Every finding on record at Bickford Health Care Center

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #6) reviewed for ADLs, the facility failed to ensure the record directed staff how to transfer the resident, and failed to ensure an assessment was completed timely for a change in transfer ability. The findings include: Resident #6's diagnoses included dementia, anxiety, and rheumatoid arthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #6 had a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen, indicative of moderate cognitive impairment and required substantial/maximal assistance with toilet use and transfers, was dependent with wheelchair use, and was 60 inches tall (5 feet) and weight was 94 pounds. The Resident Care Plan (RCP) dated 1/6/2026 indicated an alteration in mobility. Interventions directed to transfer with assistance of one (1) staff to wheelchair. Additional review of the RCP identified although the RCP continued to direct one (2) staff for transfers, the transfer status was updated on 7/15/2025 to include two (2) staff for transfers. The RCP directed both one (1) and two (2) staff were required for transfers. A physician's order dated 1/8/2026 directed out of bed with assistance of one (1) to wheelchair with cushion and max assistance for car transfers from wheelchair, use gait belt and max assistance with wheelchair positioning. Nurse Aide (NA) care card directed transfer assist of one (1), and mobility assist of one (1). Record review identified Resident #6 was discharged from the facility on 3/18/2026. Interview and facility documentation review with NA #2 on 3/24/2026 at 11:26 AM identified she reads the resident NA care cards prior to providing resident care, and she did not recall how Resident #6 transferred.Interview and review of facility documentation with NA #3 on 3/25/2026 at 11:40 AM identified she was the regular NA providing care for Resident #6, and stated Resident #6 required one (1) staff assist for transfers in/out of the wheelchair. NA #3 stated she thought it would be safer to use a mechanical lift for the transfers for Resident #6 due to weakness. Interview and review of record on 3/25/2026 at 12:05 PM with RN #3 (supervisor) indicated Resident #6's transfer status was via mechanical lift (Hoyer lift) because Resident #6's legs were weak. Interview and facility documentation review with RN #2 on 3/24/2026 at 10:55 AM identified Resident #6 required a mechanical lift (Hoyer lift) for transfers in/out of the wheelchair. RN #2 further indicated the NAs need to follow the care card for resident transfer status. Record review of failed to identify a physician order, RCP, or NA care card directed transfers with mechanical lift. Additional interview with RN #2 on 3/24/2026 at 1:24 PM identified Resident #6 did not have a physician order for NA care card that directed use of the Hoyer lift. Interview and record review on 3/25/2026 at 1:27 PM with DON identified she was not aware that staff were using a mechanical lift to transfer Resident #6. The DON stated if there was a change in the resident's transfer status, there should have been an RN assessment or therapy evaluation to determine if a mechanical lift was appropriate. Further, the physician/APRN and responsible party should be notified, orders obtained, and the RCP and NA care card should be updated. The DON stated if Resident #6 was still in the facility, she would make a request for a therapy evaluation of transfer status. Although attempted, interviews with the previous DNS/ DNS #3 and NA #4 were not obtained during the survey. Although requested, a facility policy was not provided regarding direction for staff regarding transfer status or resident assessments. Review of facility Hoyer Lift (mechanical lift) dated 11/2025 directed in part, a Hoyer lift should be used for residents who are too heavy to move by yourself or who are not able to be transferred by other means. Review of facility Care Plans Policy dated 11/2025 directed in part; it is the policy of the facility to have an Interdisciplinary Care Plan for each resident. The RCP will address the residents' needs on an individual basis, including physical needs.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #4) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with physician orders and the plan of care, and for one of five residents (Resident #7) reviewed for accidents, the facility failed to ensure an alarm was in use in accordance with physician orders and the plan of care. The findings include: Resident #4's diagnoses included mild cognitive impairment, peripheral vascular disease, diabetes mellitus, and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen (6/15), indicative of severe cognitive impairment, and required substantial/maximal assistance with transfers. Physician order dated 9/12/2025 directed staff to transfer Resident #4 out of bed to a tilt-in-space custom wheelchair (CWC) per 24-hour positioning plan with two-persons using a mechanical lift. The Resident Care Plan dated 9/19/2025 identified Resident #4 had an alteration in ADL (activities of daily living) function. Interventions directed to use a Hoyer (mechanical) lift for transfers with assistance of two (2) staff. The facility Reportable Event Form dated 10/6/2025 at 11:22 AM identified during a transfer Resident #4 banged his/her left leg on the left leg of the custom wheelchair (CWC) and had a two (2) centimeter (CM) open hematoma (collection of clotted blood within tissues). Resident #4 denied any pain. A treatment was provided, and the wound was monitored. On 10/7/2025 the wound was noted to be a nine (9) cm coagulated (clotted blood) hematoma. Resident #4 was transferred to the hospital for evaluation on 10/9/2025, and was followed by a wound physician. The Reportable Event summary dated 10/10/2025 identified NA #1 received discipline and education regarding the transfer of Resident #4. Interview with the Director of Therapy (DOT) on 3/19/2026 at 10:35 AM identified Resident #4 was evaluated on 3/12/2025, and the evaluation directed staff to utilize a Hoyer lift for transfers with the assistance of two (2) staff members for resident safety. The DOT stated the resident's plan of care directed use of the Hoyer lift for transfers with two-person staff, and the facility policy directed two (2) staff for Hoyer lift transfers. Interview with NA #1 on 3/24/2026 at 9:25 AM identified on 10/6/2025, during morning care, Resident #4 reported bilateral lower extremity pain during morning care, and was wearing geri-sleeves on his/her legs for skin protection. NA #1 stated she requested assistance from the nurse to transfer Resident #4 out of bed, and the nurse responded that she would assist after she completed her medication pass. NA #1 stated she then performed the Hoyer lift transfer independently, without the benefit of a second staff member present, and transferred Resident #4 into the CWC alone. Further, NA #1 stated Resident #4 was wearing geri-sleeves on his/her legs for skin protection when she provided care, and did not removed them when she provided care. NA #1 stated the transfer was completed without any observable incident, and stated she maintained support of the Resident #4's lower extremities throughout the transfer and did not notice any bumps or trauma. Following completion of the transfer, Resident #4 reported bilateral lower extremity pain and she notified the nurse. NA #1 stated a Hoyer lift transfer requires two (2) staff and stated that she should have waited for assistance in accordance with the resident's plan of care and facility policy, before transferring Resident #4. Interview with DON #2 on 3/24/2026 at 12:00 PM identified any Hoyer lift transfer requires two (2) staff for safety. On 10/6/2025, NA #1 stated she transferred Resident #4 using a Hoyer lift transfer independently, without the required two-person assistance. DON #2 stated Resident #4 likely sustained the injury/hematoma to his/her leg during the transfer, and NA #1 should not have completed the transfer alone. Interview with DON #1 on 3/24/2026 at 12:55 PM identified on 10/6/2025 NA #1 stated she transferred Resident #4 using a Hoyer lift transfer independently, without the required two-person assistance. DON #1 NA #1 should not have completed the transfer alone and she was not able to identify how the injury occurred; Resident #4 had complained of pain prior to the transfer. DON #1 stated Resident #4 complained of pain after the transfer, she assessed Resident #4 and identified a hematoma with an open are on the left lower leg. DON #1 stated although Resident #4 complained of the pain after the transfer, and the hematoma was identified after the transfer, she could not determine if the injury occurred as a result of the transfer. 2. Resident #7's diagnoses included dementia, osteoporosis, repeated falls, and major depressive disorder. The significant change in condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a BIMS score of six out of fifteen (6/15), indicative of being severe cognitive impairment and required substantial/maximal to dependent assistance with transfers. Physician order dated 6/24/2025 directed to ensure the motion sensor alarm was on when in bed, check sensor in room on wall for green light and check alarm box at desk that it is turned on. The Resident Care Plan dated 7/9/2025 identified Resident #7 was at risk for falls. Interventions directed sensor motion alarm in place for all shifts (24/7), kept by the East-Wing charge nurse, and to always remain in the on position, call bell in reach and remind resident to use it for assistance. The facility Reportable Event Form dated 7/31/2025 at 7:15 AM identified Resident #7 was observed sitting on bathroom floor with his/her back to the wall, and complained of right arm pain. Resident #7 was transferred to the hospital, and was diagnosed with a right non-displaced clavicle fracture. Resident #7 returned to the facility the same day with a right arm sling and orders to follow-up with an orthopedic physician in one week. A nursing note dated 7/31/2025 at 9:18 PM identified Resident #7 returned from the hospital at 6:45 PM and diagnosed with a right nondisplaced clavicle fracture. Vital signs were stable, had no complaints and was in no acute distress. The Reportable Event Summary dated 8/5/2025 identified care was last offered at 6:30 AM by NA #5, was seen again by NA #5 at 6:50 AM, and was seen at 7 AM by the RN supervisor. NA #5 stated the alarm did not sound during the night shift and was not aware there was a sensor alarm in the resident's room over her bed. At 7:20 AM staff NA #6 observed Resident #7 on the floor in the T-Wing Hall bathroom, and indicated the alarm was not sounding. Resident #7 stated he fell on the ground and complained of arm pain. The summary further indicated RN #4 documented the bed sensor on the wall was turned on. Resident #7 was diagnosed with a non-displaced right clavicle fracture. Facility investigation identified seven (7) staff indicated they did not hear an alarm sound, and the alarm box was found to be in the off position by DNS; the facility conclusion was the motion sensor box at nursing station appeared to be off. Interview with DON #2 on 3/24/2026 at 12:00 PM identified on 7/31/2025, Resident #7 had physician-ordered and care plan-directed motion sensor alarms in place, including a bedside alarm that also sounded an alarm at the nursing station, that would alert staff to any attempts to ambulate independently. DON #2 stated the facility investigation identified no staff heard an alarm sound prior to the fall. DON #2 stated that RN #4 initially indicated the alarms were in the on position, however, subsequent review determined the alarms were in the off position and the alarm system at the nursing station was not activated at the time of the incident. Interview with DON #1 on 3/24/2026 at 12:55 PM identified on 7/31/2025 at approximately 7:20 AM, she was notified that Resident #7 had a fall, and no motion sensor alarms were sounding. DON #1 stated that, per the resident's plan of care, both the bedside alarm and the corresponding alarm at the nursing station were required to be in the on position to alert staff when the resident attempted to ambulate. DON #1 stated the facility investigation determined the alarms were in the off position at the time of the incident. Review of the Care Plan Policy dated 11/2025 directed in part, the care plan will address resident needs on an individual basis. Although requested, the facility did not provide a policy for surveyor review regarding following physician orders.

Based on clinical record review, facility policy review, and interviews for two of two residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to ensure the clinical record was complete and accurate to include the name of the individual documenting in the electronic medical record, in accordance with facility policy. The findings include: Resident #1's diagnoses included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and required assistance with ADLs. The Resident Care Plan (RCP) dated 1/6/2026 identified an alteration in self-care. Interventions directed to assist with ADLs. Nursing note dated 3/5/2026 at 6:53 AM identified Resident #1 received schedule pain medications. The note was signed 2LPN pool2 LPN (sic). Nursing note dated 3/6/2026 at 11:13 PM identified Resident #1 tolerated medications/fluids well. The note was signed 2LPN pool2 LPN (sic). Nursing note dated 3/7/2026 at 1:48 AM identified Resident #1 accepted medications, had no pain and was sleeping in naps. The note was signed poolnurse (sic) supervisor RN. Resident #2's diagnoses included bipolar, psychotic disorder and anxiety. The admission (MDS assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no/moderate/severe cognitive impairment, had delusions and rejected care four (4) to six (6) out of the prior seven (7) days. The Resident Care Plan (RCP) dated 12/3/2025 identified a care plan for accusatory behaviors. Interventions directed two (2) staff for all care. Facility reportable event dated 3/8/2026 at 1 to 1:30 PM, identified Resident #2 alleged verbal abuse by the 11 PM to 7 AM staff. Nursing note dated 3/8/2026 at 1:33 AM identified the assigned Nurse's Aide (NA) and the nursing supervisor offered Resident #2 care. Resident #2 was irritable, loud and yelled at staff to get out now and close my door. Additional review of the note identified the staff signature identified the author as poolnurse (sic) supervisor RN. Additional record review identified a nursing note dated 3/1/2026 at 2:46 PM was signed 2LPN pool2 LPN (sic). Interview, clinical record review, and facility documentation review with the Director of Nursing (DON) on 3/9/2026 at 2:21 PM identified the nursing notes were signed to identify the nurse was an agency (pool) nurse. The DON stated all agency nurses use the same login for access to the electronic medical record (EMR). The DON stated if she needs to identify who wrote a nursing note written by an agency staff, then she would need to check the facility schedule to identify who was working on the day and shift. The DON stated all agency RNs have one general login that is used by all the agency RNs and does not display the RN's name. Further, she stated all agency LPNs use one login, and all agency NAs also share one login. The DON stated she was aware the common login access for agency staff was a long-standing practice, and stated the notes should include the name of the person writing the note. Although review of the facility policy with the DON identified nursing notes should include the name and title of the individual, she was unable to explain why agency staff are not provided with individual login access for the EMR. Review of facility Charting and Documentation Policy dated 11/25, directed in part, documentation will include the name and title of the individual who provided care, and the signature and title of the individual documenting.

Based on facility documentation review, and interviews for facility review of QAPI, the facility failed to ensure quarterly Medical Staff meetings were held. The findings include:Interview and facility documentation review with the Administrator on 3/3/2026 at 9:40 AM identified the facility currently had a Medical Director that was unavailable to come into the facility since 2/19/2026. The Administrator stated the facility had one (1) additional physician that had retired at an unknown time in 2025 and had not been replaced. Interview and facility documentation review with the Administrator on 3/3/2026 at 2:37 PM identified she was unable to produce Medical Staff/QAPI meeting minutes and agendas for the prior 12 months. The Administrator stated the last Medical Staff/QAPI meeting was in September or October 2025, however she was unable to provide documentation that the meeting occurred. Further, the Administrator stated she had planned to have a Medical Staff/QAPI meeting last Thursday (2/26/2026), however they did not have a quorum to be able to meet. Although requested, no facility policy was provided for surveyor review.

Based on facility documentation, facility policies and interviews, the facility failed to ensure the provision and oversight of a Medical Director in accordance with federal requirements. The findings include: Interview and review of facility documentation with the Administrator and Director of Nursing (DON) on 3/3/2026 at 9:10 AM identified the facility had no current physicians that came to the facility. The DON stated the facility had one (1) physician, the Medical Director, the Medical Director was currently not available to come to the facility and was available only by phone. The DON stated that during 2025 there were two (2) physicians, but the second physician retired at an unidentified date last year, and was not replaced. All residents in the facility were patients of either the Medical Director who was not available to come to the facility, or Optum (a service with APRN coverage). The DON stated weekly Medical Director rounds on done every Thursday, and no physician did Medical Director rounds last week on 2/26/2026 and no one was scheduled for 3/5/2026; the last rounds were conducted on 2/19/2026 (12 days ago). Interview with the Administrator on 3/3/2026 at 9:40 AM identified the facility had no Medical Director available to come into the facility for weekly rounds. The Administrator stated after the second physician retired during 2025 on an unknown date, she called two (2) physicians to inquire about coverage and then she was waiting for the Medical Director to find a second physician to come to the facility. The Administrator stated she did not advertise or use a staffing agency to locate a second physician because she was relying on the Medical Director to do the search. Interview identified the facility failed to demonstrate that the designated Medical Director (MD #1) provided routine, ongoing oversight within the facility, including a presence in the building at least weekly. Facility record review failed to identify a current, executed contract outlining the responsibilities, availability, and coverage expectations of the Medical Director. Additionally, the facility was unable to provide documentation of a contingency agreement or alternate coverage plan to ensure Medical Director services were maintained in the event the appointed Medical Director was unavailable or failed to provide required services. Although requested, the facility was unable to provide a policy outlining the roles and responsibilities of the Medical Director, including expectations for facility involvement and oversight.

Based on clinical record review, facility documentation, facility policies, and staff interviews, for two of five residents (Resident #1 and #2), reviewed for wandering behaviors, the facility failed to ensure elopement risk assessments were completed timely and a physician order for wander guard use was obtained timely for Resident #1, failed to replace Resident #2's wander guard device timely, and failed to ensure implementation of every 15-minute safety checks for Resident #2 after the resident's wander guard device malfunctioned and was not replaced on 2/27/2026. The findings include: Resident #1's diagnoses included dementia with behavior disturbances and depression. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) and was unable to complete the interview, indicating severe cognitive impairment. The MDS assessment indicated Resident #1 had no pacing or wandering behaviors and ambulated independently with supervision with a wheelchair. Section E: Behaviors, was coded to identify Resident #1 had delusions. Section E0600 identified Resident #1 did not intrude on the privacy or activity of others. Section E0900 identified Resident #1 had no wandering behaviors. Section P: Restraints and Alarms was coded to identify no wander/elopement alarm was used. The Resident Care Plan (RCP) dated 12/16/2025 identified Resident #1 roams into other resident's rooms. Interventions directed staff to ensure resident does not roam into rooms. Clinical record review identified Resident #1 had a wander guard in use during 2024 per nursing notes. Additional review failed to identify the date the wander guard (wander/elopement alarm) was initiated and the date it was discontinued, and failed to identify a physician order was in place that directed wander guard use. Record review failed to identify any elopement risk assessments were completed from the time of admission (during 9/2024) through 2/18/2026. Elopement risk evaluation dated 2/19/2026 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, had a history of wandering into unsafe areas, and displayed behaviors that may indicate an attempt to leave (the facility). Interview and review of clinical documentation with the DON on 3/3/2026 at 2:15 PM identified elopement risk evaluations should be completed on admission, quarterly, and upon any readmission to the facility. The DON stated elopement risk evaluations should have been performed quarterly for Resident #1, stated they were not done, and was unable to explain why they were not completed timely. Further, the DON stated if a wander guard is in use, there should be physician orders that direct the use and it should be signed on the Medication Administration Record to reflect the device was in use, signed every shift that it was in place, and every day that it was functioning. Review of the Wandering Risk Assessment Policy dated 11/2025 directed in part, a wandering risk assessment will be utilized and completed on all residents to determine their risk level. Assessments will be done upon admission and quarterly. Although requested, a facility policy regarding physician orders for wander guard placement checks every shift was not provided for surveyor review. 2. Resident #2's diagnoses included dementia, transient ischemic attacks, and syncope. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severe cognitive impairment, had no wandering behaviors, transferred with moderate assistance, used a wheelchair for mobility, had no impaired range of motion of the lower extremities, did not walk, and had a wander/elopement alarm daily. Elopement risk evaluation dated 12/30/2025 identified Resident #2 ambulated independently, was cognitively impaired with poor decision-making skills, and displayed behaviors that may indicate an attempt to leave. Resident Care Plan dated 1/22/2026 identified Resident #2 was at risk for elopement. Interventions directed to check wander guard function and placement every shift and daily. Nursing note dated 2/27/2026 at 9:01 PM by LPN #3, identified the wander guard was in place but was not functioning and the supervisor was notified. Initiated every 15-minute checks in place. Nursing note dated 3/1/2026 at 11:27 AM by RN #4, identified wander guard #3349 replaced to the right ankle (two days after the wander guard was identified not functioning). Wander guard was checked and confirmed to be functioning. Interview with the Director of Nursing (DON) on 3/3/2026 at 2:15 PM identified that on 2/27/2026, Resident #2's wander guard device malfunctioned and the facility had no additional wander guard devices available to replace the device. The DON stated there may have been extra devices located in the former DON's office however, she did not have access to that office to verify if there were or were not any devices; the staff on the unit did not have access to any device to replace the wander guard. The DON stated, per facility policy, a malfunctioning wander guard device is to be replaced immediately to ensure continuous elopement protection and the staff should have had access to a replacement device. The DON stated Resident #2 was placed on every 15-minute safety checks until a replacement device could be obtained, and it was replaced on 3/1/2026 (two days after the device malfunctioned). Although requested, the DON was unable to provide documentation that the every 15-minute checks were performed on 2/27, 2/28 and 3/1/2026 until the new wander guard was applied. Interview and record review with the DON on 3/3/2026 at 2:15 PM identified the facility should have documented the every 15-minute checks and was unable to explain why there was no documentation. Review of the Wander-Guard Security System Policy dated 11/2025 directed in part, a wander guard security device will be placed on any resident that the care team decides is at risk for wandering away from the facility. The Policy further directed non-functional devices are to be replaced and the 11 PM to 7 AM nurse to check function daily. Although requested, a facility policy regarding physician orders for wander guard placement checks every shift was not provided for surveyor review. Wander-Guard Security System Policy dated 11/25 directed in part, non-functional devices are to be replaced. The Policy further directed the 11 PM to 7 AM nurse to check function daily. The facility Documentation Policy dated 11/25 directed in part, the facility will ensure nursing documentation is accurate, timely, complete, and reflective of the care provided.

Based on observations and interviews for facility egress review, the facility failed to ensure staff knew how to silence door alarms, failed to responded to door alarms timely, and failed to ensure exit doors were secured to prevent unauthorized exit. The findings include:Observation and interview on 3/3/2026 at 8:11 AM with RN #2 identified the facility staff were doing every 15-minute rounds on thirteen (13) facility egress doors on a rotating basis. Review of the schedule identified the rounds started with labeled on a map as Door #12, and then on the rotating basis it would take three (3) hours and fifteen (15) minutes to next check Door #12 again. Observation of Door #8 (near the hairdresser) identified the alarm sounded and RN #2 did not know how to silence the alarm. Continuous observation identified multiple staff walked by the alarming door. RN #2 asked NA #1 how to silence the alarm - NA #1 stated she does nothing with doors. RN #2 asked Housekeeper #1 what to do and Housekeeper #1 had no information. RN #2 then asked the Housekeeping Director, and the Housekeeping Director stated that the alarm was actually the alarm ringing for Door #10 (back door to the back parking lot). RN #2 asked Housekeeper #2 what to do, and Housekeeper #2 stated to enter the code in the keypad next to the door, and when that did not silence the alarm Housekeeper #2 stated he thought it was the back door by the kitchen (Door #10). The Housekeeping Director then again stated it was Door #10 alarming, and observation of Door #10 (back door to the back parking lot) with the Housekeeping Director identified Door #10 was not alarming. At 8:31 AM the door was still sounding an alarm, and RN 2 asked the Housekeeping Director who she should call. At 8:32 AM the Director of Nursing (DON) arrived and took the keys from RN #2 and went to the back door (Door #10) to silence the alarm. The DON was joined by [NAME] #1 who also stated the alarm was caused by the back door. [NAME] #1 took the keys and attempted to silence the back door (Door #10) alarm and stated the door was not alarming. The DON then stated, maybe it's not this door and [NAME] #1 and the DON walked back to Door #8 near the hairdresser and using the key, [NAME] #1 silenced the alarm at 8:37 AM. Observation and interview with RN #2 and the DON of the back door to the back parking lot, Door #10 on 3/3/2026 at 8:37 AM identified the door was secure and alarmed when the door was opened. The DON entered a code in the keypad next to the door to attempt to silence the alarm; the alarm continued to sound. Continuous observations identified the alarm continue to alarm without staff response. Staff were observed in the kitchen adjacent to the door hallway and did not respond to the alarm. At 8:44 AM, the Director of Maintenance arrived and silenced the alarm. interview with the Food Service Director and [NAME] #1 identified they did not respond to the alarming back door (Door #10) because they thought it was not the back door alarming. Interview identified staff should always respond to an alarming door to identify which door alarmed and if a resident had exited through the door. Observation and interview with the DON, Administrator and Food Service Director on 3/3/2026 at 11:31 AM identified the door near the nursing station leading to the basement and outside the side of the building, Door #12, had a keypad on the wall next to the door. The keypad light was red, and turned green after the code was entered and allowed opening of the door without any alarm sounding. After going through the door and closing the door, the light remained green and there was no way to re-arm the door from the top of the stairwell that led to the basement and to outside (without going down the stairs). On the stairwell side of the door, there was a button to push to unlock the door for entering the unit, but the button did not re-lock/re-arm the door. Re-entry from the stairwell into the unit side of the door identified the light was still green. The DON then re-entered the code in the keypad to relock/re-arm the door and the light turned red. When the light was red, the DON was able to open the door without difficulty and no alarm sounded. Subsequent to surveyor inquiry, the facility placed an employee on the door for constant observation until a new alarm was applied to the door. No facility policy was provided for surveyor review regarding securing egress doors.

Based on clinical record reviews, facility documentation, facility policies and interviews for five of five residents (Resident #1, #2, #3, #4, and #5), the facility failed to ensure a complete and accurate record to include wander guard devices for function and placement. The findings include:Resident #1's diagnoses included dementia with behavior disturbances and depression. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) and was unable to complete the interview, indicating severe cognitive impairment. The MDS assessment indicated Resident #1 had no pacing or wandering behaviors and ambulated independently with supervision with a wheelchair. Section E: Behaviors, was coded to identify Resident #1 had delusions. Section E0600 identified Resident #1 did not intrude on the privacy or activity of others. Section E0900 identified Resident #1 had no wandering behaviors. Section P: Restraints and Alarms was coded to identify no wander/elopement alarm was used. The Resident Care Plan (RCP) dated 12/16/2025 identified Resident #1 roams into other resident's rooms. Interventions directed staff to ensure resident does not roam into rooms. Elopement risk evaluation dated 2/19/2026 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, had a history of wandering into unsafe areas, and displayed behaviors that may indicate an attempt to leave (the facility). Physician order dated 2/17/2026 directed staff to check the placement and function of the wander guard every shift. Review of the MAR/TAR (Medication and Treatment Administration Record) for the month of February 2026 failed to document (the box to document was blank) that Resident #5's wander guard was checked for placement on 2/23/2026 (evening and night shift). 2. Resident #2's diagnoses included dementia, transient ischemic attacks, and syncope. The quarterly MDS assessment dated [DATE] identified Resident #2 had a BIMS score of six (6), indicating severe cognitive impairment, had no wandering behaviors, transferred with moderate assistance, used a wheelchair for mobility, had no impaired range of motion of the lower extremities, did not walk, and had a wander/elopement alarm daily. Elopement risk evaluation dated 12/30/2025 identified Resident #2 ambulated independently, was cognitively impaired with poor decision-making skills, and displayed behaviors that may indicate an attempt to leave. The RCP dated 1/22/2026 identified Resident #2 was at risk for elopement. Interventions directed to check wander guard function and placement every shift and daily. Physician order dated 2/11/2026 directed staff to check the placement and function of the wander guard every shift. Review of the MAR/TAR from 2/13 through 2/28/2026 identified the staff failed to document Resident #5's wander guard was checked for placement (the box to document was blank) on 2/13 (day and evening shift), 2/14 (evening shift), 2/15 (evening shift), 2/23 (day and night shift), 2/24 (evening shift), and 2/26/2026 (night shift). 3. Resident #3's diagnoses included dementia with behavioral disturbances. The significant change in condition MDS assessment dated [DATE] identified Resident #3 had a BIMS score of eight out of fifteen (8/15), indicating severe cognitive impairment, had no wandering behaviors in the prior seven (7) days, ambulated independently, and had a wander/elopement alarm used daily. The RCP dated 1/20/2026 identified Resident #3 wanders (moves with no rational purpose, seemingly oblivious to needs or safety). Interventions directed use of a device that alarms when wanders and to check for proper functioning of device every 11 PM to 7 AM shift. Elopement risk evaluation dated 1/8/2026 identified Resident #3 ambulated independently, was cognitively impaired with poor decision-making skills, and displayed behaviors that may indicate an attempt to leave. Physician order dated 1/22/2026 directed staff to check the placement of the wanderguard every shift. Review of the MAR/TAR for the month of February 2026 identified the staff failed to document Resident #3's wander guard was checked for placement (the box to document was blank) on 2/9 (day shift) and 2/22/2026 (day shift) . 4. Resident #4's diagnoses included vascular dementia with behavior disturbances, Alzheimer's disease, and depression. Elopement risk evaluation dated 11/11/2025 identified Resident #4 ambulated independently, was cognitively impaired with poor decision-making skills, and displayed behaviors that may indicate an attempt to leave (the facility). The annual MDS assessment dated [DATE] identified Resident #4 had a BIMS score of six out of fifteen (6/15), indicating severe cognitive impairment, had no pacing or wandering behaviors, ambulated independently with supervision with a walker and had no wander/elopement alarm. The RCP dated 2/5/2026 identified Resident #4 had been observed near doors to the outside and was at risk for wandering/elopement. Interventions directed staff to ensure a wander guard to the ankle, and to check placement and functioning every shift. Physician order dated 2/9/2026 directed staff to check the placement of the wander guard every shift. Review of the MAR/TAR for the month of February 2026 identified the staff failed to document Resident #4's wander guard was checked for placement and function (the box to document was blank) on 2/2 (night shift), 2/9 (day shift), and 2/23/2026 (day and evening shift). 5. Resident #5's diagnoses included Alzheimer's disease and depression. The quarterly MDS assessment dated [DATE] identified Resident #5 had a BIMS score of ninety-nine (99) indicating Resident #5 was unable to complete the interview and had severe cognitive impairment for daily decision making, had wandering behaviors daily, ambulated independently with supervision, and had no wander/elopement alarm. The RCP dated 12/23/2025 identified Resident #5 wandered through out the hallway and into other rooms. Interventions directed to check wander guard every shift and as needed and redirect if found wandering in resident's rooms. Elopement risk evaluation dated 12/23/2025 identified Resident #5 ambulated independently, was cognitively impaired with poor decision-making skills and had a history of wandering into unsafe areas. Physician order dated 1/20/2026 directed staff to check the placement of the wander guard every shift. Review of the MAR/TAR from 2/13/2026 through 2/28/2026 identified the staff failed to document Resident #5's wander guard was checked for placement (the box to document was blank) on 2/13/2026 (day shift) and on 2/23/2026 (evening shift). Interview and review of clinical documentation with the DON on 3/3/2026 at 2:15 PM identified it was her expectation that nursing staff document all areas of provided care, and the staff should have documented on the MAR/TAR that the wander guard placement and function was checked. The DNS stated the documentation was missing, as listed above, for Residents #1, #2, #3, #4, and #5 and was unable to explain why it was not done. Review of a Documentation Policy dated 11/25 identified the facility will ensure nursing documentation is accurate, timely, complete, and reflective of the care provided to promote patient safety. All nursing staff are required to document patient care timely, and required documentation included treatments.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #4) reviewed for wandering, the facility failed to ensure the assessment accurately reflected the resident's status for behaviors and wander/elopement alarm at the time of the assessment. The findings include:Resident #4's diagnoses included vascular dementia with behavior disturbances, and depression. Elopement risk evaluation dated 11/11/2025 identified Resident #4 ambulated independently, was cognitively impaired with poor decision-making skills, and displayed behaviors that may indicate an attempt to leave the facility. Resident Care Plan dated 11/11/2025 identified Resident #4 was at risk for wandering/elopement and had been observed near doors to the outside. Interventions directed staff to ensure a wander guard to the ankle, and to check placement and functioning every shift. Physician order dated 1/1/2026 directed a wander guard device to Resident #4's ankle, and to check placement and function every shift. The annual Minimum Data Set assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen (6/15), indicating severe cognitive impairment. Resident #4 had no pacing or wandering behaviors and ambulated independently with supervision with a walker. Section E: Behavior was coded it indicate Resident #4 had delusions, and had no wandering behaviors. Section P: Restraints and Alarms was coded to identify no wander/elopement alarm was used. Interview with the DON on 3/3/2026 at 2:15 PM identified Resident #4's baseline behavior was to always wander up and down the hallways in the facility. The DON stated the MDS nurse will utilize, but was not limited to a resident's assessments, care plans, and progress notes, to ensure the resident's MDS was coded/completed accurately. The DON stated the MDS should accurately reflect a resident's care for all sections, including behaviors/wandering and wander/elopement alarm use. The DON stated Resident #4's MDS dated [DATE] did not accurately reflect Resident #1's behaviors. Although requested, the facility did not provide a policy regarding the accuracy of MDS assessments for surveyor review. Review of the Documentation Policy dated 11/2025 identified the facility will ensure nursing documentation is accurate, timely, complete, and reflective of the care provided.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1), the facility failed to adequately supervise a resident with a diagnosis of dementia and was identified wander risk who ambulated independently. Resident #1 was able to exit the facility without staff knowledge in subfreezing temperatures. The failure resulted in a finding of Immediate Jeopardy. The findings include:Resident #1's diagnoses included dementia.Record review identified Resident #1's code status was Do Not Resuscitate (DNR).The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors, transferred with moderate assistance, ambulated independently with supervision, and had no wander/elopement alarm.Elopement risk evaluation dated 11-24-2025 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, made statements that he/she was leaving and displayed behaviors that may indicate an attempt to leave. Physician order dated 12-7-2025 directed to ambulate with four (4) wheeled rolling walker with supervision. Physician order dated 1-15-2026 directed to check wander guard bracelet placement every shift and check function daily.The Resident Care Plan dated 1-31-2026 identified Resident #1 had a wander guard on the right ankle. Interventions directed to redirect if near doors to outside. Check functioning per protocol. Review of Nurse Aide (NA) documentation dated 2-8-2026 identified rounds were completed and Resident #1 was observed at 1 AM, and 3 AM sleeping in his/her bed.The Facility Reported incident form dated 2-8-2026 at 5:00 AM identified Resident #1 was found outside of the building around 5:12 AM and was immediately brought back into the building. NA #1 written statement dated 2-8-2026 identified about 1:30 AM she observed Resident #1 sleeping in bed and she placed the walker next to the bed so he/she could hold it if he/she got up. The statement indicated NA #1 saw Resident #1 again at 3:30-ish, sleeping in bed. Then about 4:30 AM, Resident #1 was not on his/her bed. I went around again, I couldn't find Resident #1 on his/her bed. I first went to the bedroom to look for him/her, I went round the rooms looking for him/her, then I went on the other wing to check and told my co-worker who also started searching with me while I went outside (to) look she went and told the nurse. The co-worker came outside the building to join me, while we both was looking around she stopped, Resident #1 laying on the floor, by the walkway. I run quickly to get the nurse, also got some blankets. NA #3 written statement dated 2-8-2026 identified at about 4:45 AM she observed NA #1 looking for Resident #1 and asked NA #4 to assist in searching. Around 5 AM NA #3 informed the nurse that we were unable to locate Resident #1, and we search all areas inside the building. The nurse then suggested they put on jackets and check outside. The statement indicated as NA #3 walked down the sidewalk toward the post office (next door building), she observed Resident #1 on the ground. I immediately called out to my co-worker who then went to notify the nurse. Resident #1 was then brought back inside and they began attempting to warm him/her up while waiting for instructions.NA #4 written statement dated 2-9-2026 identified shortly after 4:30 AM, NA #1 asked for help that they could not find the patient. NA #4 told NA #1 to search her unit and he would search the other unit. After searching they met and he told NA #1 to go with him to search the back hallway area. They went to the back hallway to the back outside door. NA #4 asked NA #1 to prop open the door while he searched the back parking lot and between the cars. NA #4 then went to the nurse's station and RN #1 told them to get their coats to go outside to look. NA #4 got my phone and the time was 5:11 AM and after he went to search the back parking lot area, he returned to the nursing station and as he approached the front door he saw RN #1 pulling a wheelchair into the building with Resident #1 in wheelchair, NA #1 and NA #3 was with RN #1. The wander guard alarm triggered as Resident #1 was wheeled inside and I shut it off with the code. Resident #1 was transferred into bed. I checked for Resident #1's pulse on his/her right pulse and felt he/she was really cold and could not feel pulse. Resident #1 was unresponsive. RN #1 asked for a stethoscope and he said he thought he heard a heartbeat. NA #4 used the pulse ox (finger device to measure blood oxygen level) and had no reading. NA #4 helped get warm wet towel for the NAs and then left the room. Registered Nurse (RN) #1 written statement dated 2-8-2026 identified a NA informed him at approximately 5 AM that Resident #1 was not in his/her room. Immediately he instituted room checking to all the facility again, no success. He then instructed outside searching, then Resident #1 was found on the sidewalk outside of the facility. Resident #1 was only responding to pain stimuli and blinking his/her eyes. Resident #1 was brought back to the facility and applied warm blanket. 911 was called and upon arrival Resident #1 was still unresponsive.Nursing note written by the Director of Nursing (DNS) dated 2-8-2026 at 1:05 PM identified Resident #1 was observed by the overnight shift not to be in his/her room upon rounding. Per supervisor, a search was done, and Resident #1 was located on the grounds outside and was immediately brought inside the building. Assessment was done, warm clothes and blanket provided. 911 was called. Per Emergency Medical Technician (EMT) report, Resident #1 was pronounced deceased at around 6:46 AM. Family, physician and police were notified.Review of local weather on 2-8-2026 at 1:53 AM identified the temperature at 1:53 AM was 1 degree Fahrenheit with a wind of 14 mph, and at 5:53 AM the temperature was 0 degrees F with a wind of 12 mph. Observation on 2-8-2026 at 2:10 PM identified a local police car in front of the building near the edge of the property with yellow tape around an area of the sidewalk and snow near the post office, and snow covered the ground. The sidewalk in front of the building along the street was shoveled to the approximate property line, the sidewalk along the driveway was shoveled, and snow on both sides of the sidewalk was approximately twenty (20) inches high. The pile of snow at the end of the shoveled sidewalk on the side closest to the building was taller than the approximate four (4) foot tall snow stake marking the edge of the sidewalk. The sidewalk beyond the property line was not shoveled.Interview and record review with the Administrator and DNS on 2-8-2026 at 2:22 PM identified Resident #1 had a history of dementia, ambulated independently with a walker, was a known wander risk, wore a wander guard bracelet, and had left the building without staff knowledge. Per staff, Resident #1 was last seen about 3:00 AM and was identified missing at about 4:45 AM. The NAs searched the two (2) nursing units before notifying the RN supervisor/RN #1. When NA #1 and NA #4 were unable to locate Resident #1 they notified RN #1 about 5 AM (approximately 30 minutes after NA #1 identified Resident #1 was missing). RN #1 then initiated a search inside the building and then directed an outside search when Resident #1 was not located. Staff found Resident #1 about 5:12 AM, lying on the sidewalk at the front of the building. RN #1 directed a staff member to bring a wheelchair outside, and Resident #1 was lifted into a wheelchair and was returned inside the building. Resident #1 was unresponsive, and staff then removed Resident #1's wet clothing, applied dry clothing and blankets and then called 911. The Administrator and DNS stated Resident #1 should not have been able to exit the building without staff knowledge, the NAs should have notified the nurse immediately when Resident #1 was identified missing, and 911 should have been called immediately after Resident #1 was found outside. Further, the facility had no video of the doors, and they did not know how Resident #1 got out of the facility. The Administrator stated the wander guard alarm sounded when Resident #1 was returned into the building. Observation and interview with the Administrator on 2-8-2026 at 3 PM identified the only door in the facility with a wander guard alarm was the double fire doors near the nurse's station that led to the lobby. Observation identified an exit door at the end of the hallway near Resident #1's room that led to the hairdresser and dietary area identified the door had no alarm system to alert staff if a resident went through the door. Next to dietary, there was a hallway that led to an exit door, also with no alarms. Going through that door was a door that led to the outside. The outside door had a keypad code for the door and the required code to unlock the door was posted on the wall above the keypad. The Administrator stated the code was posted above the keypad for staff use. Pressing on the door, the door opened and alarmed. Entering back into the hallway identified the door alarm was not audible inside the hallway. The Administrator stated the alarm did not alert at the nurse's station to notify staff that the door was opened. The Administrator stated they did not know how Resident #1 exited the building, and that it was a potential that a resident could exit through that door without staff knowledge, however she did not think Resident #1 could have walked that far to exit the back of the building and then be found in the front of the building. Interview with the DNS on 2-8-2026 at 3:41 PM identified Resident #1 was wearing sneakers and socks, pajama long sleeve top and pajama pants when he/she was found on the sidewalk.Interview with the Director of Maintenance on 2-8-2025 at 3:41 PM identified he was aware the exit door by dietary had the required keypad code posted and stated it should not be posted, that he should have taken it down before. He stated the doors leading to that exit were not alarmed and the facility never had a resident exit out that door. He believed Resident #1 exited out the lobby door but was unable to say how Resident #1 was able to exit through the doors with the wander guard alarm system. He stated the doors were tested and functioning correctly and the door alarmed when Resident #1 was returned into the building.During an interview and record review with NA #1 on 2-9-2026 at 11:06 AM, NA #1 stated she observed Resident #1 in his/her bed at 1 AM and about 3:30 AM. NA #1 stated she identified Resident #1 missing about 4:35 or 4:45 AM and searched the unit with NA #3, and NA #3 notified RN #1. She then went to the back door near the kitchen with NA #4 and NA #4 searched the back parking lot. Then when she and NA #3 searched the front of the building, NA #3 located Resident #1 lying on his/her left side on the sidewalk in front of the building. Resident #1 was not moving, and his/her eyes were opening and closing. Resident #1 was wearing sneakers, socks, and pajamas, and his/her clothes were cold with ice on them. NA #1 stated she went into the building to get blankets, RN #1 brought a wheelchair and Resident #1 was returned inside the building and put into bed. The staff removed his/her clothes, dressed him/her in a johnny, and gave incontinent care, and tried to warm him/her up with warm blankets and towels with warm water, and RN #1 was running in and out of the room, and the only response was opening and closing his/her eyes. NA #1 stated when the ambulance came, they administered CPR. Interview and record review with RN #1 on 2-9-2026 at 9:34 AM identified he was notified about 5 AM that Resident #1 was missing, and staff had already searched the facility without telling him that she was missing. He stated Resident #1 was known to exit seek and that was why he/she had a wander guard and he directed a second search inside and then to search outside. RN #1 stated he thought Resident #1 could have gone out the back door. NA #1 told him that Resident #1 was found outside in front of the building. Resident #1 was brought back inside in a wheelchair, had no response to painful stimuli, only blinked his/her eyes, and had a pulse. No blood pressure was heard (recorded) on the blood pressure machine, a temperature was attempted to be obtained, and the thermometer read LOW and his/her pulse was between 20's and 30's. He stated he wanted to make sure they get warm blankets for hypothermia and people were emotional with the situation. RN #1 stated he did paperwork, then called the Administrator who conferenced in the Director of Nursing (DNS) and he told them he was going to send him/her to the hospital and then he called 911. RN #1 stated he was informed that he called 911 at 6:23 AM (1 hour and 11 minutes after he/she was found outside). RN #1 stated he looked at Resident #1's code status, it was just me, and he looked to get help he needed and to call facility people above him, and to do an assessment. He wanted the DNS and Administrator, to make sure he informed them that we had an emergency. He had to assess Resident #1 first before calling 911. Review of thermometer manufacturer manual identified the thermometer reads LO if the temperature is less than 89.6 degrees Fahrenheit.Interview and record review with the DNS and Administrator on 2-9-2026 at 1:56 PM identified the DNS received a conference call from the administrator and RN #1 on 2-8-2026 at 6:08 AM (56 minutes after Resident #1 was found outside). The DNS stated that RN #1 indicated during the call that he had not called 911 because they were trying to get Resident #1 warm, and she directed RN #1 to call 911. Interview identified staff should have notified RN #1 immediately when Resident #1 was identified missing, and 911 should have been called immediately after Resident #1 was found. Review of EMS run sheet dated 2-8-2026 identified EMS was called at 6:23 AM and EMS initiated treatment of the resident at 6:35 AM for a question of a cold exposure out of the facility. On arrival with police on scene, Resident #1 was found unresponsive, pulseless, apneic (not breathing). Staff reported the resident had wandered out of the facility possible 30 minutes prior and found laying on the ground outside, not responding to staff, placed in a wheelchair and returned into facility and bed when 911 was called. EMS noted severely cold temperatures. Once confirmed pulseless, Resident #1 was transferred to a stretcher and CPR was initiated due to no CPR bed board available and unknow DNR (Do Not Resuscitate), monitor placed with pads, asystole (no pulse) on monitor, no lung or heart sounds, extremely cold to touch with thermometer reading LO. Nurse provided paperwork for DNR. EMS also noted lividity (discoloration of the skin due to pooled blood after death) on the left flank (between ribs and hips), left hand and knee with possible blistering from outside temperature and positioning. Pupils were fixed and non-reactive. No other traumatic injuries noted. EMS noted resident was in a hospital gown with adult depends on. Patient was extremely cold to the touch and pale along with the lividity on the left side. Patient presumed (death) at 6:46 AM.Observation of video obtained by local police identified a person (probable Resident #1) was observed at the back of the building near the rear parking lot at 1:50 AM (1 hour and 10 minutes before the NA documented that Resident #1 was alleged to be observed sleeping in his/her bed at 3 AM). The person came into view at the back corner of the building and walked along the side of the building past the main entrance toward the road. The person observed, appeared to be walking quickly, was upright (not stooped over), had no walker with them, and appeared to have no difficulty walking (no stumbling, weaving or unsteadiness). Continued observation identified when the person was nearing the front corner of the building (beyond the main facility entrance) near the road, his/her pace had slowed. Review of a second video obtained by local police identified the person appeared at the apron of the driveway at 1:55 AM (1 hour and 5 minutes before NA #1 documented Resident #1 was observed sleeping in his/her bed). The person was observed to hesitate near the road and then turned to his/her right and walked on the sidewalk in front of the building next to the road. The person's pace was slower, and there was snow along both sides of the sidewalk. As the person approached the property line, he/she stopped walking and at 1:57 AM, he/she bent down for a moment, then stood back upright and took a few steps forward. At 1:58 AM (1 hour and 2 minutes before NA #1 documented Resident #1 was sleeping in bed), the person was observed to fall face forward and extend both his/her hands out in front of him/her as he/she fell forward. There was no further movement observed on the video viewed. Continued review of video identified Resident #1 was still lying on the ground at the end of the sidewalk and two (2) people appeared at the apron of the driveway at 5:11 AM (3 hours and 21 minutes after Resident #1 was observed at the back of the building). One (1) person was observed to walk toward Resident #1, reached Resident #1, and the other person joined him/her. At 5:12 AM, one (1) person then walked back toward the building and out of view when in the direction of the main facility entrance. At 5:13 AM a person (possible RN #1) with a white/light colored top/jacket appeared at the driveway and was walking toward Resident #1. At 5:14 AM the person with the light-colored jacket arrived at Resident #1, and one of the first two (2) people returned to the building. At 5:15:31 a person returned from the building and RN #1 went back toward the facility main entrance, and staff next to Resident #1 covered him/her with a large white colored object - possibly a blanket. RN #1 reappeared on the video at 5:17:37. At 5:17:48 RN #1 turned onto the sidewalk pushing a wheelchair and arrived at Resident #1 at 5:18:10. At 5:18:44 (3 hours and 28 minutes after Resident #1 was first viewed on the video tape) Resident #1 was transferred into the wheelchair with the light-colored item or blanket over him/her. One staff member was observed to then pull the wheelchair backwards while one was near the wheelchair and RN #1 was walking bent over (facing Resident #1) and holding onto either the wheelchair or Resident #1. They reached the driveway at 5:19:32 and the video ended. Review of facility Elopement Management Policy dated 11-25 directed in part, if an employee discovers a resident is missing, to inform the supervisor or DNS while staff do a quick and thorough search of the unit and other departments. The supervisor or DNS will page overhead Calling Dr Hunt, and the Supervisor of DNS will instruct the NAs on the unit to repeat search of the unit as well as instruct to search outside the facility. Notify the police department within 15 minutes of not successfully locating the missing resident. When the missing resident is returned to the facility the nurse will immediately and thoroughly assess the resident for injuries.Review of facility Change in Condition Policy dated 06/23 directed in part 911 should be called immediately if a resident is unresponsive. Part 2: Based on clinical record review, facility documentation, facility policy review, and staff interviews, for four of four residents (Resident #1, #2, #3 and #4), reviewed for wandering behaviors, the facility failed to ensure three emergency exit doors were maintained in proper working order and failed to ensure the exit doors fully closed and latched after opening, and failed to ensure the exit doors sounded an alarm when not closed fully to alert staff when the doors were not secured. The findings include: Resident #1's diagnoses included dementia. Elopement risk evaluation dated 11-24-2025 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, made statements that he/she was leaving and displayed behaviors that may indicate an attempt to leave. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors, transferred with moderate assistance, ambulated independently with supervision, and had no wander/elopement alarm. Physician order dated 12-7-2025 directed to ambulate with four (4) wheeled rolling walker with supervision. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors, transferred with moderate assistance, ambulated independently with supervision, and had no wander/elopement alarm. The Resident Care Plan dated 1-31-2026 identified Resident #1 had a wander guard on the right ankle. Interventions directed to redirect if near doors to outside. Check functioning per protocol. Physician order dated 1-15-2026 directed to check wander guard bracelet placement every shift and check function daily. Resident #2's diagnoses included Alzheimer's disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) indicating Resident #2 was unable to complete the interview, and had severe cognitive impairment for daily decision making, had wandering behaviors daily, transferred with supervision assistance, ambulated independently with supervision, and had no wander/elopement alarm. Resident Care Plan dated 12-23-2025 identified Resident #2 wanders through out the hallway and into other rooms. Interventions directed to check wander guard every shift and as needed and to redirect into the hallway if found wandering in other resident's rooms. Elopement risk evaluation dated [DATE] identified Resident #2 ambulated independently, was cognitively impaired with poor decision-making skills and had a history of wandering into unsafe areas. Resident #3's diagnoses included dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating severe cognitive impairment, had no wandering behaviors, transferred with moderate assistance, ambulated independently with a wheelchair, and had wander/elopement alarm daily. Elopement risk evaluation dated 12-30-2025 identified Resident #3 ambulated independently, was cognitively impaired with poor decision-making skills and displayed behaviors that may indicate an attempt to leave. Resident Care Plan dated 1-22-2026 identified a risk for elopement. Interventions directed to check function and placement of wander guard every shift and daily. Resident #4 had diagnoses that included dementia. Significant change MDS dated [DATE] identified Resident #4 had a BIMS score of eight (8) indicating severe cognitive impairment and had no wandering behaviors in the prior seven (7) days, walked independently and used a wheelchair with independent mobility. Observation and interview with the Administrator on 2-8-2026 at 3:00 PM identified the only door in the facility with a wander guard alarm was the double fire doors near the nurse's station that led to the lobby. Observation identified an exit door at the end of the hallway near Resident #1's room that led to the hairdresser and dietary area identified the door had no alarm system to alert staff if a resident exited the unit and went through the door. Next to dietary, there was a hallway that led to an exit door, also with no alarms. Going through that door was a door that led to the outside. The outside door had a keypad code for the door and the required code to unlock the door, and the required code was posted on the wall above the keypad. The Administrator stated the code was posted above the keypad for staff use. Pressing on the door, the door opened and alarmed, and exited into the back parking lot. Entering back into the hallway (inside the inner door) identified the door alarm was not audible inside the hallway. The Administrator stated the alarm did not alert at the nurse's station to notify staff that the door had been opened. The Administrator stated they did not know how Resident #1 exited the building when he/she eloped on 2-8-2026. The Administrator stated it was a potential that a resident could exit through the exit door near dietary without staff knowledge, however she did not think Resident #1 could have walked that far to exit the back of the building and then be found in the front of the building. Continued observation identified the hallway near the front of the building identified an exit door that led to an enclosed courtyard. Observation of the door identified the door did not latch upon re-entry into the building and required several attempts to latch the door and then enter the code to reset the alarm. Observation of the dining room near the nurse's station identified a second door that led to the same courtyard. The door required a code to be entered to open the door. Observation of the door after it was opened identified the door did not lock when closed - it did not reactivate the lock. Interview with NA #5 and NA #6 who were present in the dining room at the time of the observation, identified the door had two (2) codes that could be entered. One (1) code would unlock the door and automatically relock it after the door was closed fully and relatched. The other code, which was the code the Administrator entered, unlocked the door and allowed for multiple entries/exits without relocking. Observation of the courtyard identified the courtyard was fenced in with two (2) gates in the fencing, both gates opened easily when a button was pushed and opened to the parking lot near the street. Additional observation identified the sidewalk where Resident #1 was found (that had previously had yellow police tape) had piles of snow on both sides of the walkway. Observation on 2-9-2026 at 11:45 AM identified the following regarding emergency exit door functionality and security: a. Rear Exit Door (back parking lot):The door was initially secured. After entering the access code, the surveyor opened the door, upon self-closure, the door failed to latch and did not re-lock. A faint alarm briefly activated; however, when the door was manually pushed closed, and the alarm ceased. The surveyor repeated the process, and the door again failed to latch or lock and did not activate an alarm, allowing unrestricted entry and exit. b. Kitchen Exit Door near the hairdresser (to the left upon immediate exit of Resident #1's unit):The door was initially secured. After entering the access code and opening the door, the door failed to latch or re-lock upon self-closure. No alarm sounded after closure, permitting unrestricted entry and exit. c. T-Wing Exit Door (wing closest to the street that led into the courtyard):The door was initially secured. After entering the access code and opening the door, the door failed to latch or re-lock upon self-closure. No alarm activated, allowing unrestricted entry and exit. Interview and observation conducted on 2-9-2026 at 11:55 AM with the Director of Maintenance (DOM), Director of Nursing (DON), and Administrator regarding the T-Wing emergency egress door identified the following: Upon entry of the access code, the emergency door opened and activated a single external alarm indicating possible movement through the doorway. However, upon closure, the door failed to properly latch and lock and the alarm did not sound despite the door not being fully secured. As a result, the door could be freely opened from both the inside and outside without restriction or alarm activation. During the observation, the DOM acknowledged the latch/lock mechanism was not functioning properly and stated that weather stripping along the door frame may be interfering with proper latching. The DOM immediately began removing the weather stripping during the interview. The DOM further stated he would inspect and address all egress doors, contact the egress lock vendor for repair, and implement staff monitoring ( watch person) at each affected egress door to ensure resident safety. Interview and observation of the exit doors with the DON, Administrator and DOM on 2-10-2026 at 9:37 AM identified the small dining room door and the T unit doors did not latch, and did not alarm to alert staff when the doors were ajar and were not latched. The DOM stated the doors were in winter mode, and no one would go outside in the cold and that the keypads had no alarm function to alert staff and the keypads were old. Subsequent to surveyor inquiry, staff were placed at the doors to monitor. State Building and Fire Safety on-site, information provided on 2-10-2026 at 2:25 PM identified the exit doors with keypads have alarms and the alarm function was turned off. All alarms were turned back on and were functioning correctly. Although requested, the facility did not have a policy for ensuring proper functioning of emergency exit doors.

Based on observation, record review, and staff interviews, the facility failed to ensure the resident was free from neglect when the facility failed to notify the local police department within 15-minutes when a resident was identified missing from the facility in accordance with facility policy, and failed to notify emergency services timely when a resident was found unresponsive outside the building in below freezing temperatures. The failures resulted in a finding of Immediate Jeopardy. The findings include:Resident #1's diagnosis included dementia.The elopement evaluation dated 11-24-2025 identified Resident #1 was ambulatory or had independent wheelchair location, was cognitively impaired, made statements that he/she was leaving, and displayed behavior that he/she may attempt to leave. The evaluation identified Resident #1 was at risk for elopement and had a care plan for the risk.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors, transferred with moderate assistance, ambulated independently with supervision, and had no wander/elopement alarm.The Resident Care Plan (RCP) dated 12-2-2025 identified Resident #1 had a wander guard on the right ankle. Interventions directed staff to redirect Resident #1 if near the doors, check wander guard functioning per protocol. Physician order dated 12-7-2025 directed to ambulate with four (4) wheeled rolling walker with supervision. Physician order dated 1-15-2026 directed wander guard to right ankle, check placement every shift, and check function daily.Review of Nurse Aide (NA) documentation dated 2-8-2026 identified rounds were completed and Resident #1 was observed at 1 AM, and 3 AM sleeping in his/her bed.The Facility Reported incident form dated 2-8-2026 at 5:00 AM identified Resident #1 was found outside of the building around 5:12 AM and was immediately brought back into the building. NA #1 written statement dated 2-8-2026 identified about 1:30 AM she observed Resident #1 sleeping in bed and she placed the walker next to the bed so he/she could hold it if he/she got up. The statement indicated NA #1 saw Resident #1 again at 3:30-ish, sleeping in bed. Then about 4:30 AM, Resident #1 was not on his/her bed. NA #1 searched other rooms looking for Resident #1, then I went on the other wing to check and told my co-worker who also started searching with me while I went outside (to) look she went and told the nurse. The co-worker came outside the building to join me, while we both was looking around she stopped, Resident #1 (was) laying on the floor, by the walkway. I run quickly to get the nurse, also got some blankets. Registered Nurse (RN) #1 written statement dated 2-8-2026 identified a NA informed him at approximately 5 AM (30 minutes after NA #1 identified Resident #1 was missing) that Resident #1 was not in his/her room. He immediately instituted a room search again, with no success. He then instructed an outside search, then Resident #1 was found on the sidewalk outside of the facility. Resident #1 was only responding to painful stimuli and blinking his/her eyes. Resident #1 was brought back to the facility and applied warm blanket. 911 was called and upon arrival Resident #1 was still unresponsive.Nursing note written by the Director of Nursing (DNS) dated 2-8-2026 at 1:05 PM identified Resident #1 was observed by the overnight shift not to be in his/her room upon rounding. Per supervisor, a search was done, and Resident #1 was located on the grounds outside and was immediately brought inside the building. Assessment was done, warm clothes and blanket provided. 911 was called. Per Emergency Medical Technician (EMT) report, Resident #1 was pronounced deceased at around 6:46 AM. Family, physician and police were notified.Review of local weather on 2-8-2026 at 1:53 AM identified the temperature at 1:53 AM was 1 degree Fahrenheit with a wind of 14 mph, and at 5:53 AM the temperature was 0 degrees Fahrenheit with a wind of 12 mph. Observation on 2-8-2026 at 2:10 PM identified a local police car in front of the building near the edge of the property with yellow tape around an area of the sidewalk and snow near the post office, and snow covered the ground. The sidewalk in front of the building along the street was shoveled to the approximate property line, the sidewalk along the driveway was shoveled, and snow on both sides of the sidewalk was approximately twenty (20) inches high. The pile of snow at the end of the shoveled sidewalk on the side closest to the building was taller than the approximate four (4) foot tall snow stake marking the edge of the sidewalk. The sidewalk beyond the property line was not shoveled.Interview and record review with the Administrator and DNS on 2-8-2026 at 2:22 PM identified Resident #1 had a history of dementia, ambulated independently with a walker, was a known wander risk, wore a wander guard bracelet, and had left the building without staff knowledge. Per staff, Resident #1 was last seen about 3:00 AM and was identified missing at about 4:45 AM. The NAs searched the two (2) nursing units before notifying the RN supervisor/RN #1. When NA #1 and NA #4 were unable to locate Resident #1 they notified RN #1 about 5 AM (Approximately 30 minutes after NA #1 identified Resident #1 was missing). RN #1 then initiated a search inside the building and then directed an outside search when Resident #1 was not located. Staff found Resident #1 about 5:12 AM, lying on the sidewalk at the front of the building. RN #1 directed a staff member to bring a wheelchair outside, and Resident #1 was lifted into a wheelchair and was returned inside the building. Resident #1 was unresponsive, and staff then removed Resident #1's wet clothing, applied dry clothing and blankets and then called 911. The Administrator and DNS stated the NAs should have notified the nurse immediately when Resident #1 was identified missing about 4:30 or 4:35 AM, and 911 should have been called immediately after Resident #1 was found outside. During an interview and record review with NA #1 on 2-9-2026 at 11:06 AM, NA #1 stated she observed Resident #1 in his/her bed at 1 AM and about 3:30 AM. NA #1 stated she identified Resident #1 missing about 4:35 or 4:45 AM and searched the unit with NA #3, and NA #3 notified RN #1. She then went to the back door near the kitchen with NA #4 and NA #4 searched the back parking lot. Then when she and NA #3 searched the front of the building, NA #3 located Resident #1 lying on his/her left side on the sidewalk in front of the building. Resident #1 was not moving, and his/her eyes were opening and closing. Resident #1 was wearing sneakers, socks, and pajamas, and his/her clothes were cold with ice on them. NA #1 stated she went into the building to get blankets, RN #1 brought a wheelchair and Resident #1 was returned inside the building and put into bed. The staff removed his/her clothes, dressed him/her in a johnny, and gave incontinent care, and tried to warm him/her up with warm blankets and towels with warm water, and RN #1 was running in and out of the room, and the only response was opening and closing his/her eyes. NA #1 stated when the ambulance came, they administered CPR. Interview and record review with RN #1 on 2-9-2026 at 9:34 AM identified he was notified about 5 AM (approximately 15 to 30 minutes after Resident #1 was identified missing) that Resident #1 was missing, and staff had already searched the facility without telling him that she was missing. He stated Resident #1 was known to exit seek and that was why he/she had a wander guard and he directed a second search inside and then to search outside. RN #1 stated he thought Resident #1 could have gone out the back door. NA #1 told him that Resident #1 was found outside in front of the building. Resident #1 was brought back inside in a wheelchair, had no response to painful stimuli, only blinked his/her eyes, and had a pulse. No blood pressure was heard (recorded) on the blood pressure machine, a temperature was attempted to be obtained, and the thermometer read LOW and his/her pulse was between 20's and 30's. He stated he wanted to make sure they get warm blankets for hypothermia and people were emotional with the situation. RN #1 stated he did paperwork, then called the Administrator who conferenced in the Director of Nursing (DNS) and he told them he was going to send him/her to the hospital and then he called 911. RN #1 stated he was informed that he called 911 at 6:23 AM (1 hour and 11 minutes after he/she was found outside). RN #1 stated he looked at Resident #1's code status, it was just me, and he looked to get help he needed and to call facility people above him, and to do an assessment. He wanted the DNS and Administrator, to make sure he informed them that we had an emergency. He had to assess Resident #1 first before calling 911. Review of thermometer manufacturer manual identified the thermometer reads LO if the temperature is less than 89.6 Fahrenheit.Interview and record review with the DNS and Administrator on 2-9-2026 at 1:56 PM identified the DNS received a conference call from the administrator and RN #1 on 2-8-2026 at 6:08 AM (56 minutes after Resident #1 was found outside). The DNS stated that RN #1 indicated during the call that he had not called 911 because they were trying to get Resident #1 warm, and she directed RN #1 to call 911. Interview identified staff should have notified RN #1 immediately when Resident #1 was identified missing, when the resident was not found within 15 minutes the police should have been notified, and 911 should have been called immediately after Resident #1 was found. Review of EMS run sheet dated 2-8-2026 identified EMS was called at 6:23 AM and EMS initiated treament of the resident at 6:35 AM for a question of a cold exposure out of the facility. On arrival with police on scene, Resident #1 was found unresponsive, pulseless, apneic (not breathing). Staff reported the resident had wandered out of the facility possible 30 minutes prior and found laying on the ground outside, not responding to staff, placed in a wheelchair and returned into facility and bed when 911 was called. EMS noted severely cold temperatures. Once confirmed pulseless, Resident #1 was transferred to a stretcher and CPR was initiated due to no CPR bed board available and unknow DNR (Do Not Resuscitate), monitor placed with pads, asystole (no pulse) on monitor, no lung or heart sounds, extremely cold to touch with thermometer reading LO. Nurse provided paperwork for DNR. EMS also noted lividity (discoloration of the skin due to pooled blood after death) on the left flank (between ribs and hips), left hand and knee with possible blistering from outside temperature and positioning. Pupils were fixed and non-reactive. No other traumatic injuries noted. EMS noted resident was in a hospital gown with adult depends on. Patient was extremely cold to the touch and pale along with the lividity on the left side. Patient presumed (death) at 6:46 AM.Review of facility Elopement Management Policy dated 11-25 directed in part, if an employee discovers a resident is missing, to inform the supervisor or DNS while staff do a quick and thorough search of the unit and other departments. The supervisor or DNS will page overhead Calling Dr Hunt, and the Supervisor of DNS will instruct the NAs on the unit to repeat search of the unit as well as instruct to search outside the facility. Notify the police department within 15 minutes of not successfully locating the missing resident. When the missing resident is returned to the facility the nurse will immediately and thoroughly assess the resident for injuries.Review of facility Change in Condition Policy dated 6/23 directed in part 911 should be called immediately if a resident is unresponsive.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written transfer agreement policy to ensure appropriate transfer arrangements with a hospital. The findings include: Review of facility documentation failed to produce a written transfer agreement policy outlining the facility's process for transferring residents to a hospital when medically necessary.Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to provide the requested transfer agreement policy at the time of survey. The Administrator reported that due to a recent facility-wide evacuation, binders containing important documents were relocated; however, the requested documentation could not be produced.Additionally, the facility was unable to provide evidence of a current written transfer agreement or documentation verifying formalized arrangements with a hospital to ensure timely transfer of residents requiring acute care services.

Based on clinical record reviews, facility documentation, facility policy review and interviews for three of four residents (Resident #1, #2, and #3) reviewed for wandering behaviors, the facility failed to ensure the clinical record was complete and accurate to include rounds performed for resident location (Resident #1's care checks) and to accurately document the resident's (#1, #2, and #3) wander guard devices. The findings include: Resident #1's diagnoses included dementia. Elopement risk evaluation dated 11-24-2025 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, made statements that he/she was leaving and displayed behaviors that may indicate an attempt to leave. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors, transferred with moderate assistance, ambulated independently with supervision, and had no wander/elopement alarm. Physician order dated 1-15-2026 directed to check wander guard bracelet placement every shift and check function daily. The Resident Care Plan dated 1-31-2026 identified Resident #1 had a wander guard on the right ankle. Interventions directed to redirect if near doors to outside. Check functioning per protocol. Physician order dated 1-31-2025 directed to check wander guard bracelet placement every shift and check function daily. Record review identified the physician order for wander guard use was reviewed with monthly physician order reviews, with the most recent dated of 1-15-2016. Review of the MAR/TAR (Medication and Treatment Administration Record) for the month of February 2026 identified the following:An order to check function of wander guard to left ankle once daily, RN #2 failed to document that this was performed on 2-2 and 2-4-2026.An order to check the placement of the wander guard to left ankle every shift, RN #2 failed to document that this was performed on 2-2 and 2-4-2026. Facility reportable event (RE) dated 2-8-2026 at 9:46 AM identified Resident #1 had a with diagnosis of dementia and history of wandering, was found outside of the building around 5:12 AM and was immediately brought back into the building. Nursing note written by the Director of Nursing (DNS) dated 2-8-2026 at 1:05 PM identified Resident #1 was observed by the overnight shift not to be in his/her room upon rounding. Per supervisor, a search was done, and Resident #1 was located on the grounds outside and was immediately brought inside the building. Assessment was done, warm clothes and blanket provided. 911 was called. Per Emergency Medical Technician (EMT) report, Resident #1 was pronounced deceased at around 6:46 AM. Family, physician and police were notified. Review of Nurse Aide (NA #1) Care Check Rounds Documentation (shift rounds) identified NA #1 indicated she observed Resident #1 asleep in his/her bed at 1:00 AM and again at 3:00 AM. Additional review of the rounds documentation identified NA #1 provided care, including turning and repositioining, for Resident #1's roommate (Resident #5) at 3:30 AM. NA #1 written statement dated 2-8-2026 identified about 1:30 AM she observed Resident #1 sleeping in bed and she placed the walker next to the bed so he/she could hold it if he/she got up. The statement indicated NA #1 saw Resident #1 again at 3:30-ish, sleeping in bed. Then about 4:30 AM, Resident #1 was not on his/her bed. The statement identified after searching the facility, Resident #1 was found outside laying on the sidewalk in front of the facility. During an interview and record review with NA #1 on 2-9-2026 at 11:06 AM, NA #1 stated she observed Resident #1 in his/her bed at 1 AM and again about 3:30 AM. Observation of video obtained by local police identified a person (probable Resident #1) was observed at the back of the building near the rear parking lot at 1:50 AM (1 hour and 10 minutes before the NA documented that Resident #1 was alleged to be observed sleeping in his/her bed at 3 AM). The person came into view at the back corner of the building and walked along the side of the building past the main entrance toward the road and then appeared at the apron of the driveway at 1:55 AM (1 hour and 5 minutes before NA #1 documented Resident #1 was observed sleeping in his/her bed). Additional video review identified staff located Resident #1 on the sidewalk in front of the building at 5:11 AM. Resident #2's diagnoses included Alzheimer's disease, dementia, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) indicating Resident #2 was unable to complete the interview, and had severe cognitive impairment for daily decision making, had wandering behaviors daily, transferred with supervision assistance, ambulated independently with supervision, and had no wander/elopement alarm. Resident Care Plan dated 12-23-2025 identified Resident #2 wanders through out the hallway and into other rooms. Interventions directed to check wander guard every shift and as needed and to redirect into the hallway if found wandering in other resident's rooms. Elopement risk evaluation dated [DATE] identified Resident #2 ambulated independently, was cognitively impaired with poor decision-making skills and had a history of wandering into unsafe areas. Review of the MAR/TAR for the month of February 2026 identified the following:An order to check functioning of wander guard to left ankle once daily, RN #2 failed to document that this was performed on 2-2, 2-3, and 2-4-2026.An order to check placement of wander guard to left ankle every shift, RN #2 failed to document that this was performed on 2-2, and 2-4-2026. Resident #3's diagnoses included dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating severe cognitive impairment, had no wandering behaviors, transferred with moderate assistance, ambulated independently with a wheelchair, and had wander/elopement alarm daily. Elopement risk evaluation dated 12-30-2025 identified Resident #3 ambulated independently, was cognitively impaired with poor decision-making skills and displayed behaviors that may indicate an attempt to leave. Resident Care Plan dated 1-22-2026 identified a risk for elopement. Interventions directed to check function and placement of wander guard every shift and daily. Review of the MAR/TAR for the month of February 2026 identified the following:An order to check placement of wander guard to left ankle every shift, LPN #2 failed to document that this was performed on 2-3-2026, and LPN #3 failed to document the placement was checked on 2-5-2026.Additional review failed to identify a physician order was obtained to monitor the wander guard for placement every shift and to check the function daily. Interview and record review with the DON on 2-10-2026 at 3:30 PM identified it was her expectation that nursing staff document all areas of provided care that was performed. The DON stated that Resident #1, #2, and #3's documentation was incomplete/missing, and that the nursing staff should have ensured all areas were documented if performed. The DON stated orders should be obtained for all residents to check wander guard placement every shift and function daily, and the nurse should document when it is done. Interview failed to identify why they were not done. Interview failed to identify why NA #1 documented on 2-8-2026 that she observed Resident #1 asleep in his/her bed at 3 PM, when the video showed Resident #1 exited the facility at 1:50 AM. Review of a Documentation Policy dated 11/25 identified the facility will ensure nursing documentation is accurate, timely, complete, and reflective of the care provided.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide evidence of a written agreement designating a Medical Director responsible for implementation of resident care policies and coordination of medical care in the facility. The findings include:Review of facility records failed to produce a written contract or agreement verifying the appointment and ongoing contractual relationship between the facility and the Medical Director. Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to locate the Medical Director contract at the time of the survey. The Administrator reported the facility recently experienced a facility-wide evacuation during which important binders were relocated; however, the requested contract could not be produced. Additionally, the facility was unable to provide a policy or procedure outlining the process for maintaining, retaining, or ensuring accessibility of the Medical Director contract.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written transfer agreement policy to ensure appropriate transfer arrangements with a hospital. The findings include: Review of facility documentation failed to produce a written transfer agreement policy outlining the facility's process for transferring residents to a hospital when medically necessary.Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to provide the requested transfer agreement policy at the time of survey. The Administrator reported that due to a recent facility-wide evacuation, binders containing important documents were relocated; however, the requested documentation could not be produced.Additionally, the facility was unable to provide evidence of a current written transfer agreement or documentation verifying formalized arrangements with a hospital to ensure timely transfer of residents requiring acute care services.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide evidence of physician coverage available 24-hours per day for emergency care. The findings include: Review of facility documentation failed to produce a written agreement, contract, or other documentation verifying physician services are available 24-hours a day to respond to resident medical emergencies Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to provide documentation demonstrating how physician services are ensured on a 24-hour basis. The Administrator reported that due to a recent facility-wide evacuation, important binders were relocated; however, the requested documentation could not be produced at the time of survey. Additionally, the facility was unable to provide a policy or procedure outlining how 24-hour physician availability is arranged, maintained, and verified to ensure timely medical oversight during emergencies.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written agreement for radiology and other diagnostic services to ensure required diagnostic services were available timely to meet resident needs. The findings include: Review of facility documentation failed to produce a written agreement or contract verifying arrangements for radiology and other diagnostic services when such services are not provided directly by the facility. Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to locate the requested radiology services contract at the time of survey. The Administrator reported that due to a recent facility-wide evacuation, binders containing important documents were relocated; however, the requested agreement could not be produced. The facility was unable to provide documentation verifying how radiology and other diagnostic services are formally arranged and maintained in compliance with regulatory requirements.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written agreement for laboratory services to ensure required laboratory services are available timely to meet resident needs. The findings include: Review of facility documentation failed to identify a written agreement or contract verifying arrangements with a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory for the provision of laboratory services when such services are not provided directly by the facility. Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to locate the requested laboratory services contract at the time of survey. The Administrator stated that due to a recent facility-wide evacuation, binders containing important documents were relocated; however, the requested agreement could not be produced. The facility was unable to provide documentation verifying how laboratory services are formally arranged and maintained in compliance with regulatory requirements.

Based on clinical record reviews, facility documentation, facility policy review, and interviews for one of four residents (Resident #1 and #3) reviewed for wandering behaviors, the facility failed to ensure physician orders were obtained that directed to check the wander guards function, and failed to ensure an elopement risk assessment was completed timely. The findings include: Resident #1's diagnoses included dementia. Elopement risk evaluation dated 11-24-2025 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, made statements that he/she was leaving and displayed behaviors that may indicate an attempt to leave. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors, transferred with moderate assistance, ambulated independently with supervision, and had no wander/elopement alarm. Physician order dated 1-15-2026 directed to check wander guard bracelet placement every shift and check function daily. The Resident Care Plan dated 1-31-2026 identified Resident #1 had a wander guard on the right ankle. Interventions directed to redirect if near doors to outside. Check functioning per protocol. Physician order dated 1-31-2025 directed to check wander guard bracelet placement every shift and check function daily. Record review identified the physician order for wander guard use was reviewed with monthly physician order reviews, with the most recent dated of 1-15-2016. Review of Resident #1's Elopement Risk Evaluations identified the following:A quarterly elopement risk evaluation was completed on 1-30-2025.The next quarterly elopement risk evaluation was performed on 6-3-2025 (124 days later).The next quarterly elopement risk evaluation was performed on 11-24-2025 (174 days later). 2. Resident #3's diagnoses included dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating severe cognitive impairment, had no wandering behaviors, transferred with moderate assistance, ambulated independently with a wheelchair, and had wander/elopement alarm daily. Elopement risk evaluation dated 12-30-2025 identified Resident #3 ambulated independently, was cognitively impaired with poor decision-making skills and displayed behaviors that may indicate an attempt to leave. Resident Care Plan dated 1-22-2026 identified a risk for elopement. Interventions directed to check function and placement of wander guard every shift and daily. Review of Resident #3's Elopement Risk Evaluations identified the following:An admission elopement risk evaluation was completed on 7-4-2025.The next quarterly elopement risk evaluation was performed on 12-30-2025 (179 days later). Although additional record review identified a physician order that directed to check wander guard placement every shift, review failed to identify a physician order that directed nursing staff to perform function checks of Resident #3's wander guard. Interview and record review with the DON on 2-10-2026 at 3:30 PM identified Elopement risk evaluations are completed on admission, quarterly, and readmissions to the facility, and physician orders should be obtained that directed staff to check daily function of the wander guard bracelets. The DON stated the elopement risk evaluations for Resident #1 and Resident #3 were not completed quarterly (every 90 days) and they should have been completed. Interview failed to identify why they were not completed timely. DON was unable to identify why the assessments were not completed timely and why a physician order was not obtained that directed to check function of Resident #3's wander guard. Review of the Wandering Risk Assessment Policy dated 11/25 directed in part, a wandering risk assessment will be utilized and completed on all residents to determine their risk level. The assessment will be completed upon admission and quarterly. Review of the Wander-Guard Security System Policy dated 11/25 directed in part, the wander guard security device will be placed on any resident that the resident care team decides is at risk for wandering away from the facility. The 11 PM to 7 AM supervisor shall check the door alarms and signaling devices on the resident. The night shift nurses are responsible for replacing any non-functional devices. Further, the policy directed that elopement risk assessments will be completed upon admission, quarterly, and annually.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #1 and #5) reviewed for wandering behaviors, the facility failed to ensure the physician was notified timely following Resident #1's significant change in condition and failed to ensure the physician was notified timely when laboratory results were received (Resident #5). The findings include: Resident #1's diagnoses included dementia. Record review and facility documentation review identified MD #1 was the attending physician/Medical Director. Elopement risk evaluation dated 11-24-2025 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, made statements that he/she was leaving and displayed behaviors that may indicate an attempt to leave. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no pacing behaviors, wandering presence and frequency indicated the behavior occurred one (1) to three (3) days, transferred with moderate assistance, ambulated independently with supervision, and had no wander/elopement alarm. The Resident Care Plan dated 1-31-2026 identified Resident #1 had a wander guard on the right ankle. Interventions directed to redirect if near doors to outside. Check functioning per protocol. Physician order dated 1-15-2026 directed to ambulate with four (4) wheeled rolling walker with supervision. The facility submitted reportable event (RE) dated 2-8-2026 at 9:46 AM identified Resident #1 had a with diagnosis of dementia and history of wandering, was found outside of the building around 5:12 AM and was immediately brought back into the building. Nursing note written by the Director of Nursing (DNS) dated 2-8-2026 at 1:05 PM identified Resident #1 was observed by the overnight shift not to be in his/her room upon rounding. Per supervisor, a search was done, and Resident #1 was located on the grounds outside and was immediately brought inside the building. Assessment was done, warm clothes and blanket provided. 911 was called. Per Emergency Medical Technician (EMT) report, Resident #1 was pronounced deceased at around 6:46 AM. Family, physician and police were notified. A nursing note dated 2-10-2026 at 5:19 AM written by RN #1 identified on 2-8-2026 at approximately 5:00 AM, RN #1 was approached by a certified aid who reported a missing resident. A perimeter search of the building identified Resident #1 was found on the sidewalk, lying on his/her left side, and upper body on the snow. Resident #1 was blinking his/her eyes and responding to painful stimuli when applied and was not verbal. Resident #1 was brought back to the facility and placed in his/her room and into bed. RN #1 performed an assessment, including temperature, which indicated Low reading and had low pulses. Warm blankets and incontinent care was provided. Emergency services were called, with family and primary care physician were informed. All facility Administrators were contacted. EMS (emergency medical services) arrived, and Resident #1 was pronounced after evaluation. Addition review of the facility RE and investigation dated 2-8-2026 at 5:00 AM failed to identify that the physician was notified. Interview and record review with RN #1 on 2-8-2026 at 9:34 AM identified he was the Supervisor and Charge Nurse on 2-8-2026 when Resident #1 was identified missing and subsequently found outside the building at 5:12 AM. RN #1 stated he notified the Administrator and Director of Nursing (DON), and the Infection Control Nurse prior to calling 911. Interview failed to identify he called the physician. Interview with MD #1 on 2-10-2026 at 10:33 AM identified he was not notified of the incident that occurred on 2-8-2026. Interview with Technical Support (TS #1) with the facility physician on-call services on 2-11-2026 at 11:30 AM identified MD #1 was covering his own office during the hours of 11:00 PM (2-7-2026) through 7:00 AM (2-8-2026); there were no other providers on-call covering for MD #1. Although attempted, a subsequent interview with RN #1 regarding notification of the physician was unable to be obtained during the survey. Interview with the DON on 2-10-2026 at 3:30 PM identified that during the facility investigation of Resident #1's elopement that occurred on 2-8-2026, the investigative team was unable to determine whether RN #1 notified the physician at the time of the incident. The DON stated that RN #1 should have notified the on-call physician following initiation of emergency medical services. The DON stated the physician was on-call during that time and would have provided further medical direction, which likely would have included transfer to the hospital. Resident #5's diagnoses included influenza A, urinary tract infection, and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen (15/15), indicative of being cognitively intact and was partial to substantial assistance for ADL's (activities of daily living). Resident Care Plan dated 12-21-2025 identified Resident #5 was at risk for nutritional status related to vitamin deficiency and hypomagnesemia. Interventions directed to administer medications per physician orders, obtain lab work as ordered and report abnormal findings to the physician (routine thyroid lab work). laboratory results dated [DATE] identified Resident #5's TSH (Thyroid Stimulating Hormone) with free T4, reflex test result was 9.73 (normal range is 0.34 - 5.60 units/mL). The laboratory results did not have physician's signature of acknowledgement. Record review failed to identify the physician was notified of the laboratory results obtained on 12-30-2025. A physician progress note dated 1-14-2026 by APRN #1 identified Resident #5 had hypothyroidism and was seen for follow up related to a UTI (urinary tract infection. Resident #5 had complaints of dysuria in the past days, and urine was positive for E- coli, and was started on Ciprofloxacin (antibiotic). Recent labs reviewed TSH results of 9 on 12-20-2025, currently on Levothyroxine (treatment for hypothyroidism) 50 mcg (micrograms) daily, plan to increase to 75 mcg daily and recheck TSH in six (6) weeks. Interview and record review with the DON on 2-13-2026 at 1:45 PM identified the DON was unable to verify if the nursing had notified a physician/APRN regarding Resident #5's elevated TSH levels. Interview with MD #1 on 2-13-2026 at 2:30 PM identified the facility usual practice is for the facility to fax laboratory results to his office and MD #1 will review, sign, and send back the documents to the skilled nursing facility. MD #1 was unable to confirm if Resident #5's laboratory results from 12-30-2025 were reviewed by himself but indicated he was on-site at the facility on 1-1 and 1-8-2026 and was not notified of the lab results. Although attempted, an interview with APRN #1 was unable to be obtained during the survey. Review of the facility Change in Condition Policy dated 4/17 directed in part, the facility shall notify the resident, his or her attending physician, 911 as indicated, and representative (sponsor) of changes in the resident's medical/mental condition. The nurse will notify the residents' attending physician or on-call physician when there has been:An accident or incident involving the resident.A discovery of injuries of an unknown source.A reaction to medication.A significant change in the resident's physical/emotional/mental condition.A need to alter the resident's medical treatment significantly.Refusal of treatment or medications.Abnormal laboratory reports.A need to transfer the resident to a hospital/treatment center.A discharge without proper medical authority; and/orInstructions to notify the physician of changes in the resident's condition.

Based on observation, clinical record review, facility policy review and interviews, the facility failed to ensure residents at high risk for pressure ulcer development were promptly assessed and provided timely preventative interventions. Specifically, for one sampled resident (Resident #7), the facility failed to implement turning and repositioning, and other preventive measures despite known risk factors and an existing pressure injury and failed to develop and implement a care plan to prevent pressure ulcers. These failures resulted in the development of a new pressure injury to the coccyx that progressed to an unstageable wound and ultimately to a Stage 4 pressure ulcer, causing actual harm. Resident #7 was admitted on [DATE] with diagnoses that included dementia, nutritional deficiency, stage 4 pressure ulcer wound, and osteoarthritis.The W-10 (inter-agency patient referral form) dated 8/1/24 identified Resident #7 required assistance with Activities of Daily Living (ADL's), assistance of 2 staff for transfers, and had the presence of a stage 3 pressure wound to the left heel.RN #1's nurse's note dated 8/1/24 at 3:16 PM identified Resident #7 was admitted to the facility in stable condition and was adjusting to his/her room. Resident #7's lower extremity was dry, peeling and had a stage 3 pressure ulcer to the left heel. The left heel pressure ulcer wound measured 1.0 centimeters (cm) in length and 1.0 cm in width and had good granulation tissue in the wound bed. The physician was at the facility and admitted the resident.Review of the clinical record on 8/1/24 failed to reflect that a Braden Scale assessment (used to predict the risk of pressure ulcer development) had been completed upon admission for Resident #7.The wound physician's initial evaluation dated 8/8/24 identified Resident #7 had an unstageable wound to the left heel related to pressure. The wound size was documented as 0.6 centimeters (cm) in length by 0.5 centimeters (cm) in width by 0.1 centimeters (cm) in depth. The treatment plan directed: cleanse the wound followed by the application of calcium alginate to the base of the wound and secure with a dry clean dressing daily and as needed when soiled/saturated. It further recommended to follow the facility pressure ulcer prevention protocol to include a pressure redistribution mattress, wheelchair pressure redistribution cushion per facility policy, offload heel, and turn and reposition every two hours.The admission MDS assessment dated [DATE] identified Resident #7 had severe cognitive impairment, required extensive assistance for bed mobility, personal hygiene, toileting, dressing, transfers, and was non-ambulatory. The assessment further identified Resident #7 was always incontinent of bladder and bowel and was at risk for the development of pressure ulcers and had one unstageable pressure wound.RN #1's nurse's note dated 8/14/24 at 8:11 PM identified Resident #7 had an open area to the coccyx. The coccyx area was cleansed with wound cleanser and border dressing was applied. The physician was notified and recommended a wound consultation.Resident #7's care plan dated 8/14/24 identified Resident #7 had an unstageable coccyx wound. Care plan interventions directed to observe the area for worsening, increased redness and report to the physician, provide treatment as ordered, provide incontinent care approximately every 2 hours and as needed, turn and re-position every 2 hours and air mattress set according to the resident's weight. Further review of Resident #7's care plan from 8/1/24 to 8/13/24 failed to identify that a care plan was developed and implemented to minimize the risk of developing a pressure ulcer until he/she developed a second pressure wound to the coccyx.The wound physician's progress notes dated 8/15/24 identified Resident #7 was seen for follow up evaluation of the unstageable wound to the left heel. The left heel wound was stable. In addition, the wound progress notes identified a new Deep Tissue Pressure Injury (DTPI) to the coccyx related to pressure was evaluated. The wound size was documented as 3 cm in length by 0.5 cm in width by 0.1 cm in depth and non-blanchable ecchymosis. The treatment plan identified: cleanse the wound and apply calcium alginate to the wound bed and secure with border foam daily and change as needed if dislodged or soiled.Review of nurses' notes from 8/1/24 to 8/15/24 failed to identify that Resident #7 was turned and repositioned every two hours as directed by the wound physician on 8/8/24.The nurse's note dated 8/16/24 at 6:43 PM identified Resident #7 was transferred out of bed to the wheelchair with the assistance of two people. The treatments to the left heel and coccyx wound were administered, and Resident #7 was turned and repositioned in bed. The wound physician's progress note dated 8/22/24 identified the unstageable left heel wound was improving without complications. The coccyx had become an unstageable wound and had worsened. The coccyx wound size was documented as 4.5 cm in length by 3.4 cm in length by 0.8 cm in depth. The treatment plan was to cleanse the wound, apply 1/4 strength Dakin's moist gauze to the wound base and change twice per day and as needed when soiled or dislodged.The wound physician's progress notes dated 9/5/24 identified that the unstageable wound to the left heel was resolved. The unstageable coccyx wound continues to worsen. The physician manually pulled a copious amount of necrotic (dead tissue) tissue from the wound bed, and a large amount of purulent drainage was noted. The coccyx wound was documented as 6 cm in length by 7 cm in width by 2.5 cm in depth with undermining 4.3 cm in depth from 12 o'clock to 12 o'clock. The coccyx wound was noted to increase in overall dimension size and depth to the wound bed. The treatment plan directed to cleanse the wound, apply 1/4 strength Dakin's moist gauze to the base of the wound and secure with border foam and change twice a day.The wound physician's progress note dated 9/12/24 identified that the unstageable wound to the coccyx had become a stage 4 coccyx pressure wound. The wound was documented as 7 cm in length by 7 cm in width by 3 cm in depth with undermining of 5.5 cm in depth from 12 o'clock to 12 o'clock. The treatment plan directed to cleanse the wound, apply 1/4 Dakin's moist gauze to the wound base and secure with border foam twice a day and as needed when soil or dislodge.The Braden Scale assessment dated [DATE] identified Resident #7 had a score of 13 which indicated a moderate risk of developing a pressure ulcer.Review of the wound physician's weekly progress notes from 9/19/24 to 1/5/26 identified Resident #7 continued to have a stage 4 wound to the coccyx. The physician continues to monitor and provide the treatment plan for the stage 4 coccyx wound.The current wound physician's progress note dated 1/12/26 identified that the stage 4 coccyx wound was evaluated. The wound was documented as 7.4 cm in length by 2.1 cm in width by 1.5 cm in depth with undermining measurement of 1.1 cm in depth from 12 o'clock to 12 o'clock. The wound healing was stalled. The treatment plan was to cleanse with 1/2 strength of Dakin's solution, apply crushed metronidazole (anti-bacterial) then calcium alginate with silver, secure with gauze and dry clean dressing twice per day and change as needed when soiled soil or dislodged.Observation on 1/7/25 at 9:45 AM identified Resident #7 was in his/her room lying on his/her back on a low air loss mattress with a positioning wedge device noted to his/her side, but the positioning wedge was not properly tucked in to put the resident on his/her side. Interview with RN #1 (per diem nursing supervisor) on 1/7/26 at 12:15 PM identified that she was responsible for assessing the resident when admitted to the facility. She identified that Resident #7 was admitted with a stage 3 pressure ulcer wound to the left heel and she called the physician to obtain a treatment order. She identified that she would complete a Braden Scale assessment on admission to assess the resident's risk for developing a pressure ulcer. She also identified that Resident #7 would be a high risk for developing a pressure ulcer because of the limited mobility, incontinence, and admitted with a stage 3 pressure ulcer wound to the left heel. She further identified that any resident admitted to the facility with a high risk of developing a pressure ulcer wound would have a care plan for turning and repositioning program, treatment to the wound as ordered by the physician, recommended for an air mattress and these interventions would be implemented immediately on admission. She could not recall whether she assessed Resident #7 for risk for developing a pressure ulcer or developed a care plan to minimize the risk of developing; however, she identified that it would be indicated in the physician's order for the turning and repositioning and/or it would be documented in the nursing progress notes that the resident was being turn and repositioned. In addition, she identified that there was a new open wound on the coccyx that was reported on 8/14/24 and she had provided a treatment and updated the physician and recommended for a wound consult.Interview with MD #2 (wound specialist) on 1/7/26 at 1:35PM identified that he had been following Resident #7's stage 4 coccyx wound that was related to a pressure. He identified that Resident #7 was at high risk of developing a pressure ulcer due to limited mobility, incontinence and presence and/or history of pressure ulcer. Additionally, MD #2 identified that the facility should determine the resident's risk of developing a pressure ulcer and immediately implement interventions such as low air loss mattress, develop a repositioning plan, provide timely incontinent care to minimize the risk of developing a pressure ulcer wound. He further identified that Resident #7 stage 4 to the coccyx wound healing had stalled because of decline in medical condition such as total dependent for staff, poor nutrition and he/she was in the hospice care program due to decline in medical condition.Observation of wound care with LPN #1 on 1/8/25 at 10:30 AM identified Resident #7 was in his/her room lying on his/her back on a low air loss mattress. LPN #1 removed the old dressing, which had a small amount of drainage noted on the old foam dressing. Resident #7 noted with a stage 4 wound on his/her coccyx.Interview with LPN #1 on 1/8/25 at 11:00 AM identified that the nurse aides are responsible for turning and repositioning the resident. She identified that she is responsible for ensuring that the resident is being turned and repositioned frequently. She identified Resident #7 required total assistance from the staff for turning and repositioning. She further identified that she documents in the nurses' notes whether a resident is being turned and repositioned and the care plan would indicate whether he/she needed to be turned and repositioned frequently.Interview with the DNS on 1/12/26 at 9:10 AM identified that the registered nurses are responsible for assessing the resident on admission. She noted that she expects the resident to be assessed comprehensively such as but not limited to completing the Braden Scale assessment, fall risk assessment, elopement, and head to toe assessment. She identified that the Braden Scale assessment is used to assess the resident's risk of developing pressure ulcers. She also identified that any residents who are at risk of developing a pressure ulcer would be in a turning and repositioning program, air mattress maybe added, wound consultation and provide a timely treatment to the wound. She identified that the care plan should be implemented immediately to minimize the risk of developing a pressure ulcer wound. She identified that she was not DNS at that time and she could not provide a reason why there was no care plan implemented until Resident #7 developed another pressure injury to the coccyx. Although she identified that she was not the DNS when Resident #7 was admitted to the facility, she would expect the nursing staff to assess the resident for risk of developing a pressure ulcer and immediately implement a care plan to minimize the risk of developing a pressure ulcer. She further identified that Resident #7 would be at high risk of developing a pressure ulcer because he/she was admitted with pressure wound, limited mobility, impaired cognition. The Pressure Ulcer Prevention/Assessment Plan policy identified the purpose of the policy was to minimize the development of pressure ulcers. The policy indicates on the day of admission that a Braden Scale assessment will be completed on all residents. The pressure ulcer prevention plan indicated that any residents admitted with a DTI should be considered a high risk for pressure ulcers and facility interventions should include mild to moderate interventions, spenco boots while in bed, and every 1 hour turning and repositioning. The facility would initiate these interventions upon admission and written in the physician's orders.The facility failed to assess the resident's risk for pressure ulcer development and failed to implement measures to prevent the development of the pressure ulcer to the coccyx resulting in the development and progression of the pressure ulcer to a stage 4 to the coccyx. With appropriate assessments and interventions, the development of the pressure wound was avoidable.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to report a deterioration in wound status to the physician, ensure wound care was completed in accordance with physicians orders, and ensure an air mattress was provided timely which resulted in a deterioration of a pressure ulcer. The findings include: Please cross reference F 580 and F 658. Resident #1's diagnoses included Parkinson's disease (a movement disorder of the nervous system that worsens over time), dementia with behavioral disturbances, type 2 diabetes mellitus and muscle weakness. A Braden assessment dated [DATE] identified that Resident #1 was a moderate risk for developing pressure ulcers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status completed identifying short-term and long-term memory problems indicative of severely impaired cognition, was always incontinent of bladder, frequently incontinent of bowel, had two (2) stage two (2) pressure ulcers, one (1) which was present on admission and required assistance with bed mobility and Activities of Daily Living, and was at risk for developing additional pressure ulcers. The Resident Care Plan (RCP) dated 12/31/24 identified Resident #1 had a new stage 2 pressure ulcer (partial thickness skin loss, presenting as a shallow open ulcer with a red or pink wound bed) with interventions that included turning and repositioning the resident every two hours and as needed, keeping the bed linens dry, therapy to screen for custom wheelchair positioning, visits with the wound physician as needed and treatment to the coccyx as ordered and to follow the skin care protocols. a) A wound physician note dated 2/4/2025 at 6:04 AM identified that Resident #1 had a stable stage 2 pressure ulcer to the coccyx measuring 2.5 centimeters (cm) in length by 0.3 cm in width by 0.2 cm in depth with a scant amount of serosanguinous drainage (fluid that's discharged from a wound that's a mixture of the watery part of blood and red blood cells)., 100 percent (%) granulation tissue (new pink or red tissue that forms in the healing process of wounds) and no odor was noted. The treatment recommendations included cleansing the wound with wound cleanser, applying hydrogel (provides moisture to the wound, promotes granulation tissue and encourages complete healing) to the wound bed and then securing with a dry, clean dressing daily and as needed. A nurse's note dated 2/8/2025 at 4:55 PM identified that Resident #1's coccyx wound had worsened, reporting that there was slight tunneling 0.5 cm depth and was 1.5 cm length by 0.5 cm width and that the resident was to be reassessed by the wound team for further evaluation and treatment update. A nurse's note dated 2/9/2025 at 5:00 PM identified that Resident #1's coccyx wound had worsened, reporting that there was slight tunneling 0.5 cm depth and was 1.5 cm length by 0.5 cm width and that the resident was to be reassessed by the wound team for further evaluation and treatment update. Review of progress notes dated 2/8, 2/9, 2/10/2025 failed to identify that the nursing supervisor nor a provider was notified of the deterioration of Resident #1's wound. A wound physician note dated 2/11/2025 at 6:52 AM identified that Resident #1 had a worsening stage 2 pressure ulcer to the coccyx measuring 3.5 centimeters (cm) in length by 1.6 cm in width by 0.2 cm in depth with a moderate amount of serosanguinous drainage, 75 percent (%) granulation tissue (new pink or red tissue that forms in the healing process of wounds) and 25 % eschar tissue (dead tissue that forms over healthy skin and over time falls off) with no odor was noted. The treatment recommendations included cleansing the wound with wound cleanser, applying calcium alginate with silver (an antimicrobial dressing that helps absorb moderate to heavy wound drainage that's at a high-risk for infection) to the wound bed and then securing with a dry, clean dressing daily and as needed. Interview with Licensed Practical Nurse (LPN) #1 on 3/14/2025 at 12:03 PM identified that on 2/8/2025 and 2/9/2025, she notified the Nursing Supervisor (Registered Nurse (RN) #3) that Resident #1's wound had worsened and that tunneling was present but was unsure if the provider was notified, stating that would have been RN #3's responsibility to notify the provider. Interview with RN #3 on 3/14/2025 at 3:06 PM identified that LPN #1 did not notify her on 2/8/2025 or 2/9/2025 that Resident #1's wound had worsened and that tunneling was present. She identified that if she had, she would assessed Resident #1's wound and notified the provider if her assessment greatly differed from the last time the resident was seen by Medical Doctor (MD) #1 and she would have written a note documenting everything she had observed and done. b) A wound physician note dated 2/18/2025 at 6:40 AM identified that Resident #1 had a worsening unstageable pressure ulcer to the coccyx measuring 3.2 centimeters (cm) in length by 1.7 cm in width by 0 cm (unable to determine) in depth with a small amount of serous drainage (a clear fluid that drains from wounds and is a sign of healing), 100 percent (%) slough tissue (nonhealing tissue that needs to be removed from the wound for healing to take place) and no odor was noted. The treatment recommendations included cleansing the wound with wound cleanser, applying Santyl (a prescription ointment that removes dead tissue from wounds so that they can start to heal) to the wound bed and then securing with a dry, clean dressing daily and as needed. The note identified that the wound continues to deteriorate and was now unstageable so Santyl will now be started and recommend for the resident to be placed on an air mattress for pressure offloading. i. A physician's order dated 2/18/2025 directed to apply Santyl ointment to the coccyx open area. Cleanse open area with wound cleanser/Normal Saline, apply Santyl, pat dry and cover with dry clean dressing daily. Review of the Medication Administration History for February 2025 identified that the above wound treatment was transcribed on 2/18/2025 and had been signed off as administered on 2/19, 2/20, 2/21, and 2/22/2025. An administration note dated 2/18/2025 at 12:36 PM identified that the treatment was not administered, as it was completed by the wound team. An administration note by LPN #1 dated 2/23/2025 at 1:57 PM identified that the Santyl was unavailable and that the wound was cleansed and alginate was applied followed by a dry clean dressing until the medication arrived. Interview with LPN #1 on 3/14/2025 at 12:03 PM identified that on 2/23/2025, the Santyl was unavailable, so she notified the Nursing Supervisor (RN #3) and although she was unsure if RN #3 notified the provider or obtained dressing orders pending the delivery of the Santyl, she reported that she applied calcium alginate per the previous treatment order so that the drainage was contained. She identified that she should follow orders when administering treatments and medications but reported that she thought it was better than no treatment. Interview with RN #2 (Infection Control nurse) on 3/14/2025 at 12:14 PM identified that on 2/18/2025 the treatment was not done during the wound care visit as stated in the nurses note, as they don't carry a house stock of Santyl. RN #2 further identified that it was not appropriate for LPN #1 to apply calcium alginate to Resident #1's wound on 2/23/2025 without first notifying the provider and requesting an alternative treatment pending the delivery of the Santyl. ii. A nurse's note dated 2/23/2025 written by LPN #5 at 11:51 PM identified that the wound on Resident #1's coccyx appeared infected the area was cleansed and covered. A nurse's note dated 2/24/2025 at 12:12 AM identified that the nurse (LPN #5) had called the writer (RN #4) into the resident's room to assess the coccyx wound and that the wound was noted to be black and contain slough. It reported that the resident's family member was present and was concerned that the wound was infected. The note identified that vital signs were obtained and were within normal limits but that the resident appeared to be in discomfort, so medication was given. RN #5 called MD #2 (wound doctor) for any recommendations, but that MD #2 did not pick up, so she left a message. It identified that report was given to the next shift to follow-up in the morning. Review of the clinical record failed to identify that the physician was notified on 2/23/2025 when the wound appeared to be infected. An Advanced Practice Registered Nurse (APRN) note dated 2/24/2025 at 7:30 PM identified that she was requested to see Resident #2 for their wound, but reported that she did not assess the wound, as a treatment was already in place. The note identified that the family was notified and was upset that the dressing was not removed and the area assessed but she reported to them that MD #1 would assess the wound the next morning. Although attempted, interviews with RN #4 and LPN #5 were not obtained. iii. The clinical record failed to identify that an order was in place or that the resident was placed on an air mattress as recommended by the wound care doctor on 2/18/15. Interview with RN #2 (Infection Control nurse) on 3/14/2025 at 12:14 PM identified that she must not have read down far enough in MD #1's note and missed the recommendation for the air mattress on 2/18/2025, stating that an order should have been entered to check function and settings every shift and it should have been applied on 2/18/2025, but because the recommendation was missed, it was not, and maintenance was not notified to either apply and house stock air mattress or order an air mattress for Resident #1. Interview with MD #1 (wound physician) on 3/14/2025 at 11:20 AM identified that when he assessed Resident #1's wound on 2/25/2025, the resident did not have an air mattress in place to his/her bed as recommended on 2/18/2025. Interview and with RN #1 on 3/14/2025 at 11:36 AM identified that she could not speak for the 2/18/2025 visit with MD #1 as to why the air mattress was not entered as an order, but stated the air mattress was currently in place and set to 180 pounds, normal pressure, and that on 2/25/2025 when the air mattress was recommended again on MD #1's note, she must have forgotten to enter the order for the air mattress, as all air mattresses should be entered as an order for the nurses to ensure function and settings every shift. A wound physician note dated 2/25/2025 at 7:06 AM identified that Resident #1 had a worsening unstageable pressure ulcer to the coccyx measuring 4 centimeters (cm) in length by 1.7 cm in width by 0 cm (unable to determine) in depth with a moderate amount of serosanguinous drainage (fluid that's discharged from a wound that's a mixture of the watery part of blood and red blood cells)., 100 percent (%) slough tissue (nonhealing tissue that needs to be removed from the wound for healing to take place) and no odor was noted. The treatment recommendations included cleansing the wound with wound cleanser, applying Santyl (a prescription ointment that removes dead tissue from wounds so that they can start to heal) to the wound bed and then securing with a dry, clean dressing daily and as needed. The note identified that the wound is again measuring larger but that they are starting to debride with Santyl, recommending for the resident to offload pressure from the area and that he/she would benefit from a back to bed schedule to offload pressure, as well as a low air loss mattress. Interview with APRN #1 on 3/14/2025 at 1:51 PM identified that for Resident #1, she would review and sign off on any treatment recommendations from MD #1 that she thought were appropriate, including the Santyl and air mattress to Resident #1's bed and stated she would expect that they both be entered as physician's orders when recommended. She reported that if there was a change in Resident #1's wound, including size, tissue appearance, drainage and skin surrounding the wound, or if the Santyl was unavailable, and if MD #1 was unavailable at the time, she would expect to be notified so that she could direct the staff in a treatment plan or offer an alternative treatment or substitute. She identified that it not appropriate for staff to administer a different treatment from what is ordered without first notifying a provider. Interview with MD #1 (wound physician) on 3/14/2025 at 11:20 AM identified that the further decline in Resident #1's wound from 2/18/2025 to 2/25/2025 was due to the inconsistent treatment application of the Santyl and the air mattress not being implemented as recommended for offloading the area on 2/18/2025. Interview with the Director of Nurses on 3/14/2025 at 10:37 AM on identified that he could not speak to whether or not the physician was notified of the provider of the change in condition of the wound, however, if they did it should be documented in the clinical record. The DNS further identified that he was unsure what happened with the air mattress and was unsure why the Santyl was unavailable on 2/23/25. Review of the Prevention of Pressure Ulcers policy (undated) directed, in part, that the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family, and are addressed. Review of the Administration of Medication Overview policy (undated) directed that medications will be administered by licensed personnel as ordered by the physician for the treatment of disease and maintenance of resident's health. Although requested, facility policies for Air Mattresses and Physician's Orders were not provided.

Based on clinical record review, facility documentation and interviews for one (1) of three (3) residents (Resident #2) reviewed for accidents, the facility failed to complete monthly maintenance checks to ensure resident's bedframes were free from sharp/jagged edges in accordance with manufacturer's recommendations resulting in a laceration to the leg requiring (8) eight sutures. The findings included: Resident #2 had diagnoses which included Parkinsonism, major depressive disorder, epilepsy and epileptic syndromes. Review of Resident #2's Care Plan dated 10/1/24 identified a history of Parkinson's disease and an assist of one with transfers with interventions that directed to encourage the resident to participate in care, assistance with activities of daily living, and to use assistive devices to enhance activity of daily living performance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of eleven (11) indicative of moderate cognitive impairment and required moderate assistance of one staff member for transfers. Review of the Facility Licensing and Investigations Sections Reportable Event Form dated 11/18/24 at 6:30 PM identified Resident #2 had sustained an 8.0 centimeter by 0.4 centimeter by 0.25 centimeter laceration to his/her right leg due to a sharp-edged area on his/her bedframe during a transfer. Resident #2 complained of burning and discomfort. The report further identified the Medical Director was notified and directed the resident be sent to the emergency department. Review of the hospital Discharge summary dated [DATE] identified Resident #2 was seen in the emergency department for a right leg laceration and had eight (8) stitches placed. Interview with Resident #2 on 12/11/24 at 10:30 AM identified being transferred to his/her bed from his/her wheelchair with the assistance of a Nurse Aide (NA), his/her leg encountered something sharp on the bed frame, after transferring from his/her wheelchair to his/her bed and cut his/her leg open, and indicated it was a very painful experience. Interview with NA #1 on 12/11/24 at 12:40 PM identified that on 11/18/24 he/she had transferred the resident from the wheelchair to his/her bed on the day without any problem. NA #1 indicated Resident #2 held onto his/her walker for support after standing up from his/her wheelchair while NA#1 assisted in guiding the resident's transfer to his/her bed. NA #1 indicated that once Resident #2 had pivoted and sat onto his/her bed, he/she had noticed blood on the floor near the resident's bed and then noticed a sharp, jagged edge on the bedframe that had come into contact with Resident #2's leg. Interview with the President of Facility Operations, on 12/11/24 at 10:15 AM identified that resident bed safety checks were performed yearly by an outside vendor which included assessing the resident's beds for function and electrical safety, however, not for structural hazards. The President identified the area of the bedframe that injured Resident #2 was due to a defect along the edge of one of the hallowed, metal support bars that created a sharp, jagged edge, the ends of these hallowed, metal support bars were generally milled smooth and covered by a plastic cap, but over time, the caps detach from the bedframe and expose the hollowed end. The President indicated the caps, once detached, were generally not replaced as their use was for cosmetic purposes only, and were not concerned the ends of the metal support bars were exposed as they were milled smooth. The President identified that the facility did not have any bed safety checks in place to prevent injury hazards. Interview with Person #1 (the vendor hired to perform the annual bed safety checks) on 12/11/24 at 11:02 AM identified the resident's beds were assessed for functional and electrical safety only during annual bed checks, assessing the bedframe for any structural hazards/anomalies was not part of the annual safety check. Interview with Person #2 and Person #3 (both representatives of the manufacturer of the bed) on 12/11/24 at 2:16 PM and 2:29 PM identified end caps on the bed frame should be replaced if missing to provide a safe surface for residents. Interview with the Director of Nurses (DNS) on 12/11/24 at 12:12 PM identified monthly bed frame checks have now been instituted to monitor for any safety hazards with the bed. The DNS further identified the [NAME] on the Resident #2's bed frame was immediately filed down and taped heavily to prevent any further injury from occurring. A new end cap was applied to the bed frame when the shipment was received. Subsequent to the incident the facility that on 11/19/24 all the facility's bed frames were assessed and no other hazardous anomalies/defects were found. Review of manufacturer guidelines for preventative maintenance directed to visually inspect the bed and accessories for broken welds or cracks, and check for loose hardware, (which includes end caps) monthly.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #1's diagnoses included cerebral infarction, pericardial effusion, chronic kidney disease, depression, anxiety, congestive heart failure, atrial fibrillation, osteoarthritis, and osteoporosis. The Resident Care Plan (RCP) dated 5/9/22 identified an Activities of Daily Living (ADL) functional deficit due to extended hospital stay, weakness, deconditioning and confusion. Interventions directed to encourage resident to participate in care, provide assistance with ADL's as per care card and as needed, PT/OT/ST evaluation and treatment as indicated and use assistive devices to enhance ADL performance as recommended from therapy. A nursing admission assessment dated [DATE] identified Resident #1 had moderate cognitive impairment. Review of the clinical record identified Resident #1 sustained a fall on 6/18/22 between 3:00 AM to 3:10 AM and was subsequently sent to the ED for evaluation. A hospital discharge summary dated 6/26/22 identified that Resident #1 was admitted on [DATE] with a new right mildly displaced humeral fracture, and acute hypoxic respiratory failure. Discharge instructions were for non-weightbearing and a sling to the right upper extremity with outpatient follow up with orthopedic physician, and continue pain management. Review of the Medication Administration Record (MAR) from 7/1/22 through 7/14/22 identified Resident #1 had complaints moderate to severe pain 9 out of the 14 days reviewed in the right arm. A nurse's note dated 7/15/22 at 12:21 PM identified Resident #1 reported nurse aides from previous shift (NA #2 and NA #3) displayed aggressive behavior towards him/her, specifying the pulling of injured right upper extremity, an assessment was done, the physician and family were notified of the incident. Resident #1 complained of severe pain to extremity, a physical therapist assessment also provided an adjustment of Resident #1's sling and provided education regarding extremity positioning for optimal support. Review of an incident report dated 7/15/22 at 1:40 PM identified Resident #1 reported an injury to his/her right arm that was pulled during care on the 11:00 PM-7:00 PM shift. Additionally, the report identified the physician and family were notified and an investigation was initiated. A physician's order dated 7/15/22 directed for an x-ray of the humerus. A radiology report dated 7/15/22 at 9:02 PM identified Resident #1 with a fracture involving right humeral neck with moderate displacement (the previous X-ray on 6/18/22 showed mild displacement), the shoulder joint is grossly intact and modest osteopenia. The conclusion to the report identified an acute fracture involving right humeral neck with moderate displacement. A nurse's note dated 7/15/22 at 10:50 PM identified Resident #1 had an x-ray with results noted as fracture involving right humeral neck with moderate displacement, shoulder joint grossly intact with osteopenia. The conclusion identified an acute fracture involving right humeral neck. A nurse's note dated 7/17/22 at 8:35 PM identified the writer (RN # 1) contacted MD #1 (who was on call for the resident's attending physician) and informed him of the results of the situational background and results of the x-ray. The note further identified MD #1 requested the resident be evaluated by PT and evaluation, and ordered treatment of non-weightbearing to right upper extremity in sling to continue. An interdisciplinary referral to rehab dated 7/20/22 identified Resident #1 was currently on physical and occupational therapy services with a non-weightbearing status to the right upper extremity. The referral further identified according to x-rays and physician recommendation, will continue to maintain protocol for right upper extremity based on orthopedist weight bearing status implemented by them. A physician's order dated 7/28/22 directed for an orthopedic consult for right shoulder fracture. An orthopedic consultation note dated 8/2/22 identified Resident #1 was being seen for follow up of a fracture of the right arm. The note further identified follow up for right 2-part humeral neck fracture that has displaced compared to x-rays from the hospital on 6/18/22. Additionally, the note identified the recommendations were to wear sling with elbow hanging out of splint 24 hours a day 7 days a week for 4 weeks, sleep upright so gravity doesn't cause further displacement and follow up in 4 weeks. Interview with Resident #1 on 8/4/22 at 11:25 AM identified those 2 women (NA #2 and NA #3) pushed and grabbed his/her right upper extremity. Resident #1 further identified when he/she asked NA #2 and NA #3 to use the bathroom, they said no and pushed the resident's shoulder and told him/her to stay in bed. Interview with NA #1 on 8/4/22 at 11:32 AM identified while walking the floor on 7/15/22 Resident #1 was ringing his/her call bell and when she went to attend to Resident #1, the resident reported to her what happened on the previous shift at which time, she and another NA (NA#4) reported it to the nurse (RN#1). Interview and with SW #1 on 8/4/22 at 11:56 AM identified Resident #1 reported to him that 2 NA's (NA #2 and NA #3, who were not facility employees, but agency employees) were physically rough and very rude to him/her. Additionally, SW #1 identified Resident #1 was very anxious regarding this issue. Interview and record review with RN #1 on 8/4/22 at 1:49 PM identified NA #1 and NA #4 reported to her Resident #1 told them the NA's from the 11:00 PM - 7:00 AM shift (NA #2 & NA #3) had pulled the resident's arm. RN #1 identified the assessment of Resident #1 found no bruising, but an increase in pain the right upper extremity. RN #1 further identified she called the physician to report and received the order for an x-ray of the right upper extremity. A review of the investigation dated 7/15/22 identified a statement by NA #2 and #3 dated 7/15/22 at 3:19 PM that they had provided incontinent care to Resident #1 on 7/15/22 on the 11:00 PM to 7:00 AM shift. NA #3 and NA#2 identified that they assumed Resident #1 was incontinent due to the resident wearing an adult brief. Additionally, NA #2 identified that she assisted Resident #1 on several occasions with putting the sling back on the right upper extremity. NA #2 and #3 identified at no time did Resident #1 complain of pain, was pushed, or denied use of the bathroom during care on 7/15/22. Interview with PTA #1 (Therapy Program Manager) on 9/14/22 at 11:45 AM identified Resident #1 did wear his/her sling prior to 7/15/22, however, did not wear it the way it was intended to be worn. PTA #1 further identified Resident #1 would reach out for objects even with the non-weightbearing status and the sling would be in the wrong position. PTA #1 indicated that although the resident was compliant with wearing the sling, he/she was non-compliant with wearing it correctly. Additionally, PTA #1 identified education was provided to the resident as well as the facility staff on proper use of the sling and how to wear it as well as education on non-weightbearing status. PTA #1 identified Resident #1's carryover was not great and ability to understand and carry over was inconsistent due to cognitive deficits. Interview with MD #1 on 8/4/22 at 12:44 PM identified he was on call on 7/15/22 when the incident was reported to him at which time, he ordered an x-ray. Additionally, MD #1 identified the x-ray report indicated the fracture of the right upper extremity was not a new fracture, but it was worse than the initial fracture. MD #1 further indicated that he referred Resident #1 to the orthopedic physician who also thought the x-ray was worse after the incident. Interview with the Orthopedic Physician's Assistant on 8/29/22 at 12:10 PM identified that the resident wearing the sling incorrectly, and non-compliance with non-weight bearing instructions could have caused the fracture to be further displaced. Further interview with SW #1 on 9/14/22 at 12:41 PM identified upon admission in May 2022, Resident #1 presented as alert and oriented. SW #1 identified he/she performs the Brief Interview for Mental Status (BIMS) testing for residents and he/she had not identified a noticeable decline in Resident #1's cognition. Additionally, SW #1 identified Resident #1's most recent BIMS score showed moderate impairment but the resident presented as very consistent cognitively and did not identify any type of decline. SW #1 further identified the resident may have occasional forgetfulness but in his/her opinion the resident is alert and oriented and is aware of what is going on and is able to interact across all departments, participate in activities and able to use an I-pad to FaceTime family and friends without difficulty. Interview with the Administrator on 9/14/22 at 12:53 PM identified that although the facility could not substantiate abuse, the conclusion made by the facility was that NA #1 and NA #2 had put her back to bed and pushed him/her on the right shoulder while doing so, however, the facility did not believe it was done deliberately. The administrator further identified that the worsening of the displaced fracture could have been due to the incorrect wearing of the sling. Additionally, NA#2 and NA#3's nursing agency was called and told that the facility did not want them to return to the facility. Multiple attempts to interview NA #2, NA #3, and NA #4 were unsuccessful. Review of the Abuse Prohibition Policy dated 5/2022 directed in part the facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation and misappropriation of his/her personal property. The policy further defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

Based on review of the clinical record, review of facility documentation and interview for one of three sampled resident's reviewed for accidents (Resident #22), the facility failed to provide the resident with the appropriate supervision resulting in a fall with an injury. The findings include: Resident # 22's [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] identified a risk for falls, required physical support for balance and was legally blind. physician's orders [REDACTED].The significant change MDS assessment dated [DATE] identified severely impaired cognition, required extensive assistance of two for transfers, bed mobility and toileting, and was not steady, only able to stabilize with staff assistance when moving from sitting to standing and/or moving on and off the toilet. The September 2016 care plan identified a risk for falls with interventions which included place personal items within reach and place bed in the lowest position and lock brakes.The nurse ' s notes dated 10/16/16 identified at 11:30 AM Resident #22 was found on the floor in the shower room. The resident's pants were half way down the legs and the resident identified she/he hit her/his head on the floor. The physician was notified and the resident was transferred to the ED for an evaluation. At 7:30 PM the resident returned to the facility with a [DIAGNOSES REDACTED].Review of the facility investigation identified the assigned NA (NA#1), left the resident unattended while seated on the toilet in the shower room. Interview and review of a written statement regarding the incident with NA#1 on 5/3/17 at 10:30 AM identified she left the shower room to retrieve linen from the cart in the hall and when she returned the resident was on the floor.Interview, review of the clinical record and the facility investigation on 5/3/17 at 10:45 AM with the DNS identified it is the facility practice not to leave a resident who utilizes a bed or chair alarm unattended when toileting. The DNS further identified it was the responsibility NA#1 not to leave the resident unattended in the shower room due to Resident #22's poor safety awareness.

Based on review of the clinical record and interviews for one of two sampled residents reviewed for hospitalization (Resident#25), the facility failed to implement physician orders [REDACTED]. The findings include: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission assessment dated [DATE] identified constipation as the resident's bowel elimination pattern with [MEDICATION NAME] as the bowel treatment. An admission MDS assessment dated [DATE] identified the resident without cognitive impairment, extensive to total assistance from staff for most activities of daily living, occasionally incontinent for urine and always continent for his/her bowel status. Needs to be in sequential order. admission orders [REDACTED].M. (morning), Magnesium oxide 400 mg (milligrams) twice daily and the Bowel Protocol for [MEDICATION NAME] 10 Milligram (MG) at bedtime, prn (as often as needed) for constipation- utilize 1st, [MEDICATION NAME] 10 MG suppository peri-rectal every day and when needed for constipation -utilize 2nd, disposable enema peri-rectal every day and when needed for constipation utilize 3rd. Review of the nursing flow sheet identified that during the period of 4/07/15 to 4/17/15, Resident #25 was moving his/her bowels daily on 4/07, 4/08, and 4/09/15, but on 4/10/15 and 4/11/15 the resident was identified as being constipated for 6 shifts or more. On 4/12/15 although it was noted that the resident had not moved his/her bowels during the night shift (11 P.M. to 7 A. AM.), on the day shift (7 A.M. to 3 P.M.) the resident was noted as having a small BM. Further review of the nursing flow sheets noted Resident # 25 had a small BM on 4/12/15, the resident remained constipated until 4/14/15 at 12:00 P.M. at which time the resident had a large BM. Review of the when needed Kardex identified on 4/13/15 at 12:00 P.M. during the first shift, the resident was given part #1 of the bowel regime that included [MEDICATION NAME] 10MG at 12:00 P.M. without affect per nursing flow sheet. On 4/13/15 at 9:00 P.M. noted the resident received part #2 of the bowel regime that included [MEDICATION NAME] 10 MG suppository (peri-rectally) with initial comments that results were pending, nursing flow sheet identified that during the evening shift on 4/13/15, the resident did not have a BM. Upon further review of the clinical record noted that although part #1 and #2 of the bowel regime was initiated on 4/13/15, documentation was lacking to reflect that part #3 (i.e. peri-rectal enema was administered after the initiation of the facility's bowel protocol for Resident #25. The nurse's notes dated 4/14/15 at 12:00 P.M. identified RN#3 manually removed a large bowel movement from Resident # 25 and indicated fecal disimpaction. Further review of the clinical record identified that the resident continued to have problems with constipation from 4/15/17 through 4/16/15 and no documented bowel movements ( 6 shifts) . The April 2015 Medication Administration Record [REDACTED]. The nurses notes dated 4/17/15 identified the physician was notified and directed the facility staff to administer a fleets mineral oil enema and to transfer the resident to emergency room for evaluation. Review of hospital documentation dated 4/21/15 identified constipation, manual dis- impaction, x ray identified decreasing constipation with increasing fecal impaction in the rectal area, the resident received [MEDICATION NAME] ( bowel removal prep) and noted with a few hours the resident had a large bowel movement. On 8/27/15 at 9:50 A.M. an interview and review of the clinical record with the DNS indicated facility staff failed to administer and obtain the appropriate enema that the resident required for his/her bowel regimen in accordance to the plan of care.

Based on clinical record reviews, review of facility documentation and interviews for one of three residents reviewed for falls (Resident #32), the facility failed to ensure safe wheelchair (W/C) positioning/transportation. The finding includes: Resident #32 ' s (R #32) [DIAGNOSES REDACTED]. The assessment dated [DATE] identified that R #32 had mildly impaired cognition, utilized a wheelchair propelled by staff for locomotion and had constant, severe pain daily. Physician orders [REDACTED]. The plan of care dated 4/16/13 noted an approach to ensure proper body alignment when in bed or chair. Review of facility documentation dated 6/29/13 at 2:00 PM noted that R #32 tilted forward from the wheelchair and fell as NA #11 transported the resident from the bathroom. The facility investigation dated 7/1/13 through 7/2/13 and subsequent interview with the Director of Nursing (DON) on 8/22/13 at 1:00 PM identified that NA #11 reported that he/she did not have to transport the resident far and so did not have the resident's wheelchair footrests in place when the resident fell . The interview further indicated that the resident was seated toward the front and not the back of the wheelchair seat because the resident refused to sit back due to pain. NA #11 failed to ensure that R #32 was seated upright, was not flexed forward, and that the resident received the benefit of the tilt from the wheelchair during the wheelchair transport. Interview with Physical Therapist #2 (PT #2) on 8/22/13 at 11:55 AM noted that the Resident's sitting balance was fair but the resident's musculature was too weak to hold the resident upright. The x-ray report dated 6/29/13 indicated that R #32 sustained an impacted fracture of the right humeral head as a result of the fall.

Based on clinical record review and interview, for one sampled resident reviewed for pressure sores, (Residen t#26), the facility failed to follow policy and procedures related to an existing pressure sore and/or ensure measures were in place to prevent a pressure sore. The findings include: Resident #26 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Braden skin risk assessment dated [DATE] indicated the resident was a significant risk fo developing skin integrity problems. An assessment dated [DATE] identified intact cognition, total dependence on staff for ADLS including bed mobility and transfers, bilateral upper and lower extremity range of motion limitations, and the existance of a Stage II pressure ulcer with interventions including a turning and repositioning program. Occupational Therapy plan of care dated 8/8/12 indicated Resident #26's current level of bed mobility as moderate to maximum asssistance. a. The W-10 transfer documentation dated 8/4/12 indicated a Stage II pressure sore to the coccyx with duoderm. The Admission Nursing assessment dated [DATE] also identified a Stage II pressure sore to the coccyx with three 1cm surrounding areas. Review of the medical record failed to identify further monitoring and/or documentation of the areas. Facility Pressure Reduction Protocol indicated pressure ulcer progress will be followed on the weekly pressure ulcer healing assessment. b. Nursing note dated 8/16/12 identified a 1.75 x 2 cm, purple, soft, tender area of the inner right ankle surrounded by a 4 x 6 cm reddened area. The area was noted to be intact and painful to touch. physician's orders [REDACTED]. Interview and review of the clinical record with the DNS on 11/14/12 at 8:45 AM failed to provide evidence that preventive meausres were put in place for heel protection until after the pressure area developed. Pressure reduction protocol policy indicated possible preventive measures for residents at risk for or having exisitng pressure sores included to position to alleviate pressure over bony prominences and shearing forces over the heels, elbows, base of head and ears. :

Based on record review, review of facility documentation and staff interview, for one of four sampled residents reviewed for nutrition/hydration (Resident #28), the facility failed to ensure the resident was offered food/fluids and/or for one of four sampled residents reviewed for abuse (Resident #66) the facility failed to ensure that the resident remained free from mistreatment. The findings include: a. Resident #28's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified a problem with short/ long term memory and requiring total assistance of two staff members for bed mobility and transfers. The MDS further noted the resident required total assistance of one for dressing, eating and personal hygiene. A care plan dated 11/2/11 identified a problem with oral pharengeal dysphagia and a risk for aspiration. Interventions include to assist with feeding, feed slowly, check for pocketing, and stop feeding for 30 minutes if he/she is not swallowing. The care plan further identified the resident received a regular puree diet and may have this liquefied and given via cup. The resident also received pudding thick liquids.physician's orders [REDACTED].#28 was enrolled in hospice services. Nurses notes from RN#5 (the previous DNS) dated 11/28/11 at 8:00AM identified the resident in bed with decreased respiration and increased secretions. The resident was placed on the side in a flat position and presented with a decrease in audible secretions. The resident was not responsive to verbal stimulation. The nurses notes further identified the physician was notified with a notation of "informed request for Roxanyl order." A physician's orders [REDACTED]. Nurse Aide flow sheets dated 11/28/11 lunch and supper, 11/29/11 breakfast, lunch, and supper, 11/30/11 breakfast and lunch, and 12/1/11 breakfast and lunch identified the resident was NPO (nothing by mouth). Nurses notes dated 11/30/11 at 2:00PM identified the resident was NPO all day. On 11/8/12 at 9:58AM, interview with NA#1 noted that the staff was instructed by RN#5 that R#28 was not to be fed from 11/28/11 because the resident might aspirate. On 11/8/12 at 10:38AM, interview with RN#1 noted that he was instructed during report from the 11:00PM to 7:00AM nurse on 11/30/11 that RN#5 did not want the staff to attepmt to feed the resident because the resident was having trouble swallowing. RN#1 further noted that Resident #28 "always has trouble swallowing" and a drop of fluid placed on the resident's tongue would stimulate swallowing. RN#1 further noted that Resident #28's medication was also withheld (([MEDICATION NAME] 100mg po QD) on 11/29/11 and 11/30/11 because RN#5 made the resident NPO.Nurses notes dated 12/1/11 at 8:30PM noted Person #1 called the facility regarding the status of the resident's dietary intake. Nurses notes further identified that Person #1 had been informed at that time that Resident #28 had been NPO per order of RN#5 (previous DNS) since 11/28/11. Nurses notes further identified that Person #1 did not want Resident #28 to be NPO. Nurses notes further identified at 9:15PM, that Resident#28 tolerated a soft diet of yogurt and thickened liquids without difficulty.On 11/8/12 at 2:20PM, interview with NA#2 noted that she fed the resident supper, under the direction of the nursing supervisor on 11/30/11 despite RN#5's directive of NPO. On 11/8/12 at 1:30PM, interview with MD#1 identified that he had not been notified that RN#5 had made the resident NPO until approached by Nurse Aides on 12/2/11 and would not have ordered that. On 11/8/12 at 11:20AM, interview with the Administrator identified that he thought the resident was made NPO for only 1 meal. He further noted that he was made aware that the resident was NPO for approximately 3 days when the daughter brought it to his attention on 12/2/11. R#28 continues to reside in the facility. The facility withheld fluids and nutrition without the benefit of an accurate assessment and/or physician notification. b. Resident's #66 [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #66 had short and long term memory problems, severely impaired cognition, was totally dependent on staff for activities of daily living, required two person assistance with transfers, and rejected care 4 to 6 days a week but less than daily. The care plan dated 6/12/12 identified resident with behaviors such as fearfulness and yelling with care at times. Interventions directed staff to introduce self and others, explain all procedures, and speak slowly, clearly and in simple phrases. A physician's orders [REDACTED]. A Reportable Event Form dated 6/20/12 identified that on 6/19/12 NA#3 witnessed Resident #66 being struck in the arm with a damp towel by NA #4. NA #4 was angry with the resident for screaming during a shower and being resistive to care. After the incident the resident was noted by the charge nurse to be emotionally upset. Summary of investigation submitted by the DON on 6/22/12 noted that Resident #66 frequently yelled loudly during care, and became fearful and resistive. The summary also indicated that NA #3 did not immediately report the incident. NA #4 denied most of the allegations, stating he was angry with NA #3, not the resident, and while he was loud, and verbally inappropriate, he would never strike or scare a resident. Further review noted that NA #4 resigned. Interview with NA #3 on 11/7/12 at 3:10 PM indicated that while she was helping in the shower room, she observed Resident #66 screaming and refusing to stand up. She further indicated that NA #4 became angry, yelling at the resident, pacing back and forth, and hit the resident's arm with the towel. The resident became very upset, told NA #4 not to touch her/him anymore and was crying. NA #3 indicated that after witnessing the event, she did not immediately inform her charge nurse of what had taken place because she was in shock. Further interview identified that NA #4 continued to provide care to the resident during 3:00 PM to 11:00 PM shift. Several attempts to contact NA #4 were unsuccessful. Interview with the Administrator 11/13/12 at 2:00 PM noted that during the investigation, NA #4 identified that although he threw the towel, he did not hit the resident. NA #4 further stated that he yelled at NA #3 with the resident present in the shower room. The administrator indicated that Resident #66 could become very upset hearing a loud tone of voice. Review of the abuse policy identified that it is the policy of the facility to provide for its residents an atmosphere which is free from abuse of any sort including, but not limited to: verbal abuse, physical abuse, sexual abuse, mental abuse, misappropriation of resident property and involuntary seclusion.

Based on observation, clinical record review, facility policy and staff interview for one of three residents reviewed for pressure ulcers (Resident #1), the facility failed to ensure that weekly wound assessments were conducted in accordance with facility policy and/or failed to implement interventions to prevent the development and/or promote healing of a pressure ulcer. The findings include: Resident #1's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had intact cognition (BIMS score of 15), did not exhibit any behaviors, was independent with activities of daily living (ADL) and had two stage two pressure ulcers. A care plan dated 12/10/12 identified that the resident had a stage two pressure ulcer on the left buttocks with interventions that included to turn and reposition the resident every two hours. A revised care plan dated 12/21/12 identified that the coccyx area had a 4 mm pinhole sized wound with interventions to apply a [MEDICATION NAME] dressing, to change weekly and as needed and to maintain weekly documentation regarding the area. On 12/22/12 a care plan revision indicated that the resident's bilateral heels were reddened. Review of the physician's orders [REDACTED]. On 1/25/13 the physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. a. Although nurses' narrative notes dated 1/15/13 described the resident's right heel as slightly pink and indicated that the area was not open, on 1/26/13 a nurse's note identified the right heel as red and tender and noted that both heels were to be off the bed with the resident's bilateral legs on a pillow. On 1/27/13 a nurse's note indicated that although the right heel had decreased redness, the resident had a pin point scabbed area and indicated that skin prep was applied. On 1/29/13 a nurse's note identified that the pinpoint scab on the resident's right heel was red and tender. Two days later on 1/31/13 a nurse's note again mentioned a small scabbed area on the right heel. However, the clinical record failed to reflect any further documentation regarding the right heel area or any revisions to the care plan. b. Weekly wound assessments dated 1/2/13 identified a stage two pressure ulcer located on the left buttocks measuring 4 centimeters (cm) by 5 cm by 1 mm. Nine days later on 1/11/13 documentation identified that the measurements of the pressure ulcer had not changed from the previous assessment. Although on 1/16/13 the area was noted to measure 4 cm by 5 cm by 3 mm, on 1/23/13 the area was described as a stage two pressure ulcer measuring 4 mm round. No further weekly wound assessments were conducted until 2/13/13, twenty-one days later when the stage two pressure ulcer on the left buttocks was noted to measure 2 cm in diameter and to be without drainage or odor with the peri-wound noted to be pink. No change in the area was identified. Observation of Resident #1 with RN #1 on 2/13/13 at 4:00 PM identified a stage two pressure ulcer approximately 1 centimeter in diameter on the coccyx as well as the resident's right lateral heel area having an 8 cm blanchable area with an unstageable area approximately 2 cm in diameter in the center. Both heels were noted to be off loaded. The facility's Skin Integrity Management policy identified that residents with a wound will have weekly wound assessments conducted and documented to include the type of wound, location, measurement, stage, signs of infection and presence of pain. Interview and review of the clinical record including the wound assessment log with the DNS on 2/13/13 at 3:30 PM indicated the Assistant Director of Nursing (ADNS) was responsible for conducting and documenting weekly wound assessments. The DNS identified the ADNS had resigned approximately three weeks ago, and no weekly wound assessments had been conducted since 1/23/13. Additionally, the DNS indicated that when R#1's right heel was identified as a scabbed area, the plan of care should have reflected new interventions to prevent further decline.