Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to immediately notify the department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation for 1 of 3 sampled residents (# 6). Findings include, but are not limited to:

a. A review of Resident 4's progress notes and Unusual Incident/Injury Reports did not indicate an occurrence of a reportable event on or around 08/25/23.

b. A review of Resident 5's progress notes and Unusual Incident/Injury Reports did not indicate an occurrence of a reportable event on or around 08/26/23.

c. A review of Resident 6's progress notes and Unusual Incident/Injury Reports indicated the following:

·On 10/04/23 Resident 6 had an unwitnessed fall, and there were no indications on how abuse or neglect were ruled out. The report indicated resident slid out of bed. There was no indication that the department was notified of the 10/04/23 incident.

·On 10/07/23 an injury of unknown cause was then observed on Resident 6. S/he had a 10-inch scratch on his/her back.

·On 10/13/23 there was an Unusual Incident/Injury Report completed for Resident 6 regarding a 'found on floor' incident with observed abrasions on both knees. There was no indication that the department was notified of the 10/13/23 incident.

In an interview on 06/17/24, Staff 1 (Executive Director) and Staff 2 (RN) did not know why incidents were not reported due to occurring under previous ownership.

The facility had a change of ownership on 01/01/24.

The facility failed to immediately notify the department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

A review of Resident 4's service plan dated 08/24/23 indicated Resident 4 returned to facility on 08/19/23 with an update to service plan of a 1:1 sitter due to impulsivity and high fall risk.

A review of Resident 4's progress notes dated 08/01/23 - 09/30/23 indicated the following:

·On 09/03/23 at 3:43 am resident was placed on alert charting. Resident 4's 1:1 care staff went to lunch. The other care staff on the floor was looking after the resident. Resident was found by the 2nd floor med tech laying on his/her right side with his/her eyes closed. Blood was on the floor and coming from his/her head.

In an interview with Staff 1 (Executive Director) and Staff 2 (RN) no additional information was provided regarding Resident 4 ' s care plan not being following under previous ownership.

The facility had a change of ownership on 01/01/24.

The facility failed to ensure the implementation of services.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on observation and interview, conducted during a site visit on 06/17/24, it was confirmed the facility failed to coordinate with off-site health services for residents. Findings include, but are not limited to:

A call was placed to the facility mainline phone number on 06/21/24 at 8:17 pm. The phone rang, went unanswered for two minutes. At 8:19 pm a Verizon Wireless "Call cannot be completed as dialed please check the number and try again" message played before the phone call was disconnected.

On 06/25/24 at 12:11 pm the facility mainline was called. Staff 5 (Reception) answered and stated s/he answers the phone during business hours and at approximately 4:00 pm s/he switched the phones to night mode and the med techs on shift could still answer the phones, but the phone should go to a voice messaging system. The compliance specialist requested Staff 5 turn the phone system to night mode to ensure voice messaging system was enabled.

A call was then placed to the facility mainline on 06/25/24 at 12:16 pm after Staff 5 switched the phone system to night mode. The phone rang and went unanswered for two minutes and then the same Verizon Wireless message from 06/21/24 played and the call was disconnected.

A call was place to the facility mainline on 06/25/24 at 12:20 pm and spoke to Staff 3 (Business Office Manager). Staff 3 stated s/he had also tried to call facility while phone system was switched to night mode and experienced the same message and call disconnection.

The facility failed to coordinate with off-site health services for residents.

The findings of the investigation were reviewed with and acknowledged by Staff 3 (Business Office Manager) via phone call on 06/25/24.

Verbal Plan of Correction:

Business Office Manager was to follow up with Century Link on 06/25/24 to troubleshoot the voicemail system and would have the system operational as soon as possible.

Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to ensure a safe medication administration system for 1 of 1 sampled resident (# 7). Findings include, but are not limited to:

A review of Resident 7's 06/01/23 - 08/31/23 MAR's indicated the following:

·06/01/23 Omeprazole 20mg not available, ordered from pharmacy;

·06/01/23 Polyethylene glycol powder not available, ordered from pharmacy;

·06/01/23 Enoxaparin Sod withheld due to no nurse available to inject medication; and

·07/02/23 - 07/05/23 Lacosamide 150mg seven doses were not administered due to med not received from pharmacy.

A review of Resident 7's progress notes from 06/01/23 - 08/31/23 indicated on 07/03/23 Resident 7's PCP was notified the resident was out of Lacosamide and that the pharmacy was faxing an incorrect doctor.

In an interview on 06/17/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Business office manager) and Staff 4 (RCC) did not have additional information to provide regarding Resident 7's missed medications.

The facility had a change of ownership on 01/01/24.

The facility failed to failed to ensure a safe medication administration system.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on observation and interview, conducted during a site visit on 06/17/24, it was confirmed the facility failed to provide a secure outdoor recreation area. Findings include, but are not limited to:

At 11:47 am a large gait from the courtyard exiting to the parking lot was observed to be propped open with a cinderblock and no staff or residents were in sight.

In an interview on 06/17/24, Staff 10 (Maintenance Director) stated the gait should be closed and locked at all times.

At 11:58 am Staff 1 (Executive Director) was notified of the gate being propped open and a head count of all residents was requested.

At 12:07 pm Staff 1 confirmed all residents were accounted for.

At 1:45 pm the previously propped open gate was observed to be unsecured. During a walkthrough of the remainder of the courtyard a gate to the facility's HVAC system was unlocked and opened. There was a pair of steel double doors in the unsecured HVAC area that were unlocked and opened to the street north of the facility.

Staff 1 was immediately alerted to the unsecured courtyard.

The facility failed to provide a secure outdoor recreation area.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

A written plan of correction was requested and provided by Staff 1.