Every finding on record at Beaumont Nursing and Rehabilitation

Based on interview and record review the facility failed to have qualified professional(s) who was qualified as a therapeutic recreation specialist or an activities professional who was licensed or registered by the State to for 1 of 1 facility reviewed for qualifications of activity professionals.The facility failed to ensure a qualified Activities Professional was in place to direct their activities program for the previous 12 weeks. There was no qualified Activity Director in place from 5/12/2026 and as of 08/12/2026 (date of survey exit).This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities.During interviews with ten (10) random residents from 8/10/2026 to 08/12/2026, who wish not to be identified, they stated activities of their interest, like bingo, ice cream socials, group crafts, or visiting musicians have not been offered in the last 2 months.Record Review of the personnel files indicated the facility did not have an activities professional/activities director and the position was open. Record review of Activity Calendars for June and July 2026 did not indicate regularly consistent activities scheduled for the residents.During an interview on 08/12/2026 at 1:40 p.m., the HR D stated she had been in her position since 7/20/2026 and the facility had been seeking to employee an activity director since she acquired the HR responsibilities. During an interview on 08/12/2026 at 1:45 p.m., the CHR E stated she was the facility's corporate human resource, and this was her third week in her position. She said the AD position was open, and the facility was actively seeking a qualified candidate through advertisements, word of mouth and internet job posting. She said the previous AD was employed from 3/31/2026 to 5/12/2026 and the position had been open since her departure.During an interview on 08/12/2026 at 4:23 p.m., the Administrator stated he had interviewed several candidates for the Activity Director position but during interview process found the individuals to be unemployable. He said since he had not found a qualified candidate for the Activity Director position, he was looking at some of his current staff to enroll in the training courses for Activity Director. He stated none of his current staff are registered for the training currently. He said he had volunteers visiting occasionally to assist with activities, but they were not certified. He stated he did not have anyone else who met the Activity Director requirements. He stated it was important to have an Activity Director on staff who met requirements to meet the residents' interests and preferences, and support his or her physical, mental, and psychosocial well-being. Record review of the facility's policy titled Individualized Activity Programs, dated 2011, indicated: The Activity Director and staff will provide individual programming to meet individual needs and interests. Practice Guidelines: 1. The Activity Director determines the need for individual programming through the resident assessment process. (Residents who are in isolation, ordered bed rest, or prefer to not be included in group situations.) 2. Individual programs are developed and implemented regularly consistent with individualized leisure interests and based on the assessment. 3. One- on- one activities are provided regularly for those residents unable or unwilling to attend groups unless otherwise indicated by assessment. 4. Individual programs are coordinated by the Activity Director and documented in the plan of care. 5. Activity Director or Assistant trains and coordinates support staff and volunteers to provide some of the in-room activities for residents. 6. Goals, type of intervention and response are documented and reflected in monthly or quarterly progress notes as required. 7. The Activity Director and Staff regularly (at least quarterly) assess the ability or the interest of the residents to join group activities.

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistently with professional standards of practice for 1 of 5 residents reviewed for respiratory care. (Resident #56)The facility failed to ensure Resident #56 received bi-pap for 3 days and not obtaining parameters for the bi-pap machine and oxygen levels to be maintained. This failure could place residents at risk of illness, respiratory complications, and accidents.Findings included: Record review of a face sheet dated 08/10/25 indicated Resident #56 was a [AGE] year old male admitted [DATE] with diagnoses including acute respiratory failure with hypercapnia (a life-threatening condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from the blood), COPD (chronic lung condition in which the lungs are damaged) and cerebral infarction (when a blood vessel that feeds the brain gets blocked and can affect brain cells) and dependence on supplemental oxygen (your body requires extra oxygen via nasal canula {tube to bring oxygen into someone's nose} to keep blood oxygen levels safely usually above 90%). Record review of Resident #56's electronic records on 08/11/2026 did not indicate an MDS due to his admission on [DATE]. Record review of Resident #56's baseline care plan, initiated on 08/07/2026 did not address supplemental oxygen use or bi-pap use.Record review of Resident #56's Order Summary report dated 08/10/2026 indicated oxygen use at 2 to 4 liters per nasal canula for COPD with a start date of 08/07/2026 with no orders for a bi-pap machine.Record review of Resident #56's Previous Nursing facilities stay physician orders dated 07/10/2026 indicated Bi-pap machine at bedtime and as needed with settings of expiratory positive airway pressure 6 centimeters of water pressure (keeps airways from collapsing when breathe out), Inspiratory Positive Airway Pressure (helps push oxygen into the lungs when breathe in) of 18 per centimeters water, rate of 15 and fraction of inspired oxygen at 35% (the concentration of oxygen a person breathes in). This document was sent to the facility for preadmission assessment.Record review of Resident #56's Summary Report from previous hospitalization on 06/25/2026 indicated he was admitted to a hospital, Respiratory: Managed with supplemental oxygen via nasal cannula (2-3 LPM) to maintain saturations above 90% due to his chronic history of COPD and respiratory failure. Special Monitoring Needs: Frequent monitoring of respiratory status, oxygen saturation, and adherence to Bi-pap therapy at night is critical due to chronic hypercapnic respiratory failure.Equipment . Bi-pap Machine: required for nocturnal use to manage chronic hypercapnic respiratory failure. This document was sent to the facility for preadmission assessment.Record review of Resident #56's hospice orders on 08/07/2026 indicated admitted to hospice services, oxygen at 3 Liters per nasal canula but no order for a bi-pap machine or settings for the bi-pap machine. Record review of Resident #56's Progress Notes indicated on:*08/10/2026 at 2:18 p.m., oxygen saturation of 97%, oxygen at 3/liters per nasal canula, no SOB, no cough, and clear lungs.*08/09/2026 at 7:13 p.m., oxygen saturation 98%, oxygen at 3/liters per nasal canula, no SOB, no cough, and clear lungs. *08/09/2026 at 11:13 p.m., oxygen saturation 97%, oxygen at 3/liters per nasal canula, no SOB, no cough, and clear lungs. *08/09/2026 at 3:13 a.m., oxygen saturation 98%, oxygen at 3/liters per nasal canula, no SOB, no cough, and clear lungs. *08/08/2026 at 2:36 p.m., oxygen saturation 97%, oxygen at 3/liters per nasal canula, no SOB, no cough, and clear lungs. *08/07/2026 at 1:26 a.m., oxygen saturation 97%, oxygen at 3/liters per nasal canula, no SOB, no cough, and clear lungs.Record review of oxygen saturation with oxygen per nasal cannula indicated:*08/12/2026 11:14 a.m., 94%;*08/11/2026 12:25 p.m., 94%;*08/11/2026 12:24 p.m., 94%;*08/11/2026 8:54 a.m., 96%;*08/10/2026 4:32 p.m., 97%;*08/10/2026 4:31p.m., 97%;*08/10/2026 7:28 a.m., 98%;*08/10/2026 5:34 a.m., 98%;*08/10/2026 5:32 a.m., 98%;*08/09/2026 1:31 a.m., 98%;*08/09/2026 1:30 a.m., 98%;*08/09/2026 05:06 a.m., 98%;*08/09/2026 05:05 a.m., 98%;*08/09/2026 12:18 a.m., 98%;*08/09/2026 12:17 a.m., 98%;*08/08/2026 5:20 a.m., 95%;*08/08/2026 5:19 a.m., 95%;*08/08/2026 12:47 a.m., 94%;*08/08/2026 12:46 a.m., 94% and*08/07/2026 1:27 p.m., 97%. During an observation and interview on 08/10/2026 at 10:25 a.m., Resident #56 was sitting in his wheelchair wearing oxygen at 3 liters per nasal canula. He had no observed shortness of breath, and his respirations were even and unlabored. He denied being short of breath. He said he used the bi-pap machine every night for 5 to 6 hours. The bi-pap machine was on his night side table on the right side of his bed. He said he did not sleep when in use, he slept during the day around 11:00 a.m., to 3:00 p.m. Resident #56 said he was not able to use the bi-pap Friday (8/07/2026), Saturday (08/08/2026), or Sunday (08/09/2026). He stated his kids had brought all his stuff and he could not find the connector part for the bi-pap machine to connect the hose and mask to it. Resident #56 said he did not tell any staff in the facility he was missing a piece to make the bi-pap machine work. He said he told the Hospice RN C that he was missing a piece to make the bi-pap work. Resident #56 said when he had problems related to the bi-pap machine, he hallucinated but he has not been hallucinating since not having the bi-pap machine. He said he can feel dizzy when his CO2 was high, but he was only dizzy one time when he stood up this weekend on (08/08/2026) but he did not wobble or fall. He just sat down. Resident #56 said he had no other symptoms from not using his Bi-pap machine. During an interview at 08/10/2026 at 10:45 a.m., Resident #56 said the staff found the missing bi-pap machine piece and it was working. He said he would use it within the hour.During an interview on 08/10/2026 at 12:39 p.m., Hospice RN C said she admitted Resident #56 into the facility. She wrote admission orders, added his primary diagnoses, ordered medication, and a bedside table to be delivered. She said she was not aware he had a bi-pap machine; she did not see it in the facility. His family members were present; she did not see the bi-pap machine. She said she was not ordering DME and did not look at the DME section of her electronic chart for Resident #56. Hospice RN C said Resident #56 did not tell her he was missing a piece of the bi-pap machine and the family nor facility notified her that they needed orders for it or had a concern with the bi-pap machine. She said she would have given the orders this weekend if needed. The Hospice RN said she asked the patient what he needed and verified with the nurse what was needed. She said Resident #56 did not mention the bi-pap machine. She said she was not aware Resident #56 did not use his bi-pap machine for 3 nights. Hospice RN C would not answer the question related to resident risk. She said I apologize the orders for the bi-pap machine were not completed but he had an order now. Hospice RN C said the bi-pap machine was not equipment provided by hospice.During an interview on 08/10/25 at 2:00 p.m., LVN A said she was responsible for providing care for Resident #56 today (08/10/2026) the day shift. She said he was receiving oxygen therapy, but she was unaware he was on a bi-pap machine LVN A said Resident #56 had no dizziness, or hallucinations, and only slight SOB after therapy but he was wearing oxygen as ordered. She said she applied breathing treatments at 8:00 a.m., and 11:00 a.m., and his pulse ox was 97 % before and after both treatments. LVN A said Resident #56 did not mention the bi-pap machine to her. She said she did not check for or ask about orders for the bi-pap machine because she was unaware of it. She did not see bi-pap machine on the 24-hour report. LVN A said she had been trained on bi-pap machines, how to set it up and put it on the resident. She said the DME supplier educated them on settings when a resident had a bi-pap machine. She said the Admissions person was responsible for ensuring all equipment for the resident was at the facility and in working order and the DON was the back up. LVN A said the potential resident risk of not having orders for a Bi-pap machine and the equipment not working was a potential of respiratory complication.During an interview on 08/11/26 at 11:20 a.m., the ADON said she was the nurse that admitted Resident #56, he came from home, brought his own medication, boxes and boxes of stuff, an electric wheelchair, and the bi-pap machine. She said she did not see the paperwork from the hospital. The ADON said Hospice RN C was at the facility and she received orders for the resident but did not receive orders for the bi-pap machine. The ADON said Resident #56 did not say anything about how he used the bi-pap machine. She said she was aware he came from another facility then went home and was admitted into this facility from home. The ADON said Resident #56 was alert and orientated and could tell you, his needs. She said she did not get any orders for the bi-pap machine; she was unaware Hospice RN C did not write an order for the bi-pap machine or settings. The ADON said the nurse admitting the resident was responsible for ensuring there were orders for all equipment. She said she should have gotten orders for the bi-pap machine. The ADON said all resident records were uploaded into a resident's chart. She was educated in the admission process, and all medication and equipment needed orders. The ADON said Resident #56 arrived at the end of her shift and she did not ask if he had equipment or if it worked. She said Resident #56 said he said he applied the bi-pap machine himself when he went to bed. The ADON said herself and the DON ensured orders are completed the next business day. Which was today 08/10/2026. She said the potential resident risk of not having orders and not using the bi-pap machine was potentially respiratory concerns. She did not review the notes in the miscellaneous records. During an interview on 8/11/2026 at 12:30 p.m., the DON said she reviewed Resident #56's paperwork and was aware he had a bi-pap machine on admission. She said the Marketer said he was bringing it from home. The DON said Resident #56 was hospice resident and she assumed he would bring the bi-pap machine from home and hospice would write orders for it. She said she was not here when Resident #56 admitted and was not told hospice did not write orders for it. She said the corporate nurse in the facility was making rounds and notified her there were no orders for the bi-pap machine. The DON said her expectation of the Weekend supervisor was to make sure staff was doing what they are supposed to do and not work on admissions. The DON said her expectation was the nurse starting the admission to complete the admission, check all admission paperwork. She said they should call hospice or the staff on call with any issues. She said if the nurse did not finish the admission, the next shift will finish it. The DON said the bi-pap machine should have orders for it and it should have been working. She was made aware he was on bi-pap machine when she accepted him a month ago. The DON said she put Resident #56's medication orders in Friday prior to admission, but did not activate. She said she did not have settings for the bi-pap machine. She said the settings were usually received from the hospital. The DON said his machine was preset. She thought it would be in the admission orders. The DON said the potential negative outcome of not getting orders and not putting on bi-pap machine was respiratory issues. The DON said no one notified her this weekend to tell there was a bi-pap machine without orders and not working. She said the ADON had access to Resident #56's records uploaded in the chart. The DON said for new admissions she reviewed information, made staff aware of admission and needs. She said she was responsible for making sure staff were aware of needed equipment and care. The DON said the facility had backup equipment to replace non-working equipment, but she was not aware Resident #56's bi-pap machine was not working and that he went without it for 3 nights. The DON said her expectation if a resident has a bi-pap machine, had orders, make sure it functioned properly and staff help put it on the resident. She said Resident #56 was only resident on a bi-pap machine in the facility at this time. During an interview on 08/10/2026 at 1:00 p.m., LVN A said she was responsible for providing care for Resident #56 this morning (08/10/2026). She said she saw him this morning on rounds. He was up in his bed. She said he had so many contraptions in his room She was unaware he was on a bi-pap machine. LVN A said Resident #56 had no dizziness, or hallucination but was slightly SOB after therapy. Resident #56 was wearing oxygen at 3 liters per nasal cannula. She gave him a breathing treatment at 8:00 a.m., and 11:00 a.m. She said his pulse ox was 97 % before and after both treatments. He had oxygen on. Resident #56 did not mention the bi-pap machine not used or not working to her. LVN A said she did not ask about orders for a bi-pap machine because she was unaware of it. She did not see a bi-pap on the 24-hour report. LVN A said she had been trained in the use of a bi-pap machine and how to set it up and put it on the resident. She said the DME supplier educated the staff on settings when a resident had a bi-pap machine. She said the Admissions person was responsible for ensuring all equipment for the resident was at the facility, had orders and was working and the DON was the back up. LVN A said the potential resident risk of not having orders for a Bi-pap machine and the equipment not working was a potential respiratory complication. During an interview on 08/10/2026 at 4:40 p.m., The Administrator said Hospice RN C was responsible for ensuring orders for the bi-pap machine for Resident #56 were completed in the resident's chart. The backup was the ADON and DON the next business day (08/10/2026) would review the chart and resident and ensure there were orders for all equipment and all equipment was working. He said the admission nurse was responsible for inspecting and verifying all equipment was in proper working condition and all services and orders were administered. The Administrator said all nurses were in-serviced with routine in-services on areas of concern and suggested concerns. He said the resident risk of no orders for the bi-pap machine and not receiving it would depend on the acuity level of the resident. He said Resident #56 was low risk of potential complications. The Administrator said his expectation was nurses to input all needed orders, inspect and verify all equipment was in proper working order and residents receive all needed services, all nurses be aware of all resident needs and notify administrative nurses of needs. If a resident brought his own equipment staff be aware of it. He said he approved all orders for any needed equipment if the resident's equipment was not effective. During an interview on 08/11/2026 at 12:51 p.m., LVN B said she was responsible for providing care for Resident #56, Sunday (08/09/2026). She said she saw a lot of mechanical apparatus but did not look too close to see what they were. She said she was not aware Resident #56 had a bi-pap machine and did not see any orders for it. She said she did give him a breathing treatment. LVN B said she was educated on how to apply a bi-pap machine and had worked with some previously. She said Resident #56 did not mention the bi-pap machine or having problems with the bi-pap machine. She said the potential risk of equipment not working and not using a bi-pap machine for 3 days was it could be a risk depending on the resident's condition. LVN B said it could possibly worsen his condition. During Phone calls on 08/12/2026 at 7:00 a.m., message left to LVN G that provided care to Resident #56 on 08/08/26 and 08/09/2026 doubles to return call related to an incident. LVN G did not return call. Record review of an undated facility policy titled, General Administration CPAP/ Bipap indicated, Bipap is the application of positive airway pressure that varies in magnitude during inspiration {breathing in} and expiration {breathing out}. Two pressure settings; one for inspiratory and lower setting for expiratory. Procedure: 1. Position mask on resident. 2. Secure mask by pulling the straps tight enough to allow minimal leak. 5. Press the ON button on the Bipap and the machine will begin delivering air pressure per the physician orders. If pressure setting are to be changed, the facility change the settings per the physician orders. 9. If the machine is not operating correctly, the supplying DME company is to be contacted immediately. It did not indicate orders required.

Based on interviews and record review, the facility failed to provide infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program, for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the mandatory infection prevention and control program training. This failure could place residents at risk of being cared for by untrained staff.Record review of personnel record for PT F indicated a hire date of 01/31/2025.Review of the facility's training log, undated, showed no evidence of infection prevention and control program training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed infection prevention and control program training. During an interview on 08/12/2026 at 1:42 p.m., HR D stated she was newly appointed to the facility HR position and was currently being training on her job duties, which will include reviewing and reporting annual training but currently did not have access to view or run reports regarding annual training completion in the computerized training system. Said PT F was a shared employee with another sister facility and was currently on vacation out of the country. During an interview on 08/12/2026 at 1:48 p.m., CHR E said annual required training was computer generated quarterly and staff were provided emails regarding required completion and/or the delinquent courses. CHR E said the annual training completion was reported to the appropriate department heads routinely. CHR E said percentages of completion and delinquent staff were included in the report. CHR E said employees are assigned training quarterly and it was the employee's responsibility to complete training timely, including infection prevention and control program training. She said ultimately the HR department, including herself, was responsible for monitoring employees that were not completing the required training timely and reporting the delinquent staff to the appropriate department heads for appropriate disciplinary actions. CHR E said both the facility HR and department head (director of rehabilitation) responsible facility staff were newly employed or recently appointed to the position and both in training and learning their job responsibilities. CHR E said staff not completing the annual training as required could lead to missed updates and/or poor performance. An attempted interview on 08/12/2026 at 3:15 p.m. with PT F was unsuccessful, no return call to voicemail and text message.During an interview on 08/12/2026 at 4:15 p.m., the Administrator said HR department is responsible for reporting the facility staff's completion of the annual computerized training routinely. Requested a policy regarding required annual training. He said the facility HR staff was new to her position and was being provided with access and training in the monitoring and reporting of the computer-generated training completion and delinquent staff. He said PT F was a shared employee with another sister facility which was the primary facility for assigning computerized training. He said PT F had not completed his assigned computerized training on infection prevention and control program training and he was unable to provide required training due to assigned training not being completed. He said it was the responsibility of the employees to complete their training on time. He said the department heads were responsible for ensuring staff completed the assigned training and the annual training completion should be monitored closer and delinquent staff should be held accountable. He said he completed random checks on annual trainings completion. He stated not completing annual infection control training as required could lead to employees not receiving updated or changed infection control information. A policy addressing annual employee training was requested from the Administrator, CHR E, on 08/12/2026 at 3:00 p.m. but was not provided prior to exit.

Based on observation, interview and record review, the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 17 residents (Resident #56) reviewed for baseline care plans.The facility failed to ensure Resident #56's baseline care plan was completed within 48 hours of admission on to include oxygen administration and bi-pap (a non-invasive medical device that helps people breathe by delivering two alternating pressure levels a higher pressure when you breath in and lower pressure when you breathe out) machine use.This failure could place residents at risk of not having needs met Findings included: Record review of a face sheet dated 08/10/25 indicated Resident #56 was a [AGE] year old male admitted [DATE], diagnoses included acute respiratory failure with hypercapnia (a life-threatening condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from the blood), COPD (chronic lung condition in which the lungs are damaged) and cerebral infarction (when a blood vessel that feeds the brain gets blocked and can affect brain cells) and dependence on supplemental oxygen (your body requires extra oxygen via nasal canula to keep blood oxygen levels safe usually above 90%). Record review of Resident #56's electronic records on 08/11/2026 did not indicate an MDS due to his admission on [DATE]. Record review of Resident #56's baseline care plan, initiated on 08/07/2026 did not address supplemental oxygen use or bi-pap use. Record review of Resident #56's Order Summary report dated 08/10/2026 indicated oxygen use at 2 to 4 liters per nasal canula for COPD with a start dated of 08/07/2026 with no orders for bi-pap machine. During an observation and interview on 08/10/2026 at 10:25 a.m., Resident #56 was sitting in his wheelchair wearing oxygen at 3 liters per nasal canula. He had no observed shortness of breath and his respirations even and unlabored. He denied being short of breath. He said he used the bi-pap machine every night for 5 to 6 hours. During an interview on 08/10/25 at 1:00 p.m., LVN A said she was responsible for providing care for Resident #56 today (08/10/2026) day shift. She said he was receiving oxygen therapy, but she was unaware he was on a bi-pap machine.During an interview on 08/11/26 at 11:20 a.m., the ADON said she was the nurse that admitted Resident #56 and was responsible for opening the 48-hour baseline care plan. She said the DON or MDS nurse would complete it the next business day. She said she initiated the baseline care plan but did not add oxygen use or bi-pap to the 48-hour baseline care plan. The ADON said the potential resident risk was that staff may not be aware of all the resident's needed care. During an interview on 8/11/2026 at 12:30 p.m., the DON said the nurse that admitted a resident was responsible for initiation of the 48-hour baseline care plan. She said the MDS nurse and DON triggered the baseline care plan the next business day. The DON said the ADON did not trigger, view all in the computer system and trigger all items that would have completed the 48-hour care plan. She said she did review Resident #56's information on Monday (08/10/2026) and completed the comprehensive care plan. The DON said there was no resident risk due to the staff having orders to follow except for the bi-pap and no care would be missed. The DON said her expectation was the admitting nurse completely trigger all items on the 48-hour care plan to address all resident needs. During an interview on 8/11/2026 at 1:30 p.m., the Administrator said the admitting nurse was nurse was responsible for initiating the baseline care plan. He said the DON and Administrator were responsible over site of pertinent information. He said the staff were educated on completion of baseline care plans. The Administrator said the ADON initiated the baseline care plan but did not populate with all information. He said the resident risk was low due to nursing follow up on next business day. The Administrator said his expectation of 48-hour care plans was initiated within 48 hours of admission and followed up on next business day by the DON and ADON. Record review of an undated facility policy titled, Base Line Care Plans indicated, . This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The baseline care plan will – be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including but not limited to- initial goals based on admission orders, physician orders. It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, .documents the interim approaches for meeting the resident's immediate needs, .

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objective and timeframes to meet a resident's medical, nursing, and 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 1 (Resident #11) of 17 residents reviewed for care plans.The facility failed to care plan Resident #11's external male catheter with urine collection system (uses suction to pull urine through tubing to the connected collection canister) when he admitted on [DATE] with an urine collection system.This failure could affect residents by placing them at risk of not receiving care and services to meet their needs. Findings included:Record review of Resident #11's admission record indicated a [AGE] year-old male admitted on [DATE] with diagnosis of anxiety disorder (persistent and excessive worry that interferes with daily activities), chronic pain syndrome (a condition where ongoing physical pain lasts past three to six months), scoliosis (a medical condition that causes the spine to curve sideways), and end stage heart failure (most severe phase of the disease where the heart can no longer pump well).Record review of Resident #11's admission MDS assessment, dated 06/08/2026, indicated a BIMS score of 13 indicating Resident #11 was cognitively intact with little to no impairment. He was dependent on staff for toileting and personal hygiene. He was always incontinent. Record review of the comprehensive care plan for Resident #11 with print date of 08/10/2026 indicated no care plan for the external catheter urinary wicking system. The care plan indicated he was incontinence with bladder. The interventions included providing incontinent care at least every 2 hours and applying moisture barrier after each episode and no mention of the external catheter urinary wicking system. The care plan did not address who would reapply the external catheter urinary wicking system, empty the canister, when and frequency needed.During an interview and observation on 8/10/26 at 2:00 p.m., Resident #11 said he used the external catheter urinary wicking system. He said he pays for the supplies himself and had been doing this for a long time at home. He said he ordered containers and bags as he pointed across his room to boxes. On the floor next to the bed were 2 urine collection containers. One of the containers was full of dark yellow urine. He said he needed assistance with the setting up of the system and for bag to be reapplied as needed. During an interview on 08/11/2026 at 4:00 p.m., DON said the hospice nurse applied the external catheter urinary wicking system weekly on Mondays. The DON said there were no orders or documentation for it being changed. The DON said the external catheter urinary wicking system should have been addressed on Resident #11's care plan to ensure care and services on admission were provided to assist him with assistance as was needed. She said there was no policy for the external catheter urinary wicking system. She said the CNAs or the nurses should assist with emptying the container. During an observation and interviews on 08/11/2026 at 4:10 p.m., Resident #11 said the bag had been off since yesterday, then he told the DON the bag just came off. The DON and Regional nurse were changing his brief, and bag was not seen in the brief or in the bed. The DON and Regional Nurse finished cleaning Resident #11 and they applied the external catheter urinary wicking system.

Based on interviews, and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 17 residents ( Resident #11) reviewed for activities.The facility failed to provide Resident #11 in room activities since his admission on [DATE]. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included:Record review of Resident #11's admission record indicated a [AGE] year-old male admitted on [DATE] with diagnosis of anxiety disorder (persistent and excessive worry that interferes with daily activities), chronic pain syndrome (a condition where ongoing physical pain lasts past three to six months), scoliosis (a medical condition that causes the spine to curve sideways), and end stage heart failure (most severe phase of the disease where the heart can no longer pump well).Record review of Resident #11's admission MDS assessment, dated 06/08/2026, indicated a BIMS score of 13 indicating Resident #11 was cognitively intact with little to no impairment. The following activities were somewhat important to Resident #11: doing his favorite activity, listening to music, and keeping up with the news.Record review of Resident #11's Comprehensive Care Plan, dated 07/30/2025, indicated to provide a program of activities that is of interest and accommodates. The goal was to be satisfied with activities and be assisted to attend activity functions.During an interview on 08/10/2026 at 9:39 a.m., Resident #11 said he stayed in bed and did not have in-room activities. He said when he first got here someone talked to him about his preferences of activities. He said he would like a word search book, and he had not told anyone. During an interview on 08/10/26 at 3:00 p.m., the Administrator said he had just hired a part-time person. and was looking for in-room activity logbook from the previous activity director. During an interview on 08/12/2026 at 9:00 a.m., the Administrator said he expected the ADs to provide in-room activities and could not find the log of the in-room activities. He said he would provide policy on activities. During an interview on 08/12/2026 at 1:45 p.m., the CHR E stated she was the facility's corporate human resource, and this was her third week in her position. She said the AD position was open, and the facility was seeking a qualified candidate. She said the previous AD was employed from 3/31/2026 to 5/12/2026 and the position had been open since her departure.Record review of the facility's policy titled Individualized Activity Programs, dated 2011, indicated: The Activity Director and staff will provide individual programming to meet individual needs and interests. Practice Guidelines: 1. The Activity Director determines the need for individual programming through the resident assessment process. (Residents who are in isolation, ordered bed rest, or prefer to not be included in group situations.) 2. Individual programs are developed and implemented regularly consistent with individualized leisure interests and based on the assessment. 3. One-on-one activities are provided regularly for those residents unable or unwilling to attend groups unless otherwise indicated by assessment. 4. Individual programs are coordinated by the Activity Director and documented in the plan of care. 5. Activity Director or Assistant trains and coordinates support staff and volunteers to provide some of the in-room activities for residents. 6. Goals, type of intervention and response are documented and reflected in monthly or quarterly progress notes as required. 7. The Activity Director and Staff regularly (at least quarterly) assess the ability or the interest of the residents to join group activities.

Based on observation, interview, and record review, the facility failed to provide the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 1 resident (Resident #11) reviewed for external catheters. The facility failed to ensure physician orders for the external male catheter with a urine collection system (used suction to pull urine through tubing to the connected collection canister) for Resident #11 when he admitted on [DATE].This failure could place residents at risk of not receiving care and services and could cause decline in conditions.Findings included:Record review of Resident #11's admission record indicated a [AGE] year-old male admitted on [DATE] with diagnosis of anxiety disorder (persistent and excessive worry that interferes with daily activities), chronic pain syndrome (a condition where ongoing physical pain lasts past three to six months), scoliosis (a medical condition that causes the spine to curve sideways), and end stage heart failure (most severe phase of the disease where the heart can no longer pump well).Record review of an admission telephone order dated 05/27/2026 indicated no order or instructions for the external catheter urinary wicking system.Record review of Resident #11 physician's orders dated August 2026 indicated no orders or instructions for the external catheter urinary wicking system.Record review of Resident #11's admission MDS assessment, dated 06/08/2026, indicated a BIMS score of 13 indicating Resident #11 was cognitively intact with little to no impairment. He was dependent on staff for toileting and personal hygiene. He was always incontinent. Record review of the comprehensive care plan for Resident #11 with print date of 08/10/2026 indicated no care plan for the external catheter urinary wicking system. The care plan indicated he was incontinent with bladder. The interventions included providing incontinent care at least q2h and apply moisture barrier after each episode and no mention of the external catheter urinary wicking system. The care plan did not address who would reapply the external catheter urinary wicking system, empty the canister, when and frequency needed.During an interview and observation on 8/10/26 at 2:00 p.m., Resident #11 said he used the external catheter urinary wicking system. He said he pays for the supplies himself and had been doing this for a long time at home. He said he ordered containers and bags as he pointed across his room to boxes. On the floor next to the bed were 2 urine collection containers. One of the containers was full of dark yellow urine. He said he needed assistance with the setting up of the system and for bag to be reapplied as needed. During an interview on 08/11/2026 at 4:00 p.m., DON said the hospice nurse applied the external catheter urinary wicking system weekly on Mondays. The DON said there was no documentation for it being changed. The DON said the external catheter urinary wicking system should have been addressed on Resident #11's physician's orders to ensure care and services were provided to assist him with assistance as needed. She said there was no policy for the external catheter urinary wicking system. During an observation on 08/11/2026 at 4:10 p.m., Resident #11 said the bag had been off since yesterday, then he told the DON the bag just came off. The DON and Regional nurse were changing his brief, and bag was not seen in the brief or in the bed.

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 17 residents (Resident #11) reviewed for storage and labeling of medications.The facility failed to ensure Resident #11 did not have medications Neosporin and prescribed miconazole 2% (anti-fungal cream) at the bedside.These failures could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.The findings include:Record review of Resident #11's face-sheet indicated he was a [AGE] year old male, admitted to facility on 05/27/26. His diagnosis included: hypertension, heart Failure, schizoaffective disorder bi-polar type, chronic pulmonary edema, anxiety disorder and adult failure to thrive.Record review of Resident #11's admission MDS dated [DATE] indicated in the resident is usually understood or usually understands others and had clear speech and had a BIMS of 13 which indicated the resident was cognitively intact for decision making.Record review of Resident #11's electronic record on 08/11/26 indicated there was no Care Plan addressing the resident may keep medications at bedside or to self-administer medications.Record review of the electronic record on 08/11/26 indicated Resident #11 did not have a Self-Administration Medication Assessment initiated or completed.Record review of Resident #11's consolidated report of current Physician orders dated 8/2026 indicated no scheduled or PRN order for Neosporin or prescribed miconazole 2% ointment, self-administer medications or to leave at bedside.Observation during initial tour, on 08/10/26 at 9:30 a.m., Resident #11 was in the room and the door was open. On his bedside table was an opened and used 1-ounce tube of Neosporin with no pharmacy label. On the bedside nightstand was an opened and used tube of prescription labeled miconazole 2% ointment.Observations and interview on 08/11/26 at 10:00 a.m., Resident #11 was in his room laying in his bed. When asked where does he put the Neosporin and how often does he use it? Resident #11 said that he uses Neosporin on his groin whenever it's dry and to keep infection from starting and that he ordered it from Amazon approximately 2 weeks ago. Resident #11 further said he used the prescribed miconazole 2% ointment on his feet to help with itching and the nurses left it in the room one day, but he couldn't remember when. Resident #11 said he had not notified the nurses about the medications because he was not aware that he had to tell them since the medications were over-the-counter medications. Resident #11 also said he did not report it to the nurses because the areas cleared up and didn't see any point in it. Resident #11 also said no one from the facility had contacted him about the medications, or that they could not be left out unattended at the bedside. When asked if he stored the medications in a different area Resident #11 said I keep it out like that very much like you see it there is not much room here to put things.During an interview on 08/10/2026 at 10:10 a.m., LVN-A said she had assessed Resident #11 this morning and had not noticed any medications left out at his bedside. LVN-A said no residents should have medications at their bedside. She said she did not know of any residents having medications in their rooms. She said a physician's order must be on file for the resident to receive the medication as well as to self-administer medications. She said a resident could take inappropriate amounts of the medication or another resident could wander in the room and get the medication and take it. She said residents could have an allergic reaction or become ill from taking unprescribed medication.During an interview on 08/10/26 at 10:18 a.m., CMA-H said she had administered medication to Resident #11 this morning but had not noticed any medication left at the beside. CMA-H said she's not aware of any resident having medications in their room. She said a resident can make themselves sick by taking unprescribed medications. She said all medications must have a physician's order and be given by a nurse or medication aide.Interview on 08/11/26 at 11:20 a.m., the DON said she was not aware of the mediations at Resident #11's bedside. The DON said her expectation is for nursing staff to follow facility policy and procedure and not leave medications at the bedside. The DON said Resident #11 would need a doctor's order and medication self-administration assessment completed before he would be able to keep meds at the bedside and administer them himself. The DON revealed she would have to look in the computer to see if Resident #11 had an order or med assessment, after looking in the computer the DON stated to surveyor that Resident #11 did not have an order for medications Neosporin and prescribed miconazole 2% or to leave medications at bedside and no self-administer medication assessment had been done for Resident #11. The DON said leaving medications at the bedside puts residents at risk of not taking them properly or giving them to someone else to take, but that she (DON) felt Resident #11 was cognitively intact enough to take the medication correctly and would need to have a MD order or Self-Med Assessment first. The DON agreed that residents in the facility must have a doctor's order to receive medications and that no resident can keep medication in their rooms and are not allowed to self-medicate. She stated there must be a physician's order to leave the medication at the bedside and an order for the resident to self-medicate.Review of the facility's undated policy titled, Self-Administration of Medication by Resident indicated, in part: .2. If the resident desires to self-administer medications an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. 3. The interdisciplinary team determines the residents' ability to self-administer medications by means of completing the Self Administration of Medication assessment in PCC. 4. The results of the interdisciplinary team assessment are recorded.5. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is ineffective. Adhere to the State Health Departments Rules on this matter b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the supplying pharmacy. Adhere to the individual State Health Departments rules as it relates to documentation for a resident that self-administers medications.6. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and then give unauthorized medications to the charge nurse for return to the family or responsible party .

Based on interviews and record review, the facility failed to provide required effective communications training for direct care staff for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the mandatory effective communication training. This failure could place residents at risk of being cared for by untrained staff.Record review of personnel record for PT F indicated a hire date of 01/31/2025.Review of the facility's training log, undated, showed no evidence of effective communication training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed effective communication training. During an interview on 08/12/2026 at 1:42 p.m., HR D stated she was newly appointed to the facility HR position and was currently being training on her job duties, which will include reviewing and reporting annual training but currently did not have access to view or run reports regarding annual training completion in the computerized training system. Said PT F was a shared employee with another sister facility and was currently on vacation out of the country.During an interview on 08/12/2026 at 1:48 p.m., CHR E said annual required training was computer generated quarterly and staff were provided emails regarding required completion and/or the delinquent courses. CHR E said the annual training completion was reported to the appropriate department heads routinely. CHR E said percentages of completion and delinquent staff were included in the report. CHR E said employees are assigned training quarterly and it was the employee's responsibility to complete training timely, including effective communication training. She said ultimately the HR department, including herself, was responsible for monitoring employees that were not completing the required training timely and reporting the delinquent staff to the appropriate department heads for appropriate disciplinary actions. CHR E said both the facility HR and department head (director of rehabilitation) responsible facility staff were newly employed or recently appointed to the position and both in training and learning their job responsibilities. CHR E said staff not completing the annual training as required could lead to missed updates and/or poor performance. An attempted interview on 08/12/2026 at 3:15 p.m. with PT F was unsuccessful, no return call to voicemail and text message.During a group interview on 08/12/2026 at 4:15 p.m., the Administrator said the HR department is responsible for reporting the facility staff's completion of the annual computerized training routinely. Requested a policy regarding required annual training. He said the facility HR staff was new to her position and was being provided with access and training in the monitoring and reporting of the computer-generated training completion and delinquent staff. He said PT F was a shared employee with another sister facility which was the primary facility for assigning computerized training. He said PT F had not completed his assigned computerized training on effective communication and he was unable to provide required training due to assigned training not being completed. He said it was the responsibility of the employees to complete their training on time. He said the department heads were responsible for ensuring staff completed the assigned training and the annual training completion should be monitored closer and delinquent staff should be held accountable. He said he completed random checks on annual trainings completion. He stated not completing the annual effective communication training as required could lead to employees not receiving updates or changes necessary for proper communication. A policy addressing annual employee training was requested from the Administrator and CHR E, on 08/12/2026 at 3:00 p.m. but was not provided prior to exit.

Based on interviews and record review, the facility failed to provide required Quality Assurance Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 1 of 23 (PT F) staff sampled for licensure and training.The facility failed to ensure that PT F had completed the mandatory QAPI training. This failure could place residents at risk of being cared for by untrained staff.Record review of personnel record for PT F indicated a hire date of 01/31/2025.Review of the facility's training log, undated, showed no evidence of QAPI training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed QAPI training. During an interview on 08/12/2026 at 1:42 p.m., HR D stated she was newly appointed to the facility HR position and was currently being training on her job duties, which will include reviewing and reporting annual training but currently did not have access to view or run reports regarding annual training completion in the computerized training system. Said PT F was a shared employee with another sister facility and was currently on vacation out of the country. During an interview on 08/12/2026 at 1:48 p.m., CHR E said annual required training was computer generated quarterly and staff were provided emails regarding required completion and/or the delinquent courses. CHR E said the annual training completion was reported to the appropriate department heads routinely. CHR E said percentages of completion and delinquent staff were included in the report. CHR E said employees are assigned training quarterly and it was the employee's responsibility to complete training timely, including QAPI training. She said ultimately the HR department, including herself, was responsible for monitoring employees that were not completing the required training timely and reporting the delinquent staff to the appropriate department heads for appropriate disciplinary actions. CHR E said both the facility HR and department head (director of rehabilitation) responsible facility staff were newly employed or recently appointed to the position and both in training and learning their job responsibilities. CHR E said staff not completing the annual training as required could lead to missed updates and/or poor performance. An attempted interview on 08/12/2026 at 3:15 p.m. with PT F was unsuccessful, no return call to voicemail and text message.During a group interview on 08/12/2026 at 4:15 p.m., the Administrator said HR department is responsible for reporting the facility staff's completion of the annual computerized training routinely. Requested a policy regarding required annual training. He said the facility HR staff was new to her position and was being provided with access and training in the monitoring and reporting of the computer-generated training completion and delinquent staff. He said PT F was a shared employee with another sister facility which was the primary facility for assigning computerized training. He said PT F had not completed his assigned computerized training on QAPI and he was unable to provide required training due to assigned training being not completed. He said it was the responsibility of the employees to complete their training on time. He said the department heads were responsible for ensuring staff completed the assigned training and the annual training completion should be monitored closer and delinquent staff should be held accountable. He said he completed random checks on annual trainings completion. He stated not completing the annual QAPI training as required could lead to employees not receiving updates or changes necessary and facility QAPI goals. A policy addressing annual employee training was requested from the Administrator and CHR E, on 08/12/2026 at 3:00 p.m. but was not provided prior to exit.

Based on interviews and record review, the facility failed to provide required Ethics training, for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the mandatory Ethics training. This failure could place residents at risk of being cared for by untrained staff.Record review of personnel record for PT F indicated a hire date of 01/31/2025.Review of the facility's training log, undated, showed no evidence of ethics training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed ethics training. During an interview on 08/12/2026 at 1:42 p.m., HR D stated she was newly appointed to the facility HR position and was currently being training on her job duties, which will include reviewing and reporting annual training but currently did not have access to view or run reports regarding annual training completion in the computerized training system. Said PT F was a shared employee with another sister facility and was currently on vacation out of the country. During an interview on 08/12/2026 at 1:48 p.m., CHR E said annual required training was computer generated quarterly and staff were provided emails regarding required completion and/or the delinquent courses. CHR E said the annual training completion was reported to the appropriate department heads routinely. CHR E said percentages of completion and delinquent staff were included in the report. CHR E said employees are assigned training quarterly and it was the employee's responsibility to complete training timely, including Ethics training. She said ultimately the HR department, including herself, was responsible for monitoring employees that were not completing the required training timely and reporting the delinquent staff to the appropriate department heads for appropriate disciplinary actions. CHR E said both the facility HR and department head (director of rehabilitation) responsible facility staff were newly employed or recently appointed to the position and both in training and learning their job responsibilities. CHR E said staff not completing the annual training as required could lead to missed updates and/or poor performance. An attempted interview on 08/12/2026 at 3:15 p.m. with PT F was unsuccessful, no return call to voicemail and text message.During a group interview on 08/12/2026 at 4:15 p.m., the Administrator said HR department is responsible for reporting the facility staff's completion of the annual computerized training routinely. Requested a policy regarding required annual training. He said the facility HR staff was new to her position and was being provided with access and training in the monitoring and reporting of the computer-generated training completion and delinquent staff. He said PT F was a shared employee with another sister facility which was the primary facility for assigning computerized training. He said PT F had not completed his assigned computerized training on ethics and he was unable to provide required training due to assigned training not being completed. He said it was the responsibility of the employees to complete their training on time. He said the department heads were responsible for ensuring staff completed the assigned training and the annual training completion should be monitored closer and delinquent staff should be held accountable. He said he completed random checks on annual trainings completion. He stated not completing annual ethics training as required could lead to employees not receiving updated or changed facility ethics information. A policy addressing annual employee training was requested from the Administrator, CHR E, on 08/12/2026 at 3:00 p.m. but was not provided prior to exit.

Based on interviews and record review, the facility failed to provide required behavioral health training, for 1 of 23 (PT F) staff sampled for licensure and training. The facility failed to ensure that PT F had completed the required behavioral health training. This failure could place residents at risk of being cared for by untrained staff.Review of the facility's training log, undated, showed no evidence of training for behavioral health for PT F. Record review of personnel record for PT F indicated a hire date of 01/31/2025.Review of the facility's training log, undated, showed no evidence of behavioral health training for PT F.Record review of the training log for the previous 12 months (08/12/2025 to 08/12/2026) provided by human resources department indicated no evidence that PT F completed behavioral health training. During an interview on 08/12/2026 at 1:42 p.m., HR D stated she was newly appointed to the facility HR position and was currently being training on her job duties, which will include reviewing and reporting annual training but currently did not have access to view or run reports regarding annual training completion in the computerized training system. Said PT F was a shared employee with another sister facility and was currently on vacation out of the country. During an interview on 08/12/2026 at 1:48 p.m., CHR E said annual required training was computer generated quarterly and staff were provided emails regarding required completion and/or the delinquent courses. CHR E said the annual training completion was reported to the appropriate department heads routinely. CHR E said percentages of completion and delinquent staff were included in the report. CHR E said employees are assigned training quarterly and it was the employee's responsibility to complete training timely, including behavioral health. She said ultimately the HR department, including herself, was responsible for monitoring employees that were not completing the required training timely and reporting the delinquent staff to the appropriate department heads for appropriate disciplinary actions. CHR E said both the facility HR and department head (director of rehabilitation) responsible facility staff were newly employed or recently appointed to the position and both in training and learning their job responsibilities. CHR E said staff not completing the annual training as required could lead to missed updates and/or poor performance. An attempted interview on 08/12/2026 at 3:15 p.m. with PT F was unsuccessful, no return call to voicemail and text message.During a group interview on 08/12/2026 at 4:15 p.m., the Administrator said HR department is responsible for reporting the facility staff's completion of the annual computerized training routinely. Requested a policy regarding required annual training. He said the facility HR staff was new to her position and was being provided with access and training in the monitoring and reporting of the computer-generated training completion and delinquent staff. He said PT F was a shared employee with another sister facility which was the primary facility for assigning computerized training. He said PT F had not completed his assigned computerized training on behavioral health care and services and he was unable to provide required training due to assigned training not being completed. He said it was the responsibility of the employees to complete their training on time. He said the department heads were responsible for ensuring staff completed the assigned training and the annual training completion should be monitored closer and delinquent staff should be held accountable. He said he completed random checks on annual trainings completion. He stated not completing annual behavioral health training as required could lead to employees not receiving updated or changed behavioral health information. A policy addressing annual employee training was requested from the Administrator, CHR E, on 08/12/2026 at 3:00 p.m. but was not provided prior to exit.

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #1). The facility failed to provide adequate supervision for Resident #1, who resided on the secured unit due to high risk for elopement and history of elopement, from leaving the facility unsupervised on 11/24/2025. Resident #1 was found at a local hospital emergency room where he had been taken by local police. The facility was not aware that the resident was missing for approximately 1.5 hours until a family member and local police called facility staff about his whereabouts. The noncompliance was identified as PNC (past noncompliance). The IJ began on 11/24/2025 and ended on 11/25/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of potential accidents, injuries, harm, or death.Findings included:Record review of Resident #1's face sheet dated 01/27/2026 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with diagnoses including: early onset Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), dementia (loss of cognitive functioning), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety (persistent and excessive worry that interferes with daily activities), depression (mental illness that negatively affects how you feel, the way you think and how you act), alcohol abuse, and impaired cognitive function. Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 had clear speech, usually understood others, and was usually understood by others. He had a BIMS score of 03 indicating severe cognitive impairment. He had behaviors of inattention and wandering daily. He required supervision assistance with ADLs and could feed himself. He was continent of bladder and bowel. He was independent with mobility and walked unassisted. He was independent with eating and putting shoes on/taking off. Record review of care plans for Resident #1 indicated he had a care plan initiated on 11/06/2025 and revised on 11/10/2025 indicating he was at risk for wandering. Goals included: The resident will not leave facility unattended and the resident's safety will be maintained through the next review period. He had another care plans initiated on 11/06/2025 which indicated he was at risk for elopement and required a secure unit. Care plan goals included: Will not feel isolation and will feel safe and secure in the care received while on the secure unit. Interventions included: Supervise closely and make regular compliance rounds whenever resident is in room, assess, record and report potential elopement, determine the reason the resident is attempting elopement and intervene as appropriate. This care plan was updated on 11/25/202025 and indicated he had eloped from the secure unit and a new intervention initiated on 11/25/2025 indicated 1:1 monitoring was in use. Review of Resident #1's Progress Notes in the electronic record indicated the following:*Progress note dated 11/05/2025 at 4:44 p.m., authored by LVN B indicated behaviors of wandering.*Progress note dated 11/07/2025 at 8:49 p.m., authored by RN C indicated Resident #1 observed to be confused and disoriented and required frequent redirection. Resident #1 was given prescribed meds but remained restless and agitated. He continued to wander and repeat statements despite verbal reassurance.*Weekly summary note dated 11/12/2025 at 6:49 a.m. authored by LVN D indicated in the last week resident wanders daily.*Weekly summary note dated 11/19/2025 at 6:42 a.m. authored by LVN D indicated in the last week resident wanders daily.* Progress note dated 11/23/2025 at 1:15 p.m., authored by LVN E indicated Resident #1 was constantly going into Resident #2's room (female). Staff observed him open the closed door and walk in and go toward female resident's bed. LVN E instructed him to come out of her room and not to open her door when it was closed. Female resident's family member was visiting, and he notified LVN E Resident #1 had come in the room a few times. The family member expressed concerns about safety, and he did not appreciate Resident #1 coming into the female's room. The family member requested to keep Resident #1 out of the room.*Progress administration notes continued with entries on 11/16/2025 at 9:23 a.m., 11/16/2025 at 1:02 p.m., 11/17/2025 at 12:02 p.m., 11/18/2025 at 10:17 p.m., 11/19/2025 at 7:13 a.m., 11/20/2025 at 6:58 a.m., 11/20/2025 at 3:03 p.m., 11/21/2025 at 7:18 a.m., 11/22/2025 at 9:35 a.m., 11/22/2025 at 5:59 p.m., 11/23/2025 at 9:01 a.m., 11/23/2025 at 6:13 p.m., 11/24/25 at 8:47 a.m., 11/24/25 at 4:17 p.m. regarding behaviors observed but no indications of the type of behaviors.*Progress Notes dated 11/25/2025 at 2:21 a.m., authored by the DON, indicated she was notified that Resident #1 had eloped and was at local hospital for evaluation and treatment under emergency direct order, per shift nurse. Shift nurse received phone call from Resident #1's family member and was informed that Resident #1 was in police custody and being sent to local ER for evaluation around midnight. Resident #1 eloped from facility, shift nurse attempted to enter resident's room and was unable so went through adjoining room and noted that resident had room door barricaded and window broken. Observation of secure unit courtyard indicated outside chair/bench placed against fence to climb over fence. MD notified, new order to refer to behavioral unit, and RP gave verbal consent for resident to be referred to behavioral hospital. Record review of Resident #1's elopement incident report and LVN F's statement dated 11/25/2025 indicated LVN F was at the facility on 11/24/2025 at 10:00 p.m. for her shift after receiving report from the previous shift nurse, and made rounds and checked on residents. LVN F said Resident #1 was in bed when she peeked in his room during rounds. She received a phone call around 12:00 a.m. from a family member inquiring about Resident #1's location. She went to Resident #1's room and was unable to enter the room the door was barricaded, she went around to the adjoining bathroom and entered Resident 1's room. She found the door had been barricaded with furniture, TV face down on floor, window broken. Resident #1 was missing. Observation of secure unit courtyard found a bench lying slanted on the fence as a ladder. Record review of Resident #1's ER records dated 11/25/2025 indicated Resident #1 was admitted to the ER at 11:36 p.m The narrative indicated he had dementia, and was brought to the ER via local police department. Resident #1 was at local fast food restraint attempting to break into someone's car, and ended up being held up at gunpoint. Resident #1 broke the window of the first floor in a secure nursing facility, used a chair in the courtyard and scaled the fence, then made his way to where local police department picked him up. The records indicated he was at a normal mental baseline, and there was no indication for a psychiatric admission. Resident #1 was discharged on 11/25/2025 back home. Record review of the staff schedule for 11/24/2025 indicated LVN F and CNA A were assigned to work the secure unit on the 10:00 p.m. to 6:00 a.m. shift. Record review of the timesheets for 11/24/2025 indicated LVN F clocked in at 9:56 p.m. and clocked out at 6:53 a.m. on 11/25/2026. CNA A clocked in at 10:05 p.m. and clocked out at 6:09 a.m. on 11/25/2026. Record review of the police incident report dated 11/24/2025 at 10:20 p.m. indicated the local police department was called to a location (0.3 miles from facility) for possible crime on private property, victim was a white male (Resident #1). During an interview on 1/27/2025 at 9:30 a.m., the Administrator said the ADON called him on 11/24/2025 at 11:58 PM and informed him that Resident #1 had eloped from the facility and was in custody of the local police department. He called the facility and learned that Resident #1 was in his room resting during the 10 PM shift change. Staff reported that Resident #1's door had been barricaded with furniture, and he took trim from his window and pried the window open. He said the bench in the secure unit courtyard and a trash can was found against the wooden fence. He said the police informed him Resident #1 was found across the street at a local ER facility attempting to break into a car and the cops were called. He said no one at the facility was aware Resident #1 was missing until they received a call from family members and local police department. During an interview and observation on 1/27/2026 at 10:45 a.m., LVN E was sitting in a chair in Resident #1's room (across from nurses' station). Resident #1 was sleeping in his bed. LVN E said she was providing 1:1 monitoring for Resident #1 for the day shift because he was at risk for elopement. She said if he was not being supervised, he would elope. She said since his admission to the facility he was always looking for his keys, wallet, and car so he could leave. She said he had behaviors of wandering, going to exit doors but easily redirected, and talking about ways to get out. She said he is independent with his care, so she is there to assist. She says she always stays with him, must always have eyes on him. During an interview on 1/27/2025 at 11:30 a.m., LVN D said she was the nurse for the unit. She said Resident #1 had behaviors of wandering, exit seeking, pacing and looking for keys, wallet and car to leave. She said he was admitted to the behavior hospital twice, once after the elopement and another time after exit seeking, hard to redirect and being aggressive with staff. She said Resident #1 was very lucid at times, but then has periods of confusion. She said he had a history of eloping and that was why he was admitted to the secure unit. She said he required frequent monitoring due to exit seeking and wandering into others' rooms. During an interview and observation on 01/27/2026 at 1:00 p.m., LVN E said Resident #1 had been up to the dining room for lunch and just received a shower and shave. Resident #1 in bed, freshly shaven, and well groomed. Resident #1 said he was having a good day and denied abuse or neglect from facility staff and/or other residents. Resident #1 did not recall the elopement incident from November 2025. LVN E said she always remained with him. LVN E said he went to the window and looked out a few times and opened up the dresser drawer looking for his keys and wallet, but he was easily redirected. During an interview on 1/27/2026 at 1:30 p.m., CNA H said she worked the secure unit all shifts. She said she checked residents every hour to see if residents were in the rooms they are assigned to. She said residents wandered in and out of each other's rooms sometimes. She said Resident #1 had to be monitored closely and redirected because he would wander into the wrong room. She said he would talk about his work history and seemed very intelligent and then in the next conversation he would be confused. She said he wandered, paced up and down halls, and talked about going home. During an interview on 1/27/2026 at 4:00 p.m., CNA M said she was the CNA for the 2 - 10 pm shift on 11/24/2025, the day of his elopement. She said she saw Resident #1 around 9:00 p.m He had been up late that evening and came to the dining room and she offered him a snack. She said he was given a snack and redirected to his room. She said Resident #1 did not have a routine sleep pattern; some evening he would go to his room and go to sleep and other evening he would wander and pace the halls. She said Resident #1 did talk about leaving and going home frequently and had a history of exit seeking/elopement prior to admission; that was why he was admitted to the secure unit. She said that Resident #1 would attempt to elope if he was not under 1:1 supervision/monitoring. During an interview on 1/27/2026 at 4:15 p.m., LVN B said she was the LVN for the 2 - 10 pm shift on 11/24/2025, the day of his elopement. She said she recalled seeing Resident #1 wandering up and down the hall attempting to enter other resident's room prior to her leaving the night of his elopement, and she redirected him to his room around 9:45 p.m. She said she reported to the oncoming nurse and left the facility around 10:00 p.m. She said Resident #1 was in the secure unit due to elopement risk, exit seeking and progression of his dementia/Alzheimer's disease. She said Resident #1's behaviors included wandering, exit seeking, wandering into others room, looking for his keys, wallet, and car and requested to leave. She said he would wander the halls and push on other residents' doors and would require redirecting. She said that Resident #1 did not have a routine sleep pattern and required medications for insomnia at times. She said that the residents on the secure unit required frequent monitoring, and she rounded on residents at least every two hours and more frequently for some to administer medications. During an interview on 1/27/2026 at 4:28 p.m., the ADON said she received a phone call and photo images on 11/24/2025 around 11:50 PM from facility staff reporting that the family reported Resident #1 was in police custody and he had eloped from the secure unit. She said staff sent her images of his damaged window, bent window screen, bench and trash can against secure unit courtyard wall, and his room in disarray and door barricaded. She said the facility staff reported that an elopement protocol was initiated and all other residents were accounted for. During an interview on 1/27/2026 at 8:15 p.m., CNA A said she was the CNA working in the secure unit on 11/24/2025 when Resident #1 eloped. She said when she came in around 10:00 p.m., she went to the secure unit and made her first rounds and peeked in Resident #1's door just enough to see what appeared to be him lying in the bed. She said he had a sign up on his door saying he didn't want anyone entering his room. She said she completed her rounds on the secure unit, left the secure unit to assist another CNA with resident care, and then went to a break room to enter her task on the kiosk. She said she returned to the secure unit around 11:30 to 11:45 p.m. and heard LVN F on the phone regarding the location of Resident #1. She said she and LVN F went to Resident #1's room and was unable to open the door. She said they entered the room through an adjoining bathroom and found that Resident #1 had barricaded the door with furniture, his TV was on the floor, and his window was broken. She said when she left the secure unit, she notified LVN F she was going to be off the unit. She said she did not recall when Resident #1 placed the signage on his door. She said Resident #1 would sleep some nights and be up wandering and pacing other nights. She said Resident #1 would ask for his keys, wallet, and is the location of his vehicle because he needed to leave. She said that she made rounds and monitored the residents on the secure unit at least every 2 hours but usually more frequently. Unsuccessful attempts were made to contact LVN F on 1/27/2026 at 8:00 p.m. and 1/28/2026 at 8:17 a.m., left message with no return call. During an interview on 1/28/2026 at 8:42 a.m., the Family Member said she was contacted by the local police department that Resident #1 was in police custody and taken to local ER for evaluation after he attempted to break into a car at a local fast-food restaurant after eloping from skilled nursing secured facility. She said when she called the facility, they were unaware that Resident #1 was missing. She said that during the initial facility tour, family members indicated to facility staff, the windows may be an issue because Resident #1 was a contractor and could probably manipulate them, but was informed by facility staff they had a locking mechanism on the for safety and bars were not allowed on the windows due to fire safety which was understandable. She said she was told Resident #1 had eloped from those same windows. During an interview and observation on 1/28/2026 at 10:15 a.m., CNA G was sitting in a chair in Resident #1's room. Resident #1 sitting in bed watching TV. CNA G said she was providing 1:1 monitoring with Resident #1 which included always having their eyes on him and providing care as needed. CNA G said she went wherever he went. CNA G said that she felt if Resident #1 was not on 1:1 monitoring, he would attempt to elope. CNA G said he looked for his wallet and keys and asked where his car was so he could go home. CNA G said he had periods of confusion, and other times he talked about him being a builder or contactor, how he could escape, and repairs needed at the facility. Resident #1 denied eloping from the facility in November 2025 and expressed he was pleased with the care provided by facility safe and felt safe. During an interview on 1/28/2026 at 12:18 p.m., the responding police officer said that the police department was contacted twice regarding Resident #1. He said the first encounter, at a freestanding ER (0.3 miles from the facility), Resident #1 was loitering in the lobby and staff called police. He said the first officer on scene thought he was transient and asked him to leave the establishment and he complied. He said they later received a call from local fast-food restaurant (approximately .5 miles down the road) and bystanders, that a gentleman (Resident #1) was trying to get inside the cars and someone had pulled a gun on him. He said he went to the scene to find the same victim (Resident #1) from the earlier report. He said Resident #1 was able to provide his name and previous residential address (out of town). He said he took Resident #1 to a local ER, and they identified Resident #1 and contacted emergency contacts listed during a previous hospital visit. He said he contacted a family member, and they provided information that he was a resident at a local nursing facility's secure unit. He said he contacted the facility and facility administrator with the location of the resident and his admission to the local ER for evaluation. He said he was concerned for Resident #1's safety, and luckily police were able to respond to the call quickly and no one was injured. During an interview on 1/28/2026 at 1:00 p.m., the DON said she came to the facility when Resident #1 was reported missing on 11/24/2025. She said the ADON notified her, around 11:45 p.m. on 11/24/2025, Resident #1 had eloped and was at a local ER. She said she called the administrator, but he was already aware of the incident. She said she informed the Administrator to notify her of Resident #1's return to the facility and she would provide the initial 1:1 monitoring upon his return. She came to the facility and checked on the secure unit residents with no other concerns identified. She said the RCN provided training to the management staff, and then they initiated in-servicing staff and elopement drills. She said Resident #1 did not return to the facility until 11/25/2025 at 7:45 a.m. due to a transportation delay. She said upon Resident #1's return to the facility, he was placed on 1:1 monitoring and room change closer to secure unit nurses' station. She said she completed the pain and skin assessment on Resident #1 upon his return to the facility with no pain or injuries found. She said she completed elopement risk on all the residents after the elopement incident. She said she was not initially aware Resident #1 being held at gunpoint or threatened with a gun, just that he tried to break into someone's care. She said she was later notified of Resident #1 being held at gunpoint during the morning meeting on 11/25/2026. She said Resident b#1 was transferred to a behavioral hospital for evaluation on 11/25/2026 between 3-4 p.m. She said Resident #1 attempted to elope at the behavioral hospital also. She said Resident #1 had remained on 1:1 monitoring while at the nursing facility. During an interview on 1/28/2026 at 2:30 p.m., the Administrator said he was aware that Resident #1 was held at gun point after his elopement, but was not aware that the local police had two encounters with Resident #1. He said he did recall Resident #1's family mentioning the windows during the initial tour, but they were provided information regarding bars on windows were restricted and windows were secured with required window locks. He said he felt that the facility had done everything they could to keep Resident #1 safe and were still monitoring him 24 hours a day, 7 days a week. Review of the facility's Elopement Prevention Policy undated indicated Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.Physical Plant 1. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts.keypad exit magnetic locks, secured unit, .3.All exit devices will be maintained by the manufacturer's recommendations and function of each door device will be verified weekly and a log maintained. Staff Training: Staff will receive training during their orientation process and then annually regarding elopement prevention, operation of all exit devices, and actions to take if elopement occurs. Review of the facility's Elopement Response Policy undated indicated Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented.4. Should an employee discover a resident is missing from the facility, he/she should: A. report to the charge nurse .C. make a thorough search of the building and premises. If not located: D. notify Administrator and Director of Nursing; E. notify responsible party; F. notify attending physician; G. notify . Area Director of Operations . The facility took the following actions to correct the noncompliance prior to surveyor entrance: *Record reviews of electronic records indicated all residents were assessed for elopement risk on 11/25/2025. No issues identified. *Record review of the provider investigation folder, the facility's plan of removal dated 11/25/2025 indicated the following corrective actions were taken: *Resident #1 returned to facility on 11/25/2025 at 7:45 a.m., placed on 1:1 monitoring until transferred to behavioral hospital. *All residents received an elopement risk assessment completed by DON, ADON, and designee. No additional findings were identified. *All secure unit residents assessed and monitored after the incident by LVNs, DON, ADON, and designee. No additional findings were identified. *Door code was changed 11/25/2025. *Damaged furniture was replaced 11/25/2025. *The Administrator, DON, and ADON were in-serviced 1 on 1 by the Regional Compliance Nurse on following in-services: Abuse and Neglect; Resident Rights: Elopement Prevention and Elopement Response. *The Medical Director was notified of the Immediate Jeopardy on 11/25/2025 by the DON. *An ADHOC QAPI meeting was conducted by the interdisciplinary team to include the Medical Director on 11/25/2025. *Elopement drills were conducted 11/25/2025 on all shifts by Administrator/Designee.In-services: *The following in-services were initiated on 11/25/2025 for all direct care staff by the DON, ADON, and/or Regional Compliance Nurse in person and/or via phone. All staff who were not present for in-services were not permitted to work their assignment until in-serviced. All new hires will be in-services during facility orientation. All agency staff will be in-serviced prior to working their floor assignment. Observations during the investigation from 1/27/2026 through 1/28/2026 indicated the nine secure unit resident room windows were secure and new window locks observed. The observation of the secure unit courtyard indicated two heavy cemented benches with a 6-foot fence, and keypads or locks on exit gates. During an interview and observation on 11/27/2026 at 11:00 a.m., MNT K said that he did repairs to Resident #1's room after the incident. He said that the window stool/apron had been removed, and the window lock forcefully removed, and window pried open with the outer screen bent. During observation of Resident #1's previous room (room incident occurred), MNT K explained the repairs and said he had replaced the window locks with ones that needed a special tool to remove. He said that he replaced the screen outside and replaced all the window locks in the secure unit resident's room. He said that he had received in-service, and participated in elopement drills several times after the elopement. Record review of an invoice dated 11/25/2025 indicated the facility ordered and received 32 sliding window locks. Record review of an Education In-Service Attendance Record with subject of abuse, neglect, resident rights, elopement prevention and response conducted by regional dated 11/25/2025, indicated that 3 management staff members (1 administrator, 1 director of nursing and 1 assistant director of nursing) all signed the in-service record regarding elopement response, elopement response, resident rights, abuse and neglect. Record review of an Education In-Service Attendance Record with subject of Elopement Response dated 11/25/2025, indicated that 59 staff members (1 Administrator, 1 Business office manager, 1 MA, 17 LVNs, 1 MA, 20 CNAs, 7 Housekeeping/laundry, 4 dietary staff, 1 Marketer, 1 Social worker, 1 activity director, 1 maintenance worker, and 3 therapist) signed the in-service record regarding elopement response. Record review of an Education In-Service Attendance Record with subject of Elopement Prevention dated 11/25/2025, indicated that 59 staff members (1 Administrator, 1 Business of manager, 1 MA, 17 LVNs, 1 MA, 20 CNAs, 7 Housekeeping/laundry, 4 dietary staff, 1 Marketer, 1 Social worker, 1 activity director, 1 maintenance worker, and 3 therapist) signed the in-service record regarding elopement prevention. Record review of an Education In-Service Attendance Record with subject of Abuse, neglect and resident rights dated 11/25/2025, indicated that 59 staff members (1 Administrator, 1 Business of manager, 1 MA, 17 LVNs, 1 MA, 20 CNAs, 7 Housekeeping/laundry, 4 dietary staff, 1 Marketer, 1 Social worker, 1 activity director, 1 maintenance worker, and 3 therapist) signed the in-service record regarding abuse, neglect and resident rights. Record review of a Wander/Elopement Drill Report dated 11/25/2025 indicated a mock elopement/missing resident drill was conducted at 10:30 a.m., and 18 staff (Regional nurse, 1 Business office, 3 dietary staff, 3 housekeeping/laundry staff, 5 CNAs, 1 MA, 1 LVN, 1 maintenance and 2 therapists) participated. Record review of a Wander/Elopement Drill Report dated 11/25/2025 indicated a mock elopement/missing resident drill was conducted at 4:23 p.m. and 13 staff (3 LVNs, 1 MDS Nurse, 2 MAs, 2 CNAs, 3 dietary staff, 1 business office, and 1 activity director) participated. Some were staff who were not listed on the other drill on 11/25/2025. Record review of a Wander/Elopement Drill Report dated 11/28/2025 indicated a mock elopement/missing resident drill was conducted at 10:00 p.m., and 6 staff (3 LVNs, and 3 CNAs) participated. Some were staff who were not listed on the other drill on 11/25/2025. Record review of the Employee Staff List indicated all staff members had been trained in Elopement prevention and response. Record review of the facility's incident reports from 07/27/2025 through 01/27/2026 indicated there were no elopements. During an interview on 11/27/2026 at 10:45 a.m., LVN G said she had received in-service and participated in elopement drills several times after the elopement. During an interview on 11/27/2026 at 10:49 a.m., LVN D said she had received in-service and participated in elopement drills several times after the elopement. During an interview on 11/27/2026 at 1:45 p.m., HSK J said she had received in-service and participated in elopement drills several times after the elopement. During an interview on 11/27/2026 at 2:00 p.m., CNA L said she had received in-service and participated in elopement drills several times after the elopement. During an interview on 11/27/2026 at 4:00 p.m., CNA M said she had received in-service and participated in elopement drills several times after the elopement. During an interview on 11/27/2026 at 4:15 p.m., LVN B said she had received in-service and participated in elopement drills several times after the elopement. During a phone interview on 1/27/2026 at 8:15 p.m., CNA A said she had received in-service on 03/23/25 and participated in elopement drills several times after the elopement. During interviews on 11/28/2026:* at 9:00 a.m. LVN X said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.* at 10:15 a.m. CNA G said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.* at 11:20 a.m. HSK O said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol. * at 11:25 a.m. HSK Q said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.* at 11:31 a.m. CNA P said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.*at 1:45 p.m. MDS Nurse said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.* at 1:41 p.m. DS Y said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.* at 1:45 p.m. DS ZZ said she had only worked at the facility for about a week but received elopement in-service during her orientation and was able to verbalize the protocol.* at 1:50 p.m. DS BB said she had only worked at the facility for about a week but received elopement in-service during her orientation and was able to verbalize the protocol.* at 2:10 p.m. HSK S said he had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.* at 2:12 p.m. CNA T said she had only worked at the facility for less than a month but received elopement in-service during her orientation and was able to verbalize the protocol.* at 2:15 p.m. CNA U said she had worked at the facility for less than a month but received elopement in-service during her orientation and was able to verbalize the protocol.* at 2:20 p.m. SLP AA said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol. She said she did 1:1 monitoring with Resident #1 and was trained to keep resident in direct eye contact and prevent elopement.* at 3:31 p.m. CNA V said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.* at 3:35 p.m. CNA W said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol.* at 4:15 p.m. SW said she had received in-service and participated in elopement drills several times after the elopement and was able to verbalize the protocol. On 11/28/2025 at 4:35 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/24/2025 and ended on 11/25/2025. The facility had corrected the noncompliance before survey began.

During an observation on 06/09/25 at 12:35PM the pureed food served in the facility was observed. On each puree tray there was a main plate with 3 foods including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. During an interview on 06/09/25 at 02:30 PM, [NAME] F said he made the puree this day. He said he was not trained on how to make the puree. He said he was not sure if there was a recipe for the puree. He said he did not follow a recipe for the puree this day. He said his puree usually comes out more like mashed potatoes. He said he was running behind today and he was in a hurry. He said the old Dietary Manager left about a month ago. He said the risk to the resident was possible choking. During an interview on 06/11/25 at 11:34 AM, the DON said she expected [NAME] F to have been trained to make puree foods. She said he came from a sister facility. She said he has been here a few months. During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the cook to make the puree properly. She said a Dietary Manager should train and be able to expect the staff to do the puree correctly. She said she expected [NAME] F to have been trained on puree preparation. She said he normally does the puree when he works. She said he was trained at another facility on the puree. Record review of [NAME] F's Dietary Staff/Cook Proficiency, dated 04/11/25, indicated he was marked as satisfactory on the section pertaining to the following topic: Demonstrates understanding of: *Therapeutic and mechanically altered diets, including regular with mech/ground meat vs. mechanical soft . The proficiency did not specifically address pureed diets. Record review of the Facility's undated policy, Employee Orientation, stated: All individuals will have the basic information to perform their job efficiently and effectively. All new employees will receive orientation to the facility an especially to the Dietary Department. Procedure 1. The Dietary Service Manager conducts orientation on an individual basis with the new employee before being assigned a schedule. 2. In-Service Training sessions are scheduled monthly and conducted by either the dietitian or the dietary service manager. All dietary employees on duty are required to attend, with the goal of at least two hours of inservice training each quarter .training is also assigned to dietary employees monthly and must be completed by month's end. Possible topics include: - General and Therapeutic diets . Record review of the Texas Administrative Code chapter 228 subchapter (b) (d) indicated: All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment . Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 out of 6 dietary staff (Cook F, Kitchen Staff BB, Kitchen Staff CC, and Kitchen Staff DD) The facility failed to ensure Kitchen Staff BB, CC, and DD had a current food handlers certificate The facility failed to ensure [NAME] F was trained and competent to prepare the pureed food. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. Findings included: During an observation of the kitchen on 6/9/2025 at 8:45 a.m., [NAME] F was preparing for the lunch meal. Review of the food handler's certificates of completion provided by the facility on 6/10/2025, revealed Kitchen Staff BB, Kitchen Staff CC, Kitchen Staff DD did not have a food handler's certificate. Kitchen Staff BB had a hire date of 5/1/2025, Kitchen Staff CC had a hire date of 2/6/2025 and Kitchen Staff DD had a hire date of 4/3/2025. During an attempted interview on 6/10/2025 at 10:00am Kitchen Staff BB, Kitchen Staff CC and Kitchen Staff DD were not available for interview. During an interview on 6/11/2025 at 9:20 a.m., the travelling CDM H said the dietary manager was responsible for making sure staff got their food handlers certification but since the facility did not have a dietary manager it was the Administrators responsibility. The Dietary Manager stated the failure could potentially put residents at risk for food borne illness and cross contamination. During an in interview on 6/11/2025 at 9:58 a.m., Registered Dietician G said by Kitchen Staff BB, Kitchen Staff CC, and Kitchen Staff DD working without having their food handler's certification was they could possibly handle food inappropriately which could cause residents to become sick by food borne illness. During an interview on 6/11/2025 at 11:44 a.m., the Administrator said he expected the dietary staff have their food handler certificates within 30 days of hire. The Administrator said the importance of obtaining the food handler certificate training was to teach staff to follow proper procedures and prevent infection control issues. The Administrator said the facility did not have a specific policy for obtaining food handler's certifications and they followed the Texas Administrative Code.

Based on observation, interview, and record review, the facility failed to ensure the each resident received food prepared in a form to meet their individual needs for 4 of 4 residents (Residents #4, #31, #30, and #16) reviewed for pureed diet consistency. The facility failed to ensure Resident #4 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #31 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #30 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #16 was served a pureed diet as ordered by the physician. These failures could place residents at risk of choking, aspiration, and/or death. Findings included: 1. Record review of Resident #4's face sheet, dated 06/09/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dysphagia (difficulty swallowing food or liquids), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and cognitive communication deficit (communication problem stemming from difficulties with cognitive processes, rather than with speech or language itself). Record review of Resident #4's quarterly MDS assessment, dated 03/21/25, indicated she had a BIMS score of 03, which indicated severe cognitive impairment. She was sometimes able to make herself understood and she was sometimes able to understand others. She was completely dependent on staff for the activity of eating. The assessment indicated she has signs and symptoms of a possible swallowing disorder including holding food in mouth/cheeks or residual food in mouth after meals and coughing or choking during meals or when swallowing medications. She required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Record review of Resident #4's Order Summary Report, dated 06/09/25, indicated she had an order for: *Fortified/Enhanced diet. Pureed Texture. The start date was 02/12/24. Record review of Resident #4's care plan, last revised 05/23/25, indicated a focus of Resident #4 has a fortified/enhanced diet with pureed texture. Interventions included the resident has a pureed diet, and speech therapy and treatment per physician's orders as condition warrants. Record Review of Resident #4's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet . .Entrée .Smashburger [with] grilled onions Starch .Zesty Fry Sauce . .waffle fries Vegetable .Tomato Juice . Dessert .Apple Fried Pie . During an observation on 06/09/25 at 12:35 PM, Resident #4 was being fed lunch in the dining room by CNA A. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. During an interview on 06/09/25 at 12:43 PM, Speech Therapist B said that the food on Resident #4's plate was a mechanical soft consistency. She said Resident #4 was supposed to have pureed consistency. She said the resident being served the wrong consistency could cause her to choke or aspirate. During an interview on 06/09/25 at 12:46 PM, CNA A said the pureed food consistency varies. She said the DON and LVN C checked the tray before she took the tray to Resident #4. She said since the nurse checked the tray, she thought it was okay. She said the resident did not cough or choke. She said the risk was that the resident could choke or aspirate on her food. 2. Record review of Resident #31's face sheet, dated 06/09/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Huntington's disease (a progressive neurodegenerative disorder that affects movement, thinking, and emotional abilities). Record review of Resident #31's quarterly MDS assessment, dated 04/18/25, indicated he had a BIMS score of 11, which indicated moderate cognitive impairment. He was able to make himself understood and he was able to understand others. He was completely dependent on staff for the activity of eating. He required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Record review of Resident #31's Order Summary Report, dated 06/09/25, indicated he had an order for: *Fortified/Enhanced diet. Pureed Texture. The start date was 05/30/25. Record review of Resident #31's care plan, last revised on 06/09/25, indicated a focus of Resident #31 has a diet order other than regular and may be at risk for unplanned weight loss or gain. Interventions included the resident has a pureed diet and serve diet and snacks as ordered. Record Review of Resident #31's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet . .Entrée .Smashburger [with] grilled onions Starch .Zesty Fry Sauce . .waffle fries Vegetable .Tomato Juice . Dessert .Apple Fried Pie . During an observation on 06/09/25 at 12:43 PM, Resident #31's lunch tray was in his room on his bedside table. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. 3. Record review of Resident #30's face sheet, dated 06/09/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (occurs when the blood supply to the brain is interrupted, leading to brain tissue death), and dementia (a general term for the loss of cognitive function, including memory, language, problem-solving, and reasoning, which can interfere with daily life). Record review of Resident #30's quarterly MDS assessment, dated 03/31/25, indicated a BIMS was not conducted due to the resident being rarely/never understood. She was rarely/never able to make herself understood and she was rarely/never able to understand others. She was completely dependent on staff for eating. The assessment indicated she had signs and symptoms of possible swallowing disorder including loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. She required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Record review of Resident #30's Order Summary Report, dated 06/09/25, indicated she had an order for: * Fortified/Enhanced diet. Pureed Texture. Divided plate. Pleasure feedings as tolerated. The start date was 01/24/25. Record review of Resident #30's care plan, last revised 05/27/25, indicated a focus of Resident #30 is at risk for unplanned weight loss or gain. Resident #30 is prescribed a fortified/enhanced diet, pureed texture. Interventions included serve diet and snacks as ordered and the resident has a pureed diet. During an interview on 6/9/25 at 12:50 p.m., LVN D said that she already fed Resident #30. She said that Resident #30 was on a pureed diet. She said that pureed food should look like baby food. She said that the food that she fed Resident #30 looked like the food in the picture the surveyor showed her. She said that it was not pureed food. 4. Record review of Resident #16's face sheet, dated 06/09/25, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included profound intellectual disabilities (Intellectual disability so severe that they are unable to live independently, require close supervision, and often have physical limitations), and cervicalgia (pain in the neck). Record review of Resident #16's annual MDS assessment, indicated a BIMS was not conducted because he was rarely/never understood. He was rarely/never able to understand others. He required setup or clean-up assistance with eating. He required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Record review of Resident #16's Order Summary Report, dated 06/09/25, indicated he had an order for: *Regular diet, Pureed texture. The start date was 05/30/25. Record review of Resident #16's care plan, last revised 03/21/25, indicated a focus of Resident #16 has a diet order other than regular and may be at risk for unplanned weight loss or gain. Regular diet, puree texture. Interventions included the resident has a pureed diet. Record review of Resident #16's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet . .Entrée .Smashburger [with] grilled onions Starch .Zesty Fry Sauce . .waffle fries Vegetable .Tomato Juice . Dessert .Apple Fried Pie . During an observation on 06/09/25 at 12:44 PM, Resident #16 was sitting in his room eating his lunch. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. There was also a separate plate on the tray that had a regular slice of apple pie on the plate. It was regular consistency and was not altered. Record review of the Facility's recipes for 06/09/25 at lunch stated: .Beef Smashburger [with] [grilled] onion . .To get the actual serving size, puree the number of portions needed, adding adequate liquid needed to achieve desired consistency as appropriate for resident, then divide the total amount equally by the number of portions pureed. Measure number of servings using the regular prepared recipe portion. Drain well to minimize the use of thickener to obtain appropriate consistency. Place in a blender or food processor. Add liquid, if needed .to assist with pureeing. Puree with a blender or food processor until smooth . .If needed, gradually add thickener . .The desired thickness should be mashed potato or pudding. There should be no large lumps or particles . .Waffle Fries . .The desired thickness should be mashed potato or pudding. There should be no large lumps or particles . .Pie, Fried Fruit Apple . .Desired thickness should be mashed potato, pudding, or applesauce texture. There should be no large lumps or particles . During an interview on 06/09/25 at 12:55 PM, Dietary Supervisor E said she was in the facility helping them out on this day. She said she normally works in another facility. She said the pureed diet food served at lunch on 06/09/25 was mechanical soft consistency. She said the risk was that the residents could choke or aspirate. During an interview on 06/09/25 at 01:10 PM, LVN C said she checked the trays as they came out of the kitchen. She said she did not question the consistency of the pureed food because the dietary supervisor had just added some liquid to the pureed food before the tray came out. She said she thought the food was closer to mechanical soft than puree. She said the resident could choke or aspirate if they ate the wrong consistency food. She said her and the DON were checking the trays before they came out of the kitchen. During an interview on 06/09/25 at 02:30 PM, [NAME] F said he made the puree this day. He said he was not trained on how to make the puree. He said he was not sure if there was a recipe for the puree. He said he did not follow a recipe this day. He said his puree usually comes out more like mashed potatoes, he said he was running behind today and he was in a hurry. He said the old Dietary Manager left about a month ago, He said the risk to the residents was possible choking. During an interview on 06/09/25 at 02:33 PM, Regional Dietician G said she expected the kitchen staff to give the proper consistency food to the residents that require an altered diet. She said they have standardized recipes for the puree. She said she usually will visit the facility once a month and observe the puree. She said the risk of the residents not getting the pureed food as ordered was they could choke or aspirate or potentially die. During an interview on 06/09/25 at 02:51 PM, the DON said she did not check off any of the pureed trays. She did not see the consistency of the pureed meals. She said she expected the staff to give the proper consistency of the meal to the residents that required an altered diet. She said the risk of the wrong consistency being served was the resident could aspirate or choke. She said she was not aware of any of the 4 residents who get pureed food choking. She said the kitchen should give the proper consistency, the nurse should check it and then the CNA should also check it. During an interview on 06/09/25 at 05:06 PM, [NAME] F said no one in management had questioned him regarding the puree before this day. He said he thought he usually had a good consistency but this day he was rushing. During an interview on 06/11/25 at 09:20 AM, Travel Certified Dietary Manager H said she was not in the facility on 06/09/25. She looked at the picture this surveyor showed her, and she said she did not think the puree was smooth enough and it was too dry. She said the risk to the resident's was choking and aspiration. She said she was last in the facility in Mid-May 2025. She said the typical procedure was that the cook would make the puree and the Dietary Manager would then check while it is on the line. During an interview on 06/11/25 at 09:38 AM, Regional Dietician G said she thought the puree diet tray served at lunch on 06/11/25 was mechanical soft in consistency and the risk was potential choking and aspiration. She said the typical procedure was that the cook would make it and the Dietary Manager would check it off. She said the facility has not had a Dietary Manager as of recent, so she expected the Administrator to watch at least one meal a day. She said she expected the Dietary Manager to remove the Puree tray if it was the wrong consistency. During an interview on 06/11/25 at 09:45 AM, Dietary Supervisor E said she did not see the puree tray before it went out of the kitchen on 06/09/25. She said she did not check the puree that [NAME] F made on 06/09/25. She said [NAME] F was plating the food that day. She said she should have checked the puree trays. During an interview on 06/11/25 at 11:21 AM, the ADON said she expected the cook to ensure that the puree was the proper consistency. She said she expected the nurse and CNA to check the tray as well. She said the picture that this surveyor showed her looked like it was too thick for puree. She said the risk was that the resident could choke or aspirate and get pneumonia. During an interview on 06/11/25 at 11:34 AM, the DON said she expected the kitchen to verify they made the proper consistency, and the nurse and CNA should also check the consistency before it was served to the residents. During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the cook to make the puree properly. She said a Dietary Manager should train and be able to expect the staff to do the puree correctly. She said the Dietary Manager should check the puree to ensure the food consistency was correct. She said on 06/09/25 she expected Dietary Supervisor E to check the puree. She said she expected the nurse to check the tray before it was sent out. She said she expected the CNA if they are feeding a resident to stop the tray if they feel it is not the proper consistency. She said the risk was choking and aspiration and/or pneumonia. Record review of the facility's undated policy, Consistency Modification, stated: We will adequately meet nutritional needs of the resident and provide food in a consistency that the resident can tolerate . .3. The pureed diet is given to residents with chewing, swallowing or choking problems. The desired consistency for blended foods is that of applesauce to mashed potatoes. Small grains may be present in some foods, but these are acceptable as long as they are no larger than the grains present in applesauce and of a consistent size. If a resident requires a smoother consistency, per speech therapist recommendation, an order for a strained puree diet can be obtained

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the refrigerators were not kept past their expiration dates and did not contain mold. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the refrigerator on 6/09/2025 at 8:45 AM, the following items were observed: (1) 1 gallon of milk that was full with an expiration date of 6/8/2025. (2) 1 container ¾ full with green beans dated 5/31/2025. (3) 2 cucumbers with mold spots, 3 red onions with mold spots. During an observation and interview on 6/9/2025 at 8:45 AM, [NAME] F said they should have checked the refrigerator and removed expired items. He said he did not know the cucumbers and onions had molded and they should have been removed from the refrigerator. He took the milk, cucumbers, and red onions out of the refrigerator and disposed of them. [NAME] F said they have not had a Dietary Manager for about 1 to 1 ½ months. He said the staff just do not care and do not check for expired foods. He said the residents could get sick by consuming expired foods. During an interview on 6/11/2025 at 9:20 AM, the Travelling CDM H said the dietary manager or whoever is responsible should be making a walk through daily, but the cook should be checking for expired foods daily. She said if there is no dietary manager the Administrator should be checking daily. She said the residents could possibly get sick by consuming expired foods. During an interview on 6/11/2025 at 9:32 AM, Registered Dietician G said that the dietary manager should be responsible for checking for expired food. She said if the facility did not have a dietary manager, then the Administrator was ultimately responsible for checking for expired foods, but all kitchen staff should be checking for expired foods. She said the resident could get sick by a food borne illness by consuming expired foods. During an interview on 6/11/2025 at 11:44 AM, the Administrator said all foods should be used or disposed of by the use by date. She said food in the kitchen should be checked daily and weekly, to ensure foods are disposed of by the expiration date. She said food borne illness was a potential risk to the resident for consuming expired foods. Record review of facility policy titled Food Storage and Supplies undated, indicated: .6. Any product with a stamped expiration date will be discarded once that date passes . 8 .If a food has developed such spoilage characteristics, it should not be eaten .

Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove and dishwasher in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. Two of six gas stove burners (left front and left back) did not light automatically, when the knob was turned, and all 6 burners had carbon buildup. The facility did not ensure the dishwasher was in working order. The temperature did not reach 120-140 degrees. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food and risk of food borne illnesses by the dishwasher not appropriately sanitizing dishes. Findings include: During an observation on 6/9/2025 at 8:45 a.m., the gas stove had six burners total, two burners located in the left front and left back had excess carbon buildup. The left front and left back burner would not light automatically. During an observation on 6/9/2025 at 8:45 a.m., the dishwasher was ran and reached temperature of 110 degrees. The dishwasher was ran a second time and reached 108 degrees. Observation of manufacturer signage posted on the wall behind the dishwasher indicated dishwasher temperatures should have been between 120-140 degrees. During an interview on 6/9/2025 08:45 a.m., [NAME] F said the 2 burners on the stove that did not automatically light had been that way since he had been employed at the facility for the last 2-3 months. He said they had a lighter they kept in the kitchen that they used to light the burners on the stove. During an observation and interview on 6/9/2025 at 8:45 a.m., Dietary Aide AA said he told the Administrator about a week ago that the dishwasher was not working properly but it had not been fixed. Dietary Aide AA said the dishwasher should be getting up to 125-130 degrees. The dishwasher had a log on the front that had not been completed since May 20, 2025. Dietary Aide AA said they had not been given a new log for June 2025. During an interview on 6/11/2025 at 9:08 a.m., Maintenance Director EE said he had worked at the facility for 23 years. He said no one had notified him that the burner on the stove was not working. He said he had worked on the oven when it was reported to him that the oven was not working, but he was not told that the burners were not lighting. He said that it was reported to him 2-3 weeks ago that the dishwasher was not working properly. He said he looked at the dishwasher and called the manufacturer who was supposed to be sending a booster, but the dishwasher had not been fixed and had not been taken out of commission. He said if the stove burner was not lighting appropriately the kitchen could fill up with gas. During an interview on 6/11/2025 at 9:20 a.m., the Travelling CDM H said the last time she was in the facility was May 2025. She said the last time she was here all equipment was in working order except for a microwave which she had replaced. She said the potential hazard for the dishwasher not working properly was diseases and cross contamination spreading throughout the building. She said by the stove not lighting properly gas could leak and cause an explosion. During an interview on 06/11/2025 at 9:32 a.m., the Registered Dietician G said this was the first time she had been to the building. She said she was hired on to the company May 12th, 2025, and had not yet made it to the facility for a visit. She said it had not been reported to her that the kitchen equipment was not functioning properly. She said food borne illness was the potential hazard to the residents for the dishwasher not working properly. She said a gas leak, explosion and fire was a danger for the stove not lighting properly. During an interview on 6/11/2025 at 11:44 a.m., the Administrator said she expected staff to notify her of issues with equipment. She said staff should not have to work with equipment that is not operational. She said food borne illness was a potential hazard for the dishwasher not working properly. She said the stove failure could cause food to not be cooked to the proper temperature and the stove could leak gas. Record review of facility policy titled Dishwashing Preparation and Dishwashing undated indicated: .c. The wash period shall be at least 40 seconds with a temperature of 120 degrees Fahrenheit in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees Fahrenheit. On 6/9/2025 surveyor requested a policy for the stove, and none was providing by the time of surveyor exit.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 8 residents (Resident #4 and Resident #13) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #4. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Disorganized Schizophrenia) was present upon Resident #4's admission date on 01/15/21. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #13. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Schizophrenia) was present upon Resident #13's admission date on 02/02/24. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: 1. Record review of Resident #4's face sheet, dated 06/09/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included disorganized schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking). The onset date for this diagnosis was 01/08/2005. Record review of Resident #4's quarterly MDS assessment, dated 03/21/25, indicated she had a BIMS score of 03, which indicated severe cognitive impairment. She was sometimes able to make herself understood and she was sometimes able to understand others. She received an antipsychotic and an antianxiety medication routinely. Record review of Resident #4's PASRR Level 1 Screening, dated 01/15/21, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #4 did not have a mental illness. 2. Record review of Resident #13's face sheet, dated 06/09/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking). The onset date for this diagnosis was 02/18/14. Record review of Resident #13's quarterly MDS assessment, dated 02/22/25, indicated he had a BIMS score of 15, which indicated intact cognition. He was able to make himself understood and he was able to understand others. He received an antipsychotic routinely. Record review of Resident #13's PASRR Level 1 Screening, dated 06/03/22, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #4 did not have a mental illness. During an interview on 06/11/25 at 09:32 AM, the MDS Coordinator said she had worked at the facility about 7 years. She said both Resident #4 and Resident #13 should have been marked yes for mental illness on the PASRR Level 1. She said it was possible for these two residents to have received services since their admission if they had been marked positive for MI on admit. She said she was going to submit a 1017 form to notify the local health authority about their diagnoses. During an interview on 06/11/25 at 11:21 AM, the ADON said she does not deal with PASRR. She said it was mostly the MDS Coordinator that deals with that. During an interview on 06/11/25 at 11:34 AM, the DON said she does not deal with PASRR. During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the PASRR Level 1 form to have the mental illness section marked yes for both Resident #4 and Resident #13. She said that she expected the person that did the admission for these residents to have ensured the PASRR Level 1 was completed accurately. She said the risk was that the resident could have had PASRR services since they were admitted with this diagnosis. Record review of the Facility's policy, PASRR Level 1 Screen Policy and Procedure, last revised 03/06/19, stated: .The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. The Type of admission is reviewed for correctness. Ensure the Name, SS number, Medicare/Medicaid numbers and DOB is correct. The Date of the PL1 is correct (i.e. correct day, month and year) and review each item on the PL1 to ensure accuracy and prevent a regulatory problem

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #37) reviewed for infection control. CNA T did not wash or sanitize her hands or change gloves while performing incontinent care for Resident #37. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an electronic Face Sheet dated 6/10/2025 for Resident #37 indicated she admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included: hypertensive chronic kidney disease (kidney damage caused by high blood pressure) dementia (a decline in cognitive abilities), acute cystitis with hematuria (irritation of the bladder with blood in the urine), muscle wasting and atrophy (decrease in muscle mass and strength). Record review of a Quarterly MDS dated [DATE] for Resident #37 indicated a BIMS of 06 which indicated severe cognitive impairment. She was dependent on staff with toileting hygiene. She was always incontinent of bowel and bladder. Record review of a Care Plan dated 1/25/2024 for Resident #37 indicated: The resident had an ADL self-care performance deficit with interventions that included: The resident requires assistance wash hands, adjust clothing, clean self, transfer on to toilet, transfer off toilet to use toilet. The care plan also indicated Resident #37 had bowel incontinence with interventions that included: Provide peri care after each incontinent episode. During an observation on 6/9/2025 at 11:52 AM in Resident #37's room revealed, CNA T and CNA R were present to provide incontinent care. Both staff washed their hands in the bathroom of Resident #37's room and donned gloves. CNA T and CNA R positioned Resident #37 in supine position to perform incontinent care. CNA T removed the blanket from Resident #37. CNA T removed a disposable wipe from the container and began cleaning Resident #37. CNA T after cleaning Resident #37's peri area CNA T without changing gloves or washing her hands placed a clean brief on Resident #37. CNA T without changing gloves or washing her hands began repositioning Resident #37 in bed and placed covers back on her. CNA D without changing gloves or washing her hands repositioned Resident #37's pillows behind her head. After CNA T repositioned Resident #37 she doffed gloves washed her hands, gathered the trash, and exited the room. During an interview on 6/9/2025 at 12:06 PM, CNA T said after the incontinent care that she should have changed her gloves and washed her hands when going from dirty to clean during incontinent care. She said by not performing incontinent care properly the resident could get an infection. During an interview on 6/9/2025 at 12:06 PM, CNA R said CNA T should have changed her gloves and washed her hands when going from dirty to clean while providing incontinent care. She said by not providing incontinent care properly the resident could get an infection. During an interview on 6/11/2025 at 11:21 am, the ADON said her, and the DON observed peri care at times. She said CNA T was normally a good CNA but was nervous due to being watched by state. She said they do competency skills check off yearly. She said CNA T should have changed her gloves and washed her hands when going from dirty to clean during incontinent care. She said by not providing incontinent care properly the resident could get an infection. During an interview on 6/11/2025 at 11:34 am, the DON said they do competency skills check off upon hire and annually. She said her expectation was to wash hands in the beginning of incontinent care and then when going from dirty to clean hands needed to be washed. She said by not providing incontinent care properly they could spread infections to the residents. During an interview on 6/11/2025 at 11:44 am, the Administrator said her expectation was for the CNAs to perform incontinent care the right way every day. She said CNA T should have washed her hands when going from dirty to clean. She said by not performing incontinent care properly they could have spread germs to the resident. Record review of C.N.A Proficiency Audit dated 9/3/2024 for CNA T indicated she had been trained and had demonstrated handwashing and perineal care for females in accordance with the facility's standard of practice. Record review of C.N.A Proficiency Audit dated 12/16/2024 for CNA R indicated she had been trained and had demonstrated handwashing and perineal care for females in accordance with the facility's standard of practice. Record review of a facility policy titled Perineal Care dated 4/27/2022, indicated, .21. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal are . 24. Doff gloves and PPE. 25. Perform hand hygiene. 26. Provide resident comfort and safety by re-clothing (if applicable-incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach . 30. Tie off the disposable plastic bag of trash and/or linen. 31. Perform hand hygiene .

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #31) of 16 residents reviewed for PASRR . The facility failed to refer Resident #31 for PASRR level II assessment, to the state-designated authority, upon receipt of a major depressive disorder recurrent severe diagnosis. These failures could place residents at risk of not receiving necessary care and/or services. Findings Included: Record review of Resident #31's admission record dated 08/24/23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Huntington's Disease (a progressive neurodegenerative disorder that affects movement, thinking, and emotional abilities), Depressive Episodes (a period of time characterized by persistent sadness, loss of interest, and other related symptoms that significantly impact daily life), Anxiety Disorder (a group of mental health conditions characterized by excessive fear or worry that significantly interferes with daily life), and Major Depressive Disorder (a mental disorder characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms affecting sleep, appetite, energy, concentration, and self-worth). The diagnosis of major depressive disorder recurrent severe had an onset date of 08/24/23. Record review of Resident #31's quarterly MDS completed on 04/18/25 revealed the following: Section C Cognitive Patterns revealed Resident #31 had a BIMS score of 11 which indicated moderate impaired cognition. Section I Active Diagnoses revealed Resident #31 had diagnoses of depression. Record review of Resident #31's care plan revealed a problem initiated on 1/22/24, The resident is taking an anticonvulsant medication for diagnosis of other specified depressive episodes. The resident will have improved mood state happier, calmer appearance, no sign or symptoms of depression, anxiety, or sadness through the review date. Record review of Resident #31's most recent PASRR Level 1 Screening revealed an assessment date of 08/21/23. The PASRR was negative for mental illness. During an interview on 6/11/25 at 9:37 a.m., the MDS Nurse said that Major Depressive Disorder qualifies for mental illness on a PASRR level one screening. She said that she would need to complete a 1017 form for a new diagnosis that a resident received after their admission and after their PASRR level one screening. She said that since Resident #31 needed to be re-assessed when a qualifying diagnosis was received. She said Resident #31 was placed at risk of not receiving the services he may have been eligible for. During an interview on 6/11/2025 at 11:22 a.m., the Assistant Director of Nurses said that PASRR evaluations are the responsibility of the MDS nurse. She said that residents who are not evaluated properly are at risk of not receiving the services they may qualify for. During an interview on 6/11/25 at 11:34 a.m., the Director of Nurses said that the MDS nurse is responsible for PASRR services. She said that residents may not get a proper evaluation and receive services they could qualify for if the PASRR evaluation was not completed properly. During an interview on 6/11/25 at 11:44 a.m., the Administrator said that Major Depressive Disorder does trigger for a PASRR level two evaluation. She said that the evaluation should have been completed for Resident #31. She said that the MDS Nurse is responsible for completing PASRR. She said that residents were placed at risk of not receiving the services they could be eligible for. Record review of facility policy titled PASRR Level 1 Screen Policy and Procedure and dated 3-6-2019 indicated, The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulation.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents and supervision. (Resident #1) The facility failed to provide adequate supervision for Resident #1 who was assessed as a high risk for elopement. On 11/08/2024 he was allowed to sit on the front porch without supervision, and facility received a phone call from another resident's family member informing facility Resident #1 was at the end of the facility's exit driveway entering the residential roadway. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/02/2024 and ended on 11/08/2024. The facility had corrected the non-compliance before the survey began. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury or harm. Findings included: Record review of Resident #1's Admission Record dated 02/12/2025 indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included congestive heart failure systolic (condition in which the heart's main pumping chamber (left ventricle) is weak), cognitive communication deficit (communication difficulty stems from an impairment in cognitive processes, these deficits can impact a person's ability to think, speak, listen, read, and interact with others ), hypertension (condition in which the force of the blood against the artery walls is too high), chronic obstructive pulmonary disease (a lung disease blocks airflow making it difficult to breathe), diabetes mellitus (chronic condition affects the way the body processes blood sugar), transient cerebral ischemic attack (temporary interruption of blood flow to the brain causes stroke-like symptoms resolve within 24 hours) and cataract, left eye (common eye condition characterized by the clouding and thickening of the natural lens in the eye, leading to decreased vision). Record review of a quarterly Elopement Risk assessment dated [DATE] indicated Resident #1 was a low risk for elopement with a score of 7. The form was signed by the DON. Record review of Resident #1's quarterly MDS assessment, dated 08/09/2024, indicated a BIMS score of 04 which indicated he was severely impaired cognitively and he was able to make himself understood and understood others. He was always continent of bowel and bladder. The Functional self-care assessment indicated he required moderate assistance with toileting hygiene, shower/bath, lower body dressing, putting on/taking of shoes, personal hygiene, and setup or clean up assistance for eating, oral hygiene, and upper body dressing. The Functional mobility assessment indicated he required moderate assistance for lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and walking 50 feet with two turns. He required supervision or touching assistance for tub/shower transfer and walking 10 feet. He was independent with rolling left to right and sitting to lying. He required a manual wheelchair for mobility and was independent wheeling himself 50 feet with two turns. Record review of Resident #1's annual MDS assessment, dated 11/09/2024, indicated a BIMS score of 03 which indicated he was severely impaired cognitively and he was able to make himself understood and understood others. He was occasionally incontinent of bowel and bladder. The Functional self-care assessment indicated he required moderate assistance with toileting hygiene, shower/bath, lower body dressing, putting on/taking of shoes, personal hygiene, and setup or clean up assistance for eating, oral hygiene, and upper body dressing. The Functional mobility assessment indicated he required moderate assistance for sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer and walking 50 feet with two turns. He required supervision or touching assistance for walking 10 feet. He was independent with rolling left to right, sitting to lying and lying to sitting on side of bed. He required a manual wheelchair for mobility and was independent wheeling himself 50 feet with two turns. Record review of Resident #1's care plan, dated 11/09/2024, indicated he resided in the secure unit related to actual elopement attempt. No interventions on care plan prior to 11/09/2024 related to Resident #1's change in elopement risk on 11/02/2024. Care plan indicated he had an ADL self-care performance deficit and required supervision as needed for bathing, bed mobility, eating, dressing, toilet use, and transfers. Record review of Resident #1's progress note dated 10/25/2024 Resident #1 was found in the parking lot. The progress note did not address if any interventions were implemented following this incident. Record review of a quarterly Elopement Risk assessment dated [DATE] indicated Resident #1 was a high risk for elopement with a score of 16. The form was signed by LVN B. The Elopement Risk assessment did not address if any interventions were implemented following this assessment. Record review of Resident #1's progress note dated 11/04/2024 Resident #1 was found in the parking lot again. The progress note did not address if any interventions were implemented following this incident. Record review of Resident #1's event note - elope or attempt dated 11/08/2024 Resident #1 had eloped from facility out the front door and was discovered in front of the facility, resident was in his wheelchair, fully dressed, on the street heading towards the convenient store. Resident #1 was returned to the facility and was placed in the secure unit for supervision. Record review of Resident #1's physician orders dated 11/08/2024 indicated Resident #1 was moved to facility secure unit. A Provider Investigation Report dated 11/08/2024 indicated the incident occurred on 11/08/24 at 04:45 p.m. Resident #1 sits on front porch with no behaviors and no supervision. Resident goes in and out of the front door frequently throughout the day. Resident #1 was reported to the charge nurse to have been leaving the facility driveway. Resident #1 said he was going to the gas station to get scratch-offs. Resident #1 was returned to the facility by CNA A. A head-to-toe assessment was conducted with no negative findings. Resident #1 was placed in secure unit for 1:1 monitoring. Resident #1's family and physician were notified of the elopement. Physician ordered Resident #1 be placed in the secure unit and family members agreed and consented. In-services were conducted with staff on elopement protocol, on accuracy of elopement assessments, and on residents sitting out front. All residents had updated elopement assessments conducted. Resident #1 remained in the facility's secure unit. Unable to interview Resident #1, he no longer resided at the facility. During an interview on 2/13/2025 7:33 a.m., LVN B said she had filled out the quarterly Elopement Risk Assessment on Resident #1 on 11/02/2024. She said she answered some of the questions based on the personal history of knowing Resident #1 and his cognitive skills, daily decision making, and behaviors and that was why it triggered him at high risk for elopement. LVN B said management staff was aware of Resident #1's high elopement risk. LVN B said the quarterly elopement risk assessment was completed to provide information for completing the quarterly MDS and updating care plan during care plan meetings if applicable. LVN B said Resident #1's family did not consent for the resident to reside on the facility secure unit until he eloped on 11/08/2024 and then they agreed with the intervention after the elopement. During an interview on 02/12/2025 at 12:20 p.m., HR C said on 11/08/2024 at approximately 4:45 p.m., she received a phone call from another resident's family member reporting Resident #1 was in his wheelchair at the end of the facility exit driveway, headed down the residential roadway. HR C said she immediately responded and notified LVN D and CNA A regarding the elopement while exiting the facility. HR C said CNA A ran down the exit driveway and residential roadway and redirected Resident #1 back to the facility. HR C said Resident #1 had a history of sitting on the front porch of the facility and greeted staff, other residents, and visitors, and she was able to monitor him from her window. HR C said she did not recall Resident #1 attempting to elope in the past but Resident #1 would ask staff and visitors to go buy him a scratch off lottery ticket occasionally when his family had not brought him any. During an interview on 02/13/2025 at 2:40 p.m., CNA A said she was working on 11/08/2024, returning from her break around 5:00 p.m. when she heard HR C said Resident #1 had eloped and was on the residential roadway headed towards the gas station. CNA A said she ran out the front door and down the roadway (approx. 50 yards from facility exit driveway) and retrieved Resident #1 and redirected him back to the facility. CNA A said Resident #1 said he was going to the gas station to buy himself a scratch-off lottery ticket. CNA A said she was not the assigned CNA working with Resident #1 on 11/08/2024 but when an elopement occurred everyone intervened. CNA A said she was familiar with Resident #1 because he moved around the facility independently in his wheelchair and would sit in the front lobby waiting for someone to disarm the alarm so he could go outside to sit on the porch. CNA A said Resident #1 would sit out on the front porch and greet visitors, staff, and other residents. CNA A said Resident #1 had been at the end of the sidewalk/parking lot area asking visitors for scratch off lottery tickets prior to the elopement but was easily redirected back into facility. CNA A said Resident #1 was allowed to sit on the facility front porch unsupervised, staff would disarm the front door, wheel him outside on porch, and frequently monitor him but would not stay outside with him. CNA A said she was not aware of any previous elopements with Resident #1 and that Resident #1 had never voiced to her about desire to leave the facility and even the day of the elopement he said he would return to the facility after he got his lottery tickets. During an interview on 02/13/2025 at 11:00 a.m., the ADON said on 11/08/2024 she had just completed her orientation and was leaving the facility when CNA A and HR C was returning to the facility with Resident #1 and was informed that Resident #1 had just eloped from the facility. The ADON said that she interviewed with Resident #1, and he said he was going to the gas station to get scratch off lottery tickets and had intentions on returning to the facility afterwards. The ADON said she notified the Administrator and Resident #1's charge nurse of the incident. The ADON said Resident #1 was placed in the facility secure unit and the charge nurse was notified of the elopement incident. During an interview on 02/13/2025 at 02:18 p.m., LVN D said she was the charge nurse for Resident #1 on 11/08/2025 and around 5:00 p.m. while in the dining room for dining observations, she noticed Resident #1 being wheeled into the facility by CNA A. CNA A reported to her that Resident #1 had eloped and was on the residential roadway between the facility and the gas station and she had redirect him back to the facility. LVN D said the ADON and CNA A took Resident #1 to the facility secure unit for monitoring. LVN D said she and LVN E contacted the physician, family and completed the required assessments. LVN D said she recalled seeing Resident #1 sitting on the front porch when entering the facility to start her shift at 2:00 p.m. LVN D said all staff monitored Resident #1 and when he wanted to go outside or inside, he would ask staff to disarm the door alarms for exiting or entering the facility. LVN D said if Resident #1 was outside that staff would check on him frequently and bring him back in the facility to provided care. LVN D said she was aware that Resident #1 had been found in the parking lot asking for scratch off lottery tickets in the past but was not aware of Resident #1 ever leaving the facility premises or requesting to leave the facility prior to the elopement on 11/08/2024. During an interview on 02/13/2025 at 02:30 p.m., LVN E said she was working the secure unit on 11/08/2024, and Resident #1 was escorted to the secure unit by CNA A on 11/08/2025 around 5:00 p.m. LVN E said Resident #1 had eloped from the facility and was being placed in the secure unit for monitoring and possible permanent placement. LVN E said she and LVN D contacted the physician, family and completed the required assessments. LVN E said Resident #1 was not exit seeking while in the secure unit, he would just sit at the back door requesting someone to take him to sit outside because he liked to sit outside and enjoy the sunshine. LVN E said that staff would go outside and sit with him in the enclosed secure unit patio area. During an interview on 02/13/2025 at 02:45 p.m., the DON said that Resident #1 liked to sit on the facility front porch and greet people entering the facility. The DON said all facility staff monitored Resident #1 while he was outside. The DON could not explain how Resident #1 got off the facility premises without any facility staff being aware. The DON said she was not aware of Resident #1's high elopement risk assessment on 11/02/2024 and the assessing facility staff should have notified her or the Administrator with the high elopement assessment risk so interventions could have been initiated to prevent elopement and keep resident safe. The DON said not intervening when residents have a high elopement risk could put the residents at risk for actual elopement and lack of supervision could cause possible harm or injury to the resident. During an interview on 02/13/2025 at 03:00 p.m., the Administrator said Resident #1 liked to sit on the facility front porch and greet people entering the facility. The Administrator said she was not aware of Resident #1's high elopement risk assessment on 11/02/2024 until she began investigating the elopement on 11/08/2024. The Administrator said the assessing staff member should have notified her or the DON of the high-risk elopement assessment so interventions could have been put in place. The Administrator said following the incident on 11/08/24, the staff were reeducated on elopement, accuracy of elopement assessments, reporting residents with high elopement assessments to the DON and/or the Administrator; management reassessed all residents for elopement risk; the elopement log was updated; and elopement drills were being conducted randomly. She said the elopement attempt was included in the QAPI report. The Administrator said all door alarms were checked the day of the elopement and was found to be working properly. The Administrator said residents were allowed to be outside unsupervised if their elopement risk assessment was low and the safety assessment indicated it was safe for them to be left alone. The Administrator said facility staff developed an individualized plan for each resident to meet their needs and maintain the least restrictive environment. The Administrator said it was common for Resident #1 to be sitting out on the front porch and she was not sure if staff had let him out on the day of the elopement or if Resident #1 had followed a family member out the door when they were exiting. The Administrator said Resident #1 was redirected back to the facility within a few minutes of the facility being aware Resident #1 was off the facility premises. The Administrator said once Resident #1 was back in the facility, a head-to-toe assessment was completed with no injuries identified, the physician and family were notified, and orders were received for Resident #1 to be placed in the secure unit. The Administrator said Resident #1 was placed in the secure unit and monitored following the elopement. The Administrator said if a resident was identified as a high risk for elopement, the assessing nurse or staff should notify her and the DON so interventions could be put in place to prevent elopement and keep the resident safe. The Administrator said if she or the DON were not notified of the high elopement risk and interventions did not get initiated, it could put the residents at risk for actual elopement and lack of supervision could cause possible harm or injury to the resident. Record review of the Elopement Prevention policy dated January 2023 indicated .1. The elopement risk assessments will be completed upon admission the assessment should be completed by reviewing the residents medical history and social history information may be obtained by reviewing current medical records if available interview with residents family or conference with the interdisciplinary team members the assessment tool should be completed and interventions implemented as indicated the elopement risk assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behaviors, and upon change of condition. Record review of an In-Service Attendance Record with subject of Elopement Response and prevention, dated 11/08/2024, indicated that 49 staff members signed the in-service record including CNA A, LVN B, HR C, LVN D and LVN E. Record review of Assessment History Elopement Risk Assessment list dated 02/11/2025 at 09:54 a.m. indicated all residents in the facility were reassessed on 11/09/2024. Record review of Incident logs from 02/01/2024 through 02/11/2025 indicated there were no other actual resident elopements from the facility. Record review of the Elopement Risk Assessment Log on 02/11/2025 indicated it was updated to include current residents assessed as high risk for elopement. During observations on 02/11/2025 from 09:00 a.m. - 02/13/2025 to 5:30 p.m., of current residents at risk for elopement indicated staff-maintained residents within eye contact and staff did not allow them to go outside of the facility without a staff member with them and/or the resident resided in the facility secure unit. During interviews on 02/11/2025 from 09:00 a.m. - 02/13/2025 to 5:30 p.m., 1 RN (RN N), and 4 LVN's (LVN B, LVN D, LVN E, and LVN O) were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure, all were aware of the new expectations to notify the DON/ADON and the Administrator immediately of any assessments identifying a resident with a high elopement risk and/or residents exit seeking, attempting or actual elopement. During interviews on 02/11/2025 from 09:00 a.m. - 02/13/2025 to 5:30 p.m., 7 CNA's (CNA A, CNA F, CNA G, CNA H, CNA I, CNA J, and CNA L), and 1 MA (MA K) were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure, all aware of residents requiring supervision if outside, and all were aware to notify the CN, DON, ADON and the Administrator immediately of any residents exit seeking, attempting or actual elopement. During interviews on 02/11/2025 from 09:00 a.m. - 02/13/2025 to 5:30 p.m., 1 Human Resource staff (HR C), 1 MDS Nurse (MDS M), Floor Tech (FT P), 1 Housekeeping staff (HSK Q), Business office staff (BO R) and maintenance staff (MT S) were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure, they were aware of the new expectations to notify CN, DON, ADON before allowing any resident outside alone, and to notify the DON/ADON and the Administrator immediately of any resident trying to go outside alone. On 02/13/2025 at 05:45 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/02/2024 and ended on 11/08/2024. The facility had corrected the noncompliance before survey began.

Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program to prevent the development and transmission of communicable diseases was implemented by the facility for 8 of 8 residents (Residents #8, #9, #10, #11, #12, #13, #17, and #18) and 13 of 13 staff (CNA J, MA K, CNA N, HSK O, LVN X, LDY P, CNA Q, CNA R, CNA S, CNA T, LVN U, CNA V, and LVN W) in the facility reviewed for infection control practices and transmission-based precautions. The facility failed to ensure facility staff (CNA J, MA K, CNA N and HSK O) wore appropriate PPE when entering COVID-19 (infectious disease caused by the SARS virus) positive residents' rooms. (Residents #8, #9 #10, #11, #12, and #13). The facility failed to ensure staff was knowledgeable on current COVID-19 (infectious disease caused by the SARS virus) protocols and interventions. The facility staff failed to follow facility infection prevention policies to prevent the spread of infections. Staff (LVN X, LDY P, CNA Q, CNA R, CNA S, CNA T, LVN U, CNA V, and LVN W) were not being tested routinely after a staff tested positive for COVID-19 (infectious disease caused by the SARS virus) on [DATE]. During the ongoing outbreak, staff were observed working with positive COVID-19 residents and negative residents. Residents # 8, #17, and #18 expired at the facility after testing positive. The facility failed to ensure facility staff had readily available access to appropriate PPE supplies in 2 of the 6 isolation carts on Hall 200. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:50 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on [DATE]. These failures could place residents at an increased risk for serious complications from a communicable disease that could diminish the resident's quality of life or possible death. The findings included: Record review of the Covid Positive Resident Log dated [DATE] indicated on [DATE] the first COVID-19 positive case was from a staff who worked the secured unit. Since the initial outbreak, 32 residents have tested positive for COVID. Three residents expired during their 14-day quarantine. During an interview on [DATE] at 8:30 a.m., the Administrator said facility census was 50 with 10 COVID-19 positive residents and with 3 staff COVID-19 positive. During an interview on [DATE] at 1:30 p.m., the DON said facility census was 46 with 11 new COVID-19 positive residents and with 5 new staff COVID-19 positive. 1. Record review of a face sheet dated [DATE] indicated Resident #8 was a [AGE] year-old male, initially admitted to the facility on [DATE] with readmitted [DATE].His diagnoses included dementia (loss of cognitive functioning), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), end stage renal disease, and COVID-19. Record review of Resident #8's MDS dated [DATE] revealed he had a BIMS score of 3 which indicated he was severely impaired cognitively. He usually could make self-understood and usually understood others. He required moderate assistance in performing most activities of daily living. He was always incontinent of bowel and bladder. Record review of Resident #8's Care plan dated [DATE] indicated he needs hemodialysis r/t renal failure, Resident goes to dialysis 3 x week with goals that resident will have immediate intervention should any s/s of complications from dialysis occur through the review period. had manipulative behavior with history of accusing people of slapping her/physically mishandling her with a goal that resident would have less than 1 episode of accusatory behavior for the next 90 days. Care plan dated [DATE] indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date. Record review of Resident #8's progress notes on [DATE] at 12:17 p.m. authored by RN L indicated Resident #8 tested positive for COVID-19 on [DATE]. Resident expired on [DATE] (5 days after testing positive for COVID-19). Record review of the order summary report, dated [DATE], indicated Resident #8 had an order, which started on [DATE], for Aerosol precautions, every shift related to COVID-19 for 10 days. Record review of a face sheet dated [DATE] indicated Resident #9 was a [AGE] year-old male, initially admitted to the facility on [DATE] with readmitted [DATE].His diagnoses included dementia (loss of cognitive functioning), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and COVID-19 (infectious disease caused by the SARS virus). Record review of Resident #9's MDS dated [DATE] revealed he had a BIMS score of 15 which indicated he was cognitively intact. He is able to make needs known and understands others. He required supervision in performing most activities of daily living. He was continent of bowel and bladder. Record review of Resident #9's Care plan dated [DATE] indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date. Record review of Resident #9's progress notes on [DATE] at 11:12 a.m. authored by RN L indicated Resident #9 tested positive for COVID-19 on [DATE]. Record review of the order summary report, indicated Resident #9 had an order, which started on [DATE], for Aerosol precautions, every shift related to COVID-19 for 10 days. During an observation on [DATE] at 12:15 p.m., CNA J entered Resident #8 and Resident #9's room on Hall 200 to provide them with lunch trays. CNA J was wearing a N-95 mask and gloves. There was a sign on the door that stated, Droplet Precautions and listed the required PPE needed to be worn in the room, which included an N-95 mask, a face shield or goggles, an isolation gown, and gloves. CNA J remained in the room for approximately 5 minutes assisting and preparing lunch tray. Upon exiting the room, CNA J removed her gloves, sanitized her hands, and walked down the hallway toward the lunch tray cart wearing the same N-95 mask. During observation [DATE] @ 12:30 p.m., insolation carts outside of room [ROOM NUMBER] and room [ROOM NUMBER] had boxes of gloves, boxes of surgical mask and N-95 mask and face shields, no gowns noted in these 2 isolation carts. During an interview on [DATE] at 1:35 p.m., CNA J said she did not wear PPE (gown and face shield) into Resident #8 and Resident #9's room because the isolation supply cart outside of the residents' room did not have any gowns or face shields available. CNA J said, I was trying to get the residents lunch served, so I went into room without gown and face shield. CNA J said, I know I should have put a gown and face shield on, but it was not readily available in the isolation cart outside door, which happens sometimes, and we do not have access to supplies to restock isolation carts. CNA J said she had received training on infection control, COVID-19 protocol, and PPE application courses via computerized online training assigned to her by facility within the last month. During an interview on [DATE] at 2:15 p.m., LVN G said Resident #8 was asymptomatic when he tested positive for COVID-19. LVN G said Resident #8 was attending his dialysis treatments and was not experiencing any severe symptoms with his COVID-19. LVN G said resident was cognitive and able to report any illness or concerns to the facility staff. LVN G said she was the nurse providing care to the resident the day he passed on [DATE], she said she had visited with him several times throughout the shift, and he had no complaints. She said she was notified by CNA that resident was not responding to verbal or tactile stimulus, when she entered the room, resident was unresponsive, no respirations, no pulse and body cool to the touch, appeared he had died in his sleep. LVN G said she provided care to positive and non-positive COVID-19 residents with her assigned residents. LVN G said that the electronic medical record identified residents positive for COVID-19, notification during shift change of all positive COVID-19 residents, signage on resident's room door identifies droplet precautions and COVID-19 precautions to follow. LVN G said that full PPE (gown, gloves, face mask and N-95 should be applied prior to entering COVID-19 positive residents' rooms, worn while providing care to resident and removed prior to exiting room and placed in red bag in room for disposal. LVN G said PPE was available in isolation cart when needed. LVN G said she had received training on COVID-19 and PPE precautions in the last month. 2. Record review of a face sheet date [DATE] indicated Resident #18 was a [AGE] year-old, initially admitted to the facility on [DATE] with readmitted [DATE]. Her diagnoses included dementia (loss of cognitive functioning), urinary tract infection, gastro-esophageal reflux disease without esophagitis (stomach contents leak backward from the stomach into the esophagus (food pipe), COVID-19, and history of COVID-19, history of cancer of the rectum and stomach and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #18's MDS dated [DATE] revealed she had a BIMS score of 0 which indicated he was severely impaired cognitively. She had cognitive loss/dementia with diagnosis of Alzheimer's Disease. She was noted to have disorganized thinking. She required total assistance in performing most activities of daily living. She was always incontinent of bowel and bladder. Record review of Resident #18's Care plan dated [DATE] indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date. Record review of Resident #18's progress note dated [DATE] authored by LVN G indicated resident was diagnosed with a urinary tract infection and started on antibiotic treatment ordered by hospice services. Record review of Resident #18's progress notes dated [DATE] authored by DON indicated resident tested positive for COVID-19 during routine testing for exposure. Resident #18 received antibiotic treatment for COVID-19. Record review of Resident #18's progress note dated [DATE] authored by LVN DD indicates resident was admitted to new hospice for a diagnosis of senile degeneration of the brain. Record review of Resident #18's Covid Assessment date [DATE] authored by LVN G indicates that covid finding include a productive and non-productive Cough, with no new or worsen symptoms, regular respirations, and clear breath sounds. Interventions include monitoring/assessing every shift for Covid concerns. Indicates resident remain on droplet precautions and resides in room by herself. Record review Resident #18's of the progress note dated [DATE] (13 days after testing positive for COVID-19) authored by LVN BB indicated Resident #18 was provided care multiple times throughout the shift with no discomfort or complaints. The CNA entered the resident's room around 2:00 a.m. to find the resident unresponsive, no respirations or heart rate so CPR was initiated. EMS arrived and continued CPR and then discontinued CPR. The hospice nurse was notified, and hospice arrived to pronounce the resident had expired. 3. Record review of a face sheet dated [DATE] indicated Resident #17 was a [AGE] year-old female, initially admitted to the facility on [DATE] with readmitted [DATE]. Her diagnoses included personal history of cancer of the rectum, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #17's MDS dated [DATE] revealed she had a BIMS score of 0 which indicated she was severely impaired cognitively. She was noted to have disorganized thinking. She could make her needs known and understands other. She required minimal assistance in performing most activities of daily living. She was occasionally incontinent of bladder and continent of bowel. Record review of Resident #17's Care plan dated [DATE] indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date. Record review of Resident #17's progress note dated [DATE] authored by DON indicated resident tested positive for COVID-19 during exposure testing, facility staff (LVN A and CNA CC) working the secure unit tested positive for COVID-19 on [DATE]. Resident asymptomatic at time of testing. Resident expired on [DATE] (14 days after testing positive for COVID-19). Record review of Resident #17's Covid Assessment date [DATE] authored by LVN A indicates under covid finding include no cough or covid findings, with no new or worsen symptoms, regular respirations, and clear breath sounds. Interventions include monitoring/assessing every shift for Covid concerns. Indicates resident remain on droplet precautions and resides in room by herself. During an interview on [DATE] at 2:15 p.m., LVN G said Resident #17 was asymptomatic with her COVID-19 positive test results. LVN G said Resident #17 had behavioral episodes including yelling and screaming out. LVN G said Resident #17 resided on the secure unit because of her cognitive state. LVN G said she works with positive and negative residents. 4. Record review of a face sheet dated [DATE] indicated Resident #10 was a [AGE] year-old female, initially admitted to the facility on [DATE]. Her diagnoses included CVA/Stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain burst), Diabetes (a chronic condition that affects the way the body processes blood sugar) and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #10's MDS dated [DATE] revealed she had a BIMS score of 15 which indicated she was cognitively intact. She could make her needs known and understands other. She required total assistance in performing most activities of daily living. She was always incontinent of bladder and bowel. Record review of Resident #10's Care plan dated [DATE] indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date. Record review of Resident #10's progress note dated [DATE] authored by LVN A resident c/o stuffy nose, headache, and sore throat. The resident was tested for Covid and was positive for COVID-19. Record review of the order summary report, dated [DATE], indicated Resident #10 had an order, which started on [DATE], for Aerosol precautions, every shift related to COVID-19 for 10 days. During an observation on [DATE] at 12:18 p.m., MA K entered Resident #10's room (resided on Hall 200) to provide her with a lunch tray. MA K was wearing a N-95 mask and gloves. There was a sign on the door that stated, Droplet Precautions and listed the required PPE needed to be worn in the room, which included an N-95 mask, a face shield or goggles, an isolation gown, and gloves. MA K remained in the room for approximately 5 minutes assisting and preparing lunch tray. Upon exiting the room, MA K, removed her gloves, sanitized her hands, and walked down the hallway toward the lunch tray cart wearing the same N-95 mask. During an interview on [DATE] at 1:50 p.m., MA K said she did not wear PPE (gown and face shield) into Resident #10's room because the isolation supply cart outside of the residents' room did not have any gowns or face shields. MA K said, I was trying to help the I get the lunch tray served. MA K said, I know I should have but a gown and face shield on, but it was not readily available in the isolation cart outside of the resident's room. MA K said she should have gone to central supply closet and got gowns or contacted central supply personnel regarding isolation cart needing to be restocked. MA K said she had received training on infection control, COVID-19 protocol, and PPE application courses via computerized online training assigned to her by facility within the last month. During an interview on [DATE] at 12:20 p.m., RN L said all staff was instructed to wear appropriate PPE when entering positive COVID-19 residents' room. RN L said the required PPE for entering a COVID-19 positive room was an isolation gown, gloves, an N-95 mask, and a face shield. RN L said it was important to wear the recommended PPE to protect other residents and staff. RN L said, I have spoken with CNA J and MA K and reeducated them on PPE when entering positive COVID-19 residents' rooms. During observation [DATE] @ 12:30 p.m., insolation carts outside of room [ROOM NUMBER] and room [ROOM NUMBER] had boxes of gloves, boxes of surgical mask and N-95 mask and face shields, no gowns noted in these 2 isolation carts. During an observation and interview on [DATE] at 9:00 am, CS M said she restocked the isolation carts twice a day (usually morning and evening prior to leaving) and more frequently if notified. CS M showed the location of the PPE supplies in the supply closet on each hall with PPE supplies (gowns, gloves, N-95 mask, and face shields) and a large supply room that had additional PPE supplies. CS M said nursing staff had access to the supply closets on the hall and she and management held the key to the large supply room. CS M said she was not aware of any needed PPE supplies and if the isolation carts were low, staff could notify her or collect the supplies from the supply closet on the halls. 5. Record review of a face sheet dated [DATE] indicated Resident #11 was an [AGE] year-old male, initially admitted to the facility on [DATE] and readmitted on [DATE]. His Senile Degeneration of the Brain (is the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age), Covid (infectious disease caused by the SARS virus) and Pressure ulcer of sacral (caused by something putting pressure on or rubbing your skin). Record review of Resident #11's MDS dated [DATE] revealed he had a BIMS score of 00 which indicated he was severely impaired cognitively. He could usually make his needs known and usually understands other. He required total assistance in performing most activities of daily living. He was foley catheter for urinary incontinence and always incontinent of bowel. Record review of Resident #11's Care plan dated [DATE] indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date. Record review of Resident #11's progress note dated [DATE] authored by DON, resident was tested for Covid per facility protocol and was positive for COVID-19. Resident placed in Aerosol Precautions. Record review of the order summary report, dated [DATE], indicated Resident #11 had an order, which started on [DATE], for Aerosol precautions, every shift related to COVID-19 for 10 days. Record review of a face sheet dated [DATE] indicated Resident #12 was a [AGE] year-old male, initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnosis is included Type 2 Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Esophagitis (inflammation of the esophagus), and Covid (infectious disease caused by the SARS virus). Record review of Resident #12's MDS dated [DATE] revealed she had a BIMS score of 00 which indicated he was severely impaired cognitively. He could sometimes make his needs known and sometimes understands other. He required supervision assistance in performing most activities of daily living. He was foley catheter for urinary incontinence and always incontinent of bowel. Record review of Resident #12's Care plan dated [DATE] indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date. Record review of Resident #12's progress note dated [DATE] authored by DON, resident was tested for Covid per facility protocol and was positive for COVID-19. Resident placed in Aerosol Precautions. Record review of the order summary report, dated [DATE], indicated Resident #12 had an order, which started on [DATE], for Aerosol precautions, every shift related to COVID-19 for 10 days. During an observation and interview on [DATE] at 9:00 a.m., CNA N entered to provide care for Resident #11 and Resident #12 who resided on Hall 100. CNA N was wearing a N-95 mask and gloves. There was a sign on the resident's door that stated, Droplet Precautions and listed the required PPE needed to be worn in the room, which included an N-95 mask, a face shield or goggles, an isolation gown, and gloves. CNA N remained in the room for approximately 6 minutes providing care to residents. Upon exiting the residents' room, CNA N removed her gloves and sanitized her hands walked down the hallway past other residents and visitors wearing same N-95 mask. CNA N said Residents #11 and #12 were no longer under isolation precautions and they forgot to remove the isolation sign. During interview on [DATE] at 9:15 a.m. the DON said Resident #11 and Resident #12 were currently under droplet isolation precautions due to both residents' testing positive for COVID-19 on [DATE]. She said the residents' isolation was due to end on [DATE]. The DON said she informed CNA N that Residents #11 and #12 remained under droplet isolations and she should be wearing her PPE while providing resident care. The DON said she verbally instructed CNA N just now about properly applying PPE, droplet precautions protocols and facility residents who currently required droplet precautions. 6. Record review of a face sheet dated [DATE] indicated Resident #13 was a [AGE] year-old female, initially admitted to the facility on [DATE]. Her diagnosis is included schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), Dementia (loss of cognitive functioning), and Covid (infectious disease caused by the SARS virus). Record review of Resident #13's MDS dated [DATE] revealed she had a BIMS score of 15 which indicated she was cognitively intact. She could make her needs known and understands other. She required limited assistance in performing most activities of daily living. She was always continent of bowel and bladder. Record review of Resident #13's Care plan dated [DATE] indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date. Record review of Resident #13's progress note dated [DATE] authored by DON, resident was tested for Covid per facility protocol and was positive for COVID-19. Resident placed in Aerosol Precautions. Record review of the order summary report, dated [DATE], indicated Resident #13 had an order, which started on [DATE], for Aerosol precautions, every shift related to COVID-19 for 10 days. During an observation and interview on [DATE] at 9:45 a.m., HSK O was standing outside of Resident #13's room on Hall 100 in full PPE (gown, gloves, N-95 mask, face shield), with a trash can sitting on top of the housekeeping cart while HSK O replaced the trash liner. There was a sign on Resident #13's door that stated, Droplet Precautions and listed the required PPE needed to be worn in the room, which included an N-95 mask, a face shield or goggles, an isolation gown, and gloves. HSK O said she had just finished cleaning Resident #13's room and she forgot a trash liner on the cart, so I came back out to the cart to get trash liner for the resident's room trash can. HSK O identified the trash can on her housekeepers' cart as the trash can she brought out of Resident #13's room. HSK O said she had just started working at the facility the previous weekend but had been trained on droplet precautions and wearing PPE. When asked if she was supposed to wear the PPE out of the residents' room that was under droplet precautions, she said that during her observation training, other housekeeping staff had done it, so she thought it was OK. During interview on [DATE] at 9:55 a.m., RN L said Resident #13 remained under droplet isolation precautions due the resident testing positive for COVID-19 on [DATE]. RN L said she informed HSK O that Resident # 13 remained under droplet isolations, and she should be wearing her PPE while in the resident's room, and PPE should be removed prior to exiting the resident's room. 7. During an interview on [DATE] at 11:45 a.m., LVN X said she was not tested routinely by facility since outbreak on [DATE]. LVN X said she was tested for COVID-19 by the facility on [DATE] because she became symptomatic (cough and congestion) and tested positive. LVN X said she was sent home and quarantined for 7 days with 2 negative tests 48 hours apart before returning to work. LVN X said she has received training on infection control, COVID-19 precautions/protocol and PPE application. LVN X said that she applied PPE prior to entering COVID-19 positive residents' rooms. LVN X said staff were notified in the EMR on the communication board when residents were positive for COVID-19 and as a charge nurse she notified her staff when residents tested positive for COVID-19 and who required isolation precautions. During an interview on [DATE] at 12:30 p.m., LDY P said he was working in the laundry department today due to the laundry staff being out with COVID-19. LDY P said that if he was symptomatic, the facility would test him. LDY P said he wore full PPE (gloves, gowns, N-95 mask, face shield) while handling the dirty laundry as he was told to treat all dirty laundry as contaminated and to use PPE when handling. He said he received computer-based training on infection control, COVID-19 protocol, and PPE use at the end of [DATE]. LDY P said he had not been tested for COVID-19 by the facility in over a week or maybe 2. LDY P said he did have contact with residents at various times while out in the halls and when he delivered laundry to the resident's rooms. He said he applied full PPE to deliver laundry to residents on isolation. He said he also worked in the housekeeping department and cleaned residents' rooms. During an interview on [DATE] at 1:45 p.m., CNA J said she had not been tested by the facility for COVID-19. CNA J said, if I was symptomatic, I would be tested . Do I need to go get tested ? CNA J said she worked with both non-positive and positive COVID-19 residents. During an interview on [DATE] at 1:50 p.m., CNA Q said she had not been tested by the facility for COVID-19. CNA Q said she had not been having symptoms of COVID-19 and the facility was only testing staff who had symptoms. CNA Q acknowledged that residents/staff could be asymptomatic and have COVID-19. CNA Q said she worked with both non-positive and positive COVID-19 residents. During an interview on [DATE] at 2:15 p.m., CNA R said she had not been tested by the facility for COVID-19. CNA R said she had not been having symptoms of COVID-19, so she had not been tested . CNA R acknowledged that residents/staff could be asymptomatic and have COVID-19. CNA R questioned if she should be tested for COVID-19. CNA R said it had been over 2 weeks since she was last tested by the facility for COVID-19. CNA R said she worked with both non-positive and positive COVID-19 residents. During an interview on [DATE] at 2:30 p.m., CNA S said he had not been tested by the facility for COVID-19. CNA S said she had not been having symptoms of COVID-19, so she had not been tested . CNA S acknowledged that residents/staff could be asymptomatic and have COVID-19. CNA S questioned if she should be tested for COVID-19. CNA S said it had been over 2 weeks since she was last tested by the facility for COVID-19. CNA S said she worked with both non-positive and positive COVID-19 residents. During an interview on [DATE] at 2:35 p.m., CNA T said she had not been tested by the facility for COVID-19. CNA T said she had not been having symptoms of COVID-19, so she had not been tested . CNA T acknowledged that residents/staff could be asymptomatic and have COVID-19. CNA T questioned if she should be tested for COVID-19. CNA T said it had been over 2 weeks since she was last tested by the facility for COVID-19. CNA S said she worked with both non-positive and positive COVID-19 residents. During an interview on [DATE] at 2:41 p.m., LVN U said she had not been tested by the facility for COVID-19. LVN U said she had only been employed for a few weeks with facility. She said she received training on COVID-19, infection control and PPE application/use during orientation. She said she had not been tested for COVID-19 since she started working at the facility. LVN U said she wore a surgical mask when caring for non-positive COVID-19 residents and N-95 and full PPE while caring for positive COVID-19 residents. LVN U said she was assigned to work with both non-positive and positive COVID-19 residents. During an interview on [DATE] at 2:45 p.m., CNA V said she had not been tested by the facility for COVID-19. CNA V said she had not been having symptoms of COVID-19, so she had not been tested . CNA V said it had been over 1 week since she was last tested by the facility for COVID-19. CNA V said she worked with both non-positive and positive COVID-19 residents. CNA V said she had received training on COVID-19 protocols in the last month. During an interview on [DATE] beginning at 3:21 p.m., LVN W said she had not been tested by the facility for COVID-19. LVN W said she tested herself at home frequently before entering the facility because of her own medical concerns. LVN W said she received computer-based training on COVID-19, infection control and PPE application/use from facility in the last month. LVN W said she wore an N-95 mask when caring for non-positive COVID-19 residents and wore the full PPE (N-95 mask, gown, gloves, face shield) while caring for positive COVID-19 residents. LVN W said she was assigned to work with both non-positive and positive COVID-19 residents. During an interview on [DATE] at 3:30 p.m., the DON said the facility was only testing symptomatic staff for COVID-19. The DON was unable to provide a log of facility staff's COVID-19 test results. The DON said she thought the policy indicated only to test staff for COVID-19 if they were experiencing symptoms. The DON said nursing staff were working with positive and non-positive residents. The DON said they were following the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic from the CDC for guidance for COVID-19 protocol. During an interview on [DATE] at 3:35 p.m., the DON said she was the infection preventionist for the facility and responsible for overseeing infection control, she said that the health department had been notified on the outbreak, but no guidance provided. She said prevention measures initiated by facility included handwashing and standard precautions training, signs for staff and visitors related to infection control, COVID, and PPE