Every finding on record at Woodland Springs Nursing Center

Based on interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and hazards.The facility failed to ensure Resident #1 did not elope from the facility through his room window after disabling the alarm and leave through a back gate that was unlatched and walk two blocks to a corner store that's a high crime area at a busy intersection. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 02/18/2026 and ended on 02/24/2026. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for accidents, injuries, and hospitalization that could lead to death. Findings included: Record review of Resident #1's admission record dated 02/27/2026, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 diagnoses included: unspecified dementia (loss of memory), unspecified mood disorder, and primary hypertension(high blood pressure). Record review of Resident #1's Quarterly MDS assessment, dated 12/02/2025, revealed the resident had a BIMS score of 3 which indicated the resident had severe cognitive impairment.Record review of Resident #1's care plan, dated 02/27/2026, revealed Resident #1 was care planned for impaired cognitive function due to dementia. Resident #1 was care planned for elopement with interventions of redirecting Resident #1 and educating him on the protocol and hazards of leaving the facility. Review of most recent Elopement Risk Assessment dated 10/19/2025, revealed Resident #1 was at risk for elopement due to dementia. Review of elopement incident report dated 02/18/2026 at 7:31 p.m. written by the ADM reflected Resident #1 eloped through the back gate after an argument with POA. Resident #1 was assessed head -to-toe no injuries observed. The incident was reported to the DON, Administrator, Nurse Practitioner, and the family. The staff in the facility was alerted, and the facility was searched. Approximately 20 minutes later, the resident was located in front of the facility carrying a beer. He was escorted back to the facility and placed on one-on-one monitoring. All preventive measures were initiated, including in-service training for the staff. Review of Resident #1's nursing progress note dated 02/18/2026 written by LVN A at 7:00 pm, reflected At approximately 6:45 pm resident at nurse's station yelling and stating he is [AGE] years old, can leave if he wants, and requesting staff to get him a beer. Resident verbalized that he is not in jail and staff cannot keep him in the unit. Attempts were made to verbally redirect residents without success. Resident's POA was notified and spoke with the resident via telephone. During phone conversation, resident became increasingly agitated, yelling at POA, and then returned to his room while continuing to argue. After phone call was conducted, this nurse went to the resident's room to reassess and found resident not present. Bathroom and closet checked, resident not located. Window noted to be closed; however, window screen observed to be pushed back. This nurse immediately proceeded outside the secure unit to search the premises. Secure unit gate found ajar. DON Administrator, and Nurse Practitioner notified immediately of suspected elopement. Approximately 20 minutes later, resident returned to the facility independently carrying a beer and was escorted back to the secure unit by staff without incident. Head-to-toe assessment completed. No injuries noted. Vital signs obtained and within normal limits. Resident alert and oriented to baseline. Resident stated he just wanted to get a beer. Resident placed on 1:1 monitoring per staff for safety and to prevent further elopement attempts. Staff currently monitoring the resident closely. Will continue to monitor and report any changes in condition or behavior. In an interview with Resident #1 on 02/27/2026 at 9:45 a.m., he stated he could not recall the date and time when he used a butter knife from lunch to take the bolts out his room window to be able to climb out the window and slide under the privacy fence to go the [NAME] store to get a beer. Resident # 1 stated he was bored and thought about going out of the window to the corner store to get a beer because he felt like he was in prison. Resident #1 stated he was not able to go anywhere without staff always monitoring and watching him. Resident # 1 stated after he climbed out the room window he closed the window back down. Resident # 1 stated he learned how to remove bolts from windows from the east side of San [NAME]. Resident # 1 stated he slid his body under the bottom of the fence because he wanted to go to the [NAME] store to get a beer. Resident #1 stated he was not afraid of the neighborhood in his hometown where he went to the [NAME] store to get beer and tacos. Resident # 1 stated he was in his hometown where he was familiar and did not know he was in his hometown Resident #1 stated that the [NAME] store was just a couple of blocks down the street and he was not gone from the facility for no more than 20 minutes. Resident #1 stated when he returned to the facility staff had been looking for him.In an interview with the DON on 02/27/2026 at 11:00 a.m., she stated when the surveyor came in on 02/27/202 the elopement had been corrected. The DON stated received her elopement training with the corporate nurse on 02/18/2026. The DON stated all staff were provided elopement training by 02/24/2026. The DON stated all facility residents elopement assessments were completed on. 02/24/2026. The DON stated care plans were updated, elopement drills completed, and an additional alarm was placed on the secured gate on the secured unit on 02/24/2026. The DON stated all residents on the secured unit along with the other residents' rooms windows were checked. The DON stated the elopement binder was updated on 02/18/2026 to make sure all residents at risk for elopement were in the binder. The DON stated the IDT met on 02/23/2026 and determined to continue 1 to 1 with Resident #1 until the additional alarm was placed on 02/24/2026. In an interview with the Nurse Practitioner on 02/27/2026 at 4:14 p.m., the Nurse Practitioner stated Resident #1 had a BIMS of 3 and was placed on the secured unit for exit seeking. The Nurse Practitioner stated that Resident #1 posed a danger to himself and most likely would get lost due to his dementia if he left the facility unattended.In an interview with the Medical Doctor on 02/27/2026 at 4:40 p.m., the Medical Doctor stated that Resident # 1 was placed on the secured unit for exit seeking behaviors. The Medical Doctor stated that Resident # 1 had a BIMS score of 3 and was not safe leaving the secured unit as Resident #1 was not able to fully understand consequences or actions of what could happen when he had left the facility. The Medical Doctor stated when Resident # 1 went out the window he did not know the consequences of being outside in the dark in an area he was not familiar with. The Medical Doctor stated that Resident was not able to do IDLs which is the lack of function to take care of himself day to day, The Medical Doctor stated Resident # 1 was not able to carry out a normal adult life due to dementia. The Medical Doctor stated that Resident #1's dementia was not getting better and it was not safe for Resident #1 when he left the facility because he could have ended up hurt.In an interview with Maintenance Supervisor on 02/27/2026 at 5:39 p.m., the Maintenance Supervisor stated he was not at the facility when Resident #1 left the facility. The Maintenance Supervisor stated he could not recall the exact date he received a call from the ADM informing him Resident #1 had left the facility. The Maintenance Supervisor stated he searched for Resident #1 along the way to the facility and Resident # 1 retuned around 7:30 pm. The Maintenance Supervisor stated it was determined that the secured unit gate magnet did not latch properly. He stated Fire, safety was called out, and additional alarm was placed on the gate 02/24/2026. The Maintenance Supervisor stated the Maintenance Worker were responsible to make sure the gate was working properly and was expected to check the window and gate alarms daily for malfunction. The Maintenance Supervisor stated he received elopement training on 02/19/2026, with the DON over what to do when there was an elopement, making sure all magnets on the gates catch to make sure they are locked, and to make sure windows and gates are checked daily.In an interview with LVN A on 02/27/2026 at 7:07 p.m., LVN A stated she could not recall the exact date last week she called Resident #1 POA because he wanted to leave the facility. She said Resident # 1 stated he was grown and asked why he could not leave the facility. LVN A stated a little before 7:00 pm she called Resident #1's POA by phone to help settle Resident # 1 down. LVN A stated Resident # 1 got more upset and yelled he was [AGE] years old and could leave if he wanted and requested beer. LVN A stated that Resident # 1then got off the phone with his POA shortly after and she was on the phone with Resident #1's POA a couple of minutes after 7:00 pm and then went to Resident # 1's room to check on him and he was not there. LVN A stated she checked Resident #1's room, bathroom, closet, and the window. LVN A stated the window was shut and she was not able to tell the bottom part of the screen was pushed out. LVN A stated she contacted the ADM, DON, Nurse Practitioner that Resident #1was missing, she then went outside, and the secured gate was wide open. LVN A stated she immediately started searching for Resident #1 outside of the facility. LVN A stated Resident # 1 returned to the facility 20 minutes later with a beer in his hand after going to the corner store a couple blocks down the street from the facility. LVN A stated Resident # 1 was placed on 1on 1 supervision until the secured gate was fixed on 02/24/2026. LVN A stated she received elopement training the same night of the elopement on 02/18/2026 with the DON. LVN A stated she was trained on the elopement protocol, what to do in case of elopement, and to make sure all residents are accounted for. An interview with the DON on 02/27/2026 at 7:55 p.m., the DON stated she was not at the facility when Resident #1 went out the secured gate when the latch did not close properly on 02/18/2026 around 7:00 pm. The DON stated it was expected for the maintenance worker to make sure the secured gate latched completely when it was last used around 3:00 pm. The DON stated this could have resulted in harm if Resident #1 had been hit by a car and it was dark outside. The DON stated she completed her elopement training with the corporate nurse on 02/18/2026. The DON stated that the elopement training was over the elopement protocol and what to do when there was an elopement. An interview with the ADM on 02/27/2026 at 8:10 p.m., the ADM stated Resident # 1 went out the secured gate that had a latch malfunction on 02/18/2026 a little before 7:00 pm .The ADM stated that Resident #1 could have experienced a negative outcome with harm if he was injured or did not come back to the facility . The ADM stated it was expected for the maintenance worker to make sure the gate was latched properly when it was last gone out earlier that day on 02/18/2026 around 3:00 pm. The ADM stated all staff elopement training had been completed by survey entrance on 02/27/2026. The ADM stated that corporate nurse completed his training on elopement on 02/18/2026 and the DON completed all staff elopement training on 02/24/2026. The ADM stated the corporate nurse completed in-services over elopement, elopement protocol, time frame to report elopement, search for resident, check windows, and doors.In an interview with Maintenance Worker on 03/02/2026 at 9:45 a.m., the Maintenance worker stated he was expected to make sure the secured outside gate was latched properly once the gate was used earlier that day around 3:00 pm when the funeral home picked up a body. The Maintenance Worker stated the gate was checked and visually appeared to be shut but it was later determined after Resident # 1 left the facility, the secured gate latch mechanism did not lock completely. The Maintenance Worker stated Fire and Safety came out and placed an additional alarm on the gate on 02/24/2026. The Maintenance Worker stated he was expected to check gates, doors, and windows daily. The Maintenance Worker stated not double checking the secured gate, Resident # 1 was able to go through the secured gate and possibly could had been injured or hurt. The Maintenance Worker stated he completed his elopement training on 02/19/2026 with the DON. The Maintenance Worker stated he learned what to do in case of elopement, check the entire facility, check outside the facility, check the neighborhood, check windows, and doors.In an interview with Resident #1's POA on 03/02/2026 at 2:28 p.m., Resident #1's POA stated the evening of 02/18/2026 close to 7:00 pm LVN A called her because Resident #1 was upset and wanted to leave the facility to go get a beer. Resident #1's POA stated she did not think Resident #1 would actually leave the facility. Resident # 1's POA stated it was not safe for Resident #1 to have left the facility, he could have been hurt, thank God he came back, he was not familiar with the area he was in. Resident #1's POA stated Resident #1 told her he went out the side gate and went to the store in the neighborhood to get a beer. Resident #1's POA stated that Resident # 1 had dementia but was really smart and told her he felt like he was in jail, he could not go anywhere, and that people were always watching him. Resident #1's POA stated she explained to Resident #1 that he was in the secured unit for his safety after trying to leave the facility on several occasions. Resident #1's POA stated she had to talk to Resident # 1 like a toddler and Resident #1 did have trouble remembering his family members, but remembered things he had done in the past. Resident # 1's POA stated Resident #1 thought he was currently in his hometown and Resident #1 and possibly would not have returned to the facility and that was not safe for Resident #1. Review of the facility's Safety and Supervision of Resident policy, dated 2001, revealed Our facility strives to make the environment as free from accident hazards as possible, Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Policy Interpretation and Implementation Facility Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:e. unsafe wandering.Review of the facility's Wandering and Elopements policy, dated 2001, revised March 2019 revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 02/18/2026 and ended on 02/24/2026. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: - Reviewed Wandering/Elopement Assessments that was conducted on all residents was completed on 02/24/2026.- Reviewed Inservice training on elopement policy, safety, supervision, keeping gates locked, what to do when a resident left the facility, and a team member would check the doors twice per shift was completed on 02/24/2026.- Reviewed Elopement binder that was updated and where the binder was located was completed on 02/24/2026.- Reviewed Care plans updated on all residents that were an elopement risk was completed on 02/24/2026.- Reviewed Assessment on Resident #1, Reviewed Resident #1's updated care plan, 1to 1 supervision was completed on 02/24/2026.- Reviewed QAPI elopement meeting documentation that was completed on 02/19/2026- Reviewed complete elopement incident report on the elopement that was completed on 02/19/2026- Reviewed additional alarm invoice that was placed on the outside secured gate and in good working order was completed on 02/24/2026.- Reviewed POC maintenance would monitor secure unit alarm every shift daily and a blue light flashes and alarm would ring at nurse's station when the gate was opened, and the alarm was triggered was completed on 02/24/2026.- Reviewed POC each resident room that was on the secure unit would be checked each shift to ensure windows and screens was in place completed on 02/18/2026.- Reviewed elopement drill and hands-on staff education that was completed on 02/24/2026.- Reviewed -POC once each shift staff would cross reference the census to physical resident presence was completed on 02/18/2026.- Reviewed Performance Improvement Project that was completed on 02/21/2026.- Reviewed Complete Corrective Action plan that was completed on 02/24/2026.- Reviewed IDT meeting notes it was determined that Resident #1 would continue with 1 to 1 monitoring until the additional alarm was added to the secure unit gate on 02/24/2026. It was also decided that the q 4-hour gate and census checks would also remain in place until the installation of the gate alarm was completed on 02/23/2026.- Reviewed POC all residents' rooms were checked for potential deficient practices. None were noted. No other residents had left the facility, and no one was exit seeking was completed on 02/18/2026.- Reviewed -POC the lever-style handle that allowed secured gate to open had been removed. The emergency exit button remained unchanged. This emergency button allowed the gate to be opened only in emergencies.- Reviewed POC DON/designee would report any occurrences in morning meeting the following business day x4 weeks or discontinued by IDT was completed on 02/19/2026.-Reviewed POC if there was an issue with a resident that had attempted to leave the building it would be reported to Administrator, DON, ADON, Designee immediately, so interventions could begin was completed on 02/19/2026.

Based on interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of three residents (Resident #1) reviewed for any significant medication errors, in that: The facility failed to ensure Resident #1 received his medications as prescribed by the physician. This failure affected residents by putting them at risk of exacerbation of their health conditions and deterioration of their health. Findings included: Record review of Resident #1's face sheet dated 12/30/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses paraplegia, unspecified (paralysis affecting the lower half of the body (legs and sometimes trunk), but without specific details on the exact cause, severity (complete vs. incomplete), or level of spinal cord involvement provided in the medical record), stage four pressure ulcer or right buttock (a severe, deep open wound involving full-thickness tissue loss, where skin, fat, muscle, tendon, or even bone is exposed), other acute osteomyelitis, left ankle and foot (a sudden, serious bacterial or fungal infection in the bone, causing pain, swelling, redness, warmth, and possibly fever, often resulting from an injury, wound (especially with diabetes/poor circulation), or surgery, requiring urgent treatment with antibiotics and sometimes surgery to prevent permanent bone damage or amputation), scoliosis (a medical condition where the spine develops an abnormal sideways curve, often resembling a C or S shape, instead of being straight). Record review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS score of 15, indicating cognition was intact. Record review of Resident #1's care plan, dated 12/29/2025, reflected Resident #1 had an infection and was on antibiotic therapy r/t sepsis (the body's extreme reaction to am untreated infection). Goal: Resident #1 would be free from complications related to infection through the review date 1/01/2026. Intervention/tasks included administering antibiotic as per MD orders, encourage po fluids if not contraindicated, monitored reactions and notify MD. Record review of Resident #1's care plan 12/22/2025 did not reflect he was receiving antibiotic therapy. Observation and record review of Resident #1's discharge orders, dated 12/23/2025, from a hospital stay revealed Resident #1 was discharged with two (2) antibiotics Linezolid 600 mg BID and Cipro 500 mg BID to be given 12/22/2025 through 12/27/2025. During an interview and observation on 12/30/2025 at 2:15 p.m., Resident #1 was asked if he was given his medication and he responded no. He stated he had antibiotics ordered when he was discharged from the hospital and the facility did not know until he asked about the medication. He stated he expected the nurses to have his medication. Resident appeared to be clean sitting in the wheelchair. During an interview on 12/30/2025 at 5:35 p.m., the PCP revealed she was more familiar with Resident #1 in the hospital. She described his medical condition and stated healing was difficult for Resident #1. The PCP stated because of osteomyelitis the CT scan was inconclusive, and the 3rd toe amputee was the source control. Resident #1 had multiple rounds of antibiotics and was battling with the infection. The PCP stated the antibiotic was to make sure the infection cleared. The amputation cleared him, but the 2 antibiotics were just to make sure everything was clear. The PCP stated the antibiotics were given to ensure the infection was cleared. She stated the blood cultures they took while in the hospital did not reveal any growth. The PCP stated he could have a flare up of another infection. During an interview on 12/30/2025 at 6:05 p.m., LVN A revealed when a resident was discharged from the hospital it was the responsibility of the charge nurse on duty to put the orders in the electronic system. LVN A stated Resident #1 was readmitted back into the facility after her shift. She stated she caught the Cipro 500 mg BID medication Resident #1 was prescribed. LVN A stated Resident #1 asked about his discharge paperwork regarding his antibiotics the doctor prescribed for him, and she stated she was going to investigate it. The NP made rounds on the morning of 12/24. She notified the NP that Resident #1 did not receive his antibiotics and asked what to do next. LVN A stated he was supposed to be on the antibiotics for three days and he stated to extend it to five days, so she put the order in for five days. She stated the medication should have been in the e-kit (a small supply of medications kept in the home to quickly treat symptoms that may occur in a terminally ill patient). She thought Resident #1 received his medication on 12/25. Once she put it in the orders, he should have gotten the evening dose. The initial dose is given by the nurse and then the med tech can give medication. LVN A stated the adverse reaction that could happen with Resident #1 the antibiotics is he could go septic shock. During an interview on 12/30/2025 at 6:15 p.m., Charge Nurse A revealed it was everybody's responsibility to make sure orders were correctly put into the electronic system. Charge Nurse A stated the marketing person would bring the discharge paperwork to the nurses then the nurses will add the necessary documentation into the computer. The DON and ADON are supposed to go behind the nurse to make sure it is done. Sometimes the ADON or the DON would put the orders in. Charge Nurse A stated he does not know why the medications were missed. He stated Resident #1 returned to the facility about 9:20 p.m. after being gone for 72 hours and readmitted as a new admit. He stated he gave Resident #1 the initial medication for one of the medications and he had to call the pharmacy for the Linezolid medication. He stated the paperwork reflected what happened during resident hospital stay and not the medication. He stated the next morning, the paperwork that came reflected the doctors' medication orders. He stated he was advised by another nurse he had two medications on his discharge paperwork, and she went to see if they had it in their e-kit and the Cipro was the only one and he reached out to the pharmacy to get the medication sent in the Charge Nurse stated that it was the resident's right to get his medication. Charge Nurse A stated the adverse reaction that could happen with Resident #1 not receiving the antibiotics is he could die. During an interview on 12/30/2025 at 7:05 p.m., The DON stated The Charge Nurse A did not put the orders in and when DON asked the charge nurse why they were not put in he stated he did not see them on the discharge medication list. DON stated once they realized the error, they notified the NP and did a medication error report. Resident #1 was given an order to restart the medication on 12/26/25. The DON stated Linezolid medication was on back order due to the holidays, and they did not have any in their ekit. The DON stated they tried to go through other pharmacies but did not have a contract with any other company. They have gone in the past to pick up the medications when it happens but the pharmacy they use is the company pharmacy. The DON stated they were waiting for the medication, no date was provided, and it showed a status out for delivery. The DON stated an adverse reaction that could happen to Resident #1 not receiving his prescribed medication was the condition could worsen or delay the healing. Review of facility undated medication reconciliation policy reflected the facility reconciled medication frequently throughout a resident's stay to ensure that the resident was free of any significant medication errors, and that the facility's medication error rate was less than 5 percent. Policy and Explanation and Compliance Guidelines: 3. Pre-admission Processes:a. Obtain current medication list from referral sources (i.e. hospital, home health, hospice, or primary care provider). b. Obtain current medication/admission orders. c. Verify resident identifiers. d. Forward to nursing unit accepting the resident. 4. admission Process: b. Compare orders to hospital records, etc. Obtain clarification orders as needed. e. Order medications from pharmacy in accordance with facility procedures for ordering medications. f. Verify medication received match the medication orders.

Based on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for rights. The facility failed to ensure Resident #1's doctors' orders were followed by not providing his antibiotic medications on 12/23/2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem and diminished dignity. Findings included: Record review of Resident #1's face sheet dated 12/30/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses paraplegia, unspecified (paralysis affecting the lower half of the body (legs and sometimes trunk), but without specific details on the exact cause, severity (complete vs. incomplete), or level of spinal cord involvement provided in the medical record), stage four pressure ulcer or right buttock (a severe, deep open wound involving full-thickness tissue loss, where skin, fat, muscle, tendon, or even bone is exposed), other acute osteomyelitis, left ankle and foot (a sudden, serious bacterial or fungal infection in the bone, causing pain, swelling, redness, warmth, and possibly fever, often resulting from an injury, wound (especially with diabetes/poor circulation), or surgery, requiring urgent treatment with antibiotics and sometimes surgery to prevent permanent bone damage or amputation), scoliosis (a medical condition where the spine develops an abnormal sideways curve, often resembling a C or S shape, instead of being straight). Record review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS score of 15, indicating cognition was intact. Record review of Resident #1's care plan, dated 12/29/2025, reflected Resident #1 had an infection and was on antibiotic therapy r/t sepsis (the body's extreme reaction to am untreated infection). Goal: Resident #1 would be free from complications related to infection through the review date 1/01/2026. Intervention/tasks included administering antibiotic as per MD orders, encourage po fluids if not contraindicated, monitored reactions and notify MD. Record review of Resident #1's care plan 12/22/2025 did not reflect he was receiving antibiotic therapy. Observation and record review of Resident #1's discharge orders, dated 12/23/2025, from a hospital stay revealed Resident #1 was discharged with two (2) antibiotics Linezolid 600 mg BID and Cipro 500 mg BID to be given 12/22/2025 through 12/27/2025. During an interview and observation on 12/30/2025 at 2:15 p.m., Resident #1 was asked if he was given his medication and he responded no. He stated he had antibiotics ordered when he was discharged from the hospital and the facility did not know until he asked about the medication. He stated he expected the nurses to have his medication. Resident appeared to be clean sitting in the wheelchair. During an interview on 12/30/2025 at 6:05 p.m., LVN A revealed when a resident was discharged from the hospital it was the responsibility of the charge nurse on duty to put the orders in the electronic system. LVN A stated Resident #1 was readmitted back into the facility after her shift. She stated she caught the Cipro 500 mg BID medication Resident #1 was prescribed. LVN A stated Resident #1 asked about his discharge paperwork regarding his antibiotics the doctor prescribed for him, and she stated she was going to investigate it. The NP made rounds on the morning of 12/24. She notified the NP that Resident #1 did not receive his antibiotics and asked what to do next. LVN A stated he was supposed to be on the antibiotics for three days and he stated to extend it to five days, so she put the order in for five days. She stated the medication should have been in the e-kit (a small supply of medications kept in the home to quickly treat symptoms that may occur in a terminally ill patient). She thought Resident #1 received his medication on 12/25. Once she put it in the orders, he should have gotten the evening dose. The initial dose is given by the nurse and then the med tech can give medication. LVN A stated it was the residents' right to receive all their medications on time. During an interview on 12/30/2025 at 6:15 p.m., Charge Nurse A revealed it was everybody's responsibility to make sure orders were correctly put into the electronic system. Charge Nurse A stated the marketing person would bring the discharge paperwork to the nurses then the nurses will add the necessary documentation into the computer. The DON and ADON are supposed to go behind the nurse to make sure it is done. Sometimes the ADON or the DON would put the orders in. Charge Nurse A stated he does not know why the medications were missed. He stated Resident #1 returned to the facility about 9:20 p.m. after being gone for 72 hours and readmitted as a new admit. He stated he gave Resident #1 the initial medication for one of the medications and he had to call the pharmacy for the Linezolid medication. He stated the paperwork reflected what happened during resident hospital stay and not the medication. He stated the next morning, the paperwork that came reflected the doctors' medication orders. He stated he was advised by another nurse he had two medications on his discharge paperwork, and she went to see if they had it in their e-kit and the Cipro was the only one and he reached out to the pharmacy to get the medication sent in the Charge Nurse stated that it was the resident's right to get his medication. During an interview on 12/30/2025 at 7:05 p.m., The DON stated The Charge Nurse A did not put the orders in and when DON asked the charge nurse why they were not put in he stated he did not see them on the discharge medication list. DON stated once they realized the error, they notified the NP and did a medication error report. Resident #1 was given an order to restart the medication on 12/26/25. The DON stated Linezolid medication was on back order due to the holidays, and they did not have any in their ekit. The DON stated they tried to go through other pharmacies but did not have a contract with any other company. They have gone in the past to pick up the medications when it happens but the pharmacy they use is the company pharmacy. The DON stated they were waiting for the medication, no date was provided, and it showed a status out for delivery. The DON stated it was the residents' right to receive their medication on time. Review of facility resident rights policy dated December 2016 reflected: Employees should treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: a. a dignified existence. b. be treated with respect, kindness, and dignity.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safetyThe facility failed to correctly label and date items in the dry storage and refrigerated areas. The facility failed to correctly label and date three containers of dry beans. There was one date on the container. No indication of what the items were and when they were placed in the container and when they should be used by. The pantry had several packages of dry cereal and pasta with only a date on the packages. There was no indication of when these items were opened and when the items should be discarded. In the walk-in refrigerator had an expired prepared item stored with a use by 11/15/2025 date stored inside. There were other undated items stored in the walk-in refrigerator as well. These failures could place residents at risk for food-borne illness and cross contamination.Observation of the kitchen on 12/02/2025 at 8:45 a.m., revealed in the dry storage area, three bins of dry beans with only one date on a label. These bins had a label with only one date marked on it. There was no indication when the items were placed in the container and when they could no longer be used. There were several bags of cereal that were opened and resealed that did not have dates indicating when they were opened and when they could no longer be used. There were two to three bags of pasta noodles that were not labeled and dated properly. Observation of the reach-in refrigerator on 12/02/2025 at 9:10 am., revealed a container with Zuc/Ham marked on the label with a use by date of 11/15/2025 on it stored in the walk-in refrigerator. There was a package of celery, a package of carrots, and beans with no date on the package stored in the refrigerator. In an interview with the Dietary Manager on 12/02/2025 at 9:25 a.m., stated that he recently started the position in the past few months and he did not receive any information from the previous manager. He stated he was trying to get things in order but has not gotten everything in place as he would like to. He hopes to have everything in order by the end of the year. He stated that he planned to use the USDA polices as the foundation to his new policies. He stated he understands the need to know when food comes in and when it should be discarded. He stated he does not want anyone to get sick from his kitchen. Interview with [NAME] A , on 12/03/2025 at 11:50 a.m., stated they all helped with putting up the food when the truck comes. She stated she marked her date on the package when she took it out of the box. Interview with [NAME] B 12/04/2025 at 1:25 p.m. revealed that everyone helped put the food on the shelf and they dated the box when they got it. Interview with the Administrator on 12/04/2025 at 2:15 p.m. revealed that the food manager is new and is doing a good job so far. He was unaware of the packaging not meeting the labeling requirement. Record review of the Facility Policy Food Receiving and Storage, Revised November 2022. Dry Food Storage4. Dry foods that are stored in bins are removed from original packaging, labeled and dated( use bydate) Such foods are rotaed using a first in-first out system. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date) 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date frozen or discarded.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (halls 100,200 and 300) of three halls reviewed for the pest control program.The facility had live gnats in a resident's room and numerous dead insects found in the catchment trays below the hand sanitizer disbursement units.This failure could place residents at risk for the spread of infection, cross-contamination and decreased quality of life.Findings included:In an observation on 12/02/2025 at 1:24 p.m., the wall mounted, Hand Sanitizer Automatic Disbursement Unit across from room [ROOM NUMBER]A the catchment tray below hand the sanitizer unit had four dead insects in the liquid collected in tray.In an observation on 12/02/2025 at 1:26 p.m., the wall mounted, Hand Sanitizer Automatic Disbursement Unit next to room [ROOM NUMBER] had a dead fly and two other dead insects in the catchment tray below the hand sanitizer unit.In an observation on 12/02/2025 at 1:27 p.m., the wall mounted, Hand Sanitizer Automatic Disbursement Unit next to room [ROOM NUMBER] had two dead insects in the catchment tray below the hand sanitizer unit.In an observation on 12/02/2025 at 1:28 p.m., the wall mounted, Hand Sanitizer Automatic Disbursement Unit next to 200-hall shower room (across) from room [ROOM NUMBER] was found to have one dead insect in the catchment tray below the hand sanitizer unit.In an observation on 12/02/2025 at 1:31 p.m., the wall mounted Hand Sanitizer Automatic Disbursement Unit on the 300-hall in front of shower room had one dead insect found in the catchment tray below the hand sanitizer unit.In an observation on 12/02/2025 at 1:32 p.m., the wall mounted Hand Sanitizer Automatic Disbursement Unit on the 300-hall next to room [ROOM NUMBER] had 30 plus dead insects observed in the catchment tray below the hand sanitizer unit.In an observation on12/02/2025 at 1:33 p.m., the wall mounted Hand Sanitizer Automatic Disbursement Unit next to room [ROOM NUMBER] was found to have nine dead insects in the catchment tray below the hand sanitizer unit.In an observation on 12/02/2025 at 1:35 p.m., the wall mounted Hand Sanitizer Automatic Disbursement Unit next to room [ROOM NUMBER] was found to have six dead insects in the catchment tray below the hand sanitizer unit.In an observation and interview on 12/03/2025 at 9:54 a.m., CNA C was observed changing sheets in room # 326. Two live gnats were noted to have been flying around in the room. She stated she also had seen the gnats. She stated she had seen gnats in resident rooms around the facility. She stated that she would report insect problems in the pest sighting log or the maintenance log. Both Residents #1 and #3 were in the room but were unable to respond to questions due to severe cognitive impairment.In an interview on 12/02/2025 at 2:02 p.m., the Housekeeping Supervisor stated that her team was responsible for keeping resident rooms, hallways, bathrooms and common areas clean in the facility. She stated she was not aware of dead insects in the catchment trays below the hand sanitizers in the hallways. She stated she had seen a few gnats in resident rooms around the facility and that she and her staff were to write down sightings in the pest control logbook. She stated that the logbooks were behind the nursing station desks.In an interview on 12/03/2025 at 10:30 a.m., the Maintenance Supervisor stated that he and his assistant refilled the wall mounted hand sanitizer units. He stated he noticed the dead insects in the catchment trays below the units and that he would be sure to tell the Housekeeping Supervisor to have the units cleaned. He stated that staff could either tell him about insects in the facility or they could write it down in the pest sighting logbook found behind the nursing station. He stated that pest control visited the facility monthly and if needed could be called in more often.In an interview on 12/04/2025 at 10:19 a.m., the ADON stated that she was unaware of any insects in the catchment trays below the hand sanitizers. She stated she and the nursing staff used the wall mounted hand sanitizers every day, but she never noticed the dead insects until now and the nursing staff had not reported it to her. She stated having dead insects in plain view could affect residents' quality of life because it made the facility look dirty and that live insects could spread disease or cause cross-contamination.In an interview on 12/04/2025 at 11:06 a.m., the ADM stated the Maintenance staff refilled and serviced the automatic hand sanitizers, but housekeeping was responsible for cleaning them. He stated having live insects in resident rooms or around the facility could cause cross contamination and that having dead insects visible in the hallways could affect resident's quality of life as the facility could be viewed as not clean. Record review of the Pest Sighting logbook from 06/01/2025 to 12/03/2025 found no entries from any staff. Review of the maintenance logbook from 06/01/2025 to 12/03/25 found one entry, dated 07/12/2025 referencing flies and gnats at the end of the 300-Hall.Record review of the Pest Control contract and visit receipt/descriptions of service found the contract was active. Pest Control visited the facility on a monthly basis with the last visit being 12/03/2025. No extra visits were found for the last 3 months.Record review of the grievance log from May 01, 2025 to present found no relevant complaints about insects from residents.Record review of the facility's policy revised July 2013 and titled Pest Control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program for insects and rodents

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for one (Hall 300) of three halls reviewed for environment. The facility failed to ensure bathroom floors and fixtures were in good repair for room numbers 350, 352, 354, and 355. This failure could place residents at risk for diminished quality of life due to the lack of a well-kempt environment. Findings included: An observation on 12/03/2025 at 9:54 a.m., of the bathroom for Room # 350 revealed the center drain in the middle of the bathroom floor had pushed through the tile approximately 1 inch, around a 7 inch crescent around the drain appeared to have missing tiles with some remaining tiles still connected to the central drain pipe presenting sharp tile edges and presenting a 3/4 inch raised possible trip hazard.An observation on 12/03/2025 at 9:56 a.m., of the bathroom in room [ROOM NUMBER] a patch of 2/2 inch tiles were missing from the floor exposing bare concrete in a patch of 6/4 inches, additionally the tiles behind the toilet had separated from the wall leaving a 1/2 gap between the floor and the wall and the tiles were discolored with a reddish stain that resembled rust.An observation on 12/03/2025 at 9:59 a.m., of the bathroom in room [ROOM NUMBER] revealed the bathroom was missing a bracket to hold toilet paper, approximately 3 feet along the edge of the floor and wall of the toilet appeared to be stained red resembling rust.An observation on 12/03/2025 at 10:02 a.m., of the bathroom in Room # 355 revealed the bathroom floor was missing a section of tiles approximately 8 inches by 6 inches exposing the bare concrete beneath and presenting a possible trip hazard.In an interview on 12/04/2025 at 10:30 a.m., the Maintenance Supervisor revealed he was aware of the issues with several bathrooms on the 300 Hall. He stated the building was settling and had broken some of the tiles and that some of the drainage pipes had raised up on one side of the hallway. He stated he was working on some bids to fix the bathrooms but would not be able to produce any proof of the bids or when the bathroom issues would be fixed. He stated the raised pipes and missing tiles could be a trip hazard.In an interview on 12/04/2025 at 11:06 a.m., the ADM revealed he had been aware of the bathroom floor/drainpipe issues on the 300 Hall, he stated the issues were being looked into but that he had no timeline for when the issues would be fixed. He stated that although there were residents living in those affected rooms/bathrooms, he had not received any complaints. He stated that having missing/discolored tiles and raised drainpipes in the resident bathrooms could present possible trip hazards and affect resident attitudes about the facility. He stated he would ask the Maintenance Supervisor to find some temporary fixes until the issues could be resolved.Review of the maintenance log from 06/01/2025 to 12/03/2025 found no entries for resident bathrooms.Review of a facility policy named Maintenance Service and dated December 2009 reflected that: Maintenance shall be provided to all areas of the building, grounds and equipment in a safe and operable manner at all times.a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines.b. maintaining the building in good repair and free from hazards

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for four (Residents #12, #41 #90, and #91) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #41, #90, #12, and #91. These failures could place residents at risk for equipment in unsafe operating condition, that could cause injury. Findings included: Record review of Resident #41's annual MDS assessment, dated 09/18/2025, reflected he was a [AGE] year-old male admitted [DATE] with diagnoses including dementia (confusion), hypertension (high blood pressure), and limited range of motion lower extremities (limited movement with legs). Further review of the MDS reflected the resident was severely cognitively impaired and unable to make decisions for themselves. Record review of Resident #41's plan of care, dated 09/18/2025 with updates, reflected goals and approaches included wheelchair mobility for locomotion. Observation and interview on 12/02/2025 at 8:30 a.m., revealed Resident #41 was sitting in his wheelchair, in the main dining room and had no skin problems. The wheelchair's right and left armrest were cracked with foam exposed. Resident #41 stated the wheelchair arms were rough and he did not like how it felt on his arms. Resident #41 stated he did not know who to tell about his wheelchair. Record review of Resident #90's quarterly MDS assessment, dated 10/06/2025, reflected he was an [AGE] year-old male admitted [DATE] with diagnoses including mood disorder (mental illness), hypertension (high blood pressure), and limited range of motion lower extremities (limited movement with legs). Further review of the MDS reflected the resident was moderately cognitively impaired and unable to make decisions for themselves. Record review of Resident #90's plan of care, dated 10/06/2025 with updates, reflected goals and approaches included wheelchair mobility for locomotion. Observation and interview on 12/02/2025 at 12:41 p.m., revealed Resident #90 was sitting in his wheelchair, in the main dining room and had no skin problems. The wheelchair's left armrest was cracked with foam exposed. Resident #90 stated that he was happy with his wheelchair, and he did not know who to tell about the armrest, but now that he thought about it could be fixed , so the wheelchair looked better. Record review of Resident #91's quarterly MDS assessment, dated 09/01/2025, reflected she was a [AGE] year-old female admitted on [DATE], with diagnoses including cerebral palsy (brain muscular disease), and anxiety (nervous disorder). Further review of the MDS reflected the resident was cognitively alert and able to make decisions for herself. Record review of Resident #91's care plan, dated 12/07/2025 with updates, reflected goals and approaches included wheelchair mobility. Observation and interview on 12/02/2025 at 12:00 p.m., revealed Resident #91 was sitting in her wheelchair in the main dining room and the wheelchair's left armrest was missing and right armrests were cracked with exposed foam. There were no skin tears on her arms. Resident #91 stated the armrest that was missing was cold. Resident #91 stated she had not told anyone about the armrest, she was just grateful to have a wheelchair. Review of Resident #12's quarterly MDS assessment, dated 11/12/2025, reflected she was a [AGE] year-old female admitted [DATE], with diagnoses including muscle weakness (generalized muscle weakness), and depression (sadness). Further review of the MDS reflected the resident was severely cognitively impaired and unable to make decisions for herself. Review of Resident 12's updated plan of care, dated 11/13/2025 with updates, reflected goals and approaches included wheelchair mobility. Observation and interview on 12/02/20205 at 12:12 p.m., revealed Resident #12, as in her wheelchair in the main dining room, and the wheelchair's right armrest was missing. The back of the wheelchair had a dried white substance on the entire back of the wheelchair. There were no skin tears on the arms. Resident #12 stated to leave her alone, she did not want to be spoken to. In an interview on 12/02/2025 at 12:15 p.m., CNA B stated when a resident's wheelchair needed repair the staff were to report it to the Director of Rehabilitation. CNA B was unaware of any log or system to be used to report broken equipment. CNA B stated she had not reported anything recently and was unaware of any equipment (wheelchairs) needing repair. In an interview on 12/03/2025 at 2:25 p.m., the Director of Rehabilitation revealed the staff reported to the rehab team if equipment needed repair. The Rehabilitation team will repair the wheelchairs. The supplies that are ordered for repair of the wheelchairs are ordered by the Director of Rehabilitation through the Administrator. The Director of Rehabilitation stated maintenance had nothing to do with the repair of the wheelchairs. If the facility needs new wheelchairs for the residents, the Rehabilitation team orders them. The Director of Rehabilitation stated if the wheelchair was a specialty chair, the team must contact the company that made the wheelchair. The Director of Rehabilitation stated there was no log for the staff to write in, the rehab department either saw the wheelchair or the staff told them directly if the wheelchair needed repair. The Rehabilitation Team did not make special rounds to search for wheelchairs that required repairs. In an interview on 12/04/2025 at 11:00 a.m., the Administrator revealed he did not have anything to do with the repair of wheelchairs. The Administrator stated if he saw worn wheelchairs, he informed the therapy department to order new ones. The Administrator stated he ordered new wheelchairs not too long ago, and there should be no wheelchairs that required repairs at the facility. The Administrator stated there was no system for communication concerning repair of wheelchairs. Review of the Facility's Policy titled Assistive Devices and Equipment dated revised July 2017 reflected, Our facility provides, maintains, trains and supervise the use of assistive devices and equipment for residents. 1. Devices and equipment that assist with resident mobility, safety, and independence and provided for residents. These include but are not limited to: a. Wheelchairs (manual and powered); . c. Device condition- devices and equipment will be maintained on schedule and . Defective or worn devices will be discarded or repaired.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (CNA B) staff members and 1 of 2 residents (Resident #19) reviewed for infection control procedures. CNA B failed to change their soiled gloves and perform hand hygiene during incontinent care for Resident #19. These failures could place residents at risk for cross contamination and infections. Findings included:Record review of Resident #19's quarterly MDS Assessment, dated 09/01/2025, revealed an [AGE] year-old male admitted on [DATE]. Resident #19 had diagnoses which included Alzheimer's disease (forgetfulness and confusion), anorexia, (does not want to eat), and dementia (confusion). Resident #19 was severely cognitively impaired and unable to make decisions for himself and required one staff member for assistance with activities of daily living. Observation on 12/04/2025 at 1:30 p.m., CNA B entered the room to perform incontinent care and activities of daily living with Resident #19. During this time an attempt was made to interview Resident #19 , he did not respond to questions and did not communicate during the observation. CNA B used hand gel in the hallway and placed gloves on. CNA B picked up her incontinent wipes and entered the room. Resident #19 was lying on his left side in the bed. CNA B explained to the resident what she was going to do, and the resident agreed. CNA B pulled the pants of Resident #19 down; he had taken off his brief, had smeared bowel movement on his pants and had placed his brief in the trashcan. CNA B wiped the penal shaft area with a disposable wipe, discarded the wipe. CNA B used another wipe on the groin area and discarded it. CNA B assisted with repositioning Resident #19 to his right side. CNA B then used another wipe on the left buttocks and then used another wipe on the right buttocks. CNA B used another wipe on the rectum, after placing a clean brief under Resident #19, discarding dirty wipes. CNA B assisted with repositioning Resident #19 to his left side while pulling the clean brief under the resident. CNA B, without changing her soiled gloves or washing her hands, fastened the tabs of the clean brief. CNA B then with her soiled gloves opened the drawers, looked for clean pants, while touching all the clothing in the drawer. CNA B located a pair of clean pants, placed on the resident's pants, assisted with repositioning him on his back and covering him with a sheet and a blanket. CNA B placed her gloves in the trashcan, gathered the trash bag, placed the incontinent wipes back on top of the dresser, and left the room, without washing her hands or using hand sanitizer. An interview on 12/02/2025 at 2:00 p.m., CNA B stated she got nervous when the surveyor entered the room with her and forgot what to do. CNA B stated she knew she did not change her gloves or wash her hands. CNA B stated she was trained in infection control, changing gloves and handwashing. The CNA stated that if she did not change her gloves and wash her hands or use sanitizer, she could spread germs to herself and other residents.An interview with the DON, who was the infection control preventionist on 12/04/2025 at 10:45 a.m., the DON stated the staff when performing incontinent care should be changing gloves from dirty to clean and washing their hands or using the available hand sanitizer. The DON stated she just had an in-service in the past 3 months presenting the importance of changing gloves and washing hands during care and incontinent care and CNA B was in attendance. The DON stated during the in-service the staff did not ask any questions and appeared to understand and indicated they knew everything. The DON stated if the CNA appeared nervous then the staff would do what they would usually. The DON stated if the staff did not change gloves and clean their hands when they should, they could spread germs to themselves and the residents.Record review of the in-service dated 10/19/2025 reflected infection control/hand hygiene. The in-service included proper procedure as to when to wash hands, wear gloves, and what to do while performing incontinent care. CNA B had signed the attendee record for the training. Record review of the Facility's Policy titled Handwashing/Hand Hygiene, dated October 2023, reflected: Policy statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for hand hygiene: 1. Hand hygiene is indicated: a. immediately before touching a resident; . c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. 5. The use of gloves does not replace handwashing/hand hygiene Record review of the Facility's Policy titled Perineal Care, dated February 2018 reflected: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition . Steps to procedure 1. Place equipment on bedside . 2. Wash and dry your hands thoroughly . 7. Put on gloves . [steps to perform incontinent care for male/female] . 10. Remove gloves and discard into designated container. 11. Wash and dry hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable . 16. Wash and dry hands thoroughly

Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity for one (Resident #38) of eighteen residents reviewed for resident rights. The facility failed to ensure CNA A did not stand over Resident #38 while assisting the resident with his meal in the dining room on 12/02/2025. This failure could place residents at risk of feeling rushed to eat or not interested in eating, which could result in weight loss and decreased psycho-social well-being of anguish or frustration. Findings included: Record review of Resident #38's quarterly MDS Assessment, dated 10/01/2025, revealed a [AGE] year-old male who admitted [DATE] with a staff assessment BIMS score of 00 (Severely impaired). He required partial/moderate assist with eating and active diagnoses included Alzheimer's' disease (confusion and memory loss), dementia (confusion), anxiety disorder (nervous), and mood disorder (mental illness). He had a mechanically altered and therapeutic diet and issues with swallowing food and drinks. Record review of Resident #38's Care Plan, dated 01/31/2025, revealed, The resident has history of difficulty swallowing related to, dementia (confusion) and Alzheimer's disease (forgetfulness and confusion): Goals - The resident will not having choking episode through the next review period: 01/08/2025 and intervention: Eating - The resident requires set up assist of (1) staff for eating, and to monitor for changes in conditions with nutritional intake. Observation and interview attempt with Resident #38 on 12/02/2025 at 8:15 a.m. in the dining room on the secured unit revealed CNA A was standing next to Resident #38 who was sitting in his chair, the resident did not respond to any questions and just looked at staff. There was 90% of Resident #38's breakfast on her plate and CNA A had a spoon in her hand with food on it. CNA A lifted up the food and was telling Resident #38 he needed to eat his food and to try and take just a few more bites. Resident #38 opened his mouth and took the bite of food. He did not respond verbally to CNA A. Observation on 12/02/2025 at 12:15 p.m. in the dining room on the secured unit, CNA A was standing next to Resident #38 who was sitting in his chair. There was 45% of Resident #38's lunch on his plate and CNA A stated to the surveyor she was going to try and get him to take a couple of more bites of his lunch. The CNA A stated Resident #38 had a very good appetite. Resident #38 continued to eat until he completed his lunch meal. Interview on 12/02/2025 at 12:45 p.m., CNA A stated they were supposed to sit down to feed the residents. CNA A stated she knew she was supposed to have gotten a chair and she had just forgotten. CNA A said she was trained and it was against the residents' rights to stand over him while assisting him to eat. CNA A stated she was sorry, but the resident did not seem to notice she was standing because he still ate well. CNA A stated she was in-serviced on Resident Rights and knew this was part of not dignifying their rights. Interview on 12/02/2025 at 10:45 a.m., the DON stated the staff should be seated at eye level when assisting the residents to eat. She stated sitting down while assisting the residents to eat was good for the staff to see how the residents swallowed. She stated feeding the residents standing up was a dignity issue. Record Review of the in-service, dated 09/2025, reflected Resident Rights . To include how to assist a resident to eat with dignity. CNA A had signed the in-service to have attended. Record Review of the facility policy and procedure titled Assistance with meals, dated July 2017, reflected Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. Not standing over residents while assisting them with meals; .

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to prevent a diversion of Resident #1's Hydrocodone-Acetaminophen Oral 10-325 MG tablet, 60 tablets reported missing on 08/18/2025. The failure could place residents at risk for medication error and delay therapy. Findings include:Record review of Resident #1's face sheet, printed 08/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] and discharged on 08/27/2025 to Oceans Behavioral Hospital. His diagnoses included mild cognitive impairment of uncertain or unknown etiology (Mild cognitive impairment is the in-between stage between typical thinking skills and dementia), type 2 diabetes mellitus without complications (a stage of the disease where a person has elevated blood sugar levels but has not developed any chronic complications), hyperlipidemia (excess of lipids or fats in your blood), gout (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet, deposition of chalkstones, and episodes of acute pain). Record review of Resident #1's comprehensive MDS assessment, dated 07/16/2025, Section C (Cognitive Patterns) reflected a BIMS score of 09, which indicated moderately impaired.Record review of Resident #1's physician's order reflected an order, dated 03/18/2025 for Hydrocodone-Acetaminophen Oral 10-325 MG tablet. Give 1 tablet by mouth every 4 hours as needed for pain. Record review of Resident #1's Medication Administration Record (MAR) for Hydrocodone-Acetaminophen Oral 10-325 MG tablet revealed the medication was scheduled to be given PRN for pain. The MAR revealed that staff gave the resident the medication on the following dates and times:Charted Date Time Pain Level (a scale is used to measure his or her pain so that the doctor can plan how best to manage it)8/17/2025 3:32 PM/7:43 PM 78/18/2025 05:14 AM/9:20 PM 5/78/19/2025 8:24 PM 88/20/2025 05:21 AM 88/25/2025 10:33 PM 08/26/2025 06:00 AM/10:00 AM 10Record Review or the resident electronic health records revealed Resident #1 was discharged out of the facility as of 08/27/2025Record review of the Provider Investigation Report, dated 08/18/2025, reflected, On 08/18/2025 at 09:30 AM, by the ADON that Resident #1 were missing 60 tabs out of 180 tabs of Hydrocodone /APAP 10/325 from the facility's med cart. We started a facility wide search immediately. The Administrator and nursing staff were not able to locate the drugs. They have started a formal investigation. Consultant pharmacy, regional nurses notified. Incident reported to Police Department. In-serviced started on control substance documentation and storage., interviewed the nursing staff that worked on the cart the day before up to when the medication went missing, an audit of the medication carts were done to make sure no other medications were missing and all other counts were accurate. After the investigation was completed, the medication was not found and the administrator and nursing staff wan unable to determine who took the medication. During an interview with the ADON on 8/28/2025 at 5:20 PM revealed she stated she worked the medication cart on 8/17/2025 from 6 am to 2 pm. She handed the med cart and keys to an agency worker who worked the cart from 2 pm to 10 pm. She stated the narcotic medication count was accurate, and they signed off once it was switched over. She stated whenever there was a shift change, staff were to count the cart with the person they were giving the cart to and if there were any discrepancies, they were to report it to the ADON, DON or the ADM. The ADON stated when the staff came in on Monday 8/18/2025 morning, the nurse that was supposed to take over the cart was late, and another nurse took over the cart. Once the LVN came in, they counted the meds, and it was allegedly accurate. The LVN came to her about 8:30 AM and advised her that the Hydrocodone-Acetaminophen Oral 10-325 MG table was missing and the medication count sheet in which the medications was listed was also missing. She stated there was an investigation conducted, and they viewed cameras, drug tested staff that had access to the cart, they notified the doctor and the pharmacy consultant. The ADON stated the nurse that reported the medication missing was no longer with the company due to being terminated because of excessive tardiness and missing days. The other nurse was agency, and she was no longer allowed to return to the facility. She stated Resident #1's medication was PRN, and he had enough medication that he did not miss a dosage. She stated with the drug diversion it could have cause the resident not to have his meds and could have been left in pain. During an interview with the SC on 8/29/2025 at 10:18 AM revealed the drug diversion happened between agency nurses. On 8/18/2025, LVN B noticed the missing meds and it was reported. She stated when drug diversion occurred, policy stated to call whoever was on call, the ADON, DON or Administrator and they would come in and began an investigation on the missing medication and report it to state, drug screen staff involved, get statement from nurse/MA involved. An interview with MA A on 8/29/2025 at 11:05 AM revealed when drug diversion occurs, the policy is to report to charge nurse and the DON for them to investigate. She stated she has not had any issues with the count being off. She stated when she gets the cart from another med tech or nurse, they count the medication cart together, and they sign off that the count is correct, and they sign the narcotic book and hand off the keys. She stated if she had any issues with the count she knows to report it. An interview with LVN A on 8/29/25 at 12:52 PM revealed narcotic count is done with off going and ongoing nurse, and both sign off together. She stated if the count is off, she doesn't accept the cart, she will call management which is the DON, ADON, Administration. She stated a negative outcome will be the resident missed their medication and based on the type of medication; they can have an adverse reaction. Record review of a statement dated 8/20/2025 taken from LVN B stated she worked on 8/17/2025 the night shift 10 PM to 6 AM. She stated when she came on shift, she counted the carts with the nurse leaving and the count was correct. She stated when she got off, she counted with the oncoming nurse, and the count was correct. She stated she do not know of any missing narcoticsAn interview with the ADM on 8/29/2025 at 1:08 PM revealed he was notified about the narcotics missing. He stated he notified the doctor about the missing medication and the quantity on hand for Resident #1. He stated Resident #1 was assessed and there was no negative outcome and there was enough medication for Resident #1. He stated that medication cart that was worked by all nurses and a MA that day and they were drug tested. He stated the last nurse, which was an agency nurse whom is no longer working for the company and was not able to be interviewed,, whom was the last person to work the cart was asked not to return to the facility. There were agency nurses that worked the 2 PM to 10 PM and the 10 PM to 6 AM shift were agency nurses. He stated the last dosage of medication Resident # 1 was administered was 8/18/2025 at 5:15 AM and again on 9:21 AM and that is when it was found missing. He stated law enforcement was notified and provided an item number. He stated they have watched the cameras and were not able to determine what happened to the medication. He stated the way the nurses are positioned with the med cart, the cameras did not show anyone taking medication from the cart or the pages out of the book. All the other medications carts were counted to make sure no other medications were missing. He stated a negative outcome that can happen is there will be missing medication, and the resident could miss a dose of their medication. Record review of the undated policy of Injection Safety - Drug Diversion, revealed drug diversion is referring to the theft or other deviation that removes a prescription drug from its intended path from the manufacturer to the patient. 1. All drugs and biologicals, including controlled substances, are stored in lock compartments and only authorized personnel have keys to locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). 2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications, including documentation and disposition of medications. 3. Staff with access to controlled medications are trained on the facility's policy for the administration and accountability of controlled substances. Each employee is required to report suspicion or known diversion of a controlled substance to the Director of Nursing or Administrator.

Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director (AD) reviewed for qualified professionals, in that: Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director (AD) reviewed for qualified professionals, in that: The facility failed to have a qualified AD to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.The findings included:During an interview with the AD on 07/15/2025 at 2:00 PM, The AD stated she has been the AD since March 2025. The AD stated she was an assistant AD/CNA before she was the AD. The AD stated that the previous AD was fired in February 2025, and she has been the AD since. The AD stated that she has been helping as a CNA and transportation driver and hasn't had the time to start her certification. The AD stated that she has enrolled in the appropriate class but could not provide any evidence of her enrollment.During an interview with the ADM on 07/15/2025 at 2:45 PM, the ADM stated that the current AD was previous the AD assistant. The ADM stated that he thought the current AD was enrolled in taking the appropriate classes to have her AD certification. The ADM stated once the appropriate classes were completed then the facility would reimburse the current AD for completing her certification. The ADM stated that he did not have any information that the AD was enrolled in the appropriated classes for her AD certification. The ADM stated a negative outcome would be if the AD did not know the appropriate activity director guidelines due to not completing the AD certification. The ADM stated the facility did not have a policy regarding activities/activities director.Review of the facility Activities Director job description, not dated, reflected must be qualified therapeutic recreation specialist who is: licensed or registered, if applicable by the state in which practicing.

Based on interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 7 residents (Resident #1) reviewed for abuse and neglect, in that:Based on interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 7 residents (Resident #1) reviewed for abuse and neglect, in that:The facility did not report an incident of potential neglect for Resident #1 to the State Survey Agency within 24 hours, when Resident #1 fell out of his wheelchair while being transported on the facility's van on 06/25/25.This failure could place residents at-risk of not having incident and accident investigations reported within the timeframe required. Findings included:Record review of Resident #1's admission record, dated 06/10/2025, reflected an [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Chronic kidney disease stage 4 (when your kidneys are damage and can't filter blood properly), type 2 diabetes mellitus without complications (when the body cannot use insulin correctly and sugar builds up in the blood without any common health problems associated with the disease), muscle weakness (reduced ability of the body to contract muscle properly, resulting in a lower strength in one or more muscle), and lack of coordination (having difficulty controlling your movements and making them work together smoothly). Record review of Resident #1's Quarterly MDS assessment, dated 07/08/2025, reflected the resident had a BIMS score of 09, which indicated moderate cognitive impairment. Resident #1 required substantial/maximal assistance in the areas of toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Resident #1 requires substantial/maximal assistance in the area of shower/bathe self.Record review of Resident #1's care plan, dated 07/15/2025, reflected Resident #1 was care planned for moderate risk for falls r/t unsteady, weak and use of psychoactive, requires assist with ADL's, ADL self-care performance deficit r/t confusion, impaired balance, limited mobility, limited physical mobility r/t weaknessReview of Resident #1's nursing progress note, dated 06/25/25, reflected a progress note entered by the AD that stated, While being transported in [facility name] van from hospital seat belt buckle came loose causing resident to slide onto floor in sitting position resident was at facility when incident occurred witnessed by ADRecord review of Resident#1's witness fall assessment, dated 06/25/2025, reflected was assessed for injuries none noted able to [NAME] was assisted to chair x3 staff and gait.Record review of Resident#1's EMS Patient Care Report, dated 06/25/2025, reflected upon arrival to scene FD is on scene. PT is found inside of a PT transport shuttle for nursing home. Pt was helped up from floor into wheelchair by FD. Pt declines of hurting anywhere and does not want to go to hospital. LVN who was driving the bus stated she hit the brakes too hard and caused Pt to fall out of chair. Once Pt is settled in seat. EMS advise driver to pull out of busy traffic into parking lot to obtain vitals on Pt. Once obtained, Pt still declines wanting to be seen at hospital. Pt is presented with refusal form and educated on risks associated with not being seen at hospital. Pt repeats risk and still declines. Refusal form signed by Pt. Pt declines any other needs at this time.During an interview with Resident #1 on 07/15/2025 at 11:45 AM., Resident #1's stated that he was headed to facility from being picked up at from hospital by the AD in the facility's van. Resident #1 stated they were almost to the facility when the AD hit her brakes, and he slid out of his wheelchair. Resident stated that he was not buckled up when he slid out of his wheelchair. Resident #1 stated both the AD and ADM knew that he slid out of wheelchair due to his seat belt not being buckled. Resident #1 stated that he was not hurt and laughed about the incident. Resident #1 stated that the incident happened a few blocks away from the facility and the local EMS and fire department responded to the incident. Resident #1 stated that the ADM came to the scene of the incident to check on him. Resident #1 stated he didn't remember the date of the incident but stated he believes it happened last month (June 2025).During an interview with the AD on 07/15/2025 at 2:00 PM, The AD stated she was bringing Resident #1 to the facility after he had been discharged from the hospital. The AD stated a few miles away from the facility she had to hit her brakes quickly due to the light turning yellow. The AD stated that Resident #1 slid out his wheelchair onto the floor. The AD stated Resident #1 was buckled when leaving the hospital but at the time of the incident Resident #1 was not wearing a seatbelt. The AD stated she doesn't how the seat belt came a loose. The AD stated she called 911 and the facility's ADM. The AD stated that EMS checkout Resident #1 and there were no injuries. The AD stated that she had not had anything like that happen to her before. The AD stated that she was not aware that the incident was not reported to the state. During an interview with the NC on 07/15/2025 at 2:30 PM, The NC stated she was not aware of the incident. The NC stated that she was told by staff that Resident #1 was buckled in his wheelchair at the time of the incident. During an interview with the ADM on 07/15/2025 at 2:45 PM, The ADM stated that the AD was bring Resident #1 back from the hospital when the AD hit her brake causing Resident #1 to slide to the floor. The ADM stated that the AD stated she wasn't speeding, and Resident #1 did not have any injuries from the incident. The ADM stated that AD notified him and EMS of the incident. The ADM stated he went to the scene of the incident to check on the resident and AD. The ADM stated that the residents seat buckle came loose which caused the resident to slide out of his chair. The ADM stated that they followed the facility's protocol, and the incident was not reportable.Review of the facility's Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy, dated September 2022, revealed All reports of resident abuse (including injuries of unknown origin) neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented or reported.Policy Interpretation and ImplementationReporting Allegation to the administrator and Authorities1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.2. The administrator of the individual making the allegation immediately reports his or her suspicions to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility;b. The local/state ombudsman;c. The resident's representative;d. Adult protective services (where state lay provides jurisdiction in long term care);e. Law enforcement officials;f. The resident's attending physician; and g. The facility medical director.3. Immediately is define as:a. Within two hours of an allegation involving abuse or result in serious bodily injury; orb. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on the interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for #25, whose records were reviewed for PASRR services. The facility failed to get a PASRR eval when Resident #25's Level 1 PASRR screening indicated the resident had mental illness diagnoses of schizoaffective disorder, bipolar type, and anxiety. Findings included: This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The facility failed to complete a PASRR screening on Resident #25. Findings included: Record review of Resident #25's face sheet dated 06/25/2025 revealed the resident was admitted to the facility 08/24/2024 with diagnoses that included: Unspecified dementia, schizoaffective disorder, bipolar type (a mental health condition involving psychotic symptoms like hallucinations and delusions alongside mood episodes of mania and sometimes depression), and borderline intellectual functioning. Resident #25 was diagnosed, schizoaffective disorder, bipolar type on 7/18/2024. Record review of Resident #25's quarterly MDS assessment, completed on 06/04/2025, Section C, revealed a BIMS score of 08/15, indicating moderate cognitive impairment. Section I (Active Diagnoses) indicated Resident #25 had diagnoses of schizophrenia (e.g., schizoaffective and schizophreniform disorders). Section N (Medications) indicated Resident #25 was taking antipsychotic medications. Record review of Resident #25's care plan, dated 04/02/2025, revealed Resident #25 exhibits/reports mood problem related to mood disturbance and Psychosis. She was receiving the antipsychotic medication Seroquel, and the interventions included monitoring for behavior management to reassure the patient about the progress he is making towards goals. Record review of the documents in Resident #25's electronic health record revealed a PASRR 1 evaluation dated 08/27/2024, indicating the resident did not have a primary diagnosis of dementia, mental illness, intellectual disability, or developmental disability. Record review of Resident #25's physician order, dated 12/27/2024, revealed an order for Seroquel Oral Tablet, 50 MG, give 1 tablet by mouth two times a day related to schizoaffective disorder, bipolar type. The order date and start date was 12/27/2024. During an interview on 06/25/2025 at 3:13 PM, the DON stated that Resident #25's Level II PASRR evaluation was not completed . The DON explained that either the MDS coordinator or the ADON completes the Level II PASRR screening at the facility. She mentioned that the resident received more services through Part B than with PASRR services . Resident #25 was not receiving services through PASRR. The DON also noted that the resident was receiving therapy services, but those services were not provided through PASRR. During an interview on 06/25/2025 at 3:13 PM, the ADON MDS Minimum Data Set coordinator said that she was primarily responsible for handling the PASRR screenings, although the MDS occasionally performs them. The ADON stated she conducted the PASRR screening for Resident #25. She mentioned that if a resident comes from the hospital, there could be an issue because sometimes they do not provide a PASRR. The ADON said she checks whether a resident was receiving NSF and Medicaid services. ADON that when a resident gets a new diagnosis, they get a new PASRR screening. She also stated that if the PASRR was not completed on time, it could result in a delay in services. Review of facility policy dated March 2019 and titled admission Criteria reflected the following: 9. All new admissions and re-admissions are screen for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid preadmission screening and resident review process. a. The facility conducts a level I PASARR screens for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the State PASARR representative for the level II evaluation and determination screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible evident MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state designated authority.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accidents hazards. The facility failed to ensure Resident #1, who received anticoagulant therapy, received adequate supervision when she experienced blunt trauma on 05/14/25 when she hit her head and, approximately 10 hours later, on 05/15/25, was transferred to the hospital due to vomiting and subsequently passed away. An Immediate Jeopardy (IJ) situation was identified on 05/22/25. While the IJ was removed on 05/26/25, the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, hospitalization and death. The findings include: Record review of Resident #1's face sheet, dated 05/21/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] and 05/12/25. Resident #1 had diagnoses which included hemiplegia and hemiparesis (hemiplegia and hemiparesis both refer to weakness or paralysis on one side of the body), morbid (severe) obesity due to excess calories (refers to having a Body Mass Index [BMI] of 40 or higher, or a BMI of 35 or higher with at least one obesity-related health condition), and cellulitis of left lower limb (a bacterial skin infection that can cause redness, swelling, warmth, and pain in the affected area). Record review of Resident #1's admission MDS assessment, dated 03/24/25, reflected a BIMS of 11, which indicated moderate cognitive impairment. Section N (Medications) reflected she was taking an anticoagulant (blood thinner). Record review of Resident #1's admission care plan reflected: Resident #1, care plan focus, dated 02/07/22, had potential for bleeding related to anticoagulant therapy. Resident #1, care plan focus, dated 03/15/25, was at risk for injury, falls related to excessive clutter in room. Resident #1, care plan focus, revision dated 05/08/25, required extensive-total assist with intervention, dated 05/08/25, provide assist as needed check q 2 hrs. & prn. Resident #1, care plan focus, revision dated 05/03/22, Resident #1 had ADL self-care performance deficit related to pain and hemiplegia and hemiparesis following cerebral infarction (a type of stroke that occurs when blood flow to the brain is interrupted leading to a lack of oxygen and nutrients to brain tissues) affecting left non-dominant side with intervention revised on 05/08/24 Transfer: The resident requires extensive to total assistance by 2 staff to move between surfaces as necessary. ***mechanical lift*** and Resident #1 is also able to do a self-transfer if she isn't feeling weak Resident #1 care plan focus revision, dated 04/08/25, reflected Resident #1 has a history of verbally aggressive behavior. Observation on 05/23/25 at 1:48 PM of facility video footage of Resident #1's hallway on 05/14/25 beginning at 2:00 PM revealed at 2:49 PM on 05/14/25, CNA A entered Resident #1's room alone with a mechanical lift. No other staff member was observed entering or leaving Resident #1's room with CNA A and the mechanical lift. At 2:56 PM, CNA A left Resident #1's room and put the mechanical lift next to the wall outside of Resident #1's room. Record review of Police Incident Report, dated 05/17/25, reflected a police officer received a call from the hospital about a questionable death and a judge ordered an autopsy on a female who was believed to be a victim of abuse or neglect which caused her death. The report reflected Resident #1 was sent to the hospital due to nausea and vomiting that started around 3:00 AM. Hospital staff reported Resident #1 was coherent and alert and told them she hit her head on the cabinet the day prior 'during repositioning in bed on a sling.' Resident #1 reported to the hospital that she, 'was laid back and struck her head on the cabinet very hard.' Record review of the preliminary autopsy report, dated 05/17/25, reflected preliminary cause of death: blunt force trauma to the head, subdural hematoma of right cerebral hemisphere (a condition where blood collects between the skull and the surface of the right side of the brain. This occurs due to a head injury or other causes) and evidence of uncal herniation (a type of brain herniation where a portion of the temporal lobe [the uncus] is forced downwards and through the tentorial incisura due to increased intracranial pressure. It's a serious condition that can cause significant neurological damage and is often a life-threatening emergency.) Record review of hospital records, dated 05/15/25, reflected Emesis [vomiting] per EMS nausea/vomiting since 3:00 AM given Reglan (treats symptoms of gastroesophageal reflux disease [a condition where stomach acid and sometimes stomach contents flow back into the esophagus, the tube connecting your mouth to your stomach]), Zofran (prevents nausea and vomiting) at nursing home. 'PT states she hit head at NH (no LOC); H/O CVA, LT- sided weakness, [hospital] transport. Pt. reports that she hit her head on a cabinet yesterday Record review of hospital records Medical Decision Making, dated 05/15/25, reflected CT (computed tomography) did reveal a chronic appearing hygroma with acute intracranial hemorrhage (a situation where a patient presents with a long-standing subdural hygroma (a collection of cerebrospinal fluid) that is suddenly complicated by a fresh hemorrhage in the subdural space (a layer of cells called [NAME] border cells). Patient observations: PT alert and oriented X4 [someone who is alert and oriented to person, place, time, and event], cooperative, frequent request for nausea/pain meds [medication] upon arrival. Record review of hospital records, dated 05/15/25, reflected Injury Type: blunt trauma PT states she, 'hit her head on a wooden cabinet 05/14/25 while being lifted into a WC at NH' Record review of hospital records, dated 05/15/25, Brief History - she reports that yesterday during repositioning in bed on sling, she was asked to lay back and struck her head on a cabinet very hard. She had a cephalohematoma (an accumulation of blood under the scalp) but otherwise no issues related to this. She was found to have had an acute chronic subdural hematoma in the setting of recent acute mild traumatic brain injury secondary to her recent head trauma (the patient had a recent head trauma that caused initial bleeding, and then later, the blood clot organized into a chronic subdural hematoma) while at the care facility. Record review of hospital course/summary records, dated 05/17/25, reflected Resident #1 was a [AGE] year-old female with a past medical history of diabetes mellitus type II (blood sugar regulation disorder) and cerebrovascular accident (a medical condition where blood flow to the brain is suddenly disrupted leading to brain cell death and potential neurological damage) left sided and lower extension deficits (often associated with specific muscle imbalances or conditions), who was at her care facility when she developed nausea and vomiting. She said she reportedly struck her head on a cabinet. She was on chronic anticoagulation Lovenox (a medication that helps prevent blood clots from forming and is a type of anticoagulant) 100 mg twice a day for diabetes mellitus type II and cerebrovascular accident who was at her care facility when she developed persistent nausea and vomiting. The patient was unable to use or move her left upper and left lower extremity. She was found to have an acute on chronic subdural hematoma in the setting of recent acute mild traumatic brain injury secondary to her recent head trauma (refers to a situation where there is a new [acute] bleeding within an existing [chronic] subdural hematoma) while at the care facility. She is non-ambulatory due to prior cerebrovascular accident. The patient required intubation (a flexible tube is inserted into a person's airway to help them breath) in the emergency department for depressed Glasgow Coma Scale (a neurological scale used to assess the level of consciousness in people with head injuries) and was evaluated by the neurosurgery team who decided that her prognosis was exceedingly poor. She had a fixed and dilated right pupil (can be a serious sign, potentially indicating a neurological issue like stroke, brain injury or intracranial [within the skull] bleeding) as well as decerebrate posturing (a neurological sign indication severe brain damage, characterized by abnormal extensor responses (a reflex in which the big toe extends upward and the other toes fan outward when the sole of the foot is stroked) specifically in the upper and lower limbs. The patient did not make any neurologic recovery. Palliative care was consulted, and the patient was transitioned to comfort care on 05/17/25. She passed away at 12:48 AM on 05/17/25. Record review of LVN C's Nurses Note, dated 05/14/25 at 10:38 PM, reflected CNA'S reported to this nurse while they were transferring the resident from bed to shower chair the resident started to sliding down and they eased the resident down to the floor. I asked resident what happened the resident stated while they were transferring her, she was sliding down and they eased her to the floor. I assessed the resident head to toe and all body parts no injury noted resident denies pain. Vital signs - blood pressure 106/61, pulse 75, temperature 97.3, respiratory rate 18, oxygen saturation 97% room. Record review of LVN D's Nurses Notes reflected dated created 05/15/25 at 6:00 AM reflected, Resident noted to have nausea/vomiting. PRN zofran and reglan administered. C/O headache as well. PRN APAP administered. Resident noted to be diaphoretic (sweating heavily). VS: 97.0 [temperature] 132/57 [blood pressure] 72 [pulse]18 95% on room air [oxygen saturation] Increased weakness noted as well. Resident cleaned up and vomited two more times. Call returned by [MD], made aware of change in condition. New order received to transfer to ER for evaluation and tx. Call placed to daughter made aware of transfer to [hospital]. On call notified of transfer. Record review of resident #1's orders reflected aspirin oral capsule 81 mg (aspirin) give 81 mg by mouth one time a day related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side start date 01/31/2024 no discontinued dated. Record review of Resident #1's Neurological Check Assessment forms beginning 05/14/25 at 5:36 PM through 05/14/25 at 8:30 PM by LVN C and 05/14/25 at 10:30 PM through 05/15/25 at 5:15 AM by LVN D reflected: 05/14/25 at 5:36 PM, temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 5:50 PM, temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 6:07 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 6:25 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 7:00 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 7:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 8:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 10:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 11:15 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 12:30 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 1:30 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 4:15 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 5:15 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. Record review of CNA A's Employee Warning Report dated 05/16/25 reflected supervisor's/employer's statement, staff member suspended pending investigation of incident involving resident that occurred 05/14/25. During investigation, staff member was observed violating facility safety/nursing policies. Staff member has given multiple different accounts of incident, making it difficult to verify what actually occurred discussed with CNA A by phone and employee declined to sign document. Interview on 5/21/25 at 2:30 PM with CNA A revealed CNA A and CNA B were transferring Resident #1 together using a gait belt from Resident #1's bed into a shower chair and Resident #1 began to wiggle and she and CNA B eased Resident #1 to the floor. After Resident #1 was on the floor, CNA B got the mechanical lift and both CNA A and CNA B transferred Resident #1 into the shower chair using the mechanical lift. CNA A said when the nurse came into assess Resident #1, Resident #1 was in bed. She said Resident #1 did not hit her head and if Resident #1 hit her head, she would have told the nurse. Interview on 05/21/25 at 5:35 PM with CNA B reflected she worked the 2:00 PM - 10:00 PM shift on 05/14/25 and she and CNA A went into Resident #1's room to assist Resident #1 with her shower. CNA B said she thought it was about 3:30 PM on 05/14/25. CNA B said Resident #1 was wearing a gait belt and when she and CNA A were transferring Resident #1 from her bed to her shower chair Resident #1 became weak and they gently sat Resident #1 down on the floor of her room. CNA B said Resident #1 did not fall and she did not hit her head. She said after Resident #1 sat on the floor, they used a mechanical lift to transfer Resident #1 from the floor to her shower chair and they wheeled Resident #1 into the shower using the shower chair. CNA B said after Resident #1 was in her bed after her shower, LVN C came to assess Resident #1 . Interview on 05/21/25 at 1:16 PM with LVN C revealed CNA A and CNA B reported to her they were transferring Resident #1 from her bed to the shower chair and Resident #1 began to slide down and the CNAs eased Resident #1 down to the floor of Resident #1's room. The CNAs informed LVN C of the incident after Resident #1 was in her bed. LVN C said she did not know how the CNAs got Resident #1 from the floor to the bed. LVN C thought the CNAs used a mechanical lift, but she did not witness them using a mechanical lift to transfer Resident #1 from the floor to her bed. She said after the CNAs informed her Resident #1 slide to the floor, she assessed Resident #1. LVN C said Resident #1 was not a mechanical lift transfer prior to this incident but Resident #1 had been declining and just returned from the hospital. CNA C said she assessed her from head to toe and did not find any trauma to Resident #1's head. She said Resident #1 denied pain and was talking without difficulty. LVN C said the CNAs should have called her to assess Resident #1 before they moved Resident #1 because she was the charge nurse and residents were not to be moved when they were on the floor. Interview on 05/23/25 at 1:24 PM with LVN D revealed LVN D worked the 10:00 PM - 6:00 AM shift beginning 05/14/25 and conducted neurological checks on Resident #1 that evening. LVN D said on 05/15/25 Resident #1 had vomited, and she cleaned her up and gave her PRN nausea medication. LVN D stated Resident #1 had a fall during the 2:00 PM - 10:00 PM shift from a chair and this occurred before LVN D's shift started. LVN D said she was not told Resident #1 hit her head. LVN D said Resident #1 was not herself, not at baseline and she was sweating. Interview on 05/22/25 with a FP G at 9:05 am who was employed with the autopsy company that conducted Resident #1's autopsy, revealed Resident #1's injures were consistent with a fall and the injuries could have occurred even from a minor fall. He said her subdural hemorrhage was caused by trauma and it would have been exceedingly rare for her to have had those injuries if she had not had a fall. He said if she received treatment sooner, potentially, she might have survived or at least had a better chance of survival. He said because Resident #1 was on anticoagulants, a fall would work in tandem for causing catastrophic bleeding. He said the autopsy photos were consistent with a fall and there was a pretty significant contusion (an injury to soft tissue that causes bleeding without breaking the skin) of the frontal scalp and the back of the scalp. He said her trauma exhibited in the autopsy was from a fall and not a natural death. Interview on 06/11/25 at 9:15 am with a FP G at 9:15 am who was employed with the autopsy company that conducted Resident #1's autopsy and was the FP who conducted Resident #1's autopsy revealed that Resident #1's had an acute bleed that was a day or two old but could not say that it was not an older bleed. She stated there was a subdural contusion (a lift threatening condition where blood collects between the brain and its outer covering) underneath the scalp at the hairline and it did look like she hit her head. Interview on 05/21/25 at 12:36 PM with the DON reflected CNA A and CNA B reported to her that during a transfer with Resident #1, from her bed to a shower chair they broke a fall meaning the CNAs repositioned a person to prevent a fall from happening. The DON said most days Resident #1 did well with staff assisting her with transfers, but she was weak. The DON said she told the CNAs when in doubt, use a mechanical lift and sometimes Resident #1 needed a mechanical lift. The DON said after the CNAs, broke the fall Resident #1 was upset and cursing. She said that when the staff, broke her fall she decided to treat it like a fall and LVN C assessed Resident #1 and the DON wanted close attention paid to Resident #1 because Resident #1 could be difficult. The DON said they used the buddy system to care for Resident #1 because Resident #1 was challenging. The DON stated Resident #1 had a history of calling 911 to come to the facility to take her to the hospital. She said she wanted the nurses to conduct neurological checks on Resident #1 because she wanted to treat the situation where the CNAs broke her fall as if it were a fall and because of Resident #1's history of calling 911 and telling them she needed treatment. The DON stated she wanted the staff to go above and beyond, and they conducted the neurological checks to be on the safe side. Interview on 05/26/25 at 11:23 AM with the Administrator revealed, after observing on 05/23/25 the facility video footage of Resident #1's hallway on 05/14/25 at 2:49 PM, CNA A entered Resident #1's room alone with a mechanical lift. The Administrator said if CNA A was transferring Resident #1 using a mechanical lift, there should have been two people transferring Resident #1 to prevent any accidents and for the safety of Resident #1 . Interview on 05/22/25 at 5:30 PM with MD E revealed she received a call from the facility on 05/15/25 about Resident #1's nausea and vomiting. She said she did not remember the call very well and did not document the call in her records which she usually did. MD E said if Resident #1 was given PRN medication for the vomiting and she was still vomiting, she needed to go to the ER. She said she did not remember if they discussed Resident #1 falling or any discussion that Resident #1 hit her head. Record review of the facility's, undated, policy Safe Lifting and Movement of Residents, , reflected: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and movement of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include residents' preferences for assistance, residents' mobility, resident size, weight bearing ability, cognitive status, whether the resident is usually cooperative with staff and the residents' goals for rehabilitation, including restoring and maintaining functional abilities. Record review of the facility's, undated, policy Neurological Assessment, reflected: The purpose of this procedure is to provide guidelines for a neurological assessment 1. upon physician order 2. when following an unwitnessed fall 3. subsequent to a fall with a suspected head injury 4. when indicated by resident condition When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (often a sign of increased arterial stiffness or a decreased ability of the heart to pump effectively) a difference between systolic pressure (the higher number in the blood pressure reading and diastolic pressure (the pressure in your arteries when your heart is at rest between beats, allowing the heart to refill with blood). This may be indicative of increasing intracranial pressure. Record review of the facility's, undated, policy Falls-Clinical Protocol reflected all should be categorized as 1. those that occur while trying to rise from a sitting or lying to an upright position for an individual who has a fall, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. those that occur while upright and attempting to ambulate and 3. other circumstances such as sliding out of a chair or rolling from a low bed to the floor Falls should also be identified as witnessed or unwitnessed events. This was determined to be an Immediate Jeopardy (IJ) on 05/22/25 at 5:27 PM. The ADM was notified. 5:. The ADM was provided with the IJ template on 05/22/25 at 5:27 PM . The following Plan of Removal submitted by the facility was accepted on 05/24/25 at 4:02 PM: Plan of Removal Immediate Jeopardy On 05/22/2025 an abbreviated survey was initiated. On 05/22/25, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate jeopardy states as follows: The facility failed to ensure Resident #1 received adequate supervision when she experienced trauma to the head, and approximately 10 hours later was transferred to the hospital due to vomiting and subsequently passed away. Action: The DON was in-serviced by Corporate Consultant on safe transfers, mechanical lift safety guide, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25, 6:22 PM. The DON will educate the ADON/ADM/designee and all direct care staff, PRN, new staff and agency staff upon hire: safe transfers, mechanical lift use, falls-clinical protocol, and incident and accident reporting before the beginning of next scheduled shift. All current staff, PRN, agency and new hires will receive this training prior to working their next shift. The retention of the training will be monitored by performing a pre/post test. Start Date: 05/22/2025 Completion Date: 05/23/2025 Responsible: DON/ADON/Therapy/designee Action: All current and new residents that require the use of the mechanical lift/2 person assist will have the care plan KARDEX reviewed to ensure they are up to date. Seventeen residents have been identified that currently use the lift or 2 person assist. Start Date: 05/22/2025 Completion Date: 05/23/2025 Responsible: MDS/designee Action: The DON/ADON/Therapy to help conduct lift competencies on all current, PRN, and new nursing staff and will be maintained in the employee file. The retention of the training will be monitored by performing a pre/posttest and will be maintained in the employee file. This will be conducted prior to working the next shift. All agency staff will complete a competency prior to working a shift. The DON/designee will monitor conduct three random observations of transfer with lifts and/or 2-person assists a week for the next 4 weeks then three random observations of transfer w/lifts and/or 2-person assists monthly thereafter. All findings will be reported to the QAPI team. Start Date: 05/22/2025 Completion Date: 05/23/2025 Responsible: Therapy/designee The charge nurse/DON/ADON will assess each resident that has been identified to use a mechanical lift to determine if any other residents have had any injury related to use of a lift. This will be completed on 5/23/25. Seventeen residents have been identified that use a mechanical lift. A facility-wide survey was completed 05/23/25, all residents deny that they have suffered any accidents or hazards. The DON was in-serviced by RN Corporate Consultant on 05/22/25 on safety and supervision. This in-service was then provided to the nursing staff, CMA's and CNA's on 05/23/25. All in-services will be provided to the two agency companies and will be required before working their next shift and future shifts. This will be ongoing. The agencies will provide signed confirmation on their electronic platform. The DON/ADON/ADM will be responsible for ensuring the education is completed prior to working a shift. A QAPI plan is being initiated with this POR , the DON and Administrator will carry out the plan and monitoring. The Corporate consultants will monitor the plan monthly with each site visit for the next 6 months . Monitoring of the POR included the following: Interview on 05/24/25 at 4:45 PM with the CC revealed she in-serviced the DON on the facility policy regarding safety and supervision, safe transfers, mechanical lift safety guidelines, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25 at 6:22 PM. The CC discussed with the DON the safety and supervision of residents in general and during transfers and the falls protocol and using the mechanical lift for safe transfers and safety during 2-person non-mechanical lift transfers. The CC in-serviced the DON on educating her staff that even if they suspected there was an injury to the head, or any injury, nurses needed to notify the MD and send the resident to the hospital at that time. She in-serviced the DON on educating CNAs to report in a timely manner to the nurses anything out of the ordinary that occurred during transfers or during CNA involvement with resident care and safety. Interview on 05/24/25 with the DON at 4:00 pm revealed she was in-serviced by the CC and together they reviewed the facility policy procedures on safety and supervision, safe transfers, mechanical lift guidelines, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25 at 6:22 PM. They discussed ensuring the safety of residents who used a mechanical lift and residents who were a two person assist. The DON said during the in-service they discussed the requirement for nurses to call the MD and get an order for the resident to go to the hospital if there was even a suspicion of the resident hitting their head or had any safety issues. CNAs were to report to their charge nurse any type of fall, incident, or accident even if they thought it was minimal. It needed to be reported to the charge nurse because it was the responsibility of the charge nurse to follow up with the resident and escalate as needed. It was the responsibility of the charge nurse to report any suspected head injury to the MD. It was the responsibility of the Abuse and Neglect coordinator to report any concerns of abuse and neglect and the responsibility of the DON to assist with investigations as directed and follow up with any reported suspicion of head injury. It was the responsibility of the charge nurse to make sure CNAs were reporting to the nurses any and all concerns about resident care and safety and problems or concerns with resident transfers and the nurse's responsibility to follow up with those concerns to the MD and to notify on call staff. Interview on 05/25/25 at 9:26 AM with the DOR reflected

Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, the facility ensured that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of five residents (Resident #2) reviewed for quality of care. 1. The facility failed to ensure that Resident #2 was prepared for his scheduled eye doctor appointments. 2. The facility failed to ensure Resident #2 did not eat prior to his scheduled eye surgery on 7/15/2024. 3. The facility failed to ensure Resident #2 received an exam for medical clearance prior to his eye procedure on 5/21/2025. 4. The facility failed to have Resident #2 at his scheduled appointment on 3/3/2025 and resident was a no call/no show for this appointment. These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life, or further vision deficits. Findings included: Record review of Resident #2's face sheet, dated 5/22/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnosis which included unspecified vision loss, unspecified glaucoma (a group of eye conditions that can cause blindness), Type D Diabetes Mellitus without complications (blood sugar disorder) and Hyperglyceridemia (elevated level of fat in the blood) Record review of Resident #2's quarterly MDS, dated [DATE] reflected a BIMs of 10, which indicated mild cognitive impairment. Section B; Vision reflected Resident #2 was severely impaired and did not wear corrective lenses. Record review of Resident #2's care plan, dated 5/22/2025, reflected the focus: [Resident #2] is legally blind unspecified glaucoma. Also, the focus [Resident #2] refuses to attend appts at [location outside current city], also refuses to attend appointments d/t weather or if resident isn't agreeable to treatment plans; Goal: The resident will cooperate with care through next review date; and allow the resident to make decisions about treatment regime, to provide sense of control, Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, Provide resident with opportunities for choice during care provision, Spoke with Staff at [eye doctor] regarding resident refusing additional tx and refusal of appointments in [location outside current city]. During an interview on 5/21/2025 at 4:10 pm, Resident #2 stated he did not remember missing any eye appointments, but he didn't always know when they were. He stated the facility took care of that for him. He stated he was legally blind in his left eye and had poor vision in his right eye. He stated he did remember missing an eye procedure because he ate but no one at the facility told him he couldn't eat, and they took him to the dining room for breakfast and lunch that day. He stated he was not aware the eye doctor needed medical clearance for his most recent surgical procure earlier this month, but they [the facility] keep track of all that, I don't. he stated the staff with him was supposed to check him out and make his next appointments and he was not aware of any problems with not showing up for a scheduled appointment. During an interview on 5/22/2025 at 9:30 AM, the EYD stated they had been treating Resident #2 for over a year and often had issues with the nursing facility following instructions for surgery and getting the resident to appointments. The EYD stated one surgical procedure had to be canceled at the last minute, delaying care because Resident #2 had eaten meals prior to the procedure and was supposed to be NPO. He stated his office had to fit in an appointment the next day to prevent the resident from further vision deterioration. He stated for another procedure to help the resident with his vision, he required medical clearance from the NF doctor and the medical clearance was never completed by the NF doctor. He stated he and the anesthesiologist had to complete the medical clearance right before the procedure so it would not be canceled - further delaying critical vision treatments for Resident #2. The EYD stated he was concerned Resident #2 would have further deterioration in his vision without timely attendance at follow up appointments and surgical procedures. He stated it was important that all appointments and procedures be completed on time as scheduled to prevent further potential loss of the vision Resident #2 had remaining in his one eye and to prevent blindness. During an interview on 5/24/2025 at 1:24 PM, the ADM stated his expectation was that residents would get to their appointments at the date and time of their scheduled appointment. He stated they would try to get the resident to appointments at the doctor's office unless the resident refused. He stated he was not aware of any transportation problems getting residents to and from appointments. He stated he was aware one appointment had to be rescheduled for Resident #2 because he ate breakfast, and they asked the EYD office if they could change the appointment and they were able to change it. The ADM stated he was not aware the EYD faxed the NF asking for medical clearance for Resident #2 for a surgical procedure - he stated this was a medical/clinical question for the DON. During an interview on 5/25/2025 at 1:45 PM, the DON stated once the facility was aware of the appointment date and time they coordinated with the ADM, activities director and designees to ensure the completion of the appointment. If the resident refused an appointment the team encouraged them to go, educated them why they needed to go, and alerted the family and physician of the missed appointments. The NF attempted to get any rescheduled refusals or conflicting appointments rescheduled as the clinic allowed. The ADM DON and activities staff get residents to their appointments and submit any follow up information to the charge nurse and medical records. She stated they did not have a designee for coordinating appointments it was a collaborative effort by the DON, the ADM and Activities - they all worked together to get them to their appointments. The DON stated they did have residents who refused to go to appointments - there were various reasons why they did not want to go. She stated the NF might have conflicting appointments which could cause an appointment already scheduled to have to be rescheduled. She stated she did not recall a resident being taken to the dining room for breakfast and lunch when he was NPO and his procedure having to be canceled. She stated she was aware a surgical clearance that had a delay in return of completion by a physician - but clearance so the procedure would not cancel, and risk further delay to Resident #2. Record review of an email from the EYD surgical coordinator, dated 5/22/205, reflected Resident #2: After patient's appointment on 2/20/2025 the patient was never checked out and left his appointment, so our office had to call to request to schedule his follow up appointment (reference 4). This would be in reference to the 3/3 no showed appointment. Our office attempted to schedule multiple times with no answer. We left multiple voicemails and finally spoke with someone on 2/27/2025 who scheduled the appointment [for 3/3/2025]. For his procedure July 15th [2024] it was rescheduled because he ate. We were not notified by the patient or nursing facility. We were notified by the surgery center that he ate breakfast and lunch after being told to be NPO. For his procedure scheduled for May 21, 2025, the patient was scheduled and given instructions on May 14, 2025. These were physically given and emailed. When the facility was called to request the patient's pre-operative clearance, we were notified that they were not aware it was needed. Record review of eye doctor records reflected: Audio recordings were provided and revealed Multiple messages were left for the NF between 2/20/2025 and 2/27/2025 requesting NF contact eye doctor for follow up appointment. Email dated 7/16/2024 reflected Resident #2's procedure from yesterday 7/15 [24] was cx-ed [canceled]. He ate breakfast and lunch. Fax confirmation dated 7/1/2024 to NF with pre-surgery instructions patient has surgery scheduled for July 15th [2024] and we are missing information regarding the patient's demographics. The attached documents need to be filled out signed and faxed back to [Eye doctor] at [fax number provided] Communication note dated 5/20/2025 at 1:46 pm requested clearance. Communication note dated 5/21/2025 at 9:43 am [NF staff] said she is looking into where it is Communication note dated 5/21/2025 I spoke to nurse [staff name], she stated that they were not aware that he had to have medical clearance prior to surgery, that the person that brought him was not the regular transportation person, it was someone in admissions. She said that if we call [local family medicine clinic] that they could possibly clear him for surgery, since he was already fasting. Communication note dated 5/21/2025 at 10:06 am for Resident #2 Spoke with [NF staff] on her personal number [phone number]. She is one of the nurses at [NF]. I informed her that since the facility was unable to get his pre-op done for surgery, we will have someone do it at the facility so he could still proceed today. She confirmed with me that he has been fasting and did have transportation to have him at [name] Surgery Center at 11:45AM. Review of facility policy Transportation, Diagnostic Services revised [DATE] reflected: Our facility will assist residents in arranging transportation to/from diagnostic appointments when necessary. Should it become necessary to transport a resident to a diagnostic service outside the facility, the Social Service Designee or Charge Nurse shall notify the resident and inform them of the appointment. 2. The resident's representative (sponsor) will be responsible for transporting the resident to his or her lab appointment. 3. Should it become necessary for the facility to provide transportation, nursing/administration will be responsible for arranging the transportation. 4. A member of the Nursing Staff, or Administration, will accompany the resident to the diagnostic center when the resident's family is not available. 5. Requests for transportation should be made as far in advance as possible, so as to not have conflicting scheduled appointments. 6. The use of volunteers to transport residents to appointments must be approved by the Administrator.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency for incidents of alleged abuse and neglect for one out of eight residents (Resident #1) in that: The facility failed to report to Health and Human Services alleged abuse occurred in the facility secured unit involving Resident #1 and Resident #2. During Resident #1's 05/15/25 LA Update meeting, Resident #1 reported he was hit by Resident #2. The date of alleged occurrence was unknown. This failure could place residents at risk of abuse, neglect, pain, and diminished quality of life. Findings included: Review of Resident #1's face sheet dated 05/16/25, reflected a [AGE] year-old male original admission date of 08/15/16, and readmissions 08/15/16 and 04/18/25 with diagnoses of paranoid schizophrenia (characterized by delusions of persecution), major depressive disorder, and schizoaffective disorder, bipolar type (a mental health condition characterized by a combination of schizophrenia symptoms (like delusions and hallucinations) and symptoms of bipolar disorder (like mania and depression). Review of Resident #1's MDS, dated [DATE], reflected a BIMS score of 10 reflecting moderate cognitive impairment. Review of Resident #1's care plan focus revision dated 04/04/25 reflected Resident #1 was PASRR positive for mental illness paranoid schizophrenia/schizoaffective disorder (a mental illness characterized by symptoms of both schizophrenia and mood disorders like mania or depression) with interventions of PASRR services for mental illness. Review of Resident #2's face sheet dated 05/22/25, reflected an [AGE] year-old male original admission date of 10/22/245 with diagnoses of unspecified dementia (a diagnosis given when a person exhibits symptoms of dementia but the underlying cause or specific type of dementia cannot be clearly identified), macular degeneration (a leading cause of vision loss in people 60 and older) and chronic obstructive pulmonary disease (a chronic progressive lung disease that make it difficult to breath). Review of Resident #2's MDS, dated [DATE], reflected a BIMS score 3 reflecting severe cognitive impairment. Review of Resident #2's care plan focus dated 10/13/24 reflected impaired cognitive function related to dementia (a term for a group of brain disorders that cause a decline in thinking, memory, and reasoning abilities, significantly impacting daily life) with intervention dated 10/13/24 ask yes/no questions to determine resident's needs. Record review of PASRR Comprehensive Service Plan (PCSP) Form dated 05/15/25 for Resident #1 reflected the following: Type of meeting - LA update Reason for meeting - change in service Resident #1 PASRR positive for mental illness only Meeting participants - Resident #1, LA, and facility ADON LA comments reflected - Team met for LA Update to initiate MI PASRR services . [Resident #1] reported another resident assaulting him in his bathroom earlier this month, causing him to hit his head on the toilet resulting in a bump on his head. He stated that the facility would not call 911 and would not allow him to call 911. Team explained to [Resident #1] that the facility staff may have determined that his injury did not require a higher level of care. [Resident #1] . Team encouraged [Resident #1] to follow his medication regimen to ensure that he was not experiencing situations as a result of his mental illness, as he has a history of this. [Resident #1] stated he will continue to refuse his Vistaril. Review of a document dated 05/16/25 listed the sending fax number of the facility and receiving fax number of Health and Human Services intake reporting number and reflected that a self report was made by the facility DON. The document reflected, Please see attached LTC (long term care) facility self-report. Please forward all correspondence to [email for the DON]. The self-repot included Resident #1's client information and the brief narrative reflected, per HHSC (Health and Human Services) surveyor [Resident #1] reported to external cm that he was beat up by a resident and a little girl, sitting on edge of bed. No fax confirmation included with faxed self-report. Record review on 05/16/25 of Texas Unified Licensure Information Portal - the online portal used by healthcare providers in Texas to report various incidents, including those related to abuse and neglect reflected no initial self-report by the facility for an incident involving Resident #1 and Resident #2. Interview on 05/16/25 with Resident #1's PASRR LA at 2:07 pm reflected the ADON was present in the PASRR LA update meeting during the entire meeting including when Resident #1 said Resident #2 assaulted him. Interview on 05/16/25 with the ADON at 5:54 pm reflected when the PASRR LA representative arrived at the facility for Resident #1's PASRR meeting she was passing out pills to other residents and told Resident #1's LA that she would join the meeting when she was finished passing out the pills. The ADON said it was about 10 or 15 minutes before she joined Resident #1's PASRR meeting. The ADON said at the time she was present during the meeting Resident #1 made no statement that Resident #2 hit him, and Resident #1 made no statement that he told staff he wanted to go to the hospital because of being hit by Resident #2. Interview and observation on 05/16/25 at 1:42 pm with Resident #1 in the facility secured unit revealed Resident #1 said Resident #2 hit him in his head with his fist and there were no witnesses. He said it happened sometime after Resident #1 went to the inpatient psychiatric clinic. Resident #1 said he did not bleed when he was hit, and he pointed to the left side of his forehead head with his right hand and surveyor observed no injury. Resident #1 said he felt safe at the facility, but sometimes other people got into other people's business. Interview and observation on 05/17/25 at 7:52 pm with Resident #2 in the facility secured unit revealed Resident #2 looking at the vending machine and telling the surveyor he wanted crackers. Resident #2 spoke incoherently and pointed at the food items in the vending machine. When Resident #2 was asked if he felt safe at the facility, he said, Yes. Resident #1 was observed in the same area with Resident #2 and no negative interactions were noted between Resident #1 and Resident #2. Interview on 05/17/25 with CNA A at 4:30 pm revealed Resident #1 had not told her that Resident #2 hit him. She said that Resident #1 and Resident #2 share a bathroom and sometimes they yelled at each other, but she had not witnessed or been told by Resident #1 that he was hit or injured by Resident #2. She said if Resident #1 told her that Resident #2 hit him, she would have reported it immediately to the charge nurse. She said that the Administrator was the ANE coordinator, and she would also report ANE to the Administrator. She said she was trained in ANE when she was hired at the facility and the facility conducted in-service training on ANE several times a year. She said everyone was responsible for reporting ANE. She said that she was not concerned about any resident-to-resident abuse in the secured unit but if she saw or heard of any abuse she would report it immediately. Interview on 05/17/25 with RN B at 5:06 pm revealed she worked in the secured unit and Resident #1 never told her that Resident #2 hit him. She said she was not concerned about Resident #1 and Resident #2 having any altercations. She said if there was an allegation of Resident #2 hitting Resident #1, she would separate them immediately, even if the event was not witnessed but reported to her by one of the residents and report it immediately to the Administrator or the DON. She said anyone who heard about or witnessed ANE was responsible for reporting. She said she was trained in ANE when she began working at the facility and she had frequent in-services regarding ANE. She said ANE was a hot topic because it was important to know about what to do if abuse was witnessed or reported and anyone one who saw or heard about abuse was responsible for reporting the ANE. Interview on 05/16/25 with the facility SW at 6:16 pm revealed she checked on Resident #1 on a weekly basis and put a behavior note in his progress notes for each check-in. She revealed Resident #1 had a history of making allegations that were not true, mostly about the staff. She stated that if he told her that another resident hit him or if he reported he was abused, either witnessed or unwitnessed, she would report it immediately to the Administrator, because he was the Abuse and Neglect Coordinator for the facility. She said that if the Administrator was not available, she would report it to the DON. She said that they could not assume that a resident who had mental health issues or a history of false statements was not abused, it needed to be reported to ensure the safety of the resident. She said she was trained on ANE when she was hired at the facility and she conducted the ANE education, that was based on the facility policy, for new residents who entered the facility so they would know the facility did not tolerate abuse and to education new residents on the types of abuse. She said the facility conduced monthly in-services on ANE education and training. Interview on 05/16/25 with the psychiatric NP at 6:34 pm revealed Resident #1 had a history of refusing to take his medication and recently refused 2 psychiatric telehealth visits with her. She said Resident #1 had mood swings, would curse at the staff, and made a lot of allegations that he was being abused by staff. She said Resident #1 did not tell her that he was hit by Resident #2 but was confident that the facility would have reported it to the state if they were aware the resident made an allegation that he was hit by Resident #2. She said the facility was, on top of it and even if a resident was delusional and reported an allegation of abuse, the facility would still report it. Interview on 05/17/25 with the Administrator at 6:34 pm revealed he was not aware of any abuse regarding Resident #1 until 05/16/25 at about 5:00 pm when he was shown the PASRR Comprehensive Service Plan (PCSP) Form dated 05/15/25. He said the PASRR person did not tell him about any abuse involving Resident #1 and if she knew of abuse, she should have told him. He said the facility had an in-service on abuse and neglect every month. He said if a resident said someone hit them, and the resident had a history of false allegations he would report the allegation to the state regardless of the residents past history of false allegations. He said the allegation involving Resident #1 and Resident #2 was not reported because he was not aware of Resident #1's allegation. He said it was everyone's responsibility in the facility to report ANE and anyone could pick up the phone and call the HHSC hotline, or they could call or tell him about the alleged abuse and he would report all allegations of ANE. He said he did not know the details of what happened during Resident #1's PASRR meeting with the ADON. He felt the PASRR person should have reported it to him even though it was discussed in Resident #1's PASRR meeting. He said the ADON had been trained in ANE and knew how to report ANE. Review of facility in-services reflected in-services on Abuse, Neglect and Exploitation dated 12/18/24, 01/16/25, 02/16/25, 03/05/25, 04/16/25, and 05/15/25. Review of facility policy Abuse Investigating and Reporting, undated, reflected all alleged violation involving abuse, neglect, exploitation, or mistreatment including injuries of an unknown source and misappropriation of property will be reported by the facility administrator or his/her designee to the following persons or agencies: the state licensing slash certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the Residents Representative (Sponsor) of Record, Adult Protective Services (where state law provides jurisdiction in long-term care), law enforcement officials, the resident's attending physician and the medical director. An alleged violation of abused, neglect, exploitation, or mistreatment (including injuries of unknown sources and misappropriate of resident property) will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury or twenty-four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Verbal/written notices to agencies may be submitted via special carrier fax email or by telephone.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision for 1 of 1 resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 did not elope from the facility on [DATE]. Resident #1 was missing from the facility from approximately 5:00 am to 8:00am am until he was located by police. An IJ was identified on [DATE] at 4:10 PM. While the IJ was removed on [DATE] at 7:45AM, the facility remained out of compliance at a level of no actual harm at a scope of isolated with a potential for more than minimal harm, that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for falls, injuries, dehydration, hospitalization , and death. Findings included: Record review of Resident #1's admission recorded dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included: dementia (brain diseases that cause declining thinking, memory, and reasoning skills), psychosis (mental state where a person's perception of reality is different from other such as hallucinations and delusions), depression (feeling sad, unhappy, or miserable), major depressive disorder (mood disorder that can cause a persistent feeling of sadness and loss of interest), muscle weakness(when your muscle feel tired, weak, or unable to exert their usual force), abnormality of gait and mobility (any deviation from a normal walking pattern, including changes in the rhythm, coordination, and stability of movement), lack of coordination(not being able to move your body smoothly and precisely), and symbolic dysfunction (disorder that affects a person's ability to perceive or perform certain activities). Record review of Resident #1's Annual MDS assessment, dated [DATE], revealed the resident had a BIMS score of 03 indicating the resident had severe cognitive impairment. Resident #1 required supervision or touching assistance in the following areas: personal hygiene, putting on/taking off footwear, lower body dressing, upper body dressing, shower/bathe self, toileting hygiene, and oral hygiene. Record review of an Elopement Risk assessment dated [DATE], reflected Resident #1 was a risk for elopement. Record review of local weather with outside temperatures for the local area on [DATE] from 5:00am 8:00am temperatures ranged from 28 degrees to 30 degrees F. Record review of progress note, dated [DATE], reflected nurse was made aware of elopement at approx. 0800 that resident was not in room or unit. This nurse made staff aware of situation and head count and search initiated of building and surrounding area of outside perimeter. Resident was seen approximately 0500 near day room and was unable to sit down on couch and returned to room at this time. Call placed to DON, made aware of situation. Call placed to emergency contact, made aware and will keep updated. Record review of progress note, dated [DATE], reflected DON responded to report by charge nurse of suspected elopement. CODE Pink response measure deployed, unable to locate resident facility premises. Administrator and Corporate Team alerted of incident; local PD dispatched for further assistance. Resident located near facility by local PD. Nursing Admin arrived at scene, where Resident #1 refused to be transported back to facility. After several minutes of convincing by the officer on scene, Resident #1 was transported to facility by police car. Upon arrival to the facility, Resident #1 became increasingly irate and agitated, adamantly refusing to return to facility. Resident #1 stated, Don't come near me, I'm not going in there, and if you force me I'll f**k you up and everyone else back there. Police Dept able to eventually de-escalate the situation. Resident #1 demanded that we give him his belongings and release him now! I explained to Resident #1 that we would have to get an order from his physician in order to release him and have a meeting with our Team and his friend to come up with a plan for him to leave safely. Resident #1 began to yell and curse and said, I'm not waiting on a Dr, I'm leaving now, I'm a grown man and it's my choice, I'm not in prison! PD stated, Resident #1 is his own Responsible Party and appears to be alert and cognitive and the facility cannot hold him here against his will. I explained to PD that resident had history of alcohol-induced dementia, and I did not feel comfortable releasing him into the community with no secure discharge plan. Local PD began asking a series of questions to attempt to review his cognitive status. They stated Resident #1 knew his name, the year, his whereabouts, where he was from, and named several people on his contact list. I explained to local PD that LTC settings have clinical assessments used to determine a resident's cognitive status, and PD attempted to assist me with completing this assessment to no avail. Resident #1 grew agitated towards the end of the assessment, began to make threats of physical violence, and did not allow completion. At this time, I requested that the officers encourage Resident #1 to go to the local hospital for further evaluation to rule out infection, abnormal labs, etc. After several moments, Resident #1 was transferred to local hospital via police car. IDT team, ombudsman, medical director, corporate team notified. Record review of progress note, dated [DATE] at 10:31am, reflected the DON spoke w/staff from local hospital re: transfer of Resident #1 to in-patient psychiatric hospital. Stated that another psychiatric evaluation had been completed and per the new psychiatric evaluation, resident did not meet criteria for in-patient psych stay. Local hospital staff stated, Resident #1 continued to refuse to return to the nursing facility and continued to make threats of physical harm if made to return to facility. DON requested that local hospital staff forward clinical updates/evaluation notes and results to e-fax for review as soon as possible, so that resident updates could be discussed with Administrator, Clinical Consultant, IDT Team and appropriate interventions and measures are able to be put in place. Emphasized to local hospital staff that we are willing to accept resident back, however we want to ensure the safety of the residents and staff upon his return. Encouraged local hospital to connect Resident #1 with a counselor or social worker that may be able to help him cope with the emotions that he was experiencing, and acceptance of his need to be in a long-term care setting. DON requested that local hospital stay in close contact with the nursing facility so that we may collaborate on a safe transfer for the resident. Anticipated to connect [DATE] after the nursing facility IDT meeting and local hospital doctor rounds/team meeting to discuss further. Record review of Resident #1's care plan, dated [DATE], revealed Resident #1 was care planned for risk of side effects/complications from antidepressant use related to depression, deep vein thrombosis, difficulty making decisions dementia associated with alcoholism with behavioral disturbance, placed in secure unit d/t history of elopement, physically aggressive behavior, h/o of wandering, and impaired comprehension. Record review of a police report date [DATE], revealed the local pd was notified Resident #1 was missing at 8:33am on [DATE]. The record review also revealed Resident #1 was located at 10:16am on [DATE]. An interview with the MD on [DATE] at 1:11pm, revealed the MD was told that Resident #1 departed through a window, the doors had an alarm but not the windows. The MD stated Resident #1's elopement could have caused Resident #1 harm from hypothermia(a condition that occurs when body temperature drops below 95 degrees Fahrenheit or 35 degrees Celsius.) or possible death. The MD stated Resident #1's elopement was unacceptable. An interview with the DON on [DATE] at 11:27am, revealed the DON stated she was informed by the charge nurse that Resident #1 was noticed missing around 7:30am on [DATE]. The DON stated a CNA noticed that Resident #1 wasn't in his normal seat for breakfast. DON stated the staff then checked all of the rooms, smoking area, rest room and therapy room but Resident #1 could not be found. The DON stated staff searched all over the facility inside and outside. The DON stated she advised staff to go to Resident #1 room and it was noticed that his window was ajar. The DON stated that's when the local PD was notified Resident #1 was missing. The DON stated Resident #1 was found ,d+[DATE] away blocks from the facility by the local PD and returned. The DON stated once Resident #1 was in the parking lot of the facility having behaviors, so the local PD took him to a local hospital for an evaluation. The DON stated that Resident #1 did not qualify for inpatient stay and was return to the facility later the same day. The DON stated that some negative outcomes of Resident #1's elopement could have been the resident could have been injured or died . The DON stated that expectations for residents' supervision to be carried out appropriately, all residents were safe, and their needs are being met. An observation and interview with Resident #1 on [DATE] at 12:25pm, revealed that Resident #1 stated that he was feeling good and did not have any thought of leaving the facility. Resident #1 did not state how he left the facility. Resident #1 was in his room lying in bed at the time of the interview. An interview with CNA A on [DATE] at 2:42pm, revealed that CNA A stated she worked on [DATE] when Resident #1 eloped. CNA A stated she usually laid eyes on all residents when the shift started but not on that day because she was running late so she just went to working. CNA A stated that around breakfast time she noticed she had seen Resident #1 in the common area, so she went to Resident #1's room and opened the door but he wasn't there. CNA A stated she checked the common area and his room twice but couldn't locate Resident #1. CNA A stated she then notified the nurse that Resident #1 was missing. CNA A stated her, and the nurse went to Resident #1's room that was when the nurse noticed Resident #1's window was open. CNA A stated that Resident #1 could have been hurt or died due to his elopement. Review of the facility's Safety and Supervision of Resident policy, dated [DATE], revealed Our facility strives to make the environment as free from accident hazards as possible, Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Policy Interpretation and Implementation Facility Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: e. unsafe wandering . This was determined to be an Immediate Jeopardy on [DATE] at 4:10 pm. The DON was notified. The DON was provided with the IJ template on [DATE] at 4:10 pm. The Plan of Removal was accepted on [DATE] at 7:45 am and included the following: All listed items will be completed by [DATE] with continued follow-up: 1. Elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy and procedure review was facilitated by DON with all facility staff. [DATE]. 2. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. 3. The facility will implement census checks every 4 hours until further review, facility wide. Charge Nurses and/or Designee will be responsible for completion. 4. Window alarms were placed on each window in the secure unit by the Maintenance/Life Safety Team. Completed [DATE]. Placement and checking function will be performed by Charge Nurse/designee each shift. 5. Every resident will have an updated wandering risk scale completed by Charge Nurse/designee by [DATE]. 6. New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s). 7. Any resident that attempts to leave or wishing to leave will be reported to the DON/designee and new interventions will be put in place at that time. 8. Twice a week, for 3 months or until the pattern of compliance is maintained, the DON/designee will check the monitoring logs to ensure compliance, any non-compliance will be reported to the facility administrator. 9. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings on [DATE]. Members of the IDT Team including DON, ADON, Director of Rehab, Maintenance Director, Admission/Marketing Team, Social Services Director, Activities Director, Business of Manager, and Central Supply Director. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. Plan of Removal completion date is [DATE]. Monitoring for Plan of Removal was completed on [DATE] as follows: Record review on [DATE] at 9:00am, reflected staff were inserviced on elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy. 48 staff were inserviced on elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy Record review on [DATE] at 10:35am, reflected all 89 residents had updated wandering assessments. Record review on [DATE] at 10:40am, reflected census check were being completed every four hours. Observation on [DATE] at 9:30am, reflected window alarms on all windows in the secure unit were working. There were 12 rooms on the secure unit. Each alarm was triggered and could be heard from a far distance. Staff responded to the window alarms appropriately. During interviews on [DATE] from 9:50 am - 11:45 am with six staff members (2 6am - 2pm LVNs, 2 6am-2pm CNAs, 2 2pm-10pm LVNs 2 2pm-10pm CNAs, 2 10pm-6am LVNs, and 2 10pm-6am CNAs), who were able to articulate information from the following in-services: Elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy and procedure. All staff interviewed stated if any residents that attempt to leave or wishing to leave they would report it to the DON/designee immediately. During an interview with the DON on [DATE] at 11:50am, revealed the DON stated the facility had not any new admissions, no new hires, and no resident had attempted to leave or wished to leave since Resident #1's elopement. The DON stated that all patio furniture was removed from the smoking area due to Resident #1 elopement. The DON stated that with the information gather it was likely that Resident #1 used the patio furniture to get over the fence to elope. While the IJ was removed on [DATE] at 7:45AM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be free from Abuse as defined in this subpart to protect 2 (Resident #42 and Resident #62) of 82 residents from Resident's # 52 aggressive behavior. 1. The facility failed to protect the residents from an aggressive resident with behaviors (Resident # 52). Resident #62 sustained an injury to her foot that required her to be taken to the hospital for evaluation. 2. The facility failed to put interventions in place to ensure the safety of Resident # 52 and other residents at the facility. On 08/30/24 at 6:16 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/31/24, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed the residents at risk for abuse. Findings included: Review of Resident # 42's Quarterly MDS dated [DATE] revealed a [AGE] year-old male admitted to the facility 03/25/2022 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), stroke (a condition in which poor blood flow to the brain causes cell death) and anxiety disorder (significant and uncontrollable feeling of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired). Resident #42 had a BIMS score of 11 which suggested moderate cognitive impairment. Review of Resident # 62's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted to the facility 01-30-2024 with diagnoses that included cerebralvascular accident (a condition in which poor blood flow to the brain causes cell death), anxiety disorder (significant and uncontrollable feeling of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired). Resident #52's BIMS score was 15 which suggested no cognitive impairment. Review of Resident # 52's face sheet dated 8/30/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial paralysis due to a blockage in the brain impeding blood flow), unspecified mood (affective) disorder (any in a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood), major depressive disorder, recurrent, severe with psychotic symptoms (sadness and hopelessness with symptoms of seeing, hearing, smelling, or believing things that are not real), and intermittent explosive disorder (a condition that causes repeated, sudden outburst of impulsive, violent behavior, or angry verbal outburst). Review of Resident #52's Quarterly MDS dated [DATE], revealed a BIMS score of 08 which indicated a moderate cognitive impairment. Section E0200 Behavioral symptoms revealed no physical behavioral symptoms directed to others, no verbal behavioral symptoms directed toward others, and no other behavioral symptoms not directed toward others. Review of Resident # 52's care plan, dated 04/02/2023 and updated 2/20/2024, revealed Resident # 52's h/o using profanity and verbally aggressive with staff and resident's r/t intermittent explosive disorder. On 04/07/2023 cursed out nurse, 04/19/2023 cursed out resident, 04/20/2020 cursed staff and residents, 05/03/2023 cursed out nurse, 05/20/2023 cursed out nurse and CNA, 06/01/2023 cursed out nurse, 06/08/2023 cursed nurse, 06/09/2023 cursed nurse, 06/11/2023 cursed CNA, 06/12/2023 cursing staff, 06/15/2023 cursed out nurse, 06/20/2023 cursed out nurse, 06/23/2023 cursing in dining room, 07/24/2023 cursed out resident, 07/25/2023 cursed resident out, 08/02/2023 cursing staff, 08/13/2023 cursed out nurse, 08/23/2023 resident in common area, calling female resident a fucking whore, 08/24/2023 residents behavior, unacceptable, cursing, and yelling at nurse, and 08/29/2023 cursing staff and residents: 1/31/2024 verbal aggression initiated, 2/19/2024 verbal aggression initiated. Review of Resident #52's Progress notes dated 8/30/2024 at 11:49 am written by the SW revealed Spoke with the resident regarding incident that happened over the weekend. When SW asked him about it, he responded, 'you don't know?' Resident then stated that he was attacked by the other resident who hit him. He stated he needed to contact his family to let them know that he had been attacked. SW informed him that he has the right to call his family and asked if he needed assistance, he responded no, he can do it. The incident is still under investigation. Several residents were witnesses and state that Resident # 52 was the instigator. Review of Incident and accident report which was not a part of the medical record dated 8/25/2024 at 09:02 am completed by LVN J, At approximately 9 am , once breakfast was completed, this nurse was assessing another resident her breathing treatment when a resident came wheeling down the hall stating, they are fighting. I did not immediately understand what was going on, then I realized everyone was moving towards the dining hall and I followed. Once I arrived in the dining hall the residents were being separated. I spoke and found a housekeeper who had witnessed most of the incident, Resident # 52 was verbally, harassing Resident #42, Resident # 42 told him something around the lines of leave me alone I'm not bothering you or anyone. Resident #52 preceded to go around the wall towards Resident #42 and continued to verbally harass him then threw something towards Resident #42's direction. Resident #42 then picked up a chair to hit Resident # 52 and staff members removed the chair from Resident # 42's hands, then Resident #42 attempted to hit Resident #52. Due to a lot of bodies and movement it is unsure if Resident #42 actually hit Resident #52. In an interview on 8/27/2024 at 10:00 am with Resident # 52 he stated he did not wish to answer questions at that time. In an interview on 8/27/2024 at 10:30 am with Resident #42, he stated that Resident #52 always picked on him and this last weekend he pushed to far and he felt he had to do something . He did not share details of the other incidents but stated that the administrator and other staff were aware of the situation. In an interview on 8/27/2024 at 11 am with Resident #62, she reported that when Resident #52 threw a bowl this weekend, it hit her foot. There was a bruise, swelling, and pain. She was sent to the Emergency R room that afternoon for evaluation. The doctor will follow up with her today about the foot as she was still in pain . The resident stated this happened on Saturday and several staff member were present, she stated that this is an ongoing issue but did not elaborate for the other incidents. During the Resident council meeting on 8/28/224 at 10 am revealed many of the residents stated there was a resident in the facility that is verbally and aggressive behavior (Resident # 52), resident report the facility is aware of the behaviors and do not appear to be doing anything about it. Several residents stated that there were afraid of (resident #52 because of his aggressive behaviors) , one resident stated he now carries a cane with him when he leaves his room so that he can protect himself from (Resident #52). In an interview on 8/29/2024 at 11 am with the DON, she stated that she was aware of the incident and did not know if it was reported to the state, as the administrator was the one that was responsible for that. She was not sure if it would qualify as reportable or not. She stated all they could do was redirect Resident # 52 when he got upset to help keep the other residents safe in the dining room. The DON stated an incident report was completed and the incident was not part of the medical record. She stated they were actively seeking placement for the resident and were having placement issues with Resident # 52 because of the behaviors . In an interview on 8/29/2024 at 11:30 with the ADM, he stated that he looked into the resident-to-resident altercation and felt that there was no intent for the bystander resident to be harmed so he did not report it. The ADM stated he was notified on Saturday of the event and did his investigation on Monday. He stated he was aware of the 24 hours requirement to report abuse which resident to resident altercation is considered. He acknowledged that and was not sure what he needed to report. He stated the injury to Resident # 62 by Resident # 52 was an accident and not intentional, he stated from the staff report over the phone to him on Saturday he determined that the injury was unintentional and did not do an investigation till Monday. The ADM stated Resident #52 was a difficult case, and that he never should have been admitted to the facility. He stated the more they document Resident #52's behaviors the more difficult placement will be. He stated he was afraid to put him on a one to one because that could set him off and may result in him getting physical. The ADM stated he is not really is not sure what to do, until they get him accepted at another facility. He stated his expectation that the staff keep them and the other resident's safe from Resident # 52's behaviors. The ADM stated Resident #52 's behavior did place the residents and staff at risk for abuse. He stated Resident #52 was difficult to deal with and they had been seeking placement for Resident # 52 in a more appropriate facility but had not found a placement yet that would accept him with his behaviors. The ADM stated there were no special interventions in place at this time for his behaviors. In an interview on 8/29/2024 at 11:45 am with the SW, she stated that she was trying very hard to get Resident # 52 to a different facility. SW stated she is aware of the concerns of the other resident with the behaviors of Resident # 52, She stated that her interventions with Resident # 52 are to discuss the behavior with him and try to redirect it., she admitted that most times this is not successful. She stated Resident # 52 is not currently on any kind of behavior modification plan and the psychiatric NP sees him, and the local authority follows. him with services. She stated there is a policy for dealing with aggressive residents but the she does not use the interventions with Resident # 52 and he is not responsive to it, Her goal for Resident # 52 is to keep him and the other residents safe until placement can be found. Review of Tulip 8/29/2024 at noon revealed no reported incident from the 8/26/2024 or 8/27/2024. Review of the facility policy Abuse Prevention Program revised December of 2016 stated As part of the abuse prevention, the administration will 1. Protect our resident from abuse by anyone including but not necessarily limited to facility, staff, other residents. Review of the facility policy Resident to Resident Altercations/aggressive behavior Revised September 2022 Facility staff should monitor resident for aggressive behavior, instance of behavior should be reported immediately .If you are unable to prevent an aggressive behavior or altercation, your priority is to ensure the safety of yourself and anyone around. This was determined to be an Immediate Jeopardy (IJ) on [8/30/2024 at 5:25 PM The ADM] were notified. The ADM] was provide with the IJ template on [8/30/2024 at 5:25 PM]. The following Plan of Removal submitted by the facility was accepted on 08/31/24 at 12:35 PM and reflected the following: The alleged deficient practice was the facility failed to protect the residents from an aggressive resident with behaviors and failed to put interventions in place to ensure the safety of the resident and other residents. 1. Identification of Residents Affected or Likely to be Affected: The following actions were taken to prevent Resident # 52 from perpetrating additional abusive behaviors. (Completion Date: 8/30/2024) The Medical director was notified of the current IJ at the facility. Resident # 52 was admitted to hospital on 8/30/24. admitted via emergency detention order on 8/30/24. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Abuse policies were reviewed/updated on 8/30/24. The Administrator/designee re-educated all staff on facility abuse policies. This will be completed by 8/31/24. The administrator/DON were provided re-education from the corporate nurse and COO on 8/30/24 7:30 PM. All residents were reviewed by the SW and marketing director with no aggressive behaviors found at this time. 8/31/24 11:30 am. The administrator/designee provided re-education to all staff on abuse prevention and reporting. The DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. In the event of any future resident to resident abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psychiatric evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. New staff will be educated and trained on facility abuse policies upon hire during general orientation. Agency staff will be educated and trained on facility abuse policies prior to starting shift. Abuse Prevention and Response policies made available for review at all times. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/31/24. Monitoring of facility's Plan of Removal included the following: 1. Audit of Policies : Abuse and Neglect, Reporting, care plans and documentation to show they were reviewed by the corporate nurse and the administrative team were educated on 8/30/2024. 2. In-services to Staff on Abuse and Neglect were started on 8/30/24 and per audit completed at 2:30 PM on 8/31/2024 all staff scheduled from 8/30/2024 thru 8/31/2024 have completed the training. All administrative staff completed the training, plan was for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 3. In-services to Nursing staff and IDT team on Care plans and documentation were started on 8/30/2024 and per audit on 8/31/2024, all nursing staff on duty and all IDT team members have completed training. The plan was for the remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 4. Per interview with administrator, 1:1's will be determined by himself, and the DON and in-services will be done at that time to address the residents needs. 5. Interviews with 9/18 staff members on duty 8/30 /2024 and on 8/31/2024 in the day and evening shift revealed they have all had training and all were able to verbalize the training and the process for reporting and managing resident to resident aggression . The ADM was informed the Immediate Jeopardy (IJ) was removed on 8/31/2024 at 5:45 PM ). The facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident's, establish policies and procedures to investigate any such allegations for 3 out of 16 residents reviewed for abuse. The facility failed to follow and implement its policy regarding Resident # 52's verbal and physical abuse of other residents to ensure the safety of all residents . An IJ was identified on 08/30/24. The IJ template was provided to the facility on [DATE] at 6:16 PM. While the IJ was removed on 08/31/24, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. This failure could put all residents at risk from abuse. Finding include: Review of Resident # 52's face sheet dated 8/30/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, ( partial paralysis due to a blockage in the brain impeding blood flow), Unspecified mood ( Affective) disorder ( any in a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood) Major depressive disorder, recurrent, severe with psychotic symptoms (sadness and hopelessness with symptoms of seeing, hearing, smelling or believing things that are not real) and Intermittent Explosive Disorder ( a condition that causes repeated, sudden outburst of impulsive, violent behavior or angry verbal outburst). Review of Resident #52's Quarterly MDS dated [DATE], revealed a BIMS score of 08 (indicates a Moderate cognitive impairment) Section E0200 Behavioral symptoms revealed no physical behavioral symptoms directed to others, no verbal behavioral symptoms directed toward others, and no other behavioral symptoms not directed toward others. Review of Residents # 52 care plan 04/02/2023 and updated 2/20/2024 revealed Resident #52's h/o using profanity/verbally. aggressive with staff and resident's r/t intermittent explosive disorder. 04/07/2023 Cursed out nurse,04/19/2023 Cursed out resident,04/20/2020 cursed staff and residents,05/03/2023 Cursed out nurse,05/20/2023 Cursed out nurse and CNA, 06/01/2023 Cursed out nurse,06/08/2023 cursed nurse,06/09/2023 cursed nurse,06/11/2023 Cursed CAN,06/12/2023 Cursing staff,06/15/2023 Cursed out nurse,06/20/2023 Cursed out nurse,06/23/2023 cursing in dining room,07/24/2023 cures out resident,07/25/2023 cursed resident out,08/02/2023 cursing staff,08/13/2023 cursed out nurse,08/23/2023 Resident in common area, calling female resident a fucking whore,08/24/2023 Residents behavior, unacceptable, cursing and yelling at nurse and,08/29/203 cursing staff and residents,1/31/2024 verbal aggression initiated,2/19/2024 verbal aggression initiated Review of Resident's #52 Process notes dated 8/30/2024 at 11.49 am written by the SW revealed Spoke with the resident regarding incident that happened over the weekend. When SW asked him about it, he responded, you don't' Know?' Resident then stated that he was attacked by the other resident who hit him. He stated he needed to contact his family to let them know that he had been attacked. SW informed him that he has the right to call his family and asked if he needed assistance, he responded no, he can do it. The incident is still under investigation. Several residents were witnesses and state that Resident # 52 was the instigator. Review of Incident and accident report which is not a part of the medical record dated 8/25/2024 09:02 am completed by LVN J, At approximately 0 am, once breakfast was completed, this nurse was assessing another resident her breathing treatment when a resident came wheeling down the hall stating, they are fighting. I did not immediately understand what was going on, then I realized everyone was moving towards the dining hall and I followed. Once I arrived in the dining hall resident where being separated. I spoke and found a housekeeper who had witnessed most of the incident, Resident # 52 was verbally, harassing Resident #42, Resident # 42 told him something around the lines of leave me alone I'm not bothering you or anyone, Resident #52 preceded to go around the wall towards Resident #42 and continued to verbally harass him then threw something towards Resident #42's direction. Resident #42 then picked up a chair to hit Resident # 52 and staff members removed the chair from Resident # 42's hands, then Resident #42 attempted to hit Resident #52. Due to a lot of bodies and movement it is unsure if Resident #42 actually hit Resident #52. Review of Resident # 42 Quarterly MDS dated [DATE] revealed a [AGE] year-old male admitted to the facility 03/25/2022 with diagnosis that include Alzheimer's disease ( A progressive disease that destroys memory and other important mental functions), Stroke ( a condition in which poor blood flow to the brain causes cell death) and Anxiety disorder (significant and uncontrollable feeling of anxiety and fear such that a person's social, occupational and personal functions are significantly impaired). BIMS score of 11 (8-12 suggests moderate cognitive impairment) Review of Resident # 62 Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted to the facility 01-30-2024 with diagnosis that include Cardiovascular Accident ( a condition in which poor blood flow to the brain causes cell death) Anxiety disorder (significant and uncontrollable feeling of anxiety and fear such that a person's social, occupational and personal functions are significantly impaired).BIMS score of 15 ( 13-15 suggest no cognitive impairment) Interview 8/27/2024 at 10:00 am with Resident # 52 he does not wish to answer questions at this time. Interview 8/27/2024 at 10:30 am with Resident #42, he stated that Resident #52 always picks on him and this last weekend he pushed too far, and he felt he had to do something. Interview 8/27/2024 at 11 am with Resident #62 reported that when Resident #52 threw a bowl this weekend, it hit her foot and there was a bruise, swelling and pain, she was sent to the ER that afternoon for evaluation, the doctor will follow up with he today about the foot as she is still in pain. During the Resident council meeting on 8/28/224 at 10 am revealed many of the residents stated there was a resident in the facility that is verbally and aggressive behavior (Resident # 52), resident report the facility is aware of the behaviors and do not appear to be doing anything about it. Several residents stated that there were afraid of (resident #52 because of his aggressive behaviors) , one resident stated he now carries a cane with him when he leaves his room so that he can protect himself from (Resident #52). Interview 8/29/2024 at 11 am with the DON, she stated that she was aware of the incident and does not know if it was reported to the state, as the administrator is the one that is responsible for that. she is not sure if it would qualify as reportable or not. she stated all we can do is redirect Resident # 52 when he gets upset, Staff are to monitor Resident # 52 when in common area's to assist in this to keep the others residents safe. They do have a policy for aggressive residents, Resident's #52 is resistance to any interventions. She stated her expectation is that all resident's incident should be reflected in the Resident's progress notes. Interview 8/29/2024 at 11:30 with ADN He stated that he looked into the resident-to-resident altercation and feel that there was no intent for the bystander resident to be harmed so he did not report it. ADN stated he was notified on Saturday by phone of the incident with Resident # 52 did his investigation on Monday He stated the facility policy it that resident to resident are to be reported within 24 hours, he stated that he determined the injury to Resident # 62 foot was not intention and did not meet the reporting requirement. Interview 8/29/2024 at 11:45 am with SW, she stated that she is trying very hard to get Resident #52 to a different facility. She stated that the Facility does have a policy for Resident-to-Resident altercations that include separating the residents involved, and they do that with Resident #52. She does not know how many incidents with Resident's #52's behavior there are but she thinks at the minimum he is verbally aggressive two to three times a week. Review of Tulip 8/29/2024 at noon revealed no reported incident from the 8/26/2024 or 8/27/2024. Review of facility policy 8/29/2024 at 12:30 PM Resident to Resident Altercations/aggressive behavior Revised September 2022 Facility staff should monitor resident for aggressive behavior, instance of behavior should be reported immediately .If you are unable to prevent an aggressive behavior or altercation, your priority is to ensure the safety of yourself and anyone around. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/31/24 at 12:35 PM and reflected the following: The alleged deficient practice was the facility failed to follow and implement a policy regarding verbal and physical abuse of other residents and ensure the safety of other residents. 3. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering's an adverse outcome. (Completion Date: by. 8/30/24) The Administrator or designee immediately ensured the safety and well-being of all residents. Resident #52 was sent to psych hospital for inpatient stay by an emergency detention warrant obtained through the county judges office on 8/30/24. 4. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/30/24) Resident #52 was taken to psych hospital on 8/30/24, Oceans hospital. Abuse policies were reviewed 8/30/24 by both corporate nurses at 6:30 PM The Administrator and DON were re-in serviced by the corporate nurse and COO on 8/30/24 at 7:30 PM. All residents were reviewed by the SS and marketing director, and no one is exhibiting aggressive behaviors at this time on 8/31/24 at 11:30 am. Abuse investigation procedure and documentation process were reviewed 8/30/24 by both corporate nurses at 6:30pm. The administrator and designees educated all staff on facility abuse policies. Started on 8/30/24 and will be completed by 8/31/24. The administrator and designees educated all staff on abuse prevention and reporting, started on 8/30/24 and will be completed by 8/31/24. The Social Services Director began discussing facility abuse policies with residents and families at the initial care plan conference for all new residents that enter the facility. New staff will be educated and trained on facility abuse policies upon hire during general orientation. Agency staff will be educated and trained on facility abuse policies prior to starting shift. Abuse Prevention and Response policies made available for review at all times. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/31/24. The alleged deficient practice is the facility failed to protect the residents from an aggressive with behaviors and failed to put interventions in place to ensure the safety of the resident and other residents. Monitoring of facility's Plan of Removal included the following: 1. Confirmation that Resident was discharged on [DATE] to Ocean' behavioral hospital. 2. Audit of Policies to show they were reviewed by the corporate nurse and the administrative team were educated on 8/30/2024. 3. In-services to Staff on Abuse Neglect were started on 8/30/24 and per audit completed at 2:30 PM on 8/31/2024 all staff scheduled from 8/30/2024 thru 8/31/2024 have completed the training. All administrative staff completed the training, plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 4. In-services to Nursing staff and IDT team on Care plans and documentation were started on 8/30/2024 and per audit on 8/31/2024, all nursing staff on duty and all IDT team members have completed training, Plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 5. Per interview with administrator, 1:1's will be determined by himself and the DON and in services will be done at that time to address the resident's needs. 6. Interviews with 9/18 staff members on duty 8/31/2024 revealed they have all had training and all were able to verbalize the training and the process for reporting and managing resident to resident aggression. An IJ was identified on 08/30/24. The IJ template was provided to the facility on [DATE] at 6:16 PM. While the IJ was removed on 08/3124, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment . For 1 (Resident # 52) of 16 reviewed. The facility failed to develop and implement a comprehensive care plan for Resident # 52 that included interventions to ensure safety from the residents aggressive physical and verbal behaviors. On 08/30/24 at 6:16 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/31/24, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure put the resident at risk from their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident # 52's face sheet dated 8/30/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, ( partial paralysis due to a blockage in the brain impeding blood flow), Unspecified mood ( Affective) disorder ( any in a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood) Major depressive disorder, recurrent, severe with psychotic symptoms (sadness and hopelessness with symptoms of seeing, hearing, smelling or believing things that are not real) and Intermittent Explosive Disorder ( a condition that causes repeated, sudden outburst of impulsive, violent behavior or angry verbal outburst). Review of Resident #52's Quarterly MDS dated [DATE], revealed a BIMS score of 08 (indicates a Moderate cognitive impairment) Section E0200 Behavioral symptoms revealed no physical behavioral symptoms directed to others, no verbal behavioral symptoms directed toward others, and no other behavioral symptoms not directed toward others. Review of Residents # 52 care plan 04/02/2023 and updated 2/20/2024 revealed Resident #52's h/o using profanity/verbally aggressive with staff and resident's r/t intermittent explosive disorder. 04/07/2023 Cursed out nurse,04/19/2023 Cursed out resident,04/20/2020 cursed staff and residents,05/03/2023 Cursed out nurse,05/20/2023 Cursed out nurse and CNA, 06/01/2023 Cursed out nurse,06/08/2023 cursed nurse,06/09/2023 cursed nurse,06/11/2023 Cursed CNA,06/12/2023 Cursing staff,06/15/2023 Cursed out nurse,06/20/2023 Cursed out nurse,06/23/2023 cursing in dining room,07/24/2023 cures out resident,07/25/2023 cursed resident out,08/02/2023 cursing staff,08/13/2023 cursed out nurse,08/23/2023 Resident in common area, calling female resident a fucking whore,08/24/2023 Residents behavior, unacceptable, cursing and yelling at nurse and,08/29/203 cursing staff and residents,1/31/2024 verbal aggression initiated,2/19/2024 verbal aggression initiated Review of Resident's #52 Process notes dated 8/30/2024 at 11.49 am written by the SW revealed Spoke with the resident regarding incident that happened over the weekend. When SW asked him about it, he responded, you don't' Know?' Resident then stated that he was attacked by the other resident who hit him. He stated he needed to contact his family to let them know that he had been attacked. SW informed him that he has the right to call his family and asked if he needed assistance, he responded no, he can do it. The incident is still under investigation. Several residents were witnesses and state that Resident # 52 was the instigator. Review of Incident and accident report which is not a part of the medical record dated 8/25/2024 09:02 am completed by LVN J, At approximately 0 am, once breakfast was completed, this nurse was assessing another resident her breathing treatment when a resident came wheeling down the hall stating, they are fighting. I did not immediately understand what was going on, then I realized everyone was moving towards the dining hall and I followed. Once I arrived in the dining hall resident where being separated. I spoke and found a housekeeper who had witnessed most of the incident, Resident # 52 was verbally, harassing Resident #42, Resident # 42 told him something around the lines of leave me alone I'm not bothering you or anyone, Resident #52 preceded to go around the wall towards Resident #42 and continued to verbally harass him then threw something towards Resident #42's direction. Resident #42 then picked up a chair to hit Resident # 52 and staff members removed the chair from Resident # 42's hands, then Resident #42 attempted to hit Resident #52. Due to a lot of bodies and movement it is unsure if Resident #42 actually hit Resident #52. During the Resident council meeting on 8/28/224 at 10 am revealed many of the residents stated there was a resident in the facility that is verbally and aggressive behavior (Resident # 52), resident report the facility is aware of the behaviors and do not appear to be doing anything about it. Several residents stated that there were afraid of (resident #52 because of his aggressive behaviors) , one resident stated he now carries a cane with him when he leaves his room so that he can protect himself from (Resident #52). In an interview on 8/29/2024 at 11:45 am with the SW, she stated that she was trying very hard to get Resident # 52 to a different facility. SW stated she is aware of the concerns of the other resident with the behaviors of Resident # 52, She stated that her interventions with Resident # 52 are to discuss the behavior with him and try to redirect it., she admitted that most times this is not successful. She stated Resident # 52 is not currently on any kind of behavior modification plan and the psychiatric NP sees him, and the local authority follows. him with services. She stated there is a policy for dealing with aggressive residents but the she does not use the interventions with Resident # 52 and he is not responsive to it, her goal for Resident # 52 is to keep him and the other residents safe until placement can be found. In an interview on 8/29/2024 at 11:30 with the ADN, he stated that he looked into the resident-to-resident altercation and felt that there was no intent for the bystander resident to be harmed so he did not report it. The ADN stated he was notified on Saturday of the event and did his investigation on Monday. He stated he was aware of the 24 hours requirement to report abuse which resident to resident altercation is considered. He acknowledged that and was not sure what he needed to report. He stated the injury to Resident # 62 by Resident # 52 was an accident and not intentional, he stated from the staff report over the phone to him on Saturday he determined that the injury was unintentional and did not do an investigation till Monday. The ADN stated Resident #52 was a difficult case, and that he never should have been admitted to the facility. He stated the more they document Resident #52's behaviors the more difficult placement will be. He stated he was afraid to put him on a one to one because that could set him off and may result in him getting physical. The ADN stated he is not really is not sure what to do, until they get him accepted at another facility. He stated his expectation that the staff keep them and the other resident's safe from Resident # 52's behaviors. The ADN stated Resident #52 's behavior did place the residents and staff at risk for abuse. He stated Resident #52 was difficult to deal with and they had been seeking placement for Resident # 52 in a more appropriate facility but had not found a placement yet that would accept him with his behaviors. The ADN stated there were no special interventions in place at this time for his behaviors. Review of Policy Care Plans, comprehensive Person-centered revised December 2016 on 8/30/2024 at 1:30 PM revealed The comprehensive, person-centered care plan will be. Describe the services that are to be furnished to attain or maintain the resident highest practicable physical, mental and psychosocial well-being. This was determined to be an Immediate Jeopardy (I) on [Date] at [Time]. The [identifier of people notified] were notified. The [identifier of the person given the I template ] was provide with the IJ template on [Date] at [Time]. The following Plan of Removal submitted by the facility was accepted on 08/31/24 at 12:35 PM and reflected the following: The alleged deficient practice was the facility failed to develop and implement a comprehensive care plan that included interventions to ensure safety from the residents aggressive, physical, and verbal behaviors. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 8/30/24) This Resident was discharged on [DATE] with no plan to return to the facility. The facility issued an emergency discharge to ensure the safety of other residents. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/31/24) Every incident should result in a revision of the care plan to prevent recurrence of any altercation. All residents were reviewed by the SS and marketing director with no one exhibiting aggressive behaviors at this time of 8/31/24 @ 11:30 am. The IDT team will be in-serviced on the care plan revision policy and process by the corporate nurse/DON by 8/31/24. The DON or designee will audit each care plan after each incident to ensure interventions were in place to protect the well-being of other residents as appropriate. In-serviced by corporate nurses at 8:00 PM on 8/30/24. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP ) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. QAPI will be completed by corporate nurse by 8/30/24. New staff will be educated and trained on facility abuse policies upon hire during general orientation. Agency staff will be educated and trained on facility abuse policies prior to starting shift. Abuse Prevention and Response policies made available for review at all times. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/31/24. Monitoring of facility's Plan of Removal included the following: 3. Confirmation that Resident # 52's was discharged on [DATE] to behavioral hospital. 4. Audit of Policies to show they were reviewed by the corporate nurse and the administrative team were educated on 8/30/2024. 5. In-services to Staff on Abuse and Neglect were started on 8/30/24 and per audit completed at 2:30 PM on 8/31/2024 all staff scheduled from 8/30/2024 thru 8/31/2024 have completed the training. All administrative staff completed the training, plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 6. In-services to Nursing staff and IDT team on Care plans and documentation were started on 8/30/2024 and per audit on 8/31/2024, all nursing staff on duty and all IDT team members have completed training, Plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 7. Per interview with administrator, 1:1's will be determined by himself and the DON and in services will be done at that time to address the resident's needs. 8. Interviews with 9/18 staff members on duty 8/31/2024 revealed they have all had training and all were able to verbalize the training and the process for reporting and managing resident to resident aggression. An IJ was identified on 08/30/24 at 6:16 PM . The IJ template was provided to the facility on [DATE] at 6:16 PM. While the IJ was removed on 08/3124, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.

Based on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #1) of 5 residents reviewed for notification of change. The facility failed to: 1. Notify the physician when Resident #1 had a significant change in condition marked by inability to swallow breakfast, then difficulty swallowing morning medications, and then Resident #1 refused his lunch; this resulted in Resident #1 being sent to ER and had pieces of food removed from his throat in the emergency room and was diagnosed with pneumonia and septic shock (life-threatening condition caused by a severe infection that requires immediate medical attention). This failure could place residents at risk of not receiving interventions, treatments, and care by recognizing and addressing the physical, mental, and neurological dysfunctions such as altered state of consciousness, nausea, vomiting, cognitive decline, confusion, memory loss, and changes in behavior in an effective and timely manner to prevent residents from further harm, injury, or death. Findings included: Record review of Resident #1's undated face sheet, printed on 01/16/24, revealed that he was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses that included dementia, moderate intellectual disabilities, Down Syndrome (a genetic disease that causes intellectual disabilities, shorter neck, and protruding tongue), and reduced mobility. Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score could not be formed, so the staff assessment for mental status revealed Resident #1 had severely impaired cognition. In Section B it stated that he was rarely/never understood, and rarely/never understands others. Further review revealed that Resident #1 required setup or clean-up assistance for eating; moderate assistance for oral hygiene and upper body dressing, substantial/maximal assistance for toileting and shower/bathe, lower body dressing, putting on/off footwear, and personal hygiene. Under section K, swallowing/nutritional status reflected he did not require mechanically altered or therapeutic diet. Record review of Resident #1's undated care plan revealed Resident #1 was at high risk for malnutrition with an intervention of report new onset of chewing or swallowing problems; Resident #1 had a diagnosis of allergies and an intervention to observe for side effects of the medication which included pain when swallowing and persistent sore throat (notify physician if present). Further review revealed Resident #1 was incontinent of bowel and bladder with an intervention to observe for acute behavioral changes and to notify physician of behavioral changes. Further review revealed Resident #1 has dementia with an intervention to notify the physician of cognitive changes. Resident #1's care plan revealed that he took antipsychotic medication, and he should be monitored for signs and symptoms of change in mood or behavior and to report to the physician if noted. Record review of Resident #1's active orders on EHR revealed an order to monitor the resident's vital signs for health maintenance every shift starting 12/17/23. Further review revealed an order for Regular Diet, Regular Texture, Thin Consistency entered 12/16/23 and further revealed an order that stated May crush meds and/or open capsules as needed every shift entered 12/17/23. Record review of Resident #1's progress notes on EHR revealed a progress note written by LVN A with an effective date of 01/13/24 at 1:45 pm and created 01/13/24 at 2:53 pm that stated MA B reported Resident #1 would not swallow his medications and was holding them in his mouth. LVN A further wrote will continue to monitor for any significant changes or concerns and will notify PCP of any abnormal findings. There were no progress notes related to Resident #1's change in condition prior to 1:45 pm on 01/13/24. During an interview on 01/16/24 at 11:07 am with LVN C she stated that Resident #1 was usually alert and spent most of his day in a geri-chair (large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) near the nurses' station. She said he required total care and assistance with meals. She said he can grab smaller foods and eat them. She further stated Resident #1 had no swallowing problems, he takes his medications whole, and never had respiratory problems. She also stated that he has a good appetite, never refused meals, and enjoyed snacks whenever they were provided. During an interview on 01/16/24 at 11:36 am with MA D he stated Resident #1 took his medication fine; MA D would place medication in Resident #1's mouth, cue him here is your medicine, and give him water and he swallowed without any issues. He stated that Resident #1 has a good appetite and he had never seen Resident #1 choke or have swallowing issues. During an interview on 01/16/24 at 12:47 pm with CNA E she stated she arrived on 01/13/24 at five something in the morning and noticed Resident #1 was already in front of the TV by the nurses' station, which was abnormal, and she was told he kept trying to get out of bed and that was why he was by the nurses' station. She tried to feed breakfast to Resident #1, which was ground sausage with gravy on it, and when she put it in Resident #1's mouth he made no attempt to chew it. CNA E was concerned and went to get a small spoon to remove the sausage from Resident #1's mouth, then she gave him some juice and he would not swallow that either and it came out of his mouth. She said he was not acting normal for him, his eyes were not active, he was not interested in anything, and he was usually an avid eater. After the nurse passed medications, CNA E told LVN A that Resident #1 was not eating. CNA E stated that she thought LVN A took vitals and said they would keep an eye on him and see how he did at lunch. CNA E stated that Resident #1 usually fidgeted, moved his arms and legs and was alert, but on 01/13/24 he seemed sleepy. CNA E stated he did not do well at lunch either. She stated that LVN A decided to send Resident #1 to the hospital and CNA E assisted getting Resident #1 ready and on the stretcher with EMS personnel. Record review of Resident #1's vital signs on EHR tab revealed on 01/13/24 at 9:30 am his oxygen on room air was 97% documented by LVN A. It further revealed his pain was 0 and his temperature was 97.9 Fahrenheit on 01/13/24 at 9:30 am per LVN A's documentation. Further review revealed the last documented blood pressure, pulse, and respiration rate was recorded 01/11/24 at 11:27 pm. Record review of Resident #1's progress notes on EHR revealed a progress note written by LVN A with an effective date of 01/13/24 at 1:45 pm that stated MA B said Resident #1 was holding his meds in his mouth and she would continue to monitor; the record then revealed a progress note written by LVN A on 01/13/24 at 2:30 pm which stated CNA E reported that Resident #1 refused breakfast and lunch. LVN A then entered a progress note linked to an order for a barium swallow study dated 01/13/24 at 3:20 pm. Further record review revealed LVN A entered a progress note dated 01/13/24 at 3:45 pm stated EMS was called to transport Resident #1 to the ER due to change in behavior and abnormal vital signs : blood pressure 98/48, pulse 68, oxygen saturation 88% and O2 was applied. Awaiting arrival of EMS. Further review revealed a progress note dated 01/13/24 at 4:06 pm stating LVN A attempted to contact RP #1; followed by a progress note dated 01/13/24 at 4:12 pm stating LVN A attempted to contact RP #2. During an interview on 01/16/24 at 1:32 pm with MA B she stated that Resident #1 was sleepy on 01/13/24 when she tried to give him his morning medications; she gave him his medication but he held it in his mouth, so she gave him resource (a thickened liquid) and the medicine went down. She gave him more resource and he held it in his mouth and it spilled out of his mouth. MA B told LVN A and then MA B went to wait for food for herself. Record review of Resident #1's Medication Admin Audit Report for 01/13/24 revealed that MA B administered Resident #1's morning medications at 10:44 am. During an interview on 01/16/24 at 1:56 pm with LVN A she stated Resident #1 refused breakfast , which he had done in the past, and then MA B said Resident #1 was not swallowing his medications. LVN A put in an order for a swallow study for Resident #1. She stated Resident #1 did not eat breakfast or lunch per CNA E, so she checked his vital signs in the afternoon and said his blood pressure was low and oxygen was low, around 88%, so she called the non-emergency ambulance number for evaluation of altered mental status, not eating, and vital signs. LVN A was defensive and further interview was not going to be productive. During an interview on 01/17/24 at 5:39 pm with MD she stated she was not informed that Resident #1 had a change in behavior, refused meals nor that he did not swallow his medication. She stated it was her expectation that she be notified for any change in condition for any of her residents. Record review of the hospital emergency department provider notes for date of services of 01/13/24 revealed provider was at Resident #1's bedside 01/13/24 at 4:38 pm. It further revealed under history that the chief complaint was altered mental status and that EMS noted Resident #1 had a rightward gaze, left arm twitching, periods of apnea (stopped breathing), hypotension (low blood pressure), and unequal and sluggish pupils. Further review revealed his presenting vitals were temperature of 98.3 Fahrenheit, blood pressure of 91/43, pulse of 76, oxygen saturation of 94%, and respiratory rate of 12 on 01/13/24 at 4:44 pm. Review of the physical exam portion revealed he appeared ill and he had multiple small and medium sized pieces of questionably hamburger meat to the posterior oropharynx (middle part of the throat behind the mouth) which were removed with ring forceps; oropharynx was very dry with dry mucous membranes. It further stated there were intermittent brief periods of apnea and corresponding drop in pulse oxygen. The section for imaging results revealed a CT of the abdomen that showed ground glass opacity (hazy increased lung opacity through which structures can still be seen, often indicates infection or lung damage) in the base of both lungs with an area of consolidation in the right middle lobe and left lower lobe. The impression documented by the physician interpreting the imaging stated 1. Areas of ground glass opacity and consolidation in the visualized lung bases worrisome for pneumonia. Further review revealed during EMS transport his oxygen saturation dropped to 60% requiring 15 L nonrebreather. His blood pressure in the emergency room dropped to 79/51 and 12 L non-rebreather was used. Pneumonia was diagnosed and antibiotics were started. Resident #1's RP wanted continued care for a few days to see if Resident #1 would improve, if not he wanted to transition to hospice care. During an interview with a hospital nurse on 01/15/24 at 6:15 pm she stated that Resident #1 was being treated for pneumonia and they could not rule out aspiration pneumonia. She also stated Resident #1, who was in the ICU bed, also had a diagnosis of septic shock. During an interview on 01/16/24 at 4:18 pm with the DON she stated that her expectation of her nursing staff was that after Resident #1 did not swallow his breakfast and LVN A was notified, LVN A should have done a focused assessment, which would include checking Resident #1's oral cavity to ensure his airway was not impaired, try to get the resident to talk (if able) and cough if possible, collect all vital signs and check skin color. She stated that not performing a thorough assessment focused on choking/breathing/airway could cause harm by not being able to breathe. Record review of a sign posted on the wall in the dining room revealed breakfast time for Resident #1's hall was at 7:30 am. Record review of the Acute Condition Changes policy, revised 03/18, revealed .1. Physician will help identify individuals at risk for change of condition 3. Direct care staff will recognize subtle but significant changes in the resident with the examples decrease in food intake, increased agitation, change in skin color . 8. Nursing staff will contact the physician or on-call physician (within approximately one-half hour or less)

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to: 1. Ensure staff conducted a thorough assessment of Resident #1 (which delayed Resident #1 from being sent to the emergency room ), who was unable to swallow his breakfast on 01/13/24 at 9:00 am and had pieces of food removed from his throat in the emergency room and was diagnosed with pneumonia and septic shock (life-threatening condition caused by a severe infection that requires immediate medical attention) This failure could affect all residents by placing them at risk of not receiving quality care and treatments, injury, hospitalization , and/or death. Findings included: Record review of Resident #1's undated face sheet, printed on 01/16/24, revealed that he was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses that included dementia, moderate intellectual disabilities, Down Syndrome (a genetic disease that causes intellectual disabilities, shorter neck, and protruding tongue), and reduced mobility. Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score could not be formed, so the staff assessment for mental status revealed Resident #1 had severely impaired cognition. In Section B it stated that he was rarely/never understood, and rarely/never understands others. Further review revealed that Resident #1 required setup or clean-up assistance for eating; moderate assistance for oral hygiene and upper body dressing, substantial/maximal assistance for toileting and shower/bathe, lower body dressing, putting on/off footwear, and personal hygiene. Under section K, swallowing/nutritional status reflected he did not require mechanically altered or therapeutic diet. Record review of Resident #1's undated care plan revealed Resident #1 was at high risk for malnutrition with an intervention of report new onset of chewing or swallowing problems; Resident #1 had a diagnosis of allergies and an intervention to observe for side effects of the medication which included pain when swallowing and persistent sore throat (notify physician if present). Further review revealed Resident #1 was incontinent of bowel and bladder with an intervention to observe for acute behavioral changes and to notify physician of behavioral changes. Further review revealed Resident #1 has dementia with an intervention to notify the physician of cognitive changes. Resident #1's care plan revealed that he took antipsychotic medication and he should be monitored for signs and symptoms of change in mood or behavior and to report to the physician if noted. Record review of Resident #1's active orders on EHR revealed an order to monitor the resident's vital signs for health maintenance every shift starting 12/17/23. Further review revealed an order for Regular Diet, Regular Texture, Thin Consistency entered 12/16/23 and further revealed an order that stated May crush meds and/or open capsules as needed every shift entered 12/17/23. Record review of Resident #1's progress notes on EHR revealed a progress note written by LVN A with an effective date of 01/13/24 at 1:45 pm and created 01/13/24 at 2:53 pm that stated MA B reported Resident #1 would not swallow his medications and was holding them in his mouth. LVN A further wrote will continue to monitor for any significant changes or concerns and will notify PCP of any abnormal findings. There were no progress notes related to Resident #1's change in condition prior to 1:45 pm on 01/13/24. Record review of Resident #1's vital signs on EHR revealed the following vital signs and date/time last documented: 01/11/24 11:27 pm Blood Pressure 112/64 01/11/24 11:27 pm Pulse 70 01/11/24 11:27 pm Respiratory rate 18 breaths/minute 01/13/24 9:30 am Temperature 97.0 01/13/24 9:30 am Oxygen 97% on room air During an interview on 01/16/24 at 11:07 am with LVN C she stated that Resident #1 was usually alert and spent most of his day in a geri-chair (large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) near the nurses' station. She said he required total care and assistance with meals. She said he can grab smaller foods and eat them. She further stated Resident #1 had no swallowing problems, he takes his medications whole, and never had respiratory problems. She also stated that he has a good appetite, never refused meals, and enjoyed snacks whenever they were provided. During an interview on 01/16/24 at 11:36 am with MA D he stated Resident #1 took his medication fine; MA D would place medication in Resident #1's mouth, cue him here is your medicine, and give him water and he swallowed without any issues. He stated that Resident #1 has a good appetite and he had never seen Resident #1 choke or have swallowing issues. During an interview on 01/16/24 at 12:47 pm with CNA E she stated she arrived on 01/13/24 at five something in the morning and noticed Resident #1 was already in front of the TV by the nurses' station, which was abnormal, and she was told he kept trying to get out of bed and that was why he was by the nurses' station. She tried to feed breakfast to Resident #1, which was ground sausage with gravy on it, and when she put it in Resident #1's mouth he made no attempt to chew it. CNA E was concerned and went to get a small spoon to remove the sausage from Resident #1's mouth, then she gave him some juice and he would not swallow that either and it came out of his mouth. She said he was not acting normal for him, his eyes were not active, he was not interested in anything, and he was usually an avid eater. After the nurse passed medications, CNA E told LVN A that Resident #1 was not eating. CNA E stated that she thought LVN A took vitals and said they would keep an eye on him and see how he did at lunch. CNA E stated that Resident #1 usually fidgeted, moved his arms and legs and was alert, but on 01/13/24 he seemed sleepy. CNA E stated he did not do well at lunch either. She stated that LVN A decided to send Resident #1 to the hospital and CNA E assisted getting Resident #1 ready and on the stretcher with EMS personnel. Record review of Resident #1's vital signs on EHR tab revealed on 01/13/24 at 9:30 am his oxygen on room air was 97% documented by LVN A. It further revealed his pain was 0 and his temperature was 97.9 Fahrenheit on 01/13/24 at 9:30 am per LVN A's documentation. Further review revealed the last documented blood pressure, pulse, and respiration rate was recorded 01/11/24 at 11:27 pm. Record review of Resident #1's progress notes on EHR revealed a progress note written by LVN A with an effective date of 01/13/24 at 1:45 pm that stated MA B said Resident #1 was holding his meds in his mouth and she would continue to monitor; the record then revealed a progress note written by LVN A on 01/13/24 at 2:30 pm which stated CNA E reported that Resident #1 refused breakfast and lunch. LVN A then entered a progress note linked to an order for a barium swallow study dated 01/13/24 at 3:20 pm. Further record review revealed LVN A entered a progress note dated 01/13/24 at 3:45 pm stated EMS was called to transport Resident #1 to the ER due to change in behavior and abnormal vital signs : blood pressure 98/48, pulse 68, oxygen saturation 88% and O2 was applied. Awaiting arrival of EMS. During an interview on 01/16/24 at 1:32 pm with MA B she stated that Resident #1 was sleepy on 01/13/24 when she tried to give him his morning medications; she gave him his medication but he held it in his mouth, so she gave him resource (a thickened liquid) and the medicine went down. She gave him more resource and he held it in his mouth and it spilled out of his mouth. MA B told LVN A and then MA B went to wait for food for herself. Record review of Resident #1's Medication Admin Audit Report for 01/13/24 revealed that MA B administered Resident #1's morning medications at 10:44 am. During an interview on 01/16/24 at 1:56 pm with LVN A she stated Resident #1 refused breakfast , which he had done in the past, and then MA B said Resident #1 was not swallowing his medications. LVN A put in an order for a swallow study for Resident #1. She stated Resident #1 did not eat breakfast or lunch per CNA E, so she checked his vital signs in the afternoon and said his blood pressure was low and oxygen was low, around 88%, so she called the non-emergency ambulance number for evaluation of altered mental status, not eating, and vital signs. LVN A was defensive and further interview was not going to be productive. Record review of the hospital emergency department provider notes for date of services of 01/13/24 revealed provider was at Resident #1's bedside 01/13/24 at 4:38 pm. It further revealed under history that the chief complaint was altered mental status and that EMS noted Resident #1 had a rightward gaze, left arm twitching, periods of apnea (stopped breathing), hypotension (low blood pressure), and unequal and sluggish pupils. Further review revealed his presenting vitals were temperature of 98.3 Fahrenheit, blood pressure of 91/43, pulse of 76, oxygen saturation of 94%, and respiratory rate of 12 on 01/13/24 at 4:44 pm. Review of the physical exam portion revealed he appeared ill and he had multiple small and medium sized pieces of questionably hamburger meat to the posterior oropharynx (middle part of the throat behind the mouth) which were removed with ring forceps; oropharynx was very dry with dry mucous membranes. It further stated there were intermittent brief periods of apnea and corresponding drop in pulse oxygen. The section for imaging results revealed a CT of the abdomen that showed ground glass opacity (hazy increased lung opacity through which structures can still be seen, often indicates infection or lung damage) in the base of both lungs with an area of consolidation in the right middle lobe and left lower lobe. The impression documented by the physician interpreting the imaging stated 1. Areas of ground glass opacity and consolidation in the visualized lung bases worrisome for pneumonia. Further review revealed during EMS transport his oxygen saturation dropped to 60% requiring 15 L nonrebreather. His blood pressure in the emergency room dropped to 79/51 and 12 L non-rebreather was used. Pneumonia was diagnosed and antibiotics were started. Resident #1's RP wanted continued care for a few days to see if Resident #1 would improve, if not he wanted to transition to hospice care. During an interview with a hospital nurse on 01/15/24 at 6:15 pm she stated that Resident #1 was being treated for pneumonia and they could not rule out aspiration pneumonia. She also stated Resident #1, who was in the ICU bed, also had a diagnosis of septic shock. During an interview on 01/16/24 at 4:18 pm with the DON she stated that her expectation of her nursing staff was that after Resident #1 did not swallow his breakfast and LVN A was notified, LVN A should have done a focused assessment, which would include checking Resident #1's oral cavity to ensure his airway was not impaired, try to get the resident to talk (if able) and cough if possible, collect all vital signs and check skin color. She stated that not performing a thorough assessment focused on choking/breathing/airway could cause harm by not being able to breathe. Record review of a sign posted on the wall in the dining room revealed breakfast time for Resident #1's hall was at 7:30 am. Record review of the Acute Condition Changes policy, revised 03/18, revealed .2. The nurse shall assess and document vital signs, neurological status, pain, level of consciousness 3. Direct care staff will recognize subtle but significant changes in the resident with the examples decrease in food intake, increased agitation, change in skin color

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents and to ensure the resident environment remained as free of accident hazards as is possible for one of twenty-seven residents reviewed for accidents (Resident #14) and two of five halls reviewed for smoking hazards (halls 100 and 200). 1. he facility failed to ensure safety of therapy provided to Resident #14 by means of heat therapy with a moist heating pack resulted in a burn injury to Resident #14's left shoulder. 2. The facility was utilizing ashtrays made of combustible materials. These failures placed residents at risk of injury, pain, and infection. Findings include: 1. During initial observation rounds and interview on 5/10/2022 at 9:13 a.m., Resident #14 was noted to be sitting up in a wheelchair, a dressing was noted to be on his left shoulder. Resident #14 reported that his shoulder had a burn from therapy leaving a heating pad on too long. Limited range of motion was noted on his left side due to a stroke. Review of Resident #14's face sheet reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Epilepsy, unspecified, Difficulty in walking not elsewhere classified, Unsteadiness on feet, Other lack of coordination, Cystitis unspecified without hematuria, Muscle Weakness (generalized), Pain, unspecified, Type 2 Diabetes Mellitus without complications, Personal history of transient ischemic attack (TIA) and cerebral, Infarction without residual deficits, Anemia unspecified, unspecified age-related cataract, hyperlipidemia unspecified, insomnia unspecified, unspecified visual loss, Essential (primary) hypertension, Hemiplegia and hemiparesis following cerebral infarction, affecting left non-dominant side, gastroesophageal reflux disease without esophagitis, and dysphagia unspecified. Review of Resident #14's Quarterly MDS assessment dated [DATE], reflected Resident #14 was assessed to have a BIMS score of 12 indicating moderate cognitive impairment. Resident #14 was assessed to require extensive to supervisory assistance for all ADLs, he received Occupational Therapy 4 out of the 7 days and Physical Therapy 5 out of the 7 days, and he did not have any skin conditions prior to 04/14/2022. Review of Resident #14's Active Physician Orders, dated 05/12/2022 with a start date of 04/21/2022, reflected an order, Cleanse wound left shoulder with saline or wound cleanser, pat dry, apply collagen, anasept, border gauze. Change every day shift until wound is healed. Review of an Incident Report which was dated 04/18/2022, reflected that Resident #14 reported a wound to left shoulder on 4/18/22. The incident report stated, wound reddened area, small scab with no bleeding, prn pain medication given and cleansed with normal saline, triple antibiotic ointment (TAO) applied and covered with non-adherent dressing. Observation of Resident #14's wound on 05/12/22 at 11:00 AM, RN C removed the dressing to left shoulder of Resident #14. The wound appeared superficial, with only some light scarring appearance to skin and with no signs of infection noted. Review of a written statement provided by the PTA dated 04/18/2022, stated On April 14, 2022, I treated Resident #14. He received a hot pack on his left shoulder while completing an activity with his right arm. There were six (6) layers between patient skin and the actual hot pack. Patients' ability to feel sensation, skin integrity, and skin appearance on left shoulder were all checked and passed assessment before placement of hot pack. Throughout the ten (10) minute hot pack treatment session patient was verbally asked and assessed for overheating of hot pack which can lead to burning. Patient had no complaints, stating that it was feeling good and was not too hot. Once hot pack was removed patients' skin was checked again where some normal redness was found. The blanching test was performed on red areas and results indicated that patient still had adequate blood flow and no burns were noted. Patient completed rest of therapy exercises with no complaints, signs, or symptoms of any issue. Review of a written statement provided by the DOR dated 4/18/2022 stated I was informed by nursing that Resident #14 was complaining about a wound on his shoulder and that he felt it was a result of a hot pack he received in therapy on Thursday. I spoke to him and he told me that he did not realize the hot pack was too hot at the time, but he believes now that it must have been. Resident #14 has chronic shoulder pain in his stroke affected left shoulder and often requests a hot pack. Sensation is intact and there have been no complaints in previous sessions. I spoke with the therapist who treated him with a hot pack that day and she explained that standard protocols were followed and there was no evidence of discomfort or injury at the time of treatment. Review of Resident #14's Wound Physicians note (Initial wound evaluation and management summary), dated 04/20/2022, reflected .He has a burn wound of the left, dorsal shoulder for at least 7 days duration, and also revealed that wound measurements were 1.5cm X 0.7cm x not measurable (length x width x depth), and additional wound detail states heating pad in therapy. Notes also reflected that thick adherent devitalized necrotic tissue .100%), and surgical excisional debridement procedure was performed to remove necrotic tissue and establish the margins of viable tissue. Further review of the wound evaluation & management summary reflected no burn degree listed. In an interview with the DON on 05/11/22 at 09:11 AM, the DON stated that she thought the full thickness was from the debridement process, and not from the burn itself. She stated they were not aware of the burn until the 18th of April 2022, when Resident #14 started complaining. Once they were made aware, they started treatment and the doctor came and started the debridement process. In an interview with the DOR on 05/12/22 at 10:10 AM, he stated that Resident #14 had been receiving hot packs regularly with no issues before. He also stated that he did not know about the burn until the next day if it really was a burn. He also stated that he looked at the skin the next day and the skin was gone. The DOR stated that he was unsure if it really was a burn or if it was another skin issue. He stated that they always use at least 6 layers between the skin and a hot pack, and that there are two layers on the hot pack itself, and they include an additional 4 layers. Stated that they use a hydro regulator for their hot packs, so it is wet/moist heat, and the hydro regulator is maintained at a temperature range of 165-168 degrees. He stated that they do not document each step of the procedure while doing treatments because they would not have time to provide all the treatments they provide if they had to document each step. He also stated that Resident #14 was still receiving physical therapy, but that he was not on speech therapy and had not been in the last year. Observation of temperature logbook revealed that all temperatures of hydro regulator appeared within range specified above and that temperatures were checked daily. In an interview with the DON on 05/12/22 at 04:05 PM, she stated that she would not speculate on how the burn happened, but that what she understood, per therapy, is that they had performed a treatment with a hot pad and stated he had received treatments before with no issues. The DON stated that RN C worked on the Friday (4/15/2022) after Thursday (4/14/2022) treatment, and the resident did not verbalize any complaints until Monday (4/18/2022), when RN C communicated to her (DON), that wound occurred because of the hot pack in therapy. She stated the expectation would have been that she be notified of any injury, which she was, but the burn itself was entirely the responsibility of the therapy department. In an interview with the ADM on 5/12/2022, she stated that she was not aware of how the burn on Resident #14's left shoulder happened, because she had only been here since last Monday (5/2/2022). 2. Observation on 5/11/2022 at 1:10 p.m., revealed the following ashtrays on the patio at the end of the secure unit (hall 200): two hard plastic chimney style ashtrays with small openings in the top and the inside of the openings lined with metal; and one chimney-style ashtray made of thin plastic in two parts. Eight smoking residents and one staff person were seated in different areas around the patio and outside yard while a ninth resident sat with the group and did not smoke. All smoking residents used the available ashtrays. There was no lidded, metal trash can in the vicinity of the smoking area. Observation on 5/12/2022 at 10:58 a.m., revealed the following ashtrays on the patio at the end of hall 100: -three hard plastic chimney style ashtrays with small openings in the top and the inside of the openings lined with metal; one chimney-style ashtray made of thin plastic in two parts, the bottom of which was a plastic bowl holding a metal bucket, and the top of which was a very thin plastic neck through which cigarette butts were dropped to land in the bucket; and a few metal tabletop ashtrays without lids. Observation of this area on 5/12/22 at 11:15 a.m., revealed seven residents and one staff person seated in chairs and at picnic tables smoking and using all three types of ashtrays. There was no lidded, metal trash can in the vicinity of the smoking area. During an interview on 5/12/2022 00/00/00 at 5:12 p.m. at 11:14 a.m., the ADM stated she had just started a week prior, and one of the first things she noticed when she walked around the building was the unacceptable ashtrays. When asked if anything had been initiated to replace the ashtrays, she stated that more of the metal tabletop ashtrays had been ordered, and they come with lids. She stated that she had seen other facilities use red metal wastebaskets that have a push pedal to open, but she was concerned that people would put trash in them, and the trash would be another fire hazard. Review of policy dated July 2017 and titled Hazardous Areas, Devices, and Equipment reflected the following: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.

Based on interviews and record reviews, the facility failed to ensure the resident's rights to be free from neglect on two (2) separate occasions for one (Resident #1) of twenty-seven (27) residents reviewed for neglect. A. VD transported Resident # 1 on 08/03/2021 in the facility van for a medical appointment. Before returning to the facility, VD left Resident #1 unattended while he went into the store. While Resident #1 was unsupervised, she exited the van and went into the store and purchased a cigarette lighter. This failure placed Resident #1 at risk of heat exposure, elopement, serious injury or possible death. B. Resident #1 was unattended on 08/07/2021, with a cigarette lighter in her room. Resident #1 used the lighter while in bed wearing oxygen and caught her clothing and bedding on fire, melted her nasal cannula and the lighter. Resident #1 contacted the local Fire Department and reported the fire. The Fire Department contacted the facility. sustained, after she dialed 911 and notified the local Fire Department of the fire. This failure placed Resident #1 at risk, resulting in first and second degree [CONDITION(S)] to both hands and her being transported to the ED for treatment. This failure also placed all other residents at risk of being injured by fire or possible explosion resulting in injury or death. Findings include: Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set revealed Resident #1 was assessed to have a Brief Interview for Mental Status (BIMS) score 14 of 15 indicating cognitively intact. Resident #1 was assessed on 8/10/21 for smoking safety and was scored as a 2.0 - Safe to smoke with supervision. Review of Resident #1's Comprehensive Care Plan dated 02/09/21 reflected Resident #1 had a high risk for fall r/t unsteady, use of psych meds, Alteration in cognitive status 3/31/21 scored 17/30 - Patient's impulsivity significantly impacting problem solving and safety awareness, Actual Falls dated 5/18/21, 6/17/21 and 6/18/21, Safety issues due to smoking poor d/t impulse control, The resident has limited physical mobility r/t weakness. A. In an interview on 08/10/2021 at 1:12 PM, In an interview with AD, he stated that the VD has been put on suspension after being verbally counseled on 8/7/2021, regarding leaving residents unattended in the facility van. He stated he wanted to ensure the VD was aware of the seriousness of the situation since he had been previously verbally instructed to not make unscheduled stops leaving residence in the van. DON, was present during interview. In an interview on 8/10/21 at 4:53 PM, with VD, he stated he had never been informed that Resident #1 required supervision. He stated, she has a mind and has always been able to carry a conversation. She was in regular population and gets out and does things on her own. She does all her own paperwork at her doctor visits. He stated he was not aware she was one that needed to be watched at all times. He stated did not even know she could walk independently until he saw her walking back to the van after exiting the store. Record Review of Treatment Administration Record (TAR) for August 2021 revealed an order to Check wander guard each shift that it is on and working properly check with verichip pocket tag reader and take her to the door monitored with alarms every shift for wander guard. The start date was listed at 01/25/2021 at 2:00pm and discontinued 08/10/2021 at 9:52pm. Record Review of Progress Notes reflected, several entries dated in February 2021 stating Resident #1 has had increased wandering and agitation, has to be redirected to her room, has to be reminded to wear oxygen, loud verbal outburst, chewing cigarette butts. Record Review of Progress Notes revealed, forty (40) different entries stating, .remains a high risk for elopement, during the months of April 2021 to August 2021. Record Review of Progress Notes reflected, an entry dated 8/8/21 at 12:18pm stating, Resident #1 Requires supervision due to behavioral issues and impaired decision-making ability. B. Observation of Resident #1's right hand on 08/10/2021 at 10:30am revealed right hand wrapped in gauze dressing with date 8/10/21 written on the dressing. During interview at that time resident reported she was lighting a cigarette while she was sleeping and burned her hand, so she called 911. In an interview on 8/10/21 at 6:11 PM, with DON, she stated on 7/18/21 an empty cigarette packet was found in the Resident #1's bedding. The staff reported they did not smell smoke; they searched her room and did not find any type of cigarettes or lighters at that time. On 7/28/21, Resident #1 was found on the patio smoking unattended. The resident informed staff that she purchased a cigarette lighter and cigarettes while she was out of the building for her CT. After staff took up that lighter and cigarettes, they did a search and did not find any cigarettes or lighters in her room or purse. DON stated on 8/7/21, after Resident #1 had started the fire, they checked the whole facility for any other residents that may have lighters and did not find any. Record Review of Progress Notes reflected, an entry dated, 3/9/21 at 4:21pm, stating Resident was coming down the yelling about a smoke break. I noticed that resident was hiding something under her shirt. Asked resident what she had and she handed me a cigarette and a lighter. Asked resident where she got it from and she states from another resident. Record Review of Progress Notes reflected, an entry dated 5/5/21 at 7:46am, stating Resident #1 continue to go outside to smoke unattended. Record Review of Progress Notes reflected, and entry on 7/16/21 at 6:47am stating Resident #1 was On patio smoking cigar asked her where she obtained it she became upset and cursing. Record Review of Progress Notes reflected, an entry dated 8/7/21 at 5:45am stated, Behavior: Resident non-compliant with facility smoking policy. Resident stated to nurse that she had no idea how fire started, which was not the truth. Upon examination of her room, the blanket that had caught fire along with a lighter melted into it was found stuffed into one of her dresser drawers. Resident then states, I didn't want you to find that. Incident: Resident was attempting to light a cigarette butt in her room, dropped lighter which caught blanket on her bed on fire. She then proceeded to put the fire out with her hands and after she had extinguished it, called the local fire department stating, a fire started in my room and I had to put it out with my hands and now I'm hurt. That is when this nurse received phone call from fire department asking if there was still an active fire. They were informed there was not, but since dispatched would be here to examine resident's room and burn injury. Time: 0145 Evaluation: For safety of resident and other residents infacility, she will have to be on the secure unit. Record Review of Progress Notes reflected, an entry dated 8/7/21 at 6:09am stated, At approximately 0145, this nurse receives a call from the Fire Department stating that Resident #1 called saying a fire had started in her room in which she had to put out with her hands, and now she was hurt. They asked if there was still an active fire in building and they were informed there was not. Since they had been dispatched, they would be arriving at facility to inspect resident's room and injury. Upon waiting for their arrival, this nurse was searching resident's room as she said she had no idea how it happened, all the sudden it was just on fire. However, this was not the truth as this nurse found a charred blanket with a lighter melted into it stuffed in one of her dresser drawers. When nurse asks resident why she lied about having a lighter, she replied, you weren't suppose to find that. Resident #1 states I don't know what happened, all the sudden blanket was just on fire and I had to put it out. When asked why she did not call for help she said, cuz I knew I was gonna be in trouble, so I called the Fire Department instead. Careful inspection of resident's room completed by this nurse and fire department. [CONDITION(S)] to hands assessed, sterile gauze wet with sterile NS placed over [CONDITION(S)] and hand wrapped with kerlix. Areas of right hand with charring and blistering, appear second degree. Resident sent to local hospital ED for further evaluation and treatment. Record Review of Progress Notes reflected, an entry dated 8/8/21 at 12:18pm stating, Resident #1 Requires supervision due to behavioral issues and impaired decision-making ability. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of skin assessments dated 08/08/2021 reflected, [CONDITION(S)] to Right palm, thumb, first, second, third and fourth fingers, the Left hand first finger.

Based on observation, interviews and record reviews the facility failed to ensure that each resident receives adequate supervision to prevent accidents and hazards. The facility failed to provide adequate supervision and routine resident checks for Resident #1 when she was transported for a medical appointment out of the facility. Resident #1 was able to exit the van when the driver left her alone in the vehicle and obtained a cigarette lighter and lighter. Resident #1 lit cigarette in facility with oxygen on and notified 911 that Resident #1 was injured. Fire department notified EMS, who notified the facility and Resident #1 was sent to the emergency room and diagnosed with first and second degree [CONDITION(S)] to her right and left hands. This deficient practice could place residents at risk for physical harm or death with possible facility explosion. Findings Include: Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: need for continuous supervision, cognitive communication deficit, [CONDITION(S)], major depressive disorder, [CONDITION(S)] disorder, generalized anxiety disorder, wedge compression fracture of T5-T6 vertebra, unsteadiness on feet, abnormalities of gait and mobility, reduced mobility, unspecified [CONDITION(S)], malignant neoplasm of upper lobe, right bronchus or lung, acute and chronic [CONDITION(S)] with hypercapnia, [MEDICATION(S)] dependence, chronic obstructive pulmonary disease, shortness of breath, Diabetes mellitus type two, hypertension, problem related to unspecified psychosocial circumstances, problem related to care provider dependency. Review of Resident #1's Quarterly Minimum Data Set revealed Resident #1 was assessed to have a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. Resident #1 was assessed on 8/10/21 for smoking safety and was scored as a 2.0 - Safe to smoke with supervision. Review of Resident #1's Comprehensive Care Plan dated 02/09/21 reflected Resident #1 had a high risk for fall r/t unsteady, use of psych meds, Alteration in cognitive status 3/31/21 SLUMS 17/30 - Patient's impulsivity significantly impacting problem solving and safety awareness, Actual Falls dated 5/18/21, 6/17/21 and 6/18/21, Safety issues due to smoking poor d/t impulse control, The resident has limited physical mobility r/t weakness. Observation of Resident #1's right hand on 08/10/2021 at 10:30am revealed right hand wrapped in gauze dressing with date 8/10/21 written on the dressing. During interview at that time resident reported she was lighting a cigarette while she was sleeping and burned her hand so she called 911. In an interview on 08/10/2021 at 1:12 PM, In an interview with AD, he stated that the VD has been put on suspension after being verbally counseled on 8/7/2021, regarding leaving residents unattended in the facility van. He stated he wanted to ensure the van driver was aware of the seriousness of the situation since he had been previously verbally instructed to not make unscheduled stops leaving residence in the van. DON, was present during interview. In an interview on 8/10/21 at 4:53 PM, with VD, he stated he had never been informed that Resident #1 required supervision. He stated, she has a mind and has always been able to carry a conversation. She was in regular population and gets out and does things on her own. She does all her own paperwork at her doctor visits. He stated he was not aware she was one that needed to be watched at all times. He stated did not even know she could walk independently until he saw her walking back to the van after exiting the store. In an interview on 8/10/21 at 6:11 PM, with DON, she stated on 7/18/21 an empty cigarette packet was found in the Resident #1's bedding. The staff reported they did not smell smoke, they searched her room and did not find any type of cigarettes or lighters at that time. On 7/28/21, resident #1 was found on the patio smoking unattended. The resident informed them that she purchased a cigarette lighter and cigarettes while she was out of the building for her CT. After they took up that lighter and cigarettes, they did a search and did not find any cigarettes or lighters in her room or purse. She stated on 8/7/21, after Resident #1 had started the fire, they checked the whole facility for any other residents that may have lighters and did not find any. Record Review of Treatment Administration Record (TAR) for August 2021 revealed an order to Check wander guard each shift that it is on and working properly check with verichip pocket tag reader and take her to the door monitored with alarms every shift for wander guard. The start date was listed at 01/25/2021 at 2:00pm and discontinued 08/10/2021 at 9:52pm. Record Review of Progress Notes reflected, several entries dated in February 2021 stating Resident #1 has had increased wandering and agitation, has to be redirected to her room, has to be reminded to wear oxygen, loud verbal outburst, chewing cigarette butts. Record Review of Progress Notes reflected, an entry dated, 3/9/21 at 4:21pm, stating Resident was coming down the yelling about a smoke break. I noticed that resident was hiding something under her shirt. Asked resident what she had and she handed me a cigarette and a lighter. Asked resident where she got it from and she states from another resident. Record Review of Progress Notes revealed, forty (40) different entries stating, .remains a high risk for elopement, during the months of April 2021 to August 2021. Record Review of Progress Notes reflected, an entry dated 5/5/21 at 7:46am, stating Resident #1 continue to go outside to smoke unattended. Record Review of Progress Notes reflected, and entry on 7/16/21 at 6:47am stating Resident #1 was On patio smoking cigar asked her where she obtained it she became upset and cursing. Record Review of Progress Notes reflected, an entry dated 8/7/21 at 5:45am stated, Behavior: Resident non-compliant with facility smoking policy. Resident stated to nurse that she had no idea how fire started, which was not the truth. Upon examination of her room, the blanket that had caught fire along with a lighter melted into it was found stuffed into one of her dresser drawers. Resident then states, I didn't want you to find that. Incident: Resident was attempting to light a cigarette butt in her room, dropped lighter which caught blanket on her bed on fire. She then proceeded to put the fire out with her hands and after she had extinguished it, called the local Fire Department stating, a fire started in my room and I had to put it out with my hands and now I'm hurt. That is when this nurse received phone call from fire department asking if there was still an active fire. They were informed there was not, but since dispatched would be here to examine resident's room and burn injury. Time: 0145 Evaluation: For safety of resident and other residents infacility, she will have to be on the secure unit. Record Review of Progress Notes reflected, an entry dated 8/7/21 at 6:09am stated, At approximately 0145, this nurse receives a call from the Fire Department stating that A Resident called saying a fire had started in her room in which she had to put out with her hands, and now she was hurt. They asked if there was still an active fire in building and they were informed there was not. Since they had been dispatched, they would be arriving at facility to inspect resident's room and injury. Upon waiting for their arrival, this nurse was searching resident's room as she said she had no idea how it happened, all the sudden it was just on fire. However, this was not the truth as this nurse found a charred blanket with a lighter melted into it stuffed in one of her dresser drawers. When nurse asks resident why she lied about having a lighter, she replied, you weren't suppose to find that. Resident states I don't know what happened, all the sudden blanket was just on fire and I had to put it out. When asked why she did not call for help she said, cuz I knew I was gonna be in trouble, so I called the Fire Department instead. Careful inspection of resident's room completed by this nurse and fire department. [CONDITION(S)] to hands assessed, sterile gauze wet with sterile NS placed over [CONDITION(S)] and hand wrapped with kerlix. Areas of right hand with charring and blistering, appear second degree. Resident sent to hospital ED for further evaluation and treatment. Record Review of Progress Notes reflected, an entry dated 8/8/21 at 12:18pm stating, Resident #1 Requires supervision due to behavioral issues and impaired decision making ability. Review of Resident #1's Physician Orders reflected an order dated 08/10/2021, Monitor burn to right hand daily for signs of infection: more redness, swelling, or pain; warmth, pus, a bad smell, and any red streaks around the burn. Review of Physician Orders of Resident #1 dated 08/10/2021 reflected, Cleanse and rinse the burn to your right hand, pat dry, place a sterile dressing over the burn and wrap with kerlix daily. Review of Physician Orders of Resident #1 dated 08/09/2021 reflected, Raise (elevate) the burned area above the level of resident's heart while sitting or lying down. Record Review of skin assessments dated 08/08/2021 reflected, [CONDITION(S)] to Right palm, thumb, first, second, third and fourth fingers, the Left hand first finger.