Every finding on record at The Springs of Brinkley

Based on record review and interview, the facility failed to ensure Resident # 54's representative was promptly notified of a fall, for one (Resident #54) out of one resident reviewed for notification of change. Specifically, Resident #54 had an unwitnessed fall on 12/03/2025. Based on record review and interview, the facility failed to ensure a resident's representative was promptly notified of a fall, for one (Resident #54) of one resident reviewed for notification of change in condition. The findings include: Review of Resident #54's admission Record revealed the facility admitted the resident with diagnoses that included intervertebral disc degeneration, bilateral primary osteoarthritis of knee, age related physical debility, and repeated falls. The admission Record indicated that Resident #54's child was their Power of Attorney (POA) for care, as well as being their responsible party and emergency contact. Review of Resident #54's quarterly Minimum Data Set with an Assessment Reference Date of 11/17/2025, revealed a Brief Interview for Mental Status score of 10, which indicated the resident had moderate cognitive impairment. Review of Resident #54's Care Plan Report initiated on 12/03/2025, revealed the resident had an actual fall on 12/03/2025. Review of Resident #54's Order Summary Report, revealed an order with a start date of 12/03/2025 for two-view x-rays of the back, pelvis and left hip STAT for fall. The Order Summary Report also revealed an order with a start date of 12/03/2025 for two-view x-rays of the lumbar spine, pelvis and left hip STAT for fall. Review of Incidents and Accidents (I & A) Falls revealed Resident #54 had a documented fall under the Fall Un-Witnessed Incidents on 12/03/2025 at 3:00 AM. Review of Resident #54's Progress Note dated 12/03/2025 at 3:00 AM, revealed Resident #54 was observed by staff on the floor of the resident's room. The resident had a skin tear to the left ear and was assisted to bed by two staff members and neurological checks were started. The Progress Note revealed the Medical Director was notified of the fall on 12/03/2025 at 3:15 AM. The Family Notification section indicated Will call in AM. Review of Resident #54's Progress Note dated 12/04/2025 at 3:40 PM, indicated a voice mail was left for the resident's representative that paperwork had been sent to [a radiology provider] regarding an appointment. Progress Note dated 12/04/2025 at 4:10 PM indicated the resident's representative returned the call. During an interview 03/17/2026 at 12:28 PM, resident representative indicated a call was received from the facility, the resident representative returned the call and was told about the fall. The resident representative reported the unidentified nurse indicated I meant to call you the other night. During an interview on 03/19/2026 at 12:25 PM, the Administrator reported the nurse should notify the family of a change in condition or incident, if they did not get an answer they go to the next person on the list for notification, document each attempted notification and pass the task on to the next nurse if contact had not been made. She reported that the nurse who was responsible for making the call to the resident representative would receive a verbal or written write-up. Review of facility policy titled, Change in a Resident's Condition or Status, revised February 2021, revealed Unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury. The Change in a Resident's Condition or Status policy also revealed except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Review of Grievance Log indicated on 12/4/2025 Resident # 54's representative filed a grievance with the facility with reason for grievance as Not notified of fall.

Based on record review, observation, interview, and video review, the facility failed to ensure effective care planned interventions were created and implemented following new on-set of wandering and/or elopement associated behaviors, in which Resident #1 attempted on multiple occasions to exit the facility and voiced intent to exit the facility in the future. At the time of the survey, there were 8 residents in the secured unit at risk of eloping. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.10(c)(3) (Comprehensive Care Plans) at a scope and severity of J. The IJ began 01/13/2026 at 6:03 AM, when Resident #1 voiced intent to leave the facility by exiting out of the window. There were no interventions put in place to address exit seeking behaviors. The Administrator and Director of Nursing were notified of the IJ on 02/20/2026 at 2:30 PM. A removal plan was requested. The removal plan was accepted by the State Agency on 02/22/2026 at 11:56 AM. The findings include: A review of an admission Record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included traumatic brain injury, cerebral infarction (stroke), and altered mental status. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2026 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated the resident was cognitively intact. The MDS also indicated Resident #1 was independent with ambulation. A review of a BIMS dated 02/19/2026 revealed Resident #1 scored a 2, which indicated the resident had moderately impaired cognition. A review of Resident #1's Care Plan, initiated on 08/25/2025, revealed the resident needed to be on the secured unit related to traumatic brain injury and elopement risk. Care Plan interventions included providing therapeutic activity such as reminiscing theme kit activities, touch therapy, and doll therapy as needed. The Care Plan interventions also included for staff to administer and monitor the effectiveness and side effects of medication as ordered. No additional interventions had been added after the date of 08/25/2025 to address new onset behaviors or elopement attempts identified at later dates. Review of the Medication Administration Record (MAR) with a start date of 02/05/2026 revealed a physician order for [a sedative medication] 25 mg, to be given at bedtime related to irritability, anger, and altered mental status. Another physician order for [an antidepressant] with a start date of 11/20/2025 indicated to give 5mg in the morning related to irritability and anger. The MAR also included a physician order with a start date of 04/22/2025 which indicated staff were to monitor antidepressant medication for changes in mental status and insomnia every day and every night. A review of Progress Notes, dated 01/13/2026 at 6:03 AM, revealed Resident #1 was up all night walking the halls. Resident #1 refused to go to bed and was going in and out of other residents' rooms. The resident's sibling was contacted and asked to talk to Resident #1 about voicing that they did not live in the facility. The sibling talked to the resident, but nothing changed. Resident #1 indicated they were going to get out of the window. There were no interventions put in place to provide guidance to facility staff in identifying and/or addressing exit seeking behaviors. A review of a Progress Note dated 01/13/2026 at 3:02 PM, revealed Resident #1 had been seeking elopement since returning from a home visit. Resident #1 admitted to staff the desire to leave and had been looking for ways to get out. Staff had tried to redirect Resident #1 with no success. The Progress Note also indicated when staff went out of a locked door Resident #1 followed the staff out the locked doors. The resident verbalized to staff that the resident was not staying in the facility and showed force when the staff tried to get Resident #1 back on the unit. There were no interventions put in place to address the exit seeking behaviors. A review of a Progress Note dated 01/13/2026 at 6:29 PM, revealed Resident #1 was talking loudly and being aggressive towards staff. The resident stated the desire to get out of the facility. Resident #1's sibling was called, and the resident calmed down shortly after talking with sister. An elopement assessment was completed. There were no interventions put in place to prevent exit seeking or address the aggressive behaviors. A review of a Progress Note dated 02/17/2026 at 4:25 AM, revealed LPN #9 was notified at 4:25 AM that Resident #1's window was busted and the resident was not in the facility. The nurse checked the secure unit and the perimeter for Resident #1. The nurse notified the Administrator at 4:28 AM that Resident #1 had busted the window in the room in which they resided and had eloped from the facility. Police were notified at 4:30 AM. Police found and returned the resident to the facility at 5:05 AM. A full body audit was completed upon return, with no injuries noted to Resident #1. The immediate intervention was identified as searching for the resident and getting the resident back to the facility safely. A review of an elopement assessment dated [DATE] indicated Resident #1 was able to ambulate independently without an assistive device. The resident had evidence of following staff, peers, and/or strangers. Upon return from a home visit the resident had been up wandering the halls and standing beside the locked exit doors. Resident #1 had followed staff out trying to exit the facility. A [City] Police Department Incident Report, dated 02/17/2026 at 4:31 AM, indicated the police department received a call on 02/17/2026 at approximately 4:31AM, related to a missing person. At approximately 4:50 AM, the police were advised that Resident #1 was possibly on the south end of town in an apartment complex. The police received a call from a citizen stating Resident #1 was almost struck by their vehicle as they were going to work. At approximately 5:00 AM, Resident #1 was found and transported back to the facility. Resident #1 informed the police that [the resident] was walking to find family. The police were informed that Resident #1 had gotten out of [the resident's] room by throwing an end table through the window. A review of an OLTC Witness Statement Form, dated 02/17/2026 from Certified Nurse Assistant (CNA) #1 revealed, [Resident # 1] was coming in and out of [the resident's] room the early part of the shift. [Resident #1] asked what time it was, and best of my knowledge I think it was around 9:30 PM to 10:00 PM. [Resident #1] went back to [the resident's room] room and was not seen again until [the resident] arrived back to the facility. During an interview on 02/18/2026 at 11:13 AM, the Director of Nursing (DON) indicated CNA #1 reported that she fell asleep during her shift and did not hear the window break when Resident #1 left the facility. During a telephone interview with CNA #1 on 02/18/2026 at 1:52 PM, CNA #1 revealed Resident #1 had been trying to start a fight with another resident for two days, prior to the elopement CNA #1 indicated Resident #1 asked what time it was at approximately 9:30 PM. Resident #1 went back to [the resident's] room, and the CNA did not go back to check on [the resident]. CNA #1 stated the resident usually went back and forth out of [the resident's] room through the night, and staff does not normally go back to [the resident's] room to check on [Resident #1]. CNA #1 indicated Licensed Practical Nurse (LPN) #6 was coming back from break and noticed one of the windows were broken. The staff then went to each room, and realized Resident #1 was not in bed. CNA #1 indicated that Resident #1 was missing between 3:30 AM and 4:00 AM. CNA #1 indicated staff went out the door screaming for the resident, everything got out of control, and she could not recall what happened after that. CNA #1 indicated the police escorted the resident back to the facility, and she was not informed where the resident was found, nor had she asked where [the resident] went when leaving the facility because she did not want to upset them. CNA #1 indicated she usually does not get a break and sometimes cannot go to the bathroom because there is no one to relieve her. CNA #1 stated she was sitting in the third room doorway, located approximately three doors down from Resident #1's bedroom on the other side of the hall, and did not hear the window break when Resident #1 eloped CNA #1 indicated she dozed off for about 30 minutes that night and was not sure of the time, but that she had not dozed off at the time of the resident's elopement. CNA #1 indicated that following the last time Resident #1 went out with family, the resident began trying to leave the unit. CNA #1 stated for the last three weeks there had been only one aide on the unit. They have been pulling the second aide scheduled for the unit to another unit. CNA #1 indicated her schedule was 7:00 PM-6:00 AM. During an interview on 02/18/2026 at 3:00 PM, the Administrator indicated that she watched the camera footage from the night of the elopement, which revealed CNA #1 had the hall lights off and a chair in the doorway so the camera could not see her. During a phone interview on 02/18/2026 at 3:25 PM, CNA #2 indicated that Resident #1 went home on 14-day leave. The CNA indicated during that time Resident #1 had a seizure and was confused when returned to the facility. CNA #2 indicated that Resident #1 gets up as if they are going to work every morning. CNA #2 indicated that Resident #1 goes door to door and asks how to get out. CNA #2 indicated on the night of the elopement LPN #6 had been coming back into the building when LPN #6 noticed the window had been busted out. Within an hour of the staff reporting the resident missing ,the police returned the resident to the facility, around 4:30 AM-5:00 AM. During an interview on 02/18/2026 at 4:35 PM, Resident #1 indicated they were going to do some work for the unit when they left the unit yesterday morning. The resident was not able to indicate how they got off the unit. During an interview on 02/19/2026 at 6:55 AM, CNA #3 indicated she had been employed at the facility since November of 2025 and worked on the unit from 7:00 PM-7:00 AM. CNA #3 indicated Resident #1 watched the staff to see if they are paying attention to [the resident]. CNA #3 indicated Resident #1 would walk up and down the halls. CNA #3 also indicated that the resident talked about leaving the facility, but she had never observed them trying to elope. During an interview on 02/19/2026 at 7:08 AM, CNA #4 indicated she had been employed at the facility since August 2025 and worked all halls. CNA #4 indicated that Resident #1 walked from door to door all the time, and the resident never talked about leaving the facility to [CNA #4]. The CNA indicated the resident thinking [the resident] is in prison. During a telephone interview with a [Local Police Department] Police Officer on 02/19/2026 at 8:52 AM, the officer indicated [apartment complex] was added to the police report because that was where Resident #1 almost got hit by a car. The police officer stated they (the police department) received a call from a citizen stating they almost hit Resident #1 with their car at approximately 4:50 AM. The officer indicated that Resident #1 was found by the school on 02/17/2026. The officer indicated the school was located at an address which Google maps showed to be 1.9 miles, or 42 minutes walking distance from the facility. During observations on 02/19/2026 at 12:05 PM this surveyor drove from the facility to the location where the resident was found by law enforcement. Resident #1 would have had to cross an intersection and travel areas of the road that did not have sidewalks available to arrive at that location. A review of the facility's camera footage on 02/19/2026 at 3:15 PM revealed Resident #1 was repeatedly going back and forth from the room in which they resided to the day room, to the bathroom. The resident went into their residential room at 3:12 AM and did not come back out. The camera footage was reviewed from 8:00 PM on 02/16/2026 until 5:00 AM on 02/17/2026. During an interview on 02/20/2026 at 8:33 AM, the DON indicated that Resident #1 was admitted to the secure unit because of a history of wandering. The DON indicated that she was not aware that Resident #1 had prior elopement attempts before 02/27/2026. The DON indicated that Resident #1 was not safe leaving the facility (alone, without staff). She indicated the resident was confused, and trying to reach their home in [a town approximately 55 miles from the facility]. The DON indicated to ensure Resident #1 does not elope again the resident was moved to the opposite side of the hallway on the same unit. To further prevent elopement, shatter proof mesh had been ordered for the windows but had not been installed. The resident was currently on 1:1 (supervision). The DON indicated the resident will remain 1:1 through the weekend. The DON reiterated that Resident #1 was not safe walking where they were found. During an interview on 02/20/2026 at 8:50 AM, the Administrator indicated that Resident #1 was admitted to secure unit because of behaviors, wandering, anger issues, and the resident thinking [the resident] was still in prison. The Administrator indicated she was not aware of any previous elopement attempts besides the resident walking back and forth. The Administrator reported a BIMS was completed on the resident recently, and the resident had received a score of 2, which indicated the resident had severe cognitive impairment. The Administrator indicated she had not reached out to the police officer and was not aware of where the resident was found during the elopement. The Administrator indicated that the resident was found between 4:55 AM and 5:00 AM. The Administrator indicated she was not aware the resident had voiced a plan to escape through the window. During an interview on 02/20/2026 at 10:42, the MDS Coordinator indicated that the nurses or the CNAs inform her of changes with residents, but she was responsible for updating the care plans. The MDS Coordinator indicated no one told her about the behaviors Resident #1 had on 01/13/2026. She indicated that a care plan was in place for Resident #1 prior to the elopement. During a telephone interview on 02/20/2026 at 11:02 AM, LPN #5 indicated she talked to LPN #10 who wrote the note on 01/13/2026 indicating that Resident #1 was staring at the bathroom window. LPN #5 indicated LPN #10 informed her Resident #1 did not attempt to elope. LPN #5 indicated LPN #10 informed her that she reported the resident staring out the window to the oncoming nurse, but she could not recall if she told the Administrator. During an interview on 02/20/2026 at 3:54 PM, CNA #7 indicated that she had been employed at the facility for two years and regularly worked on the unit. The CNA indicated Resident #1 had begun exit seeking after returning from a visit with family for a few days. The CNA indicated the resident came back from a family visit, a different person. During a telephone interview with Resident #1's family member on 02/20/26 at 4:28 PM, the family member indicated Resident #1 did not receive nighttime medications for two nights during the leave of absence with family. The family member indicated the missed doses were not back-to-back, and they did not remember the names of the medications. During an interview on 02/20/26 at 5:25 PM, CNA #8 indicated Resident #1 started having behaviors when [the resident] came back from a family visit. The CNA indicated Resident #1 walked back and forth to the doors, but they had not witnessed the resident trying to get out (of the facility). CNA #8 indicated that any behaviors or elopement concerns should be charted. The CNA indicated she had not been informed to do anything different since the resident had been on 1:1. The CNA indicated that she worked with Resident #1 on Wednesday, Thursday, and Friday of this week (February 18-20, 2026). During a telephone interview on 02/23/26 at 5:42 AM, LPN #6 indicated that she was outside on break when she noticed the window (to Resident #1's room) was broken. The LPN indicated she went on the unit and asked CNA #1 to go to Resident #1's room with her. LPN #6 indicated she informed LPN #9 about the window and started searching the building then. LPN #6 indicated she charts behaviors, calls the doctor, then calls the DON when a resident is having behaviors. LPN #6 indicated that she was not aware of any behaviors that Resident #1 had since she did not work with [this resident]. During a phone interview on 02/23/26 at 5:55 PM, LPN #9 indicated one of the nurses went outside to smoke around 4:25 AM and noticed the window was broken. LPN #9 indicated Resident #1 was not on the unit, or in the parking lot. LPN #9 indicated he called the Administrator and the police and informed them that there had been an elopement. LPN #9 indicated the family was called after the Administrator arrived at the facility. LPN #9 indicated the Administrator, and the DON went out looking for Resident #1. LPN #9 indicated the police called and returned Resident #1 to the facility around 5:05 AM. LPN #9 indicated the DON is notified of changes that need to be made to the care plan by the nurses. A review of a policy titled, Wandering and Elopements, revealed if a resident is identified as at risk for wandering, elopement, or other safety issues the resident's care plan will include strategies and interventions to maintain the resident's safety. A policy titled Missing Resident, revealed it is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents. A review of an in-service report dated 02/17/2026 revealed rounding should be completed every two hours for all residents. At no time should staff be asleep during their shift. This is grounds for termination. A review of a policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, revealed neglect is defined as, failure to provide goods and services as necessary to avoid physical harm. A review of a form titled, Personnel Action Form, revealed CNA #1 was terminated effective 02/17/2026. The termination reason was sleeping while on duty. Onsite Verification: The IJ was removed on 02/23/2026 at 12:31 PM. On 02/23/2026 at 8:45 AM per Plan of Removal (POR) dated 02/22/2026- Step #1 is corrective action- The facility revised Resident #1's care plan to include individualized elopement prevention interventions. Per record review the care plan was updated to include all interventions per POR. Per POR- Step #2 is identification of others with the potential to be affected. On 02/17/26 the facility completed new elopement risks assessments for residents residing on the secured unit. For any resident scoring moderate or high risk: A. On 02/20/2026, care plans were reviewed to ensure individualized elopement interventions were present. B. Environment exit safety checks completed 02/17/2026. Per record review of all residents on secured unit all care plans have been revised/updated as per POR. Per POR -Step #3: Systemic changes to ensure deficient practice does not recur: A. staff education- Beginning 02/17/2026, nursing and direct care staff received in- service education on elopement policy and missing resident procedures. B. On 02/20/2026 nursing and direct care staff were in-serviced on the following: 1. definition and examples of elopement and exit seeking behaviors. 2. early warning signs requiring interventions. 3. Requirements to notify nurse/administrator/DON of new or increased behaviors. C. On 02/20/2026 nurse management responsible for updating care plans were in-serviced on: 1. Mandatory care plan revision following behavior changes with individualized interventions. D. On 02/19/2026, shatter-resistant film was ordered for front-facing secured unit windows and will be installed by facility maintenance director when received. Invoice from [online vendor] given to show that shatter-resistant film was ordered and per-tracking order the shatter-resistant film is due to arrive on 02/24/2026. Per POR Step #4: Monitoring: A. DON/Designee will review the 24-hour report three times weekly for four weeks to identify new or increasing exit-seeking behaviors. B. DON/Designee will complete weekly audits of five residents for four weeks to identify: 1. Elopement risk assessments completed. 2. Individualized interventions are present. 3. Documentation reflects staff implementation. After 4 weeks, audits will decrease to monthly for two months, then transition to routine QAPI monitoring. Per interim DON all unit resident's records were reviewed on Friday and will review the 5 resident charts on every Friday. The DON completed 24-hour monitoring over the weekend and will monitor 3 times a week. Calendar was reviewed to show when she monitored the 24-hour report with no negative findings.

Based on observations, interviews, and record review, the facility failed to ensure increased supervision was provided by staff during periods of increased exit seeking behaviors for one (Resident #1) of four sampled residents reviewed for elopement. The lack of effective supervision resulted in Resident #1 eloping from the facility, and the facility staff being unaware of the residents' whereabouts. At the time of the survey, there were eight residents residing on the locked unit. The findings are: A review of an admission Record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses of traumatic brain injury, cerebral infarction, and altered mental status. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2026 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident was cognitively intact. The MDS also included that Resident #1 was independent with ambulation. A review of a BIMS dated 02/19/2026 revealed Resident #1 scored a 2 which indicated the resident had moderately impaired cognition A review of Resident #1's Care Plan, initiated on 08/25/2025, revealed the resident needed to be on the secured unit related to traumatic brain injury and elopement risk. Care Plan interventions included providing therapeutic activity such as reminiscing theme kit activities, touch therapy, and doll therapy as needed. The Care Plan interventions also included for staff to administer and monitor the effectiveness and side effects of medication as ordered. Review of the Medication Administration Record(MAR) with a start date of 02/05/2026 revealed a physician order for [a sedative medication] 25 mg, to be given at bedtime related to irritability and anger, altered mental status. Another physician order for [an antidepressant] with a start date of 11/20/2025 indicated to give 5mg in the morning related to irritability and anger. The MAR also included a physician order with a start date of 04/22/2025 which indicated staff were to monitor antidepressant medication for changes in mental status and insomnia every day and every night. A review of Progress Notes, dated 01/13/2026 at 6:03 AM, revealed Resident #1 was up all night walking the halls. Resident #1 refused to go to bed and was going in and out of other residents' rooms. The resident's sibling was contacted and asked to talk to Resident #1 about voicing that they did not live in the facility. The sibling talked to the resident, but nothing changed. Resident #1 indicated they were going to get out of the window. A review of a Progress Note dated 01/13/2026 at 3:02 PM, revealed Resident #1 had been seeking elopement since returning from a home visit. Resident #1 reported to staff the desire to leave and that the resident had been looking for ways to get out. Staff had tried to redirect Resident #1 with no success. The Progress Note also indicated when staff went out of a locked door Resident #1 followed the staff out the locked doors Resident #1 verbalized to the staff that [the resident] was not staying in the facility and showed force when the staff was trying to get the resident back on the unit. A review of a Progress Note dated 01/13/2026 at 6:29 PM, revealed Resident #1 was talking loudly and being aggressive towards a staff member. The resident reported wanting to get out of the facility. Resident #1's sibling was called, and the resident calmed down shortly after talking with sibling. An elopement assessment was completed. A review of a Progress Note dated 02/17/2026 at 4:25 AM, revealed LPN #9 was notified at 4:25 AM that Resident #1's window was busted and the resident was not in the facility. The nurse checked the secure unit and the perimeter for the resident. The Nurse then notified the administrator at 4:28 AM that Resident #1 had busted the window in the room in which the resident resided and had escaped. Police were notified at 4:30 AM. Police found resident and returned the resident to the facility at 5:05 AM. A full body audit was completed upon return, with no injuries noted to the resident. The immediate intervention listed was for staff to search for the resident and get the resident back to the facility safely. A review of an elopement assessment dated [DATE] indicated that Resident #1 was able to ambulate independently without an assistive device. The resident had a history of following staff, peers, and/or strangers. Upon return from a home visit the resident had been up wandering the halls and standing beside the locked exit doors. Resident #1 had followed staff out trying to exit the facility. A [City] Police Department Incident Report, dated 02/17/2026 at 4:31 AM, indicated the police department received a call on 02/17/2026 at approximately 4:31 AM, related to a missing person. At approximately 4:50 AM the police were advised that Resident #1 was possibly on the south end of town in an apartment complex. The police received a call from a citizen stating Resident #1 was almost struck by their vehicle as they were going to work. At approximately 5:00 AM Resident #1 was found and transported back to the facility. Resident #1 informed the police that they were walking to find family. The police were informed that Resident #1 had gotten out of their room by throwing an end table through the window. A review of an OLTC Witness Statement Form, dated 02/17/2026 from Certified Nurse Assistant (CNA) #1 revealed, Resident # 1 was coming in and out of [the resident's] room the early part of the shift. Resident #1 asked what time it was, and best of my knowledge I think it was around 9:30 PM to 10:00 PM. Resident #1 went back to [the resident's] room and was not seen again until [the resident] arrived back to the facility. During an interview on 02/18/2026 at 11:13 AM the Director of Nursing (DON) indicated CNA #1 reported that she fell asleep during her shift and did not hear the window break when Resident #1 left the facility. During a telephone interview with CNA #1 on 02/18/2026 at 1:52 PM, the CNA revealed Resident #1 had been trying to start a fight with another resident for two days (prior to the elopement). CNA #1 indicated Resident #1 asked what time it was at approximately 9:30 PM. Resident #1 went back to the resident's room, and the CNA did not go back to check on [the resident]. CNA #1 stated, the resident usually goes back and forth out of [the resident's] room through the night, and the staff does not normally go back to the room to check on the resident. CNA #1 indicated Licensed Practical Nurse (LPN) #6 was coming back from break and noticed one of the windows was broken. The staff went to each room, and then realized Resident #1 was not in bed. CNA #1 indicated that the resident went missing between 3:30 AM and 4:00 AM. The CNA indicated staff went out the door screaming for the resident, everything got out of control, and she could not recall what happened after that. CNA #1 indicated the police escorted the resident back to the facility, and she was not informed where the resident was found. The CNA indicated that she usually does not get a break and sometimes cannot go to the bathroom because there is no one to relieve her. The CNA indicated that she did not hear the window break when Resident #1 eloped. The CNA indicated that she was sitting in the third room doorway, approximately three doors down from Resident #1's room ,on the opposite side of the hall, near the nurse's station. CNA #1 stated that she dozed off for about 30 minutes that night, and was not sure of the time, but she had not dozed off at the time the resident eloped. CNA #1 indicated the last time Resident #1 went out with family the resident had tried to leave the unit. The CNA indicated for the last three weeks there had been only one aide on the unit. The facility administration had been pulling the second aide scheduled for the unit to another unit. CNA #1 indicated that her schedule was 7:00 PM-6: 00 AM. During an interview on 02/18/25 at 3:00 PM, the Administrator indicated that she watched the camera footage which revealed CNA #1 had the hall lights off and a chair in the doorways so the camera could not see her. During a phone interview on 02/18/2026 at 3:25 PM, CNA #2 indicated Resident #1 went home on 14-day leave. The CNA indicated was confused when returned to the facility. CNA #2 indicated that Resident #1 gets as if going to work every morning. The CNA indicated that Resident #1 goes door to door and asks how to get out. CNA #2 indicated on the night of the elopement LPN #6 was coming back into the building when she noticed the window had been busted out. Within an hour of the staff reporting the resident missing, the police returned the resident to the facility, around 4:30 AM-5:00 AM. The DON indicated that Resident #1 was not safe walking in the area they were found. During an interview on 02/18/2026 at 4:35 PM, Resident #1 indicated they were going to do some work for the unit when they left the unit yesterday morning. The resident was not able to indicate how they got off the unit. During an interview on 02/19/2026 at 6:55 AM, CNA #3 indicated she had been employed at the facility since November of 2025 and worked on the unit from 7:00 PM-7:00 AM. The CNA indicated Resident #1 watched the staff to see if they are paying attention to [the resident]. CNA #3 indicated Resident #1 would walk up and down the halls. CNA #3 also indicated that the resident talked about leaving the facility, but she had never observed them trying to elope. During an interview on 02/19/2026 at 7:08 AM, CNA #4 indicated she had been employed at the facility since August 2025 and she worked all halls. The CNA indicated that Resident #1 walked from door to door all the time, and the resident never talked about leaving the facility [to CNA #4]. The CNA indicated the resident thinks [the resident] is in prison. During a telephone interview with a [Local Police Department] Police Officer on 2/19/2026 at 8:52 AM, the officer indicated [the apartment complex] was added to the police report because that was where Resident #1 almost got hit by a car. The police officer stated they received a call from a citizen stating they almost hit Resident #1 with their car at approximately 4:50 AM. The officer indicated that Resident #1 was found by the school on 02/17/2026. The officer indicated the school was located at an address Google maps showed to be 1.9 miles, or 42 minutes walking distance from the facility. During observations on 02/19/2026 at 12:05 PM this surveyor drove from the facility to the location where the resident was found by law enforcement. Resident #1 would have had to cross an intersection and travel areas of the road that did not have sidewalks available to arrive at that location. A review of the facility's camera footage on 02/19/2026 at 3:15 PM revealed Resident #1 was repeatedly going back and forth from the room in which they resided to the day room, to the bathroom. The resident went into their residential room at 3:12 AM and did not come back out. The camera footage was reviewed from 8:00 PM on 02/16/2026 until 5:00 AM on 2/17/2026. During an interview on 02/20/2026 at 8:33 AM, the DON indicated that Resident #1 was admitted to the secure unit because of a history of wandering. The DON indicated that she was not aware that Resident #1 had prior elopement attempts before 02/27/2026. The DON indicated that Resident #1 was not safe leaving the facility. She indicated the resident was confused, and trying to reach their home in [a town approximately 55 miles from the facility]. The DON indicated to ensure Resident #1 does not elope again the resident was moved to the opposite side of the hallway on the same unit. To prevent elopement shatter proof mesh was ordered for the windows but had not been installed. The resident was currently on 1:1 (supervision). The DON indicated the resident will remain 1:1 through the weekend. During an interview on 02/20/2026 at 8:50 AM, the Administrator indicated that Resident #1 was admitted to secure unit because of behavior, wandering, anger issues, and the resident thinking[the resident] was still in prison. The Administrator indicated she was not aware of any previous elopement attempts besides the resident walking back and forth. The Administrator reported a BIMS was completed on the resident recently, and that the resident had a score of 2 which indicated the resident had severe cognitive impairment. The Administrator indicated she had not reached out to the police officer and was not aware of where the resident was found during the elopement. The Administrator indicated that the resident was found between 4:55 AM and 5:00 AM. The Administrator indicated she was not aware the resident voiced a plan to escape through the window. During an interview on 02/20/2026 at 10:42 the MDS Coordinator indicated that the nurses or the CNA's informs her of changes with residents, and she was responsible for updating the care plan. The MDS Coordinator indicated no one told her about the incident Resident #1 had on 01/13/2026. She indicated that a care plan was already in place before Resident #1 eloped. During a telephone interview on 02/20/2026 at 11:02 AM, LPN #5 indicated she spoke with the nurse that wrote the note on 01/13/26 and the nurse indicated that Resident #1 was staring at the bathroom window. LPN #5 indicated the nurse told her Resident #1 did not attempt to elope. LPN #5 indicated the nurse said she reported the resident staring out the window to the oncoming nurse, but she could not recall if she told the Administrator. During an interview on 02/20/2026 at 3:54 PM, CNA #7 indicated that she had been employed at the facility for two years and regularly worked on the unit. The CNA indicated Resident #1 had begun exit seeking after returning from a visit with family for a few days. The CNA indicated the resident came back from a family visit, a different person. During a telephone interview with Resident #1's family member on 02/20/26 at 4:28 PM, the family member indicated that Resident #1 did not receive nighttime medications for two nights during the leave of absence with family. The family member indicated the missed doses were not back-to-back, and they did not remember the names of the medications. During an interview on 02/20/26 at 5:25 PM, CNA #8 indicated Resident #1 started having behaviors when [the resident] came back from a family visit. The CNA indicated Resident #1 walked back and forth to the doors, but CNA #8 had not witnessed the resident trying to get out. The CNA indicated that any behaviors or elopement concerns should be charted. CNA #8 indicated she had not been informed to do anything different since the resident had been on 1:1. The CNA indicated that she worked with Resident #1 on Wednesday, Thursday, and Friday of this week (February 18-20, 2026). During a telephone interview on 02/23/26 at 5:42 AM, LPN #6 indicated she was outside on break when she noticed the window (to Resident #1's room) was broken. The LPN indicated she went on the unit and asked CNA #1 to go to Resident# 1's room with her. The LPN indicated she informed LPN #9 about the window and started searching the building then. LPN #6 indicated she charts behaviors, calls the doctor, then calls the DON when a resident is having behaviors. LPN #6 indicated that she was not aware of any behaviors that Resident #1 had since she did not work with [this resident]. During a phone interview on 02/23/26 at 5:55 PM, LPN #9 indicated one of the nurses went outside to smoke around 4:25 AM and noticed the window was broken. LPN #9 indicated Resident #1 was not on the unit, or in the parking lot. LPN #9 indicated he called the Administrator and the police and informed them that there was an elopement. LPN #9 indicated the family was called after the Administrator arrived at the facility. LPN #9 indicated the Administrator, and the DON went out looking for Resident #1. LPN #9 indicated the police called and returned Resident #1 to the facility around 5:05 AM. LPN #9 indicated the DON is notified of changes that need to be made to the care plan by the nurses. A review of a policy titled, Wandering and Elopements, dated March 2019, revealed if a resident is identified as at risk for wandering, elopement, or other safety issues the resident's care plan will include strategies and interventions to maintain the resident's safety. A policy titled Missing Resident, dated March 2019 revealed it is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents. A review of an in-service report dated 02/17/2026 revealed rounding should be completed every two hours for all residents. At no time should staff be asleep during their shift. This is grounds for termination. A review of a policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, dated April 2021 revealed neglect is defined as failure to provide goods and services as necessary to avoid physical harm. A review of a form titled, Personnel Action Form, revealed CNA #1 was terminated effective 02/17/2026. The termination reason was sleeping while on duty. Following the incident on 02/17/2026 Resident #1 was placed on 1:1 supervision and continued, was moved to a different room on the other side of the hallway within the unit, and shatter proof mesh was ordered for the facility windows. The facility also terminated CNA #1 effective 02/17/2026, with the reason of falling asleep while on duty. The facility re-educated staff who worked on the unit following the incident on 02/17/2026, that rounding should be completed every two hours for all residents, and at no time should a staff member be asleep during their shift. Nurses, support, and administrative staff were interviewed over multiple shifts to verify understanding of training with no negative findings. These actions were performed before the survey team entered the facility, and verified by interview, observation and document review, resulting in this finding being cited at past non-compliance.

Based on record review, interviews, and facility policy review, it was determined that the facility failed to prevent resident to resident abuse for two (Resident #1 and Resident #3) of four residents reviewed for abuse. The findings include: Resident #1: A review of Resident #1’s admission Record indicated the facility admitted the resident on 07/25/2024, with diagnoses which included metabolic encephalopathy (brain dysfunction) and Parkinson’s disease, with dyskinesia (involuntary muscle movements). A review of Resident #1’s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/2025, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #1 required substantial/maximal assistance when using a manual wheelchair. A review of Resident #1’s Care Plan, revised on 05/28/2025, indicated the resident was at risk for wandering. Further review of Resident #1’s Care Plan indicated the resident crawled on their hands and knees in the hallways and rooms at times. Resident #1’s Care Plan included interventions that directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. A review of Resident #1’s Order Summary Report revealed an order, with a start date of 11/14/2024, for staff to monitor the resident for agitation and an increase in elopement, delusions, hallucinations, psychosis, and aggression. Resident #1’s Order Summary Report also revealed the resident had an order for hospice, dated 01/16/2025. Resident #2: A review of Resident #2’s admission Record indicated the facility admitted the resident on 02/28/2025, with diagnoses which included Alzheimer’s disease, adjustment disorder with disturbance of conduct, dementia with agitation, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, and hallucinations. A review of Resident #2’s quarterly MDS with an ARD of 06/04/2025, revealed a BIMS score of 03, which indicated the resident had severe cognitive impairment. Resident #2’s MDS also revealed the resident was independent for transfers. A review of Resident #2’s Care Plan, revised on 03/14/2025, indicated the resident had delirium or an acute confusional episode relate to Alzheimer’s, dementia, mild neurocognitive disorder with behavioral disturbance. Incident: A review of an “OLTC [Office of Long-Term Care] Incident and Accident Report,” dated 03/16/2025, indicated Resident #1 was attempting to crawl into Resident #2’s room and was kicked in the face by Resident #2. Both residents resided on the men’s behavioral unit. The residents were separated immediately. Resident #2 was placed on 1:1 observation, while Resident #1 was sent to the emergency room. A review of an OLTC Witness Statement, dated 03/16/2025, indicated Certified Nursing Assistant (CNA) #8 heard a commotion in the hall while she was in the nurse’s station. She walked out in the hallway and saw Resident #2 trying to push their door closed and kicking Resident #1, who was crawling on the floor. CNA #8 indicated Resident #1 was attempting to crawl into Resident #2’s room, so she immediately separated them and called the nurse. A review of an OLTC Witness Statement, dated 03/16/2025, indicated Licensed Practical Nurse (LPN) #9 observed Resident #2 trying to push their door closed while kicking Resident #1, who was on the floor crawling. She indicated that when she arrived, Resident #1 had an injured nose and skin tears. LPN #9 revealed that she provided care, contacted hospice, and sent Resident #1 to the emergency room. A review of Resident #1’s emergency room Records, dated 03/16/2025, revealed the resident was crawling into another patient’s room and was kicked in the head and face multiple times with steel toe boots. Resident #1’s emergency room Records also revealed the resident had contusions of the nose, scalp, head, and part of the neck, with a deviation and laceration to their nose, and bruising to their left hip. During an interview on 07/15/2025 at 10:15 AM, CNA #7 indicated she always worked on the secure unit, and there were usually 13-15 residents that resided there. During a phone interview on 07/15/2025 at 11:10 AM, CNA #8 revealed she was working the secure unit by herself and stated, when she was coming out of a resident room she saw Resident #1 going into Resident #2’s room, and Resident #2 kicked Resident #1. She stated that Resident #2 liked to be by themselves and was placed in a room by themselves as an intervention for their behavior, upon admission. CNA #8 revealed Resident #2 had a bedroom door that opened at the top, and the resident had left the door open. During a phone interview on 07/16/2025 at 12:20 PM, LPN #9 revealed Resident #1 was in the family room on the unit, crawling around on the floor. [Resident #1’s] nose was bleeding when I saw [pronoun]. She revealed there were no interventions put in place to prevent Resident #1 from going into another resident’s room. LPN #9 stated CNA #8 was in another resident’s room when the incident happened. She indicated Resident #1 crawled around the unit a lot. LPN #9 also indicated that at the time of the incident there was only one staff member on the unit. She revealed she felt there was not enough staff to take care of the residents on the locked unit, and revealed the intervention, after the incident, was for Resident #2 to keep their door closed. During an interview on 07/15/2025 at 1:55 PM, the Administrator revealed Resident #2 was admitted to the facility with behaviors. She further revealed that she received a referral from Resident #2’s previous facility that the resident had only one incident and had been on 1:1 observation with no further incidents. The Administrator stated the referral indicated Resident #2 had attacked another resident with no injuries and was put on the unit in a room by themselves. She revealed that a half door was put on Resident #2’s room to keep other residents from going in. The Administrator confirmed that Resident #1 crawled and Resident #2’s door was opened. She verified CNA #8 was not available to always monitor Resident #1, since she was the only staff on the unit, and Resident #1 was seen on the camera trying to push Resident #2’s door open. The Administrator confirmed Resident #1 had been crawling around the unit since they were admitted . Resident #3: A review of Resident #3’s admission Record revealed the facility admitted Resident #3 on 04/22/2025, with diagnoses which included focal traumatic brain injury (TBI), stroke, convulsions, high blood pressure, anger, and altered mental status. A review of Resident #3’s Care Plan revealed the resident had an activities of daily living self-care deficit related to short term memory loss and behavioral issues. Resident #3’s Care Plan also revealed the resident had impaired cognitive function related to TBI and stroke. The Care Plan indicated Resident #3 needed assistance with shaving. The Care Plan did not indicate Resident #3 resided on the secure unit. A review of Resident #3’s admission MDS with an ARD revealed a BIMS score of 11, which indicated moderate cognitive impairment. A review of Resident #3’s Order Summary Report did not reveal an order indicating the resident required residence on the secure unit. Resident #7: A review of Resident #7’s admission Record revealed the facility admitted the resident on 11/02/2024, with diagnoses which included schizophrenia, major depressive disorder, and generalized anxiety disorder. A review of Resident #7’s quarterly MDS with an ARD of 04/30/2025, revealed a BIMS of 15, which indicated the resident was cognitively intact. A review of Resident #7’s Care Plan revealed the resident was admitted to the secure unit due to schizophrenia, anxiety, and being an elopement risk. Incident: A review of an Office of Long Term Care (OLTC) Incident and Accident Report (I&A) with a discovery date of 06/27/2025 at 10:45 AM revealed a “Summary of Incident” that included, “Administrator notified by Ombudsman that [Resident #3] reported to [family member] that “[Resident #7] hit [Resident #3] in the head.” Resident had been transported on 06/27/2025 to ED (emergency department) for abrasion to top of the head that had been addressed previously…” In Section 762-Findings and Actions Taken, the facility documented, “After thorough investigation, the facility could not conclude whether a resident-to-resident event had occurred. However, based on the assessment of the resident and hospital paperwork…[Resident #3] did not have any identified injuries…Conclusion: On 06/27/2025, after being sent out to the ED for assessment of the abrasion, resident returned to the facility with no new orders or injuries noted. While the facility cannot rule out a potential unwitnessed resident altercation, there is no evidence of resident abuse or resultant injury.” During an interview on 07/15/2025 at 8:35 AM, the Administrator stated the incident with the razor cut on Resident #3’s head initially happened on 06/22/2025. The facility did not enter the incident on the Incident & Accident (I&A) log because they did not think anything had happened between the two residents and no allegations were made at that point. During an interview on 07/15/2025 at 1:57 PM, the Administrator stated on 06/22/2025, CNA #2 heard a “commotion” and went to identify the source. CNA #2 found Resident #3 with blood on their head. The Administrator stated later, Resident #7 was seen ambulating down the hall with a razor in hand. The Administrator stated CNA #1 had just gotten back from lunch and Resident #7 gave CNA #1 the razor. The Administrator stated, We thought Resident #7 attempted to help Resident #3 shave Resident #3’s head. The Administrator stated, I thought the razor was one of the facility razors and thought a staff member might have left the razor in the room or in someone’s room. The Administrator stated on the morning of 06/23/2025, I discovered the Incident Report had not been completed. The Administrator stated they had not completed an I & A report for this incident because the nurse was responsible for completing the report, but when it was discovered the report had not been completed, then the Director of Nursing (DON) should have completed it. During a follow-up interview on 07/15/2025 at 4:27 PM, the Administrator stated, I had come out to the facility early on 06/23/2025, when the first incident happened and had a soft file on the incident. A review of the Administrator’s Soft File report, revealed CNA #2 provided a written statement that indicated CNA #2 heard a commotion and went into the residents’ room. Resident #3 was standing by their bed with blood on their head, while Resident #7 was standing by their own bed. A photo of Resident #3’s head was included, with a visible cut. A Skin Check, dated 06/23/2025, identified a six-centimeter laceration to Resident #3 scalp. During an interview on 07/14/2025 at 12:28 PM, Resident #3 told this surveyor that Resident #7 hit them with a piece of iron and cut their head. This surveyor observed a scabbed over linear laceration on the top of Resident #3’s head. During an interview on 07/14/2025 at 1:23 PM, the Director of Nursing (DON) stated the incident on 06/22/2025 was unwitnessed. The DON stated once the staff heard “the commotion,” CNA #2 went to check on the issue and saw a cut on Resident #3’s head. The DON stated that CNA #2 also saw Resident #7 had a razor, so staff took it and put it up. The DON stated there were little spots of blood on the floor beside Resident #3’s bed. The DON revealed Resident #3’s injury was treated with steri-strips, and there was no bruising or complaints following the incident. The DON stated they did not find any metal objects in the resident’s room, We did find razors, but could not say the other resident did it or if Resident #3 did it themself. The DON revealed Resident #3 was sent to the hospital on [DATE]. A review of ED Nurse Documentation dated 06/27/2025 at 8:15 AM, revealed Resident #3 stated they were struck over the head with a piece of iron by Resident #7, due to Resident #7 believing Resident #3 had taken their belongings. The document described the mechanism of injury as a blow from an iron pipe. A review of a form titled, CT (computed topography) Head Without IV Contrast, dated 06/27/2025 at 8:55 AM, revealed an impression that indicated, “Acute linear fracture visualized through the anterior and posterior wall of the left front sinus extending into the superior left ethmoid sinuses, superior segment of the medial left orbital wall, and superiorly into the lower anterior left frontal bone.” This indicated there was a fresh, straight-line break in the front left sinus bone. The crack extended into nearby areas, including part of the bone between the eyes, the inside edge of the left eye socket, and the lower front part of the left forehead bone. During a phone interview on 07/15/2025 at 10:33 AM, Resident #3’s family member stated on 06/27/2025, the facility notified them the resident was being sent to the hospital because they had a cut on their head due to being shaved. Resident #3’s family member stated they were told it happened when the resident, or the resident’s roommate [Resident #7], tried to shave Resident #3’s head, and cut the resident’s head. The family member stated the DON told them they believed the resident had been digging into the cut on their head, making it bleed. Resident #3’s family member stated Resident #3 told them that Resident #7 had hit Resident #3 in the head with a pipe, because the Resident #7 thought Resident #3 stole their things. During a follow-up phone interview on 07/15/2025 at 12:31 PM, Resident #3’s family member said Resident #3 did not have an electric razor, and initially they were told the residents cut was caused by a regular razor. During Resident #3’s Care Plan meeting on 06/30/2025, they were told Resident #3’s cut was caused by an electric razor. The family member said the facility was “assuming everything,” and could not explain definitively what had occurred. During an interview on 07/15/2025 at 11:17 AM, CNA #2 stated they worked the secure unit the night Resident #3 sustained the cut to the top of the head, which CNA #2 confirmed was not the same day Resident #3 was sent to the hospital. CNA #2 said, I heard a commotion and went to check what it was and found [Resident #3 and Resident #7] standing by their own beds, and [Resident #3] had blood on them. CNA #2 stated the incident was around 9:00 -10:00 PM, and revealed the nurse came and evaluated Resident #3 and later found a razor, which looked like the ones the facility provided. CNA #2 stated they did not know how Resident #3 got the razor. During a phone interview on 07/15/2025 at 3:54 PM, LPN #5 said CNA #2 came and told them Resident #3 was bleeding and that Resident #7 had hit Resident #3. LPN #5 said both Resident #7 and Resident #3 reported that Resident #7 had struck Resident #3, but no one witnessed it. LPN #5 said they completed a paper I & A report per instructions provided by the DON. LPN #5 said no one else saw the report and did not remember passing on this information in report, but the I&A report was left at the nurse’s station. LPN #5 said, I wanted to send the resident out just because [pronoun] was hit on the head, but the Administrator told me not to send resident out. LPN #5 revealed they were asked to backdate the I & A report in the computer. During an interview on 07/15/2025 at 4:50 PM, LPN #4 said LPN #5 did not leave a paper I & A report on 06/23/2025. LPN #4 revealed they did not remember if neurological checks were done. LPN #4 and this surveyor looked in the computer system and no neurological checks were found for Resident #3 on 06/22/2023. During a phone interview on 07/16/2025 at 4:06 PM, the Medical Director (MD) stated the facility informed them that Resident #3 had sustained an abrasion to the top of the head while trying to shave. The MD could not remember the date they were notified of the incident, but said it was before July 1st. The MD stated they had seen the laceration and had determined the wound did not have any soft tissue injury or bruising like you would expect if the resident had been hit with an iron bar. The MD said it appeared to be from a razor cut, with a linear opening like a razor. The MD stated, If the resident had been hit with an iron bar, the wound would be popped open from pressure like popping open a lemon or orange. A review of a policy titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” revised April 2025, indicated residents have the right to be free from abuse, this includes abuse from other residents. A review of a policy tiled, “Resident Rights,” revised February 2021, indicated federal and state laws guaranteed certain basic rights to all residents of this facility. These rights included the resident’s right to: be free from abuse and neglect. An in-service training regarding abuse and dealing with behaviors on the unit was completed on 03/16/2025. Following the March 16, 2025 incident involving Residents #1 and #2, the following was completed on or before 03/26/2025: Residents were immediately separated Resident #2 was placed on 1:1 observation A half-door was installed on Resident #2's room to prevent entry by other residents These interventions remained in place and effective as confirmed by the Administrator during the survey Staff educated on abuse Immediate incident investigating and reporting protocols were followed Resident #1 expired on hospice prior to the survey Following the June 22, 2025 incident involving Residents #3 and #7, the following was completed on or before 06/27/2025: Immediate safety interventions were implemented Increased safety rounds were instituted Sharp objects were removed from resident areas Staff educated on abuse Immediate incident investigating and reporting protocols were followed The survey team was able to verify the facility had performed the aforementioned corrections via interview and record review.

Based on observation, interview, record review, and policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and hand hygiene was performed to prevent the possible spread of infection for 1 (Resident #5) of 1 resident sampled for infection prevention and control. The findings are: Per a Centers for Medicare and Medicaid Services (CMS) memorandum titled, Enhanced Barrier Precautions in Nursing Homes and dated 03/20/2024, EBP refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. It stipulated EBP are indicated for residents with wounds and/or indwelling medical devices, even if the resident is not known to be infected or colonized with an MDRO and indicated EBP be employed when performing high-contact resident care activities, including wound care: any skin opening requiring a dressing. Review of Resident #5's diagnosis sheet indicated diagnoses of pressure ulcer of unspecified heel and skin graft infection. Resident #5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/2024 indicated a Brief Interview for Mental Status (BIMS) of 03, indicating the resident's cognitive status was severely impaired. The MDS indicated that the resident was dependent on staff for activities of daily living (bathing, dressing, grooming, toileting) as well as transfers and bed mobility and that the resident had one stage 3 pressure ulcer and one unstageable deep tissue injury. Resident #5's Care Plan with a revision date of 12/23/2024 indicated the resident was on EBP related to wounds, and indicated staff were to wear a gown and gloves during high contact care activities. On 02/04/2025 at 11:20 AM, prior to the treatment being performed, a one inch circle of a bright red substance, resembling blood, was noted to the bottom fitted sheet at the foot of Resident #5's bed, in the area the resident's heel would rest. Licensed Practical Nurse (LPN) #6, accompanied by the Director of Nursing (DON), entered Resident #5's room and was observed providing wound care to Resident #5's right heel. LPN #6 washed her hands and entered the resident's room and began treatment without donning a gown. The front of LPN #6's scrubs repeatedly came into contact with the sheets on Resident #5's bed during the treatment. LPN #6 removed the soiled dressing from the heel of Resident #5, then removed her gloves. Without performing hand hygiene, LPN #6 applied a new pair of gloves and cleaned the wound on the resident's heel. With soiled gloves the LPN opened a clean dressing package. LPN #6 removed the soiled gloves, and without performing hand hygiene applied a new pair of gloves. LPN #6 then applied the dressing to the wound. On 02/04/2025 at 11:45 AM, LPN #6 confirmed she should have performed hand hygiene with each glove change. She said she normally would have washed her hands between glove changes, but the resident's room did not have a sink. When asked what she could have done without soap and water, LPN #6 stated, I could have used alcohol hand sanitizer, but I didn't have it. On 02/04/2024 at 11:50 AM, LPN #6 and the DON acknowledged EBP, which included gowns and gloves, were required to be utilized when performing high contact activities with residents that have an indwelling device such as a catheter or feeding tube or that have a wound. On 02/04/2025 at 3:10 PM, LPN #7 related all residents on EBP were identified by a sign on the door of their room, so staff knew gloves and gowns were required prior to providing care to those residents. LPN #7 related PPE (Personal Protective Equipment) supplies were kept in a supply room beside hall 200's nurses' station, to which she had the key, and she would put supplies out at the nurses' station for use by staff. On 02/04/2025 at 3:14 PM, CNA #8 confirmed residents with EBP were identified by signage on the door of their room and required staff to wear gowns and gloves and masks at times. CNA #8 stated the staff got PPE supplies from the linen closet but most of the time they were unable to locate supplies there and must go to the brief room which was located on the 100 Hall. On 02/04/2025 at 2:20 PM, the DON stated residents on EBP were identified by signage on the door to their rooms, and it was in their electronic health record. The DON reported PPE was kept in a drawer in each resident's room. The DON then accompanied this surveyor to 4 different resident rooms, who were identified by the DON as being on EBP and was unable to locate PPE in the rooms. On 02/04/2025 at 2:33 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated that residents on EBP were identified by signage by their bed, and they included gowns, gloves and goggles if required. She reported the supplies were kept locked in her office but now they were located in the central supply closet, so staff had access to it. On 02/04/2025 at 2:45PM the DON came to this surveyor and stated the ADON/IP had just informed her that the EBP supplies had been moved under the sink in the room of each resident with EBP last week. A list of residents on EBP obtained from the DON included 5 residents who had indwelling devices on the 200 Hall, but did not include any residents identified as having a wound, including Resident #5. Review of the facility policy for Infection and Prevention Control indicated, it is designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Review of the facility policy for Enhanced Barrier Precautions with no indication or revision date, showed enhanced barrier precautions would be provided for residents with wounds and/or indwelling medical devices. The policy also indicated the facility would make gowns and gloves available immediately near or outside of the resident's room.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the North Hall was free of water and wet linens affecting 2 (Resident #31 and #39) sampled residents when ambulating in the hallway to prevent falls, and accidents; failed to ensure the North Hall shower door tub room was locked to prevent residents from having access to open razors, and to prevent falls on wet, soapy floors; failed to ensure the tub room on the North Hall, being used to store portable oxygen tanks, was kept locked to prevent resident accidents or injuries failed to ensure 1 smoker requiring supervision (Resident #39) of 1 sampled (Resident #39) was not smoking without supervision to prevent accidents or injuries; failed to ensure the 200 Hallway was free of missing tile with an uneven surface to prevent accidents and injury; and failed to ensure an aerosol can of a name brand insect spray was not stored in a resident's room for 1 (Resident #53) of 1 sampled resident. The findings include: 1a. On 08/12/2024 at 10:28 AM, soaking wet, rolled up linens were observed resting in the floor against the soiled linen and equipment room doors across the hall from 2 resident bathrooms on the North Hall. b. On 08/12/2024 at 10:29 AM, during an interview, the Floor Tech stated the hot water heater had been leaking for a couple of weeks and said if water stands on the floor it would cause a risk of someone falling and pointed out the resident bathrooms across the hall. Housekeeper #3 stated the linens on the floor outside the soiled linen and equipment room were changed out when they get soaked, and confirmed administration is aware of the hot water heater leaking. c. On 08/13/2024 at 4:49 PM, water was observed resting in the hallway floor beyond the wet rolled up linens, and a yellow wet floor sign. d. During an interview with the Director of Nursing (DON) on 08/14/2024 at 3:30 PM, the DON stated when staff see that something is broken or there is a problem they are expected to notify maintenance or someone to fix it and confirmed it was a risk for falls. e. On 08/14/24 at 4:30 PM, a large puddle of water was observed outside the baseboard of the soiled linen door on the North Hall. f. On 08/12/24 at10:35 AM, the North Hall shower room was found unlocked with soapy, wet, slick floors, and open packages of razors resting on a table on the right side of the room. There was an uncapped razor in a basket on the floor, and in a bag on the table. g. On 08/12/24 at 11:10 AM, Certified Nursing Assistant (CNA) #4 accompanied the Surveyor to the shower room on the North Hall and confirmed the shower door was supposed to be locked, open razors could cause injury to a confused resident, and CNA #4 confirmed residents could fall on the wet, soapy floor. h. During an interview with the DON on 08/13/24 at 2:29 PM, the DON confirmed the shower door should be locked so residents do not have access to the razors because they could harm themselves, and the soapy floor caused a risk for falls. i. On 08/12/24 at 10:43 AM, the North Hall tub room was observed unlocked, and on the left side of the room were unused concentrators, 20 portable oxygen tanks in the rack, and 1 full portable tank, and 1 empty portable tank in a small cart. j. On 08/12/24 at 10:59 AM, during an interview, the DON was asked what the tub room is used for, and the DON confirmed the room was used to store oxygen. The Surveyor asked if the room was supposed to be locked and the DON confirmed the door should be kept locked because the tanks could fall on someone or explode. 2. Review of Resident #39's Medical Diagnosis, revealed diagnoses of acute respiratory failure, chronic obstructive pulmonary disease, and alcohol dependence. a. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/2024 suggested a Brief Interview for Mental Status (BIMs) of 15 (13-15 indicates cognitively intact). b. Review of Resident 39's Care Plan, initiated 05/24/2024, revealed the resident required assistance and supervision when smoking. c. On 08/13/24 at 10:10 AM, Resident #39 was observed smoking while sitting outside alone in the smoker's area. Resident #39 said a staff member provided the cigarette, lit it, and left the resident alone in the smoking area. d. During an interview with Registered Nurse (RN) #5 on 08/13/24 at 10:45 AM, RN #5 confirmed Resident #39 was a supervised smoker, should not have been smoking alone outside, and could have been burned or had an accident. e. On 08/13/24 at 10:41 AM, the DON was asked if staff were expected to stay with residents while they smoked when they are assessed and require supervision. The DON confirmed residents are to allow staff to light their cigarettes and are not to be left alone outside smoking because they could harm themselves or start a fire. f. A review of Resident 39's Smoking Safety Screen, initiated 05/24/24 indicated the resident can smoke safely with supervision and cannot light residents own cigarette. g. Review of a facility policy titled, Smoking Policy-Residents, indicated, Residents with a smoking restriction will require supervision by a staff, or family member while smoking. h. On 08/12/2024 at 11:00 AM, several pieces of tile were missing, forming a large open area of uneven concrete. Resident #32 was observed walking up and down the length of the hallway, walking through the uneven area multiple times. i. On 08/15/2024 at 10:00 AM, the Maintenance Supervisor was interviewed about the area, he stated the area had been in place for several weeks and he was going to grind the area down. The Maintenance Supervisor measured the area and stated the area was Two feet long and two feet wide. j. On 08/12/2024 at 1:03 PM, Resident #53 was awake and sitting up in the resident's room in a wheelchair. The lunch meal tray was on the bedside table and the resident was preparing to eat. There was a 12-ounce (oz.) aerosol spray can of [name brand] insect spray observed on the counter by the sink. The can indicated the spray kills flies, mosquitoes and gnats. k. On 08/13/2024 at 9:08 AM, Resident #53 was lying in bed, awake with the television on. There was a 12-ounce (oz.) aerosol spray can of [name brand] insect spray observed on the counter by the sink. The can indicated the spray kills flies, mosquitoes and gnats. l. On 08/13/3024 at 8:37 AM, there was a resident wandering in the hallway that Resident #53 resided on and the resident who was wandering was observed entering another resident's room. m. On 08/14/2024 at 8:37 AM, Licensed Practical Nurse (LPN) #2 and this surveyor entered the resident's room as the nurse was preparing to administer the resident's morning medications. There was a 12-ounce (oz.) aerosol spray can of [name brand] insect spray observed on the counter by the sink. The can indicated the spray kills flies, mosquitoes and gnats. n. On 08/15/2024, a website, [name].com, was reviewed and indicated the product was not to be sprayed directly on people, is flammable and the contents were under pressure. 51064 37925

Based on observation, record review, interview, and facility policy reviews, it was determined the facility failed to repair or replace a leaking water heater in a timely manner for 2 sampled (Resident #31, Resident #39) capable of ambulation or self-propelling on North Hall to ensure a sanitary, orderly, and comfortable interior. The findings are: a. On 08/12/24 at 10:28 AM, wet linens and water extending beyond a yellow caution sign were observed resting on the floor outside the soiled linen and equipment room on the North Hall. b. On 08/12/24 at 10:29 AM, during an interview the Floor Tech stated the hot water heater had been leaking a couple of weeks on North Hall and Housekeeping #3 stated the hot water heater had been leaking for many weeks. c. On 08/13/24 at 9:25 AM, a review of the maintenance log hanging up outside the Administrators office did not show documentation of a leaking hot water heater. d. On 08/13/2024 at 4:00 PM, the Maintenance Director stated the leaking hot water heater should have been documented on paper a long time ago. e. On 08/14/24 at 10:30 AM, during an interview with the Maintenance Supervisor (MS), the MS was asked how long the hot water heater has been leaking in the North Hall equipment room, and the Surveyor was referred to the Administrator. f. On 08/14/2024 at 10:45 AM, during an interview the Administrator was unable to confirm the exact date the North Hall water heater started leaking but was able to provide documentation of 2 plumbing estimates to replace the hot water heater, dated 06/25/2024, and 07/11/2024. g. Review of a facility policy titled Maintenance Service, revised 12/2024, indicated The maintenance department is responsible for maintaining the facility building in a safe and operational manner at all times.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure care plans were revised to reflect the changing needs and preferences for 2 (Residents #11 and #35) of 20 (Residents #1, #4, #8, #11, #12 , #13, #14, #17, #19, #20, #21, #31, #32, #34, #35, #38, #39, #42, #49 and #53) sampled residents reviewed for care plan revisions. The findings include: 1. Review of the Medical Diagnosis, revealed Resident #11 had diagnoses of stroke, chronic obstructive respiratory failure, and acute respiratory failure. a. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/25/2024 suggested a Brief Interview for Mental Status score of 9 (8-12 indicates moderately impaired). Section K0529 indicates the resident had a feeding tube on admission and while a resident. b. Review of Resident #11's Physician Orders, dated 05/23/2024, revealed continuous [diabetic tube feeding formula] 1.2 calorie at 65 cubic centimeters per hour. c. Review of Resident #11's Care Plan, dated 05/31/2024, revealed Resident was on a [non-diabetic tube feeding formula] 1.5 at 55 cc per hour (Revised, 02/05/2024) related to difficulty swallowing. d. On 08/14/2024 at 12:30 PM, the MDS Nurse was asked to pull up Resident #11's care plan, physician orders, and comprehensive MDS from 05/25/2024, and verify interventions implemented on the care plan for tube feeding. e. On 08/14/2024 at 12:38 PM, the MDS Nurse confirmed Resident #11 had an increase and change in tube feeding prior to the Admission MDS, dated [DATE], it was not revised on the care plan dated 05/31/2024. The Surveyor asked why is it important for the care plan to be accurate. The MDS Nurse confirmed the care plan should be revised to reflect accurate tube feeding to make sure Resident #11 gets needed nutrients. f. Review of a facility policy titled Care Planning-Interdisciplinary Team, Revised, 03/2024, did not address care plan revisions. g. On 08/15/2024 at 10:15 AM, the Administrator was asked for an MDS policy. The Chief Nursing Officer (CNO) clarified surveyor was looking at revisions, and stated they did not have a policy related to revisions. 37925 2. Resident #35 had a diagnosis of seizures indicated on an, Order Summary Report, dated 08/13/2024 that was reviewed. a. The Order Summary Report, dated 08/13/2024, was reviewed and indicated Resident #35 had a physician's order for Dilantin 100 milligrams (mg) by mouth three times a day for seizures and was ordered on 02/27/2024. Resident #35 was prescribed Levetiracetam 500 mg by mouth two times a day for seizures and was prescribed on 02/27/2024. b. A Care Plan, dated 08/07/2024, was reviewed and indicated Resident #35 had a seizure disorder related stroke. The interventions included seizure precautions as indicated but did not list the precautions to monitor the resident for. The interventions included giving the medications as ordered, but it did not list the medications or the side effects to monitor the resident for.

Based on observation, interview and record review, the facility failed to ensure manufacture's guidelines found on the container were followed to prevent the potential for food spoilage and / or growth of bacteria, foods were stored properly after being opened and dietary staff washed their hands and changed gloves during the meal preparation to decrease the potential for food borne illnesses for residents who received meals from 1 of 1 kitchen. This had the potential to affect 49 residents (Census: 51), as indicated on a list provided by the District Dietary Manager on 08/15/2024. The findings are: On 08/12/2024 at 11:07 AM, initial rounds were conducted in the kitchen and the following observations were made: 1. The Storage Room: a. There was a 32-ounce (oz.) bottle of [brand name] Lemon Juice Concentrate with an opened dated of 7/22/2024, observed on the shelf. There was about a fourth of the liquid left in the bottle. It was not cold and there was no condensation on the bottle. The label on the bottle indicated refrigerate after opening. b. There was a plastic bin observed on the bottom shelf with rice and it had a foam cup inside, directly in the rice. 2. On 08/14/2024 at 9:17 AM, this surveyor entered the kitchen to observe the lunch meal preparation (prep). During the meal prep, Dietary Staff #6 removed a pair of gloves, washed her hands and took a red cutting board, rinsed it off in the sink. Without washing her hands, she put on a clean pair of gloves and pealed an onion and diced it with a knife. During the meal prep, she washed her hands, put on a clean pair of gloves, picked up one of two packages of tortilla shells that were placed in the work area by the Dietary Manager, opened the package with her gloved hands, reached inside and began removing the shells one at a time, placing them in a metal pan. During the meal prep, Dietary Staff #6 had on gloves and picked up a scoop to place the cooked meat mixture over the tortilla shells in the pan. With the same gloved hands, she reached in a bag of shredded cheese with her right hand, removed some of the cheese and sprinkled it over the meat mixture. She poured the remaining shredded cheese in a plastic pitcher and began shaking the pitcher so the cheese could fall over the meat mixture. During the meal prep, she used gloved hands to open the second package of tortilla shells that the Dietary Manager had placed in the work area, and she reached inside and began removing the shells one a time, placing them in two different metal pans. She did not change her gloves or wash her hands. During the meal prep, she washed her hands and picked up a pair of black oven gloves, placed them in the work area and put on a pair of clean gloves and continued with the lunch meal prep without washing her hands or changing gloves. 3. On 08/14/2024 at 9:21 AM, there was a metal cart observed in the corner where the dietary staff prepares the pureed food. On the top shelf there was an open bag of breadcrumbs that was not properly sealed or dated and a bag with slices of bread inside that was not properly sealed. 4. On 08/14/2024 at 11:03 AM, the steam table was observed and there was brown residue on the bottom of the pans. 5. On 08/15/2024 at 9:29 AM, Dietary Staff #6 was interviewed, and she confirmed food / dry goods should be wrapped with [brand name] clear wrap, put it in a [brand name] storage bags with the opened and use by date on it. She confirmed hands should be washed in the kitchen before, during, and after, something has been touched while performing a task and before putting gloves on. She confirmed gloves should be changed before touching something. She confirmed the steam table pans are cleaned and she has scrubbed the pans, and they feel gritty. She confirmed the foam cup should not be left inside the bin of rice due to possible cross contamination. 6. On 08/15/2024 at 9:47 AM, the Dietary Manager was interviewed and confirmed the bottle of lemon juice should have been stored in the refrigerator after it was opened. She confirmed the steam table pans were cleansed with the products recommended by the facility and pieces were coming off the bottom of the pans. 7. A QRT Hand Washing policy dated 09/01/2021, provided by the District Dietary Manager (DDM) on 08/15/2024, was reviewed and indicated hand should be washed as often as possible and to wash hands before starting to work with food, utensils, or equipment, before putting on gloves and as often as needed during food preparation and when changing tasks. 8. A Safe Storage of Food policy date 09/01/2021, provided by the DDM on 08/15/2024, was reviewed and indicated all foods will be wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination and all perishable foods will be maintained at a temperature of 41 degrees Fahrenheit (F) or below, except during necessary periods of preparation and service.

Based on observation, interview, and record review, the facility failed to ensure a glucometer machine was cleansed after being used for 1 (Resident #107) of 1 sampled resident observed during a glucometer check. The findings are: An Order Summary Report dated 08/14/2024, was reviewed and indicated Resident #107 had a diagnosis of type 2 diabetes mellitus. There was no order for a random blood sugar check. On 08/13/2024 at 4:49 PM, Resident #107 was sitting in a wheelchair and asked Registered Nurse (RN) #5 for a blood sugar check. She put on gloves, held Resident #107's third (3rd) finger on the right hand, pricked it with a lancet and collected a sample of blood on the test strip. The machine's screen displayed 116 after a few seconds. RN #5 discarded her gloves and tossed the used items in the trash. She placed the glucometer machine directly in the top right drawer of the medication cart without cleaning it, closed the drawer and sanitized her hands. She opened the door of the unit to leave, and this surveyor stopped her. RN #5 was interviewed, and she confirmed she placed the glucometer back in the medication cart without cleaning it. She confirmed the glucometer was supposed to be cleansed after being used but was going to clean it later. A Blood Sampling-Capillary (Finger Sticks) policy, revised September 2014, provided by the Director of Nursing (DON) on 08/15/2024, was reviewed and indicated reusable equipment was to be cleansed and disinfected after each use.

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered at the physician's ordered flow rate to decrease the potential for respiratory complications for 1 (Resident #38) of 2 (Residents #38 and #39) sampled residents who were reviewed for oxygen. The findings are: Resident #38 had diagnoses of heart failure and issues with the respiratory system (breathing), indicated on an Order Summary Report dated 08/13/2024 that was reviewed. There was an order for oxygen to be administered at two liters per minute (2 l/min) by way of (via) a nasal cannula as needed for shortness of breath and ordered on 07/12/2024. A Care Plan with a completed date of 07/25/2024 was reviewed on 08/13/2024 and indicated Resident #38 had an altered respiratory status/difficulty breathing related to heart disease and the oxygen setting was 2 liters per nasal cannula and was to be humidified. On 08/13/2024 at 2:49 PM, the Electronic Medication Administration Record (eMAR) was reviewed and indicated the oxygen should be at 2 liters per minute by way of a nasal cannula as needed for shortness of breath. There was no documentation in any of the boxes that the resident had oxygen in use for 08/01/2024 to 08/13/2024. On 08/12/2024 at 12:27 PM, Resident #38 was lying in bed, awake, with a nasal cannula in use. The oxygen concentrator was on and set at 3.5 l/min. On 08/13/2024 at 8:16 AM, Resident #38 was lying in bed on the right side with eyes closed. The nasal cannula was in the resident's nose and the oxygen concentrator was on and set at 3.5 l/min. On 08/13/2024 at 4:05 PM, Resident #38 was lying in bed on the right side awake. A nasal cannula was in the resident's nose and the oxygen concentrator was on at 4 l/min with a humidifier bottle attached to the concentrator. On 08/14/2024 at 4:52 PM, during an interview and concurrent observation, Registered Nurse (RN) #5 was asked to look at the oxygen concentrator and to state what the flow rate was set at. She looked at the concentrator and confirmed the resident's oxygen concentrator was set at 4 l/min. She walked to the medication cart, reviewed Resident #38's orders in the electronic health record and confirmed the resident's order was for 2 l/min. She was asked who monitors the oxygen rate. She stated, We usually glance at it and confirmed the nurses were responsible for monitoring the oxygen flow rate. An Oxygen Administration policy, revised 06/2024, provided by the Director of Nursing on 08/15/2024, was reviewed and indicated oxygen is administered under orders of a physician, except in cases of emergencies. It also indicated the staff would document the beginning and continued assessment of the resident's condition requiring oxygen and the response to oxygen use.

Based on observation, interview, and record review, the facility failed to ensure fingernails were cleaned and trimmed for 1 (Resident #35) sampled resident who was reviewed for nail care. The findings are: 1. Resident #35 had diagnoses of muscle weakness and altered mental status as indicated on an Order Summary Report dated 08/13/2024. a. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/2024 indicated Resident #35 had a Brief Interview for Mental Status (BIMS) score of 06 indicating the resident was severely cognitively impaired. b. The Care Plan dated 08/07/2024 was reviewed and indicated Resident #35 had an activities of daily living (ADL) self-care performance deficit. The interventions for nail care indicated checking nail length and trim and clean as necessary. c. The ADL Task: Nail Care was reviewed on the electronic health record on 08/13/2024 and indicated no data found. d. On 08/12/2024 at 1:09 PM, Resident #35 was sitting up in bed awake. The fingernails on both hands were greater than a quarter (1/4) inch in length with a dark brown substance under them. Resident #35 confirmed fingernails are trimmed maybe once a year. e. On 08/13/2024 at 8:35 AM, Resident #35 was sitting up in bed finishing breakfast. The fingernails on both hands were greater than 1/4 inch in length and there was a dark substance underneath the nails on both hands. f. On 08/15/2024 at 11:46 AM, Licensed Practical Nurse (LPN) #2 looked at Resident #35's fingernails and described them as too long, and dirty. She confirmed the resident was not a diabetic and Certified Nursing Assistants (CNA) were responsible for providing nail care on the residents' bath/shower days. 51064

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure a comprehensive care plan was provided for 1 (Resident #11) of 20 (Residents #1, #4, #8, #11, #12, #13, #14, #17, #19, #20, #21, #31, #32, #34, #35, #38, #39, #42, #49, #53) sampled residents requiring a comprehensive care plan to ensure residents receive appropriate care. The findings include: 1. Review of the Medical Diagnosis revealed Resident #11 had diagnoses of stroke, chronic obstructive respiratory failure, and acute respiratory failure. a. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/25/2024 suggested a Brief Interview for Mental Status score of 9 (8-12 indicates moderately cognitively impaired). Section I6300 indicated the resident had respiratory failure, Section O0110 indicated the resident was on oxygen on admission, and while a resident, and had a tracheostomy on admission and while a resident. b. On 08/14/2024 at 12:25 PM, the MDS Nurse was asked about measurable interventions on Resident #11's care plan for Respiratory failure, tracheostomy, and oxygen. The MDS Nurse said she was unable to find those areas on the care plan because the care plan was vague, and should be addressed to keep the resident well, help to assess the resident and to prevent rehospitalization s. c. During an interview with the MDS Nurse on 08/14/2024 at 12:40 PM, the MDS Nurse was asked what the process for forming a comprehensive care plan. The MDS Nurse revealed a baseline care plan is formed, and she checks what triggers after the MDS is updated using the guidance of the Resident Assessment Instrument (RAI) manual. d. Review of a facility policy titled, Care Planning-Interdisciplinary Team, indicated, Comprehensive care plans are based on resident assessments by the Interdisciplinary Team (IDT). d. Review of a facility policy titled Care Plans, Comprehensive Person-Centered, (Revised, March 2023) revealed the Interdisciplinary Team (IDT) reviews and updates care plans when a resident is readmitted from a hospital, when warranted, and with the required quarterly MDS assessment.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to provide a bed hold notice prior to discharge for 1 (Resident #11) of 2 sampled residents (Resident #11 and Resident #54) who were discharged or transferred to the hospital. The findings include: a. On 08/14/24 at 11:08 AM, the Business Office Manager (BOM) was asked to look at the last two bed holds for Resident #11. The BOM confirmed Resident #11 did not get a bed hold because the resident was not cognitive, his family member cannot be reached, and she was newly hired 11/2023 and did not know it was her job to get a bed hold. b. On 08/14/2024 at 11:15 AM, the BOM was asked why bed holds were given to residents. The BOM stated she did not know, and thought it was a Medicare/Medicaid requirement to ensure the safe transfer of residents. c. On 08/14/24 at 11:30 AM, the Administrator revealed the facility has an action plan for bed holds and was asked to provide the documentation. d. On 08/14/24 at 2:00 PM, the Administrator provided an action plan, dated 07/31/2024, stating the BOM/Social Designee will audit all transfers for 30 days to ensure a transfer letter is initiated and negative findings addressed. The Administrator will also complete a random audit with a target completion date of 08/16/2024. e. A review of the Clinical Review Profile shows Resident #11 is the responsible party and guarantor. f. Review of a facility policy titled, Bed Holds and Returns indicated, Residents or representatives will be informed of bed hold policies in writing prior to transfers and therapeutic leaves. g. On 08/15/24 at 9:00 AM, the Administrator told Surveyors the BOM did not become responsible for bed holds until 6/12/2024 after the previous business office manager left on 05/03/2024, despite Resident #11's bed hold from a transfer on 03/24/2024 being signed by the current BOM on 04/17/2024. The problem with bed holds not being completed was identified on 07/31/2024 according to an action plan started on 07/31/2024.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents personal funds were returned within 30 days of death for 1 (Resident #207) of 3 sampled (Residents #207, #14, #6) sampled residents. The findings are: On 8/13/2024 at 11:20 AM, upon review of the facility, Progress Notes, Resident #207 passed away on 3/15/2024, and upon review of facility financial records continues to show an active balance on the account of $94.08. On 8/14/2024 at 2:07 PM, interviewed Business Office Manager regarding the resident continuing to have a positive balance of $94.08 five months following death of resident. She stated, I was waiting on the corporate office to advise me of whether or not to return the money in the account to the residents' family because the resident had an outstanding balance owed to the facility. Review of a facility policy titled, Management of Residents' Personal Funds, dated/revised March 2021, stated the facility they manage the resident's funds in accordance with federal/state requirements.

Based on observation and interview, the facility failed to ensure the kitchen area air conditioner intake filter and vents were clean to prevent potential food borne illness. This failed practice had the potential to affect 47 residents who received food from the kitchen (total census: 49), according to the Diet List provided by the Dietary Manager on 08/21/23 at 10:55 AM. The findings are: 1. On 08/21/23 at 11:03 AM, the following observations were made in the Kitchen: a. Observed the air conditioner unit located in the middle of kitchen area. The air intake filter and vents had a dark brown/black substance and dark brown fuzzy particles of debris stuck to the vents which was over the food prep table area. b. A dietary employee was rolling silverware in napkins on the prep table for residents to use with lunch. c. Two large open bags of frozen tater tots were on the prep table by the oil fryer. d. An open box of frozen hamburger patties were on the prep table. 2. On 08/21/23 at 2:00 PM, the Surveyor asked the Dietary Manager to look at the air conditioning out vent and describe what she saw. The Dietary Manager stated, Well it looks like dust to me. The Surveyor asked her to describe what she saw on the wall by the air conditioner out vent. She stated, Dust and dirt. The Surveyor asked if the dust and dirt could get in the food that is prepped on the prep table below it. She stated, Well we don't use that table much. The Surveyor asked if the silverware rolled on that table and the tater tots sitting on the table waiting to be cooked was for the residents today. She stated, Oh, well yes. 3. On 08/21/23 at 2:10 PM, the Surveyor asked Dietary Employee (DE) #1 if the vents felt like they were blowing air. DE #1 stuck his hand up in front of the out vents blowing toward the prep table and toward the center of the kitchen and said, Yep it is blowing a little bit. Looks to me like they need to clean the intake vent, blow it out or something. 4. On 08/21/23 at 2:20 PM, the Surveyor asked the Director of Operations to describe what was on the air conditioner out vent area. The Director of Operations stated, Dust and maintenance is responsible for taking care of anything that is above the staffs heads. They should be cleaning and taking care of things like that. The Surveyor asked if the dust could get in the food that is prepped on the prep table. Stated, Of course. 5. On 08/21/23 at 2:25 PM, the Surveyor asked the Regional Manager to get a paper towel and wipe the area on the air vents. The Regional Manager got a clean white paper towel and wiped on both sides of the air conditioner vents. The Surveyor noted the paper towel had a black slimy colored substance on it. The Surveyor asked if that should be there. The Regional Manager stated, No. 6. On 08/22/23 at 11:00 AM, during lunch prep for the day, the Surveyor observed DE #2 get a pot from the hanging pot rack below the air conditioner vent to use for the preparation of the soft vegetables for puree diets. 7. On 08/22/23 at 3:20 PM, The Maintenance Supervisor and the Surveyor were standing in the door of the kitchen and able to see the air conditioner ceiling unit. The Surveyor asked if he was responsible for cleaning the ceiling air conditioner unit. He stated, Yes, I have cleaned it today. I had the filter out and cleaned it today too. The Surveyor asked, How often is it cleaned? He stated, About once a month or so. I clean it when I clean the vent-a-hood that is over the stove there. The Surveyor asked, Do you have a log showing that the unit is cleaned? He stated, Yes, it is in my safety binder that I keep. The Administrator has it right now. 8. On 08/22/23 at 3:30 PM, the Surveyor asked if the air conditioner vents have fuzzy brown particles on them and a black slimy substance on them what could that cause in the kitchen. She stated, It could contaminate the food. 9. On 08/23/23 at 8:00 AM, the maintenance log titled, Monthly High Use Exhaust Fans and Air Conditioner Vents, for the Kitchen documented cleaning was completed monthly since 04/04/22, with the last cleaning on 08/08/23. 10. A facility policy titled, Clean & Sanitary, provided by the Administrator on 08/23/23 at 8:00 AM documented, STANDARD: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. GUIDELINE: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation .

Based on observation and interview, the facility failed to ensure waste was properly contained in a dumpster with the door and lid closed to reduce the potential of insect and/or rodent infestation. The failed practice had the ability to affect all 49 residents who resided in the facility according to the Resident Census and Conditions of Residents provided by the Administrator on 08/25/23 at 1:05 PM. The findings are: 1. On 08/24/23 at 8:52 AM, upon exiting the back door of the building, the ground was littered with cigarette butts. To the right on the way to the dumpster was a brown cardboard box. The door of the dumpster was open with a white bag protruding from the opening. Located next to the dumpster, on the ground was an additional bag of trash. 2. On 08/24/23 at 9:53 AM, one half of the lid to the dumpster was open. The side door remained open with trash bags protruding. 3. On 08/25/23 at 10:00 AM, the Surveyor asked the Maintenance Supervisor what was important concerning the disposal of waste. He stated, It's important to keep the area clean and the doors closed. We have to keep the residents safe.

Based on observation, interview and record review, the facility failed to ensure that a physical restraint was released in accordance with a Physician's Order for 1 (Resident #25) of 2 (Residents #25 and #33) sampled residents with a Physician's Order for a physical restraint according to the Resident Matrix provided by the Administrator on 08/21/23 at 1:05 PM. The findings are: 1. Resident #25 had diagnoses of Alzheimer's Disease and Psychotic Disorder with Delusions due to known Physiological Condition. a. On 08/21/23 at 12:08 PM, observed Resident #25 in her room in a chair restraint. Resident #25 was slumped down in the chair, with her head hanging over the side of the chair. The restraint was around the resident's waist and tied in a knot at the back of the chair. b. A Care Plan with a revision date of 05/24/22 noted Resident #25 uses physical restraints related to leaning forward to include a lap belt while up in a geri-chair. A soft lap belt was to be applied and checked every 30 minutes. The lap belt was to be released every 2 hours for 10 minutes of exercise. When restrained Staff were to ensure Resident #25 was positioned correctly with proper body alignment. c. A Physician's Order dated 10/06/22 noted Resident #25 was to be restrained with a lap belt while up in chair due to leaning forward continuously and was to be checked every 30 minutes and released every 2 hours for ten minutes of exercise. d. On 08/23/23 at 11:13 AM, observed a staff member go into Resident #25's room. Resident #25 was in her chair with the lap restraint with her eyes closed. Resident #25 had slid down some in the chair and her head was laying over the arm rest. A staff member went into Resident #25's room and put a pillow under her arm and tried to prop her head up. Resident #25 did not wake up and the staff member left the resident's room. The restraint was not released. e. On 08/23/23 at 12:18 PM, observed Resident 25 for two hours and fifty-three minutes and the Resident was never released from her lap restraint. f. On 08/25/23 at 10:07 AM, the Surveyor asked the Administrator about the policy on restraints and when they were to be released and checked. The Administrator stated that they are to be checked every two hours and released every two hours. The Surveyor asked who was allowed to release or check the restraints. The Administrator stated that a nurse is to release the restraints, but a CNA (Certified Nursing Assistant) can check the restraints. g. On 08/25/23 at 10:44 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 how often Resident #25's restraint was to be released. LPN #3 stated, Every 2 hours. The Surveyor asked when the last time Resident 25's restraint was released. LPN #3 stated, I haven't actually observed her being released today. The Surveyor asked who can release the restraints. LPN #3 stated, The CNAs. h. On 08/25/23 at 10:48 AM, the Surveyor asked CNA #1 how often Resident #25's restraint was to be released. CNA #1 stated Every one to two hours. 2. A facility policy titled Use of Restraints provided by the Nurse Consultant documented, .10. The following safety guidelines shall be implemented and documented while a resident is in restraints: a. Restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident . c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. e. Restrained residents must be repositioned at least every two (2) hours on all shifts . 48390

Based on observation and interview, the facility failed to ensure an effective pest control program was maintained. The failed practice had the potential to affect all 49 residents residing in the facility according to the Resident Census and Conditions of Residents provided by the Administrator on 08/21/23 at 1:05 PM. The findings are: 1. On 08/21/23 at 12:34 PM, observed 5 flies on the utensils, the food items and on the lunch tray of the resident in Resident room [ROOM NUMBER] B while she was eating lunch. The Resident in bed A had one fly buzzing around her head and landed on the edge of the resident's cup while she was drinking from it. The Surveyor asked Certified Nursing Assistant (CNA) #1 if flies should be on a resident's food. She stated, No, I know they have tried several different things. 2. On 08/21/23 at 12:44 PM, 2 flies were in the Dining Room flying around 2 residents and landed on the food items of one of the resident's lunch tray. 3. On 08/24/23 at 2:18 PM, the Surveyor asked Housekeeping staff #1 and #2 if they had observed flies in the resident rooms. Housekeeper #1 and #2 unanimously agreed that flies have been seen in the resident rooms. Licensed Practical Nurse (LPN) #1 verbalized that she too was aware of flies in the resident rooms. 4. On 08/25/23 at 10:15 AM, the Surveyor asked the Administrator if she was aware of the flies in the resident rooms. She stated, They have been terrible this year. We have signed a contract with a new pest service.

Based on observation, record review, and interview, the facility failed to ensure the doors to the Electrical Equipment Room and the Water Heater Mechanical Room located in the Dining Room were locked and inaccessible by residents. This failed practice had the potential to affect 20 residents who were mobile and able to access the dining area according to a list provided by the Administrator on 08/23/23 at 8:00 AM. The findings are: 1. On 08/21/23 at 12:05 PM, during observation of the lunch meal in the Dining Room, the Surveyor observed two doors and gained access to the rooms without assistance. On the walls of the Electrical Equipment Room were 3 large electrical breaker box panels with all 3 doors open and accessible and one phone line panel was not covered. In the Water Heater Mechanical Room there was one large hot water heater with a cold pipe and a hot pipe accessible by touch, and 2 large air conditioning units in the room. 2. On 08/21/23 at 2:55 PM, the Surveyor asked the Maintenance Supervisor, Are the doors to the two rooms usually unlocked? The Maintenance Supervisor stated No, they are usually locked. I think they have been unlocked since Friday (08/18/23) when we had a breaker issue when we were working on the air conditioner. That is my responsibility, that is on me. 3. On 08/22/23 at 3:30 PM, the Surveyor ask the Administrator If the doors to the Electrical Equipment and the Water Heater Mechanical rooms in the Dining Room should be unlocked. She replied, No, they should always be locked. 4. On 08/23/2023 at 11:30 AM, the Surveyor asked the Administrator if there was a policy regarding safety of residents and locking doors of rooms containing mechanical equipment. The Administrator stated, No we don't have anything for that. They just should be locked.

Based on record review and interview, the facility failed to ensure basic life support measures, including cardiopulmonary resuscitation (CPR), were provided for a resident who was found unresponsive and without vital signs and was documented as having a Full Code status; failed to ensure licensed nursing staff were certified in Cardiopulmonary Resuscitation; failed to ensure Emergency Transport was called to assist in the resuscitation of the resident; failed to ensure licensed nursing staff documented an appropriate assessment of the resident to support the decision to withhold Cardiopulmonary Resuscitation; and, failed to ensure information regarding code status was readily accessible to staff who were responsible for the care of the residents to prevent CPR from being withheld in error for 1 (Resident #58A) of 9 (Residents #58A, #7, #13, #15, #25, #36, #43, #48 and #49) sampled residents whose code status was reviewed during the survey. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #58, who did not receive CPR when found unresponsive and without vital signs and expired on [DATE], and had the potential to cause more than minimal harm for 29 residents who had physician orders [REDACTED]. 1. Resident #58A was originally admitted to the facility [DATE], was readmitted from Hospital #1 on [DATE], and had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 10 (,[DATE] indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS) and was totally dependent on two plus persons for bed mobility and transfer. a. The Advance Directive section of the Electronic Health Record contained a form titled Denial of Advance Directive, signed by the responsible party on [DATE], which documented, .I do not wish to execute an Advanced Directive at this time . b. A physician's orders [REDACTED].Full Code . c. A Nurse's Note dated [DATE] at 4:22 a.m. documented, XXX[AGE] year old black female admitted to (Hospital #1) on [DATE] with [DIAGNOSES REDACTED]. Pertinent laboratory finding was elevated BNP (Brain Natriuretic Peptide), troponin and right hemi-[MEDICATION NAME] haziness on CXR (Chest X-ray). Urine culture reports MDR (Multi Drug Resistant) E coli (Escherichia coli). IV (Intravenous) diuresis initiated. IV [MEDICATION NAME] initiated (and) changed to Ceftriazone (and) given updates on urine culture. Arrived from hospital via ambulance per stretcher (times) 2 attendants . d. A Nurse's Note dated [DATE] at 7:53 a.m., and electronically signed by Licensed Practical Nurse (LPN) #1, documented, .(at) 5:20 a.m. called to res (resident's) room. Resp (respirations) absent, 0 (no) carotid pulse noted, 0 lung sounds auscultated, 0 pupil reaction noted, (coroner) notified, (daughter's name) noted daughter unable to verify funeral home and unable to state whether she would like to view mother. Offered family time to make a decision. Pronounced (at) 0545 (5:45 a.m.) by (coroner). Contacted daughter (at) 630am (6:30 a.m.). Denied right to view body. (Deputy coroner) contacted and body released to him at 645am (6:45 a.m.) . e. On [DATE] at 4:45 p.m., Licensed Practical Nurse (LPN) #1 was interviewed via telephone and was asked, Regarding (Resident #58A's) passing, who called you to (the resident's) room? She stated, The CNAs (Certified Nursing Assistants) on the floor. They were in the process of getting residents up for breakfast. She was asked, Do you know which one? She stated, You'd have to look at the schedule, but both (CNAs) were aware. She was asked, What did they say when they came to you? She stated, They said, 'Oh, my gosh! She's gone. She's not breathing.' I went in and did my assessment, and she had, in fact, absence of pulse and respirations and no lung sounds. She was asked, What about her pupils? Were they fixed? She stated, As best as my memory serves, yes ma'am. Her pupils were fixed and dilated. She was asked, What about lividity? She stated, No, ma'am. She was not warm, but she wasn't cold. She wasn't livid, it had not set in for a while, but she wasn't cold either. She was asked, What about rigor? She stated, No ma'am. She was asked, Are you familiar with the resident's code status? She stated, Off the top of my head, I couldn't even tell you. She was asked, Did you attempt resuscitation? She paused, and stated, She had already expired, ma'am. I made a few breaths attempts, I did. Was that not in my note? I don't know the exact number of minutes. She was asked, Did you begin chest compressions? She stated, I did a few breaths, but not any chest compressions. f. On [DATE] at 6:10 p.m., Registered Nurse (RN) #2 was asked, Are you CPR certified? She stated, I will look and see if mine is still in date. She was asked, How do staff know what code status a resident has? She stated, They have an Advance Directive, one way or the other. She was asked, Let's say a resident is a full code. What should staff do if they find the resident unresponsive? She stated, They should check vitals (vital signs), apical pulse, blood pressure, pupils fixed and dilated and respirations. She was asked, For how long? She stated, Sixty seconds. I said sixty seconds, but (DON) told me it was thirty. She was asked, What about lividity? She stated, Yes. She was asked, What about rigor? She stated, Absolutely, and if anything, we are starting compressions and calling an ambulance. She was asked, Did your staff do that with (Resident #58A)? She stated, I'm assuming she did. I was not here, but that is our policy, and she is not new, so I am sure she did. She was asked, How do you monitor nurses' documentation regarding resident's expiration? She stated, We usually look at their stuff, and I thought she had charted it. And I'm not going to lie. I try to monitor their notes. She was asked, When you begin CPR, which step do you begin with, breaths or compressions? She stated, Compressions. She was asked, Do you in-service the staff on CPR? She stated, Honestly, (DON) keeps up with it. She was asked, How long have you worked here? She stated, On and off for [AGE] years. I've been back since (MONTH) (2018). I know she had an in-service with the nurses on 30 or 60 seconds, but I don't know when that was. I know that it is not required. She was asked, What system do you have in place to ensure that there is staff here that is trained in CPR? She stated, The nurses are trained in CPR, and there is always at least one nurse on 11 to 7 (11:00 p.m. to 7:00 a.m.). Sometimes there are two. g. On [DATE] at 6:48 p.m., CNA #6 was interviewed via telephone and was asked, Were you working when (Resident #58A) passed? She stated, Yes. She was asked, Do you remember what happened? She stated, Basically, the resident was hollering out at first of shift. We went to make sure she was okay. And we did 12:00 (a.m.) o'clock rounds to make sure she was dry, and we went back around 1:00 a.m. because she was hollering out and made sure she was okay. We went back at three something to make sure she was ok. And we put fresh underwear on her, and at five, me and (CNA #7) went to get her ready to get up for breakfast. She was unresponsive and we went and told the nurse. The nurse took vitals (vital signs) and she couldn't find no vitals, and she told us to make sure she was okay, and she started calling and doing what she had to do. She was asked, Were you in there when the nurse came in? She stated, Yes. She was asked, What did she do? She stated, She felt for a pulse, and listened to her chest, and she did what nurses are supposed to do. She was asked, Did she push on her chest? She stated, No ma'am. She was asked, Did she put her mouth on the resident's mouth and give her a breath? She stated, No ma'am. She was asked, Did she bring an ambu (artificial manual breathing unit) bag in? She stated, No. She was asked, Did she bring the crash cart in? She stated, No, ma'am. She was asked, You said she went and made phone calls. Did she call an ambulance? She stated, No, ma'am. She stated, Did an ambulance come? She stated, No, ma'am. She was asked, Did she say anything about the resident's code status? Full code or DNR (Do Not Resuscitate)? She stated, No, ma'am. h. On [DATE] at 4:55 p.m., the Director of Nursing (DON) was asked, Are your nursing staff trained in CPR? She stated, No. We have a few CNAs who went to class who do transport. She was asked, How would you know whether the staff are competent in handling a code emergency? She stated, They should have learned in nursing school. They were trained in nursing school. She was asked, Do you have a copy of their CPR certification? She stated, No. She was asked, Where is your crash cart located? She stated, We don't have a crash cart per se. We have an emergency box. She was asked, Where is the ambu bag located? She stated, It is over at the other nursing station, I hope. The ambu bag was located in a bag on the North Hall nursing station, attached to a portable oxygen tank. i. On [DATE] at 5:20 p.m., on the North Unit, LPN #2 was asked, What shift do you work? She stated, 3 to 11 (3:00 p.m. to 11:00 p.m.). She was asked, How long have you worked in this facility? She stated, Seven years. She was asked, If a resident codes, (found without vital signs), what is your responsibility? She stated, I would administer CPR, assess air, breaths 2, 30 chest compressions, check, and repeat. She was asked, Are you CPR certified? She stated, I was certified in 2014, and I recertified online. She was asked, How often should you recertify? She stated, Every year. j. On [DATE] at 5:35 p.m., RN #2 was asked, How long have you worked for the facility? She stated, On and off for [AGE] years. I have been here for a year, for the last year. She was asked, If a resident codes, (found without vital signs), what is your responsibility? She stated, See if they are DNR / Full Code. If Full Code, start CPR. Stop if they are greater than 60 seconds, check all vitals. She was asked, Are you CPR certified? She stated, I was. I need to look. She was asked, What are the steps for CPR? She stated, Check breathing, start CPR, start compressions 60 to 2 breaths, have somebody call an ambulance. She was asked, Are you required to be certified? She stated, The copy is not in my file. She was asked, Where is the ambu bag and emergency box located? She stated, There is an East Wing cart in the med (medication) room. There is an ambu bag on the North Wing and the East Wing. k. On [DATE] at 5:37 p.m., Registered Nurse (RN) #1 was asked, How long have you worked at this facility? She stated, I have worked here off and on for [AGE] years. I've been back a year. She was asked, If a resident codes, (found with vital signs), what is your responsibility? She stated, Check code status. Assess, notify doctor. Initiate CPR. I think 30 to 2, 30 compressions to 2 breaths, check for pulses and continue on. She was asked, Are you CPR certified? She stated, I just came from [MEDICAL TREATMENT] unit a year ago. I had to have it there. It is good for, I want to say, 2 years. She was asked, Where is the ambu bag and emergency box located? She stated, There is one emergency box and ambu bag with an oxygen set up on the East Wing and the North Wing. l. On [DATE] at 5:44 p.m., Licensed Practical Nurse (LPN) #3 was asked, How long have you worked at the facility? She stated, Seven years. She was asked, If a resident codes, what is your responsibility? She stated, I would check the resident's chart for code status. Initiate CPR. Start chest compressions. When asked about the correct breath to compression ratio, the LPN stated, I can't really tell you. First holler for help. Breaths with use of an ambu bag. She was asked, Are you CPR certified? She stated, I am not certified. She was asked, How often should you be recertified? She stated, Need to be certified every 2 years. She was asked, Where is the ambu bag and Emergency box located? She stated, In the med room. Crash cart is in there. m. On [DATE] at 11:00 a.m., the personnel file for LPN #1 contained no documentation of CPR certification. n. On [DATE] at 11:37 a.m., the Administrator was asked, Should you have someone who is certified in Basic Life Support (BLS) for Health Care Providers on duty every shift? The Administrator stated, Yes, and to be honest, I thought they were. They let it lapse on me. The Administrator was asked, Was there someone on every shift who was certified in Basic Life Support (BLS) for Health Care Providers? Administrator stated, No. o. The immediate jeopardy was removed and the scope / severity reduced to G on [DATE] at 7:13 p.m., when the facility implemented the following Plan of Removal: 1.) . Review all residents' charts for DNR status. 2.) Documentation (DNR Status) will be posted at each nurses station, each resident status. 3.) In services will be conducted on each shift until all nurses and CNAs know what to do if a resident codes, beginning 3:00 p.m. to 11:00 p.m. on [DATE]. 4.) A full staff in service will be conducted [DATE] with all staff on policy and procedures with Advance Directives and DNR. 5.) Each resident that is admitted will be informed of rights for DNR, and additional names will be posted as needed for code status. 6.) Nursing staff will be interviewed randomly by DON or ADON (Assistant Director of Nursing) monthly on policy and procedures for full code and DNR. 7.) QA (Quality Assurance) Committee will review nurse's interviews pertaining to CPR monthly. 29 residents will be affected with a full code status. A CPR (certified) employee will be on staff at all times .

Complaint # (AR 473) was substantiated (all or in part) with these findings. Based on observations, record review and interview, the facility failed to ensure interventions to prevent further weight loss were promptly developed, consistently implemented, re-evaluated for effectiveness, and revised as necessary for 1 (Resident #1) of 2 (Resident #1 and #3) case mix residents who had a weight loss. The failed practice resulted in a pattern of harm for Resident #1, who experienced a severe weight loss and had the potential to cause more than minimal harm for 3 residents with weight loss as per a list provided by the Assistant Director of Nursing (ADON) on 8/10/15 at 10:55 a.m. The facility failed to ensure dietary assessments were conducted to include the calculation of protein needs to ensure wound healing for 2 (Resident # 2 and #4) of 4 (Residents #1 through #4) case mix residents with wounds. The failed practice had the potential to cause more than minimal harm to 7 residents with wounds as per a list provided by the Assistant Director of Nursing (ADON) on 8/10/15 at 10:55 a.m. The findings are: 1. Resident #1had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/22/15 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required limited assist with activities of daily living, and had a weight loss. a. The resident's weight from February 2015 - April 2015 was as follows: February -122 pounds. March-116 pounds April-116 pounds May 13th -110 pounds This resident lost 12 pounds in 3 months which represented a 9.8% weight loss within 3 months. b. The Registered Dietician Report dated 5/4/15 documented .Rec (recommend) Add MVI (multivitamins) with mineral and consider appetite stimulant .wound needs good intake to heal . 1) A physician order [REDACTED]. c. An 'Investigative Protocols -Unintended Weight Loss Investigative Protocol' form dated 5/10/15 documented, Resident not eating well. Assisted (at) meals, Ref (refuses) to eat frequently .Interventions: Resident is enc (encouraged) and will continue to be enc to take po meals, Had antidepressant med (medication) (change) that had to be (changed) back. d. The Plan of Care dated 12/20/14 and updated 6/22/15 documented, .Problem: 5/7/15 Poor nutrition-related to depression - D/C (discontinue) [MEDICATION NAME] and start [MEDICATION NAME] 15 mg (milligrams) at hs (bedtime) . On 5/18/15 a hand written entry documented, Increased sedation noted - not eating- D/C [MEDICATION NAME] -Restart [MEDICATION NAME]. e. The resident's weight beginning May 25, 2015 to July 30, 2015 was as follows; May 25th-108 pounds May 27th-108 pounds June-106 pounds July 16th-98 pounds July 23rd-96 pounds July 30th-94 pounds This resident lost an additional 14 pounds which represented 12.9 % weight loss in 2 months. f. A physician order [REDACTED]. The Plan of Care entry dated 7/15/15 documented, Glucerna 1 can with meals. A physician order [REDACTED]. mg/5m (milliliter), Give 5 cc q am -poor appetite. g. On 8/5/15 at 7:26 a.m., the resident was served her breakfast. She was not served or offered Glucerna with her meal. h. As of 8/5/15 at 1:00 p.m., there were no weekly weights documented for June. The ADON (Assistant Director of Nursing) was asked, Why was the resident not weighed weekly in June? She stated, She (Resident #1) didn't trigger 5% loss for May until June. She was then asked, Did you talk with the physician about an appetite stimulant? She stated, The physician started the resident on [MEDICATION NAME] and she (Resident #1) became over sedated so they discontinued that ([MEDICATION NAME]) and put the resident back on her [MEDICATION NAME]. The ADON was asked, Did you put any other interventions in place? She stated, No. She was then asked, Did you talk with the physician about another appetite stimulant? She stated, No, he doesn't like to use any other until it's a last resort. The ADON was asked, Who is responsible to address weight loss of 7.5 % or greater in 3 months and/or 10% or greater in 6 months? She did not reply. The DON stated, The RD (Registered Dietician) addresses that. She was asked, When was the RD last here? She stated, In May. 2. Resident # 2 had a [DIAGNOSES REDACTED]. The Admission MDS with ARD of 7/10/15 documented the resident scored 12 (8-12 indicates moderately impaired) on a BIMS, was dependent on staff for all activities of daily living and had 1 Stage II and 2 unstageable pressure ulcers. a. The Plan of Care developed 7/10/15 documented, .Problem: Resident has pressure ulcers .Approaches: Provide diet as ordered and monitor nutritional status and dietary needs; consult dietitian PRN (as needed). b. As of 8/5/15 at 12:27 p.m., there was no dietary assessment that addressed the additional nutritional requirements (increased calories and protein) needed to enhance wound healing for the resident. When asked if the resident's nutritional needs had been addressed by the Registered Dietician (RD), the Food Service Supervisor (FSS) stated that she had tried to call the RD about (Resident #2) but could not get a hold of her (Registered Dietician). The FSS stated, I've never been trained to calculate dietary needs. The ADON and I meet weekly and put interventions in place. When asked if she knew when the RD was last at the facility, the FSS stated, In May (2015). 3. Resident #4 had [DIAGNOSES REDACTED]. a. The Plan of Care with a review date of 5/28/15 documented, .Problem: Resident is at risk for developing a pressure ulcer .Approaches: Provide diet as ordered and monitor nutritional status and dietary needs; consult dietitian PRN . b. A weekly skin audit report dated 7/6/15 documented, Left ankle- unstagable 2 cm (centimeter) x (times) 2 cm. On 7/31/15 the report documented, 2 cm x 2 cm unstagable area to left ankle round. c. The Nutrition Therapy assessment dated [DATE] did not address the resident's additional nutritional needs to enhance wound healing. 4. The facility policy/procedure titled 'Skin Assessments' provided by the Director of Nursing on 8/5/15 documented, All residents are assessed upon admission for skin problems . Any resident who has a pressure sore is also assessed by the DON, Physician and dietician for lab value and nutrition which may contribute to the development of pressure sores and preventive measures which need to be implemented in the resident's care plan .

Complaint # (AR 473) was substantiated (all or in part) with these findings. Based on observations, record review, and interview, Nursing Administration failed to ensure procedures/guidelines were in place to monitor for continued weight loss, to ensure the prompt development, consistent implementation, and revisions when determined ineffective of interventions to prevent further weight for 1 (Resident #1) of 2 (Resident #1 and #3) case mix residents who had a weight loss. The failed practice resulted in a pattern of harm for Resident #1, who experienced a severe weight loss and had the potential to cause more than minimal harm to 3 residents with weight loss as per a list provided by the Assistant Director of Nursing (ADON) on 8/10/15 at 10:55 a.m. Nursing Administration further failed to ensure dietary assessments were conducted to include the calculation of additional nutritional needs to enhance and promote wound healing for 2 (Resident # 2 and #4) of 4 (Residents #1 through #4) residents with wounds. The failed practices had the potential to cause more than minimal harm to 7 residents with wounds as per a list provided by the Assistant Director of Nursing (ADON) on 8/10/15 at 10:55 a.m. The findings are: 1. The facility's 'Nursing Administrator' job description provided by the Director of Nursing (DON) on 8/10/15 documented the following responsibilities: a. Develops, promotes and assures implementation of standards of nursing practice that are consistent with high quality of care. b. Oversees and assures the appropriateness of nursing assessment, care planning, and care interventions for all residents. c. Identifies and facilitates correction of deficiencies in nursing services or poor quality of resident care. 2. Resident #1had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/22/15 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required limited assist with activities of daily living, and had a weight loss. a. The resident's weight from February 2015 - April 2015 was as follows: February -122 pounds. March-116 pounds April-116 pounds May 13th -110 pounds This resident lost 12 pounds in 3 months which represented a 9.8% weight loss within 3 months. b. The Registered Dietician Report dated 5/4/15 documented .Rec (recommend) Add MVI (multivitamins) with mineral and consider appetite stimulant .wound needs good intake to heal . 1) A physician order [REDACTED]. c. An 'Investigative Protocols -Unintended Weight Loss Investigative Protocol' form dated 5/10/15 documented, Resident not eating well. Assisted (at) meals, Ref (refuses) to eat frequently .Interventions: Resident is enc (encouraged) and will continue to be enc to take po meals, Had antidepressant med (medication) (change) that had to be (changed) back. d. The Plan of Care dated 12/20/14 and updated 6/22/15 documented, .Problem: 5/7/15 Poor nutrition-related to depression - D/C (discontinue) [MEDICATION NAME] and start [MEDICATION NAME] 15 mg (milligrams) at hs (bedtime) . On 5/18/15 a hand written entry documented, Increased sedation noted - not eating- D/C [MEDICATION NAME] -Restart [MEDICATION NAME]. e. The resident's weight beginning May 25, 2015 to July 30, 2015 was as follows; May 25th-108 pounds May 27th-108 pounds June-106 pounds July 16th-98 pounds July 23rd-96 pounds July 30th-94 pounds This resident lost an additional 14 pounds which represented 12.9 % weight loss in 2 months. f. A physician order [REDACTED]. The Plan of Care entry dated 7/15/15 documented, Glucerna 1 can with meals. A physician order [REDACTED]. mg/5m (milliliter), Give 5 cc q am -poor appetite. g. On 8/5/15 at 7:26 a.m., the resident was served her breakfast. She was not served or offered Glucerna with her meal. h. As of 8/5/15 at 1:00 p.m., there were no weekly weights documented for June. The ADON (Assistant Director of Nursing) was asked, Why was the resident not weighed weekly in June? She stated, She (Resident #1) didn't trigger 5% loss for May until June. She was then asked, Did you talk with the physician about an appetite stimulant? She stated, The physician started the resident on [MEDICATION NAME] and she (Resident #1) became over sedated so they discontinued that ([MEDICATION NAME]) and put the resident back on her [MEDICATION NAME]. The ADON was asked, Did you put any other interventions in place? She stated, No. She was then asked, Did you talk with the physician about another appetite stimulant? She stated, No, he doesn't like to use any other until it's a last resort. The ADON was asked, Who is responsible to address weight loss of 7.5 % or greater in 3 months and/or 10% or greater in 6 months? She did not reply. The DON stated, The RD (Registered Dietician) addresses that. She was asked, When was the RD last here? She stated, In May. 3. Resident # 2 had a [DIAGNOSES REDACTED]. The Admission MDS with ARD of 7/10/15 documented the resident scored 12 (8-12 indicates moderately impaired) on a BIMS, was dependent on staff for all activities of daily living and had 1 Stage II and 2 unstageable pressure ulcers. a. The Plan of Care developed 7/10/15 documented, .Problem: Resident has pressure ulcers .Approaches: Provide diet as ordered and monitor nutritional status and dietary needs; consult dietitian PRN (as needed). b. As of 8/5/15 at 12:27 p.m., there was no dietary assessment that addressed the additional nutritional requirements (increased calories and protein) needed to enhance wound healing for the resident. When asked if the resident's nutritional needs had been addressed by the Registered Dietician (RD), the Food Service Supervisor (FSS) stated that she had tried to call the RD about (Resident #2) but could not get a hold of her (Registered Dietician). The FSS stated, I've never been trained to calculate dietary needs. The ADON and I meet weekly and put interventions in place. When asked if she knew when the RD was last at the facility, the FSS stated, In May (2015). 4. Resident #4 had [DIAGNOSES REDACTED]. a. The Plan of Care with a review date of 5/28/15 documented, .Problem: Resident is at risk for developing a pressure ulcer .Approaches: Provide diet as ordered and monitor nutritional status and dietary needs; consult dietitian PRN . b. A weekly skin audit report dated 7/6/15 documented, Left ankle- unstagable 2 cm (centimeter) x (times) 2 cm. On 7/31/15 the report documented, 2 cm x 2 cm unstagable area to left ankle round. c. The Nutrition Therapy assessment dated [DATE] did not address the resident's additional nutritional needs to enhance wound healing. 5. The facility policy/procedure titled 'Skin Assessments' provided by the Director of Nursing on 8/5/15 documented, All residents are assessed upon admission for skin problems . Any resident who has a pressure sore is also assessed by the DON, Physician and dietician for lab value and nutrition which may contribute to the development of pressure sores and preventive measures which need to be implemented in the resident's care plan .

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure all exit doors were secured to decrease the potential for elopement for 2 (Residents #1 and #3), failed to provide supervision to prevent elopement for 1 (Resident #1) and failed to develop and implement interventions for 1 (Resident #3) of 2 (Residents #1 and #3) case mix residents who wandered and were at risk for elopement. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death for Resident #1 who eloped from the facility and was not located for 1 hour and 18 minutes and had the potential to affect 3 residents who were assessed as being at risk for elopement, according to a list provided by the Director of Nursing (DON) on 4/25/13 at 11:15 a.m. The facility was notified of the Immediate Jeopardy on 4/25/13 at 1:05 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/4/13 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on the brief interview for mental status BIMS), had wandering behavior that occurred 4 to 6 days a week but less than daily and was independent for transfers and ambulation. a. An Elopement Risk Assessment with an entry date of 2/19/13 documented, "...Interventions... Exit and stairwell alarms... frequent monitoring... utilization of a check in/out log... Summary / Conclusions / Recommendations - resident does look for family often - wheels in w/c (wheelchair) or ambulates ad lib (as desired). Monitored very closely by staff. Doors have alarms. Resident has not eloped. Family aware. Will cont. (continue) to monitor closely..." b. The Resident Plan of Care dated 3/4/13 documented, "Wandering behavior- always trying to 'Go home to mama'- Behaviors discouraged by staff when they occur- Monitor whereabouts closely." c. The resident's undated Closet Plan of Care received from the DON on 4/24/13 documented, "...Observe for wandering." d. A Nurse's Notes dated 3/16/13 at 4:00 a.m. documented, "Res (Resident) (up) and over on Old Wing of facility. 4:30 a.m.- (Up) and on the end of East Wing of facility, assisted back to rm (room) by East CNA (Certified Nursing Assistant) (at) 4:40 a.m. 4:44 a.m. - Door alarm sounded on North, North CNAs aware (and) side door of North wing noted (with) door ajar- Res. eloped..." 1) An Incident / Accident Report dated 3/16/13 at 4:44 a.m. documented, "...Res (resident) eloped out of N (North) wing side door, missing (without) staff being able to locate until 6:02 a.m. Res. located (and) assisted back... (without) apparent injuries... Additional comments and/or steps taken to prevent recurrence: Res. observed 1:1 (with) CNA (at) door. South Wing doors closed that lead to back exit..." 2) The Resident Plan of Care dated 3/16/13 documented, "Res. eloped from facility on 11/7 (11:00 p.m. to 7:00 a.m.) shift - (no) injury noted - will discuss meds (medications) (with) (physician) and (change) to 1 on 1 (with) staff when elopement behavior begins, to monitor whereabouts very closely- (meds changed)." 3) The Division of Medical Services (DMS) form 7734 dated 3/18/13 documented, "...Summary of Incident- Resident had been wandering on the East Wing and the East Wing CNA had just brought the resident back to his room. The resident then exited the building out the North Wing Exit Door. The alarm sounded and CNAs responded, but did not see the resident outside the door. All staff inside building were alerted and search began..." e. On 4/25/13 at 9:06 a.m., CNA #1 stated, "He (Resident #1) still does the same thing, he still tries to get out... we have to sweet talk him to get him to sit outside the door while we're making rounds, we don't know that he will still be sitting there." When asked if he is on 1:1 monitoring when this occurs, CNA #1 stated, "No, there are 2 people (working) on this hall; no the nurse does not watch him while we're making rounds, since that happened the new nurse (name) will watch him but not the other nurses." When asked if there was documentation for monitoring the resident, CNA #1 stated, "No, there's no documentation for monitoring." 2. Resident #3 had [DIAGNOSES REDACTED]. The MDS with an ARD of 3/1/13 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on the BIMS, required the assistance of one person for transfer and ambulation and had no limitation in range of motion. a. The Elopement Risk assessment dated [DATE] documented, "...impaired with poor decision making, [DIAGNOSES REDACTED]." The summary documented, "Resident is alert with confusion. Has dx (diagnosis) of Psychosis r/t (related to) hx (history) of Breast Ca (Cancer) with mets (metastasis) to the brain. Resident can ambulate but is unsteady. Has been observed talking about leaving to go live with children. Has to be monitored closely by staff." b. The Nurse's Notes dated 2/25/13 for the 11:00 p.m. to 7:00 a.m. shift documented, "Resident has been awake all night long trying to leave. States 'I'm going home. You can't make me stay.' Hitting at and pushing on staff. Redirected without success. Will monitor closely." c. The Nurse's Notes dated 2/28/13 at 5:00 a.m. documented, "Res (resident) has made several attempts to leave tonight. When encountered by staff becomes agitated." d. The Resident Plan of Care dated 3/1/13 did not address the risk for elopement. The undated Closet Plan of Care (for use by Certified Nursing Assistants) documented, "...confused - observe wandering and falls easily." The Closet Plan of Care did not address the risk for elopement. e. The Nurse's Notes dated 3/1/13 for the 11:00 p.m. to 7:00 a.m. shift documented, "Resident up and down since 2400 (midnight) trying to leave facility. Redirected to room each time." f. The Nurse's Notes dated 3/1/13 at 4:00 a.m. documented, "Resident opening exit doors trying to go home. Redirected to room. Monitoring closely." g. The Nurse's Notes dated 3/2/13 at 10:00 a.m. documented, "...Resident does have occasional episodes that she is leaving, becomes very agitated even has episodes that are attempts to fight..." h. The Nurse's Notes dated 3/20/13 at 7:00 p.m. documented "Res has made several attempts to leave out of East Wing end door several times. Refused Ativan times three attempts." i. The Nurse's Notes dated 3/20/13 at 7:10 p.m. documented, "Notified (Physician) of resident's elopement attempts and also of refusal of Ativan. Received T.O (telephone orders) for Haldol 3 mg (milligram) IM (intramuscular) at this time." j. The Nurse's Notes dated 3/21/13 for the 3:00 p.m. to 11:00 p.m. shift documented, "Resident walking down hallway with unsteady gait, states she is looking for the bus to go home." k. The Nurse's Notes dated 3/22/13 at 12:00 p.m. documented, "Increased anxiety. Wanting to leave. Going to various doors trying to leave. Administered Ativan as ordered." l. The Nurse's Notes dated 4/20/13 7:00 a.m. to 3:00 p.m. shift documented, "...Res tried to get out east door and redirected and becomes mad and agitated at times. She does (have) episodes that she tries to fight you redirecting her." m. On 4/24/13 at 8:40 a.m., 11:05 a.m. and 1:10 and on 4/25/13 at 8:15 a.m., the resident was in a wheelchair without a personal safety alarm device in use. On 4/24/13 at 2:30 p.m., when asked about an alarm for the resident, Licensed Practical Nurse (LPN) #7 stated, "She does not have a chair alarm." n. On 4/24/13 at 1:40 p.m., the Director of Nursing (DON) was asked to review the 3/1/13 Plan of Care and the Closet Plan of Care with the surveyor and point out pertinent interventions for potential elopement. The DON stated, "There are no interventions for potential elopement." 3. An Elopement Policy and Procedure provided by the DON on 4/24/13 documented, "...Procedure: The facility has alarms on all doors to the outside of the facility..." a. On 4/25/13 at 10:40 a.m., all exit doors were checked. The exit door on Old Wing-door C (back door), according to the floor plan provided by the facility on 4/25/13, was not secured and did not have a functional alarm. Staff call this the "Back door." b. On 4/25/13 at 11:02 a.m., the Administrator stated, "There's no working alarm on this door... there was an alarm, we took it off." When asked, "Could a resident go out?" the Administrator stated, "Sure." When asked how long it was inoperable, the Administrator stated, "Month and a half, give or take." c. On 4/25/13 at 11:22 a.m., Registered Nurse (RN) #1 was asked about the alarm on the door. The RN stated, "It hasn't worked this year." d. On 4/25/13 at 11:55 a.m., Dietary Staff #1 was asked about the alarm on the door. Dietary Staff #1 stated, "I've been here a year and that door has never alarmed." 4. The Immediate Jeopardy was removed and the scope and severity reduced to an "E" on 4/25/13 at 3:05 p.m. when the facility initiated the following plan of removal: a. An audible alarm was applied to the Old South Wing Back Door at 1:50 p.m. on April 25, 2013 by Maintenance Personnel. b. Three residents are at risk for elopement. c. Elopement Assessments were completed by RN (Registered Nurse) on all three residents. Elopement risks and interventions will be implemented on all residents at risk for elopement in each resident's care plan on April 25, 2013. d. All staff will be inserviced: 7-3 (7:00 a.m. to 3:00 p.m.) at 2:30 p.m. 4/25/13. All other shifts will be inserviced at the beginning of the shift on 4/25/13 beginning at 3:00 p.m. All employess will be inserviced by DON / Designee and in-service sheets will be used for documentation. Inservice training will be on-going, to include new hires and staff returning from leave. Inservice sheet will be used for staff signature. Inservice will inform all staff: 1. All residents at risk for elopement 2. Ensure all door alarms in working order before each shift begins 3. Report to administrator if a door alarm does not function properly immediately. e. The Maintenance Supervisor / Designee will check all door alarms to insure all alarms are working properly daily. Any door alarms not working will be repaired immediately.