Every finding on record at The Summit

Based on record review and an interview, the facility failed to ensure a resident's medical record was accurately documented in accordance with accepted professional standards and practices. The facility failed to ensure activities of daily living tasks performed were accurately documented for 1 (Resident #1) of 3 sampled residents. Findings: Review of a policy titled Documentation with a revision date of 03/2026 read in part.Clinical Record Accuracy: It is the policy of this facility to maintain accurate, complete and timely clinical records in accordance with the regulatory requirements. Review of Resident #1's medical record revealed an admission date of 01/10/2023, with diagnoses that included in part.Moderate Protein- Calorie Malnutrition, Atrial Fibrillation, Type 2 Diabetes with Diabetic Neuropathy, Dementia, Schizophrenia, Major Depressive Disorder, and Essential Hypertension. Review of Resident #1's MDS with an ARD of 05/12/2026 revealed Resident #1 has a BIMS score of 3, indicating severe cognitive impairment. Resident #1 required substantial/ maximum assistance with ADLs. Review of a nursing progress note dated 05/20/2026, documented by S3LPN, read in part. Resident #1 was not feeling well and did not eat lunch. Review of the facility's meal intake documentation revealed that, for lunch on 05/20/2026, Resident #1 was documented as having consumed 100% of the meal. On 06/23/2026 at 1:29 p.m., S3LPN confirmed that Resident #1 did not consume lunch on 05/20/2026. S3LPN further acknowledged that the meal intake documentation indicating Resident #1 consumed 100% of the meal intake was inaccurate and did not reflect the resident's actual intake. Review of the facility tasks titled, Offer resident fluids every 2 hours while awake, revealed documentation indicating that staff offered Resident #1 fluids on 05/21/2026. Review of the medical record revealed Resident #1 was hospitalized on [DATE] and was not present in the facility. On 06/23/2026 at 4:35 p.m., S2DON acknowledged that the documentation regarding Resident #1's meal intake on 05/20/2026 was inaccurate. S2DON confirmed documentation should have accurately reflected Resident #1's actual meal consumption, but did not. S2DON also acknowledged that documentation indicated staff offered Resident #1 fluids on 05/21/2026. S2DON confirmed Resident #1 was hospitalized at that time and confirmed documentation was inaccurate.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented for 2 (Resident #1 & Resident #3) of 3 sampled residents. Findings:Review of a policy titled Physician Orders with a revision date of 09/2025 read in part. It is the policy of this facility that all physician orders shall be implemented timely and carried out in a professional manner. Resident #1Review of Resident #1's medical record revealed an admission date of 01/10/2023, with diagnoses that included in part.Moderate Protein- Calorie Malnutrition, Atrial Fibrillation, Type 2 Diabetes with Diabetic Neuropathy, Dementia, Schizophrenia, Major Depressive Disorder, and Essential Hypertension. Review of Resident #1's MDS with an ARD of 05/12/2026 revealed Resident #1 has a BIMS score of 3, indicating severe cognitive impairment. Resident #1 required substantial/ maximum assistance with ADLs. Review of Resident #1's laboratory results, which included a written physician's order dated 01/14/2026, read in part. increase oral fluid intake by 500 ml three times daily for three days. Review of the laboratory results revealed S3LPN acknowledged receipt of the physician's order by signature. On 06/23/2026 at 1:29 p.m., an interview with S3LPN confirmed there was no documentation indicating the physician's order dated 01/14/2026 to increase Resident #1's oral fluid intake had been implemented. On 06/24/2026 at 9:41 a.m., an interview with S5MedicalRecords confirmed there was no documentation in Resident #1's medical record indicating the physician's order dated 01/14/2026 to increase oral fluid intake had been implemented. On 06/24/2026 at 11:09 a.m., an interview with S4NP revealed that verbal and written physician orders are expected to be implemented by facility nursing staff. On 06/24/2026 at 2:30 p.m., an interview with S1CorporateRN confirmed there was no documentation indicating the physician's order dated 01/14/2026 to increase Resident #1's oral fluid intake had been implemented and documented in the resident's medical record, but should have been. Resident #3Review of Resident #3's medical record revealed an admission date of 05/24/2024, with diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, Dementia, Anxiety, Essential Hypertension, and Diabetes Mellitus. Review of Resident #3's MDS with an ARD of 05/18/2026 revealed Resident #3 has a BIMS score of 3, indicating severe cognitive impairment. Resident #3 was dependent on staff for all ADLs. Review of Resident #3's comprehensive care plan, with a revision date of 06/09/2026, read in part. Resident #3 had the potential for abnormal laboratory values related to the diagnosis of anemia. Care plan interventions included monitoring laboratory results as ordered. Review of Resident #3's laboratory results revealed a written physician's order dated 05/14/2026 which read in part. follow up with a complete blood count (CBC) in four weeks. On 06/24/2026 at 1:47 p.m., an interview with S5MedicalRecords confirmed the physician's order for a repeat CBC was not completed as ordered. On 06/24/2026 at 2:30 p.m., S1CorporateRN confirmed that the laboratory test was not completed as ordered by the physician, but should have been.

Based on interview and record review, the facility failed to: Ensure the Director of Nursing services and the infection preventionist attended the Quality Assessment & Assurance (QAA) committee's quarterly meeting; andConduct QAA meetings at least quarterly for the year of 2025. This had the potential to affect 88 residents who resided in the facility.Findings: Review of the facility's QAA committee meeting minutes for Quarter 1 of 2026 dated 03/23/2026 revealed the meeting's attendance signature sheet did not include the signature of the facility's Director of Nursing services or the infection preventionist. In an interview on 04/08/2026 at 3:15 p.m., S9 Administrator confirmed the Director of Nursing and the infection preventionist did not attend the QAA meeting for Quarter 1 of 2026 on 03/23/2026. In an interview on 04/08/2026 at 3:40 p.m., S9 Administrator acknowledged there was no QAA quarterly meeting minutes for Quarter 3 of 2025. S6 Collaborating Home Administrator confirmed the facility did not have QAA meeting minutes for Quarter 3 of 2025 but should have.

Based on observation and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident as evidenced by having expired medications available for resident use for 2 (Resident #82 and Resident #89) residents. This had the potential to affect 88 residents who resided in the facility.Findings:Review of the revised policy dated 10/19 titled Destruction of Unused, Expired or Discontinued Medications revealed, in part, .All outdated, discontinued and/or recalled drugs, and all containers with illegible or no labels will be given to the Director of Nursing (DON) for proper disposition.In an interview with S7 LPN and observation of Cart #2 on 04/08/2026 at 9:37 a.m., revealed two expired medications, Resident #82's narcotic of Tramadol 50mg with an expiration date of 02/08/2026 and Resident #89's medication of Cyclobenzaprine 5mg with an expiration date of 01/29/26. S7 LPN confirmed both medications listed above were on the cart for use and expired but should not have been. In an interview on 04/08/2026 at 10:40 a.m., S1 DON confirmed S7 LPN had expired medications on Cart #2 that had not been properly disposed of but should have.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure respiratory equipment/Bi-PAP was stored properly for 1 (Resident #7) of 2 residents reviewed for respiratory care. The total sample size was 41 residents.Findings:Review of a facility policy on 04/08/2026 at 8:32 a.m. titled, CPAP/BiPAP Device review date of 01/2024 revealed in part .The manufacturer's policies and procedures will be followed for the use and care of this equipment. Review of Resident #7's medical record revealed an admission date of 01/13/2015 with diagnoses, which included in part . Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Obstructive Sleep Apnea (Adult), and Personal History of Transient Ischemic Attack (TIA). Review of Resident #7's Quarterly MDS with ARD of 01/20/2026 revealed a BIMS of 15, which indicated intact cognition and required use of a non-invasive mechanical ventilator (BiPAP). Review of Resident #7's 04/2026 physician orders revealed orders in part .-Remove BiPAP one time a day related to Obstructive sleep apnea (adult).Review of Resident #7's care plan with an initial date of 01/22/2026 revealed the following in part .Focus: Resident has sleep apnea. Interventions: BiPAP every night. During review of Resident #7's care plan revealed no evidence of refusal of the BiPAP or the resident taking his BiPAP mask off on his own. In an interview on 04/06/2026 at 8:31 a.m., Resident #7's revealed he used a BiPAP every evening for sleep apnea. Resident #7 revealed the nurse would apply the BiPAP mask before bedtime and would remove the mask in the morning after he woke up. Resident #7 was unsure if the nurse put the BiPAP mask in a storage bag after each use. Observation, at the time of interview, revealed Resident #7's BiPAP mask was not in use and placed directly on the resident's bedside dresser, unbagged and unlabeled. In an interview on 04/07/2026 at 7:41 a.m., Resident #7's revealed he used his BiPAP last night. Observation, at the time of interview, revealed Resident #7's BiPAP mask was not in use and placed directly on the resident's bedside dresser, unbagged and unlabeled. Observation on 04/07/2026 at 11:59 a.m. revealed Resident's #7's BiPAP mask was not in use and placed directly on the resident's bedside dresser, unbagged and unlabeled. In an interview on 04/07/2026 at 1:00 p.m., S3 LPN revealed she was assigned to Resident #7, and he required the use of a BiPAP at night. S3 LPN revealed the nurse on duty was responsible for application of the mask before bedtime and would remove the mask in the morning. S3 LPN revealed the nurse should clean the BiPAP mask and store it in a labeled bag, when not in use. S3 LPN revealed Resident #7 does not refuse his BiPAP or take the mask off on his own.On 04/07/2026 at 1:15 p.m., S3 LPN accompanied this surveyor to Resident #7's room. S3 LPN confirmed Resident #7's BiPAP mask was not in use and placed directly on the resident's bedside dresser, unbagged and unlabeled. S3 LPN confirmed Resident #7's BiPAP mask should have been properly stored and labeled in a bag, but was not.In an interview on 04/08/2026 at 9:18 a.m., S1 DON revealed when a resident's BiPAP was not in use, the BiPAP mask should be cleaned with soap and water and stored in a labeled bag. S1 DON confirmed that all nurses were aware to store a BiPAP mask in a labeled bag when not in use.

Based on interview and record review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment within 14 days for 1 (Resident #56) of 1 sampled resident investigated for Resident Assessment.Findings:Review of resident #56's medical record revealed an admission date of 09/02/2025 and a discharged date of 02/11/2026. Further review of resident #56's medical record on 04/07/2026 revealed the Discharge Minimum Data Set (MDS) assessment had not been completed after the resident discharged on 02/11/2026. In an interview on 04/07/2026 at 3:09 p.m., S5 MDS LPN confirmed the discharge MDS assessment for resident #56 was not completed within the 14-day timeframe.

Based on interview and record review the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #100) of 1 residents reviewed for transfer/discharge. The total sample size was 41. Findings:Review of a facility policy on 04/08/2026 at 10:11 a.m. titled, Discharge Transfer and Planning with a review date of 03/2026 revealed the following in part .Ombudsman Notification: The community shall notify the resident and the resident's representative(s) of the transfer or discharge via the Discharge/Transfer Notice, and the notices must be sent to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. Notice to the Office of the State LTC Ombudsman must occur before or as close as possible to the actual time or transfer or discharge except when an emergency transfer occurs. Review of Resident #100's medical record revealed an admission date of 01/09/2026 and a discharge date of 02/02/2026, which included diagnoses of Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Acute Respiratory Failure with Hypercapnia.Review of Resident #100's 02/2026 physician's orders revealed the following order .Discharge home with Home Health and medications on 02/02/2026 one time only. Review of Resident #100's 02/2026 nursing progress notes revealed the following in part .02/02/2026- Resident discharged home with home health.Review of Resident #100's Discharge Summary for 02/02/2026 revealed the following in part .Notes: discharged home to home/community with home health. Review of a facility report on 04/08/2026 at 9:36 a.m. titled, Louisiana Ombudsman Program/Emergency Transfer Log for 02/2026 revealed Resident #100's discharge on [DATE] was not included on the notification report. In an interview on 04/07/2026 at 4:27 p.m., S1 DON revealed Resident #100 admitted for therapy services and had a planned discharge home with home health in 02/2026.In an interview on 04/08/2026 at 9:31 a.m., S2 Accounts Manager revealed she was responsible for notification of transfers/discharges to the Louisiana Ombudsman Program. S2 Accounts Manager revealed she only submitted the emergency transfers to the Louisiana Ombudsman Program. S2 Accounts Manager revealed she was unaware to notify the Ombudsman of non-emergency transfer/discharges, such as a planned discharged , and confirmed Resident #100 discharge on [DATE] was not submitted to the Louisiana Ombudsman Program.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 (#6) of 2 (#6, #102) residents reviewed for environment. The facility failed to ensure Resident #6 had a call light in reach in order to call for assistance. Total sample size: 41 residents. Findings: Review of a policy titled Call Light/Bell with a revision date of 01/2024 read in part.Purpose:1. To provide the resident a means of communication with staff members.Procedure:7. Leave the resident comfortable. Place the call light within the resident's reach before leaving the room. Review of Resident #6's medical record revealed an admit date of 10/14/2025 with diagnoses that included in part: Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Cerebellar Artery, Diabetes, Cardiomyopathy, Paroxysmal Atrial Fibrillation, Intervertebral Disc Displacement, and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side. Review of Resident #6's quarterly MDS with an ARD of 01/22/2026 revealed Resident #6 was dependent on staff for ADLs. A BIMS exam was not conducted on Resident #6 due to being rarely or never understood. Review of Resident #6's Care Plan dated 01/29/2026 read in part.Resident #6 was at risk for falls related to impaired mobility. Interventions included ensuring the call light was placed within reach. On 04/06/2026 at 10:32 a.m., observation revealed Resident #6 lying in bed with the call light not within reach. Further observation of the call light revealed it was not within reach due to insufficient cord length. On 04/07/2026 at 1:48 p.m., observation revealed Resident #6 sitting upright in a geri-chair in his room with the call light not within reach. Further observation of the call light revealed it was not within reach due to insufficient cord length. Interview with Resident #6 revealed he was able to identify the call light as the device used to request assistance. Resident #6 stated I can't reach it most of the time, so I holler out for help. On 04/07/2026 at 1:56 p.m., accompanied by S4LPN to Resident #6's room. S4LPN confirmed that Resident #6's call light was not within reach. S4LPN further confirmed that the call light could not be reached by Resident #6 when in bed or seated in the geri-chair due to insufficient cord length. S4LPN confirmed Resident #6 is cognitively aware and able to appropriately use the call light when available. On 04/07/2026 at 2:00 p.m., accompanied by S1DON to Resident #6's room. S1DON confirmed Resident #6's call light was not within reach, but should have been.

Based on observation, interview and record review, the facility failed to ensure a Resident fed by enteral means received the appropriate treatment and services for 1 (#3) of 3 Sampled Residents. The facility failed to ensure the resident's tube feeding was administered per the physician orders.Findings:Record Review revealed Resident #3 was admitted to the facility on [DATE] and had diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Cerebral Infarction, Aphasia following CVA (Cerebral Vascular Attack), Hemiplegia and Hemiparesis following CVA affecting right dominant side, Abnormal Weight Loss, Pressure Ulcer of Sacral Region-Stage 2, Pressure Ulcer of Right Hip- Stage 2, and Pressure Induced Deep Tissue damage of Left ankle and Left Heel. Review of Resident #3's Quarterly MDS with an ARD of 01/20/2026 revealed Resident #3 BIMS was not assessed due to memory problem. Resident #3 was dependent on staff for eating. Resident #3 had a feeding tube. Review of Resident #3's Comprehensive Person Centered Care Plan with target completion date of 04/23/2026 revealed in part. Resident #3 received tube feeding; Fibersource at 60 ml/hr. Review of Resident #3's Current 02/2026 Physician Orders read in part.Enteral Feed, Fibersource @ 60ml/hr. Start date 02/17/2026. Review of Resident #3's 02/2026 EMAR read in part.Enteral Feed Order, every shift tube feeding formula Fibersource at 55 ml/hr. Start Date-11/11/2025. Discontinued Date- 02/17/2026.Enteral Feed Order, every shift tube feeding formula Fibersource at 60 ml/hr. Start Date-02/17/2026. Review of Resident #3's Departmental Progress notes read in part.02/17/2026 1:44 p.m. S3RD documented; Recommendation: Increase tube feed to Fibersource @ 60 ml/hr.02/17/2026 3:48 p.m. S1DON documented; Resident #3 with new order to increase tube feed to Fibersource @ 60ml/hr. Observation on 02/23/2026 at 10:45 a.m. revealed Resident #3 received tube feeding of Fibersource at 55ml/hr. via pump.Observation on 02/23/2026 at 4:08 p.m. revealed Resident #3 continued to receive tube feeding of Fibersource at 55ml/hr. via pump.Observation on 02/24/2026 at 8:25 a.m. revealed Resident #3 received tube feeding of Fibersource at 55ml/hr. via pump.Observation on 02/24/2026 at 12:25 p.m. revealed Resident #3 continued to receive tube feeding of Fibersource at 55ml/hr. via pump. Interview on 02/24/2026 at 12:50 p.m. with S2LPN, and observation of Resident #3's set tube feed rate. S2LPN confirmed Resident #3 tube feeding was infusing at 55ml/hr., but should be at 60ml/hr.

Based on record review and interview, the facility failed to transmit a Discharge MDS (Minimum Data Set) Assessment within 14 days of completion for 2 (Resident #34 and Resident #40) of 2 sampled residents with MDS record over 120 days old. Findings: Resident #34 Review of Resident #34's medical records revealed an admission to the facility on [DATE] and a discharged from facility on 11/19/2024. Reviews of Resident #34 MDS transcription report revealed no Discharge MDS was initiated or completed after discharge. Resident #40 Resident #40 was admitted to the facility on [DATE] and was discharged from the facility on 10/28/2024. Review of Resident #40's MDS transcription report revealed no discharge MDS was initiated or completed. Interview on 04/14/2025 at 03:50 p.m. with S4 MDS LPN revealed she is to complete a discharge MDS as soon as the resident discharged from the facility unless the discharge is planned, then she will open for the day they discharged . S4 MDS LPN confirmed that a discharge MDS was not completed for Resident #34 and Resident #40 after discharge but should have been done. Interview on 04/14/2025 at 3:55 p.m. with S2 DON confirmed that no Discharge MDS was completed for Resident #34 and Resident #40 on discharge but should have been.

Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #77) of 2 (Resident #77 and Resident #20) sampled residents investigated for abuse, in a total sample of 28. Findings: Review of the facility's policy titled Incident Investigation and Reporting with a revision date of 05/2024 revealed in part . 1. Each Resident residing in the facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property. Abuse: Abuse is the willful infliction of injury. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. Resident #77 Review of Resident #77's medical record revealed an admitted [DATE], with diagnoses that included in part .Acute Respiratory Failure with Hypoxia, Muscle Weakness, Pain Unspecified, Bipolar Disorder, Puerperal Psychosis, Generalized Anxiety Disorder, Major Depressive Disorder with Psychotic Symptoms and Insomnia. Review of Resident #77's Quarterly MDS with an ARD of 02/12/2025, revealed Resident #77 had a BIMS score of 15, indicating intact cognition. The MDS revealed Resident #77 was dependent for bed mobility, toileting and transfer, and required 2+person physical assist. The MDS revealed Resident #77 used a manual wheelchair for mobility, and had no impairment to upper or lower extremities. Review of Resident #77's Care Plan with a Target Date of 05/09/2025 read in part . 1. Resident has verbal behavioral symptoms directed towards other at times, with interventions that included in part .Approach resident calmly, do not argue with resident. Resident #20 Review of Resident #20's medical record revealed an admitted [DATE], with diagnoses that included in part .Major Depressive Disorder, Acquired Absence of Right Below Knee and Intermittent Explosive Disorder. Review of Resident #20's Annual MDS with an ARD of 03/20/2025, revealed Resident #20 had a BIMS score of 12, indicating moderately impaired cognition. The MDS revealed Resident #20 was independent with bed mobility, transfer, eating and required limited assistance with toileting. The MDS revealed Resident #20 used a manual wheelchair for mobility, and had no impairment to upper extremities. Review of Resident #20's Care Plan with a Target Date of 06/24/2025, revealed in part . 1. Mood: Resident has potential for Altered Mood related to targeted behaviors of agitation/aggression, with interventions that included in part .observe for changes in mental status, do not argue with resident, Psych evaluation if needed, notify physician of increased behaviors. Review of a Facility Incident Report dated 03/20/2025 at 2:37 p.m., and documented by S1 Administrator, read in part .Resident #77 notified the nurse that she and Resident #20 were in an argument that turned physical. Resident #77 stated that Resident #20 did not hit her, but had tried to. Resident #77 stated she hit Resident #20 on his arm. The residents were on X Hall when the argument began. Staff were passing food trays. The nurse notified Administrator and DON. The nurse assessed for injury and Resident #20 had no redness, no mark, no bruising to his upper right arm, and no complaints of pain. Both resident's RP and physicians were notified. The police were notified and recorded the incident. Interview on 04/15/2025 at 8:30 a.m. with Resident #77, revealed last month 03/2025 (couldn't remember the exact date), she was in her wheelchair passing by Resident #20 in the hallway. Resident #77 stated Resident #20 started talking nonsense to her, and they started arguing. Resident #77 stated Resident #20 started swinging trying to hit her. Resident #77 stated she swung back and hit Resident #20 on his arm. Interview on 04/15/2024 at 8:56 a.m. with S1 Administrator revealed according to surveillance video, on 03/16/2025 at 6:15 p.m., Resident #77 and Resident #20 were going down X hall in their wheelchairs. Resident #77 and Resident #20 started arguing and attempted to hit each other. S1 Administrator confirmed Resident #77 made contact (hit) with Resident #20's right arm. S1 Administrator stated the video was no longer available for viewing. Interview on 04/15/2025 at 3:01 p.m. with S11CNA , revealed he was passing trays on Hall X on 03/16/2025, and witnessed Resident #77 and Resident #20 arguing and swinging at each other; however, S11 CNA stated he did not see Resident #77 hit Resident #20 on the upper right arm. S11 CNA stated Resident #20 and #77 were separated and taken to their rooms with no further incident.

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #5) resident of 20 sampled residents. The facility failed to ensure Resident #5's care plan reflected accurate and current data by failing to resolved/discontinue a previous hospice care plan. Findings: Review of a facility policy on 04/16/2025 at 2:00 p.m. titled, Care Plan Process revised on 12/2024 revealed the following in part .The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged, and must be consistent with each resident's written plan of care. The facility shall use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care .Review and revise the current care plan, as needed. Review of Resident #5's medical record revealed a re-admitted [DATE], with diagnoses that included in part . Alzheimer's Disease, End Stage Renal Disease, Ataxia Following other Non-traumatic Intracranial Hemorrhage, and Pseudobulbar Affect. Review of Resident #5's Annual and State Optional MDS with an ARD of 03/20/2025 revealed a BIMS score of 3, which indicated severe cognitive impairment. Resident #5 required total dependence with two persons for transfers, toilet use, and bed mobility. Resident #5 was not receiving hospice services. Review of Resident #5's current physician orders revealed in part . 08/05/2024 (start date): Admit to the facility for long term care. No active physician orders for hospice services. Review of Resident #5's care plan with an initial date of 09/13/2024 revealed in part . Focus: Resident is on hospice services with a diagnoses of CVA (cerebrovascular accident). Interventions: Staff to provide comfort measures; assess for verbal and nonverbal pain indicators; reposition for comfort as needed; facility nurse to notify hospice promptly of any changes and declines; involve hospice services in care conference; respect and honor the resident's wishes; hospice CNA to assist with ADLs (activities of daily living) as needed: notify Medical Director and hospice if interventions are ineffective; and facility and hospice social worker to visit periodically and offer support. In an interview on 04/15/2025 at 9:34 a.m., S7 LPN revealed that Resident #5 was not currently receiving hospice services. In an interview and record review on 04/16/2025 at 11:31 a.m., S9 MDS LPN revealed she is responsible for updating and revising resident care plans. S9 MDS LPN confirmed Resident #5's current care plan reflected hospice services and Resident #5 was not currently receiving hospice services. S9 MDS LPN confirmed Resident #5's hospice care plan should have been resolved/discontinued to reflect the current plan of care, but was not.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to obtain a physician's order for 1 (#6) of 1 resident sampled for respiratory care. The facility failed to ensure a physician's order was obtained for oxygen administration. Findings: Review of the facility's policy on 04/15/2025 titled, Oxygen-Administration, Concentrator, Storage, Assemblage, last reviewed on 01/2024 read in part .Purpose: To provide adequate tissue oxygenation by providing supplemental oxygen. Procedure: 1. Obtain appropriate physician's order. Review of Resident #6's medical record revealed an admitted [DATE] with a re-entry date of 03/13/2025 with diagnoses that included in part .Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Acute on Chronic Systolic (Congestive) Heart Failure, Sleep Apnea, and Asthma. Review of Resident #6's Admission/Medicare-5 Day MDS with an ARD of 06/19/2025 revealed a BIMS score of 15, indicating intact cognition and requires continuous oxygen therapy. Review of Resident #6's care plan with a review date of 06/17/2025 revealed in part .The resident has Congestive Heart Failure. Intervention: oxygen as ordered. The resident has Coronary Artery Disease. Intervention: oxygen as ordered. The resident has COPD and Asthma. Intervention: oxygen/bi-pap as ordered. The resident has Sleep Apnea. Intervention: oxygen as ordered. In an observation and interview on 04/14/2025 at 10:09 a.m. Resident #6 was observed lying in bed with 3 liters/minute of oxygen being administered via nasal cannula. Resident #6 stated, Sometimes I'm on 2 liters of oxygen or 3 liters of oxygen. In an observation and interview on 04/15/2025 at 10:02 a.m. Resident #6 was observed lying in bed with 3 liters/minute of oxygen being administered via nasal cannula. Resident #6 stated she wears her oxygen continuously. Review of Resident #6's 04/2025 physician orders revealed no order for oxygen administration. Review of Resident #6's 04/2025 EMAR revealed no documentation of oxygen administration. In an interview on 04/15/2025 at 10:32 a.m. S6 LPN stated Resident #6 wears continuous oxygen except during therapy. S6 LPN stated Resident #6 has always worn oxygen. S6 LPN confirmed Resident #6 does not have order for oxygen administration. In an interview on 04/15/2025 at 11:03 a.m. S5 Medical Records LPN confirmed there was no physician's order for oxygen administration for Resident #6 after returning to the facility from the hospital on 03/13/2025. In an interview on 04/15/2025 at 11:12 a.m. S2 DON confirmed a physician's order for oxygen administration should have been obtained for Resident #6, but had not been.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in a secure manner by failing to ensure medications were not left at the bedside for 1 (Resident #10) resident of 20 sampled residents. Findings: Review of a facility policy on [DATE] at 1:35 p.m. titled, Administration of Medications with a revision date of ,d+[DATE] revealed in part .Purpose: To administer medications in accordance with best practice. 4. Medications shall be administered by the person who prepared the dose. 7. Stay with the resident until the resident takes all medications. Topical Medications: 1. Only qualified professionals are allowed to administer medication per state laws. Review of a facility policy on [DATE] at 1:35 p.m. titled, Destruction of Unused, Expired or Discontinued Medications with a revision date of ,d+[DATE] revealed in part .All containers with no labels will be given to the Director of Nursing (DON) for proper disposition. 1. Unused or discontinued non-controlled medications are to be destroyed by the DON (designee) and another licensed nurse. Review of Resident #10's medical record revealed a re-admitted [DATE], with diagnoses that included in part . Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, Paraplegia Complete, Peripheral Vascular Disease, Metabolic Encephalopathy, and Orthostatic Hypotension. Review of Resident #10's Quarterly MDS with an ARD of [DATE] revealed a BIMS score of 15, which indicated intact cognition. Resident #10 required extensive assistance with two persons for bed mobility, transfers, and toilet use. Review of Resident #10's current physician orders revealed in part . [DATE] (start date): Nystatin powder 15gm 100000 unit/ 1gram apply topically to skin folds as needed daily for redness every 24 hours. Review of Resident #10's care plan with an initial date of [DATE] and revision date of [DATE] revealed in part . Focus: Resident is at risk for impaired skin integrity related to inability to turn self without staff assist. Interventions: Treatments as ordered. Resident #10 was not care planned for self-administration of medications, powders, creams, ointments, and/or treatments. Further review of the medical record revealed there were no physician's orders to allow Resident #10 to store any medications in the room at the bedside and there were no assessments to determine if Resident #10 was safe to have the medications stored at the bedside to self-administer. Observation on [DATE] at 10:11 a.m., revealed an unattended powdered substance in a small, clear, plastic medication container located on Resident #10's bedside dresser table. In an interview on [DATE] at 10:11 a.m., Resident #10 revealed the powdered substance in the clear, plastic container was Nystatin powder and stated that the staff apply the powder to her skin when her brief is changed. In an observation and interview on [DATE] at 10:20 a.m., S6 LPN accompanied surveyor to Resident #10's bedroom. S6 LPN confirmed that the powdered substance in the clear, plastic container was Nystatin powder and should not be left unattended at the resident's bedside. S6 LPN confirmed the Nystatin powder should have been discarded properly, but was not. In an interview on [DATE] at 9:34 a.m., S7 LPN revealed that Resident #10 had active physician orders for Nystatin powder to be applied to the resident's skin folds as needed daily for redness. S7 LPN confirmed that Nystatin powder should not be left unattended at Resident #10's bedside because she does not self-administer any medications or powders. S7 LPN confirmed that Resident #10's Nystatin powder should had been stored in a locked medication or treatment cart and not stored at the bedside. In an interview on [DATE] at 12:00 p.m., S3 QI Nurse confirmed that Nystatin powder should not be left at a resident's bedside for any reason. In an interview on [DATE] at 1:25 p.m., S2 DON confirmed that Nystatin powder should not have been left unattended at Resident #10's bedside. In an interview on [DATE] at 2:27 p.m., S8 Treatment LPN confirmed that Nystatin powder is stored on the locked treatment cart and should not be stored unattended at the resident's bedside. S8 Treatment LPN confirmed that after application of Nystatin powder, any remaining Nystatin powder should be discarded properly.

Based on observation, interview and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of an infectious communicable disease. The facility failed to ensure all staff adhered to Enhanced Barrier Precautions for 1 (Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for Quality of Care. Findings: Review of the facility policy titled: Enhanced Barrier Precautions, revealed in part .Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Wounds generally include chronic wounds, not shorter lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Observation on 05/13/2024 at 9:00 a.m. of the exterior of Resident #3's door revealed an Enhanced Barrier Precautions sign with instructions to wear gloves and a gown for high-contact resident care activities, which included bathing/showering, transferring, dressing, changing linens, providing hygiene, device care or use; central line, urinary catheter, feeding tube, tracheostomy and wound care: any chronic wound taped to the outside of Resident #3's room door. A plastic storage bin was observed to the left of Resident #3's room entrance that contained yellow gowns and biohazard bags. Review of Resident #3's May 2024 Treatment Administration Record revealed in part . Cleanse vascular ulcer to left malleolus with wound cleanser, pat dry. Apply Santyl with 4X4 and cover with ABD pad then wrap with Kerlex and secure with paper tape. Change Q Monday per MD. Order date 03/05/2024. Cleanse arterial ulcer to left lateral foot with wound cleanser, pat dry. Apply Santyl with 4X4 and cover with ABD pad then wrap with Kerlex and secure with paper tape. Change Q Monday per MD. Order date 03/05/2024. Cleanse arterial ulcer to left lateral shin with wound cleanser, pat dry. Apply Santyl with 4X4 and cover with ABD pad then wrap with Kerlex and secure with paper tape. Change Q Monday per MD. Order date 03/28/2024. Observation on 05/13/2024 at 12:25 p.m. revealed S1 LPN performing wound care on Resident #3's left foot. S1 LPN was observed wearing a mask and gloves only while performing wound care. S1 LPN then called for assistance and S2 CNA entered Resident #3's room wearing a mask. S2 CNA donned gloves and proceeded to hold up Resident #3's left leg as instructed by S1 LPN. S1 LPN then proceeded to clean and redress Resident #3's wounds. Interview with S1 LPN after completion of wound care revealed Resident #3 was on Enhanced Barrier Precautions. S1 LPN stated she thought she only needed to wear a gown to perform wound care if the resident had a stage 2 ulcer or worse. S1 LPN confirmed the signage on Resident #3's door stated a gown should be worn when providing wound care to chronic wounds. S1 LPN confirmed she nor S2 CNA wore a gown while providing wound care to Resident #3 and they should have.

Based on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment. The facility failed to ensure: 1. The front face coverings for air condition/heater units in rooms a, b, c, d, e, and f were properly secured; 2. The walls in rooms, b, c, e, and f did not have peeling sheet rock; 3. The wall mounted molding near the bedside table in room d, did not have a split in the molding with splinters visible. 4. Handrails on Hall A were cleaned and free of debris and dead insects, and chipped paint was repaired; 5. The floor in Room b had been cleaned of dust and dead insects; and 6. Resident #16's enteral feeding pump was free of dried, splattered feeding. Findings: Room a 03/05/2024 at 9:18 a.m. - the front face covering to the wall mounted air condition/heater unit was not secured to the unit. Room b 03/04/2024 at 11:45 a.m. and 03/05/2024 at 8:15 a.m. - a moderate amount of gray dust, and dead black insects were observed on the floor beside, and underneath the air condition/heater unit. The wall mounted air conditioner/heater front face covering was not secured to the unit. There was an opening between the air conditioner/heater unit and the wall, and the surveyor was able to visualize the outside through the opening. The walls near the head of the beds were noted to have peeling sheet rock. Room c 03/52024 at 11:05 a.m. - The front face covering of the wall mounted air condition/heater unit was not secured to the unit. The walls near the head of the beds were noted to have peeling sheet rock. Room d 03/05/2024 at 11:05 a.m. - The front face covering of the wall mounted air condition/heater unit was not secured to the unit. The wall mounted molding near the bedside table was noted to have a split in the molding with splinters visible. Room e 03/05/2024 at 11:05 a.m. - The front face covering of the wall mounted air condition/heater unit was not secured to the unit. The walls near the head of the beds were noted to have peeling sheet rock. Room f 03/05/2024 at 11:05 a.m. - The front face covering of the wall mounted air condition/heater unit was not secured to the unit. The walls near the head of the beds were noted to have peeling sheet rock. Hall A 03/05/2024 at 11:05 a.m. - The handrails were noted to have chipped paint pieces, dead crickets, paper wrapping and dust inside of the rails. Observation on 03/05/2024 at 10:55 of Room b, accompanied by S7 Housekeeping Supervisor, and interview of S7 Housekeeping Supervisor at that time, revealed the floor had been cleaned and mopped earlier that morning. S7 Housekeeping Supervisor confirmed after inspecting the area, that the area beside and underneath the air condition/heater unit was dirty and needed to be cleaned. Observation on 03/05/2024 at 11:30 a.m. of Rooms a and b air condition/heater units, accompanied by S6 Maintenance Supervisor, confirmed the ac units were not properly secured in the frame. S6 Maintenance Supervisor stated in 11/2023 (unable to recall date), all of the units were pulled out for cleaning by an outside contractor, and replaced. S6 Maintenance Supervisor stated he had checked the units, and confirmed that many were loose and had missing screws which needed to be replaced. Observations on 03/05/2024 at 11:45 a.m. and accompanied by S1 Administrator, confirmed the air conditioner/heater units needed to be properly fitted, and the walls was in need of repairs. S1 Administrator stated she was not aware of the units, nor of the repairs needed on the walls in Rooms b, c, e, and f and wall mounted molding in Room d. S1 Administrator after inspecting Hall A handrails, confirmed the inside of the rails needed to be cleaned. S1 Administrator stated it was the responsible of the housekeepers to keep the handrails clean. 44315 Review of Resident #16's Medical Record revealed an admitted [DATE] with diagnoses that included Gastrostomy status, Dysphagia following Cerebral Infarction, Ulcerative Chronic Proctitis with Intestinal Obstruction, Hypo-osmolality, Hyponatremia and Hemiplegia following Cerebrovascular Disease affecting right non-dominant side. Review of Resident #16's Quarterly MDS with an ARD of 11/07/2023 revealed a BIMS score of 06, indicative of severe cognitive impairment. Resident #16 required nutritional approaches that included a feeding tube for 51% or more intake by artificial route. Review of Resident #16's Care Plan with a target date of 02/07/2024, revealed a problem of NPO status with need for enteral feeding per PEG tube, secondary to late effect CVA with dysphagia and potential for weight loss. Approaches included in part . Fiber source HN @ 65ml/hour. Observation on 03/04/2024 at 11:13 a.m. of Resident #16 revealed Fiber source HN tube feeding in progress at 65cc/hour per enteral feeding pump. Numerous spots of dried tube feeding drippings were splattered on the face of the enteral feeding pump. Observation on 03/05/2024 at 8:55 a.m. revealed Resident #16's enteral feeding pump had not been cleaned, and numerous spots of dried tube feeding drippings remained splattered on the face of the enteral feeding pump. Interview on 03/05/2024 at 9:58 a.m. with S9 Housekeeper revealed the housekeepers are supposed to clean the tube feeding pumps and poles every day. S9 Housekeeper confirmed the dried residue on the feeding pump was from the drippings of the tube feeding milk in the bag hanging over the pump. Interview on 03/05/2024 at 10:03 a.m. with S3 LPN in Resident #16's room confirmed the above findings, and stated Resident #16's tube enteral feeding pump should have been cleaned every day, and had not been.

Based on interview, observation and record review, the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #13, Resident #27, and Resident #34) sampled residents in a total sample of 30. The facility failed to ensure a person-centered plan of care was: 1. Implemented for 1 resident (Resident #13) reviewed for impaired mobility. The facility failed to ensure a positioning device was provided to a resident to prevent further complications and contractures. 2. Developed and implemented for 1 resident (Resident #27) that addressed Resident #27's left hand contracture. 3. Developed for 1 resident (Resident #34) who required oxygen therapy. Findings: Resident #13 Review of Resident #13's Medical Record revealed an admitted [DATE] with diagnoses that included Hemiplegia following Cerebral Infarction affecting Left Dominant Side, Unspecified Sequelae of Non-traumatic Intracerebral Hemorrhage, Bell's Palsy, Osteoarthritis, Spinal Stenosis, Generalized Muscle Weakness, Essential Primary Hypertension and other Idiopathic Peripheral Autonomic Neuropathy. Review of Resident #13's EMAR for 03/2024 revealed a Nursing Instruction order dated 11/24/2021, to Ensure Hand Roll is in place as preventative for skin breakdown. Review of Resident #13's Quarterly MDS with an ARD of 01/18/2024, revealed a BIMS score of 08, which indicated moderate cognitive impairment. The MDS revealed in part .that resident #13 was coded for functional limitation in ROM with impairment on one side to his upper extremities. Review of Resident #13's Care Plan with a target completion date of 04/26/2024, revealed a potential for decreased mobility, with approaches that included in part . Hand roll to left hand. Observation on 03/04/2024 at 1:11 p.m. of Resident #13 revealed his left hand did not have a hand roll in place. Observation on 03/05/2024 at 8:39 a.m. of Resident #13 revealed his left hand was without a hand roll in place. Interview at that time with Resident #13 revealed he couldn't remember the last time he had his hand roll. Observation on 03/05/2024 at 11:40 a.m. of Resident #13, revealed the resident did not have a hand roll to his left hand. Interview on 03/05/2024 at 11:41 a.m. with S8 CNA, Resident #13's CNA, revealed she was not aware that Resident #13 had a hand roll for his left hand. Interview on 03/06/2024 at 12:06 p.m. with S6 LPN Assessment nurse confirmed Resident #13 was care planned for a hand roll to his left hand, and did not have one on and should have. 41124 #27 Review of Resident #27's clinical record revealed Resident #27 was admitted to the facility on [DATE]. Resident #27 had diagnoses that included Chronic Obstructive Pulmonary Disease, Pressure Ulcer; Stage 2, Pressure Ulcer of Sacral Region; Stage 3, Acquired Absence of Right Leg Above Knee, Muscle Weakness, and Acquired Absence of Left Leg Above Knee. Review of Resident #27's Yearly MDS with ARD 12/14/2023 revealed Resident #27 was dependent on staff for bathing, toileting, personal hygiene, and upper and lower body dressing. Observation on 03/04/2024 at 9:00 a.m. revealed Resident #27 awake in bed dressed in a hospital gown. A contracture was observed to Resident #27's left hand with no splinting or positioning devices observed in use. Observation on 03/05/2024 at 9:02 a.m. revealed Resident #27 asleep in bed, contracture to left hand with no splinting device present. Observation on 03/06/2024 at 9:34 a.m. revealed Resident #27 asleep in a geri chair at his bedside. Contracture observed Resident #27's to left hand. Review of Resident #27's CPOC with a target date of 03/14/2024 revealed Resident #27's care plan did not indicate Resident #27 had a contracture to the left hand. Interview on 03/06/2024 at 9:45 a.m. with S2 DON confirmed Resident #27 was not care planned for having a contracture to his left hand and should have been. Interview also revealed Resident #27 was not care planned for assistive devices to prevent further progression of the left hand contracture and should have been. 44844 Resident #34 Review of Resident #34's medical record revealed an admitted [DATE], with diagnoses which included in part .Iron Deficiency Anemia, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Acquired absence of left leg Above Knee and Pain. Review of Resident #34's Admission MDS with an ARD 02/02/2024, revealed a BIMS score of 12 (indicating moderately impaired cognition). The MDS was coded as blank for oxygen therapy. Review of Resident #34's care plan revealed no problem/need related to oxygen therapy. Observation on 03/04/2024 at 10:15 a.m. revealed Resident #34 in bed with oxygen via nasal cannula in place. Observation on 03/05/2024 at 9:11 a.m. revealed Resident #34 in bed with oxygen via nasal cannula in place. Review of Resident #34's Physician's Orders dated March 2024 read in part .Oxygen at 2 liters per nasal cannula as needed for Shortness of Breath. Interview and record review on 03/06/2024 at 9:00 a.m. with S6 LPN Assessment Nurse of Resident #34's care plan confirmed she had not been care planned for oxygen with appropriate approaches, and she should have been.

Based on observation, interview and record review the facility failed to ensure the MDS Assessment accurately reflected a residents' status during the observation period for 1 (Resident #27) of 2 (Resident #13 and Resident #27) residents sampled for positioning and mobility. Findings: Review of Resident #27's clinical record revealed Resident #27 was admitted to the facility on [DATE]. Resident #27 had diagnoses that included Chronic Obstructive Pulmonary Disease, Pressure Ulcer; Stage 2, Pressure Ulcer of Sacral Region; Stage 3, Acquired Absence of Right Leg Above Knee, Muscle Weakness, and Acquired Absence of Left Leg Above Knee. Review of Resident #27's Yearly MDS (Minimum Data Set) Assessment with ARD (Assessment Reference Date) 12/14/2023 indicated Resident #27 had no functional limitation in range of motion (ROM) to the upper extremities. Observation on 03/06/2024 at 11:00 a.m. revealed Resident #27 awake in a geri-chair at his bedside. Interview with Resident #27 at the time of observation revealed he was only able to move his left arm by picking it up with his right arm. Observation revealed Resident #27 lifted his left upper extremity with his right hand and placed it across his body. Resident #27's left upper extremity remained in a flexed position. Interview on 03/06/2024 at 3:32 p.m. with S2 DON confirmed Resident #27 had limited ROM to his left upper extremity as well as a contracture to his left hand. S2 DON confirmed Resident #27 should have been coded on the 12/14/2023 MDS Assessment for upper extremity impairment in ROM on one side and had not been.

Based on observation and interview, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Expired/ outdated items were not available for resident consumption 2. Food preparation equipment was clean 3. Cooking and serving utensils were clean and stored under sanitary conditions. The total Facility census was 102 Residents. Findings: Review of the facility's Policy and Procedure titled, Food Storage Labeling read in part . Policy: The facility will ensure the safety and quality of food following good storage and labeling procedures. Procedure: #3. b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date. Suggested time frames: Dry Storage - weekly. Review of the facility's Policy and Procedure titled, Cleaning Instructions Deep Fat Fryer read in part . Policy: Equipment shall be maintained in a clean and sanitary condition. On initial tour of the kitchen on [DATE] at 8:40 a.m. accompanied by S5 DM in the dry food storage room revealed the following items on the shelf available for use: 1.One opened plastic bag of croutons ,d+[DATE] full with an expiration date of [DATE]. 2.One opened paper 4 lb. bag of sugar ,d+[DATE] full folded partially closed and not labeled or contained. 3.One plastic bag of ice cream dry mix with powder residue noted leaking from a small hole in the bag. Observation on tour of the kitchen on [DATE] at 9:10 a.m. accompanied by S5 DM revealed: 1. Utensils drawer contained one long handled metal spoodle and 2 long handled metal spoons with yellow colored dried gel type residue and loose dark substance particles noted inside the bowl part of the spoons. 2.Large metal deep fat fryer with yellow colored dried gel type residue noted on the outer edges and sides. Multiple loose dark substance particles and dark brown crumbles scattered on the attached metal side work table and noted on the inside wall of the deep fryer and floating on the oil in the deep fryer. Interview on [DATE] at 9:10 a.m. with S5 DM confirmed the above findings. S5 DM revealed she was not aware of the bag of croutons being expired and the dietary staff should have removed the croutons from the dry storage room. S5 DM stated she did not know when the croutons were used and distributed to the residents. S5 DM revealed the ice cream dry mix should have been discarded and was not. S5 DM revealed the deep fat dryer was last used last week and should have been cleaned after use. S5 DM stated that dietary staff worker assigned to clean the deep fat fryer and wash the dishes and were responsible for ensuring that all of the cooking and serving utensils and equipment were cleaned and was not done.

Based on observation, interview and record review the facility failed to ensure each resident was treated with respect and dignity for 1 (#2) of 3 sampled residents (Resident #1, Resident #2 and Resident #3). The facility failed to ensure Resident #2 had proper footwear and adequate clothing. Findings: Review of the medical record for Resident #2 revealed an admitted [DATE], with diagnoses that included in part .End Stage Renal Disease, Anemia in Chronic Kidney Disease, Major Depressive Disorder, Age-related Physical Debility, Type II Diabetes Mellitus, Pain Unspecified and Repeated Falls. Review of Resident #2's Significant Change MDS with an ARD of 12/18/2023 revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed Resident #2 required assistance with upper and lower body dressing. Review of Resident #2's care plan with a target date of 02/02/2024, revealed in part .resident needs assistance with ADL's: Extensive assist x 1 with transfers, dressing and toileting; limited assist with bed mobility and eating, with approaches that included therapy consult as needed, and give verbal cues as needed. Observation and interview on 01/23/2024 at 3:48 p.m. with Resident #2, revealed her sitting in a wheelchair with a blue t-shirt, a pink cotton zip up jacket, and a pair of blue jean capris on. Resident #2 also had on a pair of black fuzzy slippers (with the back out). Resident #2 revealed she came to the facility from the hospital and never got the chance to return home to retrieve any of her clothes/shoes, or other belongings. Resident #2 revealed she went to dialysis 3 days a week outside of the facility. Resident #2 stated she did not have any clothes, shoes or a coat to keep her warm. Observation of Resident #2's closet at that time revealed the following: 1 pair of black jeans, 1 pair of sweatpants, 1 sweatshirt, 1 short sleeved shirt, 1 blouse, 2 muumuu gowns, and 2 coats. Resident #2 stated the 2 coats were given to her by the social worker at the dialysis center, but both coats were too small for her. Observation of Resident #2's room revealed no shoes, other than the pair of black fuzzy slippers she had on her feet. Resident #2 stated the pink cotton zip up jacket she had been wearing was given to her by another resident's granddaughter. Resident #2 stated she told staff at the facility she was cold, and needed some winter clothes and shoes (could not recall the staff she told). Resident #2 stated she did not want anyone feeling sorry for her, but being without clothes and shoes made her feel small and worthless. Telephone interview on 01/23/24 at 4:02 p.m. with the dialysis center [NAME] Clerk revealed Resident #2 came to dialysis 3 x week on Monday, Wednesday and Friday, by the nursing home transportation. The Dialysis [NAME] Clerk stated Resident #2 came to dialysis inadequately dressed for cold winter weather; with capris and slippers on, without a coat. The Dialysis [NAME] Clerk stated the Social Worker at the dialysis center had given Resident #2 two coats. Interview on 01/23/2024 at 4:11 p.m. with S3 SSD revealed Resident #2 was admitted to the nursing home from the hospital, and did not have any personal belongings upon admission. S3 SSD stated Resident #2 was given clothes from the laundry room which had been donated but couldn't remember what clothing she gave. S3 SSD stated she had not done any shopping for Resident #2, and was unaware of Resident #2 not having adequate winter clothing or shoes to wear. Observation and interview on 01/23/2024 at 4:20 p.m. with S3 SSD in attendance revealed Resident #2's closet had the following: 1 pair of black jeans, 1 pair of sweatpants, 1 sweatshirt, 1 short sleeved shirt, 1 blouse, 2 muumuu gowns, and 2 coats. Resident #2 informed S3 SSD that the 2 coats were given to her by the social worker at the dialysis center, but both coats were too small for her. S3 SSD's observation of Resident #2's room revealed no shoes other than the pair of black fuzzy slippers she had on her feet. Resident #2 informed S3 SSD that the pink cotton zip up jacket she had been wearing was given to her by another resident's granddaughter. S3 SSD confirmed the above findings at the time of observation. Interview on 01/24/2024 at 8:30 a.m. with S7 LPN revealed she provided care for Resident #2. S7 LPN stated Resident #2 required assistance with bathing and dressing. S7 LPN stated she had not noticed what Resident #2 had been wearing to dialysis, or if she had shoes on. Interview on 01/24/2024 at 8:35 a.m. with S4 CNA revealed she assisted Resident #2 with bathing and dressing. S4 CNA stated she was aware of Resident #2 not having a coat or shoes. S4 CNA revealed on the days Resident #2 went to dialysis, she left the facility with a blanket around her. S4 CNA stated she never reported Resident #2's lack of clothing or shoes to anyone, because they already knew it. Telephone interview on 01/24/2024 at 9:13 with the Social Worker at the dialysis center revealed she called the nursing home in November 2023, and spoke with S8 Accounts Manager because Resident #2 needed winter clothes and shoes. The Social Worker at the dialysis center stated Resident #2 complained of being cold and she had given her 2 coats, which she later learned were too small for Resident #2. The Social Worker stated the dialysis center would have to give Resident #2 extra blankets when she arrived, and warm her chair because she would be so cold. Social Worker at dialysis stated Resident #2 wore capris with little black slippers in the winter to dialysis. Social Worker at dialysis stated Resident #2 had revealed to her she felt like she was forgotten about in the world. Interview on 01/24/24/2024 at 9:39 a.m. with S6 Transportation/CNA revealed he took Resident #2 to dialysis 3 x a week on Monday, Wednesday and Friday. S6 Transportation/CNA stated Resident #2 always had on socks with slippers (no shoes) and wore a zip up jacket (no coat). S6 transportation/CNA stated Resident #2 complained of being cold. Interview on 01/24/2024 at 9:47 a.m. with S9 Laundry Worker revealed she usually only washed muumuus, towels, socks and underwear for Resident #2. Interview on 01/24/2024 at 10:50 a.m. with S3 SSD confirmed there was no inventory list of Resident #2's belongings in her medical chart. Interview on 01/24/2024 at 11:00 a.m. with S2 DON revealed she was unaware of Resident #2 not having adequate winter clothing or shoes; or leaving the facility inadequately dressed for dialysis. S2 DON confirmed the following: Resident #2 would have had to choose from the selection of clothes she had in her closet, which did not include a coat or shoes; and all staff were responsible for checking residents before they left the facility.

Based on record review, observation, and interview the facility failed to provide adequate supervision of a cognitively impaired resident to prevent elopement for 1 (#2) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This deficient practice resulted in an immediate jeopardy situation on 09/11/2023 at 5:10 p.m., when Resident #2, who resided on the facility's locked unit (Hall X), and had been identified as a wanderer with a history of exit seeking behaviors, was left unsupervised while outside smoking. Resident #2 climbed over a wooden fence in the courtyard area, unnoticed by staff, and was found by S7 CNA in the parking lot of a department store 900 feet from facility at approximately 5:46 p.m. on 09/11/2023. This deficient practice continued at a potential for more than minimal harm for the remaining 9 Residents on Hall X identified as being at risk for elopement (#6, #7, #8, #9, #10, #11, #12, #13, and #14). S1 Administrator was notified of the Immediate Jeopardy on 09/13/2023 at 4:05 p.m. The Immediate Jeopardy was removed on 09/14/2023 at 10:16 a.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented: The Facility's plan to remove the immediate jeopardy situation included: 1. On September 11, 2023 at 5:50 p.m., Resident #2 was immediately placed on one on one supervision. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on September 11, 2023 on Sufficient Supervision on Hall X. In-services were initiated on September 11, 2023 by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, and Sufficient Supervision on Hall X. In-services were initiated on September 13, 2023 by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides. In-services will be daily until all staff have been inserviced with date of compliance by September 15, 2023, and no employee will be allowed to work until participation of the in-services are completed. 2. The facility Quality Assurance Committee Meeting was held on September 11, 2023 6:30 p.m. with the committee consisting of facility Administrator, Director of Nurses, Medical Director via phone, Infection Preventionist, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Medical Records and Charge Nurse. Topics discussed included Federal Tag F689 and Seven Components of abuse and neglect, Supervision, Elopement, Assessment, Staff Competency. No policy changes were made; however, facility made procedural changes on September 12, 2023 to include at least two staff members working Hall X at all times. Director of Nurses (DON) or RN Supervisor will assess residents who reside on Hall X for sufficient staff supervision every shift. Facility Administrator will monitor daily to ensure sufficient staffing on Hall X each shift times twelve weeks. Corporate Regional Administrator or Quality Improvement Nurse will review monitoring tool weekly to ensure compliance. 3. Twelve residents reside on Hall X. Twelve residents were assessed and ten identified as having a risk for elopement. The facility will provide adequate supervision to reduce the risk of elopement. Measures put into place in an effort to achieve compliance has been implemented with the following interventions: Facility has implemented and reviewed the following: a). Immediate reporting of potential missing resident by all staff to their Supervisor, or if any resident verbalizes a desire to leave, or continue going to exit doors b). Immediate notification to Administrator and DON of Code W initiation c). All residents have been reassessed for Potential Elopement Risk d). Code W procedures per policy e). Nurses will continue to verify residents are in facility when rounding and throughout shift f). Current List of residents who are at risk for elopement is posted at Nurse Station g). All staff have been in-serviced on Abuse, Neglect, Injury of Unknown origin, and Elopement h). Fence Contractor has come and assessed the perimeter of the facility grounds i). CNA Supervisor has been in serviced on replacement or reassignment of staff if call-in occurs or no shows on Secure Care Unit or in General Population j). Outside patio bench was immediately removed after discovery of events leading to occurrence. On September 12, 2023, the Director of Nurses reviewed all twelve resident records who reside on Hall X for any identified exit seeking behavior. No significant findings were identified on eleven of the twelve active residents. Resident #2 was identified as having exit seeking behavior. 4. Administrator and DON received additional training on September 13, 2023 per Corporate Regional Administrator and Quality Improvement Nurse on ensuring sufficient staffing on Hall X. 5. The following agencies were notified on September 11, 2023 The Police Department was called at 5:30 p.m. by Nursing Department and notified of the Elopement. September 11, 2023 5:50 p.m. the Local Police Department was notified of resident safe return to facility. LDH was notified of the elopement within the two hour required time frame. Completion date: 09/13/2023 Findings: Review of the facility's policy titled, Elopement/Wandering-General Policy revealed a definition of elopement, and staff interventions upon receiving notice that a resident is missing from the facility. The facility did not have a policy regarding prevention of elopement from the secured unit. A policy for supervision of residents who reside on the secured unit was requested, and surveyors were informed that the facility did not have a policy. Review of Interdisciplinary Notes from an inpatient behavioral health hospital for Resident #2 revealed in part .an admitted [DATE] and discharge date of [DATE]. Reason for admission/readmission revealed: Patient is a [AGE] year-old with history of Dementia and psychotic disorder who resides at home with his family. Patient presented on a PEC from ER due to combative behavior. Reportedly he fights with family and sometimes he steals from them. - He wanders off and almost got hit with a car three times in the last week. He goes out and tries to buy beer. He stays up all night. He talks to himself. Discharge diagnoses were listed as: Dementia, Lewy Body, Severe with Agitation, History of Schizophrenia, and Alcohol Use disorder, mild to moderate. Review of Resident #2's medical record revealed he was admitted to the facility's locked unit on 06/02/2023 with diagnoses that included in part .Unspecified Dementia, Schizophrenia, Neurological Disorder with Lewy Bodies, and Alcohol Dependence. Review of Resident #2's Quarterly MDS with an ARD of 07/26/2023 revealed a BIMS score of 5, which indicated severely impaired cognition. Resident #2 required supervision with bed mobility, transferring, locomotion on the unit, and 1-person physical assist with bathing. Review of Resident #2's current comprehensive plan of care with a target date of 12/07/2023, revealed Resident #2 was not identified as a wanderer or elopement risk prior to his elopement on 09/11/2023, despite being placed on Hall X upon admission to the facility, due to his wandering behaviors while living at home. Review of Resident #2's Nurse Data Collection and Screenings dated 06/02/2023, and reassessment screenings dated 07/26/2023 by S10 LPN, each read as follows: 1. Does the resident display cognitive deficits, disorientation, intermittent confusion, or any cognitive impairments that contribute to poor decision-making skills? Answer: Yes 2. Does the resident have a diagnosis that may increase the risk of elopement? Answer: Dementia and Schizophrenia. 3. Does the resident ambulate independently, with or without an assistive device? Answer: Yes 4. Does the resident have a history or currently experiencing any of the following? (Elopement while at home, leaving facility without supervision, leaving the facility without informing staff, verbally expressed desire to go home, wanders aimlessly - moves without purpose, may enter others rooms and explores others belongings, packed belongings to go home or stayed near exit door, recently admitted or readmitted (within 30 days) and not accepting the situation.) Answer: None of the above Has family communicated that the resident has eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies? No Is the resident at risk for elopement? Answer: No Review of a written statement dated 09/11/2023 by S9 LPN read as follows: At 09/11/23 4:30 p.m., Resident #2 was seen in his room eating supper during census check with no complaints at the time. At around 5:00 p.m. I was preparing the medication cart for medication pass when S8 CNA notified me that Resident #2 has jumped the fence from the courtyard area, and left the facility grounds. Myself and other staff checked the inside and outside of the facility to locate Resident #2. S2 DON was notified and Code W was initiated. The local police department and Resident #2's responsible party was notified. At 5:45 p.m. Resident #2 was located near facility grounds by staff uninjured and unharmed. The responsible party was notified and a full head to toe assessment was obtained. A superficial abrasion and skin tear was observed to Resident #2 right palm. S2 DON spoke with Resident #2's responsible party where she refused to send him to the hospital for treatment and evaluation. Review of a written statement dated 09/12/2023 by S8 CNA read as follows: To whom it may concern, I was outside with Resident #2 while he was smoking, I heard a noise and went back inside to check on the residents. Once I went back outside to get Resident #2 he was not there. I immediately notified the nurse. Review of a written statement by S7 CNA read as follows: I responded to a Code W looking for Resident #2. As I was coming out of the local department store I spotted Resident #2 in the parking lot of the department store as he was walking back to the facility. In an interview on 09/12/2023 at 4:00 p.m., S1 Administrator stated on 09/11/2023, Resident #2 was brought outside to smoke by S8 CNA. S1 Administrator stated S8 CNA came back into the building leaving Resident #2 outside in the gated area unsupervised. S1 Administrator stated S8 CNA returned later to let Resident #2 back into the building and noticed he was missing. S1 Administrator stated she watched the facility's video surveillance footage which revealed Resident #2 stood on the seat of a bench in the courtyard area, put his foot on top of the fence, hopped over the fence, and exited the facility grounds. S1 Administrator stated the nurse was off of Hall X passing medications on another hall at the time of the elopement. S1 Administrator stated Resident #2 was found in the nearby department store parking lot by S7 CNA, and was walked back to the facility. S1 Administrator stated Resident #2 was assessed and was noted with a superficial wound to the palm of his hand from the wooden fence. S1 Administrator confirmed there should be two CNAs on Hall X at all times. S1 Administrator stated the second CNA scheduled to work Hall X at the time of the elopement, S5 CNA, was running late, but did not notify the ADON or S3 CNA Supervisor of her absence. In an interview on 09/12/2023 at 4:30 p.m., S5 CNA stated she was scheduled to work from 3:00 p.m.-11:00 p.m. on 09/11/2023. S5 CNA stated she notified S3 CNA Supervisor in advance that she was going to be running late due to a doctor's appointment. S5 CNA stated she works another job and most days she does not get to the facility until 3:30 p.m. S5 CNA stated from 3:00-3:30 p.m., there is only one CNA on Hall X until she arrives. S5 CNA showed this surveyor a text message between S3 CNA Supervisor and S5 CNA dated 09/11/2023 at 4:00 p.m. where S5 CNA notified S3 CNA Supervisor she was still at her doctor's appointment. S3 CNA Supervisor responded OK. S5 CNA stated when a resident goes out to smoke, staff are to remain with the resident at all times. S5 CNA stated S8 CNA called her at 5:22 p.m. to notify her Resident #2 was missing from the facility while she was working on Hall X alone. A telephone call to S8 CNA was attempted on 09/12/2023 at 5:17 p.m., and was unsuccessful. In an interview on 09/12/2023 at 5:40 p.m., S2 DON stated she was not aware there was only one staff member present on Hall X at the time of the elopement. S2 DON stated she was not aware S3 CNA Supervisor left Hall X and the facility at 4:20 p.m., leaving only one CNA to work Hall X on 09/11/2023, evening shift. Video footage was reviewed with S1 Administrator on 09/12/2023 at 5:53 p.m. of the elopement that occurred on 09/11/2023. The video footage revealed the following: On 09/11/2023 at 5:10 p.m., Resident #2 went over the fence near the dementia unit's smoking area. Resident #2 was unsupervised at the time. At 5:20 p.m., S8 CNA was seen checking for Resident #2 outside. A Code W was called. At 5:46 p.m. Resident #2 was seen on camera returning to facility at front door entrance with staff members present. Interview with S1 Administrator at that time revealed Resident #2 was missing from the facility, a total of 36 minutes. S1 Administrator stated Resident #2 was unsupervised at the time he eloped, and should not have been. In an interview on 09/13/2023 at 11:53 a.m., S10 LPN stated she completed Resident #2's initial assessment when he came into the facility on [DATE], and she reassessed the resident on 07/26/2023. S10 LPN stated she didn't think Resident #2 was an elopement risk because he resided on Hall X. In an interview on 09/13/2023 at 12:25 p.m., S3 CNA Supervisor confirmed Hall X should always be staffed with two CNAs. S3 CNA Supervisor stated when one of the two CNAs calls in, then someone else should be called in to replace them. S3 CNA Supervisor acknowledged she left Hall X on 09/11/2023 at 4:20 p.m. leaving S8 CNA as the only staff to on Hall X, and should not have. A telephone call attempted on 09/13/2023 at 12:35 p.m. with S8 CNA. This surveyor was unable to reach her by phone or leave a voicemail.

Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 Resident (#2) out of 6 sampled residents (#1, #2, #3, #4, #5, and #6). The facility failed to: 1. Ensure LPN/MDS Nurse accurately assessed Resident #2 who was determined to be at risk for elopement. 2. Have an effective system in place to ensure Resident #2 was adquately supervised to prevent elopement. This deficient practice resulted in an immediate jeopardy situation on 09/11/2023 at 5:10 p.m., when Resident #2, who resided on the facility's locked unit (Hall X), and had been identified as a wanderer with a history of exit seeking behaviors, was left unsupervised while outside smoking. Resident #2 climbed over a wooden fence in the smoking area unnoticed by staff, and was found by S7 CNA in a busy parking lot of a department store 900 feet from facility at approximately 5:46 p.m. on 09/11/2023. The deficient practice continued at a potential for more than minimal harm for the remaining 9 residents on Hall X who were identified as being at risk for elopement. (#6, #7, #8, #9, #10, #11, #12, #13, #14) S1 Administrator was notified of the Immediate Jeopardy on 09/13/2023 at 4:05 p.m. The Immediate Jeopardy was removed on 09/14/2023 at 10:16 a.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews, and observations that the Plan of Removal had been initiated and/or implemented. The facility's plan to remove the Immediate Jeopardy included: Brief Summary: Resident #2 was admitted to the facility on [DATE] with medical diagnoses including in part . Unspecified Dementia, mild, with anxiety, Throat Cancer, Alcohol dependence, in remission, Schizophrenia, unspecified, Neurocognitive disorder with Lewy bodies. Resident #2 had a BIMS of 5(severely impaired cognition). Resident #2 eloped from the facility on 09/11/2023 at 5:10 p.m. and was found by S7 CNA in a department store parking lot approximately 900 feet away from the facility at 5:46 p.m. The facility failed to provide supervision to Resident #2, who was at risk for elopement and resided on Hall X. Corrective Actions: 1. On September 11, 2023 at 5:50 p.m. Resident # 2 was immediately placed on one on one supervision. Quality Improvement Nurse ([NAME]) immediately initiated in-services with Registered Nurses and Director of Nursing on September 11, 2023 on Sufficient Supervision on Hall X. In-services were initiated on September 11, 2023 by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides, Dietary staff, Housekeeping and Laundry staff, Activities, Social Services and Office staff on Seven Components of Abuse and Neglect, Quality of Care, Change in Resident Medical Status, and Sufficient Supervision on Hall X. In-services were initiated on September 13, 2023 by DON and [NAME] with Registered Nurses, Licensed Nurses, Certified Nurse Aides, Temporary Nurse Aides In-services will be daily until all staff have been in-serviced with date of compliance by September 15, 2023 and no employee will be allowed to work until participation of the in-services are completed. 2. The facility Quality Assurance Committee Meeting was held on September 11, 2023 6:30 p.m. with the committee consisting of facility Administrator, Director of Nurses, Medical Director via phone, Infection Preventionist, Activities, Transportation, Social Services, Assessment Nurse, Treatment Nurse, Medical Records and Charge Nurse. Topics discussed included Federal Tags F835, and Seven Components of abuse and neglect, Supervision, Elopement, Assessment, Staff Competency. No policy changes were made, however, facility made procedural changes on September 12, 2023 to include at least two staff members working Hall X at all times. Director of Nurses (DON) or RN Supervisor will assess residents who reside on Hall X for sufficient staff supervision every shift. Facility Administrator will monitor daily to ensure sufficient staffing on Hall X each shift times twelve weeks. Corporate Regional Administrator or Quality Improvement Nurse will review monitoring tool weekly to ensure compliance. 3. Twelve residents reside on Hall X. Twelve residents were assessed and ten identified as having a risk for elopement. The facility will provide adequate supervision to reduce the risk of elopement. Measures put into place in an effort to achieve compliance has been implemented with the following interventions: Facility has implemented and reviewed the following: a) Immediate reporting of potential missing resident by all staff to their Supervisor, or if any resident verbalizes a desire to leave, or continue going to exit doors b) Immediate notification to Administrator and DON of Code W initiation c) All residents have been reassessed for Potential Elopement Risk d) Code W procedures per policy e) Nurses will continue to verify residents are in facility when rounding and throughout shift f) Current List of residents who are at risk for elopement is posted at Nurse Station g) All staff have been in-serviced on Abuse, Neglect, Injury of Unknown origin, and Elopement h) Fence Contractor has come and assessed the perimeter of the facility grounds i) CNA Supervisor has been in serviced on replacement or reassignment of staff if call-in occurs or no shows on Secure Care Unit or in General Population j) Outside patio bench was immediately removed after discovery of events leading to occurrence On September 12, 2023 Director of Nurses reviewed all twelve of resident records who reside on Hall X for any identified exit seeking behavior. No significant findings were identified on eleven of the twelve active residents. Resident #2 was identified as having exit seeking behavior. 4. Administrator and DON received additional training on September 13, 2023 per Corporate Regional Administrator and Quality Improvement Nurse on ensuring sufficient staffing on Hall X. Regional Administrator and/or QI Nurse will monitor Administrator and DON for compliance with oversight of sufficient staffing and to prevent residents on the Hall X from exiting the facility without supervision twice weekly times twelve weeks. 5. The following agencies were notified on September 11, 2023 The Police Department was called at 5:30 p.m. by Nursing Department and notified of the Elopement. On September 11, 2023 5:50 p.m. the Local Police Department was notified of resident safe return to facility. LDH was notified of the elopement within the two hour required time frame. Findings: Cross Refer to F689 Review of the facility's Elopement/Wandering-General Policy revealed in part . Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so. All residents shall be observed and evaluated for demonstration of elopement risk by using Form NS-874-Admission/Readmission Nurse Screening on admission/readmission and Form NS-712-Nurse Data Collection and Screening in the observation period of each MDS. a. After reviewing this key information, the nursing staff will determine if the resident is at risk for wandering/elopement. Review of Interdisciplinary Notes from an inpatient behavioral health hospital revealed in part .an admitted [DATE] and discharge date of [DATE]. Reason for admission/readmission revealed: Patient is a [AGE] year old with history of Dementia and psychotic disorder who resides at home with his family. Patient presented on a PEC from ER due to combative behavior. Reportedly he fights with family and sometimes he steals from them. He wanders off and almost got hit with a car three times in the last week. He goes out and tries to buy beer. He would get very angry when family tries to stop him from drinking. He stays up all night. He talks to himself. Discharge diagnoses were listed as: Dementia, Lewy body, Severe with Agitation, History of Schizophrenia, and Alcohol Use disorder, mild to moderate. Review of Resident #2's Nurse Data Collection and Screenings dated 06/02/2023, and reassessment screenings dated 07/26/2023 by S10 LPN, each read as follows: 1. Does the resident display cognitive deficits, disorientation, intermittent confusion, or any cognitive impairments that contribute to poor decision-making skills? Answer: Yes 2. Does the resident have a diagnosis that may increase the risk of elopement? Answer: Dementia and Schizophrenia. 3. Does the resident ambulate independently, with or without an assistive device? Answer: Yes 4. Does the resident have a history or currently experiencing any of the following? (Elopement while at home, leaving facility without supervision, leaving the facility without informing staff, verbally expressed desire to go home, wanders aimlessly - moves without purpose, may enter others rooms and explores others belongings, packed belongings to go home or stayed near exit door, recently admitted or readmitted (within 30 days) and not accepting the situation.) Answer: None of the above Has family communicated that the resident has eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies? No Is the resident at risk for elopement? Answer: No In an interview on 09/13/2023 at 11:53 p.m., S10 LPN stated she completed Resident #2's initial assessment when he came into the facility on [DATE] and reassessed the resident on 07/26/2023. S10 LPN stated she didn't think Resident #2 was an elopement risk because he resided on Hall X. In an interview on 09/12/2023 at 4:00 p.m., S1 Administrator stated on 09/11/2023 Resident #2 was brought outside to smoke by S8 CNA. S1 Administrator stated S8 CNA came back into the building leaving Resident #2 outside in the gated area unsupervised. S1 Administrator stated S8 CNA returned later to let Resident #2 back into the building and noticed he was missing. S1 Administrator stated she watched the facility's video surveillance footage which revealed Resident #2 stood on the seat of a bench in the courtyard area, put his foot on top of the fence, hopped over the fence, and exited the facility grounds. S1 Administrator stated Resident #2 was found in the nearby department store parking lot by S7 CNA and was walked back to the facility. S1 Administrator stated Resident #2 was assessed and was noted with a superficial wound to the palm of his hand from the wooden fence. In an interview on 09/12/2023 at 5:40 p.m., S2 DON stated she was not aware there was only one staff member present on Hall X at the time of the elopement. S2 DON stated she was not aware S3 CNA Supervisor left Hall X and the facility at 4:20 p.m., leaving only one CNA to work Hall X on 09/11/2023, evening shift. In an interview on 09/13/2023 at 12:25 p.m., S3 CNA Supervisor stated there should always be two CNAs on Hall X to ensure residents are adequately supervised. S3 CNA Supervisor stated there was only 1 CNA on Hall X at time of elopement, and there should have been 2.

Based on interviews and record reviews the facility failed to ensure a resident was free from physical abuse from other residents for 1 (#2) of 5 (#1, #2, #3, #4 and #5) sampled residents reviewed for abuse. This deficient practice resulted in actual harm on 9/11/2020 when resident #2 was attacked by resident #4, a wandering resident with behavioral problems. Resident #4 wandered into the room of resident #2 and physically attacked resident #2. Resident #2, a bilateral AKA, was in bed and not able to protect herself or move from the aggressive attack of resident #4. Resident #2 sustained an injury to her left eye, and was diagnosed with [REDACTED]. Findings: Review of the facility's Abuse Policy revealed the following in part: Seven Components to Reduce, Detect and Prevent Abuse and Neglect Prevent - The facility has policies and procedures in place in order to detect and prevent the occurrence of abuse and neglect Further review of the facility's Abuse Policy revealed no evidence that referenced resident to resident abuse. Review of resident #2's medical record revealed [DIAGNOSES REDACTED]. Review of resident #2's Annual MDS, dated [DATE], revealed a BIMS of 15 (Cognitively Intact). The MDS further revealed the resident required extensive 2 person assistance for bed mobility, dressing, and toileting; and was totally dependent upon staff for transfers and bathing. Review of resident #2's plan of care, with a target date of 01/22/2021, revealed Eye Injury: resident has [MEDICAL CONDITION]/swelling to left eye: some redness present to sclera - onset 09/11/2020. Review of resident #2's nurses' notes, dated 09/14/2020 at 5:28 p.m., revealed a late entry for 09/11/2020 at 10:00 p.m. written by the facility's DON that revealed: Reported to this writer by a charge nurse who was across the hall speaking with another resident when this resident hollered for her to go into her room. Upon entering the room this resident was noted to have swelling to left eye and she stated, the lady came into my room and hit me in the eye. When further questioned, resident #2 said resident #4 walked into her room and resident #2 told her to get out. Resident #4 said, you will not talk to me like a dog. then resident #4 hit her in the face. Resident #2's bedside table contents are noted to be on the floor. Body audit done with no other findings. MD and RP made aware of findings. Review of resident #4's Face Sheet revealed the resident was admitted to the receiving nursing facility on 09/25/2020 with [DIAGNOSES REDACTED]. The medical record revealed the resident evacuated to the receiving facility on 08/31/2020. Review of resident #4's Admission MDS, dated [DATE], revealed a BIMS of 3 (Severely Impaired Cognitively). Review of the evacuating facility's care plan, with a target date of 10/30/2020, revealed resident #4 resided on the Secured Dementia Unit. Review of the receiving facility's care plan, dated 01-21-2021, revealed resident #4 was care planned for the following problems, in part: 1. Cognition, disorganized thought related to dementia 2. Wandering/Elopement Alarm: resident has behaviors of wandering aimlessly throughout the facility secondary to dementia. Interventions; ensure alarm is functioning appropriately, redirect as needed. 3. Behaviors (9/11/2020) resident becomes easily agitated when attempted to be redirected by staff; resident becomes agitated and combative towards staff and other residents. There was no documentation in resident #4's medical record from 08/31/2020 to 09/11/2020 of an assessment for need of increased supervision. An interview with resident #2 on 01/14/2021 at 10:13 a.m., revealed that resident #4 entered her room in 09/2020 and struck her in the left eye. She stated the resident had wandered into her room on 2 previous nights and she told staff about it. Resident #2 stated that resident #4 wandered around every night. An interview on 1/14/2021 at 12:03 p.m. with S4 LPN, revealed that she worked on the evening of 09/11/2020 on Hall a. She stated that residents #2 and #4 resided on Hall a. She stated that both residents had rooms at the end on opposite sides of the hall. She stated on 09/11/2020 she observed resident #4 walking down the hall with no pants on and a wet shirt, and the resident told her that she was jumped by some girls and they took her clothes. She stated that as she was assisting resident #4 to her room for clothes, she heard resident #2 yelling and went in to check on her. She stated that she observed in resident 2's room that everything was knocked off of her bedside table, and that the water pitcher was on the floor at the end of the bed. S4 LPN stated that resident #2's left eye was swollen, and resident #2 told her that resident #4 came into her room, and she yelled at the resident to get out of her room. Resident #2 stated that resident #4 attacked her after she yelled at her. S4 LPN stated that her assessment of resident #2 revealed that her vital signs were within normal limits, her left eye was visibly swollen and no other injuries were noted. S4 LPN stated that orders were given to monitor resident #2's left eye, and to follow up with the resident's primary care physician. S4 LPN further stated that resident #4 was sent to an inpatient psych facility after this incident on 09/11/2020. She also stated resident # 4 had not been on increased supervision for wandering or behaviors. An interview with S3 SSD on 01/15/2021 at 9:20 a.m., revealed resident #4 and other residents were evacuated from another facility on 08/31/2020. S3 SSD stated that the resident was placed on the Hall a in Room c with another resident from the evacuated facility. S3 SSD stated Room c was across the hall from resident #2's room. An interview with S7 LPN Medicare Case Manager on 01/15/2021 at 9:51 a.m., revealed that no behaviors were assessed for resident #4 upon arrival on 08/31/2020 because she was not admitted at that time. S7 LPN Medicare Case Manager stated that behaviors were not assessed for the resident until she was admitted on [DATE]. A telephone interview on 01/19/2021 at 11:10 a.m. with S5 CNA, revealed that she worked on the evening of 09/11/2020. She stated that resident #4 was not on increased supervision while on Hall a. She further stated that she was not aware that resident #4 came from a secure unit at the other facility until after the incident on 09/11/2020. She stated that resident #4 had not exhibited any aggressive behaviors during her shift prior to the incident on 09/11/2020. An interview on 01/19/2021 at 12:03 p.m. with S6 LPN, revealed that she worked the 11:00 p.m. to 7:00 a.m. shift on Hall a on the night of 09/11/2021. She stated that she was aware that resident #4 had confusion and was on a secure unit at the previous facility. However, there were no beds available on the secure unit at this nursing facility at that time. She also stated that resident #4 was not on any increased supervision. A telephone interview on 01/21/2021 at 9:58 a.m. with S1 Administrator, confirmed that the capacity of the secure unit was 12 residents. She further confirmed that on the dates of 08/31/2020 through 09/11/2020 the secure unit had no vacant beds. A telephone interview on 01/21/2021 at 10:22 a.m. with S1 Administrator, revealed that the above abuse policy was the only abuse policy that the facility had, and S1 Administrator informed the surveyor that the policy also applied to resident to resident abuse although resident to resident abuse was not addressed in the policy.

Based on record review and interview, the facility failed to ensure a resident received treatment and care of abdominal wounds in accordance with professional standards of practice for 1 (#2) of 4 residents identified with wounds (#2, #3, #4 and #5), in a total sample of 5 residents (#1, #2, #3, #4 and #5). This deficient practice resulted in actual harm for resident #2 who had [DIAGNOSES REDACTED]. The bilateral abdominal nodules ulcerated into open wounds on 06/03/2020. The physician was notified; however, wound care orders were never obtained. From 06/03/2020 to 06/23/2020, wound care was performed daily to the areas without orders from the physician. The abdominal wounds were not assessed weekly after 06/03/2020 as per policy and procedure. The resident's open wounds worsened, and the resident was sent to a hospital on [DATE] with a large open abdominal wound approximately 4 cm x 6 cm, malodorous discharge with black surrounding tissue. The abdominal wound was surgically debrided on 6/26/2020. Findings: Review of the Weekly Wound Documentation Policy and Procedure revealed weekly wound documentation should be completed immediately upon identification of a skin issue. The documentation shall be completed using Wound/Skin Management Documentation Record for non-electronic documentation or the Wound Assessment Manager (WAM) for electronic documentation. Documentation should indicate the type of skin issue, the wound location, answer all the questions as applicable on the form, the form should be completed at least weekly (no longer than 7 days) and as appropriate until healed and once the wound has healed, indicate resolved. Review of resident #2's medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 5/2/2020 the resident returned to the facility with new [DIAGNOSES REDACTED]. Further review of the resident's record revealed the resident was admitted to the hosptial on 6/23/2020 and was currently in the hospital. Review of the MDS assessment dated [DATE] revealed the resident was assessed to have a BIMS of 15. The MDS also revealed the resident required extensive assistance of one person with bed mobility, transfers, walking in room, dressing, toileting and personal hygiene. She was also assessed to be severely visually impaired. Review of the Resident's Care Plan revealed an update on 06/03/2020 that addressed the resident's Skin was at risk for Impairment [MEDICAL CONDITION] (nodules) to the left lower and right lower abdomen. However, the care plan was not updated to include interventions/treatments for the open wounds to the bilateral abdominal areas. Review of the Wound Assessment Report dated 6/3/2020 and documented by S3 RN/Tx Nurse revealed the following: a new wound to the left lower quadrant was identified. The cause of the wound was unknown, the wound had serous, scant drainage, the wound bed was 25% slough and 75% eschar and measured 5 cm X 5 cm X .10 cm. Review of the narrative for the above dated report revealed the [DIAGNOSES REDACTED] nodule to the left side of the abdomen was now open and the lesion measured 5 cm X 5 cm X 0.1 cm with 75% eschar and 25% slough. The eschar was moist and gray in color with an odor noted. The hand size nodule remained tender and dark in color. The Physician and RP were notified; however, there were no physician orders for treatment of [REDACTED]. Review of the Wound Assessment Report dated 6/3/2020 revealed the following: a new wound to the right lower quadrant was identified. The cause of the wound was unknown, the wound had serous, scant drainage, the wound bed was 100% eschar and measured 5 cm X 4 cm X .10 cm. Review of the narrative for the above dated report revealed the [DIAGNOSES REDACTED] nodule to the right side of the abdomen was now open and the lesion measured 5 cm X 4 cm X 0.1 cm with 100% eschar. The eschar was moist and gray in color with an odor noted. The hand size nodule remained tender and dark in color. The Physician and RP were notified; however, there were no physician orders for treatment of [REDACTED]. Review of the June, 2020 eTARs revealed, a treatment to monitor nodules to bilateral sides of abdominal fold every day until resolved with a start date of 3/24/2020. There was no documentation on the eTARs regarding the change in the abdominal wound status from nodules to open wounds after they were identified on 06/03/2020. Further review of the eTARS from 6/3/2020 to 6/22/2020 revealed staff initials that the abdominal nodules were monitored. Interview with S3 RN/Tx Nurse on 6/30/2020 at 2:00 p.m. revealed on 6/3/2020 she was informed that the nodules to the resident's right and left lower abdominal quadrants were open wounds. She stated she assessed the wounds, cleaned the wounds with NS and put a border gauze over the wounds at that time. She stated she notified the resident's primary physician of her findings on 6/3/2020. S3 RN Tx Nurse also stated that the physician said he needed to consult with [MEDICAL TREATMENT] in order to develop a treatment plan. S3 Tx Nurse stated she went on sick leave on 6/9/2020 to 6/25/2020, and did not follow-up and consult with the physician regarding wound care orders, or notify the family of the resident's abdominal wounds status on 06/3/2020, and prior to 6/9/2020. Interview with S4 RN on 7/6/2020 at 9:28 a.m. revealed she was assigned to provide treatments to resident #2 on 6/13/2020. She stated the right abdominal wound was draining a moderate amount of drainage that had a foul odor, the tissue to the wound bed was grayish in color, and she packed the wound with 2-3 gauze 4x4s and treated the wound with Dakins' solution. She revealed she had not measured the right abdominal wound. Further interview with S4 RN on the above date and time, revealed the left lesion was approximately 2 cm X 2 cm and did not require packing. She stated she treated the left abdominal wound with Dakins solution as well. S4 RN confirmed she had not called the physician to obtain orders to treat the wounds with Dakins solution, but instead contacted the S3 Tx Nurse RN (who was on sick leave) and they both decided to treat the abdominal wounds with Dakins solution. S4 RN confirmed she had not contacted the physician to inform him that the bilateral abdominal wounds drainage had a foul odor and the wound required packing. Interview with S2 RN/DON on 07/06/2020 at 9:30 a.m. revealed she performed wound care to the resident's abdominal wounds by cleaning the wounds with NS and covering with 4 x 4 gauze on 6/14, 6/17, 6/18, 6/21 and 6/22/2020. She confirmed there were no orders for the treatment of [REDACTED]. S2 RN/DON was unable to describe the wounds, other than to state it was grayish in color. S2 RN/DON confirmed the last time a Wound Assessment was documented was on 6/3/2020. She confirmed there should have been weekly wound assessments completed and there were not. She also confirmed there were no physician treatment orders obtained for the abdominal wounds that were identified on 6/3/2020. S2 RN/DON confirmed there was no follow-up with the physician for wound treatment orders after 6/3/2020, but there should have been. Further review of the June, 2020 eTARS revealed from 06/04/2020 to 06/12/2020, 6/15/2020, 6/16/2020, 6/19/2020 and 6/20/2020, the eTARS had been initialed that the abdominal nodules were monitored. However, according to the S3 RN's treatment notes dated 06/03/2020, and interview of S3 RN Treatment nurse on 06/30/2020 at 2:00 p.m., the abdominal nodules had ulcerated into open wounds. There was no documentation in the resident's medical record that revealed the opened abdominal wounds were assessed on the above dates, or that treatments had been provided to the bilateral abdominal open wounds. S2 RN/DON revealed in an interview on 07/06/2020 at 9:30 a.m. that she had delegated the wound treatments to staff as much as possible, and they were doing the best they could. S2 RN/DON confirmed there was no documentation of assessments or treatments to the open wounds after 06/03/3030 to the time the resident was admitted to the hospital on [DATE]. The surveyor was unsuccessful in attempts to interview staff that initialed the eTAR on the above dates. Review of the hospital H&P dated 6/23/2020 revealed the resident was admitted with [DIAGNOSES REDACTED]. Treatment plan included to start on [MEDICATION NAME] and [MEDICATION NAME], CT of abdomen/pelvis with PO and IV contrast, Consult wound care and Surgery Consult. Interview with the resident's RP on 6/30/2020 at 10:00 a.m. revealed the resident had a large necrotic wound to the right side of her abdomen that was open and draining foul smelling drainage and required debridement on 6/24/2020.