the altercation (on 12/20/25), skin assessments were completed and did not show injuries, but R3 and R4 were upset at the time but currently does not show signs of being fearful of R1. On 3/18/26 at 11:30 a.m. unit manager LPN #5 was interviewed regarding R1. LPN #5 verbalized that there's nothing specific to what sets R1 off, R1 is unpredictable to any person around. R1 wants what R1 wants and wants it immediately. When R1 gets his way then R1 deescalates. One-to-one was imposed for twenty-four hours a day for several days and then was reduced to as needed which is when R1 becomes aggressive or shows anger or can't be redirected, it's removed when R1 becomes calm. LPN #5 verbalized R1 sits in dining room most of day and staff are reactive to R1's behavior. On 3/18/26 at 12:00 p.m. the social services assistant (OS #3) was interviewed. OS #3 said that R1's behaviors are sporadic, no one thing sets R1 off. When R1 wants something, it must be done right away or R1 will escalate until he gets it. OS #3 said to keep residents safe the facility is looking at alternate placement for R1. OS #3 said in the past, R1 has been sent to the hospital on an ECO (emergency custody order) but was sent back indicating R1 was stable. OS #3 said that a 30-day discharge notice has been issued for R1, but multiple attempts have been made to discharge R1 without success. On 3/18/26 at 12:30 p.m. the facilities nurse practitioner (NP) was interviewed. The NP verbalized R1 is unpredictable towards residents and needs separation when angry. NP verbalized that something needs to be put in place to have more consistency and would be fine with putting R1 on one-to-one monitoring.The facility did present an incident summary for the incident regarding R1 and R2 having a resident-to-resident altercation dated 12/25/25 and indicated an investigation was performed and R1 was issued a thirty-day discharge. The facility did not present an incident summary or investigation for the incident dated 12/20/25 involving R1, R3, and R4.On 3/18/26 at 2:12 p.m., the survey team contacted state agency supervision and discussed concerns regarding the facility's failure to ensure residents were free from abuse for residents #2, #3, #4, and #5. On 3/18/26 at 3:50 p.m. the administrator and DON were advised that immediate jeopardy (IJ) was identified regarding the facility's failure to ensure residents were free from abuse for Residents #2, # 3, #4, and #5. The administrator was informed that immediate action was needed for development and implementation of a process to ensure protection from abuse for residents and a documentation plan of IJ removal was requested.On 3/18/26 at 8:05 p.m., a plan for IJ removal regarding protection from abuse was provided by the facility. The plan was reviewed and approved by the state agency survey team/supervision and included the following.F600 Immediate Jeopardy (IJ) Removal Plan 3/18/26Resident #1 was placed on 1 to 1 supervision 3/18/2026 at 1605. The resident will remain on 1 to 1 supervision while out of bed until the resident discharges or significant change in condition limits the resident's physical ability to encounter another resident. Residents are unable to transfer from bed to wheelchair independently therefore not a risk to other residents while in bed. Residents 2, 3, 4, and 5 have been seen previously by psychiatric services and/or talk therapist between the dates of 2/19/2026 and 3/18/2026. Residents 2, 3, 4, and 5 residents receive follow up psychosocial support from facility staff on 3/18/2026. The facility will continue to attempt to find alternative placement for resident #1. All residents of the facility have the potential to be affected by this deficient practice. All residents residing in the facility will be screened for evidence of abuse and neglect starting at 16:00 on 3/18/2026. Residents who are interviewable (BIMS score of 8 or greater) will be interviewed utilizing an abuse questionnaire, non-verbal residents and residents with a BIMS score of 7 or will be assessed, head to toe, to validate the absence of signs of physical abuse. Identified concerns will be addressed according to the facility Abuse Policy. All residents will be assessed/reviewed for similar behaviors as exhibited by resident #1 by reviewing all Facility Reportable Incidents (FRIs) dating back to 12/19/2025 and care plans will be reviewed and revised with interventions for any identified residents. All staff of the facility/agency will be reeducated on the facility Abuse Policy. This education will include abuse prevention, types of abuse, and abuse reporting. All staff will receive education starting on 3/18/2026. Any staff who are not present on 3/18/2026 will be required to receive mandatory education prior to the start of their next shift. No staff member will be allowed to return to work after 3/18/2026 until this mandatory education has been completed. New hire orientation will include this training as part of the new hire process and all agency staff will be required to complete this education prior to starting work in the facility. The facility leadership team including but not limited to the NHA, DON, Social services, and activities will be provided reeducation on assessing triggers, root causes, and escalation patterns and development of an effective and sustained supervision and separation intervention for residents with behavioral disturbances by the Regional Director of Clinical Operations and Regional Director of Operations on 3/18/2026. The Medical Director was notified of the situation on 3/18/2026. The facility conducted an Ad Hoc QAPI committee to accept IJ Removal Plan on 3/18/2026. Date of completion 3/18/2026 at 23:59 On 3/19/26 starting at 9:00 a.m., the survey team verified that the above removal plan had been implemented through review of clinical records, interviews of staff of all disciplines. At the time of the verification, the facility obtained an order for an ECO [emergency custody order- which is an order for a mental health evaluation] for R1 and R1 was sent to the hospital for evaluation. Implementation of the IJ removal plan was deemed sufficient and completed as documented. The immediacy was removed as of 3/19/25 at 11:30 a.m. The scope/severity was reduced to level 2 pattern following the removal of immediate jeopardy.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of seven residents (Resident #107) followed protocols for safe smoking.The findings include:Resident #107 was observed smoking without supervision and with a cigarette that had not been provided or lit by facility staff.Resident #107 (R107) was admitted to the facility with diagnoses that included major depressive disorder, COPD (chronic obstructive pulmonary disease), anemia, dementia, anxiety, insomnia and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed R107 with moderately impaired cognitive skills.On 4/27/26 at 2:40 p.m., R107 was observed seated in the corner of the outdoor courtyard that was designated as the smoking area for residents. R107 was actively smoking holding a lighted cigarette. R107 was interviewed at this time about smoking. R107 stated a staff member had been in the courtyard and just went back inside. R107 put out the cigarette on the concrete surface and stated that smoking in the facility was usually supervised. R107 demonstrated no unsafe behavior while smoking and the resident's clothes had no indication of burns/dropped ashes. The courtyard area was posted with smoking times listed as 10:30 a.m., 2:30 p.m. and 7:30 p.m.R107's clinical record documented a smoking assessment dated [DATE] listing the resident as low risk for safety concerns with smoking and included a requirement for supervision with smoking. The assessment documented that the resident had no visual impairment, no range of motion or balance issues, no fine motor skill difficulty, no lethargy during tasks, did not drop ashes, had no history of burns to clothing/skin, and as able to light, hold and extinguish a cigarette safely. The assessment documented the resident required no adaptive or protective equipment (apron) and that the resident was able to follow facility smoking protocols for safety. This assessment documented the resident as safe to smoke with supervision.R107's plan of care (revised 3/13/26) documented the resident was deemed to be a safe smoker with staff supervision. Interventions to ensure smoking safety included supervision with smoking, education to the resident on the facility's smoking policy that included location, times and safety precautions and smoking assessments performed as needed.On 4/28/26 at 8:10 a.m., R107 was interviewed about smoking on 4/27/26 without supervision. R107 stated that staff members supervised smoking each day at the designated times (10:30 a.m., 2:30 p.m. and 7:30 p.m.). R107 stated yesterday (4/27/26) that she was finishing up my last cigarette. R107 stated the staff person supervising allowed her to finish the last couple of puffs and that was when the surveyors walked up. R107 stated she did not require an apron or device for smoking and that she had never had any safety issues during smoking. R107 denied having cigarettes or lighter on her person or in her room. R107 stated residents were not allowed to keep smoking materials in their room and that nursing kept supplies locked in the medication room. R107 stated she did not remember the name of the staff person supervising smoking yesterday afternoon (4/27/26).On 4/28/26 at 8:20 a.m., accompanied by licensed practical nurse (LPN #1), resident smoking materials were observed locked in the second-floor medication room. The box contained 3 packs of cigarettes with a lighter and was secured in the locked room. LPN #1 stated at this time that all the current smokers in the facility were supervised by staff at the designated times and that no residents were allowed to keep smoking materials in their possession. LPN #1 stated two certified nurses' aides (CNAs) from 3rd floor provided smoking supervision on the afternoon of 4/27/26.On 4/28/26 at 8:25 a.m., CNA #1 that supervised resident smoking on the afternoon of 4/27/26 was interviewed. CNA #1 stated she was passing out ice on 3rd floor and was a little late going out with the smokers on 4/27/26. CNA #1 stated she and CNA #2 did not go out with the smokers on 4/27/26 until approximately 2:45 p.m. CNA #1 stated there were three other smokers in the courtyard during the session in addition to R107. CNA #1 stated R107 was not smoking when she arrived in the courtyard, and she did not see the resident with any smoking materials. CNA #1 stated, We hand out cigarettes individually, one at a time, and light them. CNA #1 stated R107 smoked two cigarettes during the session and consumed both prior to ending the smoking session. CNA #1 stated if R107 was smoking prior to 2:45 p.m., she had no idea where she got the cigarette or lighter as the smoking supplies stayed locked in the medication room. CNA #1 stated regarding the observation of R107 actively smoking at 2:40 p.m., We were not down there yet [in the courtyard]. CNA #1 stated none of the residents were smoking when she arrived in the courtyard with the smoking supplies. CNA #1 stated R107 had never demonstrated any safety issues during smoking and did not require an apron or adaptive equipment.On 4/28/26 at 8:35 a.m. CNA #2 that supervised smoking on the afternoon of 4/27/26 was interviewed. CNA #2 stated she was with CNA #1 supervising smoking on the afternoon of 4/27/26. CNA #2 state she and CNA #1 were not out with residents at 2:30 p.m. as scheduled but were late taking the smokers out. CNA #2 stated she and CNA # 1got the smoking box from the medication room and took it to the courtyard. CNA #2 stated R107 was already in the courtyard and there was no smoking going on by any residents when they arrived in the courtyard. CNA #2 stated she and CNA #1 watched R107 smoke two cigarettes during the session with both cigarettes consumed and extinguished/discarded in the receptacle prior to the end of the session. CNA #2 stated R107 was given two cigarettes, one at a time and that staff always lighted the cigarettes for residents. CNA #2 stated she was not aware R107 had been smoking and she did not know how the resident got a cigarette or lighter. CNA #2 stated R107 was always a safe smoker, never dropping ashes or cigarettes and that the resident did not require an apron or device. CNA #2 stated R107 smoked two cigarettes in front of us and that all cigarettes and the lighter were returned and locked in the medication room after the session.On 4/28/26 at 9:10 a.m., the administrator and director of nursing (DON) were interviewed about R107 observed actively smoking unsupervised. The administrator stated all resident smoking required supervision and that he was unsure where R107 got the cigarette and/or lighter. The administrator stated that residents that smoked were required to follow facility policies to ensure safe smoking.The facility's policy titled Smoking Permitted (revised 10/20/22) documented, .The facility will implement processes to respect the resident's right to smoke and will provide an environment for safe smoking in a manner that does not infringe on any resident's rights.Residents who desire to smoke will be educated on the facility policy and practices for safe smoking.The resident will verbalize understanding of the facility policy and practices and will sign acknowledgement of receipt of the policy.Resident who desire to smoke may not keep smoking related materials [i.e. cigarettes, electronic smoking devices (e-cigarettes), refill cartridges/fluid, cigars, pipes, tobacco, lighter, lighter fluid, match, etc.] on their person when not smoking or in their room.Resident who are determined by the interdisciplinary team as needing supervision will be within eyesight of staff, family, or designated volunteer during the time that the resident is smoking.Non-compliance with smoking safety requirements is taken very seriously.The facility may initiate discharge planning for a violation of any part of this policy and for any unsafe smoking practice that poses risk to residents or for repeated non-compliance with the facility safe smoking policy/practices.This finding was reviewed with the administrator and DON on 4/28/26 at 3:00 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, clinical record review, and facility document review, the facility failed to investigate an incident of resident-to-resident abuse involving three of eleven residents in the survey sample (Resident #1, Resident #3, and Resident #4). The Findings Include: The facility did not investigate resident to resident abuse between Resident #1 (R1), R3, and R4. Diagnoses for R1 included heart failure, diabetes, dementia, hemiplegia, and seizure disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/16/2025. R1 was assessed with a cognitive score of 5 indicating severely cognitively impaired. Diagnoses for R3 include heart failure, kidney disease, dysphagia, and cognitive communication deficit. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/28/2026. R3 was assessed with a cognitive score of 12 indicating cognitively intact. Diagnoses for R4 included cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/15/2025. R4 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R1's progress notes indicated on 12/20/25 R1, R3, and R4 were in the dining area when R1 began yelling No to R2 (another resident close to the dining area). The note indicted one of the female residents (R3 or R4) said to stop it. R1 then rammed R3's wheelchair and started swinging and trying to attack R4. All residents were separated by staff. On 3/18/26 at 10:15 a.m. registered nurse (RN #2, nurse that wrote behavior note on 12/20/25) was interviewed. RN #2 said that the residents involved were separated. The director of nursing (DON) was told about R3 and R4 being involved in the altercation, skin assessments were completed and did not show injuries, but R3 and R4 were upset at the time but currently does not show signs of being fearful of R1. The administrator was asked to present all investigations and incident summaries regarding R1's aggressive behavior toward other residents. An incident synopsis and investigation were presented regarding R1's altercation with R2. However, there was no evidence of an investigation or incident summary regarding the altercation dated 12/20/25 with R3 and R4. On 3/18/26 at 3:40 p.m. the administrator and director of nursing (DON) were interviewed. The above information was presented regarding not completing an investigation for R3 and R4 related to R1. The DON verbalized there wasn't an incident synopsis or investigation because there was no actual physical abuse due to the staff separated the residents involved. On 3/19/26 at 11:50 a.m. the administrator was asked to review R3's progress note dated 12/20/25 which indicated R3 was pushed R1. The administrator verbalized he would look to see if there were any incident synopsis or investigations completed. The administrator returned and verbalized, nothing regarding this incident was found and an investigation and incident summary should have been completed. The facilities Abuse policy read in part Investigation, Designated staff will immediately review and investigate all allegations or observations of abuse. The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident [.]. No other information was presented prior to exiting on 3/19/26.

Based on staff interview, clinical record review, and facility document review the facility failed to report incidents of resident-to-resident abuse involving three of eleven residents in the survey sample (Resident #1, Resident #3, and Resident #4). The Findings Include: The facility did not report resident to resident abuse between Resident #1 (R1), R3, and R4. Diagnoses for R1 included heart failure, diabetes, dementia, hemiplegia, and seizure disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/16/2025. R1 was assessed with a cognitive score of 5 indicating severely cognitively impaired. Diagnoses for R3 include heart failure, kidney disease, dysphagia, and cognitive communication deficit. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/28/2026. R3 was assessed with a cognitive score of 12 indicating mild cognitive impairment. Diagnoses for R4 included cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/15/2025. R4 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R1's progress notes indicated on 12/20/25 R1, R3, and R4 were in the dining area when R1 began yelling No to R2 (another resident close to the dining area). The note indicted one of the female residents (R3 or R4) said to stop it. R1 then rammed R3's wheelchair and started swinging and trying to attack R4. All residents were separated by staff. On 3/18/26 at 10:15 a.m. registered nurse (RN #2, nurse that wrote behavior note on 12/20/25) was interviewed. RN #2 said that the residents involved were separated. The director of nursing (DON) was told about R3 and R4 being involved in the altercation, skin assessments were completed and did not show injuries, but R3 and R4 were upset at the time but currently does not show signs of being fearful of R1. The administrator was asked to present all investigations and incident summaries regarding R1's aggressive behavior toward other residents. An incident synopsis and investigation were presented regarding R1's altercation with R2. However, there was no evidence of an investigation or reporting incident synopsis regarding the altercation dated 12/20/25 with R3 and R4. On 3/18/26 at 3:40 p.m. the administrator and director of nursing (DON) were interviewed. The above information was presented regarding not completing an investigation or reporting the incident to the state agency for R3 and R4 related to R1. The DON verbalized there wasn't an incident synopsis was not reported or investigation because there was no actual physical abuse due to the staff separated the residents involved. On 3/19/26 at 11:50 a.m. the administrator was asked to review R3's progress note dated 12/20/25 which indicated R3 was pushed R1. The administrator verbalized he would look to see if there were any incident synopsis or investigations completed. The administrator returned and verbalized, nothing regarding this incident was found and an investigation and incident summary should have been reported. The facilities Abuse policy read in part The organization will maintain systems to ensure that all alleged violations involving abuse [.] are reported immediately, but no later than 2 hours after the allegation is made [.]. No other information was presented prior to exiting on 3/19/26.

Based on staff interview and clinical record review, the facility staff failed to develop and implement a comprehensive care plan regarding behaviors for one of eleven residents, Resident #1. The findings included: Resident #1's (R1) comprehensive care plan did not have parameters for an intervention of one to one observation in the behavior care plan. Diagnoses for R1 included heart failure, diabetes, dementia, hemiplegia, and seizure disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/16/2025. R1 was assessed with a cognitive score of 5 indicating severely cognitively impaired. Review of R1's care plan for behaviors listed an intervention put in place on 12/30/25 that read 1:1 supervision as indicated. There was no information regarding timeframe, whether the intervention was continuous, based on behavior, what consititued when it was to be used, or the duration. On 3/19/26 at 12:15 p.m. the director of nursing (DON) was interviewed. The DON reviewed R1's care plan and verbalized that R1 is placed on 1:1 when he becomes aggressive towards another resident and remains on 1:1 until R1 deescalates. The DON verbalized that the care plan should be more specific regarding 1:1 supervision. No other information was provided prior to exiting the facility on 3/19/26.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to provide medically related social services for psychosocial well-being for four of eleven residents in the survey sample. Resident 's 7, 8, 9, and 10 were not assessed by the social worker after a resident-to resident altercation. The findings include: 1. Residents 7, 8, and 9 were not assessed by the social worker after a resident-to-resident altercation. Review of a facility investigation regarding resident-to-resident altercation dated 5/18/25 included Resident 11 (R11, the aggressor) and three female residents identified as R7, R8, R9. The investigation report indicated R11 newly admitted to the facilities dementia unit for respite care on 5/17/25 had became aggressive and started touching/grabbing three females' breasts while in the dining area. R11 was removed from the area, monitored and sent to the emergency room and was later discharged from the facility on 5/19/25. R7 diagnoses include dementia, schizophrenia, depression, and cognitive communication deficit. The most recent MDS was a quarterly assessment dated [DATE]. R7 was assessed with a conative score of 7 indicating moderately impaired. R8 diagnoses include Alzheimer's disease, dementia, and anxiety. The most recent MDS was a quarterly assessment dated [DATE]. R8 was assessed severely cognitively impaired. R9 diagnoses include Alzheimer's disease, dementia, and depression. The most recent MDS was a quarterly assessment dated [DATE]. R9 was assessed with short and long-term memory problems and severely impaired conatively. Review of the clinical records for the three female residents involved did not evidence that social services had completed any emotional/psychosocial assessments related to the incident. On 7/29/25 at 4:30 p.m. the social worker (other staff, OS #1) was interviewed. OS #1 verbalized awareness of the incident but didn't recall if any assessments were completed on the residents involved and would check on this. OS #1 was unable to evidence assessments had been completed. R7, R8, and R9 were not able to be interviewed due to cognitive status, however review of clinical records and observations made throughout the survey did not indicate an emotional negative effect. The residents involved in the incident were observed in various activities and did not appear depressed, isolated, or withdrawn. Interviews with nursing staff on the dementia unit did not evidence the residents being emotionally distressed over the incident. On 7/30/25 at 4:30 p.m. the above information was presented to the administrator and DON. No other information was provided prior to the exit conference on 7/31/25. 2. Resident 10 (R10) was not assessed by the social worker after a resident-to-resident altercation. The findings include: Diagnoses for Resident #10 (R10) included: dementia, depression, insomnia, and kidney disease. The most recent MDS (Minimum Data Set) was a quarterly dated 4/17/25, R10's BIMS score was 3, indicating severely cognitively impaired. Review of a facility investigation regarding resident-to-resident altercation dated 5/19/25 included Resident 11 (R11, the aggressor) and R10. The investigation report indicated R11 newly admitted to the facilities dementia unit for respite care on 5/17/25 had become aggressive hit R10 in the face. R11 was removed from the area, placed on one-to-one monitoring and sent to the emergency room and was later discharged from the facility on 5/19/25. Review of the R10's clinical record did not evidence that social services had completed any emotional/psychosocial assessments related to the incident. On 7/29/25 at 4:30 p.m. the social worker (other staff, OS #1) was interviewed. OS #1 verbalized awareness of the incident but didn't recall if any assessments were completed on the residents involved and would check on this. OS #1 was unable to evidence assessments had been completed. Clinical records and observations made throughout the survey did not indicate an emotional negative effect from the incident. R10 was observed in various activities and did not appear depressed, isolated, or withdrawn. Interviews with nursing staff on the dementia unit did not evidence the residents being emotionally distressed over the incident. On 7/30/25 R10 was interviewed. R10 did not recall the incident, but verbalized that the staff are good, feel safe and enjoy cleaning his room. On 7/30/25 at 4:30 p.m. the above information was presented to the administrator and DON. No other information was provided prior to the exit conference on 7/31/25.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for two of eleven residents in the survey sample (Residents #6 and #10).The findings include:1. Documented neurological checks following a fall with injury were not included in Resident #6's clinical record. Resident #6 (R6) was admitted to the facility with diagnoses that included dementia with behavioral disturbance, anxiety, depression, gastroesophageal reflux, insomnia, cataracts, and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R6 with severely impaired cognitive skills. R6's clinical record documented the resident had an unwitnessed fall on 3/4/25. A nursing note dated 3/4/25 documented the resident was found on the floor in her room. This note documented physical and neurological checks were completed. The resident was observed with a large hematoma on the forehead and bruising on the upper bridge of the nose with a small break in skin. This note stated neurological checks were initiated. R6's clinical record documented a nursing note dated 3/9/25 stating the resident was tearful, holding her forehead in pain with some dizziness noted. The nurse practitioner note dated 3/9/25 documented review of this change in condition and listed, Neuro assessments are not available. Review of R6's clinical record on 7/29/25 revealed no documented neurological (neuro) checks. On 7/29/25 at 4:20 p.m., the director of nursing (DON) was interviewed about neuro checks following R6's fall on 3/4/25. The DON reviewed the clinical record and stated, No neuro checks were found. The DON stated the facility was switching from computerized assessment to paper assessments around the time of that fall and she was unable to locate the checks. On 7/30/25 at 8:10 a.m., the medical records clerk (other staff #5) was interviewed about R6's missing neuro checks. The medical records clerk presented paper copies of R6's neuro checks starting on 3/4/25. The medical records clerk was interviewed about why the neuro checks were not part of the electronic health record. The medical records clerk stated the neuro checks were documented on paper and had not been scanned into the clinical record. The medical records clerks stated she received the documents one to two weeks ago and had not prioritized scanning them because the records were old. The medical records clerk stated she thought the documents had been filed on the nursing unit, and when files were cleaned, the checks were sent to medical records. This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 7/30/25 at 4:15 p.m. with no further information presented prior to the end of the survey. 2. Assessments and an incident were not documented in resident #10's clinical record regarding a resident-to-resident altercation. The findings include: Diagnoses for Resident #10 (R10) included: dementia, depression, insomnia, and kidney disease. The most recent MDS (Minimum Data Set) was a quarterly dated 4/17/25, R10's BIMS score was 3, indicating severely cognitively impaired. A review of the facilities investigation dated 5/19/25 indicated R10 was involved in a resident-to resident altercation. According to the investigation, R10 was assessed for physical and emotional concerns and was within normal limits. Review of R10's clinical record did not evidence any assessments or progress notes related to the altercation. On 7/30/25 at 3:00 p.m. the director of nursing (DON) was interviewed. DON said on 5/19/25 she was notified that R11 was being combative towards staff and had hit R10. The DON said that the responsible party (RP) and physician were notified. 911 was called and R11 was sent to the hospital for aggressive behavior and did not return to the facility. The DON was asked about missing documentation of incident and assessments. The DON verbalized that assessments were done at the time of the event and should have been documented by nursing staff. The facilities policy titled Resident-To-Resident Altercations read in part: h. [.] document the incident, findings, and any corrective measures taken in the resident's medical/clinical record.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for two of eleven residents in the survey sample (Residents #1 and #11).The findings include:1. Facility staff failed to follow abuse prevention policies regarding reporting and investigating after Resident #1 tested positive for marijuana and methamphetamine during an emergency room visit. Resident #1 (R1) was admitted to the facility with diagnoses that included traumatic hemorrhage of cerebrum, post-traumatic hydrocephalus, epilepsy, dementia, history of substance abuse, depression, hypertension, dry eye syndrome and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. Resident #5 (R5) was admitted to the facility with diagnoses that included paraplegia, osteomyelitis, sacral pressure ulcer, history substance abuse, chronic pain, depression, polyneuropathy and neurogenic bladder. The MDS dated [DATE] assessed R5 as cognitively intact. R5 was roommate to R1 from 12/5/24 until 1/16/25. R1's clinical record documented a nursing note dated 1/13/25 stating, .Went into resident's room to give AM [morning] medicine, resident was not in bed. Found resident lying on floor in front of bathroom door. Resident had a sweatshirt under his head using it for a pillow. Resident denied falling stated he was just sleeping there, eyes glassed over and pupil's pinpoint .abrasions noted to left arm and elbow. Resident slow and sluggish answering questions .Provider aware and ordered to send to [emergency department] for evaluation .exited facility at 0853 [8:53 a.m.] .Night shift reported that room smelled of marijuana and a chemical smell last night . R1's emergency room records dated 1/13/25 documented R1 was assessed at baseline with no acute injuries or findings. R1 returned to the facility 1/14/25 at 3:39 a.m. R5's clinical record documented a social worker note dated 1/15/25 at 10:00 a.m. stating there had been reports of a chemical smell coming from the resident's room. This note documented, Director of social services (DSS), administrator, and director of nursing went to speak with resident after there were reports of a 'chemical smell' coming from the room . The social worker documented that R5 gave consent for search of his room/personal belongings and the DSS documented finding items that included 4 vape devices, 2 cans of pepper spray, 3 glass smoking devices, 3 empty containers of THC-a smoking material, half-smoked cigarette and 2 bottles of over-the-counter antacids. This note documented, .All items removed and taken to the social service office. Items were secured in the safe in the office .Resident stated that he does like to go off property to smoke . Interventions documented in response to the items found in R5's room included, removal and locking items in facility safe, education to R5 that all smoking materials had to be obtained at the time of signing out of the facility and returned to nursing upon return, resident given options to quit smoking with the resident expressing interest in nicotine gum, and bottles of antacid given to nursing for storage in medication cart. R1's clinical record documented a nursing note dated 1/15/25 stating that at 12:35 p.m., R1 was observed with .seizure-like activity while lying in bed .resemble generalized tonic-clonic .stiffening of the body, contraction to hands bilat [bilaterally], facial muscles. Seizure-like activities occurred x 3 appear to last 30 secs [seconds] each .Patient positioned laterally .Supplemental Oxygen was provided @ 2 LPM [liters per minute] . The note documented the physician was notified and ordered the resident to the emergency room for evaluation/treatment with emergency personnel listed as arriving at 1:05 p.m. The emergency room (ER) report dated 1/15/25 documented, .presenting today with chief concern for seizure. Per EMS he had 2 seizures witnessed by staff at facility and 2 witnessed by EMS .Someone from the facility called and asked if we can add on a drug screen because his roommate of 3 weeks they were concerned may have been giving him some substances .History of polysubstance/alcohol abuse prior to stroke . The drug screen performed at the emergency room on 1/15/25 documented the resident tested positive for marijuana and methamphetamines. The ER physician documented, .Psychosocial issue - I spoke with his wife about the drug screen, she will speak with the facility to ensure that it does not happen again . The resident had CT scans and x-rays performed which were negative for any findings. The resident was given a trial of Narcan, intravenous fluids and was discharged to the facility with instructions for continued use of previous anti-seizure medications. R1 returned to the facility on 1/15/25 at 10:00 p.m. with one-to-one supervision for R1 and R5 implemented by staff due to positive drug findings. The clinical record documented on 1/16/25 that staff witnessed R5 using vulgar language and verbal threats toward R1. The facility issued R5 a 30-day discharge notice on 1/16/25 due to his possession of prohibited items and verbal aggression. The police were called and R5 was sent to the emergency room on 1/16/25 with an emergency custody order. There was no facility reported incident (FRI) form sent to the state agency or notification to other agencies (adult protective services, law enforcement) regarding R1's positive drug tests results and related drug devices found in R5's room on 1/15/25. There was no documented investigation regarding R1's positive drug tests. On 7/29/25 at 3:00 p.m., the administrator was interviewed about a report to the state agency, police and adult protective services (APS) regarding R1's positive drug test for marijuana and methamphetamine. The administrator stated he did not initiate a FRI on 1/15/25. The administrator stated on 1/13/25 that R1 was thought to have a medical issue related to a seizure diagnosis and he did not suspect drugs use by R1. On 7/30/25 at 8:45 a.m., the administrator was interviewed again about a FRI. The administrator stated he did not enter a FRI about the drugs but sent a FRI on 1/16/25 regarding R5's verbal aggression and the transfer due to aggressive behaviors. The administrator stated actions had been taken following R1's positive drug test (1:1 supervision, discharge notice to R5, R5 discharged on emergency custody order, R5 moved to another floor/room with increased supervision) but that he focused that investigation on R5's unmanageable behaviors. The administrator stated he had a verbal conversation with APS about R5, the police were notified on 1/16/25 regarding the aggressive behaviors and were given the prohibited items found in R5's room on 1/15/25. The administrator stated he did not initiate a formal FRI to the stage agency, APS, or written notification to the police specifically about R1's positive drug test. The FRI dated 1/16/25 and the related investigation were reviewed. The alleged incident, witness statement and investigation summary referenced R5's aggressive verbal behaviors and subsequent transfer to the emergency room. There was no documentation on this FRI of R1's positive drug results and R5's possession of prohibited items found/removed on 1/15/25. The facility's policy titled Abuse (revised 10/20/22) documented, .The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property .Designated staff will immediately review and investigate all allegations or observations of abuse . The facility's policy titled Abuse Investigating and Reporting (revised 10/1/21) documented, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown and thoroughly investigated by facility management. Findings of abuse investigations will also be reported .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies .State licensing/certification agency responsible for surveying/licensing the facility .local/State Ombudsman .Resident's Representative .Adult Protective Services .Law enforcement officials (if applicable) .Attending Physician .Medical Director .An alleged violation .will be reported immediately but not later than .Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury .Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .The Administrator .will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 7/30/25 at 4:15 p.m. with no further information presented prior to the end of the survey. 2. The facility did not implement facility abuse policy regarding resident-to-resident altercation investigation documentation for resident #11 (R11). Diagnoses for R11 included: Alzheimer's disease, dementia, anxiety, and depression. The most recent MDS was a discharge assessment dated [DATE], assessed R11 with short-term memory problems and moderately impaired cognitive skills. In reviewing a resident-to-resident altercation investigation conducted by the facility regarding R11 (the aggressor) and three female residents (identified as R7, R8, and R9) being touched inappropriately on 5/18/25, witness statements were missing from the investigation. On 7/29/25 at 1:30 p.m. the director of nursing (DON) was made aware of the missing witness statements. The DON verbalized that she had completed the witness statements and would look for them. On 7/29/25 at 2:00 p.m. the DON returned and said that she thought the witness statements were on her computer but could not find them. On 7/29/25 at 7:55 p.m. two of the witnesses named in the investigation were interviewed via telephone (identified as certified nursing assistant, CNA #1 and licensed practical nurse, LPN #2). CNA #1 verbalized reporting everything that was observed to the DON. LPN #2 verbalized no recall of giving a witness statement. On 7/30/25 at 4:30 p.m. the above information was presented to the administrator and DON. A facility policy titled Abuse Investigation and Reporting read in part; d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. No other information was presented prior to the exit conference on 7/31/25.

Based on staff interview, facility document review, and clinical record review, the facility failed to ensure a complete and thorough investigation of an allegation of abuse and/or unusual event for two of eleven residents (Residents #1 and #11).The findings include: 1. The facility failed to ensure witness statement documentation regarding resident-to-resident altercation investigation for resident #11 (R11). Diagnoses for R11 included: Alzheimer's disease, dementia, anxiety, and depression. The most recent MDS was a discharge assessment dated [DATE], assessed R11 with short-term memory problems and moderately impaired cognitive skills. In reviewing a resident-to-resident altercation investigation conducted by the facility regarding R11 (the aggressor) and three female residents (identified as R7, R8, and R9) being touched inappropriately on 5/18/25, the investigation listed three staff members as witnesses to the altercation however, witness statements were missing from the investigation. The witnesses were identified as license practical nurse (LPN #2), certified nursing assistant (CNA #1), and CNA #3 (no longer employed at the facility). On 7/29/25 at 1:30 p.m. the director of nursing (DON) was made aware of the missing witness statements. The DON verbalized that she had completed the witness statements and would look for them. On 7/29/25 at 2:00 p.m. the DON returned and said that she thought the witness statements were on her computer but could not find them. On 7/29/25 at 7:55 p.m. two of the witnesses named in the investigation were interviewed via telephone (CNA #1 and LPN #2). CNA #1 verbalized reporting everything that was observed to the DON. LPN #2 verbalized no recall of giving a witness statement. On 7/30/25 at 4:30 p.m. the above information was presented to the administrator and DON. A facility policy titled Abuse Investigation and Reporting read in part; d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. No other information was presented prior to the exit conference on 7/31/25. 2. Facility staff failed to thoroughly investigate drug use of unknown source after Resident #1 tested positive for marijuana and methamphetamine during an emergency room visit. Resident #1 (R1) was admitted to the facility with diagnoses that included traumatic hemorrhage of cerebrum, post-traumatic hydrocephalus, epilepsy, dementia, history of substance abuse, depression, hypertension, dry eye syndrome and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. Resident #5 (R5) was admitted to the facility with diagnoses that included paraplegia, osteomyelitis, sacral pressure ulcer, history substance abuse, chronic pain, depression, polyneuropathy and neurogenic bladder. The MDS dated [DATE] assessed R5 as cognitively intact. R5 was roommate to R1 from 12/5/24 until 1/16/25. R1's clinical record documented a nursing note dated 1/13/25 stating, .Went into resident's room to give AM [morning] medicine, resident was not in bed. Found resident lying on floor in front of bathroom door. Resident had a sweatshirt under his head using it for a pillow. Resident denied falling stated he was just sleeping there, eyes glassed over and pupil's pinpoint .abrasions noted to left arm and elbow. Resident slow and sluggish answering questions .Provider aware and ordered to send to [emergency department] for evaluation .exited facility at 0853 [8:53 a.m.] .Night shift reported that room smelled of marijuana and a chemical smell last night . R1's emergency room records dated 1/13/25 documented R1 was assessed at baseline with no acute injuries or findings. R1 returned to the facility 1/14/25 at 3:39 a.m. R5's clinical record documented a social worker note dated 1/15/25 at 10:00 a.m. stating there had been reports of a chemical smell coming from the resident's room. This note documented, Director of social services (DSS), administrator, and director of nursing went to speak with resident after there were reports of a 'chemical smell' coming from the room . The social worker documented that R5 gave consent for search of his room/personal belongings and the DSS documented finding items that included 4 vape devices, 2 cans of pepper spray, 3 glass smoking devices, 3 empty containers of THC-a smoking material, half-smoked cigarette and 2 bottles of over-the-counter antacids. This note documented, .All items removed and taken to the social service office. Items were secured in the safe in the office .Resident stated that he does like to go off property to smoke . Interventions documented in response to the items found in R5's room included, removal and locking items in facility safe, education to R5 that all smoking materials had to be obtained at the time of signing out of the facility and returned to nursing upon return, resident given options to quit smoking with the resident expressing interest in nicotine gum, and bottles of antacid given to nursing for storage in medication cart. R1's clinical record documented a nursing note dated 1/15/25 stating that at 12:35 p.m., R1 was observed with .seizure-like activity while lying in bed .resemble generalized tonic-clonic .stiffening of the body, contraction to hands bilat [bilaterally], facial muscles. Seizure-like activities occurred x 3 appear to last 30 secs [seconds] each .Patient positioned laterally .Supplemental Oxygen was provided @ 2 LPM [liters per minute] . The note documented the physician was notified and ordered the resident to the emergency room for evaluation/treatment with emergency personnel listed as arriving at 1:05 p.m. The emergency room (ER) report dated 1/15/25 documented, .presenting today with chief concern for seizure. Per EMS he had 2 seizures witnessed by staff at facility and 2 witnessed by EMS .Someone from the facility called and asked if we can add on a drug screen because his roommate of 3 weeks they were concerned may have been giving him some substances .History of polysubstance/alcohol abuse prior to stroke . The drug screen performed at the emergency room on 1/15/25 documented the resident tested positive for marijuana and methamphetamines. The ER physician documented, .Psychosocial issue - I spoke with his wife about the drug screen, she will speak with the facility to ensure that it does not happen again . The resident had CT scans and x-rays performed which were negative for any findings. The resident was given a trial of Narcan, intravenous fluids and was discharged to the facility with instructions for continued use of previous anti-seizure medications. R1 returned to the facility on 1/15/25 at 10:00 p.m. with one-to-one supervision implemented by staff due to positive drug findings. The clinical record documented on 1/16/25 that staff witnessed R5 using vulgar language and verbal threats toward R1. The facility issued R5 a 30-day discharge notice on 1/16/25 due to his possession of prohibited items and verbal aggression. The police were called and R5 was sent to the emergency room on 1/16/25 with an emergency custody order. There was no facility reported incident (FRI) form sent to the state agency or notification to other agencies (adult protective services, law enforcement) regarding R1's positive drug tests and related drug devices found in R5's room on 1/15/25. There was no documented investigation regarding R1's positive drug tests. On 7/29/25 at 3:00 p.m., the administrator was interviewed about a report to the state agency, police and adult protective services (APS) regarding R1's positive drug test for marijuana and methamphetamine. The administrator stated he did not initiate a FRI on 1/15/25. On 7/30/25 at 8:45 a.m., the administrator was interviewed again a FRI and investigation. The administrator stated he did not enter a FRI about the drugs but sent a FRI on 1/16/25 regarding R5's verbal aggression and the transfer due to aggressive behaviors. The administrator stated actions had been taken following R1's positive drug test (1:1 supervision, discharge notice to R5, R5 discharged on emergency custody order, R5 moved to another floor/room with increased supervision, discharge from facility) but that he focused that investigation on R5's unmanageable behaviors. The administrator stated he had a verbal conversation with APS about R5, the police were notified on 1/16/25 regarding the aggressive behaviors and were given the prohibited items found in R5's room on 1/15/25. The administrator stated he did not have documentation regarding a formal investigation about R1's positive drug test results. The FRI dated 1/16/25 and the related investigation were reviewed. The alleged incident, witness statements and investigation summary referenced R5's aggressive verbal behaviors and subsequent transfer to the emergency room. There was no documented investigation about R1's positive drug results. The facility's policy titled Abuse Investigating and Reporting (revised 10/1/21) documented, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown and thoroughly investigated by facility management. Findings of abuse investigations will also be reported .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies .State licensing/certification agency responsible for surveying/licensing the facility .local/State Ombudsman .Resident's Representative .Adult Protective Services .Law enforcement officials (if applicable) .Attending Physician .Medical Director .An alleged violation .will be reported immediately but not later than .Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury .Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .The Administrator .will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 7/30/25 at 4:15 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to promote a safe, drug free environment for one of eleven residents in the survey sample (Resident #1).The findings include:Facility staff failed to promptly implement interventions following reports of marijuana and a chemical smell in Resident #1's room on 1/13/25. During an emergency room visit for seizures, Resident #1 tested positive for marijuana and methamphetamine following suspected illicit drug use by the resident's roommate (Resident #5). Resident #1 (R1) was admitted to the facility with diagnoses that included traumatic hemorrhage of cerebrum, post-traumatic hydrocephalus, epilepsy, dementia, history of substance abuse, depression, hypertension, dry eye syndrome and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented no drug/alcohol use since July 2021.Resident #5 (R5) was admitted to the facility with diagnoses that included paraplegia, osteomyelitis, sacral pressure ulcer, history substance abuse, chronic pain, depression, polyneuropathy and neurogenic bladder. The MDS dated [DATE] assessed R5 as cognitively intact. R1 and R5 were roommates from 12/5/24 until 1/16/25. Clinical records for R1 and R5 made no mention of marijuana/chemical smells or concerns for prohibited drugs until 1/13/25. R1's clinical record documented a nursing note dated 1/13/25 stating, .Went into resident's room to give AM [morning] medicine, resident was not in bed. Found resident lying on floor in front of bathroom door. Resident had a sweatshirt under his head using it for a pillow. Resident denied falling stated he was just sleeping there, eyes glassed over and pupil's pinpoint .abrasions noted to left arm and elbow. Resident slow and sluggish answering questions .Provider aware and ordered to send to [emergency department] for evaluation .exited facility at 0853 [8:53 a.m.] .Night shift reported that room smelled of marijuana and a chemical smell last night .R1's emergency room records dated 1/13/25 documented R1 was assessed at baseline with no acute injuries or findings. R1 returned to the facility 1/14/25 at 3:39 a.m.Clinical records for R1 and R5 documented no interventions taken in response to the report of marijuana and chemical smell documented on 1/13/25 until 1/15/25. R1 and R5's clinical records on 1/14/25 documented scheduled medication administration, wound care/assessments for both residents and a nurse practitioner visit for R1. Clinical notes/assessments on 1/14/25 made no mention or reference to the marijuana/chemical smell documented on 1/13/25 or of any current smell of marijuana/chemicals. R5's clinical record documented a social worker note dated 1/15/25 at 10:00 a.m. stating there had been reports of a chemical smell coming from the resident's room. This note documented, Director of social services (DSS), administrator, and director of nursing went to speak with resident after there were reports of a 'chemical smell' coming from the room . The social worker documented that R5 gave consent for search of his room/personal belongings and the DSS documented finding items that included 4 vape devices, 2 cans of pepper spray, 3 glass smoking devices, 3 empty containers of THC-a smoking material, half-smoke cigarette and 2 bottles of over-the-counter antacids. This note documented, .All items removed and taken to the social service office. Items were secured in the safe in the office .Resident stated that he does like to go off property to smoke . Interventions documented in response to the items found in R5's room included, removal and locking items in facility safe, education to R5 that all smoking materials had to be obtained at the time of signing out of the facility and returned to nursing upon return, resident given options to quit smoking with the resident expressing interest in nicotine gum, and bottles of antacid given to nursing for storage in medication cart.R1's clinical record documented a nursing note dated 1/15/25 stating that at 12:35 p.m., R1 was observed with .seizure-like activity while lying in bed .resemble generalized tonic-clonic .stiffening of the body, contraction to hands bilat [bilaterally], facial muscles. Seizure-like activities occurred x 3 appear to last 30 secs [seconds] each .Patient positioned laterally .Supplemental Oxygen was provided @ 2 LPM [liters per minute] . The note documented that the physician was notified and ordered the resident to the emergency room for evaluation/treatment with emergency personnel arriving at 1:05 p.m.The emergency room (ER) report dated 1/15/25 documented, .presenting today with chief concern for seizure. Per EMS he had 2 seizures witnessed by staff at facility and 2 witnessed by EMS .Someone from the facility called and asked if we can add on a drug screen because his roommate of 3 weeks they were concerned may have been giving him some substances .History of polysubstance/alcohol abuse prior to stroke . The drug screen performed at the emergency room on 1/15/25 documented the resident tested positive for marijuana and methamphetamines. The ER physician documented, .Psychosocial issue - I spoke with his wife about the drug screen, she will speak with the facility to ensure that it does not happen again . The resident had CT scans and x-rays performed which were negative for any findings. The resident was given a trial of Narcan, intravenous fluids and was discharged back to the facility. R1's ER report dated 1/15/25 did not indicate if the seizures were caused or related to the illicit drugs. Discharge instructions included continued use of anti-seizure medications as previously prescribed and instructions to not use illicit drugs.R1 returned to the facility on 1/15/25 at 10:00 p.m. with one-to-one supervision for R1 and R5 implemented by staff due to the positive drug findings. A social services note dated 1/16/25 documented, .At approximately 9:40 a.m. the writer of the note approached and asked permission to search resident, [Resident #5's] room. This was a follow up search out of concern for resident and his roommate's safety due to recent incidents concerning the roommate [R1]. Resident exercised his right to refuse to the room search. Resident was also asked about a drug screening panel, which he also refused . The clinical record documented on 1/16/25 that staff witnessed R5 using vulgar language and making verbal threats toward R1, accusing R1 of snitching. The facility issued R5 a 30-day discharge notice on 1/16/25 due to his possession of prohibited items and verbal aggression. The police were called and R5 was sent to the emergency room on 1/16/25 at 3:15 p.m. with an emergency custody order due to verbal aggression, threats and non-compliance with drug/smoking materials.R1's clinical record documented R1's room and personal belongings were searched on 1/16/25 with permission of R1's family. No evidence of drugs or prohibited devices were found.R5's physician progress note dated 1/20/25 documented R5 had a history of polysubstance abuse. This note documented that R5 stated the prohibited items found on the 1/15/25 search were in his bag from when he lived on the street and he was unaware that he had them. This note documented the resident was removed from the facility by emergency custody order on 1/16/25 and returned from the emergency department on 1/17/25 with diagnoses of polysubstance abuse. This note documented the resident reported that he had used methamphetamine in the last month due to being in a bind and expressed a desire to stop using it. The physician documented social services was assisting the resident with a safe discharge from the facility.There was no documented investigation by the facility regarding R1's positive test indicating marijuana and methamphetamine use.R1's plan of care (revised 6/2/25) made no mention of illicit drugs use prior to the 1/15/25 positive drugs tests. The care plan listed the resident had a history of seizures, impaired thought processes and impaired decision-making due to traumatic brain injury.R5's plan of care (initiated 12/16/25) documented the resident was at risk of complications due to opioid use but made no mention of a history of drug/substance abuse. Interventions included observation for signs/symptoms of lethargy, over-sedation or respiratory complications. On 7/29/25 at 12:00 p.m., R1's family/responsible party (other staff #6) was interviewed. R1's family member stated R1 had been in the facility for over two years, did not leave the facility except with a family member and had no way to access or obtain illicit drugs. R1's family member stated she requested/agreed to the drug screen on 1/15/25 because she was suspicious of R1's roommate as there had been a marijuana smell in the room one to two days before the seizures.On 7/29/25 at 3:00 p.m., the administrator and director or nursing (DON) were interviewed about R1's positive drug test. The administrator stated there had been no signs of prohibited drug use/devices prior to 1/13/25. The administrator stated R5 had a history of drug use and was new to the facility. The administrator stated R5 frequently signed out of the facility but nothing was suspicious until 1/13/25. The administrator stated R1 went to the emergency room on 1/13/25 with no acute findings and that this issue was considered to be medical and not suspicious for illicit drugs. The administrator stated R1 was not new to the facility, had frequent family involvement and there had been no concerns with R1 having/using illicit drugs. The administrator stated that R5 agreed to a search on 1/15/25 with staff finding vape devices, empty THC containers and multiple prohibited items. The administrator stated that when R1 experienced a seizure on 1/15/25, the provider requested a drug screen due to suspicions of R5 for drug use and family concerns. When asked if the positive drug test was reported/investigated, the administrator stated staff were confident that R5 was the source of illicit drugs due to his recent history and prohibited items found during the search. The administrator stated R1 had no recent seizures prior to the incident on 1/15/25 and had experienced none since R5 was monitored/removed from his room. The administrator stated R5 was issued a 30-day discharge notice on 1/16/25 due to non-compliance with smoking paraphernalia/devices. The administrator stated R5 made verbal, vulgar threats to R1 on 1/16/25 following the discharge notice and R5 was sent out of the facility on an emergency custody order. The administrator stated the custody order was not upheld and R5 returned to the facility on 1/17/25 to a private room on a separate floor from R1 with increased supervision. The administrator stated there were no further issues until 2/3/25. The DON stated on 2/3/25 vape devices and a lighter were in plain sight in R5's room. The DON stated when she removed the devices, R5 grabbed her arm and shoved her. The administrator stated R5 was monitored until police arrived and removed the resident from the facility. When asked what interventions were implemented on 1/13/25 when nursing first documented the marijuana/chemical smell in R1/R5's room, the DON stated she did not see anything done until 1/15/25 when R5's room/belongings were searched. The DON stated R1's fall on 1/13/25 was thought to be a medical issue and was not thought to be related to drugs.On 7/29/25 at 4:00 p.m., R1 was interviewed about the seizures and any drugs taken in January 2025. R1 stated the seizures were due to his brain trauma and that he did not recall taking drugs or a problem with a roommate.On 7/29/25 at 4:26 p.m., the social worker (other staff #1) was interviewed. The social worker stated R5 was found on 1/15/25 with prohibited devices like vapes. The social worker stated R5 initially had no behaviors or suspicions of drug use. The social worker stated R5 upon admission stated he had been clean for a while. The social worker stated staff reported a marijuana smell around the time of R1's fall (1/13/25) and a search was done (1/15/25). The social worker stated no drugs were found but vape devices and prohibited items were found and removed from the resident on 1/15/25. The social worker stated she did not know why the search was not done until 1/15/25 and that the social service director that did the search no longer worked at the facility.On 7/30/25 at 9:00 a.m., the licensed practical nurse unit manager (LPN #7) that cared for R1 and R5 was interviewed. LPN #7 stated R1 was found on the floor on 1/13/25 and this was thought to be related to the resident's history of seizures. LPN #7 stated R1 had been in the facility for years and there had been no prior concerns with R1 using illicit drugs. LPN #7 stated she never saw anything in R5's room indicating drug use. LPN #7 stated she recalled a search was done and prohibited items found in R5's possession but she did not remember the dates. On 7/30/25 at 10:46 a.m., the administrator and DON were interviewed again about any actions/interventions regarding R1's positive drug test. The administrator stated after searching R5 room and finding prohibited drug related devices/items, he was confident that R5 was the source of the illicit drugs. The administrator stated R5 denied having drugs in the building or giving drugs to R1. The administrator stated in response to R1's 1/15/25 positive drug results, 1:1 monitoring was initiated, 30-day notice was given to R5, R5 was removed on emergency custody order, and discharge planning assistance was provided to R5 with R5 eventually removed from the facility for assaulting the DON. The administrator presented no actions taken after the 1/13/25 note indicating marijuana/chemical smells in R1's room prior to the 1/15/25 search.On 7/30/25 at 10:30 a.m., certified nurse's aide (CNA) #5 that cared for R1 and R5 was interviewed. CNA #5 stated she had never seen anything prior to 1/13/25 indicating drug use by either resident. CNA #5 stated she was aware R5 had a history of drug use, but she had never seen or smelled anything indicating he had drugs. CNA #5 stated R1 had been in the facility for years, had family that visited frequently and that R1 had never had any signs of using drugs.The nurse that wrote the note in R1's record on 1/13/25 about smelling marijuana/chemical smell was not available for interview as she no longer worked at the facility. The facility's admission agreement/contract documented, .The Facility will not permit, without Facility's permission and a physician's order, the possession of alcohol or any controlled substance on its premises or in violation of any law. Any resident who, while on Facility premises, engages in the sale, consumption and/or unauthorized possession of alcohol or any controlled substance will be subject to discharge. Any violations of law subject the violator to discharge and possible prosecution .you are strictly prohibited from keeping smoking related items, to include but not limited to: cigarettes, cigars, electronic smoking items, matches, lighters and/or smokeless tobacco products while You are a resident of this Facility .violation of the Facility's Smoke Policy endangers the health and safety of You and other at the Facility and as such, is grounds for Your discharge .

Based on staff interview, facility document review and clinical record review, the facility staff failed to report to the state agency, adult protective services and law enforcement of a positive test result for illicit drugs for one of eleven residents in the survey sample (Resident #1).The findings include: Facility staff failed report to the state agency, adult protective services and law enforcement after Resident #1 tested positive for marijuana and methamphetamine of unknown source. Resident #1 (R1) was admitted to the facility with diagnoses that included traumatic hemorrhage of cerebrum, post-traumatic hydrocephalus, epilepsy, dementia, history of substance abuse, depression, hypertension, dry eye syndrome and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact.Resident #5 (R5) was admitted to the facility with diagnoses that included paraplegia, osteomyelitis, sacral pressure ulcer, history substance abuse, chronic pain, depression, polyneuropathy and neurogenic bladder. The MDS dated [DATE] assessed R5 as cognitively intact. R5 was roommate to R1 from 12/5/24 until 1/16/25. R5's clinical record documented a social worker note dated 1/15/25 at 10:00 a.m. stating there had been reports of a chemical smell coming from the resident's room. This note documented, Director of social services (DSS), administrator, and director of nursing went to speak with resident after there were reports of a 'chemical smell' coming from the room . The social worker documented that R5 gave consent for search of his room/personal belongings and the DSS documented finding items that included 4 vape devices, 2 cans of pepper spray, 3 glass smoking devices, 3 empty containers of THC-a smoking material, half-smoked cigarette and 2 bottles of over-the-counter antacids. This note documented, .All items removed and taken to the social service office. Items were secured in the safe in the office .Resident stated that he does like to go off property to smoke . Interventions documented in response to the items found in R5's room included, removal and locking items in facility safe, education to R5 that all smoking materials had to be obtained at the time of signing out of the facility and returned to nursing upon return, resident given options to quit smoking with the resident expressing interest in nicotine gum, and bottles of antacid given to nursing for storage in medication cart.R1's clinical record documented a nursing note dated 1/15/25 stating that at 12:35 p.m., R1 was observed with .seizure-like activity while lying in bed .resemble generalized tonic-clonic .stiffening of the body, contraction to hands bilat [bilaterally], facial muscles. Seizure-like activities occurred x 3 appear to last 30 secs [seconds] each .Patient positioned laterally .Supplemental Oxygen was provided @ 2 LPM [liters per minute] . The note documented the physician was notified and ordered the resident to the emergency room for evaluation/treatment with emergency personnel listed as arriving at 1:05 p.m.The emergency room (ER) report dated 1/15/25 documented, .presenting today with chief concern for seizure. Per EMS he had 2 seizures witnessed by staff at facility and 2 witnessed by EMS .Someone from the facility called and asked if we can add on a drug screen because his roommate of 3 weeks they were concerned may have been giving him some substances .History of polysubstance/alcohol abuse prior to stroke . The drug screen performed at the emergency room on 1/15/25 documented the resident tested positive for marijuana and methamphetamines. The ER physician documented, .Psychosocial issue - I spoke with his wife about the drug screen, she will speak with the facility to ensure that it does not happen again . The resident had CT scans and x-rays performed which were negative for any findings. The resident was given a trial of Narcan, intravenous fluids and was discharged to the facility with instructions for continued use of previous anti-seizure medications. R1 returned to the facility on 1/15/25 at 10:00 p.m. with one-to-one supervision implemented by staff due to positive drug findings. The clinical record documented on 1/16/25 that staff witnessed R5 using vulgar language and make verbal threats toward R1. The facility issued R5 a 30-day discharge notice on 1/16/25 due to his possession of prohibited items and verbal aggression. The police were called and R5 was sent to the emergency room on 1/16/25 upon an emergency custody order.There was no facility reported incident (FRI) form sent to the state agency or notification to adult protective services or law enforcement regarding R1's positive drug tests and related drug devices found in R5's room on 1/15/25. On 7/29/25 at 3:00 p.m., the administrator was interviewed about a report to the state agency, police and adult protective services (APS) regarding R1's positive drug test for marijuana and methamphetamine. The administrator stated he did not initiate a FRI on 1/15/25. On 7/30/25 at 8:45 a.m., the administrator was interviewed again about a FRI and notification to the required agencies. The administrator stated he did not enter a FRI about the drugs but sent a FRI on 1/16/25 regarding R5's verbal aggression and the transfer with emergency custody order. The administrator stated actions had been taken following R1's positive drug test (1:1 supervision, discharge notice to R5, R5 discharged on emergency custody order, R5 moved to another floor/room with increased supervision) but that he focused that investigation on R5's unmanageable behaviors. The administrator stated he had a verbal conversation with APS about R5 but this was not specifically about the positive drug test. The administrator stated the police were notified on 1/16/25 regarding the aggressive behaviors and were given the prohibited items found in R5's room on 1/15/25. The administrator stated he did not initiate a formal notification to the stage agency, APS or law enforcement about R1's positive drug test. The FRI dated 1/16/25 and the related investigation were reviewed. This FRI documented events surrounding the aggressive behaviors and included no notification to the required agencies regarding R1's positive drug test.The facility's policy titled Abuse Investigating and Reporting (revised 10/1/21) documented, .Findings of abuse investigations will also be reported .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies .State licensing/certification agency responsible for surveying/licensing the facility .local/State Ombudsman .Resident's Representative .Adult Protective Services .Law enforcement officials (if applicable) .Attending Physician .Medical Director .An alleged violation .will be reported immediately but not later than .Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury .Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .The Administrator .will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident .This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 7/30/25 at 4:15 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview and facility document review, the facility staff failed to follow professional standard of care for medication administration on two of four units (2NW and 2NS). The findings include:Facility staff observed medications left unattended in resident rooms on unit 2NW and 2NS (skilled unit).On 7/30/25 at 3:10 p.m., the director of nursing (DON) was interviewed about any issues during the last three months with medications left unattended. The DON stated unattended medications had been observed/reported on two occasions during June and July (2025) with one incident occurring on the 2NW unit and the other on 2NS unit. The DON stated the two nurses involved were re-educated and a correction plan was initiated to address the concern.On 7/30/25 at 3:30 p.m., the administrator was interviewed about the observed incidents of medication left unattended. The administrator stated there had been social media posts in the area about the facility that alleged medications were left unattended in resident rooms. The administrator stated audits were conducted to identify/validate this concern. The administrator stated there were two observations made of medications left unattended, so this issue was included in their quality improvement program with a plan of correction implemented to address the issue.The facility's policy titled General Guidelines for Medication Administration (revised 8/2020) documented, Medications are administered as prescribed in accordance with good nursing principles and practices .At a minimum, the 5 Rights - right resident, right drug, right dose, and right time - should be applied to all medication administration and reviewed .When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.), medications are administered at the time they are prepared .The resident is always observed after administration to ensure that the dose was completely ingested .The administrator presented a QAPI (Quality Assurance and Process Improvement) action plan initiated on 6/26/25 listing the issue/concern as Social media post alleged that medications were being left at bedside. The root cause analysis/related factors were identified as the 5 rights of medication administration and policy/procedures were allegedly not being followed by nursing staff. The plan listed that the media post identified no nurses or residents. The plan documented that all residents had the potential to be affected. Actions taken included the following.100% audit of all residents' rooms looking for medications left at bedside by DON or designee - completed on 7/1/25.Medication administration observation with competency checks completed each shift for 3 days by DON or designee - completed on 7/1/25.All nursing staff were educated on the policy regarding medications left at the bedside by DON or designee - completed 7/5/25.All licensed nursing staff were educated on the 5 Rights of Medication Administration by DON or designee - completed 7/5/25.A 12-week monitoring plan initiated that included medication at bedside audits 5 times per week for two weeks (completed 7/10/25), medication at bedside audit performed 3 times per week for two weeks (completed 7/24/25), and medication bedside audit weekly for eight weeks (ongoing).The compliance date for this concern was listed as 7/27/25.The audits, education and monitoring were documented at listed and training verified. Areas of improvement were identified, and nurses re-educated as needed. Resident rooms were observed upon the initial tour of the facility on 7/29/25 starting at 10:50 a.m. with no unattended medications found. Observations were made throughout the current survey with no medications observed unattended. No non-compliance regarding failure to follow professional standards was identified during the current survey and since the correction date of 7/27/25.The plan of correction was deemed acceptable and implemented as listed.This finding was reviewed with the administrator, DON and regional nurse consultant during a meeting on 7/30/25 at 4:15 p.m.This deficiency was cited as past non-compliance.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide supervision for, one of two residents in the survey sample, Resident #2, that resulted in harm to the resident. The resident left the building at 2:50 a.m. on 7/13/2023 and fell while outside the building. The resident was treated for a lacerations over his left eye and back of left side of head. In the days following the fall it was discovered the resident also had suffered a broken clavicle and a broken femur since the fall of 7/13/2023 with no other falls after 7/13/2023. The findings include: For Resident #2 (R2), the resident eloped out of the facility on 7/13/2023 at 2:50 a.m., with a fall requiring medical attention. On 7/19/2023 the resident was discovered to have a fractured clavicle and on 7/27/2023 the resident complained of pain in his right leg, an x-ray was ordered and the resident was found to have an acute fracture of his right femoral neck with slight shortening and abduction of the femoral head. The resident, age 48, was admitted on [DATE] with diagnoses that included but were not limited to: encephalopathy, diabetes, pancreatitis, anxiety disorder, recent right hip fracture without replacement, gastroesophageal reflux disease, alcohol abuse, history of falls, insomnia and wandering. On the MDS (minimum data set) assessment, prior to the fall, with an assessment reference date of 7/14/2023, an admission assessment, the resident was coded as having both short and long memory difficulties and being severely cognitively impaired for making daily decisions. In Section E - Behaviors, the resident was coded as having inattention and disorganized thinking. In Section E, it further coded the resident as having physical and verbal behavioral symptoms towards others on one to three days of the lookback period. R2 was coded as resisting care on four to six days but less than daily of the lookback period. The resident was coded as wandering behaviors that occurred four to six days of the look back period. R2 was coded, does the wandering place the resident at significant risk of getting to a potentially dangerous place, it was coded, yes. In Section G - Functional Status, the resident was coded as requiring supervision on one staff member for transfers, walking in the room or corridor, and eating. R2 was coded as requiring extensive assistance of one staff member for toileting and personal hygiene. Section G0300 - Balance During Transition and Walking, coded the resident in walking that he was not steady but able to stabilize without staff assistance. Observation was made of Resident #2 on 8/16/2023 at 11:40 a.m. R2 was in a wheelchair with his head on the table in the day room. Unable to see where Code Alert band was. A second observation was made of R2 on 8/17/2023 at approximately 9:30 a.m., the resident was in bed sleeping. Code Alert bracelet noted on left wrist. The Safety - Resident Evaluation dated, 7/8/2023, documented in part, Elopement Risk Evaluation: Mental Status - Alert with cognitive impairment (confusion, cognitive deficits, disorientation, poor decision making skills, decreased safety awareness, disturbances in judgement). Mobility: ambulatory. Predisposing Diagnosis: Does the resident have a diagnosis of dementia, organic brain syndrome, Alzheimer's disease, delusions, hallucinations, Bipolar disorder, Schizophrenia, anxiety disorder and/or depression? The resident was coded as having one or more predisposing diagnoses present. Facility Adjustment: the resident was coded as being no verbal expressions to leave facility. Elopement history: Does the resident have a history elopement attempts (at home, other facility, or current facility) in the past 6 months? The resident was coded as, no. Does the resident have a history of wandering? R2 was coded as, yes. Has the family/ responsible party voiced concerns that would indicate the resident may try to leave? The resident was coded as, no. Elopement Risk Determination: Recommendations: Based on the above evaluation, determination is as follows: the resident was coded as being at risk for elopement. WAs a wander bracelet placed on the resident? it was documented as, yes. Location of wander guard? LUE (left upper extremity). The nurse's note dated, 7/8/2023 at 3:46 a.m. documented, Res(resident) kept wandering all through the night despite several attempts to redirect him to bed. He enters into other resident rooms and attempts to pick their stuff to eat. The nurse's note dated, 7/9/2023 at 10:45 a.m. documented, Resident notes to be wandering the hallways this shift. Resident went out to he courtyard to walk, ground noted to be damp, staff attempted to have resident put his slippers on. He began yelling at staff and became combative, striking staff. Staff allowed the resident to calm down and offered him a snack. Resident sitting calmly now in the courtyard. Will continue with increased supervision r/t (related to) behaviors. The nurse's note dated, 7/9/2023 at 2:22 p.m. documented in part, Resident noted to have a witnessed fall in the courtyard at 1130 (11:30 a.m.) Resident stood when his family walked into the courtyard and lost his footing, falling onto his buttocks and hitting his head on a chair. Head to toe assessment completed. No injuries or skin issues noted. ROM (range of motion) WNL (within normal limits) .Resident noted to have grippy socks. Resident had refused per staff to not put his slippers on. Resident's mother brought a pair of tennis shoes in and assisted to putting them on. The nurse's note dated, 7/9/2023 at 4:32 p.m. documented, Resident urinated in courtyard, staff attempted to redirect and resident refused. The nurse's note dated, 7/10/2023 at 12:15 p.m. documented in part, IDT (interdisciplinary team) met to review falls. Resident had stood up from a chair and lost his footing causing him to fall. No injuries were noted after the incident. Neuro (neurological) checks were started, and resident's mother brought the resident a pair of shoes. The nurse's note dated, 7/10/2023 at 7:03 p.m. documented, Resident wondering (sic) around unit and outside, staff attempted to redirect resident, resident refused. The nurse's note dated, 7/12/2023 at 1:51 p.m. documented, Resident wandering around unit exit seeking. Redirected by staff x2. Resident was easily redirected with offering a second meal tray for lunch. The nurse's note dated, 7/12/2023 at 7:42 p.m. documented, Resident is wandering during this shift and was able to open side door. Alarm sounded and staff were able to redirect resident. All safety measures in place, call bell and fluids within reach. The nurse's note dated, 7/13/2023 at 3:42 a.m. documented, At approximately 0250 (2:50 a.m.) Resident was found outside in parking lot by staff member. This write was alerted and observed resident sitting on the floor (ground) with blood noted on face and head. Resident had grippy socks on. Unable to give a description of how he fell . Resident with two persons assisted back to his feet and redirected back in the building for further assessment. Head to toe assessment completed. Rom (range of motion) wnl (within normal limits), pupil perrla (pupil equal reactive to light). VS (vital signs) obtained wnl. Injuries noted to top of scalp, and deep laceration above lt (left) eyebrow. 911 called d/t deep laceration noted above lt eyebrow. Resident picked up by squad at around 0315 (3:15 a.m.) and transported to (initial of hospital), UM (unit manager), NP (nurse practitioner), RP (responsible party) made aware. The nurse's note dated, 7/13/2023 at 3:53 a.m. documented, Res (resident) was constantly wandering around, and trying to go out through the stair door. Was resisting every form of redirection. All efforts to get him sit down or be on his bed proved abortive. He enters into other residents' room, and each time he will be redirected to the hallway and to his room and most times to the dining room. The nurse's note dated 7/13/2023 at 8:15 a.m. documented, Resident returned from (name of hospital) ER (emergency room ), 3 sutures to left eyebrow, one staple back of head left side. Multiple abrasions to bilateral arms, neuro checks continuing. Provider aware of sutures and staples. The nurse's note dated, 7/13/2023 at 2:10 p.m. documented, I notified residents mother about residents' behaviors of refusing care and wandering today. I asked mother is there were other family living close that could come see resident. She stated she would speak to family members to see if they could come visit resident more often. The physician note dated, 7/17/2023 documented in part, Chief complaint: right hand swelling and discomfort History of Present Illness: [AGE] year old recently admitted male for long-term care services was seen today after staff reported his right hand being swollen with accompanying slight discomfort. Of note the resident speaks very little and it is very difficult to engage in meaningful conversation. He continues to wander in the hallways and on the Courtyard but is reported by the staff as 'less aggressive' and directable compared to last week. He also had a fall last week after which he was sent to the emergency room and received a staple on his scalp laceration and 3 sutures on the left eyebrow laceration .Ordered x-ray of the write complete review along with x-ray of hand. The activities note dated, 7/17/2023 at 3:02 p.m. documented, Resident walks the halls and, in the courtyard, shows no interest in offered activities. Spoke very little during initial assessment and very difficult to engage in conversation. The nurse's note dated, 7/19/2023 at 6:03 a.m. documented, Res was awake and pacing in the hallway all through the night, and was un redirectable. The nurses' note dated, 7/19/2023 at 5:49 p.m. documented in part, X-ray results received for the left shoulder, humerus, and forearm. Results showed unremarkable left shoulder, normal humerus, and unremarkable left forearm. X-Ray results received for the right shoulder, humerus and forearm. Results showed unremarkable forearm, no osseous abnormality seen involving the right humerus. An acute looking distal clavicular fracture with caudad angulation, NP (nurse practitioner) made aware of the result and gave new orders for a sling to right extremity every s shift for 2 weeks as resident allows, non-weight bearing to right extremity every shift for 6 weeks as resident allows, a repeat X-ray of the right shoulder to be completed in 2 weeks, and a ortho (orthopedic) referral. The acute looking distal clavicular fracture with caudad angulation is r/t the resident's last fall. The nurse's note dated, 7/24/2023 at 5:52 a.m. documented, Res maintained a calm shift. Slept almost throughout the night. Paced the hallway at the early part of the night shift. The nurse practitioner's note dated, 7/26/2023 at 10:37 a.m. documented in part, Today I am seeing the resident for follow-up as he was recently diagnoses with right clavicular fracture. His right arm is in a sling currently. Nursing reports he was up all night and did not fall asleep until this morning. He reports pain all throughout the night. His mother is also visiting and reports that his left leg seems more swelled than usual. He does have slightly worsened edema to the left instead of right. He does endorse calf pain with dorsiflexion. The nurse's note dated, 7/26/2023 at 12:47 p.m. documented, Resident was sitting in dining room. Resident put himself on floor and laid down with sheet. Resident was assisted back to chair denied any c/o (complaints of) pain. Resident requested to lay down in bed due to being tired. Resident was assisted back to bed. Nurse from previous shift had passed along in report resident had not been to bed all night. all safety measures in place, call bell and fluids within reach. The nurse's note dated, 7/26/2023 at 12:50 p.m. documented, This nurse called and scheduled a venous doppler US (ultrasound) for LLE (left lower extremity) r/t pain and edema. ETA (estimated time of arrival) was not provided. All safety measures in place, call bell and fluids within reach. The physician note dated, 7/27/2023 at 11:11 a.m. documented, Chief Complaint: c/o pain. Reports on this [AGE] years old male resident being in pain in LLE after which a venous doppler was requested which is pending at the moment. This morning during stand - up it was brought to my attention that the resident's mom is requesting to x-ray his hips as he is having pain and having difficulty standing and walking. the resident himself is a poor historian d/t encephalopathy .ordered bilateral hip x-rays complete views. The nurse's note dated, 7/28/2023 at 9:08 a.m. documented in part, Resident and RP/mother notified of x-ray results showing right hip fx (fracture). MD/UM (medical doctor/unit manager) aware, new order to send resident to (initials of hospital) ER [NAME] Priority transport. The nurse's note dated, 7/28/2023 at 10:10 a.m. documented, Resident admitted to (initials of hospital) r/t right hip fracture. The physician order dated, 7/7/2023, documented, Wander Bracelet, check function daily every night shift. The TAR (treatment administration record) for July 2023 documented the above order. It was documented as having been checked each night shift. The comprehensive care plan dated, 7/7/2023, documented in part, Focus (R2) has a behavior problem of wandering, yelling out and being combative with staff, urinating in inappropriate places, defecating in public places, refusing meds, treatments and care, placing self on floor. The Interventions documented, 7/7/2023 - Administer medications as ordered. Monitor/document for side effect s and effectiveness. 7/12/2023 - Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. 7/7/2023 - If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 7/7/2023 - Intervene as necessary to protect the right and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. 7/20/2023 - offer coloring supplies. 7/12/2023 - offer snacks. 7/12/2023 - Praise any indication of the resident's progress, improvement in behavior. An interview was conducted with ASM (administrative staff member) #3, R2's physician, on 8/16/2023 at 2:09 p.m. When asked to speak of R2, ASM #2 stated, the resident came to the facility after having surgery to his neck and repair of a fractured right hip. She stated she saw R2 on 7/10/2023, he was ambulating on the unit. He had had a fall on 7/13/2023 requiring staples to the back of his head and stitches to his left eyebrow. She said the documentation indicated the resident was a nocturnal wanderer, and he was observed to be defecating and urinating on the floors and outside. She stated that on 7/17/2023 the resident had right hand swelling and discomfort, she stated the resident doesn't speak much but staff told me about it. He continues to wander. She stated she ordered an x-ray of his right hand, in light of his fall on 7/13/2023. ASM #3 stated the nurse practitioner saw the resident on 7/17/2023 for an abrasion and swelling now to the entire arm. An x-ray of the entire arm and shoulder was ordered. ASM #3 stated she saw the resident on 7/18/2023 for the left elbow abrasion and now the swelling was to the entire arm. She ordered an x-ray of the entire arm and shoulder. On 7/20/2023 the record indicated the resident had a right clavicular fracture. ASM #3 stated they sent him to the ER, and he came back with a sling to his arm and to follow up with the orthopedist. ASM #3 further reviewed the clinical record and stated, on 7/26/2023, he was seen by the nurse practitioner for increased pain, his pain medications were increased. There was noted slightly increase in his edema to his left lower extremity. A venous doppler was ordered. ASM #3 stated she saw the resident on 7/27/2023 for the left lower extremity pain and edema, the doppler results were still pending. She ordered x-rays of bilateral hips. The results of the x-rays indicated the resident had an acute fracture to his right hip. We sent him to the ER. When asked if the resident had a diagnosis of osteoporosis or osteopenia, ASM #3 reviewed the x-ray results and stated the radiologist did not mention anything regarding the bone density. When asked if the fracture of the hip was related to his fall on 7/13/2023, stated, yes. When asked why, in her professional opinion, did the resident not exhibit any symptoms of the clavicular or hip fracture prior to the dates they were discovered, ASM #3 stated the resident was on scheduled Tylenol and Oxycontin after the fall and that could have masked the symptoms of the other fractures. On 8/16/2023 at 3:13 p.m. OSM #1, the maintenance director, and this writer observed all doors in the facility. All outside doors were outfitted with the 15 second delay as per the fire code. The stairwell, in which the resident went down, had the 15 second delay to the door. R2 had to go down 10 steps to get to the outside door. This outside door, at the time of the elopement, did not have the 15 second delay lock on it. OSM #1 stated that door had the old Wander Guard system attached to it but it was not connected. The outside steps were observed. There were 11 steps to the first landing, 14 steps to the second landing, 10 steps to the next landing, seven steps to the next landing and five steps to the sidewalk. The resident went down 10 steps inside the building and 47 steps outside the building. All doors off the units had a keypad system to unlock the doors in addition to the 15 second requirement for Fire Safety Code. Every time OSM #1 triggered the alarm on all of the doors, a staff member came to check why the alarm was going off. An interview was conducted with ASM #1, the administrator and ASM #4, the regional director of operations, on 8/16/2023 at 3:40 p.m. When asked how R2 was able to get down the steps, ASM #1 stated the resident was able to push the door open as it releases after the 15 second delay for fire code. ASM #1 stated R2 was a walker. He had been in an assisted living facility prior and wandering had been a challenge for them. She stated they had hoped they could provide a safer environment. It happened the first week he was here she stated, they were getting to know him. When asked if the doors or wander guard misfunctioned, ASM #1 stated as she could recall, he was on the unit and was able to push the door. He went into the stairwell. There are a few options off that stairwell to go to the stairway to the outside and to enter the lower lever of the building. ASM #1 stated the resident went outside and down the steps to the employee parking lot. She stated the doors he got through worked the way they were supposed to. The first door he went through did not take him to the outside. They looked at all doors. They realized that we had two systems in place that were not communicating with each other. They had a Wander Guard system and a Code Alert System. They got the companies involved and got the Code Alert system to be the only system in use. ASM #1 and ASM #4 were made aware of the concern for harm for R2 on 8/16/2023 at 4:00 p.m. An interview was conducted with LPN (licensed practical nurse) #1, on 8/17/2023 at 7:17 a.m. When asked to explain what he observed on 7/13/2023 regarding R2, LPN #1 stated he was working on the other floor. The nurse assigned to the other floor was on lunch break as they tell each other when they leave the floor. A CNA (certified nursing assistant) (CNA #2) called me on the phone and told me R2 was outside in the parking lot. He stated he went down there, it was dark, R2 was sitting on the ground. He asked him (R2) to stand up. R2 stood up. When R2 stood up, LPN #1 noted the blood on him. (CNA #2) and LPN #1 assisted the resident into the building. LPN #1 stated he brought him to the nurse's station on the second floor and he did an assessment of the resident. That's when he found the laceration on the back of the head and above the eyebrow. LPN #1 stated he called 911 because the laceration above the eye looked deep. LPN #1 and this writer toured the stairwell and the outside steps. LPN #1 stated he found R2 across the parking lot sitting on a storm drain cover. An interview was conducted with CNA #1 on 8/17/2023 at 7:37 a.m. When asked if she worked the floor, R2 was on, the night he went outside, CNA #1 stated yes she did work that night but she was not his assigned aide. CNA #1 was asked if she saw R2 that night, CNA #1 stated she had seen him up and walking the unit. She further stated that when he is up walking, someone walks with him. When asked why someone was not with him when he got outside, CNA #1 stated she had gone to help another aide provide care for a resident that needed two people to care for them. CNA #1 further stated the other aide and herself were at the opposite end of the unit from where R2 went out the door, they didn't hear the alarm as they were in another resident's room, providing care. When asked if R2 is easily redirectable, CNA #1 stated she didn't know about with other people, but she and R2 get along well. She asks him to sit down with her, watch TV with her, he liked to listen to music on her phone. CNA #1 was asked if the resident had a Code Alert/wander guard on that night, CNA #1 stated, yes, he had one and believed it was on his wrist, but really can't recall. When asked if R2 was alert and oriented, CNA #1 stated he was alert, but he can be a little hard to understand at times. Description of the unit. The unit is on the second floor. It is in the shape of a 90-degree angle with the nurse's station being at the point of the angle where the two halls meet. R2 resided in a room near the exit door where he had exited from near the end of the one angle of the hallway. An interview was conducted with CNA #2, the CNA that found the resident in the parking lot, on 8/17/2023 at 9:03 a.m. When asked to describe what happened the night she came to work and found R2 in the parking lot, CNA #2 stated she comes to work at 3:00 a.m. for a 12-hour shift. She stated it was 2:50 a.m. when she pulled into the parking lot and her lights flashed on him (R2) sitting on the ground. CNA #2 parked her car and went immediately over to the resident to make sure he was okay. She called into the facility and (name of LPN #1) came outside. She stated they stood the resident up and they redirected him back into the building. When asked if the resident said anything, CNA #2 stated they had asked if he was okay, and he said yes. She stated, they asked him how he got out in the parking lot, he never answered that question. An interview was conducted with RN (registered nurse) #2, the nurse assigned to R2 the night he exited the building, on 8/17/2023 at 9:06 a.m. When asked to describe the night R2 exited the building, RN #2 stated she had two CNAs that night and all of them were on their feet all night. He (R2) was busy moving, never went to bed. She stated they tried to redirect him, and he would attempt to slap us. They took turns watching him. R2 made several attempts to open the door (door to the stairwell). RN #2 stated the CNAs, and she were doing their every two-hour checks on the residents. She went on her lunch break. RN #2 stated she last saw R2 at 2:45 a.m. She stated when she got back from her break, they told her what had happened. RN #2 further stated the CNAs were attending to another resident. When asked if R2 could move quickly, RN #2 stated, R2 moves very fast, if you blink, he's gone. RN #2 stated they track him every 15 minutes. [NAME] can keep an eye on him all the time. He is one of 20 residents on the floor. An interview was conducted with LPN #2 on 8/17/2023 at 9:43 a.m., a nurse who has cared for R2. When asked to describe R2, LPN #2 stated he is incontinent of both bowel and bladder. He is extensive assistance for all his care. She stated she hasn't had any issues with him with taking him medications or insulin. R2 does require a lot of being with him. LPN #2 stated they switch out throughout the day; someone needs to be always with him. She stated, That little man is quick. LPN #2 stated before he fell outside, he was walking everywhere, and they followed him around. They attempted to redirect him. She stated he now is dependent on the wheelchair, but he still can stand up. LPN #2 stated he can still be hostile with staff and scream into your face. He can be short tempered at times, but he can be very sweet too. She stated when he is ready to go, he's ready to go now. The facility policy, Elopement/Unsafe Wandering Risk Evaluations, documented in part, Policy: The organization is committed to ensuring that all reasonable measures are in place to ensure that each resident receives adequate supervision and assistance devices to prevent accidents, including elopement and unsafe wandering .Wandering and Elopement: Wandering is random or repetitive locomotion. This movement may be goal-directed (e.g., the person appears to be searching for something such as an exit) or may be non-goal-directed or aimless .This goal directed wandering should also require staff supervision and a facility response to address safety issues. Specific Procedures/Guidance; 1. The Elopement Risk evaluation in PCC be completed by a licensed nurse/designee on admission, re-admission, and quarterly and as needed for a change in resident status. 2. If the resident is determined to be at risk for elopement or unsafe wandering, the staff will notify the resident's attending physician/practitioner and the resident' representative of the risk. 3. If the resident is determined to be at risk for elopement or unsafe wandering, preventive interventions will be implemented. a. Interventions may include but are not limited to: i. 1:1 supervision or frequent visual checks on the resident. ii. Use of 'alert' system device. iii. Placement on a secured unit/neighborhood. iv. Re-direction and diversional activities. 4. The resident's care plan will be reflective of identified risk and include person-centered interventions. 5. The medical record will document the resident's behavior including attempts and actual events of elopement or unsafe wandering and preventive interventions being implemented. The facility presented the following plan of correction: 1. (R2) exited the facility unattended 7/13/2023. (R2) was located within approximately 5 minutes. (R2) was transferred to the local hospital and treated for a laceration prior to returning to the facility. (R2) remains a resident at (Name of Facility). 2. All residents on the facility can be affected. A check of all doors was performed by the administrator, DON (director of nursing) & Maintenance. The exit door the resident used was equipped with a motion-activated camera system which alerts leadership staff when someone is near the door. A vendor was onsite 7/17/2023 and 7/18/2023 to assess door alarm functioning and plan for installation of additional alarms or updates as indicated. A keypad lock was installed on the Terrace egress door (door R2 exited building from) on 8/11/2023. 3. Maintenance staff were educated on checking exterior doors daily to ensure proper functioning of alarm systems to include wander alert systems on 8/11/2023. 4. The Medical Director was notified of the incident on 7/13/2023. 5. The facility conducted an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting reviewing the abatement plan on 7/14/2023 and updated the team on 8/11/2023. 6. Date of Compliance: 8/11/2023. All the credible evidence was reviewed. Verification of above was made through observation, resident interview, and staff interviews. Past Non-Compliance

Based on observation, staff interview, clinical record review, and facility document review, the facility failed to ensure a resident's room was free of an accident hazard for one of 25 residents, resulting in harm at past noncompliance. Resident #210 received a second degree burn from a heating element with a missing heat guard. The Findings Include: Diagnoses for Resident #210 included: Dementia, anemia, brain injury, and seizure disorder. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 9/28/22. Resident #210 was assessed with moderate cognitive impairment. On 6/12/23 review of a facility synopsis dated 11/27/22 was reviewed and read in part that Resident #210 had 4 seizures back-to-back on 11/26/22 and during the seizures Resident #210's arm had flailed, causing the arm to drop over the side of the bed, landing on a baseboard heating system resulting in a burn. It was also noted that corrective action had taken place by repositioning the bed and placing a cover guard over the baseboard heater. Review of Resident #210's closed record documented via nursing progress notes that Resident #210 had several seizures on 11/26/23, 911 was called, and Resident #210 was sent to the emergency department due to the multiple seizures. The nursing notes did not describe Resident #210's burn to right arm. Review of Resident #210's hospital records documented that Resident #210 had a Right forearm, second degree burn with partial thick skin loss and surrounding blisters. Small amount of serous drainage. Three individual statements (two nurses and one certified nursing assistant) were reviewed from the staff taking care of Resident #210 at the time of the incident. All statements indicated that Resident #210 received a burn and was being cared for but did not document condition of the baseboard heater. Only one of the staff members taking care of Resident #210 at the time of the incident, was currently working at the facility. On 6/13/23 at 8:30 AM, license practical nurse (LPN #3, unit manager) was interviewed. LPN #3 said that although not working at the time of the incident and unable to speak to exactly what happened, but did say that as a result an inservice was done about uncovered baseboard heaters and all beds were moved away from the heating units and turned so that the bed is no longer parallel to the heating system. On 6/13/23 at 10:00 AM, the regional maintenance director (other staff, OS #8) was interviewed. OS #8 said that the heating guard was tore off and voiced uncertainty of how the guard had gotten torn off. Questioned further, OS #8 verbalized that Resident #210 had behaviors and could have torn the guard off or that the bed was against the heating system and the guard could have possibly been torn off while moving the bed. When asked if there was a repair order for the missing guard, OS #8 verbalized that there probably wasn't, as that would be something that would be repaired as soon as seen and reported. Questioned further, OS #8 expressed doubt that the guard had been off for very long, stating that the staff and maintenance review and observe rooms daily. OS #8 was asked the purpose off a heating guard. OS #8 verbalized the guard is in place to prevent direct access to the heating element to prevent possible burns. On 6/13/23 at 10:10 AM, LPN #4 was interviewed. Confirming being present in the room during Resident #210's seizure activity, LPN #4 stated that Resident #210's right arm fell between the bed and wall, landing on the baseboard heater, burning Resident #210's arm. LPN #4 stated that the burn wound was cleaned, dressed, and ice applied, before sending Resident #210 to the hospital due to the multiple seizures. When asked about the guard to the baseboard heater, LPN #4 verbalized that the guard was neither seen on the heater or in the room. LPN #4 verbalized that since this incident all baseboard heaters have been reinforced with bigger guards and the beds have all been repositioned away from the heating system. On 6/13/23 at 4:35 PM, the above information was presented to the administrator and director of nursing. The administrator verbalized that although the incident happened prior to her employment and while under another company's ownership, the incident was somewhat familiar and agreed that it happened. The administrator stated that corrections had been put in place at the time and that employees were in-serviced about bed positioning, along with the baseboard guards, and that the incident continues to be part of the facility's quality assurance program and plan. On 6/14/23, a summary of the plan of correction, along with supporting evidence that the plan of correction was carried out was presented. The plan of correction included: - Facility wide audit of heaters completed to ensure bed is appropriate distance from heater. - Cover placed over Resident #210's heater. - maintenance staff, environmental staff and clinical staff to be educated on ensuring appropriate distance between bed and heater. - Skin sweeps to be completed on everyone to ensure no burns to skin in rooms with baseboard heaters. - IDT will complete quality review weekly on bed/heater spacing and will address any issues immediately. - the plan of correction date of completion was 11/28/22. Observations of bed placement in regards to appropriate distance to baseboard heaters were completed by the survey team. Also, interviews of staff evidenced knowledge of appropriate distance from heaters, along with placement of the bed not being parallel with the heating systems. Review of Resident records, along with accident logs and interviews, did not evidence other residents with concerns regarding burns from baseboard heaters. On 6/14/23 at 10:45 AM, a maintenance staff person (OS #12) accompanied this surveyor to Resident #210's former room and explained the updated heating guards. The baseboard heaters were affixed to the wall at ground level and extended approximately 6 to 8 inches up the wall. The new guards surrounded the baseboard heaters completely. Resident rooms throughout the facility were also observed and had the same new guards placed. The plan of correction was accepted. This deficiency was cited as past non-compliance. No current deficiencies were cited under the concerned regulation during the survey. No other information was presented prior to exit conference on 6/14/23.

Based on review of facility's records, interviews, and policy review, the facility failed to maintain a legionella prevention program to protect residents from contracting water-borne pathogens as part of the facility's infection prevention and control program. This failure had the potential to affect all residents residing in the facility. Additionally, the facility failed to ensure staff follow infection prevention practices for hand hygiene during dining observation. This has the potential for facility wide spread of infection and/or contamination. Findings: 1. Review of the facility's policy revised July 2017 and titled Legionella Water Management Program revealed .Facility is committed to the prevention, detection and control of water-borne contaminants, including legionella . 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2.The water management team will consist of at least the following personnel: The infection preventionist. The administrator. The medical director (or designee). The director of maintenance; and The director of environmental services. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE [American Society of Heating, Refrigerating and Air-Conditioning Engineers] recommendations for developing a Legionella water management program . Review of the CDC website titled Legionella . Prevention and Control, dated 03/25/21, indicated . The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella . Key Elements . Seven key elements of a Legionella water management program are to . Establish a water management program team . Describe the building water systems using text and flow diagrams . Identify areas where Legionella could grow and spread . Decide where control measures should be applied and how to monitor them . Establish ways to intervene when control limits are not met . Make sure the program is running as designed (verification) and is effective (validation) . Document and communicate all the activities . Principles . In general, the principles of effective water management include . Maintaining water temperatures outside the ideal range for Legionella growth . Preventing water stagnation . Ensuring adequate disinfection . Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella . Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. Review of website for ASHRAE titled Risk Management For Legionellosis, dated 10/15, indicated . The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors . Health-care facility with patient stays over 24 hours . Facilities designated for housing occupants over age 65 . The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system. Other factors that contribute to the risk are environmental conditions that promote the growth and amplification of the bacteria in the system, a means of transmitting this bacteria (via water aerosols generated by the system), and the ultimate exposure of susceptible persons to the colonized water that is inhaled or aspirated by the host providing a pathway to the lungs. The bacteria are not transmitted person-to-person, or from normal ingestion of water. Susceptible persons at high risk for legionellosis include, among others, the elderly, dialysis patients, persons who smoke, and persons with medical conditions that weaken the immune system . Review of the facility's legionella folder provided by the facility revealed documents titled Water Temp Log detailing monthly water temperature logs of multiple water sources in the facility dating back 2 years. The last document was titled Water Temp Log 03/06/23---03/12/23. Further review of the Legionella binder failed to reveal any documentation of water temperatures beyond March 2023. No other documentation of a water program was provided. During an interview on 06/13/23 at 2:03 PM, the Infection Control Preventionist (ICP, Registered Nurse (RN) 3) stated she did not know the details of the facility's Legionella prevention program and would find out. During an interview on 06/14/23 at 1:55 pm, when asked about the legionella prevention program since March, the Administrator stated she did not have the latest documentation on the facility's legionella prevention program because the maintenance supervisor who performed the task was no longer with the facility. The Administrator did not have access to the previous maintenance records. The Administrator further admitted that there were no records of the facility's ongoing legionella prevention program. 16752 2. Review of the facility's undated document titled ''Hand Hygiene'' read in part ''The facility promotes hand hygiene as a simple and effective method for preventing the spread of infection Glove use is not a substitute for hand hygiene. All staff are to perform hand hygiene during all care activities and while working in all locations within the facility.'' Review of the facility's undated document titled ''Standard Precautions'' reads in part ''Hand hygiene is performed with ABHR [alcohol based hand rub] . before and after contact with the resident . after contact with items in the resident's room; before eating and after using the restroom.'' During the lunch meal observation on 06/13/23 at 12:40 PM on unit three North West, Certified Nursing Assistant (CNA) 7 pulled a meal tray from the cart without performing hand hygiene. CNA7 served the meal tray to R19 in his room. After arranging R19's meal tray CNA7 left R19's room and went to the meal cart and removed another meal tray without performing hand hygiene. CNA7 served this meal tray to R8 who was sitting in the dining room. CNA7 prepared R8's meal tray, opening the condiment packets for R8. CNA7 left the dining room to obtain a clothing protector and placed it around R8's neck. CNA7 returned to the meal cart without performing hand hygiene and pulled another meal tray. CNA7 took this tray to R46's room. CNA7 rolled up the head of R46's bed and positioned the overbed table within the R46's reach. CNA7 left R46's room and returned to the meal cart without performing hand hygiene. CNA7 obtained a milk carton from the meal cart and placed it on a meal tray for R54. CNA7 took the meal tray to R54 and set up the meal tray and positioned the overbed table so R54 could reach the tray. CNA7 returned to the meal cart and obtained another meal tray without performing hygiene. During an Interview on 06/13/23 at 12:43 PM, CNA8 revealed it was an expectation to either wash hands or use hand sanitizer between each resident contact either in the dining room or when taking resident trays. During an interview on 06/13/23 at 1:07 PM, the ICP/RN3 stated it was an expectation for staff to perform hand hygiene between each resident contact either in the dining room or resident's room during meal service. During an interview on 06/13/23 at 1:10 PM, CNA7 revealed that she had received training to perform hand hygiene between each resident contact during meal services. CNA7 acknowledged she had not performed hand hygiene and could not explain why she did not do it.

Based on observation, facility document review, resident interview and staff interview, the facility staff failed to provide a clean, homelike environment on three of four living units. The findings include: The shower rooms on 2 new west, 2 west side, and 3 new west had black stains along caulking lines on/around the shower stall seats, black stains under the stall floor mats, missing drain covers, and deteriorated flooring at the thresholds to the stalls. On 6/12/23 at 4:22 p.m., accompanied by licensed practical nurse (LPN) #1, the shower room on 2 new west unit was inspected. There were three shower stalls. The caulked area around the seat base, back, and flooring was black on each of the three seats. The entrances to the shower stalls had deteriorated flooring and black stains around the safety strips. The shower stall floors had black stains under and around the floor mats and safety strips. LPN #1 stated at this time that certified nurses' aides (CNAs) disinfected the shower stalls after each resident and housekeeping was responsible for daily cleaning of the shower rooms. On 6/13/23 at 9:15 a.m., accompanied by CNA #2, the 2 west side unit shower room was inspected. The ceiling light was out near the entrance to the room. There were two shower stalls with black discoloration along the caulking lines around the base and back of the shower seats. There was no drain cover in the right stall and used/dirty towels were on the floor near the right stall and the sink. On 6/13/23 at 9:23 a.m., accompanied by a housekeeper (other staff #13), the 3 new west unit shower room was inspected. There were three shower stalls with black stained caulking around the base and bottom of the shower seats. The shower seat on the left stall was cracked with missing caulking at the back of the seat. The housekeeper was interviewed at this time about cleaning of the shower rooms. The housekeeper stated showers were supposed to be cleaned daily or as requested. The housekeeper stated that the cleaners they had did not remove the black stains along the caulking and flooring. On 6/13/23 at 9:33 a.m., Resident #84 was interviewed about quality of life in the facility. Resident #84 stated that the shower room on his unit .had black mold around the seats and on the floors. Resident #84 stated that since admission to the facility for almost a year now, the shower room has been stained like that. On 6/13/23 at 10:43 a.m., the housekeeping supervisor (other staff #1) was interviewed about the above shower room observations. The housekeeping supervisor stated that housekeepers were expected to thoroughly clean/disinfect the showers at least once daily and as needed. The housekeeping supervisor stated that a bathroom cleaner was used for the shower stalls, a multi-surface cleaner for the counters, and a toilet cleaner for areas in/around the commodes. The housekeeping supervisor stated that there were issues where the shower seats were attached to the stalls/flooring, in that the caulked areas had become black and deteriorated in places. The housekeeping supervisor stated that the cleaning agents used did not remove the black stains along the caulking and if too much pressure was applied, the caulking came off. When questioned, the housekeeping supervisor stated that the shower rooms were not homelike, did not have a clean appearance, and needed a remedy. The facility's housekeeping guidelines (undated) documented shower rooms were to be cleaned prior to 4:00 p.m. each day. These findings were reviewed with the administrator, director of nursing and unit managers during a meeting on 6/13/23 at 4:25 p.m. The administrator stated administration recognized that the shower rooms needed repair and upgrades. No further information was presented regarding the condition of the shower rooms prior to the end of the survey.

Based on observation, facility document review, and staff interview, the facility staff failed to store, prepare and distribute food in a sanitary manner. The findings include: 1. Food preparation/service equipment and the overall kitchen environment were dirty. Undated, out of date, and unsealed food items were stored in the refrigerator and available for use. The dishwasher was dirty and operated by staff members not using hair restraints. Stainless steel serve pans were stored nested and wet. On [DATE] at 11:05 a.m., the initial tour of the main kitchen was conducted accompanied by the cook (other staff #2). Two dietary aides (other staff #14, #15) were observed operating the dishwasher with no hair restraints in use. The dishwasher had crumbs and food particles on the top surface of the machine along with streaks of a white/orange colored substance down the front of the dishwasher panels. There was an empty, broken spray bottle on top of the machine. The hand sink near the dishwashing area was dirty with brown stains in the sink bowl. The dry storage room had a five-gallon bucket of puffed wheat cereal that was not sealed/covered. The overall storage area had a messy/disorganized appearance with food wrappers, empty boxes, and paper debris on the shelves and on the floor. The kitchen's stove was dirty with heavy, black buildup on the stove eyes and grates, along with dried food particles. During the stove inspection, the cook stated that the evening cook was responsible for cleaning the stove, which included the grates being soaked and run through the dishwasher. The knobs on the stove, convection ovens, and tilt skillet were dirty with stains/food debris. The doors to the convection oven were dirty with brown stains. The tilt skillet had accumulated brown stains at the base and at the hinges. The floor under the steam table was covered with spilled puffed cereal that the cook stated was spilled that morning during breakfast preparation. On [DATE] at 11:22 a.m., accompanied by OS #2, the walk-in refrigerator was inspected. The glass door to the reach-in portion of the refrigerator was dirty and covered with fingerprints/stains. A container of tuna salad was stored partially covered with loose plastic wrap. There was a 10-liter bucket of lemonade that had no label indicating a preparation or discard date. There was a quart container of whipped topping marked ,d+[DATE]. The manufacturer's label for the topping read, Keep frozen until ready to use. There was a cucumber laying on the floor under the front rack with a white, puffy substance on the surface. On [DATE] at 11:30 a.m., the walk-in freezer was then inspected. There was debris, trash, food wrappers on the floor. Frozen condensation was observed on the freezer ceiling and on the floor near the entrance. Condensation was dripping from the ceiling near the top door seal. Further inspection during this initial tour included the 3-compartment sink area and pan storage. Fifteen large stainless steel serve pans were on the ready-to-use rack, stored nested and wet. Water was visible along the pan rims and moisture on the inside pan surfaces. On top of the pan rack were two opened bottles of lemon juice. A stainless prep bowl stored on the clean rack had food debris along the rim. The sanitizer dispenser at the 3-compartment sink area had the cover off. The cover, on a nearby shelf, was dirty with food debris/residue. The ice machine near the sink area had brown stains on the side panel and outside of the door. On [DATE] at 12:42 p.m., the tray line/steam table service was observed. There was an opened Pepsi bottle, cell phone, and keys positioned in the prep area near the end of the steam table. There were several plastic glasses/cups observed with white looking residue giving the containers a cloudy appearance. On [DATE] at 11:45 a.m., the regional dietary director (other staff #3) who was the interim kitchen manager, was interviewed about the kitchen observations. The regional dietary director stated that staff were supposed to clean the steamers, ovens, stove eyes/grates at least every other day. The dietary director stated that he looked at the stove eyes/grates and he agreed they had not been cleaned. The regional dietary director stated the kitchen was staffed from 5:00 a.m. until 8:00 p.m. each day and that staff were expected to provide daily generalized cleaning, with duties divided between two cooks and the remaining dietary aides. The dietary director stated that leftover food items were supposed to be dated when prepared, marked with a discard date, and discarded when expired. The dietary director provided the following policies used by the facility for food safety, sanitation, storage, and service. The facility's policy titled Food Safety and Sanitation (Chapter 4: Sanitation and Infection Control ,d+[DATE]) documented, Food stored in dry storage is placed on clean racks .The room should be clean, dry and cool .All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored .When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Leftovers are used within 72 hours (or discarded) . The facility's policy titled Food Safety - Director of Dining Services' Responsibilities (Chapter 4: Sanitation and Infection Control ,d+[DATE]) documented, .The director of food and nutrition services will be responsible for providing safe foods to all individuals .The director of food and nutrition services assures all of the following .Sanitary conditions will be maintained in the food storage, preparation, and serving areas .All refrigerated and frozen foods will be stored and handled properly .Employees will follow sanitary practices .The director of food and nutrition services or designee will conduct regular inspections to assure proper food handling .Cleaning schedules will be posted and followed . The facility's policy titled Employee Sanitary Practices (Chapter 4: Sanitation and Infection Control ,d+[DATE]) documented, All food nutrition services employees will practice good personal hygiene and safe food handling procedures .All employees will .Wear hair restraints (hairnet, hat, and/or beard restraints) to prevent hair from contacting exposed food .Clean and sanitize equipment and work areas after use .Follow all federal, state and local requirements . The facility's procedure PM5 - Daily Assignments (undated) documented, .absoutley [absolutely] no cell phones allowed in the work areas. This is to include all kitchen and prep, storerooms . (Sic) The 2022 Food Code in chapter 4 on page 28 documents, .Clean equipment and utensils .shall be stored .in a self-draining position that allows air drying .Covered or inverted . (1) 2. The nourishment refrigerators on the second floor units were dirty with leftover and opened food items that had no identification or discard/use by dates. On [DATE] at 11:43 a.m., the nourishment/snack refrigerator on the 2 west side unit was inspected. The inside of the freezer section was dirty with black buildup/debris and dried liquid spills on the rack/bottom of the freezer. Stored in the refrigerator was an opened bag of lettuce that was discolored (brown/yellow) with no discard date, an opened container of guacamole dip unsealed and undated, an opened container of spinach/artichoke dip with no date, an opened container of humus spread with no date labels, and a sub-sandwich wrapped in paper. There was no name and/or date on the sandwich. On [DATE] at 9:09 a.m., accompanied by certified nurses' aide (CNA) #2, the snack/nourishment refrigerator on 2 new west unit was inspected. There was a box of leftover pizza and a McDonald's meal labeled for a current resident but with no discard date. There were two pint jars of a white semi-liquid labeled for a current resident. The jars were not labeled to identify the food product and had no use-by or discard dates marked on them. There was an opened bottle of Pepsi and a Styrofoam cup containing liquid, neither were labled with a name and/or dates. CNA #2 was interviewed at this time about the food items. CNA #2 stated that the food was supposed to be dated when placed in the refrigerator and discarded when expired. CNA #2 was unsure what the white product was in the pint jars but thought it was mayonnaise. On [DATE] at 3:00 p.m., the regional dietary director (other staff #3), serving as interim kitchen manager, was interviewed. The regional dietary director stated that kitchen staff placed snacks and juices in the unit refrigerators, but dietary staff were not responsible for resident food items. The regional dietary director stated, We do not take care of the food or refrigerators [on units]. We only put snacks in them. The facility's policy titled Food: Safe Handling for Foods from Visitors (,d+[DATE]) documented, Residents will be assisted in properly storing and safely consuming food brought into the facility for residents .When food items are intended for later consumption, the responsible facility staff member will .Ensure that the food is stored separate or easily distinguishable from the facility food .Ensure that foods are in a sealed container to prevent cross contamination .Label foods with the resident name and the current date Refrigerators/freezers for storage of foods brought in by visitors will be properly maintained and .Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for [greater than or equal to] 7 days .Cleaned weekly .The unconsumed portion of foods that have been re-heated will be discarded . These findings were reviewed with the administrator, director of nursing and unit managers during a meeting on [DATE] at 4:25 p.m. No further information was presented prior to the survey exit regarding food service concerns in the main kitchen and unit refrigerators. (1) Food Code 2022. U.S. Public Health Service. U.S. Food &Drug Administration. U.S. Department of Health and Human Services. [DATE] version.

Based on observation and staff interview, the facility staff failed to ensure proper function of the freezer in the main kitchen. The findings include: On 6/12/23 at 11:30 a.m., accompanied by the cook (other staff #2), the walk-in freezer in the main kitchen was inspected. Upon opening the door, there was water and ice on the floor, at the threshold to the unit. Water was noted dripping along the top of the freezer door. There was frozen condensation visible on the entire ceiling of the freezer. The cook was interviewed at this time about the water/ice. The cook stated that the freezer had been worked on but not repaired and that the water/ice had been there for weeks. On 6/13/23 at 11:45 a.m., the maintenance director (other staff #4) was interviewed about the freezer with condensation/ice. The maintenance director stated that he thought the kitchen manager had contacted an outside vendor for repair. The maintenance director stated that he was not sure if the vendor worked on the freezer or the outcome of the repair. The maintenance director denied knowledge of a work order for his department to assess/repair the freezer. On 6/13/23 at 12:06 p.m., the regional dietary director (other staff #3) serving as interim kitchen manager, was interviewed about the freezer. The regional dietary director stated, [Name of vendor] has been here a bunch of times. The dietary director denied knowing when the freezer was last looked at for repair. During a meeting on 6/13/23 at 4:25 p.m., this finding was reviewed with the administrator, director of nursing, and unit managers, with no other information provided regarding the freezer condensation/ice.

Based on interview and record review, the facility failed to ensure Power of Attorney (POA) for healthcare document was located in the medical record for one sampled resident reviewed for advance directives (Resident (R)11). This failure had the potential for an unauthorized person to enter a Do Not Resuscitate (DNR) directive for the resident. Findings include: Review of R11's POA dated [DATE] revealed R11's daughter (F11) and another individual appointed as attorneys-in-fact by R11. The document revealed in part the power to act on R11's behalf as follows: .1.To demand, hold and generally deal with any monies, securities and other property which now or hereafter belongs to me, or in which I may have interest. 2. To sign any note, check, security or other instrument, negotiable or nonnegotiable, whether or not the check or other instrument is drawn to the order of my Attorney, for deposit, discount, collection or otherwise. 3. To write checks upon, or otherwise withdraw, all funds or account balances now or hereafter outstanding to my credit or to the credit of my Attorneys, and to open accounts of whatever nature in my name or my Attorneys' name. 4. To vote in person or by proxy, to sell or otherwise dispose of, to cause to be registered in the name of a nominee selected by my Attorneys, and to transfer, redeem, convert or exchange any security that now belongs to me or may belong to me in the future or in which I may have interest, and to make, execute and deliver any endorsement, assignment, certification, or other document in connection with any security. 5. To buy, acquire or in property, real or personal, or intangible, including without limitation any security, option or other type of investment. Further review of the POA document failed to reveal any power to make healthcare decisions on behalf of R11. Review of the Admission Agreement dated [DATE], signed by F11 revealed: If the Patient is unable to make decisions for himself or herself, a Resident Representative should be available to make certain decisions on behalf of the Patient. Patient hereby agrees that the Resident Representative is the person selected by the Patient as the Patient's responsible person or as the person recognized under state law as having the authority to make health care and/or financial decisions for the Patient. If the Resident Representative has authority specifically conferred by a court of law or other document. Verification of such status must be provided to the Center at the time of admission. Such verification includes providing the Center with a copy of any court order, or a validly executed Power of Attorney or other legal document imbuing the representative to act on the resident's behalf. The Resident Representative authority will be limited to scope of the delegated authority by the resident, state law, or court mandated order. All rights not explicitly delegated by the Resident, state law, or the court will be reserved to the Resident. Review of the Profile tab of the electronic medical record (EMR) revealed R11's daughter was listed as Daughter, Responsible Party, POA - Financial, POA - Care, and Care Conference Person. Review of R11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R11 was admitted to the facility on [DATE] with diagnoses that included dementia, spinal stenosis, cerebral atherosclerosis, adult failure to thrive, and abnormal weight loss. R11 had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident was severely cognitively impaired. Interview with the Administrator on [DATE] at 1:27 PM revealed R11's medical POA was R11's father who was now deceased . The Administrator acknowledged that the family informed the facility upon admission that a POA for healthcare existed, but the facility failed to follow up with obtaining the document and was unaware the POA on record did not cover healthcare decisions.

Based on record review, staff interview and facility document review, the facility staff failed to prevent a significant medication error for one of 34 Residents. Resident #147 was given an extra dose of [MEDICATION NAME] (classified as an opioid) which resulted in harm. The Findings Include: Resident #147 was admitted to the facility on [DATE] with a readmission of 2/7/20. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/27/20. Resident #147 was assessed with [REDACTED]. On 2/09/20 Resident #147's medical record was reviewed and evidenced a physician's progress note dated 1/20/20 that read [AGE] year old male who I am seeing today because of medication error. Patient was given double the dose of his [MEDICATION NAME] morning dose by mistake. This was quickly addressed and I was notified to monitor vitals. Patient had decreased respirations about 2 hours later, with a reported rate of 8 (per minute). A stat order of 0.2 mg (milligrams) of [MEDICATION NAME] ([MEDICATION NAME], opioid antagonist used for opioid overdoses) was given IM (intramuscularly), and this perked the patient immediately. He was back to his baseline the rest of the afternoon. His afternoon dose of [MEDICATION NAME] was skipped. He is now resting in his bed this evening. A physician's orders [REDACTED].#147 was to receive [MEDICATION NAME] 5 milligrams at 6:00 AM and at 5:00 PM for chronic pai[DIAGNOSES REDACTED]. Resident #147's nursing notes or medication administration record (MAR) did not evidence any information regarding Resident #147's receiving an extra dose of [MEDICATION NAME]. On 02/10/20 at 2:24 PM, unit manager (license practical nurse, LPN #4) was interviewed. LPN #4 said a nurse gave an extra dose of [MEDICATION NAME] in error. When asked why the extra dose was given, LPN #4 said the night shift nurse gave the medication ([MEDICATION NAME]) when it was scheduled then the day shift nurse gave another dose at around 9:30 AM. LPN #4 said that Resident #147 had already been declining and was lethargic prior to the extra medication dose, the physician was called did not come into assesses Resident #147 at that time but did order [MEDICATION NAME]. LPN #4 was asked if an investigation was done. LPN #4 was not sure of an investigation but did say a medication error sheet was completed. On 02/10/20 at 4:12 PM the physician's assistant who wrote the physician's progress note (Other Staff, OS #2), was interviewed. OS #2 said, he was contacted via phone because an extra dose of [MEDICATION NAME] had been given and Resident #147's respiratory rate was at 8 and Resident #147 was lethargic. OS #2 said because Resident #147's respiratory rate was not at baseline, he decided to give [MEDICATION NAME]. OS #2 stated that Resident #147 responded quickly. OS #2 was asked if he knew how the medication was given in error. OS #2 took out his phone and read part of a text message indicating that a nurse had misread the MAR and gave the medication ([MEDICATION NAME]) at 9:00 AM not realizing that a scheduled dose had been given prior. On 02/11/20 at 9:45 AM, staff provided a Medication Discrepancy Report that indicated [MEDICATION NAME] was given at the wrong time. A narrative describing the incident read This nurse misread time beside of medication on MAR. Rsd (Resident) had scheduled dose [MEDICATION NAME] 5 mg @ 6 AM, gave another dose @ 9:00 AM. Outcome to Resident, read in part ( .) Rsd assessed @ 2 pm and Resp (respiratory) decreased to 8 (breaths per minute) with periods of apnea (cessation of breathing). Corrective action taken, read in part [MEDICATION NAME] ([MEDICATION NAME]) gave STAT dose 0.5 ml (milliliter) IM, rsd (Resident) alert and verbal 1 min (minute) after administration. Measures taken to prevent reoccurrence, read Pay closer attention to MAR. A policy titled General Dose Preparation and Medication Administration was obtained and read in part 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, ( .) No other information was provided prior to exit conference on 2/11/20.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess and implement care for treatment of [REDACTED].#122) resulting in the development of an infected, necrotic pressure ulcer and failed to provide pressure ulcer dressing changes in a manner to prevent infection for two of 34 residents (Residents #122 and #112). The findings include: 1a) Resident #122 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #122 as cognitively intact, requiring the extensive assistance of two people for bed mobility and one person for dressing and daily hygiene. Resident #112's clinical record documented the resident was re-admitted to the facility on [DATE] following a hospitalization . The re-admission nursing assessment dated [DATE] documented, .[MEDICAL CONDITION] noted to LUE (left upper extremity). Resident has ace wrap in place to LUE . This re-admission assessment documented the resident's only skin impairments were scabs on his right toes and bruises to the right hand. The re-admission physician orders dated 10/25/19 included no orders regarding the ACE wrap to the left arm. The clinical record documented a physician's order dated 10/28/19 for an occupational therapy (OT) consult to fit the resident for a left arm compression sleeve with instructions to, Apply ACE wrap uniformly to left forearm and elbow and upper arm until compression sleeve arrives. A nursing note and skin evaluation sheet dated 10/29/19 documented the resident was assessed with [REDACTED]. The nursing note dated 10/29/19 at 5:24 p.m. documented, .Intact blister in, (Thenar webspace) on left hand. 0 (No) tx (treatment) @ this time is needed Once the blister opens tx will begin if needed . There was no notification to the physician and/or provider about the blister and no treatment ordered or implemented. An occupational therapy (OT) note dated 10/30/19 documented, MD (physician) orders for left arm compression sleeve. Facility had ACE bandage in place this date. The ACE bandage has rubbed areas of pressure in thumb web space and opposite side lateral of pinky finger. Thumb web space has large intact blister from pressure of ACE wrap. Also area of pressure from ACE wrap at lateral aspect of wrist crease. Nursing notified of areas of pressure. It is recommended by the CLT (certified [MEDICAL CONDITION] therapist) for nursing not to replace ACE bandage. Measurements taken for left arm compression sleeve .Communication with nursing regarding this therapist recommendation with ACE as the potential for further skin breakdown and blisters to open is great. Resident #122's nursing notes from 10/30/19 through 1/9/20 included no assessment or mention of the intact blister and rubbed areas on the left hand as reported by OT. The ACE remained in use for four days after the OT recommendation to discontinue the wrap due to pressure areas on the left hand. The record documented a physician's order dated 11/4/19 to discontinue the ACE wrap to the left forearm. A physician's order dated 11/22/19 documented, Compression arm sleeve and gauntlet (glove) to be donned (put on) after breakfast & doff (take off) after dinner for max 12 hrs (hours)/day with skin checks during & after wear Except on Tues/Thur/Sat - glove donned after [MEDICAL TREATMENT] + doff before 12 AM w/ (with) skin checks during and after wear. There were no skin assessments documented related to putting on and/or taking off the compression sleeve. Ten out of eighteen weekly skin audits for Resident #122 from 10/29/19 through 1/7/20 documented a skin impairment on the resident's left hand. The 10/29/19 skin check documented an intact blister on the left hand. The skin diagrams on assessments dated 11/8/19, 11/12/19, 11/29/19, 12/6/19, 12/10/19, 12/13/19, 12/20/19, 12/24/19, 1/3/20 and 1/7/20 marked a skin impairment on the resident's left hand but documented no description of the appearance, size, color or status of the impairment. These sheets listed the marked impairments as previously identified. The 11/12/19 assessment marked the resident with a scab on the left hand. The other weekly assessments (dated 11/1/19, 11/5/19, 11/15/19, 11/19/19, 11/26/19, 12/3/19 and 12/27/19) did not document a wound on the resident's left hand. The clinical record from 10/29/19 through 1/8/20 documented no notification to the physician regarding the left hand blister and pressure areas identified by OT. There were no physician's orders for treatment of [REDACTED]. There were no documented assessments of the left hand blister after the OT note dated 10/30/19 other than scab on 11/12/19. A nursing note dated 1/9/20 documented the resident was sent to the emergency room (ER) from [MEDICAL TREATMENT] due to a change in condition. The resident was assessed at the emergency room with an infected, malodorous wound on the left hand. The emergency room record dated 1/9/20 documented the resident was received from [MEDICAL TREATMENT] after the resident became lethargic and had low blood pressure. The ER physician's examination dated 1/9/20 documented, .left hand between thumb and second index finger has open wound with purulent exudate malodorous . This ER physician's assessment documented, .with [MEDICAL CONDITION] on [MEDICAL TREATMENT], at baseline bedbound, debilitated presents with [MEDICAL CONDITION], lactic acidosis, [MEDICAL CONDITION] when he presented for [MEDICAL TREATMENT] today. A primary concern would [MEDICAL CONDITION] related to left hand wound that appears to be infected, versus complicated UTI (urinary tract infection) with chronic indwelling Foley catheter and history of complicated antibiotic resistant UTI in the past .Treat [MEDICAL CONDITION] with broad-spectrum antibiotics . The ER report listed, Infection of left hand .Patient with wound of left hand between first and second digit, purulent exudate .Broad-spectrum antibiotics with [MEDICATION NAME] and [MEDICATION NAME] IV (intravenous) . The resident was hospitalized for [REDACTED]. Readmission orders [REDACTED]. The physician's progress note dated 1/16/20 documented, .at [MEDICAL TREATMENT] was found to be hypotensive, encephalopathic, lethargic, and febrile and was admitted .He was found to have a left hand wound likely infected .Open wound of hand .this was felt to be infected status [REDACTED]. The resident was referred to a wound clinic for ongoing treatment of [REDACTED]. The wound physician's progress notes dated 1/16/20 documented the wound measured 1.6 x 0.8 x 0.4 (length x width x depth in centimeters), with moderate serosanguineous exudate, 30% thick devitalized necrotic tissue, 30% slough, 30% granulation tissue. The physician performed surgical debridement of the devitalized necrotic tissue with removal of 0.5 cm depth of tissue. The wound clinic physician documented additional assessments as follows. 1/30/20 - measured 1.5 x 0.7 x 0.4 cm with moderate serosanguineous exudate, 20% necrotic tissue, 40% slough, 30% granulation, additional surgical debridement performed to remove necrotic tissue and slough 2/6/20 - measured 2.0 x 0.5 x 0.5 cm with moderate serous exudate with scab in place, treatment orders changed to collagen powder each day with daily dressing changes Resident #122's plan of care (initiated 8/5/19; revised 2/5/20) listed the resident had left arm [MEDICAL CONDITION], was totally dependent on staff for hygiene/dressing and was at risk of skin impairment. Interventions to prevent skin breakdown included, Observed for redness, open areas, scratches, cuts, bruises and report changes to the Nurse .Monitor/document/report PRN (as needed) any changes in skin status . There was no revision to the care plan about the left hand blister and/or scab until 1/17/20, after the resident's return from the hospital following IV antibiotic treatment for [REDACTED]. On 2/10/20 at 8:41 a.m., the licensed practical nurse (LPN #2) unit manager was interviewed about assessment and treatment for [REDACTED]. LPN #2 stated the resident returned from the hospital in October 2019 with an ACE wrap on the left hand that was too tight. LPN #2 stated the blister at some point became a scab. LPN #2 stated the scab came off at [MEDICAL TREATMENT] (1/9/20) and there was a hole under it and [MEDICAL TREATMENT] sent him to the emergency room . LPN #2 stated the facility was not previously treating the scabbed area because it was not open. LPN #2 stated she was not sure when the scab started. On 2/10/20 at 9:00 a.m., LPN #1 that routinely cared for Resident #122 was interviewed about the left hand blister. LPN #1 stated the resident's left hand had a scab and when the scab came off there was a wound underneath. LPN #1 stated she was not sure what the scab was from or how the resident got the left hand ulcer. On 2/10/20 at 9:16 a.m., unit manager (LPN #2) stated she reviewed the clinical record and found a note on 10/29/19 indicating the wound started as a blister. LPN #2 stated she did not see any notification or treatment orders for the blister. On 2/10/20 at 10:00 a.m., LPN #2 stated she looked through all the notes again from 10/25/19 through 12/31/19. LPN #2 stated the only documentation about the blister was the 10/29/19 note listing an intact blister on the left hand. LPN #2 stated she found nothing about notification to the physician/provider of the left hand blister. LPN #2 stated again that the resident got the ulcer after his return from the hospital on [DATE] from an ACE wrap on the left hand that was too tight. On 2/10/20 at 11:00 a.m., the certified nurses' aide (CNA #2) that routinely cared for Resident #122 was interviewed. CNA #2 stated the resident had a scab on the left hand between his thumb and index finger. CNA #2 stated the resident had [MEDICAL CONDITION] in the left arm and wore a compression sleeve/glove. CNA #2 stated the scab was on the left hand maybe a month before it came off and there was an open place under the scab. CNA #2 stated the scab was a little smaller than dime size and she reported it to the nurse but did not remember when she reported it. On 2/10/20 at 4:25 p.m., the physician's assistant (PA) that cared for Resident #122 was interviewed about the resident's left hand ulcer. The PA stated he was not aware of a wound on the resident's left hand until after he returned from the hospital on [DATE]. On 2/11/20 at 9:40 a.m., accompanied by LPN #14, Resident #122's left hand ulcer was observed. The resident's pressure ulcer was in the space between the resident's left thumb and index finger. The ulcer was slightly smaller than the size of a quarter with irregular edges. There was black necrotic tissue along the wound edge near the thumb side with most of the remaining wound bed covered with light yellow colored slough. The visible wound bed was moist and beefy red in color. There was a small amount of reddish colored drainage on the removed dressing. On 2/11/20 at 8:40 a.m., the director of nursing (DON) was interviewed about any assessment and/or treatments for Resident #122's left hand ulcer. The DON stated the wound was identified by nursing as an intact blister on 12/29/19. The DON stated OT also assessed a large, intact pressure injury on 10/30/19 resulting from application of an ACE wrap. The DON stated she had no other documentation regarding the wound until it was identified at the emergency roiagnom on [DATE]. The DON stated the intact blister should have been assessed as a stage 2 pressure injury. The DON stated the physician should have been notified and treatment initiated when found. The DON stated from talking with the floor nurses, the wound waxed and waned from a blister to a scab. The DON stated the resident had chronic swelling in the left arm and her review indicated this was a pressure injury resulting from the ACE wrap in place for [MEDICAL CONDITION]. The DON stated some of the skin assessments marked an impairment on the left hand but documented no description and/or assessment of the wound. The facility's policy titled Performance Improvement Skin Meeting (effective 11/30/14) documented, .The Interdisciplinary team will review residents weekly with the following: Any resident with Pressure wounds .team will review each resident to ensure that interventions are established to improve the clinical condition and outcome of the resident, and review the clinical documentation for the resident to ensure that it is completed .team will review the progress of healing and develop any additional interventions as need (needed) to facilitate continue healing Current treatment effectiveness will be reviewed and revised as indicated. Review of the Pressure Ulcer/Non-Pressure Ulcer Record, the resident's care plan, nutritional status and progress notes . The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as, .localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . The NPUAP defines a stage 2 pressure injury as, .Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present . The NPUAP defines an unstageable pressure injury as, .Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (necrotic tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . NPUAP defines a medical device related pressure injury as, .injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system . (1) The NPUAP includes in best practices for the prevention of medical device-related pressure injuries (MDRPI), .Remove or move removable devices to assess skin at least daily .Educate staff on correct use of devices and prevention of skin breakdown .Be aware of [MEDICAL CONDITION] under device(s) and potential for skin breakdown . (2) These findings were reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 2/10/20 at 5:00 p.m. and on 2/11/20 at 11:10 a.m. (1) NPUAP Pressure Injury Stages. National Pressure Injury Advisory Panel. 2/12/20. www.npiap.com (2) Long-Term Care Prevention of MDRPIs. 2017. National Pressure Injury Advisory Panel. 2/12/20. www.npiap.com 1b) On 2/11/20 at 9:40 a.m., licensed practical nurse (LPN #14) was observed performing a dressing change to the pressure ulcer on Resident #122's left hand. LPN #14 placed a plastic bag with dressing supplies on Resident #122's bed covers. LPN #14 removed the supplies (gauze pads, bottle of Dakin's cleansing solution, scissors) from the bag and placed them directly onto the bedspread. LPN #14 washed her hands, put on gloves and removed the soiled dressing from the ulcer located between the resident's left thumb and index finger. LPN #14 changed gloves, applied Dakin's solution to a clean gauze pad and cleansed the wound. LPN #14 put on new gloves and cut the prescribed alginate dressing with scissors. LPN #14 changed gloves again and placed opened gauze packages on the bed covers, cut the border gauze in half and then applied collagen powder to the wound bed. LPN #14 made an additional cut of the alginate dressing with scissors that had been placed directly onto the resident's bedspread. LPN #14 put on new gloves, applied the alginate dressing to the wound and then the border gauze. LPN #14 then placed the bottle of Dakin's solution into the plastic storage bag, discarded supplies in the treatment room, placed the bag of supplies back into the treatment cart and washed her hands. The resident's pressure ulcer was in the space between the resident's left thumb and index finger. The ulcer was slightly smaller than the size of a quarter with irregular edges. There was black necrotic tissue along the wound edge near the thumb side with most of the remaining wound bed covered with light yellow colored slough. The visible wound bed was moist and beefy red in color. There was a small amount of reddish colored drainage on the removed dressing. LPN #14 prepared no clean space for the clean dressing change supplies as items, including scissors were placed directly on the resident's bedspread. LPN #14 performed no hand hygiene after removing the soiled dressing and prior to cleansing the wound. LPN #14 performed no hand hygiene after or between any of the glove changes during the dressing change observation. The scissors were not sanitized prior to cutting the dressing that was placed directly onto the wound and the scissors were placed on the resident's bed covers during the dressing change. On 2/11/20 at 9:50 a.m., LPN #14 was interviewed about lack of hand hygiene and placing supplies on the bedspread during the dressing change. LPN #14 stated she typically performed glove changes during dressing changes and did not think hand hygiene was required after removing gloves. LPN #14 stated she sanitized her scissors at times. Regarding placing clean supplies on the bedspread, LPN #14 stated the supplies were in a plastic bag and the opened gauze dressings were kept on the gauze papers. On 2/11/20 at 10:25 a.m., the director of nursing (DON) was interviewed about Resident #122's observed pressure ulcer dressing change. The DON stated hand hygiene was expected after removing soiled dressings, prior to cleaning the wound and before applying clean dressings. The DON stated hand hygiene was expected after glove changes and clean supplies were not supposed to be placed on the resident's bed. This finding was reviewed with the administrator and director of nursing during a meeting on 2/11/20 at 11:10 a.m. 2. Resident #112 was admitted to the facility on [DATE] with a readmission of 2/7/20. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/13/20. Resident #112 was assessed with [REDACTED]. On 02/10/20 at 9:10 AM, Resident #112's dressing changes wre observed with three license practical nurses identified as LPN #4 (unit manager), LPN #5, LPN #6. Resident #112 was turned, then LPN #5 washed hands, put on gloves, removed a dressing to the buttocks, then applied wound cleanser to all three wounds using the same gauze. LPN #5 then removed gloves, and put on new gloves without washing hands between glove changes. LPN #5 then applied Dakin's solution and sure prep to the outer buttock wound, and applied Hydrogel Collegen mixture to the outer wound. LPN #5 then applied sure prep to middle and inner wound, applied Collogen powder to the middle and inner wound using the same applicator, then applied a cover dressing to all three wounds. LPN #5 then moved to the left foot wounds without changing gloves or washing hands. LPN #5 removed the dressing, applied skin prep to outer foot and wound cleanser to outer heel, opened up a Calcium Alginate dressing without washing hands or changing gloves, cut a piece of the dressing, handled the dressing with the same unclean gloves and applied it to the cover dressing, then applied Collagen powder to the heel wound and applied the dressing. On 02/10/20 at 9:40 AM, LPN #5 and LPN #4 were interviewed concerning not washing hands when discarding unclean gloves and applying new gloves, cleaning three buttocks wounds using the same gauze, using the same applicator to distribute treatment to the middle and inner buttock wounds, moving to Resident #112's left foot wound without washing hands or putting on clean gloves and handling Calcium Alginate dressing with unclean gloves and applying the dressing directly to the wound. LPN #4 and #5 stated understanding. The facility's policy titled Dressing Change (effective 11/30/14) documented, A clean dressing will (be) applied by a nurse to a wound as ordered to promote healing . This policy included in procedures for a dressing change, .Assemble equipment as needed for dressing change .Place supplies on prepped work surface .Perform hand hygiene .Apply gloves .Remove and dispose of soiled dressing .Remove gloves .Perform hand hygiene .Apply gloves .Cleanse wound as ordered .Remove gloves and perform hand hygiene .Apply treatment as order and clean dressing .Discard gloves and perform hand hygiene . (Sic) On 02/10/20 at 5:21 PM, the above finding was discussed with the the administrator and director of nursing (DON). On 02/11/20 at 9:04 AM, the DON was interviewed regarding the dressing change observation. The DON stated that it was wrong to perform a dressing change that way. No other information was provided prior to exit conference on 2/11/20.

Based on observation, staff interview, visitor interview, facility document review, clinical record review and complaint investigation, the facility staff failed to provide supervision and safety devices to prevent accidents for four of eight residents in the survey sample. Three of these accidents resulted in resident harm. 1. Resident #2, legally blind with severe cognitive impairment and wandering behaviors, was found in the stairwell of the facility on [DATE] at 3:10 a.m. with a laceration to her forehead. The resident was last seen on her living unit in bed on [DATE] at 1:15 a.m. The stairwell door alarm to alert staff of any entrances to the stairwell malfunctioned and was not sounding at the time of the incident. The resident was diagnosed with [REDACTED]. Resident #2 was also observed in bed during the current survey without access to her call bell as required in her plan of care for safety. 2. Resident #4, with a history of frequent falls and severe cognitive impairment, fell on the dementia unit while unsupervised, resulting in a laceration to the back of her head requiring closure with three staples. 3. While unsupervised, Resident #1 exited the facility in her wheelchair, rolled down a hill, fell from the wheelchair, and sustained traumatic injury. The resident was sent to the hospital, emergently airlifted to higher level of care hospital and subsequently expired two days later, as result of the injuries sustained during this fall. 4. Resident #3 fell while unsupervised in the shower room on the dementia care unit. Resident #3 did not have a Dycem anti-slip device in her wheelchair as documented in her clinical record for fall prevention/safety. The findings include: 1a) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #2 with severely impaired cognitive skills, severely impaired vision and as requiring limited assistance of one person for ambulation. Resident #2's clinical record documented a nursing note dated [DATE] stating, Resident was directed to her room and put to bed about 01:15 (a.m.). Staff from another unit escorted patient to dining room & reported that resident was found in stairwell @ 0310 (3:10 a.m.). Resident had bloodied area to right forehead no actively bleeding. Area and a resident mental status & pain level assessed. (Physician) notified @0315 and ordered send out via rescue squad to the emergency room for evaluation and treatment . (sic) The emergency room report dated [DATE] documented, .Staff reported to EMS (emergency medical services) found patient at bottom of stairs. Not able to report how many steps she may have fallen. Went missing from unit somewhere between 0115 and 0310. Has hematoma/bleeding to right forehead. Pain and swelling/bruising to right hand .is legally blind. (sic) This emergency room report listed the resident was diagnosed with [REDACTED]. The resident was referred to a university neurological center for further evaluation of the subdural hematoma. The university hospital report dated [DATE] documented, .went missing from her nursing facility room .at 01:00 this morning, and she was found several hours later at the bottom of the staircase after apparently suffering a fall .originally complained of neck pain and right wrist pain .noted to have a [MEDICAL CONDITION] and bruising to her right wrist upon examination .CT head performed .visualized an SDH (subdural hematoma) 4.5 mm (millimeters) in thickness .On further our position with the nursing home, patient fell at approximately 3:00 a.m. and picked herself up and sat on the stairs without any help .She is also noted to be blind at baseline. (sic) The resident had a repeat CT scan of her head and discharged back to the facility on [DATE] with no surgical intervention required. The facility's investigation of Resident #2's fall in the stairwell documented the alert/alarm system on the stairwell door was not functioning properly at the time of the incident. Witness statements documented staff caring for Resident #2 last saw the resident at 1:15 a.m. in bed. An employee from another unit found Resident #2 in the stairwell on [DATE] at 3:10 a.m. Certified nurse's aide (CNA) #7's written statement dated [DATE] documented, At 1:15 (a.m.) I seen Resident (#2) in her bed. @ 3:10 (a.m.) another staff member brought her back to the unit from the stairwell. CNA #8, who found Resident #2 in the stairwell, wrote a statement on [DATE] stating, Reporting witness used the side stair way to clock at approx. 2:57 A (a.m.) when staff returned to the stairway to exit the building, slight noises and shuffling were heard. Reporting witness walked up the stairs to find out what the noises were, and found Resident (#2) sitting on the stairs with her head in her hands covered in blood. There was a small golf ball sized opening on her head. There was also blood on the floor .assisted resident back to her unit .Reporting witness and other aide assisted resident to the dinning (dining) room to sit down. She, the resident made several comments about feeling pain w/ (with) her head . Resident #2's plan of care (revised [DATE]) documented the resident was at risk for falls due to [MEDICAL CONDITION], wandering and gait/balance problems. Interventions to minimize injury included, anticipating and meeting resident needs, call light within reach, appropriate footwear and therapy to evaluate as needed. Multiple nursing notes in (MONTH) (YEAR) documented the resident wandered about the unit and sometimes mistakenly went into other resident rooms. Resident #2's CNA Kardex sheet (undated) listed the resident as blind and to require the assistance of one person for ambulation. On [DATE] at 1:30 p.m., the licensed practical nurse unit manager (LPN #6) was interviewed about Resident #2's fall in the stairwell. LPN #6 stated Resident #2 went out of the unit into the stairwell and fell . LPN #6 stated the door alarm was not functioning properly and did not alert staff when the resident entered the stairwell. LPN #6 stated Resident #2 was blind and frequently ambulated on the unit following the handrail. LPN #6 stated the resident at times went into other resident rooms, as she was confused and visually impaired. On [DATE] at 4:15 p.m., a certified nurse's aide (CNA #3) that routinely care for Resident #2 was interviewed about Resident #7. CNA #3 stated the resident ambulated on the unit, usually following the handrail. CNA #3 stated the resident required the assistance of one person for walking, as she was unsteady on her feet and had difficulty finding her room due to [MEDICAL CONDITION]. On [DATE] at 4:50 p.m., the administrator and director of nursing (DON) were interviewed about Resident #2's fall in the stairwell. The DON stated CNA #8 went down the stairwell from the third floor to clock out and leave work on [DATE] at 2:57 a.m. The DON stated CNA #8 reported she did not see the resident in the stairwell at that time. The DON stated when CNA #8 went back into the stairwell to go home, she heard and found Resident #2 on the stairs, bleeding from her head. The administrator stated their investigation found the alarm on the stairwell door was not functioning properly at the time of the fall. The administrator stated when they tested the alarm after the accident, the alarm sounded but only for a few seconds. The administrator stated that stairwell doors in the facility were not locked but only had alarms that sounded when the door was opened. The DON stated CNA #8 reported there was no alarm sounding when she found Resident #2 in the stairwell. The DON stated the resident was blind, ambulated on the unit, usually following the handrail and sometimes went into others' rooms. The DON stated the big issue with this accident was the malfunctioning alarm on the stairwell door. The DON stated the maintenance director reported the motherboard was bad on the door alarm unit. On [DATE] at 5:30 p.m., the registered nurse (RN #2) caring for Resident #2 at the time of the incident was interviewed by telephone. RN #2 stated she was passing medications and doing rounds when a CNA from another unit brought Resident #2 from the stairwell to the dining room. RN #2 stated she assessed the resident who had a laceration on her forehead. RN #2 stated she assumed the resident opened the door and went into the stairwell. RN #2 stated she did not see Resident #2 walking in the hall prior to the incident. RN #2 stated she heard no alarm sounding on the shift indicating anyone had entered the stairwell. RN #2 stated there was no door alarm sounding when the resident was found. RN #2 stated Resident #2 ambulated independently, usually following the handrail. On [DATE] at 6:00 p.m., the maintenance director was interviewed about the malfunctioning alarm. The maintenance director stated the alarm was supposed to sound until a staff person entered a code to stop the alarm. The maintenance director stated there were no locks on the stairwell doors, only alarms. The maintenance director stated when he checked the alarm after the incident, it alarmed for only a few seconds and stopped. The maintenance director stated his department performed daily checks on the alarm. The maintenance director presented a checklist indicating the alarm was last checked prior to the accident on [DATE]. These findings were reviewed with the administrator and director of nursing during a meeting on [DATE] at 4:30 p.m. 1b) On [DATE] at 11:30 p.m., Resident #2 was observed in bed. Her call bell was located on the floor on top of a pile of personal items located between the bed and the bedside table. The call bell was out of the resident's reach. Resident #2 was observed again on [DATE] at 1:20 p.m. in bed. The call bell was in the floor between the bed and the bedside table. Resident #2's plan of care (revised [DATE]) documented the resident was at risk for falls due to [MEDICAL CONDITION], wandering and gait/balance problems. Interventions to minimize injury included, .Call light within reach . On [DATE] at 4:50 p.m., the director of nursing (DON) was interviewed about safety interventions for Resident #2. The DON stated the call bell was supposed to be kept within the resident's reach. The DON stated the resident used the call bell but not always consistently. On [DATE] at 9:00 a.m., the licensed practical nurse (LPN #5) caring for Resident #2 was interviewed about the call bell. LPN #5 stated the call bell was supposed to be within the resident's reach when in bed. LPN #5 stated the call bell was usually attached to the side rail near the head of the bed. LPN #5 stated the resident was blind so they tried to keep the call bell and her personal items within reach. This finding was reviewed with the administrator and director of nursing during a meeting on [DATE] at 4:30 p.m. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #4 with short and long-term memory problems, severely impaired cognitive skills and to require the extensive assistance of one person for ambulation. Resident #4's clinical record documented a nursing note dated [DATE] stating, At approximately 1600 (4:00 p.m.), I was exiting the nurses station towards the dining room when a visitor alerted me that Resident had fallen. I approached Resident, she was alert and lying on her back on the ground. resident was responding to questions. Resident had blood pooling underneath her head. 911 call was initiated . The emergency room report dated [DATE] documented, Received .following a fall. She has a lac (laceration) to the back of her head, bleeding controlled . The report documented the resident was assessed with [REDACTED]. The report documented the laceration was repaired with three staples to be removed after 5 days. The resident was discharged back to the facility with orders for wound care. The facility's investigation of Resident #4's fall on [DATE] documented the fall/injury was reported by a visitor and not witnessed by any staff members. The investigation report dated [DATE] documented the resident required the assistance of one person for ambulation and stated the resident was found by a visitor in the floor in the dining room hallway with another resident in the floor next to her. A written witness statement dated [DATE] by the registered nurse working at the time of the incident documented, .a visitor alerted me that two residents had fallen. As I approached, (Resident #4) was lying on the ground on her back. Patient was alert, moaning. Patient had a pool of blood underneath her head. I immediately told staff to call 911. I was informed that the call had already been initiated by a visitor .The second patient was (Resident #3) whom was sitting upright, alert . (sic) Written statements from three CNA's working on the unit at the time of the incident documented they were providing care to other residents and did not see the incident or know what happened. Resident #4's clinical record documented the resident ambulated/wandered on the dementia unit and had experienced seven prior falls since her admission on [DATE]. A fall risk assessment completed on [DATE] documented the resident as a high risk for falls. Resident #2's plan of care at the time of the fall (revised [DATE]) listed the resident was at risk of falls due to confusion, gait/balance problems, poor safety awareness and use of psychoactive medications. Interventions to minimize falls/injury included anticipating resident needs, call light within reach, proper footwear, therapy evaluation as needed and safety checks following any fall. On [DATE] at 4:10 p.m., an interview was conducted by telephone with the visitor that found Resident #4 on [DATE]. The visitor stated that the incident occurred on [DATE] between 3:00 p.m. and 5:00 p.m. The visitor stated he was visiting in the common area on the dementia unit when he heard two loud thumps and a commotion. The visitor stated he found two women in the floor and they were unable to get up. The visitor stated one of the women was on top of the other, with the one on top bleeding from the front of her head and the one on the floor bleeding from the back of her head. The visitor stated blood was pooling on the floor with both women bleeding profusely. The visitor stated no staff were in the hall or in the common area when all of this occurred. The visitor stated he went to the nurse's station and told the nurse at the desk. The visitor stated the nurse was not able to see the residents from the station. The visitor stated he called 911 and was concerned because no staff members were there when these women fell . On [DATE] at 11:15 a.m., the licensed practical nurse unit manager (LPN #8) was interviewed about Resident #4's fall/injury. LPN #8 stated staff members did not witness Resident #4's fall. LPN #8 stated staff were busy passing out meal trays and attending to other residents at the time of the fall. LPN #8 stated she did not know what happened with the two residents or the circumstances of the fall as no staff were present when it happened. On [DATE] at 11:20 a.m., LPN #2, working on the dementia unit at the time of the incident, was interviewed. LPN #2 stated she was on the telephone with adult protective services about an abuse incident at the time of the fall. LPN #2 stated the fall was weird as she did not see Resident #4 walking in the hall prior to the incident. LPN #2 stated another staff member reported to her the residents were in the floor. LPN #2 stated when she went to the dining hall area, Resident #3 and #4 were in the floor. LPN #2 stated Resident #4's wheelchair was still in her room so she must have ambulated to the area. LPN #2 stated she saw Resident #4 in bed on [DATE] at approximately 3:30 p.m. LPN #2 stated she did not know what happened or how the resident fell as she was on the telephone. On [DATE] at 11:50 a.m., the director of nursing (DON) was interviewed about Resident #4's fall on [DATE]. The DON stated, There was a lot going on that day. The DON stated staff members were present on the unit but probably not watching Residents #3 and #4. The DON stated this fall occurred on the same afternoon as an abuse incident and staff members were focused on other things. This finding was reviewed with the administrator and director of nursing during a meeting on [DATE] at 4:30 p.m. 3. Resident #1, was originally admitted to the facility on [DATE], with the most current readmission on [DATE]. [DIAGNOSES REDACTED]. The resident's most current MDS (minimum data set) quarterly assessment dated [DATE] was reviewed and documented the resident was a 9 cognitively, indicating the resident had moderate impairment in daily decision making skills. The resident was assessed as requiring extensive assistance for bed mobility, dressing, hygiene, and locomotion on and off the unit. The resident was assessed as requiring total assistance for transfers, toileting, eating, and bathing. In section G0300. Balance During Transitions and Walking the resident was assessed and an 8 (indicating the activity did not occur) for moving from seated to standing, walking, turning around, and moving on and off toilet. The resident was assessed as not steady, only able to stabilize with staff assistance for surface to surface transfers. The resident was additionally assessed as having impairment on both sides (right/left) for upper and lower extremities for functional limitations in range of motion. A complaint investigation was conducted on [DATE] through ,[DATE]. An allegation within the complaint alleged that Resident #1 was found outside of the facility on [DATE] by staff, fell from the wheelchair and sent to the hospital and later expired as result of the injuries. The resident's room was located on the 3rd floor, indicating the resident would have used the elevator to get to the lobby and exit the building. Resident #1's most current physician's orders [REDACTED]. A fall risk assessment dated [DATE] documented, Total score of 10 or above deems resident at risk. Resident #1 was documented with a fall risk score of 14 indicating the resident was a high fall risk. An elopement risk assessment was completed dated [DATE] and [DATE] both documented that the resident is not at risk for elopement, but did document the following: .Resident has poor decision making related to MR (mental [MEDICAL CONDITION]), has .anxiety, [MEDICAL CONDITION] disorder and depression, is able to propel in w/c (wheelchair) (documented the same for both dates). An eye exam dated [DATE] documented: .(name of Resident #1) .[MEDICAL CONDITION] both eyes, [MEDICAL CONDITION] right greater than left .poor historian .depression .Neuro: Oriented to person, time, place: No . Progress notes for this resident were reviewed and documented: [DATE] - .resident is up daily in w/c .she is able to propel self is alert and oriented X 2 and able to voice wants .will bring herself down to lobby and scream 'Help!' at the top of her lungs, non compliant with smoking policy .disruptive behaviors .signature of SW. [DATE] - .up daily in w/c .able to propel self .alert and oriented X 2 .propels throughout facility .does yell out disruptively .SW. [DATE] - .hoyer lift for transfers, and may porch sit dependently with staff/family supervision .SW. [DATE] - .able to propel self .will frequently yell out disruptively, curse, cry and ask others to push her in her w/c .scream 'help' when she doesn't get what she wants right away .goes out to smoke, to vending machines .SW. [DATE] - .up out of bed daily, dressed and able to propel self .is a smoker .behaviors of yelling out, crying, asking visitors to push her in w/c, hitting hands on walls, sexually inappropriate .scream Help Me .often found at vending machines, buying snacks and drinks .SW. [DATE] - .total lift for transfers. (MONTH) porch sit with staff or family supervision .enjoys going out to smoke . [DATE] A consult documented, XXX[AGE] year old woman with MR and [MEDICAL CONDITION] is a resident here due to mental illness and physical debility .have fits of emotional liability but doesn't harm other residents or staff .requires a lot of hands on attention and reassurance .will sneak foods and frequently get snack foods in the vending machine .non compliant with her tobacco cessation recommendations .alert and awake, crying in the common area and yelling unitellibly . [DATE] - .propels self most of time, also pushed by staff . A Occupational Therapy evaluation dated [DATE] documented, .[MEDICAL CONDITION], muscle weakness, generalized abdominal pain, abnormal posture .exacerbation of impaired postural alignment and impaired w/c positing indicating the need for OT to facilitate tolerance and postural control .resident is long term care .history of poor positioning in w/c with multiple referrals to therapy .has history of upper abdominal hernia which she reports is painful when sitting upright .and leaning to her right side .has been treated multiple times for positioning and w/c mobility .has been altered or changed several times to facilitated her best positioning with poor results overall .Precautions: fall risk, poor positioning, anxiety .able to self propel her w/c .total care with all .ADL's .has had multiple falls from her w/c due to not using leg rests, having other residents propel her chair for her, and sliding from the chair due to weakness in her core .bilateral leg rests of which she often uses either none or left only .sometimes uses her right lower extremity to assist with propulsion and steering of the chair though not often to say she equally uses both upper extremity and lower extremity; Propulsion in room = Needs supervision; Propulsion in facility = Needs supervision .Propulsion Outdoors = Needs supervision; Negotiating obstacles = needs physical assist, Negotiating Curbs and Ramps = Needs physical assist .Wheelchair .management = Needs physical assist .Brakes = Needs physical assist .she has demonstrated poor control of her trunk even with extensive therapy services .unable to reposition self .she will ask for assistance at times but is not always aware of her postural deficits .uses her right lower extremity to assist at times with mobility holding her left lower extremity in extension and raised from the floor though cannot use this extremity functionally .Underlying impairments: Cognition, body awareness, insight, judgement, limitations in ROM (range of motion), joint mobility, pain, postural alignment/control, static and dynamic balance, vision loss, fine motor coordination .decreased safety awareness and coordination .Right upper extremity ROM = impaired; Left upper extremity ROM = Impaired right/left lower extremity ROM = Impaired (poor mobility of BLE (bilateral lower extremities) with right knee valgus deformity) Right shoulder ROM = impaired .left hand ROM = impaired .summary of coordination impairments: decreased should flexion/abduction limits her overall coordination along with limited ROM in her left hand/fingers .oriented to: self .Problem solving: Severe impairment .Follow directions: Mild impairment .Safety awareness: Severe impairment .Insight and Judgement: Severe impairment .patient with mental illness along with MR limits her higher level of reasoning skills and prevents her from having adequate insight, problem solving skills, and safety awareness. She has a general awareness of the sensation of falling though this awareness does not affect her behaviors that put her at risk of falls . The resident's CCP (comprehensive care plan) documented, .([DATE]) has had an actual fall related to poor balance .PT (physical therapy) consult for strength and mobility .vital signs as ordered and as needed .([DATE]) safety checks x 72 hours, neuro checks placed on early riser get up list .([DATE]) Is at risk for falls related to Unaware of Safety Needs .call light within reach .bed in low potion .wearing appropriate footwear .provide services to improve abilities (PT, OT, ST, psych, etc.) .needs assistance with ADLs .needs assistance/escort to activity functions .high back w/c .totally dependent on 2 staff for repositioning and turning .dressing .toilet use .transferring .mechanical lift .anticipate and meet resident's needs .Impaired cognitive function .impaired thought processes related to [MEDICAL CONDITION] disorder and ID (intellectual disability) .cue, reorient and supervise as needed .may porch sit with staff/family supervision .Monitor (name of resident) after administration of antianxiety medication for safety .meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increased risk of falls .opioid pain medication .monitor for increased risk of falls .has visual impairments related to [MEDICAL CONDITION] . On [DATE] at approximately 9:00 AM, the DON (director of nursing) and the administrator were asked for the investigation on Resident #1's fall outside of the facility. The investigation was presented, along with a binder that the administrator stated was a 4 point plan that he wanted to share to show what all the facility has done. The information was reviewed and documented in summary that on [DATE] at approximately 7:30 AM the resident had a fall from her wheelchair outside of the facility. It was documented that the resident had a laceration right temporal area and swelling of the right arm and other injury to right temporal side and right elbow. A fall root cause analysis report was included, that documented, locomotion status: independent .w/c .propelling self in w/c .INTERNAL/RESIDENT CONTRIBUTING FACTORS: Wandering, anxiety, agitation, restlessness .last dose of medications given at 6:00 AM (narcotics) .(antidepressant) .(antianxiety) .Diagnoses: [REDACTED].sent to ER at 7:40 AM .resident observed on ground outside . A witness statement dated [DATE] by CNA #9 documented (name of CNA #9) came from up stairs got report and (name of resident #1) was singing I asked her to stay up here breakfast was coming and I would feed her soon, and went to give a resident a shower. last time saw (name of resident #1) was at 7:10 AM (CNA signature [DATE]). A witness statement dated [DATE] by CNA #10 documented (name of CNA #10) I clocked out at 7:17 am, when I was going to my car that was parked in the visitors parking lot I seen resident come out of staff ed room singing and was in lobby when I when (sic) out to leave (signature of CNA #10 [DATE]). A witness statement by CNA #2 documented (Name of NA#2) I got here around 7:10 AM to 7:15 AM and came in through the side door from employee parking lot.(NAME)the receptionist was at the desk at some point between 7:15 AM and 7:30 AM. (name of resident #1) was downstairs and came into the classroom next to the lobby. She went out of the classroom singing around 7:20 AM (signature [DATE]) A statement by the medical records coordinator, OS (other staff) #10 documented (name of OS #10) coming to work @ (at) 7:20 saw (name of resident #1) laying in driveway. Went inside to get help, had (name) call her nurse, (name of resident) up against curb on ground w/c had turned & (and) flipped her out laying on side (Right) head bleeding @ temple, had knot, Right arm cut & bleeding. restorative aides & transportation came out to help. Nurse out to assess - sent resident to emergency room (signature of OS #10 [DATE]). The ADON witness statement documented that the ADON interviewed a resident, .at approximately 2:00 PM, resident frequently assisted (name of Resident #1) by pushing her in her w/c to the lobby .(resident) stated he had not pushed the resident to the lobby that morning. No further information was included with this investigation to determine how how the resident got downstairs to the lobby, and how the resident was able to leave the facility without staff present or providing supervision. The resident's MARs (medication administration records) were reviewed and documented that the resident received all 6:00 AM medications, which included, but not limited to: [MEDICATION NAME] 1.5 mg (milligrams), aspirin 81 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 500 mg, and [MEDICATION NAME] ,[DATE] mg. It was documented that the resident received a [MEDICATION NAME] 50 mg injection on [DATE]. On [DATE] at 6:00 PM the maintenance director was interviewed regarding the doors to the facility and concerns regarding Resident #1 were expressed. The maintenance director stated that the front doors are now locked manually with a key and that if a resident has a wanderguard on, the door would lock, or if the door was already open it would alarm. The maintenance director stated that people could walk in anytime, but not come between the hours of 8 PM and 8 AM. The maintenance director stated that the receptionist is here usually by 7:30 AM, but their hours start at 8 AM. The maintenance director stated we have locked the doors down manually and we have installed a camera in the lobby at the door and one outside at the door. On [DATE] at approximately 5:30 PM the DON and administrator and were made aware of concerns regarding this resident and the fall with injury. The DON and administrator stated that the resident was ambulatory throughout the facility in her wheelchair without supervision. The DON and administrator were made aware of the concerns surrounding this that the resident had an expansive history of behaviors and poor judgment and safety awareness. The DON stated that the resident had a BIMS score of 9 and the resident was able to make decisions on her own. The administrator stated that the resident had never attempted to leave the facility that they were aware of and that the main entrance doors were fixed to prevent residents from leaving the facility. The administrator stated that before this happened, all staff and all residents and anyone inside the facility could go to the main entrance door and the doors would open, anytime day or night. The doors were locked on the outside to prevent anyone from coming in form the outside between the hours of 8:00 PM until 8:00 AM and after that the doors were open for entry or exit from the outside or inside during those hours. The administrator stated that anyone could leave the facility anytime day or night if they were inside, there was no locking mechanism in place to prevent residents from exiting the building. A fall policy was requested at this time. The fall policy was presented and documented, .residents who have had a fall in the last 60 days .new residents .appropriateness of intervention and care plan reduction of [MEDICAL CONDITION] medications .least restrictive restraints .Plan of care .utilize fall prevention P[NAME] (plan of care), individualize interventions, review and revise interventions .Fall- assess for injury and treat, notify .complete incident report .chart .investigate to determine cause .staff meeting to determine cause .complete fall response action plan .

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to ensure two of eight residents were free from sexual abuse. Facility staff failed to provide adequate supervision and implement effective interventions to protect Residents #6 and #7 from sexual abuse by Resident #5 on the dementia care unit. Staff members observed Resident #7, with severe cognitive impairment and wandering behavior, in Resident #5's bed. Resident #5, with a history and ongoing treatments for sexually aggressive behaviors had his hand in Resident #7's pants/brief with his penis exposed. Resident #5 was then observed on top of Resident #7 in his bed while exposed. Three days later, staff observed Resident #5 sexually abusing Resident #6 in the dining room. The findings include: 1. Resident #5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/19/19. Resident #5 was assessed as moderately impaired in his cognitive status with a total cognitive score of 10 out of 15. This MDS documented the resident wandered and had behaviors directed toward others almost daily. Resident #5's clinical record was reviewed on 05/08/2019 at approximately 2:00 p.m. Social Service Progress Notes included: 6/27/2018 - .Behavior Status: Sexually Inapp. (inappropriate). Urinating on floor . 9/25/2018 - .Behavior Status: Sexually Inapp. Taking off clothes. Urinating on floor. Sitting self on floor . 11/21/2018 - .Sensory/Communication Status .Inappropriate responses at times .Behavior Status: Other behavioral symptoms not directed toward others. Wandering. Standing up on bed/chairs . 2/19/2019 - .Behavior Status: Verbal behavioral symptoms directed toward others. Sexually Inapp. Taking Clothes Off . 3/4/2019 - .Behavior Status: Taking off clothes. Wandering. Climbing 1/2 wall. Urinating on floor. Sexually Inapp .Resident unable to be in Dayroom at times-refusing to keep clothes on . Documentation in the Interdisciplinary Progress Notes included the following: 12-19-18 at 0500 (5:00 a.m.) Resident up during entire 11-7 shift. Took brief off multiple times, urinated on floor and bed and took clothes off. Snacks and water given but behaviors continued throughout night. 1-8-19 at 0500 Resident .sexually inappropriate with staff, pulling his penis out of brief, laying on bed trying to get staff to perform oral sex. Staff redirected him and told him he was inappropriate. Resident didn't respond after that. Continue throughout the night with other behaviors. 1-19-19 at 1400 (2:00 p.m.) Resident has been walking into other residents room, redirected by staff. Has been making sexual remarks to staff offering to pay money for sex. Assisted to chair at nurse station where he began to pull pants down and expose himself. Assisted back to room . 1-20-19 at 2100 (9:00 p.m.) Resident being walked to dinning (sic) room, restless, making unsafe solo transfer OOB (out of bed). On way to dinning (sic) room, resident grabbed both of CNA's (certified nursing assistant) wrist, bent and shook her, required two other staff members to get resident to release her. Given 1:1; snacks and calmed down. Resident again jumps up out of chair, starts swinging for no apparent reason. 1:1; remained calm. Had to recalm resident. MD (physician) called. No medical orders. 1-21-19 at 0700 (7:00 a.m.) Resident up all night wandering into other rooms, removing his brief constantly and urinating in the floor, sat on night stand and attempted to climb on bed. Unable to redirect most of the night. 2-1-19 at 2:00 p.m. .Resident ambulating in the halls. Making inappropriate responses (sexual) to staff . 2-8-19 7-3: Staff came to this writter (sic) and stated that the 'resident was on his knees given oral sex to the chair.' (sic) This writter (sic) removed the resident from the dinning (sic) room where he was at, to his room away from the other residents. Dr. (Name) was called and prescribed [MEDICATION NAME] 10 mg (milligrams) daily. Resident would try to grab you while walking him to his room, he came out of his room playing with his nipples . 2-10-19 7-3: .Resident asking staff for sex earlier in the shift. Resident redirected to his room . 2-16-19 3-11: .Resident was in dining area and was seen by other residents and staff with his hand up another residents shirt. Residents separated, education done with resident about inappropriate behaviors. Resident denied any wrong doing . 2-25-19 at 0230 (2:30 a.m.) Resident up during this shift wandering, disrupting other residents who are sleeping and telling female staff that he wants to talk to them about sex. Is not able to be redirected entire night. While sitting in dining room, resident got up from chair and climbed onto the top of the divided wall. Took several minutes to redirect with assistance of one other staff member. 03-08-2018 IDT (Interdisciplinary Team) met to discuss resident in weekly behavior meeting. Resident cont on [MEDICATION NAME] for depression. Resident has behaviors of sitting on floor, sexual behaviors, wandering and disrobing . 3-10-19 7a-3p Resident has been up wandering in halls and into rooms. Grabbed a female's hand in hallway. Residents separated and redirected. 3-18-19 0600 (6:00 a.m.) Resident up most of night wandering and disturbing other residents. Unable to redirect, continues to take brief off and urinate in floor multiple times during shift and walks into hallway naked touching his genitals. 3-25-19 at 0640 (6:40 a.m.) Resident has been awake during entire shift. Disturbing other residents, walking into hallway naked, continues to take off dry briefs and urinate in the floor and unable to redirect entire shift. Resident taken to dining room and he pushed around chairs and tables. When trying to redirect, resident became combative with staff . 3-30-19 at 1530 (3:30 p.m.) Resident closed door to room, staff checked resident. Resident observed pulling on fluorescent light above roommate's bed. Light cover, one fluorescent bulb and parts associated in resident's hands and the roommate bed. Resident sat on roommate's bed. Redirected and reoriented to room and safety policies. Resident cont to require frequent checks and redirection. 4-6-19 12:30 p.m. Resident noted to be sexually inappropriate with staff, attempting to touch them. Very hard to redirect. Wandering the unit. When redirected to his room resident goes through the bathroom into another resident's room in which he keeps coming to the nurse's station asking for someone to get him out. Psych doctor paged and gave new orders to increase [MEDICATION NAME] to 40 mg Q day (everyday) . 4-13-19 at 1443 (2:43 p.m.) Resident with increased sexual behaviors. Redirected and 1:1 offered. Dr. (Name) at (Hospital) notified, verbal order given .Dr. (Name) will follow up with resident on Thursday . There was no mention of the incident with Resident #7 that happened on this date in Resident #5's clinical record. 4-14-19 at 1630 (4:30 p.m.) This nurse tried to redirect resident to his room as he was wandering in hallway with shuffling gait. Resident stated, 'I have to be out to [***] .' I stated to resident that was inappropriate and touched his arm to redirect to his room. Resident grabbed this nurses arm with both hands and began twisting it painfully stating 'then lets go to my room and make it a good visit.' I asked the resident to let go, resident twisted harder. I asked again and resident stated 'I like what I see and I need to [***] .' I then yelled for assistance. CNA's took resident off my arm and redirected to room. UM (unit manager) called NP (nurse practitioner) on call (Name) consulted Dr. (Name) to send to ER (emergency room ) for eval due to sexual aggression, assault to staff, non-directable behaviors with aggression, for the safety of the resident safety of other residents and staff . (sic) 4-16-19 2:35 p.m. Resident s/p (status [REDACTED]. Resident noted to be taking his clothes off . 4-16-19 3-11P At approximately 1630 (4:30 p.m.) resident standing on roommate bed, pulling on light fixtures, this nurse and 2 CNA assisted off bed to floor, resident than began touching self. (sic) Redirected and assisted resident to dining area. At approx 1725 (5:25 p.m.) a resident yelled, and this nurse observed resident with one hand in a female resident's pants with other hand on her breast. Resident was redirected, son called to assist in redirection. Several moments later resident repeated behavior with same female resident and became aggressive with 2 CNA's who approached and attempted to redirect. This nurse again assisted in redirection, directed resident to sit at table for dinner. Discussed with UM and MD on call. (Name) City Police arrived, resident displayed no behaviors at that time, and told police nothing happened. After police exited, resident briefly rested in the dining area. Approx 2100 (9:00 p.m.), after resident had returned to room resident exited room and was ambulating unit hall wearing only t-shirt, resident was toileted and cont to ambulate without pants and brief, following this nurse, and was unable to redirect. Resident was assisted to dining room, another brief was put on. Moments later resident at nurse desk without pants and brief. Resident's son called again. Resident sat in chair without pants and brief talking with son. 2153 (9:53 p.m.) (Name) City Police escorted resident out of building. Behavior Symptom Monitoring Flow Records dated (MONTH) (YEAR) through (MONTH) 16, 2019 showed repeated documentation of Resident #5 wandering, sitting self on floor, standing on bed/chairs, urinating on floors, taking clothes off, sexual inappropriateness, and combativeness. On 4/16/19, the day Resident #5 was removed from the facility by the police, documentation at 4:30 p.m., 5:25 p.m., and 9:10 p.m. included sexual inappropriateness. The DON (director of nursing) went before the magistrate on 4/16/19 to obtain an ECO (emergency custody order) to have Resident #5 removed from the facility. The ECO was obtained 4/16/19 at 8:52 p.m. Geriatric Psychiatry Notes included: 1/31/19 - .Dementia with behaviors .Staff report increased sexual behaviors over last few months - touching female breasts and making sexual statements. Put his hands down shirt of female residents .Plan: Sexual behaviors may have worsened secondary to decreased SNRI (Serotonin [MEDICATION NAME] Reuptake Inhibitor) (Sept. (YEAR)) or decreased [MEDICATION NAME] (Dec (YEAR)). Will increase [MEDICATION NAME] back to 225, daily to help decrease libido. If no change, consider oral [MEDICATION NAME]. 2/14/19 - .dementia with behaviors. Seen 2 weeks ago when [MEDICATION NAME] increased for [MEDICAL CONDITION]. Staff called me 2/8/19 secondary to pt. performing oral sex on chair leg and continued groping of female staff/residents. Started oral [MEDICATION NAME] .Plan: Will attempt to reduce aripiprazole to 2.5, daily to reduce parkinsonism. Cont other meds for now. 3/21/19 - I have seen and evaluated this 61 yo (year old) male for inappropriate sexual behavior. Last seen 2/14/19 when [MEDICATION NAME] decreased to reduce EPS (extrapyramidal symptoms). Staff report worse sexual behaviors - he has been wandering into residents rooms, attempting to grope female staff/residents. On exam he denies .Plan: As pt threatening safety of other residents will increase MPA to 20 mg, daily. Will also add prn [MEDICATION NAME] for sleep . physician progress notes [REDACTED].He recently has had increased behaviors of episodes of sexually inappropriate behavior. He is following Dr. (Name) for psych med management . Resident #5's CCP (comprehensive care plan) included: Focus: .psychosocial well-being problem .Interventions: Consult with: Pastoral care, Social services, Psych services as he or his family requests .When conflict arises, remove (Name) Resident #5 to a calm safe environment and allow to vent/share feelings .Date Initiated: 10/03/2018. Focus: (Name) Resident #5 has a behavior problem urinating on floor, wandering, getting up in the middle of the night with confusion, sits self on floor, prefers to be nude, sleeps in others beds, stands up on furniture, sexually inappropriate r/t (related to) [MEDICAL CONDITION] .Interventions: .Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 10/03/2018. Resident #7 was admitted to the facility on [DATE] with a re-admission on 7/16/15. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #7 with short and long-term memory problems and severely impaired cognitive skills. This MDS listed the resident had wandering behaviors and was rarely and/or never able to make herself understood. Resident #7's clinical record documented a nursing note dated 4/13/19 stating, At 1:45 PM, this writer was alerted by CNA's (certified nurses' aides) that resident was observed laying in (Resident #5's) bed. (Resident #5) was observed (with) his hand down this residents pants and had his penis exposed. This resident was immediately redirected and taken to her room. Skin noted to be warm, dry and intact. Resident had no s/s (signs/symptoms) of distress. 15 minute checks implemented. Staff will ensure residents do not ambulate around other residents room, and during mealtimes residents will sit on opposite sides of the dining room while staff monitors the area . (sic) The facility's investigation dated 4/16/19 documented, .After investigation, facility is able to substantiate resident to resident encounter at it was witnessed by staff. Both residents currently reside on (dementia care unit). The residents were separated immediately; room changes have been refused by responsible parties as both residents exhibit exit seeking behaviors and require a locked unit. No further interactions have occurred between residents . The facility's investigation included written witness statements from staff members working at the time of the incident. A written statement by the housekeeper dated 4/13/19 documented, I was going to clean (Resident #5's) room and the door was shut so I knocked on the door and then opened it. When I opened the door (Resident #5) was standing in front of (Resident #7) with his brief and pants pulled down and (Resident #7) was sitting on the bed. I went to the nurses station to let them know and (CNA #5 and CNA #6) went to the room and when they opened the door (Resident #5) was on top of (Resident #7) with his pants down. They got (Resident #7) out of the room. CNA #5's written statement dated 4/13/19 documented, .housekeeper .came and got me & (CNA #6) because (Resident #5) had (Resident #7) on his bed with his hand inside her pants, Also (Resident #5) had his penis exposed .Earlier during lunch he also was trying to touch her in the dinning (dining) room. (sic) CNA # 6's statement dated 4/13/19 documented, .were alarted (alerted) by a staff member .of house keeping that resident (#5) had another resident in his room (with) the door closed. Upon arriving to his room (Resident #5) had his pants down on the floor penis exposed with his hand in (Resident #7's) breif (brief) . (sic) Resident #7's clinical record documented the resident had a history of [REDACTED]. A care plan note dated 3/12/19 documented the resident was oriented to self only, frequently refused to respond and daily walked about the dementia care unit independently. Resident #7's plan of care (revised 3/13/19) listed the resident had wandering and exit seeking behaviors, impaired safety awareness, impaired cognition, garbled speech and impaired decision-making abilities. Interventions to minimize behaviors included, Anticipate and meet (Resident #7's) needs .Explain all procedures .Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternate location as needed .Monitor behavior episodes and attempt to determine underlying cause .Check placement of wander guard .Distract (Resident #7) from wandering by offering pleasant diversion, structured activities, food, conversation .Identify pattern of wandering . On 5/8/19 at 12:30 p.m., the licensed practical nurse (LPN #2) working on the dementia unit on 4/13/19 was interviewed. LPN #2 stated that on 4/13/19 the housekeeper reported a resident was in Resident #5's room. LPN #2 stated she went to Resident #5's room with other staff. LPN #2 stated when she walked in the room Resident #7 was on the bed with Resident #5 standing with his pants/brief down and penis exposed. LPN #2 stated Resident #5 was known to make sexual comments and have sexual behaviors. LPN #2 stated Resident #7 and Resident #5 were independently ambulatory on the unit, with Resident #7 wandering about the unit daily. When asked what interventions were in place to prevent this incident, LPN #2 stated staff members were supposed to monitor the residents and redirect them as needed. On 5/8/19 at 2:45 p.m., the housekeeper that first witnessed the 4/13/19 incident was interviewed. The housekeeper stated she cleaned rooms routinely on the dementia care unit. The housekeeper stated that on 4/13/19 she went to clean Resident #5's room. The housekeeper stated the door to Resident #5's room was closed so she knocked, got no answer and then entered the room. The housekeeper stated Resident #7 was sitting on the edge of Resident #5's bed near the head of the bed. The housekeeper stated Resident #5 was standing in front of Resident #7 with his pants/brief down and his penis exposed. The housekeeper stated she went to the nursing station and reported her observation and followed staff back to Resident #5's room. The housekeeper stated when they got back to the room, Resident #5 was on top of Resident #7 in bed. The housekeeper stated Resident #7 had her clothes on but Resident #5's penis was exposed with his pants/brief down. The housekeeper stated she had seen Resident #5 grab another resident's (Resident #8) breast before and grabbed at residents' arms when they went by him in the hallway. The housekeeper stated she did not report the witnessed grabbing of Resident #8's breast because nurses and aides were present at the time and were already aware of the incident. On 5/9/19 at 10:00 a.m., the director of nursing (DON) and administrator were interviewed about Resident #7's abuse on 4/13/19. The DON stated Resident #5 had a history of [REDACTED]. The DON stated prior to the incident on 4/13/19 with Resident #7, the interventions in place to ensure safety included redirection and separating Resident #5 from inappropriate interactions with other residents. The DON stated they did not want Resident #5 pulling or hanging onto other residents or staff members. The DON stated supervision was the main intervention along with attempting to anticipate things. The DON stated they also tried to provide consistent caregivers for Resident #5. These findings were reviewed with the administrator, director of nursing and corporate consultant during a meeting on 5/9/19 at 10:30 a.m. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS was a quarterly assessment with an ARD of 03/28/2019. Resident #6 was assessed as severely impaired in her short and long term memory and daily decision making skills. Resident #6's clinical record was reviewed on 05/08/19 at approximately 3:00 p.m. An Interdisciplinary Progress Note dated 4/16/19 included: Resident involved with another resident who was sexually inappropriate by being observed having one hand in her pants and one hand on her breast in the dining area x2 (times two) this evening . A note dated 4/17/19 7p-7a: Resident rested well with no signs or symptoms of distress or anxiety. Verbally states 'I am okay.' 'No, I am not in pain.' . A second note dated 4/17/19 7a-7p: Resident s/p (status [REDACTED]. No unusual behaviors. No c/o (complaints of) pain/discomfort . No further documentation was noted in the clinical record. The Director of Social Services was interviewed at 3:30 p.m. on 5/8/19 regarding any follow-up visits with Residents #6 and #7. She stated, We did not interview either of those ladies. I really can't tell you why. Sometimes the nurses document everything and sometimes we do. If I don't know about it directly, then I don't document. If I do an interview or evaluation then I document it in the record. At 5:30 p.m. the DON was interviewed regarding expectations of the Social Worker. The DON stated, There is no policy. It is a reasonable expectation they would do an assessment. The CCP for Resident #6 did not include any documentation regarding the incident from 4/16/19 or any documentation for emotional or physical distress. On 5/8/2019 at 2:45 p.m., LPN #1 (licensed practical nurse) and also UM (unit manager) was interviewed regarding if an assessment was completed on Resident #6 on 4/16/19. LPN #6 stated, LPN #4 did complete a head to toe assessment. It was documented on a skin evaluation sheet. Perineal area was assessed. No issues were noted. She (LPN #4) handed me the assessment when completed and I gave to (Name) DON. There were no changes in her (Resident #6) behavior after the incident. CNA #1 was interviewed at 2:55 p.m. regarding the incident between Resident #5 and Resident #6 that occurred on 04/16/2019. CNA #1 stated, I was in the dining room charting. He walked up behind her and put his hand down her shirt. We moved him to the other side of the room. He walked right back over to her and put his hand down the back of her pants. That's when we took him to his room. He was up on his roommate's bed after we took him back to his room. I never saw him touch any other residents until (Name) Resident #6. He would touch staff and say sexual things. We would redirect him and he would stop. Some days he wouldn't do or say anything sexual and other days we would take him to his room, give him lotion and tissues and let him go at it. LPN #2 was interviewed at 3:05 p.m. regarding Resident #5 and his behaviors. LPN #2 stated, He would walk by and grab your (staff) butt, a firm grab. Prior to (Name) Resident #7 I had not seen him do anything to another resident. RN #1 (registered nurse) was interviewed at 3:10 p.m. regarding the incident on 4/16/19 that involved Resident #5 and Resident #6. RN #1 stated, He (Resident #5) put his hand on her breast on the outside of her shirt and put his hand down her pants. She just sat there. She can be verbal, but not appropriately. Actually, another resident yelled out. We redirected him and then he did it again. That is when we removed him from the dining room. (Name) Unit Manager stated there had been another episode over the weekend with another resident. They tried to get him to the ER then. I don't know if he went or not. I was working the Northside of the unit that day and she was on the Southside. I did notice a change in her (Resident #6), but nothing I could put my finger on to document. Like I said, I was working the other side of the unit that day and wasn't directly caring for her. I did ask the UM what the long term plan for him was because he could not be redirected or calmed down. That is when we called and got an order to send him out to the ER. LPN #16 was interviewed on 05/09/2019 at 8:40 a.m. regarding an incident on 2/8/19 with Resident #5 and an unidentified resident. LPN #18 stated, I don't remember anything other than what I wrote there. I called Dr. (Name) and she gave a med order. I gave it at 2:20 p.m. when it came in and then I leave at 3:00. I don't usually work that unit. I believe I was pulled over there that day. LPN #4 was interviewed at 8:50 a.m. regarding the incident on 4/16/19 with Residents #5 and #6. LPN #4 stated, I believe I was working the day of (Name) Resident #6. I didn't witness anything. I took him to his room and the other nurse working contacted everybody. I never saw him touching anyone. He never said anything inappropriate to me and I never heard him say anything to anyone else. Regarding Resident #6 and any changes in her behavior or demeanor, LPN #4 stated, I haven't noticed any changes in behavior for her. I did do a head to toe assessment including the peri area that day. I didn't find anything. The DON was interviewed at 9:55 a.m. on how Resident #5 's behaviors were handled by staff. The DON stated, Ongoing monitoring. Re-direct, re-direct, re-direct. Separate him. Med management. He responded very well to one CNA, so we would try to assign that CNA to him. He was really good at redirecting him. At 10:00 a.m., NP #1 (nurse practitioner) was interviewed regarding the two incidences with Resident #5 and Residents #6 and #7. NP #1 stated, I wasn't on-call for the first incident (with Resident #7), but talking to (Name) NP #2, from memory the facility called her about this resident (Resident #6). The police refused to take Resident #5 without an ECO. We do not go to the magistrate and get an order to ECO somebody. We are on-call for several different places and we can't do that. (Name) NP#2 is working today, but in clinic right now. I will ask her to call you, but I don't know what time that will be. At 10:25 a.m. the DON was interviewed regarding Resident #5 and the incident with Resident #7 that occurred on 04/13/19 and then the incident with Resident #5 and Resident #6 that occurred on 04/16/19. The DON stated, We tried to get him out of here on the 13th. APS (adult protective services) was here and the police were here. EMS (emergency medical systems) refused to come and transport him (Resident #5). The police told them (EMS) they were here and he (Resident #5) was sitting in a chair and was calm. APS spoke with EMS also, and they still refused. Reagarding Resident #5's behaviors and the nursing note from 4/14/19. The DON stated, The police and APS were here again and EMS refused to come and transport him (Resident #5) again. Regarding if the Medical Director was involved in trying to get Resident #5 out to be evaluated, the DON stated, I don't know who all they were getting orders from. He was aware of the situation. That's all I can say. Regarding the incident that occurred on 4/16/19, the DON stated, EMS refused to transport this day also. We had to go to the magistrate and get an ECO. The police then transported the resident to the hospital. At 12:35 p.m. LPN #15 was interviewed about an incident that occurred on 2/16/19 with Resident #5. LPN #15 stated, I do remember the incident, but I can't remember who the female resident was. Regarding the incident on 4/14/19 involving Resident #5, LPN #15 stated, I wrote that note. Yes, he grabbed my wrists and tried to pull me in his room. I called the police because he had become aggressive. He had gone over the top. I was going to press charges, but the Commonwealth told me they wouldn't charge him because of his dementia, [MEDICAL CONDITION] and he was on a locked unit. He always had behaviors, coming out of his room nude, making sexually inappropriate comments, touching people. I know they did several medication changes, but other than that, no, I don't think anything was done. The NP on that day was great. She was going to come from (City Name) and have him committed that night. I couldn't get him into (Psych Hospital Name). That is why he wasn't sent out. I was very upset and the nurse coming on was upset also. How was one nurse and one CNA going to handle him? What if there was an emergency on the unit? At 1:20 p.m., NP #2 was interviewed. NP #2 stated regarding Resident #5's behaviors on 4/14/19, I got a call the resident was exhibiting aggressive behaviors. I believe he had grabbed a staff member, causing bruising. Staff were not safe, so I thought, send him to the ER for evaluation. I then got a call that the police couldn't take him because he wasn't homicidal or suicidal and was not exhibiting aggressive behavior at the time. The same thing with EMS. That is when I thought he may could get some good rest that night so I canceled the ER order and ordered an extra dose of [MEDICATION NAME]. I did not get anymore calls that night. The facility's policy titled Abuse, Neglect, Exploitation & Misappropriation (revised 11/28/17) documented, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property .Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property .Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to .Unwanted intimate touching of any kind especially of breast or perineal area .sexual contact is non-consensual if the resident either .Appears to want the contact to occur, but lacks the cognitive ability to consent .The Company recognizes that resident abuse can be committed by other residents, visitors, or volunteers .The center is committed to the prevention of abuse, neglect, misappropriation of resident property .The following systems have been implemented .Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indications of abuse . No further information was received by the survey team prior to the exit conference on 05/09/19. This is a complaint deficiency.

Based on resident interview, staff interview, clinical record review, facility document review and during the course of a complaint investigation, the facility staff failed to ensure one of 8 resident's were free of abuse; Resident #1 was involuntary confined against her will. Resident #1 was put to bed against her will by a staff member. After the resident told the staff member multiple times, yelling and screaming that she did not want to be put to bed, the staff member proceeded to put the resident to bed against her will and refused to get the resident up. Findings include: Resident #1, was originally admitted to the facility on [DATE], with the most current readmission on [DATE]. [DIAGNOSES REDACTED]. The resident's most current MDS (minimum data set) was a quarterly assessment dated [DATE], and documented the resident was a 9 cognitively, indicating the resident had moderate impairment in daily decision making skills. The resident was assessed as requiring extensive assistance for bed mobility and dressing. The resident was assessed as requiring total assistance for transfers, toileting, eating, and bathing. The resident was assessed as requiring extensive assistance for all other ADL's (activities of daily living). In section G0300. Balance During Transitions and Walking the resident was assessed and an 8 (activity did not occur) for moving from seated to standing, walking, turning around, and moving on and off toilet. The resident was assessed as not steady, only able to stabilize with staff assistance for surface to surface transfers. The resident was additionally assessed as having impairment on both sides (right/left) for upper and lower extremities for functional limitations in range of motion. On [DATE] at approximately 5:00 PM, the investigation for Resident #1 regarding allegations of abuse for Resident #1 were requested. On [DATE] at 9:30 AM, the investigation was presented and reviewed. The investigation documented the following: A facility reported incident was filed and completed on [DATE] for an incident that occurred on [DATE] regarding Resident #1. The description of the incident documented, XXX[DATE] .two residents (no names documented) came to the DON's (Director of Nursing) office, ADON (Assistant Director of Nursing) and ED (executive director) were in attendance. The two residents alleged that on Saturday [DATE], (Resident #1) was 'mistreated' by staff. Both residents stated (Resident #1) was yelling louder than usual while receiving care .Employee action: None. Investigation completed and no action necessary .Facility internal investigation: Completed on [DATE] . The following statements were attached to the above facility investigation: A statement by RN (Registered Nurse) #3 (nurse on duty 4//,[DATE]) documented, XXX[DATE] (Resident #1) was extremely upset, crying and hollering .medicated at 1500 .continued to be upset .assessment completed and was negative, vital signs WNL (within normal limits). (CNA #4) told resident that 'if you don't get it together, I'm putting you to bed.' Subsequently during my medpass, (CNA #4) puts resident in her bed. Resident continues to get even more upset .(Resident #1) expressed to me that she did not want to stay in the bed. I returned to the nurses station and asked (CNA #4) if she could please go and get resident out of bed, she (CNA #4) quickly responded, 'No.' She (CNA #4) said, 'you don't know these residents, I've worked here for three years.' (CNA #4) immediately called the unit manager (LPN/licensed practical nurse #13) .signature of RN (#3) [DATE] .signature of DON [DATE] A statement by CNA #4 (alleged perpetrator), dated [DATE] documented, .I, (Name of CNA #4) was in the process of laying (Resident #1) down and she began to scream loudly. (Names of 3 residents) came to (Resident #1's) window to she (sic) why she was screaming, I told them 'she was fine' and continued to get her situated I finished cleaning her and laying her down, when I came out her (sic) room the same residents that came to her window were now at her door waiting for me to come out. When I did (Resident #10) said to me 'I (CNA) need to get (Resident #1) back up or he was going to report me for torturing her.' I then said to him that I didn't have to explain anything to him regarding (Resident #1) and walked away. I let the charge nurse (RN #3) what (sic) had just happened, I also notified unit manager and DON of the issue .signature of CNA #4 date: [DATE] .signature of DON date: [DATE]. A typed witness statement by the administrator documented in summary that on [DATE] (Name of Resident #9 and Resident #10) made an allegation that Resident #1 was mistreated by a staff member, to which they were unable to name alleged staff member, on [DATE]. They provided details of the situation and felt the resident was being mistreated. It was determined not to have been mistreatment as the staff were attempting to assess and treat the resident for a change of condition. On [DATE] the two residents did not provide any additional details of the occurrence. Once they were finished detailing their concerns, they were assured that the ED and DON were aware of the situation in which they were describing and felt that while their concerns were valid, the resident was not being mistreated based upon firsthand knowledge gained by the DON. A typed witness statement by the DON documented, in summary, that on [DATE] at approximately 2:30 PM, the DON received a text message from the unit manager (LPN #13) that there was an issue on the unit between CNA #4 and RN #3. Immediately after the text message, CNA #4 called the DON and stated that something was wrong with Resident #1 and that she had put the resident to bed and RN #3 stated that the resident was fine and she needed to be gotten back up. The DON got off the phone with CNA #4 and called the nurses station to speak with RN #3. RN #3 stated that she had checked the resident's vital signs and they were normal and that the resident wanted to get up but CNA #4 refused for the resident to get up. RN #3 stated that she and CNA #4 had an argument about it and CNA #4 was refusing a work assignment. The DON told RN #3 that she thought CNA #4 was advocating for the resident. Neither the nurse (RN #3) nor CNA #4 received disciplinary action. On [DATE] a staff member (not named) came to the DON's office and reported that Resident #9 and Resident #10 were talking about Resident #1 being abused. The DON immediately went to the unit and requested that both residents come to her office. They came the office, the ED was present and stated they believed Resident #1 had been abused. The DON explained to them that she understood their perception. On [DATE] at 9:45 AM, the DON (director of nursing) and administrator were interviewed with the survey team present. The DON was asked if CNA #4 was a current employee. The DON stated that she was and that CNA #4 had worked yesterday. The DON stated that two residents were saying that a CNA (unidentified) was mistreating Resident #1 and that the allegations were unsubstantiated because they didn't know who the CNA was and that the residents did not provide a name of the CNA. The DON stated that the resident was in crises and that CNA #4 was acting as an advocate. The DON was asked what the crises was and the DON stated that the resident had been complaining of chest pain and right arm pain. The DON stated that the staff had called her regarding the crises and they were trying to figure out a treatment option. The DON was asked if this resident was in such a crisis, why the resident was not sent out for evaluation. The DON stated that they do an assessment first and that is why the CNA was putting the resident to bed, to get an assessment. The administrator and DON stated that the residents did not give a name as to which CNA was mistreating or abusing the resident. The administrator and DON stated that they interviewed the two residents and no information was provided to help them identify which CNA it was. The administrator stated that the residents did not provide a name and did not even give a description to help with identification. Interviews were conducted with Resident #9 and Resident #10, both resident's most current MDS information was reviewed prior to the interviews and revealed that both residents were assessed with [REDACTED]. On [DATE] at 2:50 PM, Resident #9 was interviewed regarding being a witness to the above incident with Resident #1. Resident #9 stated that it happened in the hall and that she was right outside of her door, and saw the whole thing. The resident stated that she was standing in the hall waiting for her lunch tray, at her room, right outside the door (actually standing in the hall). Resident #9 stated that this occurred around lunch time, because staff were passing out lunch trays and that CNA #4 (named the CNA) had brought a lunch tray to her roommate, but had not brought hers yet and she was standing in the hall waiting on hers. Resident #9 stated that Resident #1 was in her wheelchair heading toward the nurse's station when CNA #4 went up the hall and grabbed her wheelchair by the handles and began pulling her backwards towards the resident's room. Resident #9 stated that she didn't see that Resident #1 was doing anything wrong, but once the CNA grabbed her and started pulling her backwards she began yelling and screaming. Resident #9 stated that Resident #1 was yelling and screaming and saying to the CNA, please don't put me to bed, I don't want to go to bed and kept on repeating that over and over again. The resident stated that the CNA pulled her all the way down the hall backwards and into her room and slammed the door shut. Resident #9 stated that Resident #1 was screaming and yelling the whole time. Resident #9 stated that a short while later around 1:00 PM, she and Resident #10 and another resident went out to smoke. Resident #9 stated that Resident #1 was still screaming and yelling and that the courtyard/smoking area is ground level with this unit and Resident #1's room window was open to the courtyard. Resident #9 stated that she and Resident #10 went toward the resident's window to see if she was ok and that CNA #4 pulled the blind back and asked them, what we were looking at and shut the blind back. Resident #9 stated that they tried to report it, but no one wanted to listen. Resident #9 stated that they told the nurse (named RN #3) and asked, can't you do something. The resident stated that the nurse didn't do much of anything and told them, it was out of her hands. Resident #9 stated that she and Resident #10 went down to speak with the DON and administrator, on either Monday ([DATE]th) or Tuesday ([DATE]th); that she thought it was (MONTH) 8th because it was after Resident #1 died . The resident stated that DON and administrator didn't want to hear from the residents and stated they told them what was heard and seen, and they told us that CNA #4 was doing exactly what she was supposed to be doing. On [DATE] at 3:05 PM an interview was conducted with Resident #10. Resident #10 stated that CNA #4 (named the CNA) was trying to put Resident #1 to bed in the afternoon and Resident #1 was begging, No, No I don't want to go to bed. Resident #10 stated that Resident #1 was screaming for all she was worth and she just kept yelling and screaming that she did not want to go to bed. Resident #10 stated that he went to the nurse's station and talked to the nurse (named -RN #3) and the nurse told CNA #4 to let Resident #1 stay up and CNA #4 told the nurse that she was putting her to bed and that's that. Resident #10 stated that he looked at RN #3 and she just threw her hands up and stated, It's out of my hands. Resident #10 stated that after Resident #1 died , either Monday or Tuesday that he and Resident #9 had a meeting with the DON and administrator and told them exactly what CNA #4 had done and the DON and administrator told the residents that CNA #4 was doing exactly what she was supposed to. Resident #10 stated, We were appalled! Resident #10 stated that the DON and administrator did not want to hear the residents. An interview was conducted with RN #3 on [DATE] at 3:50 PM. RN #3 stated that she is an agency nurse, but has worked at the facility for a while and knew Resident #1 well. RN #3 stated that Resident #1 wasn't having a very good day. RN #3 stated that CNA #4 was taking Resident #1 to her room and the resident was screaming and hollering. RN #3 stated that the resident yelling out was not an unusual occurrence for the resident, but on this day CNA #4 told the resident If you don't get your act together I'm going to put you to bed. RN #3 stated that the resident was saying, Please don't put me to bed repeatedly and CNA #4 took her straight down the hall to her room. RN #3 was asked when the CNA took the resident down the hall if she pulled the resident backwards down the hall. RN #3 stated, Yes, I saw her (CNA #4) pulling her (resident) backwards down the hall. RN #3 stated that she finished what she was doing and she and another CNA went down the hall to check on Resident #1. RN #3 stated that they were trying to get the resident calmed. Resident #1 was asked by RN #3 if she (resident) wanted to stay in bed and resident stated, No. RN #3 stated that once the resident was talked to she'd (resident) calmed down and RN #3 stated that she went and asked CNA #4 to Please get Resident #1 out of bed, CNA #4 stated, No. RN #3 stated that within minutes of that conversation CNA #4 went and got on the phone with the unit manager (LPN #13) and then the DON. RN #3 stated that she visually saw CNA #4 pulling the resident backwards down the hall and the resident was yelling and hollering that she did not want to go to bed and CNA #4 put the resident to bed anyway, even after she was told by the RN to leave her up. RN #3 stated that CNA #4 kept doing what she was doing, while the resident was trying to resist by pushing her feet down on the floor while CNA #4 pulled her backwards. RN #3 was asked if she thought this was appropriate behavior or treatment of [REDACTED].#4 and the RN stated, No, but she (CNA #4) got on the phone (to DON and UM) and I felt defeated at that point. RN #3 stated that she let the DON and UM know her feelings about the situation and that she (RN) spoke to the UM herself and that the UM informed her that she (UM) was not surprised and had problems with CNA #4 in the past. RN #3 stated that she did talk to the DON, but stated she honestly didn't remember what she had said and then stated that Resident #10 came to her and she told him, I'm so sorry. RN #3 stated that she remembered telling Resident #10 that it was out of her hands because she felt defeated when she tried to get CNA #4 to get the resident back up and the CNA refused and then called the UM and the DON. RN #3 stated that CNA #4 acted like that was her plan. On [DATE] at 4:15 PM CNA #4 was interviewed with the survey team present. CNA #4 was asked to describe the events that took place with Resident #1 on [DATE]. CNA #4 stated that she had gotten Resident #1 up that morning around 4:30 AM and later in the day the resident started complaining that her arms and legs were hurting. The CNA stated, I kept telling her if you are hurting I'm going to lay you down. CNA #4 stated that it was reported that the resident had been down in the lobby earlier that day screaming. CNA #4 stated that she laid the resident down around 1:00 PM and that the resident's window was open, which is open to the court yard/smoking area. CNA #4 stated that the resident was screaming and yelling and that it was echoing throughout the courtyard and that three residents came over to the window to see what was going on. CNA #4 stated that she told the residents, I'm doing what is necessary, I said I don't have to explain a reason. CNA #4 stated that she put the blind down in the resident's room and told the agency nurse (RN #3) that she (resident) needs time to herself. CNA #4 stated that the residents were accusing her (CNA #4) of abuse and she went immediately to the nurse's station and called the UM (LPN #13) and called the DON. CNA #4 was asked why she called LPN #13 and the DON, what was going on that she felt the need to call upper management. CNA #4 stated, .because they were accusing me. CNA #4 was asked what the UM said in response to being accused of abuse. CNA #4 stated, Didn't say a lot, thanked me. CNA #4 was asked what the DON said regarding the allegation of abuse. CNA #4 stated, The same thing, not much. CNA #4 was asked for clarification as to what the DON said in response to the allegation of abuse. CNA #4 stated that she didn't say much, she thanked me too. CNA #4 was asked again what was the reason for the immediate phone call to the UM and the DON and the CNA stated, I called because I was being accused of abuse. CNA #4 was asked if that was the only reason for the phone calls to the UM and DON and the CNA stated, Yes. CNA #4 was asked why she continued to take the resident to her room if she was screaming and yelling that she did not want to lay down or go to bed. CNA #4 stated that the resident will often lay down and rest and went on to say that the resident had been up since 4:30 AM and she was yelling. CNA #4 was asked if the resident told her that she did not want to go to bed or that she did not want to lay down. CNA #4 stated, Yes, she did say that. CNA #4 was asked again why she took the resident against her will and laid her down, when it was evident that the resident did not want to be in the bed. CNA #4 stated, That's the thing, she would have been fine. CNA #4 was made aware that the resident did not want to be in bed and did not want to go to bed, but was put in her to bed anyway, against her will. CNA #4 stated that when Resident #1 acts like that the staff normally put her to bed. CNA #4 was asked where did that come from and was asked if that was part of the resident's care plan. CNA #4 stated that she did not know if this was part of the Resident #1's care plan, that it is just what was done. CNA #4 was asked if she pulled the resident down the hall backwards to her room and the CNA stated, No that sounds like a horror movie (laughed). The resident's CCP (comprehensive care plan) was reviewed and documented, behavior problem .yelling out when needs aren't met .frequently crying, curses at staff .depression, anxiety, ineffective coping skills .anticipate and meet needs .explain all procedures before starting and allow her time to adjust .intervene as necessary to protect the rights and safety .approach/speak in a calm manner .remove from situation and take to alternate location as needed .monitor behavior . On [DATE] at 4:50 PM, the administrator and DON were again interviewed in a meeting with the survey team. The DON stated that they report immediately and that they did not feel this was abuse or mistreatment, that they did a 100 % audit and did not reveal any abuse. The DON stated again that the resident was in crises and that CNA #4 was being an advocate. The DON stated that the resident has these behaviors and screams and yells and it is common to lay her down to get her to calm. The DON was made aware that the resident's comprehensive care plan did not identify that Resident #1 was to be put to bed for behaviors. The DON was made aware of the investigation that included interviews from witnesses and staff that were involved, which did not reveal the resident was in crises, but revealed the resident did not want to be put to bed and was done so against the resident's will. The DON was made aware that the resident repeatedly told the CNA, no and the CNA put the resident to bed and the resident had no way of getting up due to the fact the resident was totally dependent upon staff. The DON was made aware that residents have the right to refuse and choose and that no means no. The DON stated, I hear what you are saying. The DON stated, It's not like they described to me. The DON and administrator were made aware of the above interviews and that the information was not matching up and that there was no information and/or documentation that the resident was in crises and that the information gathered did not match what the DON and administrator were saying. The DON stated, It doesn't sound like it. On [DATE] at 6:10 PM, the UM (LPN #13) was interviewed via telephone. The UM stated that on [DATE] she received a call from CNA #4 regarding an issue with the agency nurse. The UM stated that CNA #4 told her that the RN #3 told her to get Resident #1 back and that CNA #4 told the RN, No and that CNA #4 had just put her to bed. The UM stated that she told CNA #4 that if the resident is asking to get up, then CNA#4 needs to get her back up. The UM stated that the CNA then told her that this nurse doesn't know her (resident). The UM stated that she had a conversation with CNA #4 a week before regarding this same thing. The UM stated that she was in her office and that she overheard CNA #4 tell Resident #1 that if she didn't stop yelling she was going to put her to bed. The UM stated that she immediately left her office and confronted CNA #4 and told her that she could not do that and that the CNA again responded to the UM, if she keeps yelling like that, I'm putting her to bed. The UM stated that CNA #4 did not put Resident #1 to bed that day after this conversation. The UM stated that she got a call from RN #3 after the conversation with CNA #4 and RN #3 had asked CNA #4 to get the resident up and the CNA refused. The UM stated that she reported this information to the DON via phone and had also let the DON know about what had transpired a week prior with CNA #4 wanting to put the resident to bed and stated that the DON responded back that the situation had been taken care of. The UM stated that she did not receive any follow up as to what happened as a result of her reporting this information to the DON. The UM stated that the staff don't get follow up and don't get any information regarding investigations on things like this. The facility abuse policy (Abuse, Neglect, Exploitation, & Misappropriation) was reviewed and documented, .Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment .willful infliction .unreasonable confinement .willful .individual must have acted deliberately .used as a means to correct or control behavior .humiliation, intimidation, fear, shame, agitation or .isolating a resident from social interaction or activities .Neglect .failure to take precautionary measures to protect the health and safety of a resident .failure to report observed or suspected abuse, neglect .involuntary seclusion .separation of a resident from other residents or .confinement to his/her room (with or without roommates) against the resident's will .seclude the resident .leaving and closing the door .Acts of abuse directed against residents are absolutely prohibited .All employees have a duty to respect the rights of all resident's to treat them with dignity and to prevent others from violating their rights .any .who witnesses or has knowledge of an act of abuse or allegation of abuse, neglect .is obligated to report such information immediately, but no later than 2 hours .any employee shall be deemed to have violated this obligation .fails to report .abuse witnessed or known .makes a false or misleading or incomplete report of abuse .the abuse coordinator or designee shall investigate all reports .immediately the suspect shall be segregated from residents pending the investigation .any suspect who is an employee or contract service provider identified, will be suspend pending the investigation .once an allegation is reported the executive director is responsible for ensuring that the reporting is completed timely and appropriately .protect the rights of residents .report the results of all investigations to the ED (executive director) .any employee who is found to have committed an act of resident abuse shall be discharged from employment . On [DATE] at 10:00 AM, a meeting with the DON, administrator and facility quality specialist, was conducted with the survey team. The facility staff were informed of concerns regarding abuse and neglect of Resident #1 by CNA #4. The DON and administrator stated that they did not know of this allegation until [DATE], even though the interview with CNA #4 revealed that CNA #4 reported the allegation of abuse herself to the DON and the UM via phone on [DATE]. No further information and/or documentation was presented prior to the exit conference to evidence that CNA #4 did not abuse Resident #1 by putting the resident in involuntary confinement.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide supervision to prevent an accident resulting in harm for one of 24 residents in the survey sample: Resident # 24; and also failed to ensure handrails were in good repair on two of three units in the facility. 1. Resident #24, assessed with [REDACTED]. 2. Facility staff failed to ensure the safe condition of handrails. Handrails had damaged areas with sharp exposed edges on the second floor and third floor living units. Findings include: Resident # 24 was admitted to the facility 6/11/03 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 10/7/16 and had Resident # 24 assessed as having moderate impairment in cognition with a total summary score of 09 out of 15. The clinical record was reviewed 7/19/17 beginning at 10:00 a.m. A nurses' note dated 10/16/16 at 7:00 a.m. documented the following: Approximately 6:36 a.m. resident had went downstairs to the lobby, in which resident does everyday and throughout the day, resident went down this morning and went outside through the automatic sliding doors, resident is independently mobile once assisted by (one) into her wheelchair, she uses left sided legrest while up in wheelchair due to post CVA (stroke) though does use right upper and lower extremity to wheel herself, resident lost control of her wheelchair when going outdoors and wheelchair appeared to go down the sidewalk, which does have an incline, and proceeded onto the blacktop approximately 10-15 feet before wheelchair flipped over, resident was assisted immediately by employees (several) coming into work that morning. After interviewing multiple staff members, it is known for sure that resident was not outside at 6:30 a.m. per staff, whom reported to work at this time parking in the nearby parking lot which has 100% view of the facility entrance where resident was noted to have fallen. 1st CNA whom arrived to assist resident arrived at 6:36 a.m. and noticed a wheelchair in the entrance drive of the facility, once she reached resident's side employee called into facility for nurses, nurse arrived outside and phoned 911 immediately, resident was assessed by several nurses, 911 EMT's arrived within approximately 5 minutes and took over assessing pt., pt. was not moved until EMT's were ready to transport her to local hospital, resident was noted to have some abrasions/ injuries to her face, unsure what other injuries may have as well, writer notified DON immediately as well as calling RP, whom did not answer, message was left. Charge nurse for 7 p.m.-7 a.m. spoke with hospital person, history and physical and med list given to EMT's. 10/16/16 8:30 a.m. VDH, APS,Ombudsman all notified of above incident. 10/16/16 8:40 a.m. (name of doctor) notified of fall, . 10/16/16 9:30 a.m. writer spoke to hospital charge nurse, nurse verified that resident had broken her left hip and was being admitted , charge nurse also verified that they did speak with RP. The care plan for Resident # 24 was then reviewed. The care plan for safety included: Focus: The resident has the potential for injury related to poor safety awareness, history of stroke with left sided weakness, impaired vision, dementia with behaviors, communication deficit where she usually understands, .history of falls as evidenced by decreased mobility. Under Goals documented The resident will not injure themselves in a fall through next review. The resident will not sustain serious injury through next review. (It should be noted here that due to the clinical record reviewed as a closed record, the electronic portion for the care plan did not indicate a date as a discharged resident). Interventions for the safety care plan included Assess resident ability with hot liquids; Be sure call light within reach; Encourage resident to report any safety concerns to nurse; Maintain clear pathway, free of obstacles However, there was not a care plan to address the resident going outside nor interventions how staff were going to address keeping the resident safe for that activity. On 7/19/17 at 10:45 a.m. the DON (director of nursing) was interviewed about the incident. The DON stated (name of resident # 24) usually went outside to 'porch sit' she did that all through the day; she had not been assessed to be an elopement risk. The DON was asked for the investigation of the incident. The DON also asked at that time if surveyors were looking at a harm level deficiency, would we tell them. This surveyor told the DON that the survey team was considering harm for this particular resident. On 7/19/17 at 10:45 a.m. the DON (director of nursing) was interviewed about the incident. The DON stated (name of resident # 24) usually went outside to 'porch sit' she did that all through the day; she had not been assessed to be an elopement risk. The DON was asked for the investigation of the incident. The investigation was reviewed, to include witness statements. The witness statements were consistent in several staff documenting that upon arriving to work between 6:40 a.m. and 6:50 a.m. an empty wheelchair was observed near the front entrance of the facility, and the resident was observed on the ground. Depending upon the time of arrival, staff either observed the resident on the ground, or observed the emergency staff already in place. There were no witness statements from staff already in the building on the night shift; therefore, it was not known by staff interviewed what time the resident actually left the building; only when she was found by staff arriving for the day shift. The DON confirmed staff on the floor did not see the resident leave the floor. (The resident was on the second floor during her stay; the only elevator to accommodate a wheelchair was located towards the back side of the unit). On 7/19/17 at 1:45 p.m. LPN (licensed practical nurse) # 2, who was the current unit manager, was interviewed about the incident. LPN # 2 was still working in the facility, and had been a witness to the incident. LPN # 2 stated I've worked here for years, and knew the resident fairly well as I worked here since 2001, and she was a resident here from 2003 until that incident. She would go all over the building once staff got her up, dressed, and in her wheelchair. She mainly just stayed within the building, but would also go to the lobby to look for her daughter. She was always telling me that her daughter was coming to visit, and she wanted to go to the lobby to look for her. Sometimes I would go down to the lobby with her so I could show her that her daughter wasn't down there, and get her to come back upstairs. I do remember telling the previous unit manager, who is no longer here, that she shouldn't be allowed to go downstairs unattended. She had never done anything before, but she had dementia and you just never know when a thought hits them what they'll do, but I was told that was against her rights. She had never gone outside at that time of morning before. On 7/19/17 at 3:15 p.m. the receptionist, who has a desk in the front lobby, was asked if she was working the morning the resident went outside and fell . The receptionist stated Well, I come to work between 7 a.m. and 7:30 a.m. so I would not have seen her exit the building. I was not working the day that happened, but I saw her here in the lobby almost daily, but I never saw her go outside. On 7/19/17 during an end of the day meeting with facility staff beginning at 4:50 p.m. the administrator and DON were informed of the above findings and the potential for harm. The administrator and DON appeared to understand the significance of the event. On 7/20/17 at approximately 10:00 a.m. the DON asked this surveyor if she could present additional information of the incident. This surveyor said yes, and the DON brought in a copy of minutes from a quality assurance meeting which had been held after Resident # 24 had fallen. The documentation included a plan of action for the provision of supervision to prevent accidents, elopements, and falls with injuries. The action plan was dated with a date of compliance 10/20/16. The DON asked if past noncompliance could be considered. This surveyor advised the DON that due to other current deficient practice falling within the same area, past noncompliance could not be considered. The DON verbalized her understanding. No further information was provided prior to the exit conference. THIS IS A COMPLAINT DEFICIENCY. 2. Facility staff failed to ensure the safe condition of hand rails. Hand rails had damaged areas with sharp exposed edges on the second floor and third floor living units. On 7/20/17 at 7:30 a.m. the second floor living unit was inspected. When exiting the small elevator on the second floor there was a broken, separated section of hand rail at the corner below the directory sign. On the second floor unit identified as 2 N/S, the hand rail outside room 210 had a crescent shaped crack (about 1 1/2 inches long) along the bottom with a sharp pointed edge exposed along the rail. There was an approximately 3/4 inch gap in the hand rail outside of room 212 where sections of the rail had separated. The hand rail section between rooms 214 and 216 had a very sharp edge along the bottom about midway the rail. This section of rail had two broken places where the rail sections connected. Near the entrance to the courtyard area the corner section of the hand rail was separated. Residents were observed on this unit ambulating and self-propelling in wheelchairs along the hallways. On 7/20/17 at 7:50 a.m. the licensed practical nurse unit manager (LPN #6) was shown the damaged, unsafe handrail sections and interviewed about the rails. LPN #6 stated the damaged areas were sharp and she had not noticed them before. LPN #6 stated she would get maintenance to repair the rails. On 7/20/17 at 8:10 a.m. the third floor living unit identified as 3 N/S was inspected. The hand rail outside room 306 had a sharp exposed corner where the rail section was damaged. This was shown to the maintenance director at the time of the observation. The maintenance director stated he was not aware of the damaged hand rails until today. These findings were reviewed with the administrator and director of nursing during a meeting on 7/20/17 at 11:45 a.m.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide supervision and safety devices for fall/injury prevention for two of 25 residents in the survey sample. 1. Facility staff failed to provide a chair alarm and supervision to Resident #7 as required by a post-fall assessment. Resident #7 fell in her room and was assessed to need a chair alarm and 15 minutes safety checks. Resident #7 fell the next day from her wheelchair while unsupervised and without use of a chair alarm. The 15 minute safety checks were not conducted in the hour prior to the fall. The resident sustained [REDACTED]. 2. Resident #3 had no chair alarm in use as required in the plan of care. The findings include: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #7 with short and long-term memory problems and severely impaired cognitive skills for decision-making. Resident #7's clinical record was reviewed on 7/8/14. A nursing note dated 2/22/14 at 3:15 p.m. documented the following: "Called to Rm (room). Res (resident) on floor lying on (L) side, head resting on rail of bottom of roommate (roommate) overbed table...No bruising noted @ this time, no open areas. Res. had been sitting in w/c (wheelchair) in her room (after) being changed for incont. (incontinence) issue @ 2:30 p.m..." (sic) A post-fall investigation dated 2/22/14 documented the resident "got up from w/c (wheelchair) unassisted + fell ." The report listed a chair alarm was implemented after the fall. The form stated in bold letters "Care Plan must be updated." The clinical record documented a post-fall resident safety check form initiated after the fall on 2/22/14. Fifteen minute safety checks were initialed/signed off by nursing staff from 2/22/23 at 3:30 p.m. through 2/23/14 at 9:45 a.m. Resident #7 fell the next day (2/23/14) from her wheelchair while in the day area. A nursing note dated 2/23/14 documented, "9:50 (a.m.) called to Dayroom where res was lying on her (R) Side (with) arm under her + behind her back - c/o (complained of) pain in arm when asked - did not move res. but called 911...they had to dress skin tears of (R) arm near elbow + back of (R) hand. Left facility @ 1015..." The hospital emergency room report documented the resident sustained [REDACTED]. The emergency room report dated 2/23/14 stated, "...brought in with pain in her right shoulder...She (Resident #7) fell out of her wheelchair today...She has got a hematoma on the right side of her head above the eye...She has a large skin tear on the right hand approximately 6 cm (centimeters), almost V-shape. There is also another 3 cm on the right elbow...She had a lot of pain with range of motion of her right shoulder...The skin abrasions were cleaned and SoloSite was placed...As far as her right shoulder, x-rays were taken which reveal a proximal humerus fracture which is significant displacement...As far as her head, I talked to the family...I cannot rule out underlying intracranial injury or hemorrhage...They (family) felt comfortable with holding off on any imaging. They understand that there could be a bleed...The patient was placed in a sling..." This report documented the resident's [DIAGNOSES REDACTED]. The fall investigation dated 2/23/14 documented the resident was sitting in her wheelchair in the dayroom when the fall occurred. The report documented the time of the fall as 10:55 a.m. and listed the resident was last toileted on 2/23/14 at 7:30 a.m. The reported documented the chair alarm was not in use at the time of the fall. The report section titled "Conclusion: (Indicate what may have caused the accident)" was blank. The report included an interview with a cognitively intact resident in the day room at the time of the fall. This report stated, "interviewed Resident regarding incident in dining room. res (resident interviewed) stated that (Resident #7) stood up from wheelchair, tripped + fell . Resident states she began yelling for help and staff came quickly." The last assessment of the resident prior to the fall on 2/23/14 was documented on a neurological assessment flow sheet. This sheet documented the resident was assessed 2/23/14 at 8:15 a.m. and listed the resident was in the dining room at a table at the time of the assessment. The resident's care plan in place at the time of the falls listed the resident was at risk for falls due to her cognitive status, unsteady gait and history of falls. Interventions listed to prevent falls included, "Assess resident's ability to comprehend directions...Assess resident's ability to follow directions...Visual reminders...Medication review...Monitor for orthostatic hypertension...Assure clear pathways in room...Assure adequate lighting...Assure proper fitting shoes...Activities...Call bell within reach...3/4 rails for increase mobility...put res in w/c not plain chair..." Resident #7's care plan made no mention of the resident's fall on 2/22/14 and had not been updated to include use of the chair alarm. The record documented no physician's order for use of a chair alarm. The occupational therapy progress note and discharge summary for Resident #7 documented the resident declined in upper extremity strength after the fractured humerus. The resident started occupational therapy (OT) on 2/24/14 and was discharged on [DATE] with goals not met for wheelchair positioning and good sitting posture as the resident reached her highest possible potential. Prior to the fall the resident was able to maintain proper posture/sitting position in a standard wheelchair. After the fall the resident required the use of a reclining geri-chair for safe positioning when out of bed. The OT discharge report dated 3/21/14 stated, "Pt (patient) is positioned in good alignment and posture in Geri chair during the day...Safety precautions include provision of a chair alarm and vigilant supervision..." On 7/9/14 at 9:30 a.m. the director of nursing (DON) was interviewed about Resident #7's falls. The DON stated the 15 minute checks were initiated as a facility protocol for safety. The DON stated the 15 minute checks were used to check on the resident to be sure they were okay and to "be sure safety interventions were in place." The DON stated she was not employed at the facility in February 2014 when the falls occurred. On 7/9/14 at 10:00 a.m. the certified nurses' aide (CNA #3) that routinely cared for Resident #7 was interviewed. CNA #3 stated the resident had used a geri-chair when out of bed since the fractured arm in February 2014. CNA #3 stated the resident has "never used alarms that I'm aware of." CNA #3 stated she was not working the weekend in February 2014 when the resident had the falls. On 7/9/14 at 10:55 a.m. the licensed practical nurse (LPN #6) caring for Resident #7 on 2/22/14 and 2/23/14 was interviewed. Concerning the fall on 2/22/14, LPN #6 stated the CNA's were "running behind" that day and they got a CNA from another unit to perform incontinence care with Resident #7. LPN #6 stated this CNA left Resident #7 in the wheelchair in her room after changing her brief. LPN #6 stated, "She (Resident #7) was not where we could keep eye on her." LPN #6 stated they usually kept Resident #7 in the hall or day area where staff could watch her as she would attempt to get up unassisted. LPN #7 stated she sometimes brought Resident #7 down the hall with her while giving medications so she could watch her. Concerning the fall the next day on 2/23/14, LPN #6 stated she was the only nurse working on the unit that day along with two CNA's. LPN #6 stated that morning she had a hospice resident requiring hourly medications, was passing medications to other residents and had a resident with a clogged feeding tube. LPN #6 stated after Resident #7 was found in the floor in the day area, "The aides went and got the nurse from the other unit. They couldn't find me." LPN #6 stated, "I was down the hall giving meds (medications). I had a clogged feeding tube and had someone passing." LPN #6 was interviewed about the 15 minute check sheet documenting that she checked the resident every 15 minutes on 9/23/14 from 8:45 a.m. until 9:45 a.m. LPN #6 stated she did not check the resident as documented on the form. LPN #6 stated, "I was the only nurse with two aides." LPN #6 stated, "I tried to check that day. It's obvious I wasn't in the day room." LPN #6 stated the resident did not have an alarm in use at the time of the 2/23/14 fall. LPN #6 stated she was the nurse that completed the post-fall reports. Concerning the use of the chair alarm as listed after the 2/22/14 fall, LPN #6 stated, "That doesn't look like my writing." LPN #6 stated they usually got a physician's order for use of a chair alarm. On 7/9/14 at 4:20 p.m. a facility requested interview was conducted the CNA #5 that was working on Resident #7's unit on 2/23/14. CNA #5 stated she had seen Resident #7 not long before the fall sitting at a table in the day area. CNA #5 stated she was down the hall answering a call bell and when she came back to the area Resident #7 was in the floor. CNA #5 stated the resident had no chair alarm in place at the time of the fall. CNA #5 stated, "It looked like the chair slid back. The wheelchair wasn't locked." On 7/10/14 at 8:10 a.m. the physical therapist (PT) and certified occupational therapy assistant (COTA) that treated Resident #7 after her fractured arm were interviewed. The PT stated after the fracture Resident #7 could not maintain proper position in a standard wheelchair. The PT stated different types of chairs/cushions were tried with Resident #7. The COTA stated the resident declined after the fracture as the resident "was no longer able to maintain her position" when seated. The COTA stated the resident was now in a geri-chair for comfort as she was unable to keep proper positioning in a standard wheelchair. The facility's post-fall investigation for the 2/22/14 fall documented a chair alarm would be implemented for fall/injury prevention. This alarm was not in use with the resident on 2/23/14 when she fell resulting in a fractured arm, skin tears and a hematoma to her head. The 15 minute safety checks were not performed in the hour prior to the fall as required in the facility's post-fall protocol. The resident's care plan was not updated regarding the fall on 2/22/14 or use of a chair alarm. These findings were reviewed with the administrator and director of nursing on 7/9/14 at 2:20 p.m. 2. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a significant change with an assessment reference date (ARD) of 5/13/14 coded the resident being assessed by staff as having both long and short term memory loss and needing assistance with decision making. On 7/8/14 at 1:45 p.m., the resident was observed in the dining area in a wheelchair. No chair alarm was observed. On 7/9/14 at 8:10 a.m., the resident was observed being fed breakfast in the dining area in a wheelchair. No chair alarm was observed. The clinical record was reviewed on 7/8/14 and 7/9/14. A nurse's note documented "6/2/14 - Res (resident) fell at 6:50 a.m." The current care plan for falls with an implementation date of 12/5/13 and a target date of 9/2/14 included the intervention for bed and chair alarms, implemented on 6/2/14. A 6/3/14 verbal physician's order sheet documented "2. Chair alarm while in chair. 3. Check for placement and functionallity q (every) shift." On 7/9/14 at 9:30 a.m., the unit manager and this surveyor observed the resident in the dining area. No chair alarm was observed. The unit manager stated "I will have to check to see if she is supposed to have a chair alarm." At 9:40 a.m., the unit manager advised this surveyor that the resident was to have a chair alarm on and went to see if it was in her room. The unit manager came out and went into a supply room and brought out a chair alarm. At 9:45 a.m., the unit manager stated "there is a call to maintenance for batteries. The battery in the chair alarm was not working." At 9:50 a.m. the chair alarm was in place. On 7/9/14 at 1:25 p.m., the administrative team was made aware of the findings during a meeting with the survey team. No other information was provided to this surveyor prior to the exit conference on 7/10/14.