Autumn Care Of Marion

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with Guardian, witnesses, resident, Psychiatric Provider, Nurse Practitioner (NP), and staff, the facility failed to provide the necessary supervision to prevent Resident #1 from exiting the facility unsupervised and without staff's knowledge through one of two doors that did not alarm when opened. Resident #1 was at risk for falls, her diagnoses included dementia, and she had been identified with a decline in cognition with signs of increased confusion and disorientation in the months prior to March 2026. Staff reported these signs included getting lost in the hallways, not being able to figure out how to get back to her room and forgetting that she required supervision to smoke. On 3/2/26 around 10:00 AM an unknown individual found Resident #1 outside of the facility in her wheelchair on the opposite side of the road as the facility, in the roadway, trying to self-propel up the road. Staff were unaware the resident had left the facility without supervision. In addition, not all staff were aware Resident #1 had exited the facility to understand the need for heightened awareness for her safety and whereabouts. Resident #1 was not injured; however, there was a high likelihood of serious harm, injury, or death with risks that included getting lost, falling with an inability to get out of harm's way, and/or getting hit by a car. Additionally, the facility failed to ensure staff were aware of Resident #1's unsupervised exit. The deficient practice affected 1 of 3 reviewed for accidents.Immediate Jeopardy began on 3/2/2026 when Resident #1 exited the facility unsupervised and without staff's knowledge. Immediate Jeopardy was removed on 3/5/2026 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure all staff and providers are aware of the elopement, education is completed and monitoring systems put into place are effective.The findings included:Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included dementia, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) following cerebral infarction, anxiety and depression.The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 was [AGE] years old and cognitively intact. She had age related nuclear cataracts (a slow-developing, common eye condition where the center [nucleus] of the eye's lens gradually hardens and yellows, causing blurry vision) and her vision was assessed as adequate with corrective lenses. Resident #1 had no functional limitations with range of motion and she utilized a wheelchair. She required partial/moderate assistance with upper body dressing and substantial/maximum assistance with lower body dressing, putting on/taking off footwear, and transfers. She was independent with self-propelling her wheelchair.The active care plan as of 3/1/26 revealed Resident #1 was care planned for requiring supervised leave of absences and her mental function varied over the course of the day related to medical conditions. Resident #1's care plan also included the risk for decreased/ impaired vision and the risk for falls secondary to decreased mobility, abnormal gait, muscle weakness. There were no interventions documented for the for care planned problem areas.Resident #1's active physician orders as of 3/1/26 included Namenda (used to treat moderate to severe dementia) 5 milligrams (mg) two times a day.An interview with Nurse #2 was conducted on 3/24/26 at 1:57 PM. Nurse #2 reported that Resident #1 has had a decline the last couple of months prior to March 2026 with increased episodes of confusion and increased anxiety, as well as several urinary tract infections beginning sometime in January 2026. Nurse #2 explained that Resident #1 would get lost in the hallways some days and could not figure out how to get back to her room. She further explained that the resident would forget she required supervision when she went out to smoke. Nurse #2 reported that Resident #1 was changed from independent to supervised smoking in late January due to her not being able to hold the cigarette well. Nurse #2 reported she was not aware of any changes to Resident #1's supervision except with smoking. An interview with Nurse #3 on 3/24/26 at 12:54 pm revealed she had been caring for Resident #1 for about five years and knew her pretty well. Nurse #3 reported that Resident #1 had been declining over the last several months prior to March 2026. She indicated the resident had been seen by the psychiatric provider and the Nurse Practitioner (NP) and her dementia medications had been adjusted. Nurse #3 went on to say that Resident #1 would get confused and disoriented while moving down the hallway and would become anxious and have to be redirected. Nurse #3 reported that it had become more difficult to redirect Resident #1 in the last several weeks. Nurse #3 explained that in several instances Resident #1 did not remember she now required supervision to smoke and would become angry when she asked to go out and the staff had to remind her she had to wait for someone to take her. Nurse #3 reported that Resident #1 was changed from independent to supervised smoking in late January due to her not being able to hold the cigarette well. During an interview with Nurse Aide (NA) #1 on 3/24/26 at 1:14 PM she stated that Resident #1 had become more confused over the last several months, had episodes of increased anxiety, and became more difficult to redirect. NA #1 indicated that Resident #1 would often become disoriented when she was out on the halls and when she (NA #1) would attempt to redirect her the resident became upset. NA #1 reported she had made the nurse responsible for Resident #1 aware anytime she noticed a change in Resident #1, she stated she did not remember which nurses she told. A progress note written by the Director of Nursing (DON) on 3/2/26 at 10:30 AM indicated Resident #1 attempted elopement and was intercepted. The resident continually stated, I just want to go home. The DON indicated reorientation to the resident's situation was attempted without success. The Psychiatric Provider was in the facility and assessed the resident. The Nurse Practitioner (NP) was also in the facility and assessed the resident with new orders given. A wanderguard (electronic wander management bracelet) was placed on Resident #1 for safety and her guardian was made aware. The note indicated Resident #1 had never attempted to show any signs that she would attempt elopement. An interview with the DON on 3/24/2026 at 2:58 PM revealed on the morning of 3/2/2026 management staff were in the morning meeting and Witness #2 came into the conference room telling them a resident was outside. He reported that the staff in the morning meeting immediately left the conference room to locate the resident. The DON stated that they (staff) were all shocked when they discovered it was Resident #1, as this was not normal for her. He reported that when they found Resident #1, she was on the road just past the gravel parking lot. He stated Resident #1's mentation was altered, she was what I would describe as manic. He reported that it was difficult to make the resident understand the danger she was in on the road and why she needed to return to the facility. The DON reported Resident #1 was difficult to convince to come back to the facility, as she kept attempting to propel herself via wheelchair further up the hill on the road stating she needed to go and take care of her son. He indicated they were able to get Resident #1 back to the facility and the Psychiatric Provider was in the facility, so he asked her to assess Resident #1. The DON stated that during the assessment Resident #1 was not making a lot of sense and referred to her adult son as a baby. The DON revealed that he was aware Resident #1 had experienced a decline over the last several months and had several medication changes. He explained that Resident #1 had become more confused and had been changed from an independent to supervised smoker back in January due to the increased confusion. He reported that when Resident #1 was returned to the facility on 3/2/26 he asked Nurse #4 to place a wanderguard on Resident #1 and do an elopement assessment. The DON stated he told Nurse #4 to use the progress note he completed (completed by the DON on 3/2/26 at 10:30 AM) as a resource to complete the elopement assessment. The DON was unable to explain why he wrote in the progress note that Resident #1 attempted elopement and was intercepted by staff. The DON reported that Resident #1 did elope and was found down the road below the gravel parking lot. He reported that he felt sure he had verbally reported to all staff that Resident #1 had actually left the facility and went down the road and had not just attempted elopement. He revealed he did not keep track of the staff he verbally reported this information to. He reported that he felt that it was important for all staff to know that Resident #1 had actually left the building and went down the road and not that she just attempted to elope because an attempt to elope is a lot less dangerous than an actual elopement. The DON spoke about how Resident #1 exited the facility on 3/2/26. He indicated it was determined that Resident #1 exited out the side door of the facility. He explained that the side door of the facility and the front door of the facility were the only two exterior doors that did not alarm when opened. He further explained that the side door had a wanderguard alarm on it only prior to Resident #1's unsupervised exit on 3/2/26 and Resident #1 did not have a wanderguard in place until after the unsupervised exit. The DON indicated the side door was the only door that could not be easily visualized by the receptionist. An observation of the facility was conducted on 3/24/26 at 4:30 PM. The facility was a one-story construction that visitors could enter via the paved or the gravel parking lot. Immediately outside of the side door of the facility was an approximately 50-foot wheelchair ramp that led by the side of the front porch to the front of the facility and into the main paved parking lot of the facility. At the end of the wheelchair ramp to the right led to a paved hill that was used to enter and exit the paved parking lot. The entrance/exit to the paved parking lot had ditches filled with six-to-eight-inch jagged rocks and led out into a well-traveled main road that had a posted speed limit of 35 miles per hour and had blind curves on each side of the facility's driveway, which made it difficult to see any oncoming traffic. To the left of the wheelchair ramp led back to the front of the facility. Straight ahead of the wheelchair ramp led across the paved parking lot and into a gravel parking lot of the facility. Resident #1 was found on the opposite side of the road from the facility on the two-lane roadReview of weather data from Weather Underground for 3/2/26 at 10:00 AM revealed the recorded temperature was 56 degrees Fahrenheit with light winds and no precipitation. Review of google earth revealed that there was 47 feet from the side door of the facility to the end of the wheelchair ramp, 157 feet from the end of the wheelchair ramp to the main road and 258 feet from facility parking lot to where Resident #1 was found. The slope out of the parking lot was 8.9 degrees. An interview with Assistant Director of Nursing (ADON) #1 revealed that on the morning of 3/2/26 management staff were in the conference room for morning meeting when Witness #2 came into the room and reported that a resident was out on the road. ADON #1 reported that everyone in the room went out to find the resident. She indicated that when they found Resident #1 she was just past the gravel parking lot and was on the opposite side of the road from the facility, in her wheelchair, in the road. ADON #1 stated Resident #1 was upset, not easy to console, and was adamant that she must continue down the road and not go back to the facility when staff got to her. She reported Resident #1 was stating she wanted to go home to see her son. ADON #1 reported they wheeled Resident #1 back into the building, assessed her and she began to calm down. ADON #1 recalled that Resident #1 did not have any injuries. ADON #1 reported Resident #1 had not indicated in the past that she wanted to leave the facility. ADON #1 stated Resident #1 had experienced a decline over the last several months prior to 3/2/26 and was not safe to be outside without supervision. A telephone interview with Witness #1 on 3/24/26 at 2:00 PM revealed that on the morning of 3/2/26 she was on the front porch of the facility and remembered seeing Resident #1 coming down the ramp beside the front porch of the facility and observed her go out into the paved parking lot in front of the facility. Witness #1 reported she assumed the resident was going outside to enjoy the morning. Witness #1 reported she (Witness #1) continued into the facility to get her family member who she was visiting and came back out to the porch where they were joined by Witness #2. Witness #1 stated she didn't remember seeing Resident #1 when she returned to the front porch of the facility. Witness #1 reported there may have been five to eight minutes between her seeing Resident #1 and when another visitor came to the porch to tell Witness #2 and her (Witness #1) that someone (Resident #1) was in a wheelchair down the road. Witness #1 stated that Witness #2 went inside to tell the staff about Resident #1 being in the road. Witness #1 reported that a lot of the staff came out of the facility and went down the road, and a few minutes later came back pushing Resident #1 in her wheelchair. A telephone interview with Witness #2 on 3/24/26 at 1:49 PM revealed she was sitting on the front porch of the facility on 3/2/26 around 10:00 AM with Witness #1 and someone, who Witness #2 assumed was a family member of another resident, came up onto the porch and told her there was a lady in her wheelchair across the road heading up around the curve. Witness #2 reported she went inside the facility and when she saw no one at the front desk she went to the conference room to let the staff know that Resident #1 was out in the road in her wheelchair. Witness #2 reported all the staff in the conference room went out to get Resident #1 and she observed a passerby standing with Resident #1 on the opposite side of the road down past the gravel parking lot. An interview with Nurse #2 conducted on 3/24/26 at 1:57 PM revealed she was at the morning meeting with all department heads on 3/2/26. She reported that on the morning of 3/2/26 she was sitting on the side of the table in the conference room where she could see out the windows into the hallway. She stated she saw Resident #1 come down the hall self-propelling in her wheelchair around 10:00 AM, which was not unusual for Resident #1 as she frequently visited the front desk. Nurse #2 reported that several minutes later Witness #2 came into the conference room and said Resident #1 was outside. Nurse #2 stated everyone in the conference room ran out to get Resident #1. She stated the resident was found just past the gravel parking lot area, on the opposite side of the road as the facility in the roadway trying to self-propel herself via wheelchair up the road. Nurse #2 reported there was a passerby outside with the resident trying to get her out of the road when she (Nurse #2) arrived. Nurse #2 did not know who the passerby was. An interview with NA #1 on 3/24/26 at 1:14 PM indicated she was familiar with the elopement on 3/2/26 involving Resident #1 and was her assigned aide on that day. NA #1 revealed Resident #1 was sitting at the nurse's station around 9:30 AM on the morning of 3/2/26. NA #1 reported that was Resident #1's normal routine as she waited at the nurse's station for someone to take her out to smoke. NA #1 stated that a while later she noticed Resident #1 was no longer at the nurse's station. She was unable to recall the time but reported she was still doing morning rounds so it was sometime before 10:30 AM. She indicated the next time she saw Resident #1 she (the resident) was being pushed down the hall in her wheelchair by the DON. NA #1 reported she was made aware by one of the nurses, she could not recall which one, that Resident #1 had attempted elopement from the facility but didn't succeed. NA #1 stated she was not aware through present date that Resident #1 had gotten out of the building and went down the road. NA #1 reported she was not aware of any other occasions where Resident #1 had tried to elope, and Resident #1 had never said anything to her about wanting to leave or needing to care for her adult son. During an interview on 3/24/26 at 10:50 AM with Resident #1 she stated she left the building in her wheelchair (on 3/2/26) and went down the hill of the paved parking lot and up the road. She reported she did not go through the gravel parking lot because she knew she could not push her wheelchair through the gravel. Resident #1 stated she was wearing a sweatshirt, long pants, socks and shoes, and her toboggan (winter hat). Resident #1 reported she felt like something was wrong with her adult son and she needed to be the one caring for him. Resident #1 indicated she wasn't sure why she felt she needed to leave on 3/2/26 to go take care of her son, she just felt like her son needed her and she should be the one caring for him. She stated she did not let anyone know that she was leaving the facility and was unsure why she didn't tell anyone. Resident #1 indicated she had gotten out to the road via wheelchair and had passed the gravel parking area when two people, who she thought were from the nearby church, stopped her and told her they were afraid she was going to get hit by a car. Resident #1 reported she didn't remember where those people went, she reported she thought they stayed there with her until the Administrator and DON got there. Resident #1 stated that the Administrator and DON came and got her and brought her back to the facility. She stated she liked it at the facility but was concerned about her adult son and who was taking care of him.During a follow-up interview on 3/24/26 at 5:03 PM with Resident #1 she stated she did not have a cell phone to call for help on 3/2/26 if she needed it and was not wearing a coat because she did not think she needed a coat.An interview was conducted with Resident #1's State Appointed Guardian on 3/24/26 at 10:04 AM. The Guardian reported that she had been made aware by the facility that Resident #1 had been having increased confusion and increased anxiety prior to March 2026. She reported she had noticed Resident #1 was repeating herself a lot during their visits and was more concerned about the well-being of her adult son. The Guardian reported that these changes had led her to begin the process of filing for full guardianship. She explained that full guardianship gave her the ability to make all decisions regarding personal, care, residence, medical treatment and financial affairs for Resident #1. She further explained that at the time of the 3/2/26 incident she had limited guardianship which gave the guardian limited power only in areas where the person could not make decisions. Resident #1's State Appointed Guardian reported that she obtained guardianship over Resident #1 because the resident had not demonstrated the ability to make sound decisions, and there was no family member who could make sound decisions on Resident #1's behalf. Resident #1's State Appointed Guardian reported that Resident #1 had a son that was blind and Resident #1 had previously been his primary caregiver and the Guardian believed that this contributed to Resident #1 wanting to leave the facility on 3/2/26. Interview with Nurse #4 on 3/24/26 at 12:57 PM revealed she was asked by the DON and the ADON #1 on 3/2/26 to put a wanderguard on Resident #1. Nurse #4 reported the DON also asked her to fill out an elopement assessment on Resident #1 on 3/2/26, and to read his 3/2/26 progress note about the attempted elopement for the information she would need to complete the assessment. Nurse #4 stated the progress note did not have a location as to where Resident #1 was found. She explained that she made the DON aware that the progress note did not include a location and the DON stated he would complete that part of the assessment. Nurse #4 reported she spoke with Resident #1 before completing the assessment on 3/2/26 and Resident #1 stated she wanted to go home and take care of her son. Nurse #4 reported that Resident #1 was crying and repeating she was sorry for leaving when Nurse #4 spoke to her. Nurse #4 stated she was not given any details on the elopement or attempted elopement of Resident #1 by the DON or by Resident #1. Nurse #4 reported she did not know through present date (3/24/26) that Resident #1 had left the building on 3/2/26. She explained that the progress note completed by the DON led her to believe it was an attempted elopement and the resident had been intercepted by staff. An interview with Nurse #5 on 3/24/26 at 12:41PM indicated she had given Resident #1 her medications between 7:45 and 8:00 AM on the morning of 3/2/26 and she noted no concerns with Resident #1 at that time. She reported Resident #1 was in her room in her wheelchair at the time and she was dressed. Nurse #5 reported the next time she saw Resident #1 was at approximately 11:00 AM when Nurse #4 was putting a wanderguard bracelet on her. Nurse #5 reported the DON and Assistant Director of Nursing (ADON) #1 explained to Nurse #5 that Resident #1 had attempted to leave the facility. Nurse #5 reported that to present date (3/24/26) she had not been made aware that Resident #1 had left the building. Nurse #5 stated Resident #1 had never told her (Nurse #5) that she wanted to leave the facility and had never expressed needing to leave to care for her adult son. A Psychiatric Provider note dated 3/2/26 indicated Resident #1 was seen for psychiatric follow up due to staff request. Per the DON, Resident #1 attempted elopement, and was intercepted by staff. Resident #1 was continually stating I just want to go home. The DON stated Resident #1 was placed on every 15-minute checks for 24 hours due to attempted elopement. Per the DON, Resident #1 had no prior history of exit seeking behavior. Resident #1 was followed for a known history of depression, anxiety, and a recent diagnosis of dementia. Per staff, Resident #1 had ongoing confusion. Resident #1 was a fair historian. Resident #1 was assessed after attempted elopement and she stated, I just wanted to go home. Staff discussed with resident she was not safe to go home and needed help with activities of daily living. Resident #1 stated I know, I know I can't go, there's no one to take care of me. She then repeated, I just want to go home. She stated, I need to care for my child, he needs me, it should be me taking care of him. Resident #1 was referring to her grown son who had impaired vision. She stated they were good to her at facility, but she did not like being away from home. When asked if there was any trigger or inciting event, Resident #1 initially stated no. She later stated she was upset that she could not go outside and smoke when she wanted to. Resident #1 was a supervised smoker. The resident stated, I know I shouldn't have done that; I won't do it again. The Psychiatric Provider indicated she discussed Resident #1 with the NP who stated she was ordering a head computed tomography scan (CT scan) to evaluate for possible CVA (cerebrovascular accident) or vascular changes due to history of past CVA. Also discussed increasing Namenda for dementia. Resident #1 now had a wanderguard in place. An interview with the Psychiatric Provider on 3/24/26 at 2:12 PM revealed she was at the facility on 3/2/26 when it was reported to her that Resident #1 had attempted to leave the facility and was intercepted by staff. The Psychiatric Provider revealed that to present date (3/24/26), she did not recall anyone reporting to her that Resident #1 actually left the building. The Psychiatric Provider reported the staff had already interviewed the resident prior to her assessment on 3/2/26, however, during the interview with the Psychiatric Provider the resident told her a very different story than what she had told the facility staff. The Psychiatric Provider could not remember the details of what Resident #1 told her. The Psychiatric Provider stated that it was out of the ordinary for Resident #1 to attempt to leave the facility and she found Resident #1 to be very confused and tearful on 3/2/26. The Psychiatric Provider indicated Resident #1 had been treated for a UTI, so she assumed that played a part in her disposition on 3/2/26, although she was not being treated for an active infection. The Psychiatric Provider reported Resident #1 had been experiencing increased confusion and depression over the last three months prior to 3/2/26 and her Cymbalta (a medication used to treat depression) had been increased. The Psychiatric Provider indicated that she has had no further concerns with Resident #1 since 3/2/26. Interview with the NP on 3/24/26 at 1:50 PM revealed she was made aware on 3/2/26 that Resident #1 had gotten out of the building on the morning of 3/2/26 and someone found her outside in the gravel parking lot. The NP reported she had had no concerns about Resident #1 leaving the facility prior to 3/2/26. The NP indicated Resident #1's cognition had been declining, which included increased confusion and depression, and she had been treated for several UTI's in the last three months prior to 3/2/26. The NP stated she had consulted with the Psychiatric Provider after the elopement and increased Resident #1's Nameda (a medication used to treat dementia). The NP indicated that after the elopement she also ordered a CT scan and it did show Resident #1 to have encephalomalacia, (softening of the brain tissue consistent with dementia). The NP reported she spoke with Resident #1 after the incident on 3/2/26 and the resident was apologetic for leaving but could not tell the NP why she left, only that she wanted to go home. The NP reported she did not know who found Resident #1 or how long she had been outside the facility. The NP reported she had not had any new concerns since the incident on 3/2/26. The NP reported that due to Resident #1's increased confusion, decreased mobility and being wheelchair bound her risk of being outside the facility unassisted included turning the wheelchair over and sustaining an injury, getting lost, or kidnapped and/or being hit by a car. The NP stated Resident #1 should not have been outside unassisted. An interview with the Maintenance Director on 3/24/26 at 2:08 PM revealed he was unsure if the side door that Resident #1 went out of was locked during business hours prior to 3/2/26. He reported the door did not alarm when Resident #1 went out because it only had a wanderguard alarm on it and Resident #1 did not wear a wanderguard bracelet at that time. He reported that the only exterior door that did not have an alarm now was the front door. He reported that the front door was monitored all day by the front desk receptionist or a member of management and then was locked at 5:00 PM when the management staff went home. During an interview with Nurse #3 on 3/24/26 at 12:54 pm she reported that she had been off for several days prior to 3/2/26 and upon returning to work she was reading thru the recent progress notes of the residents in her care and found the progress note completed by the DON alerting her to Resident #1's attempted elopement. Nurse #3 revealed that to present date (3/24/26) no one had told her that Resident #1 had actually left the facility. An interview with the Administrator on 3/24/26 at 3:20 PM revealed that on 3/2/26 the morning meeting was being held in the conference room, and the meeting was about over when Witness #2 came into the room to let staff know that a resident was in the road. The Administrator reported that she and the staff were able to catch up to Resident #1 and that she was across the road from the facility, just past the gravel parking lot, sitting in her wheelchair in the road. The Administrator stated the staff were able to get Resident #1 back into the building. She reported that Resident #1 had never indicated that she wanted to leave the facility prior to 3/2/26 and the staff were surprised by this event. The Administrator explained that Resident #1 did worry about her blind son a lot and she (the Administrator) had discussed with Resident #1's guardian that the adult son lived right down the road with other family members. The Administrator indicated she was aware that Resident #1 had started having some increased confusion a few months ago and a lot of diagnostics were completed, such as labs and scans, as well as medication changes, but she was unsure what medications had been changed. The Administrator revealed that the Psychiatric Provider and the NP both were able to assess Resident #1 on 3/2/26. The Administrator reported that Resident #1 went out the side door of the facility and that prior to 3/2/26 the side door did not alarm unless there was a wanderguard close by. The Administrator further stated the Maintenance Director put an alarm on the side door that sounded anytime the door was opened on 3/2/26 after Resident #1 was returned to the facility and management also put signs out at the nurses' station to make the nursing staff aware of the alarm. The Administrator reported that a wanderguard was placed on Resident #1's ankle for safety. The Administrator stated she was not sure why all staff did not know that Resident #1 had actually got out of the building and she would need to speak to the DON about his progress note on 3/2/26 that indicated the elopement was attempted as she was unsure why the DON would have written that. The Administrator reported she felt that it was important for all staff to know that Resident #1 had actually left the building and went down the road and not that she just attempted to elope. She explained that an actual elopement presented much more danger than just an attempted elopement. The Administrator indicated that it was not safe for Resident #1 to be out of the facility unsupervised. The Administrator was notified of immediate jeopardy on 03/24/26 at 6:00 PM.The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; On 3/2/2026, Resident #1 experienced an unsupervised exit from the facility through a side exit door and was observed off facility property by a family member, which alerted staff. The resident was immediately returned to the facility without injury by the Administrator, Director of Nursing, and Assistant Director of Nursing. The Administrator and Director of Nursing (DON) conducted an immediate review of the incident on 03/02/2026. The Administrator and DON determined the root cause to be that the side exit door did not have an alarm system installed that alerted staff to any opening of the door at the time of the incident, which allowed Resident #1 to exit the facility without staff awareness.Immediately upon the resident's return to the facility on 3/2/2026, the following actions were taken:The Administrator and DON contacted Resident #1's guardian, primary care provider, and Medical Director on 3/2/2026.Resident #1's nurse completed a head-to-toe nursing assessment on 3/2/2026, and no injuries were noted.The Administrator and Director of Nursing (DON) interviewed Resident #1. During the interview, Resident #1 verbalized a desire to go home to care for her son. The Administrator reassured Resident #1 that her son is cared for by a full-time caregiver.The Director of Rehabilitation Services completed a Brief Interview for Mental Status (BIMS) assessment on 3/2/2026, with a score of 8/15 (a score of 8 indicates moderate cognitive impairment). Resident #1's nurse completed an elopement risk assessment on 3/2/2026, and Resident #1 was identified as high risk for elopement. At the time of[TRUNCATED]

Based on record review and staff and resident interview the facility failed to maintain a complete and accurate medical record when staff documented a resident attempted elopement and was intercepted by staff. This occurred for 1 of 3 residents (Resident #1) reviewed for accurate medical recordThe findings included:A review of a progress note dated 3/2/26 written at 10:30 AM by the Director of Nursing (DON) indicated that Resident #1 attempted elopement and was intercepted. The DON indicated in the note that reorientation was attempted to her situation without success.An interview with the DON on 3/24/2026 at 2:58 PM revealed on the morning of 3/2/2026 management staff were in the morning meeting a visitor came into the conference room telling them a resident was outside. He reported that the staff in the morning meeting immediately left the conference room to locate the resident. He reported that when they found Resident #1 she was on the road just past the gravel parking lot. He stated Resident #1's mentation was altered, she was what I would describe as manic. He reported that it was difficult to make the resident understand the danger she was in on the road and why she needed to return to the facility. The DON reported Resident #1 was difficult to convince to come back to the facility, as she kept attempting to propel herself via wheelchair further up the hill on the road stating she needed to go take care of her son. He indicated they were able to get Resident #1 back to the facility. The DON was unable to explain why he wrote in the progress note that Resident #1 attempted elopement and was intercepted by staff. The DON reported that Resident #1 did elope and was found down the road below the gravel parking lot.An interview with the Administrator on 3/24/26 at 3:20 PM revealed that on 3/2/26 the morning meeting was being held in the conference room and the meeting was about over when a visitor came into the room to let staff know that a resident was in the road. The Administrator reported that she and the staff were able to catch up to Resident #1 and that she was across the road from the facility, just past the gravel parking lot, sitting in her wheelchair in the road. The Administrator reported that Resident #1 went out the side door of the facility. The Administrator reported she was not sure why all staff did not know that Resident #1 had actually got out of the building and she would need to speak to the DON about his progress note on 3/2/26 that indicated the elopement was attempted as she was unsure why the DON would have written that. The Administrator stated she expected all information entered into a resident's medical record to be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the Pharmacist in Charge and staff, the facility failed to have effective systems in place for the return, disposition, and accurate accounting of controlled medications to the pharmacy for 1 of 3 residents reviewed for misappropriation of property (Resident #134). The findings included:Resident #134 was admitted to the facility on [DATE].The physicians order dated 3/29/2025 revealed Resident #134 was to receive oxycodone (a narcotic opioid analgesic prescribed to treat moderate to severe pain by acting on the central nervous system) 5 milligrams (mg) every 6 hours as needed (PRN) for pain.The March 2025 medication administration record (MAR) revealed starting on 3/29/2025 Resident #134 received a total of 4 tablets of oxycodone 5mg. The medication was documented as administered per physician order on 3/29/2025 at 8:25 PM, on 3/30/2025 at 6:33 PM, on 3/31/2025 at 5:51 AM and 8:46 PM. No further doses were documented as administered for the remainder of the month.The April 2025 MAR revealed Resident #134 received a total of one (1) tablet of oxycodone 5mg. The medication was documented as administered on 4/1/2025 at 5:15 PM. No further doses were documented as administered for the remainer of the month.The controlled substance count record dated 3/29/2025 revealed Resident #134 had 7 tablets remaining after the last dose was administered to Resident #134 on 04/01/2025.Resident #134 was discharged from the facility on 04/02/2025.The pharmacy Controlled Substance Prescription Returned to Pharmacy form dated 4/7/2025 and signed by Nurse #1 and Nurse #2 revealed Resident #134's oxycodone 5mg with 7 tablets remaining was being returned to the pharmacy in the Controlled Medication Return Bag #1109772, due to the medication being discontinued. The form was signed as received by the pharmacy on 4/9/2025 and a note was written that read medication was not in the bag have called the facility 2 times since yesterday waiting to hear back from someone at the facility about this issue.The pharmacy Pick-Up Slip dated 4/8/2025 signed by Nurse #3 and the pharmacy driver revealed Controlled Medication Return Bag #1109772 was picked up at the facility on 4/8/2025 and was dated and initialed by the pharmacy on 4/9/2025.The pharmacy return technician who processed the Controlled Substance Prescription Returned to Pharmacy form on 4/9/2025 was unable to be reached due to no longer working for the pharmacy.During a telephone interview on 2/25/2026 at 2:39 PM Nurse #1 verified he had worked on 300 hall on the night of 4/7/2025. Nurse #1 verified he had prepared Resident #134's oxycodone for return to the pharmacy. Nurse #1 stated he took the Controlled Substance Prescription Returned to Pharmacy form to Nurse #2 and had her sign it without having the narcotic cards for Resident #134 and another resident on hand for verification. Nurse #1 stated that leaving the medication in the medication room unattended while he obtained Nurse #2's signature was not proper protocol, and it was a mistake to complete the form that way. Nurse #1 stated he should have had the medications that were being returned with him when he had the second nurse to sign the form so the medications could be verified by the 2nd nurse that signed the form and he should not have sealed the bag by himself. Nurse #1 stated Nurse #2 was not involved with the verification or return of Resident #134's oxycodone except for signing the form. Nurse #1 stated he placed Resident #134's card of narcotics that contained the 7 oxycodone along with another resident's card that contained one tablet of oxycodone and the Controlled Substance Prescription Returned to Pharmacy form in the Controlled Medication Return Bag on his own and sealed the bag and placed it in the locked narcotic drawer of the medication cart. Nurse #1 stated he did not know what happened to Resident #134's oxycodone and did not think the tablets were ever found.During a telephone interview on 2/25/2026 at 3:06 PM Nurse #2 stated Nurse #1 had asked her to sign some paperwork on 04/07/2025 but she was not involved with packaging Resident #134's medications and did not verify the medications that were being returned to the pharmacy. Nurse #2 stated she did not have access to Resident #134's medication and had no idea what happened to them. Nurse #2 stated she did not realize what she had signed with Nurse #1. Nurse #2 stated that when she was called in for the interview about the missing medication, she requested to see the form she had signed, and she was shown the Controlled Medication Return form dated 4/7/2025 that she had signed with Nurse #1. Nurse #2 verified her signature on the paper and stated she should not have signed it without making sure the medications being sent back were present in the return bag. Nurse #2 stated she knew she was supposed to verify the amount of narcotic medications that were being returned if she signed a return form and should have verified, they were in the return bag when it was sealed.During an interview on 2/25/2026 at 10:24 AM Nurse #3 verified her signature on the pharmacy pick up slip dated 4/8/2025. Nurse #3 stated when the pharmacy driver arrived at the facility for pick up 4/8/2025, Nurse #3 verified the serial number on the Controlled Medication Returned Bag matched the serial number on the pharmacy pick up ticket. Nurse #3 and the pharmacy driver signed the pharmacy pick up slip and the Controlled Medication Returned Bag was given to the pharmacy driver. Nurse #3 stated she did not recall the specific bag from 4/8/2025, but the bag would have been sealed properly for the pharmacy driver to accept it, and she would not have handed over an unsealed bag. Nurse #3 stated she did not verify the contents of the bag when it was handed to the pharmacy driver. Nurse #3 revealed the following process when pharmacy picked up controlled medications for return the nurse retrieved the sealed Controlled Medication Returned Bag from the locked narcotic drawer in the medication cart. The nurse and pharmacy driver would verify the serial number on the Controlled Medication Returned Bag matched the serial number on the pharmacy pick up ticket. The nurse and driver would sign the pickup ticket and the pharmacy driver would take possession of the Controlled Medication Returned bag. Nurse #3 stated verifying the contents of the sealed bag was not required, but after the incident in April 2025 she tried to verify the contents when she returned narcotic medication.During an interview on 2/25/2026 at 2:07 PM the Pharmacist in Charge explained when the facility had narcotics to return to the pharmacy, the Controlled Substance Prescription Returned to Pharmacy form was completed which contained the serial number of the Controlled Medication Return Bag, the pharmacy then generated a pick up ticket that contained the serial number that was on the Controlled Substance Prescription Returned to Pharmacy form. When the pharmacy driver arrived at the facility the driver and a nurse at the facility would verify the serial number on the Controlled Medication Return Bag matched the pickup ticket, the pharmacy did not require verification of the return bag contents by the driver. The Pharmacist in charge stated the driver would not accept a bag if the serial number did not match and if the seal of that bag appeared to be tampered with or was not properly sealed. The Pharmacist in Charge retrieved the pharmacy copy of the Controlled Substance Prescription Returned to Pharmacy form dated 4/7/2025 that was signed by Nurse #1 and Nurse #2 and verified the name and initials of the pharmacy return technician and the handwritten note that read medication was not in the bag have called the facility 2 times since yesterday waiting to hear back from someone at the facility about this issue matched the copy provided by the facility. The Pharmacist in Charge added that the 7 oxycodone pills never arrived at the pharmacy so the facility would still be responsible for following up on the missing medications. The Pharmacist in Charge was unable to provide a contact number for the pharmacy return technician.During a telephone interview on 2/25/2026 at 4:40 PM Assistant Director of Nursing (ADON) #1 stated she had spoken to someone from the pharmacy 4/11/2025, but did not recall the person's name or what time the call occurred, regarding Resident #134's missing oxycodone. The ADON #1 recalled Nurse #1 had packaged up narcotics to be returned and had Nurse #2 sign the paperwork. The ADON #1 stated Nurse #2 should have verified the medication since she signed the Controlled Substance Prescription Returned to Pharmacy form. The ADON #1 stated she did not notify the Director of Nursing (DON) or Administrator right away because she was waiting to hear back from the pharmacy to see if the medications had been found. The ADON #1 stated she reported the missing oxycodone to the DON on 4/12/2025. The ADON #1 stated she now knew she was supposed to report missing narcotics immediately to the DON or Administrator so it could be investigated. During an interview on 2/26/2026 at 11:41 AM the DON stated the pharmacy called the facility on 4/10/2025 and when ADON #1 went to answer the phone no one was there. The Pharmacy called back on 4/11/2025 and reported the missing medication to ADON #1. The DON indicated he was not notified until 4/12/2025. The DON stated when he was notified on 4/12/2025 the ADON #1 was waiting to hear back from the pharmacy to see if the pharmacy had found the missing medication. The DON stated on 4/14/2025 when the pharmacy had not found the medication the DON notified the Administrator. The DON stated when Nurse #1 took the form to Nurse #2 to sign, Nurse #1 should also have had the medication for verification and not left the medication unattended while he obtained Nurse #2's signature. The DON stated that when the pharmacy driver picked up controlled medications from the facility the nurse and driver only verified the serial number on the bag and the pickup ticket. The DON stated the missing oxycodone had not been found.During an interview on 2/26/2026 at 12:00 PM the Administrator stated she was notified of the missing narcotics on 4/14/2025, and the medications had not been found. The Administrator stated she expected nurses that signed Controlled Medication Return form to verify the medication that they signed for matched the medication that was placed in the return bag and no staff should sign a Controlled Medication return form without verification of the medications being returned. The Facility presented a corrective action plan that was not accepted by the state agency due to lack of new interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with the resident and staff, the facility failed to secure medications left unattended in a resident's room for 1 of 1 resident reviewed medication storage (Resident #59). Findings included:Resident #59 was admitted to the facility on [DATE].Review of Resident #59's physician orders revealed no active orders for 2% miconazole (antifungal) powder or 10% zinc oxide (topical) protective cream.During an observation of Resident #59's room on 02/23/2026 at 11:29 AM, in clear view on the nightstand beside the bed was a 3 ounce bottle of 2% miconazole antifungal powder and a 2.75-ounce tube of 10% zinc oxide protective cream.During an interview on 02/23/2026 at 11:29 AM, Resident #59 stated that Nurse Aide (NA) staff applied the miconazole powder and zinc oxide cream when incontinence care was done and she did not want to self administer either medication.During an interview and observation on 02/23/2026 at 11:34 AM, NA #1 entered Resident #59's room and stated she was assigned to the hall. She observed the zinc oxide cream and miconazole powder on the nightstand and stated those were from the facility's house stock. NA #1 explained the miconazole powder and zinc oxide cream were applied by NA staff when incontinence care was done but should not have been left in Resident #59's room, and she removed both items.An interview was conducted on 02/25/2026 at 12:17 PM with the Director of Nursing (DON) in the presence of the Administrator. The DON explained that the 2% miconazole powder and zinc oxide cream were stored on the treatment cart and should not have been left in Resident #59's room. The DON added that if Resident #59 needed the miconazole powder or zinc protective cream, a physician's order was required.

Based on observations, record review and staff interviews, the facility failed to follow their Enhanced Barrier Precautions Policy which included the use of personal protective equipment (PPE) during high contact activities for residents with wounds when the Wound Care Nurse failed to don a gown prior to providing incontinence care and prior to providing wound care on a chronic wound to Resident #74. The deficient practice occurred for 1 of 10 staff observed for infection control practices (Wound Care Nurse).The findings included:Review of the facility's policy last revised on 05/19/2025, titled Enhanced Barrier Precautions Policy read in part: Policy: Enhanced Barrier Precautions (EBP) are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. Definitions: High risk residents: those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and traches) and for all those colonized or infected with a MDRO currently targeted by the CDC.High contact activities: activities that may result in transfer of MDROs to hands and clothing of healthcare personnel, even when blood and body fluid exposure is not anticipated. These include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care. Procedure:Standard precautions such as hand hygiene always apply. Staff engaging in high-contact activities will don both gloves and gown before initiating the activity and remove the PPE before exiting the room or area where the activity occurred. Residents placed on EBP should remain on EBP for the duration of their stay or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.Signage indicating the appropriate type(s) of precautions and indicating that visitors should stop at Nurses Station before entering, will be placed on the resident's door.An observation and interview on 02/23/26 at 11:29 AM with Resident #74 revealed her resting in bed dressed for the day. Resident #74 stated she had a sore on her bottom that was dressed daily. Upon exiting her room, it was noted there was no sign on the door indicating the resident was on Enhanced Barrier Precautions (EBP) and there was no personal protective equipment (PPE) outside her room or on her door.A second observation on 02/24/26 at 9:57 AM revealed no signage on Resident #74's door and no PPE outside her room or on her door. An observation was conducted on 02/24/26 at 10:38 AM of wound care being provided to Resident #74 for her coccyx pressure wound. The Wound Care Nurse walked into Resident #74's room with her wound care supplies in her gloved hands and placed them on the head of the bed on the resident's bed sheet. Without donning a gown, she proceeded to do incontinence care on Resident #74 by cleaning her and putting a clean brief on her. The Wound Care Nurse doffed her gloves, sanitized her hands, and donned clean gloves and without donning a gown proceeded to clean the wound on Resident #74's coccyx area with normal saline. She doffed her gloves, sanitized her hands, donned clean gloves and without donning a gown placed the collagen to Resident #74's wound bed and covered the wound with an absorbent dry dressing. The Wound Care Nurse doffed her gloves sanitized her hands and gathered her trash and left the room. An interview on 02/25/26 at 10:51 AM with the Wound Care Nurse revealed Resident #74 had not been on the list of residents devised by the Infection Preventionist (IP) as needing EBP so her EBP sign was not on her door and PPE not on her door or outside her room. The Wound Care Nurse stated she thought it was odd that Resident #74 was not on precautions but said she wasn't on the list devised by the IP as needing precautions so she had not questioned it. She also stated they had gotten clarification from the IP on the evening of 02/24/26 and learned that it was not only chronic wounds (more than 6 months in duration) but all wounds that required EBP. The Wound Care Nurse stated that once she found out on the evening of 02/24/26 she placed a sign on Resident #74's door and placed a bin outside her door with PPE in it.A telephone interview on 02/25/26 at 4:50 PM with the IP revealed that she kept a list of residents with devices and wounds that required EBP and PPE when providing care to them. The IP stated Resident #74 had not been on the list because she was not aware that Resident #74 had a pressure wound to her coccyx. The IP further stated that the Wound Care Nurse thought the IP was aware of Resident #74's wound but the IP had told the Wound Care Nurse and the Director of Nursing (DON) that she was not aware that Resident #74 had a wound. The IP indicated she would have expected the Wound Care Nurse to have worn a gown when she was providing incontinence care and wound care to Resident #74.An interview with the Director of Nursing (DON) revealed he would have expected Resident #74 to have been on EBP and the Wound Care Nurse to have worn gloves and a gown while providing incontinence care and wound care to the resident.

Based on record review and interviews with staff and law enforcement, the facility failed to follow their Abuse, Neglect and Exploitation policy when the Administrator was not immediately notified of an allegation of misappropriation of narcotic medications which resulted in delayed protection of other residents and reporting for 1 of 3 residents reviewed for misappropriation of property (Resident #134). The findings included:The facility's Resident Abuse Policy: Abuse, Neglect and Exploitation indicated it was the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown origin. The facility staff were to immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator would immediately begin an investigation and notify the applicable local and state agencies. Once the Administrator and Department of Health and Human Services were notified, an investigation of the allegation or suspicion would be conducted.The Initial Allegation Report completed by the Director of Nursing (DON) dated 4/15/2025 revealed the facility became aware of an allegation of missing Oxycodone (narcotic pain medication) for Resident #134 from the sealed Controlled Medication Return Bag on 4/11/2025. Resident #134 had been discharged from the facility at the time the medication went missing. The report indicated Police Officer #1 was called on 4/15/2025 at 9:30am.During a telephone interview on 2/25/2026 at 4:40 PM Assistant Director of Nursing (ADON) #1 stated she was told on 4/10/2025 by a floor nurse, she could not remember which floor nurse, that pharmacy staff was on the phone related to an issue with narcotic medication sent back to the pharmacy. ADON #1 stated no one from the pharmacy was on the line when she got to the phone on 4/10/2025 and she did not attempt to call the pharmacy back. ADON #1 stated the pharmacy called again on 4/11/2025 and she was informed of the missing Oxycodone for Resident #134. ADON #1 stated she did not inform the DON of the missing Oxycodone until 4/12/2025 because the pharmacy was going to check to see if the medication could be found. ADON #1 stated at that time, she did not know she was supposed to report missing narcotics immediately and since the DON was not at the facility, she thought it could wait to see if the medications were found at the pharmacy before she notified the DON. ADON #1 stated she did not think the missing oxycodone was ever found. She indicated the DON and Administrator conducted the investigation.The Facility Investigation Report completed by the Administrator dated 4/18/2025 was submitted to the State Agency with an investigation summary. The report and summary revealed the facility became aware of possible drug diversion on 4/11/2025 when the pharmacy reported a missing medication card that contained seven tablets of Oxycodone 5 milligrams (mg) that were intended to be returned for Resident #134 from the sealed Controlled Medication Return Bag. The report indicated Nurse #1 and Nurse #2 were suspended pending investigation, and that Nurse #2 was given a do not return notice through the agency. The report indicated Police Officer #1 was notified on 4/15/2025 at 9:30 AM and the case number was listed as pending. During a phone interview on 2/25/2026 at 10:36 AM Police Officer #1 stated he did not recall the facility notifying him of missing Oxycodone in April 2025. Officer #1 stated he had communications, which was the phone number that was listed on the facility's initial report, conduct a search for any calls that came in regarding the facility in April 2025 and there were no calls found. Officer #1 explained that communications tracked every call that was received and kept a record of who the call was assigned to. Police Officer #1 added that the facility emailed him at times for other issues, so he reviewed his emails and did not find any emails related to missing narcotics. He stated that missing narcotics would be considered a crime that would need to be reported.Review of Nurse #1's timecard for April 2025 revealed Nurse #1 worked on the following dates and times after ADON #1 was notified by the pharmacy of the missing Oxycodone for Resident #134 (4/11/2025) and prior to initiation of the facility's investigation:4/12/2025 at 6:33 PM to 4/13/2025 at 6:55 AM4/13/2025 at 6:31 PM to 4/14/2025 at 7:31 AM4/14/2025 at 6:29 PM to 4/15/2025 at 6:57 AMDuring a telephone interview on 2/25/2026 at 2:39 PM Nurse #1 stated he did not recall the exact date he was suspended related to the allegation of drug diversion for Resident #134's Oxycodone in April 2025. The facility provided a copy of an email received from Nurse #2's agency that included the following dates and times that Nurse #2 worked at the facility after ADON #1 was notified by the pharmacy of the missing Oxycodone for Resident #134 (4/11/2025) and prior to the initiation of the facility's investigation:4/10/2025 at 2:30 PM to 4/11/2025 at 7:00 AM4/11/2025 at 2:30 PM to 4/12/2025 at 7:00 AMDuring an interview on 2/26/2026 at 11:41 AM the DON stated he was familiar with the alleged incident of missing narcotic medications for Resident #134 from April 2025. The DON stated the pharmacy called the facility on 4/10/2025 to report issues with narcotic medication that was supposed to be returned, but when ADON #1 answered the phone the pharmacy was no longer on the line. The DON indicated ADON #1 should have called the pharmacy back on 4/10/2025. The DON stated ADON #1 spoke to the pharmacy on 4/11/2025 and was notified of the missing narcotics for Resident #134. The DON stated on 4/12/2025 he was notified by ADON #1 of the missing narcotics for Resident #134 that were supposed to be sent back to the pharmacy. The DON revealed that he did not notify the Administrator of the missing narcotics until 4/14/2025 because at the time incident he did not know missing narcotics was a reportable event. He reported that he was now aware that he should have notified the Administrator of the missing Oxycodone as soon as he was notified on 4/12/2025 because missing narcotics was a reportable incident that needed to be investigated. The DON stated the initial allegation report should have been completed within 24 hours of the facility being made aware of the possible diversion. The DON spoke about law enforcement notification. He reported that he believed he contacted Officer #1 on 4/15/2025, but there was no evidence on his (the DON's) call logs. He indicated he called Police Officer #1 on a direct phone number on 4/18/2025 and left a voice mail, but there was not a police report available. The DON's call log showed a call made Police Officer #1's direct number on 4/18/2025. The DON stated the facility was unable to locate the missing medication or determine how they went missing and the allegation of diversion was unsubstantiated due to lack of evidence.During an interview on 2/26/2026 at 12:00 PM the Administrator stated she was familiar with the alleged incident of missing narcotic medications for Resident #134 from April 2025. The Administrator revealed she was first notified of the missing narcotics by the DON on 4/14/2025. The Administrator indicated that the DON reported that ADON #1 spoke to the pharmacy on 4/11/2025 and was informed of the 7 tablets of Oxycodone missing from the sealed narcotic return bag. ADON #1 then notified the DON of the missing Oxycodone on 4/12/2025. The Administrator stated that when the DON informed her of the missing narcotics on 4/14/2025, an investigation was started. The Administrator stated she should have been notified of the missing narcotics immediately. The Administrator stated she believed law enforcement was verbally notified on 4/15/2025, possibly from her cell phone as she was out of the facility at the time. She verified there was no record of law enforcement notification. The Administrator stated she expected protocol to be followed for reporting missing narcotics, and she should have been notified immediately by ADON #1 on 4/11/2025 and by the DON on 4/12/2025. The Administrator stated the facility was unable to locate the missing medication or determine how they went missing, and the allegation of diversion was unsubstantiated due to lack of evidence.The facility presented a corrective action plan to the State Agency that was not accepted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for residents with new mental health diagnoses for 5 of 7 residents reviewed for PASRR (Resident #5, Resident #12, Resident #51, Resident #71 and Resident #100). The findings include:a. Review of Resident #5's medical record revealed PASRR level I was completed 2/01/22 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Resident #5 was admitted to the facility on [DATE] with diagnosis that included hypertension, diabetes, and readmitted on [DATE] with diagnosis of post-traumatic stress disorder (PTSD) (diagnosed on [DATE]), and major depressive disorder (diagnosed on [DATE]).The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #5's current active diagnoses included post-traumatic stress disorder and major depressive disorder.There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. b. Review of Resident #12's medical record revealed PASRR level I was completed on 1/24/25 prior to admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Review of hospital Discharge summary dated [DATE] revealed Resident #12 had a history of Parkinson's disease, heart failure, coronary artery disease, anxiety disorder, major depressive disorder, and psychotic disorder with delusions due to known physiological condition. Resident #12 was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, heart failure, anxiety disorder, major depressive disorder, and psychotic disorder with hallucinations. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12's current active diagnoses included anxiety disorder, major depressive disorder, and psychotic disorder with hallucinations and had received antidepressant and antipsychotic medications within past 7 days. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. c. Review of Resident #51's medical record revealed PASRR level I was completed on 2/04/22 prior to admission to the facility with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #51 was admitted to the facility on [DATE] with diagnosis that included heart failure, diabetes, seizure disorder and readmitted on [DATE] with diagnosis that included heart failure, diabetes, seizure disorder, anxiety disorder (diagnosed on [DATE]), major depressive disorder (diagnosed on [DATE]), and psychotic disorder with delusions (diagnosed on [DATE]). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #51's current active diagnoses included anxiety disorder, major depressive disorder, and psychotic disorder with delusions. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. d. Review of Resident #71's medical record revealed PASRR level I was completed 2/06/17 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #71 was admitted to the facility on [DATE] with diagnosis that included hypertension, heart disease, and readmitted on [DATE] with diagnosis to include stroke, heart disease, hypertension, and major depressive disorder (diagnosed on [DATE]). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71's current active diagnosis to include major depressive disorder. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. e. Review of Resident #100's medical record revealed PASRR level I was completed 8/29/14 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #100 was admitted to the facility on [DATE] with dementia, hypertension and readmission on [DATE] with diagnosis to include dementia, anemia, hypertension, major depressive disorder (diagnosed on [DATE]), PTSD (diagnosed on [DATE]) and anxiety disorder (diagnosed on [DATE]). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #100's current active diagnoses included major depressive disorder, PTSD, and anxiety disorder. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. An interview on 2/26/26 at 3:55 PM with the Social Worker (SW) revealed she had started her position as the Social Worker in October 2025. She stated as the facility Social Worker she would be responsible for completing PASRR level II paperwork for residents and had just recently received Social Work training from the corporate office to include when and how to complete and submit PASRR level II paperwork. The Social Worker stated it was her understanding that residents were admitted to the facility with a PASRR level I or level II that had been completed prior to their admission and believed she would be responsible for completing and submitting PASRR paperwork when the resident received a temporary level II that required paperwork be resubmitted after 30, 60, or 90 days or if the resident had received a new mental health diagnosis or had a significant change. She revealed she believed she would be notified during their morning meetings and from the nursing staff of any residents who had received a new mental health diagnosis or had a significant change so the level II paperwork could be completed. The Social Worker stated she was not aware and did not know why the sampled residents did not have an evaluation for a Level II PASRR completed but after reviewing their mental health diagnoses, she believed Level II PASRR evaluations should have been completed. During an interview on 2/26/26 at 4:30 PM with the Administrator, she revealed the Social Worker would be responsible for completing and submitting PASRR paperwork. She stated the new Social Worker had only been in the position for a few months and to her knowledge had just received the training from corporate office on completing and submitting PASRR paperwork. The Administrator revealed she was not aware of the sampled resident's diagnosis or that they did not have a PASRR level II evaluation paperwork completed and did not know why a PASRR level II evaluation request had not been submitted. She stated that her understanding was that a PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis and that according to the sampled resident's diagnoses a PASRR level II should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews, the facility failed to provide a dependent resident with nail care for 1 of 3 residents reviewed for providing assistance with activities of daily living (Resident #47).
The findings included:
Resident #47 was re-admitted to the facility on [DATE] with diagnoses which included diabetes mellitus and dementia.
Review of Resident #47's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and required extensive assistance of 1 staff member with bathing and limited assistance of 1 staff member with personal hygiene. According to the assessment there were no behaviors and no rejection of care.
Review of Resident #47's care plan dated 06/19/23 revealed a focus area for an activities of daily living (ADL) self-care performance deficit related to dementia, impaired cognition, Parkinson's disease, and diabetes mellitus, among others. The resident is at risk for functional decline as dementia and Parkinson's disease progresses. The interventions read in part: bathing/showering - Resident #47 requires 1 staff assistance, encourage resident to complete as much of the task as he is able following set up assistance, and provide assistance as needed to complete task.
Review of Resident #47's nursing progress notes revealed no notes regarding the resident refusing showers or personal hygiene care. Review of the NA's documentation revealed no indication that resident refused care.
An observation and interview were conducted on 08/14/23 at 9:55 AM with Resident #47. He was lying on his bed watching TV in his room. His fingernails on both hands were observed to be ¼ to ½ inch beyond the ends of his fingers and some appeared to be jagged on the end. Resident #47 stated he didn't like for his fingernails to be long and said he would like for them to be trimmed but he couldn't do it himself and no one had offered to trim his nails for him.
Review of the facility's shower schedule revealed Resident #47 was scheduled for showers on Tuesdays and Fridays on 1st shift (7:00 AM to 3:00 PM).
An observation and interview were conducted on 08/15/23 at 3:57 PM with Resident #47. The resident stated he had received his shower this morning. Resident #47 stated the Nurse Aide (NA) had not trimmed his fingernails or asked him if he wanted them trimmed after his shower. The resident further stated he would like for his nails to be trimmed.
An observation and interview were conducted on 08/16/23 at 9:43 AM with Resident #47. His nails remained long and he stated staff still had not trimmed his nails.
An interview on 08/16/23 at 10:08 AM with Nurse Aide (NA) #1 revealed she had been assigned to care for Resident #47 on 08/15/23 during 1st shift (7:00 AM to 3:00 PM). She stated there had been 5 NAs assigned to the 100 hall yesterday and NA #2 had provided Resident #47 with his shower on 08/15/23. NA #1 explained on shower days if the resident needed to be shaved and their fingernails clipped that was part of the shower. She further explained they were able to clip fingernails and toenails unless the resident was diabetic and then they would let the nurse assigned to the resident know their nails needed to be clipped and the nurse clipped their nails.
A telephone interview on 08/16/23 at 2:26 PM with NA #2 revealed she had been assigned to give showers on the 100 hall on 08/15/23. She stated she had given Resident #47 his shower as scheduled on that day. NA #2 further stated she had not trimmed his nails after his shower because he was diabetic and she was not allowed to trim nails on diabetic residents. She explained with diabetic residents the NAs usually told the nurse assigned to them their nails needed to be trimmed once they had given the resident their shower. NA #2 further explained she had not noticed Resident #47's fingernails and had not told Nurse #2 the resident needed his fingernails clipped after his shower. NA #2 said she guessed she just forgot but said it was her responsibility to let the nurse know when diabetic residents needed their fingernails or toenails trimmed.
An interview on 08/16/23 at 11:19 AM with Nurse #1 revealed she was assigned to Resident #47 today but had not been assigned to him on 08/15/23. Nurse #1 stated Nurse #2 had been assigned to the resident on 08/15/23. Nurse #1 explained it was the responsibility of the NA to let the nurses know when a diabetic resident needed their fingernails trimmed after their shower and the nurse assigned to the resident would trim their nails.
An interview on 08/16/23 at 11:42 AM with Nurse #2 revealed she had been assigned to care for Resident #47 on 08/15/23. Nurse #2 explained the NAs were not allowed to cut diabetic residents' nails but it was their responsibility to let the nurse know after resident's showers if their fingernails or toenails needed to be trimmed. She stated NA #2 had not told her that Resident #47 needed his fingernails to be trimmed after she had given him his shower yesterday.
An interview on 08/16/23 at 5:00 PM with the Director of Nursing and Administrator revealed it was the responsibility of the Nurse Aide (NA) to tell the nurse when a diabetic resident needed their nails trimmed after their shower because NAs were not allowed to trim diabetic resident's nails.