Every finding on record at Avir at Garland

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 7 residents (Residents #1, #2 and #3) reviewed for pharmaceutical services. The Facility failed to administer Residents #1, #2 and #3's medications greater than one hour after the scheduled administration times. This failure could place the residents at risk of receiving less than therapeutic benefits from medications. Findings included: Record review of Resident #1's Face Sheet, dated 08/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Hypertension (high blood pressure) and Type 2 Diabetes (high blood sugar). Record review of Resident #1's annual MDS Assessment, dated 07/15/2026, reflected that the resident had no impairment in cognition with a BIMS score of 15. The annual MDS Assessment indicated the resident was receiving Anticoagulant therapy, and coded for Hypertension and Type 2 Diabetes. Record review of Resident #1's Active Physicians Order, as of 08/04/2026, reflected orders for Amlodipine, Eliquis, Baclofen, Buspirone and Metformin Record review of Resident #2's Face Sheet, dated 08/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Hypertension (high blood pressure), Type 2 Diabetes (high blood sugar), Severe Sepsis without septic shock (life-threatening medical emergency where an infection causes an out-of-control immune response) and MRSA - Methicillin-resistant Staphylococcus aureus (staph bacteria that cannot be killed by many common antibiotics). Record review of Resident #2's significant change in status MDS Assessment, dated 07/13/2026, reflected that the resident had no impairment in cognition with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was coded for septicemia, Hypertension and Type 2 Diabetes. Record review of Resident #2's Active Physicians Order, as of 08/04/2026, reflected orders for Glipizide, Amoxicillin, Carvedilol, Gabapentin. Record review of Resident #3's Face Sheet, dated 08/04/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Hypertension (high blood pressure) Record review of Resident #3's Quarterly Comprehensive MDS Assessment, dated 06/02/2026, reflected that the resident had no impairment in cognition with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was coded for Hypertension, wound infection, and Medically Complex Conditions. Record review of Resident #3's Active Physicians Order, as of 08/04/2026, reflected orders for Gabapentin, carvedilol, Ascorbic acid, Cetirizine, Aspirin 81mg, Dicyclomine, Fluticasone, Amlodipine, Senna. During an Observation on 08/04/2026 at 10:15 am to 10:35 a.m. revealed MA C was not done passing morning medications on Hallway 500, which were scheduled for 6:00 a.m., 6:30 a.m., 7:30 a.m., 8:00 a.m., and 9:00 a.m. During an interview on 08/04/26 at 1:38 p.m. with MA C, she stated that the residents in the 500 hall way wanted their medications after breakfast which makes them get their medications late. She stated that the issue was reported to the last DON who has retired, and nothing was done about it. She stated that by the time she was done with medication pass in 600 hall way, the medication pass for the 500 was already late. She stated that she has 43 residents to give medications. She stated that 500 medication pass time was 6:00 a.m. which makes it a challenge to give them their medications early since they want to eat before they get medications and it becomes a late medication pass. She stated that all medication should be given on time or one hour before or after it was scheduled. She stated that not giving the medication as scheduled could result in an overdose or not having a therapeutic dosage in the body. She stated that she reports to the nurse charge if medications were late but did not do so today. During an interview on 08/04/26 at 1:59 p.m. with LVN T she stated that MA C informed her that some medications were late, she stated that the MA informed her that some residents refused their medications till after breakfast but not sure who they were. She stated that the expectation was that all medications should be given one hour before or after the scheduled time. She stated that she will be calling the physician to inform him about the late medications to see if they can be scheduled to be given after breakfast around 9:00 a.m. to make sure they were getting their medications administered properly. She stated that giving the medications on time was to make sure that medications that were supposed to be given apart from each other don't interact and that the doses were not given too close together to prevent an overdose. She stated that the nurse ensures the medications were given on time. During an interview on 08/04/26 at 3:30 p.m. with the Regional Nurse Consultant, she stated that the expectation was that all medications should be given according to facility and regulatory compliance, document any refusal, communicate to the nurse and the nurse would call the physician to see if there was a need to hold the medication and document any orders given. She stated that medications should be given one hour before or after the scheduled time. She stated that giving medication as ordered was to make sure the medication was therapeutic, monitor adverse reactions and for timed medications to make sure that the therapeutic dose was always in the body. She stated that if the medication was not given timely it could have an adverse effect of not getting enough or getting too much medication. She stated that they have started in services on medication administration today with all the MA's and will consult with the medical director to work on accommodating the resident's preference on what time they want to get the medications. She stated that the charge nurses and the DON was ultimately responsible for making sure that medications were administered as ordered. Record review of the facility's policy date November 2022 for Documentation of Medication Administration revealed: Policy StatementA medication administration record is used to document all medications administered.Policy Interpretation and Implementation1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (eMAR).2. Administration of medication is documented immediately after it is given.3. Documentation of medication administration includes, as a minimum:a. the resident's name;b. name and strength of the drug;c. dosage;d. route of administration;e. date and time of administration;f. reason(s) why a medication was withheld, not administered, or refused (as applicable);g. initials, signature and title of the person administering the medication;h. resident response to the medication, if applicable (e.g., PRN, pain medication, etc.);

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene and changed her gloves during Resident #1's incontinent care on 08/04/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings include: Record review of Resident #1's Face Sheet, dated 08/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Hypertension (high blood pressure) and Type 2 Diabetes (high blood sugar). Record review of Resident #1's annual MDS Assessment, dated 07/15/2026, reflected that the resident had no impairment in cognition with a BIMS score of 15. The annual MDS Assessment revealed the resident was dependent for toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear; substantial/maximal assistance for shower/bathe self and partial/moderate assistance with personal hygiene. Record review of Resident #1's Comprehensive Care Plan, dated 02/05/2026, reflected the resident had bladder and bowel incontinence and one of the interventions was to Apply barrier cream or protective products as ordered to prevent skin breakdown and monitor for signs and symptoms of urinary tract infection, constipation, or fecal impaction. The care revealed the Resident is at risk for infection with intervention to Educate Resident / Representative on infection control practices. During an interview and observation on 08/04/2026 at 9:40 a.m. with Resident #1, she stated that her brief had not been changed since 3:00 a.m. and she was waiting to be changed by the CNA since she likes to be changed after breakfast. The call light was pushed during the interview at 9:40 a.m. and it was responded to at 9:50 a.m. by CNA A who came to provide incontinence care. During an Observation of incontinence care on Resident #1 by CNA A at 9:55 a.m., it was observed that she did not change her gloves and performed hand hygiene between going from a clean task of taking of old briefs, cleaning the resident perineal area. She did not change her gloves and proceeded to handle the clean brief with the same contaminated gloves she performed the cleaning with. During an interview on 08/04/26 at 10:43 a.m. with CNA A, she stated that she should have changed gloves when going from dirty to clean task which was after removing old briefs and before putting on new briefs and if her hands were visibly soiled.She stated that she should have changed her gloves to avoid transferring bacteria from the old wet brief to the clean and dry brief. She stated that not changing her gloves could cause an infection for the residents and the residents could get sick and could result in spread of infection to other residents she encounters. She stated she had been trained on proper hand hygiene a few weeks ago. She stated that she failed to follow proper hand hygiene because she was nervous and was focused on cleaning the resident. During an interview on 08/04/26 at 1:59 p.m. with LVN T, she stated that the expectation was to change gloves during cleaning going from dirty to clean task, especially after cleaning the perineum. She stated that the CNA should have put on clean gloves and sanitized her hands before handling clean briefs. She stated that hand hygiene was needed to prevent the spread of infection. She stated that not performing proper hang hygiene could cause infection to pass from resident to resident. She stated that in-services were conducted whenever a new employee comes in and it was ongoing but does not know the frequency since she has been there only 2 months. She stated that the ADON and the DON were the ones who make sure that proper hand hygiene procedures were adhered to by conducting in services. During an interview on 08/04/26 at 3:30 p.m. with the Regional Nurse Consultant, she stated that in services on hand hygiene has already been started. She stated that the expectation was for the CNA's to perform proper hand hygiene when performing peri care, change gloves and sanitize hands between dirty and clean tasks. She stated that the nursing management ensures that there were education and compliance with the policy for infection control and hand hygiene. She stated that if they do not follow the policy, they provide education with feedback performance and 1:1 trainer for observation. She stated that not following proper hand hygiene protocols could result in cross contamination of infection from residents to residents. Record review of the facility's policy Handwashing/Hand Hygiene dated October 2023, updated 01/2025 revealed: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Policy Interpretation and ImplementationAdministrative Practices to Promote Hand Hygiene1. 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.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility.Indications for Hand Hygienef. before moving from work on a soiled body site to a clean body site on the same resident; andg. immediately after glove removal. Record review of the facility's policy Perineal Care dated February 2018 revealed: 4. Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens / adult brief Record review of the facility's undated policy Standard Precaution revealed: Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care.Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one).

Based on interview and record review, the facility failed to use the services of a Registered Nurse for a minimum of eight consecutive hours a day, seven days a week, for 5 days in a 3 month reporting period .The facility failed to have RN coverage on the following dates in 2025:-October 4, -November 01, 13, 18, and 19 2025. This failure could place residents at risk of not having their nursing and medical needs met, and not receiving proper care. Findings included: Review of the CMS PBJ Staffing Data Report, a report reflecting data self-reported to CMS by the facility, dated 05/13/2026, reflected the facility had not reported RN coverage hours for the dates of October 4, 2025, November 01, November 13, November 18, and November 19 2025. An interview on 05/19/2026 at 9:30 am. with the Administrator revealed she started working at the facility on 10/01/2025. She stated that she was sure that there was a day or two when she didn't have an RN in the building. She stated that she had a nurse quit during that time and they were not able to get a replacement nurse in time to cover for her. She stated she couldn't be exact but remembers it was in November 2025. She stated the earlier unstaffed days would have been attributed to the same nurse not showing up for work. She stated that since that time she had hired a DON who was an RN, an ADON who was an RN, as well as the MDS Coordinator who was also an RN. She stated that she expected to hire an additional weekend nurse for RN coverage within the next few days. She stated that she knew that the resident's are at risk for harm when there was no RN in the facility. She stated that was the reason she had made a point to hire RN's when she had the opportunity. An interview on 05/20/2026 at 2:19 PM, with the DON revealed she started working at the facility in December 2025. She stated that she knew there were some problems with the nurses' before she came. She stated since she started working at the facility they have not had any days without a nurse. She stated that the ADON was a RN and the MDS nurse was a RN as well. She stated they were in the process of hiring another RN to cover the weekend. She stated that her staffing levels are adequate. She stated that she had a RN on the floor for the day shifts M-F. She stated that they had a weekend RN on staff. She stated that she does come in periodically overnight/weekends to monitor staffing. She stated that she feels like they are able to meet the needs of the residents with her current staffing levels. She stated the residents are at risk for harm when there is no RN in the building that is why they were hiring an additional RN. An interview with the on 05/21/2026 at 11:15 am with the ADON, revealed she started working at the facility in January 2026. She stated she was unaware of the dates before she started, but was told they had some issues with the previous staff. She stated that were hiring another RN to cover the weekends in the next few days. She stated residents are at risk for harm when there is no nurse in the building. She stated there were typically four RN's during the weekday shifts. Review of Facility Policy, received after exit. revised August 2022Staffing, Sufficient and Competent NursingPolicy StatementOur 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.Policy Interpretation and ImplementationSufficient StaffLicensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including:assuring resident safety;attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident;assessing, evaluating, planning and implementing resident care plans; andresponding to resident needs.A licensed nurse is designated as a charge nurse on each shift.A licensed nurse may be a licensed practical nurse (LPN), licensed vocational nurse (LVN), or registered nurse (RN).A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care.The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents.A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.Licensed nurses are required to supervise nurse aides/nursing assistants and are scheduled in such a way that permits adequate time to do so. Nurse aides/nursing assistants are individuals providing nursing or related services to residents in the facility, including those who provide services through an agency or under a contract with the facility. Licensed health professionals, registered dietitians, paid feeding assistants and individuals who volunteer to provide nursing or related services without pay are not considered nursing assistants and are not posted or reported as direct care staff.Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment.Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. continues on next pageMinimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determination of sufficient and competent staffing.Other resident services (e.g., administrative, food and nutrition services, specialized rehabilitation services, activities/recreational, social, therapy, environmental, etc.) are staffed to ensure that resident needs are met.Competent Staff Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas:Resident rights;Behavioral health;Psychosocial care;Dementia care;Person centered care;Communication;Basic nursing skills;Basic restorative services;Skin and wound care;Medication management;Pain management;Infection control;Identification of changes in condition; andCultural competency.Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities.Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that:programming for staff training results in nursing competency;gaps in education are identified and addressed;education topics and skills needed are determined based on the resident population;tracking or other mechanisms are in place to evaluate effectiveness of training; andtraining includes critical thinking skills and managing care in a complex environment with multiple interruptions.Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift. continues on next pageInquiries or concerns relative to our facility's staffing should be directed to the director of nursing services (DNS) or his/her designee.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one medication room (hall 500-600 medication room) of two medication rooms and one supply room of one reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the facility medication room and the supply room. These failures could place residents at risk of infection and having possible adverse effects.Findings included:In an observation on [DATE] at 09:00 a.m., the following expired supplies were observed in the 500-600 Hall medication room: -RyMed Invision-Plus Needleless IV Connector, Expiration date 02-01-2025 (Quantity 1)In an interview on [DATE] at 09:15 a.m., RN A confirmed the RyMed Invision-Plus Needleless IV Connector was expired. She stated that the Central Supply Personnel was responsible for monitoring and removing expired supplies and that she believed that was done on a weekly basis. RN A did not state how the process was monitored. She stated that the facility rotated supplies backwards by using the oldest supplies first to limit expired supplies. She stated that the risk to the residents for the expired supply was, deterioration. Particles can come off in the resident, and we don't know if they will dissolve or how the resident will react. In an observation on [DATE] at 09:40 a.m., the following expired supplies were observed in the Central Supply Room:-Apogee Catheter Insertion Kit, Expiration date, [DATE] (Quantity 36) -0.9% Sodium Chloride Injection 10 milliliters, Expiration date 07-31-2025 (Quantity 1)-0.9% Sodium Chloride Injection 3 milliliters, Expiration date 04-30-2025 (Quantity 1)-Terumo Surshield Safety Winged Infusion Set 25 Gauge, Expiration date 03-31-2025 (Quantity 1)-BD Insyte Autoguard 24 Gauge catheter, Expiration date 11-30-2024 (Quantity 1) In an interview on [DATE] the DON verified the listed supplies found in the Central Supply Room were expired. She stated that CNA B was a new employee and had only been the Central Supply Personnel for about four weeks. She stated that the Central Supply Personnel was responsible for removing any expired supplies as new supplies came in. She stated that they were in the process of creating a supply room inventory so that supplies could be ordered weekly based on need. She did not state how the process was monitored. The DON stated that the risk to residents of expired supplies was, there is a reason there is an expiration date. I would not want to use anything expired.In an interview on [DATE] at 02:30 p.m., the ADM stated the facility did not have a storage policy governing expired supplies.In an interview on [DATE] at 09:45 a.m. CNA B, Central Supply Personnel, stated she had worked at the facility for about three weeks with two weeks being on the floor and one week being in the supply room. She stated she was responsible for monitoring and disposing of expired supplies. She stated that the DON monitored the process. CNA B stated that new supplies typically arrived weekly and she rotated supplies so that older supplies were used first. She stated that she planned to check all supplies and dispose of expired supplies monthly but that she had only worked in the supply room for about a week. CNA B stated the risk to residents of using expired supplies was unknown and that is why expired supplies should not be used.Record review of the facility policy titled, Medication Administration-Intravenous Therapy stated, Licensed nursing staff shall administer IV [Intravenous] medications only through an appropriate vascular access device using aseptic technique, verified medication compatibility, and approved procedures.

Based on observations, interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one (Residents #70) of four residents reviewed for smoking. 1. The facility failed to accurately assess Residents #70 for smoking safety. These failures could place smoking residents at risk of burn accidents related to smoking supervision. Findings include: Record review of Resident #70's admission record revealed [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of ENCEPHALOPATHY (a broad term for any diseases, damage, or malfunction of the brain) other diagnosis Tobacco abuse counseling. Record review of Resident #70's Care Plan dated 03/19/2026 revealed resident 70 is a safe smoker, the resident requires supervision while smoking. Record review of resident #70's Nursing Home Quarterly MDS dated [DATE] revealed resident 70 had a BIMS score of 11 ( (Moderate cognitive impairment). Record review of Resident #70's Electronic Medical Records revealed no admission or current smoking assessment for resident #70. Observation on 05/20/2026 at 9:30 AM of Resident #70 revealed, Resident #70 was seen smoking with supervision on the patio. During an interview on 05/20/2026 at 3:00PM with LVN A revealed all residents who were smokers had their cigarettes in the lock box that was located in nurse's closet. LVN A stated the box had a key lock on it and the nurse had the key. During an interview on 05/20/2026 at 3:15 PM with Resident #70 revealed she was a smoker who was supervised while smoking. During an interview on 05/21/2026 at 9:30 AM with DON revealed Resident #70 did not have a smoking safety assessment. She stated it was probably an oversite because the facility was without a social worker. The risk was the resident could be harmed if she was not assessed for safety precautions. During an interview on 05/21/2026 at 3:40 PM with the ADMIN revealed it (smoking assessment) just slipped through the crack, the expectation for all residents who smoke to make sure they have an assessment to insure they were safe, able to hold the cigarette without accidents. The risk was she (Resident #70) could have accidentally burned herself or others. The admin stated that to date there are no reported issue with her (Resident #70) smoking. She was compliant with smoking rules and locations. Going forward the responsibility for ensuring resident assessments are complete in the timeframes was delegated to the ADON. Review of the policy Smoking Policy -Residents dated October 2022 revealed The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker or smokeless tobacco user, the evaluation will include: d)Current level of tobacco consumption.d)Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.).d)Desire to quit smoking, if a current smoker; andd)Ability to smoke safely with or without supervision (per a completed Smoking Assessment). The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Smoking Assessment.

Based on observations/interviews/record review, the facility failed to protect the resident's right to be free from mental abuse, verbal abuse, physical abuse, sexual abuse, deprivation of goods and services by staff, a resident, a visitor. The facility failed to ensure Resident #1 was free from abuse on 4/13/26, when Resident #2 struck and scratched her, which resulted in multiple bruises to her arm. This failure could place residents at risk of abuse and emotional distress.Findings include: 1.Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (a decline in memory and cognitive function), psychotic disturbance (delusions or hallucinations), anxiety disorder, and major depressive disorder. These diagnoses indicated impaired cognition, mood instability, and potential for altered perception of events. Record review of Resident #1's care plan dated 01/15/26 reflected interventions related to monitoring adverse reactions to antidepressant therapy. The care plan directed staff to observe changes in behavior, mood, or cognition, including hallucinations or delusions, as well as increased confusion, withdrawal, or decline in functional ability. Additional interventions included monitoring for gait instability, dizziness, and fall risk, reflecting the resident's vulnerability to both physical and cognitive impairment. Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 03, indicating the resident was severely cognitively impaired. The MDS that the resident had a history of psychotic disturbance. Record review of progress notes dated 04/13/26 indicated Resident #1 reported that Resident #2 clawed and scratched her. Assessment revealed visible injuries including bruising and a hematoma to the right wrist, hand, and arm, as well as bruising to the left eye. The resident denied pain at the time of assessment. Documentation indicated that Resident #1's responsible party was notified, and the decision was made to move the resident to another room with agreement from the family member. Record review of a skin assessment note dated 04/13/26 identified multiple new skin issues following the incident. These included bruising to the right outer forearm, left side of the face, and right medial shin. Additional observations included edema to the right foot and discoloration to the right leg. The documentation indicated that all injuries were acquired in-house and that no signs or symptoms of infection were present at the time of assessment. 2. Record review of Resident #2's face sheet dated 02/24/26 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: dementia (a decline in memory and cognitive function), moderate intellectual disabilities (limitations in intellectual functioning and adaptive behavior), Parkinsonism (a condition affecting movement and coordination), generalized anxiety disorder, and major depressive disorder. These diagnoses indicated impaired cognition, decreased safety awareness, and potential for behavioral symptoms. Record review of Resident #2's MDS dated [DATE] reflected a BIMS score of 05, which indicated she was severely cognitively impaired. Record review of Resident #2's care plan dated 12/19/25 reflected interventions related to monitoring adverse reactions to antidepressant therapy, including changes in mood, cognition, hallucinations, withdrawal, and decline in functional ability. Additional interventions included monitoring for gait instability, movement issues, and fall risk. Record review of Resident #2's care plan dated 04/21/26 reflected interventions to analyze and document triggers, behaviors, and effective de-escalation techniques, indicating a need for behavioral monitoring and intervention. Record review of progress notes dated 04/13/26 indicated it was alleged that Resident #2 scratched her roommate, Resident #1. Additional documentation reflected that a urinalysis and culture and sensitivity were ordered to evaluate for a possible urinary tract infection as a contributing factor. Record review a progress note dated 04/13/26 at 2:33 p.m. reflected Resident #2 received a virtual evaluation and was determined to be safe to discontinue one-on-one monitoring. Record review of progress note dated 04/14/26 at 8:17 a.m. reflected Resident #2 returned to the facility from the hospital. Assessment was completed, vital signs were within normal limits, and the resident denied pain. No new physician orders were noted, and follow-up appointments with medical providers were documented. Interview on 4/23/26 at 10:00 a.m., with the Administrator (Admin) regarding the incident revealed the residents were immediately separated following the event. The Admin stated Resident #2 was placed on 1:1 supervision and a psychiatric evaluation was completed. Following the evaluation, Resident #2 was released from 1:1 supervision. The admin reported that the families of both residents were notified and that the facility followed established policies and procedures. The admin stated this was an isolated incident and reported the residents had been roommates for a period with no prior history of physical alterations. Resident #1 and Resident #2 were separated following the incident and are no longer roommates. The admin indicated both residents have significant cognitive impairment; however, neither is the resident is assigned to a secure or locked unit. The admin stated the residents have not exhibited behaviors such as wandering or elopement that would necessitate placement on a secured unit. The admin noted both residents are experiencing cognitive decline and reiterated that this was an isolated incident. The admin stated that the facility responded appropriately in accordance with policy. Interview and observation on 4/24/26 at 2:30 p.m., with Resident #1 revealed the resident was observed lying in bed at the time of the interview. Visible bruising was noted on the resident's right arm in various stages of healing, extending along multiple areas of the arm. No visible bruising was observed on the resident's face or legs. Resident #1 spoke limited English, and translation services were facilitated through a staff member via phone. The translator stated he had assisted with communication at the time of the incident as well. Through translation, Resident #1 reported that she and her former roommate, Resident #2, had an altercation regarding the room light, stating she wanted the light on while Resident #2 wanted it off. Resident #1 stated that Resident #2 became upset and hit her on the right arm. She denied being hit, scratched, or touched on her face, legs, or any other part of her body. Resident #1 stated that Resident #2 grabbed her arm, causing the bruising observed. Resident #1 reported the area did not currently cause pain. She stated that Resident #2 was no longer her roommate, denied fear of others in the facility, and stated she felt safe. Resident #1 was unable to recall additional details and denied any prior incidents involving Resident #2 or any other residents. Interview on 4/24/26 at 2:45 p.m., the staff (translator) revealed the information provided during translation was consistent with Resident #1's initial report at the time of the incident. The staff member stated there had been no changes in the resident's account and that Resident #1 was unable to recall additional details beyond being struck on the arm. Interview and observation on 4/24/26 at 3:00 p.m., Resident #2 revealed the resident was seated in a wheelchair and appeared pleasant during the interaction. Redirection was required multiple times as the resident frequently discussed unrelated topics. When asked about any altercation, Resident #2 denied recollection of any such incident. The resident denied that anyone had hurt her or that she had placed her hands on anyone else. Resident #2 identified Resident #1 only as a lady down the hall and stated they were friends but no longer shared a room. Resident #2 did not appear to have awareness or recollection of the reported incident. Interview on 4/24/26 at 3:20 p.m., with CNA A revealed she had worked with both residents, including when they previously shared a room. CNA A stated Resident #1 had become more mobile over time and was now independently moving about the room and engaging in activities such as turning lights on and off. CNA A reported she did not witness the incident but was informed of it and believed Resident #2 may have become frustrated. She stated that prior to the incident, Resident #2 had expressed concerns that Resident #1 was blocking the doorway. CNA A reported she had personally observed Resident #1 standing in the doorway, at times limiting Resident #2's ability to exit or access the bathroom. CNA A stated the residents had verbal exchanges in the past; however, she had never observed physical aggression between them or toward others. CNA A described Resident #1 as generally pleasant and noted the residents had differing personalities. CNA A further reported that Resident #2 had occasionally displayed verbal agitation toward staff, including raising her voice, but no prior physical altercations were known. Interview on 4/24/26 at 3:59 p.m., with the DON revealed she did not witness the incident but reported that Resident #1 informed staff of the event and demonstrated her injured arm. The DON stated a psychiatric evaluation was completed for Resident #2 following the incident and that both residents were assessed to be at their baseline. The DON reported Resident #1 had visible bruises and hematoma on the arm, as well as a small red mark near the eye, which contributed to initial documentation referencing multiple injury sites. She explained staff documented all observed marks regardless of severity. However, based on follow-up with Resident #1, the resident consistently reported injury only to the arm and denied any other areas of harm. The DON indicated the initial report may have appeared more severe than the actual injuries observed. Interview on 5/01/26 at 12:30 p.m., with the Psychiatric Nurse Practitioner revealed she completed a virtual psychiatric evaluation of Resident #2 on the date of the incident. She reported Resident #2 did not recall the altercation and only mentioned that her roommate would not allow her to leave the room. She stated it was unclear whether this perception was accurate due to Resident #2's cognitive status. The Psychiatric Nurse Practitioner stated there was no indication that Resident #2 intended to initiate physical harm and described the incident as isolated. She reported that Resident #2 is typically cooperative, mild-mannered, and does not commonly present with behavioral concerns, noting this was the first reported incident of this nature. Interview on 4/24/26 at 1:45 p.m. with RN-A: An attempted phone call was made to RN-A, who previously assessed Resident #1. A voicemail message was left; however, no return call was received. Interview on 5/01/26 at 1:02 p.m., with RN A: An attempted phone call was made; a voicemail message was left. No return call was received. Interview on 4/24/26 at 1:50 p.m., with Family Member #2 (associated with Resident #2): An attempted phone call was made; a voicemail message was left. No return call was received. Interview on 5/01/26 at 1:06 p.m., with Family Member #2 (associated with Resident #2): An attempted phone call was made; a voicemail message was left. No return call was received. Interview on 5/01/26 at 1:10 p.m., with Family Member #1 (associated with Resident #1) revealed he was aware of the incident and reported the facility notified him at the time it occurred. He stated he visited Resident #1 shortly after and had no concerns regarding the care provided or the facility's response. He reported that both residents had been roommates for an extended period without prior incidents and believed the altercation stemmed from a disagreement, possibly related to lighting preferences, compounded by a language barrier. Family Member #1 stated he did not hold any concerns toward Resident #2 and continued to interact with her during visits. He described the incident as isolated and stated the facility responded appropriately by separating the residents and providing notification. He confirmed Resident #1 experienced bruising to the arm but reported she was currently doing well and voiced no concerns. Record review of the facility's undated Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy revealed that residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property. The policy indicated that the facility is responsible for protecting residents from abuse by anyone, including other residents, and for identifying, investigating, and reporting all allegations of abuse. The policy requires implementation of interventions to prevent recurrence and ensure resident safety during and after investigations.

Based on interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 out of 5 residents (Residents #1, Resident #2 and Resident #3) reviewed for medication administration. The facility staff did not follow physician orders and administered Resident #1, four Warfarin pills on 03/08/26 and 03/09/26 instead of two. The facility staff did not watch Resident #1 take her medications. The facility staff did not watch Resident #2 take her Melatonin 3MG medication.The facility staff did not watch Resident #3 take his Zolpidem Tartrate 5mg medication. These failures could affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization. Findings Included: Record review of Resident #1's face sheet, dated 03/11/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: cerebral infraction (blocked blood flow to the brain), malignant neoplasm of overlapping sites of right bronchus (cancer that spans both the bronchial air passages and lung tissues on the right side), hypoxemia (abnormally low oxygen levels in arterial blood), dysphagia (difficulty swallowing), difficulty walking, cognitive communication deficit (difficulty with verbal or non-verbal communication), iron deficiency anemia secondary to blood loss (chronic) (bleeding depletes iron faster than it could be replaced), type 2 diabetes mellitus (body resist insulin or fails to produce enough), morbid obesity (chronic, complex disease with body mass index of 40 or higher), major depressive disorder (persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), cortical age-related cataract (glare, hazy vision and difficulty with light), hypertension (blood pushing too hard against artery walls), atherosclerosis of coronary artery (disease of the arteries with plaques of fatty material), alcoholic cirrhosis of liver without ascites (heavily damaged liver from chronic alcohol consumption), gastrointestinal hemorrhage (bleeding in in stomach, intestines or rectum), muscle weakness (a reduction in physical strength), prosthetic heart valve (artificial device implanted to replace diseased valve and restore proper blood flow), peripheral vascular disease (slow, progressive circulation disorder which blocks blood vessels outside the heart and brain), hypertensive retinopathy (damage to the retinal blood vessels), bipolar disorder (extreme mood swings), heart failure (condition where the heart cannot pump blood efficiently) and hyperlipidemia (excessive fat levels in the blood). Record review of Resident #1's Quarterly MDS assessment, dated 02/13/26, reflected BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 needed setup or clean up assistance with all ADLs. Record review of Resident #1's care plan, date initiated 11/11/25, reflected Resident #1 was at risk for bleeding. Interventions included: evaluating blood in stools, change in level of consciousness, hematemesis (vomiting blood), hematuria (blood in the urine), skin for evidence of impaired coagulation (bruising, petechia, bleeding from orifice (an opening or hole)). Record review of Resident #1's order summary report, dated 03/12/26, reflected in part:Warfarin Sodium Oral Tablet 4mg- give 2 tablets by mouth at bedtime for clotting related to heart failure. Record review of Resident #1's progress notes revealed no documented rationale for not administering medication per physician's order. Record review of Resident #2's face sheet, dated 03/11/26, reflected a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #2 had diagnoses which included: hemiplegia and hemiparesis following cerebral infraction (paralysis and weakness on one side from a stroke), lack of coordination (muscle movements are clumsy or unsteady) iron deficiency anemia (body lacking sufficient iron), diaper dermatitis (skin rash in diaper area), muscle spasms (involuntary, often painful contractions of a muscle), primary insomnia (difficulty falling asleep or staying asleep), generalized anxiety disorder (persistent, excessive and uncontrollable worry), constipation (infrequent bowel movements or difficulty passing stool), muscle weakness (a reduction in physical strength), chronic cough, type 2 diabetes (high blood sugar), vitamin d deficiency (not getting enough sunlight), morbid obesity (chronic, complex disease with body mass index of 40 or higher), hyperlipidemia (excessive fat levels in the blood), major depressive disorder (persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), hypertension (blood pushing too hard against artery walls), aphasia following cerebral infarction (language disorder that affects communication skills), repeated falls and pain. Record review of Resident #2's Quarterly MDS assessment, dated 02/10/26, reflected BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #2 was dependent on staff with some ADLs such as dressing, toileting and putting on/off footwear. Resident #2 also needed substantial assistance with bathing and set up assistance with eating and oral hygiene. Record review of Resident #2's order summary report, dated 03/12/26, reflected in part:Melatonin Oral Tablet 3 MG- give 1 tablet by mouth at bedtime for insomnia. Record review of Resident #3's face sheet, dated 03/11/26, reflected a [AGE] year-old male that admitted into the facility on [DATE]. Resident #3 had diagnoses which included: chronic obstructive pulmonary disease (lung disease), reduced mobility, hypertension (blood pushing too hard against artery walls), muscle spasm (sudden, involuntary and painful contractions) of calf, major depressive disorder (persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), insomnia (difficulty falling asleep or staying asleep), disorder of central nervous system (cognitive, physical and sensory dysfunction), cognitive communication deficit (difficulty with verbal or non-verbal communication), hypokalemia (low serum potassium levels), inflammatory disorders of scrotum (acute pain, swelling and redness in the back of the testicle), difficulty in walking, hypocalcemia (low calcium levels in the blood), constipation (infrequent bowel movements or difficulty passing stool), anemia (lack of healthy red blood cells to carry sufficient oxygen to body tissues) diabetes mellitus (high sugar due to insufficient insulin production), hypo-osmolality and hyponatremia (low serum sodium and reduced plasma), fluid overload (water and salt buildup in the body), and intestinal obstruction (partial or complete blockage of the small or large intestine). Record review of Resident #3's Quarterly MDS assessment, dated 03/03/26, reflected BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #3 needed some setup assistance or independent with his ADLs. Record review of Resident #3's order summary report, dated 03/12/26, reflected in part:Zolpidem Tartrate Oral Tablet 5 MG- give 1 tablet by mouth at bedtime for insomnia. Record review of Resident #3's care plan, dated initiated 01/29/26, reflected Resident #3 was on sedative/hypnotic therapy. Interventions included: evaluating other factors potentially causing insomnia, for example: environment, lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control external factors before initiating hypnotic therapy. Monitoring/documenting/reporting PRN for following adverse effects of sedative/hypnotic therapy, preceding or accompanying hypnotic use by other interventions to try to improve sleep. In an interview on 03/11/26 at 2:51 PM, Resident #1 revealed on 03/08/26 and 03/09/26, she received two Warfarin pills in addition to her Tessalon [NAME], totaling four Warfarin pills. Resident #1 stated on 03/08/26, she received two Warfarin pills from CMA C at 7:00 PM, then approximately an hour later she received two more Warfarin pills that were administered by either CMA C or LVN D. Resident #1 was unsure of the exact staff person. Resident #1 stated it was weird that she had received two additional pills on 03/08/26 but did not say anything to the nurse. Resident #1 stated the exact same administering happened again 03/09/26. Resident #1 stated she received two Warfarin pills, one Trazadone and one cholesterol pill around 7:00 PM, then two more Warfarin pills around 8:00 PM. She stated on 03/09/26 she informed either CMA C or LVN D that she had already received her medication from someone else and was not supposed to receive another dosage. Resident #1 revealed whomever the staff had told her that they knew what Resident #1 was supposed to have administered and proceeded with giving her the medication. Resident #1 stated the medication was given to her and the staff walked off. Resident #1 revealed that instead of taking the medication, she put it under her blanket and waited until the nurse finished with her roommate then pulled the medication from under the cover. She stated she showed the medication to her roommate, Resident #2. Resident #1 stated she held onto the medication and gave it to CMA A the next morning on 03/10/26. Resident #1 told her that she was only supposed to receive two of the pills but a total of four was administered, so she did not take the last two pills administered. Resident #1 stated CMA A took the pills and told her she would speak to the nurse. Resident #1 was unsure of the exact number of times staff did not monitor her not taking medication at the time of administration. In an interview on 03/11/26 at 2:57 PM, Resident #2 revealed that Resident #1 showed her two blue pills after CMA C left their room. Resident #2 stated she witnessed CMA C did not observe Resident #1 take her medication. She stated CMA C administered the medication to Resident #1, then turned to her and took her blood pressure. Resident #2 stated that after CMA C checked her blood pressure, she administered her medication and walked out of their room. She stated she was given her Melatonin pill which CMA C did not observe her taking. She stated she held onto her pill until she was ready to go to bed. Resident #2 stated staff administered her melatonin pill hours before she was ready for sleep, so she held onto it. Resident #2 revealed staff did not always observe her or Resident #1 take their medication. Resident #2 was unaware of the exact number of times staff did not monitor her not taking medication at the time of administration. Resident #2 stated some staff such as CMA C administered her medication and walked off. In an interview on 03/11/26 at 4:14 PM, Resident #3 revealed that staff did not always observe him take his nighttime medication for sleep. Resident #3 stated staff administered his sleep medication early in the evening. He stated he held on to the medication until he was ready for sleep. Resident #3 also stated if staff passed in the hall during the time he was taking his medication, he called them over to show he took his medication. Resident #3 was unable to identify exactly what staff did not observe him taking his medications. He stated he did not know the staff as there were many different staff working at the facility. Resident #3 was unaware of the exact number of times staff did not monitor him not taking his medication at the time of administration. In an interview on 03/11/26 at 5:29 PM, CMA A stated she worked Mondays-Fridays on morning shift 6:00 AM- 2:00 PM. She stated she worked in 500 and 600 halls. CMA A revealed that between 9:00-9:30 AM on 03/09/26 during medication pass, Resident #1 gave her two Warfarin pills. CMA A stated Resident #1 told her it was the extra pills that she had not taken from the night before. CMA A asked Resident #1 why her medication was not taken. CMA A stated Resident #1 told her that staff administered her two Warfarin medications around 5:00 PM, then another staff came around 8:00 PM and two more Warfarin pills. She stated Resident #1 told her, she knew she was not supposed to be taking an additional two pills. CMA A stated that Resident #1 told her that she pretended to take the medication but hid it. CMA A also stated Resident #1 told her she was able to hide the medication because staff did not watch her take it. CMA A also stated Resident #1 told her that she told staff she had already taken the medication, but staff told her she still had to take it. CMA A stated she took the medication and gave it to the floor nurse RN B. She stated she informed RN B of the information provided by Resident #1 then continued administering medications for the day. CMA A stated protocol was to watch residents take the medication that was administered. In an interview on 03/11/26 at 6:04 PM, RN B revealed on 03/09/26 during the early afternoon before 2:00 PM CMA A gave her Resident #1 Warfarin medication. RN B stated CMA A informed her that Resident #1 did not take the medication administered at night on 03/09/26. RN B stated she held the medication until LVN D came into work at 6:00 PM, then gave the medication to her. RN B stated after passing the medication to LVN D, she allowed her to handle. RN B stated she was overworked with her tasks, so she allowed LVN D to handle it. She stated she did not know what the outcome was but figured LVN D handled it the best she could. RN B stated she should have followed up. RN B stated she should have destroyed the unused medication. In an interview on 03/11/26 at 6:36 PM, CMA C stated she worked weekend double shifts from 6:00 AM- 2:00 PM and 2:00 PM- 10:00 PM. She stated she worked double shifts on 03/07/26 and 03/08/26. CMA C stated she worked with Resident #1 on both days. CMA C stated she remembered administering Resident #1 two Warfarin (blood thinner pills) twice in the evening totaling four pills. CMA C stated she gave Resident #1 the medications that were in the system. CMA C stated the medications that Resident #1 was supposed to take popped up on her computer screen. She stated 03/07/26 was the first time she administered the Warfarin to Resident #1. She stated she could not recall how many pills she had given to Resident #1 because she administered it with her other pills. CMA C stated she watched Resident #1 take the medication, then she moved on to take Resident #2's blood pressure. She stated after she got Resident #2 blood pressure, she administered her medications and watched Resident #2 take them. CMA C stated she gave residents their medications in a cup with a cup of water. CMA C stated once the resident took the medication and finished the water, she retrieved the medication cup from the resident then threw it in the trash. CMA C stated she ensured residents took their medication by observing them swallow. CMA C stated she was not aware of Resident #1 not taking her medication. CMA C stated the risks of not taking medication was medication abuse by residents. In an interview on 03/11/26 at 6:50 PM, the DON and Administrator revealed that they were not aware of the medication errors regarding blood thinners. The DON stated the only resident that took blood thinners was Resident #1. The DON and Administrator stated that when there was a medication error, it was expected to be documented and reported to DON. The DON stated any medication returned by a Resident #1 should be discarded, documented and reported. In an interview on 03/12/26 at 11:01 AM, LVN D stated she worked an alternating shift from 6:00 PM- 6:00 AM. LVN D revealed she worked on 03/10/26 on 500 hall. She stated as soon as she got on shift that evening, RN B gave her two pills that were given by another staff. LVN D stated she asked RN B who the pills belonged to, but RN B stated she did not know. LVN D stated the pills were identified as Warfarin. LVN D stated the medication could only belong to Resident #1, since she was the only resident taking Warfarin. LVN D stated she went to Resident #1 and asked what happened, and why she did not take the medication. She stated Resident #1 told her she received her Warfarin medication from CMA C shortly after she had already taken two pills. LVN D stated on 03/08/26, she had administered Resident #1 two Warfarin pills and one Tessalon [NAME] (Benzonatate). LVN D stated she told Resident #1 she herself watched her take the medications when she administered them. She stated Resident #1 told her after she administered her medications, another nurse administered Warfarin again. She stated Resident #1 told her she did not take them and held onto the pills because she knew she was not supposed to take two more pills. LVN D stated she checked the medication aide cart and found two packs of Warfarin for Resident #1 which should not have been there. She stated Resident #1 also had Warfarin packs on the nurse's cart. She stated she removed the additional packs from the medication aide cart and put them on the nurse's cart. LVN D stated she did not know who put the medication on the med aide cart, but it should have only been on the nurse's cart. LVN D stated she discarded the pills into a sharp container that was given to her by RN B. She stated she did not document it in the medical system. LVN D stated she should have documented and reported it to the DON. In a follow-up interview on 03/12/26 at 12:09 PM, CMA C stated she only worked weekends. She stated both med aides and nurses were responsible for administering blood thinners. CMA C stated on 03/07/26 and 03/08/26 Warfarin popped up on her screen to administer to Resident #1. She stated it was the first time administering the medication Resident #1. She stated she gave Resident #1 the medication at nighttime and did not think anything was wrong. CMA C stated she observed Resident #1 take the medication. She stated she was unaware of Resident #1 not taking the medication and giving it to another nurse. In an interview on 03/12/26 at 12:26 PM, the DON stated the expectation with administering medications was for the nurse to monitor the resident while taking. The DON stated the nurse should never walk away without observing a resident take medication. The DON stated a resident should not have any medication to give back to a nurse because the nurse should have watched the medication being taken. The DON stated nurses should also check the system to ensure residents were given the right medication and dosage. The DON stated risk of giving too much medication could have had adverse effects on the resident. Record review of the facility policy titled, Administering Medications, date revised April 2019, reflected the following in part: Policy heading: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Record review of the facility policy titled, Adverse Consequences and Medication Errors, date revised February 2023, reflected in the following in part: Policy heading: The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. Medication Errors: 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional(s) services. 2. Examples of medication error include:a. Omission-a drug is ordered by not administered. b. Unauthorized drug-a drug is administered without a physician's order. c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given.g. Wrong time. Procedures 1. Review the resident's medication regimen for efficacy and actual or potential medication-related problemson an ongoing basis. 2. When a resident receives a new medication order, review the following:a. The dose, route of administration, duration, and monitoring are in agreement with current clinicalpractice, clinical guidelines, and/or manufacturer's specifications for use.b. A written diagnosis/indication supporting the use of the medication.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #1 and #2) reviewed for infection control practices. 1. RN A and CNA B failed to wear a gown while providing incontinence care to Resident #1, who was on EBP due to having pressure ulcers on her sacral area and foot.2. RN A failed to wear a gown while providing wound care to Resident #1, who was on EBP due to having pressure ulcers on her sacral area and foot.3. LVN C failed to wear a gown while providing wound care to Resident #2, who was on EBP due to having pressure ulcers on her sacral area and left ankle. These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection.Findings included:1. Record review of Resident #1's Comprehensive MDS Assessment, dated 11/18/25, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE].The resident had severe cognitive impairment with a BIMS score of 0, and her diagnoses included pressure ulcer (a skin injury caused by prolonged and constant pressure on a bony prominence) of the sacral region (the triangular bone located at the base of the spine/lower back), and pressure ulcer on the medial lateral foot (the inner side of the foot from the heel to the big toe).Record review of Resident #1's care plan, dated 01/17/26, reflected: Focus: [Resident #1] Enhanced Barrier Precautions. Staff must wear gowns and gloves during high contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Goal: [Resident #1] dignity will be maintained over the next 90 days. Interventions: Enhanced barrier precaution: staff must use gowns and gloves during high -contact care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g . Residents with wounds).Observation on 01/17/26 at 10:43 AM on Resident #1's room revealed a posting on the outside notifying staff and visitors the resident was on EBP and were required to wear a gown and gloves with all direct care of the resident. There was no PPE observed outside Resident#1 room. Observation on 01/17/26 at 10:45 AM revealed RN A and CNA B provided incontinence care to Resident #1. Neither RN A nor CNA B wore a gown as required for providing care to a resident on EBP. They only wore gloves. Observation on 01/17/26 at 11:08 AM revealed RN A prepared all the wound care supplies, and she entered Resident 1's room. RN A washed her hands, put on gloves, but she did not put on the gown. She removed the old dressing on the resident's sacral area, dated 01/16/26. She removed her gloves, washed her hands, and put on new gloves. She cleaned the wound, applied collagen powder to the wound bed, then calcium alginate, and covered the pressure ulcer with a dry dressing. She then washed her hands and put on clean gloves. RN A removed the old dressing on Resident #1's medial foot area. The dressing was observed to have some drainage and was dated 01/16/26. She removed gloves, washed hands, and put on new gloves. She then cleaned the wound, applied collagen powder to the wound bed, applied xeroform, and covered the pressure ulcer with a dry dressing. RN A did not wear a gown while providing Resident #1 with wound care.Interview on 01/17/26 at 11:37 AM with CNA B revealed she knew she was supposed to wear PPE when there was an EBP sign on the door. She stated she could not recall seeing an EBP sign at Resident #1's room. She stated she knew she was supposed to put on gloves and a gown when caring for residents with wounds. She stated she forgot because there was no cart with PPE at Resident #1 door. She stated she had done training on EBP. She stated the risk of not wearing a gown and gloves was it could lead to cross contamination.Interview on 01/17/26 at 11:41 AM with RN A revealed she forgot to wear PPE because she was anxious. She stated she was aware she was supposed to wear gloves and a gown while coming into contact with Resident #1. She stated Resident #1 had signage by the door but did not have a bin for PPE. RN A stated she knew staff were supposed to use EBP for all residents with wounds. She stated she did not wear PPE because there was none by the door. She stated failure to use EBP could place Resident #1 at risk of cross contamination. She stated she had done training on EBP. She was asked and also, I had to verify whether she had been trained on EBP.2. Record review of Resident #2's Comprehensive MDS Assessment, dated 12/26/25, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 10, and her diagnoses included pressure ulcer of sacral region and a pressure ulcer on the left ankle.Record review of Resident #2's care plan, dated 01/17/26, reflected: Focus: [Resident #2] Enhanced Barrier Precautions. Staff must wear gowns and gloves during high contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Implemented rule out feeding tube. Goal: [Resident #2] dignity will be maintained over the next 90 days. Interventions: Enhanced barrier precaution: staff must use gowns and gloves during high -contact care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (Bacteria that resist treatment with more than one antibiotic are called multidrug-resistant organisms) (e.g. Residents with wounds).Observation on 01/17/26 at 11:08 AM revealed LVN C prepared wound care supplies and then entered Resident #2's room. LVN C washed her hands and put on gloves, but she did not put on the gown. She removed the old dressing on the resident's sacral area, dated 01/16/26. She removed her gloves, washed her hands, and put on new gloves. She cleaned the wound, applied collagen powder to the wound bed, then applied calcium alginate, and covered the pressure ulcer with a dry dressing. She washed her hands and put on clean gloves. She removed the old dressing on the resident's left ankle. The dressing was observed to have some drainage and was dated 01/16/26. She then removed her gloves, washed her hands, and put on new gloves. She cleaned the wound and applied collagen powder to the wound bed, then applied calcium alginate, and covered the wound with a dry dressing. The gloves were the only PPE that LVN C wore while providing wound care to Resident #2.Interview on 01/17/26 at 12:12 PM with LVN C revealed she forgot to wear PPE, because she was nervous. She stated the facility used to put PPE in a bin by the resident's door, but today there was no PPE by the door. She stated she was aware she was supposed to wear gloves and a gown while coming into contact with Resident #2. She stated failure to use EBP could place Resident #2 at risk of cross contamination. She stated she had done training on enhanced barrier precautions.Interview on 01/17/26 at 3:02 PM with the DON revealed staff were required to wear a gown and gloves when having direct contact with the residents on EBP such as turning, incontinence care, and providing wound care. The DON stated the EBP were in place to protect the residents from exposure to infectious agents that might be on the provider's clothing. She stated she had done training on EBP, and she was not sure whether the staff were in attendance since she was new to the facility. Record review of the facility's training records for EBP, dated 11/25/25, reflected RN A, CNA B and LVN C had not attended the EBP training. To determine whether facility had done training on staffs on EBP. Record review of the facility's Enhanced Barrier Precautions policy, dated February 2025, reflected: 1. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms to residents. 2.Enhanced Barrier Precautions employs targeted gown, and gloves use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.3 .Examples of high -contact resident care activities requiring the use of gowns and gloves for EBP include:a. Dressingb. Bathing /showeringc. Transferringd. Providing hygienee. Changing linens f. changing briefs or assisting with toiletingg. Device care or use (central lines, urinary catheters, feeding tubes, tracheostomy tubes (a medical device inserted into the trachea (windpipe) to establish and maintain an airway and facilitate breathing) h. Wound care (any skin opening requiring dressing)

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #6) reviewed for dignity. The facility failed to conceal Resident #6's catheter bag from lying in public view. This failure placed residents at risk of not having their right to a dignified existence and self-determination maintained.Findings included: Record review of Resident #6's Face Sheet, dated 10/30/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnosis of Neuromuscular dysfunction of bladder (impaired bladder). Record review of Resident #6's Quarterly MDS Assessment, dated 10/22/25, reflected Resident #6 had a BIMS score of 99 (unable to complete the interview). The Quarterly MDS Assessment reflected an active diagnosis of a urinary tract infection. Record review of Resident #6's Physician Order, dated 10/30/25, reflected Foley catheter: Size 18 FR 10; Change catheter and drainage bag as needed for indications of blockage increased sediment, infection displacement as needed. In an interview and observation on 10/30/25 at 8:51 AM, LVN H was shown Resident #6's catheter bag hanging from her bed with no privacy bag. She stated the resident should have a privacy bag to cover the catheter bag for the resident's dignity. She stated nurses was required to ensure all residents with catheter bags had a privacy bag. The catheter bag was visible from the hallway. In an interview on 10/30/25 at 9:51 AM, the DON was told about Resident #6 not having a privacy bag for her catheter bag. She stated the resident required a privacy bag for their privacy. She stated she was unsure if a privacy bag was required while the residents was in their bed. She stated the nursing staff always checked to ensure all residents with catheter bags had a privacy bag. Record review of the facility's policy on Dignity, February 2011, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for three of ten residents (Residents #3, #4, and #5) reviewed for call systems access. The facility failed to ensure the call light system in Residents #3, #4, and #5's rooms was in a position that was accessible to the residents on 10/30/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #3's Face Sheet, dated 10/30/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and muscle weakness. Record review of Resident #3's Quarterly MDS assessment, dated 10/06/25, reflected a BIMS score of 99, which indicated she was unable to complete the interview. For ADL care, it reflected the resident was dependent on staff to provide all care. She had an active diagnosis of a stroke. Record review of Resident #3's Comprehensive Care Plan, dated 10/13/25, reflected the resident was a fall risk, and included an intervention of encouraging the resident to use the call light. In an observation and interview on 10/30/25 at 8:25 AM, revealed Resident #3 was lying in bed, and her call light was observed on the floor near her nightstand. In an interview and observation on 10/30/25 at 8:30 AM, RN F was shown Resident #3's call light and she stated she was unsure if the resident could use the call light. She stated the call light should be in the resident's reach so she could contact them if she needs help. She stated they should check to ensure the call lights was within the resident's reach when the nursing staff make their rounds. 2. Record review of Resident #4's Face Sheet, dated 10/30/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and reduced mobility. Record review of Resident #4's Quarterly MDS assessment, dated 10/28/25, reflected a BIMS score of 4, which indicated severe cognitive impairment. For ADL care, it reflected the resident required substantial assistance. Record review of Resident #4's Comprehensive Care Plan, dated 10/30/25, reflected the resident had urinary incontinence (involuntary leakage of urination) and one of the interventions was to ensure call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/30/25 at 8:36 AM, revealed Resident #4 was lying in her bed, her call light was located under the bed, and out of reach of the resident. 3. Record review of Resident #5's Face Sheet, dated 10/30/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included displaced fracture of the neck and back and reduced mobility. Record review of Resident #5's Quarterly MDS assessment, dated 9/25/25, reflected a BIMS score of 15, which indicated an intact cognitive response. For ADL care, it reflected the resident required substantial assistance. Record review of Resident #5's Comprehensive Care Plan, dated 10/01/25, reflected the resident was a fall risk, and included an intervention of encouraging the resident to use the call light and keeping call light within reach of the resident. In an observation and interview on 10/30/25 at 8:59 AM, revealed Resident #5 was lying in his bed, and his call light was hanging off a side rail, nearly touching the floor, and out of reach of the resident. The resident was asked if he knew where his call light was and he stated he did not know. In an interview and observation on 10/30/25 at 8:51 AM, LVN H was shown Resident #4 and #5's call lights not within reach of the residents. She stated the CNAs often forget to place the call light back within reach of the residents once they have provided care to the residents. She stated the risk of not having the call light within reach of the residents could prevent them from calling for help. In an interview on 10/30/25 at 9:51 AM, the DON was told about Resident #4 and #5 not having their call lights within their reach. She stated sometimes the staff forgot to place the call light next to the residents when they are done providing care. She stated she and the nursing staff checked to ensure call lights was within the residents' reach throughout their shifts. She stated not having the call light within their reach could result in the residents being unable to call for help. In an interview on 10/30/25 at 1:00 PM, CNA R stated she provided care to the residents on the 600-hall. She was told about Resident #3 not having her call light within reach and she stated the call light needed to be within reach of the resident so they could contact them if they needed help. She stated they checked rooms at least every two hours and they had to check to ensure call lights was within reach. Review of the facility's policy Call System, Residents, 1/2025, reflected Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. 1.Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of seven residents (Residents #1 and #2) reviewed for respiratory care. The facility failed to ensure Resident #1's nasal canula and CPAP mask was properly stored in a bag when not in use on 10/30/25. The facility failed to ensure Resident #2's nasal canula was properly stored in a bag when not in use on 10/30/25. These failures could place residents at risk of respiratory infection and not having respiratory needs met.Findings include: 1. Record review of Resident #1's Face Sheet, dated 10/30/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included COPD (long-term breathing problems). Record review of Resident #1's Quarterly MDS assessment, dated 9/03/25, reflected a BIMS score of 8, which indicated moderate cognitive impairment. For ADL care, it reflected the resident required substantial assistance. She had an active diagnosis of COPD and respiratory failure (low oxygen). Record review of Resident #1's physician's orders, dated 10/30/25, reflected CPAP: Settings 8cmh2o Apply at HS Via Nasal Pillow with 3 liters of oxygen once a day bedtime and Nasal canula (continuous) 3L/min to keep oxygen at 90% In an observation and interview on 10/30/25 at 8:52 AM, revealed Resident #1's nasal canula for her oxygen tank, attached to her wheelchair, was hanging down the back of the wheelchair unbagged. Resident #1's CPAP mask was observed sitting on top of the nightstand unbagged. Resident #1 stated she had not used the oxygen attached to her wheelchair since last night and she had not used her CPAP machine since waking up earlier today. In an interview and observation on 10/30/25 at 8:30 AM, RN F was shown Resident #1's nasal canula and CPAP mask unbagged. She stated breathing devices should be bagged when not in use. She stated not bagging the devices could result in the resident getting an infection. She stated it was the nurses' responsibility to ensure the devices are bagged when not in use. 2. Record review of Resident #2's Face Sheet, dated 10/30/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included chronic respiratory failure (lungs not functioning properly). Record review of Resident #2's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 15, which indicated the resident had an intact cognitive response. For ADL care, it reflected COPD and respiratory failure (low oxygen). Record review of Resident #2's physician's orders, dated 10/30/25, reflected Nasal canula (continuous) O2 @ (2-6) L/min, titrate oxygen to keep above 93%. In an observation on 10/30/25 at 8:54 PM, revealed Resident #2's nasal canula was observed on the floor, hanging from the wheelchair, unbagged. In an interview and observation on 10/30/25 at 8:51 AM, LVN H was shown the breathing devices for Resident #2 being unbagged when not in use. She stated the devices needed to be bagged to avoid the residents from getting an infection. She stated it was the nurses' responsibility to check to ensure the devices are bagged when not in use. In an interview on 10/30/25 at 9:51 AM, the DON was told about Residents #1 and #2 not having their breathing devices bagged and she stated the devices needed to be bagged to avoid the residents from getting an infection. She stated she and the nurses check for this throughout the day. Review of the facility's policy Oxygen Administration, 10/2010, reflected The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. 3. Assemble the equipment and supplies as needed.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents which resulted in sustained bleeding to the brain, a bruise to the scalp, and a bruising to the hands for 1 (Resident #1) of 4 residents reviewed for accidents. On 11/07/2025 Certified Nurse Aide (CNA) A attempted to perform a 1-person transfer, with a sliding board, on Resident #1 who required a 2-person transfer with a Hoyer (Mechanical lifting device to help workers transfer patients) lift for nursing staff. CNA A failed to request assistance from another staff member and was unable to complete the transfer successfully. Resident #1 fell on the floor and hit her head. Resident #1 was sent to the hospital where it was discovered that she had a traumatic brain hemorrhage. CNA A was not trained to use a sliding board for Resident #1. This was determined to be past non-compliance immediate jeopardy from 11/07/2025 to 11/11/2025 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who require a 2-person transfer, with or without a mechanical lift, at risk of injury, hospitalization, and death. The findings included: Review of the Care Plan dated 3/18/2025 revealed Resident #1 was an [AGE] year-old female admitted on [DATE]. The care plan reflected Resident #1 required assistance of 2 staff members by Hoyer lift during transfers. Resident #1 had a fear of falling from the mechanical lift and preferred a two-person transfer if safe. Resident #1 had Parkinsons Disease and was at risk for injury from increased tremors and involuntary muscle movements; tremors in the right upper extremity; neurological Aphasia (disorder that damages the brains' ability to perform language communication skills), Cerebrovascular Accident/Transient Ischemic Attack (Stroke), Non-Alzheimer's Dementia (Memory impairment for daily activities), Hemiplegia (weakness to one side of the body), Parkinsons Disease (degenerative disorder that affects movement). Resident #1 had a witnessed fall on 11/7/2025 with a serious injury of the left temporal subarachnoid hemorrhage, left frontal scalp hematoma (bruise or collection of blood). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognitive function. Resident #1 had functional abilities of 3 indicating Partial/moderate assistance for sit to lying, lying to sitting on side of bed, chair/bed to chair transfer. Record Review of the Inservice for Appropriate Transfer for all residents dated 11/11/2025. Revealed 33 Care staff check for all resident transfers. Demonstrations were given and staff returned demonstrations. Record Review of the Inservice for Abuse and Neglect dated 11/11/2025. Revealed 43 Care staff check for Abuse and Neglect training. Record Review of the Inservice for Gait Belts and Transfers for all residents dated 11/13/2025. Revealed 30 Care staff check for Gait Belts and Transfers. Record Review of the Inservice for Liftin Machine Using a Mechanical dated 11/13/2025. Revealed 29 Care Staff check for Mechanical Lift Competency. Record Review of the Inservice for Use of Sliding Board Transfers dated 11/12/2025. Revealed 10 Therapy Staff check off for not leaving sliding boards in resident rooms unattended. Review of the Employee Statement from RN D dated 11/11/2025 revealed that she was notified by a CNA C that Resident #1 had a fall. Resident #1 was on the floor. She stated that she went to the room as soon as possible and saw Resident #1 on the ground in a sitting position in front of her bed. She asked Resident #1 what happened and was informed that CNA A was transferring Resident #1 to the bed with a sliding board. She stated that Resident #1 had fallen and hit her head on the floor. Upon assessment the resident was noted to have a hematoma to the left side of her head and bruises to both of her hands. Review of the incident report dated 11/07/2025 by RN D revealed a witnessed incident. Resident #1 was oriented. Bruising was noted to Resident #1's right hand, left hand, face, and a hematoma on top of scalp. Documented the incident occurred during a transfer. Notifications were made to the physician and family member at 4:00 PM. Review of the Employee Statement from CNA C, not dated, revealed that he was working on 11/07/2025. He stated he was walking in the hall and happened to be walking by Resident #1's room at the time of the incident. He stated that he saw CNA A attempting to transfer Resident #1. He stated that he heard the sound of the fall, and he went back to the room to see what had happened. He stated he saw Resident #1 on the floor. He stated he went to notify the charge nurse immediately. Review of the Hospital Report dated 11/07/2025 revealed Resident #1 was sent to the hospital on [DATE] at 4:27 PM. Resident #1 was an [AGE] year-old female with past medical history of hypertension (high blood pressure) and left sided deficits from a prior stroke. Resident #1 presented to the emergency department for evaluation of a fall with a head strike. Resident #1 reported no pain. No other injuries. Resident #1 took blood thinners for A-fib (irregular and often very rapid heart rhythm). CT (Computed Tomography) X-Ray scan of the head/brain with contrast revealed Resident #1 suffered a small amount of subarachnoid hemorrhage in the posterior left temporal lobe (bleeding in the space below one of the thin layers that cover and protect your brain.). Review of the Employee Statement from CNA A dated 11/10/2025 revealed that she was called to Resident #1's room by Therapy Assistant B to make the bed for Resident #1. She stated she made the bed and decided to transfer Resident #1 back to bed using the sliding board. She stated Resident #1 fell and hit her head on the floor. She stated she called the nurse to come check on her. In an interview on 11/13/2025 at 10:00 AM, Administrator E revealed that CNA A transferred Resident #1 inappropriately which resulted in Resident #1 falling to the ground. She stated this was a facility self-reported incident. Resident #1 was a 2 person Hoyer lift transfer. CNA A attempted the transfer without the help of a second caregiver and with a sliding board instead of a Hoyer lift. She stated CNA A was suspended on 11/11/2025. She stated that the facility had already completed an action plan, plan of removal, and was continuing to monitor. Administrator E stated staff have been in-serviced on abuse and neglect. Administrator E stated staff have been in-serviced on how to correctly perform transfers. She stated Resident #1 returned to the facility and was doing fine. She stated the therapy department worked with Resident #1 on sliding board transfers, but the nursing staff were not supposed to use the sliding board. In an interview on 11/13/2025 at 10:30 AM with Resident #1 revealed that CNA A had never worked with her before the day of the incident. She stated that she wanted to get into bed and CNA A stated that she knew how to use the sliding board. She stated that CNA A obviously didn't know how to use the sliding board because she walked to the other side of the bed. She stated that normally the therapist would perform the transfer by having her sit on the board first and then begin to slide her up into bed. She stated that she had been working on sliding board transfers for a while now and had become good at it. She stated that normally she could do it without much assistance. In an interview on 11/13/2025 at 10:35 AM with Therapy Assistant B revealed she was working with Resident #1 in therapy and had taken her back to her room. She stated that she informed CNA A to make the bed for Resident #1 so that she could put her in bed. She stated that she went to assist another resident in the hall while CNA A made the bed. At that time CNA A attempted to perform the sliding board transfer by herself, and Resident #1 fell to the ground and hit her head. She stated that the therapy department are allowed to transfer Resident #1 with a sliding board. She stated that the nursing staff are not allowed to transfer Resident #1 with a sliding board. She understood the policies regarding sliding boards. She stated that the therapy staff recently performed inservices for sliding boards. In an interview on 11/13/2025 at 2:00 PM, CNA A stated Resident #1 was brought back to her room from therapy services. She stated that Therapy Assistant B asked her to make the bed for Resident #1 so that Therapy Assistant B could transfer Resident #1 to her bed. Therapy Assistant B informed CNA A that she would be back after a few minutes and left the sliding board in the room. CNA A stated Resident #1 asked CNA A to put her in bed. CNA A stated that she knew how to perform a sliding board transfer and Resident #1 agreed to let her perform the transfer. CNA A stated that she had not been trained on performing the sliding board transfer for Resident #1 and that Resident #1 was normally a 2-person assist. She stated she was a Hoyer assist that needs 2 people. She stated that she had been trained on sliding boards in the past. She stated she placed the sliding board under Resident #1 and she walked to the other side of the bed to prepare her bed. At that time Resident #1 attempted to scoot forward onto the sliding board from her wheelchair. Resident #1 lost balance and fell over to her side and hit the floor with her head. She stated that she was not ready for Resident #1 to start the transfer at that time. She stated that she could not prevent Resident #1 from falling because she was on the other side of the bed. She stated, CNA C notified RN D then came to assist and assess Resident #1. She stated she attempted the sliding board transfer by herself without the help of another staff member. She stated that the facility had since then performed in-services for transfers and abuse/neglect for the care staff but placed her on suspension pending investigation. In an interview on 11/13/2025 at 2:00 PM, Attending Physician G stated that he was notified of the fall that occurred on 11/07/2025. He stated that a fall during a sliding board transfer from a staff member who was not properly trained on that kind of transfer technique did put Resident #1 at a mild to severe risk of injury. He stated that the fall could have resulted in a fracture risk in combination with a brain bleed which would be a severe risk of injury. In an interview on 11/13/2025 at 2:30 PM, Administrator E revealed that it was the facility's policy to perform a Hoyer lift with two caregivers for Resident #1. She stated that the facility performed training after the incident and was continuing to train the staff before they began their next shift. She understood the policies regarding mechanical lifts, sliding boards, and the use of a Hoyer lift. She stated that he recently performed inservices for Mechanical lifts, sliding boards, and the use of a Hoyer lift. In an interview on 11/13/2025 at 3:00 PM, CNA C revealed that he was working at the time of the incident. He stated, he was walking in the hallway when he heard the sound of someone falling. He stated he went to check to see what happened and saw CNA A and Resident #1. He stated Resident #1 was on the ground. He went to get the nurse immediately to assess Resident #1. He understood the policies regarding mechanical lifts, sliding boards, and the use of a Hoyer lift. He stated that he recently performed inservices for Mechanical lifts, sliding boards, and the use of a Hoyer lift. In an interview on 11/13/2025 at 3:15 PM, Therapy Director F stated that the nursing staff should not be using the sliding board for Resident #1. He stated that the therapy department had been working with Resident #1, and she had been making progress. He stated that the nursing staff would have to be trained to perform the sliding board transfer, but that CNA A was not delegated to perform that type of transfer. He understood the policies regarding sliding boards. He stated that the therapy staff recently performed inservices for sliding boards. Review of the facility Accident and incidents policy dated 2017 revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instruction. 1. At least (2) nursing assistants are needed to safely move a resident with a mechanical lift. Review of the Lifting Machine, Using a Mechanical policy dated 2001 revealed, The facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. Review of the Care Planning - Interdisciplinary Team policy dated 2024 revealed The interdisciplinary team is responsible for the development of the resident care plans.g. other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. Review of the facility Fall Risk Management policy dated 2018 revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A Facility Transfer Policy specific to transfers and transfer techniques was requested but not provided. The facility took the following actions to correct the non-compliance on 11/11/2025: 1. Physician G, Director of Nurses H, and Resident #1's Responsible Party were notified of the fall on 11/07/2025. Documented in the incident report and confirmed with interview. 2. CNA A was suspended on 11/11/2025. Confirmed with interview. 3. Resident #1 was transferred to the emergency room (ER) on 11/07/2025 and returned on 11/12/2025. Confirmed with hospital records and interview. 4. In-services were conducted by the Administrator E and DON H and will continue to be conducted until every staff member has received the in-service at the start of their shift: a. Appropriate Transfer for all residents dated 11/11/2025. 33 Care staff check for all resident transfers. Demonstrations were given and staff returned demonstrations. b. Abuse and Neglect dated 11/11/2025. 43 Care staff check for Abuse and Neglect training. c. Gait Belts and Transfers for all residents dated 11/13/2025. 30 Care staff check for Gait Belts and Transfers. d. Lifting Machine Using a Mechanical dated 11/13/2025. 29 Care Staff check for Mechanical Lift Competency. e. Use of Sliding Board Transfers dated 11/12/2025. 10 Therapy Staff check off for not leaving sliding boards in resident rooms unattended. 5. Residents were audited to ensure the MDS matches the residents' current transfer status. 6. Resident rooms were audited for sliding boards. All sliding boards were removed until therapy can educate and check off the CNA's and communicate which residents are appropriate for sliding board transfers. 7. CNA's and Charge Nurses checked off with the Hoyer lift competency to ensure understanding and proper transfers. 8. Competency Checkoffs with direct care staff on how to check the Kardex (Nursing Documentation System) and proper transfers performed 5 times a week x4 weeks to ensure competency. Interviews on 11/13/2025 with CNA A, Administrator E, Therapy Director F, Therapy Assistant B, CNA C, DON H, CNA I, CNA J, ADON K, DON L, LVN M, CNA N, CNA O revealed they understood the policies regarding mechanical lifts, sliding boards, and the use of a Hoyer lift. They stated they recently performed inservices for Mechanical lifts, sliding boards, and the use of a Hoyer lift. On 11/13/2025 at 10:30 AM and 11:09 AM CNA J and CNA N were observed transferring Resident #2 and Resident #3 with a mechanical lift using good technique.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 5 (Resident #58, #56, #54, #61, and #120) of 18 residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Residents #58, #56, #54, #61, and #120. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. The findings included: Resident #58 Record review of Resident 58's Face Sheet, dated 03/18/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #58 had diagnoses which included unspecified dementia (mental decline that interferes with daily life) and repeated falls. Record review of Resident #58's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 02/13/2025, reflected the resident had severe impairment in cognition with a BIMS (screening tool used to assess cognitive status) score of 04. Section GG indicated the resident required substantial assistance with self-care. Record review of Resident #58's Comprehensive Care Plan, dated 02/27/2025, reflected the resident has a history of falls and is at risk for increased falls and or fractures AEB cognitive impairment, physical impairment, unsteady gait and one intervention was encourage the use of call light. An observation and interview on 03/16/2025 at 08:48 AM revealed Resident #58 sitting on the side of her bed. The call light was clipped to the light over the resident's bed and was not within the resident's reach. Resident #58 did not respond when asked if she could reach her call light. CNA F came into the resident's room and stated she would move the call light so the resident could reach it. Resident #56 Record review of Resident 56's Face Sheet, dated 03/18/2025, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included the need for assistance with personal care and other abnormalities of gait and mobility. Record review of Resident #56's Quarterly MDS Assessment, dated 02/13/2025, indicated the resident had moderate impairment in cognition with a BIMS score of 12. Section GG indicated the resident required moderate assistance with mobility. Record review of Resident #56's Comprehensive Care Plan, dated 01/09/2025, reflected the resident was at risk for falls d/t unsteady gait and at risk for increased falls and/or fractures and one intervention was to keep call light in reach at all times. During an observation and interview on 03/16/25 at 08:50 AM, Resident #56 was sitting on his bed. Resident #56 did not have a roommate. The two call lights in the room were attached to the bedrail of the unoccupied bed. Resident #56 stated he did not know where his call light was, but he did not use it much. Resident #54 Record review of Resident #54's Face Sheet, dated 03/18/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included Alzheimer's disease (a progressive brain disorder that affects the ability to think and remember things) and muscle wasting and atrophy. Record review of Resident #54's Quarterly MDS Assessment, dated 01/27/2025, indicated the resident had severe impairment in cognition with a BIMS score of 03. Section O indicated the resident received physical therapy and occupation therapy services. Record review of Resident #54's Comprehensive Care Plan, dated 02/27/2025, reflected the resident was at risk for fall r/t lack of coordination, unsteady gait. One intervention was to keep call light within reach. During an observation and interview on 03/16/25 at 9:06 AM, Resident #54 was sitting in a recliner in her room. Resident #54's call light and her roommate's call light were both attached to the roommate's bedrail. The recliner was placed between the two beds. Resident #54 was unable to answer questions because of her cognitive status. Resident #61 Record review of Resident #61's Face Sheet, dated 03/18/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #61 had diagnoses which included cerebral infarction (stroke) and other seizures (abnormal electrical activity in the brain). Record review of Resident #61's Quarterly MDS Assessment, dated 12/23/2024, indicated the resident had severe impairment in cognition with a BIMS score of 06. Section O indicated the resident received physical therapy and occupation therapy services. Record review of Resident #61's Comprehensive Care Plan, dated 02/27/2025, reflected the resident had a history of falls. Some interventions included keep call light within reach and encourage use of call light. During an observation and interview on 03/16/2025 at 9:12 AM, Resident #61 was lying in bed. Resident #61's call light was on the floor under her wheelchair. There was a nightstand between the bed and the wheelchair. Resident #61 stated it was fine and she could get to her call light if she needed it. Resident #120 Record review of Resident #120's Face Sheet, dated 03/17/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included heart failure, shortness of breath, and mini strokes. Record review of Resident #120's Quarterly Minimum Data Set (MDS) assessment, dated 02/11/25, reflected he had a BIMS score of 8 (moderate impairment). For ADL care it reflected for transfers, toileting, and bathing the resident required extensive assistance. Record review of Resident #120's Quarterly Care Plan, dated 02/24/25, reflected the resident was a risk for falls and an intervention was to encourage the resident to use the call light. In an observation and interview on 03/16/25 at 09:00 AM, CNA J observed Resident #120's call light on the floor, out of reach for the resident's use. The CNA picked up the resident's call light off the floor and clipped it to his bed. She stated the call light needed to be in reach of the resident so he could alert staff if he needed assistance. During an interview on 03/16/25 at 09:18 AM, CNA F stated the residents were assigned to her. She stated it was important for all the residents to have their call lights within reach. She stated the residents needed to be able to call staff for assistance. She stated they might be sick or need help. She stated if the residents had to use their voice to call out for help, staff might not hear them. CNA F stated she would move the call lights so the residents could reach them. During an interview on 03/16/25 at 09:23 AM, LVN H stated it was important for residents to be able to reach their call lights to alert staff if they needed assistance. LVN H stated if a resident fell or had an emergency, the call light should be placed where the resident could reach it. During an interview on 03/17/24 at 08:47 AM, the DON stated some residents don't know what to do with the call light. She stated staff may forget to go back to the residents' rooms and make sure the residents have not moved their call lights. The DON stated the residents on the unit wander in and out of the rooms. She stated when a resident goes back to their room to lay down, staff need to go to the room and make sure the call light was in reach. She stated it was important to have a call light so the residents can call for help. She stated residents on the unit rarely use the call light, but it is their method of calling for help when they were in their room. She stated staff would be in-serviced about this. During an interview on 3/18/25 at 10:10 AM, the ADON stated most of the residents in the locked unit pull their call light and disconnect it from the wall. She stated staff try to keep the call lights in the residents' reach as much as possible. The ADON stated some residents use their call light and some do not. She stated the use of a call light was different on the unit but it should be there if the resident needed it, especially when the resident was in the room. She stated everyone was responsible for ensuring the residents could reach their call light. She stated that included administration, therapy services, nursing staff, and any other member of staff. She stated if a resident could not reach their call light, they might not receive help when they need it. The facility's policy Answering the Call Light, revised March 2021, 2024, reflected 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observations, interviews, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 9 of 12 resident rooms (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9) reviewed for environment. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 03/16/25 at 11:05 Am of resident room [ROOM NUMBER] reflected the air vent along the wall of the room had thick black and brown dirt along and between the vents. The bathroom sink faucet had thick white stains along the base of the faucet. The soap dispenser had a reddish stain on the base of it. An observation on 03/16/25 at 11:12 Am of resident room [ROOM NUMBER] reflected the air vent along the wall of the room had thick black and brown dirt along and between the vents. The bathroom sink faucet had thick white stains along the base of the faucet. The soap dispenser had a reddish stain on the base of it and behind the room door was a large hole on the wall. An observation on 03/16/25 at 11:23 Am of resident room [ROOM NUMBER] reflected the air vent along the wall of the room had thick black and brown dirt along and between the vents. The bathroom sink faucet had thick white stains along the base of the faucet. The soap dispenser had a reddish stain on the base of it. The mini fridge in the room had brown and red stains inside the bottom of it. An observation on 03/16/25 at 11:28 Am of resident room [ROOM NUMBER] reflected the air vent along the wall of the room had thick black and brown dirt along and between the vents. The window ledge had dirt particles along the windowsill. The mini fridge in the room had brown and red stains inside the bottom of it. An observation on 03/16/25 at 11:31 Am of resident room [ROOM NUMBER] reflected the air vent along the wall of the room had thick black and brown dirt along and between the vents. An observation on 03/16/25 at 11:34 Am of resident room [ROOM NUMBER] reflected the air vent along the wall of the room had thick black and brown dirt along and between the vents. An observation on 03/16/25 at 11:39 Am of resident room [ROOM NUMBER] reflected the air vent along the wall of the room had thick black and brown dirt along and between the vents. An observation on 03/16/25 at 11:42 Am of resident room [ROOM NUMBER] reflected the air vent along the wall of the room had thick black and brown dirt along and between the vents. An observation on 03/17/25 at 12:24 Am of resident room [ROOM NUMBER] reflected behind a resident's bed, large amounts of drywall debris between the bed and wall. During a Resident Council meeting on 03/17/5 at 11:00 AM, Resident #50 stated her room did not get cleaned every day. She stated when she dropped items on her floor, she had seen the same items on the room floor the next day because her room was not cleaned. In an interview on 03/17/25 at 12:35 PM, Housekeeper C stated she had been at the facility a year. She stated they were responsible for cleaning the vents, windows, bathroom, dust, and the mini fridges. She stated she cleaned different halls daily. She was shown pictures of the concerns observed in room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9 and she stated they were responsible for ensuring the concerns observed were cleaned. She stated the risk of not ensuring the rooms were thoroughly cleaned could impact the health of the residents. In an interview on 03/17/25 at 12:46 PM, Housekeeper K stated she had been at the facility since August 2024. She stated they were responsible for cleaning the floors, sweep and mop, vents, windows, bathroom, dust, but the housekeeping manager cleaned the mini fridges. She stated she was responsible for cleaning the 600 hall. She was shown pictures of the concerns observed for room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9. She stated they were responsible for ensuring the concerns observed were cleaned. She stated the risk of not ensuring the rooms were thoroughly cleaned they could get sick and the items in the mini fridge should be thrown out. In an interview on 03/18/25 at 09:52 AM, the Housekeeping Supervisor, stated she had been at the facility for 2 years. She stated housekeeping were supposed to clean the bathrooms, clean the floors, wipe down furniture, take out trash, clean air vents, but she did not know who was responsible for cleaning the mini fridge in the resident rooms. She was shown pictures of the concerns observed in room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9. She stated leadership was supposed to check for any issues with resident rooms during their morning rounds. She stated the risk of not cleaning the rooms thoroughly was this was their home, and it was not homelike. In an interview on 03/18/25 at 10:30 AM, the Administrator was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9. He stated it appeared housekeeping was not doing a thorough job cleaning the resident rooms, the housekeeping supervisor was not following up and checking housekeeping work, and leadership were not checking for room cleanliness during their daily rounds. He stated he had just hired a maintenance person, to repair issues such as the hole in the resident's wall. He stated the risk of not addressing these concerns could impact infection control. Record review of the facility's policy on Homelike Environment (February 2021) reflected Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 of 6 residents (Resident #17, #26, and #34) reviewed for accident prevention. The facility failed to ensure Resident #17, and Resident #26 had physician orders for the use of a scoop mattress for fall prevention. The facility failed to ensure Resident #34 had a fall mat placed alongside her bed for fall prevention. These failures could prevent the resident from having an environment that was free and clear of accidents and hazards. Findings included: 1. Record review of Resident #17's Face Sheet, dated 03/17/25, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, dementia (cognitive decline), and history of falling. Record review of Resident #17's Quarterly Minimum Data Set (MDS) assessment, dated 03/14/25, reflected she had a BIMS score of 12 (moderate impairment). For ADL care it reflected for transfers, toileting, and bathing the resident required extensive assistance. Record review of Resident #17's Quarterly Care Plan, dated 01/12/25, reflected the resident was at risk for falls and an intervention was to provide a scoop mattress. Record review of Resident #17's physician orders, dated 03/16/25, reflected no physician orders for the scoop mattress. An observation on 03/16/25 at 09:25 AM, revealed Resident #17 had a scoop mattress on her bed. 2. Record review of Resident #26's Face Sheet, dated 03/16/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included cerebral infarction (stroke) and absence of left leg, below the knee. Record review of Resident #26's Quarterly Minimum Data Set (MDS) assessment, dated 02/05/25, reflected he had a BIMS score of 15 (intact cognitive response). For ADL care it reflected for transfers, toileting, and bathing the resident required extensive assistance. Record review of Resident #26's Quarterly Care Plan, dated 01/30/25, did not reflect the resident was a fall risk. Record review of Resident #26's physician orders, dated 03/16/25, reflected no physician orders for the scoop mattress. An observation on 03/16/25 at 11:47 AM, revealed Resident #26 had a scoop mattress on her bed. 3. Record review of Resident #34's Face Sheet, dated 03/17/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, disorders of bone density and structure (weak bones), and history of falling. Record review of Resident #34's Quarterly Minimum Data Set (MDS) assessment, dated 12/16/24, reflected she had a BIMS score of 99 (unable to complete the interview). For ADL care it reflected for transfers, toileting, and bathing the resident required total assistance. Record review of Resident #34's Quarterly Care Plan, dated 01/12/25, reflected the resident was at risk for falls and an intervention was to provide a fall mat alongside the resident's bed. In an interview oin 03/16/25 at 02:15 PM, the DON was advised of Resident #17 and Resident #26 having scoop mattresses. She stated Resident #17 was care planned for a scoop mattress because she was a fall risk but Resident #26 should not have a scoop mattress. She stated Resident #26 would be provided a different mattress and she would obtain physician orders for Resident #17. She would not provide risk of residents having scoop mattresses without physician orders. In an observation and interview on 03/17/25 at 09:55 AM, RN F stated Resident #34 had a history of falls and she had recently had an injury of unknown origin. She stated her bed should be lowered and a fall mat placed alongside her bed. RN F observed no fall mat alongside the resident's bed. She stated they had failed to place the fall mat next to the resident's bed after she had returned from the hospital. She stated the risk of the fall mat not being placed alongside the resident's bed could result in her falling out of bed and injuring herself. She stated the nurses were responsible for checking for this. In an interview on 03/18/25 at 10:10 AM, the ADON was advised Resident #34 was observed without a floor mat placed alongside her bed and she stated the nurses and CNAs were supposed to monitor her to ensure the fall mat was alongside her bed. She stated the risk of the fall mat not being placed alongside the bed could result in an injury. The facility's policy Fall Prevention Program (11/24) reflected Policy:Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for five (Resident #10, #11, #32, #49, and #120) of ten residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #120's nasal canula (flexible tube used to deliver oxygen to the nose through two prongs), for the oxygen machine was placed in a sanitary bag to avoid contamination while not in use on 3/16/2025. 2. The facility failed to ensure Resident #10's humidifier bottle (a medical device designed to increase the moisture level in supplemental oxygen) had water in it on 03/16/2025. 3. The facility failed to ensure Resident #11's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) was properly stored when not in use on 03/16/2025. 4. The facility failed to ensure Resident #49's breathing mask and nasal cannula were properly stored when not in use on 03/16/2025. 5. The facility failed to ensure Resident #32's breathing mask for her nebulizer was properly stored when not in use on 03/16/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #120's Face Sheet, dated 03/17/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included heart failure, shortness of breath, and mini strokes. Record review of Resident #120's Quarterly Minimum Data Set (MDS) assessment, dated 02/11/25, reflected he had a BIMS score of 8 (moderate impairment). The resident had an active diagnosis of respiratory failure. Record review of Resident #120's Quarterly Care Plan, dated 02/24/25, reflected the resident experienced shortness of breath and an intervention was the use of oxygen therapy. Record review of Resident #120's Physician orders, dated 03/16/25, reflected oxygen at 2 liters via nasal canula to keep oxygen saturation above 94% as needed. In an interview and observation on 03/16/25 at 09:00 AM, RN I observed Resident #120's nasal cannula hanging on the oxygen concentrator unbagged. She stated the resident's nasal canula should be bagged when it was not in use. She stated the risk of the resident's nasal canula not being bagged could result in an infection. 2. Record review of Resident #10's Face Sheet, dated 03/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure with hypoxia (insufficient amount of oxygen in the body). Record review of Resident #10's Comprehensive MDS Assessment, dated 02/02/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had respiratory failure. Record review of Resident #10's Comprehensive Care Plan, dated 02/27/2025, reflected the resident had episodes of shortness of breath and one of the approaches was to apply O2 as ordered. Record review of Resident #10's Physician Orders, dated 05/16/2024, reflected Monitor Oxygen Humidification Bottle every shift. Replace or Refill as required every shift. Observation and interview on 03/16/2025 at 8:57 AM, Resident #10 was in her bed, awake. It was observed that the resident was using oxygen at 2 liters per minute. She said she had been using since last year. She said she thought her bottle was already dry because her nose was already dry. It was observed that a prefilled humidifier bottle was attached to her oxygen concentrator and was already empty. She said she could not remember when the last time the humidifier bottle was changed. 3. Record review of Resident #11's Face Sheet, dated 03/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with acute respiratory failure with hypoxia. Record review of Resident #11's Quarterly MDS Assessment, dated 01/30/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00 (resident required significant assistance and support in daily life). The Comprehensive MDS Assessment indicated the resident had respiratory failure. Record review of Resident #11's Comprehensive Care Plan, dated 02/27/2025, reflected Resident #11's care plan for respiratory failure did not include his breathing treatment. Record review of Resident #11's Physician Order, dated 10/23/2024, reflected Budesonide 0.25 MG/2ML Suspension. INHALE THE CONTENTS OF 1 VIAL VIA NEBULIZER TWICE DAILY for acute respiratory failure with hypoxia. Observation on 03/16/2025 at 9:12 A revealed LVN A was about to do Resident #11's breathing treatment. She opened the resident's drawer and took out the resident's breathing mask. The breathing mask was not bagged. She cleaned the breathing mask before administering the breathing treatment. 4. Record review of Resident #49's Face Sheet, dated 03/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #49's Comprehensive MDS Assessment, dated 02/26/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had chronic obstructive disease and was on oxygen therapy. Record review of Resident #49's Comprehensive Care Plan, dated 01/10/2025, reflected the resident had episodes of shortness of breath and one of the approaches was to administer medications as ordered. Record review of Resident #49's Physician Orders, dated 03/10/2025, reflected Nasal Cannula (Continuous): O2 @ (2)L/Min every shift. Record review of Resident #49's Physician Orders, dated 09/13/2024, reflected Albuterol Sulfate (2.5 MG/3ML) 0.083% Nebulization solution. INHALE THE CONTENTS OF 1 VIAL VIA NEBULIZER EVERY 6 HOURS AS NEEDED for asthma (narrowing of the airways). Observation on 03/16/2025 at 8:48 AM revealed the resident was not inside her room. It was observed that the resident's breathing mask was on her chair beside the resident's bed and her nasal cannula was on the floor. Both were not bagged. Observation and interview on 03/16/2025 at 9:15 AM, LVN A stated the nasal cannula, and the breathing masks should be bagged whenever the residents were not using them to prevent cross contamination and respiratory infection. She went inside Resident #49's room and saw the breathing mask and the nasal cannula were not bagged. She said she would get a new nasal cannula and breathing mask for Resident #49. She said she did not administer Resident #49's breathing treatment but she should have checked during her morning round if it was stored properly. She said Resident #49 also had an order for continuous oxygen and would use the portable oxygen tank if she went out of her room. She said she did not notice, as well, that the nasal cannula was on the floor. LVN A then went to Resident #10's room and saw the humidifier bottle was empty. She said the oxygen concentrator had a humidifier to keep the nose of the resident moist and to prevent irritation. She said she did not notice during her morning round that Resident #11's humidifier bottle was empty or running low. She said she will get a new pre-filled humidifier bottle for resident #11. LVN A said she administered Resident #11's breathing treatment and when she took it from Resident #11's drawer, it was not inside a bag. She said she would also get a new breathing mask for Resident #11. In an interview on 03/17/2025 at 11:47 AM, the ADON stated the nasal cannula, and the breathing mask should be stored properly inside a plastic bag if the residents were not using them. She said the staff were responsible for ensuring the nasal cannula and the breathing masks were clean every time the residents would use them. She said the expectation was for all nasal cannulas and the breathing masks to be stored properly. She said another expectation was for the staff to check if the pre-filled humidifier bottle was running low or was empty. She said if it was running low, the staff should be ready to change it. She said she would coordinate with the DON to initiate an in-service about respiratory care. In an interview on 03/17/2025 at 12:14 PM, the DON stated the breathing mask and the nasal cannula were supposed to be in a bag when the residents were not using them to prevent cross contamination and worsening of respiratory issues the resident might already have had. She said the oxygen concentrator should always have water in it to prevent dryness and irritation of the nasal passageway. She said the expectation was for the staff to be mindful and make sure the breathing masks and the nasal cannulas were bagged and that there was water in the humidifier bottle. She said she would conduct an in-service about respiratory care. In an interview on 03/18/2025 at 7:53 AM, the Administrator stated everything that the residents were using should be kept clean to prevent infection. He said he would coordinate with the DON to educate and re-educate the nursing staff to bag the nasal cannulas and breathing masks if not in use and to make sure there was water in the oxygen concentrator. He said the DON will in-service the staff about the respiratory care issue. 5. Record review of Resident #32's Face Sheet, dated 03/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with post COVID-19 (an acute disease caused by a virus) condition. Record review of Resident #32's Comprehensive MDS Assessment, dated 02/02/2025, reflected the resident had severe impairment in cognition with a BIMS score of 03. Record review of Resident #32's Comprehensive Care Plan, dated 01/27/2025, reflected the resident had episodes of shortness of breath and one of the approaches was to apply O2 as ordered. Record review of Resident #32's Physician Orders, dated 04/26/2023, reflected Ipratropium-Albuterol 0.5-2.5 (3) MG/3ML Solution. INHALE THE CONTENTS OF 1 VIAL VIA NEBULIZER EVERY 4 HOURS AS NEEDED FOR COUGH AND WHEEZING for Post COVID-19 condition. Observation and interview on 03/16/2025 at 9:18 AM revealed Resident #32 was in her bed, awake. It was observed that the resident had a nebulizer machine with a breathing mask attached to it on top of her side table. The breathing mask was not bagged. When asked how long she had been using the breathing mask, the resident shrugged her shoulders. Observation on 03/18/2025 at 8:17 AM revealed Resident #32's breathing mask was still on top of the resident's side table, unbagged. In an interview on 03/18/2025 at 8:47 AM, RN C stated Resident #32 had an order for a breathing treatment as needed. He said he was not aware when was the last time the resident used the breathing mask. He said if the breathing mask was not in use, it should be bagged to prevent it from getting dirty. He said he would clean the breathing mask and would put it in a plastic bag. Record review of the facility policy Oxygen Administration reviewed February 2025 revealed Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice . Policy Explanation and Compliance Guidelines . 5. Other infection control measures include . f. Keep delivery devices covered in a plastic bag when not in use.

Based on observations, interviews, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice scoop for the ice machine in the facility kitchen was cleaned and exposed to air-borne contaminants. 2. The facility failed to ensure the ice machine was thoroughly cleaned. 3. The facility failed to ensure the kitchen floor and walls were cleaned. 4. The facility failed to ensure kitchen cooking equipment was cleaned. 5. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 6. The facility failed to ensure food in the refrigerator was labeled and dated. 7. The facility failed to ensure foods in the freezer was sealed from air-borne contaminants. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 03/16/25 from 8:44 AM to 9:01 AM in the facility's only kitchen revealed: The ice machine, located in a hallway outside the kitchen, had an ice scoop stored in a black holder, and the lid was not covering the ice scoop from air-borne contaminants. The ice scoop also had ice sitting in it, while in the scoop holder. The ice machine, located in the hallway outside the kitchen had a dirty filter and the inside wall of the machine had light brownish stains. The kitchen floor had built up dirt stains along the walls and the walls had dried brownish stains sprayed on it. One large microwave, located in the kitchen area, had dried up food stains along the inner walls of the microwave. One large table containing the drink dispensers had dark stains under a small machine, near one of the drink dispenser containers. Two containers containing flour and sugar had white and reddish stains along the lids of the containers. One long tube of ground beef, located in the refrigerator was not dated with the date the item was stored. One large box of frozen roll dough was sitting in a plastic bag unsealed from air-borne contaminants. One large box of frozen vegetable blend was sitting in a plastic bag unsealed from air-borne contaminants. Observations on 03/17/25 at 11:00 AM in the facility's only kitchen revealed: One large tea dispenser, located in the kitchen area, had tea in it and it did not have a lid placed on the top dispenser to avoid air-borne contaminants. In an interview and observation on 03/17/25 at 10:15 AM, the Dietary Manager was shown pictures and observed the concerns discovered in the kitchen. She stated she had a cleaning schedule for her team, and she followed up with them to ensure that the tasks were completed. She stated they had not had time to complete a deep cleaning because of their staffing challenges. She stated they attempted to clean the kitchen and equipment at least once a month. She stated she would remind staff to ensure they completely seal the foods observed in the freezer. She stated her staff often get in a hurry and forget to completely seal the items in the bags. She stated everyone was responsible for ensuring all food were labeled and dated once it was received from the vendor. She stated they cleaned the ice machine once a month. She observed the tea dispenser not being covered after the tea was prepared and she stated that it should have been covered. She stated the risk of not addressing these concerns could result in air-borne and food contamination. In an interview on 03/18/25 at 10:30 AM, the Administrator was shown pictures of the concerns observed in the facility kitchen. He stated they needed to do a more thorough job cleaning in the kitchen area and ensured that foods were stored correctly. He stated the risk of not addressing these concerns could result in an infection. Record review of the facility's policy on Kitchen Sanitation and Cleaning Schedules (undated), revealed All surfaces, including floors, walls, storage shelves, prep tables, trash cans, and all food contact surfaces must be routinely cleaned and sanitized. Ceilings, vents, light fixtures, pipes, and any other potentially contaminated surface will be cleaned as needed. All equipment must be thoroughly washed and sanitized between uses, in different food preparation tasks and anytime contamination occurs or is suspected. Food Storage and Sanitation Do not store scoops in the ice machine or food bins. Clean bins when empty. Store scoops in a sanitary manner to prevent contamination. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observations, interviews, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of twelve (Resident #42 and Resident #15) residents reviewed for infection control. 1. The facility failed to ensure CNA D did not use gloves taken from the pocket of her scrub top while providing incontinence care to Resident #42 on 03/17/2025. 2. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinence care to Resident #15 on 03/17/2025. This failure could place residents at risk of cross-contamination and development of infections. The findings included: 1. Record review of Resident #42's Face Sheet, dated 03/18/2025, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #92 had diagnoses which included cognitive communication deficit and the need for assistance with personal care. Record review of Resident #42's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 01/25/2025, indicated the resident had severely impaired cognition with a BIMS (screening tool used to assess cognitive status) score of 5. Section G reflected Resident #42 required extensive assistance with toileting. Record review of Resident #42's Comprehensive Care Plan, dated 01/20/2025, reflected the resident was incontinent of bowel and bladder and at risk for skin breakdown. One intervention was to check for incontinence every 2 hours and as needed. On 03/17/2025 at 09:24 AM, CNA D and CNA E were observed providing incontinence care for Resident #42. CNA D and CNA E were wearing gloves. CNA D pulled the privacy curtain around Resident #42's bed and told the resident she was going to change his brief. CNA E pulled down the sheet and blanket to uncover Resident #42 and unfastened the tabs on each side of the brief. CNA D pulled the brief down and used wipes to clean the front of the resident. CNA D dropped the wipes into a trash bag on the floor next to her. CNA E assisted CNA D to turn Resident #42 on his left side and CNA D removed the soiled brief. CNA D cleaned the residents bottom and dropped the soiled brief and wipes into the trash bag on the floor next to her. CNA D removed her gloves and washed her hands in the resident's restroom. CNA D pulled a pair of gloves from the pocket of her scrub top and put them on. CNA E assisted CNA D to roll the resident to his right side and CNA D placed the clean brief under the resident. CNA E straightened the resident's brief and assisted the resident to roll to his back. CNA E secured the tabs and pulled up the blanket to cover the resident. CNA D and CNA E removed their gloves and washed their hands in the resident's restroom. During an interview on 03/17/2025 at 11:55 AM, CNA D stated she was a new CNA and had been at the facility about a month. CNA D stated she did not have access to gloves in the resident's room because the boxes of gloves were stored on a cart in the hall. CNA D stated she took the gloves she needed from the supply cart in the hall and put them in her pocket before going into the resident's room. CNA D agreed carrying clean gloves in the pocket of her scrub top posed a risk for cross-contamination. CNA D stated during her training there were boxes of gloves in the rooms to use during resident care. CNA D stated she would find out what the expectation was for taking gloves into the resident's room. During an interview on 03/18/25 at 08:55 AM, the DON stated CNA D should have placed the gloves in a clean bag to take into the resident's room. The DON stated CNA D should not have placed the gloves in the pocket of her scrub top to carry into the resident's room. The DON stated that was cross contamination. The DON stated the facility would provide in-service training to staff. During an interview on 03/18/2025 at 10:00 AM, the ADON stated CNA D should not have placed gloves in the pocket of her scrub top to use for providing resident care. The ADON stated that was cross contamination. The ADON stated CNA D should have placed the gloves in a clean bag to carry into the resident's room. The ADON stated the facility would provide in-service training to staff. 2. Record review of Resident #15's Face Sheet, dated 03/18/2025, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included Alzheimer's disease (a progressive brain disorder that affects the ability to think and remember things) and the need for assistance with personal care. Record review of Resident #15's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 01/07/2025, indicated a BIMS (screening tool used to assess cognitive status) test was not conducted because the resident was never or rarely understood. The staff assessment indicated the resident had severely impaired cognitive skills for daily decision making. Section G reflected Resident #15 required extensive assistance with toileting. Record review of Resident #15's Comprehensive Care Plan, dated 01/21/2025, reflected the resident was incontinent of bowel and bladder related to cognitive impairment. One intervention was to monitor for incontinence every two hours or as needed and change the resident promptly. On 03/17/2025 at 10:40 AM, CNA F and CNA G were observed providing incontinence care for Resident #15. CNA F pulled the curtain around the bed to provide privacy and told the resident she was going to change his brief. CNA F and G washed their hands in the resident's restroom and put on clean gloves. The incontinence care supplies were on a towel that was draped over the resident's bedside table. CNA F pulled down the brief, cleaned the front of the resident, and dropped the wipes into the wastebasket next to her. CNA F changed gloves without using hand sanitizer or washing her hands. CNA G assisted CNA F to turn the resident to his left side and CNA F cleaned the resident's bottom. CNA F removed the soiled brief and dropped it into the wastebasket next to her. CNA F changed gloves without washing her hands or using hand sanitizer. CNA G assisted CNA F to turn Resident #15 to his left side and CNA F placed a clean brief under the resident. CNA F applied barrier cream to his bottom and CNA G assisted with rolling Resident #15 to his back. CNA G secured the tabs on each side of the brief and pulled up the blanket to cover Resident #15. CNA F and CNA G washed their hands in the resident's restroom after providing care. During an interview on 3/17/25 at 10:53 AM, CNA F stated she should have taken a bottle of hand sanitizer into the room when she provided incontinence care for Resident #15. CNA F stated the facility recently had training about hand washing or using hand sanitizer when providing resident care. CNA F stated it was important to use hand sanitizer or wash your hands after removing dirty gloves to prevent infection. During an interview on 03/17/25 at 12:05 PM, LVN H stated the facility provided in-service training on handwashing frequently. LVN H stated staff were provided with small bottles of hand sanitizer to carry around with them. He stated CNA F should have washed her hands or used hand sanitizer when she took off her dirty gloves and before she put on clean gloves. LVN H stated it was important, so staff did not transmit infection. During an interview on 03/18/25 at 08:55 AM, the DON stated CNA F should have used hand sanitizer or washed her hands each time she removed soiled gloves. The DON stated during training she told staff to provide resident care correctly every time, even when no one was watching. She stated CNA F's failure to use hand sanitizer or wash her hands when providing care caused cross contamination and increased the risk of infection. She stated the facility would provide an in-service training to staff members. During an interview on 03/18/25 at 10:10 AM, the ADON stated her expectation of staff was to use hand sanitizer or wash their hands between glove changes to reduce infection. She stated CNA F should have washed her hands or used hand sanitizer when she changed gloves during incontinence care for Resident #15. The ADON stated staff would receive in-service training. Review of the facility's policy Handwashing/Hand Hygiene, revised 01/20/23, reflected 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Hand hygiene must be performed prior to donning (putting on) and after doffing (removing) gloves.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #50) of nine residents reviewed for Privacy. The facility failed to ensure RN B assessed and flushed Resident #50's midline catheter (a device inserted in the veins used for treatment) inside the resident's room on 03/17/2025. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment. Findings included: Record review of Resident #50's Face Sheet, dated 03/17/2025, reflected a [AGE] year-old female resident admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection on 01/27/2025. Record review of Resident #50's Quarterly MDS Assessment, dated 12/12/2024, reflected the resident was unable to complete the interview to determine the BIMS score. Record review of Resident #50's Physician Order, dated 03/16/2025, reflected ERTAPENEM 1 GM /100 mL NS . ACTIVATE, MIX, & INFUSE 1 BAG INTRAVENOUSLY AT A RATE OF 200 ML/HR EVERY 24 HOURS FOR 14 DAYS for urinary tract infection. Record review of Resident#50's Physician Order, dated 03/17/2025, reflected Midline on right arm for IV (intravenous: administering fluids or medications directly into a vein) antibiotics. Observation and interview on 03/17/2025 at 12:01 PM revealed Resident #50 was in the hallway with RN B. Resident #50 was observed with midline to the left upper arm with scant bleeding. RN B said she was assessing the resident's IV site if it was infiltrated or dislodged because there was blood surrounding the IV site. She said she would try to flush it to see what was going on with the resident's IV and see if she needed to transfer her IV. RN B took the IV flush syringe from the top of her cart and started to flush the resident's IV. Observation on 03/17/2025 at 12:04 PM revealed the DON told RN B that she should assess and flush the IV site inside the resident's room to provide privacy. In an interview on 03/17/2025 at 12:07, the DON stated she did not see RN B flushing Resident #50's IV. She said if she did, RN B was not providing privacy to the resident. She said even if she was just assessing the IV site, the assessment should be done inside the resident's room with door closed or the privacy curtain pulled. She said all treatments should be done inside the room to provide privacy and dignity and to avoid embarrassment. The DON said the expectation was for the staff to make sure that when they were providing any kind of treatment, they should do it inside the residents' room with the door closed or with the privacy curtain were pulled. She concluded that she would continually remind the staff the importance of providing privacy and dignity through an in-service. In an interview on 03/17/2025 at 12:43 PM, RN B stated she should have assessed and flushed Resident #50's IV site inside her room to provide privacy and dignity. She said the IV was inserted early that morning and the order for the antibiotics wereas given the day before. She said she should have ushered the resident to her room and did the assessment and the flushing in the privacy of the resident's room. She said the DON already did a one-on-one in-service about dignity and privacy. In an interview on 03/18/2025 at 7:23 AM, the Administrator stated the expectation was for the staff to make sure that the residents were provided privacy during any treatment to prevent embarrassment. He said he would collaborate with the DON and the ADON to do an in-service about providing dignity and privacy. In an interview on 03/18/2025 at 10:07 AM, the ADON stated all treatments should be done in the privacy of the residents' room to promote dignity and privacy. She said allevery care done by the staff should be behind the door so other staff, other residents, or even the visitors would not see or speculate the medical condition of the residents. She said it did not matter if the residents care or not, the treatment should be done inside the room and not on the hallway. She said the expectation was for the staff to be mindful when they were providing any treatment. She said she would coordinate with the DON to do an in-service about privacy during treatment. In an interview on 03/18/2025 at 10:33 AM, Resident #50 stated she had an IV because she had UTI . She said a staff member inserted the IV early that morning so she could start the antibiotics. She said she was with RN B in the hallway because RN B was trying to figure out what was going on with her IV. She said she did not mind but if it should be done inside the room, then it should be done inside the room. Record review of the facility's policy, Dignity 2001 MED-PASS revised February 2021 revealed Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . Policy Interpretation and Implementation . 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during . treatment procedures.

Based on interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Resident #43) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #43's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had an external catheter (non-invasive device used to manage urinary incontinence such as Purewick). This failure could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health. Findings included: Review of Resident #43's Face Sheet, dated 03/16/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #43's Quarterly MDS Assessment, dated 01/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment did not indicate that the resident was using an external catheter. Review of Resident #43's Comprehensive Care Plan, dated 02/27/2025, reflected the resident was frequently incontinent and used Purewick (non-invasive urinary drainage device that uses suction to collect urine from the body) while in bed and one of the approaches was to check the output every shift. Review of Resident #43's Physician Order, dated 09/29/2023, reflected Purewick: Output every shift. Observation and interview on 03/16/2025 at 8:57 AM revealed Resident #43 was in her bed, awake. It was observed that the resident had a Purewick system at her bedside. The resident said she used it when she was in bed but would take it off when she went out of her room. She said she had been using a Purewick for two years. In an interview on 03/17/2025 at 6:40 AM, LVN A stated Resident #43 had been using Purewick ever since she started working in the facility two years ago. She said nurses and CNAs monitored the output every shift. She said the resident had it every time she was in bed. In an interview on 03/17/2025 at 12:14 PM, the DON stated she was not familiar with the MDS. She said if the resident was using an external catheter, then the resident's MDS should reflect it. She said the MDS Nurse was responsible for doing the MDS and if the assessment in the MDS was not accurate, the care needed by the resident would not be metD In an interview on 03/17/2025 at 1:01 PM, the MDS Nurse stated the purpose of the MDS was to collect and record pertinent data about the resident. The data collected were the resident's demographics, cognition, behavior, functional abilities, diagnosis, and if the resident was using any kind of treatment. She said the MDS was used to do a basic assessment of the resident that could be from the documentation of the nurses or through a face-to-face. She turned on her computer and went to Resident #43's profile. She said the resident had a diagnosis of neuromuscular dysfunction of bladder, had an order to monitor the output collected in the Purewick, had a care plan for the Purewick, but it was not coded for an external catheter. She said it was an oversight on her part and missed the resident was using Purewick as a form of an external catheter. She said she would audit the MDS' of the residents and would make sure that everything was coded appropriately. She said if the residents were not properly assessed, the needs would not be met, and there could be confusion in the provision of care and in doing the care plan. In an interview on 03/18/2025 at 7:53 AM, the Administrator stated the MDS was done to reflect the current condition of the resident. He said if there was no accurate assessment, there could be a misunderstanding about the care needed. He said he would coordinate with the DON and the MDS Nurses to evaluate and resolve the issue. Record review of the facility policy, Certifying Accuracy of the Resident Assessment 2001 MED-PASS, Inc. (Revised November 2019) revealed Policy Interpretation and Implementation . 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods . 4. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for elopements. The facility failed to ensure Resident #1 received adequate supervision and remained in the facility's secured care unit, which resulted in her elopement from the facility on 10/04/2024. The facility failed to provide adequate supervision to Resident #1 to ensure Resident #2 did not facilitate Resident #1's elopement on 10/04/2024. The noncompliance was identified as PNC IJ. The noncompliance began and ended on 11/25/2024. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of injury and a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet, dated 11/25/2024 at 9:40 AM, revealed she was a [AGE] year-old female admitted [DATE]. Relevant diagnoses included cerebral infarction (blood supply to the brain is blocked or reduced,) brain and lung cancer that had metastasized (spread,) and Neurocognitive disorder further detailed by unspecified symptoms and signs involving cognitive functions and awareness. She resided in the facility's secured unit. Record review of Resident #1's Admission MDS dated [DATE] revealed she was admitted from home/community and had a severe cognitive impairment with BIMS score of 05. Resident #1's MDS stated she had recent wandering behavior. Resident #1 did not require any mobility aides for ambulation. Resident #1 required setup or clean-up assistance for most cares due to cognitive impairment and was occasionally incontinent of bowel and bladder. Record review of Resident #1's Wandering Assessment completed upon admission 08/29/2024 revealed she was at risk for wandering/elopement and resided in facility's secured unit. Record review of Resident #1's Comprehensive Care Plan dated 11/20/2024 revealed she had neurocognitive disorder and resides in the secure unit due to her wandering and poor safety awareness. 10/04/2024 Resident observed by staff sitting outside on the bench. Interventions included: -Ensure resident was wearing proper fitting and appropriate footwear -To complete wander alert [documents] and place in elopement binder -Take picture of resident every quarter because I may have changed my appearance and/or weight -Elopement assessments to be completed upon admission, quarterly, and with any significant change of condition -To provide resident with redirection, comfort measures and address basic needs when wandering behavior is exhibited Record review of Resident #2's Face Sheet , dated 11/26/2024 at 1:38 PM, revealed he was [AGE] year-old admitted on [DATE]. Relevant diagnoses included cerebral infarction (blood supply to the brain is blocked or reduced,) and type 2 diabetes (insulin resistance.) Record review of Resident #2's Admission MDS dated [DATE] revealed he was admitted from home/community and was cognitively intact with BIMS score of 15. Resident #2's MDS stated he did not have any recent wandering behavior but was resistive to cares recently. Resident #2 required a walker as a mobility aide. Resident #2 required setup or clean-up assistance or was independent for most cares and was occasionally incontinent of bowel and bladder. Record review of Resident #2's Comprehensive Care Plan dated 11/25/2024 revealed he enjoyed listening to country music, walks outside and playing cards. Additionally, Resident #2 was documented as resistive to cares at times. Interventions included: -Always ask for help if resident becomes abusive/resistive -Convey acceptance of resident during periods of inappropriate behavior -Encourage diversional activities -Keep environment calm and relaxed -Redirect resident as needed -Remove from public area when behavior is unacceptable -Staff to continue to educate resident on the importance of cares and interventions In interview and observation with Resident #1 on 11/21/2024 at 10:58 AM, she was in the facility's secured unit resting in her room on her bed. She was observed with proper fitting and appropriate footwear. She was clean, well dressed, and appeared to not be in any distress. She stated she recalled the elopement incident but did not remember the date, she denied she was injured because of the incident, and stated she went outside because she just wanted to get some sun. In interview and observation with Resident #1 on 11/26/2024 at 9:29 AM, she ambulated in the hallway of the facility's secured unit. She was observed with proper fitting and appropriate footwear. She was clean, well dressed, and appeared to not be in any distress. She reported she was having a good day and had no complaints. Record review of facility's Progress Note for Resident #1 by LVN A on 10/04/2024 at 3:44 PM revealed At about 1235, a resident alerted staff by yelling out that, this resident had exited the door and staff immediately chase after this resident while alerting other staff. A staff who was coming back from her break entered the building with the resident and said that, she saw this resident sitting outside on a chair near the main entrance to the facility. Head to toe assessment done and no injury noted. RP, DON, and MD made aware. Elopement watch initiated. Record review of Facility Event Summary with a look-back period of 10/01/2024-11/21/2024 revealed on 10/04/2024 at 12:54 PM, LVN A wrote [Resident #1] observed by staff sitting outside on the bench in front of the building. Head to toe assessment performed and no injuries noted. Resident stated she was 'getting some sun'. Resident [in] line of [sight] observation. Additional documented revealed the physician and RP were notified, and care plan reviewed. DON e-signed the incident status as closed on 10/09/2024. Interviews attempted with LVN A on 11/21/2024 2:44 PM and 11/25/2024 at 2:00 PM were unsuccessful. In interview with CNA C on 11/21/2024 at 11:10 AM revealed she was working the day of Resident #1's elopement, 10/04/2024, and around mid-day she at the facility's parking lot sitting in her car while on her lunch break. She stated she saw Resident #1 outside sitting on the bench near the front door. She stated she immediately went to Resident #1 and re-directed her back inside to her secured unit. CNA C stated Resident #1 was outside approximately 1.5 minutes. CNA C stated that Resident #1 told her upon her return to the facility that a gentleman opened the door, for her and that was how she got outside. In interview with Resident #2 on 11/25/2024 at 11:20 AM he stated he recalled the incident with Resident #1. Resident #2 stated he was watering the plants in the front of the building the day of the incident. He stated he saw the resident sitting on the bench located outside in the front of the facility building. He denied letting Resident #1 out of the building and stated she was not outside for very long. Resident #2 stated after Resident #1's elopement, he was educated by the Administrator and DON on the importance of not opening the facility front door for any residents. He stated at that time of Resident #1's elopement, he was aware of the facility's front door code, but declined to disclose how he obtained the code. He stated after Resident #1's elopement, the facility changed the front door code, and he did not know it currently. In interview with facility's Administrator on 11/25/2024 at 11:01 AM, he stated based on his investigation Resident #1 exited through the secured unit door. He was not able to determine how Resident #1 exited the secured unit; but he determined Resident #1 was let outside the facility's front door by Resident #2 while he was watering the plants in the front of the building. He stated Resident #2 was high functioning, had a BIMS score of 15, resided in an unsecured environment, and was able to sign himself in and out of the facility as he pleased. He stated there was not a way to disable the door alarms without the location/door specific code. He stated both the secured unit and the facility's doors were alarmed with a code that only facility staff had access to. The facility Administrator stated since Resident #1's elopement, all the door codes have been changed and a sign has been placed on the front door to not allow any residents out unassisted. He stated his expectations were for his residents in the secured unit to remain in the secured unit. He further stated it was the responsibility of facility staff to supervise and monitor the residents to identify and re-direct wandering behaviors. Finally, he stated it was nursing leadership's responsibility to ensure any additional and/or resident specific assessments and/or interventions were in place to prevent resident elopements. In interview with facility's DON on 11/26/2024 at 11:47 AM, she stated based on her investigation, CNA C reported to her that she saw Resident #1 outside while she was on her lunch break. DON stated she was not sure how Resident #1 exited the secured unit; but she concluded that Resident #2 let Resident #1 out of the facility's front door while he was watering the plants. She stated there was not a way to disable the door alarms without the location/door specific code and to her knowledge the doors did not malfunction. She stated both the secured unit and the facility's doors were alarmed with a code that only facility staff was permitted to have access to. DON further stated since Resident #1's elopement, all the door codes have been changed probably twice already. She stated after Resident #1's elopement, she ensured proper notification to Resident #1's provider and RP, that Resident #1 was assessed for injury/harm, that Resident #1's Comprehensive Care Plan was reviewed, that maintenance performed a facility-wide inspection of doors for functionality, she conducted a facility-wide elopement drill, and provided In-services to her staff specific to elopements and the prevention of any potential piggy-backing of residents that may get out of the secured unit without staff's awareness. She stated her expectations were for the residents in the secured unit to remain in the secured unit and it was facility staff's responsibility to monitor and supervise the residents. DON stated it was nursing leadership's responsibility to ensure the Elopement Binder was at the secured unit's nurses' station, the documents were completed and quarterly updated, and any other resident specific interventions were in place to prevent resident elopements. In interview with Resident #1's RP on 11/25/2024 at 10:07 AM, she stated she was Resident #1's RP and that her family member resides in the secured unit at [Facility.] She stated she was notified by LVN A on 10/04/2024 about Resident #1's elopement. Resident #1's RP denied any successful elopements from the facility prior to 10/04/2024, but stated she had elopements from home prior to her admission which necessitated her admission to the facility's secured unit. In interview with facility's Maintenance on 11/25/2024 at 9:30 AM revealed after Resident #1's elopement on 10/04/2024, he ensured all the doors at the facility were operating as required. In observation of facility's front door on 11/21/2024, 11/22/2024, 11/25/2024, and 11/26/2024 at approximately 9:00 AM revealed a sign posted on the front door that stated, Please do not let our residents out unassisted. In observation of facility's secured unit front and back doors and facility main entrance/exit door on 11/21/2024 at 9:29 AM and 2:00 PM, doors demonstrated appropriate function and were secured with a multi-digit code for entry and exit. In observation of facility's Elopement Binder located at the secured unit's nurses' station on 11/26/2024 at 9:26 AM, revealed Resident #1's Wander Alert documents with relevant identification and notification details in the binder with a recent, recognizable photograph of Resident #1. In interview with CNA C on 11/21/2024 at 11:10 AM she stated the importance of proper footwear for Resident #1, stated the location and purpose of the facility's Elopement Binder at the secured unit's nurses' station, and the importance of providing Resident #1 with redirection and comfort measures to address basic needs when wandering behavior is exhibited. In interview with CNA D on 11/26/2024 at 9:26 AM she stated the importance of proper footwear for Resident #1, the location and purpose of the facility's Elopement Binder at the secured unit's nurses' station, and the importance of providing Resident #1 with redirection and comfort measures to address basic needs when wandering behavior is exhibited. In interview with LVN B on 11/21/2024 at 11:15 AM he stated the importance of proper footwear for Resident #1, stated the location and purpose of the facility's Elopement Binder at the secured unit's nurses' station, the requirement of an accurate wandering/elopement assessment to be completed upon admission, quarterly, and upon a resident's change of condition, and the importance of providing Resident #1 with redirection and comfort measures to address basic needs when wandering behavior is exhibited. In interview with facility's DON on 11/26/2024 at 11:47 AM stated the importance of proper footwear for Resident #1, that the facility's Elopement Binder was located at the secured unit's nurses' station and was required to be created upon admission, updated quarterly, and/or upon a change of condition, and that she was responsible to ensure resident wandering/elopement assessments were completed upon admission, quarterly, and with any significant change in condition. DON stated the importance of all staff providing Resident #1 with redirection and comfort measures to address her basic needs when wandering behavior is exhibited as stated in her Comprehensive Care Plan. In interview with facility Administrator on 11/25/2024 at 11:01 AM he stated the importance of proper footwear for Resident #1, that the facility's Elopement Binder was located at the secured unit's nurses' station and both the Elopement Binder and wandering/elopement assessments were required to be updated upon a resident's admission, quarterly, and in response to a resident's change of condition. Administrator also stated the importance of his staff to provide Resident #1 with redirection and comfort measures to address her basic needs when wandering behavior is exhibited. Record review of Resident #1's Comprehensive Care Plan dated 11/20/2024, reviewed on 11/25/2024 at 9:00 AM revealed sufficient identification of Resident #1's wandering/elopement behaviors and detailed list of multiple interventions prior to investigation. Record review of Resident #1's Wandering Assessments reviewed on 11/25/2024 at 9:30 AM revealed sufficient assessment of Resident #1's risk for wandering/elopement that necessitated her need to reside in facility's secured unit. Record review of facility Inservice titled, Elopement/Wandering .Secured Unit/Missing Resident, dated 10/04/2024 conducted by facility's DON revealed facility policy, protocols, and procedures which specifically included to ensure no resident exits behind you when entering or exiting the secure unit. Please wait till the door is locked before walking away . Document revealed multiple staff signatures. Record review of facility document titled, Elopement Drill dated 10/10/2024 conducted by facility's DON revealed facility's elopement drill was completed. Document revealed multiple staff signatures. Record review of facility's Inservice titled, Elopement Drill dated 10/10/2024 conducted by facility's DON revealed facility's elopement policy, protocols, procedures, provided to staff. Document revealed multiple staff signatures. Record review of facility's documentation of Maintenance of the doors, dated 10/04/2024, revealed that he personally ensured all doors were operating as required. Review of facility policy, Wandering and Elopements, dated 09/01/2023 revealed The facility will ensure that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care . Monitoring and managing residents at risk for elopement or unsafe wandering . a person-centered care plan will be developed based on the risk factors identified in the risk assessment . adequate supervision will be provided to help prevent accidents or elopements . The noncompliance was identified as PNC IJ. The noncompliance began and ended on 11/25/2024. The facility had corrected the noncompliance before the investigation began.

Based on observations, interviews and record reviews, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of six residents reviewed for Neglect. CNA A and LVN B failed to prevent neglect, such as ensuring Resident #1 received the necessary care and services to prevent harm and LVN B's failure to notify the oncoming Nurse, DON and Administrator about Resident #1's fall on 08/02/24. Subsequently Resident #1 sustained fractures of her Tibia (Shinbone) and Fibula (calf bone) of her left lower leg and was taken to the hospital on 08/08/24. An Immediate Jeopardy (IJ) was identified on 08/11/24. An IJ Template was provided to the facility on [DATE] at 3:38 pm. While the Immediate Jeopardy was removed on 08/12/24 at 7:50 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not being assessed and treated in a timely manner and appropriately, with Doctors interventions, which could result in a decline in their psycho-social well-being and health resulting in internal bleeding or death. Findings included: Record review of the facility's Abuse and Neglect policy dated 10/2023 revealed, Policy Statement: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Policy Interpretation and Implementation: 1. The facility will develop and implement written policies and procedures that: a. Prohibit abuse, neglect, and exploitation of residents and misappropriation of resident property . VI. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective all other required agencies (e.g., law enforcement when applicable) within specified timeframes. CMS Definition of neglect: Neglect is the failure of a facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with a BIMS Staff Assessment score of 2 (Moderate impaired cognition), no speech, with a memory problem and severely impaired. She had upper extremity impairment on one side and lower extremity impairment of both sides. Her functioning abilities and goals: Self-care: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for all ADLs including (toileting, personal hygiene). Her functioning abilities and goals: Mobility: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for roll left and right and for chair/bed to chair transfer. She was always incontinent to bladder and bowel, has a progressive neurological conditions with diagnoses of hypertension. She had Multiple Sclerosis (nerve degeneration), Gastronomy status (feeding tube), Cardiac arrhythmia (arrhythmia (irregular heartbeat), dysphagia (not able to swallow properly), muscle weakness, atrial fibrillation (irregular heartbeat), and lack of coordination. She was 5'6 and 132 pounds. Record review of Resident #1's August 2024 Order Summary Report revealed orders for: Eliquis 5 mg, folic acid 1 mg. senna 8.6 mg. tramadol 50 mg. Enteral Feeding tube, Enteral stoma site care, NPO, Enteral formula pump administration. Record review of Resident #1's Care Plan printed 8/10/24 revealed, Multiple sclerosis: assist with ADL and comfort measures as needed, Abdominal binder: to keep G-tube in place keep head and bed elevated. Geri-chair: make as comfortable as possible, falls (Resident has a history of falling related to mobility due to Multiple Sclerosis): place resident in a fall prevention program. Multiple sclerosis at risk for a decline in current ADLs and injuries due to increased injuries and assist with ADL's and comfort measures as needed. Cognitive loss/dementia: allow time for task and responses. Communication has aphasia approach in calm manner. Falls - keep call light within reach, ADL Functional status: ambulation/transfers amount of assist: total x 2 non-ambulatory, bathing/hygiene assist: total x1, resident care as per policy, toileting amount of assist total x1. Record review of Resident #1's Progress notes reviewed from 08/02/24 to 08/09/24 did not reveal she had any falls or incidents. Record review of Resident #1 X-Ray results dated 08/08/24 at 8:03 pm revealed, Clinical information: Bruising, swelling, Test procedures: Left tibia and fibula, two views. Findings: Proximal tibial and fibular shafts fracture. No osteolytic or osteosclerotic lesions. No signs of bone infection. Impression:1. Proximal tibial and fibular shafts fracture. 2. CT is recommended. Record review of Resident #1's Hospital Emergency Department Doctor's note dated 08/08/24 revealed, Chief complaint: Leg deformity: patient here from [Nursing Facility]. Left leg swelling noted and ecchymosis found this morning. On Eliquis .Patient is bed bound and nonverbal. Radiology: Tibia/fibula, left 2 views final result: Impression: Proximal left tibial and fibular fractures, negative left ankle and knee joint. Soft tissue swelling. Osteopenia. Record review of Resident #1's Progress note 08/02/2024 [Recorded as Late Entry on 08/09/2024 06:19 PM] by LVN B revealed, Events - fall: 11:06PM On 2nd of August, CNA call attention to this nurse to room [ROOM NUMBER]B and reported to this nurse that she rolled resident down to the floor mat while giving care. Observed and assess resident on the floor mat., no apparent injury noted at that time. No S/S of pain noted at that time. Resident was helped back to bed with the help of the CNA. Record review of Resident #1's Incident/Accident Report completed date 08/09/24 at 6:08 pm by LVN B revealed, Event date 08/02/24 at 5:57 pm, in resident room, yes fall was witnessed, no injury and no pain, ROM without pain/limitations, no rotation/deformity/shortening noted .notifications: Attending physician faxed: no, Physician notified: no, Resident Representative notified: no, care plan reviewed: no. Record review of Resident #1's Hospital Orthopedic Doctor note dated 08/09/24 revealed, Orthopedic diagnosis: Left Proximal tibia fracture. Orthopedic plan: Closed management of left proximal tibial fracture, knee immobilization, non-weight bearing. History of present illness: A [AGE] year-old female with multiple advance medical issues including MS, who is nonverbal at baseline .The patient is nonverbal, non-ambulatory. I do not think she would be a very good candidate for surgical intervention. I will plan for a knee immobilization and follow-up in the outpatient setting. Observation on 08/09/24 at 3:40 pm, Resident #1's room revealed a thin blue floormat that was approximately two inches height and six feet in length on the left side of Resident #1's bed. Observation on 08/10/24 at 3:37 pm, Resident #1 was at the hospital lying flat on her back, in bed watching Television, she nodded yes to her name. She shook her head no she was not hurting. When asked had she fallen out of bed, she looked at her left leg and did not shake or nod her head. There was a G-tube next to her bed she and she did not appear to be in pain. Her left leg was bent at a 45-degree angle with a knee immobilizer on it. Interview on 08/09/24 at 6:43 pm, CNA A stated on 08/02/24 after dinner she checked Resident #1 and incontinent care was needed. She stated she was standing right in front of the window with the bed elevated and while caring for Resident #1, she turned her towards the door then towards her. She stated she put the bed linen on the floor then rolled her to the right to clean her and afterwards she tried to grab her bed sheets at the foot of her bed. She stated then Resident #1 started shaking and rolled off the bed so she went to get LVN B who came to assess the resident and made sure she was okay. She stated she and LVN B got Resident #1 back to bed and got her dressed then LVN B asked her what happened and she told her she was doing incontinent care and the resident rolled to the floor. She stated Resident #1 was nonverbal but did not appear to be in any pain and her leg was not swollen or in a weird position. She stated she was not sure if the nurse called to have any x-rays done and did not see anyone come out to do x-rays during her shift. She stated there was most likely no x-rays done because the resident was not crying because she checked on her frequently and changed her about four more times that night. She stated typically they reported falls to the DON and from there the DON notified the Administrator. She stated she did not report this fall to the DON and Administrator because it was the weekend and the DON was not at the facility. She stated today 08/09/24 she came back to work and reviewed her assignment and did her walk through to get her eyes on the residents and noticed Resident #1 was not at the facility. She stated she asked Staffing Coordinator F what happened to Resident #1 and was told she went to the hospital with an injury unknown origin of her leg. She stated Staffing Coordinator F told her there was an investigation about Resident #1's injury and that she needed to talk to the Administrator. She stated on 08/09/24, she wrote up her statement and spoke to the DON about what happened on 08/02/24. She stated on 08/09/24 around 6:00 pm she was suspended and was told they would let her know more information later after they completed their investigation and would get back with her soon. She stated she did not ever want to step on anyone's toes when she told LVN B about what happened to Resident #1 and did not think to report it to the DON also. She stated in her eyes Resident #1 had a rollover onto the floor. She stated she received training today 08/09/24 on abuse and neglect and for if the resident's fall was guided, she was supposed to report it to their Administrator. She stated Resident #1 she believed was a 1 person assist for ADL care and for transfers was Hoyer 2 person assist. She stated she knew the resident's level of care by asking the nurse what the resident's transfer status and care needs were. She stated not being really sure on how to use the POC in the EMR system because when she clicked on that tab it did not have the resident's mobility statuses in them. She stated the POC only had the resident's demographic info. She stated she should have reported this fall to the Administrator because there was a change in Resident #1's health. She stated if she would have reported it to the Administrator and DON, this whole situation would not have happened. She stated on Friday 08/02/24 she worked from 2:00 pm to 6:00 am then worked Sunday 08/04/24 from 2:00 pm - 6:00 am. She stated she also worked today 08/09/24 from 2:00 pm to 6:00 pm. She stated falls, including guided falls could cause death, injured bones, and internal bleeding. Interview on 08/10/24 at 9:09 am, LVN B stated she worked the overnight shift and last took care of Resident #1 Last Friday 08/02/24, Tuesday 08/06/24 and Wednesday 08/07/24. She stated yesterday 08/09/24 she heard Resident #1 had a leg fracture. She stated she was very surprised Resident #1 was injured. She stated the DON spoke to her about what she knew about Resident #1's fall on 08/02/24 then the DON told her she should have completed an incident report and called her Doctor. She stated she did a late add nurses note and incident/accident report on 08/09/24 per the DON's request. She stated last Friday 08/02/24 after meal service, after 11:00 pm she was at the nurses' station and CNA A stood at Resident #1's room door calling her name out loud about needing help putting Resident #1 back to bed. She stated she saw Resident #1 in her room and her bed was in the lowest position and Resident #1 was on the left side of her bed on the floor. She stated Resident #1 was on her back and her left leg was turned to the left, and her head and buttocks was flat on the floormat, she was on her back. She stated her left leg was paralyzed and for her care they normally used a pillow to prop it in place. She stated when Resident #1 was on the floor her Gtube port was okay and the tubing was still connected to the gtube pump. She stated there was no pillow under Resident #1's leg and the bed linen and pillow was on her bed. She stated she assessed Resident #1 and did not find anything wrong with her and she had no signs or symptoms of pain, then she and CNA A put her back to bed. She stated asking CNA A why Resident #1 on the floor and CNA A was said she rolled her onto the floor to give her incontinent care. She stated CNA A did not say Resident #1 fell but said she guided her to the floormat. She stated if CNA A told her Resident #1 had fallen, she would have reported it to her Doctor, the Administrator and DON. She stated she would have also documented it in Resident #1's nurses notes and completed an incident report and called her family. She stated she would have followed up with her to ensure she was fine and added Resident #1 was on scheduled Tramadol she received at 12:00 am and PRN Tylenol. She stated there was no increase in giving her more pain medications. She stated Resident #1's floor mat next was next to her bed 24/7 and Resident #1 normally did not get care on the floor mat that was why she questioned CNA A about it. She stated there was not anything propping her left leg, she checked on Resident #1 four or five times that night. She stated Resident #1 watched television and slept and she was given her Tramadol at midnight and she was asleep rest of the night. She stated she did not tell the oncoming nurse or the DON about her being on the floor because she got busy and did not suspect anything was wrong. She stated she got busy with taking care of other residents forgot to document at nurses note. She stated there was no swelling or redness of her legs during her 08/02/24 shift. She stated she returned to work Tuesday 08/06/24 the nurse reported Resident #1 had left leg swelling and her Doctor ordered for a doppler study for edema. She stated the doppler study result came back Wednesday 08/07/24 was negative and she faxed that result to her Doctor. She stated there were no new orders and she took a picture of Resident #1's left leg and sent it to her Doctor. She stated she got a call from the DON yesterday 08/09/24 around 4:00 pm and she returned the call around 4:49 pm and the DON told her to come to the facility. She stated a little after 5:00 pm she gave the DON her statement and completed Resident #1's incident report and completed in-service trainings on neglect/abuse, who was the abuse coordinator and the DON told her she should have reported this to her and called her Doctor and family. She stated she had the mind to call the DON but forgot and stated if a resident fell and the Doctor, DON or family was not notified could result in delayed injury. She stated that was why she always documented but she forgot to document Resident #1's fall and said after the DON spoke to her, she now knew why she should have completed a nurses note and reported it to her Doctor, DON, and family. She stated in general the residents were on the floor mat for care if they were uncooperative, but Resident #1 was never uncooperative and never on the floor for incontinent care. She stated she thought it was odd Resident #1 was on the floormat. She stated Resident #1 was a 1 person assist for incontinent care because she was not that heavy. heavy, but needed 2 person Hoyer assist for some care needs. She stated Resident #1 was bed bound with left sided weakness upper and lower and alert and oriented x1. She stated Resident #1 was not able to express her needs because she was aphasic and knew her name. She stated Resident #1 was able to gesture responses by nodding and shaking her head. She stated there was 1 nurse and 1 aide for on the norm for 21 residents. She stated she did not know Resident #1 was a 2 person assist for bed mobility but if a resident was skinny 1 person could do incontinent care on her. She stated only 1 CNA worked that side of the hall where Resident #1 was and CNA A never asked her for assistant with doing Resident #1's incontinent care. She stated she did not know Resident #1's MDS Assessment changed her bed mobility to 2-person assistance. She stated at night they had been 1 person assist with her incontinent care. She stated the nurses were responsible for ensuring the residents were getting proper care and cleaned and dry and checked every 2 hours. She stated she did not look at the Resident's Plan of Care to determine if they were 1 or 2 person assist by knowing the residents and going by the 24-hour report. She stated the DON suspended her and CNA A pending the investigation of Resident #1. She stated not reporting something bad could cause the resident to get bruised, skin tear or injured. Interview on 08/09/24 at 4:45 pm, the Police Detective stated he visited Resident #1 at the hospital and gathered other information and opened a case to further investigate the circumstances involving Resident #1's leg injury. He stated he had spoken to CNA A who said on 08/02/24 she was cleaning Resident #1 and she turned around then the resident kept rolling and fell out of the bed. He stated CNA A said she asked LVN B to help get Resident #1 off of the floor then LVN B picked up Resident #1 and put her back onto her bed. The Police Detective stated as of right now there was no documentation of the resident falling and no one knew what happened to her leg and the resident was not able to say what happened. He stated the Administrator and DON said they just discovered it from CNA A's statement. He stated Resident #1 sustained two fractures of her left tibia and left fibula that was approximately one inch below her knee. He stated Resident #1's roommate said she remembered a nurse and CNA coming in really fast one night but was not able to see or know what happened. He stated he was getting ready to interview LVN B to gather more information. Interview on 08/09/24 at 7:26 pm, the DON stated she received a report on 08/06/24 about Resident #1's left leg appearing shiny and red like she had irritated rash. She stated her Doctor ordered a doppler study of her left leg and the results came back negative. She stated the area on her leg started swelling up more and getting darker red and her Doctor diagnosed her with cellulitis and ordered antibiotics. She stated yesterday 08/08/24 her leg was still looking red and her Doctor ordered an X-ray and the result came back yesterday morning for two fractures of her left tibia and fibula. She stated they reported 08/08/24 to HHSC and an injury of unknown origin because of the darkness of her leg that looked to be spreading to other areas of her leg. She stated she was just finding out today 08/09/24 around 4:30 pm Resident #1 fell Friday night of 08/02/24. She stated there were no notes in her medical records and no incident reports. She stated Resident #1's fall should have been reported to her and the Administrator to they could have started investigating and reported this incident to HHSC. She stated had they had known soon they would have reported this incident immediately. She stated they were currently doing in-service trainings with all staff, doing skin and pain assessment of all the residents. She stated they were doing a lot of trainings on abuse/neglect, notification to the resident's Doctor, DON and Administrator and did 1:1 trainings with LVN B and now they were training all staff. She stated the therapy staff were assisting with the trainings. She stated it was too early in her investigation and was not sure if Resident #1 was a 1 or 2 person assist for ADL's but said she would follow-up with surveyor. She stated CNA A said she was doing Resident #1's incontinent care and when she turned to get some linen, Resident #1 rolled out of her bed. She stated CNA A told her that LVN B was alerted and Resident #1 was assessed but there was not any documentation of a nurses note, no notifications to her Doctor, family, herself, or Administrator. She stated LVN B confirmed everything that happened she went into the room the resident was on the floor, and CNA A explained she had guided the resident to the floor. She stated LVN B said she did a head-to-toe assessment and when asked why she not documented the assessment LVN B said it got so busy and she forgot. The DON stated she informed Resident #1's Doctor about Resident #1's fall with injury and he was upset because no one had called him 08/02/24. She stated the Doctor was at the facility visiting patients Monday 08/05/24 and no one told him about this until today 08/09/24 around 4:30 pm. She stated particularly concerning was CNA A said she noticed Resident #1's left leg was swollen on Sunday 08/04/24 and did not report it to anyone assuming the nurses were aware of it. She stated ADON C assessed Resident #1 then she was transferred to the hospital. She stated she spoke to LVN B on 08/09/24 around 4:00 pm she confirmed Resident #1 had fallen on 08/02/24. She stated LVN #1 was suspended. She stated she interviewed CNA A around 3:30 pm or 4:00 pm and CNA A was removed off the floor and interviewed with the Corporate Nurse Representative. She stated CNA A was sent to the conference room and until they received her statement. She stated she told CNA A she was suspended until they completed their investigation and sent her home. She stated LVN B came to the facility to drop off her statement and said she had not worked in the past two days. She stated the staff knew how to go into the EMR POC to review the resident's level of care and was not aware of any issues with that. She stated they were still investigating this incident and felt like the incident was not intentional and people just needed to think when they did resident care and thought about the processes beforehand. She stated from what she was told Resident #1's bed was at the level of CNA's hips. She stated Resident #1 did have tremors and twitched a lot and said she was not sure if she was 1 or 2 or Hoyer lift yet. She stated Resident #1 was not able to express her needs but was good at communicating by nodding and shaking her head. She stated Resident #1 required the use of a wheelchair and was not sure if she could move her legs but was in the process of finding out more. She stated unreported and undocumented falls could have adverse effects because neuro checks needed to be done to monitor if they have a change of mental status, get injured need more pain and was a form of neglect. She stated Resident #1 has routine pain medication and since 08/02/24 she had not had any increased pain. She stated after Resident #1 fell her Doctor should have been called and the fact that CNA A said the resident fell off the bed LVN B should have called her Doctor for further instructions. She stated the last she heard they were not going to do surgery to repair her left tibia and fibula because of her MS diagnosis. Interview on 08/09/24 at 8:21 pm, the Administrator stated he found out Resident #1 fell [DATE] and they were currently doing their investigation. He stated today 08/09/24 CNA A said Resident #1 fell last Friday 08/02/24 and that she and LVN B got her back into bed and they suspended her. He stated they called LVN B to tell them her story and she was interviewed then they decided to suspend LVN B pending investigation for not following their events protocol procedure. He stated they needed to ensure there was not anything missed and added up to the point they knew Resident #1 could not move and something was going on with her leg so he reported this incident to HHSC. He stated yesterday 08/08/24 Resident #1 was transferred to the hospital after her x-ray result showed she had fibula and tibia fractures of her left leg. He stated ever since then they were doing employee trainings on abuse/neglect, resident transfer techniques, reporting events and change in condition. He stated the DON and ADON was responsible for ensuring the nursing staff were following their protocols. He stated they reviewed all of Resident #1's documentation today and there was not any documentation about her falling. He stated unreported and undocumented falls could cause all kinds of things could happen such as pain, worsening condition, tons of things, no follow up on the resident's status. He stated they spoke to the Medical Director about Resident #1's fall with injury and they planned to continue to do trainings, getting statements for the staff. He stated they were reviewing her documents and other residents to protect all the residents and to see if they could do something another way, communicate better. He stated Resident #1 was a 1 person ADL assist resident because she was able to assist with turning and a petite lady and it was easy to turn her one way from to the other. Interview on 08/10/24 at 11:00 am with the Hospital RN stated Resident #1 admitted to the hospital because of a fractured tibia and fibula. She stated she was stable right now and was currently awake but nonverbal and just nodded in agreement to everything and was not good at following commands. She stated Resident #1 did not appear to be in any pain and no surgery was planned yet and they were doing conservative treatments on her. She stated there were no discharge plans at this time and her pain levels were fine but grimaced when providing care then but when still no signs or symptoms of pain. She stated she had not been given any pain medications since she admitted on [DATE] but had Doctor orders for Norco for moderate pain. She stated she Resident #1 has Doctor orders for Ativan for anxiety, morphine for severe pain and Tylenol for mild pain/headache. She stated Resident #1 had an immobilizer on her left leg and stated both her arms were contracted (right arm moved a little more and her left arm was more contracted). She stated her left leg was completed contracted and stated she was a 2 person assist because it was hard to turn her because she was very stiff. She stated Resident #1 was given 4 mg. of morphine on 8/8/24 at 10:15 pm in the ER via her G-tube. Interview on 08/11/24 at 2:28 pm, ADON C stated last Tuesday 08/06/24 LVN D reported Resident #1 had redness of her left leg and her Doctor was called and he ordered for her to get a doppler study that came back negative. She stated on Thursday 08/08/24 LVN O reported something was going on with Resident #1's left leg was swollen and the color was reddish and greenish. She stated she assessed Resident #1's left leg and tried to move her leg but when she moved her leg back the resident flinched her leg back. She stated she asked her was she in pain and she moved head but it was not a distinct nod or shake. She stated she asked Resident #1 was her leg in pain and she gestured yes. She stated she was not crying or appeared to be in pain and noticed the upper part of chin had discoloration and swelling from under her kneecap to her lower leg. She stated she notified Resident #1's Doctor herself and he ordered doxycycline, x-ray and lab work and she contacted her FM. She stated when her x-ray results came back showing she had a fractured tibia and fractured fibula shaft, they sent her to the hospital. She stated Resident #1 was a Hoyer lift transfer resident and she was a 1-person physical assist for incontinent care/bed mobility. She stated Resident #1's legs were contracted and a draw pad was needed to reposition her and reason why she always asked for assistance when providing her care. She stated she was a G-tube resident also and normally another staff was needed for ensure the tubing to stayed intact. She stated Resident #1 fell on [DATE] and she did not find out about it until Friday 08/09/24. She stated Oh yes if a resident had a guided fall or an assisted fall is a fall and a change in the resident's level of positioning. She stated Resident #1 had never been uncooperative with ADL care, but her legs were contracted and left hand was contracted. She stated she had never seen Resident #1 getting incontinent care on the floor mat and there were no reports of such. Interview on 08/11/24 at 4:13 pm, LVN D stated she worked on 08/06/24 around 10:00 am and Resident #1 was not able to speak but could follow verbal commands. She stated on 08/06/24 she was giving her medications through her g-tube and Resident #1 was different and her mood was flat and she asked Resident #1 was she good and she did not nod her head yes like she usually did and she was not her normal self. She stated when she flipped her blanket back, she noticed her knee looked different, both of her legs were contracted, but the lower part of her left knee was swollen and purplish and when she moved her left leg, she pulled it back and guarded with it. She stated Resident #1 was not her regular self she saw the left knee was a little swollen with a little purplish bruise, from her knee to her ankle. She stated she took a picture and sent it to her Doctor because she took Eliquis and was not sure if she had a blood clot of not. She stated her Doctor ordered a doppler study then when she returned to work on 08/09/24 she found Resident #1 was transferred to the hospital because her leg was getting bigger. She stated 911 was called and they took her to the hospital. She stated Resident #1 has never been non-compliant with care and had not ever seen her getting ADL care on her floor mat. She stated Resident #1 was supposed to be on her bed for all care needs. She stated if a resident was on the floor mat due to having a guided fall was the same as a fall and the Doctor needed to be called immediately. She stated the Doctor needed to be called for special instructions on what to do, and the nurses were supposed to assess the resident and know the residents blood pressure and vitals and do neuro checks for 72 hours and complete an incident report. She stated Resident #1 was a 2 person assist Hoyer lift resident and 1 person assist for bed mobility and ADL care. She stated Resident #1 used a Geri chair because she could not use a regular chair because she had a stroke affecting her left side and was not able to sit up in a wheelchair. She stated Resident #1 was good following commands but could not speak but she could look at their face and body language for signs of pain. She stated monitoring checks and notifying the next nurse to follow up on the resident monitoring was also needed. She stated if a resident had a fall and it was not reported or documented the resident could get injured more or lose their life. Interview on 08/12/24 at 12:53 pm, MDS Coordinator E, stated Resident #1's ADL status ranged and it depended on if she had any Muscle spasms related to her Multiple Sclerosis disease process. She stated Resident #1's status varied because on some days she was a little more rigid than other days. She stated Resident #1 was a 1 to 2 person assist for bed mobility and hygiene on the MDS Assessment and stated she believed her care plan had her as a 2 person assist for bed mobility. She stated she would have to review that and get back with the surveyor. She stated Resident #1 was no longer on hospice as of last month and stated the resident's MDS's should match what their Care Plans were. She stated Resident #1 was an extensive assist, Hoyer lift resident. She stated both of Resident #1's legs were both contracted. She stated she admitted with the leg contractures and was able to wiggle her legs with both of her legs bending at a 45-degree angle. She stated Resident #1 received most times received be [TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be free from neglect as defined in this subpart for one (Resident #1) of six residents reviewed for Neglect. CNA A failed to ensure Resident #1 did not fall out of bed on 08/02/24 while she was providing incontinent care and LVN B failed to document assessing Resident #1's fall, LVN B failed to notify Resident #1's Doctor, LVN B failed to complete an incident report, and LVN B failed to notify the oncoming Nurse, DON, and Administrator about Resident #1's fall. Subsequently, Resident #1 was sent to the hospital 08/08/24 and was diagnosed with two fractures Tibia (Shinbone) and Fibula (Calf bone) of her left lower leg. An Immediate Jeopardy (IJ) was identified on 08/11/24. An IJ Template was provided to the facility on [DATE] at 3:38 pm. While the Immediate Jeopardy was removed on 08/12/24 at 7:50 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place all residents at risk of having increased distress and pain resulting in a decline in their psycho-social well-being and health resulting in internal bleeding, more injuries from being moved or death. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with a BIMS Staff Assessment score of 2 (Moderate impaired cognition), no speech, with a memory problem and severely impaired. She had upper extremity impairment on one side and lower extremity impairment of both sides. Her functioning abilities and goals: Self-care: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for all ADLs including (toileting, personal hygiene). Her functioning abilities and goals: Mobility: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for roll left and right and for chair/bed to chair transfer. She was always incontinent to bladder and bowel, has a progressive neurological conditions with diagnoses of hypertension. She had Multiple Sclerosis (nerve degeneration), Gastronomy status (feeding tube), Cardiac arrhythmia (arrhythmia (irregular heartbeat), dysphagia (not able to swallow properly), muscle weakness, atrial fibrillation (irregular heartbeat), and lack of coordination. She was 5'6 and 132 pounds. Record review of Resident #1's August 2024 Order Summary Report revealed orders for: Eliquis (blood thinner) 5 mg, folic acid 1 mg. senna 8.6 mg. tramadol 50 mg. Enteral Feeding tube, Enteral stoma site care, NPO, Enteral formula pump administration. Record review of Resident #1's Care Plan printed 8/10/24 revealed, Multiple sclerosis: assist with ADL and comfort measures as needed, Abdominal binder: to keep G-tube in place keep head and bed elevated. Geri-chair: make as comfortable as possible, falls (Resident has a history of falling related to mobility due to Multiple Sclerosis): place resident in a fall prevention program. Multiple sclerosis at risk for a decline in current ADLs and injuries due to increased injuries and assist with ADL's and comfort measures as needed. Cognitive loss/dementia: allow time for task and responses. Communication has aphasia approach in calm manner. Falls - keep call light within reach, ADL Functional status: ambulation/transfers amount of assist: total x 2 non-ambulatory, bathing/hygiene assist: total x1, resident care as per policy, toileting amount of assist total x1. Record review of Resident #1's Progress notes reviewed from 08/02/24 to 08/09/24 did not reveal she had any falls or incidents. Record review on Resident #1's Plan of care (POC) report dated 08/02/2024 at 7:06 pm revealed, CNA A provided Incontinent care. Record review of Resident #1 X-Ray results dated 08/08/24 at 8:03 pm revealed, Clinical information: Bruising, swelling, Test procedures: Left tibia and fibula, two views. Findings: Proximal tibial and fibular shafts fracture. No osteolytic or osteosclerotic lesions. No signs of bone infection. Impression:1. Proximal tibial and fibular shafts fracture. 2. CT is recommended. Record review of Resident #1's Hospital Emergency Department Doctor's note dated 08/08/24 revealed, Chief complaint: Leg deformity: patient here from [Nursing Facility]. Left leg swelling noted and ecchymosis found this morning. On Eliquis .Patient is bed bound and nonverbal. Radiology: Tibia/fibula, left 2 views final result: Impression: Proximal left tibial and fibular fractures, negative left ankle and knee joint. Soft tissue swelling. Osteopenia. Record review of Resident #1's Incident/Accident Report completed date 08/09/24 at 6:08 pm by LVN B revealed, Event date 08/02/24 at 5:57 pm, in resident room, yes fall was witnessed, no injury and no pain, ROM without pain/limitations, no rotation/deformity/shortening noted .notifications: Attending physician faxed: no, Physician notified: no, Resident Representative notified: no, care plan reviewed: no. Record review of Resident #1's Progress note 08/02/2024 [Recorded as Late Entry on 08/09/2024 06:19 PM] by LVN B revealed, Events - fall: 11:06PM On 2nd of August, CNA call attention to this nurse to room XXXX and reported to this nurse that she rolled resident down to the floor mat while giving care. Observed and assess resident on the floor mat., no apparent injury noted at that time. No S/S of pain noted at that time. Resident was helped back to bed with the help of the CNA. Record review of Resident #1's Hospital Orthopedic Doctor note dated 08/09/24 revealed, Orthopedic diagnosis: Left Proximal tibia fracture. Orthopedic plan: Closed management of left proximal tibial fracture, knee immobilization, non-weight bearing. History of present illness: A [AGE] year-old female with multiple advance medical issues including MS, who is nonverbal at baseline .The patient is nonverbal, non-ambulatory. I do not think she would be a very good candidate for surgical intervention. I will plan for a knee immobilization and follow-up in the outpatient setting. Observation on 08/09/24 at 3:40 pm, Resident #1's room revealed a thin blue floormat that was approximately two inches in height and six feet in length on the left side of Resident #1's bed. Observation on 08/10/24 at 3:37 pm, Resident #1 was at the hospital lying flat on her back, in bed watching Television, she nodded yes to her name. She shook her head no she was not hurting. When asked had she fallen out of bed, she looked at her left leg and did not shake or nod her head. There was a G-tube next to her bed she and she did not appear to be in pain. Her left leg was bent at a 45-degree angle with a knee immobilizer on it. Interview on 08/09/24 at 6:43 pm, CNA A stated on 08/02/24 after dinner she checked Resident #1 and incontinent care was needed. She stated she was standing right in front of the window with the bed elevated and while caring for Resident #1, she turned her towards the door then towards her. She stated she put the bed linen on the floor then rolled her to the right to clean her and afterwards she tried to grab her bed sheets at the foot of her bed. She stated then Resident #1 started shaking and rolled off the bed so she went to get LVN B who came to assess the resident and made sure she was okay. She stated she and LVN B got Resident #1 back to bed and got her dressed then LVN B asked her what happened and she told her she was doing incontinent care and the resident rolled to the floor. She stated Resident #1 was nonverbal but did not appear to be in any pain and her leg was not swollen or in a weird position. She stated she was not sure if the nurse called to have any x-rays done and did not see anyone come out to do x-rays during her shift. She stated there was most likely no x-rays done because the resident was not crying because she checked on her frequently and changed her about four more times that night. She stated typically they reported falls to the DON and from there the DON notified the Administrator. She stated she did not report this fall to the DON and Administrator because it was the weekend and the DON was not at the facility. She stated today 08/09/24 she came back to work and reviewed her assignment and did her walk through to get her eyes on the residents and noticed Resident #1 was not at the facility. She stated she asked Staffing Coordinator F what happened to Resident #1 and was told she went to the hospital with an injury unknown origin of her leg. She stated Staffing Coordinator F told her there was an investigation about Resident #1's injury and that she needed to talk to the Administrator. She stated on 08/09/24, she wrote up her statement and spoke to the DON about what happened on 08/02/24. She stated on 08/09/24 around 6:00 pm she was suspended and was told they would let her know more information later after they completed their investigation and would get back with her soon. She stated she did not ever want to step on anyone's toes when she told LVN B about what happened to Resident #1 and did not think to report it to the DON also. She stated in her eyes Resident #1 had a rollover onto the floor. She stated she received training today 08/09/24 on abuse and neglect and for if the resident's fall was guided, she was supposed to report it to their Administrator. She stated Resident #1 she believed was a 1 person assist for ADL care and for transfers was Hoyer 2 person assist. She stated she knew the resident's level of care by asking the nurse what the resident's transfer status and care needs were. She stated not being really sure on how to use the POC in the EMR system because when she clicked on that tab and it did not have the resident's mobility statuses in them. She stated the POC only had the resident's demographic info. She stated she should have reported this fall to the Administrator because there was a change in Resident #1's health. She stated if she would have reported it to the Administrator and DON, this whole situation would not have happened. She stated on Friday 08/02/24 she worked from 2:00 pm to 6:00 am then worked Sunday 08/04/24 from 2:00 pm - 6:00 am. She stated she also worked today 08/09/24 from 2:00 pm to 6:00 pm. She stated falls, including guided falls could cause death, injured bones, and internal bleeding. Interview on 08/10/24 at 9:09 am, LVN B stated she worked the overnight shift and last took care of Resident #1 Last Friday 08/02/24, Tuesday 08/06/24 and Wednesday 08/07/24. She stated yesterday 08/09/24 she heard Resident #1 had a leg fracture. She stated she was very surprised Resident #1 was injured. She stated the DON spoke to her about what she knew about Resident #1's fall on 08/02/24 then the DON told her she should have completed an incident report and called her Doctor. She stated she did a late add nurses note and incident/accident report on 08/09/24 per the DON's request. She stated last Friday 08/02/24 after meal service, after 11:00 pm she was at the nurses' station and CNA A stood at Resident #1's room door calling her name out loud about needing help putting Resident #1 back to bed. She stated she saw Resident #1 in her room and her bed was in the lowest position and Resident #1 was on the left side of her bed on the floor. She stated Resident #1 was on her back and her left leg was turned to the left, and her head and buttocks was flat on the floormat, she was on her back. She stated her left leg was paralyzed and for her care they normally used a pillow to prop it in place. She stated when Resident #1 was on the floor her Gtube port was okay and the tubing was still connected to the gtube pump. She stated there was no pillow under Resident #1's leg and the bed linen and pillow was on her bed. She stated she assessed Resident #1 and did not find anything wrong with her and she had no signs or symptoms of pain, then she and CNA A put her back to bed. She stated asking CNA A why Resident #1 on the floor and CNA A was said she rolled her onto the floor to give her incontinent care. She stated CNA A did not say Resident #1 fell but said she guided her to the floormat. She stated if CNA A told her Resident #1 had fallen, she would have reported it to her Doctor, the Administrator and DON. She stated she would have also documented it in Resident #1's nurses notes and completed an incident report and called her family. She stated she would have followed up with her to ensure she was fine and added Resident #1 was on scheduled Tramadol she received at 12:00 am and PRN Tylenol. She stated there was no increase in giving her more pain medications. She stated Resident #1's floor mat next was next to her bed 24/7 and Resident #1 normally did not get care on the floor mat that was why she questioned CNA A about it. She stated there was not anything propping her left leg, she checked on Resident #1 four or five times that night. She stated Resident #1 watched television and slept and she was given her Tramadol at midnight and she was asleep rest of the night. She stated she did not tell the oncoming nurse or the DON about her being on the floor because she got busy and did not suspect anything was wrong. She stated she got busy with taking care of other residents forgot to document at nurses note. She stated there was no swelling or redness of her legs during her 08/02/24 shift. She stated she returned to work Tuesday 08/06/24 the nurse reported Resident #1 had left leg swelling and her Doctor ordered for a doppler study for edema. She stated the doppler study result came back Wednesday 08/07/24 was negative and she faxed that result to her Doctor. She stated there were no new orders and she took a picture of Resident #1's left leg and sent it to her Doctor. She stated she got a call from the DON yesterday 08/09/24 around 4:00 pm and she returned the call around 4:49 pm and the DON told her to come to the facility. She stated a little after 5:00 pm she gave the DON her statement and completed Resident #1's incident report and completed in-service trainings on neglect/abuse, who was the abuse coordinator and the DON told her she should have reported this to her and called her Doctor and family. She stated she had the mind to call the DON but forgot and stated if a resident fell and the Doctor, DON or family was not notified could result in delayed injury. She stated that was why she always documented but she forgot to document Resident #1's fall and said after the DON spoke to her, she now knew why she should have completed a nurses note and reported it to her Doctor, DON, and family. She stated in general the residents were on the floor mat for care if they were uncooperative, but Resident #1 was never uncooperative and never on the floor for incontinent care. She stated she thought it was odd Resident #1 was on the floormat. She stated Resident #1 was a 1 person assist for incontinent care because she was not that heavy. heavy, but needed 2 person Hoyer assist for some care needs. She stated Resident #1 was bed bound with left sided weakness upper and lower and alert and oriented x1. She stated Resident #1 was not able to express her needs because she was aphasic and knew her name. She stated Resident #1 was able to gesture responses by nodding and shaking her head. She stated there was 1 nurse and 1 aide for on the norm for 21 residents. She stated she did not know Resident #1 was a 2 person assist for bed mobility but if a resident was skinny 1 person could do incontinent care on her. She stated only 1 CNA worked that side of the hall where Resident #1 was and CNA A never asked her for assistant with doing Resident #1's incontinent care. She stated she did not know Resident #1's MDS Assessment changed her bed mobility to 2-person assistance. She stated at night they had been 1 person assist with her incontinent care. She stated the nurses were responsible for ensuring the residents were getting proper care and cleaned and dry and checked every 2 hours. She stated she did not look at the Resident's Plan of Care to determine if they were 1 or 2 person assist by knowing the residents and going by the 24-hour report. She stated the DON suspended her and CNA A pending the investigation of Resident #1. She stated not reporting something bad could cause the resident to get bruised, skin tear or injured. Interview on 08/09/24 at 4:45 pm, the Police Detective stated he visited Resident #1 at the hospital and gathered other information and opened a case to further investigate the circumstances involving Resident #1's leg injury. He stated he had spoken to CNA A who said on 08/02/24 she was cleaning Resident #1 and she turned around then the resident kept rolling and fell out of the bed. He stated CNA A said she asked LVN B to help get Resident #1 off of the floor then LVN B picked up Resident #1 and put her back onto her bed. The Police Detective stated as of right now there was no documentation of the resident falling and no one knew what happened to her leg and the resident was not able to say what happened. He stated the Administrator and DON said they just discovered it from CNA A's statement. He stated Resident #1 sustained two fractures of her left tibia and left fibula that was approximately one inch below her knee. He stated Resident #1's roommate said she remembered a nurse and CNA coming in really fast one night but was not able to see or know what happened. He stated he was getting ready to interview LVN B to gather more information. Interview on 08/09/24 at 7:26 pm, the DON stated she received a report on 08/06/24 about Resident #1's left leg appearing shiny and red like she had irritated rash. She stated her Doctor ordered a doppler study of her left leg and the results came back negative. She stated the area on her leg started swelling up more and getting darker red and her Doctor diagnosed her with cellulitis and ordered antibiotics. She stated yesterday 08/08/24 her leg was still looking red and her Doctor ordered an X-ray and the result came back yesterday morning for two fractures of her left tibia and fibula. She stated they reported on 08/08/24 to HHSC of an injury of unknown origin because of the darkness of her leg that looked to be spreading to other areas of her leg. She stated she was just finding out today 08/09/24 around 4:30 pm Resident #1 fell Friday the night of 08/02/24. She stated there were no notes in her medical records and no incident reports. She stated Resident #1's fall should have been reported to her and the Administrator so they could have started investigating and reported this incident to HHSC. She stated had they had known sooner they would have reported this incident immediately. She stated they were currently doing in-service trainings with all staff, doing skin and pain assessment of all the residents. She stated they were doing a lot of trainings on abuse/neglect, notifications to the DON and Administrator. She stated the therapy staff were assisting with the trainings. She stated they were currently interviewing staff. She stated CNA A said she was doing Resident #1's incontinent care and when she turned to get some linen, Resident #1 rolled out of her bed. She stated CNA A told her that LVN B was alerted and Resident #1 was assessed but there was not any documentation of a nurses note, no notifications to her family, herself, or Administrator. She stated LVN B confirmed everything that happened she went into the room and the resident was on the floor, and CNA A explained she had guided the resident to the floor. She stated LVN B said she did a head-to-toe assessment and when asked why she did not document the assessment, LVN B said it got so busy and she forgot. The DON stated she informed Resident #1's Doctor today 08/09/24 about Resident #1's fall with injury and he was upset because no one had called him on 08/02/24. She stated the Doctor was at the facility visiting patients Monday 08/05/24 and no one told him about this. She stated ADON C assessed Resident #1 then she was transferred to the hospital. She stated she spoke to LVN B on 08/09/24 around 4:00 pm and she confirmed Resident #1 had fallen on 08/02/24. She stated LVN #1 was suspended. She stated she interviewed CNA A around 3:30 pm or 4:00 pm and CNA A was removed off the floor and interviewed with the Corporate Nurse Representative. She stated CNA A was sent to the conference room and until they received her statement. She stated she told CNA A she was suspended until they completed their investigation and sent her home. She stated LVN B came to the facility to drop off her statement and said she had not worked in the past two days. She stated the staff knew how to go into the EMR POC to review the resident's level of care and was not aware of any issues with that. She stated they were still investigating this incident and felt like the incident was not intentional and people just needed to think when they did resident care and thought about the processes beforehand. She stated from what she was told Resident #1's bed was at the level of CNA A's hips. She stated Resident #1 did have tremors and twitched a lot and said she was not sure if she was 1 or 2 person assist or Hoyer lift yet. She stated Resident #1 was not able to express her needs but was good at communicating by nodding and shaking her head. She stated Resident #1 required the use of a wheelchair and was not sure if she could move her legs but was in the process of finding out more. She stated unreported and undocumented falls could have adverse effects because neuro were checks needing to be done to monitor if they had a change of mental status, got injured and needed more pain medication and was a form of neglect. She stated Resident #1 had routine pain medication and since 08/02/24 she had not had any increased pain. She stated after Resident #1 fell her Doctor should have been called and the fact that CNA A said the resident fell off the bed, LVN B should have called her Doctor for further instructions. She stated the last she heard they were not going to do surgery to repair Resident #1's left tibia and fibula because of her MS diagnosis. Interview on 08/09/24 at 8:21 pm, the Administrator stated he found out Resident #1 fell on [DATE] and they were currently doing their investigation. He stated today 08/09/24 CNA A said Resident #1 fell last Friday 08/02/24 and that she and LVN B got her back into bed and they suspended her. He stated they called LVN B to tell them her story and she was interviewed then they decided to suspend LVN B pending investigation for not following their events protocol procedure. He stated they needed to ensure there was not anything missed and added up to the point they knew Resident #1 could not move and something was going on with her leg he reported this incident to HHSC. He stated yesterday 08/08/24 Resident #1 was transferred to the hospital after her x-ray result showed she had fibula and tibia fractures of her left leg. He stated ever since then they were doing employee trainings on abuse/neglect, resident transfer techniques, reporting events and change in condition. He stated the DON and ADON was responsible for ensuring the nursing staff were following their protocols. He stated they reviewed all of Resident #1's documentation today and there was not any documentation about her falling. He stated unreported and undocumented falls could cause all kinds of things could happen such as pain, worsening condition, tons of things, no follow up on the resident's status. He stated they spoke to the Medical Director about Resident #1's fall with injury and they planned to continue to do trainings and get statements from the staff. He stated they were reviewing her documents and other residents' documents to protect all the residents and to see if they could do something another way to communicate better. He stated Resident #1 was a 1 person ADL assist resident because she was able to assist with turning and a petite lady and it was easy to turn her one way from to the other. Interview on 08/10/24 at 11:00 a.m. with the Hospital RN stated Resident #1 admitted to the hospital because of a fractured tibia and fibula. She stated she was stable right now and was currently awake but nonverbal and just nodded in agreement to everything and was not good at following commands. She stated Resident #1 did not appear to be in any pain and no surgery was planned yet and they were doing conservative treatments on her. She stated there were no discharge plans at this time and her pain levels were fine but grimaced when providing care then but when still no signs or symptoms of pain. She stated she had not been given any pain medications since she admitted on [DATE] but had Doctor orders for Norco for moderate pain. She stated she Resident #1 has Doctor orders for Ativan for anxiety, morphine for severe pain and Tylenol for mild pain/headache. She stated Resident #1 had an immobilizer on her left leg and stated both her arms were contracted (right arm moved a little more and her left arm was more contracted). She stated her left leg was completed contracted and stated she was a 2 person assist because it was hard to turn her because she was very stiff. She stated Resident #1 was given 4 mg. of morphine on 8/8/24 at 10:15 pm in the ER via her G-tube. Interview on 08/11/24 at 2:28 pm, ADON C stated last Tuesday 08/06/24 LVN D reported Resident #1 had redness of her left leg and her Doctor was called and he ordered for her to get a doppler study that came back negative. She stated on Thursday 08/08/24 LVN O reported something was going on with Resident #1's left leg was swollen and the color was reddish and greenish. She stated she assessed Resident #1's left leg and tried to move her leg but when she moved her leg back the resident flinched her leg back. She stated she asked her was she in pain and she moved head but it was not a distinct nod or shake. She stated she asked Resident #1 was her leg in pain and she gestured yes. She stated she was not crying or appeared to be in pain and noticed the upper part of chin had discoloration and swelling from under her kneecap to her lower leg. She stated she notified Resident #1's Doctor herself and he ordered doxycycline, x-ray and lab work and she contacted her FM. She stated when her x-ray results came back showing she had a fractured tibia and fractured fibula shaft, they sent her to the hospital. She stated Resident #1 was a Hoyer lift transfer resident and she was a 1-person physical assist for incontinent care/bed mobility. She stated Resident #1's legs were contracted and a draw pad was needed to reposition her and reason why she always asked for assistance when providing her care. She stated she was a G-tube resident also and normally another staff was needed for ensure the tubing to stayed intact. She stated Resident #1 fell on [DATE] and she did not find out about it until Friday 08/09/24. She stated Oh yes if a resident had a guided fall or an assisted fall is a fall and a change in the resident's level of positioning. She stated Resident #1 had never been uncooperative with ADL care, but her legs were contracted and left hand was contracted. She stated she had never seen Resident #1 getting incontinent care on the floor mat and there were no reports of such. Interview on 08/11/24 at 4:13 pm, LVN D stated she worked on 08/06/24 around 10:00 am and Resident #1 was not able to speak but could follow verbal commands. She stated on 08/06/24 she was giving her medications through her g-tube and Resident #1 was different and her mood was flat and she asked Resident #1 was she good and she did not nod her head yes like she usually did and she was not her normal self. She stated when she flipped her blanket back, she noticed her knee looked different, both of her legs were contracted, but the lower part of her left knee was swollen and purplish and when she moved her left leg, she pulled it back and guarded with it. She stated Resident #1 was not her regular self she saw the left knee was a little swollen with a little purplish bruise, from her knee to her ankle. She stated she took a picture and sent it to her Doctor because she took Eliquis and was not sure if she had a blood clot of not. She stated her Doctor ordered a doppler study then when she returned to work on 08/09/24 she found Resident #1 was transferred to the hospital because her leg was getting bigger. She stated 911 was called and they took her to the hospital. She stated Resident #1 has never been non-compliant with care and had not ever seen her getting ADL care on her floor mat. She stated Resident #1 was supposed to be on her bed for all care needs. She stated if a resident was on the floor mat due to having a guided fall was the same as a fall and the Doctor needed to be called immediately. She stated the Doctor needed to be called for special instructions on what to do, and the nurses were supposed to assess the resident and know the residents blood pressure and vitals and do neuro checks for 72 hours and complete an incident report. She stated Resident #1 was a 2 person assist Hoyer lift resident and 1 person assist for bed mobility and ADL care. She stated Resident #1 used a Geri chair because she could not use a regular chair because she had a stroke affecting her left side and was not able to sit up in a wheelchair. She stated Resident # was good following commands but could not speak but she could look at their face and body language for signs of pain. She stated monitoring checks and notifying the next nurse to follow up on the resident monitoring was also needed. She stated if a resident had a fall and it was not reported or documented the resident could get injured more or lose their life. Interview on 08/12/24 at 12:53 pm, MDS Coordinator E, stated Resident #1's ADL status ranged and it depended on if she had any Muscle spasms related to her Multiple Sclerosis disease process. She stated Resident #1's status varied because on some days she was a little more rigid than other days. She stated Resident #1 was a 1 to 2 person assist for bed mobility and hygiene on the MDS Assessment and stated she believed her care plan had her as a 2 person assist for bed mobility. She stated she would have to review that and get back with the surveyor. She stated Resident #1 was no longer on hospice as of last month and stated the resident's MDS's should match what their Care Plans were. She stated Resident #1 was an extensive assist, Hoyer lift resident. She stated Resident #1 got out of bed rarely and when she did, they transferred her to a Geri-chair. She stated their interdisciplinary team updated the residents Care plans with an RN or DON verifying the information was accurate. She stated the Care plans showed each resident's proper level of care, detailed safety issues on how to care for the residents. She stated if the resident's care plans were inaccurate it could lead up to injury due to them not receiving the proper care. She stated the nurses and cna's used care plans to know how to take care of each of the residents and whatever data was on the resident's MDS Assessments were reflected on their care plans. She stated the DON was responsible for ensuring the Care Plans were accurate. She stated both of Resident #1's legs were both contracted. She stated she admitted with the leg contractures and was able to wiggle her legs with both of her legs bending at a 45-degree angle. She stated Resident #1 received most times received bed baths. She stated it was reported on 08/02/24 Resident #1 had a change in position and was assisted to the floor, which was still considered a fall. She stated, 'Oh definitely' LVN B should have called Resident #1's Doctor on 08/02/24, because the Doctor may have wanted to order x-rays and do a follow up visit. She stated the nurses needed to ensure the residents did not have any post injuries at t [TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #1) of six residents reviewed for Change in condition. LVN B failed to notify Resident #1's Doctor on 08/02/24 after CNA A asked her to assist with picking Resident #1 off the floormat and putting her back to bed. Subsequently, Resident #1 was sent to the hospital on 08/08/24 and currently at the hospital diagnosed with two fractures (Tibia and Fibula) of her left lower leg. An Immediate Jeopardy (IJ) was identified on 08/12/24. An IJ Template was provided to the facility on [DATE] at 12:10 pm. While the Immediate Jeopardy was removed on 08/12/24 at 7:50 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not being assessed and treated in a timely manner and appropriately, with Doctors interventions, which could result in a decline in their psycho-social well-being and health resulting in internal bleeding, pain when being moved causing further injury or death. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with a BIMS Staff Assessment score of 2 (Moderate impaired cognition), no speech, with a memory problem and severely impaired. She had upper extremity impairment on one side and lower extremity impairment of both sides. Her functioning abilities and goals: Self-care: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for all ADLs including (toileting, personal hygiene). Her functioning abilities and goals: Mobility: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for roll left and right and for chair/bed to chair transfer. She was always incontinent to bladder and bowel, has a progressive neurological conditions with diagnoses of hypertension. She had Multiple Sclerosis (nerve degeneration), Gastronomy status (feeding tube), Cardiac arrhythmia (irregular heartbeat), dysphagia (not able to swallow properly), muscle weakness, atrial fibrillation (irregular heartbeat), and lack of coordination. She was 5'6 and 132 pounds. Record review of Resident #1's August 2024 Order Summary Report revealed orders for: Eliquis (blood thinner) 5 mg, folic acid 1 mg. senna 8.6 mg. tramadol 50 mg. Enteral Feeding tube, Enteral stoma site care, NPO, Enteral formula pump administration. Record review of Resident #1's Care Plan printed 8/10/24 revealed, Multiple sclerosis: assist with ADL and comfort measures as needed, Abdominal binder: to keep G-tube in place keep head and bed elevated. Geri-chair: make as comfortable as possible, falls (Resident has a history of falling related to mobility due to Multiple Sclerosis): place resident in a fall prevention program. Multiple sclerosis at risk for a decline in current ADLs and injuries due to increased injuries and assist with ADL's and comfort measures as needed. Cognitive loss/dementia: allow time for task and responses. Communication has aphasia approach in calm manner. Falls - keep call light within reach, ADL Functional status: ambulation/transfers amount of assist: total x 2 non-ambulatory, bathing/hygiene assist: total x1, resident care as per policy, toileting amount of assist total x1. Record review of Resident #1's Progress notes reviewed from 08/02/24 to 08/09/24 did not reveal she had any falls or incidents. Record review of Resident #1's X-Ray results dated 08/08/24 at 8:03 p.m. revealed, Clinical information: Bruising, swelling, Test procedures: Left tibia and fibula, two views. Findings: Proximal tibial and fibular shafts fracture. No osteolytic or osteosclerotic lesions. No signs of bone infection. Impression:1. Proximal tibial and fibular shafts fracture. 2. CT is recommended. Record review of Resident #1's Hospital Emergency Department Doctor's note dated 08/08/24 revealed, Chief complaint: Leg deformity: patient here from [Nursing Facility]. Left leg swelling noted and ecchymosis found this morning. On Eliquis .Patient is bed bound and nonverbal. Radiology: Tibia/fibula, left 2 views final result: Impression: Proximal left tibial and fibular fractures, negative left ankle and knee joint. Soft tissue swelling. Osteopenia. Record review of Resident #1's Progress note 08/02/2024 [Recorded as Late Entry on 08/09/2024 06:19 PM] by LVN B revealed, Events - fall: 11:06 PM On 2nd of August, CNA call attention to this nurse to room XXXX and reported to this nurse that she rolled resident down to the floor mat while giving care. Observed and assess resident on the floor mat., no apparent injury noted at that time. No S/S of pain noted at that time. Resident was helped back to bed with the help of the CNA. Record review of Resident #1's Incident/Accident Report completed date 08/09/24 at 6:08 p.m. by LVN B revealed, Event date 08/02/24 at 5:57 p.m., in resident room, yes fall was witnessed, no injury and no pain, ROM without pain/limitations, no rotation/deformity/shortening noted .notifications: Attending physician faxed: no, Physician notified: no, Resident Representative notified: no, care plan reviewed: no. Record review of Resident #1's Hospital Orthopedic Doctor note dated 08/09/24 revealed, Orthopedic diagnosis: Left Proximal tibia fracture. Orthopedic plan: Closed management of left proximal tibial fracture, knee immobilization, non-weight bearing. History of present illness: A [AGE] year-old female with multiple advance medical issues including MS, who is nonverbal at baseline .The patient is nonverbal, non-ambulatory. I do not think she would be a very good candidate for surgical intervention. I will plan for a knee immobilization and follow-up in the outpatient setting. Observation on 08/09/24 at 3:40 p.m., Resident #1's room revealed a thin blue floormat that was approximately two inches height and six feet in length on the left side of Resident #1's bed. Observation on 08/10/24 at 3:37 p.m., Resident #1 was at the hospital lying flat on her back, in bed watching television, she nodded yes to her name. She shook her head no she was not hurting. When asked had she fallen out of bed, she looked at her left leg and did not shake or nod her head. There was a G-tube next to her bed and she did not appear to be in pain. And her left leg was bent at a 45-degree angle with a knee immobilizer on it. Interview on 08/09/24 at 6:43 p.m., CNA A stated on 08/02/24 after dinner she checked Resident #1 and incontinent care was needed. She stated she was standing right in front of the window with the bed elevated and while caring for Resident #1, she turned her towards the door then towards her. She stated she put the bed linen on the floor then rolled her to the right to clean her and afterwards she tried to grab her bed sheets at the foot of her bed. She stated then Resident #1 started shaking and rolled off the bed so she went to get LVN B who came to assess the resident and made sure she was okay. She stated she and LVN B got Resident #1 back to bed and got her dressed then LVN B asked her what happened and she told her she was doing incontinent care and the resident rolled to the floor. She stated Resident #1 was nonverbal but did not appear to be in any pain and her leg was not swollen or in a weird position. She stated she was not sure if the nurse called to have any x-rays done and did not see anyone come out to do x-rays during her shift. She stated there was most likely no x-rays done because the resident was not crying because she checked on her frequently and changed her about four more times that night. Interview on 08/10/24 at 9:09 a.m., LVN B stated she worked the overnight shift and last took care of Resident #1 Last Friday 08/02/24, Tuesday 08/06/24 and Wednesday 08/07/24. She stated yesterday 08/09/24 she heard Resident #1 had a leg fracture. She stated she was very surprised Resident #1 was injured. She stated the DON spoke to her about what she knew about Resident #1's fall on 08/02/24 then the DON told her she should have completed an incident report and called her Doctor. She stated she did a late add nurses note and incident/accident report on 08/09/24 per the DON's request. She stated last Friday 08/02/24 after meal service, after 11:00 pm she was at the nurses' station and CNA A stood at Resident #1's room door calling her name out loud about needing help putting Resident #1 back to bed. She stated she saw Resident #1 in her room and her bed was in the lowest position and Resident #1 was on the left side of her bed on the floor. She stated Resident #1 was on her back and her left leg was turned to the left, and her head and buttocks was flat on the floormat, she was on her back. She stated her left leg was paralyzed and for her care they normally used a pillow to prop it in place. She stated when Resident #1 was on the floor her G-tube port was okay and the tubing was still connected to the g-tube pump. She stated there was no pillow under Resident #1's leg and the bed linen and pillow was on her bed. She stated she assessed Resident #1 and did not find anything wrong with her and she had no signs or symptoms of pain, then she CNA A put her back to bed. She stated when she asked CNA A why Resident #1 on the floor, CNA A said she rolled Resident #1 onto the floor to give her incontinent care. She stated CNA A did not say Resident #1 fell but said she guided her to the floormat. She stated if CNA A told her Resident #1 had fallen, she would have reported it to her Doctor. She stated she would have also documented it in Resident #1's nurses notes and completed an incident report and called her family. She stated she would have followed up with her to ensure she was fine and added Resident #1 was on scheduled Tramadol she received at 12:00 am and PRN Tylenol. She stated there was no increase in giving her more pain medications. She stated Resident #1's floor mat next was next to her bed 24/7 and Resident #1 normally did not get care on the floor mat that was why can questioned CNA A about it. She stated there was not anything propping her left leg, she checked on Resident #1 four or five times that night. She stated Resident #1 watched television and slept and she was given her Tramadol at midnight and she was asleep rest of the night. She stated she did not tell the oncoming nurse or the DON about her being on the floor because she got busy and did not suspect anything was wrong. She stated she got busy with taking care of other residents forgot to document at nurses note. She stated there was no swelling or redness of her legs during her 08/02/24 shift. She stated she returned to work Tuesday 08/06/24 the nurse reported Resident #1 had left leg swelling and her Doctor ordered for a doppler study for edema. She stated the doppler study result came back Wednesday 08/07/24 was negative and she faxed that result to her Doctor. She stated there were no new orders and she took a picture of Resident #1's left leg and sent it to her Doctor. She stated she got a call from the DON yesterday 08/09/24 around 4:00 pm and she returned the call around 4:49 pm and the DON told her to come to the facility. She stated a little after 5:00 pm she gave the DON her statement and completed Resident #1's incident report. The DON told her she should have reported this to her and called her Doctor and family. She stated she had the mind to call the DON but forgot and stated if a resident fell and the Doctor, DON or family was not notified could result in delayed injury. She stated that was why she always documented but she forgot to document Resident #1's fall and said after the DON spoke to her, she now knew why she should have completed a nurses note and reported it to her Doctor and family. She stated she thought it was odd Resident #1 was on the floormat. She stated Resident #1 was bed bound with left sided weakness, upper and lower and alert and oriented x1. She stated Resident #1 was not able to express her needs because she was aphasic and knew her name. She stated Resident #1 was able to gesture responses by nodding and shaking her head. She stated the nurses were responsible for ensuring the residents were getting proper care and cleaned and dry and checked every 2 hours. She stated the DON suspended her and CNA A pending the investigation of Resident #1. She stated not reporting something bad could cause the resident to get bruised, get skin tears or injured. Interview on 08/09/24 at 4:45 p.m., The Police Detective stated he visited Resident #1 at the hospital and gathered other information and opened a case to further investigate the circumstances involving Resident #1's leg injury. He stated he had spoken to CNA A who said on 08/02/24 she was cleaning Resident #1 and she turned around then the resident kept rolling and fell out of the bed. He stated CNA A said she asked LVN B to help get Resident #1 off of the floor then LVN B picked up Resident #1 and put her back onto her bed. Police Detective stated as of right now there was no documentation of the resident falling and no one knew what happened to her leg and the resident was not able to say what happened. He stated the Administrator and DON said they just discovered it from CNA A's statement. He stated Resident #1 sustained two fractures of her left tibia and left fibula that was approximately one inch below her knee. He stated Resident #1's roommate said she remembered a nurse and CNA coming in really fast one night but was not able to see or know what happened. He stated he was getting ready to interview LVN B to gather more information. Interview on 08/09/24 at 7:26 p m, the DON stated she received a report on 08/06/24 about Resident #1's left leg appearing shiny and red like she had irritated rash. She stated her Doctor ordered a doppler study of her left leg and the results came back negative. She stated the area on her leg started swelling up more and getting darker red and her Doctor diagnosed her with cellulitis and ordered antibiotics. She stated yesterday 08/08/24 her leg was still looking red and her Doctor ordered an X-ray and the result came back yesterday morning for two fractures of her left tibia and fibula. She stated she was just finding out today 08/09/24 around 4:30 pm Resident #1 fell Friday night on 08/02/24. She stated there were no notes in her medical records and no incident reports. She stated they were currently doing in-service trainings with all staff and doing skin and pain assessments of all the residents. She stated the staff trainings were on notifications to the resident's Doctor and did 1:1 trainings with LVN B and now they were training all staff. She stated it was too early in her investigation and was not sure if Resident #1 was a 1 or 2 person assist for ADL's but said she would follow-up with the surveyor. She stated CNA A said she was doing Resident #1's incontinent care and when she turned to get some linen, Resident #1 rolled out of her bed. She stated CNA A told her that LVN B was alerted and Resident #1 was assessed but there was not any documentation of a nurses note and no notifications to her Doctor. She stated LVN B confirmed everything that happened she went into the room the resident was on the floor, and CNA A explained she had guided the resident to the floor. She stated LVN B said she did a head-to-toe assessment and when asked why she did not document the assessment LVN B said it got so busy and she forgot. The DON stated today 08/09/24 she informed Resident #1's Doctor about Resident #1's fall with injury and he was upset because no one had called him 08/02/24. She stated the Doctor was at the facility visiting patients Monday 08/05/24 and no one told him about this until today. She stated ADON C assessed Resident #1 then she was transferred to the hospital. She stated she spoke to LVN B on 08/09/24 around 4:00 pm she confirmed Resident #1 had fallen on 08/02/24. She stated LVN #1 was suspended. She stated LVN B came to the facility to drop off her statement and said she had not worked in the past two days. She stated Resident #1 was not able to express her needs but was good at communicating by nodding and shaking her head. She stated Resident #1 required the use a wheelchair and was not sure if she could move her legs but was in the process of finding out more. She stated unreported and undocumented falls could have adverse effects because neuro checks needed to be done to monitor if they had a change of mental status, got injured or needed more pain medications. She stated Resident #1 had routine pain medication and since 08/02/24 and she had not had any increased pain. She stated after Resident #1 fell her Doctor should have been called and the fact that CNA A said the resident fell off the bed, LVN B should have called her Doctor for further instructions. She stated the last she heard the hospital were not going to do surgery to repair her left tibia and fibula because of her MS diagnosis. Interview on 08/09/24 at 8:21 p.m., the Administrator stated he found out Resident #1 fell [DATE] and they were currently doing their investigation. He stated today 08/09/24 CNA A said Resident #1 fell last Friday 08/02/24 and that she and LVN B got her back into bed and they suspended her. He stated they called LVN B to tell them her story and she was interviewed then they decided to suspend LVN B pending investigation for not following their events protocol procedure. He stated yesterday 08/08/24 Resident #1 was transferred to the hospital after her x-ray result showed she had fibula and tibia fractures of her left leg. He stated ever since then they were doing employee trainings on reporting events. He stated the DON and ADON were responsible for ensuring the nursing staff were following their protocols. He stated they reviewed all of Resident #1's documentation today and there was not any documentation about her falling. He stated unreported and undocumented falls could cause all kinds of things to happen such as pain, worsening condition, tons of things, no follow up on the resident's status. He stated they spoke to the Medical Director about Resident #1's fall with injury and they planned to continue to do trainings and get statements from the staff. He stated they were reviewing her documents and other residents to protect all the residents and to see if they could do something another way to communicate better. Interview on 08/10/24 at 11:00 a.m., with the Hospital RN stated Resident #1 admitted to the hospital because of a fractured tibia and fibula. She stated she was stable right now and was currently awake but nonverbal and just nodded in agreement to everything and was not good at following commands. She stated Resident #1 did not appear to be in any pain and no surgery was planned yet and they were doing conservative treatments on her. She stated there were no discharge plans at this time and her pain levels were fine but grimaced when providing care then but when still she had no signs or symptoms of pain. She stated she had not been given any pain medications since she admitted on [DATE] but had Doctor orders for Norco for moderate pain. She stated she Resident #1 has Doctor orders for Ativan for anxiety, morphine for severe pain and Tylenol for mild pain/headache. She stated Resident #1 had an immobilizer on her left leg and stated both her arms were contracted (right arm moved a little more and her left arm was more contracted). She stated her left leg was completed contracted and stated she was a 2 person assist because it was hard to turn her because she was very stiff. She stated Resident #1 was given 4 mg. of morphine on 8/8/24 at 10:15 pm in the ER via her G-tube. Interview on 08/11/24 at 1:45 p.m., the DON stated they updated the staff trainings that were conducted by herself and Nursing Supervisors RN G and LVN H. She stated they were reviewing the other resident's records to see if any other residents were affected no other residents were affected. She stated they started notification of changes trainings on 08/09/24. She stated she they started doing Resident's skin and pain assessments on Friday morning of 08/09/24. She stated LVN B said CNA A told her while giving Resident #1 incontinent care CNA A guide rolled the resident to the floor. Interview on 08/11/24 at 2:28 pm, ADON C stated last Tuesday 08/06/24 LVN D reported Resident #1 had redness of her left leg and her Doctor was called and he ordered for her to get a doppler study that came back negative. She stated on Thursday 08/08/24 LVN O reported something was going on with Resident #1's left leg was swollen and the color was reddish and greenish. She stated she assessed Resident #1's left leg and tried to move her leg but when she moved her leg back the resident flinched her leg back. She stated she asked her was she in pain and she moved head but it was not a distinct nod or shake. She stated she asked Resident #1 was her leg in pain and she gestured yes. She stated she was not crying or appeared to be in pain and noticed the upper part of chin had discoloration and swelling from under her kneecap to her lower leg. She stated she notified Resident #1's Doctor herself and he ordered doxycycline, x-ray and lab work and she contacted her FM. She stated when her x-ray results came back showing she had a fractured tibia and fractured fibula shaft, they sent her to the hospital. She stated Resident #1 was a Hoyer lift transfer resident and she was a 1-person physical assist for incontinent care/bed mobility. She stated Resident #1's legs were contracted and a draw pad was needed to reposition her and reason why she always asked for assistance when providing her care. She stated she was a G-tube resident also and normally another staff was needed for ensure the tubing to stayed intact. She stated Resident #1 fell on [DATE] and she did not find out about it until Friday 08/09/24. Interview on 08/11/24 at 4:13 pm, LVN D stated she worked on 08/06/24 around 10:00 am and Resident #1 was not able to speak but could follow verbal commands. She stated on 08/06/24 she was giving her medications through her g-tube and Resident #1 was different and her mood was flat and she asked Resident #1 was she good and she did not nod her head yes like she usually did and she was not her normal self. She stated when she flipped her blanket back, she noticed her knee looked different, both of her legs were contracted, but the lower part of her left knee was swollen and purplish and when she moved her left leg, she pulled it back and guarded with it. She stated Resident #1 was not her regular self she saw the left knee was a little swollen with a little purplish bruise, from her knee to her ankle. She stated she took a picture and sent it to her Doctor because she took Eliquis and was not sure if she had a blood clot of not. She stated her Doctor ordered a doppler study then when she returned to work on 08/09/24 she found Resident #1 was transferred to the hospital because her leg was getting bigger. She stated 911 was called and they took her to the hospital. She stated Resident #1 was supposed to be on her bed for all care needs. She stated if a resident was on the floor mat due to having a guided fall was the same as a fall and the Doctor needed to be called immediately. She stated the Doctor needed to be called for special instructions on what to do, and the nurses were supposed to assess the resident and know the residents blood pressure and vitals and do neuro checks for 72 hours and complete an incident report. She stated Resident #1 was a 2 person assist Hoyer lift resident and 1 person assist for bed mobility and ADL care. She stated Resident #1 used a Geri chair because she could not use a regular chair because she had a stroke affecting her left side and was not able to sit up in a wheelchair. She stated Resident #1 was good following commands but could not speak but she could look at their face and body language for signs of pain. She stated monitoring checks and notifying the next nurse to follow up on the resident monitoring was also needed. She stated if a resident had a fall and it was not reported or documented the resident could get injured more or lose their life. Interview on 08/12/24 at 12:53 pm, MDS Coordinator E, stated Resident #1's ADL status ranged and it depended on if she had any Muscle spasms related to her Multiple Sclerosis disease process. She stated Resident #1's status varied because on some days she was a little more rigid than other days. She stated it was reported on 08/02/24 Resident #1 had a change in position and was assisted to the floor, which was still considered a fall. She stated, 'Oh definitely' LVN B should have called Resident #1's Doctor on 08/02/24, because the Doctor may have wanted to order x-rays and do a follow up visit. She stated the nurses needed to ensure the residents did not have any post injuries at that moment and further down the road. Interview on 08/12/24 at 2:33 pm, Medical Director/Resident #1's Doctor stated he had not received a call from anyone on 08/02/24 or from LVN A about Resident #1 falling. He stated LVN B should have called him for Resident #1's change in condition and completed an incident/accident report. He stated the first question on the incident/accident report asked had the Doctor been notified. He stated the facility wanted the Doctor called for any falls with or without injury, because there could be some reason why the resident fell . He stated if they had a seizure or became dizzy that might qualify for more investigation. He stated the DON notified him on 08/09/24 of Resident #1's fall on 08/02/24 that LVN B found her on the floor and put her back to bed and did not report it to anyone. He stated Resident #1 was bed bound and needed total assist and he wondered how this could have happened. He stated if CNA A and LVN B would have reported Resident #1's fall, she could have been assessed sooner and a follow up visit done with a full investigation of what caused it. He stated Resident #1 could not roll or turnover and had no muscular tone and not able to speak. He stated he wondered how Resident #1 could have fallen out of bed if she was total assist. He stated a guided fall was the same as a fall. He stated after finding out about Resident #1's fall they have had an Ad hoc QAPI Meeting on 08/12/24, to discuss their plan to prevent this from happening again. He stated they started re-educating the staff with various in-service trainings and continue to review their plan and make changes as needed and continue to discuss in their QA meetings. Review of the Facility's Provider Investigation Report dated 08/08/24 revealed on 08/02/24 at 8:00 pm. Alleged Perpetrators: CNA A and LVN B denied the allegation and no witnesses: Assessment: On 08/08/24 at2:11 p.m.by ADON C, indicated Resident #1 was assessed for an injury of unknown origin: Resident lying in bed with head above bed elevated, alert, and able to respond to questions by nodding. Left lower leg swollen warm and painful to touch, venous doppler negative, x-rays confirmed proximal tibial and fibula fracture of left leg. No treatment, resident transferred to the hospital. Provider response: RP, DON Physician notified, X-rays confirmed fracture resident transported to Hospital, satisfaction survey completed, Skin assessment completed on other residents, In services on transfers, bed mobility and Hoyer lifts. In- services on abuse and neglect. Interviews with staff. CNA A and LVN B suspended pending Investigations. Investigation Summary: On 8/2/24 in the PM. C.N.A. was providing incontinent care for Resident #1, Resident #1 rolled to the mat on the floor. C.N.A. notified LVN B. Nurse and C.N.A. assisted resident back to bed. No Documentation or Notification was given on 8/6/24 Nurse noted left leg swelling, Physician ordered a venous doppler. Doppler study had negative result. On 8/8/24 DR notified of doppler result and ordered x ray. X-rays confirmed proximal tibia and fibula shaft fracture. Administrator notified HHSC of injury of unknown origin Resident was transported to Hospital. In-services were started on Abuse, Neglect and Reporting, Transfer, Bed Mobility and Hoyer lifts. Event policy and notification. During interviews it was determined by CNA A, Resident #1 was picked up off the floor on 8/2/24. She stated that Nurse assisted her putting Resident #1 back to bed. LVN B confirmed that she assisted Resident #1 back to bed. LVN B and CNA A were suspended pending investigation. HHSC Investigator entered the building on 8/9/24 at 3:15 pm, HHSC reentered on 8/11/24 lJ was put in place at 5:30 pm. HHSC lowered the IJ 8/12/24 at 7:30 pm. Staff members LVN B and CNA A were terminated. Where others notified: Physician, RP, Ombudsman, Police, HHSC Facility investigation findings: Confirmed Provider action taken post investigation: HHSC onsite 8/09/24, 8/11/24, 8/12/24, Resident returned to facility 8/12/24, In-services on abuse neglect, reporting, Bed mobility and transfer, Events documentation and reporting to appropriate people with evidence based follow up. LVN B and CNA A were suspended and terminated. Record review of : Employee Statements dated 8/8/24, 8/9/24, Safe Survey Resident Interviews dated 8/9/24, Inservice trainings: Abuse and neglect definitions in-service dated 8/8/24, Check offs: Moving/positioning, assisting with dated 8/11/24, 8/12/24, Post Fall Physical Assessment Test dated 8/11/24, 8/12/24, Transfer training and bed mobility dated 8/9/24, Notification of change training dated 8/9/24, Employee Abuse investigation questionnaire dated 8/9/24, LVN B Employee Corrective Action Form suspended dated 8/9/24 and CNA A Employee Corrective Action Form suspended dated 8/9/24. [END] Record review of LVN B's Timesheet printed on 08/09/24 revealed she worked on: 08/02/24 5:45 pm - 7:40 am, 08/06/24 5:30 pm - 7:46 am, 08/07/24 5:26 pm - 7:51 am. Record review of an Article Tibia & Fibula Fracture (Broken Shinbone/Calf Bone) (clevelandclinic.org) last reviewed 06/01/23 revealed, Overview: What are tibia and fibula fractures? Tibia and fibula fractures are two broken bones in your lower leg. Your tibia is your shin bone. Your fibula is your calf bone. Because they're usually caused by major trauma like car accidents or falls, people often break both their tibia and fibula during the same injury. It's rare, but you can fracture one of your tibia or fibula without breaking the other. You might need surgery to repair your bones and physical therapy to regain your ability to move your leg. Record review of the facility's Change in condition policy revised 04/20/23 revealed, Policy statement: Our facility promptly notifies the resident, his or her attending physician, healthcare provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician, healthcare provider or physician on call when there has been a (an): a. accident or incident involving the resident . An Immediate Jeopardy (IJ) was identified on 08/12/24 at 12:10 pm. The Administrator was notified and the IJ Template was provided to the Administrator on 08/12/24 at 12:10 pm. The following Plan of Removal was accepted on 08/12/24 at 4:45 p.m., revealed the following: Plan of Removal 580: Notify of Changes (Injury/Decline/Room Etc.)< [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1 ) of six residents reviewed for Quality of Care. CNA A failed to provide incontinent care with a second staff member assisting, which resulted in Resident #1 falling out of bed. And LVN B failed to notify Resident #1's Doctor on 08/02/24 after CNA reported Resident #1 on the floor and assisted with getting Resident #1 on the floor. LVN B did not complete and document doing a head to toe assessment and incident report and did not monitor the resident or do neuro checks and notify other nursing staff to continue monitoring the resident. Subsequently, Resident #1 was sent to the hospital on 08/08/24 and was currently at the hospital diagnosed with two fractures, a Tibia (Shinbone) and Fibula (Calf bone) of her left lower leg. After administrative review, an IJ was identified on 08/28/24. The Administrator was notified and an IJ template was provided on 08/28/24 at 12:57 pm. While the IJ was removed on 08/12/24 at 7:50 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not being assessed and treated in a timely manner and appropriately, with Doctors interventions, which could result in a decline in their psycho-social well-being and health resulting in internal bleeding, pain when being moved causing further injury or death. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE] with a BIMS Staff Assessment score of 2 (Moderate impaired cognition), no speech, with a memory problem and severely impaired. She had upper extremity impairment on one side and lower extremity impairment of both sides. Her functioning abilities and goals: Self-care: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for all ADLs including (toileting, personal hygiene). Her functioning abilities and goals: Mobility: Coded 01. Dependent helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for roll left and right and for chair/bed to chair transfer. She was always incontinent to bladder and bowel, has a progressive neurological conditions with diagnoses of hypertension. She had Multiple Sclerosis (nerve degeneration), Gastronomy status (feeding tube), Cardiac arrhythmia (irregular heartbeat), dysphagia (not able to swallow properly), muscle weakness, atrial fibrillation (irregular heartbeat), and lack of coordination. She was 5'6 and 132 pounds. Record review of Resident #1's August 2024 Order Summary Report revealed orders for: Eliquis (blood thinner) 5 mg, folic acid 1 mg. senna 8.6 mg. tramadol 50 mg. Enteral Feeding tube, Enteral stoma site care, NPO, Enteral formula pump administration. Record review of Resident #1's Care Plan printed 8/10/24 revealed, Multiple sclerosis: assist with ADL and comfort measures as needed, Abdominal binder: to keep G-tube in place keep head and bed elevated. Geri-chair: make as comfortable as possible, falls (Resident has a history of falling related to mobility due to Multiple Sclerosis): place resident in a fall prevention program. Multiple sclerosis at risk for a decline in current ADLs and injuries due to increased injuries and assist with ADL's and comfort measures as needed. Cognitive loss/dementia: allow time for task and responses. Communication has aphasia approach in calm manner. Falls - keep call light within reach, ADL Functional status: ambulation/transfers amount of assist: total x 2 non-ambulatory, bathing/hygiene assist: total x1, resident care as per policy, toileting amount of assist total x1. Record review of Resident #1's Progress notes reviewed from 08/02/24 to 08/09/24 did not reveal she had any falls or incidents. Record review of Resident #1's X-Ray results dated 08/08/24 at 8:03 p.m. revealed, Clinical information: Bruising, swelling, Test procedures: Left tibia and fibula, two views. Findings: Proximal tibial and fibular shafts fracture. No osteolytic or osteosclerotic lesions. No signs of bone infection. Impression:1. Proximal tibial and fibular shafts fracture. 2. CT is recommended. Record review of Resident #1's Hospital Emergency Department Doctor's note dated 08/08/24 revealed, Chief complaint: Leg deformity: patient here from [Nursing Facility]. Left leg swelling noted and ecchymosis found this morning. On Eliquis .Patient is bed bound and nonverbal. Radiology: Tibia/fibula, left 2 views final result: Impression: Proximal left tibial and fibular fractures, negative left ankle and knee joint. Soft tissue swelling. Osteopenia. Record review of Resident #1's Progress note 08/02/2024 [Recorded as Late Entry on 08/09/2024 06:19 PM] by LVN B revealed, Events - fall: 11:06 PM On 2nd of August, CNA call attention to this nurse to room XXXX and reported to this nurse that she rolled resident down to the floor mat while giving care. Observed and assess resident on the floor mat., no apparent injury noted at that time. No S/S of pain noted at that time. Resident was helped back to bed with the help of the CNA. Record review of Resident #1's Incident/Accident Report completed date 08/09/24 at 6:08 p.m. by LVN B revealed, Event date 08/02/24 at 5:57 p.m., in resident room, yes fall was witnessed, no injury and no pain, ROM without pain/limitations, no rotation/deformity/shortening noted .notifications: Attending physician faxed: no, Physician notified: no, Resident Representative notified: no, care plan reviewed: no. Record review of Resident #1's Hospital Orthopedic Doctor note dated 08/09/24 revealed, Orthopedic diagnosis: Left Proximal tibia fracture. Orthopedic plan: Closed management of left proximal tibial fracture, knee immobilization, non-weight bearing. History of present illness: A [AGE] year-old female with multiple advance medical issues including MS, who is nonverbal at baseline .The patient is nonverbal, non-ambulatory. I do not think she would be a very good candidate for surgical intervention. I will plan for a knee immobilization and follow-up in the outpatient setting. Observation on 08/09/24 at 3:40 p.m., Resident #1's room revealed a thin blue floormat that was approximately two inches height and six feet in length on the left side of Resident #1's bed. Observation on 08/10/24 at 3:37 p.m., Resident #1 was at the hospital lying flat on her back, in bed watching television, she nodded yes to her name. She shook her head no she was not hurting. When asked had she fallen out of bed, she looked at her left leg and did not shake or nod her head. There was a G-tube next to her bed and she did not appear to be in pain. And her left leg was bent at a 45-degree angle with a knee immobilizer on it. Interview on 08/09/24 at 6:43 p.m., CNA A stated on 08/02/24 after dinner she checked Resident #1 and incontinent care was needed. She stated she was standing right in front of the window with the bed elevated and while caring for Resident #1, she turned her towards the door then towards her. She stated she put the bed linen on the floor then rolled her to the right to clean her and afterwards she tried to grab her bed sheets at the foot of her bed. She stated then Resident #1 started shaking and rolled off the bed so she went to get LVN B who came to assess the resident and made sure she was okay. She stated she and LVN B got Resident #1 back to bed and got her dressed then LVN B asked her what happened and she told her she was doing incontinent care and the resident rolled to the floor. She stated Resident #1 was nonverbal but did not appear to be in any pain and her leg was not swollen or in a weird position. She stated she was not sure if the nurse called to have any x-rays done and did not see anyone come out to do x-rays during her shift. She stated there was most likely no x-rays done because the resident was not crying because she checked on her frequently and changed her about four more times that night. Interview on 08/10/24 at 9:09 a.m., LVN B stated she worked the overnight shift and last took care of Resident #1 Last Friday 08/02/24, Tuesday 08/06/24 and Wednesday 08/07/24. She stated yesterday 08/09/24 she heard Resident #1 had a leg fracture. She stated she was very surprised Resident #1 was injured. She stated the DON spoke to her about what she knew about Resident #1's fall on 08/02/24 then the DON told her she should have completed an incident report and called her Doctor. She stated she did a late add nurses note and incident/accident report on 08/09/24 per the DON's request. She stated last Friday 08/02/24 after meal service, after 11:00 pm she was at the nurses' station and CNA A stood at Resident #1's room door calling her name out loud about needing help putting Resident #1 back to bed. She stated she saw Resident #1 in her room and her bed was in the lowest position and Resident #1 was on the left side of her bed on the floor. She stated Resident #1 was on her back and her left leg was turned to the left, and her head and buttocks was flat on the floormat, she was on her back. She stated her left leg was paralyzed and for her care they normally used a pillow to prop it in place. She stated when Resident #1 was on the floor her G-tube port was okay and the tubing was still connected to the g-tube pump. She stated there was no pillow under Resident #1's leg and the bed linen and pillow was on her bed. She stated she assessed Resident #1 and did not find anything wrong with her and she had no signs or symptoms of pain, then she CNA A put her back to bed. She stated when she asked CNA A why Resident #1 on the floor, CNA A said she rolled Resident #1 onto the floor to give her incontinent care. She stated CNA A did not say Resident #1 fell but said she guided her to the floormat. She stated if CNA A told her Resident #1 had fallen, she would have reported it to her Doctor. She stated she would have also documented it in Resident #1's nurses notes and completed an incident report and called her family. She stated she would have followed up with her to ensure she was fine and added Resident #1 was on scheduled Tramadol she received at 12:00 am and PRN Tylenol. She stated there was no increase in giving her more pain medications. She stated Resident #1's floor mat next was next to her bed 24/7 and Resident #1 normally did not get care on the floor mat that was why can questioned CNA A about it. She stated there was not anything propping her left leg, she checked on Resident #1 four or five times that night. She stated Resident #1 watched television and slept and she was given her Tramadol at midnight and she was asleep rest of the night. She stated she did not tell the oncoming nurse or the DON about her being on the floor because she got busy and did not suspect anything was wrong. She stated she got busy with taking care of other residents forgot to document at nurses note. She stated there was no swelling or redness of her legs during her 08/02/24 shift. She stated she returned to work Tuesday 08/06/24 the nurse reported Resident #1 had left leg swelling and her Doctor ordered for a doppler study for edema. She stated the doppler study result came back Wednesday 08/07/24 was negative and she faxed that result to her Doctor. She stated there were no new orders and she took a picture of Resident #1's left leg and sent it to her Doctor. She stated she got a call from the DON yesterday 08/09/24 around 4:00 pm and she returned the call around 4:49 pm and the DON told her to come to the facility. She stated a little after 5:00 pm she gave the DON her statement and completed Resident #1's incident report. The DON told her she should have reported this to her and called her Doctor and family. She stated she had the mind to call the DON but forgot and stated if a resident fell and the Doctor, DON or family was not notified could result in delayed injury. She stated that was why she always documented but she forgot to document Resident #1's fall and said after the DON spoke to her, she now knew why she should have completed a nurses note and reported it to her Doctor and family. She stated she thought it was odd Resident #1 was on the floormat. She stated Resident #1 was bed bound with left sided weakness, upper and lower and alert and oriented x1. She stated Resident #1 was not able to express her needs because she was aphasic and knew her name. She stated Resident #1 was able to gesture responses by nodding and shaking her head. She stated the nurses were responsible for ensuring the residents were getting proper care and cleaned and dry and checked every 2 hours. She stated the DON suspended her and CNA A pending the investigation of Resident #1. She stated not reporting something bad could cause the resident to get bruised, get skin tears or injured. Interview on 08/09/24 at 4:45 p.m., The Police Detective stated he visited Resident #1 at the hospital and gathered other information and opened a case to further investigate the circumstances involving Resident #1's leg injury. He stated he had spoken to CNA A who said on 08/02/24 she was cleaning Resident #1 and she turned around then the resident kept rolling and fell out of the bed. He stated CNA A said she asked LVN B to help get Resident #1 off of the floor then LVN B picked up Resident #1 and put her back onto her bed. Police Detective stated as of right now there was no documentation of the resident falling and no one knew what happened to her leg and the resident was not able to say what happened. He stated the Administrator and DON said they just discovered it from CNA A's statement. He stated Resident #1 sustained two fractures of her left tibia and left fibula that was approximately one inch below her knee. He stated Resident #1's roommate said she remembered a nurse and CNA coming in really fast one night but was not able to see or know what happened. He stated he was getting ready to interview LVN B to gather more information. Interview on 08/09/24 at 7:26 p m, the DON stated she received a report on 08/06/24 about Resident #1's left leg appearing shiny and red like she had irritated rash. She stated her Doctor ordered a doppler study of her left leg and the results came back negative. She stated the area on her leg started swelling up more and getting darker red and her Doctor diagnosed her with cellulitis and ordered antibiotics. She stated yesterday 08/08/24 her leg was still looking red and her Doctor ordered an X-ray and the result came back yesterday morning for two fractures of her left tibia and fibula. She stated she was just finding out today 08/09/24 around 4:30 pm Resident #1 fell Friday night on 08/02/24. She stated there were no notes in her medical records and no incident reports. She stated they were currently doing in-service trainings with all staff and doing skin and pain assessments of all the residents. She stated the staff trainings were on notifications to the resident's Doctor and did 1:1 trainings with LVN B and now they were training all staff. She stated it was too early in her investigation and was not sure if Resident #1 was a 1 or 2 person assist for ADL's but said she would follow-up with the surveyor. She stated CNA A said she was doing Resident #1's incontinent care and when she turned to get some linen, Resident #1 rolled out of her bed. She stated CNA A told her that LVN B was alerted and Resident #1 was assessed but there was not any documentation of a nurses note and no notifications to her Doctor. She stated LVN B confirmed everything that happened she went into the room the resident was on the floor, and CNA A explained she had guided the resident to the floor. She stated LVN B said she did a head-to-toe assessment and when asked why she did not document the assessment LVN B said it got so busy and she forgot. The DON stated today 08/09/24 she informed Resident #1's Doctor about Resident #1's fall with injury and he was upset because no one had called him 08/02/24. She stated the Doctor was at the facility visiting patients Monday 08/05/24 and no one told him about this until today. She stated ADON C assessed Resident #1 then she was transferred to the hospital. She stated she spoke to LVN B on 08/09/24 around 4:00 pm she confirmed Resident #1 had fallen on 08/02/24. She stated LVN #1 was suspended. She stated LVN B came to the facility to drop off her statement and said she had not worked in the past two days. She stated Resident #1 was not able to express her needs but was good at communicating by nodding and shaking her head. She stated Resident #1 required the use a wheelchair and was not sure if she could move her legs but was in the process of finding out more. She stated unreported and undocumented falls could have adverse effects because neuro checks needed to be done to monitor if they had a change of mental status, got injured or needed more pain medications. She stated Resident #1 had routine pain medication and since 08/02/24 and she had not had any increased pain. She stated after Resident #1 fell her Doctor should have been called and the fact that CNA A said the resident fell off the bed, LVN B should have called her Doctor for further instructions. She stated the last she heard the hospital were not going to do surgery to repair her left tibia and fibula because of her MS diagnosis. Interview on 08/09/24 at 8:21 p.m., the Administrator stated he found out Resident #1 fell [DATE] and they were currently doing their investigation. He stated today 08/09/24 CNA A said Resident #1 fell last Friday 08/02/24 and that she and LVN B got her back into bed and they suspended her. He stated they called LVN B to tell them her story and she was interviewed then they decided to suspend LVN B pending investigation for not following their events protocol procedure. He stated yesterday 08/08/24 Resident #1 was transferred to the hospital after her x-ray result showed she had fibula and tibia fractures of her left leg. He stated ever since then they were doing employee trainings on reporting events. He stated the DON and ADON were responsible for ensuring the nursing staff were following their protocols. He stated they reviewed all of Resident #1's documentation today and there was not any documentation about her falling. He stated unreported and undocumented falls could cause all kinds of things to happen such as pain, worsening condition, tons of things, no follow up on the resident's status. He stated they spoke to the Medical Director about Resident #1's fall with injury and they planned to continue to do trainings and get statements from the staff. He stated they were reviewing her documents and other residents to protect all the residents and to see if they could do something another way to communicate better. Interview on 08/10/24 at 11:00 a.m., with the Hospital RN stated Resident #1 admitted to the hospital because of a fractured tibia and fibula. She stated she was stable right now and was currently awake but nonverbal and just nodded in agreement to everything and was not good at following commands. She stated Resident #1 did not appear to be in any pain and no surgery was planned yet and they were doing conservative treatments on her. She stated there were no discharge plans at this time and her pain levels were fine but grimaced when providing care then but when still she had no signs or symptoms of pain. She stated she had not been given any pain medications since she admitted on [DATE] but had Doctor orders for Norco for moderate pain. She stated she Resident #1 has Doctor orders for Ativan for anxiety, morphine for severe pain and Tylenol for mild pain/headache. She stated Resident #1 had an immobilizer on her left leg and stated both her arms were contracted (right arm moved a little more and her left arm was more contracted). She stated her left leg was completed contracted and stated she was a 2 person assist because it was hard to turn her because she was very stiff. She stated Resident #1 was given 4 mg. of morphine on 8/8/24 at 10:15 pm in the ER via her G-tube. Interview on 08/11/24 at 1:45 p.m., the DON stated they updated the staff trainings that were conducted by herself and Nursing Supervisors RN G and LVN H. She stated they were reviewing the other resident's records to see if any other residents were affected no other residents were affected. She stated they started notification of changes trainings on 08/09/24. She stated she they started doing Resident's skin and pain assessments on Friday morning of 08/09/24. She stated LVN B said CNA A told her while giving Resident #1 incontinent care CNA A guide rolled the resident to the floor. Interview on 08/11/24 at 2:28 pm, ADON C stated last Tuesday 08/06/24 LVN D reported Resident #1 had redness of her left leg and her Doctor was called and he ordered for her to get a doppler study that came back negative. She stated on Thursday 08/08/24 LVN O reported something was going on with Resident #1's left leg was swollen and the color was reddish and greenish. She stated she assessed Resident #1's left leg and tried to move her leg but when she moved her leg back the resident flinched her leg back. She stated she asked her was she in pain and she moved head but it was not a distinct nod or shake. She stated she asked Resident #1 was her leg in pain and she gestured yes. She stated she was not crying or appeared to be in pain and noticed the upper part of chin had discoloration and swelling from under her kneecap to her lower leg. She stated she notified Resident #1's Doctor herself and he ordered doxycycline, x-ray and lab work and she contacted her FM. She stated when her x-ray results came back showing she had a fractured tibia and fractured fibula shaft, they sent her to the hospital. She stated Resident #1 was a Hoyer lift transfer resident and she was a 1-person physical assist for incontinent care/bed mobility. She stated Resident #1's legs were contracted and a draw pad was needed to reposition her and reason why she always asked for assistance when providing her care. She stated she was a G-tube resident also and normally another staff was needed for ensure the tubing to stayed intact. She stated Resident #1 fell on [DATE] and she did not find out about it until Friday 08/09/24. Interview on 08/11/24 at 4:13 pm, LVN D stated she worked on 08/06/24 around 10:00 am and Resident #1 was not able to speak but could follow verbal commands. She stated on 08/06/24 she was giving her medications through her g-tube and Resident #1 was different and her mood was flat and she asked Resident #1 was she good and she did not nod her head yes like she usually did and she was not her normal self. She stated when she flipped her blanket back, she noticed her knee looked different, both of her legs were contracted, but the lower part of her left knee was swollen and purplish and when she moved her left leg, she pulled it back and guarded with it. She stated Resident #1 was not her regular self she saw the left knee was a little swollen with a little purplish bruise, from her knee to her ankle. She stated she took a picture and sent it to her Doctor because she took Eliquis and was not sure if she had a blood clot of not. She stated her Doctor ordered a doppler study then when she returned to work on 08/09/24 she found Resident #1 was transferred to the hospital because her leg was getting bigger. She stated 911 was called and they took her to the hospital. She stated Resident #1 was supposed to be on her bed for all care needs. She stated if a resident was on the floor mat due to having a guided fall was the same as a fall and the Doctor needed to be called immediately. She stated the Doctor needed to be called for special instructions on what to do, and the nurses were supposed to assess the resident and know the residents blood pressure and vitals and do neuro checks for 72 hours and complete an incident report. She stated Resident #1 was a 2 person assist Hoyer lift resident and 1 person assist for bed mobility and ADL care. She stated Resident #1 used a Geri chair because she could not use a regular chair because she had a stroke affecting her left side and was not able to sit up in a wheelchair. She stated Resident #1 was good following commands but could not speak but she could look at their face and body language for signs of pain. She stated monitoring checks and notifying the next nurse to follow up on the resident monitoring was also needed. She stated if a resident had a fall and it was not reported or documented the resident could get injured more or lose their life. Interview on 08/12/24 at 12:53 pm, MDS Coordinator E, stated Resident #1's ADL status ranged and it depended on if she had any Muscle spasms related to her Multiple Sclerosis disease process. She stated Resident #1's status varied because on some days she was a little more rigid than other days. She stated it was reported on 08/02/24 Resident #1 had a change in position and was assisted to the floor, which was still considered a fall. She stated, 'Oh definitely' LVN B should have called Resident #1's Doctor on 08/02/24, because the Doctor may have wanted to order x-rays and do a follow up visit. She stated the nurses needed to ensure the residents did not have any post injuries at that moment and further down the road. Interview on 08/12/24 at 2:33 pm, Medical Director/Resident #1's Doctor stated he had not received a call from anyone on 08/02/24 or from LVN A about Resident #1 falling. He stated LVN B should have called him for Resident #1's change in condition and completed an incident/accident report. He stated the first question on the incident/accident report asked had the Doctor been notified. He stated the facility wanted the Doctor called for any falls with or without injury, because there could be some reason why the resident fell . He stated if they had a seizure or became dizzy that might qualify for more investigation. He stated the DON notified him on 08/09/24 of Resident #1's fall on 08/02/24 that LVN B found her on the floor and put her back to bed and did not report it to anyone. He stated Resident #1 was bed bound and needed total assist and he wondered how this could have happened. He stated if CNA A and LVN B would have reported Resident #1's fall, she could have been assessed sooner and a follow up visit done with a full investigation of what caused it. He stated Resident #1 could not roll or turnover and had no muscular tone and not able to speak. He stated he wondered how Resident #1 could have fallen out of bed if she was total assist. He stated a guided fall was the same as a fall. He stated after finding out about Resident #1's fall they have had an Ad hoc QAPI Meeting on 08/12/24, to discuss their plan to prevent this from happening again. He stated they started re-educating the staff with various in-service trainings and continue to review their plan and make changes as needed and continue to discuss in their QA meetings. Review of the Facility's Provider Investigation Report dated 08/08/24 revealed on 08/02/24 at 8:00 pm. Alleged Perpetrators: CNA A and LVN B denied the allegation and no witnesses: Assessment: On 08/08/24 at2:11 p.m.by ADON C, indicated Resident #1 was assessed for an injury of unknown origin: Resident lying in bed with head above bed elevated, alert, and able to respond to questions by nodding. Left lower leg swollen warm and painful to touch, venous doppler negative, x-rays confirmed proximal tibial and fibula fracture of left leg. No treatment, resident transferred to the hospital. Provider response: RP, DON Physician notified, X-rays confirmed fracture resident transported to Hospital, satisfaction survey completed, Skin assessment completed on other residents, In services on transfers, bed mobility and Hoyer lifts. In- services on abuse and neglect. Interviews with staff. CNA A and LVN B suspended pending Investigations. Investigation Summary: On 8/2/24 in the PM. C.N.A. was providing incontinent care for Resident #1, Resident #1 rolled to the mat on the floor. C.N.A. notified LVN B. Nurse and C.N.A. assisted resident back to bed. No Documentation or Notification was given on 8/6/24 Nurse noted left leg swelling, Physician ordered a venous doppler. Doppler study had negative result. On 8/8/24 DR notified of doppler result and ordered x ray. X-rays confirmed proximal tibia and fibula shaft fracture. Administrator notified HHSC of injury of unknown origin Resident was transported to Hospital. In-services were started on Abuse, Neglect and Reporting, Transfer, Bed Mobility and Hoyer lifts. Event policy and notification. During interviews it was determined by CNA A, Resident #1 was picked up off the floor on 8/2/24. She stated that Nurse assisted her putting Resident #1 back to bed. LVN B confirmed that she assisted Resident #1 back to bed. LVN B and CNA A were suspended pending investigation. HHSC Investigator entered the building on 8/9/24 at 3:15 pm, HHSC reentered on 8/11/24 lJ was put in place at 5:30 pm. HHSC lowered the IJ 8/12/24 at 7:30 pm. Staff members LVN B and CNA A were terminated. Where others notified: Physician, RP, Ombudsman, Police, HHSC Facility investigation findings: Confirmed Provider action taken post investigation: HHSC onsite 8/09/24, 8/11/24, 8/12/24, Resident returned to facility 8/12/24, In-services on abuse neglect, reporting, Bed mobility and transfer, Events documentation and reporting to appropriate people with evidence based follow up. LVN B and CNA A were suspended and terminated. Record review of : Employee Statements dated 8/8/24, 8/9/24, Safe Survey Resident Interviews dated 8/9/24, Inservice trainings: Abuse and neglect definitions in-service dated 8/8/24, Check offs: Moving/positioning, assisting with dated 8/11/24, 8/12/24, Post Fall Physical Assessment Test dated 8/11/24, 8/12/24, Transfer training and bed mobility dated 8/9/24, Notification of change training dated 8/9/24, Employee Abuse investigation questionnaire dated 8/9/24, LVN B Employee Corrective Action Form suspended dated 8/9/24 and CNA A Employee Corrective Action Form suspended dated 8/9/24. [END] Record review of LVN B's Timesheet printed on 08/09/24 revealed she worked on: 08/02/24 5:45 pm - 7:40 am, 08/06/24 5:30 pm - 7:46 am, 08/07/24 5:26 pm - 7:51 am. Record review of an Article Tibia & Fibula Fracture (Broken Shinbone/Calf Bone) (clevelandclinic.org) last reviewed 06/01/23 revealed, Overview: What are tibia and fibula fractures? Tibia and fibula fractures are two broken bones in your lower leg. Your tibia is your shin bone. Your fibula is your calf bone. Because they're usually caused by major trauma like car accidents or falls, people often break both their tibia and fibula during the same injury. It's rare, but you can fracture one of your tibia or fibula without breaking the other. You might need surgery to repair your bones and physical therapy to regain your ability to move your leg. Record review of the facility's Incident/Accident policy revised July 2017 revealed, Policy statement: All accidents or incidents involving residents .ocurring on our premises shall be investigateed and reported to the Administrator. Policy: 1. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promply initiate and document investigation of teh accident or incident. The following data , as applicable, shall be included on the Report of Incident/Accident form: a The date and time the incident took place .5. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and s [TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Residents #1) of four residents reviewed for elopement. 1. The facility failed to ensure Resident #1who had severe cognitive impairment and lacked safety awareness eloped from the facility on 10/22/23 at 5:53 p.m. and was located by police on 10/24/23 at an unknown location and taken to the hospital for evaluation. 2. The facility failed to assess Resident #1's risk for elopement quarterly according to their policy/procedure. 3. The facility failed to ensure staff were trained and able to demonstrate competency in elopement and supervision. An Immediate Jeopardy was identified on 10/24/23 at 4:02 p.m. While the Immediate Jeopardy was removed on 10/25/23 at 3:45 p.m., the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for severe injury and/or death. Findings included: Review of Resident #1's annual MDS assessment, dated 10/02/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included intracerebral hemorrhage in brain stem (bleeding within the brain a life-threatening type of stroke), seizure disorder, heart failure and encephalopathy (Encephalopathy-a group of conditions that cause brain dysfunction that can appear as confusion, memory loss, and personality changes). The MDS reflected the resident had a BIMS of 3 indicating severe cognitive impairment, occasionally incontinent of bowel/blader, required physical assistance and/or supervision of staff for eating, dressing, personal hygiene, and toileting. Review of Resident #1's care plan edited on 10/06/23 revealed the resident's risk for elopement, was addressed due to new environment, ambulation status, dementia, wandering and a history of elopement on 03/31/23 and 05/10/23 when he exited a window into the fenced and secured courtyard. The care plan addressed the resident's diagnoses of encephalopathy and residing in the Secure Unit due to wandering and poor safety awareness. Interventions included monitoring the resident closely, performing elopement assessments quarterly, quarterly reviews for continued placement on the Secure Unit and reporting exit seeking behaviors to the Administrator, DON, physician, and responsible party. Care plan goals were Resident #1 would not elope from the secured unit and would be safe in the secured unit due to wandering and poor safety awareness. Review of Resident #1's most recent Elopement Evaluations, dated 05/10/23, and 10/09/23 revealed the resident was ambulatory, cognitively impaired, with poor decision-making skills and made statements that he was leaving. The evaluation dated 05/10/23 reflected Resident #1 had broken and climbed out of a window. The evaluations further reflected the resident was at risk for elopement. There was no evidence of a quarterly evaluation being completed in 08/2023. Review of Resident #1's Secure Unit Evaluation dated 03/13/2023 revealed the resident was independently ambulatory, exhibited wandering behavior, had long/short-term memory loss, and cognitive skills for daily decision making were moderately impaired. There were no other Secure Unit Evaluations available. Review of in-service training dated 06/28/23, revealed staff received training related to showers and restroom doors. The training reflected in part All unit doors, outside exit door, outside gates and interior entrance/exit doors should never be left open for any reason except in the case of emergency evacuations. When entering and exiting the unit staff will monitor that no resident leaves unaccompanied and the maglock are energized, and all doors are properly locked. The training did not address exit seeking behaviors, elopement prevention or training to ensure staff were able to demonstrate competency in elopement and supervision. Review of in-service training dated 07/14/23, revealed staff received training related to dementia, with aggressive behaviors. The training did not address exit seeking behaviors, elopement prevention or training to ensure staff were able to demonstrate competency in elopement and supervision. Interview with the Administrator on 10/24/23 at 10:00 a.m., he stated Resident #1 resided on the Secure unit, eloped on the evening of 10/22/23 after dinner and was still missing. The facility's missing resident procedure was implemented and the entire facility inside and outside was searched. Staff also searched the surrounding neighborhood, and the police were notified. The Administrator stated the nurse on duty during the evening of 10/22/23 was passing medications and thought Resident #1 was in the bathroom. Later when she was unable to locate the resident, she contacted the DON and the facility's missing resident procedure was implemented. He stated he theorized Resident #1 exited the secure unit behind a staff who was taking a cart of dirty trays out and the staff did not notice the resident. He stated sometime in May 2023 the resident broke a window on the secure unit, exited the window into the fenced and locked courtyard and was immediately retrieved and brought back inside. The Administrator stated the resident made verbal statements about wanting to leave to the physician, but he had not been aware of the resident making the statements until yesterday (10/23/23) when the physician told him. He further stated staff had reported Resident #1 had exhibited no exiting seeking behaviors. Additionally, the Administrator stated he had verbally instructed staff that there should always be at least one staff in the front area of the Secure Unit (desk or day area close to door) to monitor residents. Interview on 10/24/23 at 10:10 a.m. the SW stated after Resident #1's attempted elopement in May 2023 she attempted to have the resident admitted /evaluated at an in-patient psychiatric setting, but she was not able to because the facility she contacted was full. She stated she had checked on the resident daily but did not say how long the daily checks lasted. The SW stated the resident had been stable and had made no other attempts to elope from the facility prior to 10/22/23. Interview on 10/24/23 at 10:13 a.m. the DON stated after Resident #1 attempted to elopement in May 2023, the resident was placed on every 15-miniute checks for a few days until the facility was comfortable the resident would not attempt to elope. The DON stated there had been no formal training provided related to one staff staying in the front area, near the exit doors in the secure unit and she did not have any documentation of the verbal instructions provided to staff. The DON stated she would check for any documented training related to elopement prevention. The DON further stated in-service training had been in progress since Monday but not all staff had received the training yet. Observation on 10/24/23 at 10:30 a.m., revealed staff on the Secure Unit consisted of one licensed nurse and two CNAs who were all in the front area of the unit interacting with five residents. Interview with LVN A on 10/24/23 at 10:30 a.m., revealed the nurse was not on duty when Resident #1 eloped. LVN A stated he recalled receiving some type of in-service training approximately one year ago related to not providing the door code to anyone who did not work at the facility, making sure the door closed/locked when entering/exiting the unit and making sure no residents followed him out. He stated he was aware that there should always be at least one staff in the front area of the unit, at the desk or in day area near the exit doors at all times. LVN A stated he was not aware of Resident #1 exhibiting any exit seeking behaviors, but the resident would wander around on the unit. He never heard the resident say anything about leaving. Interview on 10/24/23 at 10:34 a.m. CNA B stated she was not on duty when Resident #1 eloped. She stated she recalled receiving training related to not providing the door code to anyone who did not work at the facility, making sure the door closed/locked when entering/exiting the unit and making sure no residents followed her out. CNA B was unable to recall when she had received the training. She was not aware of Resident #1 exhibiting any exit seeking behaviors, but he did wander around the unit. Interview on 10/24/23 at 10:38 a.m., CNA C stated she was not on duty when Resident #1 eloped. She stated she recalled receiving training related to not providing the door code to anyone who did not work at the facility, making sure the door closed/locked when entering/exiting the unit and making sure no residents followed her out. CNA C was unable to recall when she had received the training. She stated she was not aware of Resident #1 exhibiting any exit seeking behaviors, but he did wander around on the unit. Interview on 10/24/23 at 11:05 a.m., the Administrator stated he had reviewed the camera footage and observed Resident #1 exiting the front door of the facility at 5:53 p.m. He stated he did not see the resident cross the street (a busy 4 lane road). He stated the front door to the facility and back door to smoking area are not locked. Interview on 10/24/23 at 11:44 a.m., the DON stated nurses were responsible for completing quarterly elopement evaluations. She stated she had a main screen on her computer that let her know what elopement evaluations were coming due and which ones were overdue. The DON stated she was in the process of rescheduling and completing assessments as they had not been scheduled appropriately. She further stated she had overlooked Resident #1's overdue quarterly elopement evaluation. Interview on 10/24/23 at 12:15 p.m. the Administrator stated the delay on the Secure Unit door lock had a 5 second delay on exiting and a 3 second delay on entering and that may have contributed to Resident #1's elopement. He stated the delay had been reset so that the lock delay was 3 seconds on entering and exiting. Interview on 10/24/23 at 12:26 p.m., the DON stated interventions to address Resident #1's elopement included staff performing a head count on the Secure Unit three times a day, after each meal and at midnight. Interview on 10/24/23 at 1:30 p.m. CNA D stated she was on duty during the evening shift on 10/22/23 when Resident #1 eloped. She stated the last time she recalled seeing the resident was at approximately 5:00 p.m. eating dinner in the day area. She stated sometime after dinner she took the cart (she was unable to recall what time) with dirty dinner trays out of the unit. She stated she usually checked the door to make sure it locked or listened for the latch to lock when she exited. CNA D stated she did not do either on the evening of 10/22/23 and does not know why, she just forgot. She did not see the resident after she returned from dropping off the tray cart. Sometime after LVN F arrived on duty at approximately 7:40 p.m. the nurse told her she was unable to find Resident #1 and all staff began a search. She further stated the resident would occasionally stand near the exit door but was easily redirected. CNA D stated she did not know if any staff had been in the front area of the Secure Unit during the time she left with the trays. Additionally, she stated she had received training related to working on the unit but was unable to recall when she received the training. Interview on 10/24/23 at 1:56 p.m., LVN E stated when Resident #1 eloped on 10/22/23 she was scheduled to work the day shift from 6:00 a.m. to 6:00 p.m. but stayed late to cover for the oncoming nurse (LVN F) who arrived late at approximately 7:30 p.m. She was dancing with Resident #1 after dinner at approximately 5:45 p.m. and did not recall seeing CNA D leave the unit with the tray cart. The last time she saw the resident was shortly after dancing with him and he was going down the hallway away from the exit door. She stated she then went to assist another resident in their room and recalled Hospitality Aide G was in the day area with other residents. LVN E stated she was aware and had received training in the past that there must be someone in the front area of the secure unit at all times. She further stated Resident #1 had exhibited no exit seeking behaviors. Interview on 10/24/23 at 2:19 p.m., LVN F stated she did not normally work on the Secure Unit, and when Resident #1 eloped on 10/22/23 she was the night shift nurse scheduled to work from 6:00 p.m. to 6:00 a.m. She arrived late to work at approximately 7:40 p.m. and after receiving report she was immediately on the floor making rounds and passing medications. She stated she noticed Resident #1 was not in his room for medications and assumed he was in the bathroom. After completing the medication pass, she returned to the resident's room and discovered she was unable to locate him. The nurse checked with the CNA and Hospitality Aide to see if they were providing the resident with a shower, and they told her no shower was being provided. The nurse stated after she was unable to locate the resident, she called LVN E to see if Resident #1 had gone out with family. LVN E told her the resident had not gone out and was on the unit. LVN F stated she followed the facility's missing resident protocol to include notifying the DON, police, and family. Facility staff searched inside, outside and in the surrounding vicinity but were unable to locate Resident #1. LVN F stated she had not observed the resident exhibit any exit seeking behaviors. She stated she had received training related to working in the secured unit and had worked in many secured units during her career. She was aware not to share the code to the secure unit door, check the surrounding environment when entering and exiting the unit to see if a resident was close by. Interview on 10/24/23 at 2:35 p.m., Hospitality Aide G stated she was on duty 10/22/23 during the evening shift when Resident #1 eloped. She stated she was assigned to the resident and the last time she saw him was at approximately 5:45 p.m. in the day area with LVN E. After that she was assisting another resident in their room. At approximately 8:00 p.m. CNA D asked her if she had seen the resident they began searching for the resident and was unable to locate him. She stated Resident #1 liked to stand next to the door, but she would talk to him and get him to do something else. She stated she had received training about always checking to make sure no resident was behind her when leaving the unit, someone should always be in the front area near the door and not all staff in resident rooms at same time. Hospitality Aide G was unable to recall when she had received the training. Interview on 10/25/23 at 9:40 a.m. the Administrator stated Resident #1 had been located by police on 10/24/23. He did not know any specifics but stated the resident was not harmed or injured and had been taken to the hospital by police as a precaution. He further stated the DON was out for the day. Interview on 10/25/23 at 11:28 a.m. the facility's Clinical Resource Nurse stated Secure Unit Evaluations were to be completed quarterly and along with elopement evaluations helped determine a resident's risk for elopement. All residents in the Secure Unit had updated and current Secure Unit evaluations completed since the facility's policy was to complete the evaluations on admission and quarterly. She stated the Secure Unit evaluations had not been consistently completed for residents in the unit. She further stated the DON had been in the process of completing/updating the evaluations possibly because she (the DON) had determined they had not been done. Interview on 10/25/23 at 11:41 a.m. the ADON stated she was only able to locate one Secure Unit Evaluation for Resident #1 dated 03/13/23. She stated nurses were responsible for completing the evaluations quarterly. Interview on 10/25/23 at 11:58 a.m., Resident #1's physician stated Resident #1's verbalizations related to going home were episodic and not necessarily a threat to elope, but just a statement that he wanted to be with his family. The physician stated he was not aware of the resident exhibiting any exit seeking behaviors. Interventions to address a resident with exit seeking behaviors could include redirection and psychiatric evaluations. His expectation would be that staff made room checks throughout their shifts. Interview on 10/25/23 at 3:54 p.m. the Administrator stated it was important to address exiting seeking behaviors to ensure residents received appropriate care that could include medication adjustments and/or psychiatric evaluations. The Administrator stated cognitive residents at risk for elopement could elope and get hurt. Review of the facility's P/P entitled Wandering and Elopements revised 05/15/23 revealed Policy Statement: The center will identify residents who are at risk for unsafe wandering and/or elopement. The center will strive to prevent harm while maintaining the least restrictive environment for residents. Review of the facility's P/P entitled Secure Unit Overview revised 03/18/23 revealed Purpose: The Secure Unit is designed to provide a holistic approach of care for the resident with cognitive impairment and with exit-seeking behaviors. The P/P reflected Resident assessments would be completed by the interdisciplinary team prior to admission to the Secured Unit, quarterly and with significant change in condition. An Immediate Jeopardy was identified on 10/24/23 at 4:02 p.m. and the Administrator was informed of an IJ in the area of accidents/supervision. The IJ template was provided via email on 10/24/23 at 4:02 p.m. The facility's Plan of Removal was accepted on 10/25/23 at 11:18 a.m. and reflected: Plan of Removal: 689: Free of Accidents Hazards, and Supervision/Devices (Immediate) Action: Searched for Resident # I inside and outside the building. Called a Code Pink. Notified the Administrator, Police, Notified MD, and Responsible Party. Continue to search for the missing resident and work with the local police department (called local hospitals/ERs/bus station/ homeless [NAME]/ gas stations and businesses around [NAME] Nursing and Rehab). Checked all doors/gates for the secured unit and ensured they were secured. Person(s) Responsible: Charge Nurse, Director of Nursing, and Administrator Date: 10/22/2023 by 10PM (Identification) Action: Resident head count performed with all residents residing at [NAME] Nursing and Rehabilitation. No other missing residents identified. Person(s) Responsible: Charge Nurse Date: I0/22/2023 by 10PM (Identification) Action: Elopement assessment performed on all residents at [Facility Name] Any residents residing on the secured unit have elopement assessment, secured unit assessment, orders, consent and care plans in place. Person(s) Responsible: Director of Nursing Date: 10/23/2023 by 10PM (Prevention) Action: Education provided to all staff including-Elopement & Missing Resident Policy Ensuring the secured unit door is shut and latched prior to walking away from the unit doors. Reporting residents voicing 'they want to leave to Charge Nurse and Administrator. All staff will be educated prior to working their next shift. All new staff will be educated prior to working their first shift. Person(s) Responsible: Administrator, Director of Nursing, and /or Designee Date: I 0 /23 /2023 by 10PM (Prevention) Action: Maintenance Director worked with the door latch to ensure it ''latches quickly enough (3 seconds) and stays secured'' once shut. Sign placed on unit doors (coming in and going out) stating-Please ensure the door latches prior to walking away. Person(s): Maintenance Director Date: l 0/23/2023 by 4:45PM Action: Ad Hoc QAPl performed by center IDT and Medical Director to inform him of the incident and our plan in place. Person(s) Responsible: Administrator Date: 10/23/2023 by 2PM. Review of in-service training records to include attendance records, instruction topics and competency questions dated 10/22/23 and 10/23/23 revealed education included performing head counts, checking to ensure Secure Unit door latched after exiting and before walking away, three second door lock delay, being aware of surroundings at all times, reporting resident verbalizations of wanting to leave. Interviews were conducted with facility staff across multiple shifts on 10/25/23 from 12:44 p.m. to 1:25 p.m. and form 2:39 p.m. to 3:43 p.m. Staff interviewed were Housekeeping Staff H, Housekeeping Staff I, Activity Director, LVN A, CNA B, LVN F, CNA J, CNA K, CNA L, Dietary Staff M, LVN N, CNA O, CNA P, CNA Q and Dietary Manager. Staff verbalized comprehension of the in-service training provided to include monitoring the Secure Unit door when entering/exiting, ensuring at least one staff remains in front area of unit at all times and reporting to Administrator and/or DON of residents exhibiting exit seeking behaviors. The Administrator was notified on 10/25/23 at 3:45 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two of two residents (Residents #1 and #2) reviewed for supervision. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility unsupervised. Resident #1 had moderately cognitive impairment, wandering behavior, and lacked safety awareness. Resident #1 eloped from the facility walking to the local pharmacy that was 150 yards away and located on a busy street, the temperture ranged from 48 degrees to 64 degress, and asked to call 911, on 01/08/22 and was brought back to the facility by the emergency services. 2. The facility failed to ensure Resident #2 was adequately supervised to prevent her from leaving the facility unsupervised. Resident #2 had severe cognitive impairment, wandering behavior, and lacked safety awareness. Resident #2 eloped from the facility and walked to a local health care clinic and asked to call her daughter, the medical clinic called 911 and the police brought Resident #2 back to the facility. 3. The facility failed to ensure staff were trained and able to demonstrate competency on elopement and supervision. An Immediate Jeopardy (IJ) was identified on 03/2/22 at 5:00 p.m.The findings support an IJ that was in the past from 1/6/22 to 1/12/22., the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme weather exposure. Findings included: 1. Record review of Resident #1's quarterly MDS assessment, dated 02/17/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included intellectual disabilities, cognitive communication (unable to communicate effective), cardiac arrhythmia (unstable heart rate), and [CONDITION(S)] (kidney do not function appropriately). The cognitive section of the MDS indicated Resident #1 had moderate cognitive impairment. He had symptoms of [CONDITION(S)], which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, no [CONDITION(S)], and no wandering behavior. He had an unsteady gait. Record review of Resident #1's care plan reflected a problem identified as falls, safety, elopement risk initiated on 03/02/22 which reflected, [Resident #1] was appropriate for placement in the secured unit .cognitive deficits and high risk for elopement There were no initial interventions on the care plan, dated 06/12/22, for elopement risk and exist seeking behavior. Record review of Resident #1's Elopement Risk Assessment, dated 06/12/21, completed by Agency nurse A reflected Resident #1 was admitted for behavior management, was aware of his surrounding, had safe decision-making capabilities, did not have a history of wandering, had not attempted to leave the building. Record review of Resident #1's quarterly elopement risk evaluation, dated 11/17/21, completed by LVN B reflected the resident was not an elopement risk. Further review of the elopement risk assessments for Resident #1 reflected was no elopement risk assessment after the elopement on 01/08/22. Record review of Resident #1's Resident Progress notes by LVN D, reflected she completed note on 01/10/22 for incident that took place on 01/08/22: resident kept walking around the facility, then left the facility, went to the pharmacy and asked for a phone, the resident used the phone to call 911 ambulance, he was transported back to the facility because he was stable. Resident called the police after the paramedics left stating that he had been forced to isolate himself and he does not have Covid19. A police officer came to the building spoke with the resident. This writer called resident [family member] after the police left to inform him about the resident refusing the positive test and that he called 911 ambulance and police An observation on 03/01/22 at 11:00 a.m. revealed Resident #1 in the secured unit sitting at a dining table drinking a cup of coffee. Resident #1 was well dressed and appeared in no ditress, he said he like it here and he was happy. When Resdient #1 was asked if he recalled the incident that occurred, he did not reply. In an interview on 03/02/22 at 10:20 a.m. with the Social Worker revealed she had a care plan meeting with the responsible party for Resident #1 on 01/05/22 and there was mention of the resident had a few behavioral issues; likes to do whatever he wants to do and when he was mad, he acted out and the responsible party was made aware about the facility redirecting him. The SW was ask to explain this and she said, she had made the responsible party aware of his exit seeking behavior when he got mad and how we are always redirecting him. The SW was asked who else was in that meeting, she said she completed this one on the phone herself and could recall who else was with her. Interview on 03/01/22 at 10:40 a.m. with CNA C revealed Resident #1 was exit seeking since he admitted to the facility. CNA C said he would get mad and then threatened to leave and the resident would have to be redirected. CNA C said Resident #1 was sometimes easily redirected and other times it was harder, but she was always able to keep him inside. CNA C said there was no need to report Resident #1's wandering behavior because everyone who worked on his hallway knew about it. CNA C said she was not surprised when she heard Resident #1 had left the facility, he always talked about leaving. CNA C said she was working the day she heard Resident #1 left the facility but she did not know he was gone. The CNA stated if everyone didn't know about the residents behaviors, she would tell the charge nurse. Interview on 03/01/22 at 2:36 p.m. with LVN D revealed she was the nurse in charge on the 6:00 a.m. til 6:00 p.m. shift, when Resident #1 had eloped from the facility. LVN D said she was unaware he was gone or how long he was gone she just knew it was somtime after lunch, until emergency services brought him back. This event occurred on 01/08/22. LVN D said Resident #1 had come up to the nurse's station and he was mad that day because he had been tested for COVID-19 and was positive. He said she had given it to him when she tested him. LVN D said when emergency services brought him back he was no injured, she was told Resident #1 walked into the local pharmacy wanting to use the phone to call 911, he told the local pharmacy he had COVID-19. LVN D said emergency services had taken the chance to see if he lived at the facility, because he could not tell them where he was from or where he lived. LVN D said Resident #1 was always trying to leave the facility. LVN D said when emergency services brought the resident back to the facility she tried to place Resident #1 on the secured unit, but he refused to go. LVN D said she placed Resident #1 back in his room, told him he had to stay in his room, and continued to monitor him. LVN D said Resident #1 called the police and told them he was being forced to isolate and he did not have COVID-19. A police officer went out to the facility and spoke with him, she called the responsible party to tell them, but they said they did not care what he did or how the facility handled him. LVN D stated she monitored the resident for the rest of her shift and then told the oncoming charge nurse about what had happened. LVN D said she reported the elopement to the DON and the Administrator knew. LVN D said the policy regarding a resident who eloped was staff were to search for the resident and notify the Administrator, DON, family and once the resident was found staff document it in the progress notes and inform the Administrator, DON, and family. LVN D said she notified the DON, Administrator, and the family when Resident #1 returned to the facility. LVN D she said she could not recall if she notified the physician. LVN D said when she had returned to work (01/12/22) Resident #1 was on the secured unit. Attempts were made to contact the (Agency) charge nurse for 01/08/22 on 03/01/22 at 3:35 p.m. and was informed the nurse no longer worked for the Agency. Interview on 03/02/2022 at 10:20 a.m. with the Social Worker revealed she was very familiar with Resident #1. The Social Worker said Resident #1 had attention seeking behavior, which included exit seeking. The Social Worker said the resident had been placed on the secured unit on 01/12/22 because he kept trying to leave the facility on 01/12/22 The Social Worker stated he had to chase the resident and bring him back multiple times. The Social Worker stated she was not aware of Resident #1 leaving the facility any other time before 01/12/22. Interview on 03/02/22 at 10:44 a.m. with LVN E revealed Resident #1 was attention seeking and always tried to leave. LVN E said Resident #1 had to be monitored, because he was always getting mad and said he was going to leave. LVN E stated she did not report the residents exit seeking behavior to anyone and everyone knew about his behavior. LVN E stated there wasn't any place to document the residents wandering exit seeking behaviors in the nurse's notes. LVN E stated she was aware of Resident #1 leaving the facility. She stated she was working the day he left on 01/12/22, he left two times that day, once in the morning out of the side door into the back lot going towards the woods the SW followed him out and walked with him and sat with him outside for about 20 mins and then he came back in and once in the afternoon, when he left out of the front door and the BOM followed him out and [NAME] him to come back in. She stated she reported to the DON and now he was on the secure unit. LVN E said she had heard something about him leaving the facility prior but was unsure of when it was. LVN E said staff document in the nurses progress notes what was occurring. LVN E said the SW had called the responsible party and had been told that they really did not care what the facility did with him, I called the physician to let him know he was leaving, I had left a message, the staff continued to monitor him. Interview on 03/02/22 at 11:14 a.m. with the Business Office Manager revealed Resident #1 had been very agitated on 01/12/22 and had left the faciity on other time that day, all staff watched him, and she saw him go out of the facility and go towards the [NAME] area next to the facility, she went outside and told him to come back in and he did. On that day he was placed on the secured unit. The BOM stated Resident #1 had not left the facility like that before, but he always tried to especially when he got upset, but he has never left before, the staff all knew him and tried to redirect him. The BOM manager said he was placed on the secured unit after she brought him back in. Interview on 03/02/22 at 11:18 a.m. with the Administrator revealed step by step what the staff was supposed to take if a resident was exit seeking and what they were to do if a resident left the facility: 1. If the resident was exit seeking the staff should redirect and report to the Administrator, DON, and physician. 2. The resident should be assessed for exit seeking behavior. 3. If the resident qualified then the resident should be placed on the secured unit. The Administrator said that if it was a one time occurrence for the resident, they might not qualify and other interventions might be taken. 4. If the resident did not qualify for placement on the secured unit, other alternatives could be considered; labs, and medications adjustments. 5. If the resident left the facility, they were to initiate the elopement policy and procedure; searching, notifying Administrator, DON, physician police, and family 6. When the resident was located the nurse was to notify the Administrator, DON, physician, and family. The nurse was to document in the progress notes, fill out an incident accident report and complete a new elopement risk assessment. 7. The resident would then go through the process of placement on the secured unit or transferred if there was no space available on the secured unit. During this interview the Administrator said Resident #1 never has eloped from the facility. Resident #1 was exit seeking one time and he was placed on the secured unit. The Administrator said Resident #1 was the type of resident who would get mad and threaten to leave, but he had only been exit seeking that one time and had never left the facility before. The Administrator stated she had no idea the resident eloped on 01/08/22. The Administrator said no one had reported the incident to her like they should have when it happened and this was her first time hearing about it. The Administrator stated her staff had not reported to her that Resident #1 was exit seeking all the time and they were consistently redirecting him. The Administrator stated she learned of incidents/accidents that occurred in the facility in the morning stand up meeting everything that had occurred over night or from the previous day should be discussed. If something occurred over the weekend she should be notified. The Administrator said the staff did not follow the steps she had listed above or she would have been aware of his elopement and his behaviors getting worse or this would possible not have happened. Interview on 03/03/22 at 11:00 a.m. with the Medical Director revealed he was aware of Resident #1's elopement from the facility now, the facility informed me of the elopement on 01/08/22 last night. He was aware the resident was on the secured unit, but he thought it was because he had tried to leave the facility on 01/12/22. No one had informed him Resident #1 tried to leave before that. The Medical Director stated he had not been informed in the past by the staff that Resident #1 was always tried to leave he would have placed him on the unit sooner. The MD said that placing Resident #1 on the secured unit was the best intervention for him. In an interview on 03/01/22 at 3:10 p.m. with LVN D to clarify her Nursing progress note dated 01/08/22. LVN D said she had completed a late entry because she had to enter more information for that date. LVN D said the paramedics had told her what had happened when they brought Resident #1 back to the facility. LVN D said the emergency services told her he could not tell them where he came from, so they took a chance and brought him back to the facility. LVN D said she guessed she forgot to document who she notified, it was a very chaotic day. LVN D said she did update any assessments, regarding the elopement risk assessment. 2. Record review of Resident #2's admission MDS assessment, dated 12/23/21, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, [CONDITION(S)] (brain disorder, mental illness), unspecified dementia with behavioral disturbances (confusion with behaviors), delusional disorder (unorganized, unrealistic thinking), memory deficit following intracranial bleed (brain bleed), and auditory hallucinations (hearing voices). The cognitive section of the MDS indicated Resident #2 had severe cognitive impairment and could not express her wants and needs. She had symptoms of [CONDITION(S)], which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, hallucinations, delusions, no [CONDITION(S)], and no wandering behavior. She had an unsteady slow gait. Record review of Resident #2's care plan reflected, there were no concerns or interventions on the care plan dated 12/22/22 for elopement risk and exist seeking behavior. Record review of Resident #2's Elopement Risk Assessment, dated 12/16/21, completed by LVN B reflected Resident #2 was a new admission, was ambulatory, was not cognitively impaired, did not have poor decision-making skills, and/or pertinent diagnosis (dementia, organic brain syndrome, Alzheimer's, delusions, hallucination, anxiety disorder, depression, manic depression and [CONDITION(S)].) and the area for documentation to assess does the resident exhibit wandering, was not completed. Record review of Resident #2's history and physical, dated 12/16/21, reflected Resident #2 was unable to offer a chief complaint due to cognitive deficits, dementia . Record review of Resident #2's elopement self-report incident, regarding the self-report on 01/06/22, revealed the resident left the facility and was returned by the police on 01/06/22 around lunchtime. EMS was called due to the resident saying she had heart vibrations, the assessment by 911 revealed no treatment necessary and the resident remained at the facility. Record review of the Nursing Rehab and Action plan, dated 01/06/22, reflected Resident #2 .eloped on 01/06/22 at 12:00 p.m. returned to the facility 01/06/22 at 12:40 p.m. via police transport. Corrective action interview: staff working shifts during time of elopement . Interview on 03/01/22 at 10:40 a.m. with CNA C revealed she had assisted Resident #2, and she had been exit seeking since the time of admission, the resident always told her she heard voices in her head and the voices told her what to do. CNA C said Resident #2 would wander up and down the hallways going to the doors and talked about leaving and calling her daughter, we would just redirect her. She was easy to redirect, but she had no idea she had left the day the police had brought her back. CNA C said the staff was servicing lunch and one of the staff members said the resident was not around, the staff started looking, but by that time the police had come in with her. CNA C said she had heard Resident #2 had said she went out the door by the television room, but she did not know if that was true. The CNA stated no one asked her when she last saw the resident. Interview on 03/01/22 at 11:15 a.m. with LVN F revealed she usually worked on the secured unit, but she did know Resident #2 eloped from the facility. LVN F said the resident was exit seeking and she had no idea how she had left the facility. LVN F said since she normally worked on the secured unit, she was not aware if the Administration had known about the residents exit seeking behaviors and she did not say anything. Interview on 03/01/22 at 1:45 p.m. with CNA I revealed she only worked on the secured unit, but she did know Resident #2, she never lived on the secured unit. The CNA said she worked the day the resident left the facility. The police brought her back. CNA I said the resident had been exit seeking in the past, she stated she never took care of her, but she had redirected her and told the nurse about it. The CNA said the nurse she told was an Agency nurse, but the other staff knew also. The CNA could not recall what day she had told the Agency nurse and she did not know her name. Interview on 03/01/22 at 1:55 p.m. with CNA J revealed they did not know anything about Resident #2. The CNA said if the resident had exit seeking behavior, they would have told the nurse. The CNA stated they did not remember if they worked on the day Resident #2 eloped from the facility. Interview on 03/01/22 at 2:36 p.m. with LVN D revealed she had been the charge nurse for Resident #2 several time. LVN D said the resident would wander up and down the hallways and would go to the doorway, but the CNAs would redirect her. LVN D stated she did not reassess Resident# 2's wandering behavior because she never thought about it. LVN stated she kept trying to keep the resident safe and since the resident had not been at the facility that long she thought the resident might settle down. LVN D said she guessed she did not settle down, since she left the facility. When LVN D was ask if a resident exhibits increased exit seeking behavior what is she supposed to do, LVN D said she would monitor them closely. Interview on 03/02/22 at 10:44 a.m. with LVN E revealed she was not working the day Resident #2 had left the facility, but she had been the charge nurse for Resident #2 prior to her elopement. The LVN said Resident #2 was very psychologically impaired, and she walked all the time around the facility and asked where her daughter was. The resident was exit seeking but would listen to the nursing staff for redirection. LVN E said she would have done well in the secured unit and was not sure why she had not been placed on the unit. LVN E stated she talked to the Social Worker about considering the resident for placement prior to her elopement. LVN E said she had completed the resident's skin assessment and she had called the family because Resident #2 was so delusional and hallucinogenic. LVN E said the family member had shared with her Resident #2 had been that way for a very long time and had seen a psychiatrist for her behaviors. The LVN said the family member had said Resident #2 had begun to leave the house, let strangers in the house and let the dogs out in the neighborhood while she (family) was at work. The family member told LVN, that she just could not care for Resident #2 anymore and had been recommended to the facility by one of the psych hospitals. Interview on 03/02/22 at 11:00 a.m. with the Social Worker revealed she had been made aware of the delusional behavior of Resident #2 and she had attempted to assess her. The Social Worker stated she was unable to assess her due to her hearing voices in her head, she reported all this to the Administrator, and she called the Psych care services. The Social Worker stated she was not made aware the resident had been leaving her daughter's house and wandered around. The Social Worker stated if she had been told she would have reported it to the Administrator and DON. The DON and Administrator would decide the interventions for the resident. Interview on 03/04/22 at 4:00 p.m. with the Administrator revealed she was at the facility when the elopement happened. The resident sat in her office for about 2 hours before she went to her room to lay down. The Administrator stated she did not know how long the resident had been gone. The Administrator said she did not have any interviews with staff that had seen her leave, because no one saw her leave. The Administrator said she was surprised when the police brought her back and was very glad the resident was not injured. The Administrator said she felt the failure related to the elopements was due to agency staff, communication, and the staff that was at the facility had become complacent with the resident's behaviors. The Administrator stated she had no monitoring for the rehab action plan, and she had no interviews to determine the timeline and she was unclear on how the DON had come up with the time the resident left and the time she was returned. An interview with the previous DON was attempted on 03/02/22 at 9:13 a.m. and 2:00 p.m., messages were left and a return call was not received. Record review of the in-service training dated 01/06/22, at the time of Resident #2's elopement reflected training for: abuse, elopement policy, and neglect. There was no elopement drill training. Further review of the trainings reflected no monitoring tool to assess the knowledge of the staff following the in-service given on 01/06/22 concerning reassessment for placement for wandering and exit seeking, who to communicate the change in condition, and the appropriate places to document the behaviors. Record review of the facility's Policy and Procedure Wandering and Elopements, dated March 2019, reflected The facility will identify residents who are at risk of unsafe wandering . if identified as at risk for wandering, elopement . the resident's care plan will include strategies and interventions to maintain the residents' s safety .if an employee observes a resident leaving the premises he/she should: attempt to prevent the resident form leaving, get help form another staff members, .inform the charge nurse or Director of Nursing Services that a resident is attempting to leave .When the resident returns to the facility the Director of Nursing Services or charge nurse: . Complete and file and incident report . Record review of the facility's Policy and Procedure Accidents and Incidents, dated July 2017, reflected, All accidents and incidents involving residents . occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The nurse Supervisor/charge nurse and/or the department director or supervisor shall promptly initiate the document investigation of the accident or incident .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 .7. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the center and the analyze any individual resident vulnerabilities. This was determined to be an Immediate Jeopardy on 03/02/22 at 5:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 03/02/22 at 5:00 p.m. The following plan of removal submitted by the facility was accepted on 03/04/22 at 12:20 p.m.: Plan of Removal 3/04/22 Identified alleged deficient practice: QOC: Resident Elopement Facility Action: [Resident #2] Resident eloped 1/6/2022 and brought back by police on 1/6/2022, resident was next door at the apartment complex (did not cross the street). Resident immediately placed on 1:1 until discharge (1/6/2022, date of elopement, -1/7/2022, date of discharge to a secured building/unit) Resident's elopement assessment was updated 1/6/2022, incident and accident completed 1/6/2022 In-services began/completed over the elopement policy and abuse/neglect 1/6/2022. Post actions missing: ensure staff understanding of appropriate actions/steps regarding exit seeking residents. [Resident #1] Resident eloped 1/8/2022 and returned 1/8/2022 via EMS, resident was caddy corner at the [pharmacy] (did not cross the street). Nurse put interventions in place on 1/8/2022. Resident was placed on the secured unit when resident was redirected by staff back into the facility on [DATE]. Post actions missing: Failed to report to administrator regarding the elopement on 01/08/2022, elopement assessment performed, incident and accident performed In-services completed over the elopement policy 3/1/2022 and will continue until 100% compliant, all staff shall be in-serviced prior to next shift. Staff will be in-serviced by, Administrator, DON, or designee. Additional training initiated 3/3/2022 includes, identifying and preventing elopements, steps to take during elopements, and actions to take post elopements. This training will be completed on 3/3/2022. Test to ensure competency regarding identifying and preventing of elopements, steps to take during elopements, and actions to take post elopements began 3/1/2022 and will continue until 100% compliant, staff shall test prior to next shift. Test shall be completed on 3/3/2022. Test will be proctored by Administrator, DON, or designee. Elopement assessments performed by, RN, Interim DON, throughout the center (all residents) completed 3/2/2022 prior to 12pm. Elopement assessments can be found in the residents' medical record located in Matrix, under observations. No residents were identified as elopement risks during audit that did not reside on the secured unit. *** Ad hoc QAPI performed with Medical Director on 3/2/2022. Doctor was notified of the immediate jeopardy, informed of the steps the facility is taking (education mentioned above, testing to ensure competency, audits, and elopement assessment updates). Ensure staff's understanding on when and who to report to regarding elopements via education of the abuse policy, provider letter 19-7, and abuse coordinator reminder began on 3/2/2022 @ 12pm and to continue until 100% compliant, staff shall test prior to next shift. Staff will be in-serviced by Administrator, DON, or designee. Training to be completed by 3/3/2022. Test to ensure competency regarding reporting of missing resident/elopement began on 3/2/2022 @ 12pm and will continue until 100% compliant, all staff shall test prior to next shift. Test shall be completed on 3/3/2022. Test will be proctored by Administrator, DON, or designee. Nurses will be in-serviced on identifying and preventing elopements, steps to take during elopements, and actions to take post an elopement-this will include post actions such as: Incident and accident report, informing the administrator/DON, performing an elopement assessment starting on 3/3/2022 and to be completed on 3/3/2022 Administrator, RN, DON, and/or designee will track employees on leave and agency staff and ensure they are educated and tested prior to their next shift. Posted, at nurses' stations and time clock, step by step directions to follow if an elopement or missing resident was to occur and behaviors to look for on 3/2/2022 @ 11am. Resident #2 alleged elopement/missing resident reported to HHSC on 3/2/2022 @ 1:36pm. New hires will be in-serviced upon performing new hire paperwork/completing other required education, BOM, RN, DON, Administrator, or designee will be responsible for this education. Education provided to the Department Heads by, Administrator, to ensure they understand they will check with the nurses on Saturdays and Sundays-- did an elopement occur, was it reported to Administrator, and/or, RN, DON, did the incident and accident get completed, and did the elopement assessment get competed. Department Heads will report to Administrator, via email post each Manager on Duty shift. Education will be completed on 3/3/2022. All designees assisting with training and testing were training by Administrator and Vice President of Operations on 3/3/2022 and as needed. Identified Residents at Risk: Residents identified as elopement risks through the elopement assessments performed by RN, (bullet point #3 above) that do not reside on the secured unit. Audit resulted in no residents found. Systematic Change: All residents shall have an elopement assessment performed upon admission, quarterly, and as needed. This will be audited for compliance by RN, DON, Administrator, or designee, weekly. New admission/readmission will be audited the next clinical meeting, post admission. Any missing assessments will be corrected upon discovery and results will be shared in monthly QAPI meetings. During clinical meetings, M-F, and Manager on Duty report, over the weekends, Administrator, RN, DON, or Department Head designee will check with nurses x7 days a week, did an elopement occur, was it reported to Administrator, and/or, RN, DON, did the incident and accident get completed, and did the elopement assessment get competed. Residents exhibiting exit seeking behaviors will be evaluated for the secured unit, employees will have an understanding of what exit seeking behaviors appear as through the above education/competencies. Staff shall react appropriately to elopement/behaviors leading up to elopement through education and nurses' assessments. Responsible Party: It is the Administrator, or designee, and the Director of Nursing, or designee's responsibility to follow the actions and systematic changes listed above. The administrator, or designee, and The Director of Nursing, or designee, will report their findings of the above actions and systematic changes through their QAPI process. The Medical Director was notified on 3/02/22 of t [TRUNCATED]

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator or the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for one of 2 residents (Resident #1) reviewed for reporting incident allegations. The facility staff failed to report to the Administrator and the State Survey Agency, an incident regarding Resident #1 eloping from the facility on 01/08/22. The failure to report the elopement on 01/08/22 with Resident #1 to the Administrator allowed the resident another attempt to exit the facility on 01/12/22. An Immediate Threat was identified. The facility remains out of compliance at a scope of a no actual harm but potential for more than minimal harm at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of possible neglect, and/or it may have resulted in subsequent elopements. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 02/17/22, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The cognitive section of the MDS indicated Resident #1 had moderate cognitive impairment. He had symptoms of [CONDITION(S)], which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, no [CONDITION(S)], and no wandering behavior. He had an unsteady gait. Record review of Resident #1's care plan reflected a problem identified as falls, safety, elopement risk initiated on 03/02/22 which reflected, [Resident #1] was appropriate for placement in the secured unit .cognitive deficits and high risk for elopement There were no initial interventions on the care plan, dated 06/12/22, for elopement risk and exist seeking behavior. Record review of Resident #1's Elopement Risk Assessment, dated 06/12/21, completed by Agency nurse A reflected Resident #1 was admitted for behavior management, was aware of his surrounding, had safe decision-making capabilities, did not have a history of wandering, had not attempted to leave the building. Record review of Resident #1's quarterly elopement risk evaluation, dated 11/17/21, completed by LVN B reflected the resident was not an elopement risk. Further review of the elopement risk assessments for Resident #1 reflected was no elopement risk assessment after the elopement on 01/08/22. Record review of Resident #1's Resident Progress notes by LVN D, reflected she completed note on 01/10/22 for incident that took place on 01/08/22: resident kept walking around the facility, then left the facility, went to the pharmacy and asked for a phone, the resident used the phone to call 911 ambulance, he was transported back to the facility because he was stable. Resident called the police after the paramedics left stating that he had been forced to isolate himself and he does not have Covid19. A police officer came to the building spoke with the resident. This writer called resident [family member] after the police left to inform him about the resident refusing the positive test and that he called 911 ambulance and police Interview on 03/01/22 at 10:40 a.m. with CNA C revealed there was no need to report Resident #1's wandering behaviors because everyone who worked on his hallway knew about it. CNA C said she was not surprised when she heard Resident #1 had left the facility, he always talked about leaving. The CNA stated if everyone didn't know she would tell the charge nurse. Interview on 03/01/22 at 2:36 p.m. with LVN D revealed she was the nurse in charge when Resident #1 had eloped from the facility. LVN D said she was unaware he was gone, until emergency services brought him back. This event occurred on 01/08/22. LVN D said Resident #1 had come up to the nurse's station and he was mad that day because he had been tested for COVID-19 and was positive. LVN D said the resident said she had given it to him when she had tested him. LVN D stated she knew what had happened with Resident #1 because when emergency services brought him back, she had been told he walked into the local pharmacy wanting to use the phone to call 911, Resident #1 told the local pharmacy he had COVID-19. LVN D said that emergency services had taken the chance to see if he lived at the facility, because he could not tell them where he was from or where he lived. LVN D stated she reported this to the DON and the Administrator knew. LVN D stated the policy for a resident who had eloped was the staff were to search for the resident and notify the Administrator, DON, and family and once the resident was found she was to document it in the progress notes and inform the Administrator, DON, and family. LVN D stated she notified the DON, Administrator, and the family when Resident #1 returned to the facility. Interview on 03/02/22 at 10:44 a.m. with LVN E revealed Resident #1 was attention seeking and always tried to leave. LVN E said Resident #1 had to be monitored, because he always got mad and said he was going to leave. LVN E stated she did not report Resident #1's exit seeking behavior to anyone because everyone knew about his behavior. LVN E stated she was aware of Resident #1 leaving the facility she was working the day he left, 01/12/22, he left two times that day, once in the morning and once in the afternoon both time he had a staff member with him. She stated she reported to the DON and now the resident was on the secure unit. LVN E said she had heard something about Resident #1 leaving the facility prior but was unsure when it was. Interview on 03/02/2022 at 10:20 a.m. with the Social Worker revealed she was very familiar with Resident #1. The Social Worker said Resident #1 had attention seeking behavior, which included exit seeking. The Social Worker said the resident had been placed on the secured unit on 01/12/22 because he kept trying to leave the facility on 01/12/22 The Social Worker stated he had to chase the resident and bring him back multiple times. The Social Worker stated she was not aware of Resident #1 leaving the facility any other time before 01/12/22. Interview on 03/02/22 at 11:14 a.m. with the Business Office Manager revealed Resident #1 had been very agitated on 01/12/22 and had left the faciity on other time that day, all staff watched him, and she saw him go out of the facility and go towards the [NAME] area next to the facility, she went outside and told him to come back in and he did. On that day he was placed on the secured unit. The BOM stated Resident #1 had not left the facility like that before, but he always tried to especially when he got upset, but he has never left before, the staff all knew him and tried to redirect him. The BOM manager said he was placed on the secured unit after she brought him back in. Interview on 03/02/22at 11:18 a.m. with the Administrator, she said Resident #1 never eloped from the facility. Resident #1 was exit seeking one time and they placed him on the secured unit. The Administrator said Resident #1 was the type of resident who would get mad and threaten to leave, but he had only been exit seeking that one time and had never left the facility before. The Administrator stated she had no idea about the event on 01/08/22 occurred. The Administrator said no one had reported the incident to her and this was her first time she heard about it. The Administrator stated her staff did not report to her that Resident #1 was exit seeking all the time and that they were consistently redirecting him. The Administrator said she would report the incident now that she had been made aware. The Administrator said that even though she was out of the facility at the time of the elopement the staff should have called her. The Administrator said she expects her staff to communicate with her or the DON and then the DON communicate with her. This was a serious occurrence, and she was very grateful nothing happened to the resident. The Administrator said the staff had been in-serviced on reporting elopement and she did not understand why they did not call her. An interview with the previous DON was attempted on 03/02/22 at 9:13 a.m. and 2:00 p.m., messages were left and a return call was not received. Record review of the facility's abuse/neglect policy, dated July 2021, revealed, Policy Statements: . residents have the right to be free from abuse, neglect .all reports of resident neglect shall be promptly reported to local, state, and federal agencies . Training and prevention: Neglect: the failure of the Center, its employees .to provide goods and services to a resident that are necessary to avoid physical harm .Reporting/Response: Reporting all alleged violations to the Administrator, designee, state agency .the results of all investigation must be reported by the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation .the facility should oversee the implementation of corrective action and evaluate whether it is effective .