Every finding on record at Avir at Enchanted Rock

Based on observation, interview and record review, the facility failed to ensure the accurate administration of medications for 1 of 6 residents observed for medication administration. (Resident # 1) LVN B administered an incorrect dose of Xanax to Resident #1. This failure could place the 6 residents who received medications administered by LVN B at risk of not receiving the intended therapeutic benefit of their medications.Findings included: Record review of Resident #1's face sheet dated 6/22/2026 indicated she was admitted on [DATE] and re-admitted [DATE], and her diagnoses included vascular dementia (brain damage caused by poor blood flow), Alzheimer's disease (progressive brain disorder), anxiety disorder (excessive, persistent uncontrollable fear or worry) and osteoarthritis (cartilage wears down over time).Record review of the quarterly MDS assessment, dated 5/14/2026, showed a BIMS score of 3 which indicted severe cognitive impairment.Record review of the care plan indicated The resident is on hypnotic therapy. Record review of physician orders dated 6/2026 indicated Resident #1 was to receive Xanax Oral Tablet 0.25 MG (Alprazolam), Give 1 tablet by mouth two times a day During an interview on 6/22/2026 at 1:00 p.m., LVN B acknowledged she had administered the wrong dose of Alprazolam to Resident #1. She gave 1 mg when she should have given 0.25 mg. During an interview on 6/22/206 at 1:15 pm with ADON, she stated she was informed of the medication error, the resident was assessed and was placed on 2-hour monitoring. She stated that there were no adverse effects to the resident. During an interview on 6/222026 at 1:40 pm with the DON, she stated was also informed of the medication error and that the doctor and family members were made aware. She stated that the resident was placed on 2-hour monitoring and no adverse effects towards the resident were observed. During an interview on 6/22/2026 at 1:55 pm with the Administrator, she stated the medication error was not reported because due diligence had been completed and the resident had no detrimental outcome. Record review of the policy titled, Administering Medications, dated 4/2019, revealed, Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Residents #1) reviewed for accuracy of records: Nursing staff failed to document medication administration in the MAR for Resident #1 on 05/10/2026. The failure could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings include: Record review of Resident #1's face sheet, dated 05/13/2026 revealed an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter (break in the bone surrounding a hip implant). Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Record review of Resident #1's order summary dated 05/13/2026 reflected the following: -Acetaminophen tablet 500 MG, give 2 tablets by mouth three times a day for pain, do not exceed 3 GM/DAY with an order date 04/23/2026. Record review of Resident #1's MAR indicated no documentation of medication administration on 05/10/2026 for midday for the order Acetaminophen tablet 500 MG, give 2 tablets by mouth three times a day for pain, do not exceed 3 GM/DAY. During an interview on 05/13/2026 at 2:55 p.m., the DON stated he was the one who gave Resident #1 their medication on 05/10/2026. The DON stated he knew he gave Resident #1 the medication but must not have documented it. The DON stated residents should not have blanks in their MAR because it could mean the residents didn't receive their medication or the nurse did not document correctly. Record review of the facility's policy titled, Administering Medications, revision date April 2019, revealed: 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #44) reviewed for supervision. The facility failed to prevent Resident #44 from going out a window without staff awareness. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of other resident elopements and harm the resident with injury or death. The findings include:Record review of Resident #44's admission Record revealed she was admitted to the facility on [DATE] with diagnoses including: dementia, muscle weakness, cognitive communications deficit, partial legal blindness, and need for assistance with personal care. Record review of Resident #44's [DATE] consolidated orders and MAR was documented for visual checks on resident #44's wander guard every 2 hours start date of [DATE]. Record Review of Consolidated orders for [DATE] was documented every 2 hour monitoring of residents physical location every 2 hours for exit seeking start date [DATE], and end date [DATE]. Record review of Resident #44 had consolidated orders for [DATE] and MAR was documented for visual checks on resident #44's wander guard every 2 hours start date of [DATE]. Record Review of Consolidated orders for [DATE] was documented every 2 hour monitoring of residents physical location every 2 hours for exit seeking start date [DATE], and end date [DATE]. Record review of Resident #44's Quarterly MDS dated [DATE] revealed a BIMS of 3, indicating she was severely impaired. Record review of MDS for Resident #44 was documented she required a wheelchair, she was independent with upper/lower body dressing, sit to lying and chair to chair transfer. Record review of Resident #44's comprehensive care plan date initiated [DATE] revealed Resident #1 had wandered out of facility door and was re- directed on [DATE]. Intervention was a wander guard placement to wrist, functioning every shift, if attempt to elope, divert or redirect and notify the charge nurse, and notify the MD with exit seeking behaviors. Resident #44 was at risk for falls related to impaired vision, and very poor safety awareness. Resident #44's care plan was documented she was in the courtyard unattended on [DATE] with 2 hours monitoring for locations, wear a wander guard and check device for placement.Record review of Resident #44 was found outside in courtyard between 400 and 300 halls trying to come into 400 hall door at end of the hallway by Maintenance Supervisor who was working in a room down 400 hall. Maintenance Supervisor opened door at end of 400 hall to direct Resident #44 back into building. Resident #44 was brought back into building by CNA C ambulated with one person assistance. Resident#44 didn't have her wheelchair outside with her. When asked what Resident #44 was doing outside she stated, Well [NAME] when it's a life-or-death situation you will do whatever it takes to get out. Investigation started on how Resident #44 got out of building and into secured courtyard. Skin assessment done by this ADON A with no injuries noted at this time. MD notified of incident and lab orders given. DON and administrator notified of incident. Resident #44 returned to her room where she wanted to lie down. ADON A stated upon investigation it was noted resident had gotten out of building and into secured courtyard through a window in room [ROOM NUMBER]. ADON A stated Resident #44 had poor vision and impaired cognition. Upon trying to enter room [ROOM NUMBER] to investigate the situation at hand door was jammed and only able to open partially. After squeezing my way through door opening it was noted that all the drawers at base of closet were pulled out preventing door to open completely. Resident's #44 wheelchair was noted setting in front of the window. ADON A stated the window was open and screen pushed out onto ground outside of building. A fire extinguisher was noted to be missing from outside 300 hall door and noted on the opposite side of fence closest to the 400-hall exterior door. ADON A stated the gates were still latched on fence.Record review of this courtyard had a 5-feet high metal fence with gates that had latches but were not locked. There was approximately 92 feet from 300 hall window and 400 hall exit door. The weather was fair that day. (Google maps distance from 300 to 40 hall. https://www.google.com/maps/@30.2644225,-98.8819717,55m/data=!3m1!1e3?entry=ttu&g_ep=EgoyMDI2MDQxMy.Record review of Resident #44's elopement risk assessment dated [DATE] revealed she was at high risk.Record review of Resident #44's psychological visit was dated [DATE] and added 2 new medication changes. This 5 days after the incident dated on [DATE]. Observation on [DATE] at 10:15 AM during initial rounds revealed Resident #44 was in her room with door closed, after she opened the door and standing, she was confused and walking around in her room with half her clothes on. Observed on [DATE] at 11:75 AM outside between 300 hall and 400 hall, in the courtyard, had a black metal fence that had 2 gates with latches. During an interview on [DATE] at 11:73 AM Maintenance Supervisor stated he responded to the alarm and saw Resident #44 on the outside of the 400 hall exit door. Interview with the Maintenance Supervisor stated he had let Resident #44 in the door that required a code to come in. The Maintenance Supervisor stated ADON A came and assessed Resident #44. Maintenance Supervisor stated he found out that the resident went out the 300-hall room window. Resident #44 was found outside of 400 hall courtyard at approximately 4 PM by Maintenance Supervisor after she tried to get back in the building from the outside and opened the 400 hall exit door that set off an alarm. The Maintenance Supervisor stated he had alarmed the 300 hall barrier doors, limited the 300 hall room windows from opening, and limited window from opening in Resident #44's room. During an interview on [DATE] at 3 PM with CNA C stated the Maintenance Supervisor told her Resident #1 had gone down 300 hall with her wheelchair, went out the window from a 300-hall room, and walked across the courtyard to the exit door on the 400 hall where he found her. CNA C stated Resident #44 was confused, ADLs she was independent, for showers she required total assistance. CNA C stated Resident #44 mobilized with a wheelchair and wandered the halls. During an interview on [DATE] at 3:27 PM with then ADON A (previous ADON-does not work at this facility) stated she came back to facility in February 2026. ADON A stated Resident #44 was confused, she mobilized in wheelchair, resident was able to walk and usually walks in her room and moves her furniture around. ADON A stated Resident #44 was partially blind. ADON A stated she uses her walker because she gets tired of walking or standing up. ADON A stated maybe Resident #44 heard some gun shots from the dining room TV show. (this was on the other side of Resident #44's). ADON A stated Resident #44 came into her office and was asking if she was ok. ADON A stated Resident #44 was distressed. ADON A stated Resident #44 then went out of her office and about 20 minutes later she heard a door alarm, and she was going down the 400 hall. ADON A stated she saw the Maintenance Supervisor and the CNA C walking down the 400 hall with Resident #44. ADON A assessed Resident #44 and she had no injuries. ADON A notified the ADM, MD and family. ADON A stated she did have at the time of the incident. ADON A stated the Interventions were psychological services and alarm on 300 hall smoke barrier doors. Nurse assessment notified the ADM, MD and family. During an interview on [DATE] at 6:03 PM with CNA B stated she had seen Resident #44 lying down at 3 PM, and at approximately 4 PM, she saw Resident #44 walking down the 400 hall with Maintenance Supervisor and another CNA C. During an interview on [DATE] at 10:51 AM with the DON stated he was not in the facility when Resident #44 went out the window. The DON stated he was trained on exit seeking. The DON stated only Resident #44 had a revised elopement assessment-risk is 29 (high risk). The DON stated the new interventions that were in place after Resident #44 incident was alarms on Resident #44's windows and on the 300 hall limited opening, a psychological referral with medication changes, a urine test, that was dated [DATE] and was negative. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:25 PM. While the IJ was removed on [DATE] at 2:56 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm. IJ verification: F689 Accidents and Hazards: During an interview on [DATE] 1:75 PM with ADM stated she did not report because Resident #44 did not get out of the building. The facility took the following actions to ensure residents were adequately monitored and supervised to prevent elopement. PIR and Validation: Problem: F689 - Free of Accident Hazards/Supervision/Devices- Adequate Supervision The facility needs to take immediate action to ensure residents are adequately supervised to prevent elopement. Plan: 1)All residents will have a new elopement assessment completed, Residents identified as an as high risk for wandering and who are exit seeking will have a wander-guard applied by [DATE]. 2) All staff in facility will be in-serviced on elopement policy and safety and supervision of Residents by [DATE] by the DON or ADON with staff signatures required on sign in sheet. Staff will not be allowed to work a shift until they have completed the in-service training. New hires will be in-serviced before working a shift. The sign-in sheet will be submitted to QAPI. 3)Windows in unoccupied rooms will be secured to limit opening to prevent egress by Maintenance Supervisor by [DATE] with screws in window frames to limit opening to no more than 6 inches. Locks will be verified functional. Screens will not be considered a safety intervention. 4)Windows in resident rooms occupied by exit seeking resident will have alarm applied to window by Maintenance Supervisor by [DATE] and/or residents will be relocated as appropriate. 5) The Administrator/Designee will monitor the effectiveness of the intervention with: - Daily reviews for 14 days - Weekly reviews for 30 days - Ongoing monitoring through QAPI thereafter - This will be documented on a tracking log and submitted to QAPI 6) Maintenance Supervisor will check that all exit door locks are functioning by [DATE]. - Conduct daily checks of all window restrictors and locks for 14 days - Then weekly checks for 30 days Documentation will be maintained on a Window Safety Audit Tool and reported to the Administrator / DON and QA Committee. 7) Residents with wander-guards had their wandering care planned by [DATE]. 8) Staff nurses will conduct every 1-hour visual check on residents with wander-guards going forward beginning [DATE]. This is to be documented on the Nurse Medication Administration Record in the Electronic Health Record as long as resident has wander-guard. 9) All interventions and monitoring will be tracked through the facility QAPI program. Audits will continue for a minimum of 30 days and until sustained compliance is achieved with no negative trends. Immediate Actions Taken: - Window involved in incident secured immediately - Resident assessed with no injury - All other residents assessed for elopement risk - All staff re-educated immediately Verification: Monitoring included the following: During an interview on [DATE] 1:75 PM, the ADM stated she did not report because Resident #44 did not get out of the building. Record review of Resident #20's chart revealed he had an elopement assessment completed on [DATE]. Record review of Resident #5's chart revealed he had an elopement assessment completed on [DATE]. Record review of Resident #25's chart revealed he had an elopement assessment completed on [DATE]. Record review of Resident #2's chart revealed he had an elopement assessment completed on [DATE]. Record review of Resident #58's (new admit) chart revealed he had an elopement assessment completed on [DATE]. Record review of Resident #6's chart revealed he had an elopement assessment completed on [DATE]. Record review of Resident #44's chart revealed he had an elopement assessment completed on [DATE]. Record review of Resident #45's chart revealed he had an elopement assessment completed on [DATE]. A record review of the facility's daily census for [DATE] revealed a census of 46 residents of whom 8 were assessed an elopement risk. A record review of the 46 residents revealed all were assessed for an elopement risk. A record review of the facility's Happy Feet book revealed it was kept at the nurses' station. The book contained a list of residents who were assessed as elopement risks. The residents listed were supported with their demographic information and admission records. The book revealed 8 of the 46 residents were assessed as A High Risk for Elopement. The following residents were assessed as a risk for elopement: Resident #2 Resident #5 Resident #6 Resident #20 Resident #25 Resident #44 Resident #45 Resident #58 During observations on [DATE] between 5:00 to 5:11 PM with the ADON revealed the following residents had a wander guard bracelet on their persons: Resident #2 Resident #5 Resident #6 Resident #20 Resident #25 Resident #44 Resident #45 Resident #58 2) All staff in facility will be in-serviced on elopement policy and safety and supervision of Residents by [DATE] by the DON or ADON with staff signatures required on sign in sheet. Staff will not be allowed to work a shift until they have completed the in-service training. New hires will be in-serviced before working a shift. The sign-in sheet will be submitted to QAPI. A record review of the facility's employee roster revealed 50 employees were listed, of the 50 employees 23 were interviewed; 14 staff worked the 6:00 AM to 6:00 PM shift and 9 worked the 6:00 PM to 6:00 AM shift. A record review of the facility's in-service titled Policy and Procedures on Wandering and Elopement, dated [DATE], revealed, .policies and procedures to be performed while a resident is wandering and / or exit seeking; properly state the chain of command in case of occurrence; describe what is the Happy Feet book and what it contains, and it's location. Further review revealed 50 employees received the in-service training which included a review of the Wandering and Elopements policy, dated [DATE], Policy Statement The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 6:00 AM to 6:00 PM shift.During an interview on [DATE] at 4:20 PM. CNA D stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA D stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA D stated she would alert the nurse immediately if she learned a resident had eloped. CNA D stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 4:21 PM, LVN E stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. LVN E stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. LVN E stated she would alert the DON immediately if she learned a resident had eloped. LVN E stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 4:22 PM, MA F stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. MA F stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. MA F stated she would alert the nurse immediately if she learned a resident had eloped. MA F stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 4:23 PM, LVN G stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. LVN G stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. LVN G stated she would alert the DON immediately if she learned a resident had eloped. LVN G stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 4:30 PM, DA H stated he received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. DA H stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. DA H stated he would alert the nurse immediately if he learned a resident had eloped. DA H stated he usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 4:32 PM, LVN I stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. LVN I stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. LVN I stated she would alert the nurse immediately if she learned a resident had eloped. LVN I stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 4:34 PM, CNA J stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA J stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA J stated she would alert the nurse immediately if she learned a resident had eloped. CNA J stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 4:36 PM, CNA K stated he received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA K stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA K stated he would alert the nurse immediately if he learned a resident had eloped. CNA K stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 6:09 PM, HK R stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. HK R stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. HK R stated she would alert the nurse immediately if she learned a resident had eloped. HK R stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 6:21 PM, HK S stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. HK S stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. HK S stated she would alert the nurse immediately if she learned a resident had eloped. HK S stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 6:27 PM, HK T stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. HK T stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. HK T stated she would alert the nurse immediately if she learned a resident had eloped. HK T stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 7:52 PM, SLP X stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. SLP X stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. SLP X stated she would alert the nurse immediately if she learned a resident had eloped. SLP X stated she usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 7:55 PM, OTA Y stated he received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. OTA Y stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. OTA Y stated he would alert the nurse immediately if she learned a resident had eloped. OTA Y stated he usually worked the 6:00 AM shift to 6:00 PM shift. During an interview on [DATE] at 8:08 PM, LVN Z stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. LVN Z stated the training included the code for a resident who eloped was a code White and when a code white is was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. LVN Z stated she would alert the nurse immediately if she learned a resident had eloped. LVN Z stated she usually worked the 6:00 AM shift to 6:00 PM shift. 6:00 PM to 6:00 AM shift. During an interview on [DATE] at 5:46 PM, LVN L stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. LVN L stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. LVN L stated she would alert the DON immediately if she learned a resident had eloped. LVN L stated she usually worked the 6:00 PM shift to 6:00 AM shift. During an interview on [DATE] at 6:00 PM, LVN W stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. LVN W stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. LVN W stated she would alert the nurse immediately if she learned a resident had eloped. LVN W stated she usually worked the 6:00 PM shift to 6:00 AM shift. During an interview on [DATE] at 6:00 PM, LVN M stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. LVN M stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. LVN M stated she would alert the DON immediately if she learned a resident had eloped. LVN M stated she usually worked the 6:00 PM shift to 6:00 AM shift. During an interview on [DATE] at 6:01 PM, CNA N stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA N stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA N stated she would alert the nurse immediately if she learned a resident had eloped. CNA N stated she usually worked the 6:00 PM shift to 6:00 AM shift. During an interview on [DATE] at 6:06 PM, CNA O stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA O stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA O stated she would alert the nurse immediately if she learned a resident had eloped. CNA O stated she usually worked the 6:00 PM shift to 6:00 AM shift. During an interview on [DATE] at 6:07 PM, CNA P stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA P stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA P stated she would alert the nurse immediately if she learned a resident had eloped. CNA P stated she usually worked the 6:00 PM shift to 6:00 AM shift. During an interview on [DATE] at 6:08 PM, CNA Q stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA Q stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA Q stated she would alert the nurse immediately if she learned a resident had eloped. CNA Q stated she usually worked the 6:00 PM shift to 6:00 AM shift. During an interview on [DATE] at 6:36 PM CNA U stated he received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA U stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA U stated he would alert the nurse immediately if he learned a resident had eloped. CNA U stated he usually worked the 6:00 PM shift to 6:00 AM shift. During an interview on [DATE] at 6:33 PM, CNA V stated she received an in-service from the ADON on the topic of residents who wandered and had a risk for elopement. CNA V stated the training included the code for a resident who eloped was a code White and when a code white was called staff were to refer to the Happy Feet book located at the nurses' station and identify the resident who had eloped and search the facility and the surrounding areas. CNA V stated she would alert the nurse immediately if she learned a resident had eloped. CNA V stated she usually worked the 6:00 PM shift to 6:00 AM shift. 3)Windows in unoccupied rooms will be secured to limit opening to prevent egress by Maintenance Supervisor by [DATE] with screws in window frames to limit opening to no more than 6 inches. Locks will be verified functional. Screens will not be considered a safety intervention. Per POR submitted all unoccupied rooms have windows secured with screws preventing access to the courtyard. Observations on [DATE] at 3:52 PM with Maintenance Supervisor revealed: Observations on [DATE] between 3:52 PM to 4 PM in the 100 hall revealed 7 rooms that were unoccupied and had screws in the windows. No concerns. Observation on [DATE] between 4:03 PM to 4:06 PM in the 200 hall revealed 2 rooms that were unoccupied and had screws in the windows. No concerns. Observations on [DATE] between 4:11 PM to 4:21 PM on the 300 hall revealed 13 rooms that were unoccupied and had screws in the windows. No concerns. Observations on [DATE] between 4:40 PM to 4:42 PM on the 400 hall revealed 3 rooms that were unoccupied and had screws in the windows. No concerns. 4)Windows in resident rooms occupied by exit seeking resident will have alarm applied to window by Maintenance Supervisor by [DATE] and/or residents will be relocated as appropriate. Observation on [DATE] between 5:00 to 5:11 PM, with the ADON, revealed they checked, with wander guard checker device, that the wander guards are were working and not expired for Residents #20, #5, #25, #2, #6, #44, #45 and #58. Observation on [DATE] between 5:21 PM to 5:32 PM revealed all Residents #20, #5, #25, #2, #6, #44, #45 and #58's windows were checked to ensure they had an alarm. Interview on [DATE] at 8:51 PM, the DON stated he was checking windows, alarms are were functional on windows, the nursing with visual check for 1 hour checks on the wander-guards and QUAPI is scheduled for [DATE]. No other comments. 6) Maintenance Supervisor will check that all exit door locks are functioning by [DATE]. - Conduct daily checks of all window restrictors and locks for 14 days - Then weekly checks for 30 days Documentation will be maintained on a Window Safety Audit Tool and reported to the Administrator / DON and QA Committee. Exit Doors checked with Maintenance Supervisor: Interview on [DATE] between 4:32 PM to 4:43 PM with the Maintenance Supervisor revealed he checked the exit doors and windows. Observation on [DATE] at 4:32 PM revealed the exit door on the 100 hall was checked. No concerns. Observation on [DATE] at 4:29 PM revealed the exit door on the 200 hall was checked. No concerns. Observation on [DATE] at 4:30 PM revealed the exit door on the 300 hall was checked. No concerns. Observation on [DATE] at 4:35 PM revealed the exit door on the 300 hall was checked. No concerns. Observation on [DATE] at 4:43 PM revealed the front door was checked, no concerns. Record review of Window Safety Audit Tool Form revealed the Conduct daily checks of all window restrictors and locks for 14 days and the weekly checks for 30 days by the Maintenance Supervisor, was started on [DATE]. 7) Residents with wander-guards had their wandering care planned by [DATE]. Record review of Resident #20's chart revealed he had a wander-guard care plan, dated [DATE]. Record review of Resident #5's chart revealed he had a wander-guard care pl[TRUNCATED]

Based on record reviews and interviews, the facility failed to use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility's reviewed for registered nurse (RN) services. The facility failed to have an RN on 11 dates during the period reviewed 11/1/2025 through 4/15/2026. This failure could place residents at risk of not having the services of an RN.Based on interview and record review the facility failed to ensure, except when waived, the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility's reviewed for registered nurse (RN) services. The facility failed to have an RN on 11 dates during the period reviewed from 11/1/2025 through 4/15/2026. This failure could place residents at risk of not having the services of an RN. The findings include: A record review of the facility's RN timecards for the period dated 11/1/2025 through 4/15/2026 revealed 11 dates with no RN coverage. The review revealed the following dates without the services of an RN: 11/15/2025, Saturday.11/16/2025, Sunday.12/27/2025, Saturday.12/28/2025, Sunday.12/29/2025, Monday.2/28/2026, Saturday3/1/2026, Sunday.3/14/2026, Saturday.3/15/2026, Sunday.3/29/2026, Sunday.4/13/2026, Monday. During an interview on 4/16/2026 at 4:00 PM, the DON stated the 11 dates identified where the facility did not have the services of an RN were correct. The DON stated the potential negative outcome for residents could be they would not have the services of an RN's critical thinking skills. A record review of the facility's Staffing, Sufficient and Competent Nursing, dated August 2022, revealed Policy Statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Sufficient Staff. A registered nurse provides services at least 8 hours every 24 hours seven days a week.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person centered care plan for each resident, consistent with the resident's rights that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and ensure the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for 3 of 8 residents (Residents #42, #22 and #4) reviewed for care plans. 1. The facility failed to ensure a care plan was developed to address Resident #42's verbal suicide discussion with her caregiver. 2. The facility failed to ensure a care plan was developed to address Resident #22's discharge plans. 3. The facility failed to ensure a care plan was developed to address Resident #4's discharge plans. These failures could place residents at risk of staff not being aware of resident care plans and residents not receiving necessary care. The findings include:1.Record review of Resident #42's admission Record, dated [DATE], documented she was admitted to the facility on [DATE]. Resident #42 had diagnoses which included recurrent depressive disorder (common, serious mental health conditions characterized by persistent sad, empty, or irritable moods, accompanied by somatic and cognitive changes that significantly interfere with daily functioning) , primary generalized osteoarthritis (a common, chronic wear-and-tear degenerative joint disease caused by the gradual breakdown of cartilage, leading to pain, stiffness, and decreased mobility.), muscle weakness, restlessness and agitation, pain, Alzheimer's Disease (a progressive, irreversible brain disorder that destroys memory, thinking skills, and eventually the ability to perform daily tasks), unspecified Dementia (a general term for a progressive decline in cognitive function-including memory, language, and behavior-severe enough to interfere with daily life) and suicidal ideations (SI). Record review of Resident #42's Comprehensive MDS, dated [DATE], documented she had a BIMs score of 11/15 (moderately impaired). Resident #42's Active diagnosis was suicidal ideations. Record review of Resident #42's care plan, dated [DATE] with completed date of [DATE], did not reflect the resident's discussion of suicidal ideation. Record review of Resident #42's consolidated orders for [DATE], documented, she had orders for psychosocial services and as well as, medication management. Record review of Resident #42's progress note, dated [DATE] at 7:06 PM, note text: Upon return to the facility, caregiver reported to this nurse the resident had verbalized thoughts of wanting to commit suicide and described a potential plan involving tying a bedsheet into a noose. Caregiver also reported that both of the resident's parents died by suicide. This nurse assessed the resident privately in her room. The resident was asked if she was experiencing any concerning thoughts or thoughts of harming herself. Resident#42 denied any thoughts of self-harm. When asked directly if she had thoughts of committing suicide, the resident responded, Where did you hear that from? Resident stated, I may have mentioned that I was ready to die in a conversation I had with my recently, but I would not kill myself. I just know that my time is coming; I am old. I would not leave behind, referring to her stuffed panda. This nurse provided reassurance regarding resident safety within the facility and offered supportive listening. Resident was asked if she would like to speak with a counselor or the facility social worker. Resident responded, I would like to speak to someone all the time. I know I am here by myself, and my is trying to bring me back home; he just cannot take care of me. No additional concerns reported or observed at this time. Residents are resting in bed with call bell within reach. Record review of Resident #42's progress notes, dated on [DATE], documented Resident #42's nurse, notified the MD, recommended psychological services, notified spouse, Start 15-minute checks. Nurse notified DON on duty and Resident #42 was sent to emergency room for evaluation. Resident #42 arrived to the facility on [DATE] at 2:04 AM and started 15-minute checks for the next 24 hours, removed harmful items from room, and Resident #42 slept with no concerns. Record review of Resident #42's progress notes, start date of [DATE], revealed she was checked every 15 minutes by a nurse. Record review of Resident #42's psychological services visit, dated [DATE], documented the visit was prompted by a reported incident in which the resident expressed suicidal content. She was evaluated in her room while sitting in a wheelchair with no acute physical distress noted prior to his thoughts assessment during the encounter appeared restless, agitated, and anxious. Staff reported recent incident in which the resident verbalized with an intent to harm herself using a bed sheet. However, during the evaluation of resident, she denied suicidal ideation and stated she did not want to harm herself, and said it expressed their desire to return going to her ranch. The resident remained confused and forgetful and was alert and oriented to self only. She's neatly dressed but appeared unfocused and unfortunately not located throughout duration, which limited availability order history obtained staff report no evidence of psychotic symptoms and none were observed during assessment. Despite her cognitive impairment and behavioral concerns her sleep and appetite were reported to be adequate. The mood appeals labeled with underlying anxiety, though full assessment was limited due to her cognitive status. Given the recent suicide I need suicidal statements, safety precautions have been initiated, including monitoring every 15 minutes. I'm going to be medication management will be adjusted as clinically indicated safety operations the patient is not in any acute danger to self or others however, this is the situation may change based on treatment outcomes slash worsening I'm going to go to condition, and psychosocial stressors. Observation on [DATE] at 10:26 AM revealed Resident #42 was sitting in her w/c and seemed to be confused. Resident #42 seemed to be confused of where she was and wanted to go home to the ranch. No expressions of SI.During an interview on [DATE] at 10:27 AM with the MDS nurse, stated Resident #42's care plan did not mention her SI, due to she was not aware of it. 2. Record review of Resident #22's admission Record, dated [DATE], documented a [AGE] year old, female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), diabetes II (a chronic condition where high blood sugar levels result from the body's inability to properly use insulin (insulin resistance) or make enough of it. ), difficulty walking, mild cognitive impairment, cognitive communications deficit and need for assistance with personal care. Record review of Resident #22's Quarterly MDS, dated [DATE], documented her BIMs score was 12/15 (moderately impaired). Resident #22 required a walker, a wheelchair to mobilize and was independent with upper/lower body dressing. MDS stated she was responsible for MDS and care plans. MDS stated she was not aware of Resident #22's SI and would have placed it in her caer plan if she knew about it. MDS stated this would alert staff for Resident #22's SI and what to be aware of with interventions to follow up on. Record review of Resident #22's care plan, dated [DATE], revealed no discharge planning in her care plan. 3. Record review of Resident #4's admission Record, dated [DATE], documented the resident was admitted to the facility on [DATE] and re-admitted on [DATE], she was [AGE] years old Resident #4 had diagnoses which included dementia (a progressive, irreversible syndrome causing decline in memory, thinking, and behavior), need for assistance with personal care, major depressive disorder (fatigue, appetite changes, insomnia or hypersomnia, feelings of worthlessness, trouble concentrating, and suicidal thoughts) and cognitive communication deficit. Record review of Resident #4's Comprehensive MDS, dated [DATE], documented her BIMs score was 13/15 (cognitively intact). Resident #4 used a wheelchair to mobilize, and she was independent with upper/lower body dressing.Record review of Resident #4's Care plan, dated [DATE], revealed no discharge planning in her care plan. During an interview on [DATE] 6:20 PM, the MDS nurse stated she did not have a discharge plan for Resident #22 and #4 in their care plans. The MDS nurse stated she did not have a care plan for Resident #42's SI. The MDS nurse stated it was important and they should have a discharge plan and was used as a form of communication to staff on what the president's plan of care and may impede in residents' plans. No policy for care plans was provided. MDS stated it must have been a computer glitch.

Based on interviews, observations, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 2 residents (Resident #27 and Resident #52) reviewed for quality of care.1. Resident #27 was readmitted with a cervical collar (a neck brace, a medical device used to support, stabilize, and immobilize the neck and cervical spine after injury or surgery) and did not have orders to manage or maintain the cervical collar for 40 days.2. Resident #52 was admitted with a cervical collar and did not have orders to manage or maintain the cervical collar for 6 days.This deficient practice could place residents at risk of not receiving adequate care, harm, or injuries.The findings include:1. Record review of Resident #27's admission record dated 04/17/2026 revealed he was admitted to the facility on [DATE], was discharge to the hospital on [DATE] and readmitted on [DATE] with a diagnosis of Posterior displaced type 2 dens fracture (a break at the second bone down from the skull in your neck). Record review of Resident #27's discharge MDS dated [DATE] revealed Resident #27 was a [AGE] year-old male admitted for long term care with assistive supports for activities of everyday life (ADL). Resident #27 was assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment. Record review of Resident #27's admission nursing note dated 10/30/2025 by LVN CC revealed Resident #27 had a history of syncope [a episode when the brain does not receive enough oxygen for a short period leading to a brief loss of consciousness and can cause a fall] with resulting odontoid fracture [also known as a dens fracture, particularly affecting the cervical C2 vertebrae] and C1-C2 screw fixation [screws holding the cervical C1 and C2 vertebrae in place]. Cervical collar is in place and must be worn at all times.Record review of Resident #27's hospital records dated 03/16/2026 revealed Resident #27 was admitted for acute metabolic encephalopathy (short term reversible brain dysfunction causing altered consciousness and neurological symptoms) and had previous cervical spine surgery with hardware and screws and at discharge had a need for a cervical neck brace. Record review of Resident #27's care plan dated 04/15/2026 revealed no nursing focuses, goals, nor interventions for Resident #27's cervical collar. During an interview on 04/13/2026 at 11:18 AM CNA N stated she cared for Resident #27 who wore a neck brace. CNA N stated she had no instructions on the CNA care plan for caring for the neck brace, but she never removed the brace and would clean around the brace. During an interview on 05/02/2026 at 09:49 AM, LVN DD said she would briefly remove Resident #27's cervical collar daily to assess the surgical site on the back of his neck. LVN DD reviewed Resident #27's physician's orders in his electronic clinical record and confirmed there were no orders for the cervical collar or when it was to be removed or for how to care for the cervical collar. Observation of and interview on 05/02/2026 from 10:03 AM to 10:11 AM, revealed Resident #27 was wearing a hard cervical collar with pads on the inside of the collar and on the outside were Velcro straps on the side of the cervical collar so it could be removed. Resident #27 said he was wearing the cervical collar because he broke his neck when he had a fall at home, and he woke up in the hospital he had the cervical collar on his neck. Resident #27 stated he had worn another cervical collar in the past but has had his current cervical collar for 2 to 3 months. Resident #27 said when he saw his physician he asked if he could take it off to clean it and he was told to keep it on, .but I have taken it off a time or two to clean my neck. Resident #27 said that he had not gotten any sores or irritations from wearing the collar and he will put a washcloth between his neck and the collar to clean his neck. When asked if the CNAs or nurses had removed his collar, Resident #27 said that he didn't know if it was a nurse or a CNA who removed it but when they did, they have taken it off long enough to do whatever they needed to do, and they make sure that I don't move my head. During a telephone interview on 05/02/2026 at 3:38 PM, Physician FF stated she was the on-call physician and was covering for Resident #27's Physician EE, but she was not familiar with Resident #27's care. Physician FF said she was contacted on 05/02/2026 about Resident #27 and gave the orders for Resident #27's cervical collar to be worn and to be checked by the nurses.Record review of Resident #27's physician's orders summary dated 05/02/2026 revealed two orders, with a start date of 05/02/2026 at 10:45 AM, for a cervical collar may be worn; and for 2 nurses to inspect skin under c-collar [cervical collar] for any skin issues once a day. During an interview on 05/02/2026 at 4:23 PM, RN E said she was the nurse who readmitted Resident #27 on 03/23/2026, and he was wearing a cervical collar at that time. RN E said she didn't remember if the hospital discharge records had orders for his cervical collar or for how to care for the collar. RN E said she had contacted Resident #27's Physician EE for clarification on a medication order when he was readmitted , but she didn't remember getting clarification orders for his cervical collar. RN E stated clarification orders should have been obtained the day of a readmission or admission; and there should be orders for any medical devices which included cervical collars. 2. Record review of Resident #52's admission record dated 04/14/2026 revealed an admission date of 04/10/2026 with a diagnosis of displaced posterior arch fracture of first cervical vertebra (a break to the first spinal bone which supports the head). Record review of Resident #52's admission MDS admission assessment dated [DATE] revealed Resident #52 was a [AGE] year-old male admitted from a short-term hospital for long term care and his BIMS score was 9 out of 15 indication his cognitive skills for daily decision making were moderately impaired. Record review of Resident #52's hospital records dated 04/08/2026 revealed, Assessment / Plan: [AGE] year-old man with history of chronic kidney disease, . had ground level fall . found to have a right C1 burst fracture. continue C-Collar at all times for at least 12 weeks, possibly 6 months, but will need to be re-evaluated at clinic. Please provide patient with a second pair of pads for hygiene. Included in Resident #52's hospital records were education material on a cervical spine fracture and how to care for the cervical collar.Record review of Resident #52's physician's summary orders dated 05/02/2026 revealed the physician order on 04/16/2026 for C-collar [cervical collar] to be worn at all times, every day and night, but there were no orders for cervical collar care, instructions for how to care for the collar nor orders for skin care and or monitoring skin. Record review of Resident #52's care plan dated 04/13/2026 revealed no focus, no goals, nor no interventions for Resident #52's cervical collar. During an observation and interview on 04/13/2026 at 11:00 AM revealed Resident #52 in his bed. Resident #52 wore a cervical collar. Resident #52 stated he was told never to remove his brace but could briefly remove the brace to have hygiene care. Resident #52 stated some of the staff provided care by washing the skin around his collar. During an interview on 04/13/2026 at 11:03 AM CNA D stated she was the CNA for Resident #52 who wore a cervical collar. CNA D stated she had no instructions for caring for Resident #52's cervical collar on Resident #52's CNA care plan. CNA D stated she would not remove the collar per Resident #52's instructions but would clean Resident #52's skin around his cervical collar. During an interview on 04/16/2026 at 6:10 PM RN AA stated she was the charge nurse for Resident #27 and Resident #52. RN AA stated she had been the RN charge nurse since December 2025. RN AA stated Resident #27 and Resident #52 both wore cervical collars for support with their cervical spine fractures. RN AA reviewed both residents' physicians' orders and recognized neither had orders for their cervical collars. During a telephone interview on 05/02/2026 at 3:58 PM, Resident 27's Physician GG stated the nurses had contacted her about getting an order for Resident #27's cervical collar but could not remember when it was. Physician GG said she remembers seeing in Resident #27's hospital paperwork instructions for the cervical collar, how to care for the collar, and for the collar to be worn for a minimum of 6 weeks, then it would be re-evaluated. Physician GG said Resident #27's cervical collar should be always left on except when it was briefly removed to clean around his neck. During an interview on 05/02/2026 at 4:34 PM, the ADON said when a resident was admitted or readmitted , the nurse would verify the physician's orders and if the resident was admitted with a medical device, brace or cervical collar the nurse should ensure there was an order for the medical device. The ADON said the harm of not having orders for a cervical collar or for care of the cervical collar could result in proper care not being provided to the resident.During an interview on 05/02/2026 at 5:10 PM, the Administrator said when a resident was admitted or readmitted with a medical device such as a cervical collar, the nurse would contact the resident's physician to verify the orders received from the receiving facility; and if there were no orders for the cervical collar, the nurse wound obtain an order from the resident's physician. The Administrator stated the harm of not having an order for the cervical collar could result in the nursing staff not providing the proper care of the collar.Record review of the Physician Orders policy, revised February 2025, revealed The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services.5. Physician orders are essential for the comprehensive care of the residents. These orders encompass various aspects, including leave of absence, evaluations, medications and treatment regimen, and therapy.consultations with other physicians; dietary plans; activity instructions; x-rays; laboratory work; .and any other orders as needed.11. admission orders-the licensed nurse will verify admission or readmission order with the physician or physician extender for all residents admitting or readmitting.

Based on observation, interview and record review the facility failed to ensure, in response to allegations of abuse, neglect, exploitation, or mistreatment must have evidence that all alleged violations were thoroughly investigated for 1 of 8 residents (Resident #44) reviewed for abuse and neglect. The facility failed to investigate that Resident #44 went out a window without staff awareness. This deficient practice could place residents at risk of harm and other resident elopements. The findings include:Record review of Resident #44's admission Record revealed she was admitted to the facility on [DATE] with diagnoses including: dementia, muscle weakness, cognitive communications deficit, partial legal blindness, and need for assistance with personal care. Record review of Resident #44's March 2026 consolidated orders and MAR was documented for visual checks on resident #44's wander guard every 2 hours start date of 5/7/2025. Record Review of Consolidated orders for April 2026 was documented every 2-hour monitoring of resident's physical location every 2 hours for exit seeking start date 3/19/2026, and end date 4/11/2026. Record review of Resident #44 had consolidated orders for April 2026, and MAR was documented for visual checks on resident #44's wander guard every 2 hours start date of 5/7/2025. Record Review of Consolidated orders for April 2026 was documented every 2-hour monitoring of resident's physical location every 2 hours for exit seeking start date 3/19/2026, and end date 4/11/2026. Record review of Resident #44's Quarterly MDS dated [DATE] revealed a BIMS of 3, indicating she was severely impaired. Record review of MDS for Resident #44 was documented she required a wheelchair, she was independent with upper/lower body dressing, sit to lying and chair to chair transfer. Record review of Resident #44's comprehensive care plan date initiated 2/6/2026 revealed Resident #1 had wandered out of facility door and was re- directed on 5/7/2025. Intervention was a wander guard placement to wrist, functioning every shift, if attempt to elope, divert or redirect and notify the charge nurse, and notify the MD with exit seeking behaviors. Resident #44 was at risk for falls related to impaired vision, and very poor safety awareness. Resident #44's care plan was documented she was in the courtyard unattended on 3/19/2026 with 2 hours monitoring for locations, wearing a wander guard and check device for placement. Record review of Resident #44 was found outside in courtyard between 400 and 300 halls trying to come into 400 hall door at end of the hallway by Maintenance Supervisor who was working in a room down 400 hall. Maintenance Supervisor opened door at end of 400 hall to direct Resident #44 back into building. Resident #44 was brought back into building by CNA C ambulated with one person assistance. Resident#44 didn't have her wheelchair outside with her. When asked what Resident #44 was doing outside she stated, Well [NAME] when it's a life-or-death situation you will do whatever it takes to get out. Investigation started on how Resident #44 got out of building and into secured courtyard. Skin assessment done by this ADON A with no injuries noted at this time. MD notified of incident and lab orders given. DON and administrator notified of incident. Resident #44 returned to her room where she wanted to lie down. ADON A stated upon investigation it was noted resident had gotten out of building and into secured courtyard through a window in room [ROOM NUMBER]. ADON A stated Resident #44 had poor vision and impaired cognition. Upon trying to enter room [ROOM NUMBER] to investigate the situation at hand door was jammed and only able to open partially. After squeezing my way through door opening it was noted that all the drawers at base of closet were pulled out preventing doors from opening completely. Resident's #44 wheelchair was noted sitting in front of the window. ADON A stated the window was open and screen pushed out onto ground outside of building. A fire extinguisher was noted to be missing from outside 300 hall door and noted on the opposite side of fence closest to the 400-hall exterior door. ADON A stated the gates were still latched on fence. Record review of this courtyard had a 5-feet high metal fence with gates that had latches but were not locked. There was approximately 92 feet from 300 hall window and 400 hall exit door. The weather was fair that day. (Google maps distance from 300 to 40 hall. https://www.google.com/maps/@30.2644225,-98.8819717,55m/data=!3m1!1e3?entry=ttu&g_ep=EgoyMDI2MDQxMy. Record review of Resident #44's elopement risk assessment dated [DATE] revealed she was at high risk. Record review of Resident #44's psychological visit was dated 3/24/2026 and added 2 new medication changes. This was 5 days after the incident dated 3/19/2024. Observation on 4/12/2026 at 10:15 AM during initial rounds revealed Resident #44 was in her room with door closed, after she opened the door and standing, she was confused and walking around in her room with half her clothes on. Observed on 04/15/2026 at 11:75 AM outside between 300 hall and 400 hall, in the courtyard, had a black metal fence that had 2 gates with latches. During an interview on 04/15/2026 at 11:73 AM Maintenance Supervisor stated he responded to the alarm and saw Resident #44 on the outside of the 400 hall exit door. Interview with the Maintenance Supervisor stated he had let Resident #44 in the door that required a code to come in. The Maintenance Supervisor stated ADON A came and assessed Resident #44. Maintenance Supervisor stated he found out that the resident went out of the 300-hall room window. Resident #44 was found outside of 400 hall courtyard at approximately 4 PM by Maintenance Supervisor after she tried to get back in the building from the outside and opened the 400 hall exit door that set off an alarm. The Maintenance Supervisor stated he had alarmed the 300 hall barrier doors, limited the 300 hall room windows from opening, and limited window from opening in Resident #44's room. During an interview on 04/15/2026 at 1:75 PM, the ADM stated she did not report the incident because Resident #44 did not get out of the building. ADM stated she was responsible in reporting allegations to the STATE. ADM stated she did bring to corporate and they decided this incident was not responsible. During an interview on 04/15/2026 at 3 PM with CNA C stated the Maintenance Supervisor told her Resident #1 had gone down 300 hall with her wheelchair, went out the window from a 300-hall room, and walked across the courtyard to the exit door on the 400 hall where he found her. CNA C stated Resident #44 was confused, ADLs she was independent, for showers she required total assistance. CNA C stated Resident #44 mobilized with a wheelchair and wandered the halls. During an interview on 4/15/2026 at 3:27 PM with then ADON A (previous ADON-does not work at this facility) stated she came back to facility in February 2026. ADON A stated Resident #44 was confused, she mobilized in wheelchair, resident was able to walk and usually walks in her room and moves her furniture around. ADON A stated Resident #44 was partially blind. ADON A stated she uses her walker because she gets tired of walking or standing up. ADON A stated maybe Resident #44 heard some gun shots from the dining room TV show. (this was on the other side of Resident #44's). ADON A stated Resident #44 came into her office and was asking if she was ok. ADON A stated Resident #44 was distressed. ADON A stated Resident #44 then went out of her office and about 20 minutes later she heard a door alarm, and she was going down the 400 hall. ADON A stated she saw the Maintenance Supervisor and the CNA walking down the 400 hall with Resident #44. ADON A assessed Resident #44 and she had no injuries. ADON A notified the ADM, MD and family. ADON A stated she did have at the time of the incident. ADON A stated the Interventions were psychological services and alarm on 300 hall smoke barrier doors. Nurse assessment notified the ADM, MD and family. During an interview on 04/15/2026 at 6:03 PM with CNA B stated she had seen Resident #44 lying down at 3 PM, and at approximately 4 PM, she saw Resident #44 walking down the 400 hall with Maintenance Supervisor and another CNA C. During an interview on 4/16/2026 at 10:51 AM with the DON stated he was not in the facility when Resident #44 went out the window. The DON stated he was trained on exit seeking. The DON stated only Resident #44 had a revised elopement assessment-risk is 29 (high risk). The DON stated the new interventions that were in place after Resident #44 incident was alarms on Resident #44's windows and on the 300 hall limited opening, a psychological referral with medication changes, a urine test, that was dated 3/19/2026 and was negative. Record review of the facility's policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, documented -All reports of resident abuse, neglect, are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Policy Interpretation and Implementation, Reporting Allegations to the Administrator and Authorities:Investigating Allegations7. All allegations are thoroughly investigated. The administrator initiates investigations.8. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations.9. The Administrator provides supporting documents and evidence related to the alleged incidents to the individual in charge of the investigation.13. That individual conducting the investigation of a minor; and we use the documentation and evidence, k. Reviews all events leading up to the alleged incident, and l. Documents the investigation completely and thoroughly.Follow up report:move in five business days of the incident, the administrator will provide a follow-up investigation report.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours, if the events that caused the allegation did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 8 residents (Resident #44) reviewed for abuse and neglect. The facility failed to report to the State Survey Agency that Resident #44 went out a window without staff awareness. This deficient practice could place residents at risk by not reporting hazards and can affect residents' safety. The findings include:Record review of Resident #44's admission Record revealed a female who was admitted to the facility on [DATE]. Resident #44, was [AGE] years old, had diagnoses which included: dementia ( a progressive decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain), muscle weakness, cognitive communications deficit, partial legal blindness, and need for assistance with personal care. Record review of Resident #44's March 2026 consolidated orders and MAR was documented for visual checks on Resident #44's wander guard every 2 hours, start date of 5/7/2025. Record review of Resident #44's Consolidated orders for April 2026 was documented every 2-hour monitoring of resident's physical location every 2 hours for exit seeking start date 3/19/2026, and end date 4/11/2026. Record review of Resident #44's consolidated orders for April 2026, and MAR documented visual checks on Resident #44's wander guard every 2 hours start date of 5/7/2025. Record review of Resident #44's Consolidated orders for April 2026 was documented every 2 hours monitoring of the resident's physical location every 2 hours for exit seeking start date 3/19/2026, and end date 4/11/2026. Record review of Resident #44's Quarterly MDS, dated [DATE], revealed a BIMS of 3, which indicated she was severely impaired. Resident #44 required a wheelchair, she was independent with upper/lower body dressing, sit to lying and chair to chair transfer. Record review of Resident #44's comprehensive care plan, date initiated 3/19/2026, revealed Resident #1 wandered out of the facility door and was re- directed on 5/7/2025. Intervention was a wander guard placement to the wrist, functioning every shift, if attempt to elope, divert or redirect and notify the charge nurse, and notify the MD with exit seeking behaviors. Resident #44 was at risk for falls related to impaired vision, and very poor safety awareness. Resident #44's care plan documented she was in the courtyard unattended on 3/19/2026 with 2 hours monitoring for locations, wearing a wander guard and check device for placement. Record review of progress note dated 3/19/2026 3:55 PM Resident #44 was found outside in the courtyard between 400 and 300 halls trying to enter into the 400 hall door at the end of the hallway by the Maintenance Supervisor, who was working in a room down 400 hall. The Maintenance Supervisor opened the door at end of 400 hall to direct Resident #44 back into the building. Resident #44 was brought back into the building by CNA C, the resident ambulated with one person assistance. Resident #44 didn't have her wheelchair outside with her. When asked what Resident #44 was doing outside she stated, Well [NAME] when it's a life-or-death situation you will do whatever it takes to get out. The Investigation started on how Resident #44 got out of building and into the secured courtyard. Skin assessment done by this ADON A with no injuries noted at this time. MD notified of incident and lab orders given. The DON and administrator notified of incident. Resident #44 returned to her room where she wanted to lie down. ADON A stated upon investigation it was noted the resident had gotten out of building and into the secured courtyard through a window in room [ROOM NUMBER] (another resident room). ADON A stated Resident #44 had poor vision and impaired cognition. Upon trying to enter room [ROOM NUMBER] to investigate the situation at hand, the door was jammed and only able to open partially. After squeezing my way through door opening it was noted that all the drawers at base of closet were pulled out preventing doors from opening completely. Resident's #44 wheelchair was noted sitting in front of the window. ADON A stated the window was opened and the screen pushed out onto the ground outside of building. A fire extinguisher was noted to be missing from outside 300 hall door and noted on the opposite side of fence closest to the 400-hall exterior door. ADON A stated the gates were still latched on fence.Record review google maps revealed this courtyard had a 5-feet high metal fence with gates that had latches but were not locked. There was approximately 92 feet from 300 hall window and 400 hall exit door. The weather was fair that day. (Google maps distance from 300 to 40 hall. https://www.google.com/maps/@30.2644225,-98.8819717,55m/data=!3m1!1e3?entry=ttu&g_ep=EgoyMDI2MDQxMy.Record review of Resident #44's elopement risk assessment, dated 5/7/2025, revealed she was at high risk.Record review of Resident #44's psychological visit, dated 3/24/2026, and added 2 new medication changes. This was 5 days after the incident, dated 3/19/2024. Observation on 4/12/2026 at 10:15 AM during initial rounds revealed Resident #44 was in her room with the door closed, after she opened the door and stood, she was confused and walking around in her room with half her clothes on. Observed on 04/15/2026 at 11:725 AM outside between 300 hall and 400 hall, in the courtyard, had a black metal fence that had 2 gates with latches. During an interview on 04/15/2026 at 11:73 AM, the Maintenance Supervisor stated he responded to the alarm and saw Resident #44 on the outside of the 400 hall exit door. The Maintenance Supervisor stated he let Resident #44 in the door that required a code to come in. The Maintenance Supervisor stated ADON A came and assessed Resident #44. The Maintenance Supervisor stated he found out the resident went out of the 300-hall room window. Resident #44 was found outside of the 400 hall courtyard at approximately 4 PM by the Maintenance Supervisor after she tried to get back in the building from the outside and opened the 400 hall exit door that set off an alarm. The Maintenance Supervisor stated he had alarmed the 300 hall barrier doors, limited the 300 hall room windows from opening, and limited windows from opening in Resident #44's room. The Maintenance Supervisor stated he reported the incident to ADON A. During an interview on 04/15/2026 at 1:75 PM, the ADM stated she did not report the incident because Resident #44 did not get out of the building. ADM stated she was responsible in reporting allegations to the STATE. ADM stated she did bring to corporate and they decided this incident was not responsible. During an interview on 04/15/2026 at 3 PM, CNA C stated the Maintenance Supervisor told her Resident #1 had gone down 300 hall with her wheelchair, went out the window from a 300-hall room, and walked across the courtyard to the exit door on the 400 hall where he found her. CNA C stated Resident #44 was confused, ADLs she was independent, for showers she required total assistance. CNA C stated Resident #44 mobilized with a wheelchair and wandered the halls. During an interview on 4/15/2026 at 3:27 PM with then ADON A (previous ADON-does not work at this facility) stated she came back to the facility in February 2026. ADON A stated Resident #44 was confused, she mobilized in a wheelchair, the resident was able to walk and usually walked in her room and moved her furniture around. ADON A stated Resident #44 was partially blind. ADON A stated she used her walker because she got tired of walking or standing up. ADON A stated maybe Resident #44 heard some gun shots from the dining room TV show. (this was on the other side of Resident #44). ADON A stated Resident #44 came into her office and was asking if she was ok. ADON A stated Resident #44 was distressed. ADON A stated Resident #44 then went out of her office and about 20 minutes later she heard a door alarm, and she was going down the 400 hall. ADON A stated she saw the Maintenance Supervisor and the CNA walking down the 400 hall with Resident #44. ADON A assessed Resident #44 and she had no injuries. ADON A notified the ADM, MD and family. ADON A stated she did have her wheelchair at the time of the incident. ADON A stated the interventions were psychological services and alarm on 300 hall smoke barrier doors. Nurse assessment notified the ADM, MD and family. During an interview on 04/15/2026 at 6:03 PM, CNA B stated she saw Resident #44 lying down at 3 PM, and at approximately 4 PM, she saw Resident #44 walking down the 400 hall with the Maintenance Supervisor and another CNA C. During an interview on 4/16/2026 at 10:51 AM, the DON stated he was not in the facility when Resident #44 went out the window. The DON stated he was trained on exit seeking. The DON stated only Resident #44 had a revised elopement assessment-risk of 29 (high risk). The DON stated the new interventions that were in place after Resident #44 incident were alarms on Resident #44's windows and the 300 hall limited opening, a psychological referral with medication changes, a urine test, that was dated 3/19/2026 and was negative.DON stated they follow the abuse, neglect policy for reporting inclines with harm, and not sure why they (quapi/corporate) decided not to report. Record review of the facility's policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, documented -All reports of resident abuse, neglect, are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Policy Interpretation and Implementation, Reporting Allegations to the Administrator and Authorities 1. If Resident Abuse Neglect, Exploitation, if resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law and HHSC putting guidelines.2. Administrator for the individuals making location immediately reports his or her suspicion to the following persons or agencies. a. The State license/certification agency responsible for survey/licensing the facility.3. Immediately is defined as b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.6. Allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions if any are needed for the protection of residence.

Based on observations, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 of 6 residents (Residents #26 and #27) reviewed for infection prevention measures. RN BB assessed Residents #26's blood sugar with a glucometer (a portable device used to measure blood sugar levels; A drop of blood obtained via a lancing device is placed on the edge of the strip which was inserted into the meter) and did not disinfect the glucometer with an appropriate blood borne pathogen (germs or infectious agents and include viruses, bacteria, fungi, and parasites) disinfectant; and then proceeded to assess Resident #27's blood sugar with the same glucometer used for Resident #26. This failure could place residents at risk for blood borne pathogen infections.Based on observations, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Residents #26 and #27) reviewed for infection control. RN BB assessed Residents #26's blood sugar with a glucometer (a portable device used to measure blood sugar levels; A drop of blood obtained via a lancing device is placed on the edge of the strip which was inserted into the meter) and did not disinfect the glucometer with an appropriate blood borne pathogen (germs or infectious agents and include viruses, bacteria, fungi, and parasites) disinfectant; and then proceeded to assess Resident #27's blood sugar with the same glucometer used for Resident #26. This failure could place residents at risk for blood borne pathogen infections.Findings included: 1. A record review of Resident #26's admission record, dated 4/17/2026, revealed an admission date of 7/29/2024 with a diagnosis of type II diabetes (a disorder characterized by high blood sugar resulting from the body's inability to use insulin properly and, over time, a failure to produce enough insulin). A record review of Resident #26's quarterly MDS assessment dated [DATE] revealed Resident #26 was a [AGE] year-old female admitted for LTC and assessed with a BIMS score of 12 which indicated moderate cognitive impairment. A record review of Resident #26's care plan, dated 4/17/2026, revealed, The resident has diabetes mellitus, date initiated 8/5/2024 . The resident will have no complications related to diabetes through the review date . A record review of resident #26's physicians orders, dated 4/16/2026, revealed the physician prescribed, on 3/2/2026, for nursing staff to assess Resident #26's blood sugar levels prior to meals and at bedtime. 2. A record review of Resident #27's admission record, dated 4/17/2026, revealed an admission date of 3/23/2026 with a diagnosis of type II diabetes. A record review of Resident #27's admission MDS assessment, dated 3/16/2026, revealed Resident #27 was a [AGE] year-old male admitted for LTC and supported with his diabetes. A record review of Resident #27's care plan, dated 4/16/2026, revealed, The resident has diabetes . the resident will have no complications related to diabetes through the review date . A record review of resident #27's physicians' orders, dated 4/16/2026, revealed the physician prescribed, on 2/27/2026, for the resident to receive insulin lispro (a fast-acting human insulin analog used to treat type 1 and type 2 diabetes by controlling blood sugar spikes, particularly after meals) prior to meals by first assessing Resident #27's blood sugar levels. A record review of the Texas HHSC's website:https://www.hhs.texas.gov/sites/default/files/documents/glucometer-use-care-quality-control.pdfaccessed 4/16/2026, titled Tips for Glucometer Use and Care revealed, Steps in Use: . Disinfect the glucometer according to manufacturer recommendations.a. Properly disinfect glucometers to prevent spread of diseases like Hepatitis B, Hepatitis C, and HIV. Even when devices are used by a single person only, consider the potential for contamination during storage and disinfect accordingly. *Note: DO NOT assume that a glucometer was cleaned after the last use.c. Follow the manufacturer's recommended chemical contact (dwell) time, before using the meter.*Note: DO NOT USE ALCOHOL to disinfect a glucometer, as this is not adequate for disinfection to prevent cross contamination, and it can damage equipment. A record review of the glucometers manufactures website https://www.medline.com/media/catalog/Docs/MKT/LITe22140_MAN_EvenCare%20G2_19W4233811.pdfAccessed 4/16/2026, titled Blood Glucose Monitoring System Healthcare Professional Operator's Manual revealed, Operator's Manual and In-Service Guide: . Important: Users need to adhere to standard precautions when handling or using this device. All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. A new pair of clean gloves should be worn by the user before testing each patient. Cleaning and Disinfecting: Important; DO NOT use glass cleaners or household cleaners on the meter.Materials needed:. Gloves A validated disinfecting wipe .The following products are validated for disinfecting the (Brand name) Meter: (Brand name) Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8) (Brand name) Disinfecting, Deodorizing, Cleaning Wipes with Quaternary Ammonium and Alcohol (EPA Registration Number: 59894-10) (brand name) Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) (Brand name) Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1). During an observation on 4/15/2026 at 11:20 AM, RN BB assessed Resident #26 for his blood sugar level, with a glucometer, and cleansed the glucometer with alcohol wipes and then assessed Resident #27, with the same glucometer, for his blood sugar level and cleansed the glucometer with alcohol wipes. During an interview on 4/15/2026 at 11:32 a.m., RN BB stated she had one glucometer to check residents' blood sugar levels. RN BB stated she used alcohol wipes to cleanse the glucometer prior to use, after use, and in between residents. RN BB stated she used alcohol wipes to cleanse the glucometer instead of the Germicidal blood borne wipes because the facility was out of wipes. RN BB stated she had not reported the lack of germicidal blood borne pathogen wipes to the DON. RN BB stated the potential negative outcome to residents could be the spread of blood borne pathogens. During an interview on 4/16/2026 at 4:00 p.m., the DON stated the expectation for nurses when assessing residents' blood sugar levels was for nurses to disinfect the glucometer with the approved germicidal disinfecting wipes and not alcohol wipes, in between resident uses. The DON stated he was not notified there were no germicidal wipes and and stated the facility did have the correct germicidal wipes to disinfect the glucometers and if RN BB had searched and or requested for the wipes she would have received the wipes. The DON stated the failure to disinfect the glucometer with the approved disinfectant wipes for blood borne pathogens could be the spread of blood borne pathogens. A record review of the facility's Obtaining a Finger Stick Glucose Level policy dated October 2011, revealed, Purpose: the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Equipment and supplies: the following equipment and supplies will be necessary when performing this procedure: . Clean the glucometer with germicidal wipes /or bleach and water solution diluted with a 1 to 9 ratio before initial use, after final use, and between each resident following manufacturer recommendations.

Based on observations, interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized, for 1 of 6 residents (Resident #55) reviewed for accurate records. LVN Z inaccurately documented care for Resident #55. This failure could place residents at risk for inaccurate records.Based on observations, interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 6 residents (Resident #55) reviewed for medical records. LVN Z inaccurately documented care for Resident #55. This failure could place residents at risk for their needs not being met accurately.Findings included: A record review of Resident #55's admission record, dated 4/14/2026, revealed an admission date of 4/11/2026 with diagnoses which included urinary tract infection (UTI, a common infection caused by bacteria entering the urinary system, typically affecting the bladder and urethra) and urinary retention. A record review of Resident #55's admission MDS dated [DATE] revealed Resident #55 was a [AGE] year-old male admitted from a short-term hospital stay. A record review of Resident #55's hospital records dated 4/10/2026 revealed Resident #55 had a UTI and was started on antibiotics and supported for his urinary retention, . Assessment and plan: [AGE] year-old male with a past medical history of . benign prosthetic hyperplasia (BPH a common enlargement of the prostate gland in older men. The prostate grows, squeezing the urethra and causing bothersome urinary symptoms like incomplete bladder emptying.) . Chronic urinary retention: home in / out catheterization -- continue so here. A record review of Resident #55's physician's orders revealed the physician had prescribed for Resident #55 to receive straight in / out urinary catheterizations 4 times a day at 3:00 AM, 9:00 AM, 3:00 PM and again at 9:00 PM, to support his BPH and history of UTI's. During observations on 4/14/2026 from 2:05 PM until 4:00 PM revealed Resident #55 in his room, attended physical therapy, and returned to his room. observations revealed LVN Z had not provided care for Resident #55. During an observation on 4/14/2026 at 4:00 PM revealed LVN Z was in an office speaking with the ADON. During an interview on 4/14/2026 at 4:15 PM Resident #55 stated he had not received his 3 PM urinary catheterization. During an interview on 4/15/2026 at 4:00 PM LVN Z stated she had performed an in and out catheter for Resident #55 on 4/14/2026 on or about 4:30 PM. LVN Z stated she was unaware that Resident #55 had a physicians' order which called for him to have an in and out catheter 4 times a day at specific times. LVN Z stated Resident #55's orders had been updated and she had not reviewed the new orders. LVN Z stated the previous order called for Resident #55 to receive an in and out urinary catheter 4 times a day however the times were not specified. LVN Z stated therefore she was unaware that Resident #55 was scheduled to have an in and out catheter at 3:00 PM and therefore performed the catheterization around 4:30 PM. LVN Z stated that she erred on the documentation of the in and out catheter and documented that she performed the procedure at 3:30 instead of 4:30 PM. LVN Z stated the potential negative outcome to residents was they may not receive the therapeutic effects of their physicians orders and a potential for inaccurate records. During a joint interview on 4/15/2026 at 5:00 PM the Administrator and the DON stated their expectation was for nursing staff to follow physicians' orders and to review physicians' orders prior to taking their shift on the floor for each resident and following those orders. The Administrator and the DON stated the potential negative outcome could be residents would not receive the therapeutic effects of their physicians' orders. The Administrator and the DON stated they expected nursing staff to document accurately the correct dates, correct times, correct residents, correct documentation for procedures. The administrator stated the potential negative outcome for residents would be inaccurate reports. A record review of the facility's Charting and Documentation policy dated July 2017, revealed, Policy statement: All services provided to the resident, progress towards the care plan goals, or any changes in the resident medical, physical, functional or psychosocial condition, shall be documented in the resident medical record. The medical record should facilitate communication between the interdisciplinary team regarding the residents' condition and response to care. Policy interpretation and implementation: . Documentation in the medical record will be objective, complete, add accurate.

Based on observations, interviews and record review, the facility failed to ensure- Food safety requirements. The facility must store, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 (1 kitchen) in that: The nourishment room, in hall 100, had 2 food items that were open and not dated. This could affect all residents that keep food in the nutrition room and could result in food borne illness The Findings:Observations on 4/15/2026 at 8:49 AM in the 100 hall nourishment room, in the refrigerator had a weenie wrap that was opened with no date. The 2nd food item in the refrigerator had a chicken express box that was opened, with no date. This contained 2 small containers of eaten mashed potatoes, and 1 piece of chicken that was eaten. During an interview on 4/15/2026 at 8:33 AM with the MDS nurse confirmed the weenie wrap that was open with no date and the chicken express box that was opened, with no date. Interview on 4/15/2026 4:47 PM with ADM stated the food was removed from the refrigerator. The ADM stated this could cause a food borne illness, if not properly labeled. ADM did not provide a policy, before exit.

Based on observations interviews, and record reviews, the facility failed to ensure that its Residents were free of any significant medication errors for 1 of 6 residents (Resident #22) reviewed for significant medication errors. On 4/15/2026 LVN G administered Resident #22's insulin, via an injection pen, and did not follow the manufactures' administration instructions. This failure could place residents at risk for not receiving the therapeutic effects of their medications.Based on observations, interviews, and record reviews, the facility failed to ensure that its residents were free of any significant medication errors for 1 of 6 residents (Resident #22) reviewed for significant medication errors. On 4/15/2026 LVN G administered Resident #22's insulin, via an injection pen, and did not follow the manufactures' administration instructions. This failure could place residents at risk of not receiving the therapeutic effects of their medications.Findings included: A record review of Resident #22's admission record, dated 4/17/2026, revealed an admission date of 1/10/2026, with diagnosis of type II diabetes mellitus (a chronic condition characterized by high blood sugar levels caused by insulin resistance (cells not using insulin properly and insufficient insulin production by the pancreas). A record review of Resident #22's quarterly MDS assessment, dated 1/15/2026, revealed Resident #22 was a [AGE] year-old female admitted for LTC ADL supports, medication administration, for her type II diabetes. A record review of Resident #22's physicians' orders, dated 4/14/2026, revealed the physician prescribed for Resident #22 to receive insulin aspart before meals and again at bedtime, . Inject as per sliding scale: if 150 - 200 = 2 units; . subcutaneously (directly underneath the skin, specifically within the fatty tissue) before meals and at bedtime related to type 2 diabetes mellitus . A record review of the Resident #22's 3ml insulin aspart 100units/ml injection pen manufactures website https://www.novo-pi.com/novolog.pdf ; accessed 4/15/2026, titled Highlights of Prescribing Information revealed, Instructions For Use: 3 milliliter insulin pen prefilled pen 100 units per milliliter. Introduction: please read the following instructions carefully before using your injection pen. (brand name) injection pen is a disposable single patient use dial-a-dose insulin pen. You can select doses from 1 to 60 units in increments of 1 unit . Attaching the needle: . Screw the needle tightly onto your injection pen. Giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units. Hold your injection pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. During an observation and interview on 4/15/2026 at 11:37 AM, LVN G assessed Resident #22's blood sugar level at 163 and prepared Resident #22's 3ml insulin aspart injection pen, 100ml/ml, by applying a needle to the injection pen and set the dosage to 2 units and administered the insulin to Resident #22 without an air shot of 2 units prior to administering Resident #22's insulin dose. LVN G stated she was unaware of priming/ air shot the injection pen and had not performed the procedure prior to administering Resident #22 insulin. LVN G stated she would review the manufactures instructions for the injection pen. During an interview on 4/15/2026 at 4:00 PM, the DON stated the expectation for insulin injection administration with injection pens was to follow manufactures instructions for use which included priming the needle for accurate dosing. The DON stated the potential risk for residents if the injection pen was not primed could be a small under dosage of insulin. A record review of the facility's policy titled, Insulin Administration, dated September 2014, revealed, Purpose: to provide guidelines for the safe administration of insulin to residents with diabetes. Preparation: . the type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. the nursing staff will have access to specific instructions from the manufacturer, if appropriate, on all forms of insulin delivery systems prior to their use.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #55) reviewed for urinary retention (the inability to fully empty the bladder, resulting in urine being held back even when the bladder feels full. It can be a sudden, painful, and dangerous inability to urinate requiring emergency care or a long-term condition with difficulty urinating or a weak stream.) Resident #55 had a need for straight in / out urinary catheterization (a flexible tube designed to drain urine from the bladder, which is inserted and removed immediately after the bladder is empty) 4 times a day and LVN Z performed the procedure late by 1 1/2 hours. This failure could place residents at risk for urinary retention, pain, and / or infection.Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #55) reviewed for incontinence. (the inability to fully empty the bladder, resulting in urine being held back even when the bladder feels full. It can be a sudden, painful, and dangerous inability to urinate requiring emergency care or a long-term condition with difficulty urinating or a weak stream.) The facility failed to perform a urinary catheter on time for Resident #55 who had a need for straight in / out urinary catheterization (a flexible tube designed to drain urine from the bladder, which is inserted and removed immediately after the bladder is empty). This failure could place residents at risk for urinary retention, pain, and/or infection.Findings included: A record review of Resident #55's admission record, dated 4/14/2026, revealed an admission date of 4/11/2026 with diagnoses which included urinary tract infection (UTI, a common infection caused by bacteria entering the urinary system, typically affecting the bladder and urethra) and urinary retention. A record review of Resident #55's admission MDS, dated [DATE], revealed an [AGE] year-old male admitted from a short-term hospital stay. A record review of Resident #55's hospital records, dated 4/10/2026, revealed Resident #55 had a UTI, was started on antibiotics, and supported for urinary retention, . Assessment and plan: [AGE] year-old male with a past medical history of . benign prosthetic hyperplasia (BPH a common enlargement of the prostate gland in older men. The prostate grows, squeezing the urethra and causing bothersome urinary symptoms like incomplete bladder emptying.) . Chronic urinary retention: home in/out catheterization -- continue so here. A record review of Resident #55's physician's orders revealed the physician had prescribed for Resident #55 to receive straight in/out urinary catheterizations four times a day at 3:00 AM, 9:00 AM, 3:00 PM and again at 9:00 PM, to support his BPH and history of UTIs. During observations on 4/14/2026 from 2:05 PM until 4:00 PM, Resident #55 was in his room, attended physical therapy, and returned to his room. Observations revealed LVN Z had not provided care for Resident #55. During an observation on 4/14/2026 at 4:00 PM, LVN Z was in an office speaking with the ADON. During an interview on 4/14/2026 at 4:15 PM, Resident #55 stated he had not received his 3:00 p.m. urinary catheterization. During an interview on 4/15/2026 at 4:00 PM, LVN Z stated she performed an in and out catheter for Resident #55 on 4/14/2026 on or about 4:30 PM. LVN Z stated she was unaware that Resident #55 had a physicians' order which called for him to have an in and out catheter four times a day at specific times. LVN Z stated Resident #55's orders were updated and she had not reviewed the new orders. LVN Z stated the previous order called for Resident #55 to receive an in and out urinary catheter four times a day; however, the times were not specified. LVN Z stated she was unaware that Resident #55 was scheduled to have an in and out catheter at 3:00 PM and performed the catheterization around 4:30 PM. LVN Z stated the potential negative outcome to residents would be that they may not receive the therapeutic effects of their physicians' orders and a potential for inaccurate records. During a joint interview on 4/15/2026 at 5:00 PM, the Administrator and the DON stated their expectation was for nursing staff to follow physicians' orders and to review physicians' orders prior to taking their shift on the floor for each resident and following those orders. The Administrator and the DON stated the potential negative outcome could be residents would not receive the therapeutic effects of their physicians' orders. A policy was not requested and not provided.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #1. #2 and #3) reviewed for infection control in that: The facility failed to ensure the Activity Director utilized hand hygiene during meal service between resident contact for Residents #1, #2 and #3. This deficient practice could affect all residents and place them at risk for infection. The findings were:Record review of Resident #1's face sheet dated 1/08/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: moderate dementia with mood disturbance (a person with dementia who also experiences depression, anxiety and aggression), type 2 diabetes mellitus with diabetic neurological complication (diabetes that also affects the nervous system) and generalized muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated a moderate impairment. Her functional ability for eating included set-up/clean-up assistance. Record review of Resident #1's Care Plan dated 7/31/2024 indicated the resident was able to eat with meal tray set up and supervision. Record review of Resident #2's face sheet dated 1/08/2026 revealed a [AGE] year-old-male admitted on [DATE] with diagnoses which included: acute kidney failure, type 2 diabetes mellitus without complications and blindness in one eye. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. His functional ability was listed as independent. Record review of Resident #2's Care Plan dated 7//31/2025 indicated the resident was able to eat his meal tray with set-up assistance. Record review of Resident #3's face sheet dated 1/08/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: speech and language deficits following cerebrovascular disease (a group of disorders that affects blood flow to the brain), type 2 diabetes mellitus without complications and pain in the joint. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. His functional abilities indicated he was independent with eating. Record review of Resident #3's Care Plan dated 7/31/2024 indicated the resident was able to eat with meal tray set up and supervision. During an observation on 1/08/2025 at 12:08 p.m., the Activity Director was observed holding an unknown female residents spoon and offering her bites of food off the spoon. The Activity Director then helped push the residents wheelchair closer to the table, handed her the spoon, encouraging the resident to feed herself and walked to the open kitchen door where hall trays were being prepped. The Activity Director did not wash or sanitize her hands after contact with the unknown female resident. After a couple of minutes of talking to other staff, she grabbed a hallway meal cart and headed down the hallway with the food trays. During an observation on 1/08/2025 at 12:15 p.m. the Activity Director delivered Resident #1's lunch meal tray to the resident in her room. She assisted with setting up the meal tray on the bedside table and then exited the room without washing or sanitizing her hands between resident contact. During an observation on 1/08/2025 at 12:17 p.m., the Activity Director delivered Resident #2's lunch meal tray to the resident in his room. She moved several items off the bedside table, including throwing an item in the trash. She exited the room without washing or sanitizing her hands and then immediately grabbed the meal tray for Resident #3. Surveyor attempted to intervene at this point. The Activity Director moved quickly into Resident #3's room, still without washing or sanitizing her hands between resident contact and set up the meal tray for Resident #3. The Activity Director did not wash her hands or sanitize while in the resident room or upon exit. Surveyor intervened to prevent next tray from being touched. During an interview on 1/08/2025 at 12:20 p.m., the Activity Director stated she did not wash or sanitize her hands between resident contact because she did not directly touch the food. She acknowledged she was assisting with feeding a female resident in the dining room. The Activity Director was unable to identify the resident. She stated she needed to act fast with the unknown female resident because if she did not try to get her started with eating the resident would wheel her wheelchair out of the dining room without eating. She stated she did not need to use hand hygiene since she was not directly touching the food. She said with the hallway trays it was more important to deliver the food quickly, so the food did not get cold. She stated that was why she did not use hand hygiene. She stated she had received training for hand hygiene but was nonspecific with her answer and could not state when she had been trained or what was taught. She stated she did not know she was supposed to use hand hygiene between residents, after feeding or when passing trays. She stated hand hygiene was not on her radar because she does not pass trays often and today, she was just trying to help out. During an interview on 1/08/2025 at 1:28 p.m. RN A stated staff should utilize hand hygiene between residents to prevent infection. She stated staff should use hand sanitizer after contact when passing trays and wash their hands after using hand sanitizer 2-3 times. During an interview on 1/08/2025 at 1:42 p.m., the Infection Preventionist stated staff should utilize hand hygiene before and after patient contact and care. She stated that included coming in contact with any of the resident's belongings or touching the resident. She stated staff should sanitize their hands between each tray to prevent cross contamination. She stated staff should wash their hands or use hand sanitizer after feeding a resident, even if they do not touch the resident or touch the food because it is still cross-contamination. The Infection Preventionist stated staff were trained on hand hygiene with in-service on Infection Control. She stated she was unsure when the last training took place. She stated all staff were trained including the Activity Director. The Infection Preventionist stated the facility did not currently have a DON. During an interview on 1/08/2025 at 2:27 p.m., the Infection Preventionist stated she reviewed in-service training. She stated staff had been trained on basic infection control and influenza but not hand hygiene. Record review of the Activity Directors training revealed she completed Hand Hygiene Basics for 0.25 training hours on 11/13/2025 and completed About Infection Control and Prevention on 11/12/2025 for 1.00 training hour. Record review of the facilities policy titled Handwashing/Hand Hygiene dated 1/2025 revealed: The facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene: a. immediately before touching a resident c. after contact with blood, body fluids, or contaminated surfaces d. after touching a resident e. after touching the resident's environment.

Based on observations, interviews, and record reviews the facility failed to ensure a process which provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 2 of 6 residents (resident #1 and Resident #2) reviewed for procedures for accurate acquiring, receiving, dispensing, and administering of all drugs, in that: 1. The facility had Resident #1's controlled medications unsecured, 3 loose, 0.25mg pills of clonazepam stored in the ADON's desk drawer separated from the narcotic count sheet. 2. The facility had Resident #2's controlled medications unsecured, a bottle of liquid Dilauded, loose in a narcotic drawer separated from the narcotic count sheet. These failures could place residents at risk for safety from medication errors. The findings included: 1 a record review of Resident #1's admission record dated 7/8/2025, revealed an admission date of 8/17/2024 with a discharge date of 10/15/2024 with a diagnosis which included anxiety disorder. A record review of Resident #1's discharge MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for long term palliative care and discharged to the hospital via emergency services. A record review of Resident #1's physicians orders dated 8/18/2024, revealed the physician had prescribed Resident #1 to receive clonazepam 0.25mg, daily, 1 pill by mouth at bedtime for anxiety. A record review of Resident #1's narcotic count sheet dated 9/18/2024 revealed the pharmacy delivered 14 pills of clonazepam 0.25mg. further review revealed facility nurses documented Resident #1 had received 11 administrations of the drug and had received her last dose on the evening of 10/15/2024 and had 3 remaining pills left. A record review of the facility's CMS form 3613A provider investigation form dated 3/10/2025 revealed a search of the previous DON and ADON's offices evidenced many controlled narcotic drugs which were not returned to the pharmacy for destruction after residents had discharged . The facility coordinated with the pharmacy to process the drugs for destruction; after the process the pharmacy and the DON discovered 3 loose pills identified as clonazepam 0.25mg. further search of the offices of the previous DON and ADON revealed a narcotic count sheet for clonazepam 0.25mg for Resident #1 without the card of narcotics attached. The conclusion was plausible the 3 loose pills may have been Resident #1's. further review revealed, . Drug Diversion . numerous narcotic medications were found in the ADON desk drawer. There were narcotics in there from June 2024. 3 tablets of clonazepam 0.25mg were found loose in the drawer . 2 A record review of Resident #2's admission record dated 7/10/2025 revealed an admission date of 3/3/2024 and a discharge date of 10/20/2024 with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), senile (related to dementia) degeneration of brain, and encounter for palliative care (a focus on the comfort, care, and quality of life for individuals with a serious illness). A record review of Resident #2's discharge MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for palliative long-term care related to his diagnosis of dementia. A record review of Resident #2's physicians orders dated 10/19/2025 revealed the physician prescribed for Resident #2 to receive hydromorphone 1mg sub lingual, under his tongue, every 3 hours for pain. A record review of Resident #2's October 2024 electronic medication administration record revealed nurses documented on 10/19/2024 that Resident #2 received 3 doses of hydromorphone 1mg/1ml for effective pain relief. A record review of Resident #2's narcotic count sheet dated 10/19/2024 revealed the pharmacy delivered to the facility a bottle of liquid hydromorphone which contained 30ml at a concentration of 1mg per ml, 1mg/ml. further review revealed the document was void of any documentation for any administrations. A record review of the facility's CMS form 3613A provider investigation form dated 3/10/2025 revealed a search of the previous DON and ADON's offices evidenced many controlled narcotic drugs which were not returned to the pharmacy for destruction after residents had discharged . The facility coordinated with the pharmacy to process the drugs for destruction; after the process the pharmacy and the DON discovered a narcotic count sheet for Resident #2's bottle of liquid hydromorphone 30ml at 1mg/ml. The document revealed the pharmacy delivered the drug on 10/19/2024. The DON and the ADON reviewed the document and revealed there was no documentation for any drug administrations. A record review of Resident #2's narcotic count sheet for hydromorphone dated 10/19/2024 revealed the pharmacy delivered a bottle of liquid hydromorphone which contained 30ml of hydromorphone at a concentration of 1mg/ml. further review revealed no documentation for any administrations. During an observation on 7/10/2025 at 3:50 PM revealed the facility's discontinued narcotic storage cabinet in the ADON's office secured behind a locked closet door. Further observation revealed a bottle of liquid hydromorphone for Resident #2 dated 10/19/2024 and contained 27lm of liquid medication. The bottle was not stored with the narcotic count sheet. During an interview on 7/10/2025 at 1:33 PM ADON B stated she was the ADON during the period from 2/1/2024 to 3/1/2025. ADON B stated during the period of 2/1/2025 through 2/12/2025 DON A was the DON. ADON B stated during the DON's tenure she had not processed the narcotics to be returned to the pharmacy for discharged residents and kept the sole key to the to the cabinet in which the drugs were stored. ADON B stated DON A had no more room in the cabinet for discontinued narcotics and began to store the drugs in the ADON desk. The ADON stated she protested and had reported the incident to the leadership to include the regional nurse and the administrator. ADON B stated she worked with DON C during the last week in February 2025 and began to coordinate with DON C to process narcotics for destruction and resigned prior to the completion of the process. During an interview on 7/11/2025 at 11:50 AM DON C stated she was the DON for the end of February 2025 and then on through March, and April 2025 and at the end of February 2025 she had learned that ADON B and DON A had not processed discontinued narcotics for return and destruction to the pharmacy since June of 2024. DON C stated, it was a mess . they had narcotics everywhere in the closet, which was not locked, and in ADON B's desk. DON C stated she coordinated with the pharmacy and eventually settled all the narcotic drugs with the pharmacy prior to her resignation as the DON in April 2025. DON C stated she discovered 3 loose pills identified as 0.25mg clonazepam in the drawer of ADON B's desk and in DON A desk a narcotic count sheet for Resident #2's liquid hydromorphone but no bottle of the hydromorphone was located. During an interview on 7/10/2025 at 11:00 AM the current ADON stated she was the ADON as of 3/1/2025 and had learned from DON C that DON A and ADON B had not processed discontinued narcotics to be returned to the pharmacy for destruction for the months of June 2024 through early February 2025. The ADON stated she reviewed the discontinued narcotic storage cabinet today (7/10/2025) and discovered a bottle of liquid hydromorphone, 1mg/1ml, which contained 27ml of medication. The ADON stated the bottle was labeled for Resident #2. The ADON stated Resident #2's October 2024 MAR revealed he was administered 3 doses prior to his discharge and thus the bottle she discovered more than likely was the bottle for the narcotic count sheet which was found without the bottle. The ADON stated the policy, and procedure was for the nurse who administered a narcotic to a Resident was to immediately after the administration document the administration in the residents electronic MAR and then immediately document the administration on the residents' paper narcotic count sheet. The ADON stated the policy and procedure for the residents who had narcotics after they were discharged was for the nurses to alert the DON who would then remove the narcotics from the medication carts and then coordinate with the pharmacy monthly to destroy the medications. The ADON stated the narcotics should be accompanied by the paper narcotic count sheet, the narcotic count sheet should accurately document the remaining doses of medication remaining. During an interview on 7/10/2025 at 12:10 PM the current DON stated he was the DON for the last 3 paychecks (since the end of May 2025) and had learned from DON C that DON A and ADON B had not processed discontinued narcotics to be returned to the pharmacy for destruction for the months of June 2024 through early February 2025. The DON stated he had learned from DON C that 3 loose pills of 0.25mg clonazepam were discovered in the desk drawer for ADON B and the bottle of Resident #2's dilauded was missing. The DON stated the expectation was for all narcotics to be controlled in a manner where the drugs are secured and accounted accurately with the narcotic count sheet. The DON stated the process was for the nurse who administered a narcotic to a Resident was to immediately after the administration document the administration in the residents electronic MAR and then immediately document the administration on the residents' paper narcotic count sheet. The DON stated the policy and procedure for the residents who had narcotics after they were discharged was for the nurses to alert the DON who would then remove the narcotics from the medication carts and then coordinate with the pharmacy monthly to destroy the medications. The DON stated the narcotics should be accompanied by the paper narcotic count sheet; the narcotic count sheet should accurately document the remaining doses of medication remaining. The DON stated the risk to residents was a loss of security control for their narcotics and could expose residents for a risk of overdosing and or under dosing. A record review of the facility's Controlled Substances policy dated November 2022, revealed, Policy StatementThe facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. 13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. 14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. 15. The consultant pharmacist or designee routinely monitors controlled substance storage records. A record review of the United States of America's Drug Enforcement Administration's website titled Drug scheduling https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdfAccessed 7/14/2025, revealed clonazepam was a controlled narcotic on the schedule IV and hydromorphone a controlled narcotic on the schedule II. Further review revealed, Drug SchedulesDrugs, substances, and certain chemicals used to make drugs are classified into five (5) distinct categories or schedules depending upon the drug's acceptable medical use and the drug's abuse or dependency potential. The abuse rate is a determinate factor in the scheduling of the drug; for example, Schedule I drugs have a high potential for abuse and the potential to create severe psychological and/or physical dependence. As the drug schedule changes-- Schedule II, Schedule III, etc., so does the abuse potential-- Schedule V drugs represent the least potential for abuse.

Based on Observation, Interview and Record Review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 3 (Resident #3) PASSAR services in that: The facility failed to submit a complete and accurate request for nursing facilityspecialized services in the LTC Online Portal within 20 business days after the date of IDT meeting.This failure could affect residents on PASARR services and could result in Resident not proving PASARR services.The findings: Record review of Resident #3's admission Record dated 07/09/2025 documented he was admitted on [DATE], re-admitted on -2/04/2024 with diagnoses of Parkinson's disease, and Intellectual Disabilities. Record review of Resident #3's Quarterly MDS dated [DATE] documented his BIMs score was 5/15 (severely impaired), mobilized with wheelchair and had a diagnosis of Parkinson's disease, and Intellectual Disabilities.Record review of Resident #3's Care Plan dated 04/15/2025 documented he had a diagnose of Intellectual Disability and he had a PASSAR care plan that included a specialized wheelchair. Record review of Resident #3's IDT PCSP meeting was dated 04/24/2025 attended meeting was Resident #3, MDS and PASSAR agent. Record review of the IDT PCSP meeting revealed they discussed starting Occupational (OT) and Physical Therapy (PT). Record review of Resident #3's NFSS dated 4/11/2025 was referred to Occupational Therapy for rehabilitation through PASRR program to maintain mobility and ADL participation due to Intellectual Disabilities, Parkinson's disease, unsteadiness on feet and tremors. Resident #3 would benefit to work on his balance, standing, coordination and monitoring of behaviors by the DOR. This NFSS form Authorization Type was new. Record review of this NFSS OT Portal history included: on 4/25/2025 at 3:19 PM was denied due to Authorization Type as RESTART, please resubmit as a RESTART.Record review of Resident #3 NFSS dated 4/13/2025 was referred to PT Therapy for rehabilitation through PASRR program to maintain mobility and ADL participation due to Parkinson's disease. muscle weakness, abnormalities of gait and mobility.to prevent functional decline. Resident #3 could benefit from independently and safety.to maximize functional independence and decrease risk of falls by DOR. This NFSS form Authorization Type was new. Record review of Resident #3's PT NFSS Portal history included: on 4/25/2025 at 3:20 PM was denied due to Authorization Type as RESTART, please resubmit as a RESTART.Observation and Interview on 07/9/2025 at 11:16 AM with Resident #3, he was sitting in specialized wheelchair, and he stated the wheelchair was comfortable.Interview on 07/10/2025 at 2:00 PM with MDS stated Resident #3's the dated of the IDT Annual PCSP meeting was on 4/24/2025 and they discussed starting up again, therapy. Interview on 07/10/205 at 3:00 PM with the DOR stated for Resident #3's she did fill out the NFSS for PT and OT for Resident #3 The DOR stated she had to resubmit the NFSS form because the Authorization Type was documented new, instead of RESTART. The DOR stated she was not aware of the PASSAR rule to submit NFSS within 20 business days from the last IDT meeting. Interview on 07/20/2025 at 5:00 PM with the Corporate CEO stated he did not have a PASSAR policy and would follow the STATE regulations.

Based on observations, interviews, and record review the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater for 1 of 1 facility in that:The facility failed to post the Nursing Staff posting and have retention for 18 months. This failure could affect all residents and could result in resident not being aware of which staff were working for the day or not being aware of the census for the day.The Finding: Observation on 7/8/2025 at 10:00 AM while walking halls, there was no observation of the nurse staff posting posted. Observation on 7/9/2025 at 10:50 AM while walking halls, there was no observation of the nurse staff posting posted. Observation on 7/9/2025 at 5:00pm while walking halls, there was no observation of the nurse staff posting posted. Observation on 7/9/2025 at 5:01 PM revealed the Direct Care Daily Staffing, dated March 14, 2025, was sitting under the Receptionist counter. Interview on 7/9/2025 at 5:00pm with the ADM and Receptionist, responsible for posting the Nurse staffing information were not aware that it needed to be posted and was not sure they needed to keep 18 months. The Receptionist stated it was her responsibility to post the Direct Care Staffing sheet and had stopped. The Receptionist stated the last Direct Care Staffing posted was March 14,2025.Record review of Posting Direct Care Daily, Staffing Numbers, dated August 2022, was documented Our facility will post on a daily basis for each nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. 1 Within 2 hours of beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for resident care is posted in a prominent location and in a clear and readable format. Shift staffing information is recorded on a form for each shift. 6. Records of staffing information for each shift are kept for a minimum of 18 months or as required by state law.

Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 3 of 8 (Resident #21, Resident #51 and Resident #207) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #21, Resident #51 and Resident #207. These failures could place residents at risk of not receiving care and services to meet their needs. The findings were: Record review of Resident #21's face sheet, dated 02/10/2025, revealed Resident #21 was admitted on [DATE], with diagnoses which included: chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, unspecified cirrhosis of liver, chronic viral hepatitis C, essential (primary) hypertension, heart failure, ischemic cardiomyopathy, and cognitive communication deficit. Record review of Resident #21's Admission MDS assessment, dated 01/13/205, revealed Resident #21's BIMS score was 00 indicating severe cognitive impairment. Record review of Resident #21's electronic medical record revealed Resident #21 did not have a completed baseline care plan. Record review of Resident #51's face sheet, dated 02/09/2025, revealed Resident #51 was admitted on [DATE], with diagnoses which included: laceration without foreign body of right cheek and temporomandibular area, subsequent encounter, unspecified abnormalities of gait and mobility, unspecified fall, subsequent encounter, dysphagia, pharyngoesophageal phase, dysphagia, oropharyngeal phase, essential (primary) hypertension, and cognitive communication deficit. Record review of Resident #51's Admission MDS assessment, dated 01/27/2025, revealed Resident #51 was not able to complete the brief interview for mental status. Record review of Resident #51's electronic medical records revealed Resident #51 did not have a completed baseline care plan. Record review of Resident #207's face sheet, dated 02/12/2025, revealed Resident #51 was admitted on [DATE], with diagnoses which included: fracture of other parts of pelvis, subsequent encounter for fracture with routine healing, wedge compression fracture of unspecified thoracic vertebra subsequent encounter for fracture with routine healing, age-related osteoporosis without current pathological fracture, major depressive disorder, single episode, anxiety disorder, unspecified, peripheral vascular disease, unspecified, hypothyroidism, unspecified, and other specified polyneuropathies. Record review of Resident #207's Admission MDS assessment, dated 02/02/2025, revealed Resident #207's BIMS score was 12 indicating moderate cognitive impairment. Record review of Resident #207's electronic medical records revealed Resident #207 did not have a completed baseline care plan. During an interview on 02/11/2025 at 3:23 p.m. the DON stated baseline care plans were done by the charge nurses. She stated she would open them, and the charge nurse was to fill them out. The DON stated there was a link in PCC (Point Click Care) where she could see what was still outstanding and what still needed completing. During an interview on 02/12/2025 at 10:43 a.m. LVN C the MDS Coordinator stated baseline care plans were done by the admission nurses or the charge nurses. LVN C further stated the DON would check for the completion. LVN C stated the importance of the base line care plans were to set the standards for the resident's stay it was for time between when the comprehensive care plan was completed. During an interview and record review on 02/12/2025 at 11:48 a.m. the DON reviewed the baseline care plans of Residents #21, #51 and #207 with the Administrator present during the interview and review of records. The DON stated the three residents' baseline care plans had not been completed. The DON and Administrator stated resident's baseline care plans should be completed within 72 or 3 days from admission. The DON stated the importance was to identify and understand what the resident was like. During an interview on 02/12/2025 at 3:46 p.m. LVN A stated she used to write all the care plans and was the ADON at one time for the facility. LVN A stated baseline care plans are supposed to be done on day 3 after a resident was admitted . LVN A stated sometimes the nurses do them, but an RN had to open them first. LVN A stated the nurses had a check list that would tell them what they were supposed to do each day after admission. LVN A stated it got passed down from nurse to nurse. During an interview on 02/12/2025 at 3:54 p.m. LVN B stated she hadn't been told to do baseline care plans. LVN B further stated they wanted them to do the initial assessment when a resident came in, and the functional abilities, but she had never been told anything about the base line care plan. Record review of facility's policy titled Baseline Care Plan, revised 07/18/2024, read Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.', Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. be developed within 48 hours of a resident's admission. b. be initiated/opened by the RN. c. May be completed by IDT staff. d. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. initial goals based on admission orders. ii. Physician orders. iii. Dietary orders .

Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 8 residents (Resident #46) whose records were reviewed for code status. The facility failed to obtain a DNR order and complete a care plan for Resident #46 after the completion of the Texas OOHDNR dated [DATE]. This deficient practice could affect any resident who requested a DNR code status and could result in staff providing CPR for a resident who did not wish to be resuscitated. The findings were: Record review of Resident #46's face sheet, dated [DATE], revealed she was admitted on [DATE] wit diagnoses which included: hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non-dominant side, nontraumatic acute subdural hemorrhage, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hyperlipidemia and essential (primary) hypertension. Record review of resident #46's Admission MDS assessment, dated [DATE], revealed the resident's BIMS score was not obtained due to resident not being able to complete the Brief Interview for Mental Status. Record review of Resident #46's care plan, initiated date of [DATE], revealed Resident #46 had a focus of Full Code and interventions revealed Continue CPR until resident responds or until EMS arrives to take over the code. Record review of Resident #46's physician order summary report, dated [DATE], revealed a physician order reading, **Code Status***FULL CODE***. Record review of Resident #46's Texas OOHDNR (out of hospital do not resuscitate) dated [DATE], completed by Resident #46's Medical Power of Attorney, revealed Based on the known desires of the person, or a determination of the best interest of the person, I direct that none of the following resuscitation measures be initiated or continue for the person: cardiopulmonary resuscitation (CPR) . During an interview on [DATE] at 5:17 family member/MPOA of Resident #46 stated Resident #46 did not wish to receive CPR. The family member further stated Resident #46 had an OOHDNR from California and she had to do it over when she moved to Texas. Family member stated the Texas OOHDNR was completed when Resident #46 after she admitted to the facility. During an interview on [DATE] at 10:43 a.m. LVN C the MDS Coordinator stated change orders at that time would have gone through the social worker and further stated the social worker would have been responsible for revising the care plan with the correct code status. LVN C stated those changes were important due to it putting resident at risk of being resuscitated against what she wanted. LVN C stated the social worker before would monitor the code status and would update everything, making sure all the forms were in place. During an interview on [DATE] at 11:48 a.m. the DON with the Administrator present reviewed Resident #46's code status and stated the OOHDNR was completed on [DATE]. The DON further stated Resident #46's orders read full code and the care plan read Resident #46 was a full code. She further stated the social worker was responsible at the time to let people know so they could put it in the order. The DON stated the MDS coordinator (LVN C) would have been responsible for updating the care plan had she been aware. The DON stated by this not having been communicated it would cause CPR to be performed on a DNR patient especially if it was not the wishes of the resident which could be bad. The DON further stated this could cause mental suffering. The Administrator interjected it could extend life of the resident if they did not want it. During an interview on [DATE] at 3:46 p.m. LVN A stated a resident's code status was in the computer and they popped up on the MARs. She stated they were all over the place and on the crash cart itself they had a list of resident's code status. LVN A stated the communications were usually by a copy of the OOHDNR being provided or emailed to them with a message asking them to change the order. During an interview on [DATE] at 3:54 p.m., regarding a resident's code status, LVN B stated they checked on the computer for sure, and she would take her computer with her when she was working. LVN B stated would know a resident's code status through PCC. (Point Click Care). LVN B further stated they were informed many times of code status change through the 24-hour report. LVN B stated they needed to be informed immediately so an order could be obtained. Record review of facility's Communication of Code Status policy, implemented ,d+[DATE], read Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. Policy Explanation and Compliance Guidelines: 1. The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive. 4. The resident's code status should be entered into the resident physician order in the EMR.

Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #207) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #207. This deficient practice could place residents at risk of keeping them from calling for help as needed. The findings were: Record review of Resident #207's face sheet, dated 02/12/2025, revealed she was admitted to the facility on [DATE] with diagnoses which included: fracture of other parts of pelvis, subsequent encounter for fracture with routine healing, wedge compression fracture of unspecified thoracic vertebra, subsequent encounter for fracture with routine healing, muscle weakness (generalized), unspecified abnormalities of gait and mobility, and age-related osteoporosis without current pathological fracture. Record review of Resident #207's Admission MDS assessment, dated 02/02/2025, revealed the resident's BIMS score was 12, which indicated moderate cognitive impairment. The Admission MDS assessment further revealed Resident #207 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, sit to lying, lying to sitting on the side of bed, sit to stand, chair/bed to chair-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #207's care plan, initiated date of 01/31/2025, revealed Resident #207 had a problem of The resident has an alteration in musculoskeletal status r/t pubic fx & thoracic compression fx. and interventions revealed Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Observation and Interview on 02/09/2025 at 10:54 a.m. revealed Resident #207 in bed with her call light lying across the arm of her on the recliner side with the recliner in the standing position approximately 3 feet from Resident #207. Resident #207 stated she did not know where her call light was as she felt around on the bed. Resident #207 further stated she usually had it. When informed it was on the recliner, she stated that was of course where she last had it, and she was not able to reach it while in her bed. During an interview on 02/09/2025 at 11:07 a.m. CNA D stated during her round she forgot to put it back on Resident #207. CNA D further stated Resident #207 would not have been able to reach it where it laid on the recliner. CNA D stated Resident #207 did typically use the call light. CNA D stated the use of the call light was in case they were having an emergency. The CNA further stated a resident could fall or something worse could happen if they did not have their call light. During an interview on 02/11/2025 at 3:59 p.m. the DON stated call lights were supposed to be placed right next to the resident or within reach so they could use. The DON stated Resident #207 did use her call light. The DON further stated call lights were so any resident needing assistance would have assistance from or CNAs or nursing staff. The DON stated by not having their call lights they could potentially try to get up by themselves or they could search for it, and it could cause them to potentially tumble out of bed looking for it. Record review of facility's Call lights: Accessibility and Timely Response policy, implemented date 07/2022, read Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations with the resident's room.

Based on interviews, observations, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 26 residents (Resident #1, #2, and #3) reviewed for accidents and hazards supervision, in that: 1. Resident #1 was found in in another town about an hour's drive from the facility. 2. Resident #2 was spotted going down looking (sic) at cars outside of the facility and had not been supervised the whole time she was outside of the facility. There were no assessments (to include skin assessments) done for Resident #2. 3. Resident #3 eloped and was found walking down the street. Resident #3 had a wander guard but nursing staff did not hear any door alarm with this exit. An IJ was identified on 01/16/25 at 04:45 PM, The IJ template was provided to the facility on [DATE] at 05:45 PM. While the IJ was removed on 01/19/25 at 01:06 PM, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on supervision and elopement. This deficient practice could result in a risk to the residents' health and safety and placed the residents at risk of heat or cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. The findings included: 1. Record review of Resident #1's Admission record, dated 01/15/25, reflected a [AGE] year-old male with admitted [DATE] and discharge date [DATE]. It reflected Resident #1 had diagnoses to include alcohol abuse with intoxication delirium (a mental state in which you are confused, disoriented, and not able to think or remember clearly) and alcohol dependence with alcohol-induced persisting amnestic disorder (a disturbance in memory). Record review of Resident #1's BIMS assessment, dated 09/04/24, reflected a score of 10 out of 15, indicating moderate impairment. Record review of Resident #1's Baseline Care Plan assessment, dated 08/30/24 and created by ADON B, reflected no answers for sections 3. Health Conditions . B. Level of Consciousness/Cognition . H. Safety Risks . 9. Is the resident an elopement risk?, mental health needs, and behavioral concerns. Record review of Resident #1's Elopement Risk Assessment, dated 08/31/24, reflected Resident #1 was Moderately impaired-decisions poor; cues/supervision required with One or more times [previous attempts to leave residence/facility] in the last week. It further revealed Resident #1 did not recognize stop lights and signs, did not know precautions when crossing streets, did not know location of current residence, did not know location of current residence, and did not recognize physical needs. The assessment further revealed he was at high risk for elopement and Wanderguard appropriate at this time-initiate wanderguard interventions. Record review of Resident #1's September 2024 MAR, dated 01/15/25, reflected: VISUAL CHECK EVERY 2 HOURS . for elopement risk with a start date of 08/31/2024. WANDER GUARD CHECK PLACEMENT EVERY SHIFT . with a start date of 09/04/24 and D/C Date of 09/10/24. Record review of Resident #1's hospital documents, dated 08/30/24, revealed Resident #1 was admitted to the hospital on 08/20/24. The hospital documents reflected Resident #1 comes into the ED today from the local jail for altered mental status . He was going through alcohol detox and thought related to his detox but he complete(d) the program today and still was not in a normal mental status. [Resident #1] is disoriented and can give his name but not his date of birth, the current year, where he is. Record review of Resident #1's Nurse's Note, authored by LVN C, dated 08/31/24 at 01:28PM, reflected Resident has attempted to get out of the back doors to the facility several times this shift. He states that he wants to go home . Obtained new order from PCP for medications to assist with anxiety and added 2 hour location checks to charting. Resident continues to insist that he has to leave. Record review of Resident #1's progress notes in PCC reflected no mention of Resident #1 leaving the facility on 09/04/24. Record review of a statement provided by the DON AK, authored by the DON AK, undated, reflected, I was notified by [ADON B] that [Resident #1] was no longer in the facility, facility was searched and head count was done to ensure other residents were all accounted for. Every resident with the exception of [Resident #1] was accounted for. Sign out book was checked, resident had not signed out. When facility and property was checked, it was noted that pillows and personal effects were placed on an employee's car. Family, administration and authorities were notified. [Received] notification from authorities that resident was pulled over in a vehicle (that did not belong to him) and taken to (another town) for further detainment. [Administrator G] went to pick up resident and brought him back to facility. Full body assessment done per [DON AK]. No injuries or discolorations noted at this time. No s/s of distress. Resident was apologetic for leaving without notifying anyone. [Resident #1] was alert and oriented and knew what he was doing was wrong but continued to leave the facility [without] signing out. Resident suffers from alcoholism which causes some disorganized thinking processes. Resident was able to explain what roads he took to get to where he was at and that he took a car without permission. Resident was safely brought back to facility via [Administrator G] and was encouraged to enter a detox center. Resident agreed and was ultimately safely discharged to another facility that specializes in detox from substance abuse. During an interview on 01/15/25 at 12:45 PM, Resident #1's RP revealed Resident #1 was confused but she did not know how confused or how bad his condition was after his hospital stay, several weeks before admission. She revealed the facility should have Resident #1's hospital documentation to reflect his mental status. She revealed she did not want to get the facility in trouble because it was her fault that she didn't realize what his new baseline mental status was. She revealed she would think the facility would have assessed Resident #1 to know how to care for resident and should have kept eyes on Resident #1 to prevent him from leaving the facility as she found out that his mental status was poor, after Resident #1 left the building. Resident #1's RP did not reveal any details about where the resident was found but the administrator had to drive to pick up Resident #1 from another location. During an interview on 01/15/25 at 01:17PM, RN A revealed she did not do the 4 AM check on 09/04/24 , which was a part of the doctor's orders to check on Resident #1 every 2 hours. RN A revealed when the morning shift was coming into the facility, they saw clothes that had Resident #1's name on them. RN A went to Resident #1's room and he was gone. During an interview on 01/15/25 at 02:45PM, LVN F revealed she knew Resident #1 was an elopement risk due to his behavior from the previous day. She revealed the nursing staff found Resident #1 was not in his room when the 6AM staff came in for their shift. The nursing staff searched inside and outside of the facility and found Resident #1 was no longer on the premises. LVN F revealed she called Administrator G and another nurse (unidentified) called the DON. She revealed Administrator G instructed her to call the local police department to report a missing person. LVN F could not identify what staff member called the local police department. She revealed Administrator G found out Resident #1 was in another town about an hour's drive away from the facility went to pick him up, brought Resident #1 back to the facility, and worked on placing Resident #1 in a different facility this same day. LVN F revealed she felt this incident was considered an elopement, however, LVN F was corrected by Administrator G this was not an elopement because Resident #1 could explain what and why he left the facility. LVN F further revealed she recalled Resident #1 did not have a wander guard bracelet on because there were not enough wander guard bracelets available at this time. LVN F revealed she was not trained on elopements or wandering after this incident . LVN F knew what to do for residents who wandered or were at risk for elopement. During an interview on 01/16/25 at 06:35 AM, the CDM revealed after the incident involving Resident #1, the dietary department was trained on elopement and signed a sheet someone from the nursing department handed them. She further revealed her whole department signed a sheet to prove they got trained. (This sign-in sheet was not able to be produced by the facility.) During an interview on 01/16/25 at 08:13 AM, the DON revealed Resident #1 did not elope but left AMA because he had intact cognition but presented with disorganized thinking due to his alcoholism. She revealed she was told by nursing staff that Resident #1 was not in his room during a visual check. She revealed Resident #1 was on visual checks because she thought it was good protocol to have him on visual checks because he had disorganized thinking. She further revealed Resident #1 did not sign out on pass and he had doctor's orders to go out on therapeutic pass. The DON revealed she did not know if Resident #1 was capable of driving a car. She revealed she did not know if Resident #1 was an elopement risk but an elopement risk assessment would let the staff know. She revealed when Resident #1 was not in his room, they did a head count, and they couldn't find him on the premises. The DON revealed at this point, he was considered missing and they called the authorities, PCP, RP, and Administrator. When they called the authorities, they found him at another town'spolice department. She revealed the family who owned the car Resident #1 took from the nursing home parking lot did not decide to press charges against Resident #1. The DON revealed she started working at the facility in May 2024. She revealed staff were trained on wandering and elopement before this incident. She revealed Administrator G stated corporate risk management team did not consider this an elopement and the facility was advised not to report this incident to HHSC. She further revealed Administrator G said risk management advised the facility not to document in PCC and to do a soft file (physical copy) of this incident to include assessments of Resident #1. The DON revealed she trained everyone face to face, but she did not have a staff roster when training her clinical staff to train all of these staff members. The DON revealed if she did not get to train nursing staff, she left it in the binder where nurses signed in for their shift. She further revealed the nursing staff know to read what she puts in the binder and sign off that they read the pertinent documents. The DON revealed she only trained her department and no other departments. She further revealed she did not train the office staff. During an interview on 01/16/25 at 01:40PM, Confidential Staff N revealed they heard no one was going to report when Resident #1 eloped and was found in a different city about an hour away. They further revealed ADM G picked Resident #1 and brought him back to the facility but was not aware of anything else. They revealed they were told not to report this incident to HHSC because the facility was going to handle this incident a different way. During an interview on 01/16/25 at 02:37PM, ADM G revealed Resident #1 had alcohol induced dementia. ADM G revealed Resident #1 told him he looked out the window one night and thought he saw his wife's car and it was time to go home. ADM G revealed he remembered the facility staff called him, the police were involved, they tracked his phone, and the authorities had pulled him over in another town about an hour away. ADM G revealed he drove to the town to pick Resident #1 up from the police station. He revealed Resident #1 did not know where he was going. He revealed they had a conversation with the facility's ownership immediately about this incident. ADM G further revealed he thought this incident was reportable. ADM G revealed the COO gave them direction to not report this incident to HHSC. ADM G revealed Resident #1 did not have a wander guard bracelet. He revealed the front doors going outside did not lock overnight. He revealed he remembered knowing this was an issue, figuring out how to prevent residents from leaving the facility overnight. ADM G after he picked up Resident #1 he filled out a self-report form, in-serviced some staff about ANE and elopement and was still working on this. He revealed he started the paperwork as soon as he came into the building because he knew he was on the clock to complete in order to report to HHSC. During an interview on 01/16/25 at 04:16PM, the Medical Director revealed Resident #1 was at risk for elopement and he requested for everything to be done before Resident #1 left the building on 09/04/24. He further revealed he was contacted after this incident and the expectation was to ensure Resident #1 did not leave the facility for the resident's safety. 2. Record review of Resident #2's Admission record, dated 01/15/25, reflected an [AGE] year-old male with admitted [DATE] and discharge date [DATE]. It reflected Resident #2 had diagnoses to include dehydration, altered mental status, muscle weakness, abnormalities of gait or mobility, lack of coordination, dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and depression. Record review of Resident #2's Care Plan, close date 09/09/24, reflected focus The resident is an elopement risk/wanderer r/t impaired safety awareness, initiated 08/15/24 with interventions to include WANDER ALERT bracelet check placement and functioning q shift. Record review of Resident #2's August 2024 MAR, dated 01/15/25, reflected: WANDER GUARD CHECK FOR FUNCTION EVERYDAY. with a start date of 08/14/24 and D/C Date 09/03/24, filled out appropriately for day and night shifts. VISUAL CHECK EVERY 2 HOURS with a start date of 08/14/24 and D/C Date 09/03/24, filled out appropriately. Record review of Resident #2's Elopement Risk Assessment, dated 08/14/24, reflected Resident #2 was Moderately impaired-decisions poor; cues/supervision required with One or more times [previous attempts to leave residence/facility] in the last week. It further revealed Resident #2 did not recognize stop lights and signs, did not know precautions when crossing streets, did not know location of current residence, did not know location of current residence, and did not recognize physical needs. The assessment further revealed he was at high risk for elopement and Wanderguard appropriate at this time-initiate wanderguard interventions. Record review of Alert Note, authored by AD, dated 08/22/24 at 12:06PM, reflected, AD finished exercise group in main dining room and on the way back to AD office alarm in activities room was going off. AD looked out the outside door to make sure no one had gone out. Upon looking down the sidewalk resident was spotted going down looking (sic) at cars. She thought her son was out there. AD approached and redirected resident back to building and inside. AD and resident went to find the charge nurse to let her know about the adventure. [DON] was at the nurse's station as well, so she is (sic) aware of the incident. Record review of Resident #2's progress notes and assessments reflected no skin assessments were done after Resident #2 was found outside of the facility on 08/22/24 around 12:06PM. During an interview on 01/15/25 at 12:15 PM, LVN E revealed if a resident left the building and there were no eyes on the resident, she would complete a skin assessment on resident. After reading the alert note on 08/22/24 at 12:06PM, LVN E revealed she would have done a skin assessment on Resident #2 because Resident #2 exited the building and it appeared there was some time where a staff member wasn't with Resident #2. During an interview on 01/16/25 at 08:13 AM, the DON revealed Resident #2 was found on the facility sidewalk by the AD. She revealed Resident #2 was still on property and this incident was not reported because Resident #2 was on the premises. During an interview on 01/16/25 at 01:05PM, the AD revealed she had heard the door next to her office sound, so she went to check to see if a resident had left the building. She revealed Resident #2 was observed walking on the sidewalk between the nursing home parking lot (on her left) and the facility building/yard (on her right). The AD revealed Resident #2 was able to walk past 3 trees on the right side of her before she laid eyes on Resident #2. The AD revealed she was able to go outside and redirect Resident #2 to come back into the facility. The AD revealed she was trained on elopement this morning and had already been trained prior to this morning. During interview on 01/16/25 at 10:57 AM, the DON revealed there were no skin assessments done for Resident #2 on or after 08/22/24. 3. Record review of Resident #3's Admission record, dated 01/15/25, reflected a [AGE] year-old female with admitted [DATE] and discharge date [DATE]. It reflected Resident #3 had diagnoses to include abnormalities of gait and mobility, repeated falls, lack of coordination, muscle weakness, hypertension (high blood pressure), and dementia. Record review of Resident #3's Care Plan, close date 03/20/24, reflected focus The resident is an elopement risk/wanderer r/t impaired cognition Dementia wandering about in wc not easily redirected . 3/17/24 eloped from facility, located and easily redirected back to facility . 3/13/24 eloped out front doors to sidewalk easily redirected back into facility, initiated 02/07/24, with interventions to include WANDER ALERT bracelet applied check placement and function q shift, initiated 02/13/24, careplan meeting pending for alternated placement for secure unit for safety, initiated 03/14/24, 1:1 initiated, still attempting to assist family to find a suitable secured unit for her safety, initiated 03/18/24. Record review of Resident #3's March 2024 MAR, dated 01/15/25, reflected: WANDER GUARD CHECK PLACEMENT EVERY SHIFT, with a start date 02/12/24 and D/C date 03/25/24, filled out appropriately for day and night shifts. WANDER GUARD CHECK FOR FUNCTION EVERYDAY, every shift with a start date 02/12/24 and D/C Date 03/25/24, filled out appropriately for day and night shifts. Record review of Resident #3's Elopement Risk Evaluation V 2.0, dated 03/13/24, reflected Resident #3 was at risk for elopement. Record review of Resident #3's admission MDS assessment, dated 02/12/24, reflected Resident #3 had a BIMS score of 05 out of 15, indicating severely impaired cognition. Record Review of written statement in intake 491104's investigation provided by the facility, undated, by COTA J reflected I was alerted by [Unidentified resident] that [Resident #3] was outside. [unidentified resident] stated that she saw her walking down a road opposite direction of our building from her window. I immediately found [LVN F] to alert her of [Resident #3] being outside. We both left the building to look in the direction of where [unidentified resident] last saw her go. [LVN F] was able to quickly locate [Resident #3] and guide her back to the building. Record review of written statement in intake 491104's investigation provided by the facility, dated 03/17/24, by DON K reflected .[Resident #3] continues on [every 15 minute] checks that were initiated Friday, 3/15/24 . [LVN F] reports wanderguard device has been alarming appropriately but they did not hear any door alarm with her last exit from the [building]. She is unsure why there was no alarm sounding when she went to retrieve her through the front door exit. During an interview 01/15/25 02:02 PM, the Business Office Manager was not aware if she was trained on elopements. She revealed she would contact the Administrator or the DON if she saw a resident leaving the facility. She revealed she would try to redirect the resident and try to stop the resident from leaving the facility. She would try to get help, even calling someone while trying to help resident. During an interview on 01/15/25 at 03:14 PM, RN H revealed she had received an in-service on wander guards and what to do for residents who wandered but had not been trained on elopements. She revealed it would be a good idea to be trained on elopements because she was not aware of how to help her coworkers if an elopement occurred. RN H stated rhetorical questions (questions to make a point rather than to get an answer) like Do we notify the doctor or RP?. She revealed she was present when Resident #1 eloped and stated she was not asked for a witness statement, which she felt would be the procedure for this incident to figure out how this resident left the building. Observation 01/16/25 at 04:32AM revealed the facility's front door was locked from the outside. However, it was revealed the doors were not locked going from the inside of the facility to the outside of the facility. During an interview and observation on 01/16/25 at 04:38AM with ADON B, ADON B revealed there were 2 doors to open before accessing the outside, in the front of the building. The first door had a machine attached to the door that should lock the doors if a resident with a wander guard bracelet approached the door. She further revealed if a resident had a wander guard the first door should lock itself to prevent these residents from walking outside, however, if the 1st door was held open for 15 seconds, then the resident could walk out but the alarm will continue to sound. She revealed when the alarm sounded, the staff would look to see what exit was alarming to investigate if a resident left the building or not. She further revealed the second and last door that goes to the outside did not have an alarm. ADON B revealed residents without wander guards could open both doors to exit the front of the building without any alarms sounding. ADON B further revealed if a resident was allowed to go out on pass and wanted to leave, they would have to sign out with staff. She revealed there were no current residents that sign out on pass during the overnight shift. During an interview on 01/16/25 at 05:27AM, the current administrator (Administrator I) revealed if there was a confirmed elopement or abuse, neglect, exploitation, he would print the current staff roster and train 100% of all facility staff members. He revealed he would be important for all staff to know what to do in the case of these situations. During a combined interview on 01/16/25 at 05:51AM, RN A and CNA D revealed they did not recall being trained about topics that included elopement or residents who wander after the incident where Resident #1 left the facility. RN A revealed she did know a little bit of what to do if a resident eloped and she would check all the rooms and outside of the facility if the door alarmed. CNA D revealed those residents with wander guards would alarm the door if they opened the door to exit the facility. RN A revealed she knew what residents were at risk for elopement because it popped up on her point of care screen. CNA D revealed she knew residents were at risk for elopement if they were wearing a wander guard, but it did not show her on her point of care screen. During an interview on 01/16/25 at 01:54PM, OT AQ revealed since February 2024, she had not received any training to include elopement and Abuse, Neglect, and Exploitation. She was educated on Elopement this morning to include pay attention to exit seeking behaviors. During an interview on 01/16/25 at 04:09PM, COTA J revealed Resident #3 left the building and walked down the road and about 1 to 2 blocks away from the facility before an unidentified resident told her they saw Resident #3 outside. She revealed she did not recall how Resident #3 got out and that the door alarms did not sound when resident left the building. She revealed she was trained on elopement before this incident and refreshers after . Record review of in-service about policy Wandering and Elopements, dated 03/17/24, reflected 20 staff were in-serviced. Requested staff roster for 03/17/24 on 01/15/25 at 09:50AM and no staff roster was able to be provided. Record review of in-service, undated, titled Elopement Risk Residents/Q2hr checks, reflected 8 nurses were in-serviced. The summary of this in-service reflected, As nurses, we need to make sure we are constantly laying eyes on our residents especially our elopement risk residents. Rounds must be made at the very least, 2hrs, if not sooner. It is our responsibility to keep our residents safe. It is of the upmost importance that we are correctly documenting our 2hr checks on these resident and appropriately documenting exit seeking behaviors. This is not an option. An Immediate Jeopardy (IJ) was identified and presented to Administrator I on 01/16/25 at 05:45 PM. A Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 01/17/25 at 06:19 PM. 1) Resident #1, Resident #2 and Resident #3 no longer reside in facility. 2) DON Inserviced all staff on elopement policy, 1/16/2025 those who cannot be reached by telephone will be in-serviced when they return to work before taking the floor, by DON. This will be ongoing process and new hire employees will be in-serviced on elopement policy during hire process. 3) Maintenance to verify all wanderguards in use in facility are functional 1/16/25. This was completed 01/16/25. Verified by administrator. Maintenance will make these checks daily Monday thru Friday and nursing staff makes the checks on weekends. These daily wanderguard checks are documented in Point Click Care Nurse Medical Administration Record. 4) Maintenance to verify all doors with wanderguards or alarms are functional this was completed 1/16/25 verified by the administrator. Door locks are checked Monday through Friday by Maintenance. Maintenance documents on his written log. Doors with wanderguard alarms alert and locks the door when resident with wanderguard approaches. Doors with wanderguard system do not alert if staff or visitors open door. Doors with other exit alarms alert when staff, residents or visitors open door. The front door also has the receptionist observing during business hours. When the receptionist leaves the doors are unlocked for staff and visitors but lock automatically with approach of resident with wanderguard. The facility monitors doors after hours by staff responding to alarms. A visitor exiting and a resident behind them with a wanderguard still sets off the alarm as witnessed by Surveyor. Staff responds to door alarms to ensure the safety of residents who wander. Front double door doors will be locked with keypad. Staff will unlock for visitors to enter or exit. 5) Updated elopement assessment on all current residents 1/16/25. Completed by DON, ADON, and MDS nurse. Residents with wanderguards are identified for staff in the front of the elopement binder, on the home dashboard of Point Click Care and the Kardex. Residents may be at high risk for elopement but not actively exit seeking. Until we see exit seeking behavior, they would not be deemed appropriate for an actual wander guard. At the bottom of the elopement risk assessment, it asks if a wanderguard is indicated. If the answer is yes then we would apply a wanderguard. Nurses in-serviced on 1/17/2025 by Administrator to ensure that checks ordered by physician are completed and documented timely. Nurses not in facility today will be in-serviced before they begin their next shift in the facility, this will include new hires. Interdisciplinary team will review elopement assessments that trigger for high risk to determine if a wander guard is warranted. 6) Residents with wanderguards have current orders, careplan and elopement assessment. Completed by ADON on 1/16/25 7) Elopement binders equipped with all high risk for elopement resident facesheets at the front, and all other residents facesheets behind the tab were placed at the nurses station and at the receptionist desk by the DON/Administrator. 8) Staff were inserviced by BOM regarding the elopement binders, where they are located, and how to use them on 01/16/2025. 9) The administrator inserviced on 1/16/2025 the DON and ADON to update the facesheets in the elopement binder with any new admission, or change in elopement risk from low risk to high risk. All nursing staff were inserviced on the elopement policy, including all assessments and notifications to RP and provider that are required, by the DON on 01/16/2025. All nursing staff will receive the inservice prior to starting their next shift. 10) All residents at high risk for elopement will be identified on the C NA Kardex. This inservice will be delivered by the DON to all staff on 01/16/2025. All staff will receive this inservice prior to starting their next shift. 11) All residents who are at high risk for elopement will be added to the home dashboard on the EMR by the DON on 01/16/2025. An inservice will be provided by the DON on 01/16/2025. All nursing staff will receive this inservice prior to beginning their next shift. 12) Facility completed internal investigations on the three elopement incidents. 13) Medical Director informed of IJ on 1/16/2025 by Administrator 14) Ad Hoc QAPI, 1/16/2025 reviewed the IJ, What occurred and what the facility has in place to prevent it from recurring. POR verification was as follows: Record review of facility's discharge list, dated 01/17/25, reflected Residents #1, 2, and 3 were discharged . Resident #3 discharged home on 3/18/24; Resident #1 discharged home on 9/4/24; and Resident #2 discharged to an ALF on 9/3/24. Record review of facility's in-service sheets dated 01/16/25 at 5:45 PM to 01/17/25 at 5:30 PM reflected: 41 staff working had been in-serviced on elopement (100% training rate). Total paid staff was 65. Record review of Logbook Documentation, dated 01/16/25-01/18/25, reflected all doors passed for magnetic door locks(100 hall, 200 hall, 300 hall, 300 hall service door, 400 hall, family room, front door, main dining room, small dining room, therapy rehab gym) and resident monitoring system (400 hall, therapy rehab gym, front door, and Residents #4-10). Record review of the home dashboard of Point Click Care, posted 01/16/25, reflected: Residents at High Risk for Elopement: Resident #4 Resident #5 Resident #6 Resident #7 Resident #25 Resident #24 Resident #23 Resident #22 Resident #21 Resident #20 Resident #19 Resident #18 Resident #9 Resident #10 Resident #26 Resident #16 Resident #15 Resident #13 Resident #12 Resident #8 Resident #14 Resident #17 Resident #11 Record review of facility's high risk elopement list included Resident #11 to Resident #26 whose scores were 10 or above, indicating high risk for elopement on their respective elopement risk assessments, dated 01/16/25: Record review of the 7 residents with wander guard orders (Resident #4 to Resident #10) reflected: care plans listed elopement with interventions, MD orders approved wander-guard and elopement assessments present. Record review of AD HOC QAPI sign in sheet, reflected a QAPI meeting was held on 01/16/25. Observation on 01/17/25 at 08:11PM revealed the Administrator (ADM I) had to let out this Investigator from the building after punching in a code into the keypad. Observation and record review on 01/18/25 at 08:40AM revealed a sign on the front door reflecting Inside Door Locked Please use doorbell. After going through the first front door and approaching the second door to get into the facility, it was observed the Maintenance Dire [TRUNCATED]

Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse for 1 of 24 residents (Resident #21) reviewed for abuse and neglect, in that: The facility failed to implement their policy to report and investigate Resident #21's 11/21/23 fall with a serious injury, per [state agency] guideline. The Administrator, DON, and LVN D did not report Resident #21's fall with a fracture to the state agency. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment, contributing to further serious injuries. The findings included: Record review of Resident #21's Face Sheet, dated 1/12/24, revealed an admitted [DATE] with diagnoses which included fracture of .part of neck of left femur (thigh bone), lack of coordination, cognitive communication deficit, dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, osteoporosis (bone strength weakens and is susceptible to fracture), arthritis (swelling and tenderness of one or more joints), and abnormalities with gait and mobility. Record review of Resident #21's MDS admission assessment, dated 11/14/23, revealed Resident #21 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #21 was assessed with a need for help with self-care and functional cognition. Resident #21 used a walker and a wheelchair in the past 7 days. Resident #21's admission performance was substantial/maximal assistance for the following: toileting hygiene, putting on/taking off footwear, and lower body dressing. Resident #21 had a fall in the last month prior to admission. Record review of Resident #21's care plan revealed Resident #21 had the following: Problem: Transfers, initiated 11/13/23, with an intervention of 1 person assist .Problem: Ambulation/Mobility, initiated 11/13/23, with an intervention of 1 Person Assist and Uses [NAME] .Problem: The resident has limited physical mobility, initiated 11/13/23, with an intervention of The resident uses a walker for walking .Problem: The resident has impaired cognitive function/dementia or impaired thought processes, initiated 11/13/23, with an intervention of Cue, reorient and supervise as needed. Record review of Resident #21's Nurse's Note, authored by LVN D, on 11/21/2023 at 01:42 PM revealed, It was reported to this nurse that [Resident #21] had fallen in her room during independent transfer. It was noted [Resident #21] was unable to move left hip after the fall during assessment. [Resident #21] c/o pain to left hip which was new pain for her. EMS called to send resident to ER for evaluation and treat due to above information. [Resident #21] left facility via EMS at 1342 [01:42 PM]. There were no other notes pertaining to an investigation of the 11/21/2023 incident. During an interview on 01/13/24 at 03:26 PM, the Administrator revealed the DON and LVN D did not report Resident #21's fall on 11/21/23 fall that resulted in a fracture. Record Review of Resident #21's incident reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. Record Review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. There was no record of a Provider Investigation Report of the 11/21/2023 fall with serious injury. Record review of the facility's Change in a Resident's Condition or Status, revised February 2021, revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):1. Accident or incident involving the resident. Record review of the facility's Accidents and Incidents-Investigating and Reporting, revised July 2017, revealed, 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 3. The facility is in compliance with current rules and regulations governing accidents and/or incidents . 5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. 6. The director of nursing services shall ensure that the administer receives a copy of the Report of Incident/Accident form for each occurrence. 7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Record Review of Long-Term Care Regulation Provider Letter, revised 01/19/23, revealed A provider must report reportable incidents to [state agency] Complain and Incident Intake In addition to reporting an incident, a provider must investigate, or ensure that an investigation was completed, to determine why it occurred, what actions the provider will take in response to the incident and what changes will be made to help prevent a similar incident from occurring. On 1/17/2024 at 11:11 AM, there was a request for the Abuse, Neglect, Exploitation policy from the Administrator. No policy was provided. This was determined to be an Immediate Jeopardy on 01/12/2024. The Administrator was notified and provided the IJ template on 01/12/2024 at 07:14 PM. The following Plan of Removal submitted by the facility was accepted on 01/13/2024 at 06:25 PM. Plan of Removal Immediate Jeopardy On 01/12/2024 during annual survey at [facility] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that an event occurred at the facility constituting an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: the facility failed to develop and implement a base line care plan to support Resident #21( ' s) needs for safety related to the assessed high fall risk and experienced a fall with a serious injury. 11/11/23 Resident was assessed by admitting nurse LVN B as high fall risk with a history of falls. (see Action Item #1) MDS nurse C assessed Resident #21 as not a fall risk without a history of falls. (see Action Item #2) Record reviews of Resident #21's incidents reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #3) Record review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #4) Record reviews of Resident #21's nursing assessments revealed no record of change in condition related to Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #5) During an interview on 01/12/2024 with MDS C nurse revealed after Resident #21's 11/25/2023 admission post hospitalization for evaluation and treatment of a hip fracture, she did not update Resident #21's care plan. (see Action Item #2) A record review of the facility's nursing staff in-services from January 2023 through December 2023 revealed no staff training for falls completed after the incident on 11/21/2023. (see Action Item #6) Action #1: Facility Assistant Directors of Nursing (ADONs) completed a Fall Risk Assessment on current residents within the facility on 1-12-2024. Census was 71 and 71 residents had a new Fall Risk Assessment completed. Monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: ADONs, Director of Nursing and Administrator to review completion. Action #2: DON and Administrator inserviced the MDS Nurse on review of fall risk assessments of residents and to reflect on the MDS when completing the MDS for accuracy. MDS nurse also educated on updating the plan of care after review of incident reports for falls and when any resident fall has been identified. Monitoring will continue for new admission review by the clinical leadership (DON,ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: MDS Nurse, Director of Nursing and Administrator to review completion. Action #3: DON and Administrator inserviced the Licensed Nurses on completion of incident reports as required for resident falls and falls with injury timely after the event occurrence. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator to review completion. Action #4: DON and Administrator will review Tulip reporting guidelines and will follow required reporting serious injury reporting. Administrator and DON inserviced by Chief Clinical Officer on incident reporting process. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator Action #5: DON and ADON's inserviced the Licensed Nurses on change of condition and assessment and documentation for any resident with an identified change in condition. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Action #6: DON and ADONs inserviced the Nursing staff on fall management including identification of risk, baseline care plan, care plan interventions, monitoring for falls. Any nursing staff member not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for nursing staff to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Administrator [Facility] 1/12/2024 POR Verification Evidence Action #1: Record review of the facility fall risk assessments revealed a census of 71 residents assessed as a fall risk. All 71 residents were revised for care plans with fall risk interventions. A record review of the facility's New Admission IDT Care Plan Checklist dated 01/13/2024 revealed monitoring will continue for new admissions review by the clinical leadership (dons, ADON's) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Further record review revealed the monitoring included Resident identifiers, diagnoses, fall risk assessments, IDT post admission plan of care completed, care plan updated, and a quality of life manager review. During an interview on 01/13/2024 at 02:45 PM the Administrator stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. During an interview on 1/13/2024 at 03:25 PM the DON stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Action #2: Record review of the facility's in-services revealed the MDS nurse C received an in-service dated 01/12/2023, fall risk assessment and fall risk managing. Action #3: A record review of the facility's nursing staff roster dated 01/13/2024 revealed 78 Nursing staff to include 25 Licensed nurses and 53 CNA's. A record review of the facility's staffing schedule dated 01/13/2024 revealed 6 Licensed nurses worked the 06:00 AM to 06:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 Licensed nurses worked the 06:00 PM to 06:00 AM shift. A record review of the facility's Accident and Incidents in-service records dated 01/12/2024 through 01/13/2024, revealed 12 nurses were in-serviced. Action #4: During an interview on 01/13/204 at 02:45 PM revealed the Chief Clinical Officer in-serviced the Administrator and the DON on TULIP reporting. A record review of the facility's TULIP reporting in-service, dated 01/13/2024 revealed, DON and Administrator will review TULIP reporting Guidelines and will follow required reporting serious injuries. Action #5: A record review of the facility's Change of Condition in-service dated 01/13/2024 revealed 13 nurses were in-serviced. Action #6: Licensed Nurses work 12 hour shifts-6a-6p,6p-6a; C.N.A. staff work 8 hour shifts (6-2,2-10,10-6) A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 19 CNA's received the training. A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 12 nurses received the training. A record review of the facility's staffing schedule dated 01/13/2024 revealed 10 CNA's worked the 06:00 AM to 02:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 8 CNA's worked the 02:00 PM to 10:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 CNA's worked the 02:00 PM to 06:00 AM shift. A record review of the facility's nursing roster revealed a nursing staff of 78, including 53 CNAs and 25 Nurses. 32 staff members were interviewed and a sample of the 18 from all 3 shifts were documented as follows: During an interview on 1/13/2024 at 12:31 PM, ADON A and ADON E revealed that they received four in-services that included: falls, baseline care plans, incident reporting, and change of conditions. CNA 06:00 AM to 02:00 PM shift: During an interview on 1/13/2024 from 01:31 PM- 01:36 PM, CNA G, CNA H, CNA I, CNA L revealed that they received recent training to include care plans and policy for falls. Licensed nurse 06:00 AM to 06:00 PM shift: During an interview on 01/13/2024 from 01:31 PM- 01:36 PM, LVN F, LVN J, LVN K, CMA M revealed that they received recent training to include care plans, when to report an incident, and policy for falls. CNA 02:00 PM to 10:00 PM shift: During an interview on 1/13/2024 at 3:50 PM, CNA O, CNA V, CNA W revealed that they were trained on the policy for falls and care plans. During an interview on 1/13/2024 at 4:20 PM, CNA P revealed that she was trained on knowing care plans, knowing her residents, reporting to nurses, and recognizing change in conditions. CNA 10:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:59 PM, CNA N revealed that she was trained on fall protocol, change of conditions, and documenting to include incident reporting, care plans. During an interview on 1/13/2024 at 4:15 PM, CNA Q revealed that they were trained on care plans and falls. Licensed Nursing 06:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:54 PM, LVN R revealed that she had been a nurse for a while and was trained on care plans, falls, change in conditions, and reporting incidents. During an interview on 1/13/2024 at 4:15 PM, LVN U revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. During an interview on 1/13/2024 at 4:18 PM, LVN S revealed that he received training to include falls, reporting incidents, care plans, and change in conditions. During an interview on 1/13/2024 at 4:23 PM, LVN T revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

Based on interviews and record reviews the facility failed to ensure, based on the comprehensive assessment of residents, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 24 residents (Resident #21) reviewed for quality of care, in that: The facility failed to ensure Resident #21 received appropriate assessments and interventions due to being at high risk for falls. The facility failed to develop Resident #21's care plan to address interventions for risk of falls. Resident #21 had a fall on 11/21/2023 which resulted in an emergency hospitalization for a hip fracture and was admitted to the facility without any interventions for Resident #21's high fall risk. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of not receiving the necessary medical assessments and treatments and contribute to a decline in health status. These findings included: Record review of Resident #21's Face Sheet, dated 1/12/24, revealed an admitted [DATE] and re-admitted [DATE] with diagnoses which included fracture of .part of neck of left femur (thigh bone), lack of coordination, cognitive communication deficit, dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, osteoporosis (bone strength weakens and is susceptible to fracture), arthritis (swelling and tenderness of one or more joints), and abnormalities with gait and mobility. Record review of Resident #21's MDS admission assessment, dated 11/14/23, revealed Resident #21 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #21 was assessed with a need for help with self-care and functional cognition. Resident #21 used a walker and a wheelchair in the past 7 days. Resident #21's admission performance was substantial/maximal assistance for the following: toileting hygiene, putting on/taking off footwear, and lower body dressing. Resident #21 had a fall in the last month prior to admission. Resident #21 also had 91 minutes of individual occupational therapy in the last 7 days and 59 minutes of individual physical therapy in the last 7 days. The Care Area Assessment Summary for falls revealed the care area for falls was triggered, For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. Record review of Resident #21's MDS assessment, dated 11/28/23, revealed Resident #21 had the following declines, when compared to her 11/14/23 MDS admission assessment: Instead of needing substantial/maximal assistance, Resident #21 was dependent for putting on/taking off footwear. Instead of partial/moderate assistance, Resident #21 needed substantial/maximal assistance for toilet transfer. Resident #21 had a new active diagnosis of hip fracture. Resident #21 had a fall in the last month, in the last 2-6 months, and had a fracture related to a fall in the last 6 months. Resident #21 had a new health condition of Hip Replacement. Resident #21 had a new skin condition of a surgical wound. fall in the last month prior to admission. Resident #21 also had 82 minutes of individual occupational therapy in the last 7 days and 67 minutes of individual physical therapy in the last 7 days. There was no Care Area Assessment Summary for this assessment. Record review of Resident #21's care plan revealed Resident #21 had the following: Problem: Transfers, initiated 11/13/23, with an intervention of 1 person assist .Problem: Ambulation/Mobility, initiated 11/13/23, with an intervention of 1 Person Assist and Uses [NAME] .Problem: The resident has limited physical mobility, initiated 11/13/23, with an intervention of The resident uses a walker for walking .Problem: The resident has impaired cognitive function/dementia or impaired thought processes, initiated 11/13/23, with an intervention of Cue, reorient and supervise as needed. Problem: The resident has an alteration in musculoskeletal status LEFT HIP FX .initiated 12/29/23, with interventions Anticipate and meet needs . Problem: The resident has impaired visual function, initiated 11/13/23, with an intervention of Ensure appropriate visual aids glasses are available to support resident's participation in activities . Record review of Resident #21's care plan revealed no documentation of Resident #21 being at risk for falls after admission on 11/11/23 and re-admission on 11/25/23. Record Review of a Nurse's note, authored by LVN B, on 11/11/23 at 01:05 PM revealed, [Resident #21] arrived via [van] for a fall. ***FULL CODE*** No know[n] allergies. A&0 x 3 with confusion. Skin intact Record review of Resident #21 ' s Nurse's Note, authored by LVN D, on 11/21/2023 at 1:42 PM revealed, It was reported to this nurse that [Resident #21] had fallen in her room during independent transfer. It was noted [Resident #21] was unable to move left hip after the fall during assessment. [Resident #21] c/o pain to left hip which was new pain for her. EMS called to send resident to ER for evaluation and treat due to above information. [Resident #21] left facility via EMS at 1342 [01:42 PM]. Record Review of Resident #21's hospital visit, dated 11/21/23, revealed chief complaint of hip fracture with diagnosis that included fracture of .part of neck of left femur (thigh bone) and fracture of part of her left arm [bone] and discharge recommendations for physical therapy and occupational therapy at a Skilled Nursing Facility. During an interview on 01/12/24 at 01:47 PM, MDS nurse C revealed there had been an issue of completing eINTERACT Change in Condition assessments. There was training on completing change in condition assessments. MDS nurse C stated Change in Condition assessments were completed after an injury and after falls. MDS nurse C stated after a resident falls, progress notes and incident reports were to be completed. MDS nurse C further revealed if a resident was a fall risk, it should be documented in the resident's care plan. MDS nurse C revealed that she thought every resident in the facility should be considered at risk for falls. MDS nurse C revealed that a resident's initial care plan came after the IDT admission assessment and Resident #21's care plan was missing Resident #21 she was at risk for falls. MDS nurse C noted that Resident #21's Fall Risk Assessment showed that Resident #21 was a high fall risk. After Resident #21 admission on 11/25/23, after being sent to the hospital for her 11/11/23 fall, the MDS nurse C admitted to not updating Resident #21's care plan to reflect that Resident #21 was at risk for falls. During an interview on 01/12/24 at 03:23 PM, ADON A revealed Resident #21 came back to the facility on [DATE]. ADON A revealed there was not an incident report for the 11/21/23 fall, because Resident #21 went to the hospital and the incident report should have been done when Resident #21 came back. ADON A read aloud the 11/21/2023, Resident #21's nurse progress note, authored by LVN D, to provide information about this incident. ADON A stated that EMS was called and LVN D wrote Resident #21 had left hip pain. ADON A could not give further details about this incident. ADON A further revealed that nursing staff was trained on making incident reports but it would be good to re-train the nursing staff. During an interview on 01/12/24 at 04:33 PM, LVN D revealed that she was not aware of Resident #21 had a fall on 11/11/23. During an interview on 01/12/2024 at 06:04 PM, ADON A revealed there could be an education for when to fill out an incident report and training on falls. ADON A revealed the baseline care plan included falls. ADON A revealed the MDS nurse was to ensure that at risk for falls was added to resident care plans for interventions. During an interview on 01/13/24 at 01:07 PM, the Medical Director revealed there was a high turnover of staff and visiting nurses who did not know specific care for the residents. She further revealed they may not be familiar with the facility's policies. The Medical Director revealed most residents should be identified as high fall risks, making sure there were interventions in place like call lights working. The Medical Director stated since Resident #21 fell before that it would be a given to include being at risk for falls in her care plan. She stated residents with no interventions for those at risk for falls could have recurrent falls. During an interview on 01/13/24 at 01:47 PM, CNA I (who worked on 11/21/23 from 6 AM to 2 PM with Resident #21) revealed she did not recall a fall that occurred on this day. During an interview on 01/13/24 at 01:59 PM, NP Y, who worked for Resident #21's doctor and has worked with Resident #21 to her admission to the facility revealed he recounted care for Resident #21 as follows: Prior to being admitted to this facility, Resident #21 fell , went to the hospital, and then went back to her Assisted Living Facility. She was prescribed medication for pain and became increasingly confused. She had to go back to the emergency room . She was treated and assessed at the hospital, and it was determined that she needed to go to a nursing facility for some rehab. NP Y revealed Resident #21 had dementia and it could have contributed to her fall. NP Y revealed after her 11/21/23 fall, Resident #21 sustained a fracture to her shoulder and her hip. He revealed Resident #21 came back to the nursing home facility to continue rehab. NP Y further revealed his expectation was for the facility to have interventions to prevent falls because Resident #21 was a high fall risk. He recommended that Resident #21 should have been monitored every 2 hours and have her call bell within reach, at the very least. NP Y also mentioned Resident #21 had a UTI, which could have also contributed to her 11/21/23 fall. During an interview on 01/13/24 at 02:08 PM, the DON revealed that all nursing management staff were out, with covid the week of 11/21/23 when the fall occurred. The COVID outbreak date was 11/15/23. The DON revealed that the baseline care plan Kardex for the CNAs was created after the Interdisciplinary team (IDT) assessment. The DON revealed, if a resident had a fall, a risk assessment report would trigger a fall risk assessment to be completed and an action plan would be triggered as well. The DON revealed MDS nurse C was responsible for completing baseline care plans. The DON revealed that LVN D would be able to give more details about Resident #21 ' s 11/21/2023 fall. During an interview on 01/13/24 at 03:26 PM, the Administrator revealed Resident #21 was identified as a high risk for falls due to a fall risk assessment. The Administrator revealed the facility ' s electronic medical record system did not automatically add Resident #21 was at risk for falls on her care plan. The Administrator revealed that they now know how to make sure residents who are assessed as at risk for falls get added to resident care plans. The Administrator revealed that this was important for residents to prevent injuries and for their overall safety. The Administrator further revealed that the care plan should be a story of the Resident and their time in the facility. The Administrator also revealed after Resident #21 ' s 11/21/23 fall, the family and physician were not notified. Resident #21 was discharged on [DATE] and unavailable for observation. The phone number listed on Resident #21's admission record was called without an answer and a message was left on 01/13/24 at 12:06 PM and 05:50 PM, There was no response back. This was the phone number for Resident #21 and Resident #21's Responsibly Party (RP). Record review of the facility's 2023 in-service training records revealed there were no staff trainings completed after Resident #21 ' s 11/21/2023 fall with a serious injury incident. Record Review of Resident #21's Assessments from November to December 2023, revealed that the facility failed to complete an eINTERACT Change in Condition Evaluation V4.2. Record Review of Resident #21's Assessments revealed that the facility completed NSG: FALL RISK EVALUATION V2 assessments, 11/11/2023 (for Admission) and 11/25/2023 (for Reentry), which reflected Resident #21 was at High Risk for falls. Record review of the facility's Admission Assessment and Follow Up: Role of the Nurse policy, revised September 2012, revealed the following: .7. Conduct an admission assessment (history and physical), including: a. A summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall status prior to admission . 9. Conduct supplemental assessments (following facility forms and protocol) including: c. Fall risk assessment Record Review of the facility's policy Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the following: .1. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .3. The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .11. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change .12. The interdisciplinary team reviews and updates the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay Record review of the facility's Fall Risk Assessment policy, revised March 2018, revealed .1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time Record review of the facility's Falls and Fall Risk, Managing policy, revised March 2018, revealed the following: 1. Resident-Centered Approaches to Managing Falls and Fall Risk .1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .7. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling 2. Monitoring Subsequent Falls and Fall Risk .1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified Record review of the facility's Change in a Resident's Condition or Status policy, revised February 2021, revealed the following: .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status Record Review of the facility's Charting and Documentation policy, revised July 2017, revealed the following: .2. The following information is to be documented in the resident medical record: a. objective observations; c. Treatments or services performed; d. Changes in resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate This was determined to be an Immediate Jeopardy on 01/12/2024. The Administrator was notified and provided the IJ template on 01/12/2024 at 07:14 PM. The following Plan of Removal submitted by the facility was accepted on 01/13/2024 at 06:25 PM. Plan of Removal Immediate Jeopardy On 01/12/2024 during annual survey at [facility] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that an event occurred at the facility constituting an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: the facility failed to develop and implement a base line care plan to support Resident #21( ' s) needs for safety related to the assessed high fall risk and experienced a fall with a serious injury. 11/11/23 Resident was assessed by admitting nurse LVN B as high fall risk with a history of falls. (see Action Item #1) MDS nurse C assessed Resident #21 as not a fall risk without a history of falls. (see Action Item #2) Record reviews of Resident #21's incidents reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #3) Record review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #4) Record reviews of Resident #21's nursing assessments revealed no record of change in condition related to Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #5) During an interview on 01/12/2024 with MDS C nurse revealed after Resident #21's 11/25/2023 admission post hospitalization for evaluation and treatment of a hip fracture, she did not update Resident #21's care plan. (see Action Item #2) A record review of the facility's nursing staff in-services from January 2023 through December 2023 revealed no staff training for falls completed after the incident on 11/21/2023. (see Action Item #6) Action #1: Facility Assistant Directors of Nursing (ADONs) completed a Fall Risk Assessment on current residents within the facility on 1-12-2024. Census was 71 and 71 residents had a new Fall Risk Assessment completed. Monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: ADONs, Director of Nursing and Administrator to review completion. Action #2: DON and Administrator inserviced the MDS Nurse on review of fall risk assessments of residents and to reflect on the MDS when completing the MDS for accuracy. MDS nurse also educated on updating the plan of care after review of incident reports for falls and when any resident fall has been identified. Monitoring will continue for new admission review by the clinical leadership (DON,ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: MDS Nurse, Director of Nursing and Administrator to review completion. Action #3: DON and Administrator inserviced the Licensed Nurses on completion of incident reports as required for resident falls and falls with injury timely after the event occurrence. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator to review completion. Action #4: DON and Administrator will review Tulip reporting guidelines and will follow required reporting serious injury reporting. Administrator and DON inserviced by Chief Clinical Officer on incident reporting process. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator Action #5: DON and ADON's inserviced the Licensed Nurses on change of condition and assessment and documentation for any resident with an identified change in condition. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Action #6: DON and ADONs inserviced the Nursing staff on fall management including identification of risk, baseline care plan, care plan interventions, monitoring for falls. Any nursing staff member not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for nursing staff to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Administrator [Facility] 1/12/2024 POR Verification Evidence Action #1: Record review of the facility fall risk assessments revealed a census of 71 residents assessed as a fall risk. All 71 residents were revised for care plans with fall risk interventions. A record review of the facility's New Admission IDT Care Plan Checklist dated 01/13/2024 revealed monitoring will continue for new admissions review by the clinical leadership (dons, ADON's) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Further record review revealed the monitoring included Resident identifiers, diagnoses, fall risk assessments, IDT post admission plan of care completed, care plan updated, and a quality of life manager review. During an interview on 01/13/2024 at 02:45 PM the Administrator stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. During an interview on 1/13/2024 at 03:25 PM the DON stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Action #2: Record review of the facility's in-services revealed the MDS nurse C received an in-service dated 01/12/2023, fall risk assessment and fall risk managing. Action #3: A record review of the facility's nursing staff roster dated 01/13/2024 revealed 78 Nursing staff to include 25 Licensed nurses and 53 CNA's. A record review of the facility's staffing schedule dated 01/13/2024 revealed 6 Licensed nurses worked the 06:00 AM to 06:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 Licensed nurses worked the 06:00 PM to 06:00 AM shift. A record review of the facility's Accident and Incidents in-service records dated 01/12/2024 through 01/13/2024, revealed 12 nurses were in-serviced. Action #4: During an interview on 01/13/204 at 02:45 PM revealed the Chief Clinical Officer in-serviced the Administrator and the DON on TULIP reporting. A record review of the facility's TULIP reporting in-service, dated 01/13/2024 revealed, DON and Administrator will review TULIP reporting Guidelines and will follow required reporting serious injuries. Action #5: A record review of the facility's Change of Condition in-service dated 01/13/2024 revealed 13 nurses were in-serviced. Action #6: Licensed Nurses work 12 hour shifts-6a-6p,6p-6a; C.N.A. staff work 8 hour shifts (6-2,2-10,10-6) A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 19 CNA's received the training. A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 12 nurses received the training. A record review of the facility's staffing schedule dated 01/13/2024 revealed 10 CNA's worked the 06:00 AM to 02:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 8 CNA's worked the 02:00 PM to 10:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 CNA's worked the 02:00 PM to 06:00 AM shift. A record review of the facility's nursing roster revealed a nursing staff of 78, including 53 CNAs and 25 Nurses. 32 staff members were interviewed and a sample of the 18 from all 3 shifts were documented as follows: During an interview on 1/13/2024 at 12:31 PM, ADON A and ADON E revealed that they received four in-services that included: falls, baseline care plans, incident reporting, and change of conditions. CNA 06:00 AM to 02:00 PM shift: During an interview on 1/13/2024 from 01:31 PM- 01:36 PM, CNA G, CNA H, CNA I, CNA L revealed that they received recent training to include care plans and policy for falls. Licensed nurse 06:00 AM to 06:00 PM shift: During an interview on 01/13/2024 from 01:31 PM- 01:36 PM, LVN F, LVN J, LVN K, CMA M revealed that they received recent training to include care plans, when to report an incident, and policy for falls. CNA 02:00 PM to 10:00 PM shift: During an interview on 1/13/2024 at 3:50 PM, CNA O, CNA V, CNA W revealed that they were trained on the policy for falls and care plans. During an interview on 1/13/2024 at 4:20 PM, CNA P revealed that she was trained on knowing care plans, knowing her residents, reporting to nurses, and recognizing change in conditions. CNA 10:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:59 PM, CNA N revealed that she was trained on fall protocol, change of conditions, and documenting to include incident reporting, care plans. During an interview on 1/13/2024 at 4:15 PM, CNA Q revealed that they were trained on care plans and falls. Licensed Nursing 06:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:54 PM, LVN R revealed that she had been a nurse for a while and was trained on care plans, falls, change in conditions, and reporting incidents. During an interview on 1/13/2024 at 4:15 PM, LVN U revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. During an interview on 1/13/2024 at 4:18 PM, LVN S revealed that he received training to include falls, reporting incidents, care plans, and change in conditions. During an interview on 1/13/2024 at 4:23 PM, LVN T revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

Based on nterview and record review the facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #21 had an unwitnessed fall with a serious injury on 11/21/23, per [state agency] guideline. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of their corrective actions. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment, contributing to further serious injuries. The findings included: Record review of Resident #21's Face Sheet, dated 1/12/24, revealed an admitted [DATE] with diagnoses which included fracture of .part of neck of left femur (thigh bone), lack of coordination, cognitive communication deficit, dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, osteoporosis (bone strength weakens and is susceptible to fracture), arthritis (swelling and tenderness of one or more joints), and abnormalities with gait and mobility. Record review of Resident #21's MDS admission assessment, dated 11/14/23, revealed Resident #21 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #21 was assessed with a need for help with self-care and functional cognition. Resident #21 used a walker and a wheelchair in the past 7 days. Resident #21's admission performance was substantial/maximal assistance for the following: toileting hygiene, putting on/taking off footwear, and lower body dressing. Resident #21 had a fall in the last month prior to admission. Record review of Resident #21's care plan revealed Resident #21 had the following: Problem: Transfers, initiated 11/13/23, with an intervention of 1 person assist .Problem: Ambulation/Mobility, initiated 11/13/23, with an intervention of 1 Person Assist and Uses [NAME] .Problem: The resident has limited physical mobility, initiated 11/13/23, with an intervention of The resident uses a walker for walking .Problem: The resident has impaired cognitive function/dementia or impaired thought processes, initiated 11/13/23, with an intervention of Cue, reorient and supervise as needed. Record review of Resident #21's Nurse's Note, authored by LVN D, on 11/21/2023 at 01:42 PM revealed, It was reported to this nurse that [Resident #21] had fallen in her room during independent transfer. It was noted [Resident #21] was unable to move left hip after the fall during assessment. [Resident #21] c/o pain to left hip which was new pain for her. EMS called to send resident to ER for evaluation and treat due to above information. [Resident #21] left facility via EMS at 1342 [01:42 PM]. There were no other notes pertaining to an investigation of the 11/21/2023 incident. During an interview on 01/13/24 at 03:26 PM, the Administrator revealed the DON and LVN D did not report Resident #21's fall on 11/21/23 fall that resulted in a fracture. Record Review of Resident #21's incident reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. Record Review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. There was no record of a Provider Investigation Report of the 11/21/2023 fall with serious injury. Record review of the facility's Change in a Resident's Condition or Status, revised February 2021, revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):1. Accident or incident involving the resident. Record review of the facility's Accidents and Incidents-Investigating and Reporting, revised July 2017, revealed, 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 3. The facility is in compliance with current rules and regulations governing accidents and/or incidents . 5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. 6. The director of nursing services shall ensure that the administer receives a copy of the Report of Incident/Accident form for each occurrence. 7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Record Review of Long-Term Care Regulation Provider Letter, revised 01/19/23, revealed A provider must report reportable incidents to [state agency] Complain and Incident Intake In addition to reporting an incident, a provider must investigate, or ensure that an investigation was completed, to determine why it occurred, what actions the provider will take in response to the incident and what changes will be made to help prevent a similar incident from occurring. On 1/17/2024 at 11:11 AM, there was a request for the Abuse, Neglect, Exploitation policy from the Administrator. No policy was provided. This was determined to be an Immediate Jeopardy on 01/12/2024. The Administrator was notified and provided the IJ template on 01/12/2024 at 07:14 PM. The following Plan of Removal submitted by the facility was accepted on 01/13/2024 at 06:25 PM. Plan of Removal Immediate Jeopardy On 01/12/2024 during annual survey at [facility] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that an event occurred at the facility constituting an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: the facility failed to develop and implement a base line care plan to support Resident #21( ' s) needs for safety related to the assessed high fall risk and experienced a fall with a serious injury. 11/11/23 Resident was assessed by admitting nurse LVN B as high fall risk with a history of falls. (see Action Item #1) MDS nurse C assessed Resident #21 as not a fall risk without a history of falls. (see Action Item #2) Record reviews of Resident #21's incidents reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #3) Record review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #4) Record reviews of Resident #21's nursing assessments revealed no record of change in condition related to Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #5) During an interview on 01/12/2024 with MDS C nurse revealed after Resident #21's 11/25/2023 admission post hospitalization for evaluation and treatment of a hip fracture, she did not update Resident #21's care plan. (see Action Item #2) A record review of the facility's nursing staff in-services from January 2023 through December 2023 revealed no staff training for falls completed after the incident on 11/21/2023. (see Action Item #6) Action #1: Facility Assistant Directors of Nursing (ADONs) completed a Fall Risk Assessment on current residents within the facility on 1-12-2024. Census was 71 and 71 residents had a new Fall Risk Assessment completed. Monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: ADONs, Director of Nursing and Administrator to review completion. Action #2: DON and Administrator inserviced the MDS Nurse on review of fall risk assessments of residents and to reflect on the MDS when completing the MDS for accuracy. MDS nurse also educated on updating the plan of care after review of incident reports for falls and when any resident fall has been identified. Monitoring will continue for new admission review by the clinical leadership (DON,ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: MDS Nurse, Director of Nursing and Administrator to review completion. Action #3: DON and Administrator inserviced the Licensed Nurses on completion of incident reports as required for resident falls and falls with injury timely after the event occurrence. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator to review completion. Action #4: DON and Administrator will review Tulip reporting guidelines and will follow required reporting serious injury reporting. Administrator and DON inserviced by Chief Clinical Officer on incident reporting process. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator Action #5: DON and ADON's inserviced the Licensed Nurses on change of condition and assessment and documentation for any resident with an identified change in condition. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Action #6: DON and ADONs inserviced the Nursing staff on fall management including identification of risk, baseline care plan, care plan interventions, monitoring for falls. Any nursing staff member not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for nursing staff to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Administrator [Facility] 1/12/2024 POR Verification Evidence Action #1: Record review of the facility fall risk assessments revealed a census of 71 residents assessed as a fall risk. All 71 residents were revised for care plans with fall risk interventions. A record review of the facility's New Admission IDT Care Plan Checklist dated 01/13/2024 revealed monitoring will continue for new admissions review by the clinical leadership (dons, ADON's) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Further record review revealed the monitoring included Resident identifiers, diagnoses, fall risk assessments, IDT post admission plan of care completed, care plan updated, and a quality of life manager review. During an interview on 01/13/2024 at 02:45 PM the Administrator stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. During an interview on 1/13/2024 at 03:25 PM the DON stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Action #2: Record review of the facility's in-services revealed the MDS nurse C received an in-service dated 01/12/2023, fall risk assessment and fall risk managing. Action #3: A record review of the facility's nursing staff roster dated 01/13/2024 revealed 78 Nursing staff to include 25 Licensed nurses and 53 CNA's. A record review of the facility's staffing schedule dated 01/13/2024 revealed 6 Licensed nurses worked the 06:00 AM to 06:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 Licensed nurses worked the 06:00 PM to 06:00 AM shift. A record review of the facility's Accident and Incidents in-service records dated 01/12/2024 through 01/13/2024, revealed 12 nurses were in-serviced. Action #4: During an interview on 01/13/204 at 02:45 PM revealed the Chief Clinical Officer in-serviced the Administrator and the DON on TULIP reporting. A record review of the facility's TULIP reporting in-service, dated 01/13/2024 revealed, DON and Administrator will review TULIP reporting Guidelines and will follow required reporting serious injuries. Action #5: A record review of the facility's Change of Condition in-service dated 01/13/2024 revealed 13 nurses were in-serviced. Action #6: Licensed Nurses work 12 hour shifts-6a-6p,6p-6a; C.N.A. staff work 8 hour shifts (6-2,2-10,10-6) A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 19 CNA's received the training. A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 12 nurses received the training. A record review of the facility's staffing schedule dated 01/13/2024 revealed 10 CNA's worked the 06:00 AM to 02:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 8 CNA's worked the 02:00 PM to 10:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 CNA's worked the 02:00 PM to 06:00 AM shift. A record review of the facility's nursing roster revealed a nursing staff of 78, including 53 CNAs and 25 Nurses. 32 staff members were interviewed and a sample of the 18 from all 3 shifts were documented as follows: During an interview on 1/13/2024 at 12:31 PM, ADON A and ADON E revealed that they received four in-services that included: falls, baseline care plans, incident reporting, and change of conditions. CNA 06:00 AM to 02:00 PM shift: During an interview on 1/13/2024 from 01:31 PM- 01:36 PM, CNA G, CNA H, CNA I, CNA L revealed that they received recent training to include care plans and policy for falls. Licensed nurse 06:00 AM to 06:00 PM shift: During an interview on 01/13/2024 from 01:31 PM- 01:36 PM, LVN F, LVN J, LVN K, CMA M revealed that they received recent training to include care plans, when to report an incident, and policy for falls. CNA 02:00 PM to 10:00 PM shift: During an interview on 1/13/2024 at 3:50 PM, CNA O, CNA V, CNA W revealed that they were trained on the policy for falls and care plans. During an interview on 1/13/2024 at 4:20 PM, CNA P revealed that she was trained on knowing care plans, knowing her residents, reporting to nurses, and recognizing change in conditions. CNA 10:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:59 PM, CNA N revealed that she was trained on fall protocol, change of conditions, and documenting to include incident reporting, care plans. During an interview on 1/13/2024 at 4:15 PM, CNA Q revealed that they were trained on care plans and falls. Licensed Nursing 06:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:54 PM, LVN R revealed that she had been a nurse for a while and was trained on care plans, falls, change in conditions, and reporting incidents. During an interview on 1/13/2024 at 4:15 PM, LVN U revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. During an interview on 1/13/2024 at 4:18 PM, LVN S revealed that he received training to include falls, reporting incidents, care plans, and change in conditions. During an interview on 1/13/2024 at 4:23 PM, LVN T revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of their corrective actions.

The facility remained out of compliance at severity of no actual harm with a potential for more than minimal harm. Based on interviews and record reviews, the facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 3 residents (Resident #1) reviewed for receiving nursing services in that: 1. The nurses did not report Resident #1's weight gain to the physician as ordered. 2. The nurses did not follow physician orders to weigh Resident #1 daily. 3. The nurses did not report to the physician Resident #1 was not weighed daily per orders. 4. The nurses were unable to contact Resident #1's physician when the resident had a change of condition on 12/29/2022 which required emergency services and a transfer to the emergency room . These failures resulted in the identification of an Immediate Jeopardy (IJ) on 01/17/2023 at 4:50 p.m. While the IJ was removed on 01/20/2023, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its corrective systems. These failures could place residents at risk for health status decline and deny the physician opportunities to intervene on behalf of the resident(s). The findings included: A record review of Resident #1's Admission Record, dated 01/01/2023, revealed an admitted [DATE], with diagnoses of a head laceration (cut), heart failure, pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart which causes the heart to work harder to pump blood into the lungs), and a cardiac pacemaker (medical device implanted under the skin to assist the heart with beating). The Admission Record indicated Resident #1's primary physician was Physician A. Further review of the Admission Record under Miscellaneous Information revealed Resident #1 was discharged from the facility on 12/30/2022 to another nursing home. A record review of Resident #1's Admission MDS, dated [DATE], revealed Resident #1 was a [AGE] year-old female diagnosed with heart failure and her cognitive skills for daily decision making were intact with a BIMS (Brief Interview of Mental Status) score of 13 out of 15, and required assistance of 1 person with locomotion. A record review of Resident #1's Care Plan dated 01/01/2023, revealed Resident #1 had a need for monitoring and support for her heart failure and a cardiac pacemaker. The interventions were monitor, document, report, any signs, and symptoms of coronary artery disease .dependent edema [swelling]. A record review of Resident #1's Physician's Order Summary dated 01/01/2022, revealed an order dated 11/26/2022, for nurses to weigh Resident #1 daily and report to Physician B (Resident #1's cardiologist [heart doctor]) any weight gain of 3 pounds or more in 1 day and/or a 5-pound weight gain over 3 days. A record review of Resident #1's Daily Weight Record revealed a weight gain of 3.4 pounds from 116 pounds on 11/29/2022 to 119.4 pounds on 11/30/2022. Further review revealed Resident # 1 was not weighed on 12/04/2022, 12/23/2022, 12/25/2022, and 12/26/2022. A record review of Resident #1's Nursing Progress Notes dated 12/19/2022, authored by the Registered Dietician (RD) indicated the resident's weight was 123.2 pounds on 12/08/2022, 126.2 pounds on 12/14/2022, and was 126.4 pounds on 12/19/2022 which was a significant weight gain of 10.2 pounds, an 8.8% increase in 21 days. A record review of Resident #1's Nursing Progress Notes dated 12/23/2022, authored by LVN C documented the reason why Resident #1 was not weighed daily was due to Resident on contact isolation. A record review of Resident #1's Nursing Progress Notes dated 12/26/2022 revealed a note authored by LVN D documented the reason why Resident #1 was not weighed daily was due to on isolation for COVID-19. A record review of Resident #1's Nursing Progress Notes dated 12/27/2022, authored by LVN D documented the reason why Resident #1 was not weighed daily was due to on isolation and can-not leave room. Record review of Resident #1's emergency room Nursing Home Transfer form dated 12/29/22, located in the resident's electronic clinical record under the Miscellaneous tab, revealed Resident #1 was admitted to the emergency room at 13:51 (01:51 p.m.). The report revealed Resident #1's Physician B (her cardiologist) was contacted who recommended Resident #1's Lasix (diuretic medication to release fluid from the body) be increased to 40 mg twice a day, then 40 mg once a day. The Nursing Home Transfer form revealed Resident #1 received Lasix 40 mg IV (intravenous) at the hospital for peripheral edema (swelling to the hands or feet), was provided with new orders for Lasix 40 mg BID (twice a day) for 2 days and was discharged at 16:36 (04:36 p.m.) on 12/29/22 back to the facility. Record reviews of Resident #1's Medical Record on 01/01/2023 failed to reveal any documents (nurses notes or assessments) related to Resident #1's change of condition on 12/29/2022 which required emergency services and a transfer to the emergency room . During an interview on 01/01/2023 at 1:10 p.m., Resident #1 stated on 12/29/2022 she was taken to the emergency room at the hospital. Resident #1 stated her primary care physician (Physician A) informed the emergency room doctor he had not received any messages from the nursing home concerning her weight gain and swelling. Resident #1 stated her body was swollen from 13 pounds of excess fluid and the emergency room nurse had to cut off her wedding ring before administering intravenous medications. Resident #1 stated the emergency room doctor reported the amount of excess fluid was extremely serious due to her heart condition and may have contributed with problems getting her head wound to close. Resident #1 stated LVN A and RN B cared for her on 12/29/2022 and discovered her left arm and left side of her body were swollen to the point her clothes were not fitting her and she was losing circulation to her left hand and feet. Resident #1 stated she requested the nurses call her physician to which they replied, we cannot it is Christmas holidays, and the doctor is not available. Resident #1 stated she was eventually transported to the hospital where she received care. Resident #1 stated she was not weighed daily and was told we do not have a scale. Resident #1 stated the facility did have a scale, I was weighed on a wheelchair scale and a 'stand on scale', but when they moved me to the COVID-19 isolation room they did not weigh me daily. During an interview on 01/01/2023 at 5:20 p.m., LVN A stated she and RN B assessed Resident #1 on 12/29/2022 with a swollen left body side, which included her arm and hand. LVN A stated she and RN B called Resident #1's physician (Physician A), reached the physician's office, and left a message for the physician to return their call. LVN A stated the physician did not call back and after 2 more attempts to reach the physician failed, she and RN B arranged for the facility's van driver to transport Resident #1 to the emergency room . LVN A stated she was not aware of Resident #1's gradual weight gain over the month. LVN A stated she had not documented any findings surrounding the events of Resident #1's weight gain, swelling, change of condition, attempts to reach the physician, details surrounding the transport of Resident #1 to the hospital, I have no excuse .I thought RN B was going to write the notes. During an interview on 01/01/2023 at 5:37 p.m. RN B stated she and LVN A assessed Resident #1 on 12/29/2022 and discovered Resident #1 with pain and swelling to her left side of her body which included her left hand, I was concerned for the lack of circulation and swelling to her left ring finger. RN B stated she and LVN B attempted to call Resident #1's physician more than 3 times without success, RN B stated each time over the course of 2 hours they left messages with Resident #1's physician office (Physician A) for an urgent call back, with no call back from the physician. RN B stated the situation grew to a stressful situation where she did not believe the situation called for a 911 call but was serious enough to warrant LVN A and herself to arrange for the facility's van driver to transport Resident #1 to the hospital's emergency room . RN B stated she was not aware of Resident #1's gradual weight gain over the month. RN B stated she had not documented any findings surrounding the events of Resident #1's weight gain, swelling, change of condition, attempts to reach the physician, details surrounding the transport of Resident #1 to the hospital, I know I should have documented . I did not .I thought LVN B documented. RN B stated the failure to document could place residents at risk for harm by inaccurate medical records. Further interview on 01/14/2023 at 4:15 p.m. RN B stated she did not contact the medical director when she and LVN A were unable to contact Physician A about Resident #1's change of condition. In a telephone interview on 01/14/2023 at 11:30 a.m., Physician A stated she honestly could not remember if the facility had contacted her about Resident #1's weight gain, stated it would have been Resident #1's cardiologist (Physician B) who would have been notified about the weight change since he had prescribed her diuretics. Physician A stated she was not notified Resident #1's weights were not obtained daily as ordered. Physician A stated her office nurse did notify her Resident #1 had been sent to the ER. On 01/14/2023 at 1:24 p.m., the surveyor called Physician B (Resident #1's cardiologist) without success of contacting him by the time the surveyor exited the facility. During an interview on 01/01/2023 at 6:10 p.m. the Administrator and the DON stated the events surrounding Resident #1's 12/29/2022 need for emergency services were not handled as best as could be. Resident #1 could have and should have been weighed daily even in the COVID-19 isolation unit. The DON stated the facility had scales the staff could have used to assess Resident #1 for weight gain. The DON stated the nursing staff could and should have reported to him and the physician the lack of a daily weights for Resident #1. The DON stated the inability to give Resident #1's physician a report was a serious problem the Administrator and himself would investigate. The Administrator concurred. The Administrator and the DON stated the failure could have placed Resident(s) at risk for serious harm for health status decline and inaccurate records. Further interview on 01/14/2023 at 10:44 a.m., the DON stated he was not aware Resident #1's weights were not obtained daily as ordered. The DON stated, I know there was a difficulty in reaching a response from some of the physicians and Physician A was one of the ones that are difficult to get a hold of. The DON stated we have changed physician groups since then to Physician Group C who started providing services to residents. The DON stated on 01/16/2023 the facility would approach the residents and their responsible parties who reside on 100 Hall to ask them if they want to switch their primary physician to the physician with Physician Group C. Then residents on the other halls would also be approached to slowly phase out the local physicians that are difficult to reach. The DON stated newly admitted residents had the option of receiving services from Physician Group C and several newly admitted residents had chosen Physician Group C for their primary physician. The DON stated the physician with Physician Group C had given the DON his cell phone number, does not mind being called 24-hours a day and was prompt in returning calls from the facility. In an interview on 01/14/2023 at 11:43 a.m., the Administrator stated the facility had started to use the services from Physician Group C. The Administrator stated they did not have a contract with Physician Group C as the physician with that group was not their medical director. The Administrator stated he did have emails with Physician Group C he could provide to the surveyor. Record review of email correspondence from Physician Group C to the Administrator, dated 1/2/2023, revealed Physician Group A provided the facility with an onboarding form. Record review of email correspondence from the DON to Physician Group C, dated 01/10/2023, revealed the DON had requested information of the groups medical personnel to set up their electronic medical records access. In an interview on 01/14/2023 at 1:45 p.m., RN A stated she had called Physician Group C yesterday (01/13/2023), left a message and received a call back in about 20 minutes. In an interview on 01/14/2023 at 2:00 p.m. LVN E stated she has not had a change in a resident's condition that needed an immediate response from the physician. LVN E stated the response times from the local physicians would vary and often they would not get back to the facility until the next day for non-urgent issues. LVN E stated the facility recently started working with Physician Group C; she had worked with Physician Group C before, and it was nice having a group (of physicians) who answers right away. In an interview on 01/14/2023 at 11:57 a.m. with the DON, he revealed the facility had not done any in-services since 12/27/2022 which was about abuse and neglect. In an interview on 01/14/2023 at 4:47 p.m., the DON stated the facility did not have a policy directing staff who they should contact when the resident's physician could not be notified. The DON stated the policy on a resident's change of condition mentioned contacting the resident's physician. Record review of the Change in a Resident's Condition or Status policy, revised February 2021, revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition; .g. need to transfer the resident to a hospital/treatment center; .2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); . Record review of facility's Abuse/Neglect/Misappropriation Prevention Program dated April 2021 read: .Protect residents from abuse, neglect .develop and implement policies and protocols to prevent and identify .neglect of residents . The Administrator was notified by phone on 01/17/2023 at 4:50 p.m. that an Immediate Jeopardy was identified due to the above failures and the IJ template was provided via email. The facility's plan of removal (POR) was accepted on 01/18/2023 at 4:30 p.m. and included: Abatement plan for IJ called 01/17/2023 around 5 p.m. today at Windcrest Nursing and Rehab, 210 W Windcrest Street, Fredericksburg, Texas 78624. Summary of details which lead to outcomes: IJ called relating to facility not ensuring licensed nurses were assessing residents and reporting abnormal findings to the physician according to physician orders, that could likely result in serious harm to this 1 resident, that was identified during the investigation. The following plan of action outlines immediate interventions employed by the facility to abate any further concerns surrounding the above issue. 1. On 01/01/2023, the two licensed nurses were educated by the DON on facility protocols for assessing and reporting abnormal findings physician orders. This included education on the protocols for assessing a resident with change of condition, reporting process to physicians for change of condition, documenting in clinical record, and following physician orders. DON/designee, will continue to monitor, daily, in morning meeting, the assessments and change of conditions for the past 24 hours, and following of physician orders to reporting changes to be documented in the clinical record. 2. DON/designee educated facility licensed nurses on using the current process from 01/01/23, change of condition, daily weights. This process has been effective since 01/01/2023 going forward, with no concerns identified by DON/designee for any of the above. DON/designee continue to review 24-hour report daily regarding assessment of residents, changes of condition, notification to physicians and documentation in the clinical record. 3. Morning clinical stand up has identified no other concerns since 01/01/2023 going forward. 4. DON/designee will continue to monitor daily, for assessments, complying with physician orders, change of condition for any potential issues that might occur and will address when identified. 5. All licensed nurses will be educated by DON/designee, on the facility protocols regarding changes of condition, notifications associated with and documentation of incident identified on an ongoing basis as needed. Chart review will be conducted by DON/designee utilizing 24-hour report, for follow-up on appropriate assessments, change of condition, reporting to physician, and documenting the event in the clinical. 6. During daily morning clinical meeting, documentation from the past 24 hours will be reviewed by the DON/designee to ensure assessments, change of conditions, reporting to physicians, and documentation of events are in the clinical record. Since the identified concern noted on 01/01/2023, this process has been in place and no identified issues or concerns were identified per guidance. Any concern found will be addressed at the time identified. DON/designee will continue to review clinical documentation daily on an ongoing basis to ensure nursing assessments, change of condition, reporting and documenting is completed. On 01/18/2023 through 01/20/2023, the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by: During an observation and interview on 01/18/2023 at 3:43 p.m., Resident #2 was in her room in bed watching TV, receiving continuous oxygen at 3.5 liters per minute; w/c and walker were present. Call light was within reach. The resident revealed: the care she received was pretty good. She was given the assistance she needed for ADLs. She revealed that interventions for her CHF included medications, monitoring, and taking of vital signs. She stated that daily I am weighed for fluid retention .right now I am not retaining fluids . She stated that she knew the signs of fluid retention which included swelling of the legs. She felt that the facility and MD were monitoring her weight and fluid retention. She had no complaints about her care and did not feel neglected. During an observation and interview on 01/18/2023 at 4 p.m., Resident #4 was in his room sitting on a w/c, cleaned and groomed, call light was within reach, no skin tears or bruises present. The resident revealed his care was good and his needs were met. The resident stated that he was weighed every day and sometimes twice in the month of December and January 2023. Observation and interview on 01/18/2023 at 5 p.m. of Hot Zone (Hall 300) revealed: a sitting weight chair was present in the Hot Zone. Observation of Resident #3 revealed she was sitting on a coach watching TV, alert and oriented, receiving continuous oxygen at 2 liters per minute. The resident revealed she had been weighed two times since she was moved to the Hot Zone. The resident stated that weights were taken as an indicator of any fluid retention for her CHF. The resident described her care as excellent and her needs were met. The resident denied any neglect around treatments and interventions for her multiple diagnoses. During an interview on 01/18/2023 at 5:15 p.m., LVN F revealed: Resident #3 was weighed the two days she was in the Hot Zone; and the resident was being monitored for any change of condition. LVN F would notify the MD if there was a change of condition. LVN F stated she attended training on assessing a resident for change of condition, reporting to the physician, and following physician orders. During an interview on 01/19/2023 at 9:22 a.m., the DON revealed: the DON provided in-service on change of condition and notification of physician on 01/01/2023 to LVN A and RN B. Also, the training involved monitoring a resident in the COVID-19 unit and documenting a weighing a resident in the COVID-19 unit. Documentation of education for the latter nursing staff was placed in the employee files.[ Surveyor interviewed LVN A and RN B on the training received from the DON] During an interview on 01/19/2023 at 9:28 a.m., RN B (day shift) revealed: she received in-service on 01/01/2023 on change of condition, following MD orders, and contacting MD. The highlight that stood out from the training was to contact the facility's physician when you cannot contact the primary. Also, the MD orders need to be followed and documented even if the resident was in the Hot Zone. RN B stated the system failure was not contacting the MD to address the fluid retention in the resident's arm. Likewise, RN B had received training on abuse and neglect. During an interview on 01/19/2023 at 9:37 a.m., LVN A (day shift) revealed: she received in-service training on 01/01/2023 on the topics of change for condition, contacting the MD, and following MD orders. The highlights of the training were to contact the MD or the facility MD to address a change of condition, and to follow MD orders. LVN A stated the system failure was lack of communications from the MD's office; the resident's arm was swelling and the whole left side of the body was swelling; resident was on the COVID-19 for 10 days. Also, LVN A had received training on abuse/neglect in the past. During an interview on 01/19/2023 at 10:05 a.m., LVN E (day shift) revealed: she received training on change of condition and the highlight was to call the MD and if nurse could not find the primary MD to call the facility MD. Also, nursing staff needed to follow MD orders even if the resident was in the COVID-19. She also received training on abuse/neglect. During an interview on 01/19/2023 at 10:12 a.m., LVN G (day shift) revealed she attended in-service on change of condition and MD notification. She recalled the highlights were to contact the facility MD if no contact was made with primary MD. Also, follow MD orders regardless of the location of the resident. Also, contact RP and MD immediately when there is a change of condition. During an interview on 01/19/2023 at 10:18 a.m., Med Aide H (morning shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, Med Aide H received abuse/neglect training in the past. The highlights of the training were: concerns need to be voiced involving a change of command as soon as possible to the charge nurse. During an interview on 01/19/2023 at 10:31 a.m., CNA I (morning shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, CNA I received abuse/neglect training in the past. The highlights of the training were: contact nursing staff when there was a change of condition. CNA I stated there was a weight scale in the Hot Zone to weigh residents. During an interview on 01/19/2023 at 10:40 a.m., CNA J (morning shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, CNA J received abuse/neglect training in the past. The highlights of the training were: to contact the charge nurse if there was a change of condition and to closely monitor a resident. CNA J stated that training revealed there was a weight scale in the Hot Zone for weighing residents. During an interview on 01/19/2023 at 10:58 a.m., LVN L stated: he attended morning meetings this week (01/16/2023 to 01/19/2023) and the meetings discussed assessments, change of conditions, reporting to physicians, and documentation of events are in the clinical record. Also, meetings emphasized to follow through on any change of condition or assessments of new admissions. Regarding new admissions, residents would be put in the warm zone regarding their vaccination history and signs and symptoms of COVID-19. LVN L stated that training revealed there was a weight scale in the Hot Zone for weighing residents. During an interview on 01/19/2023 at 10:53 a.m., CNA K (night shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, CNA K received abuse/neglect training in the past. The highlights of the training were: to report any change of condition to the charge nurse. CNA K stated that training revealed there was a weight scale in the Hot Zone for weighing residents. During an interview on 01/19/2023 at 11 a.m., LVN L (night shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, LVN L received abuse/neglect training in the past. The highlights of the training were: document change of condition, notifying the MD in timely manner and follow-up with any new orders given. As a nurse, to monitor, document, and report findings whether the resident is improving or declining. LVN L stated that training revealed there was a weight scale in the Hot Zone for weighing residents. During a joint interview on 01/19/2023 at 11:10 a.m., the Administrator stated morning reports are held at 9 a.m. to discuss assessments, change of conditions, reporting to physicians, and documentation of events are in the clinical record. Since 01/01/2023 to 01/19/2023, there have been 13 new admissions and the assessments and MD follow-up were discussed at the morning meetings. The DON added that the focus of the morning meetings was the discussion of the 24-hour report. The clinical part of the meeting's attendees were: Administrator, DON, 2 ADON, MDS nurse and Director of Rehab and charge nurses. Immediacy per the DON for Resident #1 was removed when the resident was sent to the hospital on 12/29/22 and a weight was placed in the COVID-19 unit. During an interview on 01/19/2023 at 7:28 p.m., CNA M (evening shift) stated: education was provided on change of condition, contacting the MD, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: to report a change of condition if a changed occurred to the nurse; follow orders on daily weights. If working in the COVID unit there was a scale present; just sit the resident on a chair, get a reading to tell the nurse. During an interview on 01/19/2023 at 7:33 p.m., CNA N (evening shift) revealed: education was provided on change of condition, contacting the MD, weight assessment and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: inform the charge nurse if there was a change of condition in the resident; and follow MD orders on weights. In the Hot Zone there was a chair that takes weights and once weights are taken give the result to the charge nurse. During an interview on 01/19/2023 at 7:37 p.m., Med Aide O (evening shift) revealed: education was provided on change of condition, contacting the MD, weight assessment, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: observe for reactions to medications and adverse effects to medications and inform the charge nurse; follow MD orders regardless of time; in the Hot Zone there was a weight chair; and sanitize after every use. During an interview on 01/19/2023 at 7:43 p.m., Student Nurse Aide P (evening shift) revealed: education was provided on change of condition, contacting the MD, weight assessment and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: monitor resident's change of condition and report changes to the nurse. As for weight assessment, we should take weights before breakfast .in the Hot Zone there is a wheel scale chair for weights. During an interview on 01/19/2023 at 7:47 p.m., LVN Q (night shift) revealed: education was provided on change of condition, contacting the MD, weight assessments, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: report and document change of condition and notify the MD if no call the facility MD and call the DON and send resident to ER. The main highlight on weight assessments was to follow MD orders and document. In the Hot Zone there was a permanent weight chair for weighing residents. Care and service should continue in the Hot Zone LVN Q stated, because the residents are people. During an interview on 01/19/2023 at 7:55 p.m., LVN R (night shift) revealed: education was provided on change of condition, contacting the MD, weight assessment, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: document a change of condition and if you cannot find the primary MD call the facility MD and last option is to send resident to ER. As for weight assessment document and if there was a discrepancy re-weigh the resident. LVN R added, In the Hot Zone you can weigh a resident by the use of the weighing chair. During an interview on 01/19/2023 at 8:03 p.m., CNA S (evening and night shift) revealed: education was provided on change of condition, contacting the MD, weight assessment and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: report any change of condition to the charge nurse; document and take weights per MD orders. In the Hot Zone there was a weight chair. During an interview on 01/20/2023 at 9:59 a.m., RN T (Nurse Consultant) revealed: education was provided on change of condition, contacting the MD, weight assessment, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: change of condition needs to be reported immediately to the MD; if one cannot locate the on-call MD; if no contact with an MD; send to the ER. The highlight on weight assessment was to follow the order; and document. There was weight scale chair in the COVID-19 unit was placed permanently on 01/01/2023. During an interview on 01/20/2023 at 10:32 a.m., Med Aide U (day shift) revealed: education was provided on change of condition, contacting the MD, weight assessment, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: if change of condition occurred notified the charge nurse immediately. Regarding weight assessment, if resident is in the COVID-19 unit there was a scale to measure the resident; and follow MD orders on weights. During an interview on 01/20/2023 at 10:35 AM, LVN F (day and evening shift) revealed: education was provided on change of condition, contacting the MD, weight assessment and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: check mental status and take vitals and contact the MD; if primary MD is not available contact the facility MD; if major change send to ER. Regarding the weight assessment training: follow MD orders and for residents in the COVID-19 unit use the weight chair; the chair was in the Hot Unit around December 2022 (LVN F worked in the Hot Unit between the months of December 2022 and January 2023). Record review of em [TRUNCATED]