Every finding on record at Avir at Woodlands

Based on observation, interview, and record review the facility failed to employ sufficient number of staff to carry out the functions of the food and nutrition service department for 1 of 1 kitchenThe facility failed to ensure there were sufficient number of staff who prepared meals in the kitchen and served cooked food to residents at posted mealtimes. This failure could place residents at risk of not having their nutritional needs met and delay assistance with activities of daily living. Findings included:During an observation on 08/11/2025 at 09:50 AM the resident mealtimes posted outside of the kitchen read: Breakfast 7:15 AM Memory Care7:45 AM Hall trays, 8:00 AM Main Dining Room.Lunch 11:15 AM Memory Care, 11:45 AM Hall trays, 12:00 PM Main Dining RoomDinner 4:15 PM Memory Care, 4:45 PM Hall Trays, 5:00 PM Main Dining RoomDuring an observation on 08/11/2025 at 09:51 AM revealed 1 DM, 1 [NAME] and 1 dishwasher in the kitchen preparing for lunch meal. During an observation on 08/11/2025 at 1:10 PM the hall trays for long term care residents were sent out of the kitchen. , one hour and 20 minutes past posted mealtime.During an observation on 08/11/2025 at 1:30 PM the meal was delivered to meal service area located in the main dining room.During an observation on 08/11/2025 at 2:05 PM meal service completed, and all residents had been served,. During an observation on 08/12/2025 at 08:28 AM revealed breakfast being served in the main dining room.During an observation on 08/13/2025 at 12:15 PM the hall trays were delivered to Hall 400. During an observation on 08/13/2025 at 12:27 PM meal arrived from the kitchen to service area in main dining room. , 27 minutes past posted mealtime. During an observation on 08/13/2025 at 12:42 PM first meal tray was delivered to first resident in the main dining room. , 42 minutes past pasted mealtime. During a group interview on 08/12/2025 at 11:00 AM 8 of 8 residents stated meals were not on time. The residents' stated meals were 1-2 hours late. The residents stated there was a sign by the menu that stated when meals were to be served. The residents stated the meals were never served at the time posted. The residents stated when lunch was late then activities, such as BINGO, were also late. During an interview on 08/13/2025 at 2:25 PM with the DM, she stated meal service was late due to being understaffed. She stated there should have been one cook, one dishwasher and 2 dietary aides for each meal. The DM stated meal service being late effects resident a great deal. The DM stated medications must be held or given later. The DM stated the residents were used to having meals at a certain time and being late with meals can affect their attitude and how much the residents would eat. The DM stated she was responsible for making sure meals were served on time. The DM stated the ADMN also monitored meal service.During an interview on 08/13/2025 at 2:45 PM the DON stated her expectations were that meals would be served on time per schedule. The DON stated meals being late affected the residents' medications and their activities of daily living activities, such as showers and incontinent care. During an interview on 08/13/2025 at 2:50 PM the ADMN stated her expectation was for meals to be served at the time posted. The ADMN stated meals were not being served on time due to a large turnover in kitchen staff. The ADMN stated meal service not being on time can affect the resident's medication routine and activities of daily living such as showers and incontinent care. The ADMN stated the residents had the expectation of meals being served on time. The ADMN stated meal service times were monitored by the department heads. The ADMIN stated she had been trying to hire more kitchen staff but had not had many qualified applicants. Record review of facility's grievance log dated April 2025, May 2025, June 2025 and July 2025 revealed residents filed a grievance concerning meals being late. Record review of facility's policy titled, Food and Nutrition Services not dated revealed: Policy statement: Each resident is provided with a nourishing palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preference of each resident.3. Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled mealtime, and in accordance with the resident's medication requirements.9. Meals are scheduled at regular times to assure that each resident receives at least three (3) meals per day. Mealtimes are posted in facility common areas.

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 7 of 90 (02/02/2025, 02/15/2025, 02/16/2025, 03/01/2025, 03/02/2025, 03/15/2025 and 03/16/2025) days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 02/02/2025, 02/15/2025, 02/16/2025, 03/01/2025, 03/02/2025, 03/15/2025 and 03/16/2025.This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included:Record review of the facility's Direct Care Staff Daily Report for Fiscal Year Quarter 2 (January 1, 2025, to March 31, 2025), revealed on 02/02/2025, 02/15/2025, 02/16/2025, 03/01/2025, 03/02/2025, 03/15/2025 and 03/16/2025 there was no evidence of 8 hour RN coverage. During an interview on 08/13/2025 at 2:15 PM the DON stated her expectation was to have RN coverage 8 hours a day. The DON stated the ADMN was responsible for making the staffing schedule. The DON stated she did not feel there was a negative impact to residents, because she was available by phone and lived close to the facility. The DON stated what led to failure was the inability to hire RN's. During an interview on 08/13/2025 at 3:30 PM the ADMN stated her expectation was to follow policy and have RN coverage 8 hours a day. The ADMN stated she was responsible for creating the staffing schedule. The ADMN stated she did not feel there was a negative effect on residents, due to the support staff available by phone. The ADMN stated what led to failure was the facility did not have a weekend RN during the months of February and March. The ADMN stated they had been trying to hire a RN during the time frame. The ADMN stated they did not have a policy for RN staffing.

Based on observation, interview, and record review the facility failed to employ sufficient staff to carry out the functions of the food and nutrition service department for 1 0f 1 kitchen. The facility failed to ensure that meals were served at the post mealtimes. This failure could place residents at risk of not having their nutritional needs met and delay assistance with activities of daily living.Findings included:During an observation on 08/11/2025 at 09:50 AM resident mealtimes posted outside of kitchen: Breakfast 7:15 AM Memory Care7:45 AM Hall trays, 8:00 AM Main Dining Room.Lunch 11:15 AM Memory Care, 11:45 AM Hall trays, 12:00 PM Main Dining RoomDinner 4:15 PM Memory Care, 4:45 PM Hall Trays, 5:00 PM Main Dining RoomDuring an observation on 08/11/2025 at 09:51 AM observed 1 DM, 1 [NAME] and 1 dishwasher in the kitchen preparing for lunch meal. During an observation on 08/11/2025 at 1:10 PM hall trays for long term care residents were sent out of the kitchen.During an observation on 08/11/2025 at 1:30 PM the meal was delivered to meal service area located in the main dining room.During an observation on 08/11/2025 at 2:05 PM meal service completed, and all residents had been served. During an observation on 08/12/2025 at 08:28 observed breakfast being served in main dining room.During an observation on 08/13/2025 at 12:15 PM hall trays were delivered to Hall 400.During an observation on 08/13/2025 at 12:27 PM meal arrived from the kitchen to service area in main dining room.During an observation on 08/13/2025 at 12:42 PM first meal tray was delivered to first resident in the main dining room. During a group interview on 08/12/2025 at 11:00 AM 8 of 8 residents stated meals are not on time. The residents' stated meals are 1-2 hours late. The residents stated there was a sign by the menu that states when meals are to be served. The residents' stated the meals are never served at the time posted. The resident's stated when lunch is late then activities such as BINGO was also late. During an interview with DM on 08/13/2025 at 2:25 PM stated meal service was late due to being understaffed. She stated there should have been one cook, one dishwasher and 2 dietary aides for each meal. DM stated meal service being late effects resident a great deal. DM stated medications must be held or given later. The DM stated the residents were used to having meals at a certain time and being late with meals can affect their attitude and how much the residents would eat. The DM stated that she was responsible for making sure that meals are served on time. DM stated the ADMN also monitors meal service.During an interview with DON on 08/13/2025 at 2:45 PM DON stated her expectations was that meals would be served on time per schedule. DON stated meals being late affect the residents' medications and activity of daily living activities such as showers, incontinent care. DON stated all residents eat meals from the kitchen. During an interview with ADMN on 08/13/2025 at 2:50 PM stated her expectations were that meals be served at the time posted. ADMN stated meals were not being served on time due to a large turnover in kitchen staff. ADMN stated meal service not being on time can affect the resident's medication routine and activities of daily living such as showers and incontinent care. ADMN stated the residents had an expectation of meals being served on time. ADMN stated meal service times are monitored by department heads. ADMIN stated had been trying to hire more kitchen staff but had not had many qualified applicants. Record review of facility's grievance log residents filed a grievance concerning late meals in April, May, June and July of 2025.Record review of facility's policy titled: Food and Nutrition Services (no dated) revealed Policy statement: Each resident is provided with a nourishing palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preference of each resident.3. Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the resident's medication requirements.9. Meals are scheduled at regular times to assure that each resident receives at least three (3) meals per day. Mealtimes are posted in facility common areas.

Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #44) of 5 residents reviewed for baseline care plan completion.The facility failed to complete Resident #44's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.Findings included:Record review of Resident #44's face sheet dated 08/12/2025 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses fracture of femur, high blood pressure, atrial fibrillation (abnormal heart rhythm) and muscle weakness.Record review of Resident #44's admission MDS dated [DATE] revealed in Section C - Cognitive Patterns revealed a BIMS score of 15 (cognitively intact).Record review of Resident #44's electronic medical record revealed Resident #44's baseline care plan was initiated on 08/13/2025. During an observation and interview on 08/12/2025 at 11:35 AM Resident #44 was sitting in her room in her wheelchair. Resident #44 stated she was at facility for breaking her hip.During an interview on 08/13/2025 at 11:07 AM the RNC stated her expectation was that baseline care plans should have been completed within 48 hours of admission. The RNC stated she had initiated the baseline care plan for Resident #44 today. The RNC stated that the baseline care plan had not been completed in the required 48 hours. The RNC stated the charge nurse, and the DON were responsible for completing the baseline care plan. The RNC did not provide a reason for what to led to failure. During an interview on 08/13/2025 at 2:15 PM the DON stated her expectation was baseline care plans should have been completed within the 48 hours of admission. The DON stated the charge nurse was responsible for initiating the baseline care plan. The DON stated what led to failure was oversight by staff. During an interview on 08/13/2025 at 3:30 PM the ADMN stated her expectation was baseline care plans should have been completed within 48 hours of admission. The ADMN stated the charge nurse was responsible for completing the baseline care plan. The ADMN stated the DON was responsible for monitoring to ensure the baseline care plans were completed within 48 hours. The ADMN stated she did not think there was a negative effect on resident not having baseline care completed. The ADMN did not give a reason for the failure of Resident #44's baseline care plan completed. Record review of the facility policy titled, Care Plans-Baseline dated March 2022, revealed A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 2 residents (Resident #2, and Resident #6) reviewed for care plans in that:Resident #2 did not have a comprehensive care plan in place that included a code status of do not resuscitate. Resident #6 did not have a comprehensive care plan in place that included use of a trapeze (equipment attached to a resident's bed to aide in independent repositioning).This failure could affect residents by placing them at risk of not receiving individualized care and services to achieve their goals.The findings included the following:Review of Resident #2's Resident Face Sheet dated [DATE], revealed he was an [AGE] year-old male initially admitted to the facility on [DATE] and had a most recent admission date of [DATE] with medical diagnoses including pancreatic cancer, pressure ulcer on sacrum (lower part of the back), shortness of breath, low thyroid function, depression, anxiety, high blood pressure, macular degeneration, weakness, and bladder cancer. Under Other Information, DNR, Yes was entered.Review of Resident #2's Quarterly MDS Assessment, dated [DATE], Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed he had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Review of Resident #2's physician's order dated [DATE] revealed an order **Code Status: ***DNR***. Review of Resident #2's miscellaneous records revealed an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order signed by Resident #2's physician and notarized on [DATE].Review of Resident #2's Comprehensive Care plan reviewed/revised [DATE] revealed: Focus Resident and or RP/family have advance directive of choice to be FULL CODE status. Observation on [DATE] 8:28 AM Resident # 2 was in his bed sleeping. Resident #6Review of Resident #6's Resident Face Sheet, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses including intracerebral hemorrhage (brain bleeding), urinary incontinence (inability to control urine output), dysphagia (problems with swallowing), anxiety, shortness of breath, depression, post-traumatic stress disorder, high blood pressure, myocardial infarction (heart attack), chronic kidney disease, and pain.Review of Resident #6's Quarterly MDS Assessment, dated [DATE], revealed he had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Review of Resident #6's physician orders dated [DATE] revealed Trapeze to be used for mobility. Review of Resident #6's Comprehensive Care Plan reviewed/revised [DATE] revealed use of a trapeze was not addressed on the care plan. Observation on [DATE] at 10:08 AM, revealed a trapeze device to assist the resident with repositioning was attached to the headboard of Resident #6's bed. During an interview on [DATE] at 11:33 AM, LVN A stated she was not aware that Resident #6's trapeze was not on his care plan, she thought it was. She stated she did not think the resident would suffer adverse effects of the trapeze not being on the care plan. During an interview on [DATE] at 2:24 PM, with the DON and the RNC, the DON stated she was surprised Resident #6's trapeze was not on the care plan. She stated she could not explain why it was not. The DON stated her expectations were for care plans to be completed on time and accurate. She stated she could not think of an adverse effect on the resident if the trapeze was not addressed on the care plan. The RNC stated the CAAs provided the basis for care planning. She explained the facility conducts IDT meetings every weekday morning at which time acute events were identified and a decision made by the team to add to the care plan. She stated it was important to include everything on the care plan, so the staff were aware. The DON stated the ADON was responsible for reviewing/revising care plans. The RNC stated the DON was ultimately responsible for the accuracy of the care plans. During an interview on [DATE] at 2:39 PM, the ADON stated she had been in the ADON position for 4 months. She explained training was provided on the job from the DON and corporate support. The ADON stated she did not initiate care plans but was responsible for keeping care plans up to date. She stated she did not know how the trapeze was missed on Resident #6's care plan. The ADON stated Resident #6 was the only resident with trapeze. She stated consequences to the resident of failing to include the trapeze on the care plan would be if staff was not aware he had a trapeze and he needed it. During an interview on [DATE] at 2:45 PM, the DON stated a DNR status should be care planned. She explained that could affect the resident who might receive CPR against their wishes. The DON stated she did not know what caused the failure to include Resident #2's code status on the care plan to occur. The DON stated that she and the MDS coordinator were responsible for monitoring the accuracy of the care plans. She stated care plans were reviewed quarterly, annually and with a change of condition. Review of facility policy titled Care Plans, Comprehensive Person-Centered dated 2001, revealed 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . and 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 14 (Resident #3, Resident #10 and Resident #11) residents reviewed for supervision. 1. The facility failed to provide supervision for Resident #3, who was care planned for wandering in unsafe places, to prevent him from eloping from the facility on 03/21/2025. The facility was unaware Resident #3 had exited the facility, through his unlocked window in the secure unit. The facility failed to provide adequate supervision in secured locked unit to prevent elopement on 12/05/2024 and 03/23/2025. An Immediate Jeopardy (IJ) was identified on 03/21/2025. While the IJ was lowered on 03/28/2025 at 4:45 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. 2. The facility failed to ensure Resident #10, and Resident #11 were safely secured in the facility van while being transported to and from the facility. An Immediate Jeopardy (IJ) was identified on 03/31/2025. While the IJ was lowered on 04/02/2025 at 9:23 AM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures placed residents at risk of injury due to not being supervised and placed them at risk of serious bodily harm, physical impairment, or death. Findings include: 1. Record review of Resident # 3's face sheet dated 03/24/2025 revealed a [AGE] year-old female admitted on [DATE] with a readmission on 02/19/2025 with the following diagnoses cardiac issues, seizures, and traumatic brain injury. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed: Section C - Cognitive Patterns Resident #3 had a BIMS of 14, meaning cognitively intact. Section GG Mobility Devices Resident #3 required the use of a walker. Record review of Resident #3's Care Plan updated on 03/21/2025 revealed: Problem: start date 10/09/2024 I am on the memory care unit due to exit seeking behaviors. On 3/21/25 had actual Elopement through bedroom window-High Risk 20. Goal: Resident will remain free from injury related to exit seeking/elopement attempts through next quarter. Approach: Start Date 03/21/2025 Consider Medication Review if behaviors continue or escalate; Start Date- 03/21/2025 Consider psych consult with increase in behaviors; Start Date- 03/21/2025 Ensure all basic needs are met when resident. becomes anxious or aggressive. Offer toileting, snack, fluids, comfort. Etc.; Start Date- 12/05/2024 Resident must be accompanied by staff while in courtyard. Start Date- 10/09/2024 Assess/ record/ report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, attempts to leave facility. Start Date- 10/09/2024 Check doors & windows for security and for proper functioning and placement per facility protocol. Start Date-10/09/2024 Develop and activities program to divert. attention and meet needs for social, cognitive stimulation; Start Date- 10/09/2024 Discuss with resident/ family risks of elopement. and wandering; Start Date- 10/09/2024 If resident is missing from facility, follow elopement protocol, notify MD and family. immediately, and document; Start Date- 10/09/2024 Placement on secure unit for high risk for elopement; Start Date: 10/09/2024. Supervise closely and make regular compliance rounds whenever resident is in room. Record review of Resident #3's physician orders revealed Start date of 10/09/2024 Admit to facility secure unit. Record review of Resident #3's progress notes revealed: Date 10/24/2024 at 4:52 PM documented by LVN C creating a map of the exits of the Secure Unit, when asked the Resident did not respond and only nodded to agree with the co-conspirators statement of getting out of here. This Nurse explained to Resident that his placement here was agreed between his mother and himself to promote independence in a safe environment. Resident stated, I don't care, I can leave if i want to. Further education given on importance of remaining safe as well as dangers surrounding facility. Resident was not agreeable to education and walked away. Date: 12/05/2024 at 15:42 PM documented by LVN C Resident found by Staff on ALF Patio attempting to gain entry to ALF. ALF Patio is separated from Secure Unit Courtyard by 4ft locked fence. [NAME] located pushed against fence beside bush. Resident states he hopped the fence to go to [nearby town]. Resident story changed multiple times and includes wanting to sit somewhere else and wanting fresh air. Resident assessed for injury, no skin impairments or bruising noted to any part of body, Resident denies pain. PCP notified, attempted to notify Mother voice mail not available. Resident previously given freedom to come and go From Secure Unit Courtyard, at this time Staff must be present in area for Resident to venture outdoors to prevent injury from attempt to leave area and to prevent Resident eloping from facility. Date 12/10/2024 at 9:30 PM documented by LVN K Resident walking around in secure unit with walker .States, I need you to let me out of here. Resident continues to exit seek daily. All care was witnessed by staff. Date 12/12/2024 at 2:30 AM documented by LVN O res up ambulating throughout night on unit with and at times without his walker, when amb without walker res has unsteady gait. becomes upset when staff encourage use of walker and remind res staff do not wish him to fall again with potential injuries a possibilities. Also res asked CNA to open secure unit doors, while standing at the front of unit by main doors. this writer entered secure unit, res attempted to grab doors as they closed but was unable and almost fell attempting to. reminded res doors must remain closed and locked, he started yelling loudly and repeatedly, bull shit. when asked to have consideration for others who are sleeping he yells, I don't fucking care all attempts to calm res unsuccessful. res went back to his room on his own. has come out since 3 times and stood at front of unit doors pushing on handle of doors until alarm sounds, when staff attempted to redirect him from this behavior he again starts to yell and whenever staff opened door of unit to turn off or reset alarm he again grabs at door trying to walk through door with staff in doorway. after these attempts he says I give up and I'm walking out of here tomorrow. Date 12/12/2024 at 7:10 PM documented by LVN P Rsd held locked double doors of memory care unit until they opened. Attempted to exit and became angry and combative when staff attempted to intervene. CNA called out for assistance and staff immediately assisted. The rsd appeared very angry stating, I am leaving this place. I am going home to [NAME]! I'm going to walk!. Rsd was given emotional support by staff and the situation de-escalated. The rsd walked to his room in an angry manner yelling profanities. Date 12/13/2024 at 9:30 AM documented by LVN Q resident has been very restlessness and uncooperative with staff his attempt to leave the unit with holding the hand bars down for the full 15 seconds and then the alarms were alarming, and the staff had to retrieve resident before he could leave the unit unattended that is when he became increased restlessness with agitation and aggressively pacing with rollator walker staff was unsuccessful with keeping him from exiting the unit while visitors were coming into unit and staff then was able to get to him within 3 feet of him exiting the unit, this nurse was summoned to unit STAT, on arrival this nurse was able to calm him down and redirect him into sitting in the HR Desk where this nurse then called his mother to advise her of the above uncooperativeness and agitation then this nurse asked if she would attempt to talk with him to calm him down even more , he then was on the phone talking with his mother demanding her to come get him and take him home, she spoke with him approximately 10 minutes then he let this nurse speak with her again this nurse was advised that the mother was unable to come today due to she has appointments and obligations already in motion and she was unable to change them on short notice she did declare that she would be here this weekend sometime to visit him and she felt that would help him for this behavioral episode, that is when the resident agreed to go back into the unit without behaviors noted. Date 12/13/2024 at 12:42 PM documented by LVN Q Resident is at the unit doors attempting to elope and exit seeking is in high risk at present time the unit is where he is with a staff at all times due to his quick and exit abilities are placing himself in harm's way this nurse has made a call into the office of FNP at present time this nurse is on hold in que for the answering service, staff was instructed to stay with resident to help protect him from being able to exit while the staff was assisting other residents. Date 12/14/2025 at 2:30 PM documented by LVN R kitchen worker came through door that leads from kitchen into memory care kitchen. Res grabbed door and would not let go. CNA stood between res and door and called this nurse. This nurse went to memory care, finally convinced res to go outside into courtyard. Res and nurse sat on bench and talked for a while then went back inside to call his mother. Res talked to his mother for approx 15-20 min then went back to memory care. Date 12/29/2024 at 10:16 AM documented by LVN Q noted at present time resident has been with pacing and becoming agitated about wanting to go home, this nurse has attempted to redirect resident with having him have the broom and dustpan so he can sweep to redirect his focus on wanting to leave, noted has worked at this point on his redirection. Date 12/30/2024 at 12:40 PM documented by LVN P CNA reported to this nurse that the resident continues to show unprovoked aggressive behavior toward staff members. The rsd became angry this AM when the breakfast trays arrived when he wasn't immediately served before others and began cussing the CNA and banging on the table. The rsd has a hx of frequent angry outbursts with use of profanity and tendencies to use physical force. The rsd is actively exit seeking and has damaged two exit doors and his window facing the courtyard in attempts to escape. The rsd is alert and is aware this behavior is not appropriate and verbalizes that he knows it is wrong. However, the rsd exhibits ST memory deficits and appears not to remember the behaviors or appears confused at times when questioned. Date 01/02/2025 at 3:30 PM documented by LVN C Resident attempted to exit memory care Secured Unit while doors were open. Resident was immediately stopped by nearby Staff. Resident attempted to hit with walker, hit CNA with closed fist and proceeded to yelling and cuss at those stopping him. Resident would not be redirected from attempting to exit memory care. Date 02/06/2025 at 5:28 AM Documented by LVN O res went to x 2 cnas and nurse on this hall telling staff to open the doors and let him out. Res also went to all exits multiple times since 0400 of unit pushing egress on doors causing alarms to go off at these doors and not easily redirected, staff members on both sides of exit doors until res stopped pushing at doors, he also amb into doorway of other res rooms and not easily redirected. When encouraged to continue to rest through to morning meal went back to his room but yelled at this writer once let me out loudly then entered his own room. Date 02/07/2025 at 1:37 PM documented by LVN C Resident has continued previous behavior of pushing/pull on secured locked doors and pacing. Date 02/09/2025 at 2:59 PM documented by LVN C This Nurse could intervene Resident began screaming at that person This is my house I can go wherever the f**k I want. This Nurse stood between the two and prevented Resident from entering further into the room. Resident attempted to punch This Nurse, This Nurse leaned out of the way and prevented injury to either party. DON notified and instructed This Nurse to call Residents mother and have them talk on the phone. Residents Mother stated to This Nurse I don't know what to do about it She spoke with Resident via phone, Resident finally left the other persons room. After the end of the phone call Resident began pacing and trying to exit secure doors. Date 02/12/2025 at 5:01 AM documented by LVN O wanting staff to let him out, becomes angry when staff not able to, pushing at doors and setting off alarms on doors, only then does he back off the doors, Date 02/22/2025 at 4:50 PM documented by LVN C Resident has been exit seeking this shift. Pacing unit from door to door attempting to pry them open. Resident has been attempting to push past staff when doors are open. Date 02/26/2025 at 5:59 AM documented by LVN O res had behaviors through this night shift, cursing at staff when he would demand to be let out of secure unit or being given the code to the doors and staff explained that were unable to do so, res pushing and pulling at all exit doors all throughout night shift, res multiple times pulling at doors hard and almost falling backwards, staff steading res with their hands trying to keep res safe from falling and he would yell don't touch me and attempt to swing at staff. staff would encourage res not to do so for his safety. he would curse at staff and continue doing so despite encouragement. res caused alarms to go off numerous times pushing at doors. Date 02/27/2025 at 5:29 AM documented by LVN K resident continues with negative mood, continues to exit seek throughout the shift, redirected away from doors, requires constant monitoring, denies any pain, stated, are you going to let me out of here to get my pick up and go to [ Nearby City]? This nurse reassured him that she would not be assisting him in leaving facility. Date 03/02/2025 at 4:34 documented by LVN O res up walking without walker this shift and continues to ask staff and demand staff let him out of unit, continues to push at doors to attempt to exit, Date 03/03/2025 at 5:47 AM documented by LVN O res continues to attempt to leave secure unit and pushes at doors, earlier in shift got through door at end of unit that leads to AL dining room, after pushing door for 15 seconds setting off egress and releasing door, (as safety required sign on door states to do) required 3 staff members to get res to back into unit safely and reset door, res also attempted same maneuver on other dining room door that leads to outside at front of building but staff were able to get between res and door and keep him in building and safe. Date 03/04/2025 at 2:06 PM documented by SW Writer Contacted resident's mother, [insert name] to discuss recent. behaviors of pushing on the exit door to the parking lot for 15 plus seconds until the door open and then going outside to a parking lot which is next a four-lane busy highway. Resident's mother is in agreement that resident needs to be in a unit that has a fence between the road/street or no assess to the street for his safety. Date 03/07/2024 at 4:44 AM documented by LVN O res continues exit seeking this shift and pushing at doors, cursing at staff when unable to let him out of unit, res gait is unsteady when not using walker, Date 03/14/2025 at 3:51 AM documented by LVN K states, i wanna go home. Date 03/21/2025 at 2:47 PM documented by LVN C Resident displaying exit seeking behavior: pushing on doors, attempting to push past Staff to Exit . will continue to monitor for exit seeking behaviors. Date 03/21/2025 at 8:55 PM documented by LVN S at 19:59 code white was called after being unable to locate resident and finding his window open. This nurse located resident in front of [City name] Dialysis center and accompanied resident safely back to facility. Upon assessment no injuries noted to rt, rt denies pain . Rt stated I don't want to be her anymore! I want to leave RT placed on Q 15 minute checks for 24 hours. RT RP [RP name] called, situation explained stating she understands situation and has no further questions or complaints. PCP faxed. All windows in facility checked, maintenance [name] coming to ensure windows are in compliance with regulations. Rt moved to different room, resting in bed peacefully. Date 03/21/2025 at 9:51 PM documented by DON Res smiling and states I want to go home. I'm going home. Discussed risks of leaving facility against medical advice and risks associated with elopement. Verbalizes understanding and states I know, but I don't care. Date 03/22/2025 at 5:48 AM documented by LVN K Resident awake, sitting on side of bed . resident alert and oriented, talking with staff, stating he will bust out again. Continue to monitor closely Date 03/23/2025 at 4:52 PM documented by LVN C Resident exit seeking this shift. Eloped from Memory Care unit into ALF and was exiting ALF dining room door that leads to highway. Resident stopped outside door and escorted back to Memory Care. No injuries noted, Resident denies pain. Date 03/24/2025 at 1:07 PM documented by DON Clarification to note on 06/23/25 at 1652: Spoke with on duty memory care CNA on date of entry. CNA states res approached door in memory care dining room. Resident pushed on door, causing door alarm to sound. CNA immediately recognized and responded to alarm. CNA reports res was standing outside door of memory care dining room next to building. Res immediately redirected resident back through memory care dining room door without difficulty. Staff will perform 1 on 1 resident observation at this time until further placement arrangements can be made. During an observation on 03/21/2025 at 7:10 PM, Resident #3 was observed sitting at desk with CNA A. CNA A said she was the only staff that was working on the secured unit. CNA A stated if something was to happen, she would have to leave the residents to make a phone call for help or leave the unit to call for help from the other unit. During an observation on 03/21/2025 at 8:15pm, there was no lock on Resident #3's bedroom window and two of the dining room windows facing the street did not have a lock. Resident #3 had been moved to another room with an interior window that had a lock and faced the gated courtyard. During an interview on 03/24/2025 at 2:40 PM, LVN C stated she was working on 03/23/2025 but was not on the secure unit when she heard the alarm go off. LVN C stated when she entered the secure unit, she saw CNA E standing at the door (that exited out of the secure unit dining area into the parking lot) attempting to turn the door alarm off. LVN C stated she exited thru the secure door that entered the ALF and noticed the door exiting the ALF dining room (north side of building facing the major highway) was open. LVN C stated she located Resident #3 outside of the ALF door with his walker. During an interview on 03/25/2025 at 10:35 AM, the DON stated Resident #3 was placed on 15-minute safety rounds checks after his elopement on 03/21/2025 for 24 hours. Staff was responsible to ensure Resident was safe and not trying to exit seek. The resident was then placed on 1:1 supervision on 03/24/2025 at 4:54pm until he was to be transferred to another facility. The DON stated the ADMN and MM were responsible to ensure the locks were placed on window. The DON stated not having locks on the windows led to failure of Resident #3 being able to exit his window. During an interview on 3/25/25, the Administrator stated when Resident #3 returned from behavioral hospital on 02/04/2025, she asked the maintenance director to make sure that all the windows hand locks in the secure unit, because there were several that did not have locks. The ADMN stated she did not go back and follow up to ensure they were done. The ADMN stated her expectation was that MM had put the locks in the windows. The ADMN stated what led to failure was that MM did not put locks on the windows and she failed to verify the windows had locks. The ADMN stared she had not reported the incident on March 23rd because even though Resident # 3 was able to exit the secure unit, he did not leave the property. During an interview on 03/25/2025 at 1:15 PM the MD stated he had provided care for Resident #3. The MD stated due to Resident #3's traumatic brain injury he was not capable of making decisions on his own and was not safe to be out of facility on his own. The MD stated the facility was on a major highway and if Resident #3 were to have gotten out of the facility, he could have had the potential of being stuck by a motor vehicle. The MD stated having only one staff on the secure unit during a shift was not sufficient staff to supervise all the resident's needs. Record review of facility policy titled, Wandering and Elopements dated 2001 revealed; The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the residents' care plan will include strategies and interventions to maintain the residents' safety. This was determined to be an Immediate Jeopardy (IJ) on 03/21/2025 at 4:31 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 03/26/2025 at 12:30 PM. Record review of Plan of Removal accepted on 03/27/2025 at 5:17 PM reflected the following: FACILITY: [Facility Name] Facility ID Number: 110493 SURVEY TYPE: Complaint Survey SURVEY DATE: 3/26/2025 Plan for REMOVAL Plan to remove immediate jeopardy. The facility allegedly failed to ensure a resident with a known history exit seeking and elopement received with adequate supervision in a secured locked unit to prevent elopement. F689 On 3/26/2025 the Administrator notified Medical Director of immediate jeopardy. Starting on 3/26/2025 the Director of Nursing/Designee will initiate in-service on adequate supervision to prevent a resident from leaving the facility, including policies on elopement/missing resident. In the event a resident starts exhibiting exit seeking behavior that are not controlled with the following interventions redirection, assessing for unmet needs, assessing for pain, hunger, toileting, personal care, and increase in activities, the care plan team will evaluate the need for 1:1 and or alternate placement. This will be discussed during clinical morning meeting and quarterly care plan meetings for residents who reside on the secure unit. All staff including new hires and agency will be in-serviced on this policy prior to beginning their next shift. This will be completed by 3/26/2025. On 3/26/2025 12 residents residing on the secure resident, none are actively exit seeking, they are not attempting to climb out windows or exit doors. Residents were assessed by IDT round to include Administrator, Director of Nursing, Regional Nurse Consultant and direct care staff. Residents were assessed with an elopement risk assessment. On 3/26/2025 The policies for one on one have been created to include the following: Residents are placed on one on one there will be a third designated person assigned to the resident & not part of the usual staffing pattern. Criteria for 1:1 would be a resident exhibiting self-harm and uncontrolled behaviors posing risk to self and others. 1:1 supervision is defined as resident will be within line of sight of staff. Interventions used prior to placing a resident on 1:1 would be redirections, assessing pain, hunger, unmet need, toileting, and personal items. On 3/25/2025 the Resident #3 was discharged to a more a different facility with a more secure unit to eliminate the risk of elopement by this resident. Ad-Hoc QAPI meeting was held on 3/26/2025, with the Medical Director, NHA (Nursing Home Administrator), Regional Nurse Consultant, Director of Nursing, and Assistant Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. Starting on 3/26/2025, IDT (Interdisciplinary team), including Administrator, Director of Nursing an Assistant Director of Nursing will review the head count and checks window to ensure they are secure with L bracket to prevent opening more than 6 inches in the secure unit of the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday. Any negative findings will be immediately brought up to the Administrator/Designee for further action, if necessary. This will continue daily for the next 14 days. Then weekly there after. Starting 3/26/2025 RDO or designee will provide physical oversight at facility weekly x4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance by physical plant rounds Monday through Friday; Manager on Duty will monitor on weekends. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 3/26/2025. The RDO/Designee will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record review from 03/27/2025 at 5:17 PM to 03/28/2025 at 4:45 PM as follows: During an observation on 03/25/2025 between 4:45 and 4:50 PM all window in the secure unit were observed to have L brackets placed in each window. Record review of facility's EMR assessment section residents residing on secure unit on 03/28/2025 at 08:25 AM revealed elopement assessments for 12 residents currently residing on secure unit. 11 of 12 residents identified as elopement risk. Record review of the facility provided agenda for the Ad-Hoc QAPI meeting held on 3/26/2025 revealed that the MD had attended meeting and signed the agenda. Record review of electronic medical records revealed the 12 residents on the secure unit had an elopement risk assessment completed on 03/26/2025. Record review of facility provided policy revealed a policy titled One on One Resident Supervision. During an interview on 03/25/2025 at 8:40 AM the ADMN stated Resident #3 had been excepted to another facility and would be transported today to new facility. During an observation and record review on 03/25/2025 at 4:00 PM Resident #3 was not located on the secure unit. Record review revealed he had been discharged to another facility. Record review on 03/28/2025 at 09:00 AM, observed and reviewed in-services for staff located at nurses station, for One on One, Resident Rights, Staffing on Secure Unit, Elopement, and Exit seeking. Observed sign-in sheets for each in-service. Observed DON conducting an in-service with a dietary staff member. Record review of the facility provided agenda for the Ad-Hoc QAPI meeting held on 3/26/2025 revealed meeting was held and attendees had signed. Record review of facility provided documents revealed facility was performing head count and window checks daily. During an interview on 03/28/2025 at 09:10 AM, CNA A stated she was in-serviced on 03/27/2028 by DON on resident rights, secure unit staffing, one on one, exit seeking, and elopement on 03/27/2025 by DON. CNA A stated one on one was making sure resident was in line of sight and staying with them and not helping with other residents. CNA A stated the secure unit should have 2 staff on all shifts, if resident was exit seeking should try to redirect and call for help if needed. If a resident elopes, she was to try to find the resident, let the charge nurse know, do room check and head count. Residents have the right to make their own choices, refuse care, and know what medicines they are getting. During an interview on 03/28/2025 at 09:15 AM, NA G stated she was in serviced on 03/27/2025 by DON resident rights, one on one, staffing of secure unit, exit seeking and elopement on 03/27/2025 by DON. Staffing of secure unit with at least 2 staff unit each shift. NA G stated one on one meant always keeping resident in line of sight. NA G stated if residents were exit seeking to try to redirect or see if they are hungry. NA G stated residents had the right to refuse care, treated with respect, and make decisions. During an interview on 03/28/2025 at 09:20 AM, LVN H stated she was in-services on 03/27/2025 by DON on One-to One, Staffing on Secured Unit, Resident Rights, Exit Seeking, and Elopement on 03/27/2025 by DON. LVN H stated one on one meant keeping resident in line of sight and not leaving resident until another staff member can take over one on one. LVN H stated the secure unit should have been staffed with 2 staff at all times. LVNH stated if a resident was exit seeking staff should try to re-direct resident, offer food or see if the resident was in pain. LVN H stated residents had the right to refuse care, to be treated with respect and to make their own decisions. During an interview on 03/28/2025 at 09:30 AM, CNA I stated the secure unit should have 2 staff at all times, one on one meant to keep the resident in line of sight and to not leave them without someone to take the staff's place. CNA I stated for elopement should let charge nurse know, check all rooms, all areas of facility to try to locate resident. CNA I stated she had in-services on 03/27/2025 by ADON before her shift. CNA stated residents had the right to refuse care, treated with respect, and make decisions. CNA I stated other in-services she had today included Exit Seeking, Resident Rights, Staff on Secure Unit, and Elopement. During an interview on 03/28/2025 at 09:45 AM, AD said she received in-services on 03/28/2025 by DON on resident rights, one on one, secure unit staffing and elopement secure unit staffing. The AD stated one on one was keeping the resident in line of sight and secure unit should have 2 staff on all shifts. The AD stated if a resident was trying to elope to try to re-direct, get other staff to help. The AD stated if resident had eloped check on other residents, try to find missing resident and report to ADM, DON and other staff. The AD stated residents had the right to make their own choices, be treated with respect and have needs taken care of. During an interview 03/28/2025 at 09:55 AM, NA F stated she had been in-serviced on 03/28/2025 by DON on one on one, resident rights, staff on secure unit, elopement and exit seeking. NA F stated one on one meant staying with resident and keeping your eyes on them. NA F stated if resident eloped need to try to find them, call DON and ADM and let other staff know someone is missing. NA F stated residents had to the right to refuse care, treated with respect, and make decisions. Transport Aide F stated the residents had the right to be treated with respect, and to make their own choices. During an interview on 03/28/2025 at 10:28 AM, CNA J stated she worked night shift and had in-services 03/27/2025 by DON on one on one, staffing of secure unit, elopement, exit seeking, and resident rights. CNA J stated she would assist on secure unit when needed and one on one meant to keep the resident in line of sight and not leave the resident. CNA J stated if a resident was exit seeking to try to re-direct them or offer them something to eat and if a resident elopes to let all staff know, try to locate resident and notify ADM and DON and make sure all other residents are accounted for. CNA J stated residents had to the right to refuse care, treated with respect, and make decisions. During an interview on 03/28/2025 at 11:05 AM, LVN K stated she had [TRUNCATED]

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from neglect for 2 of 14 residents (Resident #10 and Resident #11) reviewed for neglect. The facility failed to ensure Resident #10 was secured with a seatbelt when being transported in the facility van to an appointment in another town approximately 47.5 miles one way on 03/26/2025. Resident #10 fell out of his wheelchair onto the floor of the facility van. The facility failed to ensure Resident #11 was secured with a seatbelt when being transported in the facility van to an appointment in another town approximately 47.5 miles one way on 03/18/2025. An Immediate Jeopardy (IJ) was identified on 03/31/2025. While the IJ was lowered on 04/02/2025 at 9:23 AM, the facility remained out of compliance at a severity level of no actual harm potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures placed residents at risk of injury due to not being supervised and placed them at risk of serious bodily harm, physical impairment, or death. Findings include: Resident #10 Record review of Resident #10's face sheet revealed an [AGE] year-old male admitted on [DATE] with the following diagnosis Diabetes Mellitus type II, Flaccid hemiplegia (compete paralysis, lack of muscle tone) Left side Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #10's Quarterly MDS dated [DATE] revealed a BIMS score of 12 meaning moderately impaired cognition. Section G Functional status: Resident #10 required extensive assist with bed mobility, transfers, and toileting. Record review of Resident #10's Care Plan dated 02/18/2025 revealed: Resident had decreased functional limitation in ROM (range of motion) to left side. Decreased mobility to left side. Approach: Ensure staff aware of resident's mobility/ADL (activities of daily living) impairments. Resident #11 Record review of Resident #11's face sheet revealed a [AGE] year-old female who was admitted [DATE] with the following diagnosis Cerebral Infarction (condition where blood flow to brain is blocked), Bilateral above the knee amputation (removal of both legs above the knee), Diabetes Mellitus type II, Congestive Heart Failure (heart disease), chronic kidney disease (kidney damage) End Stage Renal Disease (dialysis). Record review of Resident #11's Quarterly MDS dated [DATE] revealed: Section C Cognitive Status: Resident had a BIMS of 15 (Intact Cognition). Section GG-Functional Abilities GG0115 Functional Limitation in Range of Motion lower extremity impairment on both sides. Car transfer-substantial/maximal assistance. During an observation and interview on 03/27/2025 at 02:15 PM, Resident #10 was lying in bed awake, unable to move left arm. Resident #10 stated he went in the facility's van with Transport Aide F as driver to dental appointment in another town. Resident #10 stated his wheelchair was secured in the van, but he did not have on seatbelt or anything to secure him in his wheelchair. Resident stated he asked Transport Aide F to put the seatbelt on and Transport Aide F told him she did not like the seatbelt, so she did not put it on him for the drive to appointment in another town approximately 47.8 miles one way. the facility. Resident #10 stated it made him feel unsafe. Resident stated they were on interstate and a truck was ahead of them and Transport Aide F had to slam on the brakes, and Resident #10 came out of wheelchair and landed on the floor with my right leg up under the dash of the van. Resident #10 stated he asked Transport Aide F to pull over and she told him he couldn't pull over until there was an exit. Resident stated this happened approximately 30 miles from #10 stated he had to lay on the floor of the van for about 30 minutes until they got back to the facility. Resident #10 stated when they got back to the facility it took 4 people to get him out of the van and into a wheelchair. Resident stated Transport Aide F knew that he needed the seat belt but did not put it on him. During an interview on 03/28/2025 at 02:45 PM, the ADMN stated Transport Aide F was hired on 08/15/2024 and had 2 weeks training before starting van driver position. Transport Aide F initial training was on 11/01/2024. ADMN stated Transport Aide F had been checked off on competency of use of seat belts and securing wheelchairs in van again on 03/25/2025 by MM. ADMN stated Resident #11 was identified through the complaint process on 03/25/2025 of not being buckled in with seat belt when being transported. ADMN stated in-service consisted of each van driver providing a return demonstration on use of seatbelts in van for residents in a wheelchair. During an interview on 03/28/2025 at 04:00 PM, MM stated he trained Transport Aide F on 08/15/2024 by showing her how to secure a resident in a wheelchair in the facility van. MM stated Transport Aide F performed return demonstration several times on the use of wheelchair tie downs and use of seat belt. MM stated Transport aide-F had not reported any problems with seatbelt in van. MM stated Transport Aide F completed the refresher course on 03/25/2025 that included how to strap the wheelchair down with ties, and how to safely buckle residents with seat belt, and she demonstrated how to secure wheelchair in the van and to safely buckle a resident with a seat belt. MM stated Transport Aide F was instructed if the van is not safe do not drive, stop, and call 911 and notify ADMN and DON. During an interview on 03/28/2025 at 02:30 PM, Transport Aide F stated she transported Resident #10 in facility van to dental appointment in another town, on 03/26/2025 at 08:00 AM Transport Aide F stated there was construction on the interstate and she had to slam on her brakes to avoid hitting a vehicle in front of the van. Transport Aide F stated when she slammed on the brakes, Resident #10 was thrown out of his wheelchair onto the floor of the van. Transport Aide F stated she got off the interstate to see if Resident #10 was hurt and if he wanted to get back in his wheelchair. Transport Aide F stated Resident #10 told her he did not want to get back up into the wheelchair. Transport Aide F stated she did not secure Resident #10 with a seatbelt because she was not sure how to secure a resident. Transport Aide F stated she did not feel she was properly trained in how to use a seatbelt. Transport Aide F stated Resident #10's wheelchair was secure to van floor properly. Transport Aide F stated she thought Resident #10 was secure in the van with wheelchair being secure to the floor. Transport Aide F stated she was suspended until today and will not be driving the van anymore. During an interview on 03/28/2025 at 02:50 PM, Resident #11 stated on 03/18/2025 while being transported in facility van to appointment in another town, Resident #11 asked Transport Aide F to put on her seatbelt. Resident #11 stated Transport Aide F told her seatbelt did not work. Resident #11 stated Transport Aide F put on brakes, and Resident #11 had to put her hands on the back of the seat in front of her to keep from falling out of wheelchair. Resident #11 stated Transport Aide F made her feel unsafe in the van and would not go in the van if Transport Aide F was driving. During a follow-up interview on 03/28/2025 at 04:00 PM, MM stated he trained Transport Aide F by showing her how to secure a resident in a wheelchair in facility van. Transport Aide F performed return demonstration several times. MM stated Transport aide-F did not report any problems with seatbelt in van. MM stated a refresher course was done on 03/25/2025 on how to strap the wheelchair down with ties, and how to safely buckle residents in a wheelchair with seat belt, if van not safe do not drive stop and call 911 and notify ADMNIN and DON. During a follow-up interview on 03/29/2025 at 01:05 PM, Transport Aide F stated she forgot to put the seatbelt on Resident #11 on 03/18/2025 during transport to appointment. Transport Aide -F stated on 03/25/2025 refresher course, she did not buckle the seat belt was only shown how it works. Transport Aide -F stated she remembered signing the in-service sheet dated 03/25/2025 for use of seatbelt. Transport Aide F stated there was construction on the interstate and she slammed on the brakes to not wreck. Transport Aide F stated Resident #10 slid out of wheelchair and Resident #10's left leg went under dashboard. Transport Aide F stated she pulled off the interstate at the next exit. Transport Aide F stated she asked Resident #10 if he was okay and if he wanted to get back into his wheelchair. Transport Aide F stated Resident #10 told her to just drive slowly and get him back to the facility. Transport Aide-F stated Resident #10 was just lying on floor of van and not saying anything about hurting. Transport Aide-F stated she did not call the ADMN because she did not feel she need to call since they were only 20-25 minutes away from the facility. Transport Aide-F stated she was unsure of where construction was on interstate. During an interview on 03/30/2025 at 11:13 AM, the ADMN stated there were no manufacture instructions in the van that she was aware of. The ADMN stated she thought the employee chose not to follow training and safety precautions. The ADMN stated she reeducated staff on 03/27/2025 and suspended Transport Aide F and took the facility van out of service for wheelchair transports. ADMN stated facility van was scheduled for safety inspection in another town on Friday 03/28/2025 for safety inspection of seatbelts. The ADMN stated the safety inspection determined the seat belt and the wheelchair tie downs were functioning properly, but it was recommended to upgrade the system due to it being old and antiquated. The ADMN stated the facility chose to not use the facility van for wheelchair transports. The ADMN stated what led to the failure of the neglect was Transport Aide F to follow the policy and procedures. The ADMN stated the facility would prevent further neglect by conducting resident council meetings, making rounds with residents for safe surveys, observe resident care and feedback from the staff and the residents. The ADMN stated only when a resident complained, was the issue addressed. The ADMN stated competencies were conducted on hire, annually and as needed with compliance. The ADMN stated MM inspected the van weekly and reported any negative findings. The ADMN stated she would expect staff to follow procedures and policies. Record review of facility policy titled: Van Driver Orientation Policy & Procedure, not dated revealed: Policy: Each employe who is designated to drive the facility van will receive adequate orientation and training to assure the safety of all passengers . 4. The designated trainer will instruct and review with the employee procedures to follow in case of an emergency and/or accident. The instruction shall include at a minimum: the facility phone number to contact, Administrators' cell phone number to contact, immediately call 911 in case of injury to any van passenger .to contact local police in caser of an accident .thoroughly check all passengers to assure well-being and seatbelts are secure 7 Once the steps are read and the designated trainer must instruct and observe return demonstration by employee n the correct procedure for safely securing a resident in a wheelchair and an ambulatory resident using the safety belts provided in the van. The employee must demonstrate how to safely apply and tighten the safety belts to prevent a wheelchair from rolling or tilting during transport and how to secure the safety belt around the resident to prevent injury Review of facility's policy titled, Identifying Types of Abuse, dated revised September 2022 revealed: As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents 1. Neglect is the failure of the 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. 2. Neglect occurs when the facility is aware of, or should have been aware of, goods, or services that a resident requires but the facility fails to provide them, and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. 3. Neglect includes cases where the facility's indifference to disregard for resident care, comfort, or safety results in (or could result in) physical harm, pain, mental anguish or emotional distress This was determined to be an Immediate Jeopardy (IJ) on 03/31/2025 at 2:40 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 03/31/2025 at 2:40 PM and was given Three Strike Letter. Record review of Plan of Removal accepted on 04/01/2025 at 04:24 PM reflected the following: FACILITY: [Facility Name] Facility ID Number: 110493 SURVEY TYPE: Complaint Survey SURVEY DATE: 03/31/2025 Plan for REMOVAL F 600 Plan to remove immediate jeopardy. The facility failed to ensure that a resident was free from neglect when the facility failed to provide the required structures and process in place for oversight and monitoring the safety of residents being transported by Transport Aide-A. F 600 On 3/26/25 Resident # 10 was assessed by the charge nurse for injuries, resident sustained a 25cm scratch to back. Charge Nurse notified physician, obtained orders for x-rays and notified responsible party. On 3/26/2025 Residents with appointments that must be transported in wheelchairs are identified as affected by using the current van for wheelchair transportation. On 3/26/25 Safe Surveys with other residents that were transported by the facility staff in wheelchairs and those not in wheelchairs. The Safe Survey Questions: 1. Do you feel safe here? 2. If, you have a concern do you feel comfortable reporting it? 3. Do you know who the Administrator is ? 4. Do you know who the Director of Nursing is? 5. Do you know who the Ombudsman is ? 6. Do you feel safe when transported by facility staff? Findings: Resident #10 and # 11 both reported issues with same driver not following training/using seat belts to secure resident. The other 5 residents did not report safety issues, just that the van was old and rundown. Staff did share that the center has a new van on order to replace the current van. On 3/25/2025 the van driver was retrained on facility safety procedures for strapping residents into the wheelchair using the wheelchair tie downs and seatbelts by another staff member. The NHA Nursing Home Administrator observed the retraining of the van driver, by the more senior staff member with experience driving the van. The van was removed from service for transporting residents in wheelchairs on 3/26/2025. The van will not be put back in service until the complete restraint system including seatbelts for wheelchairs is replaced. The facility has purchased a new van with delivery expected this week. Residents requiring wheelchair transport will be completed by sister facilities until all staff who will drive are checked off for operations of the lift, the wheelchair tie downs and seatbelts of the new van. Administrator, Surveyor and 2 facility approved drivers observed sister facility driver demonstrate the wheelchair tie downs and seat belting prior to transporting our resident on Monday 3/31/2025. One of our van drivers accompanied the resident and the driver on the appointment. The Administrator reviewed the van driver's competencies that were completed on the vehicle. Residents will not be transported in the existing van in a wheelchair until after the restraint system is updated and all drivers are checked off on securing the wheelchair with tie downs and seatbelts system for the residents. on 4/1/25 Both van drivers have been in serviced not to use the wheelchair van until the system for securing wheelchairs is replaced with new system and competencies with return demonstration are completed by the Nursing Home Administrator/Designee. On 3/26/2025 The van driver was suspended pending investigation. The van was removed from service in transporting wheelchairs on 3/26/2025 at 11am. Van was inspected on 3/28/2025 by a company that specializes in wheelchair transport vehicles. The technician stated to the Maintenance Supervisor the system is functioning, but old and needed to be updated. The NHA Nursing Home Administrator called to follow up the inspection report, was told there was a missing part, but was unable to determine what was missing since he was not aware of what system was installed in the van. The Administrator went back out to the van along with the more senior staff member with experience driving the van and could not find anywhere else a missing part would be mounted in the floor or sides of the van. There is a seatbelt part in the floor that the technician said was missing, but during the inspection by the NHA Nursing Home Administrator and the more senior staff person with experience driving the van the part is in the floor to connect the seatbelt. There is not an inspection report. NHA Nursing Home Administrator did call and email multiple times to request the report. On 3/31/2025 The NHA Nursing Home Administrator/Designee in-serviced all staff on the state provider letter PL 2024-14 Abuse Neglect Exploitation, Misappropriation of resident property and other incidents. The NHA Administrator/Designee chose to use another format to Inservice instead of the facility's policy and procedures on Abuse, Neglect, Exploitation and Misappropriation Program and Identifying Types of Abuse as staff were just in serviced on 3/20/2025 and 3/26/2025. All staff including new hires and agency, will be required to complete the in-service prior to starting their next scheduled shift. On 3/31/2025 NHA Nursing Home Administrator/ Designee In service all staff that drive the van on safety and emergency procedures with post test. If staff fail the post test they will be retrained again and tested again. Staff will not be allowed to operate the facility van until they have successfully passed the post test. On 3/31/2025 NHA Nursing Home Administrator /Designee performed competencies and return demonstration on emergency procedures, operating the wheelchair lift, test Driver on driving and reviewing you tube video for strapping the wheelchair and buckling the person in the wheelchair on all transport staff. Staff will be suspended from driving until competencies are passed. Competencies with return demonstration will be completed on hire, annually, and PRN. On 3/27/2025 NHA Nursing Home Administrator and Regional Nurse Consultant reviewed the Van Driver Orientation List and added instructions for emergency procedures to include procedures for if a resident falls out of seat or chair to pull over, call 911, notify NHA Nursing Home Administrator. On 3/31/2025 NHA Nursing Home Administrator/Designee will conduct audits with observation to be completed for proper securement of wheelchair and seatbelt use weekly times four weeks, then weekly times two weeks and PRN there after. 3/31/25 NHA Nursing Home Administrator /Designee will interview residents who are transported by facility staff. Residents will be asked the following questions: 1 Were you buckled in and wheelchair secured? 2. Did the driver follow posted speed limits and other traffic signs? 3. Did the driver use cell phone while driving? 4. D d you feel safe while being transported? 5. Do you have any other concerns? Interviews will be conducted with residents who are transported by the center staff weekly for four weeks, then weekly for two weeks and PRN thereafter. On 3/27/2025 Ad-Hoc QAPI Held with Medical Director, NHA Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant to review the alleged deficiency, policy and procedure and the plan of removal of immediacy. Ad-HOC QAPI repeated on 3/31/2025. The NHA Nursing Home Administrator will be responsible for ensuring the plan is completed on 3/31/2025. The RDO/Designee will provide oversight by observation and record reviews to the of NHA Nursing Home Administrator to ensure that the items on the plan of removal are reviewed and completed on 3/31/2025. The RDO/ Designee will continue monitoring weekly for four weeks, then monthly for two months then as needed. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record review from 04/01/2025 at 4:24 PM to 09:23 AM as follows: During an interview on 04/02/2025 at 05:34 AM, NA T stated she/he had in-service on neglect on 04/01/2025 by DON. NA T stated neglect was not changing a resident, not answering call lights, and not keeping resident safe. NA T stated she or he would report any suspected neglect to charge nurse and ADM. During an interview on 04/02/2025 at 05:38 AM, LVN K stated she had in-service on neglect on 04/01/2025 by DON. LVN K stated neglect was the failure to provide services to resident like not giving them their medications, not keeping them clean, not answering call lights and not keeping them safe. During an interview on 04/02/2025 at 05:40 AM, LVN V stated neglect was failure to provide resident with services such as medications, providing fluids, keeping them clean, helping them when asked for help. LVN V stated she would report neglect to ADM. LVN V stated she had in-service on neglect on 04/01/2025 by DON During an interview on 04/02/2025 at 05:42 AM, NA L stated he had in-service on neglect on 04/01/2025 by DON. NA L stated neglect was leaving a resident in soiled diaper for a long time, not feeding a resident, not answering call lights, not keeping them safe. NA L stated he would report to charge nurse and ADM. During an interview on 04/02/2025 at 05:50 AM, CNA A stated had in-service on neglect. CNA A stated neglect was leaving a resident unattended, not keeping them clean, leaving them in bed for hours and not checking on them. CNA stated she would report neglect to charge nurse and ADM. During an interview on 04/02/2025 at 05:55 AM, CNA stated she had in-service on Neglect 04/01/2025 by DON. CNA W stated neglect was not changing a resident when they were wet, not giving them something to drink, not keeping them safe. CNA W stated she would report neglect to charge nurse and ADM. During an interview on 04/02/2025 at 06:05 AM, LVN Y stated she had an in-service on neglect on 04/01/2025 By DON. LVN Y stated neglect was the failure to provide care such as not keeping residents safe. She stated she would report neglect to ADM. During an interview on 04/02/2025 at 06:08 AM, LVN P stated she had in-service on Neglect on 04/01/2025 by DON. LVN P stated neglect was the failure to provide care to residents. LVN P stated the failure could be not assisting resident to eat, not providing incontinent care. LVN P stated she would report any neglect to ADM. During an interview on 04/02/2025 at 06:10 AM, CNA X stated she had in-service on Neglect on 04/01/2025 by DON CNA X stated neglect was failure to provide care, not providing hygiene care, fluids, assistance when asked. CNA X stated she would report any neglect to charge nurse and ADM. During a record review on 04/02/2025 at 06:45 AM of MM and Transport Aide B completed retraining of the facility van orientation that included a test drive with ADM, securing a resident in a wheelchair in the van and securing a resident in the seatbelt. The test drive included adhering to state driving laws, parking and backing up the van. Record review revealed this training was conducted on 03/31/2025. Record review on 04/02/2025 at 07:10 AM of RDO/designee Review of F689 and F600 POR/POC signed by RDO on 04/01/2025. Record review on 04/02/2025 at 07:15 AM of in-service provided to the staff on 04/01/2025, that drive the facility's van. The in-service included the facility van is not to be used for wheelchair transports until further notice. Record review on 04/02/2025 at 07:20 AM of the facility's in-service conducted on 03/31/2025 included the van driver's competency with emergency procedures and a completed post-test by MM and Transport Aide B. During an interview 04/02/2025 at 08:10 AM, Transport aide B stated she/he had in-service on neglect on 04/01/2025 by DON. Transport aide B stated had been re-trained on use of seatbelts in van, in-serviced on new van orientation for calling 911 and notifying ADM if a resident slid out of wheelchair or got any injury during transport. Transport Aide B stated she was observed driving the van and parking the van, following speed limit, and parking the van, and securing resident in wheelchair in van with seat belt secured. Transport Aide B stated she had watched a YouTube video on van transportation and securing a wheelchair in van. Transport Aide B stated completed a competency for seat belts and safety in the van on 04/01/2025. During a record review on 04/01/2025 at 08:20 AM record review of facility's Ad-Hoc QAPI held on 03/31/2025 with Medical Director, ADM, DON, ADON, Regional Nurse Consultant that reviewed the alleged deficiency, policy and procedures and transport injury. Record review of Van Driver Orientation List for Transport Aide F on 04/01/2025 at 08:25 AM revealed training completed on 03/25/2025 that consisted of securing a wheelchair in the facility van and securing a resident in a wheelchair with seat belt. The training included a return demonstration of securing a wheelchair and securing a resident in a wheelchair with a seat belt. During a record review on 04/01/2025 at 08:30 AM of Van Driver Orientation List for Transport Aide F revealed training completed on 11/14/2024. Record review04/01/2025 at 08:35 AM of Resident #10's EMR progress notes dated 03/26/2025 revealed a physical assessment of the resident by DON after returning from van transport. The physical assessment revealed resident sustained an 25 cm abrasion to his lower back. Record review on o4/02/2025 at 08:40 AM of facility safe assessment conducted on 03/26/2025 of Resident #11, Resident #12, Resident #13, and Resident #14 safe survey interviews conducted by ADM revealed above residents did not feel safe when transported by facility van. The residents' stated van is not in good condition. Record review on 04/02/2025 at 08:42 AM of facility safe assessment conducted on 03/27/2025 for Resident #10 revealed Resident #10 did not feel safe when transported by facility staff due to staff did not follow training. During a record review on 04/02/2025 at 08:45 AM of Transport Aide F facility counseling dated 03/26/2025 Transport Aide F was suspended pending investigation of van incident. An Immediate Jeopardy was identified on 03/31/2025. While the Immediate Jeopardy was removed on 04/02/2025 at 09:23 AM, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm and a scope of pattern, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN, the DON, and the RRN were informed of the Immediate Jeopardy was removed on 04/02/2025 at 9:23 AM.

Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 1 of 13 residents (Resident #3) reviewed for sufficient staffing The facility failed to provide sufficient staffing of Secured Locked Unit for resident with known history of elopement that required 1:1 supervision on 03/24/2025. An Immediate Jeopardy (IJ) was identified on 03/21/2025. While the IJ was lowered on 03/28/2025 at 4:45 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place the residents at risk of residents' needs, safety and psychosocial well-being not being met. The findings include: Record review of Resident # 3's face sheet dated 03/24/2025 revealed a [AGE] year-old female admitted on [DATE] with a readmission on 02/19/2025 with the following diagnoses cardiac issues, seizures, and traumatic brain injury. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed: Section C - Cognitive Patterns Resident #3 had a BIMS of 14, meaning cognitively intact. Section GG Mobility Devices Resident #3 required the use of a walker. Record review of Resident #3's Care Plan updated on 03/21/2025 revealed: Problem: start date 10/09/2024 I am on the memory care unit due to exit seeking behaviors. On 3/21/25 had actual Elopement through bedroom window-High Risk 20. Goal: Resident will remain free from injury related to exit seeking/elopement attempts through next quarter. Approach: Start Date 03/21/2025 Consider Medication Review if behaviors continue or escalate; Start Date- 03/21/2025 Consider psych consult with increase in behaviors; Start Date- 03/21/2025 Ensure all basic needs are met when resident. becomes anxious or aggressive. Offer toileting, snack, fluids, comfort. Etc.; Start Date- 12/05/2024 Resident must be accompanied by staff while in courtyard. Start Date- 10/09/2024 Assess/ record/ report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, attempts to leave facility. Start Date- 10/09/2024 Check doors & windows for security and for proper functioning and placement per facility protocol. Start Date-10/09/2024 Develop and activities program to divert. attention and meet needs for social, cognitive stimulation; Start Date- 10/09/2024 Discuss with resident/ family risks of elopement. and wandering; Start Date- 10/09/2024 If resident is missing from facility, follow elopement protocol, notify MD and family. immediately, and document; Start Date- 10/09/2024 Placement on secure unit for high risk for elopement; Start Date: 10/09/2024 Supervise closely and make regular compliance rounds whenever resident is in room. Record review of Resident #3's physician orders revealed Start date of 10/09/2024 Admit to facility secure unit. Record review of Resident #3's progress notes revealed: Date 03/23/2025 at 4:52 PM documented by LVN C Resident exit seeking this shift. Eloped from Memory Care unit into ALF and was exiting ALF dining room door that leads to highway. Resident stopped outside door and escorted back to Memory Care. No injuries noted, Resident denies pain. Date 03/24/2025 at 1:07 PM documented by DON Clarification to note on 06/23/25 at 1652: Spoke with on duty memory care CNA on date of entry. CNA states res approached door in memory care dining room. Resident pushed on door, causing door alarm to sound. CNA immediately recognized and responded to alarm. CNA reports res was standing outside door of memory care dining room next to building. Res immediately redirected resident back through memory care dining room door without difficulty. Staff will perform 1 on 1 resident observation at this time until further placement arrangements can be made. During an observation on 3/24/2025 at 9:55 AM Resident #3 was sitting in his room on his bed, no staff was in his room or within the proximity of his room. During an observation on 03/24/2025 between 12:35 and 12:40 PM, CNA B was sitting at the dining room table assisting a resident with eating their lunch, NA Z was assisting another resident in the resident's room. One resident was trying to open doors and another resident was scraping food from one plate to another plate (that were not theirs) and pouring food on to the floor. CNA B appeared flustered while trying to provide care for the three residents in the dining area. Resident # 3 left the dining area and went to his room. During an observation and interview on 03/24/2025 at 3:20 PM, Resident #3 was standing in the hallway on the secure unit with his walker. Resident #3 stated he wanted to go home and that is why he ran away yesterday. Resident #3 went into his room and sat on his bed. CNA B was observed walking away from Resident #3's room, no staff were observed in room with Resident #3. During an interview on 03/24/2025 at 4:20 PM, CNA B stated she and NA Z were the staff who had been working on the secure unit that day. CNA B stated she was not aware Resident #3 was supposed to be on 1:1 supervision. CNA B stated she and NA Z were taking turns watching Resident #3. CNA B stated 1:1 supervision meant a staff constantly with a resident. CNA B stated when a resident was on 1:1 supervision staff documented on a log their observations of resident. CNA B stated she had not been notified Resident #3 was on 1:1 supervision by the nurse or the DON. CNA B stated she had not been given a log to document 1:1 supervision. CNA B stated whoever was doing the 1:1 supervision should have been writing it down. CNA B stated the DON or nurse had not told her that she needed to do one on one for Resident #3. During an interview on 03/24/2025 at 4:30 PM, NA Z stated she had not been notified that Resident #3 was on 1:1 supervision. During an interview on 03/25/2025 at 10:35 AM, the DON stated Resident #3 was placed on 1:1 supervision on 3/23/2025, after he exited the secure unit, until a new placement could be found. The DON stated her expectation was that Resident #3 be within line of sight of staff. The DON stated that if Resident #3 was in his room, he could not be seen by staff. The DON stated the aides on the secure unit were responsible to provide 1:1 supervision for Resident #3 and different staff would come and assist on the secure unit. The DON stated she was not aware there was times Resident #3 was not on 1:1 supervision. During an interview on 03/25/2025 at 11:45 PM, the ADMN stated her expectation was that Resident #3 was placed on 1:1 supervision on 3/23/2025 after he exited the building. The AMDN stated her expectation of 1:1 supervision was that Resident #3 should have been within line of site of a staff at all times. The ADMN stated NA Z, CNA B and LVN P were responsible for 1:1 supervision along with department staff throughout the day. The ADMN stated if Resident #3 was in his room there should have been a staff member within line of site. The ADMN stated she was not aware Resident # 3 had been in his room without staff. The ADMN did not have an explanation to why staff did not know about the 1:1 supervision., she stated staff should have been notified at the beginning of their shift. The ADMN stated they did not have a policy for 1:1 supervision. During an interview on 03/25/2025 at 1:15 PM, the MD stated he had provided care for Resident #3. The MD stated due to Resident #3's traumatic brain injury he was not capable of making decisions on his own and was not safe to be out of facility on his own. The MD stated the facility was on a major highway and if Resident #3 were to have gotten out of the facility, he could have had the potential of being stuck by a motor vehicle. The MD stated having only one staff on the secure unit during a shift was not sufficient staff to supervise all the resident's needs. Record review of facility policy title, Staffing, Sufficient and Competent Nursing dated August 2022, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.' This was determined to be an Immediate Jeopardy (IJ) on 03/21/2025 at 4:31 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 03/26/2025 at 12:30 PM. Record review of Plan of Removal accepted on 03/27/2025 at 5:17 PM reflected the following: FACILITY: [Facility Name] Facility ID Number: 110493 SURVEY TYPE: Complaint Survey SURVEY DATE: 3/26/2025 Plan for REMOVAL Plan to remove immediate jeopardy. The facility failed to provide sufficient staffing of Secured Locked Unit for resident with a known history exit seeking and elopement that required 10-15 minute safety checks and 1:1 supervision. F 725 On 3/26/2025 the Administrator notified the Medical Director of the immediate jeopardy. On 3/26/2025 None of the 12 residents residing on the secure unit are identified as inappropriate for the secure unit at this time. The 12 residents residing in the secure unit were assessed by the IDT team to include the Administrator, Director of Nurses, Regional Nurse Consultant and direct care staff for appropriate placement. An elopement risk assessment was also completed on all 12 residents on 3/26/2025. On 3/26/2025 The policies for one on one have been created to include the following: Residents are placed on one on one there will be a third designated person assigned to the resident & not part of the usual staffing pattern. Criteria for 1:1 would be a resident exhibiting self-harm and uncontrolled behaviors posing risk to self and others. Interventions used prior to placing a resident on 1:1 would be redirections, assessing pain, hunger, unmet need, toileting, and personal items. On 3/25/2025 the resident #3 was discharged to a different facility with a more secure unit to eliminate the risk of elopement by this resident. Starting on 3/26/2025 the Director of Nursing/Designee will initiate in-service for all staff including new hires and agency prior to working next scheduled shift including weekends and nights on adequate supervision to be defined as two facility staff members at all times present on the secure unit. Staffing from other departments will be reassigned to work in the secure unit if needed for both day and night shifts. Residents change of condition are discussed with the care plan team during the morning meeting, quarterly, and as needed. The facility will access the need for additional interventions when evaluating the changes in a resident's condition. Ad-Hoc QAPI meeting was held on 3/26/2025, with the Medical Director, NHA (Nursing Home Administrator), (Regional Nurse Consultant), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. Starting on 3/26/2025, IDT (Interdisciplinary team), including the Administrator, Director of Nursing an Assistant Director of Nursing, will review staffing schedules in the secure unit to determine two staff are always in the secured unit daily Monday to Friday, and Manager on Duty Saturday and Sunday. Any negative findings for sufficient staffing will be immediately brought up to the Administrator/Designee for further action, if necessary. Administrator/Designee will send additional staff including center leadership team, center staff and/or agency as needed to meet sufficient staffing needs. Starting 3/26/2025 RDO or designee will provide physical oversight at facility weekly x4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance by reviewing staffing schedule and assignment sheet and staff present Monday through Friday. The Weekend Manager on Duty will monitor compliance on weekends by reviewing staffing schedules and assignment sheets. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 3/26/2025. The RDO/Designee will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record review from 03/27/2025 at 5:17 PM to 03/28/2025 at 4:45 PM as follows: Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record review from 03/27/2025 at 5:17 PM to 03/28/2025 at 4:45 PM as follows: During an observation on 03/25/2025 between 4:45 and 4:50 PM all window in the secure unit were observed to have L brackets placed in each window. Record review of facility's EMR assessment section residents residing on secure unit on 03/28/2025 at 08:25 AM revealed elopement assessments for 12 residents currently residing on secure unit. 11 of 12 residents identified as elopement risk. Record review of the facility provided agenda for the Ad-Hoc QAPI meeting held on 3/26/2025 revealed that the MD had attended meeting and signed the agenda. Record review of electronic medical records revealed the 12 residents on the secure unit had an elopement risk assessment completed on 03/26/2025. Record review of facility provided policy revealed a policy titled One on One Resident Supervision. During an interview on 03/25/2025 at 8:40 AM the ADMN stated Resident #3 had been excepted to another facility and would be transported today to new facility. During an observation and record review on 03/25/2025 at 4:00 PM Resident #3 was not located on the secure unit. Record review revealed he had been discharged to another facility. Record review on 03/28/2025 at 09:00 AM, observed and reviewed in-services for staff located at nurses station, for One on One, Resident Rights, Staffing on Secure Unit, Elopement, and Exit seeking. Observed sign-in sheets for each in-service. Observed DON conducting an in-service with a dietary staff member. Record review of the facility provided agenda for the Ad-Hoc QAPI meeting held on 3/26/2025 revealed meeting was held and attendees had signed. Record review of facility provided documents revealed facility was performing head count and window checks daily. During an interview on 03/28/2025 at 09:10 AM, CNA A stated she was in-serviced on 03/27/2028 by DON on resident rights, secure unit staffing, one on one, exit seeking, and elopement on 03/27/2025 by DON. CNA A stated one on one was making sure resident was in line of sight and staying with them and not helping with other residents. CNA A stated the secure unit should have 2 staff on all shifts, if resident was exit seeking should try to redirect and call for help if needed. If a resident elopes, she was to try to find the resident, let the charge nurse know, do room check and head count. Residents have the right to make their own choices, refuse care, and know what medicines they are getting. During an interview on 03/28/2025 at 09:15 AM, NA G stated she was in serviced on 03/27/2025 by DON resident rights, one on one, staffing of secure unit, exit seeking and elopement on 03/27/2025 by DON. Staffing of secure unit with at least 2 staff unit each shift. NA G stated one on one meant always keeping resident in line of sight. NA G stated if residents were exit seeking to try to redirect or see if they are hungry. NA G stated residents had the right to refuse care, treated with respect, and make decisions. During an interview on 03/28/2025 at 09:20 AM, LVN H stated she was in-services on 03/27/2025 by DON on One-to One, Staffing on Secured Unit, Resident Rights, Exit Seeking, and Elopement on 03/27/2025 by DON. LVN H stated one on one meant keeping resident in line of sight and not leaving resident until another staff member can take over one on one. LVN H stated the secure unit should have been staffed with 2 staff at all times. LVNH stated if a resident was exit seeking staff should try to re-direct resident, offer food or see if the resident was in pain. LVN H stated residents had the right to refuse care, to be treated with respect and to make their own decisions. During an interview on 03/28/2025 at 09:30 AM, CNA I stated the secure unit should have 2 staff at all times, one on one meant to keep the resident in line of sight and to not leave them without someone to take the staff's place. CNA I stated for elopement should let charge nurse know, check all rooms, all areas of facility to try to locate resident. CNA I stated she had in-services on 03/27/2025 by ADON before her shift. CNA stated residents had the right to refuse care, treated with respect, and make decisions. CNA I stated other in-services she had today included Exit Seeking, Resident Rights, Staff on Secure Unit, and Elopement. During an interview on 03/28/2025 at 09:45 AM, AD said she received in-services on 03/28/2025 by DON on resident rights, one on one, secure unit staffing and elopement secure unit staffing. The AD stated one on one was keeping the resident in line of sight and secure unit should have 2 staff on all shifts. The AD stated if a resident was trying to elope to try to re-direct, get other staff to help. The AD stated if resident had eloped check on other residents, try to find missing resident and report to ADM, DON and other staff. The AD stated residents had the right to make their own choices, be treated with respect and have needs taken care of. During an interview 03/28/2025 at 09:55 AM, NA F stated she had been in-serviced on 03/28/2025 by DON on one on one, resident rights, staff on secure unit, elopement and exit seeking. NA F stated one on one meant staying with resident and keeping your eyes on them. NA F stated if resident eloped need to try to find them, call DON and ADM and let other staff know someone is missing. NA F stated residents had to the right to refuse care, treated with respect, and make decisions. Transport Aide F stated the residents had the right to be treated with respect, and to make their own choices. During an interview on 03/28/2025 at 10:28 AM, CNA J stated she worked night shift and had in-services 03/27/2025 by DON on one on one, staffing of secure unit, elopement, exit seeking, and resident rights. CNA J stated she would assist on secure unit when needed and one on one meant to keep the resident in line of sight and not leave the resident. CNA J stated if a resident was exit seeking to try to re-direct them or offer them something to eat and if a resident elopes to let all staff know, try to locate resident and notify ADM and DON and make sure all other residents are accounted for. CNA J stated residents had to the right to refuse care, treated with respect, and make decisions. During an interview on 03/28/2025 at 11:05 AM, LVN K stated she had in-service [AJB1] 03/27/2025 by ADON on resident rights, elopement, exit seeking, staffing on secure unit and one on one. LVN K stated the secure unit should have 2 staff on all shifts, one on one meant keeping resident in line of sight. LVN stated residents had the right to refuse care, to be treated with respect, and make their own decisions. During an interview on 03/28/2025 at 11:17 AM, NA L stated received in-services [AJB2] on 03/27/2025 by DON on resident rights, one on one, secure unit staff, elopement and exit seeking and staffing on secure unit. NA L stated for resident's exit seeking to try to distract resident. Resident rights, the residents have the right to make their own choices, to be treated with respect and taken care of. NA L stated one on one means making sure you can see residents all the time you were with them, and the secure unit should have 2 staff on all shifts. NA L stated if a resident eloped, he would let the charge nurse know immediately and would begin looking for resident and making sure no one else is missing. During an observation on 03/28/2025 at 12:01 PM, the DON was on the secure unit performing head count of the residents and checking on the residents and the staff. During an interview on 03/28/2025 at 01:25 PM, the DON stated she prepared in-services for resident rights, one on one, Secure unit staffing, elopement and exit seeking. The DON stated she conducted in-services on 03/27/2025 with staff in-house on both shifts. DON stated all staff were provided handouts regarding information on all in-services. DON stated she was available to staff for any questions or concerns. During an interview on 03/28/2025 at 01:35 PM, ADON stated she assisted DON with preparing in-services on 03/27/2025 on resident rights, Secure unit staffing, one on one, Exit seeking, and elopement. ADON stated called staff not at facility or not able to come to facility for in-services and discussed in-service information with staff on phone. ADON stated handouts were available for all staff and would be given to staff unable to attend in person. During an observation on 03/28/2025 at 01:40 PM observed all the windows on secure unit had L brackets on the windows to prevent windows from being raised more than 6 inches. During an interview on 03/282025 at 02:10 PM, MM stated he checked windows L brackets on secure unit daily and if any not working they would be fixed immediately. MM stated he had a log sheet to document that L brackets were checked and secure. MM stated he had in services 03/27/2025 by ADON on one on one, secure unit staffing, resident rights and elopement and exit seeking. During an interview on 03/28/2025 at 02:45 PM, Housekeeper M stated she attended in-services on 03/28/2025 by DON for resident rights, one on one in secure unit. Staffing for secure unit, exit seeking and elopement. Housekeeper M stated one on one was keeping resident in line of sight and staying with the resident until someone else was available. Housekeeper M stated residents have the right to make choices and to kept clean and safe. During an attempted interview on 3/28/2025 at 3:45 PM the MD's office did not answer phone and a message was left. An Immediate Jeopardy was identified on 03/21/2025. While the Immediate Jeopardy was removed on 03/28/2025, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm and a scope of pattern, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN, the DON, and the RRN were informed of the Immediate Jeopardy was removed on 03/28/2025 at 4:45 PM.

Based on interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 7 of 10 days reviewed for sufficient staffing. The facility failed to maintain nurse staffing at the level indicated by the PPD budget on 03/23/2024, 05/11/2024, 06/13/2024, 06/18/2024, 07/02/2024, 07/05/2024 and 07/07/2024. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met. Findings included: Record review of timesheets dated 03/23/2024 revealed 168.63 hours worked by direct care staff. Per facility PPD and census, 176.70 direct care staff hours were needed. Record review of timesheets dated 05/11/2024 revealed 137.36 hours worked by direct care staff. Per facility PPD and census, 156.75 direct care staff hours were needed. Record review of timesheets dated 06/13/2024 revealed 162.33 hours worked by direct care staff. Per facility PPD and census, 171 direct care staff hours were needed. Record review of timesheets dated 06/18/2024 revealed 166.40 hours worked by direct care staff. Per facility PPD and census, 173.85 direct care staff hours were needed. Record review of timesheets dated 07/02/2024 revealed 169.02 hours worked by direct care staff. Per facility PPD and census, 176.70 direct care staff hours were needed. Record review of timesheets dated 07/05/2024 revealed 147.80 hours worked by direct care staff. Per facility PPD and census, 176.70 direct care staff hours were needed. Record review of timesheets dated 07/07 /2024 revealed 148.32 hours worked by direct care staff. Per facility PPD and census, 173.85 direct care staff hours were needed. During an interview on 07/09/2024 at 9:25 AM Resident # 26 stated the facility was short staffed and it took staff a long time to respond to call lights. Resident # 26 stated the most recent time she remembered taking a long time to answer the call light was on July 5th. She had pushed her call light because she had urinated on herself, and the aide came in and told her she would come back to change her and did not come back for over 2 hours. Resident #26 stated she did not have any skin breakdown, but that she had sensitive skin and it hurt when she had to sit in urine. During an interview on 07/09/2024 at 10:34 AM Resident #9 stated the staff take a long time to answer call lights and there have been times when there were only 2 aides to take care of the entire building. Resident # 9 stated he has had to call his family member to have someone come to his room to assist him to the restroom because no one had answered his call light. During a confidential interview on 07/09/2024 at 3:30 PM the confidential interview stated they were happy that State was in the facility as they had asked upper management for more staff as they were being told that the CNA's were to clean the MCU while working their shift. Confidential interview stated HK would go clean only on Fridays. Confidential interview stated HK had not always cleaned on Fridays and that was why it smelled of urine. Confidential interview stated it took them away from resident care and was unable to keep up with both jobs. During an interview on 07/09/2024 at 4:00 PM the HK Supervisor stated her HK staff stayed mostly on the 1-3 halls M-F and there was no specific day for those halls to be cleaned. She stated the MCU was designated to be cleaned only on Fridays, but at times had not been cleaned on a weekly basis because the CNA's were to clean that hallway. The HK Supervisor stated she had spoken to ADMN about getting more staff for HK, but no staff had been hired. She stated she only had 3 HK all day on Fridays and the aides do all the cleaning on hall 4 (MCU) due to not having enough HK staff to help clean there. The HK Supervisor stated she did not keep a cleaning log for the MCU. The HK supervisor stated she was responsible for monitoring Hall 4 (MCU). Her expectations were to have someone to help check the laundry and to check for any chemicals, clear the hallways and rooms for trash and dirty dishes. She stated the negative impact for the MCU residents were, they could not realize something was dirty because of their conditions and it was not acceptable for them to be in this environment. The HK Supervisor stated there was sometimes only one aide on the MCU, and it would be hard to watch the residents and keep it clean the way it was supposed to be. During an interview on 07/10/2024 at 6:41 PM the DON stated her expectation was for staffing to be at corporate PPD rate. The DON stated the PPD rate was 2.85 and was only hours for direct care staff. The DON stated not meeting the PPD could affect residents by the staff could have had a slower response time. During an interview on 07/10/2024 at 7:07 PM the ADMN stated her expectation was to staff the building with direct care staff at the PPD rate set by corporate. The ADMN stated the PPD rate was 2.85, and the PPD hours were determined by multiplying the rate (2.85) by the census and that would give you the number of hours needed. The ADMN stated the DON and herself were responsible to monitor staffing. The ADMN stated not meeting the PPD hours could have affected the residents by resident care could have been delayed. The ADMN stated she thought what led to the failure was the retention of staff and difficulty of staffing. Record review of facility policy titled, Hours of Work dated December 2009 revealed: facility has established hours of work in accordance with resident needs and current regulations governing our facility's staffing requirements.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. Foods were not sealed and/or labeled properly in dry food storage, refrigerator, and freezer. 2. Ice machine scoop was not stored in proper container while not in use. 3. Hairnets not being worn when needed. 4. Uncovered trash receptacle bin 5. Scoop was left inside the dry storage oatmeal container. 6. Expired food products in the dry storage area. These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on [DATE] at 9:57 AM of the kitchen revealed: Dry Storage: 1. dry oatmeal with scoop placed and left inside container dated [DATE] 2. unsealed opened 50 lb. bag of dry oats 3. opened bag of dry cereal not labeled 4. 1 box dry cereal with an expired date of [DATE] 5. 1 unsealed loaf of bread with no open date 6. 1 unsealed package of hotdog buns 7. 1 bag of 2 round kaiser rolls with an expired date of [DATE] 8. 3 loaves of bread with an expired date of [DATE] 9. 1 unsealed 16 oz bag of potato chips 10. 1 opened 49.6 oz bag of cornbread stuffing mix not labeled or dated 11. 1 opened unsealed 24 oz bag of gelatin dessert 12. 1 opened unsealed bag of Buttermilk Biscuit Mix 13. 1 bag of spaghetti noodles unlabeled and undated Refrigerator #1 1. 1 gallon of opened lime juice with no open date 2. 1 quart of opened Half and Half with no open date 3. 1 gallon of opened whole milk with no open date 4. opened sliced sandwich cheese with no open date or label 5. 9 unopened plastic bags of yellow liquid with no in date or label 6. 15 dessert bowls of pudding with no label or date. Freezer #1 1. ,d+[DATE]-gallon tub of ice cream with no open date 2. 1 unsealed bag of frozen okra with no label or open date 3. 1 opened unsealed bag of frozen pasta with no label or open date Kitchen 1. Ice machine was observed with ice scoop on top of unit and not stored in the proper area 2. Open trash receptacle with no lid in cooking area During observation on [DATE] at 11:00 AM the DA was observed not wearing a hair restraint on his beard. During an interview on [DATE] at 11:00 AM the DA stated he was supposed to be wearing a hairnet over his beard and it had been about 3 months since he had worn one. He stated he had had in-services on doing so. The DA stated not doing so, could cause residents to possibly get hair in their food, and would be contaminated. During an interview on [DATE] at 11:53 AM the DM stated there should have been no expired products in the pantry and was not aware there were. She stated all products should have had an in date, and once opened or taken out of the original box, they should have been labeled with an opened date. The DM stated she monitored for expired dates as well as monitored products being labeled and stored properly twice a week. She stated the staff usually used the products before they would have expired so had not monitored the expired products as closely. The DM also stated, hairnets should be worn on all exposed hair, even beards, in the kitchen. She stated she had told her staff multiple times a hairnet should be worn, but they had not listened to her. She stated it was unclean to not wear one, with the possibility of hair getting into the resident's food. The DM stated the uncovered trashcan receptacle was unsanitary and was always to be covered. She stated it was not to be placed in the prep and cooking area without a lid. The DM stated dietary staff knew they were to have kept the trash receptacle covered at all times. The DM stated the ice scoop was to be stored on top of the ice machine. She stated the top of the ice machine had not been cleaned or sanitized, and she never thought it was an unsanitary place to store it. She stated the negative impact to residents possibly could have been bacteria getting into resident drinks when ice was being placed in their cups causing them to get sick. The DM stated the scoop in the oatmeal should not be stored inside the bin. She stated it was unsanitary and could cause cross contamination with staff touching it. She stated all dietary Infection Control was monitored ultimately by her, as the residents were vulnerable to increased bacteria. She stated they could get sick. The DM stated all staff should also wear hairnets on any loose hair. She stated the failures were staff not doing what was asked of them and to follow through with rules and regulation of what was taught in her in-services and trainings. She stated her expectations were for the residents' food to not be contaminated with germs and bacteria. The DM stated ultimately, she had not monitored her staff or followed through with rules and regulations and keeping staff accountable. The DM stated her expectations were for staff the follow all trainings and protocols. During an interview on [DATE] at 6:27 PM, the ADMN stated the DM monitored the kitchen sanitation, cleanliness and all food preparation and products. She stated she had not seen or performed any follow up of dietary staff since she had recently started the position as ADMN. She stated she felt the failure was with staff not following through with their in-services. The ADMN stated the negative impact to residents could have been cross contamination with residents getting sick. She stated her expectations were for all staff to follow the guidelines and regulations for the health of the residents. Record review of facility policy Food Receiving and Storage dated and revised [DATE] revealed: Policy Statement-Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation-Clean Storage area: Food Services, or other designated staff, will maintain clean food storage areas at all times . Dry Foods Stored in Bins: dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in-first out system. Labeling Foods Stored in Refrigerator/Freezer: All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Expiration Dates: supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes Record review of facility policy Food Preparation and Service dated, [DATE] revealed: 7. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. 7. Dietary staff shall wear hairnet (hairnet, hat, beard restraint, etc.) so that hair does not contact food. Record review of the Texas Food Establishment Rules accessed at https://www.dshs.texas.gov/foodestablishments/pdf/Laws/TFERFieldInspectionManual032416.pdf on [DATE] revealed: Food storage containers, identified with common name of food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food . is in a container or package that does not bear an expiration date or day .food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded

Based on observations, interviews, and record reviews, the facility failed to maintain an environment that was as free from accident hazards as was possible for 2 of 4 (Hall 300 and Hall 400) halls reviewed for accident hazards. The facility failed to ensure a spray bottle of grill and oven cleaner, a bottle of rubbing alcohol, a wire metal brush and a steel wool cleaning pad were stored in a cabinet on Hall 300 that was locked and not accessible to the residents on Hall 300. The facility failed to ensure a bottle of shaving cream, a tube of antifungal powder, a tub of zinc oxide, body lotion, deodorant bottles, and a bottle of shampoo/body wash were stored in a locked shower room and not accessible to the residents on Hall 400. This failure could place residents at risk of injury due to hazardous chemicals. Findings include: During an observation on 07/08/2024 at 11:48 AM, an unlocked cabinet in the Hall 300 kitchen contained the following items: a spray bottle of grill and oven cleaner, a bottle of rubbing alcohol; a wire metal brush and a steel wool cleaning pad. During observation on 07/09/2024 at 3:37 PM, Hall 400 (MCU) shower was unlocked with chemicals and cleaners that included: shampoo and body wash, deodorant bottles, shaving cream, Antifungal powder, Zinc Oxide paste skin protectant and moisturizing body lotion. During an interview on 07/08/2024 at 12:16 PM, LVN A stated cleaning items should not have been stored in the kitchen on Hall 300. LVN A stated the kitchen was only used to serve food. LVN A stated the kitchen staff were responsible for monitoring items in the Hall 300 kitchen. LVN A stated chemicals should have been stored where residents were not able to have access. During an interview on 07/10/2024 at 6:15 PM, the ADON stated cleaning chemicals, rubbing alcohol, shampoo, lotions, and zinc oxide cream should not have been stored where residents could have been able to ingest them. The ADON stated all staff should have been monitoring and making sure hazardous items were locked where residents were not able to get to them. The ADON stated if a resident were to eat or drink hazardous materials it could have caused serious harm. During an interview on 07/10/2024 at 7:07 PM, the ADMN stated chemicals should not have been stored in a location where residents were able to access them. The ADMN stated the shower rooms should have been locked when not in use. The ADMN stated residents could have had a hazardous effect if they were to eat or drink something they were not supposed to. The ADMN stated what led to the failure was staff were not following their policies and procedures . Record review of facility policy titled, Environmental Services Safety Procedures dated 01/01/2023 revealed Staff will ensure equipment (e.g., cords, ladders, or chemicals) is properly stored and not left unattended in areas that are accessible to residents. When not in use, equipment will be stored in a locking closet, cabinet, laundry carts, or storage area for safety.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 1 (Resident #315) of 18 residents whose medications were reviewed. The facility failed to ensure Resident #315 (a male) received a female hormone replacement drug (Medroxyprogesterone) due to inappropriate sexual behaviors without review for continued necessity and documented rational for the benefit or adequate monitoring from 06/14/2024 until current. This failure could place residents at risk of being over-medicated or experiencing undesirable side effects and cause a physical or psychosocial decline in health. The findings included: Record review of Resident #315's electronic face sheet revealed: [AGE] year-old-male admitted [DATE]. Resident #315's diagnoses included: Depression, Type II diabetes mellitus, Mood disorder, Generalized Anxiety, Other sexual dysfunction not due to substance or known physiological condition, Hypertension (high blood pressure) Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident # 315's Admission MDS assessment dated [DATE] revealed: Section C Cognitive Patterns BIMS score was 06 (severe cognitive impairment). Section E Behaviors-A. Physical behavioral symptoms directed toward others (sexual) 2. Behaviors of this type occurred 4 to 6 days, but less than daily. Record review of Resident #315's Physician orders dated 07/01/2024 revealed: medroxyprogesterone (Hormone used for the treatment of sexually inappropriate behavior in patients with dementia) tablet 10 mg 1 tablet by mouth once a day. Record review of Resident #315's Care plan dated 06/18/2024 revealed: Problem start date 06/18/2024, I have been sexually inappropriate with female staff and residents. I have touched their breasts and have verbalized my wishes to touch them again. I wander in and out of rooms but am easily redirected. Goal: Problem: Resident sexual behavior will decrease. Approach: Review medications as needed. 1. Psych consult for possible medication change to decrease sexual behaviors. 2. Close monitoring and frequent rounds on Resident. 3. Redirect and correct sexual behaviors. During an interview on 07/10/2024 at 10:05 AM, the ADON stated the admitting nurse was responsible for getting consents signed for anti-psychotics, anti-depressants and all medications that require a consent. The ADON stated she checks and was to follow up to make sure all consents were signed. She stated this one just got missed due to agency staff working. She stated the negative impact on the resident would be that side effects could have been missed or why they had taken the medication. She stated Resident #315's family was aware of the medication administered for behaviors but had no consent for this one. During an interview on 07/10/2024 at 2:00 PM, Resident #315's representative stated he had not signed any consents or gave a verbal consent for this medication. He stated he knew of the medication and was accepting of it being provided to this resident but had not known there needed to be a consent signed. He stated the resident has been on this medication before entering the facility and was asked to sign the consent this day of 07/10/2024. During an interview on 07/10/2024 at 2:42 PM, the DON stated they had gotten a verbal consent from the representative and should have been in the residents' EMR. She stated the facility was to obtain consents for everything and did not know why this one was missed. The DON stated the admitting nurse monitors the consents as she was responsible for the admitting paperwork to be completed. She stated Resident #315's representative lived out of state and there would have been no way for him to sign the consent. The DON stated it was partly her fault as she had only gotten verbal consents. She stated she did not think there was a negative impact to Resident #315 since the Resident Representative was aware. She stated a negative effect on the resident were that if it wasn't the correct dose there could have been different behaviors. The DON stated it was herself as well as the ADMN give the consent trainings to the admission staff and should have done a checklist upon admission. She stated the failure was not having the communication between staff with her expectations to have the consents completed on admission. The DON stated there was no consents policy to provide.

Based on interviews and record reviews, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #41 and Resident #315) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #41's comprehensive care plan was person centered and measurable when addressing Residents delusions behavior. The facility failed to ensure Resident #315's comprehensive care plan contained Resident's medication prescribed for the treatment of sexually inappropriate behavior in patients with dementia. These failures could affect the residents by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #41 Record review of Resident #41's Admission MDS assessment dated [DATE] revealed: Section A- Identification Information revealed Resident #41 was an [AGE] year-old female admitted on [DATE] with an original admitted [DATE]; Section C-Cognitive Pattens reflected she had a BIMS score of 9 (moderately impaired cognitive status); Section D- Mood reflected Resident #41 had felt down and depressed (nearly every day); Section E- Behavior reflected Resident had delusions; Section I- Active Diagnoses reflected Resident #41 had the following diagnoses: osteoarthritis (Chronic disease that causes the breakdown of joint cartilage), Diabetes mellitus Type II, Fracture of shaft of right femur, Fracture of upper end of right humerus (upper arm), Insomnia (persistent problems falling and staying asleep), depression, dementia, and depression; Section N- Medications revealed no evidence that Resident #41 received antipsychotic, antianxiety or antidepressant medications. Record review of Resident #41's Physician Orders dated 07/01/2024 revealed no evidence of medication ordered for antipsychotic, antianxiety or antidepressant medications. Record review of Resident #41's care plan dated 05/28/2024 revealed: Problem start date 05/28/2024 Resident's RP is reluctant to consent to psychoactive medications. Family prefers to take a holistic approach to medical care. Problem: Resident will not experience any adverse effects from holistic approach. Approach Base POC on minimal pharmacological interventions. Problem: start date 05/28/2024 Resident has episodes of anxiety and is at risk of fluctuations in moods; Goal: Resident anxiety will be maintained at the level tolerable to resident and will demonstrate reduced anxiety AEB response to proper medication over the next quarter; Approach: administer medications as ordered; monitor and document s/sx of medications; monitor and documents s/sx of adverse effect of medications given r/t the underlying health problem. Problem: start date 05/28/2024 Resident has a diagnosis of depression and is at risk for fluctuations in mood, little interest or pleasure in doing things and decreased socialization; Goal: Resident will have fewer or no episodes of depression and will voice positive feeling about self over the next quarter; Approach Administer medication as ordered, monitor labs-report abnormal to MD Resident #315 Record review of Resident #315's electronic face sheet revealed: [AGE] year-old-male admitted [DATE]. Resident #315's diagnoses included: Depression, Type II diabetes mellitus, Mood disorder, Generalized Anxiety, Other sexual dysfunction not due to substance or known physiological condition, Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident # 315's Admission MDS assessment dated [DATE] revealed: Section C Cognitive Patterns BIMS score was 06 (severe cognitive impairment). Record review of Resident #315's Physician orders dated 07/01/2024 revealed: medroxyprogesterone (Hormone used for the treatment of sexually inappropriate behavior in patients with dementia) tablet 10 mg 1 tablet by mouth once a day. Record review of Resident #315's Care plan dated 06/18/2024 revealed: Problem start date 06/18/2024, I have been sexually inappropriate with female staff and residents. I have touched their breasts and have verbalized my wishes to touch them again. I wander in and out of rooms but am easily redirected. Goal: Problem: Resident sexual behavior will decrease. Approach: Review medications as needed. 1. Psych consult for possible medication change to decrease sexual behaviors. 2. Close monitoring and frequent rounds on Resident. 3. Redirect and correct sexual behaviors. During an interview on 07/10/2024 at 6:15 PM the ADON stated she and the DON were responsible for creating care plans. The ADON stated care plans should have been individualized, person centered and measurable. The ADON stated interventions should be individualized for each resident. The ADON stated Resident #41should not have had interventions for antidepressant, antipsychotics and antianxiety because she was not taking any of those medications. During an interview on 07/10/2024 at 6:41 PM the DON stated her expectation was that care plans should have been personalized and measurable. The DON stated the affect on residents not having a person specific care plan could have resulted in care or monitoring not being provided. The DON stated oversight led to failure of care plans not being person specific. Record review of facility policy titled, Care Plans- Comprehensive dated September 2010 revealed , An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals . Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process. 44728

Based on observations, interviews, record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 4 hallways (Memory Care Unit) and reviewed for safe, functional, sanitary, and comfortable environment. The facility failed to have residents' environment clean and without damage for 1 (MCU) of 4 hallways. These failures could place residents who reside in the facility in an unsafe and uncomfortable environment. Findings included: During observation on 04/08/2024 at 9:45 AM revealed: 1. Smell of urine upon entrance 2. Debris and trash in the hallway and resident rooms 3. Window frame unpainted with exposed wood and debris During a confidential interview on 07/09/2024 at 3:30 PM, the confidential interview stated they were happy that State was in the facility as they had asked upper management for more staff as they were being told that the CNA's were to clean the MCU while working their shift. Confidential interview stated HK would go clean only on Fridays. Confidential interview stated HK had not always cleaned on Fridays and that was why it smelled of urine. Confidential interview stated it took away them away from resident care and was unable to keep up with both jobs. During an interview on 07/09/2024 at 4:00 PM, the HK Supervisor stated her HK staff stayed mostly on the 1-3 halls M-F and there was no specific day for those halls to be cleaned. She stated the MCU was designated to be cleaned only on Fridays, but at times had not been cleaned on a weekly basis because the CNA's were to clean that hallway. The HK Supervisor stated she had spoken to ADMN about getting more staff for HK, but no staff had been hired. She stated she only had 3 HK all day on Fridays and the aids do all the cleaning on hall 4 (MCU) due to not having enough HK staff to help clean there. The HK Supervisor stated she did not keep a cleaning log for the MCU. The HK supervisor stated she was responsible for monitoring Hall 4 (MCU). Her expectations were to have someone to help check the laundry and to check for any chemicals, clear the hallways and rooms for trash and dirty dishes. She stated the negative impact for the MCU residents were, they could not realize something was dirty because of their conditions and it was not acceptable for them to be in this environment. The HK Supervisor stated there were sometimes only one aid on the MCU, and it would be hard to watch the residents and keep clean the way it was supposed to be. During an interview on 07/10/2024 at 2:42 PM, the DON stated the protocols for HK and cleaning the MCU was to be designated on Fridays, but they could not always clean that day due to low staffing. She stated the CNA's and Aids do a cleaning sweep with the day and night shift splitting the duties. The DON stated the staff as a whole should have been cleaning the facility areas but ultimately it fell on the Director of HK. She stated it was nursing and CNA's that monitored and clean up and if they were not able to finish it, it was HK was that finished the job. The DON stated if the environment were not cleaned the residents could possibly get sick, but it depended on what their diagnosis was. She stated the failure occurred with not having enough cleaning staff, and her expectations was that the residents environment be cleaned and completed in a timely manner. During an interview on 07/10/2024 at 6:42 PM, the ADMN stated the MCU should be cleaned before any other halls in the facility, as that hall was a high touch area. She stated the MCU hall would be more likely to spread bacteria. The ADMN stated it was the HK supervisor who should have monitored as well as herself as ADMN, but she had not had the time since being hired in that position. She stated it fell on the HK to clean in the MCU on Fridays and the CNA's being told to clean on the other days. The ADMN stated since the CNA's cleaning prior to Fridays it most likely would cause for a decrease in proper resident care when needed. She stated the failure to having done it that way was not having enough staff but had not been aware of the dirty environment. The ADMN stated her expectations were to add more staff to help on that hallway to better the environment for the residents. Record Review of facility policy Quality of Life-Homelike Environment with revised date of April 2014 revealed: Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 1. Staff shall provide person centered care that emphasizes the residents comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order; b. Comfortable lighting c. Inviting colors and decor d. Personalized furniture and room arrangements e. Pleasant neutral scents; f. Plants and flowers, where appropriate; g. Comfortable temperatures; and h. Comfortable noise levels

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 15 (01/01/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/27/2024, 01/28/2024, 02/03/2024, 02/04/2024, 02/10/2024, 02/11/2024, 02/17/2024, 02/24/2024, 02/25/2024, 03/02/2024 and 03/03/2024) of 91 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 01/01/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/27/2024, 01/28/2024, 02/03/2024, 02/04/2024, 02/10/2024, 02/11/2024, 02/17/2024, 02/24/2024, 02/25/2024, 03/02/2024 and 03/03/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Review of facility's Direct Care Staff Daily Report from 01/01/2024 to 01/31/2024 revealed on 01/01/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/27/2024 , 01/28/2024, 02/03/2024, 02/04/2024, 02/10/2024, 02/11/2024, 02/17/2024, 02/24/2024, 02/25/2024, 03/02/2024 and 03/03/2024 there was no evidence of RN coverage. During an interview on 07/09/2024 at 3:30 PM, HR stated she had been responsible for scheduling. HR stated she had a staff rotation in place where an RN would be scheduled daily. HR stated when one RN needed time off she did not think about needing to have an RN cover. During an interview on 07/10/2024 at 6:41 PM, the DON stated she was hired to be the DON in January of 2024. The DON stated when she started, HR was scheduling nursing staff, and within the last few weeks she had taken over the responsibility. The DON stated when she started there was a schedule in place that had an RN scheduled each day. The DON stated what led to the failure was HR and herself not able to find RN coverage if one of the RNs scheduled had taken time off. The DON did not think there was a negative effect to residents because the DON and ADON were always on call and able to come in or answer questions over the phone. During an interview on 07/10/2024 at 7:07 PM, the ADMN stated the expectation was to have 8 hours of continuous RN coverage daily per federal guidelines. The ADMN stated the facility did not have a policy for RN daily coverage. The ADMN stated when she started, 4 weeks ago, she realized there was not a system to track RN coverage. The ADMN stated the HR person had been doing the scheduling prior to her starting at the facility. The ADMN stated she and the DON had taken the responsibly of monitoring RN coverage. The ADMN stated she did not think having missed RN coverage had a negative effect to the residents because they had LVN coverage, and staff had access to the DON and ADON. The ADMN stated she thought what led to the failure was the retention of staff and challenge of staffing. Record review of facility policy titled, Hours of Work dated December 2009 revealed: facility has established hours of work in accordance with resident needs and current regulations governing our facility's staffing requirements.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 2 lunch meals tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 07/08/2024. There were no temperatures logged for the morning meal of 07/08/2024. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: During observation on 07/08/2024 at 11:33 AM of the temperature logbook, the breakfast temperature were not logged. During observation on 07/08/2024 at 11:34 AM, the [NAME] had not temped the food before plating began. The puree food temperatures (which were below the required temperature of 135 degrees) included: 1. pureed broccoli rice at 119 degrees 2. mechanical chicken at 117 degrees 3. pureed chicken at 132 degrees 4. pureed green beans 130 degrees During an interview on 07/08/2024 at 11:45 AM, the DM stated the food temperatures were not hot enough. The DM stated temperatures should have been done prior to plating. She stated she monitored the dietary staff and food temperatures prior to serving residents. She stated since they were not up to correct temperatures it would have to be warmed up. She stated the dietary staff have had training, but it was on a one-to-one verbal training and had not documented them. During an interview on 07/08/2024 at 11:49 AM, the Dietary [NAME] stated she did not temp the food because they were running behind with serving. She stated she was not the morning cook, but the staff should have recorded them in the logbook if they had been done. She stated the staff have one to one in-service with the DM. She stated if the food was too cold, residents may not have eaten it, with that leading to weight loss. During an interview on 07/10/2024 at 6:30 PM, the ADMN stated all food temperatures should have been taken and food kept at proper temperatures before serving residents. She stated in not doing so the negative impact for residents could have caused bacteria to build with residents possibly getting a food borne illness. She stated the failure was with the cook and not temping the food, and the staff should never be in too much of a hurry having placed the residents in jeopardy. She stated the DM was to have monitored the temperatures and food temp logs. The ADMN stated the failure was with dietary staff being in a hurry. She stated her expectations were for all food temperatures to be completed and logged into the food temperature logbooks. Record review of facility policy titled Food Preparation and Service with revised date of 2014 revealed: Policy Stated Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Food Preparation, Cooking, and Holding Temperatures and Times: 1. The danger zone open the temperature is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Review of facility policy titled Resident Nutrition Services with the revised date of November of 2009 revealed: 4. To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (45 F to 135 F) will be kept to a minimum .

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food storage. The facility failed to properly store food in the dry food storage, refrigerators and freezer in the kitchen . This failure could place residents at risk for foodborne illnesses. Findings include: During an observation on 10/06/23 at 4:15 PM of the kitchen revealed the following: Dry Food Storage 1 small can of powdered milk with an opened date of 10/26/21 with an expiration of 01/2022. 1 small can of baking powder with an open date of 01/03/22 with an expiration date of 10/18/23. 1 bag of egg noodles was half empty and unsealed. 1 bag of cereal was 3/4 empty was unsealed. 1 bottle of pancake syrup that was 2/3 empty had an unreadable opened date. 1 bottle of soy sauce was 3/4 empty and was not closed completely. 1 5-gallon tub appeared to be a brown rice with no label on the container. 1 5-gallon tub appeared to have oats on it had 1 label that stated rice with a date of 3/27 and another date on the tub that read 9/27. 1 5-gallon tub that appeared to be brown sugar had a label written on side that stated cereal. Freezer 1 clear plastic bag with what appeared to be 10 breaded chicken tenders had no label to identify the food item and it was unsealed. 2 clear plastic bags with what appeared to be popcorn shrimp had no label to identify the food item. 1 large blue bag wedged between other boxes and bags had no label to identify the food item. 1 clear plastic bag with round breaded patties had no label to identify the food item. 5 pieces of a flat rectangular bakery crust with layers of wax paper between them was uncovered and exposed to the air had no label to identify the food item. 7 meat patties with wax paper to separate the patties was wrapped in a clear plastic wrap that did not cover all the meat exposing some of the meat to the air had no label to identify the food items. The contents of the freezer were extremely packed and while inspecting items on lower shelves, 1 box slid onto the State Surveyor. Refrigerator #2 1 clear plastic tub had 4 eggs with 1 label that stated it was cranberry sauce and another label stated boiled eggs expiration date of 10/06/23. 1 commercial package of sandwich sliced turkey had an expiration date of 10/03/23. 1 large glass bowl with what appeared to be cottage cheese did not have a label to identify the food item. 1 metal pan with white roll of meat was on last shelf defrosting over the top of a box of bacon on the floor of the refrigerator. 1 metal pan Refrigerator #1 1 1-gallon jug of lime juice was 3/4 empty had a best by date of 08/10/23. 1 dispenser with a white liquid with green flecks inside had no label to identify the food item. 1 dispenser with a tan liquid inside had no label to identify the food item. 1 dispenser with a thick white substance inside had no label to identify the food item. 1 commercial tub of cottage cheese had mechanically alter meat inside had a label that stated mech (mechanical) soft ham . 1 bag of what appeared to be shredded cabbage had a stamp of best by 10/03/23. 6 bags of what appeared to be shredded lettuce had no label to identify the food item or when it was placed in the refrigerator or when to use by. 5 bags of shredded cabbage had no label to identify the food item or when it was placed in the refrigerator or when to use by. 7 bags of what appeared to be liquid eggs laid on the bottom shelf had no label to identify the food item or when it was placed in the refrigerator or when to use by. During an interview on 10/06/23 at 5:30 PM with the DM, as she went back through all the food storage areas, she said the items in the freezer were all her fault because the other freezer had gone out almost five (5) weeks prior and she had to put all frozen foods into the 1 freezer. She said originally the former maintenance director had ordered a part to fix the freezer, but it was the wrong size and the part was discontinued so the facility was awaiting a new freezer. The DM said all items no matter what they were or where they were stored needed a label to identify the food item and when it was opened. She also said all items should have been sealed. She verified items in the dry food storage room and said the egg noodles, soy sauce and cereal were not sealed. She said she did not know the last time the powdered milk or the baking powder was used other than possibly before the skilled nursing facility moved into the building. As she verified the items in the freezer, she identified the clear bag with breaded strips was breaded chicken tenders. She identified the 2 clear bags with what appeared to be popcorn shrimp were breaded popcorn shrimp. The DM said the large blue bag inside the freezer was breaded chicken fried steak patties. She said the bakery crusts were cobbler tops that the cook utilized any time they made a fruit cobbler. She said the facility had large clear plastic zipper sealed bags the cobbler tops should have been placed in. The DM said the meat patties were beef patties for hamburgers and they should not have been covered with plastic wrap but should have been placed in a clear plastic zipper sealed bag. She said she did not usually put any type of label on an item if they had not opened the item and just removed the bag from the box. Further interview revealed, the DM verification of the refrigerators identified the glass bowl did have cottage cheese that was used on the salad bar of the assisted living facility dining room earlier in the day . She said the clear plastic tub had boiled eggs that needed to be discarded that day. She said the labels stuck to containers really well and their dish washer machine did not effectively remove the old labels from containers. The DM said she thought that since the meat was in a pan and it only had another box of meat below, it was fine to defrost the meat on the shelf. She also said the meat was turkey. The DM verified the white liquid with the green flecks was ranch salad dressing, the tan liquid was thousand island salad dressing and the thick white liquid was mayonnaise . She said the bottles should have labels on them as they would be hard to identify the items. The DM said the clear bags with the green shredded items were coleslaw and lettuce and the yellow liquid was liquid eggs. She said she was not aware she needed to place labels on the items to identify them when they had not yet been opened, even after removing the bags from their shipping boxes. The DM said without a label on those items, it would be difficult to identify the food items. She said the turkey sandwich meat was brought in by a resident only a few days prior. She also said the shredded cabbage was used for coleslaw with the expiration date of 10/03/23 was shipped to the facility last week. Record review of the facility policy labeled Food Receiving and Storage, last revised 07/2014, revealed: Food shall be received and stored in a manner that complies with safe food handling practices . Dry foods that are stored in bins will be removed from original packaging, labeled and dated (used by date) . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing . Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready to eat foods . Review of the FDA Food Code 2022 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview and records review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 3 patios and 1 of 6 entrance/exit doors reviewed for environment . 1. The facility failed to ensure 2 of 3 non-designated smoking outdoor patios were free of smoke and cigarette butts. 2. The facility failed to ensure smoke did not enter hallway 300 of the nursing facility. These failures could place residents at risk for a clean and comfortable environment. Findings included: 1. Record review of Resident #210's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with medical diagnoses which included irregular heart rate, type 2 diabetes, high blood pressure, depression, and impaired vision. During an interview on 10/06/2023 at 2:28 PM, Resident #210 stated she swept up cigarette butts in the smoking area often. She said the smell of cigarette smoke still continued to be a problem for her and her neighbors. She said she would most often stay in other parts of the building or keep her door closed to cut down on the bothersome cigarette smoke smell . 2. Record review of Resident #212's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. No medical diagnoses were documented in the electronic records. During an interview on 10/07/23 at 3:09 PM, Resident #212 said she could smell cigarette smoke in her room sometimes when the exit door was opened or was left open while smokers were on the patio. Resident #212 said her neighbor went out and swept up cigarette butts in the smoking area. Resident #212 said she did not like the smell of cigarette smoke and would often keep her door closed so she would not have to smell the smoke. She said she had deodorizers in her room to cut down on the smell, but they did not always work. Resident #212 said she did not like that she had to keep her door closed all the time but felt that was the only way to keep out the smell. 3. Record review of Resident #313 face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included Sepsis, Pneumonia, Shortness of breath, Hypoxemia, Acute respiratory failure with hypoxia, COPD . Resident was a nonsmoker. During an observation and interview on 10/08/23 at 4:28 PM, Resident #313 was wearing O2 via NC lying in bed with the head of the bead elevated approximately 45 degrees. He said he could often smell the smoke when residents were outside smoking. He said there were times he had difficulty breathing from the smoke and would have a bout of coughing that sometimes got so bad he would have to go to the nurse's station for his inhaler to make it stop . 4. Record review of Resident #312 face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included functional dyspnea, shortness of breath, Respiratory disorder, Emphysema . Resident was a nonsmoker. During an observation and interview on 10/08/23 at 4:41 PM, Resident #312 was sitting up in the recliner and had an O2 concentrator near her. She said she would wear the O2 at night or when she had difficulty breathing. She said the smell of smoke would be strong in her room as the smoking residents came back in each day after their smoke break. She said it would be strong for a little while then slowly start to disappear. Resident #312 said it bothered her, but she did not think there was anything she could do about it . During an observation on 10/06/23 at 11:15AM, revealed the outside perimeter of the building, the walkway of designated smoking area was covered in dead grass. Ruts from tires were noted on each side of the walkway from the exit door. The designated smoking area had cigarette butts and ashes on the ground and cigarette butts sitting on top of the rock facade. The grass surrounding the smoking area was brown and dry. The one ashtray was full of cigarette butts. During an observation on 10/06/23 at 3:15 PM revealed the end of Hall 200 that lead to the designated smoking area had the odor of cigarette smoke. Numerous residents and staff were standing and/or sitting within 3 feet of the exit door smoking . Staff began to move residents from the smoking area back inside the building. The smell was strong up the 200 hall as well as up the 300 hall. Staff began to discard the cigarette butts from the ashtray into the red foot lever trash bin. Staff did not sweep away the ashes on the ground. As the residents entered Hall 300, there was a significant smell of smoke coming into the hallway. During an observation on 10/06/23 at 3:25 PM the patio area, just off the dining room, had 2 ceramic planters with sand inside and 5 cigarette butts in the planter to the left, 2 cigarette butts in the planter to the right. There were cigarette butts on the concrete of the patio. There was a pack of cigarettes that still contained 2 unused cigarettes sitting on the rock facade of the wall. During an interview on 10/06/2023 at 4:18 PM, the ED said she was aware of resident complaints about smelling cigarette smoke inside the building. She stated she requested the smoking section be moved after the only assisted living resident that smoked passed away but corporate said no. The ED said they used the charcoal filter bags to assist in removal of the smell of tobacco smoke. During an observation on 10/07/23 at 2:15 PM, the exit door at the end of Hall 200 had charcoal filter bags attached around the top right corner of the door. There was a mild odor of cigarette smoke in the hallway of Hall 200. During an observation on 10/07/23 at 3:25 PM, revealed the patio area just off the dining room of the assisted living unit had 2 ceramic planters with sand inside and 5 cigarette butts in the planter to the left, 2 cigarette butts in the planter to the right. There were cigarette butts on the concrete of the patio. There was a pack of cigarettes that still contained 2 unused cigarettes sitting on the rock facade of the wall. There was a large white trash can with a foot lever that had a plastic bag and numerous pieces of paper, Styrofoam, ashes, and cigarette butts inside. There was no signage on or near the patio that stated the area was a designated smoking area. During an interview on 10/07/23 at 3:30 PM, CG A said she did not know if the patio area off the dining room of the assisted living unit was a non-smoking area. She said she knew the exit door down the 200 Hall was a designated smoking area and maybe visitors of the assisted living unit went out on that patio and smoked. During an observation and interview on 10/07/23 at 3:35 PM, the ED said the patio directly off the dining room of the ALF unit was for visiting. She said she did not see any signage anywhere that stated the area was a designated smoking area. She said she saw the cigarette butts in the planters and the cigarette pack with unused cigarettes. The ED said the ALF used to have a smoker and that resident would smoke in the area and thought maybe some visitors or staff were still using the area as a designated smoking area, but it was not a designated smoking area. The staff and visitors were supposed to go to the designated smoking area down the 200 Hall . During an observation on 10/07/23 at 3:55 PM, revealed the patio just off the dining room of the nursing facility were several cigarette butts on the ground surrounding the walkway to the door, at corner of the concrete and building in the grass, between fabric windmills and other decorations in the ground. There was a long 2-foot-wide by 6-foot-wide wooden planter box that had numerous cigarette butts in the soil and laying on top of the soil as well as a used surgical mask. There was no signage marking that the patio was a designated smoking area. During an interview and observation on 10/07/23 at 4:05 PM, the ADM said the patio directly off of the dining room of the nursing facility was a non-smoking area. He verified the cigarette butts in all the patio area and said they should not have been there . Staff and visitors were only supposed to smoke in the designated smoking area outside the building near laundry. He said facility staff and visitors may have parked close to the patio area and discarded of the cigarettes as they came up to the building. He again said the patio was a non-smoking area and the area did not have signage that stated it was a smoking area. The ADM said there should not have been any cigarette butts on the ground or in the planter box in that area. He said the facility did not use the patio area as some residents would complain about the smell of smoke when a person came back inside from smoking. During an observation on 10/08/23 at 10:30 AM, there was a smell of cigarette smoke odor along 200 Hall starting at rooms 211 & 212. No smokers were at the designated smoking area. There were still charcoal filter bags attached to the door casing on the top right side of the doorframe. During an observation on 10/08/23 at 11:20AM, there continued to be cigarette butts in both planters on the patio directly off the dining room of the ALF unit . During an observation on 10/08/23 at 2:35 PM, there was a smell of cigarette smoke in the hallway leading to the designated outdoor smoking area beginning at room [ROOM NUMBER]. During an interview on 10/08/23 at 5:25 PM, the ED said she followed the smoking policy the nursing facility used regarding smoking and the admission agreement regarding the physical environment. Record review of the facility policy labeled Smoking Policy-Residents, revised December 2011, reflected: The facility shall establish and maintain safe resident smoking practices. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or nonsmoking preferences; for example, in making room assignments. Non-Smoking signs shall be prominently displayed throughout the facility where smoking is prohibited. Smoking restrictions shall be strictly enforced in all nonsmoking areas. Only facility-approved ashtrays and other smoking equipment/paraphernalia shall be used in resident living or sleeping areas. Metal containers, with self-closing cover devices, shall be available in smoking areas. Ashtrays shall only be emptied into designated receptacles Record review of the Facility Admission Agreement Form 3647, dated June 2022, Smoking Addendum reflected: Smoking is not permitted outside entry doors areas, hallways, common areas, anywhere inside the building, and patios. Residents and guests may not smoke in apartments or resident rooms. Anyone, resident or guest, smoking in any of the above smoke-free areas will be fined $500.00 per offense and is in violation of their lease and subject to eviction proceedings. All residents and guests must smoke in the designated smoking area only. Residents shall inform guests of the smoking policy and are responsible for their guests. Record review of the facility policy labeled Quality of Life-Homelike Environment, revised April 2014 reflected: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Cleanliness and order. Pleasant, neutral scents .

Based on observation, interviews and record reviews the facility failed to ensure food and drink was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meals reviewed for palatable foods. 1. The facility failed to provide residents who had an altered textured meal with food that was at a safe and appetizing temperature. 2. The facility failed to provide residents with meals that had a palatable flavor. These findings could place residents at risk of poor nutrition and weight loss. Findings include: During an observation and interview on 10/06/23 at 11:35 AM, the resident's pureed meal plates were on top of a shelf on the wall in the kitchen that had an AC duct blowing cold air on the individually prepared meal plates. The DC said she prepared the pureed meal then plated each individual plate so it would be easy to serve the residents later. She said she always put the plates up on the shelf after she prepared them. DA-A was observed to place each resident's meal plate in the microwave to warm them back up to serving temperature. DA-A then placed the plates on the top of the enclosed food cart, which also had an AC duct blowing cold air on the individually prepared meal plates. DA-A said the air blowing on top of the prepared meal plates was cold. She said when she got to the skilled nursing facility dining room she would probably need to reheat them in the microwave again to bring them back up to serving temperature. The DC and DA-A said they would not eat food that was prepared and allowed to go cold then reheated twice via a microwave if they had a choice. During an observation on 10/06/23 at 12:00 PM, DA-B was setting up resident trays with silverware and desserts in the skilled nursing facility dining room while DA-A left to get a thermometer to check the temperatures of the foods that were placed on the steam table for the skilled nursing facility dining area. He said they did not typically check the temperatures of the foods after they left the kitchen on the other side of the building and were placed in the steam table of the nursing facility dining area. He said they did not utilize the steam table for all the meals for the skilled nursing facility dining area, and maybe 2 to 3 meals a week were about all they used the steam table. During an observation on 10/06/23 at 12:18 PM, DA-A took the temperature of the individual pureed meal that measured the following: Pureed popcorn Shrimp 102.4 degrees Pureed macaroni and cheese 99.4 degrees Fahrenheit Pureed steamed broccoli 102.0 degrees Fahrenheit. DA-A reheated the pureed meal tray for a second time in the microwave behind the nurse's station and the temperatures were as follows: Pureed popcorn Shrimp 128.0 degrees Fahrenheit Pureed macaroni and cheese 121.0 degrees Fahrenheit Pureed steamed broccoli 129.0 degrees Fahrenheit . During an interview and observation on 10/06/23 at 12:30 PM, revealed the State Surveyor tasted the popcorn shrimp and it was an overtly salted popcorn shrimp, no seasoning to the macaroni and cheese, little flavor in the steamed broccoli and the dessert baked apples had hard undercooked apples. The ADM said the shrimp tasted fine to him, the macaroni and cheese could have had salt and pepper added and the apples had been hard and undercooked. The ED of the assisted living center that housed the building's kitchen said the shrimp did not taste salty to her, but she did not like or dislike the popcorn shrimp. She said she agreed the macaroni and cheese had no flavor and needed salt and pepper, she was not personally a fan of the steamed broccoli, but that was because she just did not like broccoli in that form. The ED said the apples in the dessert were hard and undercooked. During an interview on 10/06/23 at 12:45 PM with LVN-C, she said the residents always told her the food was cold. She said that made it to where residents did not want to eat, and it could lead to weight loss. She said it was a constant issue. LVN-C said she complained to the ADM, DON and ADON. During an interview on 10/06/23 at 3:30 PM with the Resident Council, they said the food was mostly cold and for the most part was terrible. The group said they had a steam table for the food and a few times a week the kitchen staff would use the steam table, the food would be warm or hot and would taste a little bit better, but the kitchen staff usually did not utilize the steam table . During an interview on 10/06/23 at 5:30 PM with the DM, she said the dietary staff were supposed to utilize the steam table in the skilled nursing facility dining area for breakfast and lunch each day. She said they typically made the meal trays and put them on the enclosed food cart for supper each night because she did not have as large of a crew for the evening meal. The DM said she was unaware the cold air ran across the areas where they placed the resident prepared pureed meal plates or the tray would need to be reheated 2 times in the microwave to maintain a palatable temperature. She said the dietary staff should have prepared the pureed food items and stored them in pans on the steam table and only plate the food at the time of food service to maintain the temperature and palatability of the food. The DM said the facility had a set menu and an alternative menu. She said if the residents did not like a meal, they had the alternate meal choice and that was all. The DM said even if the entire facility did not like a meal, corporate told her she could not take it off the menu because they had an alternate meal choice they could ask for instead. Record review of the facility policy labeled Resident Nutrition Services, revised 11/2009, reflected: Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance .To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 degrees F to 135 degrees F) will be kept to a minimum .

Based on observation, interview and record review the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 of 1 smoking area and 2 of 3 patio areas reviewed for smoking. 1. The facility failed to consider nonsmoking resident's exposure to cigarette smoke. 2. The facility failed to maintain nonsmoking areas free of cigarette butts. These failures placed residents at risk of illness and a decline in health. Findings include: Record review of Resident #210's face sheet revealed an [AGE] year-old female admitted [DATE] with medical diagnoses of an irregular heart rate, type 2 diabetes, high blood pressure, depression, and impaired vision. During an interview on 10/06/2023 at 2:28 PM, Resident #210 stated she swept up cigarette butts in the smoking area often. She said the smell of cigarette smoke still continued to be a problem for her and her neighbors. She said she would most often stay in other parts of the building or keep her door closed to cut down on the bothersome cigarette smoke smell. Record review of Resident #212's face sheet revealed she was a [AGE] year-old female admitted [DATE]. No medical diagnoses were in the electronic records. During an interview on 10/07/23 at 3:09 PM, Resident #212 said she could smell cigarette smoke in her room sometimes when the exit door was opened or was left open while smokers were on the patio. Resident #212 said her neighbor went out and swept up cigarette butts in the smoking area. Resident #212 said she did not like the smell of cigarette smoke and would often keep her door closed so she would not have to smell the smoke. She said she had deodorizers in her room to cut down on the smell, but they did not always work. Resident #212 said she did not like that she had to keep her door closed all the time but felt that was the only way to keep out the smell. Record review of Resident #313 face sheet revealed an [AGE] year-old male admitted [DATE]. He had a diagnosis list that included Sepsis, Pneumonia, Shortness of breath, Hypoxemia, Acute respiratory failure with hypoxia, COPD. Resident was a nonsmoker. During an observation and interview on 10/08/23 at 4:28PM, Resident #313 was wearing O2 via NC lying in bed with the head of the bead elevated approximately 45 degrees. He said he could often smell the smoke when residents were outside smoking. He said there had been times that he had difficulty breathing from the smoke and would have a bout of coughing that sometimes got so bad he would have to go to the nurse's station for his inhaler to make it stop. Record review of Resident #312 face sheet revealed an [AGE] year-old female that admitted on [DATE]. She had a diagnosis list that included functional dyspnea, shortness of breath, Respiratory disorder, Emphysema. Resident was a nonsmoker. During an observation and interview on 10/08/23 at 4:41PM, Resident #312 was sitting up in recliner and had an O2 concentrator near her. She said she would wear the O2 at night or when she had difficulty breathing. She said the smell of smoke would be strong in her room as the smoking residents came back in each day after their smoke break. She said it would be strong for a little while then slowly start to disappear. Resident #312 said it bothered her, but she did not think there was anything she could do about it. During an observation on 10/06/23 at 11:15AM, the outside perimeter of building, the walkway of designated smoking area was covered in dead grass. Ruts from tires were noted on each side of walkway from the exit door. The designated smoking area had cigarette butts and ashes on the ground and cigarette butts sitting on top of the rock facade. The grass surrounding the smoking area was brown and dry. The one ashtray was full of cigarette butts. During an observation on 10/06/23 at 3:15PM the end of Hall 200 that lead to the designated smoking area had the odor of cigarette smoke. Numerous residents and staff were standing and/or sitting within 3 feet of the exit door smoking. Staff began to move residents from the smoking area back inside the building. The smell was strong up the 200 halls of the Assisted Living unit as well as up the 300 hall of the Nursing unit. Staff began to discard the cigarette butts from the ashtray into the red foot lever trash bin. Staff did not sweep away the ashes on the ground. During an observation on 10/06/23 at 3:25 PM the patio area just off the dining room had 2 ceramic planters with sand inside and 5 cigarette butts in the planter to the left, 2 cigarette butts in the planter to the right. There were cigarette butts on the concrete of the patio. There was a pack of cigarettes that still contained 2 unused cigarettes sitting on the rock facade of the wall. During an interview on 10/06/2023 at 4:18 PM, ED said she was aware of resident complaints about smelling cigarette smoke inside the building. She stated she had requested the smoking section be moved after the only assisted living resident that smoked passed away but corporate said no. ED said they used the charcoal filter bags to assist in removal of the smell of tobacco smoke. During an observation on 10/07/23 at 2:15PM, the exit door at the end of Hall 200 had charcoal filter bags attached around the top right corner of the door. There was a mild odor of cigarette smoke in the hallway of Hall 200. During an observation on 10/07/23 at 3:25PM, the patio area just off the dining room of the assisted living unit had 2 ceramic planters with sand inside and 5 cigarette butts in the planter to the left, 2 cigarette butts in the planter to the right. There were cigarette butts on the concrete of the patio. There was a pack of cigarettes that still contained 2 unused cigarettes sitting on the rock facade of the wall. There was a large white trash can with a foot lever that had a plastic bag and numerous pieces of paper, Styrofoam, ashes, and cigarette butts inside. There was no signage on or near the patio that stated the area was a designated smoking area. During an interview on 10/07/23 at 3:30PM CG-A said she did not know if the patio area off the dining room of the assisted living unit was a nonsmoking area. She said she knew the exit door down the 200 Hall was a designated smoking area and maybe visitors of the assisted living unit went out on that patio and smoked. During an observation and interview on 10/07/23 at 3:35PM, ED said the patio directly off the dining room of the ALF unit was for visiting. She said she did not see any signage anywhere that stated the area was a designated smoking area. She said she seen the cigarette butts in the planters and the cigarette pack with unused cigarettes. ED said the ALF used to have a smoker and that resident would smoke in that area and thought maybe some visitors or staff were still using the area as a designated smoking area, but it was not a designated smoking area. The staff and visitors were supposed to go to the designated smoking area down the 200 Hall. During an observation on 10/07/23 at 3:55PM, the patio just off the dining room of the nursing facility were several cigarette butts on ground surrounding walkway to door, at corner of concrete and building in the grass, between fabric windmills and other decorations in the ground. There was a long 2-foot-wide by 6-foot-wide wooden planter box that had numerous cigarette butts in the soil and laying on top of the soil as well as a used surgical mask. There was no signage marking that the patio was a designated smoking area. During an interview and observation on 10/07/23 at 4:05PM, ADM said the patio directly off of the dining room of the nursing facility was a nonsmoking area. He verified the cigarette butts in all the patio area and said they should not have been there. Staff and visitors were only supposed to smoke in the designated smoking area outside the building near laundry. He said facility staff and visitors may have parked close to the patio area and discarded of the cigarettes as they came up to the building. He again said the patio was a nonsmoking area and that the area did not have signage that stated it was a smoking area. ADM said there should not have been any cigarette butts on the ground or in the planter box in that area. He said the facility did not use that patio area as some residents would complain about the smell of smoke when a person came back inside from smoking. During an observation on 10/08/23 at 10:30 AM, there was a smell of cigarette smoke odor along 200 Hall starting at rooms 211 & 212. No smokers were at the designated smoking area. There were still charcoal filter bags attached to the door casing on the top right side of the doorframe. During an observation on 10/08/23 at 11:20AM, there continued to be cigarette butts in both planters on the patio directly off the dining room of the ALF unit. During an observation on 10/08/23 at 2:35 PM, there was a smell of cigarette smoke in the hallway leading to the designated outdoor smoking area beginning at room [ROOM NUMBER]. During an interview on 10/08/23 at 5:25PM, ED said she followed the smoking policy that the nursing facility used regarding smoking and the admission agreement regarding the physical environment. Record review of facility policy labeled Smoking Policy-Residents revised December 2011: The facility shall establish and maintain safe resident smoking practices. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or nonsmoking preferences; for example, in making room assignments. Non-Smoking signs shall be prominently displayed throughout the facility where smoking is prohibited. Smoking restrictions shall be strictly enforced in all nonsmoking areas. Only facility-approved ashtrays and other smoking equipment/paraphernalia shall be used in resident living or sleeping areas. Metal containers, with self-closing cover devices, shall be available in smoking areas. Ashtrays shall only be emptied into designated receptacles . Review of Facility Admission Agreement Form 3647 dated June 2022, Smoking Addendum: Smoking is defined as inhaling, exhaling, burning, vaping, or carrying any lighted cigar, cigarette, pipe, or any other device containing any tobacco product, or any other leaf, weed, plant, or other product. Smoking is not permitted outside entry doors areas, hallways, common areas, anywhere inside the building, and patios. Residents and guests may not smoke in apartments or resident rooms. Anyone, resident or guest, smoking in any of the above smoke-free areas will be fined $500.00 per offense and is in violation of their lease and subject to eviction proceedings. All residents and guests must smoke in the designated smoking area only. Residents shall inform guests of the smoking policy and are responsible for their guests.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for falls. The facility failed to implement measures to prevent falls for Resident #1, who had a history of [REDACTED].#1 fell on [DATE] and sustained a fractured right femur, requiring surgery. Resident #1 returned to the facility 03/07/18. No additional fall interventions were put into place. Resident #1fell on [DATE], fracturing her left femur, which required an additional surgery. This facility failure affected Resident #1 and placed 43 other residents at risk of not being cared for correctly and could lead to a fall resulting in injury. Findings include: Review of Resident Face Sheet for Resident #1 dated 02/01/18 revealed she was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of MDS Quarterly dated 12/27/17 revealed Resident #1 had adequate hearing, clear speech, understood/understands/glasses, BIMS-07, inattention/disorganized thinking present/fluctuate, no behaviors, bed mobility-self performance one person with limited assistance, locomotion on unit/self-performance extensive assistance of one person, continent of bowel and bladder and no falls. Review of Resident #1's Care Plan dated 06/30/17 and reviewed 12/20/17 revealed, .resident has had frequent falls due to decreased safety awareness, weakness, confusion, leaves walker/w/c and ambulates, turns off alarms and states she knows she should call but does not call for assistance . Review of Resident #1's Physician order [REDACTED].Fall: Initiate Fall Prevention Program .Fall: Physical Therapy Consult . Review of Resident #1's Progress notes dated 03/04/18 at 11:15 a.m. revealed, .continues to need assist to bathroom x 1 for safety and slight unsteady gait . Review of Resident #1's Progress Notes dated 03/04/18 at 1:45 p.m. revealed, Heard a scream coming from resident's room at approximately 12:45 hrs. A nurse aide was closer than I and was trying to open the door. Resident was behind the door lying on her back with her neck parallel to the baseboard and her head sharply curved to the left, indicating she had probably hit her head as she fell . When asked, the resident denied hitting her head. Resident's upper extremities were as normal, grip was equal and strong. Resident c/o excruciating pain over right hip. O/E right foot was externally rotated and limb was approximately 1.5 inches shorter than the left leg. Resident could wiggle her toes on her right leg but was unable to rotate her left foot inward. Unable to examine resident's head as it was very painful for her to move . Review of the facility's self-report to DADS dated 03/05/18 revealed, .Resident fell in room while trying to self-ambulate .Nurse came in to check vitals and see of resident was injured. Noticed that right hip was externally rotated and approx. (approximately) 1.5 in (inches) shorter than left .The hospital took xray and claimed that resident has a [MEDICAL CONDITION] and was being transferred out to another hospital for treatment .Resident was ambulating in room when resident fell and fractured right hip. Resident was then shipped to local ER (emergency room ) and from the (sic) was sent to bigger hospital for surgery .Resident has padded floor due to history of falls . Review of the facility's Provider Investigation Report dated 03/05/18 (after Resident #1 fell and fractured her right hip) revealed she fell in room while trying to self-ambulate .Provider action taken post-investigation-resident has padded floor due to history of falls, no alarms on residents (sic) . Review of Resident #1's Progress Notes dated 03/07/18 at 4:45 p.m. revealed, Resident returned to facility via facility van accompanied by transport aide. DX: Closed displaced right mid cervical femur fracture with femoral head replacement . Review of Resident #1's Progress Notes dated 03/09/18 at 2:00 a.m. revealed, Walked past resident's room and noted her sitting on BSC (bedside commode) approx. (approximately) 4 feet from the end of her bed . Review of Resident #1's Progress Notes dated 03/11/18 at 5:21 a.m. revealed, This nurse and NA (name) heard res (resident) yelling from her room and we rushed to find the resident in the middle of the floor. Resident stated she needed to get up that there was too much stuff to be done to be laying around all day. Resident stated when asked that she had pain in her left hip and rated it 8/10. Resident displayed grimacing and protecting movements and cried out in pain when attempting to do ROM with res (resident). Transferred resident x 3 to chair d/t (due to) res refused to stay on floor and resident refused to go to her bed. Review of Resident #1's Progress Notes dated 03/11/18 at 5:40 a.m. revealed, Contacted (name of physician on call) to inform her of res. condition and was advised to send to (name of hospital) for eval (evaluation) and treatment. Review of the facility's Facility Event Summary Report from 02/14/18 to 03/13/18 revealed Resident #1 had an unwitnessed fall 03/04/18 that read, .Resident fell while alone in her room at approximately 13:45 hrs. (1:45 p.m.) States she was independently ambulating to bathroom . In an interview on 03/13/18 at 3:45 p.m., the Administrator said Resident #1 was found on the floor after she fell on [DATE]. He said Resident #1's floor was already padded, and that tab alarms were used in the past on her wheelchair and her bed. He said Resident #1 would turn the alarm off at times. The Administrator said Resident #1 fell on [DATE] but was not injured. He said Resident #1 fell [DATE] around 2:25 p.m. ambulating in her room, and her right leg was noted to be shorter than her left so she was sent to the local hospital and then transferred to a larger hospital for surgery after a fractured right hip was found on xray. He said Resident #1 received skilled physical therapy when she returned to the facility 03/07/18. The Administrator confirmed that physical therapy was the only intervention provided after Resident #1's fall with a fractured right hip. He said Resident #1 fell on [DATE] and complained of pain in her left hip, so she was again sent to the local hospital and then transferred to a larger hospital for surgery of a fractured left hip. He said Resident #1 did not have a low bed or a scoop mattress after she fractured her right hip, but the facility planned to get these when she returned 03/14/18. In an interview on 03/14/18 at 1:40 p.m., the DON said when a resident suffered a fall, she reviewed the event and followed up on the documentation, reviewed the care plan to see what could be put in place and talked to physical therapy to get a therapy screening. She said a fall mat or padded flooring would be put in place along with a family conference, a low bed, notes to remind the resident to call for assistance in the room, a BSC and a lift recliner. The DON said Resident #1 did not have a scoop mattress or a low bed. The DON said when Resident #1 returned 03/07/18, no interventions except physical therapy were implemented. In an interview on 03/14/18 at 1:50 p.m., the Physical Therapist said she screened Resident #1 for therapy after she fractured her right hip. She said she saw Resident #1 twice between 03/07/18 and 03/11/18. She said Resident #1 could not consistently follow instructions due to her confusion. Observation of Resident #1's room on 03/13/18 at 4:00 p.m. revealed a floor mat covering most of the width and length of her walk around surface in her room. It stretched beneath her power lift recliner but not to the edge of her twin bed. The floor mat was approximately one inch in thickness. Resident #1's bed was not one that would lower to near-floor height. Observation on 03/14/18 at 2:10 p.m. revealed Resident #1's room to have a scoop mattress on her bed. Resident #1 was not present in her room as she was still hospitalized . Observation/interview on 03/14/18 at 2:05 p.m. revealed a transport aide wheeling Resident #1 back in to the facility via wheelchair. The Activity Director assisted the transport aide in getting Resident #1 from her wheelchair into her recliner. Resident #1 complained of pain. The transport aide told Resident #1 she would let her nurse know of her pain and left the room after setting up her lunch on the overbed table. When this investigator asked Resident #1 where she had been, she answered that she had been to(NAME)and McCamey. Resident #1 then told the transport aide she needed to use the restroom and started to get up unassisted, but complained that her leg hurt. The DON arrived in Resident #1's room and asked Resident #1 if she knew why her leg hurt. Resident #1 said no, and the DON told her she had broken both of her hips. Resident #1 said, Oh my! I didn't know that! Observation on 03/14/18 at 4:00 p.m. revealed Resident #'1 room to have written signs that read, lock wheelchair prior to getting up, Stop, lock pull string, Pull your call light and call bell on chair. In an interview on 03/15/18 at 10:26 a.m., RN A said Resident #1's nurse had gone to lunch and she was covering for her on 03/04/18. She said Resident #1 was usually ambulatory with the use of a walker or wheelchair. She said she had worried about Resident #1's safety because Resident #1 was not aware of her physical limitations. RN A said she heard a scream on 03/11/18 around 1:00 p.m., coming from Resident #1's room. She said she couldn't open the door because Resident #1 was behind it, so she had to squeeze in. She said Resident #1 was on her back with her head to the right near the baseboard of the floor. RN A said Resident #1's right leg was externally rotated with shortness of the extremity noted when she arrived. She said Resident #1 complained of excruciating pain and was in too much pain to move her. She said she did a quick assessment and called 911 after putting a pillow under Resident #1's head. She said Resident #1 told her she was walking to the bathroom. Review of the facility's policy, Falls and Fall Risk, Managing, dated 2007, 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 try to minimize complications from falling .The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of [REDACTED].If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . In an interview on 03/15/18 at 2:00 p.m., the Administrator said 44 residents in the facility were at risk of falls.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #4) of 5 residents reviewed for assistance with transfers as evidenced by: 1) Resident #4, who required 2 person assist for incontinent care, rolled out of bed while receiving incontinent care by only Nurse Aide B. Resident #4 suffered a fractured femur. This failure could place 20 residents at risk of not being cared for correctly and could lead to a fall resulting in injury to resident. Findings include: Resident #4 Review of Resident Face Sheet for Resident #4 revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Annual MDS dated [DATE] indicated a BIMS (Brief Interview of Mental Status) score of 9 indicating moderate cognitive impairment. MDS indicated she had clear speech and was able to make self-understood and had the ability to understand others. MDS indicated she required extensive assistance of two staff to physically assist with bed mobility, transfers, dressing, toilet use and personal hygiene. MDS also indicated Resident #4 was always incontinent of urine and bowel. Review of Resident #4's Care plan from last care conference on 01/10/18 indicated she required extensive 2 person assistance with goal to maintain ability to participate with self-care at current level as evidenced by: completing adl's (activities of daily living) x 2 through review date. Approach was to assist x 2 with adl's and transfers edited on 01/10/18 by LVN A Review of Facility Event Summary Report dated 02/08/18 revealed Aide performed bed and brief change and resident #4 lost her balance when rolled onto her left side and fell into the floor. The physician and family were notified. Record Review of Resident #4's Nursing Progress notes dated 02/08/18 at 11:45 p.m., indicated NA B was changing resident's bed and brief. While resident #4 was on her left side, she lost her balance and rolled over side rail and into floor. Resident #4 was transferred from floor to bed with assist of 4 staff members. Resident complained of moderate to severe pain in left knee, which she reported to have landed on. Resident #4 also sustained a skin tear to left wrist 5cm in length and 1.5 cm in width, edges re-approximated and skin closure strip applied, small amount of blood discharge. Resident given PRN anxiety medication and [MEDICATION NAME] per resident request. Review of Event Report for Resident #4 indicated NA B was changing resident's bed and brief. While resident was on her left side, she lost her balance and rolled over side rail and into floor. Resident was transferred from floor to bed with assist of 4 staff members. Resident #4 complained of moderate to severe pain in left knee, which she reported to have landed on. Resident also sustained a skin tear to left wrist 5cm in length and 1.5 cm in width, edges re-approximated and skin closure strip applied, small amount of bloody discharge. Resident #4 was given prn anxiety medication and [MEDICATION NAME] per request. 02/09/18 at 12:07 a.m. Hospice A notified of fall. Hospice nurse performed assessment of resident and mobile x-ray of left knee ordered. X-ray service faxed .02/09/18 10:15 a.m., X-ray tech here to facility at this time to x-ray left knee, resident reported that she also had pain on her right great toe. Notified Hospice Nurse A and new order was received to x-ray right great toe .02/09/18 13:00 (1:00 p.m.) Hospice Nurse B here to facility and new orders received to increase frequency for [MEDICATION NAME] 4mg IR to every 4 hours as needed for pain. Per resident and family request have a minimum of 2 person assist with turning and repositioning. Ice/Warm packs every hour as needed for pain not to exceed 15 minutes per application. Stabilize left leg with blue stabilization device and ace wraps. Would transition to brace once it arrived .02/11/18 05:45 a.m., Hospice Nurse C in and increased frequency of [MEDICATION NAME] to every 2 hours .02/13/18 11:55 a.m. Received return call from Physician A office and appointment set for 02/19/18 at 1:15 p.m. in Brownwood. Observation on 02/12/18 at 4:00 p.m., Resident #4 was lying on an air bed on back with eyes closed, sleeping. Review of Accident/Incident Investigation Witness statement dated 02/14/18, Nurse Aide B documented on 02/08/18 I had answered Resident #4's call light. She requested to be changed as she had wet her brief. I knew she was a 2 person transfer and 2 person for changing but I did not seek assistance. I proceeded to change her by myself and when I rolled her over she slid off the bed. Her feet hit the ground first. I did not leave her. I stuck my head out of doorway and called to the nurse (LVN B). He came right away. In an interview on 02/14/18 at 9:20 a.m., NA B said the night resident #4 fell to floor from her bed on 02/08/18, she said resident #4 called out for assistance. She said resident #4 was wet and she went ahead and changed her. She said there was another CNA on duty but she was in another resident's room. NA B said she rolled resident #4 over to wipe her and her feet went off the bed and the resident rolled to the floor. She immediately notified LVN B, the nurse to assess the resident. She said he assessed resident #4 then four staff moved resident back to bed using a sheet. She said the resident's knee was red and swollen. She said resident #4 did not complain of pain immediately but as the night went on, she did complain of knee pain. NA B said she was not certified and had to have help with certain tasks. She said it was hard to get tasks done. She said she knew resident #4 required 2 person assist but had changed her before by herself and did fine. She said she did not ask fell ow CNA or a nurse to assist her in changing resident #4 on 02/08/18. In an interview on 02/13/18 at 3:30 p.m., LVN B revealed on 02/08/18 NA B reported to him she was in the room alone providing incontinent care to Resident #4. She reported to him, Resident #4 went over the rail. Upon his arrival, resident #4 was lying in the floor. She had a skin tear on her hand. Full assessment was completed and everything was ok. She was then lifted from the floor by four staff using a draw sheet. She did complain of her leg hurting, left leg was dented but not swollen or anything else unusual or abnormal. She had not instant bruising, redness, etc. He notified Hospice and requested an X-ray of her leg due to her complaints of pain to left leg. Hospice arrived within the hour and assessed resident and they agreed for an x-ray pending approval. Hospice nurse wrote the order and order was faxed for x-ray. Resident #4 had not been weight bearing in the past year he had worked at the facility. Resident #4 did require assist of 2 staff for all ADL's (activities of daily living) except for feeding herself. LVN B said NA B was not a certified nurse's aide. Review of Resident #4's physician's orders [REDACTED]. Resident #4 complained of pain and swelling to left knee. Portable x-ray due to patient was bedfast. Review of Resident #4's Physician order [REDACTED]. On 02/09/18, physician order [REDACTED]. Per family request Resident #4 to have a minimum of 2 person assist with turning and positioning. Physician order [REDACTED]. Physician order [REDACTED]. Review of Resident #4's x-ray of left knee on 02/09/18 post fall on 02/09/18 revealed a displaced and angulated supracondylar distal femoral fracture left. Portable x-ray of toes completed on 02/09/18 revealed no acute abnormality. Review of NA B's personnel file revealed she was hired in Dietary on 10/25/17 and transferred to Nursing on 10/27/17. Review of personnel file included a Job description signed for Cook and dated 10/25/17. No job description was signed by NA B for resident aide, nurse aide or certified nurse's aide. In an interview and record review on 02/14/18 at 12:40 p.m., ADON said she provided a copy of Review of Facility Resident Bed List report dated 01/30/18 listed resident #4 required 2 person assist and Hoyer lift. NA B signed this list on 01/30/18. ADON provided a copy of the Texas Nurse Aide Performance Record for NA B with dates of training beginning on 01/30/18 with no end date completed. ADON initialed on 01/31/18 that NA B completed classroom training on Perineal care for female, elimination care, positioning residents, turning residents on side toward you and moving resident in bed . Skills lab and Clinical had not been signed off for NA B. ADON said NA B had received classroom training for the above items. She said another CNA would sign off on the actual performance of those tasks for NA B. Review of C.N.A. Proficiency Audit dated 11/02/17 provided by ADON indicated CNA A signed off that NA B had satisfactorily completed skill check off on 11/02/18 for perineal care; female, dressing the resident, transfers of 1 person assist, 2 person assist and Hoyer lift - 2 person assist, turns/repositions residents timely/correctly, knowledge of toileting program. In an interview on 02/13/18 at 4:24 p.m., CNA A said to find out the level of assistance a resident required, she looked in the computer under plan of care. She said resident #4 required two staff assistance for all ADL's. In an interview and record review on 02/13/18 at 4:50 p.m., DON said Resident #4 required assistance of two staff for all ADL's. Resident #4 should always have two staff with incontinent care. She said NA B was a nurse's aide and had been checked off and was comfortable with her working alone. DON accessed facility computer and resident #4 required assistance of two staff for ADL's. DON accessed computer to show surveyor screen aides see when looking at resident's plan of care for amount of assistance needed. In an interview on 02/12/18 at 1:45 p.m., NA C said she had worked as a Nurse's aide for approximately 2-3 weeks but had previously worked in the kitchen. She resident #4 required two staff to roll side to side. She said since the fall, resident #4 required 4 staff so someone could hold her leg while being turned. In an interview on 02/12/18 at 2:18 p.m., CNA D said he had worked at this facility for 8 months. He said resident #4 had required assistance of 2 staff for ADL's (activities of daily living). In an interview on 02/12/18 at 3:36 p.m., DON said resident #4 was a 2 person assist for turning in bed. She said 20 residents in the facility required assistance of two staff for ADL's. She said resident #4 had not been weight bearing in past 3-4 years. She said resident #4 had been a patient of Hospice due to [MEDICAL CONDITIONS]. She said resident #4's son had refused treatment of [REDACTED]. She said Hospice had ordered an immobilizer and they were awaiting the immobilizer and an appointment with an orthopedist. She said the resident did not want treatment for [REDACTED]. Observation on 02/13/18 at 3:10 p.m., Resident #4 was in bed with eyes closed, sleeping. In an interview on 02/14/18 at 11:11 a.m., CNA C said to find out how much assistance a resident required with ADL's she looked in the computer under plan of care. She said you should never try to transfer someone or care for them alone if it says they were to have two staff. Observation on 02/14/18 at 11:20 a.m., Resident #4 was in bed positioned on back. She had her eyes closed. In an interview on 02/14/18 at 11:30 a.m., CNA A said Nurse Aides could work on the floor as a nurse aide under the supervision of a CNA until CNA class started. She said Nurse Aide class started 2-3 weeks ago. She said ADON had her teach skills, hand washing, etc. She said she worked with Nurse Aides 1 to 1 to cover proficiency audit form. She instructed NA B anytime a resident was a Hoyer lift they were automatically required to have 2 staff for all ADL's. She showed NA B how to find in the computer how much assistance a resident required for care. She said NA B was able to perform all tasks. Facility Policy: Safe Lifting and Movement of Residents dated 02/2014 indicated Policy Statement In order to protect the safety and well-being of staff and residents,, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff would document resident transferring and lifting needs in the care plan. Such assessment shall include .b. Residents mobility (degree of dependency); c. Residents size d. Weight bearing ability . In an interview on 02/14/18 at 1:33 p.m., Administrator said his expectation was for staff to follow plan of care utilizing appropriate to care for that resident. Nurses were also available to assist nurses' aides in providing care to residents. He said NA B should have requested assistance of the other aide and/or nurse to care for Resident #4. He said resident #4 required assistance of two staff for her care. In an interview on 02/12/18 at 3:36 p.m., DON said 20 residents in the facility required assistance of two staff for ADL's.

Based on observation, interviews and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 5 residents (Resident #4) reviewed for activities of daily living. 1) Nurse Aide B provided incontinent care by herself to Resident #4, who required 2-person assist with incontinent care. As a result, Resident #4 rolled out of bed onto the floor on 02/08/18, and suffered a fractured femur. This failure placed 20 residents including Resident #4 at risk for serious injury by not receiving their activities of daily living care from the appropriate number of staff required to meet the residents' needs. Resident #4 Review of Resident Face Sheet for Resident #4 revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Annual MDS dated [DATE] indicated a BIMS (Brief Interview of Mental Status) score of 9 indicating moderate cognitive impairment. MDS indicated she had clear speech and was able to make self-understood and had the ability to understand others. MDS indicated she required extensive assistance of two staff to physically assist with bed mobility, transfers, dressing, toilet use and personal hygiene. MDS also indicated Resident #4 was always incontinent of urine and bowel. Review of Resident #4's Care plan from last care conference on 01/10/18 indicated she required extensive 2 person assistance with goal to maintain ability to participate with self-care at current level as evidenced by: completing adl's (activities of daily living) x 2 through review date. Approach was to assist x 2 with adl's and transfers edited on 01/10/18 by LVN A Review of Facility Event Summary Report dated 02/08/18 revealed Aide (NA B) performed bed and brief change and resident #4 lost her balance when rolled onto her left side and fell into the floor. The physician and family were notified. Review of Accident/Incident Investigation Witness statement dated 02/14/18, Nurse Aide B documented On 02/08/18 I had answered Resident #4's call light. She requested to be changed as she had wet her brief. I knew she was a 2 person transfer and 2 person for changing but I did not seek assistance. I proceeded to change her by myself and when I rolled her over she slid off the bed. Her feet hit the ground first. I did not leave her. I stuck my head out of doorway and called to the nurse (LVN B). He came right away. Record Review of Resident #4's Nursing Progress notes dated 02/08/18 at 11:45 p.m., indicated NA B was changing resident's bed and brief. While resident #4 was on her left side, she lost her balance and rolled over side rail and into floor. Resident #4 was transferred from floor to bed with assist of 4 staff members. Resident complained of moderate to severe pain in left knee, which she reported to have landed on. Resident #4 also sustained a skin tear to left wrist 5cm in length and 1.5 cm in width, edges re-approximated and skin closure strip applied, small amount of blood discharge. Resident given PRN anxiety medication and [MEDICATION NAME] per resident request. Review of Event Report for Resident #4 indicated NA B was changing resident's bed and brief. While resident was on her left side, she lost her balance and rolled over side rail and into floor. Resident was transferred from floor to bed with assist of 4 staff members. Resident #4 complained of moderate to severe pain in left knee, which she reported to have landed on. Resident also sustained a skin tear to left wrist 5cm in length and 1.5 cm in width, edges re-approximated and skin closure strip applied, small amount of bloody discharge. Resident #4 was given prn anxiety medication and [MEDICATION NAME] per request. 02/09/18 at 00:07 a.m. Hospice A notified of fall. Hospice nurse performed assessment of resident and mobile x-ray of left knee ordered. X-ray service faxed .02/09/18 10:15 a.m., X-ray tech here to facility at this time to x-ray left knee, resident reported that she also had pain on her right great toe. Notified Hospice Nurse A and new order was received to x-ray right great toe .02/09/18 13:00 (1:00 p.m.) Hospice Nurse B here to facility and new orders received to increase frequency for [MEDICATION NAME] 4mg IR to every 4 hours as needed for pain. Per resident and family request have a minimum of 2 person assist with turning and repositioning. Ice/Warm packs every hour as needed for pain not to exceed 15 minutes per application. Stabilize left leg with blue stabilization device and ace wraps. Would transition to brace once it arrived .02/11/18 05:45 a.m., Hospice Nurse C in and increased frequency of [MEDICATION NAME] to every 2 hours .02/13/18 11:55 a.m. Received return call from Physician A office and appointment set for 02/19/18 at 1:15 p.m. in Brownwood. Observation on 02/12/18 at 4:00 p.m., Resident #4 was lying on an air bed on back with eyes closed, sleeping. In an interview on 02/14/18 at 9:20 a.m., NA B said the night resident #4 fell to floor from her bed on 02/08/18, she said resident #4 called out for assistance. She said resident #4 was wet and she went ahead and changed her. She said there was another CNA on duty but she was in another resident's room. NA B said she rolled resident #4 over to wipe her and her feet went off the bed and the resident rolled to the floor. She immediately notified LVN B, the nurse to assess the resident. She said he assessed resident #4 then four staff moved resident back to bed using a sheet. She said the resident's knee was red and swollen. She said resident #4 did not complain of pain immediately but as the night went on, she did complain of knee pain. NA B said she was not certified and had to have help with certain tasks. She said it was hard to get tasks done. She said she knew resident #4 required 2 person assist but had changed her before by herself and did fine. She said she did not ask fell ow CNA or a nurse to assist her in changing resident #4 on 02/08/18. In an interview on 02/13/18 at 3:30 p.m., LVN B revealed on 02/08/18 NA B reported to him she was in the room alone providing incontinent care to Resident #4. She reported to him, Resident #4 went over the rail. Upon his arrival, resident #4 was lying in the floor. She had a skin tear on her hand. Full assessment was completed and everything was ok. She was then lifted from the floor by four staff using a draw sheet. She did complain of her leg hurting, left leg was dented but not swollen or anything else unusual or abnormal. She had not instant bruising, redness, etc. He notified Hospice and requested an X-ray of her leg due to her complaints of pain to left leg. Hospice arrived within the hour and assessed resident and they agreed for an x-ray pending approval. Hospice nurse wrote the order and order was faxed for x-ray. Resident #4 had not been weight bearing in the past year he had worked at the facility. Resident #4 did require assist of 2 staff for all ADL's (activities of daily living) except for feeding herself. LVN B said NA B was not a certified nurse's aide. Review of Resident #4's physician's orders [REDACTED]. Resident #4 complained of pain and swelling to left knee. Portable x-ray due to patient was bedfast. Review of Resident #4's Physician order [REDACTED]. On 02/09/18, physician order [REDACTED]. Per family request Resident #4 to have a minimum of 2 person assist with turning and positioning. Physician order [REDACTED]. Physician order [REDACTED]. Review of Resident #4's x-ray of left knee on 02/09/18 post fall on 02/09/18 revealed a displaced and angulated supracondylar distal femoral fracture left. Portable x-ray of toes completed on 02/09/18 revealed no acute abnormality. Review of NA B's personnel file revealed she was hired in Dietary on 10/25/17 and transferred to Nursing on 10/27/17. Review of personnel file included a Job description signed for Cook and dated 10/25/17. No job description was signed by NA B for resident aide, nurse aide or certified nurse's aide. In an interview and record review on 02/14/18 at 12:40 p.m., ADON said she provided a copy of Review of Facility Resident Bed List report dated 01/30/18 listed resident #4 required 2 person assist and Hoyer lift. NA B signed this list on 01/30/18. ADON provided a copy of the Texas Nurse Aide Performance Record for NA B with dates of training beginning on 01/30/18 with no end date completed. ADON initialed on 01/31/18 that NA B completed classroom training on Perineal care for female, elimination care, positioning residents, turning residents on side toward you and moving resident in bed . Skills lab and Clinical had not been signed off for NA B. ADON said NA B had received classroom training for the above items. She said another CNA would sign off on the actual performance of those tasks for NA B. Review of C.N.A. Proficiency Audit dated 11/02/17 provided by ADON indicated CNA A signed off that NA B had satisfactorily completed skill check off on 11/02/18 for perineal care; female, dressing the resident, transfers of 1 person assist, 2 person assist and Hoyer lift - 2 person assist, turns/repositions residents timely/correctly, knowledge of toileting program. In an interview on 02/13/18 at 4:24 p.m., CNA A said to find out the level of assistance a resident required, she looked in the computer under plan of care. She said resident #4 required two staff assistance for all ADL's. In an interview and record review on 02/13/18 at 4:50 p.m., DON said Resident #4 required assistance of two staff for all ADL's. Resident #4 should always have two staff with incontinent care. She said NA B was a nurse's aide and had been checked off and was comfortable with her working alone. DON accessed facility computer and resident #4 required assistance of two staff for ADL's. DON accessed computer to show surveyor screen aides see when looking at resident's plan of care for amount of assistance needed. In an interview on 02/12/18 at 1:45 p.m., NA C said she had worked as a Nurse's aide for approximately 2-3 weeks but had previously worked in the kitchen. She resident #4 required two staff to roll side to side. She said since the fall, resident #4 required 4 staff so someone could hold her leg while being turned. In an interview on 02/12/18 at 2:18 p.m., CNA D said he had worked at this facility for 8 months. He said resident #4 had required assistance of 2 staff for ADL's (activities of daily living). In an interview on 02/12/18 at 3:36 p.m., DON said resident #4 was a 2 person assist for turning in bed. She said 20 residents in the facility required assistance of two staff for ADL's. She said resident #4 had not been weight bearing in past 3-4 years. She said resident #4 had been a patient of Hospice due to [MEDICAL CONDITIONS]. She said resident #4's son had refused treatment of [REDACTED]. She said Hospice had ordered an immobilizer and they were awaiting the immobilizer and an appointment with an orthopedist. She said the resident did not want treatment for [REDACTED]. Observation on 02/13/18 at 3:10 p.m., Resident #4 was in bed with eyes closed, sleeping. In an interview on 02/14/18 at 11:11 a.m., CNA C said to find out how much assistance a resident required with ADL's she looked in the computer under plan of care. She said you should never try to transfer someone or care for them alone if it says they were to have two staff. Observation on 02/14/18 at 11:20 a.m., Resident #4 was in bed positioned on back. She had her eyes closed. In an interview on 02/14/18 at 11:30 a.m., CNA A said Nurse Aides could work on the floor as a nurse aide under the supervision of a CNA until CNA class started. She said Nurse Aide class started 2-3 weeks ago. She said ADON had her teach skills, hand washing, etc. She said she worked with Nurse Aides 1 to 1 to cover proficiency audit form. She instructed NA B anytime a resident was a Hoyer lift they were automatically required to have 2 staff for all ADL's. She showed NA B how to find in the computer how much assistance a resident required for care. She said NA B was able to perform all tasks. In an interview on 02/14/18 at 12:40 p.m., ADON reviewed February schedule and she said during class the NA's work the weekends with two LVN's or one LVN and one RN supervising them. The current class started January 31, 2018. Corporate liked for NA to work 30 days prior to enrolling in Nurse Aide class to ensure they would stay. ADON said when they were hired the NA work 16 hours with a CNA or 3 days with a CNA. Once they complete the 2-3 days of check off with CNA they are classified as a resident aide. CNA checks the resident aide off on the proficiency audit. Once the resident aide was checked off, they were able to do what they were checked off on. Once classroom starts, book was covered in 2 days and the resident aides were tested over the workbook. As the workbook was covered, the resident aides demonstrated competency either with residents or in a room with fell ow students. The physical therapist checked off the resident aides the first day on how to transfer residents. The physical therapist checked each resident aide off for competency. The resident aide can test once 60 hours classroom, and 40 hours of skills. The second week of March 2018 the current class could test to become a Certified Nurse's Aide. ADON said she and the DON interviewed NA B on Friday (02/09/18) and NA B said she knew resident #4 required 2 staff for care. Review of Job Description for Nurse Aide revealed Summary: Provide Direct Nursing care to the residents once checked off for 16 hours of training by Certified Nursing Assistant. During 16 hours of training must be with/trained by Certified Nursing Assistant. Must follow all established policies and procedures and ensure that the highest degree of quality care was maintained at all times. Maintain rights of residents as set forth by the Texas Department of Health Laws and Regulations. As a Nurse Aide you may do all care as described in Certified Nursing Assistant job description one you have received 16 hours of training by Certified Nursing Aide and had all skills checked off. Prior to the 16 hours of training you must be with a certified nursing assistant. I have read this job description and the attached and fully understand the requirements set forth therein. I hereby accept the position of nursing aide and agree to abide by all requirements set forth and would perform all duties and responsibilities to the best of my ability. I understand that as a result of my employment I may be exposed to communicable diseases including AIDS and [MEDICAL CONDITION] virus. I further understand that my employment is at will, and thereby understand that my employment may be terminated at will by the facility or myself with or without notice. Place for date and employee and supervisor signature Facility Policy: Safe Lifting and Movement of Residents dated 02/2014 indicated Policy Statement In order to protect the safety and well-being of staff and residents,, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff would document resident transferring and lifting needs in the care plan. Such assessment shall include .b. Residents mobility (degree of dependency); c. Residents size d. Weight bearing ability . In an interview on 02/14/18 at 1:33 p.m., Administrator said his expectation was for staff to follow plan of care utilizing appropriate to care for that resident. Nurses were also available to assist nurses' aides in providing care to residents. He said NA B should have requested assistance of the other aide and/or nurse to care for Resident #4. He said resident #4 required assistance of two staff for her care. In an interview on 02/12/18 at 3:36 p.m., DON said 20 residents in the facility required assistance of two staff for ADL's.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of eight residents reviewed for quality of care. A. Staff failed to provide interventions for Resident #1's pain on 08/18/15 and 08/19/15, due to Resident #1's [MEDICATION NAME] (narcotic pain medication) not being available. Staff failed to request a renewal of Resident #1's prescription for [MEDICATION NAME], which requires a new prescription every 90 days, resulting in Resident #1 being without pain medication for three days. This failure placed the 19 residents receiving narcotic pain medication at risk for not receiving pain medication as ordered which could result in injury, increased pain, serious medical complications, need for increased medication, decline in condition, the need for hospitalization , or death. The findings included: Record review of Resident #1's face sheet, undated, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognitive. The MDS also revealed Resident #1 required the physical assistance of at least two staff for bed mobility, transfers, locomotion, dressing, toileting, personal hygiene, and bathing. Resident #1's MDS also revealed that she received scheduled pain medication and PRN (as needed) pain medication in the five day period prior to the assessment being conducted. Record review of Resident #1's Care Plan, dated 06/28/15, revealed Resident #1 is at risk for complications related to pain due to Neuralgia, Arthritis, lack of mobility, [MEDICAL CONDITION], and obesity. The goal identified to address this risk was for Resident #1 to not experience long term complications related to pain for 90 days. Approaches for achieving this goal included staff administering pain medication per physician's orders. In an interview on 09/25/15 at 3:05 PM Resident #1 stated that she has run out of pain medication two times since being at the facility. Resident #1 stated one of those times was for two days in August. Resident #1 stated she was in so much pain without the medication that she was crying and begging for the medication. Resident #1 stated she takes [MEDICATION NAME] for pain at least once a day, but usually takes it twice a day. Resident #1 stated that the only other pain medication she has is Tylenol ([MEDICATION NAME]), and that it doesn't touch the pain. Record review of Resident #1's Physician Order Report, dated 08/01/15-09/30/15, revealed she was ordered [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) . tablet; 5-325 mg (milligram); . give one tablet by mouth four times a day as needed for severe pain. for a [DIAGNOSES REDACTED]. The U.S. Library of Medicine identified [MEDICATION NAME] as medication consisting of a combination of [MEDICATION NAME] and [MEDICATION NAME]. The U.S. Library of Medicine indicated [MEDICATION NAME] is in a class of medications called opiate (narcotic) [MEDICATION NAME] and can be used to relieve moderate-to-severe pain. <https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 6.html> The U.S. Library of Medicine identified [MEDICATION NAME] as a medication used to relieve mild to moderate pain. The U.S. Library of Medicine also identified [MEDICATION NAME] as being in a class of medications called [MEDICATION NAME] (pain relievers). https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 4.html Record review of Resident #1's [MEDICATION NAME] Count Sheet, for 07/07/15-08/17/15, revealed in the month of August she received the following number of tablets on the identified dates: 8/1/15-2 tablets, 8/2/15-1, 8/3/15-4 tablets, 8/4/15-3 tablets, 8/5/15-1 tablet, 8/6/15-2 tablets, 8/8/15-2 tablets, 8/10/15-1 tablet, 8/11/15-2 tablets, 8/12/15-1 tablet, 8/13/15-1 tablet, 8/14/15-1 tablet, 8/15/15-2 tablets, 8/16/15-2 tablets, and 8/17/15-1 tablet. The [MEDICATION NAME] Count Sheet revealed there were no tablets remaining after the dose administered on 08/17/15 at 9:13 PM. (A count sheet is a log where staff record the following information each time they administer a narcotic or other controlled medication: their signature, the date and time the dose was administered, the dose, and the amount of medication left after the dose was administered.) Record review of the Delivery Manifest from Medicine Chest Institutional Pharmacy, dated 08/19/15, revealed Resident #1's [MEDICATION NAME] was delivered on 08/19/15 at 11:39 PM. Record review of Resident #1's [MEDICATION NAME] Count Sheet, dated 08/20/15-09/25/15, revealed the first dose administered after 08/17/15 was on 08/20/15 at 12:00 AM. Record review of Resident #1's PRN Medication Sheet and Documentation, dated August 2015, revealed on 08/19/15 Resident #1 received [MEDICATION NAME] 325 mg on 08/19/15 at 12:00 PM for pain. The results of the medications administration were described as non effective. In an interview on 09/25/15 at 3:30 PM the ADON stated that her expectation is that when there is around a seven day supply of medication left the nurses begin the process of having the medication renewed and/or refilled. The ADON stated the night shift nurses are supposed to go through the medication cart every Wednesday and Sunday and request refills for medications that are running low. The ADON stated that they were having problems with the nurses on the night shift not doing their job, but they are working on addressing this issue. In an interview on 09/29/15 at 10:30 AM LVN A stated that she remembers being the nurse for Resident #1 in August when Resident #1 ran out of pain medication. LVN A stated that she remembers Resident #1 being very upset that she was out of pain medication. LVN A stated that she works at the facility PRN and she is not aware of the process for medications being reordered. LVN A stated she does remember that there were other nurses working on trying to get the medication refilled. LVN A stated Resident #1 was complaining about pain during this time and that after assessing her pain she administered Tylenol. Record review of the facility policy entitled Guidelines for Medication Ordering, undated, revealed the following . There are four ways an order for [REDACTED]. d. Drug Re-Orders: 1. each medication prescribed for a resident must be available for use prior to the administration of the last available dose. Routinely administered medications are to be re-ordered at least 72 hours prior to the last dose in the medication container. Record review of the Resident Roster provided by the facility on 09/24/15 identified 19 residents who receive narcotic pain medication.

Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for one (Resident #2) of 12 sampled residents. The facility failed to: a) protect Resident #2 from injury. She sustained a fractured hip after she had fallen while crawling over the side rails of her bed on 10/19/10; b) determine contributing factors and implement preventive measures to protect Resident #2 after she had fallen on four occasions between 10/04/10 and 11/03/10. These failures could affect any of the 45 residents residing in the facility. Failure to determine contributing factors of accidents and initiate measures to reduce environmental hazards places residents at risk of injury or death. Findings included: Record review of Resident #2's Record of Admission revealed she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's MDS dated [DATE] revealed she had short and long-term memory impairment, her cognitive status was moderately impaired (decisions poor, cues/supervision required), she required extensive assistance of one person for transfers, had partial range of motion limitation of one hand, and was frequently incontinence of bowel and bladder and required a wheelchair for mobility. Observation of Resident #2's room on 03/01/11 at 1:10 p.m. revealed one side of the bed up against the wall and a side rail on the other side. The rail appeared to be a full side rail. It was attached to the center of the bed frame with space approximately 12 - 16 inches between the headboard and the side rail, and approximately 20 - 28 inches between the footboard and the side rail. The spaces at the head and foot of the bed did not allow adequate space for someone to safely exit the bed with the side rail in the up position. Review of an "Incident/Accident Report" dated 10/04/10 at 3:13 p.m. revealed Resident #2 "crawled over the side rail in the up position, walked across the room and slipped and sat on bottom." It was documented in the report that side rails were present and in the up position. The resident "didn't" explain what had happened. There was no apparent injury. Review of "Conclusion and Interventions of Incident" revealed "lap buddy when in wheelchair" as interventions in place to prevent incident. Review of an "Incident/Accident Report" dated 10/19/10 at 5:10 a.m. revealed Resident #2 was found lying on her left side with her head under the bed, complaining of right hip pain. It was documented in the report that side rails were present and in the up position. The type of fall was documented by facility staff as "unknown". In the "environment" section of the report, call light within reach, was marked "no" and the side rails were marked as being "full" rails. The following question, "Were the above environmental issues involved in the accident?", was not answered. It was documented that the resident said, "I was looking for the little one." Review of "Conclusion and Interventions of Incident" revealed no documentation of interventions in place to prevent incident. The resident was transferred to the local ER and found to have a fractured right hip. The resident was transferred to a regional medical center for surgical treatment. Review of an "Incident/Accident Report" dated 10/30/10 at 1:55 a.m. revealed Resident #2 was found lying on the floor in her room at the head of the bed with her feet propped up on the bed. It was documented in the report that side rails were present and in the up position. The resident was unable to explain what had happened. There was no apparent injury. Review of "Conclusion and Interventions of Incident" revealed no documentation of interventions in place to prevent incident. Review of an "Incident/Accident Report" dated 11/03/10 at 5:00 p.m. revealed Resident #2 "crawled out of bed around siderails and fell , denies pain/injury, moves all ext (extremities) except rt (right) hip Fx (fracture) as usual". It was documented in the report that side rails were present and in the up position. Response to the question, "What does the resident say caused the incident?" was documented as "NA" (not applicable). Review of "Conclusion and Interventions of Incident" revealed interventions needed to prevent recurrence as "low bed, move to a room with padded soft interlocking tiles." Review of the Significant Change MDS for Resident #2 dated 11/03/10, following surgery for [REDACTED]. Further review of Resident #2's clinical record revealed the following: a) a "Pre-restraining Assessment" dated 03/14/10 with the recommendation of a lap buddy. No alternatives to restraints were documented. A "Physical Restraint Elimination Review", dated the same day, listed the resident's status as having "visionary hallucinations". A review dated 06/06/10 listed "hallucinations diminished." A review dated 08/28/10 listed "no hallucinations." A review dated 11/07/10 listed "status [REDACTED]. b) no "Pre-restraining Assessment" for the use of side rails. An unsigned physician's telephone order dated 02/21/11 read, "May have ? length rails for positioning and safety." c) the"Physical Restraint Elimination Reviews" dated 06/06/10 through 01/15/11 did not indicate if Resident #2 was a candidate for a restraint elimination or reduction program. Review of the care plans for Resident #2 revealed no plan addressing the falls/fracture and no plan addressing the use of side rails. During an interview with the Regional Nurse Consultant on 03/03/11 at 10:10 a.m. regarding the side rail on Resident #2's bed, she said it is a 3/4 rail because of its length. The Regional Nurse Consultant said the side rail was positioned in the center of the bed to help staff with turning and positioning the resident. When asked if the resident could release the side rail she said, "No, I'm sure she can't." In an interview with facility COTA on 03/02/11 at 11:00 a.m. she stated "We should screen them when they are up for care plans but honestly it doesn't get done. We do screen and evaluate to reduce restraints if they ask, but side rails we never look at. They say it's a nursing issue". Review of CMS form 672, "Resident Census and Conditions of Residents" dated 03/01/11 revealed the facility census as 45.