This deficiency pertains to Facility Reported Incident (FRI) MI00145634. Based on observation, interview, and record review, the facility failed to prevent a serious burn injury for one Resident of 3 residents reviewed for accidents and hazards. This deficient practice resulted in a second-degree burn sustained to the upper torso of Resident #1. Findings include: Resident #1 (R1): Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 1/12/23 with diagnoses including dementia and fibromyalgia (a syndrome causing chronic widespread pain). Review of R1's most recent Brief Interview for Mental Status (BIMS) assessment, dated 5/26/24, revealed a score of 9, indicative of moderate cognitive impairment. Review of the facility investigation summary submitted to the State Agency (SA) read, in part: Date of Alleged Event: 7/1/24 .I was informed by [Certified Occupational Assistant (COTA) C] that [R1] had spilled soup on herself and was burned. I immediately went into [R1's] room. She was in bed lying at a 45-degree angle with her eyes closed and her bowl upside down on her upper abdomen. Her shirt was rolled up away from her skin. I noted a reddened area approximately 3 inches long x 4 inches wide .I interviewed [Certified Nursing Assistant (CNA) B] who delivered the tray. She told me that she brought tray in and left it, because [R1] seemed sleepy. She planned on coming back after she delivered the other trays . [Dietary Director (DD) F] stated that the soup was held at temperature of 173 f [Fahrenheit] in [the] steam table .Investigation determined resident was served soup that was hot enough to burn skin and was left unattended that was in reach of resident who was drowsy and grabbed the bowl to feed herself . On 8/19/24 at 10:30 AM, R1 was observed lying in bed, positioned to toward the right side. CNA D and CNA G were observed re-positioning R1 toward the center of the bed, as R1 was unable to complete the task independently. An interview was attempted and R1 was unable to answer specific questions related to the incident but was able to state, Yes when asked if she experienced a burn on her torso. Review of an incident report, dated 7/1/24, written by CNA B read, in part: I delivered [R1's] dinner .which was soup. I set up her soup to cool, but she was sleepy, so I left to deliver other trays . About five minutes later, the DON [Director of Nursing] grabbed me to inform me that [R1] got burnt by the soup. When we walked back into the room, she [R1] was still very sleepy and lethargic . On 8/19/24 at 12:14 PM, an interview was conducted with COTA C who verified she was treating R1's roommate at the time of the incident. COTA C stated, I was working with [R1's] roommate and the curtain was pulled between the beds, but I heard her [R1] yelling. She was shouting, 'It's hot!' COTA C stated she observed R1 in a reclined position, approximately 45 degrees, with a bowl of soup spilled on her upper torso. On 8/19/24 at 12:14 PM, an interview was conducted with CNA D regarding the proper position to place a resident when choosing to eat in bed. CNA D stated, The resident should be as close as possible to 90 degrees .you want them sitting all the way up. Review of a Skin/Wound Note, dated 7/2/24, written by Registered Nurse (RN) A read, in part: Wound to upper abdomen caused by hot liquid burn today assessed. Pain assessment completed - resident c/o [complains of] 6/10 pain at area, described as burning.Blistering present . On 8/19/24 at 12:21 PM, an interview was conducted with RN A who verified she assessed R1's burn following the incident. RN A confirmed blistering was present upon her assessment which classified the burn as a second-degree [a burn causing damage to the first and second layer of skin]. When asked about positioning expectations for meal consumption in bed, RN A stated, The angle of the bed should be upright to reduce risk of aspiration [choking] or spills. On 8/19/24 at 12:26 PM, an interview was conducted with the DON regarding the burn incident. The DON verified R1 was in a reclined position and a bowl of hot soup was left on a tray table placed over the bed. The DON stated the tray table should have been moved off to the side of the bed before CNA B left the soup unattended. The DON indicated her expectation is to place residents in an upright position should they chose to consume a meal in bed to reduce the risk of accidents. The DON confirmed the presence of blistering classified the burn as second-degree. Review of R1's EMR did not reveal any assessment for burn potential prior to the incident. Review of facility policy titled, Burns, revised 8/7/24, read, in part: [Facility Name] will prevent a burn from occurring . on admission and quarterly an assessment for burn potential will be done for all residents . Review of facility policy titled, Facility Safety Hazards P&P [Policy and Procedures], dated 3/28/24, read, in part: .Foods will be served at safe temperatures to prevent burns .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11 (R11) Review of R11's electronic medical record (EMR) revealed admission to the facility on 2/3/23 with diagnoses including chronic obstructive pulmonary disease, mild cognitive impairment, and nicotine dependence. Review of R11's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. On 4/22/24 at 10:16 AM, an entrance conference was conducted with the Director of Nursing (DON). The DON stated there were two current smokers who resided at the facility (R11 and R21). When the DON was asked about designated smoking locations and times, she stated there are no official smoking locations but R11 and R21 preferred to smoke out by the garage or in the arbor. The DON stated there were no designated smoking times or direct staff supervision. On 4/22/24 at 11:13 AM, an interview was conducted with R11 during the initial tour of the building. R11 confirmed that he smoked cigarettes. R11 stated there are no designated smoking times and he prefers to smoke in the arbor near the entrance of the building. R11 was asked the protocol for staff notification prior to leaving the building to smoke to which he replied, I don't tell them [nursing staff] or sign out unless I'm leaving the property. On 4/22/24 at 11:17 AM, R11 was observed entering the door code at the exit on the west wing and exiting the building without staff observation or knowledge. R11 was subsequently observed sitting in the arbor in a patio area, smoking without supervision. On 4/23/24 at 10:46 AM, R11 was again observed sitting in the arbor, smoking without supervision. Review of R11's Plan of Care revealed the following focus imitated 2/7/23: I am aware that it is not good for me, but do wish to continue smoking with the following interventions: 1. Cigarettes and lighter kept in lockbox inside resident's room, initiated 2/7/23. 2. Resident will let staff know when he is going outside and staff will observe from afar that he is safe and in the designated smoking area, initiated 2/7/23. 3. Smoking assessment will be completed quarterly, initiated 2/7/23. Review of R11's orders revealed the following, initiated 3/20/23: Cigarettes and light to be locked in lock box in his room AT ALL TIMES when not in use. Please verify he is using the lock box q [every] shift and prn [as needed]. Review of R11's EMR revealed an initial smoking assessment was conducted on 2/6/23. A subsequent smoking assessment was conducted on 1/9/24, nearly a year after the original assessment. On 4/23/24 at 2:14 PM, this surveyor attempted to view the preferred smoking areas from the entrance/exit of the building. This surveyor was unable to visualize either the arbor patio area due to a tree and other vegetation obscuring the view nor the side of the garage which was blocked from view by support pillars to the entryway as well as a parked vehicle. On 4/24/24 at 8:24 AM, R11 was observed walking back into the facility from outside where he had just finished smoking a cigarette unsupervised. Upon entrance to R11's room, no lock box could be visualized. When asked if he had a lock box, R11 was unable to locate it and stated, I think it's around here somewhere. R11 demonstrated that he stored his cigarettes and lighter in the pocket of his coat when not in use. R11 confirmed he did not utilize a lock box and stated, I sleep with my feet on top of my coat so nobody can steal my cigarettes or lighter. On 4/24/24 at 2:45 PM, an interview was conducted with the DON who confirmed that smoking assessments were supposed to be completed upon admission as well as quarterly. The DON was asked why R11 went nearly a year without a smoking re-assessment. The DON stated this was brought to her attention and she began to educate staff in January 2024. The DON confirmed R11's next smoking assessment was due 4/9/24 to reach compliance with the quarterly re-assessment requirement but it somehow, was missed. The DON was asked how it was determined R11 was safe to smoke unsupervised without regular assessments to evaluate. The DON stated, [R11] goes all over the place . he hasn't been deemed incompetent, but we're [facility staff] seeing things that probably should indicate it . When [R11] first got here, we monitored him for signs of elopement, and he wasn't .I can't remember if he's an elopement risk right now. I know they [nursing staff] watch him from the back door. The DON was asked if it was possible to visualize R11 from the back door to which she replied, I guess it depends on which part of the arbor he's in .there is probably areas we can't watch him. When asked about cigarette and lighter storage the DON said, They're [smoking paraphernalia] supposed to be in a lock box in his drawer, but there's times when we catch him when they're not in the lock box and we have to remind him. Review of facility policy titled, Smoking Assessment Policy and Procedure read, in part: .Residents will not be permitted to engage in smoking activity unless they are assessed during the admission process, ongoing quarterly assessments and as needed to determine the level of supervision required . .Residents who are assessed as requiring supervision for smoking, will be provided with scheduled smoking times in a designated supervised area . .All smoking material or paraphernalia (including cigarettes, cigars, pipes, tobacco, matches, lighters, etc.) must be stored at the nurse's station at all times unless they have been approved for a lock box . DPS E: Based on interview and record review, the facility failed to provide adequate supervision to prevent an unauthorized leave of absence from the facility for one Resident (#9) of five residents reviewed for safety/supervision. This deficient practice resulted in two Former Certified Nursing Assistants (CNAs)/Perpetrator I and J removing R9 from the facility to an unknown location for approximately 16 hours without guardian approval or any potentially necessary hospice medications or medical supplies. Findings include: Review of R9's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Huntington's disease (a progressive, fatal genetic disorder that affects the brain and causes involuntary movements, cognitive decline, and emotional problems), aphasia (difficulty processing, using, and/or understanding language), dysphagia (difficulty or inability to swallow), contracture of unspecified hand (a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), and alcohol abuse. Record review of R9's Minimum Data Set (MDS) assessment immediately preceding the unauthorized leave of absence (LOA) on 7/20/23, indicated R9 had severely impaired cognition - unable to complete BIMS [Brief Interview for Mental Status]. R9 was admitted to hospice services on 7/20/23. On 4/22/24 at 11:47 AM, a phone interview was conducted with R9's guardian, Guardian H who disclosed two former facility staff members had taken R9 out overnight without his permission at some point the previous fall. Guardian H indicated the facility called him the morning following the LOA to ask if facility staff that worked the previous evening had asked him for consent prior to R9's departure. Guardian H indicated he did not give approval and was unaware of R9's exit from the facility. On 4/22/24 at 1:04 PM, a follow-up phone interview was conducted with Guardian H who stated the morning following R9's leave of absence, he received a call from the facility informing him that R9 was missing. Guardian H indicated the facility informed him Perpetrator I and Perpetrator J (later identified as formerly terminated CNAs] at the facility) had taken him out of the facility the previous night and had not returned. Guardian H stated, I was freaking out. I asked if we should file a report with the police. Guardian H reiterated the facility had not called him prior for permission for R9's departure, stating, I was upset with the nursing home and their lack of calling me. The nurse who called me the morning he was missing wasn't sure where [R9] was. I was shocked .shocked that the facility would let somebody out on hospice care and not even call to even verify if it was okay. Guardian H stated that since R9 signed with hospice on 7/20/23, nobody was authorized to take R9 from the facility due to his deteriorating physical and mental condition. Review of R9's progress notes revealed the following entries: 1. 9/18/23 at 18:07 [6:07 PM] written by former Registered Nurse (RN) M: LOA with [Perpetrator J] and [Perpetrator I] to [Perpetrator J's] house at 1807 [6:07 PM]. 2. 9/18/23 at 22:24 [10:24 PM] written by RN D: Resident's responsible party for LOA was called and did not answer. 3. 9/18/23 at 23:44 [11:44 PM] written by RN D: This writer attempted to call [Perpetrator J] and [Perpetrator I] and [Guardian H]. None of them answered. DON aware. 4. 9/18/23 at 23:49 [11:49 PM] written by RN D: This writer attempted to call [Perpetrator J] and [Perpetrator I] and [Guardian H] each multiple times. None of them answered. 5. 9/19/23 at 09:48 [9:48 AM] written by RN K: LOA Returned from [Perpetrator J's] house driven by [Perpetrator J] and [Perpetrator I]. On 4/22/24 at 1:55 PM, a phone interview was conducted with RN D who was asked why R9's responsible party was not called for approval of an LOA until after R9 had already exited the building for approximately 4.5 hours. RN D stated, I think I was expecting him to be back that night and that's why I called the responsible guardian [H] .or I wasn't certain if he was supposed to return so I was trying to figure it out. RN D was asked why he attempted several subsequent phone calls to Perpetrator J, Perpetrator I, and Guardian H as documented at 11:44 PM and 11:49 PM. RN D stated, I wasn't getting through to people, and I wasn't sure if [R9] was coming back at that time. RN D was asked the protocol for a resident going on a leave of absence. RN D indicated the responsible party would sign the resident out in the Release of Responsibility for Leave of Absence binder and the charge nurse would document the departure in the EMR. When RN D was asked if the process would differ for a resident with a guardian, he stated, If somebody were to want to take a resident and they weren't the guardian, I would contact the guardian to get permission .I'm not sure of the exact protocol, but I would put it into my LOA note [in the resident's EMR]. On 4/22/24 at 2:30 PM, a phone interview was conducted with former Director of Nursing (DON) RN M who verified that Perpetrator J and Perpetrator I came to the facility around 6:00 PM on 9/18/24. RN M stated Perpetrator J and Perpetrator I informed her that they were taking R9 out for a brief leave. RN M stated, They [Perpetrator J and Perpetrator I] had taken him out in the past and they would take him to [Perpetrator J's] house. They would take him over for dinner and bring him back. That's what I would have expected . I got a call from [Perpetrator J] saying that they got him [R9] back to the facility at 9:00 AM the next morning .I was furious. RN M was asked if Perpetrator J and Perpetrator I were authorized to take R9 on a LOA. RN M stated, I didn't look at it [the approved list of responsible parties] that day. When they [Perpetrator J and Perpetrator I] took him out of the facility, I just assumed they were on the approved list. RN M stated no necessary medications, equipment, or supplies per R9's plan of care or physician orders were sent upon departure. On 4/22/24 at 2:54 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA verified that former CNAs, Perpetrator J and Perpetrator I, took R9 out of the facility on an unauthorized LOA and did not bring him back until the following morning. The NHA stated that although Perpetrator I did have permission at one time, Guardian H had since stopped anybody from removing R9 the facility following his admission to hospice (on 7/20/23) due to his declining condition. The NHA and DON both confirmed they were unaware of R9's absence from the building until arriving to the facility for work on the morning of 9/19/23. The NHA indicated they called local law enforcement after learning of the situation. The NHA stated, I didn't know what to do .What's the process for this? They basically kidnapped a resident. The NHA and DON stated they did not know why they were not contacted by RN D or former RN M on 9/18/23 after R9 left the facility and did not return. The NHA was asked if Perpetrator J or Perpetrator I had any previous history with R9. The NHA stated Perpetrator I had received disciplinary action in early 2021 after she shaved R9's legs, shaved a letter in the back of R9's hair, and drew inappropriate pictures and phrases on his skin with permanent marker. The NHA did not indicate Perpetrator I had any limited or altered contact with R9 following the incident as part of the remedial action. Review of CMS-2567 form dated 6/10/21 indicated Perpetrator I was, educated on resident's right, abuse and other policies regarding this type of behavior following the incident. The NHA verified that Perpetrator I was subsequently terminated on 3/8/23 following a separate incident with a different resident per form CMS-2567 dated 7/3/23. The NHA confirmed Perpetrator J quit working as a CNA on 12/8/21 for reasons related to her vaccination status. Review of, [County Name] County Dispatch - Call Detail Report indicated Business Officer Manager (BOM) L filed a report on 9/19/23 at 9:24 AM that read, in part: Patient missing, two people came last night around 1800 HRS [6:00 PM], said they had paperwork to take him [R9] out . [Perpetrator I] . [Perpetrator J] . On 4/22/24 at 3:50 PM, a phone interview was conducted with Perpetrator J who stated, We just took him [R9] out for a good time . Me and [Perpetrator I] took him to my house for dinner and gave him a shower. Perpetrator J stated she informed the nurse on duty, RN M, that they were taking R9 on a LOA. Perpetrator J stated she didn't take any required medications, supplies, or equipment prior to departure besides a couple incontinence briefs. Perpetrator J indicated that she and Perpetrator I transferred R9 into her private vehicle without using the care-planned transfer technique and drove to her private residence. Once there, Perpetrator J indicated R9 ate some ground up stir fry, drank some water, and then she assisted him into the shower. After showering R9, Perpetrator I stated she cut his fingernails and cut his hair. Perpetrator J stated R9 slept in a recliner, propped up so he could breathe. Perpetrator J was asked if she had permission to take R9 on a LOA to which she replied, I had permission before he [R9] was on hospice. Since he was on hospice, the process was different, and I wasn't aware of that. Apparently, I was no longer cleared [to take R9 on a LOA]. Perpetrator J was asked if she was contacted by the facility after leaving with R9. Perpetrator J stated, Yes, that night the facility called me and asked what time R9 was going to be home. I told them, 'He'll be there when we get him there.' On 4/22/24 at 4:19 PM, a phone interview was conducted with Perpetrator I who stated she and Perpetrator J arrived at the facility around dinner time and notified RN M they were taking R9 on a LOA. Perpetrator I stated that CNA R packed R9 an overnight bag. Perpetrator I stated they took R9 to Perpetrator J's personal residence where they, sang karaoke and just kind of hung out. Perpetrator I stated that R9 ate some pudding, tried a beer, but didn't like it, so he was switched to drinking pop. Perpetrator I verified R9 was given a shower at the residence because, he was covered in food and slop and slept in a recliner. Perpetrator I stated around 10:00 AM on the morning of 9/19/23, she received at text message from RN K asking when R9 was returning to the facility. Perpetuator I indicated to RN K that they were planning on returning R9, in a little bit until RN K stated that we had to bring him back immediately. Perpetrator I indicated that shortly after dropping R9 back off at the facility, she received a call from local law enforcement stating she was being charged with felony kidnapping. However, Perpetrator 'I stated the police officer ended up calling Perpetrator I back, stating R9's family no longer wished to press charges, and that they were instead upset at the facility for not knowing his whereabouts. On 4/22/24 at 4:58 PM, an interview was conducted with RN K who stated he arrived at the facility at the start of his shift around 6:30 AM on 9/19/23. RN K stated he received report from the midnight nurse, former RN M, who indicated R9 was not in the building. RN K stated, She [former RN M] seemed concerned. I don't think she was aware that R9 was going to be out overnight. RN K stated he tried calling Perpetrator J and Perpetrator I several times with no answer. RN K indicated he eventually got in contact with the NHA and BOM L who notified to the police that R9 had not returned from a LOA. On 4/22/24 at 5:11 PM, an interview was conducted with CNA R who stated Perpetrator J and Perpetrator I arrived at the facility around dinner time and stated they would return R9 to the facility around 8:00 PM. CNA R stated, 8:00 PM came around, and he [R9] didn't come back. Then it turned to 9:00 PM and everybody wanted to know, 'where is [R9]?' I tried calling both [Perpetrator J and Perpetrator I] with no answer. It turned to 11:00 PM .I left the facility after my shift but kept calling and texting with no response .I came back [to the facility] the next morning and he still wasn't there. CNA R stated she had not packed R9 an overnight bag because he was supposed to return to the facility that night. CNA R stated R9 was sent on the LOA with two briefs and approximately 6 wash cloths. CNA R stated R9 did not have food, liquid, a food/liquid thickener powder, a gait belt, eating adaptive equipment, medications, or any other medical supplies necessary per R9's plan of care when he left the building on 9/18/23. On 4/23/24 at 9:03 AM, a phone interview was conducted with former DON, N who verified she was the Director of Nursing at the time of R9's unauthorized LOA (9/18/23-9/19/23). DON N recalled she received a text message from RN D around midnight on 9/19/23 which indicated R9 left the previous evening and had not returned. Former DON N stated she arrived for work the next morning and was informed that R9 was still not at the facility. Former DON N was asked if she notified the NHA after she received the text message from RN D around midnight on 9/19/23 indicating R9 was not in the facility. Former DON N replied, I don't think I did because I was repeatedly told not to bother them .when [the NHA] arrived that morning, he was upset. He told me that this could be kidnapping, and he should have been notified immediately. Former DON N was asked if Perpetrator J and Perpetrator I had obtained permission to take R9 on a LOA. Former DON N stated, I know that the guardian in the past had given them permission to take them out, but I think that was an old, in-the-past type of deal. I think it was assumed by other staff that it was okay. Former DON N was asked if there was a protocol for residents going on a LOA to which she replied, There's a sign-out book. I'm sure there was a protocol, but I don't know if off-hand .if a resident had a guardian, I know the guardian needed to give permission . Former DON N stated she contacted R9's guardian the morning of 9/19/23 to inform him that the police had been notified of R9's unauthorized LOA. Former DON N stated, [R9's] guardian was not happy . he specifically said he did not give permission [to leave the facility]. Former DON N stated Perpetrator J and Perpetrator I were aware of R9's specialized diet but did not take thickener or any other necessary medical supplies with them. When former DON N was asked if either Perpetrator J or Perpetrator I received disciplinary action in the past regarding R9, she stated, I think the one did . I think she shaved his head or drew on him .it was something just bizarre. I believe she got reprimanded for that. On 4/23/24 at 11:01 AM, an interview was conducted with R9 who was able to answer some yes or no questions. R9 confirmed Perpetrator J and Perpetrator I took him on an overnight LOA in September 2023. R9 confirmed he drank pop on the LOA. When R9 was asked if the pop was thickened per his diet orders, he stated, No. When R9 was asked if Perpetrator J and Perpetrator I gave him a shower, he stated, Yes. Review of facility policy titled, Resident Leave of Absence dated 2/29/23 read, in part: Protocol: Residents may enjoy a leave of absence from the facility with a physician's order. The type and length of leave of absence (LOA) will be in accordance with the resident's assessed physical, mental and emotional ability and with resident and/or resident representative in involvement in requesting/obtaining the LOA . Physician's order should include type of LOA . No physician order for a LOA was identified in R9's EMR. DPS C: Based on observation, interview, and record review, the facility ensure residents were safe to smoke, supervised, and smoking paraphernalia was kept in a secure location for two Residents (R21 and R11) of five sampled residents reviewed for accidents, hazards, and supervision. Findings include: Resident #21 (R21) Review of R21's face sheet, revealed an original admission into the facility on [DATE] with medical diagnoses of the following, in part: depression, bipolar disorder, paraplegia, and pressure ulcers. Review of R21's Minimal Data Set (MDS) assessment, dated 11/28/23, revealed that R21 was cognitively intact. Review of R21's physician order, dated 11/22/23, revealed the following, in part: attempt resuscitation/CPR [cardiopulmonary resuscitation]. Review of R21's hospital Discharge summary, dated [DATE], revealed the following allergies, in part: bee stings - anaphylactic reaction. On 4/22/24 at 10:30 AM, an interview was conducted with R21 in his room and was asked about smoking and his allergies and replied, I have been going outside to smoke by myself since I was admitted here back in November. I am allergic to bee stings. I was stung when I was younger a bunch of times and I had a sever reaction. R21 was observed to have a lock box in his room and inside the lock box was a set of keys for the lock box. R21 was asked where he kept his cigarettes and lighter and replied, They are in my jacket pocket. I don't know why I have that box because I never use it. Review of R21's progress note, dated 12/2/23 at 3:06 PM, read in part, Resident's brother came for a visit. Resident's brother brought in the following items: $50 cash .2 packs of Marlboro Menthol 100's, 2 Breeze Blueberry Vape pens . Review of R21's progress note, dated 1/4/24 at 4:25 PM, read in part, .Resident outdoors smoking. Resident had removed his patch and has given it to this nurse. Review of R21's complete EMR, smoking assessment, dated 1/9/24, was the first and only initial smoking assessment and R21 was smoking prior to this assessment on the facility property. Review of R21's physician order, dated 2/1/24, read in part, Perform smoking assessment . Review of R21's physician order, dated 4/17/24, read in part, Smoking assessment one time a day every 3 months .Start date 5/9/24. On 4/22/24 at 10:00 AM, an observation was made of R21 outside of the facility siting in his wheelchair near the [NAME] entrance, between the pole barn and the garbage dumpster, and was unsupervised by facility staff. R21 was observed smoking during the following dates and times in the same designated smoking area on: 4/22/24 at 1:50 PM, 4/23/24 at 7:25 AM, and 4/23/24 at 12:15 PM. During the time of the survey and observation was made of the [NAME] entrance, between the pole barn and the garbage dumpster, and the pole barn was noted to have two bee nests located around the main door frame. On 4/23/24 at 2:05 PM, and observation was made of R21's lock box in his room and was observed to have the same set of keys as the prior observation of the lock box and no smoking paraphernalia was found within the lock box. R21's cigarettes and lighter were observed on top of a chair in his room. On 4/23/24 at 3:57 PM, an interview was conducted with RN K who was asked how long R21 had been smoking at the facility and replied, Pretty much since he has been here. He used to have a nicotine patch, but it was discontinued because he continued to smoke and refused the patch. On 4/24/24 at 5:00 PM, an observation was made of R21 outside of the facility siting in his wheelchair near the [NAME] entrance, between the pole barn and the garbage dumpster, and was unsupervised by facility staff. DPS A: Based on interview and record review, the facility failed to implement appropriate interventions to prevent a fall for one Resident (R24) of one resident reviewed for falls. This deficient practice resulting in R24 sustaining a fall with subsequent injuries requiring staples. Findings include: R24 A review of R24's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia, history of Urinary Tract Infections (UTI), and osteoarthritis. R24 scored an 8/15 on the 11/2/23 Brief Interview for Mental Status (BIMS) score indicative of moderate cognitive impairment. R24 did not have a completed Fall Risk Assessment during her stay at the facility. Review of R24's Progress Notes revealed the following entries: 12/12/23 22:35 (10:35 p.m.) Resident called out from her room at this time and staff entered. Resident was on floor and stated that she fell and hit her head. Unwitnessed falls protocol initiated. After initial set of vitals, staff attempted to assist her into a seated position to take a seated blood pressure. With very slight movement, she winced and stated that it hurt really bad in her back and neck. Staff did not continue attempt to move her. Resident stated that she felt very dizzy. 12/12/23 22:45 (10:45 p.m.) This writer dialed on-call provider number and (Nurse Practitioner (NP) P) ordered ED (Emergency Department) send out. No visible injury, though full assessment was not possible at this time to prevent unnecessary movement after resident's pain response. 12/12/23 23:05 (11:05 p.m.) Resident left [facility name] with [name of county] fire and rescue at this time to transport to [hospital name] ED. 12/13/23 2:19 a.m. Call received from [hospital name] ER. Resident was evaluated and [hospital name] staff determined pain not related to acute injury, resident was given Tylenol, x-ray was WNL (within normal limits). They will be sending her back to [facility name]. 12/13/23 6:30 a.m. She requires up to one assist with ADLs (Activities of Daily Living) due to new required supplemental oxygen .She reports dizziness with some movements and with quick movements . 2/1/24 1:45 a.m. She requires assistance of one for transfers, ambulation, toileting, dressing, bathing, and hygiene . 2/6/24 18:15 (6:15 p.m.) Resident was assessed by this nurse after falling in the women's common bathroom. Pressure applied to posterior scalp where bleeding occurred, which did stop. Swelling on posterior head observed. Vitals/neuro [neurological] were initiated per fall protocol. Mentation and vitals were at baseline. Resident was able to move her head/neck and all limbs without any c/o (complaint of) pain or discomfort. Resident was assisted into a wheelchair by two staff. NP P notified at 1820 (6:20 p.m.) of incident and gave the okay for the resident to be sent out to [hospital name]. Residents' son was notified of incident at 1824 (6:24 p.m.) and stated that he would like his mother to be sent out to [hospital name] to be evaluated. Ambulance was called at 1835 (6:35 p.m.). Resident left facility at 1850 (6:50 p.m.) . Review from R24's [hospital name] discharge summary revealed the following, in part, This is an [AGE] year-old female who presents after a fall .She was noted to have laceration with bleeding .occipital scalp laceration .3 cm (centimeters) in length, repaired by 4 staples .assessment/plan: fall, closed head injury, scalp laceration . Review of R24's Incident and Accident report dated 2/6/24 read, in part, This nurse was urgently called to the women's common bathroom by a staff member that was assisting resident. Upon entering the bathroom, the resident was lying flat on her back with her head in front of the toilet. Moderate amount of blood was observed by her posterior head. Resident description: I was backing up toward the toilet and I fell and clunked my head. A witness statement dated 2/2/24 (incorrect date as the incident had not happened yet) from Certified Nurse Aide (CNA) C read, On February 6th, 2024, I was getting (R24) ready for bed in the women's restroom after dinner. I helped her get into a nightgown, fresh socks, and a new brief before putting her shoes back on. She then stood up so we could pull her brief up, and I asked how she was feeling, to which she replied that she was feeling grand. We then walked out of the stall, and I was in front of her. I handed her a warm washcloth so she could wash her face, and right after she grabbed the washcloth[TRUNCATED]

Intake # M100143193 Based on interview and record review, the facility failed to protect one Resident (#1) of three residents reviewed for the right to be free from mental and/or potential sexual exploitation resulting in the potential for mental anguish and pain. Findings include: Resident #1(R1) Review of the quarterly MDS for R1 dated 2/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. Diagnoses included quadriplegia, bipolar depression and traumatic brain injury. On 3/13/24 at 9:10 AM, a phone interview was conducted with the Guardian (A) for R1, who indicated there was concern for possible sexual exploitation. Guardian A stated he observed an ongoing messaging stream on (social media messenger service), between R1 and a facility staff member, who at the time of the interview, Guardian A believed to be a nurse. On 3/13/24 at 9:30 AM, a staff list received from the facility, identified the staff member named by Guardian A, as a member of the housekeeping staff (Housekeeper I). On 3/13/24 at 10:47 AM, a follow-up phone interview was conducted with Guardian A, at which time picture evidence was requested of the alleged sexual/mental exploitation of R1 by Housekeeper I. On 3/13/24 at 11:00 AM, an interview was conducted with RN C who stated R1 fluctuated with his wanting to come out of his room because of a bipolar diagnosis. On 3/13/24 at 11:15 AM, an interview was conducted with R1, who denied having a girlfriend or anyone trying to initiate anything of a sexual nature with him since admission to the facility. On 3/13/24 at 11:45 AM a phone interview was attempted with Housekeeper I, but the number provided on the staff listing was disconnected. On 3/13/24 at 12:10 PM, an interview was conducted with Housekeeping Supervisor E, who was asked if the facility had a current phone number for Housekeeper I. Supervisor E stated she did have the current phone number for Housekeeper I and provided the number. On 3/13/24 at 12:30 PM, a text message was received from Guardian A with several screen shots of messages between R1 and Housekeeper I. The screen shot messages started with R1 initiating a conversation with Housekeeper I as follows: 2:03 PM on 2/24/24 R1- hello. 3:09 PM Housekeeper I- Helloooo (sic) lol (laugh out loud). 3:22 PM R1- No sending pics (pictures) now your BF (boyfriend) wouldn't like that lol. (Screen Name) is my ( another social media messaging service) name. 3:46 PM Housekeeper I- I think I added the right one lol and wat (sic) bf lol and I swear I won't send any lol. Less you ask joking lol R1 Don't say that last part. Housekeeper I- ? The whole last message lol I apologize. R1 No need to. Just know I wanna ask. Housekeeper I- lol oh you want to ask to see pics lol good to know lol. R1 Yes I do Housekeeper I- Lol to be honest I could tell you wanted to ask lol. R1 **** yes February 29 approximately 7:00 AM Housekeeper I- Good morning. R1- Morning. What you wearing? Housekeeper I- Tank top and shorts wby (what about you) R1- A sweatshirt, getting turned on because of your pics. (Implied private explicit/revealing pictures had already been shared via social media messaging services.) Housekeeper I- Awe and mmmmm I like them don't u (you). R1- Yes Housekeeper I- Oooo so wat (sic) u gonna do now lol. R1- Thinking of (sexual act) if I can. Housekeeper I- Oooo to bad I'm not there to help. R1- Wished you were. R1 then sent a picture of his private parts to this message. On 3/13/24 at 12:39 PM, a phone interview was attempted with Housekeeper I and there was no answer. A voicemail could not be left as the mailbox was full. On 3/13/24 at 1:28 PM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). Both the NHA and DON indicated staff are not permitted to have relationships with residents. On 3/13/24 at 2:42 PM, an interview was conducted with Financial Officer F, who confirmed the picture on the messages was Housekeeper I. Financial Officer F proceeded to pull Housekeeper I's (social media profile) account up and confirmed the identity of Housekeeper I.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #14 On 2/7/23 at 11:50 a.m., an observation was made of the lunch meal being served in the main dining room. During this observation, Resident #14 was observed to be sitting at a dining room table with three other Residents with his meal placed in front of him. Resident #14 stared at his meal and was not assisted by staff to eat. At 12:15 p.m., Certified Nurse Aide (CNA) D placed three green beans on Resident #14's fork and said, Do you want to take a bite? while standing over top of him and placed the fork forcefully in Resident #14's mouth. Resident #14 began to chew the green beans in his mouth while CNA D then went back over to another Resident (later identified as Resident #9) to assist with his juice. CAN D did not return over to Resident #14. At 12:20 p.m. CNA S began to assist Resident #14 with his meal and continued to stand over him while assisting. CNA S continued to stand overtop of Resident #14 until approximately 12:30 p.m. On 2/8/23 at 5:30 p.m., an observation was made of the dinner meal being served in the main dining room. During this observation, Resident #14 was observed to be sitting at a dining room table with three other residents with his dinner meal placed in front of him. Resident #14's eyes were closed and he appeared to be asleep. During the meal service, Resident #14 continued to not be assisted with meals and only one staff member attempted to wake him, but quickly moved on to pass meal trays to other residents entering the dining room. Review of Resident #14's EMR revealed admission to the facility on 7/28/21 with diagnoses including dementia with behavioral disturbance and Alzheimer's disease with late onset. Resident #14's 1/22/23 MDS assessment noted him to have severely impaired cognition and requiring extensive one person assist for eating. Review of Resident #14's care plans read, in part, .self-care deficit and physical mobility .interventions: Eating: Feed .Nutrition: I am able to feed myself, make my likes/dislikes known. I can make simple decisions .interventions: Resident is a feed, can occasionally take a bite unassisted, let me do what I can for myself, assist me as needed when I am having difficulty. Date initiated: 11/11/2022 Revision on 1/20/2023 . This deficient practice pertains to intake MI#00130116: Based on observation, interview, and record review, the facility failed to ensure that assistance was provided for eating and drinking for two Residents (#11 and #14) out of five residents reviewed for meal assistance. This deficient practice resulted in R11 not being assisted with meals, inadequate intake, and a significant weight loss of -7.8% in 15 days. Findings include: Resident #11 (R11) A review of R11's medical record revealed he admitted to the facility on [DATE] with diagnoses including dementia, major depression, dysphagia (swallowing impairment), and tremors. A review of his 11/7/22 Minimum Data Set (MDS) assessment revealed he scored 5/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating severely impaired cognition. This MDS showed he required supervision and setup help only for meals. This MDS was reviewed as the most recent MDS was still in progress and not completed. On 2/7/23 at 12:15 p.m., R11 was observed sitting at dining room table with a small bowl of tamale pie in front of him. R11 was observed to have a tremor while trying to bring a cup with apple juice and a straw to his mouth. R11 made multiple attempts to grab his fork, but due to the tremors was not able to reach his mouth. No staff were observed helping R11 with his meal. On 2/7/23 at 6:03 p.m., R11 was observed during the dinner meal. R11 was not observed to be feeding himself, nor was he assisted by staff. On 2/8/23 at 5:31 p.m., R11 was observed in the dining room with a small bowl of beef barley soup with no liquid. A spoon was sitting on the top of the food in the bowl, but R11 was making no attempts to feed himself. No staff were observed assisting R11 with his meal despite Certified Nurse Aide (CNA) E sitting next to him feeding another resident. On 2/8/23 at 5:35 p.m., R11 was asked how his food was but he did not respond. CNA E then asked R11 how his food was and R11 proceeded to shake his fist at CNA E. CNA E then asked R11 if he wanted his dessert to which he did not respond. A review of R11's progress notes revealed the following: 1/24/23 .Resident has had a need to be assisted (fed) with meals at dinner. Staff assisting as needed. Continue to monitor . No weight loss but potential for . A review of R11's weight log revealed the following: 8/31/22 167 pounds 11/30/22 171 pounds 12/30/22 170.4 pounds 1/31/23 171 pounds A review of R11's care plan revealed the following: .Self Care Deficit . Eating. I am a choke risk because I eat too fast . (2/24/21) .I am able to eat independently; set up assistance only if needed (revised 2/6/19) .Nutrition. I only have a few teeth I have not been feeding myself at dinner and may need more assist (revised 1/24/23) . On 2/15/23 at 11:42 a.m., R11 was observed being weighed by CNA F. CNA F read out and it was visualized on the scale that R11 weighed 157.6 pounds. This would indicated a 13.4 pound weight loss in 15 days, or -7.8% in 15 days, indicating a significant weight loss. On 2/15/23 at 2:00 p.m., Certified Dietary Manager (CDM) Z and Dietary Manager Y were notified that R11 had not been helped at meals by staff and had also had a 13.4 pound weight loss in 15 days. Neither CDM Z or Dietary Manager Y provided any comments as to why R11 was not receiving adequate assistance with his meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficient practice pertains to intake MI#00134067: Based on interview and record review, the facility failed to monitor for change in condition and timely send to the emergency room one Resident (#7) out of 18 residents reviewed for quality of care. This deficient practice resulted in a delay in timely transfer for Resident #7, with the potential for a decline in function. Findings include: Resident #7 (R7) A review of R7's medical record revealed he admitted to the facility on [DATE] and had diagnoses including Down Syndrome, mood disorder, chronic respiratory failure, and recent tibia and fibula fractures. A review of his 1/1/23 Minimum Data Set (MDS) assessment revealed he was assessed as severely cognitively impaired and was totally dependent on one staff person for locomotion and extensive assistance of one staff for hygiene. This MDS also showed that R7 required limited assistance of one staff for eating. A review of a 12/12/22 Nurse Practitioner (NP) R note revealed, Nurses reported patient had a generalized tonic-clonic seizure lasting about a minute when he was transferred via Hoyer lift from the bed to the chair this morning upon waking . He has had 1 other known seizure which occurred on 7/16/2022. Her was taken to the emergency room following the event . He has not had any seizures in the interim other than the one this morning . We will start patient on Keppra (an anti-convulsant medication) 500 mg (milligrams) p.o. (by mouth) twice daily . A review of R7's record revealed no tapering of the Keppra. The only documentation of monitoring the discontinuation of the Keppra was on a New/Changed Medication Log which revealed documentation regarding R7's behaviors from 12/28/22 through 12/31/22 with no notation regarding seizures. The 1/1/23 documentation revealed: day shift noted, Acting strange, 'hallucinating', tired ., the afternoon shift noted, happy, wakeful after supper, and the night shift noted only, Awake, impulsive in recliner all NOC. A review of R7's nursing progress notes revealed the following: 1/1/23 at 11:40 p.m., This RN heard a yell/high pitch screech coming from resident's room- upon entering, resident was noted to be in bed, lying on his left side, convulsing- witnessed convulsions for approximately 10 seconds. NC (nasal canula) O2 (oxygen) turned up .Resident quickly became postictal for approximately 4 mins (minutes) with snoring respirations; . will monitor closely. This note was written by Registered Nurse (RN) N. 1/2/23 5:05 a.m., . During care, resident loudly and quickly yelled out x3 (three times) with nothing precipitating it. No abnormal behaviors otherwise. Approximately 3 minutes after staff was done with care and walked out of his room, resident was heard yelling/screeching- upon arrival to room he had his hands clenched up on his neck with violent muscle contractions noted. He was quickly turned up on his left side, head and airway protected . Convulsions lasted (witnessed) for approximately 10 seconds, postictal stage approximately 4 minutes . Scratch noted on right neck area from his fingernail . Will notify guardian and physician of overnight seizure activity x2 (times two) this am. This note was also written by RN N. 1/2/23 at 11:16 a.m., Resident had another Tonic Clonic seizure approx. (approximately) 0820 (8:20 a.m.) lasting approx. 15-20 sec. He drew his arms rigidly up to his chin and began jerking vigorously. Post Ictal phase lasted approx 4-5 min . Discussed and updated (Name of Nurse Practitioner (NP) R) who states send to ER for Eval (evaluation), guardian . aware of transfer to (Name of hospital) order . This note was written by Licensed Practical Nurse (LPN) H. A review of R7's hospital notes dated 1/2/23 revealed, Pt (patient) coming from (Name of Facility) after having 3 seizures, per ems and guardian pt was removed from his Keppra due to increased aggression and has been without seizure meds 2-3 days . evidently they (the Facility) felt that the Keppra he was on was contributing to his aggression. They stopped his Keppra 2-3 days ago. Patient had a full tonic-clonic seizure activity today . It is my opinion the patient's seizure is related to him stopping his Keppra. I have reinstituted Keppra with a Keppra Bolus and load here in the emergency department. I recommend that the facility reinstitute his Keppra daily dosing. Should they wish to stop the Keppra, they should do this in discussion with the primary care provider or neurologist . A review of R7's physician orders revealed the Keppra medication was discontinued on 12/27/22. A review of a 1/11/23 NP R note for R7 revealed, The patient is seen today for follow-up of seizures. He was sent to (name of Hospital) on 1/2/2023 after having 3 seizures at the nursing facility. Patient was previously on Keppra for seizures for about 3 weeks prior to his hospital admission but this was discontinued due to irritability and agitation thought to be a side effect of the Keppra . Seizures. Continue Keppra 500 mg BID (twice per day) . A review of the SNF/NF to Hospital Transfer Form for the 1/1/23 transfer to the hospital was not fully filled out. The vitals section showed vitals taken on 1/1/23 and 1/2/23, but the date of transfer was listed as 10/10/2022 16:30 incorrectly instead of 1/2/23. It noted that LPN H had notified the responsible party and Physician K but did not document a date or a time. On 2/16/23 at approximately 11:00 a.m., the DON was asked to provide documentation that the Physician or Nurse Practitioner was notified for each of the three seizures. On 2/16/23 at 12:12 p.m., the DON reported she could only find documentation that the 3rd seizure was reported and asked if that would be sufficient. The DON was asked to provide documentation that the provider and family had been notified of the first two seizures. On 2/16/23 at 11:32 a.m., a phone call was made to RN N who did not answer. A message was left with contact information, reason for call, and a request for a call back. By the time of the exit on 2/17/23 at 10:30 a.m., RN N had not returned the call. At the time of exit on 2/17/23 at 10:30 a.m., no documentation was provided to show that RN N had informed the Physician of R7's first two seizures to determine if hospital transfer was necessary. A review of the facility policy titled, Change of Condition revised 2/4/19 revealed, Policy: Resident changes of condition will be assessed to determine, if possible, the reason for the change. The attending Doctor and responsible party will be notified . Call: Doctor and responsible party. Chart: . What doctor was informed and what he/she was informed of. Who else notified and the time . A review of the Centers for Disease Control and Prevention (CDC) document titled Types of Seizures reviewed on 9/30/20 revealed the following, .Tonic-clonic seizures, also called grand mal seizures, can make a person: Cry out. Lose consciousness. Fall to the ground. Have muscle jerks or spasms . (https://www.cdc.gov/epilepsy/about/types-of-seizures.htm) A review of the package insert documentation for the anti-seizure medication Keppra from the website www.drugs.com revealed, .Discontinuation of Keppra. Avoid abrupt withdrawal of Keppra in order to reduce the risk of increased seizure frequency and status epilepticus .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficient practice pertains to intake MI#00130116: Based on observation, interview and record review, the facility failed to obtain therapy services as documented and ordered for one Resident (#7) out of five residents reviewed for therapy services. This deficient practice resulted in Resident #7 not receiving physical therapy after a fall with fracture requiring surgical repair with a decline in functional ability. Findings include: Resident #7 (R7) On 2/10/23 at 1:50 p.m., R7 was observed sitting in a recliner in the common area by the TV in the hallway. R7 was holding onto his wheelchair in front of him and attempting to self transfer into it. CNA G was observed to talk up to the area, observe R7, get some hand sanitizer from the wall dispenser and continue on her way down the hall. CNA G did not intervene when she witnessed R7 trying to self-transfer to his wheelchair without staff assistance. A review of R7's medical record revealed he admitted to the facility on [DATE] and had diagnoses including Down Syndrome, mood disorder, chronic respiratory failure, and recent tibia and fibula fractures. A review of his 1/1/23 Minimum Data Set (MDS) assessment revealed he was assessed as severely cognitively impaired and was totally dependent on one staff person for locomotion and extensive assistance of one staff for hygiene. This MDS also showed that R7 required limited assistance of one staff for eating. A review of a facility reported incident for R7 dated 10/10/22 revealed that R7 had fallen in the morning and later in the day was sent to the hospital where it was found that he had sustained tibia and fibula fractures of the left leg. R7 underwent surgical revision for these fractures on 10/12/22. A review of an Occupational Therapy Evaluation/Care Plan for R7 completed by the OT on 10/19/22 and signed by the Nurse Practitioner (NP) R on 11/1/22 revealed, .Long Term Goals: . return to prior level of function . Treatment plan: Self care PT (patient) education. Therapeutic exercise. Therapeutic activities. Frequency: 1-2 times per wk (week) for 30 days . There were no further Occupational Therapy (OT) notes, orders, or discharge summary for R7. A review of a Physical Therapy Evaluation/Care Plan assessment for R7 revealed the following, . Treatment plan: Therapeutic exercise. Gait training. Bed mobility/transfer training . other: manual therapy. Frequency: 5 times per wk for 30 days . This evaluation was completed on 10/19/22 and signed off by the NP R on 11/1/22. A review of a Progress Report/Discharge Summary for R7 for Physical Therapy (PT) was reviewed and revealed, . Discharge summary. From 10/19/22 to 10/20/22 .Pt (patient) unable to follow any instructions to participate in any therapeutic exercises or activities at this time secondary to severity of cognitive deficits and non-weight bearing status . A review of an untitled document for therapy tracking revealed documentation of Physical Therapy on 10/19/22 for 60 minutes and 10/20/22 for 38 minutes. This document showed documentation of only 60 minutes of Occupation Therapy on 10/19/22. There were no further Occupational Therapy (OT) notes, orders, or discharge summary for R7. There were no further Physical Therapy notes, orders, or discharge summaries for R7. A review of a Therapy Orders document for R7 from the orthopedic surgery center dated 10/28/22 revealed, . Left closed displaced tibial [NAME] fracture . Treatment: PT evaluate & treat. Therapy: Range of Motion, Stretching. Other: Please work on L (left) ankle passive ROM (range of motion) to pain tolerance. Duration: 6 week therapy order . A review of an Orthopedic Surgery progress note revealed, November 28, 2022 . Pt (patient) progressing normally. Please continue fracture boot except for hygiene and exercises x (times) 4 more weeks. WBAT (weight bearing as tolerated). Skin checks BID (twice per day). Start PT (Physical Therapy) as prescribed . There was no evidence to show that the 10/28/22 orthopedic surgery orders for PT evaluation and treatment were ever completed, nor evidence to show he received any therapy services after 10/20/22. On 2/16/23 at 11:20 a.m., the DON was asked about R7's fall on 2/15/23 and she reported she was just handed the incident report at 10:47 a.m. that morning. The DON was asked to show evidence of CNA E receiving education for not following R7's care plan resulting in a fall. On 2/16/23 at 12:01 p.m., an email was received from the DON that revealed, I spoke with (name of RN I) 02/16/2023 at 1149 regarding the above. She stated that she verbally educated staff and did not hold an in-service. I verified with (Name of RN V) that (Name of CNA E) was the CENA on that did not use the gait belt. (Name of RN V) also told me that he educated the staff based on the resident's care plan . On 2/16/23 at 1:55 p.m., an interview was conducted with the DON and Owner A. When asked how CNA E was educated or disciplined for failing to following the care plan for R7, Owner A reported that RN V had written a progress note that education was done and he should have brought the issue to the DON which he did not. When asked if there was no record of in-services or one-to-one educations when staff fail to provide the correct care, Owner A reported that they just do verbal education and don document anything. When asked then how they could determine if the same staff member was failing to follow the care plan on multiple occasions if there was no documentation of the education, Owner A reported she understood how that could be helpful. The DON was notified that R7 had orders from the orthopedic surgeon on 10/28/22 for physical therapy, and a screen indicated therapy was warranted. The DON and Owner A were not able to provide any evidence that R7 received any therapy services for this certification period. A review of R7's ADL care plan initiated on 1/18/2018 revealed the intervention of . Ambulation: supervision only; uses walker . revised on 2/6/2019. At the time of the survey R7 had declined and was no longer ambulating independently, but the care plan was not revised. A review of R7's care plan for his left leg fracture initiated 11/2/22 revealed, Fracture. I fractured my Fibula and Tibia r/t a fall .Follow-up appointment at (name of Orthopedic Provider) as ordered . PT and OT to evaluate and treat if indicated. A review of R7's MDS 7/3/22 from prior to the 10/10/22 fall compared with the most recent 1/1/23 MDS revealed the following: R7 required only limited assistance of one staff with transfers prior to the 10/10/22, but as of the 1/1/23 MDS he required the extensive assistance of two or more staff for transfers. R7 required only the limited assistance of one staff for locomotion prior to the 10/10/22 fall, but as of the 1/1/23 MDS was totally dependent on one staff member for all locomotion On 2/16/23 at 11:20 a.m., the DON was asked about R7's fall on 2/15/23 and she reported she was just handed the incident report at 10:47 a.m. that morning. The DON was asked to show evidence of CNA E receiving education for not following R7's care plan resulting in a fall. On 2/16/23 at 12:01 p.m., an email was received from the DON that revealed, I spoke with (name of RN I) 02/16/2023 at 1149 regarding the above. She stated that she verbally educated staff and did not hold an in-service. I verified with (Name of RN V) that (Name of CNA E) was the CENA on that did not use the gait belt. (Name of RN V) also told me that he educated the staff based on the resident's care plan . On 2/16/23 at 1:55 p.m., an interview was conducted with the DON and Owner A. When asked how CNA E was educated or disciplined for failing to follow the care plan for R7, Owner A reported that RN V had written a progress note that education was done and he should have brought the issue to the DON which he did not. When asked if there was no record of in-services or one-to-one educations when staff fail to provide the correct care, Owner A reported that they just do verbal education and don document anything. When asked then how they could determine if the same staff member was failing to follow the care plan on multiple occasions if there was no documentation of the education, Owner A reported she understood how that could be helpful. The DON was notified that R7 had orders from the orthopedic surgeon on 10/28/22 for physical therapy, and a screen indicated therapy was warranted. The DON and Owner A were not able to provide any evidence that R7 received any therapy services for this certification period.