Every finding on record at Summit Ridge Skilled Nursing & Rehabilitation

Based on observation, staff interview, review of facility policy, and review of the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 kitchen, and failed to ensure outdated food was disposed of in 1 of 2 nourishment refrigerators. The census was 49. The findings were: Regarding sanitary environment 1. Observation on 6/17/26 beginning at 10:08 AM showed cook #1 donned gloves and performed various tasks in the kitchen; she placed frozen garlic bread on a sheet pan, entered the walk in refrigerator and exited with 2 containers that she took to the dish room, cleaned a thermometer, removed lasagna from the oven and checked the temperature, removed the vegetables from the stove and took the temperature, tested the sanitizer bucket, wiped down the counters, placed pans in the steam table, placed bread into the oven, placed lasagna into the steam table, checked the bread in the oven by lifting a piece up with gloved left hand, pureed lasagna and placed into a container, removed garlic bread out from oven and placed into containers wearing gloves and used a spatula and gloved hand to touch bread. She threw the parchment away, took the pans to the dish room, dished out vegetables, and used a gloved hand to remove vegetables out of the container and pureed, then covered the vegetables and put them into the oven. She made gravy and mashed potatoes, removed the pureed vegetables from the oven and placed them into the steam table, and took the temperature of all foods in the steam table. At 11:16 the cook doffed her gloves, washed her hands, and donned new gloves. She then set up the service area, removed chips out from boxes in the dry storage room, looked through the meal cards, and began plating food to send to Hall 3. She used gloved hands to place bread on plates, and touched the lasagna with her left hand when she cut it. At 12:21 PM she washed her hands and donned new gloves, placed a pan of lasagna in the steam table, opened a can of soup and cooked it in the microwave, and continued with tray service. At 1:11 PM she cleaned the thermometer, took the temperature of the test tray and touched the bread and vegetables with her left, gloved hand when she temped the food. 2. Observation on 6/17/26 at 10:08 AM showed dietary aide #1 donned gloves and prepared various tasks in the kitchen; she mixed drinks in pitchers, lifted the garbage can lid with gloved hands and threw garbage away, and prepared coffee. She removed a coffee filter and scooped coffee grounds into the filter. She washed coffee carafes in the sink, and lifted the lid of the trash can. At 10:27 AM she doffed her gloves, washed her hands, and donned new gloves. She made labels for drink containers, placed coffee grounds in the filter, and carried a carafe of coffee to the dining room. At 10:36 AM she washed her hands and donned new gloves, filled carafes with hot water, and wiped the counters. At 11:03 AM she doffed gloves, washed her hands. donned new gloves, and set up a container of ice and a scoop by the drink station. Without changing gloves, she placed cookies onto plates. 3. Interview on 6/17/2026 at 1:26 PM with the administrator revealed she expected dietary staff only touched food with gloved hands when at the service line. She stated if they left the service line they should take the gloves off and put new ones back on when they returned to the line. She stated they should use a tong or clean gloves to pick up bread and cookies. 4. According to the 2022 FDA Food Code showed 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. Regarding outdated food 1. Observation on 6/17/26 at 5:25 PM showed 4 cups of yogurt with a use by date of 6/12/26 in the Hall 3 nourishment refrigerator. 2. Interview with the administrator. on 6/17/26 at 5:29 PM revealed the refrigerator contained food for residents' consumption. 3. Review of the policy titled Date Marking for Food Safety last revised 5/26 showed .5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest .7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly .

Based on staff interview, and policy review, the facility failed to ensure the dietary manager met the required qualifications. The census was 49. The findings were: 1. Interview with the administrator on 6/15/26 at 12:25 PM revealed the facility did not have a dietary manager. Further interview confirmed the facility had a contract dietitian who did not work full-time in the facility. 2. Review of the policy titled Dietary Services-Staffing last revised 5/26 showed 3 .If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility will designate a person to serve as the director of food and nutrition services who: .i. A certified dietary manager; ii. A certified food service manager; .

Based on observation, resident and staff interview, and policy review, the facility failed to ensure comfortable and safe temperature levels between the temperature range of 71 to 81 degrees F, in 1 of 2 dining areas (main dining room). The census was 49. The findings were: 1. Interview with Resident #35 on 6/15/26 at 4:11 PM revealed the temperature was sometimes cold, especially in the dining room. S/he revealed the facility ran the air conditioner all the time in the dining room. 2. Interview with Resident #2 on 6/15/26 at 4:02 PM revealed the dining room was cold and facility staff had to provide something on his/her shoulders during meals. 3. Interview with 6 residents during the resident council meeting on 6/16/26 at 10:29 AM revealed the dining room and hallways were always cold. 4. Observation on 6/15/26 at 5:07 PM showed the main dining room felt cold in temperature. Observation showed 9 residents in the dining room at that time, 1 was wearing a coat, 1 had a blanket wrapped around his/her shoulders, and 2 residents had blankets on their laps. 5. Observation on 6/17/26 at 10 AM showed the dining room felt much colder than the area outside the dining room. 6. Observation on 6/17/26 at 1:22 PM showed the temperature in the main dining room, near the kitchen, registered at 68.6 degrees Fahrenheit. 7. Observation with the maintenance director on 6/18/26 at 10:31 AM showed the main dining room had 66.8 degrees Fahrenheit temperature on the surface of the table height closest to the kitchen. Further observation showed the long table, where residents were performing activities, showed a table surface temperature of 70 degrees Fahrenheit and the air vent closest to the kitchen showed air temperature of 46 degrees Fahrenheit, blowing into the dining room. Interview with the maintenance director at that time confirmed the temperature was colder than 71 degrees Fahrenheit. 8. Review of the facility policy titled Safe and Homelike Environment last revised on 5/2026 showed .7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit .

Based on observation, medical record review, staff and resident interview, and policy and procedure review, the facility failed to ensure residents received appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 sample residents (#29) reviewed for dementia care. The findings were: 1. Review of the comprehensive MDS assessment dated [DATE] showed resident #29 had severe cognitive impairment and had diagnoses which included Alzheimer's dementia, non Alzheimer's dementia, Down syndrome, seizure disorder, anxiety, depression, and bipolar disorder. Further review showed the resident was independent with ambulation. Review of the care plan initiated on 3/24/26 and last updated 6/7/26 showed the resident was at risk for adjustment/psychosocial issues secondary to the need for skilled nursing facility cares, change in routine, and relied on others to assist with activities of daily living. Care plan interventions included daily opportunities for social contact and to encourage him/her to participate in activities of his/her choice. The following concerns were identified: a. Interview with resident #2 on 6/15/26 at 4:02 PM revealed s/he felt at times, there wasn't enough staff to monitor all residents. Observation during the interview showed resident #29 entered resident #2's room uninvited. Resident #2 told resident #29 to get out twice before resident #29 left. No staff intervention was provided. b. Interview with resident #35 on 6/15/26 at 4:11 PM revealed resident #29 wandered into rooms without being invited and it made resident #35 feel like s/he didn't have any privacy. c. Observation on 6/15/26 at 4:24 PM showed resident #29 entered resident #27's room without an invitation. Resident #27 asked resident #29 to leave 3 times before s/he left. Resident #29 returned to the room at 4:29 PM and resident #27 asked him/her to leave again. No staff intervention was provided. d. Observation on 6/16/26 at 11:09 AM showed resident #29 wandered into the room of resident #46. Resident #46 told resident #29 to leave 3 times before the resident left the room. e. Interview with 6 residents during the resident council meeting on 6/16/26 at 10:53 AM revealed resident #29 wandered into residents' rooms and took food out of cupboards and clothing out of closets. Further interview revealed the residents were scared when resident #29 wandered into their rooms. f. Interview with resident #7 on 6/18/26 at 10:31 AM revealed residents wandered in and out of his/her room. g. Interview with resident #24 on 6/18/26 at 10:34 AM revealed residents wandered in his/her room and rummaged through the cupboards. Further interview revealed s/he had told staff during his/her care plan meeting, and s/he would not have that happen in his/her home. h. Interview with resident #9 on 6/18/26 at 11:35 AM revealed resident #29 had wandered into his/her room and s/he told the resident to go to the nurses' station. 2. Interview with the administrator on 6/18/26 at 12:04 PM revealed staff were expected to redirect wandering residents if they were found in another resident's room. Further interview revealed if staff didn't see a wandering resident enter another resident's room, the resident would be expected to call for help. 3. Interview with the regional director of operations on 6/18/26 at 12:12 PM revealed staff were expected to monitor residents who had wandered into another resident's room. Further interview revealed residents chose if they wanted their door closed to prevent wandering. 4. Review of the policy titled Dementia Care last revised 5/26 showed .It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychological well-being.

Based on observation, resident and staff interview, and medical record review, the facility failed to provide food that accommodated the resident's intolerances, and preferences for 1 of 2 sample residents (#40) reviewed for meal preferences. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #40 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact and had diagnoses which included malnutrition, vitamin D deficiency, anemia, cancer, history of a stroke, and hemiplegia, or hemiparesis. Further review showed the resident required set up and clean up assistance with eating. Review of the nutritional care plan last revised on 6/9/26 showed the resident was at risk for nutritional deficits secondary to weakness and a history of a stroke. Further review showed interventions which included honoring food preferences, providing house supplements twice per day, diet and snacks as prescribed, and assisting with meals as needed. Review of the quarterly nutrition evaluation dated 4/24/26 and timed 10:46 AM showed the resident disliked pork, ham, salads, and beets. Further review showed the Resident Interview section included .B. [Resident] has received a copy of the menu and the alternative menu. [Resident] states that [his/her] appetite is ok . ambulates with a wheelchair but prefers to stay in [his/her] room for meals The following concerns were identified: a. Observation on 6/15/26 at 6:06 PM showed the resident was in his/her bed and the residents meal tray was on the bedside table. Further observation showed braised pork, scalloped potatoes, peas, and a dinner roll, which was untouched. Review of the meal intake record for 6/15/26 showed at 5 PM the resident was documented as consuming 0 to 25 percent of his/her meal. Interview with the resident at that time revealed I don't eat pork, it's bad on my stomach, they know I don't eat pork, but they bring it anyway. Further interview revealed the resident was never offered an alternative ahead of time. Continued observation showed an unidentified staff member provided the resident two Uncrustables sandwiches as a meal replacement. 2. Interview with the administrator on 6/17/26 at 1:32 PM revealed the facility had an always available menu and certain items rotated on the list. She revealed residents should have been able to request additional items after all meals were served and if a resident did not eat the meal, the expectation was for staff to offer an alternative meal that was comparable in nutritional value. Further interview revealed the dietary staff should have been aware the resident didn't eat pork, aware of the his/her dislikes, preferences, nutrition assessment requests, and documented care plan interventions.

Based on observation, medical record review, resident and staff interview, and policy and procedure review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 4 sample residents (#33, #40) reviewed for weight loss. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #40 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact and had diagnoses which included malnutrition, vitamin D deficiency, anemia, cancer, history of a stroke, and hemiplegia, or hemiparesis. Further review showed the resident required set up and clean up assistance with eating. Review of the nutritional care plan last revised on 6/9/26 showed the resident was at risk for nutritional deficits secondary to weakness and a history of a stroke. Further review showed interventions which included honoring food preferences, providing house supplements twice per day, diet and snacks as prescribed, and assisting with meals as needed. Review of the quarterly nutrition evaluation dated 4/24/26 and timed 10:46 AM showed the resident disliked pork, ham, salads, and beets. Further review showed the Resident Interview section included .B. [Resident] has received a copy of the menu and the alternative menu. [Resident] states that [his/her] appetite is ok . ambulates with a wheelchair but prefers to stay in [his/her] room for meals The following concerns were identified: a. Observation on 6/15/26 at 6:06 PM showed the resident was in his/her bed and the residents meal tray was on the bedside table. Further observation showed braised pork, scalloped potatoes, peas, and a dinner roll, which was untouched. Review of the meal intake record for 6/15/26 showed at 5 PM the resident was documented as consuming 0 to 25 percent of his/her meal. Interview with the resident at that time revealed I don't eat pork, it's bad on my stomach, they know I don't eat pork, but they bring it anyway. Further interview revealed the resident was never offered an alternative ahead of time. Continued observation showed an unidentified staff member provided the resident two Uncrustables sandwiches as a meal replacement. b. Review of the resident's meal intakes from 5/20/26 through 6/17/26 showed meals were documented 83 times. Further review showed the resident consumed 0 percent to 25 percent 25 times, consumed 26 percent to 50 percent 36 times, consumed 51 percent to 75 percent 16 times, consumed 76 to 100 percent 5 times, and refused 2 times. Further review showed no evidence alternative meals were offered or provided. c. Review of the resident's weight history showed on 12/6/25, the resident weighed 185.1 pounds and on 6/15/26, the resident weighed 160.2 pounds, which was a 13.45 percent Loss. Further review showed on 5/11/26, the resident weighed 177.8 pounds and on 6/15/26, the resident weighed 160.2 pounds, which was a 9.9 percent loss. d. Interview with the administrator on 6/17/26 at 1:32 PM revealed the dietary staff should have been aware the resident didn't eat pork. Further interview revealed the dietary staff should have been aware of the resident's dislikes, preferences, nutrition assessment requests, and documented care plan interventions. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #33 had a brief interview for mental status (BIMS) score of 7 out 15, which indicated severe cognitive impairment, and diagnoses which included renal insufficiency, diabetes mellitus, non-Alzheimer's dementia, and malnutrition. Further review showed the resident required supervision or touching assistance with eating and had experienced a weight loss of 5 percent or more in the last month or 10 percent or more in the last 6 months, which was not physician prescribed. Review of the significant change MDS assessment dated [DATE] showed the resident required supervision or touching assistance with eating and had weight loss of 5 percent or more in the last month or loss 10 percent or more in the last 6 months which was not physician prescribed. Review of the nutritional care plan last revised on 6/17/26 showed the resident was at risk for nutritional deficits secondary to cognitive and age-related deficits. Further review showed interventions which included the resident receiving a house supplement twice per day to help with weight loss and provide assistance with meals as needed. Review of a physician progress note dated 6/12/26 and time 8:45 AM showed a 10 percent weight loss was identified in December 2025 and physical therapy, occupational therapy, and speech therapy were ordered to address functional decline and dysphagia. Further review showed the resident was started on Lasix (diuretic therapy) 20 milligrams (mg) on 1/13/26 to manage bilateral lower extremity edema and the resident received supplements twice daily, a fortified diet, and weekly weights. Review of the resident's weight history showed on 11/9/25, the resident weighed 139.2 pounds (lbs). and on 5/4/26, the resident weighed 119.5 lbs. which was a 14.15 percent weight loss. The following concerns were identified: a. Observation on 6/15/26 at 1:36 PM showed the resident was in his/her room in a recliner and the resident's meal tray was on the bedside table, with the cover still on. Review of the meal intake record for 6/15/26 showed at 1 PM the resident was documented as consuming 0 percent to 25 percent of his/her meal. b. Observation on 6/16/26 at 8:59 AM showed the resident was in bed and his/her meal tray was uncovered on the bedside table. Further observation showed the meal had not been eaten and no verbal cues or physical assistance was offered or provided. Observation on 6/16/26 at 9:03 AM showed the resident's meal remained un-eaten. MA-C #1 entered the resident's room to provide medications and then left the room. No verbal cues or physical assistance was offered or provided. Interview with the MA-C at that time revealed she did not provide or offer the resident's nutritional supplement because the resident doesn't like it. Review of the meal intake record for 6/16/26 showed at 11:46 AM the resident was documented as consuming 26 percent to 50 percent of his/her meal. c. Observation on 6/16/26 at 11:26 AM showed an unidentified staff member entered the resident's room with a meal tray, placed it on the bedside table, and left the room. No verbal cues or physical assistance was offered or provided. Review of the meal intake record for 6/16/26 showed at 1 PM the resident was documented as consuming 0 percent to 25 percent of his/her meal. d. Continuous observation on 6/17/26 from 3:15 PM to 5:49 PM showed the resident was in his/her room, in the recliner and the door was closed. The resident's lunch tray remained on the bedside table. No verbal cues or physical assistance was offered or provided. At 5:49 PM an unidentified staff member entered the resident's room with his/her dinner tray and moved the lunch tray from the bedside table to another table inside the room. The staff member exited the room and closed the door. No verbal cues or physical assistance was offered or provided. Review of the meal intake record for 6/17/26 showed at 1 PM the resident was documented as consuming 26 percent to 50 percent of his/her meal. e. Review of the resident's meal intakes from 5/19/26 through 6/17/26 showed meals were documented 87 times. Further review showed the resident consumed 0 percent to 25 percent 20 times, consumed 26 percent to 50 percent 39 times, consumed 51 percent to 75 percent 14 times, consumed 76 percent to 100 percent 8 times, refused meals 5 times, and was marked not applicable 1 time. Further review showed no evidence alternative meals were offered or provided. 3. Interview with the dietitian on 6/18/26 at 10:03 AM revealed he expected staff to offer alternatives or assistance if a resident consumed less than 50% and staff should be going back to residents to offer something different or offer a supplement, when they pick up the meal trays. Further interview revealed residents should be offered their supplements every time it was ordered and staff should notify administration if a resident didn't like a supplement they were ordered. 4. Interview with the administrator on 6/17/26 at 1:32 PM revealed the facility had an always available menu and certain items rotated on the list. She revealed residents should be able to request additional items after all meals were served and if a resident did not eat the meal, the expectation was for staff to offer an alternative meal that is comparable in nutritional value. 5. Review of the policy titled Nutritional Management last revised on 5/2026 showed .Compliance Guidelines: 1. A systemic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary .

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure proper storage of medications for 1 of 7 sample residents (#46) reviewed for medication administration. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #46 had a BIMS score of 14 out of 15, which indicated intact cognition, and diagnoses which included anxiety disorder, depression, psychotic disorder, and schizophrenia. Review of the admission MDS assessment dated [DATE] showed resident #29 had short-term and long-term memory impairment and decisions regarding tasks of daily life indicated Moderately impaired-decisions poor; cues/supervision required. Further review showed the resident had diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression, bipolar disorder, and down syndrome. The following concerns were identified:a. Observation on 6/16/26 at 11:09 AM showed resident #29 wandered into the room of resident #46, uninvited. Resident #46 asked resident #29 to leave three times before resident #29 left the room. b. Observation on 6/18/26 at 8:30 AM showed MA-C #1 entered resident #46's room to administer medications. At that time, a bottle of fluticasone propionate was observed on the counter near the resident's sink. Interview the MA-C at that time revealed the resident was approved to self-administer the nasal spray and was permitted to store it in his/her room.c. Review of the medical record showed no evidence resident #46 had been assessed to self-administer or store medications.d. Interview with the DON on 6/18/26 at 9:25 AM revealed the medication should have been stored in a drawer or lockbox to prevent wandering residents from obtaining the medication.e. Interview with the DON during the exit conference on 6/18/26 at 4 PM confirmed resident #46 did not have an assessment to self-administer or store medications in his/her room. 2. Review of the policy titled Resident Self-Administration of Medication last revised on 5/2026 showed .6. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in containers dispensed by the provider pharmacy .

Based on observation, medical record review, and staff and resident interviews, the facility failed to ensure timely activities of daily living (ADL) care for dependent residents in 1 of 4 sampled residents (#3) reviewed for ADL care. The findings were:1.Review of the 4/14/26 cognitive evaluation showed resident #3 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of a provider note dated 4/21/26 showed the resident required assistance with personal cares, was not ambulatory, and was unable to perform ADL's independently due to a recent above the knee amputation. Review of the care plan dated 4/13/26 showed the resident was dependent upon staff for incontinence care and had interventions which included .Provide incontinence care after each incontinent episode. and .ADL needs will be met each day. The following concerns were identified:a. Observation on 4/28/26 at 1:56 PM showed resident #3's call light was on. At 1:58 PM an unidentified staff member entered the room and was told by the resident that two staff members were required to provide care. The staff member left the resident's room and the call light remained on. At 2:04 PM the unidentified staff member was observed entering the resident's room, turned off the call light, and exited the room.b. Interview with resident #3 on 4/28/26 at 2:05 PM revealed s/he had waited approximately 45 minutes for the return of two staff members to provide incontinence care and take him/her to the shower. The resident confirmed s/he was dependent upon staff for incontinence care. In addition, the resident revealed it was not unusual to wait an hour or more for incontinent care. c. Observation on 4/28/26 at 2:15 PM showed CNA #1, CNA #2, and CNA #3 entered the resident's room with a mechanical lift and provided incontinence care. The resident stated Might as well take the gown off, it's soaking wet. Continued bservation showed the resident's bedding was removed and the mattress was wet. Interview with CNA #1 at that time confirmed the resident's brief and gown were wet.2. Interview with the DON on 4/29/26 at 11:27 AM revealed Anyone who requires assistance receives the care they need and Staff were expected to answer call lights and provide incontinence care at the time of need3. Review of the incontinence policy last revised 4/2025 showed .All residents that are incontinent will receive appropriate treatment and services.

Based on medical record review, resident representative and staff interview, facility investigation review, and policy and procedure review, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 4 sample residents (#2, #4) reviewed for abuse. This failure resulted in actual harm to resident #2 and resident #4. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #4 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment, and had diagnoses which included dementia, anxiety disorder, and hypertension. The following concerns were identified:a. Review of the facility investigation report dated 1/21/25 and timed 5:58 PM showed on 1/21/25 at 5:22 PM resident #3 grabbed resident # 4 by the arm while attempting to take his/her food tray. b. Review of a progress note for resident #4 dated 1/21/25 and timed 6 PM showed a CNA had observed resident #3 attempting to take a dinner tray from resident #4 and grabbed his/her arm and thumb.c. Interview with RN #1 on 9/17/25 at 1:45 PM revealed s/he was called to the secure unit to assess resident #4 following the incident and visualized bruising and redness on the arm of resident #4. d. Interview with the administrator on 9/17/25 at 2:28 PM confirmed the incident occurred and revealed the resident's representative was notified and agreed to a relocation of resident #4 to another dining table for meals. 2. Review of the admission MDS assessment dated [DATE] showed resident #2 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which included non-traumatic brain dysfunction, dementia, and renal insufficiency. Further review shows the resident was dependent upon staff for transferring, was wheelchair bound and resided on the secure unit at the time of the incident. The following concerns were identified:a. Review of the facility investigation dated 4/12/25 and timed 2:49 PM showed on 4/12/25 at 2:15 PM resident #2 was heard yelling, Get out of my room. The investigation showed CNA #1 responded and found resident # 3 leaning over resident #2, and resident #3 was displaying aggression. Further review showed CNA #1 was able to redirect resident #3 out of resident #2's room and reported observing a red mark on resident #2's cheek. b. Interview with CNA #1 on 9/17/25 at 1:57 PM confirmed resident #3 was found in resident #2's room, the CNA observed a red mark on resident #2's cheek, and resident #2 had reported resident #3 had slapped him/her. The CNA revealed resident #2 was upset at the situation, but was no longer fearful. c. Review of a social services note for resident #2 dated 4/14/25 and timed 12:06 PM showed the resident was moved to another room and was preparing to discharge from the facility.d. Interview with the administrator on 9/17/25 at 9:25 AM confirmed the incident occurred, resident #2 was moved to another room, and resident #2 discharged to another facility. e. Interview with the resident representative for resident #2 on 9/17/25 at 2:11 PM revealed /he was informed of the incident and the resident was not experiencing any emotional effects. The representative confirmed the resident was moved to another facility. 3. Review of the facility policy titled, Abuse, Neglect and Exploitation, last revised 6/2023, shows the facility will provide protections for the health, welfare and rights of each resident and prohibit abuse.

Based on observation, resident, resident representative, and staff interview, medical record review, and policy review, the facility failed to ensure that a resident who required assistance for activities of daily living (ADL) received appropriate services to maintain grooming and hygiene for 1 of 3 sampled residents (#1) reviewed for ADLs. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included hypertension, diabetes mellitus, and arthritis. Further review showed the resident required partial to moderate assistance with bathing and was wheelchair bound. Review of the resident's care plan dated 8/26/25 showed that the resident had alterations in ADL function secondary to weakness and pain and required assistance completing ADL task's The following concerns were identified:a. Interview with the resident on 9/16/25 at 11:33 AM revealed the resident, at times, had gone several days without a shower. The resident revealed s/he didn't have a specific time preference as long as s/he was offered a shower every couple of days. b. Interview with the resident's representative on 9/16/25 at 11:21 AM revealed the resident had gone several days without being offered a shower in the past and prior to admission the resident would shower daily. Further the representative revealed at the time of admission, the resident had requested showers three times per week. c. Review of the facility bathing schedule showed the resident was scheduled three times weekly on Monday, Wednesday, and Fridays for showering. d. Review of the resident's bathing history from 7/1/25 through 9/17/25 showed the resident was not provided or offered a shower between 7/8/25 and 7/17/25 (10 days) and between 8/14/25 and 8/22/25 (9 days). e. Interview with the DON on 9/17/25 at 10:59 AM revealed residents were offered showers on their scheduled days and according to their preference, unless the resident refused or was unavailable. She revealed staff were expected to document the bathing and any refusals. f. Interview with the DON on 9/17/25 at 1:28 PM confirmed there was no documentation the resident received or was offered a shower between the dates of 7/8/25 and 7/17/25 or 8/14/25 and 8/22/25. 2. Review of the facility policy titled Resident Showers last revised 4/2025 showed .Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 3. Review of the facility policy titled Activities of Daily Living - ADL's last revised 4/2025 showed .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene.

Based on the facility's abuse investigation forms, State Survey Agency incident database review, policy and procedure review, and staff interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of the reasonable suspicion of a crime in for 2 of 5 sample residents (#3, #7) reviewed for allegations of abuse. The findings were: 1. Review of the facility's policy Abuse, Neglect, and Exploitation, implemented on 5/30/23, showed .Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The following concerns were identified: a. Review of the facility's Resident Abuse Investigation Report Form showed a resident-to-resident altercation occurred on 12/9/24 at 6:55 PM and was reported to facility administration at 7 PM; however, review of the state survey agency incident database showed this allegation was not reported to the agency until 12/12/24 at 12:28 PM. b. Review of the facility's Resident Abuse Investigation Report Form showed a resident-to-resident altercation occurred on 12/25/24 at 7:40 AM and was reported to facility administration at 7:44 AM; however, review of the state survey agency incident database showed this allegation was not reported to the agency until 12/25/24 at 12:46 PM. 2. Interview with the former administrator, the administrator, and the social service director on 1/3/25 at 11:09 AM confirmed the allegations of abuse were not reported within the required timeframe.

Based on staff interview, medical record review, facility incident investigation review, facility performance improvement plan review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 5 (#3) residents involved in a resident-to-resident altercations. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of [DATE]. The findings were: 1. Review of the [DATE] quarterly MDS assessment for resident #3 showed the resident had short-term and long-term memory problems and diagnoses which included non-traumatic brain dysfunction, Alzheimer's disease, and dementia. The resident did not exhibit any behaviors, rejection of care, or wandering during the look-back period. The following concerns were identified: a. Review of a [DATE] and timed 9:57 PM progress note showed the resident was sitting at a table in the dining area when a resident (identified as resident #4) walked over to the resident and struck him/her on the left side of his/her face. The staff had their backs to the resident and were alerted to the altercation due to the resident calling out after the strike. The resident was assessed with no immediate injury noted and neurological assessments were initiated due to the location of the impact. Further, the progress note stated the surveillance footage was observed and confirmed the incident. b. Interview with helping hand #1 on [DATE] at 9:15 AM revealed she was sitting with resident #4 doing a puzzle when she was called away to replace an absorbent pad in one of the recliners. Both she and the nurse had their backs to the resident when resident #3 yelled ouch which alerted them to the incident. The helping hand stated resident #4 went back to the puzzle table after the incident; however, s/he appeared to be agitated. The helping hand confirmed she had stayed with the resident until the resident had gone to bed. c. Review of the facility's incident report showed resident #3 was very distraught and holding the side of [his/her] face where [resident #4] smacked [him/her] The initial assessment showed no injury; however, the next day the resident had a little bit of a bruise on his/her face. Further review of the incident report showed Camera footage showed [resident #4] was calm and working on a puzzle. [Resident #3] was sitting at the table minding [his/her] own business. After watching the video footage of incident, it was verified that [resident #4] was unprovoked. [Resident #4] intentionally walked over to [resident #3] and smacked [him/her] in the side of the face. Afterwards [resident #4] walked back over to [his/her] puzzle. d. Review of the progress notes for resident #4 showed the resident had incidents of verbal and physical aggression to both staff and residents on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. e. Interview with the administrator on [DATE] at 9:25 AM revealed after the incident on [DATE] the facility increased staffing to ensure 3 staff members were in the secure unit at all times, with sometimes 4 during the evening hours. In addition, if resident #4 was agitated the department heads would be called to assist. Further the facility stopped the extra traffic through the secure unit, scheduled a psychological evaluation for the resident, and medication changes had been prescribed for the him/her. Interventions to deescalate the resident were defined and documented in the resident's care plan and progress notes. f. Review of a [DATE] social services note showed the family of resident #4 was notified the facility was unable to meet the residents needs and referrals to other long-term care facilities, which could better meet the resident's needs, were going to be made. g. Interview with the social services director on [DATE] at 9:11 AM revealed resident #4 had been accepted at another long-term care facility and had been scheduled to be transferred on [DATE]. h. Review of resident #4's progress notes showed the resident had experienced a sharp decline in condition and expired on [DATE]. 2. Review of the Abuse, Neglect, and Exploitation policy, implemented on [DATE], showed .Prevention of Abuse, Neglect and Exploitation .B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur . 3. Review of the facility's [DATE] performance improvement plan of correction showed the key areas for improvement included behavioral health documentation, behavioral health implementation, physician involvement, and staff education. The goals were to ensure behavioral documentation and follow-ups were completed; 100% of behavioral interactions were documented, care planned, and follow-up appointments were made, if needed; and to organize an incident review committee that meets weekly. The root causes of the problem were determined to be the amount of traffic in the unit; the residents were not busy enough, lack of staff education on behavioral health in the elderly, lack of documentation when behaviors happened, and lack of communication between the nursing staff and physicians. Further review showed the plan was implemented on [DATE]. The facility was determined to be in substantial compliance as of [DATE].

Based on review of resident trust fund account statements, staff interview, and Medicaid eligibility review, the facility failed to ensure residents' right to manage their personal funds for 2 of 13 (#1, #2) sample residents with accounts at the facility. The findings were: 1. Review of the resident trust fund account statement for resident #1, with a start date of 11/15/22 showed the resident had a balance of $50.02 in the account on 4/30/24. The following concerns were identified: a. On 5/3/24 the facility received a payment of $1,267.00 from the Social Security Administration (SSA) which was deposited into the resident's account. On 5/7/24 a payment was made to the facility for $1,317.02 which left a zero balance in the resident's account. There was no evidence the resident had received his/her $50 personal needs allowance. b. On 6/3/24 the facility received a payment of $1,267.00 from the SSA which was deposited into the resident's account. On 6/3/24 a payment was made to the facility for $1,270.70 which left a balance of minus $.70 in the resident's account. There was no evidence the resident had received his/her $50 personal needs allowance. c. On 8/1/24 the facility received a payment of $1,267.00 from the SSA which was deposited into the resident's account giving the resident a balance of $1,316.60. On 8/7/24 a payment was made to the facility for $1,316.60 which gave the resident a zero balance in his/her account. There was no evidence the resident had received his/her $50 personal needs allowance. d. On 9/3/24 the balance in the resident's account was $50.00 with an interest payment of $.02 deposited on 9/30/24. On 10/3/24 the facility received a payment of $1,267.00 from the SSA which was deposited into the resident's account giving the resident a balance of $1,317.02. On 10/3/24 a payment was made to the facility for $1,267.02. There was no evidence the resident had received his/her $50 personal needs allowance as the resident's balance remained at $50.00. e. On 10/31/24 an interest payment of $.03 was deposited into the resident's account. On 11/1/24 the facility received a payment of $1,267.00 from the SSA which was deposited into the resident's account giving the resident a balance of $1,317.03. On 11/4/24 a payment was made to the facility for $1,317.03 which gave the resident a zero balance. There was no evidence the resident had received his/her $50 personal needs allowance. 2. Review of the resident trust fund account for resident #2, with a start date of 7/11/22, showed the resident had a balance of $51.37 on 4/30/24. The following concerns were identified: a. On 5/1/24 the facility received a payment of $2051.00 from the SSA which was deposited into the resident's account. On 5/7/24 a payment was made to the facility for $2,077.37 leaving the resident a balance of $25.00. There was no evidence the resident had received his/her $50 personal needs allowance. b. On 5/28/24 the facility received a payment of $2,051.00 from the SSA which was deposited into the resident's account. On 5/28/24 a payment was made to the facility for $2,051.00. There was no evidence the resident had received his/her $50 personal needs allowance. c. On 6/25/24 the facility received a payment of $2,051.00 from the SSA which was deposited into the resident's account. On 6/25/24 a payment was made to the facility for $2,076.00 which left the resident with a zero balance. There was no evidence the resident had received his/her $50 personal needs allowance. d. The resident was discharged from the facility on 7/17/24 with a return not anticipated; however, the facility received monthly payments from the SSA on 8/7, 9/3, 10/8, 11/4, and 12/2 which totaled $8,904.00. A payment to the facility was made after each of these deposits leaving the resident a zero balance on 12/2/24. 3. Interview with the former administrator on 1/3/25 at 9:50 AM revealed both residents owed the facility a large amount of money and was using the resident's personal funds allowance to pay down the balance. 4. Review of the Wyoming Medicaid Long Term Care Programs, Benefits & Eligibility Requirements retrieved from https://www.medicaidlongtermcare.org/eligibility/wyoming/ on 1/6/25 showed Wyoming Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are only allowed to keep a personal needs allowance of $50/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc.

Based on observation, medical record review, and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 2 of 4 residents (#4, #97) reviewed for behavioral and emotional needs. This failure resulted in actual harm to resident #97. The findings were: 1. Review of the 7/17/24 MDS discharge assessment for resident #97 showed s/he was admitted to the facility on [DATE] and was discharged to a short-term general hospital on 7/17/24 with a return to the facility not anticipated. Review of the 4/23/24 quarterly MDS assessment showed the resident had diagnoses which included non-traumatic brain dysfunction and non-Alzheimer's dementia. Further review showed the resident had a staff assessment for mental status which indicated moderate cognitive impairment, disorganized thinking which fluctuated in severity, exhibited verbal behavioral symptoms directed towards others 1 to 3 days of the 7-day look-back period, behavioral symptoms not directed toward others 4 to 6 days of the 7-day look-back period, and rejected care 1 to 3 days of the 7-day look-back period. The resident was coded as receiving an antianxiety medication. Review of the 12/6/23 Office Physician Progress note showed a hearing was held last week before [judge's name] to determine the patient's need for a power of attorney, and to seek placement where [s/he] could get more effective care for [his/her] emotional disturbances and be less disruptive to other patients around. The progress note showed the resident had a diagnosis of aggressive behavior due to dementia. Review of a subsequent note showed the court determined the resident to be incompetent on 12/15/23. Review of a 2/28/24 physician's verbal order showed an order was placed for the resident to have a psychological evaluation. The verbal order was signed by the physician on 3/6/24. The following concerns were identified: a. Review of the resident's entire medical record showed no evidence a psychological evaluation had been completed. b. Review of the Event Reports from 3/3/24 to 6/29/24 showed the resident had aggressive/combative behaviors on 3/3, 3/18, 3/19, 3/22, 3/27, 4/3, 4/13, 5/8, 5/18, 6/13, 6/20, and 6/29. c. Review of the resident's care plan showed a description of resident-to-resident interactions which occurred on 1/31/24, 2/12/24, 2/14/24, 3/7/24, 3/18/24, 3/19/24, 3/22/24, 3/24/24, 6/13/24, 6/20/24, and 6/29/24; however, the only intervention noted was 3/14/24 which showed My staff will attempt to place a stop sign in my doorway to keep other residents from wandering into my room. The previous interventions related to resident-to-resident interactions or behaviors were dated on or before 8/29/23. d. Review of the resident's care plan under the category of Special treatments last edited on 4/24/24 showed I will break my furniture in my room. My bed is zip tied to itself so I can't bang it on the ground. I broke the door on my nightstand, so it has been removed for my safety. e. Review of the resident's care plan under the category of Call Light, dated 5/8/24 showed My call light cords were removed for my safety and the safety of others around me due to me trying to use call light cords as whips. Call light stoppers were placed where cords were. My staff will attempt to anticipate my needs. f. Review of a progress note dated 7/17/24 and timed 10:28 PM showed pt (patient) stuck (sic) a female resident in the lower back with the back of [his/her] hand while [s/he] was walking down the hall .female suffered no apparent injury, pt's behavior continued to escalate until two staff members had to barrackade (sic) themselves along with some of the patients in two different rooms to protect themselves and patients from pt's violent behavior, charge nurse called 911 for help, officers deesalated (sic) pt's aggitation [sic], guardian and [a mental health service] were called, a zoom mental health evaluation was performed on pt, emt's [sic] were called and pt was taken from facility, md notified. g. Review of a progress note dated 7/19/24 showed the resident's guardian had notified the facility that the judge had granted an official order to have the resident placed in the state hospital. h. Interview with the NHA on 11/14/24 at 4:12 PM revealed she had an email chain related to the scheduling of the resident for a psychological evaluation which showed that due to the rural location of the facility the evaluation was not scheduled; however, an appointment with a neurologist had been scheduled for 4/10/24. The NHA confirmed no documentation of the attempts to schedule the psychological evaluation or the neurologist's progress notes had been documented in the resident's medical record. 2. Review of the 9/13/24 quarterly MDS assessment showed resident #4 was readmitted from an acute care hospital to the facility on [DATE] and had diagnoses which included cerebrovascular accident, non-Alzheimer's dementia, depression and bipolar disorder. The resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Further review showed the resident did not exhibit physical or verbal behavioral symptoms or rejection of care. Review of the resident's care plan, dated 3/22/23, showed, When I have suicidal ideations or similar behaviors my staff will try to redirect me, they may offer me to call my counselor that I see or my family. They may take me to the common area or dining room to visit and interact with people and so my staff can ensure my safety. Further review showed the resident received antipsychotic and antidepressant medications, and the last gradual dose reduction was clinically contraindicated by the physician on 2/21/24. The following concerns were identified: a. Review of a progress note dated 6/8/24 at 1:39 PM showed a CNA notified RN #1 of a note found on the resident's bedside table that stated I wish I was dead please let me die. The administrator on call and the resident's son were notified. The resident's son did not want the resident sent to the emergency department, and arrived at the facility to talk to the resident, who told his/her son s/he was just venting [his/her] feelings. Further review showed no follow up documentation. b. Review of a progress note dated 7/4/24 at 9:11 AM showed the resident sat in the hall and yelled at staff. Further review showed the resident stated I want to die; I am going to kill myself. RN #2 reported the resident's statement to the DON and the charge nurse. Further review showed no follow up documentation. c. Review of a progress note dated 9/21/24 at 12:40 PM showed CNA #1 reported a note was found on the resident's table that read, I wish I was dead; Please I was dead. The on-call administrator and resident's emergency contact were notified, and the emergency contact responded watch [him/her] and if you need any thing [sic] let me know. The plan was to monitor the resident. The resident was documented by CNA #1 as laughing with housekeeping staff at 12:50 PM, and sleeping comfortably at 1:55 PM and 3:32 PM. At 5:49 PM the resident was documented as screaming at the CNA. No further behaviors were documented on 9/21/24. d. Review of a progress note dated 11/6/24 at 7:25 AM showed CNA #2 answered the resident's call light. The resident was asleep, and the CNA saw a note on the resident's bedside table that read in part, I wish I was dead. The CNA texted LPN #1 a copy of the note, and the nurse immediately checked on the resident and found the resident asleep in his/her recliner in no obvious sign of distress. The nurse notified the DON and the NHA at 7:08 AM. The nurse called the resident's power of attorney (POA) at 7:24 AM and informed her about the note that was found in the resident's room. The POA stated she was aware the resident had these thoughts. The nurse informed the POA that the resident was asleep and not in current distress, and would be monitored by staff. e. Review of a progress note dated 11/6/24 at 9:41 AM showed a mental health agency was contacted by the administrator after being notified about the note. f. Review of a progress note dated 11/6/24 at 11:44 AM showed the mental health agency phoned to say a referral had been placed for local staff, and they would reach out with the best way to proceed. Further review of the medical record showed no evidence of any follow-up. g. Interview with the NHA on 11/13/24 at 4:54 PM revealed the mental health agency had stopped seeing the resident several months ago as they did not think their services benefited the resident. The administrator revealed the resident's daughter was called about the note on 11/6/24 and the facility was waiting on the mental health agency to proceed. No one-on-one was provided for the resident at the time the note was found. The facility did not have a current policy on suicidal behaviors. h. Interview with LPN #2 on 11/14/24 at 2:52 PM revealed the resident had been told s/he would need to be observed in the dining room if s/he mentioned any suicidal ideations. The nurse stated the resident would often say s/he didn't mean it. i. Interview with the social worker on 11/15/24 at 11:13 AM revealed she did not document conversations with residents; however, she communicated any resident behaviors to the nursing staff. Further, the interview revealed care plan interventions should be documented in the progress notes. 50485

Based on staff interview and policy and procedure review, the facility failed to implement a water management program to prevent, detect, and control the risk of water-borne pathogens. In addition, the facility failed to conduct an annual review of its infection prevention and control program (IPCP). The census was 43. The findings were: 1. Review of the facility's Infection Prevention and Control Program policy showed it was implemented on 5/22/23. There was no evidence the facility had conducted an annual review of its IPCP and updated their program, if necessary. 2. Review of the 5/22/23 IPCP policy showed .17. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with DCC's water systems. c. The Maintenance Director along with the Safety Committee serves as the leader of the water management program. Review of the 5/2021 Legionella Surveillance policy showed .2. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies. These strategies included diagnostic testing, investigation for a facility source of Legionella, physical controls, and temperature controls. There was no documentation the facility had performed the primary prevention strategies. 3. Interview with the former NHA on 11/15/254 at 11:34 AM confirmed the IPCP policy had not been reviewed in the past year and no documentation was available to show the water management program had been implemented.

Based on staff interview, the facility failed to ensure the dietary manager met the required qualifications. The facility census was 43. The findings were: 1. Interview with the dietary manager on 11/14/24 at 2:08 PM revealed she had not completed the Certified Dietary Manager coursework; however, planned to have it done soon. Further interview with the dietary manager revealed the facility had a dietician on site every Tuesday for 8 hours.

Based on nursing staff schedule review and staff interview, the facility failed to have a system in place to document licensed nurses in the facility on a 24-hour basis. The findings were: 1. Review of the PBJ (payroll-based journal) Staffing Data Report for July 1 through [DATE] showed the following concerns: a. The PBJ showed the facility failed to provide nursing coverage 24 hours/day on 7/21, 7/23, and 7/30. b. Review of the working schedule showed on 7/21 the DON was on duty for 12 hours starting at 6 AM. On 9/10, 9/23, and 9/30 the DON was shown as working a 12-shift starting at 6 PM. The other days noted on the PBJ were covered by nursing staff. 2. Review of the PBJ Staffing Data Report for October 1 through December 31, 2023 showed the following concerns: a. The PBJ showed the facility failed to provide nursing coverage 24 hours/day on 10/1, 10/8, 10/29, 11/23, 12/2, 12/3, and 12/9. b. Review of the working schedule showed on 10/29 the DON worked a 12-hour shift starting at 6 AM. On 11/23 the DON worked 12 hours starting at 6 PM. In December the schedule showed the DON worked 12 hours started at 6 PM on 12/2. The other days noted on the PBJ were covered by nursing staff. 3. Interview with the NHA on 11/15/24 at 8:55 AM revealed she had only been doing the PBJ for couple of months. The former PBJ data entry person was no longer employed. Further, she stated the DON was salary, and was unable to clock in without causing problems with the payroll system. She stated there was no way of proving the DON had worked the floor, except showing it on the schedule. She stated the facility had recognized the problem and had added a performance improvement project to their quality assessment.

Based on medical record review and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (#98) reviewed for dementia care. The findings were: 1. Review of the 9/6/24 quarterly MDS assessment for resident #98 showed the resident was admitted to the facility on [DATE] and had diagnoses which included alcohol dependence with alcohol-induced persisting dementia, anxiety disorder, and depression. The resident had a BIMS score of 4 out of 15 indicating severe cognitive impairment. Further review showed the resident was coded as being administered an antidepressant. A resident-initiated transfer to another long-term care facility occurred on 9/9/24. The following concerns were identified: a. Review of the Event Forms from 8/5/24 through 9/5/24 showed the resident had a resident-to-resident altercation with aggressive/combative behaviors on 5/10, 5/18, 7/13, 7/31, 8/18, 8/20, and 9/5. b. Review of the resident's care plan in the category of Resident-to-Resident Altercation, dated 9/4/24, showed the Approach section of the care plan gave a description of the resident-to-resident altercations which occurred on 3/2/24, 3/7/24, 3/11/24, 3/13/24, 3/15/24, 3/18/24, and 4/9/24; however, the care plan failed to include any interventions. c. Review of the Cognitive Loss/Dementia care plan, dated 11/29/23, showed interventions which included my staff will direct me to my room, activities, or meals as needed to assist me. and My staff will reassure my safety as needed if I am confused. d. Review of the Behavioral Symptoms care plan, dated 6/22/23, showed the resident may become verbally and physically aggressive and interventions included to .distract me with one of the robotic therapy animals, I tend to calm down better after I have been left alone for awhile (sic). and My staff will reassure me of my safety and explain what they are doing when they are helping me. e. Review of an Office Physician Progress Note, dated 5/1/24, showed Patient is easily awoke with verbal cue. Initially disgruntled but noncombative and became interactive. Per nursing staff patient does have strong medications that are causing [him/her] to be somnolent and rarely gets out of bed until later in the afternoon. No other acute concerns per nursing staff. Further review of the progress note showed no assessment or behavioral care plan had been developed. f. Review of an Office Physician Progress Note, dated 7/18/24, showed Patient continues to be extremely somnolent and does not react well to being woken up during any encounters. Per nursing staff and director of nursing they have no acute complaints at this time . Further review of the progress note showed no assessment or behavioral care plan had been developed. g. Review of a progress note, dated 8/29/24, showed Resident was on the schedule today at 1 PM for a counseling appointment. Looking into [his/her] chart and on the appointment it was unclear where this was supposed to be at. Further the note stated the mental health agency had been called and no one had [the resident] in their records. Patient at this time has been combative so this appointment has been canceled at this time due to behavior as well not knowing where this was to be at. h. Review of the 6/12/24 Interdisciplinary Care Plan Conference Record showed the social service director had no concerns, nursing staff addressed the need for dental work, the family were happy to hear the resident had gained weight, and activities and dietary had no concerns. There was no documentation the resident's behaviors had been discussed. i. Interview with the social worker on 11/15/24 at 11:12 AM revealed she was involved in the resident's care; however, she does not document the encounters in the resident's record. Further, resident's behaviors were communicated to the administrator or the nursing staff and they made the decisions. j. Interview with the former NHA on 11/15/24 at 11:43 AM confirmed the facility failed to have a system in place to ensure a professional evaluation of the resident's behaviors was completed and effective interventions were developed. In addition, the former NHA revealed the medical director had not been consulted.

Based on observation, medical record review, policy and procedure review, and staff interview, the facility failed to ensure bed rails were evaluated for safety on a regular basis for 1 of 2 residents (#15) reviewed with bed rails. The findings were: 1. Observation on 11/12/24 at 1:15 PM showed resident #15 had an assist bar, bilaterally, at the head of the bed. Review of the resident's medical record showed the last assist bar evaluation was completed on 4/6/21. Interview with the MDS coordinator on 11/13/24 at 4:20 PM revealed safety assessments should be conducted annually and confirmed no further documentation was available. 2. Review of the 2/13/23 Use of Assistive Devices policy showed .2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care 4. DCC staff will provide appropriate assistance to ensure that the resident can use the assistive devices. This may include education or therapy sessions for training on the use of the device, safety evaluations, set up assistance, supervision, or physical assistance as needed .6. A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device .

Based on medical record review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay for 1 of 4 resident-initiated discharges (#97) reviewed. The findings were: Review of the 7/17/24 MDS discharge assessment for resident #97 showed s/he was admitted to the facility on [DATE] and was discharged to a short-term general hospital on 7/17/24 with a return to the facility not anticipated. Further review of the medical record showed no evidence a discharge summary had been completed. Interview on 11/14/24 at 5:15 PM with the NHA confirmed the discharge summary had not been completed.

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure pressure ulcers did not develop, or worsen for 2 of 2 sample residents (#50, #52) who were at risk for pressure ulcers. This failure resulted in actual harm to resident #52, who developed an un-stageable pressure injury. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #52 had a brief interview for mental status (BIMS) score of 3 and [DIAGNOSES REDACTED]. The resident was coded to require extensive assistance for bed mobility, transfers, toilet use, dressing, and personal hygiene. Further review showed the resident was at risk for pressure ulcers, and did not have any pressure ulcers at the time of the assessment. The following concerns were identified: a. Observation on 7/31/18 at 1:44 PM showed 2 CNAs positioned the resident in a shower chair, wrapped the resident in a sheet, and transported him/her down the hall for a shower. Observation at 1:59 PM showed CNA #1 and RN #1 returned the resident to his/her room and used a full body lift to transfer the resident into bed. Observation at that time showed the CNA rolled the resident towards the wall and exposed two wounds to his/her coccyx which were tan and gray in color. There was no wound dressing in place at that time. The CNA positioned the resident on his/her back and placed a pillow under, the resident's back; however, the resident's coccyx remained on the mattress. Continued observation from 2:04 PM until 4:32 PM, 2 hours and 28 minutes, showed the resident remained in the same position while in bed. Observation at 4:32 PM showed CNA #1 and CNA #2 entered the room and assisted the resident up for dinner. CNA #2 rolled the resident toward the wall and exposed the two wounds, which remained without a dressing and continued to be tan and gray in color. b. Review of a Progress Note entry dated 7/15/18 and timed 4:29 PM showed CNA's (sic) called me to (resident's name) room to show me an area on (his/her) coccyx, two open areas about a dime size each, wound was cleaned and foam padded dressing was applied. c. Review of wound documentation dated 7/26/18 showed the resident had a buttocks wound which measured 1.8 centimeters (cm) by 8 cm, had minimal drainage, and no thickness. The treatment at that time was written as Polymem (a type of wound dressing) applied after cleaning. d. Review of a physician's orders [REDACTED]. e. Interview with PTA #1 on 8/1/18 at 3:19 PM revealed that she was unsure why the team did not evaluate the resident's wound until 7/26/18 and the wound was currently un-stageable. Further, she revealed the current order should have been for a polymem dressing to be changed every day and as needed, and a dressing should have been applied following the shower. The PTA stated she would prefer the resident was not placed on his/her back or buttocks when s/he was not in the geri-chair and confirmed the wound appeared to have deteriorated since the original note on 7/15/18. 2. Review of the 3/21/18 quarterly and 5/11/18 significant change MDS assessments showed resident #50 had severe cognitive impairment, and required extensive to total assistance with positioning and transfers. Further review of both assessments showed the resident was at risk for developing pressure ulcers; but did not have any pressure ulcers at the time of the assessments. Review of the 7/15/18 nursing progress notes showed staff provided treatments for an opened quarter-sized pressure ulcer on the resident's coccyx. Further review showed no additional information about the appearance of the area. Review of the wound care monitoring documentation showed the wound care team began to monitor the pressure ulcer on 7/26/18. On 8/1/18 at 1:12 PM, RN #1 was observed changing the dressing on a pressure ulcer located on the resident's coccyx. Continued observation showed this wound was open, moist and red. During the dressing change the RN stated the resident was recently changed from a wheelchair to a geri-chair, but she was unsure whether this was after or before the resident developed the pressure ulcer. On 8/2/18 at 10:50 AM, interview with PTA #1 revealed she was responsible for monitoring pressure ulcers. She stated she first became aware of the pressure ulcer on 7/26/18. 3. Review of the policy titled Pressure Ulcers/Skin Breakdown dated 6/5/17 showed .2. In addition, the nurse shall describe and document/report the following: a Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue; .4. The physician and wound care team will assist the staff to determine etiology (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of the skin alteration .Cause Identification 1. The physician and wound care team will help identify factors contributing or predisposing residents to skin breakdown; .Treatment/Management 1. The physician and wound care team will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration .2. The physician and wound care team will identify medical interventions related to wound management; .

Based on observation, medical record review, review of manufacturer's instructions, and staff interview, the facility failed to develop and implement interventions to prevent and minimize falls for 1 of 6 sample residents (#54) reviewed for falls. This failure resulted in harm to resident #54 who sustained 2 separate hip fractures. In addition, the facility failed to assess the safety of bed wedges for 3 of 6 sample residents (#3, #19, #54) who were at risk for falls. The findings were: Review of the significant change MDS assessment with an assessment reference date of 10/13/16 showed resident #54 had [DIAGNOSES REDACTED]. The resident required the extensive physical assistance of two persons for ADLs such as bed mobility and transfers, the extensive assistance of one person for toileting, and the supervision of one person for locomotion. Further review revealed the resident was always incontinent of bladder and had a BIMS score of 3/15 (severe cognitive impairment). Review of the 5/23/17 significant change MDS assessment showed the resident was severely cognitively impaired and wandered 4 to 6 days during the 7 day look back period. The resident required the extensive physical assistance of two persons for ADLs such as bed mobility, transfers, and toileting and the extensive assistance of one person for locomotion. Review of the event report dated 11/15/16 at 11:08 PM showed the resident fell in the bathroom and fractured his/her left hip. Further event reports showed the resident continued to have repeated falls which included a fall on 5/26/17 that resulted in a fracture to the right hip. Observation during the survey on 7/17/17 at 4:10 PM showed the resident used a Merry Walker (a rolling walker with a seat and framework that surrounds the person) to ambulate around the secure unit and was at times out of sight of staff. In addition, observation on 7/19/17 at 1 PM showed the resident was in bed with a wedge in place along the edge of the bed. The following concerns were identified: a. Review of the resident's care plan in the category of falls showed no evidence interventions were developed or implemented after the November 2016 fracture. Review of the progress notes revealed the housekeeping supervisor had been educated about replacing (non-slip) strips after waxing floor and strips replaced. b. Review of the facility's event reports showed the resident had an unwitnessed fall on 11/26/16 at 2:30 PM while attempting to self-transfer out of his/her recliner. The resident was unresponsive for approximately 8 minutes and taken by ambulance to the hospital. Review of a nurse's note dated 11/26/16 and timed 5:45 PM showed the resident needs assistance for all ADLs. Supervision when eating. Uses a wheelchair for mobility pushed by staff to dining room .Uses sit to stand for transfers. However, review of the care plan in the category of falls showed no evidence interventions were developed or implemented after the incident. c. Review of the facility's event reports showed the resident had an unwitnessed fall on 11/30/16 at 5:30 AM when s/he woke up became restless, having confused orientation and extremely poor self-safety awareness, attempted to get up without assistance. Review of a nurse's note dated 11/30/16 and timed 7 PM showed the resident was placed in the dining room with 1 to 1 staff monitoring. On 12/1/16 at 1:29 PM the fall committee recommended will check for possible UTI (urinary tract infection) and further will remove air mattress to see if that's what's (sic) causing (the resident) to get OOB (out of bed) and reposition self and or sliding off bed. Review of the care plan in the category of falls showed no evidence interventions were developed or implemented after the incident. d. Review of a nurse's progress note dated 12/14/16 and timed 11:38 AM showed the resident had to be redirected several times by staff because s/he was attempting to transfer. The resident required staff assistance of 2 with transfers and ADLs, and was able to wheel self around in the unit, but staff will wheel resident to the dining room for meals. Review of the facility's event reports showed the resident had an unwitnessed fall on 12/15/16 at 8:33 PM when s/he attempted to self-transfer out of the recliner, which resulted in a skin tear to his/her left elbow. On 12/18/16 at 8:28 PM the resident had an unwitnessed fall when s/he attempted to self-transfer out of his/her bed. Review of the care plan in the category of falls showed no evidence interventions were developed or implemented after the incidents. Review of the fall committee report dated 12/22/16 showed We will schedule a pain med in the evening to help alleviate (the resident's) restless and discomfort from recent hip surgery. e. Review of the facility's event report showed the resident had a witnessed fall on 12/24/16 at 11:30 AM when s/he climbed out of the recliner in the dining room and attempted to walk. Review of the fall committee report dated 12/29/16 revealed Will get an evaluation from therapies to put the resident in a Merry Walker. Review of the care plan in the category of falls showed no evidence interventions were developed or implemented after the incident. f. Review of the facility's event reports showed the resident had an unwitnessed fall on 12/31/16 at 1:05 AM when s/he was found lying next to his/her bed. An unwitnessed fall occurred on 1/6/17 at 3 PM when the resident attempted to self-transfer from the bed to the Merry Walker. An unwitnessed fall occurred on 1/9/17 at 7:40 PM when the resident attempted to self-transfer from his/her bed which resulted in a skin tear to his/her left elbow. The fall committee report dated 1/12/17 determined the fall which occurred on 12/31/16 was not a fall because the resident wanted to lay on the floor and is care planned to do so as of 9-29-16. It was the recommendation of the committee to remove the Merry Walker from the resident's room when it was not in use. This intervention was noted in the resident's care plan. g. Review of the facility's event report showed the resident had an unwitnessed fall on 1/27/17 at 12 PM when s/he was in the dining room sitting at a table in a chair when s/he attempted to get up and sat on the floor. The fall committee report dated 2/2/17 recommended the resident be transferred from the Merry Walker to the dining room chair after the meal tray was served and then transferred back to the Merry Walker after the meal was completed. Review of the care plan in the category of falls showed no evidence interventions were developed or implemented after the incident. h. Review of the facility event report showed on 3/9/17 at 5:30 AM the resident was found sitting on the floor beside the bed. The resident's bed was in the low position and the resident had climbed over the wedge. The fall committee determined this was not a fall as s/he was care planned to sit on the floor. The safety of the wedge was not addressed. i. Review of the facility event report showed on 3/19/17 at 3:10 PM the resident attempted to lay down on the couch in the dining room while in the Merry Walker. The incident was unwitnessed. The resident had a small abrasion on his/her left shin. On 3/23/17 at 6 PM the resident attempted to self-transfer to his/her bed while still in the Merry Walker. The incident was unwitnessed. The fall committee determined on 3/23/17 staff would offer to help lay down after meals. This was added to the care plan in a note dated 3/23/17. On 3/27/17 at 7:30 AM the resident attempted to self-transfer from the Merry Walker to the bed. This incident was witnessed by Helping Hand #1 (an unlicensed aide). The fall committee determined on 3/30/17 the resident should be referred to therapy to evaluate for Merry Walker safety. Review of a PTA (physical therapy assistant) note dated 3/31/17 revealed the resident was deemed safe in shorter merry walker. j. Review of facility event reports showed the resident had additional unwitnessed falls while in his/her Merry Walker. On 5/4/17 at 6:35 PM the resident went into another resident's room and closed the door. The resident was found on the floor and had crawled out of the Merry Walker. On 5/13/17 at 3:45 PM the resident was able to open the front of the Merry Walker while in the dining room and step out of it. The resident was found on his/her hands and knees with the Merry Walker tipped over on its side. On 5/13/17 at 9:25 PM in the dining room lying on his/her back with the Merry Walker tipped over. Review of an event report dated 5/16/17 at 9:45 AM showed the resident was found laying backwards of the floor in (his/her) merry walker with (his/her) head against the heat register. Review of the fall committee report dated 5/11/17 showed the recommendation was to have staff evaluate the resident for a different Merry Walker. The next fall committee report was dated 5/18/17 showed the resident was taken out of the Merry Walker, returned to a wheelchair, and started on an antibiotic for a urinary tract infection (14 days after the 5/4/17 incident in the Merry Walker). A care plan dated 5/18/17 showed no evidence of any further interventions related to this series of falls. k. Review of an event report showed on 5/19/17 at 10:35 AM the resident had an unwitnessed fall when s/he attempted to self-transfer from the wheelchair to the bed. On 5/21/17 at 7:40 PM the resident was witnessed being in an agitated state and tried to pull the side rail off the wall which resulted in the wheelchair tipping over with the resident in it. On 5/26/17 at 8:10 PM the resident was witnessed getting up out of (his/her) wheel chair and walking, them (sic) tripped and fell and landed on (his/her) right side. This fall resulted in a right hip fracture. The fall committee report dated 6/1/17 showed Will place interventions upon (his/her) readmission to (nursing facility name). Review of the care plan in the category of falls showed no evidence interventions were developed or implemented after this fall with major injury. l. Review of the facility event reports showed the resident had unwitnessed falls on 6/18/17, 6/20/17 and 6/21/17. The fall committee report dated 6/22/17 showed no interventions were implemented. Staff were to check for a UTI and assess for pain. m. Review of an event report showed on 6/25/17 at 11 AM the resident attempted to get out of his/her wheelchair in the dining room and sat on his/her bottom which resulted in a skin tear to his/her left elbow. A Butterfly Chest Harness was placed as an immediate intervention and staff were educated. n. Review of an event report showed on 7/3/17 at 4 PM the resident was outside in the courtyard in his/her wheelchair. S/he fell forward out of the wheelchair and struck his/her forehead on the cement patio. The report showed the resident was not wearing the harness. This fall was witnessed by 2 non-licensed staff, Helping Hands #2 and #3. The report failed to contain details in regard to how many residents were in the courtyard and how many total staff members were present. The fall committee report dated 7/6/17 revealed the resident was not wearing the harness because s/he continued to remove it. The intervention recommended was to attach the harness to the wheelchair. Review of a nurse's note dated 7/9/17 showed the Butterfly chest harness was discontinued. Review of the manufacturer's instructions for the harness showed: Important Notice This is not a safety device. It is to be used only for positioning. It must be used in conjunction with a metal seat belt! Interview with the DON on 7/19/17 at 1:13 PM verified there was no seatbelt used in conjunction with the harness. o. Review of an event report showed on 7/6/17 at 10 PM the resident crawled out of bed, over the bed wedge, and crawled across the room. The resident complained of mild back pain and sustained a laceration to his/her left elbow. The immediate interventions on the report showed the resident was placed in the wheelchair with the harness on and was provided one on one supervision. Review of the care plan showed there were no interventions or updates related to this fall. p. Review of in-service training reports showed staff were informed on 2/2/17 to keep the resident in the Merry Walker until the meal was served and then transfer back to the Merry Walker immediately after the meal was completed. On 3/23/17 staff were directed to offer to help the resident lay down after meals to help prevent falls; on 6/5/17 for hip precautions; and on 6/25/17 staff were educated on the Butterfly chest harness. q. Interview with the DON on 7/19/17 at 10:50 AM confirmed the care plan did not contain clear interventions. the DON further stated the facility did not provide 1 on 1 supervision. r. Interview with the administrator on 7/20/17 at 10:33 AM revealed the fall committee meets once a week on Thursdays. She stated it was recently suggested by the DON that it should meet more often. s. Interview with the restorative services manager on 7/20/17 at 11:45 AM revealed additional documentation from the original incident reports was not available. She stated the hand-written reports were shredded after the electronic event report was closed. Related to bed wedge assessments for safety: 1. Review of the 5/23/17 significant change MDS assessment for resident #54 showed the resident had severe cognitive impairment. The resident required the extensive assistance of two persons for ADLs such as bed mobility and transfers. Observation on 7/19/17 at 1 PM showed the resident was in bed with a wedge located on the outside edge of the bed and underneath the fitted sheet. Review of the facility event report dated 3/9/17 at 5:30 AM showed the resident had climbed over the wedge and was found on the floor. An event report dated 7/6/17 at 10 PM showed the resident had crawled out of bed, over the wedge, and across the floor. The resident complained of mild back pain and sustained a laceration to his/her left elbow. Review of the medical record failed to show any assessment related to the safety of the bed wedge device. 2. Review of the 6/15/17 quarterly MDS assessment showed resident #3 had severe cognitive impairment, and was not steady during transfers and walking. Observation on 7/17/17 at 11:53 AM revealed a wedge secured under the fitted sheet on the outside edge of the resident's bed. Review of the care plan showed on 4/13/16 the facility had placed bilateral positioning bars with covers and a bed wedge on the resident bed to define the bed parameters. Review of the care plans showed on 8/18/16 the resident fell out of bed with the wedges in place. Interview with the DON on 7/18/17 at 3:10 PM stated the resident came from another facility with the wedge and the family wanted them continued here. She further verified there was no safety assessment of the device completed initially or after the fall. 3. Review of the 5/4/17 quarterly MDS assessment showed resident #19 was cognitively intact with a BIMS score of 14/15. The resident required extensive assistance for ADLs, had no range of motion impairments, and was not steady during transfers or walking. Observation on 7/17/17 at 2:32 PM showed a wedge device was affixed to the outside of the resident's bed. The wedge was secured under the resident's fitted sheet. Review of the updated fall care plan last revised on 5/11/17 showed the resident had a fall over the wedge on 12/1/16. The resident crawled over bed wedges and fell to the floor and bumped head. Review of the medical record failed to show any assessment related to the safety of the bed wedge device. 4. Interview with the DON on 7/18/17 at 3:10 PM revealed there were no safety assessments completed for the wedges. They were used as interventions for falls. Interview on 7/18/17 at 3:29 PM with the administrator revealed the wedges were positioned under the fitted sheet for patient comfort and to prevent falls. 5. Review of the manufacturer's instructions showed the wedge/bolster was removable/adjustable to increase the ease of patient bed exit .place soft rails on top of the mattress with quick-release buckles away from the resident. Warning - this device is not a substitute for side rails or other protective devices for patients at risk of injury from falls due to unassisted bed exit.

Based on observation, medical record review, staff and family interviews, and review of incident reports, the facility failed to ensure 3 of 3 residents (#7, #11 and #12) with documented elopement risks were appropriately identified, and adequate supervision was provided. In addition, interventions were not implemented to reduce further risk of elopement and potential harm. This failure resulted in a determination of immediate jeopardy for resident #7 due to a history of elopement and the potential for serious and avoidable injury. The findings were: 1. Medical record review revealed resident #7 was admitted on [DATE] from an acute care facility with [DIAGNOSES REDACTED]. Review of the acute care facility's admission and discharge summary showed the resident was admitted to the hospital on [DATE] with right-sided weakness and a,"lopsided gait" dragging his/her right foot following a previous CVA (stroke). Further, the resident had a history of [REDACTED]. Review of the 5/13/12 admission MDS assessment revealed the resident exhibited daily wandering behaviors with moderately impaired cognition and a history of falls. Further review of this document revealed s/he was unsteady with walking and turning. Review of the 8/6/12 and 10/29/12 quarterly MDS assessments revealed the resident continued to be unsteady with walking and turning. Upon entrance to the facility on [DATE] at 2:05 AM resident #7 was seen seated in an alcove across from the nurses' station. RN #1 was seated behind the desk at the nurses' station. Based on the layout of the building the RN was unable to view the resident or the front entrance/exit door. During random observations on 1/17/13 between 4:12 AM and 10:15 AM the resident was wandering in the facility with a slow, unsteady gait using a walker. At 4:12 AM the resident was walking toward the dining room. At 4:25 AM the resident was walking in the 200 hallway and stated s/he was going "to breakfast". 2. Review of the the 8/6/12 and 10/29/12 quarterly MDS assessments revealed the resident had continued cognitive decline with severe cognitive impairment. For example, during an interview on 1/17/13 at 2:20 PM with the resident s/he was unable to recall the date of admission to the facility. In addition, the resident was unable to recall the date, month, year, the current President, or the most recent holiday, questions that are, in part, included on the MDS assessment to measure the level of cognitive impairment. The resident also added s/he had not slept in [AGE] years due to "Agent Orange." Review of the medical record showed the resident was not a military veteran and there was no evidence of past exposure to Agent Orange. 3. Interview with the resident's Power of Attorney (POA) on 1/23/13 at 1:10 PM revealed the resident called his/her family often and they last visited the resident at Christmas. The POA stated the resident was "very confused" at times and would call family members then could not remember why s/he had called. The POA confirmed that 3 years ago the resident had a stroke that left him/her with right sided weakness and the inability to write. In addition, the resident did not walk very well with his/her walker and was "very unstable" on his/her feet. The POA also revealed the resident fell frequently prior to his/her admission to the facility. The POA also stated that due to the resident's confusion and unsteady gait, the resident was no longer safe to live at home. In addition, prior to being admitted to the facility, sometime during the spring of 2012, the resident left his/her apartment with a walker and was not able to make it back home. The resident was found by a stranger and returned to his/her apartment. Further, after the resident was admitted to the facility the POA stated she had been notified "a couple of times" regarding the resident leaving the facility stating the resident had, "kind of snuck out of the facility to buy cigarettes but they found (him/her)." 4. Observation on 1/17/13 at 2:05 AM revealed the front entrance to the facility was unlocked from both the outside and inside. The reception area near the front entrance was unattended and the front entry/exit door could not be viewed from within the enclosed nurses' station. Interview with RN #1 on 1/17/13 at 2:50 AM revealed the door was unlocked at all times and there were two residents (#11 and #12) with wandering behaviors who resided outside the secure unit. Resident #7 was not identified as having wandering/exit seeking behaviors by the RN. The RN revealed staff were only present at the desk nearest to the front entry/exit Monday through Friday from around 7:30 AM to 5 PM. She further revealed the facility did not have a system in place to alert staff when residents exited the front of the facility. Interview with employee #1 on 1/18/13 at 7:10 AM also verified there were two residents who wandered in the facility, residents #11 and #12. Interview with the ADON on 1/17/13 at 12:33 PM verified the front entrance/exit door was left unlocked at all times. 5. Review of the facility incident reports for resident #7 revealed the following: a. The incident report dated Sunday 8/12/12 at 7 PM showed the resident walked across the street to the church parking lot in an attempt to "buy cigarettes." Further, this was documented as an "elopement" type of incident, and the police were notified. Review of the police report revealed that on 8/12/12 at 7:08 PM, the officer was dispatched to the facility in reference to a "patient (resident) trying to run away." Interview with RN #2 on 1/17/13 at 6:55 PM revealed she was working on 8/12/12 when the resident was observed walking across the street to the church with his/her walker. The nurse indicated she called the police because the resident was "very unsteady" on his/her feet and she did not want the resident to fall and get hurt. The RN further stated the resident had always been unsteady on his/her feet and she was "afraid (the resident) would fall and hurt (him/her)self." b. The incident report dated Saturday 8/25/12 showed the resident exited the facility at 10:35 AM. The report indicated it was a "wandering" incident. The incident report showed the activities person informed the nurse the resident left the facility and the nurse then notified the acting supervisor on call. The police were called and staff went looking for the resident. Review of the police report dated 8/25/12 at 10:31 AM showed police were dispatched to the area of the facility on a report of an elderly resident that had left on a scooter. The resident was last seen headed east on Birch Street. Review of the nurse's notes dated 8/25/12, untimed, showed the resident left the front of the facility in a motorized wheelchair and was found east of the facility stuck in the dirt, which prevented him/her from going further. Observation on 1/17/13 from 12:35 PM to 12:40 PM showed 15 cars passed in front of the facility which is located on Birch Street. c. Review of the incident report dated Saturday 12/1/12 at 12:45 PM showed the incident type was documented as an "elopement." The resident was seen going through the garbage where staff went to smoke. Review of the undated nurse's note, referring to this incident, showed the resident went across the alley to look in the garbage for cigarettes. When the resident returned to the facility the staff found s/he had three cigarette butts. An interview with LPN #1 on 1/17/13 at 12:45 PM revealed that she was aware the resident was outside, however, when she went to check on the resident, the resident was across the alley at the garbage dumpster where staff go to smoke. d. Review of the resident's care plan failed to show evidence that these incidents were evaluated, potential safety risks were identified, or interventions developed to prevent further elopement attempts. Further, the care plan was not individualized to represent risks and interventions appropriate for the resident. Interview with the DON and ADON on 1/17/13 at 12:33 PM revealed they had not considered two of the three incidents as elopements since the resident only left the facility and did not leave the premises. 6. In addition to resident #7, two other residents were identified as having wandering behaviors, #11 and #12, with the potential for elopement. The residents resided in the unsecured area of the facility where there was an unlocked and unmonitored front entry/exit door on weekends and at night. The following concerns with these residents were identified: a. Review of the 12/18/12 quarterly MDS assessment for resident #11 showed s/he had [DIAGNOSES REDACTED]. The resident also had wandering behaviors that occurred daily and walked without mobility devices. Review of the care plan last updated on 12/10/12 for altered thought processes showed the resident wandered daily and had impaired cognition. Interventions included; "make staff aware of elopement risk" and "frequent monitoring of resident whereabouts due to wander risk." Review of the nurses' notes dated 11/3/12, untimed, showed the resident "wanders in the hallway, needs redirected." Review of the nurse's note written on the day shift dated 12/22/12, showed; "...wanders throughout the facility." b. Review of the history and physical dated 10/18/12 showed resident #12 had [DIAGNOSES REDACTED]. Review of the 12/16/12 quarterly MDS assessment showed s/he had moderately impaired cognition. In addition the resident was inattentive with disorganized thinking. The resident walked independently and without mobility devices. Review of 12/2012 monthly summary showed the resident had moderately impaired cognition with poor decision-making and memory problems, and behaviors included wandering. Review of the untimed nurse's note dated 1/17/13 showed the resident wandered to and from the dining room and; 'appears "lost"and confused.' Review of the care plan last updated on 12/17/12 showed the resident had altered thought processes related to progressive dementia. Interventions included "make staff aware of elopement risk" and "frequent monitoring of resident whereabouts due to wander risk." Observation on 1/18/13 at 7:55 AM showed the resident walked in the hallway independently and without any mobility devices. On 1/17/13 at 2:35 PM the administrator was notified of the immediate jeopardy related to resident #7. The facility's action plan included the following immediate changes: a. Provide 24 hour supervision of the front door. b. In-service the staff of the importance of safety related to residents exiting the facility. c. Continue 24 hour supervision until fixed. The facility action plan was accepted on 1/17/13 at 6:50 PM, and the immediate jeopardy was removed on 1/17/13 at 6:56 PM. However, deficient practice remained at a scope and severity level of an E.