Every finding on record at Westwood Health and Rehab, Inc

Number of residents sampled: Number of residents cited: Based on observation, interview, and facility record review, the facility failed to ensure dietary staff consistently contained their hair under a hair net during active meal preparation for two of two meal services observed in the facility kitchen. The findings include:During an observation of the lunch meal preparation in the facility kitchen on 08/19/2026 at 11:23 AM, Dietary Aide #1 was observed working in the dish area and replacing clean dishes around the food preparation areas of kitchen during active meal preparation with their hairnet pushed up on the back of their head, resulting in approximately eight inches of hair hanging down uncovered. During an interview on 08/19/2026 at 11:23 AM, Dietary Aide #1 stated that all their hair should be fully contained in the hairnet and confirmed they had received training regarding the requirement to keep all hair up and contained. During an observation of the lunch meal preparation on 08/19/2026 at 1:12 PM, [NAME] #2 was seen wrapping cake portions with approximately six inches of hair sticking out on the left side of their hair net. When asked how their hair was expected to be contained, [NAME] #2 responded, In the hair net, I'm sorry, I need to fix that. During an interview on 08/19/2026 at 11:25, the Dietary Manager confirmed that all hair should be contained in the hairnet and there should not be any hair uncontained by the hairnet. During an interview on 08/19/2026 at 11:25, the Registered Dietician confirmed that anyone in the kitchen should have their hair contained in their hair net while in the kitchen area, and that no hair should be sticking out or hanging down. During an interview on 08/20/2026 at 12:35 PM the Administrator confirmed it was their expectation that all hair be contained in a hairnet when staff were in the kitchen. The Administrator confirmed that [NAME] #2 and Dietary Aide #1 had been trained during orientation regarding keeping their hair covered while in the kitchen. A review of a signed and dated (07/08/26) facility job description for Dietary Aide associated with Dietary Aide #1 was conducted. Under the Duties and Responsibilities a bullet point under Safety and Sanitation revealed the expectation that food was prepared in accordance with sanitary regulations as well as facility policies and procedures. It further noted that dietary staff were to always follow all safety and infection control regulations. The document was signed with Dietary Aide #1 name and dated 07/08/26. A review of a signed and dated (07/01/26) facility job description for Dietary Aide associated with [NAME] #2 was conducted. Under the Duties and Responsibilities a bullet point under Safety and Sanitation revealed the expectation that food was prepared in accordance with sanitary regulations as well as facility policies and procedures. It further noted that dietary staff were to always follow all safety and infection control regulations. The document was signed with [NAME] #2 name and dated 07/01/26 A review of the facilities policy titled Dress Code and Personal Hygiene (Revised: May 2019) revealed: Section 2. E.: Employees were expected to keep hair arranged so it does not interfere with their work assignments or direct resident contact. Subsection (1): Depending on the duty assignment or work area, an employee with long hair may require a hair net.

Number of residents sampled: Number of residents cited: Based on interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse were reported to the Administrator and the State Survey Agency (SSA) within the required timeframe for one (Resident #41) of three residents reviewed for abuse. Specifically, the facility received a report of alleged verbal abuse involving Resident #41 on 05/10/2026 (reported by Certified Nurses Aid (CNA) # 5 to Licensed Practical Nurse (LPN #7) on 05/11/2026, one day after the incident, but did not report the allegation to the SA until 05/14/2026. The findings included: Review of an OLTC (Office of Long-Term Care) Incident and Accident Report (I&A) revealed a submitted date of 05/14/2026 at 3:26 PM. The date and time of the incident being reported was 05/10/2026 at 6:45PM, with a discovery date of 05/11/2026 at 4:00PM. The summary of the incident revealed Certified Nursing Aid (CNA) # 4 was seen screaming at resident, identified as Resident #41, in the dining room. Another staff member, CNA #5 reported hearing Resident #41 ask for watermelon and CNA #4 responded by screaming, the resident has just told us they didn't want any and why is are they asking for it now. CNA # 5 stated they got busy and it slipped their mind to report what they thought was verbal abuse at the time but reported the incident after the shift ended to the Assistant Director of Nursing (ADON). Review of an admission Document revealed Resident #41 was admitted on [DATE] with diagnoses that included symptomatic epilepsy, dementia, chronic pulmonary disease, and hypotension. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/17/2026, revealed Resident #41 had a Brief Interview for Mental Status score of 10, which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #41 was independent for all mobility and required supervision for tub/shower transfers. Review of a Care Plan revealed a focus, initiated 12/15/2025, that included Resident #41 exhibiting behavioral indicators of yelling/screaming for assistance, becoming obsessed with various subjects, and refusing meal trays. Resident #41 was described as extremely difficult to redirect and at times refusing care, meals, or assistance until they have calmed down. Interventions, if the resident refused and/or became agitated, were to try a different approach such as have another staff member attempt care, postpone care and try again later, intervene as needed to protect the rights and safety of others, approach in a calm manner, divert attention, and removed from situations as needed. During an interview on 08/19/2026 at 1:23 PM, CNA #5 stated Resident #41 refused the sides at dinner, then decided that they wanted the watermelon. CNA #4 was screaming at the resident because Resident #41 wanted the watermelon. I reported the incident the next day, I don't know why I did not report it. I should have reported this immediately. During an interview on 08/20/2026 at 11:30 AM, the Director of Nursing (DON) reported being informed of the incident on 05/11/2026, at which time CNA # 4 was suspended immediately. The DON reported being unaware of why CNA # 5 did not report the incident right away, and stated the facility provides in-services every month on reporting abuse. [CNA #4] did finish their shift on 05/10/26 because we did not know about the allegation until the next day. If I would have been contacted I would of came to the facility immediately to protect the resident. During an interview on 08/20/2026 at 1:01 PM, Licensed Practical Nurse (LPN) #7 stated CNA #5 came to them the afternoon of 05/11/206 and explained that she needed to report CNA # 4 for verbally abuse towards Resident #41. CNA #5 stated the incident happened at dinner the night previous (05/10/2026), I believe it was between 5 pm and 6 pm. I immediately called [CNA # 4] and suspended her. I started the reporting procedure with the Office of Long-Term Care, but I neglected to hit the submit button. This was my first reportable that I had to submit. I was previously trained on how to submit incident to the Office of Long-Term Care when the system was initially rolled out. During an interview on 8/20/2026 at 3:48 PM, the Advanced Practice Nurse (APN) reported that the facility contacts her with allegations of abuse and was involved with interventions put into place after an event. The APN reported that allegations of abuse toward residents should be reported immediately, and if they weren't, it could put other residents at risk for harm if the alleged perpetrator wasn't removed from the facility. The alleged perpetrator should be removed from the facility as soon as possible. During an interview on 08/20/206 at 12:20 PM, the Administrator stated the incident of verbal abuse perpetrated by CNA #4 happened on 05/10/206 during dinner time around 5:30 pm. We started our protection of the residents on 05/11/2026 after the verbal abuse was reported by [CNA #5]. [CNA #4] finished her shift on 05/10/2026 and clocked out at 11:00 PM. [CNA #4] was suspended the next day and later terminated for confirmed verbal abuse. Due to the facility policy the termination date is the last day the CNA worked which was 05/10/2026. [LPN #7] did not submit the report appropriately to the Office of Long-Term Care, they failed to hit the submit button. I finished the submission of the incident on 05/14/2026. Review of the termination letter for CNA #4, dated 05/22/2026, revealed the termination was due to violation of policies and procedures for a substantiated report of verbal abuse, the last day of employment was documented as 05/10/2026. Review of an in-service titled Abuse Prevention, dated 04/15/2026, revealed the policy statement included that residents have the right to be free from abuse, neglect, and misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. CNA #4 and CNA #5 signed this in-service. Review of an in-service provided solely to CNA #4, dated 04/29/2026, revealed it was intended to ensure all communication with residents with residents is respectful and discussed verbal abuse. CNA #4 signed this in-service. Review of a facility policy titled Abuse Investigation and Reporting (Revised July 2017) revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies as defined by current regulations and thoroughly investigated by facility management. Review of CNA #4's associated termination and facility provided documentation indicating all staff were trained/in-serviced on abuse following this incident and before the survey team entered the building, as well as LPN #7 being trained on properly submitting an allegation of abuse to the state agency, this will be cited as past non-compliance.

Number of residents sampled: Number of residents cited: Based on interview, record review, and facility policy review, the facility failed to label medications designed for multiple administration with the resident's identity for whom it was prescribed for one (Resident #46) of three residents reviewed. The findings include: During a concurrent interview and observation of a medication cart with Licensed Practical Nurse (LPN) #8 on 08/19/2026 at 2:02 pm, a bottle of over-the-counter eye drops was found that was not labeled with a resident's name. LPN # 8 stated the prior bottle had a label on it with the resident's name; I know this belongs to [Resident #46] because they are the only one that uses it. Review of the admission Record revealed Resident #46 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with retinopathy without macular edema, hypertensive heart and chronic kidney disease with heart failure, and chronic kidney disease. Review of the quarterly Minimum Data Set with an Assessment Reference Date of 07/02/2026 revealed Resident #46 had received a Brief Interview for Mental status of a 15, indicating intact cognition. Review of the Medication Administration Record (MAR) revealed Resident #46 was being administered over the counter eye drops lubricant: Instill 1 application in both eyes every morning and at bedtime related to Dry Eye Syndrome of unspecified lacrimal Gland.Order date 10/03/2025. The medication was documented as having been administered twice a day from August 1st to August 19th. During an interview on 08/20/2026 at 9:20 AM, LPN #8 stated the over-the-counter medications are stocked in the medication room, then taken to the medication carts as needed. LPN #8 reported that the nurse stocking the cart should first apply a label with the resident's name. If there is no label, we should figure out whose medication it is and label it. During an interview on 08/20/2026 at 11:30 AM, the Director of Nursing (DON) stated the nurses stock the over-the-counter medications in the medication cart. The nurse that puts the medication on the cart is responsible for labeling. If something is not labeled the nurse can label it, or staff can report it to [the DON]. If it is not labeled the medication can be given to the wrong person, the wrong route, or the wrong time. During an interview on 08/20/2026 at 12:20 PM, the Administrator stated medications on the medication cart were expected to be labeled with the resident's name to whom it was prescribed. Review of a facility policy titled Administering Medications (2001 Med-Pass Inc) revealed a policy statement that instructed medications to be administered in a safe and timely manner and as prescribed. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Number of residents sampled: Number of residents cited: Based on interviews, record review, and facility policy review, the facility failed to ensure one (Resident #41) of three residents were free from verbal abuse. The findings included: Review of Resident #41's admission Record revealed the facility admitted Resident #41 with diagnoses which included symptomatic epilepsy, dementia, chronic pulmonary disease and hypotension. Review of Resident #41's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/17/2026, revealed the resident had a Brief Interview for Mental Status score of 10 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #41 was independent for all mobility and required supervision for tub/shower transfers Review of Resident #41's Care Plan initiated on 12/15/2025, revealed the resident exhibits behavioral indicators of yelling/screaming for assistance, obsessing about how many briefs they have access to, and other subjects they get fixated on or obsessed with. During these events Resident is extremely difficult to redirect and will at times refuse care, meals or assistance until they have calmed down. Interventions if the resident refuses and/or becomes agitated try a different approach such as have another staff member attempt care, postpone care and try again later. Intervene as needed to protect the rights and safety of others. Approach in a calm manner, divert attention and removed from situation as needed. Resident refuses meal trays will ask for a PB&J and juice in their room, staff will take items to resident and then resident will come to dining room after mealtimes and demand a lunch tray, stating staff did not bring them lunch, staff will offer tray to resident and resident states they do not want it. Review of Resident #41's Office of Long-Term Care (OLTC) Reportable submitted on 05/14/206 at 3:26 PM, with the date of the incident 05/10/2026 at 6:45 PM, and a discovery date of 05/11/2026 at 4:00 PM, revealed Certified Nursing Assistant (CNA) #5 witnessed CNA #4 screaming at [Resident 41] in the dining room when Resident #41 asked for watermelon. The reportable revealed CNA #4 screamed resident had just told us [they] didn't want any and why are [they] asking for it now? CNA #5 reported they got busy and it slipped their mind to report what they thought was verbal abuse at the time. During an interview on 08/19/2026 at 1:23 PM, CNA #5 stated that Resident #41 refused the sides at dinner, then decided that they wanted watermelon. CNA #5 stated that CNA #4 screamed at Resident #41 because Resident #41 wanted the watermelon after they refused it. CNA #5 stated, I reported the incident the next day, I don't know why I did not report this immediately. During an interview on 08/20/026 at 11:30 AM, the Director of Nursing (DON) stated she was told of this incident on 05/11/2026 and CNA #4 was suspended immediately. The DON stated she did not know why CNA #5 did not report the incident right away. The DON stated the facility completed in-services every month on reporting abuse. The DON stated that CNA #4 did finish their shift on 05/10/26 because we did not know about the allegation until the next day. The DON stated, If I would have been contacted I would have come to the facility immediately to protect the resident. During an interview on 08/20/206 at 1:01 PM, Licensed Practical Nurse (LPN) #7 stated that CNA #5 notified her on the afternoon of 05/11/2026 that she needed to report CNA #4 for verbal abuse towards Resident #41 that occurred at dinner on 05/10/2026 between 5 PM and 6 PM. LPN #7 stated she immediately called CNA #4 and suspended her and started the reporting procedure with the Office of Long-Term Care [OLTC] but neglected to hit the submit button. LPN #7 stated, this was my first reportable that I had to submit. I was previously trained on how to submit an incident to the OLTC when the system was initially rolled out. During an interview on 08/20/2026 at 3:48 PM, the Advanced Practice Nurse (APN) reported that the facility contacted her with allegations of abuse, and she was involved with interventions put into place after an event. The APN stated that allegations of abuse toward residents should be reported immediately because not reporting immediately could put other residents at risk of harm if the alleged perpetrator was not removed from the facility as soon as possible. During an interview on 08/20/2026 at 12:20 PM, the Administrator stated the verbal abuse by CNA #4 happened on 05/10/2026 during dinner time around 5:30 PM. The Administrator stated, I am not sure when CNA #5 reported the incident to LPN #7, I was out of the building. We started our protection of the residents on 05/11/2026 after the verbal abuse was reported by CNA #5. The Administrator stated CNA #4 finished her shift on 05/10/2026 and clocked out at 11:00 PM. CNA #4 was suspended the next day and later terminated for confirmed verbal abuse. The Administrator stated that due to the facility policy the termination date was the last day CNA #4 worked, which was 05/10/2026. The Administrator stated LPN #7 did not submit the report appropriately to the OLTC by failing to hit the submit button.This surveyor attempted an interview with Resident #41, but the resident was not interview able. This surveyor attempted to contact CNA #4 for an interview but did not receive a response. Review of a Termination Letter dated 05/22/2026, revealed CNA #4 was terminated due to violation of policies and procedures for a substantiated report of verbal abuse, the last day of employment was 05/10/2026. Review of the facility Time Punches for CNA # 4 revealed her last day of employment was on 05/10/2026. Review of a 60-Day Performance Improvement Action Plan dated 02/18/2026, revealed concerns regarding CNA #4 brought forth by her coworkers regarding her ability to work with patients, fulfillment of CNA responsibilities, resident care satisfaction, and timely response to call lights. Review of an in-service dated 04/15/2026 titled Abuse Prevention, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. CNA #4 signed this in-service which indicated she was present for the training. Review of an in-service dated 04/29/206 indicated the subject as ensure all communication with residents is respectful, discussed verbal abuse- how to speak to residents. CNA #4 signed this in-service which indicated she was present for the training. Review of an in-service dated 05/14/2026, with the topic of If you see, hear, or suspect possible abuse report it immediately even if you are not certain abuse has occurred. Seventy-six employees signed the in-service which indicated they were present for the training. Review of a facility policy titled Abuse Prevention revised in April 2021, revealed the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following Objectives: -Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone. -Ensure adequate staffing and oversight/support to prevent burnout, stressful working situation and turnover rate. -Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Review of CNA #4's associated termination and facility provided documentation indicating all staff were trained/in-serviced on abuse following this incident and before the survey team entered the building, this will be cited as past non-compliance.

Based on record review and interview, it was determined that the facility failed to ensure that a resident's transfer or discharge was reported to the ombudsman for two (Resident #1 and Resident #3) of two residents reviewed. The findings include: Resident #1 Review of Resident #1's Medical Diagnosis revealed Resident #1 had diagnoses which included muscle wasting and atrophy, acute respiratory failure with hypoxia, moderate dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident #1's admission Record revealed the facility admitted Resident #1 on 03/27/2025, and indicated the resident was discharged to a local hospital on [DATE]. Review of Resident #1's 5-day Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 03/31/2025 revealed that the Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of a facility document titled Emergency Transfers dated February 2025, March 2025, April 2025, and May 2025 revealed a list of resident discharges that were sent to the Ombudsman. Resident #1 was not listed. During an interview on 05/28/2026 at 11:25 AM, the Administrator stated the Business Office Manager was responsible for preparing the Discharge/Transfer list to submit to the Ombudsman. The Administrator also confirmed that even though Resident #1 was expected to return when discharged , Resident #1 should have been on the April 2025 list. The Administrator stated, except for residents discharged to home, all transfers were reported to the Ombudsman. Resident # 3 Review of Resident #3's Medical Diagnosis revealed Resident #3 had diagnoses which included acute respiratory failure with hypoxia, morbid obesity due to excess calories, type 2 diabetes mellitus, anxiety disorder, and anoxic brain damage. Review of Resident #3's admission Record revealed the facility admitted Resident #3 on 01/31/2025, and indicated the resident was discharged to an area hospital on [DATE]. Review of Resident #3's 5-Day MDS with an ARD of 02/01/2025 revealed that Resident #3 had a BIMS score of 7, which indicated severe cognitive impairment. Review of a facility document titled Emergency Transfers dated February 2025, March 2025, April 2025, and May 2025, revealed a list of resident discharges that were sent to the Ombudsman. Resident #3 was not listed. During an interview on 05/28/2026 at 11:25 AM, the Administrator confirmed that even though the resident was not expected to return when discharged to the emergency department, Resident #3 should have been on the February 2025 list. The Administrator stated that except for residents who discharged home, all transfers were reported to the Ombudsman. The Administrator stated all facility-to-facility transfers should have been noted in the report sent to the Ombudsman. Review of a facility policy titled, Resident Rights revised in December 2016, revealed that the resident has the right to communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.). Both Resident #1 and Resident #3 were dependent on the facility for communication due to cognitive deficits.

Based on observation, record review, and interview, the facility failed to ensure the comprehensive person-centered care plan included an objective for monitoring a resident with wandering behaviors who was at risk for resident-to-resident altercations for 1 (Resident #44) of 3 residents reviewed for abuse. The lack of effective interventions resulted in Resident #44 having resident-to-resident abuse that occurred on 04/11/2024, 04/19/2024, 07/10/2024, 08/06/2024, 08/12/2024, 12/07/2024, 12/20/2024, 12/25/2024, and 01/09/2025. All of the incidents took place on the locked unit and Resident #44 had been kicked, hit in the face, hit in an unknown area, pushed, punched in the hand, struck in the hand, punched in the stomach, pushed down numerous times, and hit in the head. The last incident resulted in a broken hip. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.21 (Comprehensive Resident Centered Care Plan) at a scope and severity of J. The IJ began on 04/11/2024, when Resident #44 was first pushed down by another resident while residing on the secure unit. The Administrator, Director of Nursing, Nurse Consultant, and Director of Operations were notified of the IJ on 01/29/2025 at 10:28 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 01/29/2025 at 3:54 PM. The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented. The findings are: A review of a policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated the Interdisciplinary Team (IDT) along with the resident and/or resident representative develops and implements the comprehensive care plan to include measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs. Further review indicated, Care plan interventions are chosen after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making. A review of OLTC Incident and Accident Report (I&A) indicated on 01/08/2025, Resident #9 pushed Resident #44 into a wall. Resident #44 grabbed at their hip as if the resident was in pain. Both residents resided in the Alzheimer ' s unit. Resident #44 had a hip fracture as a result of this incident. The findings of the facility ' s investigation indicated, The facility can not substantiate this allegation of abuse as both residents involved are mentally deemed to have no capacity and there was no intentional means of abuse. A review of the Admission Record, indicated the facility admitted Resident #44 with diagnoses that included dementia with agitation, disorientation, insomnia, restlessness and agitation. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #44 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated moderately impaired cognitive skills for daily decision making. Resident #44 showed physical behavior symptoms directed towards others as well as wandering. Resident #44 was able to ambulate independently. A review of Resident #44 ' s care plan initiated on 03/08/2024, revealed the resident needed a secured/special care neighborhood due to dementia. The following was listed: - 04/11/2024: Physical aggression received - 04/19/2024: Physical aggression received - 07/10/2024: Physical aggression received - 08/06/2024: Physical aggression received - 08/12/2024: Physical aggression received - 08/21/2024: Physical aggression initiated - 12/07/2024: Physical aggression received - 12/20/2024: Physical aggression received - 12/25/2024: Physical aggression received - 01/09/2025: Physical aggression received The facility developed interventions that included to encourage the resident to fold laundry or take care of a baby doll when noted wandering in other resident ' s rooms, numerous interventions in place for other resident, and the resident was to be placed on 1 on 1 observation on 08/21/2024. Further review of the care plan indicated Resident #44 lacked capacity to understand and make decisions. The resident also exhibited behaviors of wandering into other residents ' rooms. A review of facility incident and accident reports for the last twelve months for Resident #44 indicated on 04/11/2024, Resident #44 was pushed down to the ground by another resident. On 4/19/2024, Resident #44 was kicked by another resident. On 7/9/2024, Resident #44 was smacked in the face by another resident. On 08/06/2024, Resident #44 was pushed to the floor by another resident. On 08/12/2024, Resident #44 ' s left hand was stuck with a closed fist by another resident. On 08/21/2024, Resident #44 hit another resident. On 12/7/2024, Resident #44 was punched in the stomach. On 12/20/2024, Resident #44 was pushed by another resident, causing Resident #44 to fall. On 12/25/2024, Resident #44 was hit in the head by another resident. On 1/8/2025, Resident #44 was pushed to the floor by another resident and appeared to be in severe pain and was sent to the emergency room . A review of Resident #44 ' s hospital records indicated on 01/09/2025, the resident was admitted to the hospital related to a fall with left hip pain and was diagnosed with a left femur fracture and required surgery. During an interview on 01/28/2025 at 2:00 PM, Certified Nursing Assistant (CNA) 13 was in Resident #44 ' s room and stated the resident was not aggressive but at times, the resident takes things that belong to other residents, which agitates those residents resulting in pushing Resident #44. During an interview on 01/28/2025 at 2:16 PM, the Director of Nursing (DON) stated Resident #44 was sent to the hospital because the resident was touching another resident who had autism. The DON stated Resident #44 used to be a CNA and likes to pick up things and was trying to pick things up in the other resident ' s room. This resulted in the other resident pushing Resident #44, causing the resident to fall. The DON stated the other resident no longer resided in the facility. During an interview on 01/29/2025 at 8:20 AM, CNA #2 stated Resident #44 was not aggressive but did go into other resident ' s rooms. CNA #2 stated interventions for Resident #44 included redirecting or distracting the resident. CNA #2 stated she was aware of an altercation between another resident and Resident #44 and stated the other resident was eating a snack when Resident #44 entered the resident ' s room and tried to grab the snack. This resulted in the other resident pushing Resident #44 to the floor. CNA #2 stated residents on the secure unit are monitored by having at least one staff member on the hall in the middle. CNA #2 stated that during the altercation, both herself and CNA #1 were at the nurse ' s station, monitoring the cameras. CNA #1 was teaching CNA #2 how to chart in the medical record. CNA #2 stated she looked up at the camera and saw Resident #44 walk towards the other resident and CNA #2 got up and ran from the nurse ' s desk to get Resident #44. This would indicate Resident #44 was not one-on-one per the resident ' s care plan. During an interview on 01/29/2025 at 8:35 AM, CNA #1 stated Resident #44 was very grabby but did not have aggressive behaviors. CNA #1 stated staff would give Resident #44 towels to fold or give the resident something to do to keep the resident ' s mind busy. CNA #1 stated she was showing CNA #2 how to chart in the medical record at the nurse ' s station and CNA #2 took off running and that ' s when she looked up at the camera and saw Resident #44 head towards Resident #9. CNA #1 stated another CNA was supposed to be monitoring the hall but did not know where that CNA went. During an interview on 01/29/2025 at 11:23 AM, the Administrator stated there were interventions in place to safeguard Resident #44 but was unable to provide them to the surveyor. The Director of Nursing (DON) stated the facility placed a stop sign on another resident ' s door but was removed because the resident did not want it. The DON also stated that there were medication changes for Resident #44 to help with anxiety. The Administrator stated the facility did monthly in-services regarding behaviors but there was a new staff member completing those in-services and the Administrator could not locate the in-services. During an interview on 01/29/2025 at 2:00 PM, Licensed Practical Nurse (LPN) 12 stated Resident #44 goes into other resident ' s rooms and staff were to distract the resident. LPN #12 stated CNA #1 and CNA #2 being at the nurse ' s station during the incident between Resident #44 and another resident was not appropriate and they should be charting at the kiosk in the hallway. LPN #12 stated that Resident #44 was trying to get something from another resident and Resident #44 was pushed, making the resident fall and resulted in a broken hip. LPN #12 stated she was not made aware of resident-to-resident interactions except from verbal reports from other shifts and she does not review the resident ' s medical record unless there is an every-shift requirement to chart. LPN #12 stated the intervention of redirecting Resident #44 was not an appropriate intervention because the resident would just continue with the behavior. LPN #12 stated that an appropriate intervention would have been to remove one of the residents from the neighborhood. Removal Plan: 1. Resident #44 who received physical aggression placed on observation 1:1 on 01/29/2025 by facility staff. 2. Resident #9 who initiated physical aggression discharged from the facility 01/09/2025 3. DON/Designee will initiate an in-service on all staff currently in facility on handling residents with behaviors on 01/29/2025 and continue training staff as they clock in until all staff have been trained. 4. On 1/29/2025, the DON/Designee will initiate in-service related to following care plan interventions for direct care staff currently in facility. Direct care staff not present will be in-serviced prior to the start of their shift. Any newly hired direct care staff will also be in-serviced. 5. DON/Designee will review all care plans for residents residing in the Dementia care unit for appropriate interventions related to behaviors and update the care plans as needed on 1/29/2025. 6. Nurse Consultant/Designee will initiate in-service with the Minimum Data Set (MDS) coordinator and all nurse managers on reviewing and updating care plans and that interventions are appropriate and effective on 1/29/2025. Onsite Verification: The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 01/30/2025. Resident #9 was verified to have been discharged from the facility on 01/09/2025. Resident #44 had a staff member one on one with the resident as of 01/30/2025. The facility assessed all residents on the unit for signs and symptoms of physical aggression and body audits were completed. A total of 30 staff interviews were conducted with staff from all shifts to verify training had been completed for behavior interventions. The staff interviewed included certified nursing assistants, licensed practical nurses, registered nurses, Administrator, business office staff, laundry staff, kitchen staff, activity staff, housekeeping staff, physical therapy staff, and maintenance staff. The staff interviewed verified they had been trained in handling residents with behaviors and dementia. A review of the in-service sheets provided indicated 45 of 105 had been provided training. Those staff who were not physically present to receive the in-services were to be in-serviced prior to the start of their shift. A total of 6 staff interviews were conducted regarding care plans being updated. The staff interviewed included the DON, the MDS Nurse, the ADON, and three LPNs.

Based on observations, interviews, and record review, the facility failed to ensure a resident was free from resident-to-resident abuse for 1 (Resident #44) of 3 sampled residents reviewed for abuse. The lack of effective behavior monitoring resulted in Resident #44 having resident to resident abuse that occurred on 04/11/2024, 04/19/2024, 07/10/2024, 08/06/2024, 08/12/2024, 12/07/2024, 12/20/2024, 12/25/2024, and 01/09/2025. Of those incidents, Resident #9 was the physical aggressor for 3 instances. On 12/07/2024, Resident #9 hit Resident #44 in the stomach. On 12/20/24, Resident #9 pushed resident #44, resulting in the resident falling. On 01/08/2025, Resident #9 pushed Resident #44, resulting in the resident falling. Resident #44 was sent to the emergency room and was found to have a fractured hip. All of the other incidents were completed by other residents on the locked unit and Resident #44 had been kicked, hit in the face, hit in an unknown area, pushed, punched in the hand, struck in the hand, and hit in the head. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on 12/07/2024 at 10:59 PM, when Resident #44 was punched in the stomach by Resident #9. The Administrator, Director of Nursing, Nurse Consultant, and Director of Operations were notified of the IJ on 01/29/2025 at 10:28 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 01/29/2025 at 3:54 PM. The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented. The findings are: A review of the facility Abuse Prevention, revised 11/16/2017 revealed during abuse investigations, Allegations involving residents will require assessment and appropriate interventions to protect the victim and other residents. lnterventions may include temporary one-on-one supervision, transfer to another level of care or discharge to a family member/responsible party. A review of OLTC Incident and Accident Report (I&A) indicated on 01/08/2025, Resident #9 pushed Resident #44 into a wall. Resident #44 grabbed at their hip as if the resident was in pain. Both residents resided in the Alzheimer ' s unit. Resident #44 had a hip fracture as a result of this incident. The findings of the facility ' s investigation indicated, The facility can not substantiate this allegation of abuse as both residents involved are mentally deemed to have no capacity and there was no intentional means of abuse. A review of State Operations Manual Appendix PP, F600 indicates, Willful actions include, but are not limited to, the following: hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing, shoving .The action itself was deliberate or non-accidental, not that the individual intended to inflict injury or harm . Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. A review of the Admission Record, indicated the facility admitted Resident #44 with diagnoses that included dementia with agitation, disorientation, insomnia, restlessness and agitation. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/2024, revealed Resident #44 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated moderately impaired cognitive skills for daily decision making. Resident #44 showed physical behavior symptoms directed towards others as well as wandering. Resident #44 was able to ambulate independently. A review of Resident #44 ' s care plan initiated on 03/08/2024, revealed the resident needed a secured/special care neighborhood due to dementia. The following was listed: - 04/11/2024: Physical aggression received - 04/19/2024: Physical aggression received - 07/10/2024: Physical aggression received - 08/06/2024: Physical aggression received - 08/12/2024: Physical aggression received - 08/21/2024: Physical aggression initiated - 12/07/2024: Physical aggression received - 12/20/2024: Physical aggression received - 12/25/2024: Physical aggression received - 01/09/2025: Physical aggression received The facility developed interventions that included to encourage the resident to fold laundry or take care of a baby doll when noted wandering in other resident ' s rooms, numerous interventions in place for other resident, and the resident was to be placed on 1 on 1 observation on 08/21/2024. Further review of the care plan indicated Resident #44 lacked capacity to understand and make decisions. The resident also exhibited behaviors of wandering into other residents ' rooms. A review of the Admission Record, indicated the facility admitted Resident #9 with diagnoses that included dementia, autistic disorder, psychosis, cognitive communication deficit, and schizophrenia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment. Resident #9 was not documented as having physical or verbal behavior symptoms directed toward others. Resident #9 had no impairments to upper or lower extremities and was able to independently ambulate. A review of Resident #9 ' s Care Plan initiated on 10/26/2024, revealed the resident needed a secured/special care neighborhood. Interventions included: administering and monitoring the effectiveness and side effects of medications as ordered, medication review with antidepressant increased, kept one-on-one observation until discharge, and to support resident ' s needs to spend time in room in self-direct pursuits. A review of facility incident and accident reports for the last twelve months for Resident #9 indicated on 12/7/2024, Resident #9 punched another resident in the stomach. On 12/20/2024, another resident wandered into Resident #9 ' s room, resulting in Resident #9 pushing the other resident, making the resident fall to the floor. On 1/8/2025, Resident #9 pushed another resident. A review of facility incident and accident reports for the last twelve months for Resident #44 indicated on 04/11/2024, Resident #44 was pushed down to the ground by another resident. On 4/19/2024, Resident #44 was kicked by another resident. On 7/9/2024, Resident #44 was smacked in the face by another resident. On 08/06/2024, Resident #44 was pushed to the floor by another resident. On 08/12/2024, Resident #44 ' s left hand was stuck with a closed fist by another resident. On 08/21/2024, Resident #44 hit another resident. On 12/7/2024, Resident #44 was punched in the stomach. On 12/20/2024, Resident #44 was pushed by another resident, causing Resident #44 to fall. On 12/25/2024, Resident #44 was hit in the head by another resident. On 1/8/2025, Resident #44 was pushed to the floor by another resident and appeared to be in severe pain and was sent to the emergency room . A review of Resident #44 ' s hospital records indicated on 01/09/2025, the resident was admitted to the hospital related to a fall with left hip pain and was diagnosed with a left femur fracture and required surgery. During an interview on 01/28/2025 at 2:00 PM, Certified Nursing Assistant (CNA) #13 was in Resident #44 ' s room and stated the resident was not aggressive but at times, the resident takes things that belong to other residents, which agitates those residents resulting in pushing Resident #44. CNA #13 stated Resident #44 did fall and break their hip and did not walk anymore and uses a wheelchair for mobility. During an interview on 01/28/2025 at 2:16 PM, the Director of Nursing (DON) stated Resident #44 was sent to the hospital because the resident was touching another resident who had autism. The DON stated Resident #44 used to be a CNA and likes to pick up things and was trying to pick things up in the other resident ' s room. This resulted in the other resident pushing Resident #44, causing the resident to fall. The DON stated the other resident no longer resided in the facility. During an interview on 01/29/2025 at 8:20 AM, CNA #2 stated Resident #44 was not aggressive but did go into other resident ' s rooms. CNA #2 stated that Resident #9 got aggressive easily and the resident would make fists and grumble, even if no one was bothering the resident. CNA #2 stated that staff remove other residents out of Resident #9 ' s way when the resident was upset or overwhelmed. CNA #2 stated she was aware of an altercation between Resident #9 and Resident #44 and stated Resident #9 was eating a snack when Resident #44 entered the resident ' s room and tried to grab the snack. This resulted in Resident #9 pushing Resident #44 to the floor. CNA #2 stated residents on the secure unit are monitored by having at least one staff member on the hall in the middle. CNA #2 stated that during the altercation, both herself and CNA #1 were at the nurse ' s station, monitoring the cameras. CNA #1 was teaching CNA #2 how to chart in the medical record. CNA #2 stated she looked up at the camera and saw Resident #44 walk towards Resident #9 and CNA #2 got up and ran from the nurse ' s desk to get Resident #44. During an interview on 01/29/2025 at 8:35 AM, CNA #1 stated when Resident #9 charges at you, staff were told to get out of the way and when Resident #9 was frustrated, the resident would hit the air or themselves. CNA #1 stated staff were advised to get the residents away from Resident #9. CNA #1 stated Resident #44 was very grabby but did not have aggressive behaviors. CNA #1 stated that Resident #9 had behaviors, and the facility had to move Resident #9 ' s roommate to a different room. CNA #1 stated that Resident #9 was autistic with mixed personalities and would freak out. CNA #1 stated she was showing CNA #2 how to chart in the medical record at the nurse ' s station and CNA #2 took off running and that ' s when she looked up at the camera and saw Resident #44 head towards Resident #9. CNA #1 stated another CNA was supposed to be monitoring the hall but did not know where that CNA went. During an interview on 01/29/2025 at 11:23 AM, the Administrator stated there were interventions in place to safeguard Resident #44 but was unable to provide them to the surveyor. The Director of Nursing (DON) stated the facility placed a stop sign on Resident #9 ' s door but was removed because Resident #9 did not want it. The DON also stated that there were medication changes for Resident #44 to help with anxiety. The Administrator stated the facility did monthly in-services regarding behaviors but there was a new staff member completing those in-services and the Administrator could not locate the in-services. During an interview on 01/29/2025 at 2:00 PM, Licensed Practical Nurse (LPN) #12 stated Resident #44 goes into other resident ' s rooms and staff were to distract the resident. LPN #12 stated CNA #1 and CNA #2 being at the nurse ' s station during the incident between Resident #44 and Resident #9 was not appropriate and they should be charting at the kiosk in the hallway. LPN #12 stated that Resident #44 was trying to get something from Resident #9 and Resident #44 was pushed, making the resident fall and resulted in a broken hip. LPN #12 stated she was not made aware of resident-to-resident interactions except from verbal reports from other shifts and she does not review the resident ' s medical record unless there is an every-shift requirement to chart. Removal Plan: 1. Resident #44 who received physical aggression placed 1:1 observation on 01/29/2025 by facility staff. 2. Resident #9 who initiated physical aggression discharged facility 01/09/2025. 3. Licensed nurse will assess all residents currently on secured unit for signs and symptoms of physical aggression as well as assess for signs of trauma and physical abuse by skin audits on 01/29/2025. 4. DON/Designee will initiate an in-service on all staff currently in facility on handling residents with behaviors as well as Dementia training on 1/29/2025. Staff not present will be in-serviced prior to the start of their shift. Onsite Verification: The IJ was removed on 01/31/2025 after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 01/30/2025. Resident #9 was verified to have been discharged from the facility on 01/09/2025. Resident #44 had a staff member one on one with the resident as of 01/30/2025. The facility assessed all residents on the unit for signs and symptoms of physical aggression and body audits were completed. A total of 30 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included certified nursing assistants, licensed practical nurses, registered nurses, Administrator, business office staff, laundry staff, kitchen staff, activity staff, housekeeping staff, physical therapy staff, and maintenance staff. The staff interviewed verified they had been trained in handling residents with behaviors and dementia. A review of the in-service sheets provided indicated 45 of 105 had been provided training. Those staff who were not physically present to receive the in-services were to be in-serviced prior to the start of their shift.

Based on record review and interview, the facility failed to acquire a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, as required, for 1 of 1 facility. The findings are: The Centers for Medicare and Medicaid Services (CMS) Guidance at tag F770 documented, .If a facility provides its own laboratory services or performs any laboratory tests directly (e.g. [for example], blood glucose monitoring, etc. [et cetera]) the provisions of 42 CFR [Code of Federal Regulations] Part 493 apply and the facility must have a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility. On 1/29/25 at 11:52 a.m., Observation of the facility's CLIA certificate documented an expiration date of 1/25/25. The Administrator was asked if the facility had a current CLIA certificate in her office. She stated, I will have to get that for you. A review of Pay.gov Payment Confirmation: CLIA Laboratory Program indicated the facility paid for the CLIA license on 1:22 PM. The facility was unable to provide a current CLIA certificate.

47916 Based on observations, interviews, and record reviews, the facility failed to (1) properly transfer 1 (Resident #41) of 9 residents reviewed for accidents; (2) ensure keys were not left in the janitor closet door unattended where chemicals were stored for 1 (100 hall) of 4 halls observed; (3) ensure the rear casters/wheels of the mechanical lift were in the unlocked position when raising and lowering residents affecting 1 (Resident #8) of 9 residents reviewed for accidents; (4) ensure the beauty shop on the secured unit was locked when not in use or when there were no staff present. The findings are: 1. A review of an Order Summary Report revealed Resident #41 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis after a stroke) affecting the dominant side. The quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 10/23/2024 revealed Resident #41 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review indicated the resident had upper and lower extremity range of motion impairment to one side. Resident #41 was able to transfer from the bed to the chair independently. A care plan with a revision date 1/30/2025 indicated that Resident #41 was a risk for falls related to balance problems. The facility developed interventions that included staff were to ensure the resident was wearing appropriate footwear when ambulating in the wheelchair and to have non-skid strips at the bedside. Resident #41 also had an activity of daily living (ADL) self-care performance deficit and was able to move between surfaces independently. During an observation on 1/28/25 8:45AM the staff were informed that Resident #41 was on the floor in their bedroom. Certified Nurse Assistant (CNA) #11 and the Medical Records Coordinator put a gait belt around Resident #41's waist. When the two staff went to pick up the resident, they placed their hands under the resident ' s arms and lifted the resident up without using the gait belt. A review of Resident #41's Incident Note dated 1/28/25 indicated that Resident #41 went to transfer themselves to a wheelchair to use the bathroom. Resident #41 did not have on proper footwear, missed the wheelchair, and went to the floor. There were no injuries. A sock was placed on the resident's foot, and non-skid strips were at the resident's bedside. Interventions included non-skid sock, non-skid strips placed on bedside, and neuro checks. During an interview on 1/29/25 at 3:56 PM the Medical Records Coordinator indicated that she and CNA #11 picked Resident #41 up off the floor when the fell on [DATE]. Medical Records Coordinator indicated that she was not sure why she picked Resident #41 up with her hand positioned under the resident's arm pits. Medical Records Coordinator indicated that Resident #41 could have received a shoulder injury by being picked up improperly. Medical Records Coordinator indicated that a lift was not used because Resident #41 transfers on their own. During an interview on 1/31/2025 the Director of Nurse (DON) indicated that staff should use a gait belt when picking a resident up from the floor after a fall. The DON indicated that a resident should never be picked up by staff placing their hands under a resident's arm pit. The DON indicated that if the staff does not use a gait belt that the resident or the staff could be injured. A review of facility policy, Falls - Clinical Protocol, with a revision date of 03/2018 did not indicate how residents should be transferred after a fall. 2. A review of a facility policy titled, Hazardous Areas, Devices, and Equipment revised July 2017, indicated that a hazard is defined as anything in the environment that has the potential to cause injury. Further review indicated, The Safety Committee will recommend measures to ensure that vulnerable residents cannot access hazardous areas in the facility (locks, alarms, supervision, etc.). On 1/27/2025 at 2:39 PM, the Housekeeping Supervisor went into the tub room on the 100 halls, left the keys to the janitor's closet in the door, and shut the door behind them. At 2:41 PM the Housekeeping Supervisor walked out of the janitor ' s closet on the 100 hall and began to walk down the hall. She was informed by the surveyor that she had left her keys in the janitor closet door. At 2:44 PM, the Housekeeping Supervisor indicated that she did not realize that she had left her keys in the door. She indicated that a resident could have gone into the closet where chemicals are stored. At 2:46 PM, the Housekeeping Supervisor opened the door to the janitor's closet. There was a gallon of glass cleaner, a gallon of bathroom cleaner, a gallon of odor solution, a gallon of sanitizer, and a container of urine cleaner in the closet. 3. A review of Medical Diagnosis revealed Resident #8 had diagnoses of dementia, heart failure, and schizoaffective disorder. A review of Resident #8 ' s annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2024 indicated a Staff Assessment for Mental Status (SAMS) was completed, which indicated the resident was moderately impaired for cognitive skills for daily decision making. Further review indicated the resident required a manual or electric wheelchair, and the resident required total care for eating, bathing, dressing, personal care, transfers, and toileting. A review of Resident #8 ' s care plan revealed a self-care performance deficit related to disease processes, requiring two staff members to transfer Resident #8 with a mechanical lift. During an observation on 01/28/2025 at 9:31 AM, Certified Nursing Assistant (CNA) #7 assisted CNA #8 were in Resident #8 ' s room to transfer the resident using a mechanical lift. Both CNAs positioned the open legs of the mechanical lift around Resident 8 ' s specialty chair. CNA #8 was observed locking the rear casters/wheels of the lift and raising Resident #8 up with the mechanical lift and sling from the chair to transfer to the bed. The CNAs positioned the lift over the resident ' s bed. With the legs open under the bed, the right rear caster/wheel of the lift was locked, and the left caster was left unlocked and resident was lowered to the bed. During an interview on 01/28/2025 at 9:34 AM, CNA #8 stated when they transferred Resident #8 using the mechanical lift, the legs of the mechanical lift were open for stability, and the rear casters/wheels were locked so the mechanical lift would not move when raising and lowering Resident #8. CNA #7 and CNA #8 both stated they have been in-serviced on using a mechanical lift. A review of Batter Powered Patient Lift User Manual, dated 2018, revealed on page 6 that it was not recommended to lock the rear casters/wheels of the mechanical lift when lifting a resident, because it could cause the lift to tip and endanger the resident and assistants. On page 12, a warning label revealed, DO NOT lock the casters of the Patient Lift when lifting an individual. [NAME] MUST be left unlocked to allow Patient Lift to stabilize during lifting procedures. During an interview on 01/29/2025 at 9:35 AM, the Director of Nursing (DON) stated during a transfer, the legs of the mechanical lift were to remain open to provide stabilizing and the rear casters/wheels were left unlocked. The DON stated leaving the rear wheels unlocked would prevent the mechanical lift from tipping. The DON stated if the weight shifts when a resident was being raised, the base of the lift would shift with the resident to prevent tipping. The DON stated it would not be appropriate to lift a resident with the rear casters locked, and stated she does not know why staff would lock the right wheel and leave the left wheel or rear caster unlocked when lowering the resident to the bed. A review of facility policy titled Lifting Machine, Using a Mechanical, revised July 2017, and it did not indicate locking the rear casters/wheels when lifting a resident with a mechanical lift. The policy did indicate that lift designs and operations may vary depending on the manufacture and staff must be trained and demonstrate competency using the lift. A review of Competency Assessment Lifting Machine, Using a Mechanical indicated a competency and/or return demonstration of using a mechanical lift. The checklist was verbatim of the above facility policy and did not indicate the rear casters should be locked. 4. During an interview on 01/31/2025 at 10:00 AM, the Administrator stated the facility did not have a policy for the beauty shop. During an observation on 01/29/2025 at 2:01 PM, while making rounds on the secure unit, the beauty shop door was noted to be open, and no staff were present. Three residents on the secured unit were wandering the hallway. One resident was in a wheelchair and two residents were ambulatory. Inside of the beauty shop was a floor scrubber and a 2-wheeled [NAME], shampoos, 2 spray bottles with clear liquid (unlabeled), vinegar, hair products and a can of clipper cleaning spray. Electrical supplies (clippers and a curling iron) were plugged in and ready for use. During an observation on 01/29/2025 at 2:06 PM, the beautician returned to the beauty shop with a resident from the main facility, while this surveyor remained beside the open door to the beauty shop. During an interview on 01/29/2025 at 2:12 PM, the beautician confirmed that the door was left ajar due to not having a key to get in after getting another resident to do the resident ' s hair. The beautician stated that the door to the beauty shop should be shut and locked when not in use or if no one is present. During an interview on 01/30/2025 at 3:15 PM, the Administrator confirmed that the beauty shop should not have been left open and was not aware that the beautician did not have a key, stating, I ' m going to make it where it has a code to get in. The Administrator stated the beautician had been working for the facility for approximately one month as a full-time certified nursing assistant and did the beauty shop 2-3 times a month. 50505

Based on observation, record review and interview, the facility failed to ensure that the resident received prompt treatment after noticing a change in condition for 1 (Resident #112) of 4 residents reviewed for abuse and/or neglect. Specifically, Resident #112 showed signs of a stroke and was not sent to the emergency room until approximately 4 hours after noticing the change in condition. The findings are: A review of an Admission Record indicated Resident #112 had diagnoses of neurocognitive disorder with Lewy bodies, chronic obstructive pulmonary disease, altered mental status, atrial fibrillation (irregular and often rapid heart rhythm that can lead to stroke), cerebrovascular disease (term for conditions that affect blood flow to your brain), cognitive communication deficit. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2025 documented the resident scored 00, (0-7 indicates the resident was severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). Further review indicated the resident ambulated with a walker and was independent with care. A review of Resident #112 ' s care plan, initiated on 11/27/2023, indicated the resident was on an anticoagulant (blood thinning) medication related to atrial fibrillation. The facility developed interventions to include administering the medication as ordered and monitor for side effects and effectiveness every shift. The blood thinning medication had a black box warning and premature discontinuation increased the risk of blood clots and to monitor for warning and side effects of the medication. Staff were to monitor, document, and report any adverse reactions of the blood thinner medication. Review of Resident #112 Progress Notes dated 10/3/2024 at 3:23 PM, staff reported to Licensed Practical Nurse (LPN) #12 that Resident #112 was acting a bit strange during smoke break. When staff spoke to the resident, there was slurred speech and the resident reported to be tired. Resident #112 denied any pain or discomfort and was alert and oriented. Resident #112 was able to ambulate with no difficulty and the resident ' s vital signs were within normal limits for the resident. LPN #12 requested the doctor to see Resident #112 during rounds. Review of Resident #112 Physician Notes indicated on 10/03/2024 at 7:35 PM, an Advanced Practice Registered Nurse (APRN) provided an interactive audio and visual telecommunication with the resident. The APRN indicated Resident #112 ' s chief complaint was a change in mental status and staff reported slurred speech and left side weakness. The staff reported that this started around 4 hours ago. Resident #112 had significant left sided facial droop on exam, had slurred speech, and complained of back pain. The APRN indicated the resident needed to be sent to the emergency room for an evaluation due to a possible stroke. The APRN indicated the resident ' s doctor was made aware of the visit and new orders. Review of Resident #112 Progress Notes dated 10/3/2024 at 7:52 PM, Registered Nurse (RN) #14 indicated Resident #112 continued with slurred speech and staff reported she the resident was not acting like themselves. The on-call provider was notified and new orders were received to send the resident to emergency room for evaluation. Review of Resident #112 Progress Notes showed no physician entries for this resident on 10/03/2024. A review of Resident #112 ' s Admission H&P [history and physical] notes indicated Resident #112 ' s family member was at the resident ' s bedside at the hospital and told the APRN the resident had stop talking all of their medication approximately 3 months ago. The resident was admitted to the hospital on 10/03/2024 at 8:06 PM. Imaging of the resident ' s head and neck indicated a medium vessel occlusion (most common artery involved in acute stroke) and Resident #112 was not a candidate for intravenous thrombolysis (the use of medication to dissolve blood clots) due to it being outside of the timeframe for administration. During an interview on 01/29/2024 at 4:48 PM. LPN #12 stated on 10/03/2024, the doctor was doing rounds in the facility and was notified of the resident ' s change in condition and that the resident needed to be seen by the doctor. LPN #12 stated staff let the resident rest until seen by the doctor. Review of OLTC Witness Statement Form, dated 01/30/2025 at 9:56 AM the Director of Nursing (DON) indicated On October 3rd, 2024, I received a phone call from the resident ' s Medical Physician (MP). Medical Physician stated that he had seen the resident per [the resident ' s] nurse ' s request. At that time, the resident did not wish to go to the hospital to be evaluated. The resident was also non-compliant with [the resident ' s] medications, including [a blood thinner]. In light of this, the residents Medical Physician called me on my personal phone and requested that a care plan be scheduled with the resident and [the resident ' s family member] to discuss goals of care and potential comfort care measures. I was on the way home from daycare with children at the time, so the time of call would have been around 5pm. This information provided above is true to the best of my knowledge. A review of Resident #112 ' s electronic health record did not indicate there was a conversation between Resident #112 ' s MP and the DON on 10/03/2024. During an interview on 01/30/2025 at 11:08 AM, The MP was asked if he saw the resident on 10/03/2024 while completing rounds on other residents at the facility and the MP stated he did not see the resident and did not have any notes on the resident for that day. Review of facility policy titled Change in a Resident ' s Condition, which indicated Our facility promptly notifies the resident, his or her primary care provider, and the resident representative of changes in the residents medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Based on interviews and record review, it was determined that the facility failed to ensure that resident to resident events were reported within 24 hours even if no serious bodily injury occurred for 1 (Resident #9) of three residents reviewed for abuse and neglect. Findings include: A review of the facility policy, Abuse Prevention, revised 11/16/2017 revealed that all reports of resident abuse, neglect, injuries of an unknown source, resident-to-resident abuse and resident-to-staff abuse are promptly and thoroughly investigated by facility management, and that when an alleged or suspected abuse is reported, the facility administrator or his/her designee, would notify the following: 1. The State licensing/certification agency 2. The resident ' s representative 3. Law enforcement 4. The resident ' s attending physician. A review of OLTC Incident and Accident Report (I&A) indicated on 01/08/2025, Resident #9 pushed Resident #44 into a wall. Resident #44 grabbed at their hip as if the resident was in pain. Both residents resided in the Alzheimer ' s unit. Resident #44 had a hip fracture as a result of this incident. The findings of the facility ' s investigation indicated, The facility can not substantiate this allegation of abuse as both residents involved are mentally deemed to have no capacity and there was no intentional means of abuse. A review of State Operations Manual Appendix PP, F600 indicates, Willful actions include, but are not limited to, the following: hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing, shoving .The action itself was deliberate or non-accidental, not that the individual intended to inflict injury or harm .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. A review of the Admission Record, indicated the facility admitted Resident #44 with diagnoses that included dementia with agitation, disorientation, insomnia, restlessness and agitation. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #44 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated moderately impaired cognitive skills for daily decision making. Resident #44 showed physical behavior symptoms directed towards others as well as wandering. Resident #44 was able to ambulate independently. A review of Resident #44 ' s care plan initiated on 03/08/2024, revealed the resident needed a secured/special care neighborhood due to dementia. The following was listed: - 04/11/2024: Physical aggression received - 04/19/2024: Physical aggression received - 07/10/2024: Physical aggression received - 08/06/2024: Physical aggression received - 08/12/2024: Physical aggression received - 08/21/2024: Physical aggression initiated - 12/07/2024: Physical aggression received - 12/20/2024: Physical aggression received - 12/25/2024: Physical aggression received - 01/09/2025: Physical aggression received The facility developed interventions that included to encourage the resident to fold laundry or take care of a baby doll when noted wandering in other resident ' s rooms, numerous interventions in place for other resident, and the resident was to be placed on 1 on 1 observation on 08/21/2024. Further review of the care plan indicated Resident #44 lacked capacity to understand and make decisions. The resident also exhibited behaviors of wandering into other residents ' rooms. A review of facility incident and accident reports for the last twelve months for Resident #44 indicated on 04/11/2024, Resident #44 was pushed down to the ground by another resident. On 4/19/2024, Resident #44 was kicked by another resident. On 7/9/2024, Resident #44 was smacked in the face by another resident. On 08/06/2024, Resident #44 was pushed to the floor by another resident. On 08/12/2024, Resident #44 ' s left hand was stuck with a closed fist by another resident. On 08/21/2024, Resident #44 hit another resident. On 12/7/2024, Resident #44 was punched in the stomach. On 12/20/2024, Resident #44 was pushed by another resident, causing Resident #44 to fall. On 12/25/2024, Resident #44 was hit in the head by another resident. On 1/8/2025, Resident #44 was pushed to the floor by another resident and appeared to be in severe pain and was sent to the emergency room . Of all of the reports, only one was reported to the State Agency. During an interview on 01/31/2025, at approximately 11:00 AM, the Administrator was unaware of the regulation that resident-to-resident altercations had to be reported to the State Agency and stated only interactions that resulted in injury should be reported.

Based on observations, interviews, and record review, the facility failed to ensure garbage and refuse was disposed of properly for one of one dumpster observed. The findings are: During an observation on 01/28/2025 at 3:00 PM, the trash dumpster gates were opened, exposing the trash dumpster and the trash inside. Sitting directly next to the dumpster was a used recliner and broken wooden fencing. A. The trash dumpster door was left open, exposing trash bags containing briefs, gloves, and other waste items inside. B. The fence around the dumpster had a large section of the fence missing, exposing a large black trash bag lying on the ground beside the dumpster that contained unknown debris and a dirty recliner sitting beside the dumpster. The black trash bag was torn open in several places. Items that had spilled out of the black trash bag included an empty sugar bag, several foam containers, plastic lids, a stack of white cups, plastic bags, used plastic gloves and an empty bottle of thickened water. [NAME] bags, used gloves, paper and other debris were on the grounds around the fencing and dumpster. C. A white bag of used rolled baby diapers was tossed on the ground along the fence that ran along the back of the facility grounds. D. Several tree limbs and brush were piled up between the fencing around the dumpster and the fencing along the backside of the grounds with a white plastic bag on the ground, a snicker bar wrapper, used gloves, and other debris under the limbs. E. Approximately 3 feet behind the trash bin fence was a pair of used gloves. There were several plastic bags lying along the fence row along the back yard of the facility. A white bag with rolled used briefs was observed lying on the ground along the fence of the back yard. F. A large screw, approximately 2 inches long with a sharp point, was protruding out the side of the fence post, eye level with the surveyor. 2. During an interview on 01/29/2025 at 8:15 AM, the Administrator stated the dietary department was responsible for cleaning the dumpster area. 3. During an interview on 01/29/2025 at 8:30 AM, the Dietary Manager (DM) stated she checked the dumpster three times a week to ensure the bags were picked up. The DM stated she removed the black trash bag that was on the ground yesterday (01/28/2025), and stated the bag had been there since last week. 4. During a concurrent observation and interview on 01/29/2025, at 8:37 AM, the DM and Surveyor observed the dumpster area and noted the dumpster gates surrounding the dumpster were open. The DM stated the gates were always left open. The dumpster door was noted to be opened. The DM stated the dumpster door should be closed and she closed the dumpster door. The DM stated the gloves could be a danger to a resident if the resident got the gloves because the gloves could have infectious things on them and cross contaminate the resident with whatever is on the glove. The DM stated the brush and tree limbs between the dumpster fence and the backyard fencing could be a danger to a resident if the resident walked back there and got hung up in the branches and maybe even pass away if no one thought to look back there. The DM identified a clear white plastic cup lying on the ground as being one the nurse ' s use. The DM stated the fencing had been broken and missing pieces for about a month. The DM stated the recliner was put next to the dumpster over the weekend. The DM stated she tells her staff to pick up the trash around the dumpster when they take the trash out and to make sure the door is closed to the dumpster. 5. During an observation on 01/29/2025 at 8:52 AM, the black trash bag was lying on the ground and hanging from under the dumpster, the sugar bag was hanging on the back corner of the dumpster, the glove behind the dumpster fencing was lying on the ground, the trash was under the brush and limbs, a pair of used gloves was lying on the ground beside the fencing, the bag of diapers was still lying on the ground beside the fence, two used masks were lying on the concrete just outside the dietary department. 6. During an interview on 01/29/2025 at 9:23 AM, the DM stated she did not have any training documentation and/or in-services to indicate training had been provided to dietary employees related to the disposal of refuse/garbage and/or the facility dumpster. 7. A review of facility policy Food-Related Garbage and Refuse Disposal revised 10/2017, indicated Garbage and reuse containing food wastes will be stored in a manner that is inaccessible to pests .Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure hand hygiene was performed during one of one meal service observed. Findings include: A review of a facility policy titled, Handwashing/Hand Hygiene, revised October 2023, indicated, handwashing was the primary means to prevent the spread of infections and stated that hand hygiene is indicated immediately before touching a resident, after contact with contaminated surfaces and after touching a resident or the resident ' s environment. During an observation on 01/27/2025 at 12:38 PM, Nursing Assistant (NA) #9 rubbed their hands on their shirt, then placed their hands in their lap, then picked up a spoon and started feeding a resident without sanitizing hands. After feeding the bite, NA #9 placed their hands back in between their knees, then grabbed a spoon to feed the resident, without sanitizing hands. NA #9 reached across another second resident and adjusted the resident, then picked up a glass and offered the first resident a drink without sanitizing hands. During an interview on 01/27/2025 at 1:40 PM, NA #9 stated it was a bad habit that hands were placed in between the knees and confirmed that hands should have been sanitized prior to feeding the residents after touching clothes or between the residents. During an interview on 01/31/2025 at 8:50 AM, the Director of Nursing (DON) confirmed that it is not right to hold hands between the legs and then go to assist one resident and then to move to another resident to feed without hand sanitizing in between.

Based on observation, interview, and policy review the facility failed to post, in a form and manner accessible and understandable to residents, contact information for pertinent State agencies and advocacy groups for 15 residents residing in the facility's Secure Unit. The findings are: On 01/22/2024 at 02:40 PM, observed the contact information for State agencies and the Ombudsman was not posted in the secure unit. The doorways into the secure unit were closed and secured to prevent residents from exiting and observing contact information posted in other parts of the facility. On 01/23/2024 at 08:30 AM, observed the contact information for State agencies and the Ombudsman was not posted in the secure unit. On 01/24/2024 at 08:00 AM, observed the contact information for State agencies and the Ombudsman was not posted in the secure unit. On 01/24/2024 at 01:35 PM, the Director of Nursing (DON) reported they were not aware that the contact information for State agencies and the Ombudsman was required to be posted in the secure unit. The DON confirmed that the contact information should be available to all residents. On 01/24/2024 at 01:45 PM, the Administrator confirmed that contact information for State agencies and the Ombudsman was required to be posted in the manner that it was accessible to all residents. On 01/24/2024 at 04:00 PM, the Administrator reported that the facility did not have a policy on posting required information and that state regulations were followed.

Based on observation, interview and record review, the facility failed to ensure fingernails were cleaned and groomed to promote good personal hygiene and grooming for 2 (Residents #32 and #34) of 15 (Residents #2, #3, #4, #8, #13, #21, #31, #32, #35, #38, #43, #45, #48, #105, and #106) sampled residents who were dependent on staff for fingernail care and facial hair was removed from 1 (Resident #105) of 10 (Residents #50, #105, #13, #45, #35, #41, #32, #38, #5, and #8) sampled residents who were dependent on staff for personal hygiene. The findings are: 1. Resident #32 had a diagnosis of Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/02/23 documented the resident scored 06 (0-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required partial/moderate assistance with Activities of Daily Living (ADL's). The Comprehensive Care Plan with a revision date of 12/23/23 included the need for assistance with ADLs with an intervention noted Resident #32 was able to perform personal hygiene care independently following staff set up and resident required total dependence on staff for bathing. On 01/22/2023 at 2:30 PM, Resident #32 was sitting in his wheelchair in his room. A dark substance, brown in color, was observed under his fingernails. His lunch tray was in his room lying on his bed. On 01/23/24 at 09:04 AM, Resident #32 was sitting in his wheelchair in his room, with his breakfast tray on his bed. A dark substance, brown in color, remained under his fingernails. On 01/23/24 at 03:48 PM, Resident #32 was sitting in his wheelchair in his room, with his lunch tray lying on his bed. A dark substance, brown in color, was observed under his fingernails. On 01/24/24 at 09:02 AM, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to the resident's room and observed the dark brown substance under his nails. In response to the question, How does the facility clean under his nails and when should his nails be cleaned? LPN #1 stated, His nails should be cleaned, we use a small wooden stick to clean under his nails. The Surveyor asked when the hands and nails are looked at, to know when care should be preformed? LPN #1 stated, Nails should be cleaned before meals, and after using the bathroom. On 01/25/24 at 07:50 AM, in an interview with the Director of Nursing (DON), in response to the question, Are you aware that Resident #32 has dark residue under his nails? The DON responded, I will follow-up and nails should have been cleaned. 37634 2. Resident #34 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The Quarterly MDS with an ARD on 12/02/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. Resident #34's Care Plan with a revision date of 01/01/24 noted Resident #34 required substantial/maximal staff assistance to perform personal hygiene. On 1/23/24 at 9:01 AM, Resident #34's fingernails were 1/2 inch long with a thick black substance underneath his nails. Resident #34 raised his hands up, then he stated, They're still dirty. On 1/24/24 at 9:03 AM, the Surveyor asked Resident #34, How often do the staff cut your nails? He stated, They don't never cut them. He was asked, Would you like them cut? He stated, I would love to have them cut and trimmed. His nails were 1/2 inches long with a thick black substance underneath. On 1/25/24 at 9:03 AM, the Surveyor asked Resident #34, Did you get your nails cut? He stated, Not yet. His nails were 1/2 inch long with a thick black substance underneath. #3. Resident #105 had a diagnosis of malignant neoplasm of extrahepatic bile duct. The Admission MDS with an ARD on 1/03/24 documented the resident scored 14 (cognitively) on a BIMS and required staff setup or clean up assistance with personal hygiene including shaving. On 1/22/24 at 2:26 PM, Resident #105's beard was 1 inch long. Resident #105 was asked, How often do you get a shave? He stated, They don't ever ask me. He was asked, Would you like to be shaved? He stated, I would from time to time. On 1/24/24 at 3:27 PM, Resident #105 beard was 1 inch long. Resident #105 was asked, How long have you been living in this facility? He stated, A few weeks, almost a month. He was asked, When was the last time you had a shave? He stated, I was shaved at the place I was at before I came here. No one has shaved me here. I would like a nice trim. On 1/22/24 at 9:19 AM, Resident #105 was in bed. His beard was 1 inch long. On 1/25/24 at 9:56 AM, Certified Nursing Assistant (CNA) #2 was asked, How often does [Resident #105] get a shave? She stated, Usually when they ask for it, but we try to ask them on shower days. The Surveyor asked, Can you tell me why [Resident #105] hasn't been shaved? She stated, We haven't asked him if he wants one. On 01/24/24 at 4:02 PM, the Administrator provided a policy titled, Activities of Daily Living (ADLs) (Revised March 2018), that read in part, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice .

Based on observation and interview, the facility failed to ensure 1 (Resident #13) of 12 (Residents #50, #105, #13, #3, #45, #106, #35, #5, # 4, #8, #31, and #48) sampled residents who were dependent on staff for hydration always had fluids available. The findings are: Resident #13 had a diagnosis of covid 19, and unspecified severe protein-calorie malnutrition. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 10/26/24 documented the resident scored 07 (00-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). A January 2024 Physicians Order documented, .Nectar consistency . A Care Plan dated 10/23/23 documented, .Weighted Cups .Encourage good nutrition and hydration in order to promote healthier skin . On 1/22/24 at 2:42 PM, Resident #13 had a pitcher and a styrofoam cup in his room. Both were empty. On 1/24/24 at 2:56 PM, Resident #13 was in bed drinking a liquid out of a white styrofoam cup. On 1/25/24 at 9:36 AM, there were no drinking cups in Resident #13's room. On 1/25/24 at 9:45 AM, the Activity Director walked into Resident #13's room. She was asked, Does [Resident #13] have any water or cups in his room. She stated, No, he doesn't. On 1/25/24 at 9:47 AM, the Social Worker walked down to Resident #13's room and passed a cup to the Activity Director. On 1/25/24 at 9:56 AM, Certified Nursing Assistant (CNA) #2 was asked, Can you tell me why [Resident #13] didn't have water, or his weighted cup in his room. She stated, He wasted the water on him at breakfast, and we were going to bring him more when we brought out the snacks. She was asked, Should [Resident #13] have his weighted cup with water available at all times?' She stated, Yes ma'am.

Based on observation, interview, and record review, the facility failed to ensure that hazardous fluids were stored in a safe manner in 3 (rooms [ROOM NUMBER]) resident rooms located in the facility's secure unit. This failed practice had the potential to affect 10 residents identified as ambulatory by a list provided by the Administrator on 01/24/2024 at 04:00 PM. The findings are: 1. On 01/22/2024 at 02:03 PM, rooms [ROOM NUMBERS] were observed to share a bathroom. In the bathroom was an opened bottle of Perineal and Skin Cleanser. The label documented, Caution: For external use only. Avoid contact with eyes. In case of eye irritation, flush with water and contact a physician . Keep out of reach of children. a. On 01/23/2024 at 08:45 AM, the bottle of skin cleanser was observed in the bathroom for rooms [ROOM NUMBERS]. b. On 01/24/2024 at 09:00 AM, the bottle of skin cleanser was observed in the bathroom for rooms [ROOM NUMBERS]. 2. On 01/22/2024 at 02:15 PM, an opened bottle of Lens Cleaner was observed in the bathroom of room [ROOM NUMBER]. The label documented, Caution: Do not spray near eyes. Not for contact lens use. Keep out of reach of children. a. On 01/23/2024 at 08:50 AM, the bottle of lens cleaner was observed in the bathroom for room [ROOM NUMBER]. b. On 01/24/2024 at 09:05 AM, the bottle of lens cleaner was observed in the bathroom for room [ROOM NUMBER]. 3. On 01/24/2024 at 01:35 PM, the Director of Nursing (DON) confirmed that liquids such as cleansers should not be stored in resident rooms on the secured unit. 4. On 01/24/2024 at 01:45 PM, the Administrator confirmed that liquids such as cleansers should not be stored in resident rooms on the secured unit. 5. On 01/24/2024 at 03:30 PM, the Administrator provided a document titled, Acknowledgement of Prohibition of Potential Hazards. It documented, .Hazards include the following: .Personal care and other items with warnings such as Keep out of reach of children Chemicals or plants that would be poisonous if ingested .

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities for 15 residents in the facility's Secure Unit. The findings are: On 01/22/2024 at 02:15 PM, Resident #28 was asked if they were encouraged to participate in activities. Resident #28 denied being invited to join in activities. On 01/22/2024 at 02:39 PM, a bulletin board labeled, Activities of the Week was observed in the secure unit. It documented the activities planned for the week. On 01/22/2024 at 04:00 PM, a Music Social was scheduled. It did not take place. On 01/23/2024 at 11:00 AM, a game of Zingo was planned. It did not take place. On 01/23/2024 at 04:00 PM, a game of Ball Toss was planned. It did not take place. On 01/24/2024 at 11:00 AM, Creativity Art was planned. It did not take place. On 01/24/2024 at 01:27 PM, the Director of Activities was asked if residents in the secure unit had a program of activities that was being followed. The Director of Activities confirmed that a program was in place and was posted on that unit. The Director of Activities was asked who was responsible for ensuring those activities took place. The Director of Activities confirmed that they were responsible for planning the activities, and that staff working in the secure unit were responsible for carrying out the program. The Director of Activities confirmed that it was important for residents residing on the secure unit to have an ongoing program of activities. On 01/24/2024 at 02:30 PM, the Administrator acknowledged the importance of residents residing on the secure unit to have an ongoing program of activities. On 01/24/2024 at 04:00 PM, a Policy titled, Activity Programs was provided by the Administrator. It documented, Activity programs are designed to meet the needs and interests of and support the physical, mental, and psychosocial well-being of each resident.5. Activities are scheduled 7 (seven) days a week .Resident's activity participation is documented in the resident's individual medical record .

Based on observation and interview, the facility failed to ensure 1 (Resident #13) of 1 sampled resident was provided a weighted cup for fluids to prevent dehydration. The findings are: Resident #13 had a diagnosis of covid 19 and unspecified severe protein-calorie malnutrition. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/24 documented the resident scored 07 (00-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). A Care Plan dated 10/23/23 documented, .Weighted Cups .Encourage good nutrition and hydration in order to promote healthier skin . On 1/22/24 at 2:42 PM, Resident #13 had a pitcher and a styrofoam cup in his room. Both were empty. On 1/24/24 at 2:56 PM, Resident #13 was in bed drinking liquid out of a white styrofoam cup. On 1/25/24 at 9:36 AM, there were no drinking cups in Resident #13's room. On 1/25/24 at 9:45 AM, the Activity Director walked into Resident #13's room. She was asked, Does [Resident #13] have any water or a weighted cup in his room. She stated, No, he doesn't. On 1/25/24 at 9:47 AM, the Social Worker walked down to Resident #13's room and passed a cup to the Activity Director. On 1/25/24 at 9:56 AM, Certified Nursing Assistant (CNA) #2 was asked, Can you tell me why [Resident #13] didn't have water, or his weighted cup in his room. She stated, He wasted the water on him at breakfast, and we were going to bring him more when we brought out the snacks. She was asked, Should [Resident #13] have his weighted cup with water available at all times? She stated, Yes ma'am.

Based on observation, interview, and record review, the facility failed to maintain the resident rooms in a safe, functional, homelike manner for 3 (Rooms 114, 119, 121) rooms, as evidenced by trim disconnected from the walls and built in drawers failed to open and close safely. The findings are: On 01/24/24 at 10:08 AM, during environmental rounds the following observations were made: a. Standing in the entrance of room [ROOM NUMBER], inside the bathroom, on the left side of the floor, the trim was disconnected from the wall 2 inches. b. Standing in the entrance of room [ROOM NUMBER], the lower section of the built in 2-door closet had upper and lower drawers. The upper drawer toward the outside window could not be opened and safely closed. c. Standing in the entrance of room [ROOM NUMBER], the lower section of the built in 2-door closet had upper and lower drawers. The upper and lower drawers toward the bathroom could not be opened and safely closed. In addition, the floor trim on the wall from the bathroom entrance extending to the built in closet door was disconnected from the wall 1 inch. On 01/24/24 at 04:03 PM, during a tour with Maintenance Supervisor #1, in response to the question, Are you aware that the floor trim in the bathroom of room [ROOM NUMBER], is disconnected from the wall? The Maintenance Supervisor stated, I was not aware, but this will be repaired. In addition, in response to the question, Are you aware that the built in drawers in room [ROOM NUMBER] and 121 cannot be opened and closed safely, and the trim is disconnected in room [ROOM NUMBER]? The Maintenance Supervisor tried to open and close the drawers in both rooms. He stated, I will have these drawers repaired and will repair the wall trim.

Complaint # (AR 326) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure allegations of abuse were immediately reported to the Administrator and the Office of Long Term Care within 2 hours of knowledge of the allegation which resulted in a delay in initiating an investigation and implementing protective measures to prevent further potential abuse for 2(Residents #8 and #3) of 4 (Residents #3, #8, #9, and #10) sampled residents who, during the investigation of Resident #8's allegation, were found to be alleged victims of physical and / or verbal abuse by the same perpetrator (Nursing Assistant #1). These failed practices resulted in Immediate Jeopardy, which could have caused serious harm, injury, or death to Resident #8, who made an allegation of physical abuse against NA #1, and had the potential to cause more than minimal harm to 23 residents who resided on the secure dementia unit and 49 residents residing in the facility where Nursing Assistant #1 was assigned for the past 2 months, as documented on the census list provided by facility staff on 12/10/18. The Administrator was informed of the Immediate Jeopardy condition on 12/13/18 at 1:30 p.m. The findings are: 1. Resident #8 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/18 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview Mental Status (BIMS); did not have any mood or behavior symptoms; required extensive assistance of one person for bed mobility, transfers, locomotion, dressing and toilet use; and was totally dependent on staff for bathing. a. The plan of care with a target goal date of 1/15/19 addressed the resident's activities of daily living (ADL) self-care performance deficit and limited physical mobility. The Interventions documented the resident required the assistance of 1 staff to toilet and that the resident was weight-bearing. b. On 12/12/18 at 11:46 a.m., Resident #8 was sitting in the dining room of the secure dementia unit in a wheelchair. She asked the surveyor to come over to the table and stated, You need to check 11 to 7 (11:00 p.m. to 7:00 a.m. shift). The resident was asked to explain and stated, There is a man named (NA #1) he is mean, he threw me down, he said he would go get one of the 3-11 (3:00 p.m. - 11:00 p.m.) aides to put me in my place. He was helping me to the toilet and he threw me down on it. He said he would never help me again. He worked Monday (12/10/18) night. He was the only aide. At 11:54 a.m., the Surveyor went to the Nurses Desk and reported to Registered Nurse (RN) #1, the charge nurse for the secure dementia unit, the resident's allegations. RN #1 stated, She did mention that to the unit manager yesterday (Licensed Practical Nurse (LPN #1)). He (NA #1) normally works up front, but he filled in Monday night / Tuesday morning here (on the secure unit). She told the same story to the Unit Manager. The Surveyor stated to RN #1, I am reporting an abuse allegation to you; what would be your responsibility with this allegation? She responded, Since it went directly to the unit manager yesterday, I would assume she suspended him and started an investigation. c. On 12/12/18 at 12:05 p.m., as the surveyor was speaking to RN #1, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Licensed Practical Nurse (LPN) #1 all came down the hall and took Resident #8 into her room to speak to her. The surveyor asked LPN #1 what Resident # 8 reported to her yesterday and she stated, She said the little (derogatory term) boy was a little rough when he transferred me Monday night (referring to Nurse Aide (NA) #1). I reported this to ADON approximately 2 PM - 3 PM early afternoon yesterday. Normally, he doesn't work back here - I thought she (Resident #8) would have been in bed by the time he came in. He is usually on North 3 PM - 11 PM but he worked back here Monday night 11 PM - 7 am. d. At 12:18 p.m., the DON was asked what was reported to her regarding Resident #8 and she stated, ADON at approximately 3:05 PM yesterday reported (Resident #8) said (NA #1) put her down too fast and wasn't nice to her. The black boy. The DON was asked if any one talked to Resident #8 after this was reported. She stated, No. She was asked if a body audit was completed to check for injury and LPN #1 stated, not a body audit undressed. The ADON was asked what was reported to her and she stated, (Unit Manager) reported to me at approximately 3 PM yesterday (Resident #8) had reported that the black boy was not nice to her. He moved her a little faster than she would like. I reported to the DON. The DON stated, I didn't know about all this. I just got her witness statement. (NA #1) was not here yesterday we are lucky. He is not returning I am firing him. I don't want anyone working here who would do this. I will take responsibility for any failure on our part. It was reported to me that the CNA (Certified Nursing Assistant) moved her too fast on to the toilet. I did not see that as abuse and did not follow up. I see now that we should have asked more questions. e. The DMS (Division for Medical Services) 7734, Incident and Accident Same Day Reporting Form documented, .Date Submitted 12/12/18 13:00 (1:00) pm . Steps taken to prevent continued abuse or neglect during investigation . C.N.A. (NA #1) suspended immediately . f. On 12/12/18 at 1:20 p.m., the Administrator stated, I did not receive this allegation . Yes, that should have been reported yesterday and I have just sent in the 7734 (Office of Long Term Care Incident and Accident form). Nothing has been done until now. The investigation will begin. g. On 12/12/18 at 3:20 p.m., Resident #8 was asked if she had any pain from the incident with the CNA assisting her to the toilet Monday night and she stated, I have pain all the time in my knees and ankles; it's hard to tell if it is any different, but I was very nervous, anxious after that situation. I couldn't concentrate on anything. I was very nervous. h. On 12/12/18 at 5:00 p.m., the Administrator stated, We now have 3 new [MEDICATION NAME] (allegations of abuse) from this allegation, investigation, witness statements from 2 other residents and one CNA. 2. Resident #9 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 12/11/18 documented the resident score 1 (0-7) indicates severely impaired) on the BIMS. a. An Office of Long Term Care (OLTC) Incident & (and) Accident Next Day Reporting Form documented, Date & Time of Discovery: 12/12/18 at 12:15 p.m . Name of Resident: (Resident #9) . On 12/12/18 at about 15:35 (3:35 p.m.) PM during interviews with staff a staff member stated that (NA #1) during shift report told her that he got beat up by 3 female residents and he had to put one of them on the floor and put her hands on her back. The facility identified the alleged victim in this incident as Resident #9. 3. Resident #3 had [DIAGNOSES REDACTED]. An Annual MDS with ARD of 10/29/18 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS; required set-up assistance of one person for transfers, ambulation, dressing, and eating; and was always continent of bowel and bladder. a. On 12/12/18 at 4:31 p.m., the resident was asked, Do you know about any situations involving (NA #1) and residents? The resident stated, On a previous time, he took us out to smoke, a group, I said something smart and he didn't like it, and NA #1 said, 'if you say it one more time, I'll take you to the nurses station and you won't smoke again'. The resident was asked, Did you report this to anyone? The resident stated, I did not report it when it happened, but I filled out a statement today; (RN #1) had me fill out a statement. An OLTC Witness Statement Form was completed by the resident on 12/12/18 at 2:45 p.m. b. On 12/12/18 at 4:48 p.m., the Administrator was notified of Resident #3's interview and was asked about a witness statement. The Administrator stated, I don't know anything about it; I just got the reports and haven't read them yet. The resident's allegation had not been immediately reported to the Administrator by staff, as required. c. On 12/12/18 at 4:50 p.m., the DON stated, (NA #1) has only worked (secure dementia unit) once, but has taken the residents out to smoke on many different occasions. d. On 12/13/18 at 8:35 a.m., RN #1 was asked, Did you take a witness statement from (Resident #3) on 12/12/18? RN #1 stated, yes. RN #1 was asked, Did you read it? RN #1 stated, Yes. RN #1 was asked, Do you think a staff member threatening a resident is considered abuse? RN #1 stated, yes. RN #1 was asked, Did you report it? RN #1 stated, No, if he had physically. I knew the witness statement would go directly to the Administrator. I went over it with (Resident #3), read it, and I turned it over to (LPN #1, Unit Manager) and then started giving report. RN #1 was asked, What time were you giving report? RN #1 stated, At shift change, that's usually around 3:00 p.m., and yeah, I just handed it to (LPN #1). e. On 12/13/18 at 9:38 a.m., a telephone interview was conducted with LPN #1. LPN #1 was asked, Did you take a witness statement from (Resident #3) on 12/12/18? LPN #1 stated, The nurse (RN #1) handed it to me; it was hard to read. I got to page 3 and laid it down, and then someone came and got it. LPN #1 was asked, What time did this happen? LPN #1 stated, Change of shift, around 3 p.m. LPN #1 was asked, Did you read it? LPN #1 stated, I did not finish reading it. LPN #1 was asked, Do you think a staff member threatening a resident is considered abuse? LPN #1 stated, Yes. 4. Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The MDS with an ARD of 11/28/18 documented the resident scored 3 (0-7 indicates severely impaired in cognitive skills) on a BIMS and required extensive assistance of 2 persons for bed mobility and transfers. a. An OLTC Incident and Accident Report dated as submitted to OLTC on 12/12/18 at 17:16 (5:16 p.m.) documented, On 12/12/18 at 1:55 p.m. during an abuse investigation, (Resident #10) reported that (NA # 1) 'threw her down in her chair while transferring'. b. On 12/13/18 at 2:35 p.m., Resident #10 stated she had been in the facility about 3 weeks and she likes the facility. She stated, I hit my knee on something when he (NA #1) tried to transfer me into the chair. I told him it hurt - my right knee started hurting after it happened. The resident raised up her right pant leg and there were scratches on her right knee. The resident was asked, How did that make you feel? She stated, It always makes me mad, 'cause if you had a knee and it felt like this, you wouldn't want to be treated like that. Maybe this will wake them up to what is going on. 5. On 12/13/18 at 6:12 p.m., the immediate jeopardy was removed and the scope and severity lowered to an E when the facility implemented the following plan of removal: a. Completed witness statement from the residents b. Completed witness statements from all staff that worked on (MONTH) 11 and 12, (YEAR) c. Completed witness statements from all interviewable residents in the facility. d. Treatment nurse completed body audits on all residents in the facility (completed on 12/13/18) e. Suspended the unit manager for 3 working days for not communicating the incident as an abuse allegation. f. Called the accused party to come in and gave his statement of events. g. Accused party was immediately put on suspension until investigation is complete. h. DON and Administrator started in servicing all staff on proper abuse reporting. (Not complete on 12/13/18) i. Quality assurance plan was started on 12/12/18 that included staff training on timely reporting of abuse to the administrator. All staff will be trained prior to their next shift and calling all weekend and PRN (as needed) staff to come into the facility for their training prior to the employee next shift. j. Administrator /designee will monitor daily for the identification of new reportable during I & A review and morning stand up meeting.

Complaint # (AR 326) was substantiated, all or in part, with these findings. Based on interview and record review, the facility failed to ensure a thorough investigation was conducted after receiving an allegation of rape and failed to ensure protective measures were immediately implemented to prevent further potential abuse while the investigation was ongoing for 1 (Resident #1) of 1 case mix resident whose family member made an allegation of rape. The facility also failed to ensure investigations were immediately initiated regarding allegations of possible staff-to-resident physical, verbal and / or emotional abuse and protective measures were immediately put in place to prevent further potential abuse for 2 (Residents #8 and #3) of 4 (Residents #3, #8, #9, and #10) sampled residents who, during the investigation of Resident #8's allegations, were found to be the alleged victims of physical, verbal or emotional abuse by the same perpetrator (Nursing Assistant (NA) #1). These failed practices resulted in Immediate Jeopardy, which could have caused serious harm, injury, or death to Resident #8, who made an allegation of physical abuse against NA #1, and had the potential to cause more than minimal harm to 23 residents who resided on the secure dementia unit and 49 residents residing in the facility where Nursing Assistant #1 was assigned for the past 2 months, as documented on the census list provided by facility staff on 12/10/18. The Administrator was informed of the Immediate Jeopardy condition on 12/13/18 at 1:30 p.m. The findings are: 1. Resident #8 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/18 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview Mental Status (BIMS); did not have any mood or behavior symptoms; required extensive assistance of one person for bed mobility, transfers, locomotion, dressing and toilet use; and was totally dependent on staff for bathing. a. The plan of care with a target goal date of 1/15/19 addressed the resident's activities of daily living (ADL) self-care performance deficit and limited physical mobility. The Interventions documented the resident required the assistance of 1 staff to toilet and that the resident was weight-bearing. b. On 12/12/18 at 11:46 a.m., Resident #8 was sitting in the dining room of the secure dementia unit in a wheelchair. She asked the surveyor to come over to the table and stated, You need to check 11 to 7 (11:00 p.m. to 7:00 a.m. shift). The resident was asked to explain and stated, There is a man named (NA #1) he is mean, he threw me down, he said he would go get one of the 3-11 (3:00 p.m. - 11:00 p.m.) aides to put me in my place. He was helping me to the toilet and he threw me down on it. He said he would never help me again. He worked Monday (12/10/18) night. He was the only aide. At 11:54 a.m., the Surveyor went to the Nurses Desk and reported to Registered Nurse (RN) #1, the charge nurse for the secure dementia unit, the resident's allegations. RN #1 stated, She did mention that to the unit manager yesterday (Licensed Practical Nurse (LPN #1)). He (NA #1) normally works up front, but he filled in Monday night / Tuesday morning here (on the secure unit). She told the same story to the Unit Manager. The Surveyor stated to RN #1, I am reporting an abuse allegation to you; what would be your responsibility with this allegation? She responded, Since it went directly to the unit manager yesterday, I would assume she suspended him and started an investigation. c. On 12/12/18 at 12:05 p.m., as the surveyor was speaking to RN #1, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Licensed Practical Nurse (LPN) #1 all came down the hall and took Resident #8 into her room to speak to her. The surveyor asked LPN #1 what Resident # 8 reported to her yesterday and she stated, She said the little (derogatory term) boy was a little rough when he transferred me Monday night (referring to Nurse Aide (NA) #1). I reported this to ADON approximately 2 PM - 3 PM early afternoon yesterday. Normally, he doesn't work back here - I thought she (Resident #8) would have been in bed by the time he came in. He is usually on North 3 PM - 11 PM but he worked back here Monday night 11 PM - 7 am. On 12/12/18 the Human Resource (HR) Director provided a copy of nursing schedule that documented Nursing Assistant (NA) #1 filled in for a CNA (Certified Nursing Assistant) on the 11-7 shift on 12/10/18 and was the only nursing assistant on the secure dementia unit on the 11-7 shift. d. At 12:18 p.m., the DON was asked what was reported to her regarding Resident #8 and she stated, ADON at approximately 3:05 PM yesterday reported (Resident #8) said (NA #1) put her down too fast and wasn't nice to her. The black boy. The DON was asked if any one talked to Resident #8 after this was reported. She stated, No. She was asked if a body audit was completed to check for injury and LPN # 1 stated, not a body audit undressed. The ADON was asked what was reported to her and she stated, (Unit Manager) reported to me at approximately 3 PM yesterday (Resident #8) had reported that the black boy was not nice to her. He moved her a little faster than she would like. I reported to the DON. The DON stated, I didn't know about all this. I just got her witness statement. (NA #1) was not here yesterday we are lucky. He is not returning I am firing him. I don't want anyone working here who would do this. I will take responsibility for any failure on our part. It was reported to me that the CNA (Certified Nursing Assistant) moved her too fast on to the toilet. I did not see that as abuse and did not follow up. I see now that we should have asked more questions. e. The DMS (Division for Medical Services) 7734, Incident and Accident Same Day Reporting Form documented, .Date Submitted 12/12/18 13:00 (1:00) pm . Steps taken to prevent continued abuse or neglect during investigation . C.N.A. (NA #1) suspended immediately . f. On 12/12/18 at 1:20 p.m., the Administrator stated, I did not receive this allegation . Yes, that should have been reported yesterday and I have just sent in the 7734 (Office of Long Term Care Incident and Accident form). Nothing has been done until now. The investigation will begin. g. On 12/12/18 at 3:20 p.m., Resident #8 was asked if she had any pain from the incident with the CNA assisting her to the toilet Monday night and she stated, I have pain all the time in my knees and ankles; it's hard to tell if it is any different, but I was very nervous, anxious after that situation. I couldn't concentrate on anything. I was very nervous. h. On 12/12/18 at 5:00 p.m., the Administrator stated, We now have 3 new [MEDICATION NAME] (allegations of abuse) from this allegation, investigation, witness statements from 2 other residents and one CNA. 2. An Office of Long Term Care (OLTC) Incident & (and) Accident Next Day Reporting Form documented, Date & Time of Discovery: 12/12/18 at 12:15 p.m . Name of Resident: (Resident #9) . On 12/12/18 at about 15:35 (3:35 p.m.) PM during interviews with staff a staff member stated that (NA #1) during shift report told her that he got beat up by 3 female residents and he had to put one of them on the floor and put her hands on her back. The facility identified the alleged victim in this allegation as Resident #9. 3. Resident #3 had [DIAGNOSES REDACTED]. An Annual MDS with ARD of 10/29/18 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS; required set-up assistance of one person for transfers, ambulation, dressing, and eating; and was always continent of bowel and bladder. a. On 12/12/18 at 4:31 p.m., the resident was asked, Do you know about any situations involving (NA #1) and residents? The resident stated, On a previous time, he took us out to smoke, a group, I said something smart and he didn't like it, and NA #1 said, 'if you say it one more time, I'll take you to the nurses station and you won't smoke again'. The resident was asked, Did you report this to anyone? The resident stated, I did not report it when it happened, but I filled out a statement today; (RN #1) had me fill out a statement. b. An OLTC Witness Statement Form was completed by the resident on 12/12/18 at 2:45 p.m. On 12/12/18 at 4:48 p.m., the Administrator was notified of Resident #3's interview and was asked about a witness statement. The Administrator stated, I don't know anything about it; I just got the reports and haven't read them yet. The resident's allegation was not immediately reported to the Administrator by staff, as required. c. On 12/12/18 at 4:50 p.m., the DON stated, (NA #1) has only worked (secure dementia unit) once, but has taken the residents out to smoke on many different occasions. d. On 12/13/18 at 8:35 a.m., RN #1 was asked, Did you take a witness statement from (Resident #3) on 12/12/18? RN #1 stated, yes. RN #1 was asked, Did you read it? RN #1 stated, Yes. RN #1 was asked, Do you think a staff member threatening a resident is considered abuse? RN #1 stated, yes. RN #1 was asked, Did you report it? RN #1 stated, No, if he had physically. I knew the witness statement would go directly to the Administrator. I went over it with (Resident #3), read it, and I turned it over to (LPN #1, Unit Manager) and then started giving report. RN #1 was asked, What time were you giving report? RN #1 stated, At shift change, that's usually around 3:00 p.m., and yeah, I just handed it to (LPN #1). e. On 12/13/18 at 9:38 a.m., a telephone interview was conducted with LPN #1. LPN #1 was asked, Did you take a witness statement from (Resident #3) on 12/12/18? LPN #1 stated, The nurse (RN #1) handed it to me; it was hard to read. I got to page 3 and laid it down, and then someone came and got it. LPN #1 was asked, What time did this happen? LPN #1 stated, Change of shift, around 3 p.m. LPN #1 was asked, Did you read it? LPN #1 stated, I did not finish reading it. LPN #1 was asked, Do you think a staff member threatening a resident is considered abuse? LPN #1 stated, Yes. 4. Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The MDS with an ARD of 11/28/18 documented the resident scored 3 (0-7 indicates severely impaired in cognitive skills) on a BIMS and required extensive assistance of 2 persons for bed mobility and transfers. a. An OLTC Incident and Accident Report dated as submitted to OLTC on 12/12/18 at 17:16 (5:16 p.m.) documented, On 12/12/18 at 1:55 p.m. during an abuse investigation, (Resident #10) reported that (NA # 1) 'threw her down in her chair while transferring'. b. On 12/13/18 at 2:35 p.m., Resident #10 stated she had been in the facility about 3 weeks and she likes the facility. She stated, I hit my knee on something when he (NA #1) tried to transfer me into the chair. I told him it hurt - my right knee started hurting after it happened. The resident raised up her right pant leg and there were scratches on her right knee. The resident was asked, How did that make you feel? She stated, It always makes me mad, 'cause if you had a knee and it felt like this, you wouldn't want to be treated like that. Maybe this will wake them up to what is going on. 5. Resident #1 had a [DIAGNOSES REDACTED]. a. An OLTC Incident and Accident Same Day Reporting From (I&A) documented, . date and time submitted: 11/27/18 11:30 a.m Date of I&A 10/01/18 Time: unknown . Summary of Incident . On 11/27/18 at 1000 am (Resident #1's) daughter-in-law (name) was speaking to Administrator, DON, ADON, and Social Worker regarding the care of (Resident #1). She (daughter-in-law) mentioned that when her sister-in-law, (name), was here visiting her mother on (MONTH) 1, (YEAR) she thought her mother had been raped at some point Steps taken to prevent continued abuse or neglect during the investigation . Abuse in-service initiated with staff in 11/27/18 . 6. Witness statements are being obtained from all staff who worked during the shift prior to the incident. 7. DON and floor nurse checked resident for signs of abuse. None were found. The facility took appropriate measures to report and protect; however, there was no documentation that interviews were conducted with other residents to determine if they had any knowledge regarding the allegation. b. On 12/13/18 at 4:21 p.m., the Administrator was asked if any residents were interviewed during the investigation of the allegations for Resident #1. The Administrator stated, No, we did not interview any residents. c. The facility policy statement for Abuse investigation protocol documented, Interview other residents to whom the accused employee provides care or services to determine if there have been any complaints of abuse . Interview the resident's roommate. 7. On 12/13/18 at 6:12 p.m., the immediate jeopardy was removed and the scope and severity lowered to an E after implementing the following plan of removal: a. Completed witness statement from the residents b. Completed witness statements from all staff that worked on (MONTH) 11 and 12, (YEAR) c. Completed witness statements from all interviewable residents in the facility. d. Treatment nurse completed body audits on all residents in the facility (completed on 12/13/18) e. Suspended the unit manager for 3 working days for not communicating the incident as an abuse allegation. f. Called the accused party to come in and gave his statement of events. g. Accused party was immediately put on suspension until investigation is complete. h. DON and Administrator started in servicing all staff on proper abuse reporting. (Not complete on 12/13/18) i. Quality assurance plan was started on 12/12/18 that included staff training on timely reporting of abuse to the administrator. All staff will be trained prior to their next shift and calling all weekend and PRN (as needed) staff to come into the facility for their training prior to the employee next shift. j. Administrator /designee will monitor daily for the identification of new reportable during I & A review and morning stand up meeting.

Complaint # (AR 678) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure supervision was provided to prevent actual elopement for Resident #1 and potential elopement for Resident #2, to include interventions, monitoring and staff education, to prevent potential injury for 2 (Residents #1 and #2) of 2 case mix residents who exhibited exit-seeking behaviors. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who had exited the facility on 3 occasions prior to an elopement on 6/27/18 when the resident was found propelling her wheelchair in the street, and Resident #2, who exhibited exit-seeking behaviors that were not communicated to other staff members involved in the resident's care. The failed practices had the potential to affect only these 2 residents, the only residents with exit-seeking behaviors, as reported by the Director of Nursing (DON) on 6/28/18 at 3:40 PM. The facility Administrator was notified of the Immediate Jeopardy on 6/28/18 at 11:35 a.m. The findings are: 1. The facility's Elopement Policy and Procedure, provided by the Director of Nursing (DON) on 6/28/18 at 11:00 a.m., documented, Elopements Policy Statement Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall; a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. (such as), Emergency Management, Rescue Squads, etc. (et cetera)); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete an file an incident report; and f. Document relevant information in the resident's medical record. The elopement policy did not instruct staff on additional monitoring or supervision that should be provided to residents who exhibited exit-seeking behaviors. 2. Resident #1 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/9/18 documented the resident had a BIMS scored 7 (0-7 indicates severely impaired) on a brief interview for mental status, was independent with locomotion on and off the unit, used a wheelchair for mobility, and had wandering behaviors. a. The Care Plan no dated, printed 6/28/18 documented, .The resident is an elopement risk r/t (related to) history of attempts to leave facility unattended .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. b. A Nurses Note dated 5/1/18 at 4:53 a.m. documented, Confused, wanting to go home. Trying to open PT (Physical Therapy) door and front door. Redirection effective for an hour or two. Reminded resident she had gone out on pass with family this past weekend. That now she is back home and showed her, her room . c. A Nurses Note dated 5/2/18 at 8:12 p.m. documented, Resident has been exit seeking all this evening - trying to get visitors to hold door, trying to guess code .etc. She states she has to 'get home' - easily redirected . d. A Nurses Note dated 5/5/18 at 12:29 p.m. documented, Resident eloped out the front door when another family member was leaving. Went down wheelchair accessible ramp and was noticed by staff and redirected into facility. e. A Nurses Note dated 5/11/18 at 2:57 p.m. documented, Up in w/c (wheelchair) this shift. going to front door looking out. 'How do I get out of here' R/O (re-oriented) to her room and that she lives here and her family comes and visits her . f. A Nurses Note dated 5/13/18 at 10:42 a.m. documented, Resident found outside after being let out by a different family member. Resident stated going to Jacksonville. Brought back in by staff without difficulty . g. A Nurses Note dated 5/14/18 at 2:32 a.m. documented, Wakeful noc (night) in and out of w/c (wheelchair) tries to open doors to PT room, looking for way out 'to go home' redirected by staff. Easily annoyed. 'I know where my room is' . h. A Social Note dated 5/14/18 at 12:24 p.m. documented, I spoke with resident's son (name) about her door checking and how she has figured how to get out of the facility and had gotten out the door. I explained ever since she had gone out of the facility with them, all she does is door check and wants to go to 'Jacksonville'. We both agreed for her safety, she needs to be in the more secured unit. i. A Nurses Note dated 5/18/18 at 3:01 a.m. documented, .Late entry for 5/17/18 0600 (6:00 a.m.). Resident exit seeking. Trying to open exit door by nurses' station. Wants to 'get out of this dungeon .They put me here and I don't like it' Redirection and reassurance given. j. A Nurses Note dated 5/18/18 at 1:41 p.m. documented, Resident continues to exit seek, going into other residents' rooms and asking them to help her get out . Distraction/redirection constantly required. k. A Nurses Note dated 5/22/18 at 6:33 a.m. documented, .Resident has been up and down all shift wandering the halls and exit seeking . l. A Nurses Note dated 5/22/18 at 4:30 p.m. documented, .continues to go in other residents' rooms and beg them to help her get out which causes other residents to get agitated, requires constant distraction/redirection. m. A Social Note dated 5/23/18 at 11:17 a.m. documented, I called the family asking them to send the permission forms that I had e-mailed to them twice previously. (Daughter-in-law) stated that 'her and her husband had discussed it and decided that they do not want her in the unit and want her moved back up front. They want her last years on earth for her to be able to do what she wants to do.' I explained that she knows how to get out, and we feel she will do it again and the safest place at this time is the unit. (Daughter-in-law) disagreed and said, 'I want her moved back up front tomorrow. I know that your nurses are at the nurse's station, so they can see the front door.' I told her that the nurses and staff are at the dining room during meal service and (Resident #1) goes all over the facility during the day and night. (Daughter-in-law) said, 'I understand that if she gets out again, then we will move her back, but right now we want her up front.' I again told emphasized the safety of the unit and that she needs to be back there. n. A Nurses Note dated 5/24/18 at 2:08 p.m. documented, .Resident has been wandering the halls exit seeking . o. A Nurses Note dated 5/24/18 at 2:45 p.m. documented, Resident actively exit seeking throughout shift. Resident persistently checks all doors that lead to the outside and pushes on exits. Resident redirected with little to no effect. p. A Nurses Note dated 5/24/18 at 9:28 p.m. documented, .Resident has also been going to exit doors and shaking them - then yelling at staff to 'get keys' . q. A Social Note dated 5/30/18 at 9:46 a.m. documented, Resident went to the door and was pushing on it to try and get out. She asked a visitor if she would let her out. Resident was overheard by the Administrator and re-directed down the hall to get a cup of coffee. r. A Social Note dated 5/31/18 at 12:04 p.m. documented, Called (daughter-in-law) and left a message to inform her that resident continues to try and get out the door and is asking people to let her out . Asked her to return my call. s. A written timeline for Resident #1's exit-seeking was provided by the Director of Nursing (DON) on 6/28/18 at 10:31 AM and documented the following: 1.) 5/13/18 (at) 10:42 a.m. Resident found outside after being let out by a different family member. When ask resident where she was going resident stated, 'going to Jacksonville.' Resident was brought back in facility by staff member without difficulty, resident was assessed by RN (Registered Nurse) and no negative finding was found. Staff immediately put signs on the door warning visitors not let anyone else out. 2.) 5/14/18 (at) 2:32 a.m. Resident was trying to enter the PT (Physical Therapy) room when asked what happened resident stated, 'looking for a way out to go home.' Resident was redirected at this time. (At) 12:24 PM Social called and spoke with son about the incident and son (Name) agreed that the best place for the resident at this time was the unit. 3.) 5/16/18 resident remains on the unit adjusting to new environment pleasant and cooperative. 4.) 5/18/18 resident found exit seeking. Resident was redirected. 5.) 5/23/18 Family contacted Social and said they had discussed it and wants (Resident #1) moved back to the front . Social Services explained at that time the concern of safety. Family demanded (Resident #1) to be moved that day. At this time (Resident #1) was moved closer to the nurses' station. 6.) 5/24/18 Resident was exit seeking and redirected. 7.) 5/30/18 Resident exit seeking was asking visitor to open door. Resident was easily redirected with a cup of coffee. 8.) 6/27/18 At approx. (approximately) 11:19 a.m. Resident found out of facility in the road in front of building. Resident brought back by two staff members. Resident immediately assessed by DON . Resident placed on one on one and family notified . Approx 3:00 p.m. resident moved to the secured unit. t. On 6/28/18 at 10:05 a.m., the Administrator was asked if any residents had exited the facility and stated, Yes, (Resident #1) yesterday. He was asked if she was found in the road and stated, Yes. u. On 6/28/18 at 10:30 a.m., after the surveyors reviewed the written timeline for Resident #1, the DON was asked if an elopement risk assessment was done after Resident #1 exited the facility on 5/13/18 and stated, No elopement risk assessments were done immediately following (Resident #1's) elopement on 5/13/18. v. On 6/28/18 at 10:53 a.m., the DON was asked if any in-services had been conducted due to Resident #1's exit seeking behaviors and her actual elopements and stated, We conducted an in-service on 5/15/18 on the elopement policy. The in-service dated 5/15/18, provided by the DON, documented 8 signatures of staff who had attended. The DON was asked if there had been any monitoring or interventions put in place after Resident #1 was moved out of the secure unit on 5/23/18 and stated, No one specific was assigned to her to make sure she did not elope. The DON was asked if any monitoring was put into place and stated, There was no monitoring put in place after she moved out of the unit on (MONTH) 23rd. I'm unsure if another in-service was conducted with staff after (MONTH) 23rd; I'm going to check. w. On 6/28/18 at 11:20 a.m., the DON returned and stated, We have no in-services or monitoring after she was moved off the unit on (MONTH) 23rd. x. On 6/28/18 at 11:40 a.m., Certified Nurse Assistant (CNA) #1 was asked about the incident on 6/27/18 regarding Resident #1 being found in the street. The CNA stated, I was one of the people who saw (Resident #1) in her wheelchair in the road, in the south bound lane closest to the facility, across from the church. Me and (CNA #2) were in our car coming back from lunch at 11:24 (a.m.) I know the time because I had picked up my phone to call the facility and then I saw (MDS Coordinator) coming out of the front door. By the time we got to her she was in the turn lane going toward the church. A car swerved to miss her. The car slowed down, but did not stop. We stopped our car and (CNA #2) got out and pushed her to the facility front door. The CNA was asked if she and the other staff had been educated on what to do for Resident #1. The CNA stated, There's not been anything special put in place, other than one on one yesterday before she was moved back on the unit. The CNA was asked if she had been in-serviced on what to do for residents with exit seeking behaviors and stated, No, I've not been instructed on what to do with residents with exit seeking behaviors. The CNA was asked if she was aware of any other residents with exit seeking behaviors and stated another resident's name and, She attempts to get out - she pushes on the doors - but to my knowledge she hasn't gotten out. This resident was added to the case mix as Resident #2. y. On 6/28/18 at 2:00 p.m., CNA #2 was asked about the incident with Resident #1 being found in the street on 6/27/18 and stated, Me and (CNA #1) went to lunch yesterday at about 10:58 (a.m.) to 11:00 (a.m.). I clocked out for lunch . on our way back to the facility, as (we were) approaching the facility . noticed (Resident #1) in the middle of the street. I didn't see her at first; the car in front of us went around her. By the time I got out of the car and got to her, she was in the turning lane . z. On 6/28/18 at 2:10 p.m., the MDS Coordinator was asked if she observed Resident #1 outside on 6/27/18 and stated, Approximately 11:20 a.m., I clocked out to go home. I had been here since 11 p.m. the night before. I clocked and stopped at the ADON (Assistant Director of Nursing) office to let her know I was leaving. I was there less than 5 minutes. Went to go out the front door. I saw (Resident #1) after I got out the front door on the way to my car. (CNA #2) yelled my name. They were stopping their car, him and (CNA #1). I had not seen her before he yelled at me. She was in the street almost directly in front of the facility. I couldn't tell what lane she was in. I was headed over there, but (CNA #2) already had her, pushing her on the sidewalk. The MDS Coordinator was asked what interventions and/or education was done after this incident. She stated, I know we moved her to the unit and did elopement assessment on everybody today. She was asked when the assessments were done. She stated, After you surveyors got here. aa. On 6/28/18 at 3:42 p.m., the DON was asked how the in-services were conducted after any incidents and stated, All the in-services are put in a book at the nurses station by date, and the newest ones are flagged. The in-service from 5/15/18 and the one for 6/27/18 were both put in the in-service book. The one today has been in person, face-to-face, to the ones here and as they are coming into work. The DON was asked why there was no documentation regarding Resident #1's elopement except for the timeline she had typed and provided to the surveyors and stated, I don't know. bb. On 6/29/18 at 10:40 a.m., Licensed Practical Nurse (LPN) #1 was asked if she had been Resident #1's nurse on 6/27/18 when she was found in the street and what documentation she had done regarding the incident. The LPN stated, I was the nurse on duty on 6/27 when (Resident #1) was found in the street. I wasn't the one who found her out there, so when they brought her in, they immediately brought her to me. I didn't write about her getting outside, because I didn't find her out there. I did an assessment when they brought her back in. The LPN was asked if she had been in-serviced regarding what to do if a resident has exit seeking behaviors. The LPN stated, I don't recall any in-service regarding what to do if a resident has exit seeking behaviors . have been in-serviced on what to do after they elope. She was asked if she had notified the resident's physician of the elopement and stated, I don't recall that I did. She was asked if there had been an Incident/Accident Report completed and stated, No. cc. On 6/29/18 at 10:33 a.m., the DON was asked about the incident on 5/5/18 when Resident #1 had exited the facility and stated, I didn't know anything about it. This is the first I heard of it. The DON was asked if the Nurse's Notes were reviewed and stated, Yes, that would have been (MDS Coordinator's) hall to review. dd. On 6/29/18 at 10:55 a.m., the MDS Coordinator was asked if she would have been the person responsible for reviewing Resident #1's Nurse's Notes from 5/5/18 and what was done regarding the resident exiting the facility on 5/5/18 and stated, I would have been the one responsible for reviewing the Nurse's Notes on 5/5/18. I didn't notice it, and it wasn't flagged. She was asked if she had access to all notes, whether flagged or not, and stated, I have access to all notes, flagged or not. She was asked if this incident was communicated to all staff and stated, I don't know that this was passed on to anyone. I wasn't aware of it. ee. On 6/29/18 at 10:48 a.m., LPN #2 was asked if she had reported the incident on 5/5/18 when Resident #1 eloped from the facility. She stated, I reported the incident with her exiting the facility on (MONTH) 5th to our weekend RN (Registered Nurse) Supervisor. The family member of another resident came and told another nurse that, 'The lady in the wheelchair went out, and I don't think she was supposed to'. That nurse doesn't work here anymore. She went and got her before she got to the street. I talked to her, and she said she was going to Mississippi. I made sure she didn't go back outside and placed a handwritten note on the front door to not let our residents out. ff. On 6/29/18 at 11:50 a.m., the DON and Regional Nurse Consultant were asked if there had been any Incident/Accident reports completed for Resident #1's elopements and they both stated, No. 3. Resident #2 had [DIAGNOSES REDACTED]. The MDS with an ARD of 4/9/18 documented the resident scored 10 (7-12 indicates moderately impaired) on a BIMS, required limited assistance of one person for ambulation in and out of room and locomotion on and no wandering behavior exhibited. a. A Care Plan dated 4/3/18 documented, .The resident is at risk for elopement risk/wanderer . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . b. A Nurses Note dated 6/27/18 at 11:47 p.m. documented, Follow up for fall x (times) 2 and [MEDICATION NAME] dosage reduction . Resident has been awake and wandering around facility all evening and is still awake at 0000 (12 midnight). Trying to get out exit doors, going into other resident's rooms and waking them up to ask if they have a car . etc. When staff attempts to redirect or reassure she tells staff to 'shut up and go away' or laughs and rolls away . c. A Nursing Elopement Risk with Care Plan dated 6/28/18 at 8:05 a.m. documented, .Resident does not show s/s (signs and symptoms) of elopement risk at this time, resident does wander from room to room at times, redirection effective . d. On 6/28/18 at 11:40 a.m., CNA #1 was asked about the resident and reported that Resident #2 had multiple attempts of exit seeking behaviors. e. On 6/28/18 at 3:27 p.m., LPN #3 was asked about Resident #2's attempts to exit the facility on 6/27/18 and stated, Last night, her behaviors haven't been like this in a long time. She recently had a dose reduction in her [MEDICATION NAME]. She was very anxious, very adamant, demanding to go home right now asking us where the doors were, what the codes were. She went to the exit door down by the cafeteria. Had her hands on the door asking for the code. Went down immediately and brought her back. She started this approximately 11:30. We basically kept her till I left at 3:00 this morning. I did not report this to anyone because these were new behaviors of trying to get out the door. I reported this to (LPN #4); she was assigned to that hall. I wasn't assigned to that hall; I was just helping out. I wasn't aware that I was supposed to report this to the DON. I've not been told what to do in that case, just knew what to do if they actually eloped. I don't know if (LPN #4) reported this to the 7 to 3 shift. I now know, I was in-serviced, what to do when I clocked in today; you immediately notify the DON and Administrator to get further directions. I was the only one that knew she actually tried to get out the door. f. On 6/28/18 at 3:40 p.m., LPN #4 was asked about Resident #2's exit seeking behaviors the night of 6/27/18 and stated, She was awake, up in her wheelchair at the nurses station visiting with us, and going down the hall following the girls (CNAs) when they were doing their rounds. We had given her a sandwich and drink; she said she was hungry. We toileted her and tried to put in bed. Every time, she would refuse or get up within 15 minutes. Approximately 5 a.m., she agreed to laying (sic) down. At 6 a.m. she was still awake, but in bed. She was quite pleasant and cooperative. She would try to go into other residents' rooms, but that is normal for her. I'm not aware of her increased agitation, demanding where doors were and codes, or attempts to get out. It might have happened before my shift at 10:45 p.m. I don't recall anyone reporting her trying to get out the exit doors. I didn't report anything to my shift relief. I don't know if she ever attempted to exit before. I think they decreased her [MEDICATION NAME]. She normally sleeps good at night. I check on her frequently, because I never know when she is going to get up. I've been instructed on what to do if someone actually gets outside. I don't recall what to do if a resident has exit seeking behaviors here at (facility name). I just go on my past experience at other facilities. (Resident #1) is the only resident I know actually got out. g. On 6/29/18 at 11:05 a.m., during a phone interview, CNA #3 was asked if she had been told of Resident #2's exit seeking behaviors on 6/27/18 and stated, I worked with (Resident #2) the night of 6/27/18. She wouldn't go to bed. She was hanging out in the lobby with the CNAs. No one directly told me anything about (Resident #2), but I overheard one of the aides tell another aide when she was going on break they need to watch (Resident #2) close. I didn't know why, other than I knew she had fallen earlier. The CNA was asked if she had been in-serviced on residents with exit seeking behaviors and/or elopement and stated, I have not attended an in-service regarding elopement and have not been in-serviced on what to do with residents with exit seeking behaviors. The CNA was asked about the in-service book at the nurse's station and stated, I was not aware of any of these in-services in the book at the nurse's station. 4. The immediate jeopardy was removed on 6/28/18 at 4:12 p.m., and the scope and severity reduced to E when the following plan of removal was implemented: a. On 6/27/18 (at) 11:26 a.m., (Resident #1) was assisted back into the facility and immediately assessed for injury by the charge nurse with none noted. b. On 6/27/18 (at) 11:26 a.m., resident was placed with one on one staff immediately with CNA (name) until moved to the Dementia Care Unit. c. Resident was placed in the Dementia Care Unit on 6/27/18 (at) 3:00 p.m. d. Administrator and DON checked all exit doors on 6/27/18 (at) 11:30 a.m., with no issues identified. e. DON initiated an in-service with all nursing staff on 6/27/18 regarding exit seeking residents near doorway to stay with resident and notify charge nurse. f. All residents with the exception of the residents in the Dementia Care Unit have been assessed for elopement risk on 6/28/18 by the DON/Designee and no other residents are at risk at this time. g. All residents identified in general population that have been assessed as at risk for exit will be placed on every 15-minute checks until the resident is either placed on the Dementia Care Unit or discharged from the facility. h. Any issues identified will be discussed in the daily Stand Up Meeting by the Administrator/Designee Monday thru Friday 5 X (times) week X (times) 3 weeks, then 3 X (times) week X (times) 3 weeks, and weekly in conjunction with QAA (Quality Assessment and Assurance) meeting monthly until substantial compliance is achieved. i. After informed of resident (Resident #2) was documented as exit seeking, resident was placed on one on one until she was moved to the Dementia Care Unit room (room number) 4:00 p.m. on 6/28/18.

Complaint # (AR 678) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility's Administration and Nursing Administration failed to ensure deficient practices related to prevention of resident elopement were promptly identified and corrected, as evidenced by failure to ensure supervision was provided to prevent actual elopement for Resident #1 and potential elopement for Resident #2, to include interventions, monitoring and staff education, to prevent potential injury for 2 (Residents #1 and #2) of 2 case mix residents who exhibited exit-seeking behaviors. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who had exited the facility on 3 occasions prior to an elopement on 6/27/18 when the resident was found propelling her wheelchair in the street, and Resident #2, who exhibited exit-seeking behaviors that were not communicated to other staff members involved in the resident's care. The failed practices had the potential to affect only these 2 residents, the only residents with exit-seeking behaviors, as reported by the Director of Nursing (DON) on 6/28/18 at 3:40 PM. The facility Administrator was notified of the Immediate Jeopardy on 6/28/18 at 11:35 a.m. The findings are: 1. A Job Description for the Administrator, provided by the DON on 6/28/18 at 2:10 p.m., documented, .Purpose of Your Job Position The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our patients at all times. Duties and Responsibilities Administrative Functions . Interpret the facility's policies and procedures to employees . Miscellaneous Functions Ensure that all patients receive care in a manner and in an environment that maintains or enhances their quality of life . 2. A Job Description for the Nurse Supervisor, provided by the DON on 6/28/18 at 2:10 p.m., documented, .Purpose of Your Job Position The primary purpose of your job position is to supervise the day-to-day nursing activities of the facility during your scheduled shifts. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times .Duties and Responsibilities Administrative Functions Participate in maintaining written policies and procedures that govern the day-to-day functions of the nursing service department. Complete accident/incident reports as necessary. Interpret the department's policies and procedures to personnel . Nursing Care Functions . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided . Staff Development Functions Participate in developing, planning, conducting and scheduling in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department. Care Plan and Assessment Functions . Review patient care plans for appropriate patient goals, problems . 3. A Job Description for the Director of Nursing Services, provided by the DON on 6/28/18 at 2:10 p.m., documented, .Purpose of Your Job Position The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Administrator and Medical Director, to ensure that the highest degree of quality of care is maintained at all times. Duties and Responsibilities Administrative Functions Maintain written policies and procedures that govern the day-to-day functions of the nursing service department and ensure that personnel comply with such policies and procedures. Interpret the department's policies and procedures to personnel . Nursing Care Functions . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided . Care Plan and Assessment Functions Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each patient that identifies the problems/needs of the patient, indicates the care to be given, goal to be accomplished, and which professional service is responsible for each element of care as necessary. Review patient care plans for appropriate patient goals, problems . Ensure that all personnel involved in providing care to the patient are aware of the patient's care plan. Review nurses' notes to determine if the care plan is being followed . 4. A Job Description for the Charge Nurse/Shift Supervisor, provided by the DON on 6/28/18 at 2:10 p.m., documented, .Purpose of Your Job Position The primary purpose of your job position is to provide direct nursing care to the patients, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services to ensure that the highest degree of quality care is maintained at all times . Charting and Documentation Functions . Chart all reports of accidents/incidents involving patients. Follow established procedures. Care Plan and Assessment Functions Review care plans daily to ensure that appropriate care is being rendered . 5. The facility's Elopement Policy and Procedure, provided by the Director of Nursing (DON) on 6/28/18 at 11:00 a.m., documented, Elopements Policy Statement Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall; a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. (such as), Emergency Management, Rescue Squads, etc. (et cetera)); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete an file an incident report; and f. Document relevant information in the resident's medical record. The elopement policy did not instruct staff on additional monitoring or supervision that should be provided to residents who exhibited exit-seeking behaviors. 6. Resident #1 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/9/18 documented the resident scored 7 (0-7 indicates severely impaired) on a brief interview for mental status, was independent with locomotion on and off the unit, used a wheelchair for mobility, and had wandering behaviors. a. The Care Plan no dated, printed 6/28/18 documented, .The resident is an elopement risk r/t (related to) history of attempts to leave facility unattended .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. b. A Nurses Note dated 5/1/18 at 4:53 a.m. documented, Confused, wanting to go home. Trying to open PT (Physical Therapy) door and front door. Redirection effective for an hour or two. Reminded resident she had gone out on pass with family this past weekend. That now she is back home and showed her, her room . c. A Nurses Note dated 5/2/18 at 8:12 p.m. documented, Resident has been exit seeking all this evening - trying to get visitors to hold door, trying to guess code .etc. She states she has to 'get home' - easily redirected . d. A Nurses Note dated 5/5/18 at 12:29 p.m. documented, Resident eloped out the front door when another family member was leaving. Went down wheelchair accessible ramp and was noticed by staff and redirected into facility. e. A Nurses Note dated 5/11/18 at 2:57 p.m. documented, Up in w/c (wheelchair) this shift. going to front door looking out. 'How do I get out of here' R/O (re-oriented) to her room and that she lives here and her family comes and visits her . f. A Nurses Note dated 5/13/18 at 10:42 a.m. documented, Resident found outside after being let out by a different family member. Resident stated going to Jacksonville. Brought back in by staff without difficulty . g. A Nurses Note dated 5/14/18 at 2:32 a.m. documented, Wakeful noc (night) in and out of w/c (wheelchair) tries to open doors to PT room, looking for way out 'to go home' redirected by staff. Easily annoyed. 'I know where my room is' . h. A Social Note dated 5/14/18 at 12:24 p.m. documented, I spoke with resident's son (name) about her door checking and how she has figured how to get out of the facility and had gotten out the door. I explained ever since she had gone out of the facility with them, all she does is door check and wants to go to 'Jacksonville'. We both agreed for her safety, she needs to be in the more secured unit. i. A Nurses Note dated 5/18/18 at 3:01 a.m. documented, .Late entry for 5/17/18 0600 (6:00 a.m.). Resident exit seeking. Trying to open exit door by nurses' station. Wants to 'get out of this dungeon .They put me here and I don't like it' Redirection and reassurance given. j. A Nurses Note dated 5/18/18 at 1:41 p.m. documented, Resident continues to exit seek, going into other residents' rooms and asking them to help her get out . Distraction/redirection constantly required. k. A Nurses Note dated 5/22/18 at 6:33 a.m. documented, .Resident has been up and down all shift wandering the halls and exit seeking . l. A Nurses Note dated 5/22/18 at 4:30 p.m. documented, .continues to go in other residents' rooms and beg them to help her get out which causes other residents to get agitated, requires constant distraction/redirection. m. A Social Note dated 5/23/18 at 11:17 a.m. documented, I called the family asking them to send the permission forms that I had e-mailed to them twice previously. (Daughter-in-law) stated that 'her and her husband had discussed it and decided that they do not want her in the unit and want her moved back up front. They want her last years on earth for her to be able to do what she wants to do.' I explained that she knows how to get out, and we feel she will do it again and the safest place at this time is the unit. (Daughter-in-law) disagreed and said, 'I want her moved back up front tomorrow. I know that your nurses are at the nurse's station, so they can see the front door.' I told her that the nurses and staff are at the dining room during meal service and (Resident #1) goes all over the facility during the day and night. (Daughter-in-law) said, 'I understand that if she gets out again, then we will move her back, but right now we want her up front.' I again told emphasized the safety of the unit and that she needs to be back there. n. A Nurses Note dated 5/24/18 at 2:08 p.m. documented, .Resident has been wandering the halls exit seeking . o. A Nurses Note dated 5/24/18 at 2:45 p.m. documented, Resident actively exit seeking throughout shift. Resident persistently checks all doors that lead to the outside and pushes on exits. Resident redirected with little to no effect. p. A Nurses Note dated 5/24/18 at 9:28 p.m. documented, .Resident has also been going to exit doors and shaking them - then yelling at staff to 'get keys' . q. A Social Note dated 5/30/18 at 9:46 a.m. documented, Resident went to the door and was pushing on it to try and get out. She asked a visitor if she would let her out. Resident was overheard by the Administrator and re-directed down the hall to get a cup of coffee. r. A Social Note dated 5/31/18 at 12:04 p.m. documented, Called (daughter-in-law) and left a message to inform her that resident continues to try and get out the door and is asking people to let her out . Asked her to return my call. s. A written timeline for Resident #1's exit-seeking was provided by the Director of Nursing (DON) on 6/28/18 at 10:31 AM and documented the following: 1.) 5/13/18 (at) 10:42 a.m. Resident found outside after being let out by a different family member. When ask resident where she was going resident stated, 'going to Jacksonville.' Resident was brought back in facility by staff member without difficulty, resident was assessed by RN (Registered Nurse) and no negative finding was found. Staff immediately put signs on the door warning visitors not let anyone else out. 2.) 5/14/18 (at) 2:32 a.m. Resident was trying to enter the PT (Physical Therapy) room when asked what happened resident stated, 'looking for a way out to go home.' Resident was redirected at this time. (At) 12:24 PM Social called and spoke with son about the incident and son (Name) agreed that the best place for the resident at this time was the unit. 3.) 5/16/18 resident remains on the unit adjusting to new environment pleasant and cooperative. 4.) 5/18/18 resident found exit seeking. Resident was redirected. 5.) 5/23/18 Family contacted Social and said they had discussed it and wants (Resident #1) moved back to the front . Social Services explained at that time the concern of safety. Family demanded (Resident #1) to be moved that day. At this time (Resident #1) was moved closer to the nurses' station. 6.) 5/24/18 Resident was exit seeking and redirected. 7.) 5/30/18 Resident exit seeking was asking visitor to open door. Resident was easily redirected with a cup of coffee. 8.) 6/27/18 At approx. (approximately) 11:19 a.m. Resident found out of facility in the road in front of building. Resident brought back by two staff members. Resident immediately assessed by DON . Resident placed on one on one and family notified . Approx 3:00 p.m. resident moved to the secured unit. t. On 6/28/18 at 10:05 a.m., the Administrator was asked if any residents had exited the facility and stated, Yes, (Resident #1) yesterday. He was asked if she was found in the road and stated, Yes. u. On 6/28/18 at 10:30 a.m., after the surveyors reviewed the written timeline for Resident #1, the DON was asked if an elopement risk assessment was done after Resident #1 exited the facility on 5/13/18 and stated, No elopement risk assessments were done immediately following (Resident #1's) elopement on 5/13/18. v. On 6/28/18 at 10:53 a.m., the DON was asked if any in-services had been conducted due to Resident #1's exit seeking behaviors and her actual elopements and stated, We conducted an in-service on 5/15/18 on the elopement policy. The in-service dated 5/15/18, provided by the DON, documented 8 signatures of staff who had attended. The DON was asked if there had been any monitoring or interventions put in place after Resident #1 was moved out of the secure unit on 5/23/18 and stated, No one specific was assigned to her to make sure she did not elope. The DON was asked if any monitoring was put into place and stated, There was no monitoring put in place after she moved out of the unit on (MONTH) 23rd. I'm unsure if another in-service was conducted with staff after (MONTH) 23rd; I'm going to check. w. On 6/28/18 at 11:20 a.m., the DON returned and stated, We have no in-services or monitoring after she was moved off the unit on (MONTH) 23rd. x. On 6/28/18 at 11:40 a.m., Certified Nurse Assistant (CNA) #1 was asked about the incident on 6/27/18 regarding Resident #1 being found in the street. The CNA stated, I was one of the people who saw (Resident #1) in her wheelchair in the road, in the south bound lane closest to the facility, across from the church. Me and (CNA #2) were in our car coming back from lunch at 11:24 (a.m.) I know the time because I had picked up my phone to call the facility and then I saw (MDS Coordinator) coming out of the front door. By the time we got to her she was in the turn lane going toward the church. A car swerved to miss her. The car slowed down, but did not stop. We stopped our car and (CNA #2) got out and pushed her to the facility front door. The CNA was asked if she and the other staff had been educated on what to do for Resident #1. The CNA stated, There's not been anything special put in place, other than one on one yesterday before she was moved back on the unit. The CNA was asked if she had been in-serviced on what to do for residents with exit seeking behaviors and stated, No, I've not been instructed on what to do with residents with exit seeking behaviors. The CNA was asked if she was aware of any other residents with exit seeking behaviors and stated another resident's name and, She attempts to get out - she pushes on the doors - but to my knowledge she hasn't gotten out. This resident was added to the case mix as Resident #2. y. On 6/28/18 at 2:00 p.m., CNA #2 was asked about the incident with Resident #1 being found in the street on 6/27/18 and stated, Me and (CNA #1) went to lunch yesterday at about 10:58 (a.m.) to 11:00 (a.m.). I clocked out for lunch . on our way back to the facility, as (we were) approaching the facility . noticed (Resident #1) in the middle of the street. I didn't see her at first; the car in front of us went around her. By the time I got out of the car and got to her, she was in the turning lane . z. On 6/28/18 at 2:10 p.m., the MDS Coordinator was asked if she observed Resident #1 outside on 6/27/18 and stated, Approximately 11:20 a.m., I clocked out to go home. I had been here since 11 p.m. the night before. I clocked and stopped at the ADON (Assistant Director of Nursing) office to let her know I was leaving. I was there less than 5 minutes. Went to go out the front door. I saw (Resident #1) after I got out the front door on the way to my car. (CNA #2) yelled my name. They were stopping their car, him and (CNA #1). I had not seen her before he yelled at me. She was in the street almost directly in front of the facility. I couldn't tell what lane she was in. I was headed over there, but (CNA #2) already had her, pushing her on the sidewalk. The MDS Coordinator was asked what interventions and/or education was done after this incident. She stated, I know we moved her to the unit and did elopement assessment on everybody today. She was asked when the assessments were done. She stated, After you surveyors got here. aa. On 6/28/18 at 3:42 p.m., the DON was asked how the in-services were conducted after any incidents and stated, All the in-services are put in a book at the nurses station by date, and the newest ones are flagged. The in-service from 5/15/18 and the one for 6/27/18 were both put in the in-service book. The one today has been in person, face-to-face, to the ones here and as they are coming into work. The DON was asked why there was no documentation regarding Resident #1's elopement except for the timeline she had typed and provided to the surveyors and stated, I don't know. bb. On 6/29/18 at 10:40 a.m., Licensed Practical Nurse (LPN) #1 was asked if she had been Resident #1's nurse on 6/27/18 when she was found in the street and what documentation she had done regarding the incident. The LPN stated, I was the nurse on duty on 6/27 when (Resident #1) was found in the street. I wasn't the one who found her out there, so when they brought her in, they immediately brought her to me. I didn't write about her getting outside, because I didn't find her out there. I did an assessment when they brought her back in. The LPN was asked if she had been in-serviced regarding what to do if a resident has exit seeking behaviors. The LPN stated, I don't recall any in-service regarding what to do if a resident has exit seeking behaviors . have been in-serviced on what to do after they elope. She was asked if she had notified the resident's physician of the elopement and stated, I don't recall that I did. She was asked if there had been an Incident/Accident Report completed and stated, No. cc. On 6/29/18 at 10:33 a.m., the DON was asked about the incident on 5/5/18 when Resident #1 had exited the facility and stated, I didn't know anything about it. This is the first I heard of it. The DON was asked if the Nurse's Notes were reviewed and stated, Yes, that would have been (MDS Coordinator's) hall to review. dd. On 6/29/18 at 10:55 a.m., the MDS Coordinator was asked if she would have been the person responsible for reviewing Resident #1's Nurse's Notes from 5/5/18 and what was done regarding the resident exiting the facility on 5/5/18 and stated, I would have been the one responsible for reviewing the Nurse's Notes on 5/5/18. I didn't notice it, and it wasn't flagged. She was asked if she had access to all notes, whether flagged or not, and stated, I have access to all notes, flagged or not. She was asked if this incident was communicated to all staff and stated, I don't know that this was passed on to anyone. I wasn't aware of it. ee. On 6/29/18 at 10:48 a.m., LPN #2 was asked if she had reported the incident on 5/5/18 when Resident #1 eloped from the facility. She stated, I reported the incident with her exiting the facility on (MONTH) 5th to our weekend RN (Registered Nurse) Supervisor. The family member of another resident came and told another nurse that, 'The lady in the wheelchair went out, and I don't think she was supposed to'. That nurse doesn't work here anymore. She went and got her before she got to the street. I talked to her, and she said she was going to Mississippi. I made sure she didn't go back outside and placed a handwritten note on the front door to not let our residents out. ff. On 6/29/18 at 11:50 a.m., the DON and Regional Nurse Consultant were asked if there had been any Incident/Accident reports completed for Resident #1's elopements and they both stated, No. 7. Resident #2 had [DIAGNOSES REDACTED]. The MDS with an ARD of 4/9/18 documented the resident scored 10 (7-12 indicates moderately impaired) on a BIMS, required limited assistance of one person for ambulation in and out of room and locomotion on and no wandering behavior exhibited. a. A Care Plan dated 4/3/18 documented, .The resident is at risk for elopement risk/wanderer . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . b. A Nurses Note dated 6/27/18 at 11:47 p.m. documented, Follow up for fall x (times) 2 and [MEDICATION NAME] dosage reduction . Resident has been awake and wandering around facility all evening and is still awake at 0000 (12 midnight). Trying to get out exit doors, going into other resident's rooms and waking them up to ask if they have a car . etc. When staff attempts to redirect or reassure she tells staff to 'shut up and go away' or laughs and rolls away . c. A Nursing Elopement Risk with Care Plan dated 6/28/18 at 8:05 a.m. documented, .Resident does not show s/s (signs and symptoms) of elopement risk at this time, resident does wander from room to room at times, redirection effective . d. On 6/28/18 at 11:40 a.m., CNA #1 was asked about the resident and reported that Resident #2 had multiple attempts of exit seeking behaviors. e. On 6/28/18 at 3:27 p.m., LPN #3 was asked about Resident #2's attempts to exit the facility on 6/27/18 and stated, Last night, her behaviors haven't been like this in a long time. She recently had a dose reduction in her [MEDICATION NAME]. She was very anxious, very adamant, demanding to go home right now asking us where the doors were, what the codes were. She went to the exit door down by the cafeteria. Had her hands on the door asking for the code. Went down immediately and brought her back. She started this approximately 11:30. We basically kept her till I left at 3:00 this morning. I did not report this to anyone because these were new behaviors of trying to get out the door. I reported this to (LPN #4); she was assigned to that hall. I wasn't assigned to that hall; I was just helping out. I wasn't aware that I was supposed to report this to the DON. I've not been told what to do in that case, just knew what to do if they actually eloped. I don't know if (LPN #4) reported this to the 7 to 3 shift. I now know, I was in-serviced, what to do when I clocked in today; you immediately notify the DON and Administrator to get further directions. I was the only one that knew she actually tried to get out the door. f. On 6/28/18 at 3:40 p.m., LPN #4 was asked about Resident #2's exit seeking behaviors the night of 6/27/18 and stated, She was awake, up in her wheelchair at the nurses station visiting with us, and going down the hall following the girls (CNAs) when they were doing their rounds. We had given her a sandwich and drink; she said she was hungry. We toileted her and tried to put in bed. Every time, she would refuse or get up within 15 minutes. Approximately 5 a.m., she agreed to laying (sic) down. At 6 a.m. she was still awake, but in bed. She was quite pleasant and cooperative. She would try to go into other residents' rooms, but that is normal for her. I'm not aware of her increased agitation, demanding where doors were and codes, or attempts to get out. It might have happened before my shift at 10:45 p.m. I don't recall anyone reporting her trying to get out the exit doors. I didn't report anything to my shift relief. I don't know if she ever attempted to exit before. I think they decreased her [MEDICATION NAME]. She normally sleeps good at night. I check on her frequently, because I never know when she is going to get up. I've been instructed on what to do if someone actually gets outside. I don't recall what to do if a resident has exit seeking behaviors here at (facility name). I just go on my past experience at other facilities. (Resident #1) is the only resident I know actually got out. g. On 6/29/18 at 11:05 a.m., during a phone interview, CNA #3 was asked if she had been told of Resident #2's exit seeking behaviors on 6/27/18 and stated, I worked with (Resident #2) the night of 6/27/18. She wouldn't go to bed. She was hanging out in the lobby with the CNAs. No one directly told me anything about (Resident #2), but I overheard one of the aides tell another aide when she was going on break they need to watch (Resident #2) close. I didn't know why, other than I knew she had fallen earlier. The CNA was asked if she had been in-serviced on residents with exit seeking behaviors and/or elopement and stated, I have not attended an in-service regarding elopement and have not been in-serviced on what to do with residents with exit seeking behaviors. The CNA was asked about the in-service book at the nurse's station and stated, I was not aware of any of these in-services in the book at the nurse's station. 8. The immediate jeopardy was removed on 6/28/18 at 4:12 p.m., and the scope and severity reduced to E when the following plan of removal was implemented: a. On 6/27/18 (at) 11:26 a.m., (Resident #1) was assisted back into the facility and immediately assessed for injury by the charge nurse with none noted. b. On 6/27/18 (at) 11:26 a.m., resident was placed with one on one staff immediately with CNA (name) until moved to the Dementia Care Unit. c. Resident was placed in the Dementia Care Unit on 6/27/18 (at) 3:00 p.m. d. Administrator and DON checked all exit doors on 6/27/18 (at) 11:30 a.m., with no issues identified. e. DON initiated an in-service with all nursing staff on 6/27/18 regarding exit seeking residents near doorway to stay with resident and notify charge nurse. f. All residents with the exception of the residents in the Dementia Care Unit have been assessed for elopement risk on 6/28/18 by the DON/Designee and no other residents are at risk at this time. g. All residents identified in general population that have been assessed as at risk for exit will be placed on every 15-minute checks until the resident is either placed on the Dementia Care Unit or discharged from the facility. h. Any issues identified will be discussed in the daily Stand Up Meeting by the Administrator/Designee Monday thru Friday 5 X (times) week X (times) 3 weeks, then 3 X (times) week X (times) 3 weeks, and weekly in conjunction with QAA (Quality Assessment and Assurance) meeting monthly until substantial compliance is achieved. i. After informed of resident (Resident #2) was documented as exit seeking, resident was placed on one on one until she was moved to the Dementia Care Unit room (room number) 4:00 p.m. on 6/28/18.