Every finding on record at Bremond Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide necessary supervision for 1 of 3 residents (Resident #1) reviewed for accident hazards and supervision.The facility failed to protect Resident #1 from neglect when CNA A left the resident unsupervised despite the resident's identified need for supervision, resulting in Resident #1 sustaining a fall on 8/03/2026, which resulted in a left distal radial fracture.This failure could place residents at risk for physical and/or psychological harm or injury.Findings included:Record review of Resident #1's Face sheet printed 08/22/26 reflected, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included: senile degeneration of brain, not elsewhere classified (age-related deterioration of the brain that can affect how a person thinks, remembers, or function), unspecified dementia, unspecified severity, with agitation(decline in memory, thinking, not yet categorized, but experiencing behavioral disturbances like pacing, rocking, trying to exit), adjustment disorder with mixed disturbance of emotions and conduct(mental health condition that include a combination of emotional symptoms, multiple sclerosis(immune system damages nerves and affect how brain and body communicate)and benign paroxysmal vertigo(turning or moving the head could cause brief episodes of dizziness). Record review of Resident #1's MDS dated [DATE] indicated her BIMS was a 03, severe cognitive impairment. The MDS further stated for mobility, Resident #1 requires supervision or touching assistance. Record review of Resident #1's Care Plan printed 08/22/2026 reflected: I am at risk for falls related to unsteadygait, history of falls, muscle weakness, cognitive impairment, medication side effects, poor vision, or incontinence initiated 07/20/2026. Interventions/Tasks : I may be placed closer to the nurses' station if I need frequent observation.Date Initiated: 07/20/2026 and Staff will monitor me more closely, especially during high-risk times such as shiftchanges, night hours, or after medications. Date Initiated: 07/20/2026. Record review of Resident #1's nursing progress note entered by LVN C on 08/03/26 at 3:49 AM revealed: Resident had a fall at approximately 0315 [3:15 AM], unwitnessed. Resident sustained an injury, possible fracture to left wrist. Resident is sitting up at nurses station in wheelchair waiting for hospice to arrive and evaluate. Record review of Resident #1's hospital discharge date d 8/03/2026 revealed resident was diagnosed to have a left distal radial fracture(break/crack in bone). Observation conducted 08/22/2026 at 9:48 AM, the secure unit patio area was observed to have an alarm that sounded when the door opened, the area was enclosed by a fence with no exit. Observation/interview conducted 08/22/2026 at 10:08 AM, revealed Resident #1 was first sitting on her roommate's bed then she started walking around the room. Resident #1 stated she was doing fine. She stated, I can't get my wrist to heal. She stated she fell in her room and she was alright, the doctor checked her out. Resident #1 noted to have her wrist in a temporary splint. Interview conducted 08/22/2026 at 2:05 PM, Resident #1's Family Member stated they had no concerns regarding Resident #1's care at the facility, with the exception of an incident that occurred when Resident #1 fell during the middle of the night. The Family Member stated that Resident #1 was reportedly having an episode, was belligerent and wanted to go outside. Family member stated ,the staff that was attending to[ Resident #1] reportedly did not want to wrestle with the resident and told the resident she was going to grab her drink and would go outside with her. The Family Member stated by the time the staff member returned, Resident #1 had stepped outside the door to patio where the staff had left the resident standing at the doorway unsupervised. Resident #1 subsequently fell. Interview conducted 08/22/2026 at 3:31 PM, CNA A stated she had been employed with the facility since December 2025. CNA A reported that she was trained in abuse and neglect. CNA A stated that on August 3, 2026, she was working on the secure unit and had worked with Resident #1 on Saturday and Sunday nights. She stated that Resident #1 did not go to sleep on Sunday night as she had on Saturday night. After receiving her medications, Resident #1 remained seated in a rocking chair in the back area of the unit. CNA A stated she kept a close eye on Resident #1 because Resident #1 could be a little wobbly after receiving her medications.CNA A stated that Resident #1 repeatedly said she wanted to go outside to get to her car. She stated that Resident #1 eventually fell asleep in a recliner because she insisted on remaining in the chair rather than going to her bedroom.CNA A stated there was no restroom designated for staff on the secure unit unless an empty resident room was available. She stated that she went to Unit 1 to use the restroom. When she returned and was entering the code to access the secure unit, the back-door alarm sounded. CNA A stated she observed Resident #1 going outside and immediately followed her. She stated Resident #1 did not want to come back inside and remained standing near the door. CNA A stated that she then turned around and went back inside to get her drink. She stated that as she was turning around after getting her drink, she heard Resident #1 fall. CNA A stated she immediately called the nurse from her cellphone to notify them of the incident. When asked about the protocol for staff restroom breaks while working on the secure unit, CNA A stated that staff usually used the restroom while the nurses were passing medications on the unit or while the residents were asleep. CNA A stated that she received a written final warning related to the incident. She stated that she had never received a written warning. According to CNA A, she was told the final warning was issued because Resident #1 was injured. Interview conducted 08/22/2026 at 3:58 PM, LVN C stated that she went to assess Resident #1 after being notified by CNA A. LVN C stated that CNA A reported she had left the secure unit to use the restroom and upon returning to the unit, she found Resident #1 on the ground outside. LVN C stated there was no designated staff restroom located on the secure unit. She explained that facility protocol required staff to notify the charge nurse when they needed to leave the secure unit. LVN C further stated that staff have access to walkie-talkies to notify charge nurses before leaving the unit. When asked about the potential for harm when a staff member left a resident unattended, LVN C stated, Obviously, they can fall. or enter another resident's room, or otherwise place themself at risk for harm. Interview conducted 08/22/2026 at 5:08 PM, the Interim DON stated CNA A stated to her when she was returning to the secure unit she heard the door alarm to the enclosed outside area and when CNA A went to the door Resident #1 was standing outside the door and CNA A asked Resident #1 to come inside but the resident was agitated. She stated CNA A turned to get her drink and when she opened the door back up Resident #1 was on the ground. The Interim DON stated they did not have a protocol for staff relief but since the fall the facility had put out a schedule of relief for the workers on the unit. The Interim DON stated residents movements were not restricted on the secure unit, and that situations could occur at any time. She provided an example , stating that a staff member could be assisting another resident in their room when an incident involving another resident could occur. Interview conducted 08/22/2026 at 5:12 PM, the ADM stated CNA A he said when interviewed that when she was coming through the door on secure unit, she heard the door buzzer and she peeped out the door, went to grab her drink and opened the door again, Resident #1 had fallen. The ADM stated the secure unit staff were supposed to tell the other aide or nurse when they needed to leave off of the unit. The ADM stated the staff had walkie talkies and there ere some double doors that were only 20 feet away that could be opened to notify someone. Interview and observation conducted 08/22/2026 at 6:07 PM, CNA B stated she had been employed at the facility for approximately six months and had received training in abuse and neglect. She stated that on the secure unit staff were required to use the walkie-talkie to notify the appropriate staff member when they needed to leave unit to use the restroom or to attend to another task. She stated that staff followed a relief schedule and pointed to a schedule on the wall. CNA B stated that when the door alarm sounded, staff were expected to follow the resident out of the door. She also described the facility's change of faces process, explaining that was when another staff member came to assist. She stated in two to three minutes anything could happen. She further stated that if a resident as agitated she would not leave the resident unattended. Record review of the facility's policy, Abuse, Neglect and Exploitation, revised 04/11/2025, reflected: Policy:It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Definitions:. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Policy Explanation and Compliance Guidelines: The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;. Record review of the facility's policy, Secure unit Policy revised 4/25/2025 reflected: Staff ResponsibilitiesMonitor residents for changes in behavior and risk.Ensure doors and security systems are functioning properly.Conduct and document regular safety checks.Respond immediately to alarms or attempted exits.Participate in training related to dementia care and elopement prevention.

Based on interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility reviewed for infection control practices.The facility failed to ensure the previous DON's TB test was completed by 06/25/2026.This failure could place residents at risk of infection that can spark outbreaks that can spread rapidly. Findings included:Record review of previous DON's HR file on 07/17/2026 did not show the TB testing completed within 48-72 hours of the hire date of 06/22/2026. The ADON administered the TB test on 06/26/2026 to the previous DON.During an interview with the ADON on 07/17/2026 at 2:28 PM, the ADON stated she was responsible for administering the TB test to the previous DON timely when she started on 06/22/2026. The ADON stated it was expected for the TB test to have been administered within 48-72 hours of the previous DON's start date. The ADON stated the TB test was administered to the previous DON on 06/26/2026 and should have been administered on 06/25/2026. The ADON stated that there were no adverse effects or outcome with the TB test not administered timely. The ADON did not give a reason to why the TB test was not completed timely after the previous DON hire date. The ADON stated it was very important for the TB test to be conducted timely because a positive test would have affected all residents and staff that would have led to a big infection control issue.During an interview with the previous DON on 07/17/2026 at 2:44 PM, the previous DON stated she started at the facility on 06/22/2026 and her employment ended on 07/02/2026. The previous DON stated that the ADON completed her TB test on 06/26/2026 and should have administered the TB test no later than 06/25/2026. The previous DON knew the TB test was to be completed within 48-72 hours of her starting at the facility. The previous DON did not know the reason why the TB test was not administered timely within 48-72 hours of her start date.During an interview with the ADM on 07/17/2026 at 4:50 PM, the ADM stated it was expected for the ADON to have completed the TB testing timely within 48-72 hours from the previous DON's hire date of 06/22/2026. The ADM stated there were no adverse effects with the TB test not being conducted timely. The ADM stated if there was a positive test read all kinds of things could have happened. The ADM did not elaborate any further on the kinds of things that could have happened if the TB test was not conducted timely.Review of the facility policy Infection Prevention and Control Program implemented 09/01/2023 and revised 03/06/2026 reflected This Facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Review of the facility policy Employee Tuberculosis Testing implemented 09/01/2023 reflected Tuberculosis (TB) screening and testing is conducted in this facility for the purpose of early identification, evaluation, and treatment of employees with latent TB infection (LTBI) or TB disease.At the time of employment, all new staff shall undergo pre-placement screening for TB, including an individual risk assessment, TB symptoms screen, and TB test.All initial and follow-up TB test shall be administered and interpreted 48-72 hours for skin tests by a trained healthcare provider on our staff, or any licensed physician.

Based on interviews and records review, the facility failed to ensure that medical records were accurately documented for three (3) of nine (9) residents (Resident #2, Resident #8 and Resident #9) reviewed for accurate clinical records. The facility failed to ensure Resident #2, Resident #8 and Resident #9 EMRs contained orders upon admission to the secured unit with corresponding clinical criteria to admit them to the secured unit. This failure could result in errors in care and treatment and violate resident rights.Findings included: Resident #2 Review of Resident #2's face sheet dated 3/18/2026, reflected an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included: Dementia, (decline in cognitive function), muscle wasting, delusional disorders, heart failure, abnormalities of gait and mobility and lack of coordination. Review of Resident #2's quarterly MDS dated [DATE], reflected a BIMS core of 4, suggestion severe cognitive impairment. Further review of the behavior section of the MDs reflected no presence of wandering behaviors. Review of Resident #2's census reflected Resident was moved to the secured unit on 3/5/2026. Review of Resident #2's physician orders dated 3/18/2026 reflected no orders for secured unit placement prior to 3/18/2026. Review of Resident #2's care plan dated 3/18/2026 reflected a problem with a revision date of 3/1/2026: Resident exhibits impaired safety awareness and elopement risk related to cognitive impairment with a goal Resident will remain safe and free from injury related to wandering and impaired safety awareness through the next 90 days and an intervention Resident to reside in locked/secured unit with monitored entry/exit doors to reduce elopement risk. Resident #8 Review of Resident #8's face sheet dated 3/18/2026, reflected a [AGE] year-old male admitted to the facility to the secured unit on 12/23/2025 with diagnoses that included: Dementia, (decline in cognitive function), anxiety disorder, insomnia (lack of sleep), hypertension (high blood pressure), abnormalities of gait and mobility and difficulty in walking. Review of Resident #8's admission MDS assessment dated [DATE], reflected a BIMS score of 1, suggesting severe cognitive impairment. Further review of the behaviors section of the MDS reflected that the resident had no wandering behaviors exhibited in the last 7 days. Review of Resident #8's physician orders dated 3/18/2026 reflected no orders for secured unit placement. Review of Resident #8's care plan dated 3/18/2026 reflected the focus initiated on 1/13/2026: Resident has progressive cognitive impairment related to dementia/Alzheimer's disease, resulting in memory loss,disorientation, impaired judgment, and risk for injury or elopement, with a goal of Resident will remain free from injury and elopement during the care plan period. Resident #9 Review of Resident #9's face sheet dated 3/18/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] to the secured unit with diagnoses that included: Dementia (decline in cognitive function), cognitive communication deficit, lack of coordination and muscle weakness. Review of Resident #9's admission MDS assessment dated [DATE], reflected a BIMS score of 3, suggesting severe cognitive impairment. Further review of the behaviors section of the MDS reflected resident had wandering that occurred for 1 - 3 days and placed the resident at significant risk of getting to a potentially dangerous place Review of Resident #9's physicians' orders dated 3/18/2026, reflected no orders for secured unit placement. Review of Resident #9's care plan dated 3/18/2026, reflected the following problem initiated 2/26/2026: Resident exhibits impaired safety awareness and elopement risk related to cognitive impairment, resulting inwandering behavior and need for secured environment, with the goal of Resident will remain safe and free from injury related to wandering and impaired safety awareness in the secured unit through the next 90 days. During an interview on 3/18/2026 at 3:30 pm the Corporate DON stated she was not aware that residents on the secured unit did not have physician's orders in place. She stated that she found out when she arrived at the facility today that the orders were missing. The DON stated her expectation was that residents on the secured unit would have a physician's order and that the order would be entered into the EMR. She stated by placing residents on the secured unit without a physician's ' order we could be secluding them or violating their rights. She stated the facility would be correcting this today. During an interview on 3/18/2026 at 4:29 pm, the MD stated residents were evaluated for secure unit placement based on cognition levels, medical diagnoses, previous history of any elopement or wandering attempts, agitation or expression of verbal intent. The MD stated he was aware of the residents currently on the secured unit and the placement for these residents was appropriate. He stated he was not aware a physician's order was needed per the facility policy, but he would ensure this would be fixed for all residents on the unit. He stated he did not have any concerns about the residents currently placed on the unit, even though there was a documentation issue; but he did not want to put people there without an order because we don't want them to appear secluded. Review of Facility Policy Secured Unit Placement dated 9/1/2023 reflected:The facility will ensure that residents are placed in a secured unit only when clinically indicated, based on a comprehensive assessment, and in accordance with physician orders, interdisciplinary team (IDT) recommendation, and resident rights. Placement will reflect the least restrictive environment necessary to maintain resident safety and well-being.8.Documentation Requirementsa. The following must be documented:* Physician order

Based on interviews and record reviews, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices that are complete, accurately documented, readily accessible, systematically organized and protected from unauthorized release for 3 (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for maintenance of clinical records. 1. The facility failed to ensure staff documented accurately after Resident #1 was found on the floor and sent out for evaluation on 10/12/25 and returned to the facility on [DATE].2. The facility failed to ensure staff updated the care plan for Resident #2 after she reported she had a fall on 09/15/25.3. The facility failed to ensure staff accurately documented a progress note after Resident #3 had an apparent unwitnessed fall on 10/13/25. These deficient practices could place residents at risk of injuries related to falls or not receiving necessary treatment.Findings included:1. Review of Resident #1's admission record, printed 10/15/25, reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included unspecified intellectual disabilities, unsteadiness on feet, unspecified lack of coordination, dementia with agitation, and Alzheimer's disease with late onset. Review of Resident #1's MDS assessment dated [DATE] reflected he was rarely/never understood so a BIMS assessment was not completed. The MDS assessment reflected he needed set up assistance for transfers and ambulation and had no falls since the prior MDS assessment. Review of Resident #1's comprehensive care plan initiated 08/07/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment. Goal: I will remain free from injury due to falls. Interventions/Tasks: I will be given non-skid socks or footwear to help me move safely. I will be assisted with walking, transfers, or toileting as needed, based on my current ability. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #1 had an unwitnessed fall on 10/12/25 at 8:30 PM. Review of Resident #1's progress note dated 10/13/25 at 5:48 AM., and written by LVN A, reflected EMS was notified and Resident #1 was sent to the acute hospital after being found on the floor. Review of Resident #1's progress notes from 09/14/25 to 10/15/25 reflected there were no notes to address: The date and time the resident was found on the floor and sent out to the hospital or the date and time the resident had returned to the facility. During an interview on 10/14/25 at 2:25 PM., LVN B stated Resident #1 had gone out to the hospital sometime on the night shift on 10/12/14. She stated when she was coming in for her shift on the morning of 10/13/25, Resident #1 was just returning to the facility. LVN B stated if there was an unwitnessed fall, they were expected to get vital signs, complete a head-to-toe assessment, write a progress note and incident report, and notify the NP/MD, RP, and DON. She stated thorough documentation was important to ensure the residents received the proper care. During an interview on 10/15/25 at 10:57 AM, the VPCO stated the DON had told her Resident #1 had been sent out to the hospital on [DATE] because of a fall. She stated with any fall; she expected the event to be reported. That report triggered the required assessments. She expected the DON to complete an assessment and to reassess the resident before closing out the event at 72 hours as some bruises took time to develop. She stated if the documentation was missing or not accurate, there was no way to assess the outcome, and the facility may have missed something. During an interview on 10/15/25 at 11:42 AM, the DON stated she expected documentation to be accurate and timely. She expected after a fall the nurse completed a fall assessment, a progress note, an incident report, notification of the NP/MD, RP, and DON. She stated she and the ADON were responsible for monitoring the documentation and train/in-service staff, but since the ADON was out, she was responsible. The DON stated the ADON was also the MDS nurse who was responsible for care plans. She stated while the ADON was out, she was responsible for ensuring care plans were updated. During an interview on 10/15/25 at 12:18 PM, the ADM stated it was important that documentation was thorough and timely. She expected staff to take care of the resident first then complete the documentation. She stated it was her expectation that the documentation painted a picture of the resident's status so anyone would know what happened. She expected all documentation was completed before the staff left at the end of their shift. The ADM stated the new ADON was responsible for monitoring documentation, but she was out on leave, so the monitoring was done by the DON. During an observation and attempted interview on 10/15/25 at 1:28 PM, Resident #1 was sitting in a wheelchair in the dayroom. His posture was relaxed, no indicators of pain or distress observed. He made eye contact and smiled. He responded to questions with a giggle but did not respond verbally. A telephone interview with LVN A was attempted on 10/15/25 at 10:43 AM. A telephone interview with LVN A was attempted on 10/15/25 at 2:03 PM. No return call was received prior to the exit. 2.Review of Resident #2's admission record, printed 10/15/25, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), abnormalities of gait and mobility, muscle weakness, and repeated falls. Review of Resident #2's quarterly admission assessment, dated 09/08/25, reflected a BIMS score of 12 which indicated moderately impaired cognition. The assessment reflected Resident #2 needed set up assistance for transfers and ambulation. The assessment reflected no falls since the prior assessment. Review of Resident #2's comprehensive care plan, initiated 08/11/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness. Goal: I will remain free from injury. Interventions/Tasks: I will be reminded to use my call light. Staff will ensure my bed is in the lowest position, wheels are locked, and the call light is always within reach. My care plan will be updated after any fall or change in condition. Further review revealed the fall care plan did not reflect any revisions after the 09/15/25 fall. Review of Resident #2's progress note dated 09/15/25 at 5:05 AM, and written by LVN C, reflected in part, Resident reported that she fell. she stated she hit her left arm. Upon assessment, a laceration was noted. When asked if she would like to be sent out for further evaluation, resident declined. Wound cleansed. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #2 had an unwitnessed fall on 09/14/25 at 8:46 PM. Review of Resident #2's Fall Risk Evaluation, dated 09/15/25, reflected that she was at high risk of falls. During an interview on 10/15/25 at 1:20 PM, Resident #2 stated she had a fall at the facility but did not remember when it happened. She stated nothing was hurt besides her pride and she declined to be sent out to the hospital. She stated staff were attentive and checked on her frequently. 3.Review of Resident #3's admission record, printed 10/15/25, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis list reflected schizoaffective disorder, bipolar type. Review of Resident #3's medical record reflected her MDS assessment was not yet due nor completed. Review of Resident #3's baseline care plan, initiated 10/13/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment. Goal: I will remain free from injury. Interventions/Tasks: I will be given non-skid socks or footwear to help me move safely. I will be reminded to use my call light. Staff will ensure my bed is in the lowest position. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #3 had an unwitnessed fall on 10/13/25 at 7:30 PM. Review of Resident #3's progress notes from 10/13/25 through 10/15/25 at 1:03 PM, reflected no progress note regarding a fall. Review of Resident #3's Fall Risk Evaluation dated 10/13/25 at 11:28 PM, reflected a score of 14 which indicated she was at risk for falls. During an interview on 10/15/25 at 11:42 AM, the DON stated she witnessed Resident #3 on the floor on the evening of 10/13/25. She stated she treated it as an unwitnessed fall and initiated the incident report and assessments. She stated she did not document a progress note but should have. During an observation and interview on 10/25/25 at 1:45 PM, Resident #3 was observed sitting up in a wheelchair in her room dressed in clean clothes. No bruises or injuries were observed on her exposed skin. Resident #3 stated she felt good because she just had a shower. When asked if she had a fall at the facility, she stated, About 25 times. She repeated that she had about 25 falls. She denied pain, and she denied any injuries. She stated she felt safe at the facility and wanted to stay there forever. Review of the facility's Incidents and Accidents policy, reviewed/revised 04/11/25, reflected in part, It is the policy of this facility for staff to utilize (Title) to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve a resident. Compliance Guidelines: 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained for follow-up interventions. Review of the facility's Fall Prevention Program policy, Reviewed/Revised 10/14/25, reflected in part, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Compliance Guidelines: When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury.

Based on interview, observation and record review the facility failed to provide the necessary care and services for 1 of 11 (Resident #8) residents reviewed for transfer status. The facility failed to ensure that Resident #8, who was a 2 person assist in May 2025 and was changed to a mechanical transfer on 8/14/2025, did not suffer a decline in mobility. An Immediate Jeopardy (IJ) was identified on 8/15/2025. The IJ template was provided to the facility on 8/15/2025 at 4:45PM. While the IJ was removed on 8/16/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure put residents at risk for decline in activities of daily living, decreased mobility, and serious harm. Findings included: Review of Resident # 8's Face sheet on 8/12/2025 reflected an [AGE] year-old, female admitted to the facility 12/13/2023 with a diagnosis of vascular dementia (dementia caused by problems with the blood vessels in the brain), unspecified abnormalities of gait and mobility (difficulties with walking), and hypertension (high blood pressure). Review of Reentry MDS for Resident #8 dated 2/17/2025 reflected a BIMS score of 15 (indicating no cognitive impairment). Resident #8's ability to move from Lying to Sitting, ability to move from sit to stand, and Toilet transfer is listed as partial/moderate assist. There are no categories of mobility for which Resident #8 had refused to be assessed. Speech Therapy, Physical Therapy, and Occupational Therapy sections reflected 0 minutes for each category for the period prior to last MDS. Restorative Program reflected 0 minutes of restorative therapy for the period prior to last MDS. Review of Reentry MDS for Resident #8 dated 05/22/2025 reflected a BIMS score of 15 (indicating no cognitive impairment). Resident #8's ability to move from Lying to Sitting, ability to move from sit to stand, and Toilet transfer is listed as partial/moderate assist. There are no categories of mobility for which Resident #8 had refused to be assessed. Speech Therapy, Physical Therapy, and Occupational Therapy sections reflected 0 minutes for each category for the period prior to last MDS. Restorative Program reflected 0 minutes of restorative therapy for the period prior to last MDS. Review of Orders for Resident #8 reviewed on 8/13/2025 reflected no order for mechanical lift transfer. Review of Care plan for Resident #8 in EMR (electronic medical record) reflected no problems or interventions related to mobility risks or transfers. Review of Paper Care Plan for Resident #8 reflected a Problem Area, Problem Start Date: 09/20/2024, Category: ADLs Functional Status/Rehabilitation Potential, [Resident #8's] ability to (ADL: e.g., transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene) has deteriorated R/T disease process Edited: 05/22/2025 Edited By: [ADON]. Approach section listed, Follow PT/OT/ST recommendations. Edited: 05/22/2025 Edited By: [ADON], Provide assistance for ADL as needed. Edited: 05/22/2025 Edited By: [ADON], Transfer extensive assist 1-2 Edited: 05/22/2025 Edited By: [ADON], and Report any further deterioration in status to physician. Edited: 05/22/2025 Edited By: [ADON]. Problem Area started on 04/29/2024, revised by ADON on 05/22/2025 reflected: [Resident #8] is at risk for skin impairment, age related, impaired mobility. The Approaches listed for the problem area reflected, PT/OT to evaluate for rehab potential. Edited: 05/22/2025 Edited by: ADON. Problem area dated 02/20/2024, Revised 07/25/2025 and Edited by Activity Director, reflected: [Resident #8] also enjoys going outside to feed the cat. In the related Approach area, it reflected, Staff will encourage, assist, or plan out of door activities for fresh air weather permitting. Edited: 05/22/2025 Edited by: ADON and Staff will encourage or assist involvement in social groups of interest such as bible study, current events, trivia. Problem area dated 2/26/2024, edited by ADON on 5/22/2025, reflected Category: Cognitive Loss/Dementia [Resident #8] appears to have recall deficit as evidenced by: Periods of paranoia, making false accusations then denies making them, lack of acceptance or understanding of safety issue related to her living environment, Poor decision making. Goal for this problem area reflected a long-term goal target date of 8/22/2025, reflected [Resident #8] will understand helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. As evidenced by documentation in the medical record. Edited: 5/22/2025 Edited By: ADON. Related approaches dated 5/22/2025 reflected, Continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Review of Resident #8's Progress Notes in Paper Chart since 5/9/2025 -8/4/2025, reflected there were no notes indicating the resident was out of bed, nor are there any notes indicating refusals to get out of bed. There are no notes indicating a refusal of Physical or Occupational therapy during this time frame. Review of Physician Assessment for Resident #8 dated 7/12/2025 signed by Medical Director reflected fatigue, WC mobility, and weakness were chosen to describe Resident #8's general condition and extremities. There were handwritten notes reflecting, Pt. refuses BP meds and noncompliance with medications. There were no further notes regarding mobility or refusals of care. Review of Resident #8's most recent Occupational Therapy Discharge Summary prior to start of survey, for dates of service from 11/15/2024 to 11/18/2024, reflected, Discharge Recommendations: DC to this LTC facility under care of nursing. Restorative Program Established/Trained= Not indicated at this time Functional Maintenance Program Established/Trained=Not indicated at this time. Document was signed by OT F. Review of Resident #8's Summary of Occupational Therapy Daily skilled services signed by OT F dated 11/18/24 reflected, Pt (patient) declined to get out of bed, but finally agreed to work in the bed with therapy. Therapist went to pt's room x3 (three times) in order to get pt to participate. Once pt finally did agree to do therapy she was actually very cooperative and did everything requested of her. Pt education on the importance of movement/getting out of bed due to having pneumonia. Review of Physical Therapy Summary of Daily Skilled Services dated 11/18/2024 and signed by PT H, reflected, Patient requiring encouragement in order to participate proceeding to perform LE/UE (Lower Extremity/Upper Extremity) therex (therapeutic exercise) in all tolerable planes working on str (strength), endurance/ROM (range of motion) w cuing and breaks taken throughout session PRN (as needed).Review of Resident #8's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2025 and signed by OT G reflected, Personal Hygiene= Substantial/maximal assistance and Transfers section reflected, Recommended use of [mechanical] lift for all transfers. In the section labelled Reason for Therapy there is a note reflecting the following: Reason for Skilled Services: Patient requires skilled OT (occupational therapy) services to assess safety and Independence with ADLs (activities of daily living), develop and instruct on compensatory strategies, develop and instruct in exercise program, increase safety awareness, facilitate sitting tolerance and postural control, provision of pain management techniques, provision of modalities and strengthening, increase functional activity tolerance, and develop and instruct on adaptation techniques in order to enhance patient's quality of life by improving ability to return to prior level of skill performance. Review of Summary of Daily Skilled Services dated 8/14/2025 signed by OT G, the Response to Tx (treatment) section reflected Response to Session Interventions: actively participates with skilled interventions. Interview with Resident #8 on 8/12/25 at 9:41AM she stated I don't know when the last time I got up. Last time there were two people. Maybe seven days ago. She stated that she could not remember doing any therapy in the facility. She stated that she walked in the facility using a cane and now could no longer get out of bed. Observation of two person transfer on 8/13/2025 at 2:30PM with CNA A and CNA B revealed Resident #8 was lying in bed attempting to sit up. CNA A and CNA B watched Resident #8 attempt to sit up and did not offer assistance. Resident #8 stated that she was not able to sit up or stand on her own. She stated that she needed help. CNA A and CNA B did not assist after requests from resident. After 15 minutes of attempting to sit from a lying position, she refused to attempt any longer and requested to go stay in bed. She stated, I used to be able to sit and stand, but I can't anymore. No gait belt was observed in the room or in possession of the CNAs for the transfer and they were later found to be unable to properly apply a gait belt. In an interview with LVN D on 8/13/2025 at 2:47PM reflected that Resident #8 was known to be a two-person transfer. He stated that for a normal two-person transfer, if a person was struggling to sit up, the staff would assist the resident to a sitting position. In an interview with LVN C on 8/14/25 at 6:10AM she stated she had worked at the facility full time since September or October of 2024. She stated that she currently worked primarily night shifts but worked days and nights previously. She stated that Resident #8 was almost a mechanical lift now. She stated she knows Resident #8 was able to stand in May, but now she cannot. She stated she was transferring mostly by herself from the bed to the wheelchair and back at the beginning of the year with little assistance from staff. She stated that she could recall last seeing her transfer in March with little assistance from staff. She stated the last time she saw her transfer was around May with assist of two staff, where they had to physically assist her to sit up, which was not normal previously. She stated that she told dayshift at that time that the resident had shown a decline. She could not recall the date. She stated the resident refuses to get up at times. She stated that Resident #8 used to get up to feed the cats. She stated that refusals should be documented in the chart. She stated that residents have the right to refuse, but that staff should be building a relationship with the resident and try to find out the source of the refusals. She stated that residents should receive ongoing education and encouragement from staff with refusals of care. She stated that not getting out of bed can result in a decline in mobility. She stated that improper transfers can result in injuries.In an interview with CNA A on 8/14/25 at 8:45AM, she stated in the transfer with Resident #8 on 8/13/25 she should have assisted her to sit up. She denied having a gait belt for the transfer. She stated she does not use a gait belt on anyone in the facility during transfers. She stated she did not assist the resident with the transfer on 8/13/2025 because she was nervous. She stated it has been more than 3 months and less than 6 months since she's seen Resident #8 up out of bed. She stated the resident refuses to get out of bed a lot. She stated she does inform the nurse. She stated that the level of struggle she saw on 8/13/2025 from Resident #8 attempting to sit up for a transfer was new. She stated in the past, Resident #8 could help more. She stated the resident refuses a lot to get out of bed. She stated she does inform the nurse when the resident refuses. She stated that not providing assistance with transfers for residents that require assistance, can lead to residents feeling discouraged. She stated that if residents do not get out of bed they can lose their strength and ability to get out of bed. In an interview with CNA B on 8/14/2025 at 9:28AM, she said she worked at the facility for about a month. She said she had assisted Resident #8 out of bed with two people approximately two weeks ago. She stated she has seen the resident up, probably twice since she started working at the facility. She stated that she let her take her time to do some and then assisted when her when she needed it. She stated at that time she was not able to stand for the transfer. She stated they did get her in the wheelchair with two people. She stated each person stood on one side of the resident. She stated they then put their arm under her arm, and with the other hand, held on to the resident's pants. She stated that Resident #8 was able to sit up on her own two weeks prior during the transfer. She stated the resident refuses at times. She stated that not providing assistance with transfers for those residents that need it, can lead to resident' potentially giving up and possibly not wanting to try to get up. She stated that if residents do not get out of bed when they are able, they might lose their ability to get out of bed. In an interview with ADON on 8/14/2025 at 7:07AM, she stated that Resident #8 was a two-person transfer. She stated that she frequently refuses therapy. She stated there are no therapy notes for 2025. She stated she would print the last three therapy assessments for review by surveyor. She stated that there was no documentation of refusals of therapy in resident records for nursing in the last 3 months or therapy services documentation in 2025. She stated the Care Plan for the resident included being resistive to care at times, but did not include refusals of therapy. She stated she was not sure if the physical or occupational therapist spoke directly to the resident regarding her therapy opportunities and the risks of not participating in rehabilitative services. She stated that the Resident #8 refused therapy to her after her most recent hospitalization at the end of May, but that she did not document the refusal. In an interview with OT G on 8/14/2025 at 11:40AM, she stated that she worked with a different company than the previous therapists at the facility. She stated she started in the facility as a PRN (As needed) Occupational Therapist when the new company took over at the beginning of the month. She stated that she met Resident #8 on the morning of 8/14/2025. She stated that she reviewed her records. She stated that after speaking with Resident #8, she is going to recommend a mechanical lift for her transfers. She stated she has never seen it documented who has a gait belt in the facility, but if you are standing and moving them, they should have a gait belt on unless they are independent transfers or a mechanical lift is used for transfer. She stated that during transfers staff can hurt the resident's shoulders, cause shearing, or staff could drop them without a gait belt or with improper use of gait belt. She was not sure if Resident #8 was a mechanical lift prior to this assessment but stated that if a resident was screened previously as partial assist and then they are later screened as requiring a mechanical lift, that it would be considered a change in condition for the resident. In an interview with RNC on 8/14/2025 at 12:04 PM, she stated that she had been in the facility for 8 days, since the change of ownership. She stated that she was functioning as the Director of Nursing prior to the DON taking on her role at the facility. She stated that there was not a DON prior to the change of ownership, which would make the ADON responsible for supplies and resident care prior to 8/5/2025. She stated that the current owners use a different therapy company than was used previously by the facility. She stated that all residents who were not independent or mechanical lift transfers should have a gait belt on for transfers. She stated that if a resident was reaching and trying to sit up during a transfer that she would assist them with sitting position. She stated that if a resident made an effort to transfer, she would assist them with the rest of the transfer. She stated that Resident #8 should be assessed quarterly by therapy services. She stated that if there are any signs of decline, residents should be evaluated by therapy and treated per their recommendations. She stated that their responsibility as a facility is to maintain or improve status of residents, unless the situation can be helped. She stated that if a resident screens as needing a mechanical lift, when their previous recommendation was for partial assistance with transfers, that it would indicate a change in condition. She stated that if we are not assisting a resident to get out of bed, they can decline. She stated that residents do have the right to refuse care. She stated that she expected staff to encourage residents to get out of bed, to educate them regarding the consequences of not getting out of bed, to get family involved if applicable, and to perform passive range of motion if they continue to refuse to help prevent a decline in mobility. She stated that staff should try to find the source of why the resident is refusing care and address their underlying concerns. In an interview with Resident #8 on 8/14/2025 at 1:05PM she stated that she feels unhopeful when she attempts to transfer. She stated that she trusts one male staff member to transfer her. Resident observed lying in bed during the interview. In a phone interview with facility NP on 8/15/2025 at 12:04PM, she stated that she does not know of any degenerative conditions for Resident #8 that would make a decline in mobility unavoidable. She stated that the resident has some conditions which could cause pain, but that the resident nor the facility has reported an increase in pain. She stated that Resident #8 cannot transfer or stand without assistance from staff. She stated that to her knowledge, the resident could stand briefly to be assisted to the wheelchair. She stated that a new order for a mechanical lift would constitute a change in condition regarding the mobility status for Resident #8. She stated that she knows the resident to refuse care and transfers at times. She stated that she last observed the resident get up with staff assistance of 3-4 staff, gait belt, and walker on 5/23/25 when she ordered a urine culture for the resident. She stated that the extra staff present during the transfer where there to assist with collecting the urine sample. She stated that she knows Resident #8 to be a 2-person transfer. She stated that she saw a note from the morning stating that Resident #8 is now a mechanical lift transfer. She stated that when a resident is refusing to get out of bed, they should be evaluated to see if there is a change in condition. She stated that when a resident is refusing, the facility needs to ensure they are doing what they can and that it isn't just easier for staff not to get her up. She stated that not getting out of bed could contribute to a decline in mobility. She stated that not using a gait belt or using gait belts in properly could result in a fall or injuries to the resident. She stated it was a fundamental skill for a CNA and anyone who transfers residents to know how to use a gait belt. She stated she could not recall any injuries with transfers that would have warranted a gait belt. In an interview with ADON on 8/15/2025 at 1:50PM, she stated she could not believe she did not notice that Resident #8 had not been out of bed. She stated she was not aware that Resident had a change in mobility prior to the OT assessment on 8/14/2025. She stated that she could not recall seeing Resident #8 out of bed in the last few weeks. She stated that she was responsible for monitoring resident care and ensuring appropriate care was provided to Resident #8 at the time of the decline. She stated she was responsible for updating care plans at this time also. She stated that gait belt should be included in the care plan for residents that require a gait belt with transfers. She stated that she informed the physician and psychiatry about Resident #8's refusals of care in the past. She stated that she doesn't know exactly why the resident would refuse to get up recently. She stated that in the past she has given reasons like that she does not want to be forced to do things and that she does not want to put on a show for anyone. She did not recall when she stated this, but stated it was not directly related to a recent occurrence. She stated that Resident #8 does not have any family to her knowledge. She stated that Resident #8 is her own responsible party. She stated that staff try to encourage her to get out of bed with things that she likes. She stated that the facility tried to put her on skilled services when she got back from a hospital stay on 6/29/2025, but the resident refused at that time. She stated she does not have any documentation in the resident records to state that she was evaluated and subsequently refused offer of therapy. Observation of Resident #8 on 8/15/2025 at 1:56PM revealed the resident sleeping in her bed. In a follow up interview with RNC on 8/15/2025 at 2:54PM she stated that there was no evidence that an IDT meet was done related to her refusals of care. In a follow up interview with ADON on 8/15/2025 at 2:54PM she stated that there was no QAPI meeting in which Resident #8's refusals of care were discussed. In an interview with the ADMIN on 8/15/25 at 3:43 PM, he stated that he wanted everyone in the building to thrive. He stated everyone who wants to be up out of bed, should be allowed or assisted as needed to get up. He stated that therapy has a role in assisting with mobility needs of the residents. He stated all refusals should be documented. He stated the impact of not getting a resident out of bed could result in weakness. He stated that he would defer to nursing for specifics in the causes of a decline in mobility. He stated refusals for care and therapy should be care planned. He stated that after a few times of refusing, staff should notify the doctor or the NP. He stated that the facility does have to honor a resident's right to refuse. He stated it is the facility's obligation to talk to them and try to find out why they are refusing. He stated they usually have multiple staff attempt to talk to a resident about refusals of care. He stated that psychiatry services can occasionally assist with refusals of care. He stated that he was responsible for ordering the supplies for this facility. He stated there is a supply list at the nurses' station where staff can add needed supplies. He stated he made orders every Tuesday based on the list. He stated he was not aware there was a lack of gait belts available for resident use. He stated he was not aware that gait belts were not being used with residents. He stated that not using a gait belt could cause a fall or injuries, including discomfort to the residents. He stated his expectation was that residents who need gait belts should have them. Review of facility policy on Safe Resident Handling/Transfers (no date) reflected, All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them.Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur.Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.Review of Facility ADL policy (no date) stated: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care; Transfer and ambulation; Toileting; Eating to include meals and snacks; and Using speech, language or other functional communication systems.Policy Explanation and Compliance Guidelines: Conditions which may demonstrate unavoidable decline in ADLs include: Natural progression of the resident's disease state with known functional decline. Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities. Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment; counsel and/or offer alternatives to the resident or representative.The facility will maintain individual objectives of the care plan and periodic review and evaluation. The ADMIN was notified of Immediate Jeopardy on 08/15/2025 at 4:35 PM and the need for a Plan of Removal. The Plan of Removal was accepted on 08/16/2025 at 11:18 AM and was as follows: On 8/12/2025 a recertification survey was initiated at facility. On 08/15/2025 the surveyor provided an Immediate Jeopardy (IJ) Template for SNF notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Notification of the Immediate Jeopardy states as follows: F-676 - Activities of Daily Living (F676 The facility failed to ensure provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: S483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living to include mobility and transfers. Mobility Decline) 1. Immediate Actions Taken for Those Residents IdentifiedAction: Resident #8 immediately evaluated by nursing staff. Care plan updated to reflect current mobility status, interventions to maintain or improve function, and therapy recommendations. Resident requires a mechanical lift. Order placed in Point Click Care (PCC) for mechanical lift transfers. Physical Therapy referral placed in PCC for evaluation and treatment. Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 by noon Action: Facility-wide audit of all residents with transfer needs conducted to ensure correct transfer methods are documented, appropriate equipment is available at point of care, and no additional residents have experienced an undocumented decline. If equipment is not available, the DON/Designee will initiate an urgent order through the facility's contracted vendor, provide interim safe transfer methods, and ensure staff are trained on the temporary intervention until the equipment is in place. Any identified changes were addressed immediately through therapy referral and care plan updates. No changes identified.Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 by noon Action: All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy, proper gait belt use, and immediate reporting of mobility declines to the DON and/or ADON. Competency validation with return demonstration completed prior to resident care. Staff members will be educated prior to working their next shift. Staff who are not present will receive education via the telephone and complete the competency with return demonstration prior to working their next shift. All new hires and agency staff will receive education and competency evaluation with return demonstration prior to providing resident care. Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or Designee Date: 08/17/2025 by noon 2. How the Facility Identified Other Possibly Affected Residents: Action: 100% audit of all residents requiring assistance with transfers conducted to ensure accuracy of transfer status, care plans, and availability of required equipment. No other residents identified.Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or Designee Date: 08/15/2025 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Policy on Safe Resident Handling/Transfers reviewed with no changes made. Staff members will be educated on policy prior to working their next shift. Staff who are not present will receive education via the telephone and will sign the in-service sheet prior to working their next shift. All new hires and agency staff will receive education prior to providing resident care.Person(s) Responsible: VP of Clinical Operations, Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 policy reviewed08/17/2025 by noon for education of all staffAction: Change in Condition Protocol reviewed with no changes made. Staff members will be educated on policy prior to working their next shift. Staff who are not present will receive education via the telephone and will sign the in-service sheet prior to working their next shift. All new hires and agency staff will receive education prior to providing resident care.Person(s) Responsible: VP of Clinical Operations, Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 policy reviewed08/17/2025 by noon for education of all staff 4. How the Corrective Actions Will be Monitored/Ensure Comprehension, by whom and for how long: Action: All licensed nurses, CNAs, and therapy staff received immediate education on Safe Resident Handling/Transfers policy, including proper use of gait belts and mechanical lifts, and the requirement to report any resident mobility changes to nursing leadership. Staff completed a competency validation with return demonstration prior to providing further resident care. Staff not on-site were educated via telephone and completed competency validation prior to their next scheduled shift. All agency and new hire staff will receive the same education and competency validation prior to resident care assignment. Person(s) Responsible: DON, ADON, and/or DesigneeDate: 08/17/2025 by noon for education of all staffAction: DON/designee will conduct a minimum of 5 random transfer observations per shift for 4 weeks to ensure: proper transfer method is being used per care plan and gait belts/mechanical lifts are available and used appropriately. Results documented on Transfer Audit Log; noncompliance addressed immediately with re-education.Person(s) Responsible: DON, ADON, and/or DesigneeDate: Ongoing x 60 days Action: Interdisciplinary team will review all audit results in QAPI weekly for 8 weeks, then monthly for 4 months. Any identified trends will result in additional training.Person(s) Responsible: Administrator, DON, Rehab DirectorDate: Ongoing QAPI-Action: Medical Director notified of the deficient practice/IJ and Plan of Removal.Person(s) Responsible: DON, Administrator, and/or DesigneeDate: 08/14/2025 Monitoring facility's plan of removal was completed on 8/16/2025 as follows: Review of Resident #8's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2025 and signed by OT G, reflected that Resident #8 was evaluated on 8/14/2025 by nursing staff and occupational therapist. Resident #8's Care plan was updated on 8/14/2025 to reflect mechanical lift transfer and related care. Resident #8's Physician orders updated on 8/15/2025 to reflect mechanical lift transfer. There is a physician order for PT/OT (physical therapy/occupational therapy) to Evaluate and Treat dated 8/15/2025. In an interview with RNC on 08/16/2025 at 1:00PM, she stated that Resident #8 was transferred to hospital on 8/15/2025 at 8:08AM for sore throat and cough. She was not available for interview at that time. In an interview with ADON on 8/16/2025 at 1:53PM, she stated that the Facility-wide 100% audit of all residents with transfer [

Based on observation, interviews and record reviews the facility failed to ensure that resident environment remained as free from accident hazards as is possible, by not providing adequate supervision and assistance devices to prevent accidents for 4 of 11 residents (Resident #18, Resident #23, Resident #5, and Resident #3) reviewed for safe transfers. 1. The facility failed to ensure two staff members transferred Resident #18 via mechanical lift which resulted in Resident #18 suffering a skin tear due to being transferred by one staff member on 6/04/2025. 2. The facility failed to ensure CNA A and CNA B knew how to competently use transfer assistive device (gait belt) when performing a transfer from recliner to wheelchair for Resident #5 on 8/13/2025. 3. The facility failed to ensure that staff used any assistive devices (gait belt) when standing Resident #23 at the bedside resulting in a fall on 6/05/2025. 4. The facility failed to ensure that staff used any transfer assistive devices (gait belt) when transferring Resident #3 between bed and geri-chair. This failure could place residents at risk for serious injury, fracture, or death. Findings included: 1. Review of Resident #18's Face sheet dated 9/18/2020 reflected a [AGE] year-old, male admitted to the facility on [DATE]. Diagnoses included muscle wasting atrophy right and left shoulder (muscles shrinking and becoming weaker), rheumatoid arthritis (a chronic disease where the immune system attacks the joints), abnormalities of gait (abnormal way of walking) , contracture to right and left knee (condition where muscles, tendons, ligaments, or skin shorten and stiffen), and muscle wasting and atrophy of lower leg (muscles shrinking and becoming weaker). Review of Resident #18's Quarterly MDS dated [DATE] reflected a BIMS score of 15 (no cognitive impairment). In Section GG- Functional Abilities section GG0170. Mobility, Resident #18 is coded as dependent on staff for Chair/bed-to-chair transfers and, Not attempted due to medication condition or safety concerns for sit to stand transfer. Review of Resident #18's Paper Care Plan reflected a Problem area stating, Problem Start Date: 06/05/2025 Category: ADLs Functional Status/Rehabilitation Potential Resident presents with mobility limitations and requires [mechanical lift] for transfers Created: 06/05/2025 Created by: [ADON]. Related Goal area reflected, Long Term Goal Target Date: 09/05/2025 Staff will safely transfer resident utilizing a [mechanical lift] Created: 06/05/2025 Created by: [ADON]. Problem initiated for, Category: ADLs Functional Status/Rehabilitation Potential [Resident #18] requires assistance with ADL's d/t impaired mobility and incontinence of bowel and bladder. Edited by: 05/08/2025 Edited by: [ADON] with a related Approach stating, Transfer: Total with 1-2 person assist (utilize a [mechanical lift]) Wheelchair for mobility; gel cushion to wheelchair Edited: 05/08/2025 Edited by: [ADON] Review of orders dated 8/15/2025 for Resident #18 reflected an order dated 08/14/2025 reflecting, [Mechanical Lift] transfer for safety and non-weight bearing status. Review of Facility Incident/Accident Investigation Worksheet dated 6/05/2025 reflected an incident involving Resident #18 on 6/04/2025 at 11:30AM. The section titled, Describe Exactly What Happened reflected, Resident reports during transfer mech (mechanical) lift [with]sling, sling rubbed against arm causing S/T [with] minimal bleeding. No other injuries were found. [Resident] alert and oriented. No swelling or bruising noted. Under the Witness section of the form CNA A is listed as the only witness. The Follow up/steps to prevent reoccurrence and person(s) responsible: section reflected a note stating, Inservice staff proper use of lift +sling during transfer. Signature on form is illegible. Review of Inservice initiated by ADON and dated 6/5/2025 reflected, 2. When using the [mechanical] lift-please make sure sling is positioned appropriately so that it is not causing skin tears. Never use a [mechanical] lift without 2 people. Inservice signed by all staff. Review of Paper Progress Note reflected an entry on 6/4/25 stating, Resident report during transfer using mech (mechanical) lift + sling, his arm rubbed against skin causing S/T to rt (right) [lower] forearm, minimal bleeding, area was cleaned [with] wound cleanser. TAO (triple antibiotic ointment) + light dressing applied, no other injuries noted. Review of Skin Assessment for Resident #18 dated 6/4/2025 reflected a note stating, S/T (skin tear) to L (left) upper arm + R (right) lower forearm. The signature is illegible with LVN after the name. Review of staff competencies for [Mechanical] lift/Transfer prior to start of survey on 08/12/2025 reflected 7 total staff, including nurses and nurse aides, had met the Standards of Practice outlined on the form. Review of Employee List provided by facility on 8/12/25 reflected 18 total nurses and nurse aides employed at the facility on that day. 2. Review of Resident #5's Face sheet dated 8/15/2025 reflected a [AGE] year-old, female admitted to the facility on [DATE]. Diagnoses included muscle wasting atrophy right and left shoulder (muscles shrinking and becoming weaker), dementia, unsteadiness on feet, anxiety disorder (intense and excessive worry or fear), and cerebral infarction (a temporary lapse of blood flow to the brain). Review of Resident #5's Quarterly MDS dated [DATE] reflected a BIMS score of 6 (severe cognitive impairment). In Section GG - Functional Abilities, the coding reflected that Resident #5 is dependent on staff to move from sitting to standing position and to transfer from a bed to a chair or wheelchair. Review of Resident #5's Orders dated 8/15/2025 reflected an order dated 8/14/2025 for, [Mechanical Lift] for all transfer due to non-weight bearing status. Review of Resident #5's Care Plan in EMR (electronic medical record) reflected a Focus area stating, I am at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment, medication side effects, poor vision, or incontinence. Date Initiated: 08/08/2025. The related Interventions/Tasks area reflected, I will be assisted with walking, transfers, or toileting as needed, based on my current ability. Date Initiated: 08/08/2025. Review of Resident #5's Paper Care Plan reflected a Problem area stating, Problem Start Date: 09/12/2024, Category: ADLs Functional Status/Rehabilitation Potential [Resident #5's] ability to ___ (ADL: e.g., transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene) has deteriorated R/T advanced age. Edited: 05/29/2025 Edited By: [ADON]. The related Goal area reflected, Long Term Goal Target Date: 08/29/2025 Resident will not further deteriorate in ADL Edited: 05/29/2025 Edited By: [ADON]. The related Approach area reflected, Approach Start Date: 05/29/2025 Follow PT/OT/ST recommendations. Edited: 05/29/2025 Edited By: [ADON] and Approach Start Date: 05/29/2025 Provide assistance for ADL's as indicated Edited: 05/29/2025 Edited By: [ADON]. Observation of two-person transfer of Resident #5 on 08/13/2025 at 03:17 PM with OT G, CNA A, and CNA B revealed Resident #5 sitting in recliner in her room. OTA G had two gait belts in hand. She stated that she would leave the gait belts with the aides and exit the room for the transfer. CNA A and CNA B raised the recliner chair and placed the wheelchair next to the recliner. Both aides stood in front of the resident and each attempted to apply the gait belt to Resident #5. Neither CNA A or CNA B could properly apply the gait belt. CNA A stated, I am going to be honest, I usually do it without a gait belt. It has been a minute since I used a gait belt. We usually do it with two people, one on each side, without a gait belt. Resident #5 requested twice for CNA B to move the belt below her breasts because it was painful. CNA B moved the gait belt slightly lower and continued to try to secure the belt properly. After 15 minutes, Resident #5 declined to continue with the transfer. Resident #5 stated she was tired. CNA B stated, I will go down to therapy and let them train me. In an interview with OT G on 8/13/2025 at 03:37PM, she stated that the facility asked her to train the two CNA's prior to the transfer with Resident #5, but there was not time for her to do it before the surveyor arrived to observe the transfer. She stated that she was a PRN (as needed/temporary) therapist for the facility. She stated that she started on 08/01/2025 when the new company took ownership. She stated that the new ownership no longer contracted with the previous rehabilitation company used by the facility. She stated that at other facilities it was her experience that staff would be trained on transfers when they were hired at the facility. She stated there was no therapy director or physical therapist at the facility currently. 3. Review of Resident #23's Facesheet dated 8/15/2025 reflected an [AGE] year-old, female admitted to the facility on [DATE]. Diagnoses included dementia, muscle wasting atrophy right and left shoulder (muscles shrinking and becoming weaker), myocardial infarction (lapse of blood flow to the heart), abnormalities of gait and mobility, abnormalities of gait (abnormal way of walking), and history of falling. Review of Resident #23's Annual MDS assessment dated [DATE] reflected a BIMS score of 14 (no cognitive impairment). In Section GG - Functional Abilities, the coding reflected the resident requires, Supervision or touching assistance with all transfer types, indicating staff assisting the resident would provide verbal cues and/or touching/steadying and/or contact guard assistance as needed as the resident completes activity. Review of Resident #23's Orders dated 8/15/2025 reflected no orders related to mobility assistance required or any assistive devices required for transfers. Review of Resident #23's Paper Care Plan reflected a Problem area stating, Problem Start Date: 11/08/2023 Category: Falls [Resident #23] is at risk for falling R/T [] immobility,[X] muscle weakness, [] Diabetes, [X] COPD,[X] chronic pain, [X] anemia, [] dizziness, [X]vision problems, [] hearing problems,[X]incontinence , [X] neuropathy, []dehydration, [] decreased cognition. 6-5-2025- Resident had a fall while attempting to stand without assistance. 6-8-2025 Fall while at son's home while attempting to toilet self. Edited: 06/10/2025 Edited By: [ADON]. In the related Goal area it stated, Short Term Goal Date: 09/04/2025 [Resident #23] will remain free from injury. Edited: 06/04/2025 Edited By:[ADON]. In the related Approach area it stated, Approach Start Date: 06/06/2025 Assist resident with standing Created: 06/06/2025 Created By: [ADON]. Review of Patient/Resident Incident/Accident Investigation Worksheet reflected a fall without injury for Resident #23 on 06/05/2025 at 11:15AM. In the Describe Exactly What Happened field, it stated, The patient was attempting to stand up for wkly (weekly) skin assessment, lost her balance and was eased down to the floor. No bruising or injuries noted or reported. The statement is signed by RN. In the section for Follow up/steps taken to prevent reoccurrence and person(s) responsible: it stated, Patient can only stand with assistance. Administrative staff signature is illegible. The signature is dated 6/06/2025. Review of Fall Investigation Worksheet for fall on 6/05/2025 for Resident #23 reflected RN as the only witness to the fall. The statement of witness reflected, The patient verbalized she could stand with my assistance for me to complete her wkly skin assessment. She began losing her balance and was eased to the floor by this nurse. For Neuromuscular/Functional section of the form, it indicated Resident #23 has lower extremity weakness. The recommendations field stated, The patient should not attempt to stand up for skin assessment. She can be assessed better in bed. The form was filled out by RN. 4. Review of Resident #3's Face sheet dated 8/14/2025 reflected a [AGE] year-old, female admitted to the facility on [DATE]. Diagnoses included dementia, contracture (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff) of muscle in lower leg and upper arm, muscle weakness, and pain.Review of Resident #3's Quarterly MDS dated [DATE] reflected that resident was rarely or never understood and BIMS assessment was not able to be conducted to assess cognition. Section GG for Functional Abilities indicated Resident #3 had impairment to both legs, she was totally dependent on staff for all self-care and transfer types, and she is unable to use a wheelchair, walker, or cane. Review of Resident #3's Paper Care Plan reflected a Problem area stating, Problem Start Date: 06/26/2024 [Resident #23's] ability to (ADL: e.g., transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene) has deteriorated R/T Hospice End of Live Care Edited: 06/02/2025 Edited By: [ADON]. The related Approach area stated, Approach Start Date: 06/02/2025 Provide assistance for all ADL's. Edited: 06/02/2025 Edited By: [ADON], Approach Start Date: 06/02/2025 She uses Geri Chair for positioning Edited: 06/02/2025 Edited By: [ADON], Approach Start Date: 06/02/2025 Transfer extensive assist 1-2 Edited: 06/02/2025 Edited By: [ADON] Review of Resident #3's Orders on 8/15/2025 reflected an order dated 08/14/2025 for, [Mechanical Lift] Transfer due to non-weight bearing status. There are no other orders listed indicating Resident #3's related to mobility status or transfer equipment prior to 8/14/2025. The last weight for Resident #3 visible on the order screen reflected a weight of 102.2 lbs on 8/04/2025. Review of Resident #3's Occupational Therapy Evaluation and Plan of Treatment dated for Start of Care on 1/06/2025 and signed by OT F, reflected a Behaviors section indicating, Patient Behaviors: Confused, yet participative. Range of motion to both arms and legs are listed as impaired. Standing ability and sitting ability are listed as, unable. The documents do not indicate any necessary transfer devices or the number of staff required for transfers. It does not describe an appropriate transfer technique for the resident in the notes. Review of Resident #3's Physical Therapy Evaluation and Plan of Treatment dated for Start of Care on 1/6/2025 and signed by PT H, reflected the range of motion to both arms and legs are listed as impaired. Standing ability and sitting ability are listed as, unable. For the section labelled Transfers, it stated Patient requires assistance, however, will not currently address in treatment plan. In an interview with LVN C on 8/14/2025 at 5:50AM, she stated that there were two aides in the building. She stated that the aides present were both She stated that Resident #3 was a two person transfer but was already up in the Geri-chair for the day. She stated she would inform staff that surveyor wanted to observe two-person transfer. Observation of Resident #3 on 08/14/2025 at 6:00AM reflected Resident #3 lying in Geri-chair, eyes closed, well-groomed with blanket placed over her up to her lower chest. In a follow-up interview with LVN C on 08/14/2025 at 6:10AM, she stated that she transfers Resident #3 required two staff. She stated the resident is not classified as needing a mechanical lift. She stated that when she transfers Resident #3, one person stands in front of the resident and one person is behind the resident. She stated the resident is non-weight-bearing. She stated the person behind the resident would normally hold the chair steady during the transfer. She stated the resident is smaller in size, so the person not holding the chair will raise the head of the bed to sit her up, they would then place their arms under the resident's arms and lift her from the bed over to the chair. She stated the second person doesn't usually touch the resident. She stated that they do not use a gait belt with the transfer for Resident #3. She stated that for a bigger resident, one person would be on each side of the resident. She stated the staff would each then place one of their arms under the resident's arm, then assist them to either stand at the bedside or perform an assisted pivot transfer to a wheelchair. She stated she worked at the facility full-time since September or October of 2024. She stated that there was a gait belt in the breakroom now. She stated that it was not safe for staff to transfer a resident by carrying them under their arms. She stated they did it because of Resident #3's size. She stated Resident #3 was not classified as a mechanical lift transfer. She stated she knew of one resident who needed a gait belt and stated that the resident was able to stand on her own. She stated that she has not seen staff use a gait belt recently. She could not recall a specific date or time she last saw staff use a gait belt. She stated, I'm not there in the room to see the transfers usually. She stated that she usually has two CNA‘s on night shift with her. She stated there was an aide assigned to the secure unit and the second aide was helping with the rest of the residents not on the secure unit. She stated that both aides working with her that night were agency staff. She stated that when the aides are ready to transfer the two person assists and residents requiring mechanical lifts in the mornings, she will usually watch the secure unit while the aides work together to assist with residents care. She stated that she sometimes helps with ADL care. She stated that not using proper transfer equipment can result in a fall and injuries. She stated that gait belt use was a fundamental skill for a CNA. She stated that improper use of a gait belt can cause injuries depending on the placement, including skin tears. LVN C demonstrated proper use of a gate belt. In an interview with CNA E on 08/14/2025 at 6:27AM, she stated that she was employed by an agency to work shifts at the facility. She stated that she picks up shifts at the facility when she can because it is closer to her home. She stated that they do not get people up overnight usually and she was familiar with three residents that were two person transfers. She stated that Resident #3 and Resident #5 were two-person transfers. She stated Resident #3 did not require a mechanical lift. She stated that she is not heavy, but she does require two people to lift her to the chair. She stated that each staff member stands on either side of the resident and puts their arms under one side of the resident's arms and they lift the resident together to the Geri-chair. She stated that they do not use any transfer devices or equipment for the transfer for Resident #3. She stated that Resident #3 cannot assist with standing. She stated that people who cannot stand at all during the transfer usually use a mechanical lift. She stated that she does not know the residents well. She stated that she does not check the care plans or the chart to find out the transfer status of a resident. She stated that she usually asks the facility CNA's or the charge nurse how to transfer a resident. She stated they always have regular staff or a nurse available on the shift. She denied receiving any transfer training from the facility prior to starting there. She stated that she has never been trained to do a two person transfer where she was told to lift a resident who cannot stand from under their shoulder without any transfer equipment. She stated it was not safe to lift a resident for a transfer. She stated that transferring a resident without a gait belt by lifting them under their arms was something she learned to do at work. She stated that she never lifts a resident who cannot stand on their own by herself. She stated that the potential impact to the resident was that it could, hurt her. She stated that Resident #3 is, real fragile. She stated, It is a bad habit. She stated she was knowledgeable about how to use a gait belt. She stated, I only use it when they are able to stand some on their own. She stated that in other facilities gait belts are usually in the resident's rooms in the nightstand or in a basket at the bedside. She stated she believed they would be in the same place in this facility. CNA E was able to demonstrate proper application of a gait belt. She was unable to locate a gait belt in the room for Resident #5. Resident stated that she did not believe there was a belt like that in her room. She stated that gait belt use was a fundamental skill for a CNA. She stated that with improper use of a gait belt, a resident could be hurt or sustain a rib fracture if it was too tight and if it was too loose, the gait belt could hurt a resident under their arms and cause shearing to their skin or be useless in assisting with the transfer. She was unable to recall other staff members using a gait belt with a resident in the facility. She stated, I don't think anyone uses a gait belt for transfers here. In an interview with ADON on 8/14/2025 at 7:07AM, she stated that Resident #5 was a two-person transfer. She stated that Resident #3 was a 1-2-person transfer. She stated that Resident #3 was full weight bearing status to her knowledge. She stated that the last physical therapy discharge note did not state the weight bearing status of Resident #3 or transfer requirements. She stated that there is a note from occupational therapy assessment dated [DATE] to 2/06/2025 stating Resident #3 is unable to stand. The notes state that she requires assistance with transfers but does not indicate how the transfer should be performed. She stated that she would provide the most recent therapy notes from the previous rehabilitation company the facility contracted with. She stated that the care plans should be pretty accurate regarding transfer status. She denied knowledge of any falls with transfers. In an interview with Resident #18 on 8/14/2025 at 6:50AM, he stated that he transfers with a mechanical lift. He stated that he has not had any problems that he can recall. He stated that the staff usually only use one person for the lift transfer. He stated he believed he only needed one person to perform the transfer. In an interview with CNA E on 8/14/2025 at 07:06AM, she stated that a mechanical lift transfer should only be performed with two staff. She stated that Resident #18 was a mechanical lift transfer. She stated that she has never performed a mechanical lift transfer on her own. In a follow up interview with Resident #18 on 8/14/2025 at 8:36AM, he stated that he did recall an incident in early June 2025 where he received a skin tear during a mechanical lift transfer. He stated that he did not remember how many people were operating the mechanical lift during the transfer. In an interview with CNA A on 8/14/2025 at 8:45AM, she stated she had worked at the facility for 14 years. She stated that she did recall the mechanical lift transfer with skin tear incident on 6/04/2025 for Resident #18. She stated that she got him dressed, put the mechanical lift blanket under him, and got him up in the lift. She stated, I was pulling him back in the chair when my nails scraped his elbow. She stated there were no other witnesses to the event. She stated that she performed the mechanical lift transfer with Resident #18 on 6/4/25 by herself. She stated that she should have used two people for the transfer. She stated that she knew that she needed two people. She stated that she could not find the other CNA on staff that day. She stated that she should have asked the nurse to help her and she did not. She stated that she was not trained by facility on mechanical lifts. She stated that the potential risk to patient with a one-person mechanical lift transfer is that a resident could fall out of the lift. She stated that for a normal two-person transfer, she would ensure privacy for the resident. She stated she would normally sit the bed up to help if the resident needed assistance sitting. She stated they did not do that the day before. She stated it was because she was nervous. She stated that she would normally assist a resident to sit if they needed it. She stated she didn't know anyone in the building who needed a gate belt. She stated the gate belt use and transfer skills were an important skill for a CNA to have. She stated the transfers without the proper equipment can put the resident at risk of hurting themselves.In an interview with CNA B on 08/14/2025 at 9:28 AM, she said she worked at the facility for about a month. She stated she had no transfer training or gate belt training on hire. She stated that for a normal two-person transfer, staff stand on either side of the patient. She stated one person near the shoulder. She stated one person should stand near the resident's legs. Then they swing the resident together to set their shoulders up and their feet down and in a sitting position. She stated that if they are unable to sit up on their own, she would assist them. She stated each person would then stand on one side of the resident. She stated the staff would put one of their arms under the resident's arm on each side, and staff would use the other hand to hold onto the resident's pants to assist them to a standing position and either pivot to the destination or walk a few steps and sit down. She stated that she has not used a gait belt on anyone in the facility. She stated she does not know of any residents that need a gait belt in the facility. She stated it's been about four months since she used a gait belt. She stated that she was not able to apply the gait belt on Resident #5 on 8/13/2025 during the observation. She stated that knowledge of how to use a gait belt and perform transfers was an important skill for CNA. She stated that she asks the nurses to know what the ability level and transfer status of the residents in the facility. She stated she does sometimes checks the care plans to find out information about resident information and transfers. She stated that CNA A has worked at the facility for a long time and she asked her how to do the transfers for the residents. She stated she would ask the nurse to find out who needs a gait belt after the interview. She stated that improper transfers can cause a fall. She stated that improper use of a gait belt can cause a fall. She stated that the resident can also be injured by improper positioning of a gait belt. She stated that she was trained by the occupational therapist on 8/13/2025. In a follow up interview with OT G on 08/14/2025 at 11:40AM, she stated that she was not sure how many residents were 1 person, 2 person, or mechanical lift transfers in the facility. She stated that she had never seen a list of residents who required gait belts for transfers. She stated that anyone who is not independent or using a mechanical lift for transfers, should have a gait belt on during transfers. She stated that she would use a mechanical lift to transfer a resident who is unable to bear weight on their legs. She stated that Resident #3 is non-weight bearing. She stated that she just met Resident #3 on the morning of 8/14/2025. She would use a mechanical lift to transfer her. She stated that she would not recommend a one person transfer for Resident #3. She stated that she would never lift a resident from under their arms to perform a transfer. She stated that transfer recommendations from therapy staff should be in a therapy evaluation or in the care plan. She stated sometimes care plan updates do not happen immediately after a change. She stated that lifting a resident for a transfer from under their shoulders could result in a shoulder injury. She stated that improper transfers can also result in shearing injuries or falls. She stated that she was not sure how long Resident #3 had been unable to bear weight. She stated she would check the records. She stated staff should never use a mechanical lift with one person only. She stated that the potential risk to resident is injury. She stated her role was to evaluate and assess patients for their occupational performance, functional mobility, and ADL performance. In an interview with RNC on 8/14/2025 at 12:04PM, she stated that she started in the building as the acting Director of Nursing on 8/04/2025. She stated that the new company took over the building on 08/01/2025. She stated that the new Director of Nursing started on 8/11/2025, but she had not been through the training for the position and would not be familiar with the residents or corporate policies at that time. She stated her role was as Clinical Support when the Director of Nursing assumes her role in the facility. She stated that anytime staff transfer a resident they should use a gait belt. She stated she asked the ADMIN to order 30 gait belts on 08/13/2025 when staff were unable to find a gait belt outside of the two utilized by the therapy team. She stated that staff should not have to provide that. She stated that the facility should provide gait belts for residents that need them. She stated it would have been the responsibility of the previous Director of Nursing to ensure that gait belts were available. She stated that in the absence of a DON, the ADON would be responsible for gait belts. She stated she did not have time to do a mock survey or evaluate that part of the facility prior to survey entrance. She stated that staff would not use a gait belt if a resident refused the gait belt, if they were a mechanical lift transfer, or if they transferred independently. She stated that transfers without a gait belt, when one is indicated, put residents at risk for skin tears, bruising, and falls. She stated that improper use of a gait belt can cause injury to a resident. She stated it was a fundamental skill for a CNA to be able to use a gait belt for transfers. She stated she started a competency packet with transfers for the facility staff when she realized there was a problem. She stated that staff should never transfer a resident in a mechanical lift with one person. She stated that the risk to the residents of only having one staff member perform a mechanical lift transfer is injury. She stated that she was not aware of any incidents of staff using a mechanical lift with one person. She stated that she would work with therapy to start trainings for mechanical lift proficiencies with the direct care staff. She stated that for a normal two person transfer without a mechanical lift, staff would raise the head of the bed slightly, and each staff member would support either the shoulders or the legs, as assist the resident to sit. She stated that staff would then apply a gait belt, allow the resident to sit at the bedside for a moment, and ensure that the wheelchair is locked. She stated that staff would then stand to the right and left of the resident and use the gait belt and assist the resident to stand. She stated that she requested OT G to evaluate the transfers of several of the residents. She stated that staff should never lift a resident from under their arms during transfers. She stated that if a resident is non-weight bearing, they should automatically be listed as a mechanical lift transfer for the safety of the resident and the staff. She stated that movement from a partial to moderate assist to a mechanical lift transfer would indicate a decline in status. She stated that it was the responsibility of the facility to improve the status of the residents, but some situations cannot be helped. In an interview with ADON on 8/14/2025 at 2:59PM, she stated that she started at the facility in December of 2025 as MDS Coordinator/ADON. She stated that when the previous DON of the facility left in December, she had been on call for all nursing related concerns or reportables. She stated that she worked on the investigation involving Resident #18 on 6/04/2025. She stated that when she interviewed Resident #18 he stated that the fabric of the sling pulled on his skin causing the skin tear. She stated that staff should always use two people for mechanical lift transfers. She stated that the risk to the resident of only using one staff for a mechanical lift transfer is injury. She stated, You just don't do it without two people. She stated that she was not aware that there was only one person in the mechanical lift transfer on 6/04/2025. She stated that she did not know if she assumed that there were two people present for the transfer or if she [TRUNCA

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide K wear a beard guard when standing over clean dishes in the dishwashing room on 08/12/2025. 2. The facility failed to ensure Dietary [NAME] M used proper hand hygiene during food preparation on 08/13/2025. These failures could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: 1.Observation on 04/22/2025 at 9:10 AM, Dietary Aide K was not wearing a beard guard when standing in the dishwasher room over clean dishes. His beard growth was approximately 8 inches. Interview on 08/12/2025 at 9:15 AM, Dietary Aide K stated he was expected to wear a beard guard anytime he was in the kitchen area. He stated if hair fell onto plates and the hair transferred to residents' food there was a possibility a resident may become ill with some type of stomach issues (when asked what type of stomach issues he did not respond to the question). He stated germs was located on hair. Dietary Aide K stated he had been in-service on wearing beard guards. He stated it was in February 2025 or March 2025. He did not recall the exact date. 2. Observation on 08/13/25 at 7:25 AM, Dietary [NAME] L was wearing gloves when preparing puree food. She touched the right side of her shirt with her right hand. Dietary [NAME] L touched the bacon without changing her gloves. She picked up the bacon with her right hand and placed the bacon on a baking pan. Interview on 08/13/25 at 12:50 PM, Dietary [NAME] L stated she did not change her gloves after she touched her clothes. She stated she did touch pick up the bacon and place it on pan with her right hand. Dietary [NAME] L stated she did contaminate the bacon. She stated if a resident ate contaminated food there was a possibility the resident may become ill with stomach issues such as vomiting, diarrhea and nausea. She stated she had been in-service on hand hygiene and to change gloves anytime you touch anything contaminated. She stated her clothes would be considered contaminated. She stated she had been in-service on hand hygiene but did not remember the date of the in-service. Interview on 08/14/25 at 8:30 AM Dietary Manager stated hair nets or cap and beard guard on facial hair was present are required for all staff while in the kitchen. Dietary Manager stated it could negatively affect a resident if hair restraints are not worn by a resident receiving food with hair in it. Dietary Manager stated it was her responsibility to ensure beard restraints were worn by the male staff in the kitchen. Dietary Manager did not answer why dietary aide did not properly wear a beard guard while in the kitchen even though he had facial hair. She stated all staff was to wash hands after touching anything no Interview on 08/14/25 at 12:30 PM the Administrator stated his expectation was that beard restraints were to be worn by all staff in the kitchen. The Administrator stated if beard restraints are not worn there was a possibility a hair may fall into food. He stated there was a possibility if a resident ingested a hair the resident may become ill with some type of stomach issues. The Administrator stated he expected gloves to be changed, hands washed anytime staff touch contaminated items. He stated clothes would be considered contaminated. He stated there was a possibility if there was a hair or bacteria in food, a resident may develop a food borne illness. The Administrator stated the Dietary Manger was responsible for all protocols in the kitchen and he was responsible to monitor the Dietary Manager. Record review of the facility's Policy on Dietary Employee Personal Hygiene, not dated, reflected It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. Gloves are to be worn and changed appropriately to reduce the spread of infection. All dietary staff must wear hair restraints (hairnet, hat and/or beard restraint) to prevent hair from contacting food.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident #2 and Resident #7) reviewed for ADL care. The facility failed to ensure Resident # 2 and Resident #7's nails were cleaned and did not have any rough edges on 08/12/2025. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Record review of Resident #2's face sheet , dated 08/13/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia ,unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( a group of diseases and illnesses that affect your thinking, memory, and reasoning without behaviors), blindness right eye , low vision left eye ( lack of vision - it interferes with daily activities), and muscle weakness ( decreased ability to move, lift, or hold objects). Record review of Resident #2's Annual MDS, dated [DATE], reflected the resident had a BIMS score of 5, which indicated his cognition was severely impaired. Resident #2 required supervision or touching assistance with the following: personal hygiene, showers, upper and lower body dressing and, toileting hygiene. Record review of Resident# 2's Comprehensive Care Plan, revised on 05/08/2025, reflected Resident #2 ‘s ability to maintain personal hygiene has deteriorated. Intervention: Resident #2 required assistance with ADLs. Record review of Resident #2's nurses notes and there was not any refusal of nail care documented from 08/01/2025 thru 08/12/2025. Observation and interview on 08/12/2025 at 11:01 AM, revealed Resident #2 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle and ring fingernails on his right hand. Resident # 2's middle fingernail on his right hand was uneven around the edges. Resident #2 was not interviewable. Record review of Resident #7's face sheet, dated 08/13/2025, reflected a [AGE] year-old- male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified lack of coordination (the inability to smoothly and precisely control bodily movements), dementia in other diseases classified elsewhere, without behavioral disturbance, psychotic, mood and anxiety ( a group of diseases and illnesses that affect your thinking, memory, and reasoning without behaviors), and muscle weakness (decreased ability to move, lift, or hold objects). Record review of Resident #7's Annual MDS, dated [DATE], reflected the resident rarely/never understood. He had poor short- and long-term memory recall. His decision-making ability was severely impaired. Resident #7 required supervision and touching assistance with the following: personal hygiene, lower/ upper body dressing and, oral hygiene. He required partial to moderate assistance- (Helper does less than half the effort) with the following: Showers and toileting. Record review of Resident #7's Comprehensive Care Plan, dated 06/16/2025, reflected Resident # 7 was at risk for deterioration in ADLs (bed mobility, transfers, personal hygiene, dressing, eating, walking and locomotion). Provide assistance for ADLs as needed. Record review of Resident #7's nurses notes and there was not any refusal of nail care documented from 08/01/2025 thru 08/12/2025. Observation and interview on 08/12/2025 at 10:15 AM, revealed Resident #7 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle ring and fore fingernails on his right hand. Resident #2's ring and middle fingernail on her right hand were uneven around the edges. He was not interviewable. In an interview on 08/13/2025 at 2:31 PM, LVN D stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. He stated the CNAs were responsible for all other residents' nail care. LVN D stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as stomach problems nausea and vomiting. He stated she would need to ask staff questions for the reason nail care was not completed on Resident #2 and Resident #7. LVN D stated no one reported to him that Resident #2 or Resident #7 refused nail care. He stated anytime a resident refused care it was documented in the nurses' notes. In an interview on 08/13/2025 at 2:45 PM, CNA H stated the CNA s were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes (a disease occurs when blood sugar is too high). She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA H stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as vomiting and diarrhea. CNA H stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 2 and Resident #7, and they did not refuse nail care. In an interview on 08/13/2025 at 2:58 PM, CNA I stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA, I stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA I stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 2 and Resident # 7, and they did not refuse nail care. CNA I stated she did not know the last time these residents' nails were trimmed or cleaned she would need to check the medical records. In an interview on 07/31/25 at 10:20 AM, the ADON stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes. She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The ADON stated the nurse supervisor was responsible for monitoring CNAs giving ADL care which included nail care, and the ADON and DON was responsible for monitoring the nurse supervisors. Record review of the facility's Policy on Nail Care, not dated, reflected The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. Nails should be kept smooth to avoid skin injury.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one of five residents ( Resident # 3) reviewed for activities. The facility failed to provide Resident #3 in room activities on the dates of 07/03/2025 thru 08/11/2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included: Record review of Resident# 3's face sheet, dated 08/14/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included depression, unspecified ( a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder ( a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( a condition where individuals experience cognitive decline consistent memory loss, impaired thinking, etc. without behaviors). Record review of Resident#3's Annual MDS Assessment, dated 10/02/2024, reflected Resident #3 had a BIMS score of 0, which indicated her cognition was severely impaired. Resident #3 was not capable of responding to questions of her activity preferences. Record review of Resident #3's Quarterly MDS Assessment, dated 05/31/2025, reflected Resident #3 was rarely/never understood. The staff completed Resident #3 cognitive assessment. Resident #3 decision making ability was severely impaired (never/rarely make decisions). She had poor short- and long-term memory recall. Record review of Resident #3's Comprehensive Care Plan reflected (problem created on 08/15/2022) Resident #3 was dependent on staff for meeting emotional, intellectual, physical, and social needed related to Alzheimer's (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). Resident #3 care plan (revised on 08/13/2025) reflected Resident required personalized engagement to support psychosocial wellbeing. Resident #3 will participate in at least one 1:1 activity of choice a minimum of two times per week to enhance social interaction and emotional wellness. Monitor for changes in engagement levels and adjust the type of timing of 1:1 activities as needed. Record Review of the Activity In Room Participation record for the months of July 2025 and August 2025 reflected Resident #3 did not receive in room visits from 07/03/2025 thru 08/11/2025. Observation and interview on 08/12/2025 at 10:05 AM Resident was in her room lying in bed. Resident # 3's television was not on and there was not any stimulation in resident's room. Resident #3 was not interviewable. Interview on 08/14/2025 at 8:30 AM, the Activity Director stated Resident #3 did not receive in room activities from 07/03/2025 thru 08/11/2025. The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if residents were not coming out of their room, the residents were to be provided in room activities. The Activity Director stated she provided in room activities at least twice a week. She stated there was not an excuse why Resident #3 did not receive in room visits. The Activity Director stated if a resident was not receiving activities on a consistent basis there was a potential a resident may become bored, depressed, or have a decline in their quality of life. Interview on 08/14/2025 at 10:45 AM, the Administrator stated he expected in room activities be provided to the residents needing these types of activities. He stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored and isolated. He stated the Activity Director was responsible for all activities in the facility. He stated the Administrator would be responsible for monitoring the Activity Director. Record review of the facility's Activity Policy, dated not dated, reflected It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Activities may be conducted in different ways: one-to-one programs, person appropriate- activities relevant to the specific needs, interests, culture, background, etc. for the resident.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for one of five residents reviewed for infection control practices. (Resident #48). The facility failed to ensure that staff wore a gown during medication administration via g-tube (a tube inserted into the stomach) on 08/13/2025 for Resident #27 when the resident was on isolation precautions ordered 08/12/2025. There was no Enhanced Barrier Precaution signage on the door nor PPE (personal protective equipment) inside or outside of Resident 27's room. This failure could place the residents, staff and visitors risk for cross contamination. Findings included: Review of Resident #27's Face sheet dated 8/13/2025 reflected a [AGE] year-old, male admitted on [DATE]. Diagnoses included Cerebral Infarction (a temporary lapse of blood flow to the brain), Neurosyphilis (sexually transmitted infection that affects the brain and spinal cord causing cognitive changes), and Hypertension (high blood pressure). Review of Resident #27's orders reflected an order dated 8/12/2025 for Enhanced Barrier Precautions: Resident requires enhanced barrier precautions. Wear PPE per facility protocol.[BH1] [EM2] Review of Resident #27's Care Plan reflected a Focus Area stating, Resident requires Enhanced Barrier Precautions due to colonization or infection with a multidrug resistant organism (MDRO) or is at high risk per CDC criteria r/t g tube Date Initiated: 08/12/2025. Related Interventions/Tasks reflected, [NAME] gown and gloves before high-contact resident care activities (e.g., dressing, bathing, toileting, device care, wound care), Date Initiated: 08/12/2025, Maintain a supply of gowns and gloves inside or outside the room for ease of access, Date Initiated: 08/12/2025, and Place signage outside of residents room indicating Enhanced Barrier Precautions are in use (do not include specific diagnosis), Date Initiated: 08/12/2025. Observation of medication administration with LVN D on 08/13/2025 at 7:59AM[BH3] [EM4] , revealed LVN D did not wear a gown while administering medications via G-tube for Resident #27. There was no Enhanced Barrier Precaution signage on the door. There was no PPE (personal protective equipment) inside or outside of the room. In an interview with LVN D on 8/13/2025 at 8:30AM, he stated that Resident #27 should be on enhanced barrier precautions. He stated that he should have worn a gown during medication administration with a g-tube. He stated it was the responsibility of nurses and CNAs to initiate EBP for newly admitted residents. He stated that the potential impact to the resident of not wearing a gown with medication administration via g-tube could lead to infections. In an interview with ADON on 8/13/2025 at 8:39AM, she stated her expectation was that staff use gowns and gloves when providing direct care to a resident or handling the medical device for a resident, as indicated by the guidelines for enhance barrier precautions, for those residents who require it. She stated that enhance barrier precautions should be followed with g-tube medication administration. She stated it was the responsibility of nursing staff and nursing administration to implement EBP for a new resident. She stated that she printed the signs and thought they were being posted and PPE was set out by staff. She stated the potential impact to the resident of not following the guidelines is possible exposure to infection for the resident receiving care and potentially spread infection to other residents in the facility. In an interview with RNC on 8/14/2025 at 12:04PM, she stated that the was the current Infection Preventionist for the facility. She stated that she asked the newly hired DON and ADON to put the EBP sign on the door for Resident #27. She stated that she did not go back to check that it was done. She stated that Resident #27 should be on EBP for his g-tube. She stated that the potential impact to the resident of not using a gown and gloves during medication administration is the potential for cross contamination. In an interview with NP on 8/15/2025 at 12:04AM, she stated that she expected the facility to follow the guidelines for enhance barrier precautions, when appropriate. She stated the potential impact to the residents of not following the guidelines could be exposure to infection, actual infection, or issues with the device. In an interview with ADMIN on 8/15/2025 at 3:43PM, he stated that residents with g-tubes should be on enhanced barrier precautions. He stated his expectation was that staff follow the guidelines while providing care and giving medications to residents with enhance barrier precautions. Requested facility policy for Medication Administration and Enhanced Barrier precautions via email on 08/13/2025 at 09:45AM. No policy or related policy was provided before exit. Review of the CDC[BH5] guidelines for Enhanced Barrier Precautions in Nursing Homes dated 05/20/2024 reflected, EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility.

Based on interviews and record review, the facility failed to notify the resident's Ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 4 residents (Resident #1) reviewed for Discharge Rights. The facility failed to notify Resident #1's Ombudsman in writing of the transfer/discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female with an initial admission date of 08/06/2024. Resident #1 was discharged to a behavioral hospital on [DATE] with a warrant for emergency detention. Resident #1's diagnoses was Unspecified Dementia, (mental decline without a specific underlying diagnosis) unspecified severity, with psychosis disturbance (group of mental health disturbances characterized by a loss of touch with reality, leading to abnormal thoughts, perceptions and behaviors), Major Depressive Disorder (serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and Generalized Anxiety Disorder (severe ongoing anxiety that interferes with daily activities). Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 5 indicating severe cognitive impairment. Review of an Application for Emergency Apprehension and Detention dated 01/25/2025 and signed by the ADM reflected Resident #1 has been having very poor and combative behavior. She has been disturbing the peace of the community in the nursing facility. Review of a Notice of Discharge or Transfer dated 02/24/2025 for Resident #1 and e-mailed to her Guardian on 02/24/2025 reflected she was being discharged from the facility. The document did not include the correct name of the Ombudsman and no address was provided. Review of the Warrant for Emergency Detention for Resident #1 dated 3/25/2025 reflected there was reasonable cause to believe that the person evidences mental illness; that the person evidences substantial risk of serious harm to the person or others; that the risk of harm is imminent unless the person is immediately restrained; and that necessary restraint cannot be accomplished without emergency detention. In a telephone interview on 04/01/2025 at 10:53 AM, the Ombudsman stated she did not receive a copy of the discharge notification for Resident #1 of the facility's intent to discharge. In an interview on 04/02/2025 at 11:53 AM, the ADM stated I didn't send a written notice to the Ombudsman of the discharge for Resident #1. I sent one to the guardian. I should have sent a written notice to the Ombudsman, but I tried to reach her by phone twice. In an interview on 04/02/2025 at 12:37 PM, the DON stated the facility follows CMS policy, and it was a learning process. She provided a copy of the admission, transfer and discharge rights that she said the facility was supposed to follow. She stated she had started a training for employees. Review of a document dated 3/31/2025 and provided by the DON on 04/02/2025 revealed Title 42-Public Health, Chapter IV- Centers for Medicare and Medicaid Services, Department of Health and Human Services, Subchapter G- Standards and Certifications, part 483- requirements for States and Long-Term care Facilities. Transfer and Discharge- Facility requirements- (3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must (1) Notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. No documentation was provided by the ADM at the time of exit from the facility of a written notice of discharge to Resident #1's Ombudsman.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food accordance with professional standards for food service of one of one kitchen reviewed for food storage, meal prep and sanitation. 1. The facility failed to seal, label and date partially frozen chicken cubes and a personal cell phone on the food prep table. 2. The facility failed to ensure dietary staff practiced proper hand hygiene and glove use. 3. The facility failed to follow recipes when preparing pureed food. 4. The facility failed to ensure regional maintenance director and a contractor wore hair nets and a beard net when entered the kitchen, the dietary staff appropriately wore a hair net, and nursing staff wore a hair net when in the kitchen. These failures could place residents at risk for health complications and foodborne illnesses. Findings included: 1. Observation on 06/25/2024 from 9:06 AM to 9:16 AM there was an open clear plastic bag not labeled or dated of partially frozen cubed chicken on the food prep table. A cell phone was lying on the food prep table near a pot and the open bag of the partially frozen cubed chicken. In an interview on 06/25/2024 at 9:17 AM the Dietary Manager stated she had been away from the food prep area for several minutes. She stated the cubed chicken was pre-cooked. She also stated the plastic bag the chicken was stored in was not to be left opened and should have been closed until the time she was going to cook the chicken. She stated anything could fall into the bag of chicken. The Dietary Manager stated if there were flies in the kitchen the fly could fall into the open bag of chicken and fly out of the bag without the dietary staff knowledge which would contaminate the chicken cubed chicken. She also stated she was not a nurse and did not know if a resident would become ill if ingested contaminated chicken. Observation on 06/25/2024 at 9:22 AM Dietary Manager removed the cell phone from the kitchen area. She did not sanitize the food prep area and placed ladles where the cell phone was lying on the food prep area. Observation on 06/25/2024 at 9:45 AM Dietary Manager picked up one of the ladles laying on the area where cell phone was laying. She placed the ladle in the pot on the stove where dumplings were being prepared. In an interview on 06/25/2024 at 9:48 AM Dietary Manager stated she did place ladles where the cell phone was lying on the food prep table. She stated she removed the cell phone from the food prep table and did not sanitize the food prep area where the cell phone was located. Dietary Manager stated there was a potential the ladles may be contaminated after touching surface where the cell phone was lying on the food prep table. She stated cell phones are not sanitary and was considered contaminated. She also stated there was a possibility the bacteria from the cell phone could have cross contaminated the ladles. She stated she was not a nurse and does not know if a resident may become physically ill if the ladle had germs on it and was in the pot where food was being prepared. She stated she was expected to sanitize the food prep area after she removed the cell phone. She also stated the food prep area where the phone was located was not considered sanitized. Observation on 06/26/2024 from 7:10 AM to 7:25 Dietary Manager was preparing pureed food. She touched her shirt, her hair covering and the oven door handle. She did not wash or sanitize her hands and touched the outside of the fourchettes (where you place your fingers into a glove) on both gloves. She donned the gloves and touched inside the scoop. This portion of the scoop was used to hold the scramble eggs she obtained from the silver container on the steam table and she place the eggs in a white plastic container. Her middle finger and her fore finger on her right hand did touch top of the eggs when she was placing the scrambled eggs into the pureed blender. The Dietary Manager pureed the eggs and carried the pureed blender to the dishwashing room to clean before using it to puree other foods. She did not remove her gloves and before she entered the dishwashing room she touched the top of garbage can to throw away a napkin. The Dietary Manager proceeded to clean the pureed blender. She touched several surfaces on the dishwasher. She returned to the food prep area and did not change her gloves and touched part of the bacon she placed in the pureed blender. Interview on 06/26/2024 at 7:25 AM the Dietary Manager stated she did not wash or sanitize her hands prior to placing gloves on her hands when she pureed the eggs. She stated she did touch her shirt and she was in a hurry and did not know if she touched the eggs. She also stated she did touch the inside part of the scoop where eggs were placed after she dipped the scoop inside the scramble eggs on the steam table. The Dietary Manager stated it was possible she touched the garbage can lid when she discarded paper towel. She also stated she did not remove her gloves while she was in the dishwasher room and she did return to the kitchen and she did touch part of one piece of bacon without changing her gloves. She stated she was expected to change her gloves, wash hands and place new gloves on and she did not do this between tasks. She also stated there was a possibility germs or bacteria was on her gloves and she could have contaminated the containers, the scoop, and the food. She stated she was not a nurse and did not know if a resident may become ill if the ate any contaminated food. Observation on 06/26/2024 at 7:30 AM Dietary Aide B donned gloves without washing his hands and touched the lid of garbage can to throw away napkin. He touched inside of clean plates. Interview on 06/26/2024 at 7:32 AM Dietary Aide B stated he had been informed to always wash his hands before wearing gloves. He stated it was difficult to wash his hands and then wear gloves due to being difficult to attempting to place the gloves onto his hands. He stated he did not know if not washing his hands would contaminate the gloves. He did not respond to any further questions about hand sanitation, wearing gloves and touching clean plates with potential contaminated gloves. Observation on 06/26/2024 at 7:33 AM the Dietary Manager removed her gloves and placed new gloves on without washing or sanitizing her hands. She touched the fourchettes of the gloves when she donned the gloves. She touched the bread with her gloved hands and place the bread in the pureed container. After she pureed the bread and placed the bread in a silver container on the steam table, she went to her office and looked for recipes. She touched 3 manuals in her office, picked up a pen and wrote something on a sheet of paper, touched her desk, moved her personal phone on her desk and touched a cup on her desk. She was wearing the same gloves. The Dietary Manager returned to the kitchen area with the same gloves on her hands and she picked up the food thermometer and touched the part of the thermometer used to place into the food to check the temperature of the food. Interview on 06/26/2024 at 7:50 AM The Dietary Manager stated she realized she did not remove her gloves and wash her hands after she had begun touching the outside of the gloves when she was placing the gloves on her hands. She stated she knew she had already made a mistake earlier and she would probably be written out for not washing her hands or changing her gloves earlier and she thought if she was already getting written out she would just continue since she made the same mistake again. She stated she was required to change her gloves in between tasks and wash her hands prior to placing new gloves on her hands. She stated she did touch the bread without changing her gloves. She also stated when was in her office she touched the manuals, pen, paper, her cell phone on her desk and probably touched the cup on her desk. She stated she did enter the kitchen without changing her gloves and touched the part of the thermometer she placed in the food to obtain a temperature of the food. She stated she was expected to change her gloves and wash her hands after she left her office and before she obtained temperature of the food. She stated she had already made mistake of not changing her gloves and she was not thinking clearly. Interview via telephone on 06/26/2024 at 11:51 AM The Registered Dietician Consultant stated anyone enters the kitchen area was required to wear a hair net. If a male had facial hair the male was required to wear a beard net. She stated this included anyone working in other departments such as nursing and any contractors entered the kitchen. She stated hair could fall onto food, food prep areas and clean dishes. She did not respond to any other questions if someone was not wearing a hair net in the kitchen. Observation on 06/27/2024 at 10:38 AM Dietary Aide C gave Regional Maintenance Director a hair net and beard net. Dietary Aide C was wearing gloves and his middle finger and fore finger on his right hand touched the Regional Maintenance Director palm on his right hand. Dietary Aide C touched his own shirt and touched the door handle of the kitchen door. He exited the main area of the kitchen and entered the dishwashing room and touched the following clean silverware without changing his gloves: the tines (area of the fork where food is placed prior to eating the food) of six clean forks, touched inside the scoop where food is placed in a spoon of four spoons, and touched the top of four knives. Interview on 06/27/2024 at 10:41 AM Dietary Aide C stated his fingers inside his gloves did touch the Regional Maintenance Director hand. He also stated he did not change his gloves and did touch the part of the fork and spoon where residents would put the food on the fork and spoon to put the food in their mouths. He also stated he did touch the tip of the forks and there was a possibility the silverware may have germs on them from his gloves. He stated if a resident did eat some germs they may become sick with stomach problems may have diarrhea. Observation and interview on 06/26/2024from 7:30 to 7:32 AM Dietary Aide B was standing near clean plates his hair net was not covering all of his hair. There was approximately 6-8 inches of hair on the side and the back of his head not covered. Dietary Aide B stated there was a possibility hair may fall onto the plates. He stated his hair was not completely covered with the hair net. He stated he was not a nurse and did not know what possibly may happen to a resident if hair was on resident plate or food and the resident ate the hair. Observation on 06/26/2024 at 8:07 AM, CNA D entered the kitchen area without wearing a hair net. She was standing five to six feet inside the kitchen. CNA D was within approximately less than one foot next to uncovered plates of food for residents eating in their rooms. Her hair was shoulder length. In an interview on 06/26/2024 at 8:12 AM CNA D stated she was standing inside the kitchen and was standing over plates of food uncovered. She stated she was standing near the food prep area. She also stated she was expected to wear a hair net anytime anyone entered the kitchen. She stated she had been in-serviced on wearing hair nets when nursing staff entered the kitchen. CNA D stated there was a possibility her hair could have fallen onto the food as she was standing over the plate of food that was going down the hall on a hall cart. CNA D stated hair was considered contaminated and a resident may become ill if there was hair on their food and the resident ate the hair. She also stated the resident may become physically ill with vomiting or diarrhea from the bacteria from the hair. Interview on 06/27/2024 at 8:40 AM the Administrator stated he would provide all dietary staff personnel records and their check off list of training. The Dietary Manager personnel record was the only dietary personnel record provided. Observation on 06/27/2024 at 9:55 AM a Contractor entered the kitchen and he had approximately 8 inches of facial hair around his chin. He was not wearing a hair net or beard net. He was standing in the food prep area of the kitchen. Interview on 06/27/2024 at 9:58 AM the Contractor stated he was aware of wearing a hair net and beard net when he entered the kitchen and he stated he frequently made deliveries to this kitchen throughout the month. He stated he forgot to place the hair net and beard net on when he entered the kitchen. He stated he knew this was a rule and he did not follow the rules. He stated there was a possibility hair could fall onto surfaces in the kitchen. The contractor did not respond to any further questions about hair being contaminated or the importance of wearing hair net and beard net. Interview on 06/27/2024 at 10:02 AM The Dietary Manager stated the contractor had been explained to wear hair net and beard net when he entered the kitchen. She stated there was a possibility he could have contaminated the food being prepared when standing near the food prep table. She stated there were hair net and beard net accessible at the door when entering the kitchen. Requested in-services on the following: hand sanitizing/ wearing gloves, pureed food, follow recipes, and wearing hair nets/ beard nets, label/ dating food, keeping containers of food closed until ready to use, and storing personal items on the food prep tables. These in-services were not provided at time of exit. Observation on 06/27/2024 at 10:30 AM there were beard nets and hair nets stored at the entrances to the kitchen. The Regional Maintenance Director was standing by the food prep table in the kitchen area without wearing a hair net or beard net. There were containers of food on the food prep table where he was standing. Interview on 06/27/2024 at 10:35 AM the Regional Maintenance Director stated he did know to wear a hair net and beard net when he entered the kitchen. He stated this was standard protocol in every kitchen in a nursing home. He stated he was standing near the food prep table and there was food where he was standing. He also stated it was a possibility hair may fall into the food. He stated he was not a nurse and did not know what would happen to a resident if they ate food with hair on the food. Interview on 06/27/2024 at 11:15 AM the Administrator stated any staff including contractors that entered the kitchen was expected to wear hair nets and if needed a beard net. He stated there was a possibility of hair falling on food prep surfaces, plates and /or foods. He stated he was not a nurse and did not know what may happen to a resident if the resident ingested hair. He stated hair may or may not be contaminated it was according to the individual. He stated all dietary staff was expected to wear gloves when in the kitchen. The Administrator also stated he did expect the dietary staff to change their gloves in between tasks or when touch any contaminated item. He stated the staff was expected to wash hands prior to placing gloves on their hands. The Administrator did not answer any questions about if the dietary staff was wearing contaminated gloves and touched food, plates, silverware, or any food containers. He stated the staff personal items including cell phone was not to be placed on the food prep table. He stated if it was on the food prep table he did expect the table to be sanitized. The administrator did not respond to the question if the food prep table was not sanitized and food was being prepared on that table if the there was a possibility of cross contamination. Requested in-services from the dietary department such as: hand sanitizing/ wearing gloves, pureed food, follow recipes, and wearing hair nets/ beard nets, label/ dating food, keeping containers of food closed until ready to use, and storing personal items on the food prep tables. These in-services were not provided prior to exit. Record review request via email on 06/26/2024 at 5:32 PM reflected in-services given to dietary staff prior to 06/24/2024 was requested on the policies requested such as: 1. Following Recipes 2. Employee personal items where food was being prepared. 3. Hand Hygiene and wearing gloves. 4. Hair nets and beard nets. 5. Label, dating and storage of foods 6. Copy of the kitchen cleaning schedule These was not provided at the time of exit. Record review of the facilities Nutrition Policies and Procedures revised on 06/20/2203 reflected appropriate hair restraints such as hats, hair covers or nets, and beard restraints [NAME] involved in food production activities. Hand hygiene is the most important component for preventing the spread of infection. Proper hand washing technique will be used when hand washing is indicated. Wash hands before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Before handling food. After contact with soiled or contaminated articles. Antimicrobial gel cannot be used in the kitchen during food preparation. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food .3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services for one of one kitchen staff (Dietary manager) reviewed for qualified dietary staff. The facility failed to ensure the Dietary Manger completed an approved dietary manager training course. This failure could place the residents at risk for the spread of food borne illness and residents not having their nutritional needs met. Findings included: Record review of the personnel file for the Dietary Manager reflected she had not completed the certified Dietary Manager course. She had a date of hire of 03/04/2019. Interview on 06/26/2024 at 11:00 AM the Dietary Manager stated she began taking classes online approximately 3 years ago and she did finish her classes but did not take the test. She stated she did not have any proof of her passing classes online or when she signed up for the dietary manager courses. She stated she was not a certified Dietary Manger and she was not working under Registered Dietician license or a Certified Dietary Manager License. She stated she did have her food handler certificate and that was the only food service certificate she had at this time. She also stated she did not report to anyone that she did not have her certified dietary manager license and no one asked to see it until now. She stated she thought with her experience as a cook over [AGE] years and working the kitchen had justified her not being a qualified Dietary Manager. Interview via telephone on 06/26/2024 at 11:51 AM The Registered Dietician Consultant stated the Dietary Manager was not working under her license. She stated she thought the Dietary Manager had her certificate. She stated if she did not finish the Dietary Manger Course online she was not qualified to be a Dietary Manager. Interview on 06/27/2024 at 12:30 PM the Administrator stated he was not aware that the Dietary Manager did not have her certification/ license. He stated he had been in the facility for three weeks and was focusing on the nursing department and then he was going to focus on the dietary department. He stated he would be working on this issue. He stated all license of department heads was expected to be in their personnel records. He stated a registered dietician comes in and does the documentation. A request for the policy of dietary manager qualifications was made and was not provided at time of exit.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of five residents reviewed for accidents and hazards. (Resident #1). The facility failed to ensure CNA E followed Resident #1's care plan for the use of a mechanical lift for all transfers with two staff assist and failed to follow the manufacture instructions for use which resulted in Resident #1 receiving an improper and potentially dangers transfer. These failures placed residents at risk of injuries, hospitalization , or diminished quality of care. Finding Include: Review of Resident #1's face sheet dated 06/26/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Cerebral palsy (A group of disorders that affect movement, muscle tone, balance, and posture.), Anxiety Disorder (Fear characterized by behavioral disturbances.), Abnormal posture, and Contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #1 was further assessed to have functional limitation in range of motion in her bilateral upper and lower extremities. Resident #1 was further assessed to be dependent on staff for transfers. Review of Resident #1's comprehensive care plan reflected a problem dated 04/21/2021 that was revised on 04/15/2024 Resident #1 requires assistance with ADLs related to impaired cognition, impaired mobility and incontinence of bowel and bladder related to cerebral palsy. Approaches included: Transfers total assist with 2 person assist utilizing a Hoyer lift. Review of Resident #1's consolidated physician orders reflected an order dated 01/09/2019 Transfer with assist of Hoyer lift. Observation on 06/26/2024 at 1:26 PM revealed CNA E outside of Resident #1's room preparing to provide care. CNA E went to get the Hoyer lift. CNA E entered Resident #1's room alone with the Hoyer lift. Resident #1 was sitting in a specialized wheelchair and was observed to have contractures (a permanent tightening of the muscles, tendons, skin and surrounding tissues that causes the joints to shorten and stiffen) to her neck, spine, bilateral arms, and legs. Resident #1 had abnormal posture and was leaning to her right side. CNA E She positioned the mechanical lift around Resident #1's wheelchair and hooked the sling to the Hoyer lift. Without locking the wheels on the mechanical lift, she lifted Resident #1 and maneuvered the mechanical lift to the bed. CNA E then closed the legs locked the mechanical and lowered Resident #1 to the bed. In an interview on 06/26/2024 at 1:45 PM CNA E stated she was trained to use two people for mechanical lift transfers. CNA E stated she performed the transfer alone because she thought the other aide was coming to help and when she did not come; she went ahead with the transfer. CNA E stated she should have waited on the other aide for safety reasons CNA E further stated the wheels on the mechanical lift were supposed to be locked when lifting the resident. In an interview on 06/26/2024 at 1:53 PM the DON stated it was her expectation for two people be present for mechanical lift transfers for safety reasons. In an interview on 06/26/2024 at 3:27 PM Resident #1 stated the staff usually used two people to transfer her with the Hoyer but sometimes they only use one. Resident #1 stated she had not been injured during any transfers and felt safe. Review of the facility's policy Mechanical Lifts: General Guidelines dated 05/05/2023 reflected Prepare the environment by 1) Securing the appropriate number of caregivers. In most cases, a minimum of 2 people is required to operate the lift and handle the patient or resident . Review of the Hoyer lift manufacturer instruction manual dated 2024 reflected .Safety Precautions . ALWAYS lock the wheels when lifting .

Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of six residents (Resident # 15 and Resident #18). 1. The facility failed to ensure Resident # 15's nails were cleaned and did not have any rough edges. 2. The facility failed to ensure Resident # 18's facial hair was removed and nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident #15's Face Sheet dated, 06/27/2024, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of rheumatoid arthritis unspecified site (a chronic inflammatory disorder that can affect more than just your joints), unspecified lack of coordination ( uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), age- related physical debility ( generalized weakness, exhaustion, poor balance, and decreased physical activity), muscle weakness ( lack of muscle strength), and chronic pain syndrome ( long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition, such as arthritis. It may affect people to the point that they can't work, eat properly, and/ or take part in physical activity). Record review of Resident #15's Annual MDS Assessment, dated 05/02/2024, reflected the resident had a BIMS score of 12 reflected his cognition was moderately impaired. Resident # 15 did not reject care. Resident #18 was assessed to require assistance with personal hygiene, toileting, dressing, bathing, and transfers. Resident #15 had diagnosis of arthritis (joint inflammation) and muscle weakness (lack of muscle strength). Record review of Resident #15's Comprehensive Care Plan, dated 05/15/2024, reflected Resident #15 preferred bed baths. Intervention: Staff will offer shower/ bed bath three times weekly. Staff will educate Resident #15 about proper hygiene. Resident #15 had rheumatoid arthritis and was at risk for decreased in ADLs and increased joint pain. Intervention: monitor for increased joint pain- give meds/ treatment per order - assess for signs of relief of pain. Resident #15 required assistance with ADLs. Interventions: Resident #15 required assistance with bathing, dressing, toileting, transfers, and eating. Record review of Resident #15's Treatment Administration Record (TAR) dated 06/01/2024 - 06/31/2024 reflected Resident #15 did not refuse nail care. Record review of Resident #15's nurses notes from 05/01/2024 thru 06/26/2024 Resident #15 did not refuse nail care. Observation on 06/25/2024 at 10:21 AM Resident # 15 was in his room sitting in wheelchair watching television. Resident #15 had blackish hard substance underneath the forefinger and middle fingernails on his right hand. His middle and ring fingernails was rough around the edges. There was an odor of bowels on his right hand. In an interview on 06/25/2024 at 10: 24 AM Resident #15 stated he tried to clean his nails but he was not physically able to clean his own nails or trim his nails. He stated some of his nails was rough and needed to be smoothed but he was not able to do this and he would try but he was afraid he would get his nails infected if he tried. Resident #15 also stated he needed assistance with his nails and all his care. He stated someone came in yesterday (06/24/2024) to trim his nails and they said his nails did not need to be trimmed. He asked the staff to file his nails and the staff stated they did not file nails all they did was trim nails. He stated his nails were dirty yesterday afternoon after the staff left the room. He stated the person never returned to his room and he did not ask anyone else to assist him. He stated if she stated it was not their job to file the nails he was not going to ask anyone else. Resident #15 did not recall the person's name. Resident #15 stated he has not refused any nail care from staff. 2. Record review of Resident #18's Face Sheet dated, 06/26/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia (affects memory, thinking and social abilities), contracture of muscles, unspecified upper arm (occurs when your muscles, tendons, joints, or other tissues or shorten causing a deformity and can cause loss of movement in the joint), muscle weakness (lack of muscle strength). Record review of Resident #18's Quarterly MDS Assessment, dated 04/01/2024, reflected the resident had a BIMS score of 0 indicated her cognition was severely impaired. Resident #18 did not reject care. She was assessed to be dependent on staff for ADLs such as: eating, oral hygiene, toileting hygiene, personal hygiene, showers, lower body dressing and all transfers except sit to lying and lying to sitting on side of bed. Record review of Resident #18's Comprehensive Care Plan, dated 03/07/2024, reflected Resident #18 had a diagnosis of dementia (affects memory, thinking and social abilities) with expected decline in cognitive impairment over a period of time as a natural progression of the disease. Intervention: document decline in cognitive status. Resident #18 was identified needed assistance with ADLs (the type of ADLs was not specified). Record review of Resident #18's Treatment Administration Record (TAR) dated 06/01/2024 - 06/31/2024 reflected Resident #18 did not refuse nail care. Record review of Resident #18's nurses notes from 05/01/2024 thru 06/26/2024 Resident #18 did not refuse nail care. Observation on 06/25/2024 at 10:36 AM Resident #18 was sitting in her Geri chair listening to music. She had slightly curled facial hair approximately 2-3 inches long on the left side of her face near her mouth. Resident #18 had blackish hard substance underneath her nails on her middle and ring finger on the right hand. She also had hard blackish and her ring and fore finger on her left hand. In an interview on 06/25/2024 at 10:39 AM Resident #18 was not interview able. She did not respond verbally or with gestures to any questions. In an interview on 06/27/2024 at 11:00 AM the DON stated it was a joint effort between the CNAs and the nurses to complete nail care on the residents. She stated the nurses was responsible for residents with diagnosis of diabetes ( a disease in which the body's ability to produce or respond to the hormone insulin was impaired). The Director of Nurses stated nail care was scheduled by the TAR and when residents received showers. She also stated nail care was also expected to be completed as needed. She stated if a resident had blackish substance underneath their nails the substance may be dirt and not bacteria. She stated no one knows if it was bacteria underneath the residents' fingernails. The DON stated if the scent was feces was noticed underneath residents' fingernails there was a potential this may be bacteria. She stated it was a possibility a resident may become physically ill such as vomiting or diarrhea if they ingested bacteria from feces. She also stated if a resident had rough fingernails there was a possibility the resident may scratch themselves and develop a skin tear. The DON stated she did not believe women having facial hair was a dignity issue or any type of issue. She stated if a resident was not able to communicate verbally if they wanted facial hair she did not believe this was an issue for the female resident to have facial hair. She stated if there was any refusal of nail care it would be documented in the nurses notes or on the TAR. In an interview on 06/27/2024 at 11:20 AM LVN A stated the nurses and CNAs were responsible for nail care. She stated the nurses was responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN A stated it was the CNAs responsibility to clean and trim all other residents' nails. She stated the nurses checked the diabetic nails weekly and the CNAs reported to the nurses if any diabetic nails needed to be cleaned or trimmed. LVN also stated the nurse would document on the TAR (Treatment Administrator Record) and/ or nurses notes if any resident refused nail care. She stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance may had bacteria underneath the residents' nails. She also stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea. She stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear. LVN A stated she was not aware of anyone refusing nail care; however, she would need to refer to the TAR to know for certain if Resident # 15 or Resident #18 refused nail care. In an interview on 06/27/2024 at 11:30 AM CNA E stated the nurses completed all diabetic fingernails and the CNAs was responsible for all other residents' nails. She stated the CNAs was responsible to complete nail care such as trimming, filing, and cleaning the nails. She stated the staff was very busy and it was difficult to complete nail care on residents except when the resident was in the shower. CNA E also stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day there were times the staff was not able to clean, trim or file the residents' nails. CNA E stated there were also times the nursing staff may have time to do one of the nail tasks but not all three tasks such as filing, cleaning, and trimming. She stated if a resident had blackish substance underneath their nails it was usually from their bowels. She stated if a resident swallowed some of their bowels the resident may become ill with sores in their mouth, yeast infections in their mouth, get E. coli (a bacteria that is commonly found in the lower intestine of warm-blooded organisms) and may develop major stomach problems such as diarrhea. She stated she worked with Resident #15 and Resident #18 and she was not aware of them refusing nail care. She stated if a resident's nails were rough there was a possibility the resident may scratch themselves and develop a skin tear or possibly scratch their eye and cause a tear on their eyeball. Record review of the Facility Policy on ADLs dated, 05/05/2023, reflected Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. POLICY: The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. *

Based on observation, interviews, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #21) reviewed for unnecessary medications. The facility failed to ensure Resident #21 had behavior and side effect monitoring for his prescribed antidepressant medications Fluoxetine and Trazadone and his antipsychotic medication Abilify. These failures could place president at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #21's face sheet dated 06/26/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), and Major Depressive disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) Review of Resident #21's Admission MDS assessment dated [DATE] reflected Resident #21 was assessed to have a BIMS score of 8 indicate moderate cognitive impairment. Resident #21 was assessed to have inattention, disorganized thinking and altered levels of consciousness that fluctuates. Resident #21 was further assessed to have verbal behaviors one to three days a week. Review of Resident #21's comprehensive care plan reflected a problem dated 06/25/2024 Psychotropic drug use Resident #21 is at risk for adverse consequences related to receiving antipsychotic medication for treatment of Psychosis related to Alzheimer's/Dementia. Approaches included Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms Monitor resident's behavior and response to medication .Quantitatively and objectively document the resident's behavior. Review of Resident #21's consolidated physician orders reflected the following orders: *Fluoxetine 40mg oral once daily dated 03/22/2024 , *Trazodone 100 mg oral at bedtime dated 03/22/2024, *Abilify 5mg once daily dated 03/22/2024, *Behavior monitoring twice daily for antidepressant drug Fluoxetine and trazodone dated 03/04/2022, *Monitor side effected twice daily for the antidepressant medication dated 03/04/2024, *Behavior monitoring twice daily antipsychotic drug use Abilify dated 03/04/2024, and *Monitor side effects of the antipsychotic medication Ability twice daily dated 03/04/2024. Observation on 06/25/2024 at 12:05 PM revealed Resident #21 was in dining room eating his lunch. Resident #21 was noted to be shaking when feeding himself. No behaviors were observed. Review of Resident #21's Consultant Pharmacist's Medication Regimen review dated 04/17/2024 reflected Please order BEHAVIOR MONITORING for TRAZODONE, ABILIFY . Review of Resident #21's MAR dated 05/01/2024 through 05/31/2024 reflected orders were not completed on the following dates: 1) Behavior monitoring twice daily: antidepressant drug Fluoxetine *05/01/2024, *05/06/2024, *05/10/2024 through 05/12/2024, *05/18/2024 through 05/21/2024, and *05/24/2024 through 05/31/2024. 2) Behavior monitoring twice daily: antidepressant drug Trazadone. *05/01/2024, *05/06/2024, *05/10/2024 through 05/12/2024, *05/18/2024 through 05/21/2024, and *05/24/2024 through 05/31/2024. 3) Monitor for side effects twice daily Antidepressants. *05/01/2024, *05/02/2024, *05/10/2024 through 05/13/2024, *05/17/2024 through 05/21/2024, and *05/24/2024 through 05/31/2024. 4) Behavior monitoring twice daily: Antipsychotic drug Abilify. *05/01/2024, *05/01/2024, *05/06/2024, *05/10/2024 through 05/13/2024, *05/17/2024 through 05/21/2024, and *05/24/2024 through 05/31/2024. 5) Monitor for side effects twice daily Antipsychotic drug use Abilify . *05/01/2024, *05/02/2024, *05/06/2024, *05/07/2024, *05/10/2024 through 05/14/2024, *05/17/2024 through 05/21/2024, and *05/24/2024 through 05/31/2024. In an interview on 06/26/2024 at 4:00 PM LVN A stated residents on psychotropic medications such as antidepressants and antipsychotics should be monitored for behaviors and medication side effects every shift. She stated sometimes it gets missed. In an interview on 06/27/2024 at 10:01 AM the DON stated she expected staff to document and check for psychotropic medications such as antidepressants and antipsychotics side effects and behaviors. She stated moving forward she would have to monitor the MARs to make sure the monitoring is being done. Review of the facility's policy Medication Management Program dated 07/13/2021 reflected The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements . Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life . 1) Reduce Unnecessary and Supplementary Medications . b) Review medication regimen to discontinue unnecessary drugs.

Based on interview and record reviews the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, for one of five residents reviewed for unnecessary medications. (Residents #21) The facility failed to ensure Resident #21's PRN order for Haldol dated 05/06/2024 had a stop date transcribed onto the MAR to ensure the medication did not extend beyond 14 days causing Resident #21 to receive 7 doses beyond the physician ordered stop date of 05/20/2024. This deficient practice placed residents with PRN psychotropic drugs at risk for side effects of psychotropic drugs which include nausea, drowsiness, dizziness, confusion, constipation, diarrhea, and delirium and placed residents at risk for receiving unnecessary medications. Findings included: Review of Resident #21's face sheet dated 06/26/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), and Major Depressive disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) Review of Resident #21's Admission MDS assessment dated [DATE] reflected Resident #21 was assessed to have a BIMS score of 8 indicate moderate cognitive impairment. Resident #21 was assessed to have inattention, disorganized thinking and altered levels of consciousness that fluctuates. Resident #21 was further assessed to have verbal behaviors one to three days a week. Review of Resident #21's comprehensive care plan reflected a problem dated 06/25/2024 Psychotropic drug use Resident #21 is at risk for adverse consequences related to receiving antipsychotic medication for treatment of Psychosis related to Alzheimer's/Dementia. Approaches included Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms Monitor resident's behavior and response to medication .Quantitatively and objectively document the resident's behavior. Review of Resident #21's consolidated physician orders reflected the following orders: *dated 05/06/2024 Haloperidol 0.5mg one tab every 8 hours as needed for aggression. The order had a stop date of 05/07/2024. *dated 05/07/2024 for Haloperidol 0.5mg one tab every 8 hours as needed for aggression with a stop date of 05/20/2024. Review of Resident #21's MAR dated 05/01/2024 through 05/31/2024 reflected an entry for haloperidol 0.5mg one tab by mouth every eight hours as needed for aggression. No stop date was indicated on the MAR for the medication. The haloperidol was signed as given past the medication stop date on six occasions: 05/23/2024 through05/26/2024, 05/28/2024 and 05/30/2024. In an interview on 06/26/2024 at 4:00 PM LVN A stated Resident #21's order for Haldol was only supposed to be for 14 days but when it was put on the MAR no end date was indicated so we continued to use the medication as needed. In an interview on 06/27/2024 at 9:38 AM the DON stated she got the clarification for Resident #21's order for Haldol since on 05/06/2024 the order did not include a stop date so on 05/07/2024 it was clarified to have a stop date of 05/2024. The DON stated she put the order into the computer to include the stop date. She stated she did not print a new MAR she stated the nurses have access to the MARs in the computer. The DON stated they do not use the computer MARs to pass medications since they still use paper. The DON stated the change was on the change screen (24-hour report) and the nurses can see that. She stated there were a lot of steps done to prevent the error, but it occurred anyway Its Ridiculous In an interview on 06/27/2024 at 9:45 AM LVN A stated any order change does show up on the change screen but if the MARs with changes are not printed out the changes could be missed. LVN A stated that was why Resident 21's Haldol was given past the discontinuation date. Review of the facility's policy Medication Management Program dated 07/13/2021 reflected The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements . Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life . 1) Reduce Unnecessary and Supplementary Medications . b) Review medication regimen to discontinue unnecessary drugs.

Based on observation, interviews, and record review, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for one of one kitchen. The facility failed to provide puree recipes for the Dietary Manager to follow when preparing puree food. This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health. Findings included: Observation on 06/26/2024 7:10 to 7:40 AM, Dietary Manager began to pureed eggs. She placed the eggs into the pureed blender and began to puree the eggs. She did not measure the eggs or have a recipe to follow. Observation of Dietary Manger pureed bacon The bacon was not the same size. One piece of bacon was shorter. The Dietary Manger place bread into the pureed blender and added water to the bread without measuring the water. She did not measure any food she pureed. Interview on 06/26/2024 at 7:50 AM, Dietary Manger stated she was required to use juice such as orange or apple juice when she pureed bread but she always used water. When asked where her recipes were to pureed food, she stated she did not have any recipes and did not follow recipes when pureed food. She stated she always used her judgement on how much food to place into the food blender. She stated she had been cooking approximately [AGE] years and she knew how much food to use without measuring the food or follow a recipe. She stated she did not need a recipe. She exited the kitchen and entered her office to search if she did have recipes. The Dietary Manager stated she did not have the spring/ summer recipes to follow and she did not know how to get the recipes. Interview via telephone on 06/26/2024 at 11:51 AM the Registered Dietician Consultant stated all recipes was online and everyone had access to these recipes. She stated she had shown the Dietary Manager how to access these recipes. She stated all cooks including the cooks with years of experience was expected to follow the recipes especially when they are pureeing food. She also stated it was very important to use the correct measurements. The Registered Dietician Consultant stated if the correct measurements were not used the consistency of the pureed food may not be correct. She stated water was never to be used in any foods when adding liquid during the puree process. She stated it was best practice to use broth, milk, or butter. She did not respond when asked what may happen to the pureed food if water was used as the liquid during the pureed process. Interview on 06/27/2024 at 11:15 AM the Administrator stated the dietary manager had been working as a cook for a very long time and she knew what she was doing when she prepared pureed food or any type of food. He stated he did not agree with guessing how much food to be added when the dietary manager pureed the food when being observed on Tuesday (06/26/2024). He stated he was not going to answer if it was ok not to follow a resident when pureeing food. The Administrator stated when an employee had been pureeing food repetitive every day it became repetition and they knew how to measure the food without a recipe and knew what size scoop to use with all foods. He stated if a cook pureed food all the time they would have it memorized and would be able to correct the pureed food if it did not look right without using a recipe. Record review of the Facility Policy on Nutrition Policies and Procedures revised on 08/01/2020 reflected prepare puree foods as per recipe.

Based on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 1 of 5 residents reviewed for immunizations. (Resident #8) The facility failed to document in Resident #8's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal, or being informed of the benefits/risk which could cause respiratory complications and potential adverse health outcomes. Findings include: Review of Resident #8's face sheet dated 06/27/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).) , and acute respiratory failure with hypoxia (is a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide.). Review of Resident #8's quarterly MDS assessment dated [DATE] reflected Resident #8 was assessed to have a BIMS score of 6 indicating severe cognitive impairment. Resident #8 was further assessed to have been offered the influenza and pneumococcal vaccine and declined. Review of Resident #8's comprehensive care plan reflected no entries regarding immunization status. Review of Resident #8's consolidated physician orders reflected the following orders: *dated 03/10/2022 Last Pneumonia vaccine received. *dated 03/10/2022 May administer influenza vaccine annually. Review of Resident #8's immunization records in the EMR reflected no pneumonia vaccine record. Further review reflected an entry for influenza vaccine dated 09/29/2023 indicating the vaccine was not administered related resident refused based on conscientious objection. Under the section if education provided to resident/family or POA the facility checked 'no' on the form. In an interview on 06/27/2024 at 12:38 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization. In an interview on 06/27/2024 at 12:45 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the MDS coordinator but since she was not at the facility anymore and the immunizations for Resident #8 got missed. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. Review of the facility's policy Immunization Recommendations for Patients, Residents and Health care Workers dated 07/15/2021 reflected The facility complies with current immunization and vaccination recommendations and requirements (where required), for patients, residents, and staff.1. Prior to offering or providing immunizations, applicable medical screening and evaluation will be provided. This screening may be done by a licensed health care provider, such as a physician. 2. Immunizations will not be given if determined to be medically contraindicated . One-time informed consent can be part of the admission process for influenza, pneumococcal, and other vaccines eliminating the need for annual consent except in states where annual consent is required. The facility will track all staff and resident vaccination status for all vaccines. Resident vaccination status will be documented in their medical record and include: Education provided to the resident or resident representative regarding the benefits and potential risks associated with the vaccines .

Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 1 of 5 residents who were reviewed for immunizations. (Resident #7) The facility failed to document in Resident #7's medical records for having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: Review of Resident #7's face sheet dated 06/27/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Anemia (Deficiency of healthy red blood cells in blood. Red blood cells are essential to carry oxygen to all parts of the body.) , Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) and right femur fracture. Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #4 was assessed to have a BIMS score of 1 indicating severe cognitive impairment. Review of Resident #7's comprehensive care plan reflected no entries regarding immunization status. Review of Resident #7's consolidated physician orders reflected no entries regarding immunizations. Review of Resident #7's immunization records in the EMR on 06/26/2024 reflected no entry regarding COVID-19 Vaccination. In an interview on 06/27/2024 at 12:38 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization. In an interview on 06/27/2024 at 12:45 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the MDS coordinator but since she was not at the facility anymore and the immunizations for Resident #7 got missed. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. Review of the facility's policy Immunization Recommendations for Patients, Residents and Health care Workers dated 07/15/2021 reflected The facility complies with current immunization and vaccination recommendations and requirements (where required), for patients, residents, and staff.1. Prior to offering or providing immunizations, applicable medical screening and evaluation will be provided. This screening may be done by a licensed health care provider, such as a physician. 2. Immunizations will not be given if determined to be medically contraindicated . One-time informed consent can be part of the admission process for influenza, pneumococcal, and other vaccines eliminating the need for annual consent except in states where annual consent is required. The facility will track all staff and resident vaccination status for all vaccines. Resident vaccination status will be documented in their medical record and include: Education provided to the resident or resident representative regarding the benefits and potential risks associated with the vaccines .

Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 eloped from the facility on 2/28//2023 and fractured his right hip, that required surgery to treat. Resident #1 was found 2 1/2 blocks away from the facility on the ground, he had fallen and was unable to get up. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 3/1/2023 at 6:06 p.m. The (IJ) Immediate Jeopardy template was provided to the ADM on 3/1/2023 at 6:06pm. While the (IJ) Immediate Jeopardy was removed on 3/3/2023 at 4:40 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. This failure could place all residents that are elopement risk and refuse to wear a wander guard at risk for accidents, harm, and/or death. Findings included: Review of Resident #1's face sheet dated 3/2/2023, reflected a 64- year- old man, admitted to the facility on [DATE]. Resident #1 was diagnosed with Parkinson's disease (a disease of the central nervous system that affects movements), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder) not due to a substance or known physiological condition, Insomnia ( a common sleep disorder that can make it hard to fall asleep), Paranoid schizophrenia ( a psychological disorder where the lines are blurred between what is real and what isn't), delusional disorder(a belief or altered reality that is persistently held despite evidence or agreement to the contrary) and heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 5 (indicates the resident does not have the cognitive ability to understand). The MDS also reflected Resident # 1 is ambulatory with no assistance. Review of MAR dated 2/1/2023-2/282023, reflected the following orders: Resident to reside on secure unit for personal safety - start 12/29/2020 open ended 9/1/2022- Resident may have trial integration off unit into general population- open ended 9/1/2022- May have wander guard -open ended Record review of Resident #1's care plan dated 2/28/2023, reflected the following: Problem: Resident has been observed to leave the grounds within the past week without notifying staff despite reminders. Interventions: Explain to resident the policy and procedure for leaving the facility and review periodically for continued need for secure placement. The care plan did not reflect any updates of interventions in place for Resident #1 for the period of 9/1/2022 when Resident #1 came off the secure unit through 2/28/2023. Record review of Risk elopement assessments for Resident #1 reflected the following: -12/19/2017 Resident #1 was identified as risk for elopement, -9/19/2021 was not an elopement risk, with no interventions, -11/15/2022 Resident #1 was not an elopement risk, with no interventions, -5/21/2022 reflected it was unknown if Resident # 1 was an elopement risk and to remain on secure unit for safety, and. -2/23/2023 reflected Resident #1 was not a risk for elopement with the following interventions: Frequent monitoring how often not noted, keep behavior logs, review medications, utilizations of sign in/sign out logs, recreational activities, and music. Record review of facility progress notes dated 6/2/2022- 2/28/2023 for Resident #1 reflected, no monitoring notes, no behavioral log, no sign in or out sheets used by Resident #1, or any notes regarding activities or music. There was one progress note dated 2/28/2023 regarding Resident #1's refusal to wear the wander guard. In an interview on 3/1/2023 at 11:10 a.m., the hospital staff reported Resident #1 was brought into the hospital by EMS. She stated it was reported Resident #1 was found on the street trying to get up. The hospital staff stated Resident # 1 had a fractured right hip and was scheduled for surgery later in the day. She stated Resident # 1 was hallucinating and having delusional thoughts since he was admitted . In an interview on 3/1/2023 with concerned citizen stated approximately 5:25am he and his son noticed Resident # 1 had fallen and was trying to get up. He stated they called 911 for assistance, he stated Resident #1 reported that he tripped over the curb and hurt his hip. In an interview on 3/1/2023 at 12:29 p.m., LE stated EMS contacted them to come to the scene on 3/1/2023 around 5:45 a.m., LE stated they spoke with Resident #1 he was able to tell them the facility he came from, that he had fallen and was unable to get up. LE reported, Resident #1 was transported to the hospital due to his injury he sustained from falling. LE stated they went to facility and asked if anyone was missing? LE reported the staff they spoke to was not aware that anyone was missing at the time, LE stated they informed the facility of Resident #1 name and advised that he was transported to the hospital for further medical treatment. Review of Police call for service report dated 2/28/2023, reflected the facility was notified at approximately 5:50am asking if they were missing anyone from the facility. LVN A, reported that she was not aware that anyone was missing at the time. LVN A was advised that Resident # 1 had been injured and was transported to the hospital. In an interview on 3/1/2023 at 10:02 a.m., LVN A stated she was the nurse on duty last night, she stated they work 12 hours shifts 6pm to 6am. She stated Resident #1 has insomnia and walked all night looking for cigarettes. She stated she last saw Resident #1 at approximately 5:10 a.m. walking down the hall, when she was going to check on another resident who had pushed their call light. She stated she was contacted by the local police department at about 5:45 a.m. asking if they were missing anyone. She stated she was not aware that Resident #1 was missing and stated he must have gone out one of the back doors that does not have alarms. She stated Resident #1 had never attempted to elope from the facility. LVN A stated Resident #1 was found 2 1/2 blocks from the facility, stated he was headed to the post office to return some counterfeit money. LVN A stated when she looked, it appeared that she had some money missing from her purse she had behind the nurse's station. LVN A stated she immediately contacted the hospital so that she could provide any information they needed for Resident #1, she stated she then made all other notifications to the ADM, DON, and Resident #1's guardian. In an interview on 3/1/2023 at 11:19 a.m., Resident #1's Guardian stated he was admitted to the facility on [DATE] on the secure unit due to being an elopement risk. She stated he had previous elopements at previous placements and had attempted from this facility. Resident #1's Guardian stated she was notified by the facility that the secure unit would be shut down. She stated the facility completed another risk assessment for elopement and indicated Resident #1 was no longer at risk for elopement. Resident #1's Guardian stated Resident #1 was very familiar with the back doors at facility, she stated he often would go out the door when she visited as he was able to go in and out the doors as he pleased. Resident #1's Guardian stated she believed the facility shut down the secure unit due to staffing and census issues. Resident #1's Guardian stated Resident #1 refused to wear the wander guard bracelet and was unaware of any other interventions in place. She stated she was not aware of Resident #1 trying to elope since he initially admitted . Resident #1's Guardian stated she was also concerned that the incident happened at 5:45 a.m., but she did not get contacted about the incident until sometime after 7:00 a.m. In an interview on 3/1/2023 at 1:30 p.m. the DON stated LVN A who was on duty that night, contacted her around 6:39 a.m. She stated LVN A reported that the police were just at the facility asking if they had a resident missing. The DON stated LVN A was not aware Resident #1 was missing at the time when she was contacted by the police. The DON stated she advised LVN A to make all notifications, she also stated that LVN A stated Resident #1 must have gone out one of the back doors because they do not lock or alarm. The DON stated none of the doors at the facility alarm when opened unless the resident has on a wander guard bracelet. The DON stated the other residents who are an elopement risk have on a wander guard bracelet and if they get within 10 feet of any of the doors the alarms will sound. The DON stated when she started at the facility in October 2022, Resident #1 was already off the secure unit, she stated he had never tried to elope before this time. The DON was asked about previous care plans and interventions for Resident #1 because he refused to wear the wander guard bracelet, she was not able to locate any documents. The DON was not able to locate any documentation regarding Resident #1's behaviors, monitoring of Resident #1, or any sign-in/or out sheets. In an interview on 3/1/2023 at 4:30 p.m., the ADM stated all residents who have been identified as elopement risk wear a wander guard bracelet, he stated Resident #1 refused to wear his wander guard. The ADM stated he was not aware that Resident #1 tried to elope from the facility in the past he stated it must have been before he started at the facility. The ADM stated all residents have the right to be safe and it is his expectation that all residents are safe in the facility. The ADM stated the alarms on the doors alarm if the resident was wearing a wander guard and they come within 10 feet of any of the doors. The ADM stated they opened back up the secure unit on 2/28/2023. Observation and test on 3/1/2023 of all doors in facility, reflected all doors are able to be opened without any alarms going off coming in or going out the doors. The door where staff believe Resident #1 went out leads out to the side parking lot on the south end of the building. The facility is located 2 blocks from an active railroad and busy street with blinking yellow light for traffic going through. Observation on 3/1/2023 at 3:30pm of secure unit with code required secured doors. Observed two residents residing on the secure unit and staff working on the unit. Reviewed facility Abuse/Neglect policy undated reflected: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Reviewed facility Elopement Risk Assessment policy dated 11/01/2017 reflected the following: All residents are assessed on admission for elopement risk utilizing an elopement risk form. All residents are re-assessed for elopement potential by the MDS nurse /social worker or designee periodically throughout a resident's stay and with a significant change. Interventions will be added to the resident's care plan after analyzing the information obtained. The baseline care plan will identify if a resident is admitted as an elopement risk on admission. Reviewed QAPI - (Quality Assurance and Performance Improvement) held quarterly dated-September 2022- February 2023 to address elopement. An (IJ) Immediate Jeopardy was identified on 3/1/2023 at 6:06 p.m., due to the above failures. The ADM was notified on 3/1/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 3/1/2023 at 6:06pm, and a Plan of Removal (POR) was requested. A Plan of Removal was accepted on 3/3/2023 at 1:56 p.m. and reads as follows: Plan of Removal Immediate Plan of Removal Identified resident is not currently in the facility: Residents at risk of elopement have the potential to be affected. Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy on 2/28/23. Any not completed in past 90 days or found to be inaccurate were completed by the Director of Nursing on 3/1/23. Identified residents at risk reviewed using the Elopement Risk Assessment for interventions on 2/28/23, by the Director of Nursing and any issues identified were corrected appropriately at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 2/28/23. Licensed nurses will be re-educated on Abuse/Neglect, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This includes intervening if the resident verbalizes the desire to leave the facility or threatens to leave the facility or refuses to wear a wander guard. Licensed nurses will also be re-educated on documenting in progress notes, adding to the 24-hour report and updating care plans with changes of condition This education will be initiated on 2/28/23 by the Director of Nursing and completed by 3/2/23. The Director of Nursing will monitor for compliance. Any member of target audience not receiving by 3/2/23 will receive prior to next scheduled shift. This education will be presented in the new hire orientation and for any agency staff by the Director of Nursing/charge nurse. New admissions, readmissions and quarterly assessments will be reviewed in morning meeting beginning 3/2/23 Monday thru Friday as part of the clinical morning meeting process to review Elopement risks assessments for accuracy and interventions validated if indicated. The 24-hour report will be reviewed by the Director of Nursing/Assistant Director of Nursing for any documentation that may suggest a resident is expressing desires to leave the facility, if identified, interventions for safety will be implemented and care plan updated. The Medical Director was notified of the Immediate Jeopardy on 3/1/23. Ad Hoc QAPI was held by the administrator on 3/1/23 to discuss the contents of this plan. The administrator will oversee the compliance of this plan. Monitoring of Plan or Removal on 3/2/2023 was as follows: Interview on 3/2/2023 at 3:00 p.m., with hospital staff reported Resident #1 remains in the hospital in recovery from surgery. Hospital staff reported that Resident #1 has refused care by pulling out his picc line and still had delusional thoughts. Resident # 1 is scheduled to return to the facility on ce released from the hospital. Reviewed elopement risk assessments dated 3/1/2023 completed and updated for Resident #2 and Resident #3, reflected both are at risk for wandering, elopement risk, and will reside on secure unit for their safety and wear a wander guard bracelet. Observation conducted on 3/2/2023 at 3:30 p.m., of Resident #2 and Resident #3, on the secure unit. Resident #2 and Resident #3 appeared to be resting, they did not appear to be in any pain or distress. Resident # 2 and Resident # 3 was observed wearing their wander guard bracelets. In an interview on 3/2/2023 at 2:10 p.m., LVN B stated she completed the elopement drill and has been in-serviced on the policy, procedures and steps to take when there is a missing resident. LVN B stated she had also been in -serviced on abuse/ neglect, elopement, and documentation. She reported the ADM is the abuse/neglect coordinator. In an interview on 3/2/2023 at 2:20 p.m., LVN C stated she participated in the elopement drill today. She reported being in-serviced on abuse/neglect, elopement, and resident documentation. She stated she understood the process when they have a resident missing, she stated she contacts the ADM immediately if she suspected abuse/ neglect, and that she understood the importance of charting on residents. In an interview on 3/2/2023 at 2:30 p.m., LVN D stated she worked the morning of the incident. She stated she worked on 3/1/2023 from 6am to 6pm she was coming on shift when LE came to facility and asked LVN A if they had a resident missing. LVN D stated LVN A was not aware that Resident #1 was missing. She stated whenever, she worked the 6pm to 6am shift she knows she have to walk all night and check on Resident #1 because he walks all through the night. She stated when she worked, she would have to know where all her residents are at all times for safety of the residents. LVN D stated she had participated in the elopement drill at facility and knows that steps to take when they have a resident missing. She stated she had also been in-serviced on abuse/neglect and documentation. In an interview on 3/2/2023 at 2:40 p.m., CNA B stated she participated in the elopement drill today. CNA B stated they learned the code to call code white if they have a missing resident and they step to take to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed to report immediately when they see or suspect abuse/neglect. In an interview on 3/2/2023 at 2:50 p.m. CNA C stated she participated in the elopement drill today. CNA C stated they learned the code to call code white if they have a missing resident and to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed report immediately. In an interview on 3/2/2023 at 3:10 p.m., DON stated she and most of the staff have been trained on the elopement drill and what to do when they have a missing resident. She stated any staff that have not been trained are either PRN (as needed) staff or staff that only worked in the summer. DON stated the rest of the staff even agency staff as they come to work have been trained over the elopement process, abuse/neglect, and documentation. In an interview on 3/2/2023 at 3:20 p.m., the ADM stated all staff have been trained on the elopement process. He stated all staff participated in the elopement drill skills test on what to do if they have a missing resident. He stated it is his responsibility to ensure that all the residents in the facility are safe. ADM stated they are also looking at other ways to ensure the safety of the residents while maintain their independence. In an interview on 3/3/2023 at 3:40p.m., the ADM, stated on 3/1/2023 he verbally advised the MD of the IJ (Immediate Jeopardy) concerns identified. Record review of the AdHoc (for particular reason) QAPI(Quality assurance performance improvement) dated 3/1/2023 to address IJ(Immediate Jeopardy). Monitoring completed on 3/3/2023 as follows: Resident # 1 remains in hospital, Resident # 1 is scheduled to return to the facility on ce released from the hospital Observation made on 3/3/2023 at 4:10 p.m., of Resident # 2 and Resident # 3 on secure unit, no concerns noted during observation. Review of elopement assessments dated 2/28/2023, reflected all residents in facility were re-assessed for elopement risk. Two residents identified for secure unit /wander guard. These residents are currently on secure unit. Review of care plan dated 2/28/2023 for Resident #1 and Resident # 2 with current interventions: 1. Monitor for placement Q shift 2. Monitor for proper functioning 24 hours a day 3. Monitor resident in facility and document attempts to elope out of facility 4. Assess quarterly for continued use of wander guard 5. Explain to resident the policy and procedures for leaving the facility 6. Resident will reside on the secure unit for safety 7. Offer daily activities to address resident's interest 8. Review periodically for continued need for secure placement 3/3/2023 Review of in-services completed: all nursing staff verified completion except one PRN staff. 3/2/2023- Documentation Expectations 3/2/2023- Resident refusal of wander guard / immediate reporting to charge nurse 2/28/2023- Safety 2/28/2023- Elopement Drill / Policy and procedure 2/28/2023- Abuse/Neglect 2/28/2023- Elopement, Care plans, New admissions, elopement risk assessment and Quarterly assessments Record review of in-service sheet dated 2/28/2023 reflected 2 CNA's who work PRN had not completed the training. One nursing staff who only works in the summer had not received the training. In an interview on 3/3/2023 at 4:15pm with BOM (business office manager), stated they have not had any new admissions, readmissions. On 3/3/2023 at 4:40 p.m., the ADM was informed the (IJ)immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes and described the services that were to be furnished to maintain the resident's highest practicable physical well-being for one of three residents (Resident #3) reviewed for supervision when: Resident #3 had a hx of elopement behavior and elopement. The facility failed to provide a care plan reflecting how they will provide adequate supervision and implement appropriate action to provide adequate maintenance to a gate on the secure unit to help prevent Resident from eloping. Resident #3 eloped through a gate on the secure unit on 8/10/2018 and was found at a gas station beside Highway 14 and across from rail road tracks. Resident #3 eloped through the gate on several occasions prior to the 8/10/2018 elopement. This resulted in an Immediate Jeopardy (IJ) on 09/07/2018. While the IJ was removed on 09/08/2018, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice placed one resident (Resident #3) who was able to overpower the secure unit courtyard gate, at risk for injury up to and including death due to elopement. Findings Included: Review of Resident #3's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] reflected he was admitted from another nursing home, had no hearing deficits, and was understood. He understood others at times. Resident #3 had short and long term memory problems, inattention, and disorganized thinking. He was short-tempered, easily annoyed, had sleep difficulties and verbal behaviors directed toward others nearly every day. Resident #3 transferred and ambulated with supervision and did not require a mobility device. He was 5'4 and weighed 171 pounds. He took antipsychotic, antianxiety and antidepressant medications routinely. Review of Resident #3's Care Plan initiated on 03/01/2018 and updated quarterly reflected he had a behavior and he was at risk for wandering as evidenced by his history of elopement attempts and required placement on the secured unit. 08/10/2018 while electricity turned off for air conditioner repair, resident eloped out the side gate of courtyard and was found ten minutes later at neighbor's house. Returned, no injury. Goal: Will be able to wander in a safe environment without the occurrence of injury and dignity will be maintained x 90 days. Approaches: Monitor resident location frequently every 15 minute checks for 24 hours. Report any attempts to exit the building to the interdisciplinary team, family and doctor as indicated and record in clinical record. And monitor for attempts to leave facility. Extra staff member in secured unit during fire drills/electricity/power outage. Edited by DON on 08/15/2018. The care plan was last reviewed/revised on 09/06/2018 at 3:07 PM by MDS Coordinator. Resident #3's care plan did not reflect he could open the secure unit courtyard gate and leave the area and therefore was at risk every time he went outside, not just when there were problems with the electricity. The care plan did not reflect he was to be located every 15 minutes at all times or whether he was to have 1:1 supervision when he was actively exit seeking or what the staff was to do to maintain his safety on a day to day basis. It did not reflect he had got out the gate on 07/23/2018 twice and additional times since then as observed by the Maint. Director. Review of Resident #3's Physician order [REDACTED]. twice a day at 8:00 AM and PM for [MEDICAL CONDITION]. An order dated 9/10/2016 reflected the resident was to be placed on the secure unit. Review of Resident #3's Risk of Elopement/Wandering review reflected the staff had assessed him for his elopement risk on 02/08/2018, 05/26/2018, 08/10/2018 and 08/26/2018. Every assessment reflected the nurse checked yes, he had a history of [REDACTED]. The form further reflected each nurse checked his behavior was not a new behavior and family had voiced concerns that would indicate the resident may have wandering tendencies or try to leave. Review of Resident #3's TARS and MARS for (MONTH) (YEAR) reflected there was no entry for frequent observation before or after the elopement of 08/10/2018. Review of Resident #3's records reflected there was no documentation of frequent observation or safety interventions other than him residing on the secure unit. Review of Resident #3's Nurse Notes reflected: 07/23/2018 8:00 AM Found Resident #3 at the front door. He had gone out back gate and got hot and came to front door. Followed me back to his (illegible words) in corner of fence (illegible words) (not) put to bed. Will continue to monitor. Signed RN A 07/23/2018 8:20 AM Was outside secure area again but had not gone far from the gate. Came back in with redirection. Will continue to monitor. Signed RN A Further review of Resident #3's Nurse Note entries from 08/10/2018 to 08/14/2018 reflected: 08/10/2018 6:05 PM Had a power surge and gates disarmed - got out and was ambulating down street in stocking feet. Returned with staff to put his shoes on. Taken back to room. No problems noted. Signed RN A Review of the Facility Self Reporting Intake dated 08/10/2018 reflected the ADON had reported Resident #3's elopement on 08/10/2018. She recorded; Resident ambulates independently, requires frequent supervision (listed diagnoses) and has a history of exit seeking behavior and history of elopement. Resident has exited facility in past, he will check the gate and fence several times a day to see if it can be opened. She reported at approximately 6:05 PM on 08/10/2018 an unidentified caller stated 'I think you have a resident out. There is a man walking down the street with no shoes on.' .Resident #3 was found by staff walking beside the north bound lane of Highway 14 close to the gas station and liquor store. He stated he was going to Dallas. He had no injury and could not remember the event at 7:30 PM. In-services performed on elopement, abuse and neglect and resident rights, CNA (D) was moved off secure unit and another CNA assigned to secure unit. MD and family notified. Review of the Provider Investigation Report dated 08/14/18 reflected Resident #3 was independently ambulatory, did not have the capacity to make informed decisions and had a history of [REDACTED].#3 was the one resident missing after an anonymous member of the community called and reported a man with no shoes walking on the highway. Provider Response: Provider was notified of the elopement, immediately searched and identified Resident #3 was missing. He was returned to the building and was not harmed. An incident report was completed, the MD was notified, and the family representative was informed. Staff in-services completed on Resident Rights, Resident Elopement, Secure Unit and Abuse and Neglect policy and procedures. An interview was attempted, but unable to be obtained as Resident #3 did not remember leaving the premises. The Investigation Summary reflected Resident #3 had a history of [REDACTED]. The packet reflected there were multiple in-service sign in sheets but there were no documented interviews regarding Resident #3's whereabouts on the night of 08/10/2018 at any time by any staff. There were no interviews regarding how he may have gotten out, if the gates were locked or what was found at the time. The document did not reflect who checked the gates or if they were checked after the elopement or in the following days. There were no new interventions listed on the provider action taken post-investigation that would indicate the facility had initiated further safety interventions to keep Resident #3 from leaving the facility. Review of a Progress Note dated 08/13/2018 reflected the Administrator, who was also a licensed Social Worker, had entered she had interviewed Resident #3 and he stated he was going back to a homeless facility in Dallas, he did not know how he got out and he had a history of [REDACTED]. Review of Resident #3's Psychiatric Services agency notes on 07/27/2018 reflected the doctor visited the resident and did not mention the resident's elopement behaviors that had been documented in the nurse's notes on 07/23/2018. Further review of the Psychiatric Services notes reflected he visited again on 08/14/2018 and the Chief complaint was the resident is very restless, irritable and exit seeking. The resident was having delusions and thought he needed to get to The Bridge in Dallas. Plan: treatment plan: [REDACTED]. 2) increase [MEDICATION NAME] to 75 mg twice a day. Review of the facility incident reports dated 06/15/2018 to 09/06/2018 reflected there was one incident report for Resident #3 in 90 days. It was dated 08/10/2018 at 6:05 PM. RN A documented Received call from outside facility. Asked if we were missing a man wearing no shoes walking down street. Immediately room search. Found Resident #3 not in his room. Resident stated he was going to Dallas. Signed RN A The back of the incident report reflected the DON had written: Resident remains exit seeking, no injuries from incident. Does not recall incident but states he needs to go to 'Dallas, to the Bridge.' Daughter explained this was the shelter he was living at previously. Signed by DON on 08/13/2018 and the Administrator on 08/24/2018. Review of the Facility Self Reporting Intake dated 08/10/2018 reflected the ADON had reported Resident #3's elopement on 08/10/2018. She recorded; Resident ambulates independently, requires frequent supervision (listed diagnoses) and has a history of exit seeking behavior and history of elopement. Resident has exited facility in past, he will check the gate and fence several times a day to see if it can be opened. In an interview on 09/06/2018 at 10:29 AM the Maintenance Director stated, Resident #3 is pushing at the bottom of the door to get out. I saw him do it. In an interview on 09/06/2018 at 10:35 AM CMA O stated, I'm working as an aide today. Res. #3 is very fast, and he has got out several times. We catch him quick though. I haven't heard of Res. #3 leaving the unit in a long while. We are supposed to see where he is before we go in the shower or give another resident incontinent care. Then we are supposed to see where he is after we finish care on the resident. We have to hurry up with the other residents. In an interview on 09/06/2018 at 10:45 AM the Administrator stated, Res. #3 lives on the secure unit and he is exit seeking. This is not the first time he was out. He has figured out how to manipulate the gate and he peels the gate off the magnet. He just hits it short and low. My maintenance man watched him and saw how he did it. An observation on 09/06/2018 at 12:15 PM revealed the distance between the facility and the gas station and liquor store on Highway 14 was measured to be just over two tenths of one mile, and one must cross the railroad track to get there. In an interview on 09/06/2018 at 1:14 PM CNA E stated, I was in the front (on 08/10/2018). I don't think the electricity was out that night. Resident #3 can get by you in a blink of an eye. I was wondering how he was getting out. He moves fast. Observation on 09/06/2018 at 1:47 PM reflected Resident #3 was out on the secured patio rocking in a chair. No staff were outside or closely watching out the window. All the residents on the unit were ambulatory without a mobility device. A second resident, Resident #4, was also in a rocking chair outside near Resident #3. CNA E was giving resident care to a resident in the building. In an interview on 09/06/2018 at 2:00 PM RN A stated, I was charge nurse (on 08/10/2018), Resident #3 is an escape artist. No one witnessed how he left. I have no idea how he got out. We are very meticulous about checking on him now. In an interview on 09/06/2018 at 2:16 PM CNA D stated, It happened during the meal. I served his tray to him in his room between 5:30 and 6:00 PM. When found out he was missing, I went out to see which courtyard gate he went out and it was the one that was by the door I was sitting by. It was standing open about five to six inches. In an interview on 09/06/2018 at 3:42 PM the MDS Coordinator stated, Apparently, Resident #3 has figured out if you give pressure to the bottom of the gate it will let go. They are putting another magnet at the bottom of the gate. Whenever the electricity flickers it unlocks the gate. In an interview on 09/06/2018 at 3:55 PM the DON stated, We called in the 08/10/2018 elopement because Resident #3 was gone for about 10 minutes. I modified the care plan when I came back to work after a couple of days off. I put the date I was modifying the care plan on the care plan. I didn't feel I should date the frequent observation (for 8/10/18) because that would be back dating. I have never seen the frequent observation sheet document. I was told that is what they did. We do not need an incident report for the resident who steps out the door/gate and is observed by staff and assisted back in the building without leaving the property. I do not know how many times he has stepped out the gate. I didn't know these entries were in the nurse's notes (July 23, (YEAR) 8:00 AM and 8:20 AM). I have been told the care plan is to paint a picture of the resident and what he/she needs. The DON agreed the care plan did not have effective changes to keep Resident #3 from exiting the facility. She stated the RAI Manual was the care plan policy. Review of Resident #3's medical record reflected no observation forms. On 09/07/2018 at 3:55 PM the Administrator and DON were notified that an IJ situation had been identified due to the above failures. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.16 dated October (YEAR) reflected: A well developed and executed assessment and care plan: Looks at each resident as a whole human being with unique characteristics and strengths; Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident ' s functional status (MDS); Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of wellbeing (care planning). The following Plan of Removal was submitted by the Administrator, on 09/07/18 at 10:17 PM. Immediate Jeopardy Plan of Removal: Resident Neglect: Resident Elopement Issue Identified: 1. Bremond Nursing & Rehabilitation will provide a safe environment for Resident #3 who has been identified as an elopement risk, with exit seeking behavior. a. An additional magnetic lock has been installed at the bottom of the secure unit exterior gates in courtyard by the Maintenance Director effective 8:00 PM on 09/07/2018. b. Re-educate is in progress for the secure unit CNAs and nurses regarding documenting head count, power surges, resetting the unit secure unit gates, every 15-minute checks and every one-hour checks on Resident #3, and reporting unusual behaviors to the charge nurse, and the charge nurse will report concerns to the Director of Nursing. Education completion by 09/10/2018. c. Facility is currently seeking alternate placement for Resident #3 under the guidance of the Administrator. d. Daily chart checks for Resident #3 by the DON or Administrator to monitor behavior status until alternative placement has been made. 2. Bremond Nursing & Rehabilitation will complete incident reports for unusual behaviors. a. Facility initiated re-education on notification guidelines of exit seeking and gate banging behaviors. b. The charge nurses are being re-educated on documentation guidelines of unusual behaviors by the Director of Nursing. c. Re-education will be completed on 09/07/2018 by midnight. Any staff member not present will be re-educated before working their next scheduled shift. Facility staff to be completed by 09/10/2018. d. Incident reports will be tracked and trended through the internal Quality Assurance and Performance Improvement Committee. Any areas of concern will be addressed at the time of discovery. The Director of Nursing, Administrator, or On-call nurse shall be notified of exit seeking behavior. 3. Investigations of unusual behaviors will be investigated thoroughly. a. The Administrator was re-educated on components of thorough investigations to include written summaries of the interviews with individuals having firsthand knowledge of an event, resolutions and outcomes, and immediate measures taken to prevent future incidents. This will be completed by midnight (MONTH) 7, (YEAR) and monitored by the Regional Vice President until 12/07/2018. 4. The identified resident's care plan has been updated to include approaches to address the identified behaviors. a. Staff has been re-educated on approaches to deescalate Resident #3's behaviors. b. The care plan meeting was held via telephone held 09/07/2018 at 5:30 PM with the responsible party to review and update the approaches to the resident's unusual behaviors, as well as discharge planning. This was by the Administrator and the Director of Nursing. 5. The Administrator will monitor the trainings for the plan of removal. 6. The charge nurse will be responsible for checking the security of the doors at the beginning of their shift. This will be monitored by the Director of Nursing. 7. Preventative maintenance documentation will be completed by the Maintenance Director daily and monitored weekly by the Administrator. 8. Re-education of the Maintenance Director of by the Administrator regarding his responsibilities and communication of his job duties. To be completed by 09/14/2018. 9. The corporate supervisors of the Administrator will visit the building to monitor that the Administrator is recognizing dangerous situations and responding appropriately to the situations bi-monthly during a 90-day period. 10. Orientation for new staff will include training on secure unit security systems and power loss. Monitoring of the Plan of Removal was conducted by the Surveyor on 09/07/2018 between 10:05 PM and 10:45 PM. The 2-10 PM and 10-6 AM staff were in-serviced for the charge nurse to check the secure courtyard gates at the beginning of every shift, unit CNA was to document Resident #3's location every 15 minutes, the charge nurse was to document his location every hour, how to deescalate Resident #3's behaviors, exiting the gate was not a normal event and it was to be reported immediately and documented on an incident report. The DON demonstrated where the key to reset the gate was and how to reset the gate in the event of power fluctuations. The staff were instructed to notify the charge nurse and do a head count every time there was a power fluctuation. The second set of magnets were attached to the secure unit yard gates and they were functioning. Staff were interviewed for understanding. The DON stated she would be at the facility at 5:30 AM to train the 6 AM to 2 PM staff before they were allowed to work the shift. The POR was accepted by the Program Manager at 09/07/18 at 10:30 PM. Monitoring continued 09/08/2018 at 8:45 AM. The gates were locked with two magnets each, staff were interviewed for understanding/training of issues and procedures regarding resident monitoring residents at risk for elopement 80% of the nursing staff had received the training. On 09/08/2018 at 9:45 AM the Administrator was notified the IJ was removed. However, the facility remained out of compliance with potential for harm with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision to prevent accidents for one of three residents (Resident #3) reviewed for supervision when: The facility failed to provide adequate supervision and interventions for Resident #3, who had a history of [REDACTED]. Resident #3 crossed railroad tracks, and walked two tenths of a mile to State Highway 14 and was headed north towards Dallas. Resident #3 eloped through the gate of the secure unit courtyard on several occasions prior to the 08/10/2018 elopement. This resulted in an Immediate Jeopardy (IJ) on 09/07/2018. While the IJ was removed on 09/08/2018, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice placed one resident (Resident #3), who was able to over power the secure unit courtyard gate, at risk for injury up to and including death due to elopement. Findings Included: Review of Resident #3's face sheet reflected he was a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] reflected he was admitted from another nursing home, had no hearing deficits, and was understood. He understood others at times. Resident #3 had short and long term memory problems, inattention, and disorganized thinking. He was short-tempered, easily annoyed, had sleep difficulties and verbal behaviors directed toward others nearly every day. Resident #3 transferred and ambulated with supervision and did not require a mobility device. He was 5'4 and weighed 171 pounds. He took antipsychotic, antianxiety and antidepressant medications routinely. Review of Resident #3's care plan initiated on 03/01/2018 and updated quarterly reflected he had a behavior and he was at risk for wandering as evidenced by his history of elopement attempts and required placement on the secured unit. 08/10/2018 while electricity turned off for air conditioner repair, resident eloped out the side gate of courtyard and was found ten minutes later at neighbor's house. Returned, no injury. Goal: Will be able to wander in a safe environment without the occurrence of injury and dignity will be maintained x 90 days. Approaches: Monitor resident location frequently every 15 minute checks for 24 hours. Report any attempts to exit the building to the interdisciplinary team, family and doctor as indicated and record in clinical record. And monitor for attempts to leave facility. Extra staff member in secured unit during fire drills/electricity/power outage. Edited by DON on 08/15/2018. The care plan was last reviewed/revised on 09/06/2018 at 3:07 PM by MDS Coordinator. There were no new interventions added to the care plan to reflect additional daily monitoring (not just for one 24 hour period) or what the facility would do to prevent him from opening the courtyard gate and leaving (even after staff witnessed him open the gate). Review of Resident #3's Physician order [REDACTED]. twice a day at 8:00 AM and PM for [MEDICAL CONDITION]. An order dated 9/10/2016 reflected the resident was to be placed on the secure unit. Review of Resident #3's TARS and MARS for (MONTH) (YEAR) reflected there was no entry for frequent observation before or after the elopement of 08/10/2018. Review of Resident #3's records reflected there was no documentation of frequent observation. Review of Resident #3's Nurse Notes reflected: 07/23/2018 8:00 AM Found Resident #3 at the front door. He had gone out back gate and got hot and came to front door. Followed me back to his (illegible words) in corner of fence (illegible words) (not) put to bed. Will continue to monitor. Signed RN A 07/23/2018 8:20 AM Was outside secure area again but had not gone far from the gate. Came back in with redirection. Will continue to monitor. Signed RN A Further review of Resident #3's Nurse Note entries from 08/10/2018 to 08/14/2018 reflected: 08/10/2018 6:05 PM Had a power surge and gates disarmed - got out and was ambulating down street in stocking feet. Returned with staff to put his shoes on. Taken back to room. No problems noted. Signed RN A 08/10/2018 6:?? PM Checked for any injuries and fluids offered. Took fluids and found no changes to skin. Vital signs: 121/76, 98.3, 68, 20 (normal). Signed RN A 08/11/2018 11:00 PM In bed asleep. Resting quietly at this time. Close supervision required due to wandering. Remains on secure unit for safety. Gates appear intact. Will continue to monitor. Signed by LVN P. 08/13/2018 11:00 PM In bed asleep at this time. Close supervision continues to safety. Signed by LVN P. 08/14/2018 at 4:30 AM Awaken, appears extremely delusional, talking to self, looking out the window, talking constantly. Very agitated. Water given with Tylenol. After re-direction and hydration did lie down in bed. Will continue to monitor and re-direct as needed. Signed by LVN P. 08/14/2018 8:30 AM Assigned CNA reports patient is extremely restless and agitated. Pacing in hallway mumbling to himself. Not easily redirected. Patient states I got to go. Frequently walks to windows and doors as if to seek exit. Redirected away from doors for safety. Increased supervision implemented to prevent patient from (exiting written then struck out by nurse) harm. Dr. notified of increased behavior. New order received to give 50 mg [MEDICATION NAME] by mouth now times one dose and increase [MEDICATION NAME] to 75 mg by mouth twice a day. Continue to monitor. Signed by nurse. No further entries of exiting or elopement were entered in Resident #3's nurse notes. Review of the facility incident reports dated 06/15/2018 to 09/06/2018 reflected there was one incident report for Resident #3 in 90 days. It was dated 08/10/2018 at 6:05 PM. RN A documented Received call from outside facility. Asked if we were missing a man wearing no shoes walking down street. Immediately room search. Found Resident #3 not in his room. Medication nurse just given his meds, five minutes prior to this, CNA was feeding another resident in dining room. Med. nurse ran out and got her car and brought him back to facility. He walked back in and followed me to unit. He told me he was going to Dallas. Checked for injuries and fluids given. No injuries found. Signed RN A The back of the incident report reflected the DON had written: Resident remains exit seeking, no injuries from incident. Does not recall incident but states he needs to go to 'Dallas, to the Bridge.' Daughter explained this was the shelter he was living at previously. Signed by DON on 08/13/2018 and the Administrator on 08/24/2018. Review of a Progress Note dated 08/13/2018 reflected the Administrator, who was also a licensed Social Worker, had entered she had interviewed Resident #3 and he stated he was going back to The Bridge in Dallas, he did not know how he got out and he had a history of [REDACTED]. Review of Resident #3's Risk of Elopement/Wandering review reflected the staff had assessed him for his elopement risk on 02/08/2018, 05/26/2018, 08/10/2018 and 08/26/2018. Every assessment reflected the nurse checked yes, he had a history of [REDACTED]. The form further reflected each nurse checked his behavior was not a new behavior and family had voiced concerns that would indicate the resident may have wandering tendencies or try to leave. Review of Resident #3's Psychiatric Services agency notes on 07/27/2018 reflected the doctor visited the resident and did not mention the resident's elopement behaviors that had been documented in the nurse's notes on 07/23/2018. Further review of the Psychiatric Services notes reflected he visited again on 08/14/2018 and the Chief complaint was the resident is very restless, irritable and exit seeking. The resident was having delusions and thought he needed to get to The Bridge in Dallas. Plan: treatment plan: [REDACTED]. 2) increase [MEDICATION NAME] to 75 mg twice a day. Review of the Facility Self Reporting Intake dated 08/10/2018 reflected the ADON had reported Resident #3's elopement on 08/10/2018. She recorded; Resident ambulates independently, requires frequent supervision (listed diagnoses) and has a history of exit seeking behavior and history of elopement. Resident has exited facility in past, he will check the gate and fence several times a day to see if it can be opened. She reported at approximately 6:05 PM on 08/10/2018 an unidentified caller stated 'I think you have a resident out. There is a man walking down the street with no shoes on.' .Resident #3 was found by staff walking beside the north bound lane of Highway 14 close to the gas station and liquor store. He stated he was going to Dallas. He had no injury and could not remember the event at 7:30 PM. In-services performed on elopement, abuse and neglect and resident rights, CNA (D) was moved off secure unit and another CNA assigned to secure unit. MD and family notified. In an observation on 09/06/2018 at 12:15 PM the distance between the facility and the gas station and liquor store on Highway 14 was measured to be just over two tenths of one mile, and one must cross the railroad track to get there. Review of the five day Investigation Report reflected it was submitted on 08/14/2018 and signed by the Administrator. The report reflected Resident #3 was independently ambulatory, did not have the capacity to make informed decisions and had a history of [REDACTED].#3 was the one resident missing after an anonymous member of the community called and reported a man with no shoes was walking on the highway. Provider Response: Provider was notified of the elopement, immediately searched and identified Resident #3 was missing. He was returned to the building and was not harmed. The Investigation Summary reflected Resident #3 has a history of exit seeking behaviors, resides on the secure unit and he has severely impaired cognition. The packet reflected there were multiple in-service sign in sheets but there were no documented interviews regarding Resident #3's whereabouts on the night of 08/10/2018 at any time by any staff. There were no interviews regarding how he may have got out, if the gates were locked or what was found at the time. The document did not reflect who checked the gates or if they were checked after the elopement or in the following days. There was nothing recorded that would indicate the facility had initiated further safety interventions to keep Resident #3 from leaving the facility. In an interview on 09/06/2018 at 10:29 AM the Maintenance Director stated, Resident #3 is pushing at the bottom of the door to get out. He stated he had witnessed the resident get out the gate while he was working on the generator (later, he stated it was somewhere between 08/22/2018 and 08/24/2018). He further stated he had told the Administrator the facility could add additional magnets to the secure unit courtyard gates and maybe Resident #3 would not be able to push it open. In an interview on 09/06/2018 at 10:35 AM CMA O stated, I'm working as a aide today. Res. #3 is very fast, and he has got out several times. We catch him quick though. I haven't heard of Res. #3 leaving the unit in a long while. We are supposed to see where he is before we go in the shower or give another resident incontinent care. Then we are supposed to see where he is after we finish care on the resident. We have to hurry up with the other residents. In an interview on 09/06/2018 at 10:45 AM the Administrator stated, Res. #3 lives on the secure unit and he is exit seeking. This is not the first time he was out. There is one gate that if we hit it, it will not open, but he has figured out how to manipulate the gate and he peels the gate off the magnet. He just hits it short and low. My maintenance man watched him and saw how he did it. We are getting a second magnet and putting on the bottom of the gates. Res. #3 was previously homeless in Dallas, and he says he is leaving and going back to Dallas. He has no recollection of the actual elopement event (8/10/2018). How we found out he was out was that someone in the community spotted him and called us and told us one of our residents was out. In an interview on 09/06/2018 at 1:05 PM the DON stated there were routinely two nurses and three aides on duty on the evening shift and on 08/10/2018 when Resident #3 eloped. She stated The staffing is one aide on the unit at all times. The rest of the staff are primarily up front, but the nurse and the medication nurse go to the unit to provide care and make rounds. In an interview on 09/06/2018 at 1:14 PM CNA E stated, I was in the front (on 08/10/2018). I don't think the electricity was out that night. CNA D was working the back and we got a phone call that they had a resident out. They went and got him in the car. RN A sent CNA D up front and I went to the unit. CNA D was working on the unit when I started working here around (MONTH) (YEAR). She doesn't work back there anymore. Resident #3 can get by you in a blink of an eye. I was wondering how he was getting out. He moves fast. Observation on 09/06/2018 at 1:47 PM reflected Resident #3 was out on the secured patio rocking in a chair. No staff were outside or closely watching out the window. All the residents on the unit were ambulatory without a mobility device. A second resident, Resident #4, was also in a rocking chair outside near Resident #3. CNA E was giving resident care to a resident. In an interview on 09/06/2018 at 2:00 PM RN A stated, I was charge nurse (on 08/10/2018), LVN B my medications aide (med aide) was in the back (on the unit) with the CNA. As I understand it, LVN B had just given her meds (medications) and she came running out of the unit and told me someone had called and said there was resident that was walking down the road with no shoes on. We looked for Resident #3 and he was nowhere to be found. He is an escape artist. No one witnessed how he left. I have no idea how he got out. As soon as I found he was not in his room, LVN A jumped in her car and went to get him. We are very meticulous about checking on him now. Basically, CNA D told me she had not checked the gate and she told me he was in his room. But I told her he was not in his room. She did not follow our policy to know where he was. In an interview on 09/06/2018 at 2:16 PM CNA D stated, It happened during the meal. I served his tray to him in his room between 5:30 and 6:00 PM. I was trying to feed the residents. I was facing the two windows and one of the doors he would have to go through. I never saw him go past a window. There are two gates to exit the secure yard. The door I was facing is the one that alarms in the dining room area, so he couldn't have gone out that one. The other door is out of the frame and I did not hear that door open at all. I usually hear that door when they go out. LVN B was being med aide that day and she was near that door. We are pretty sure he went out there. She was right next to the door and how he got past her we do not know. I started serving food, she came within thirty to thirty five minutes to give meds. He had to have gone during that time. But the lights had flickered around 4:00 PM while I was working on the computer, and no one had left a key to get in where the re-set box was for the gates. In the locked cleaning supply room is where the button is kept to reset the gate. About an hour before supper I checked the gates and they held firm for me. I decided the electricity had not gone off at all. It was just the lights that flickered. I went out to see which courtyard gate he went out and it was the one that was by the door I was sitting by. It was standing open about five to six inches. I have just realized he would have had to go past the hedged window. I no longer work on the unit unless it is an emergency. When I tried to close the gate after I found it open after he left, it was obviously scraping on the concrete. It was hard to close. Maybe I just didn't try hard enough to see if it was unlocked earlier in the shift. I suggested putting the reset key where we could get it. The button to reset the gates was locked in the storeroom. Maybe I came out and told RN A about the gates. I really can't remember. In an interview on 09/06/2018 at 3:42 PM the MDS Coordinator stated, If the resident is still on the premises it is not a true elopement. Apparently, Resident #3 has figured out if you give pressure to the bottom of the gate it will let go. They are putting another magnet at the bottom of the gate. Whenever the electricity flickers it unlocks the gate. The aide on the unit only has to buzz to the desk when the electricity flickers. Every nurse and med aide has the key. It just has to have the reset button touched. In an interview on 09/06/2018 at 4:00 PM the DON stated, We called in the 08/10/2018 elopement because Resident #3 was gone for about 10 minutes. They had been working on the air conditioner on the roof. I don't believe the staff even knew it was happening. I was not in town when this happened. I modified the care plan when I came back to work after a couple of days off. I put the date I was modifying the care plan on the care plan. I didn't feel I should date the frequent observation (for 8/10/18) because that would be back dating. I have never seen the frequent observation sheet document. I was told that is what they did. We do not need an incident report for the resident who steps out the door/gate and is observed by staff and assisted back in the building without leaving the property. I do not know how many times he has stepped out the gate. I didn't know these entries were in the nurse's notes (July 23, (YEAR) 8:00 AM and 8:20 AM). In an interview on 09/06/2018 at 4:00 PM the Administrator stated, I didn't know these entries were in the nurse's notes (July 23, (YEAR) 8:00 AM and 8:20 AM getting out the gate). After you asked me when the magnets are going to be put in place, I found out the Maintenance Director did not order the second magnets for the secure unit courtyard gates (around 08/23/2018). I have just ordered them to be shipped over-night to the facility (09/07/2018 - 15 days later). I feel a second magnet will change the dynamics of the doors so that he cannot push it open. We have asked the Maintenance Director once a week when the magnets are coming, and he would tell us they are on the way. The Administrator stated the facility does not make incident reports unless the resident leaves the property. She stated she could not say for sure how often Resident #3 had opened the gate and was caught by staff. She stated there was no documentation of frequent observation and the surveyor had the full report. In an interview on 09/06/2018 at 5:00 PM the Maint. Director stated, I told the Administrator the solution (to keeping Res. #3 from eloping) about two weeks ago when Resident #3 started hitting the gate hard and it opened was to get a second magnet. I told the staff and they got him and brought him in. I told the Administrator what happened and told her we needed a second magnet on the gates. She was agreeable and it seemed like she was letting me handle it. My suppliers didn't have the magnets, so I needed to go back to the Administrator and have her get approval to order it from a different supplier, but I never did. The Maint. Director stated he believed he had watched Resident #3 force the gate open somewhere between 08/22/2018 and 08/24/2018 and that was when he was supposed to order the magnet. On 09/07/2018 at 3:55 PM the Administrator and DON were notified that an IJ situation had been identified due to the above failures. In an interview on 09/07/2018 at 4:00 PM the Administrator stated after Resident #3 was observed to over power the courtyard gate and exit the secure yard (about 8//22 - 8/24/18) the facility did not change what they were doing to keep Resident #3 safe. She stated whenever Resident #3 hears the fire bell go off he knows the gate will unlock and he immediately checks the gate. She stated she did not know he was getting out other than when the staff called her and said he had eloped. She stated if the staff had eyes on him, they did not make incident reports and did not put it in a nurse note or follow up on it. She stated she should have realized there should have been an incident report generated because it is not normal for a resident on the secured unit to be able to open the gate. She stated the magnets were being applied to the secure unit gates (as of 09/07/2018 early evening). The Administrator stated CNA D should have been able to hear Resident #3 hit the gate to open it, therefore, there was a question of whether the electricity went off or what happened. She stated they were not for sure what happened, and she did not have written interviews for any of the staff that were present on 8/10/2018. She stated she thought the ADON had interviewed everyone, but she had not seen the documents and did not include any interviews in the self-report. The Administrator stated she should have the staff interviews so that she could see how Resident #3 left on 08/10/2018. The Administrator stated the ADON had told her she had all the documents the ADON generated during the investigation when she sent it in. The Administrator stated she let the ADON handle the investigation and the Administrator did the final report. The Administrator did not reply when the surveyor spoke of Resident #3 leaving the gate open for other secure unit residents. In an interview on 09/07/2018 at 6:00 PM the ADON stated she was on call on 08/10/2018 and she immediately called the Administrator and told her there was an elopement. The Administrator told me to go on up to the facility. RN A had relieved CNA D of her duties on the unit and sent her up front. LVN B stated she had given him his medications just before she got the call, so he couldn't have been gone long. That happened on a Friday night (8/10/2018) and on Monday morning in the department head meeting the Maintenance Director told us he had worked on the air conditioner at some time during Friday and maybe that had something to do with the gate. Yes, Resident #3 has got out the gate since I worked here. Last week when I was working a 2-10 shift and I was here after dinner, the Maint. Director said, Hey did you know Res. #3 got out? He told me he was out in his shop and saw him three to four feet from the secured unit, so he just walked him back in. I called the DON and informed her, and she told me I did not need to do an incident report because he never left the property. I heard of another incident where he got out of the gate but just a couple of feet. I don't know who told me about that. It may have been in the morning meeting or a nurse told me. I don't think I put an entry in the nurse notes when the Maint. Director told me about him getting out. I also have a text for Wednesday, (MONTH) the 29th text that was sent at 8:27 (AM/PM ?) when the Maint. Director told me he helped him back in. I was not aware Resident #3 got out twice on 7/24/18. Review of the policy Accident/Incident Reporting dated 04/07/2014 reflected; An incident is any adverse outcome associated as a direct consequence of treatment or care. An accident is an unexpected, unintended event that can result in bodily injury. 4. Information related to accidents and incidents is documented on the appropriate worksheet: Incident/Accident, on the same shift by the person witnessing or identifying the incident or accident. 5. Submit the form to the DON. 6. The DON designates the responsible party to complete the follow-up. Review of the in-service titled Electricity and Secure Unit dated 08/10/2018 at 9:00 PM reflected: Anytime the power fails (including just a flicker off then on) Charge Nurse must go back to the secure unit and assist CNA with resetting gates on secure unit. If power fails, CNA please report to our Charge Nurse immediately! Keep residents indoors until gates are reset. Charge Nurses, if power is out for more than a few minutes additional staff must assist with secure unit. Please notify management of power failures. Review of the Elopement Policy, not dated, reflected; A prompt investigation and search will be conducted if a resident is considered missing. When the resident is located, the charge nurse will complete a head to toe assessment. Social Service designee assesses the resident for emotional distress. Attending physician and responsible party should be notified. If there is injury or other concerns, please contact your regional staff to determine if legal involvement is warranted. Elopements are included in the facility incident/accident trending. Review of the Abuse, Neglect, Exploitation, or Mistreatment policy updated on 03/08/2047 reflected: Neglect is the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. 3. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or mistreatment and will implement immediate action to safeguard resident. 5. Ongoing assessment, care planning, and monitoring of those residents with special needs that may lead to neglect, for example: c. History of self-injury; e. Residents requiring excessive nursing care or staff attention. Component V: Reporting/Response 2. An analysis is completed to determine what changes are needed, if appropriate, to prevent further occurrences. Component VI: The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. An investigation may include but is not limited to the following: E. Written summaries of interviews with individuals having first-hand knowledge of the incident. G. Measures taken to prevent future incidents. H. All documents pertaining to the investigation must be complied sic (compiled) and stored in the Administrator's office. In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. Guidelines for Investigation: G. Interview individuals having first-hand knowledge of the incident and write summaries of the interviews. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated and signed by the interviewer. H. Social Service will . implement an interdisciplinary care plan. I. The DON or designee will review the resident's medical record. The facility provided a list of two residents who were at risk for elopement. Review of Resident #3's medical record reflected no observation forms. On 09/07/2018 at 3:55 PM the Administrator and DON were notified that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator, on 09/07/18 at 10:17 PM. Immediate Jeopardy Plan of Removal: Resident Neglect: Resident Elopement Issue Identified: 1. Bremond Nursing & Rehabilitation will provide a safe environment for Resident #3 who has been identified as an elopement risk, with exit seeking behavior. a. An additional magnetic lock has been installed at the bottom of the secure unit exterior gates in courtyard by the Maintenance Director effective 8:00 PM on 09/07/2018. b. Re-educate is in progress for the secure unit CNAs and nurses regarding documenting head count, power surges, resetting the unit secure unit gates, every 15-minute checks and every one-hour checks on Resident #3, and reporting unusual behaviors to the charge nurse, and the charge nurse will report concerns to the Director of Nursing. Education completion by 09/10/2018. c. Facility is currently seeking alternate placement for Resident #3 under the guidance of the Administrator. d. Daily chart checks for Resident #3 by the DON or Administrator to monitor behavior status until alternative placement has been made. 2. Bremond Nursing & Rehabilitation will complete incident reports for unusual behaviors. a. Facility initiated re-education on notification guidelines of exit seeking and gate banging behaviors. b. The charge nurses are being re-educated on documentation guidelines of unusual behaviors by the Director of Nursing. c. Re-education will be completed on 09/07/2018 by midnight. Any staff member not present will be re-educated before working their next scheduled shift. Facility staff to be completed by 09/10/2018. d. Incident reports will be tracked and trended through the internal Quality Assurance and Performance Improvement Committee. Any areas of concern will be addressed at the time of discovery. The Director of Nursing, Administrator, or On-call nurse shall be notified of exit seeking behavior. 3. Investigations of unusual behaviors will be investigated thoroughly. a. The Administrator was re-educated on components of thorough investigations to include written summaries of the interviews with individuals having firsthand knowledge of an event, resolutions and outcomes, and immediate measures taken to prevent future incidents. This will be completed by midnight (MONTH) 7, (YEAR) and monitored by the Regional Vice President until 12/07/2018. 4. The identified resident's care plan has been updated to include approaches to address the identified behaviors. a. Staff has been re-educated on approaches to deescalate Resident #3's behaviors. b. The care plan meeting was held via telephone held 09/07/2018 at 5:30 PM with the responsible party to review and update the approaches to the resident's unusual behaviors, as well as discharge planning. This was by the Administrator and the Director of Nursing. 5. The Administrator will monitor the trainings for the plan of removal. 6. The charge nurse will be responsible for checking the security of the doors at the beginning of their shift. This will be monitored by the Director of Nursing. 7. Preventative maintenance documentation will be completed by the Maintenance Director daily and monitored weekly by the Administrator. 8. Re-education of the Maintenance Director of by the Administrator regarding his responsibilities and communication of his job duties. To be completed by 09/14/2018. 9. The corporate supervisors of the Administrator will visit the building to monitor that the Administrator is recognizing dangerous situations and responding appropriately to the situations bi-monthly during a 90-day period. 10. Orientation for new staff will include training on secure unit security systems and power loss. Monitoring of the Plan of Removal was conducted by the Surveyor on 09/07/2018 between 10:05 PM and 10:45 PM. The 2-10 PM and 10-6 AM staff were in-serviced for the charge nurse to check the secure court

Based on observation, interview and record review the facility failed to ensure each resident received the services provided or arranged by the facility met professional standards of quality for one (1) of twelve residents (Resident #9) reviewed for advance directives. One (1) of One (1) RN reviewed; RN A. RN A failed to immediately call 911on [DATE] at 7:00 AM and transfer Resident #9, who was a Hospice resident with a Full Code status (Full Code: to bring someone who is unconscious, not breathing, or close to death back to a conscious or active state again www.Merriam-Webster.com), to the hospital when he was in respiratory distress and responded to pain stimulus only. Resident #9 was pronounced dead upon arrival to the emergency room approximately one hour after having been assessed as being in respiratory distress. RN A did not check Resident #9's code status and did not know he was a full code until after 7:45 AM on [DATE]. This deficient practice affected Resident #9 and placed three (3) additional hospice residents, identified as full code, at risk for delayed emergency care which could result in increased injury or death. Findings Include: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses . The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure . Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (E) Respect the client's right to privacy by protecting confidential information unless required or allowed by law to disclose the information; (F) Promote and participate in education and counseling to a client(s) and, where applicable, the family/significant other(s) based on health needs; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (R) Be responsible for one's own continuing competence in nursing practice and individual professional growth. Review of Resident #9's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The Full Code status was not printed by his name on his Face Sheet. Review of Resident #9's Significant Change in status MDS dated [DATE] reflected a BIMS score of eight (8) which indicated his cognition was moderately impaired. Resident #9 was assessed as extensive assistance of one staff for his ADLs except transferring and bed mobility in which he was assessed as having required two people to assist him at least one time in the observation window. Resident #9 was assessed as not having experienced shortness of breath during the observation period. Hospice Care was marked as being received. Review of Resident #9's Care Plan dated [DATE] reflected a problem of Impaired Respiratory function with an upper respiratory infection and he prefers to lay flat. The Goal stated Resident will display increased respiratory function as evidenced by oxygen saturation increasing. Interventions included oxygen at two to five liters per minute via nasal cannula as needed for shortness of breath or wheezing and [MEDICATION NAME] updrafts every four hours as needed for shortness of breath or wheezing. His care plan reflected on [DATE] he was at risk for elopement and wore a safety bracelet to alert staff. Resident #9's Full Code status and Hospice care status were not care planned. In an observation on Tuesday, [DATE] at 8:08 AM RN A swiftly entered Resident #9's room. Surveyor swiftly went to the room to observe RN A bending over Resident #9 who had his eyes closed, he was pale and his body was limp and the sheet was removed down to his waist. He did not have a gown or shirt on. RN A stated, Can you get me some help, I have already called 911. Staff came to assist and CPR was initiated. The crash cart was already in the room. The ambulance arrived within two minutes approximately. Review of Resident #9's Nurse's Notes reflected an entry for [DATE] at 2:00 PM when Resident #9 told the nurse he was more comfortable when his stump was wrapped with an ACE bandage and requested her to continue wrapping it. The next entry was for [DATE] at 7:00 AM and reflected Resident #9 was exhibiting respiratory difficulty with coarse/diminished throughout all lung fields. Responding only to pain at present. Not verbally responsive. Blinks in response to questions. Oxygen at 4 liters per minute with oxygen saturation of 83% and respirations at 26 all accessory muscles in use. Family and Hospice notified of patient status change at 7:20 AM. 7:25 AM Blood pressure ,[DATE] pulse 133 respirations ,[DATE] and oxygen saturation at 86%. Extremities cool peripheral pulses not discernable (no heartbeat felt at wrists). [MEDICATION NAME] 0.5 milliliters given. Hospice notified. At approximately 7:45 AM resident displayed no signs of life (no breathing or heartbeat). 911 activated. CPR began. [DATE] at 9:00 AM Notified by hospital Resident #9 was dead on arrival. In an interview on [DATE] RN A stated the times she charted were her best estimates after Resident #9 was taken out by ambulance. Review of Resident #9's Roxanal sign out sheet reflected [MEDICATION NAME] 20 mg per one milliliter one half milliliter (10 mg) was signed out on [DATE] at 7:45 AM by RN A. In an interview on [DATE] at 9:15 AM MA F stated she had attempted to give Resident #9 his medications at 7:00 AM on [DATE] and he had oxygen on and his head was lying to the side. When she called his name to give him his medications he dropped his head to the side. I told RN A I couldn't give him his medications because he wouldn't wake up. She checked on him while I was still right there in the hall. In addition, MA F stated she knew for a fact the [MEDICATION NAME] was signed out at 7:45 AM because she made RN A sign it out when she got it so that it would not be forgotten in the event. MA F stated she told RN A it was going to be the initial dose (first time he received the medication) and she would have to chart it. MA F stated as RN A was signing out for the [MEDICATION NAME], RN A stated she thought he (Resident #9) was going. Review of Resident #9's Consolidated Physician Orders dated [DATE] reflected on page three he was a Full Code status and was admitted to Hospice care on [DATE]. The Full Code status was not printed by his name at the top of his Consolidated orders. Review of Resident #9's chart reflected upon opening the chart one of the first items visible was a STOP sign and the statement: In Case of Hospice Crisis Call US First. The Hospice office phone number was listed. The chart had a green sheet of paper with the words Full Code very near the front. Review of Resident #9's Hospice Care Plan reflected; Patient and Caregivers will have decreased fear/anxiety regarding death and dying press. Patient/caregiver will express increased sense of closure and peacefulness at the end of life. The Care Plan did not list a code status for Resident #9. Review of the Hospice Advance Directive Signature page reflected Resident #9 nor the Hospice Representative checked a box indicating whether Resident #9 did or did not have an Advance Directive in place and both Resident #9 and the Hospice Representative signed and dated the form [DATE]. Review of the 24 Hour Nurses Report dated [DATE] reflected Full Code was type written in all large capital letters beneath Resident #9's name. The facility printed residents' code status on the 24 Hour Nurses Report tool. In an interview on [DATE] at 4:45 PM RN A stated Resident #9 was able to feed himself as of yesterday (Monday [DATE]). She stated Resident #9 had [MEDICAL CONDITION] and the Medical Doctor had stated it had metastasized to his liver and he was bruising (bleeding) significantly in his stump and going up his groin. Resident #9 was on [MEDICATION NAME] routinely and [MEDICATION NAME] ([MEDICATION NAME]) as needed for breakthrough pain. RN A stated at 7:00 AM MA F told her Resident #9 did not look right. RN A stated she gave him a breathing treatment and called the hospice nurse on the hospice nurse's personal cell phone not on the Hospice phone line. RN A stated the facility policy was to call the hospice with any change of condition and they would come and assess and make the plan of care. She stated she checked Resident #9's blood pressure manually, it was ,[DATE] and she gave the [MEDICATION NAME] hoping to slow his pulse and respirations down so he could get a good deep breath. RN A stated when she talked to the hospice nurse she was taking care of urgent personal business. RN A stated she told the hospice nurse everything was pretty negative and the hospice nurse said a Hospice Nurse would be there shortly to assess Resident #9. RN A stated after she gave the [MEDICATION NAME] (just after signing it out at 7:45 AM), she pulled Resident #9's chart and saw that he was a Full Code. RN A stated she immediately called 911 and ran to the room. RN A stated if she had known he was a Full Code, she would have called 911 when she saw his low blood pressure of ,[DATE]. RN A stated she did not know if the hospice nurse knew Resident #9's code status during the conversation because they did not talk about it and she did not know he was a Full Code during the phone calls. She stated she found he was a Full Code after she gave the [MEDICATION NAME]. In an interview on [DATE] at 12:38 AM RN A stated she felt like Resident #9's airway was compromised because of him using his accessory muscles to breath (chest and abdominal muscles). In an interview on [DATE] at 5:38 PM the Hospice Administrator stated it was the hospice policy for the facility to call the hospice with changes of condition at the hospice phone number and not directly to the nurse. She stated if a resident is a Full Code status and their health condition is declining significantly the hospice expected the facility to call 911 and send them out. In an interview on [DATE] at 7:20 AM the Hospice Case Manager stated she had been called at 7:56 AM and told her Resident #9 had a change in condition. She stated she received a call at 8:04 and was told he was mottled (pale and blue) and again at 8:06 that he was being sent out with CPR in progress. The Case Manager stated no vital signs were ever told to her and she confirmed she did not discuss the resident code status during the initial calls. In an interview on [DATE] at 2:35 PM the DON stated RN A should have checked the code status when she saw he had a change of condition. In an interview on [DATE] at 4:10 PM the DON was asked if it was neglect when RN A observed Resident #9 was in respiratory distress on [DATE] at 7:00 AM and she did not call 911. The DON stated Resident #9 was not in respiratory distress when she was in Resident #9's room just immediately after she arrived at 7:10 AM on the day of his death. The DON stated Resident #9's room was the first room she entered for her morning rounds and RN A told her Resident #9 wasn't doing very good. The DON stated she walked to the head of the bed and Resident #9 was not in respiratory distress because he wasn't breathing 40 to 50 times a minute and his eyes were closed. She stated she didn't try to get him to respond to her and she did not get a stethoscope and listen to his breath sounds. The DON stated he was getting a breathing treatment. She stated she continued on her rounds and the next thing she knew the staff was called for help to his room. The DON stated it was neglect that RN A did not know the resident's code status and did not call 911 when his blood pressure was low and/or if he was in respiratory distress. In an interview on [DATE] at 4:33 PM the Administrator stated when RN A did not call 911 for Resident #9 when she assessed him to be in respiratory distress it was neglect due to his Full Code status. Review of the policy Hospice Care for Nursing Facility Residents-Written Agreements: 3. D. An agreement that it is the facility's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before hospice care was elected. Review of the facility policy for Abuse/Neglect dated [DATE] reflected; 1. The facility's Leadership prohibits neglect 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected neglect 5. the facility's Leadership will implement appropriate and necessary guidelines, which prohibit the neglect. Component IV: Identification 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect of residents for one (1) of twelve residents reviewed for neglect (Resident #9). RN A failed to immediately call 911on [DATE] at 7:00 AM and transfer Resident #9, who was a Hospice resident with a Full Code status (Full Code: to bring someone who is unconscious, not breathing, or close to death back to a conscious or active state again www.Merriam-Webster.com), to the hospital when he was in respiratory distress and responded to pain stimulus only. Resident #9 was pronounced dead upon arrival to the emergency room approximately one hour after having been assessed as being in respiratory distress. RN A did not check Resident #9's code status and did not know he was a full code until after 7:45 AM on [DATE]. This deficient practice affected Resident #9 and placed three (3) additional hospice residents, identified as Full Code status, at risk for delayed emergency care resulting in increased injury or death. Findings Include: Review of the policy Hospice Care for Nursing Facility Residents-Written Agreements: 3. D. An agreement that it is the facility's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before hospice care was elected. Review of the facility policy for Abuse/Neglect dated [DATE] reflected; 1. The facility's Leadership prohibits neglect 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected neglect 5. the facility's Leadership will implement appropriate and necessary guidelines, which prohibit the neglect. Component IV: Identification 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm. Review of Resident #9's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The Full Code status was not printed by his name on his Face Sheet. Review of Resident #9's Significant Change in status MDS dated [DATE] reflected a BIMS score of eight (8) which indicated his cognition was moderately impaired. Resident #9 was assessed as extensive assistance of one staff for his ADLs except transferring and bed mobility in which he was assessed as having required two people to assist him at least one time in the observation window. Resident #9 was assessed as not having experienced shortness of breath during the observation period. Hospice Care was marked as being received. Review of Resident #9's Care Plan dated [DATE] reflected a problem of Impaired Respiratory function with an upper respiratory infection and he prefers to lay flat. The Goal stated Resident will display increased respiratory function as evidenced by oxygen saturation increasing. Interventions included oxygen at two to five liters per minute via nasal cannula as needed for shortness of breath or wheezing and [MEDICATION NAME] updrafts every four hours as needed for shortness of breath or wheezing. His care plan reflected on [DATE] he was at risk for elopement and wore a safety bracelet to alert staff. Resident #9's Full Code status and Hospice care status were not care planned. In an observation on Tuesday, [DATE] at 8:08 AM RN A swiftly entered Resident #9's room. Surveyor swiftly went to the room to observe RN A bending over Resident #9 who had his eyes closed, he was pale and his body was limp and the sheet was removed down to his waist. He did not have a gown or shirt on. RN A stated, Can you get me some help, I have already called 911. Staff came to assist and CPR was initiated. The crash cart was already in the room. The ambulance arrived within two minutes approximately. Review of Resident #9's Nurse's Notes reflected an entry for [DATE] at 2:00 PM when Resident #9 told the nurse he was more comfortable when his stump was wrapped with an ACE bandage and requested her to continue wrapping it. The next entry was for [DATE] at 7:00 AM and reflected Resident #9 was exhibiting respiratory difficulty with coarse/diminished throughout all lung fields. Responding only to pain at present. Not verbally responsive. Blinks in response to questions. Oxygen at 4 liters per minute with oxygen saturation of 83% and respirations at 26 all accessory muscles in use. Family and Hospice notified of patient status change at 7:20 AM. 7:25 AM Blood pressure ,[DATE] pulse 133 respirations ,[DATE] and oxygen saturation at 86%. Extremities cool peripheral pulses not discernable (no heartbeat felt at wrists). [MEDICATION NAME] 0.5 milliliters given. Hospice notified. At approximately 7:45 AM resident displayed no signs of life (no breathing or heartbeat). 911 activated. CPR began. [DATE] at 9:00 AM Notified by hospital Resident #9 was dead on arrival. In an interview on [DATE] RN A stated the times she charted were her best estimates after Resident #9 was taken out by ambulance. Review of Resident #9's Roxanal sign out sheet reflected [MEDICATION NAME] 20 mg per one milliliter one half milliliter (10 mg) was signed out on [DATE] at 7:45 AM by RN A. In an interview on [DATE] at 9:15 AM MA F stated she had attempted to give Resident #9 his medications at 7:00 AM on [DATE] and he had oxygen on and his head was lying to the side. When she called his name to give him his medications he dropped his head to the side. I told RN A I couldn't give him his medications because he wouldn't wake up. She checked on him while I was still right there in the hall. In addition, MA F stated she knew for a fact the [MEDICATION NAME] was signed out at 7:45 AM because she made RN A sign it out when she got it so that it would not be forgotten in the event. MA F stated she told RN A it was going to be the initial dose (first time he received the medication) and she would have to chart it. MA F stated as RN A was signing out for the [MEDICATION NAME], RN A stated she thought he (Resident #9) was going. Review of Resident #9's Consolidated Physician Orders dated [DATE] reflected on page three he was a Full Code status and was admitted to Hospice care on [DATE]. The Full Code status was not printed by his name at the top of his Consolidated orders. Review of Resident #9's chart reflected upon opening the chart one of the first items visible was a STOP sign and the statement: In Case of Hospice Crisis Call US First. The Hospice office phone number was listed. The chart had a green sheet of paper with the words Full Code very near the front. Review of Resident #9's Hospice Care Plan reflected; Patient and Caregivers will have decreased fear/anxiety regarding death and dying press. Patient/caregiver will express increased sense of closure and peacefulness at the end of life. The Care Plan did not list a code status for Resident #9. Review of the Hospice Advance Directive Signature page reflected Resident #9 nor the Hospice Representative checked a box indicating whether Resident #9 did or did not have an Advance Directive in place and both Resident #9 and the Hospice Representative signed and dated the form [DATE]. Review of the 24 Hour Nurses Report dated [DATE] reflected Full Code was type written in all large capital letters beneath Resident #9's name. The facility printed residents' code status on the 24 Hour Nurses Report tool. In an interview on [DATE] at 4:45 PM RN A stated Resident #9 was able to feed himself as of yesterday (Monday [DATE]). She stated Resident #9 had [MEDICAL CONDITION] and the Medical Doctor had stated it had metastasized to his liver and he was bruising (bleeding) significantly in his stump and going up his groin. Resident #9 was on [MEDICATION NAME] routinely and [MEDICATION NAME] ([MEDICATION NAME]) as needed for breakthrough pain. RN A stated at 7:00 AM MA F told her Resident #9 did not look right. RN A stated she gave him a breathing treatment and called the hospice nurse on the hospice nurse's personal cell phone not on the Hospice phone line. RN A stated the facility policy was to call the hospice with any change of condition and they would come and assess and make the plan of care. She stated she checked Resident #9's blood pressure manually, it was ,[DATE] and she gave the [MEDICATION NAME] hoping to slow his pulse and respirations down so he could get a good deep breath. RN A stated when she talked to the hospice nurse she was taking care of urgent personal business. RN A stated she told the hospice nurse everything was pretty negative and the hospice nurse said a Hospice Nurse would be there shortly to assess Resident #9. RN A stated after she gave the [MEDICATION NAME] (just after signing it out at 7:45 AM), she pulled Resident #9's chart and saw that he was a Full Code. RN A stated she immediately called 911 and ran to the room. RN A stated if she had known he was a Full Code, she would have called 911 when she saw his low blood pressure of ,[DATE]. RN A stated she did not know if the hospice nurse knew Resident #9's code status during the conversation because they did not talk about it and she did not know he was a Full Code during the phone calls. She stated she found he was a Full Code after she gave the [MEDICATION NAME]. In an interview on [DATE] at 12:38 AM RN A stated she felt like Resident #9's airway was compromised because of him using his accessory muscles to breath (chest and abdominal muscles). In an interview on [DATE] at 5:38 PM the Hospice Administrator stated it was the hospice policy for the facility to call the hospice with changes of condition at the hospice phone number and not directly to the nurse. She stated if a resident is a Full Code status and their health condition is declining significantly the hospice expected the facility to call 911 and send them out. In an interview on [DATE] at 7:20 AM the Hospice Case Manager stated she had been called at 7:56 AM and told her Resident #9 had a change in condition. She stated she received a call at 8:04 and was told he was mottled (pale and blue) and again at 8:06 that he was being sent out with CPR in progress. The Case Manager stated no vital signs were ever told to her and she confirmed she did not discuss the resident code status during the initial calls. In an interview on [DATE] at 2:35 PM the DON stated RN A should have checked the code status when she saw he had a change of condition. In an interview on [DATE] at 4:10 PM the DON was asked if it was neglect when RN A observed Resident #9 was in respiratory distress on [DATE] at 7:00 AM and she did not call 911. The DON stated Resident #9 was not in respiratory distress when she was in Resident #9's room just immediately after she arrived at 7:10 AM on the day of his death. The DON stated Resident #9's room was the first room she entered for her morning rounds and RN A told her Resident #9 wasn't doing very good. The DON stated she walked to the head of the bed and Resident #9 was not in respiratory distress because he wasn't breathing 40 to 50 times a minute and his eyes were closed. She stated she didn't try to get him to respond to her and she did not get a stethoscope and listen to his breath sounds. The DON stated he was getting a breathing treatment. She stated she continued on her rounds and the next thing she knew the staff was called for help to his room. The DON stated it was neglect that RN A did not know the resident's code status and did not call 911 when his blood pressure was low and/or if he was in respiratory distress. In an interview on [DATE] at 4:33 PM the Administrator stated when RN A did not call 911 for Resident #9 when she assessed him to be in respiratory distress it was neglect due to his Full Code status. The facility provided a list of three (3) additional Hospice residents with a Full Code status.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect of residents for one (1) of twelve residents reviewed for neglect (Resident #9). RN A failed to immediately call 911on [DATE] at 7:00 AM and transfer Resident #9, who was a Hospice resident with a Full Code status (Full Code: to bring someone who is unconscious, not breathing, or close to death back to a conscious or active state again www.Merriam-Webster.com), to the hospital when he was in respiratory distress and responded to pain stimulus only. Resident #9 was pronounced dead upon arrival to the emergency room approximately one hour after having been assessed as being in respiratory distress. RN A did not check Resident #9's code status and did not know he was a full code until after 7:45 AM on [DATE]. This deficient practice affected Resident #9 and placed three (3) additional hospice residents, identified as Full Code status, at risk for delayed emergency care resulting in increased injury or death. Findings Include: Review of Resident #9's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The Full Code status was not printed by his name on his Face Sheet. Review of Resident #9's Significant Change in status MDS dated [DATE] reflected a BIMS score of eight (8) which indicated his cognition was moderately impaired. Resident #9 was assessed as extensive assistance of one staff for his ADLs except transferring and bed mobility in which he was assessed as having required two people to assist him at least one time in the observation window. Resident #9 was assessed as not having experienced shortness of breath during the observation period. Hospice Care was marked as being received. Review of Resident #9's Care Plan dated [DATE] reflected a problem of Impaired Respiratory function with an upper respiratory infection and he prefers to lay flat. The Goal stated Resident will display increased respiratory function as evidenced by oxygen saturation increasing. Interventions included oxygen at two to five liters per minute via nasal cannula as needed for shortness of breath or wheezing and [MEDICATION NAME] updrafts every four hours as needed for shortness of breath or wheezing. His care plan reflected on [DATE] he was at risk for elopement and wore a safety bracelet to alert staff. Resident #9's Full Code status and Hospice care status were not care planned. In an observation on Tuesday, [DATE] at 8:08 AM RN A swiftly entered Resident #9's room. Surveyor swiftly went to the room to observe RN A bending over Resident #9 who had his eyes closed, he was pale and his body was limp and the sheet was removed down to his waist. He did not have a gown or shirt on. RN A stated, Can you get me some help, I have already called 911. Staff came to assist and CPR was initiated. The crash cart was already in the room. The ambulance arrived within two minutes approximately. Review of Resident #9's Nurse's Notes reflected an entry for [DATE] at 2:00 PM when Resident #9 told the nurse he was more comfortable when his stump was wrapped with an ACE bandage and requested her to continue wrapping it. The next entry was for [DATE] at 7:00 AM and reflected Resident #9 was exhibiting respiratory difficulty with coarse/diminished throughout all lung fields. Responding only to pain at present. Not verbally responsive. Blinks in response to questions. Oxygen at 4 liters per minute with oxygen saturation of 83% and respirations at 26 all accessory muscles in use. Family and Hospice notified of patient status change at 7:20 AM. 7:25 AM Blood pressure ,[DATE] pulse 133 respirations ,[DATE] and oxygen saturation at 86%. Extremities cool peripheral pulses not discernable (no heartbeat felt at wrists). [MEDICATION NAME] 0.5 milliliters given. Hospice notified. At approximately 7:45 AM resident displayed no signs of life (no breathing or heartbeat). 911 activated. CPR began. [DATE] at 9:00 AM Notified by hospital Resident #9 was dead on arrival. In an interview on [DATE] RN A stated the times she charted were her best estimates after Resident #9 was taken out by ambulance. Review of Resident #9's Roxanal sign out sheet reflected [MEDICATION NAME] 20 mg per one milliliter one half milliliter (10 mg) was signed out on [DATE] at 7:45 AM by RN A. In an interview on [DATE] at 9:15 AM MA F stated she had attempted to give Resident #9 his medications at 7:00 AM on [DATE] and he had oxygen on and his head was lying to the side. When she called his name to give him his medications he dropped his head to the side. I told RN A I couldn't give him his medications because he wouldn't wake up. She checked on him while I was still right there in the hall. In addition, MA F stated she knew for a fact the [MEDICATION NAME] was signed out at 7:45 AM because she made RN A sign it out when she got it so that it would not be forgotten in the event. MA F stated she told RN A it was going to be the initial dose (first time he received the medication) and she would have to chart it. MA F stated as RN A was signing out for the [MEDICATION NAME], RN A stated she thought he (Resident #9) was going. Review of Resident #9's Consolidated Physician Orders dated [DATE] reflected on page three he was a Full Code status and was admitted to Hospice care on [DATE]. The Full Code status was not printed by his name at the top of his Consolidated orders. Review of Resident #9's chart reflected upon opening the chart one of the first items visible was a STOP sign and the statement: In Case of Hospice Crisis Call US First. The Hospice office phone number was listed. The chart had a green sheet of paper with the words Full Code very near the front. Review of Resident #9's Hospice Care Plan reflected; Patient and Caregivers will have decreased fear/anxiety regarding death and dying press. Patient/caregiver will express increased sense of closure and peacefulness at the end of life. The Care Plan did not list a code status for Resident #9. Review of the Hospice Advance Directive Signature page reflected Resident #9 nor the Hospice Representative checked a box indicating whether Resident #9 did or did not have an Advance Directive in place and both Resident #9 and the Hospice Representative signed and dated the form [DATE]. Review of the 24 Hour Nurses Report dated [DATE] reflected Full Code was type written in all large capital letters beneath Resident #9's name. The facility printed residents' code status on the 24 Hour Nurses Report tool. In an interview on [DATE] at 4:45 PM RN A stated Resident #9 was able to feed himself as of yesterday (Monday [DATE]). She stated Resident #9 had [MEDICAL CONDITION] and the Medical Doctor had stated it had metastasized to his liver and he was bruising (bleeding) significantly in his stump and going up his groin. Resident #9 was on [MEDICATION NAME] routinely and [MEDICATION NAME] ([MEDICATION NAME]) as needed for breakthrough pain. RN A stated at 7:00 AM MA F told her Resident #9 did not look right. RN A stated she gave him a breathing treatment and called the hospice nurse on the hospice nurse's personal cell phone not on the Hospice phone line. RN A stated the facility policy was to call the hospice with any change of condition and they would come and assess and make the plan of care. She stated she checked Resident #9's blood pressure manually, it was ,[DATE] and she gave the [MEDICATION NAME] hoping to slow his pulse and respirations down so he could get a good deep breath. RN A stated when she talked to the hospice nurse she was taking care of urgent personal business. RN A stated she told the hospice nurse everything was pretty negative and the hospice nurse said a Hospice Nurse would be there shortly to assess Resident #9. RN A stated after she gave the [MEDICATION NAME] (just after signing it out at 7:45 AM), she pulled Resident #9's chart and saw that he was a Full Code. RN A stated she immediately called 911 and ran to the room. RN A stated if she had known he was a Full Code, she would have called 911 when she saw his low blood pressure of ,[DATE]. RN A stated she did not know if the hospice nurse knew Resident #9's code status during the conversation because they did not talk about it and she did not know he was a Full Code during the phone calls. She stated she found he was a Full Code after she gave the [MEDICATION NAME]. In an interview on [DATE] at 12:38 AM RN A stated she felt like Resident #9's airway was compromised because of him using his accessory muscles to breath (chest and abdominal muscles). In an interview on [DATE] at 5:38 PM the Hospice Administrator stated it was the hospice policy for the facility to call the hospice with changes of condition at the hospice phone number and not directly to the nurse. She stated if a resident is a Full Code status and their health condition is declining significantly the hospice expected the facility to call 911 and send them out. In an interview on [DATE] at 7:20 AM the Hospice Case Manager stated she had been called at 7:56 AM and told her Resident #9 had a change in condition. She stated she received a call at 8:04 and was told he was mottled (pale and blue) and again at 8:06 that he was being sent out with CPR in progress. The Case Manager stated no vital signs were ever told to her and she confirmed she did not discuss the resident code status during the initial calls. In an interview on [DATE] at 2:35 PM the DON stated RN A should have checked the code status when she saw he had a change of condition. In an interview on [DATE] at 4:10 PM the DON was asked if it was neglect when RN A observed Resident #9 was in respiratory distress on [DATE] at 7:00 AM and she did not call 911. The DON stated Resident #9 was not in respiratory distress when she was in Resident #9's room just immediately after she arrived at 7:10 AM on the day of his death. The DON stated Resident #9's room was the first room she entered for her morning rounds and RN A told her Resident #9 wasn't doing very good. The DON stated she walked to the head of the bed and Resident #9 was not in respiratory distress because he wasn't breathing 40 to 50 times a minute and his eyes were closed. She stated she didn't try to get him to respond to her and she did not get a stethoscope and listen to his breath sounds. The DON stated he was getting a breathing treatment. She stated she continued on her rounds and the next thing she knew the staff was called for help to his room. The DON stated it was neglect that RN A did not know the resident's code status and did not call 911 when his blood pressure was low and/or if he was in respiratory distress. In an interview on [DATE] at 4:33 PM the Administrator stated when RN A did not call 911 for Resident #9 when she assessed him to be in respiratory distress it was neglect due to his Full Code status. Review of the policy Hospice Care for Nursing Facility Residents-Written Agreements: 3. D. An agreement that it is the facility's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before hospice care was elected. Review of the facility policy for Abuse/Neglect dated [DATE] reflected; 1. The facility's Leadership prohibits neglect 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected neglect 5. the facility's Leadership will implement appropriate and necessary guidelines, which prohibit the neglect. Component IV: Identification 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm. The facility provided a list of three (3) residents that were Hospice and Full Code status.

Based on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources to effectively and efficiently attain and maintain the highest practicable physical, mental, and psychosocial well being for two (2) of four (4) residents reviewed (Residents #2, and 7) reviewed for falls when: 1) The DON failed to insure new interventions were put in place after Resident # 7 had a fall on 10/24/2015 which resulted in a non-displaced fracture to her second metacarpal base (finger) of the left hand, in order to prevent future falls and injuries. Resident # 7 fell on [DATE], which resulted in an acute Right Distal Radial and Ulnar Fractures (both bones of the forearm where they meet the wrist). 2) Resident # 2 has a history of falls. The DON failed to insure the planned interventions of having Resident # 2's call light in reach and the bed alarm in place and functioning when in bed were implemented. 3) The Former Administrator failed to insure the police were notified when he was notified on 10/20/2015 that CNA J had arranged for a notary to come to the facilityn on 09/14/2015 and had informed the notary Resident # 1 was mentally competent to sign a legal document gifting 22.6 acres of land over to one of Resident # 1's nephews (does not have the power of attorney). On 9/15/2015 Resident # 1's nephew deeded the 22.6 acres over to CMA J's spouse. 4) The Former Administrator failed to report Resident # 3's allegations of physical abuse and Resident # 9's allegations of verbal abuse and neglect to the Texas Department of Aging and Disability Services (DADS). This deficient practice resulted in Resident # 7 sustaining additional fractures and puts residents identified by the facility as being at risk of falls at risk for abrasions, bruising and fractures due to safety measures not being identified and in place. This deficient practice placed the 29 cognitively impaired residents at risk of physical abuse verbal abuse, and misappropriation. Findings include: 1) Review of Resident # 7's Face Sheet reflected a [AGE] year old female with an admission date of [DATE] and the following Diagnosis: [REDACTED]. Review of Resident # 7's Plan of Care dated 09/29/2015 reflected a risk for fall due to cognitive impairment and [MEDICAL CONDITION] medication therapy. Interventions included resident will spend the majority of time awake in common areas of the secure unit and vocalize needs, Staff will frequently walk around with resident and remind her of hazards and to be cautious, call light is in reach and answer promptly, and assure lighting is adequate and areas are free from clutter. A second problem in the Plan of Care dated 10/27/2015 was resident had a fracture to her second metacarpal base (finger) of the left hand. Interventions include Splint wrapped in place, and monitor for signs/symptoms of pain. Observation of Resident # 7 on 11/19/2015 at 9:05 AM reflected Resident # 7 was ambulating in the common area of the secured unit. She had a splint to her right arm and had small fading bruises to both upper arms. When asked what happened to her arm she stated, I fall. I fall. That's all I do . Review of an Incident and Accident Report reflected Resident # 7 came out of her room on 10/24/2015 at 1:45 PM to report she had fallen the previous night. Resident # 7's hand was assessed as being swollen and bruised. An x-ray was obtained on 10/24/2015 which revealed Resident # 7 had a non-displaced fracture to her second metacarpal base (finger) of the left hand. Resident # 7's hand was splinted to stabilize and encourage healing. The only intervention was to monitor closely for injuries as is constantly bumping into doors etc. No new interventions were put in place to prevent future falls. Review of an Incident and Accident Report reflected Resident # 7 came out of her room on 11/16/2015 at 11:30 PM holding her right hand stating this hurts. Additional documentation on the Incident and Accident Report reflected the inner area of Resident # 7's right wrist is noted to be reddish purple in color and bruised, able to move her fingers, but complaining of pain to the wrist when touched. Resident # 7 was given Tylenol 325 milligrams, two (2) tablets for pain and the nurse elevated the right wrist on a pillow. An x-ray was obtained on 11/17/2015 which reflected an acute Right Distal Radial and Ulnar Fractures (both bones of the forearm where they meet the wrist). Resident # 7 was sent to the hospital emergency room for treatment and was returned to the facility on [DATE] at 2:25 AM. Interventions listed to prevent further falls included, already on a low bed with fall mat and continue to monitor closely (not new interventions). Interview on 11/19/2015 at 10:00 AM, the DON stated she feels her staff are monitoring Resident # 7 one on one. The DON stated in addition to monitoring Resident # 7, the one CNA on the secured unit is responsible for the care of 12 other residents. Initially, the DON stated she did not know of any interventions to prevent additional falls other than to keep the bed low and have a fall mat. Later in the interview the DON stated the facility could try a bed alarm so staff would know when Resident # 7 is out of bed and ambulating. 2) Review of Resident # 2's Face Sheet reflected a [AGE] year old male with an admission date of [DATE], with the following Diagnosis: [REDACTED]. Review of Resident # 2's Quarterly MDS assessment dated [DATE] reflected a BIMS Score of 11 indicating minimal cognitive impairment, requires maximum assistance of one (1) staff member to perform Activities of Daily Living (ADL's) with the exception of eating. Resident # 2 was assessed with [REDACTED]. Review of Resident # 2's Plan of Care updated on 09/28/2015 reflected a history of falls prior to and since admission to the facility. Interventions included: Encourage to call for assist, ensure that call light is within reach and answered promptly, assess environmental factors that may contribute to fall, Assess need for low bed/chair and or a bed alarm and low bed with fall mat. Observation on 11/17/2015 at 4:45 PM reflected Resident # 2 was lying in bed. The call light was on the fall mat. When asked, Resident # 2 stated he could not reach his call light. The bed alarm appeared to be off. When the ADON entered the room she confirmed the call light was out of reach and the bed alarm was not functioning. The mat portion of the bed alarm was found on the night stand under some papers. The ADON placed the call light within reach of Resident # 2, and when she could not get the bed alarm to work, another staff member brought new bed alarm for Resident # 2. During an interview on 11/17/2015 at 4:55 AM, CNA L stated she has been working since 2:00 PM caring for Resident # 2. She stated she saw the alarm in place earlier on her shift. She stated she was not aware why the call light was out of reach and the bed alarm was not functioning with the mat on the nightstand. Observation 11/18/2015 at 9:15 AM reflected Resident # 2's bed alarm was on the floor mat with no clip to attach near Resident # 2. The Administrator was notified and a clip was applied to the call light with the call light within Resident # 2's reach. During an interview on 11/18/2015 at 9:25 AM CNA N stated she routinely cares for Resident # 2. She stated she has never had a problem with Resident # 2 trying to take off his bed alarm. During an interview on 11/19/2015 at 10:00 AM the DON stated Resident # 2 is to have his call light in reach at all times and the bed alarm in place when he is in bed due to his history of falls. During an interview on 11/19/2015 at 12:50 PM, the Administrator stated his date of hire was 11/09/2015, and he had just completed orientation and started as the Administrator for the facility on 11/16/2015. The Administrator stated he expects his administrative staff to discuss and come up with new interventions when resident ' s experience a fall, to prevent future falls and injuries. Review of the facility policy, FALL MANAGEMENT, revised on 05/11/2015 reflected, Policy: 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls .Procedures: 4. If a fall occurs, qualified staff evaluates patient/resident for injury from the fall and initiates any immediate medical interventions necessary, investigates the potential reason for the fall, determines appropriate interventions to prevent future falls,and completes a Fall Investigation Worksheet . The DON stated they currently have identified 22 residents at risk of falls. 3). Review of Resident # 1's Face Sheet reflected an [AGE] year old female with an admission date of [DATE] and a readmission date of [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly MDS assessment dated [DATE] reflected Resident # 1 had a BIMS score of 11 indicating cognitive impairment, had impaired vision and has signs and symptoms of [MEDICAL CONDITION] which comes and goes. Review of Resident # 1's Plan of Care last updated 11/13/2015 reflected Resident # 1 has a [DIAGNOSES REDACTED]. Interventions included: Reassure resident when confusion has increased, and Verbal reminders and cues to assist resident with daily orientation. An interview was attempted with Resident # 1 on 11/17/2015 at 2:10 PM. Resident # 1 was not aware she was at the nursing home, and when a visitor arrived she was unable to identify who she was. Resident # 1 denied signing any legal documents and asked the surveyor to re-identify herself to the resident three (3)times. Review of a Provider Investigation Report dated 10/28/2015 reflected the facility first became aware that Resident # 1 had 22.6 acres of her land deeded over to CMA J's spouse on 10/20/2015. In an interview on 11/18/2015 at 12:12 PM the Business Office Manager stated on 10/20/2015 she drove to the Falls County Courthouse and obtained copies of legal documents dated 09/14/2015 showing Resident # 1 had signed a notarized document that had gift deeded 22.60 acres of land to one of her nephews. A second notarized document signed by the nephew on 09/15/2015 deeded the 22.60 acres to the spouse of CMA J. The Business Office Manager stated she did speak with the notary who notarized the document signed by Resident # 1 on 09/14/2015. The Business Office Manager stated the notary had gone to the nursing home at the request of CMA J. The notary also stated CMA J told her that Resident # 1 was competent and could sign legal documents. The Business Office Manager stated she obtained a copy of the notary's log book showing the signature of Resident # 1 and her nephew and brought all the documents to the Former Administrator. In an interview on 11/19/2014 at 2:30 PM the Former Administrator stated he did not call the police regarding the misappropriation of Resident # 1's property. He stated another nephew who has the legal Power of Attorney for Resident # 1 was aware and stated the nephew had an attorney. He also stated his corporate office had told him to not notify the police. 4). Review of Resident # 3's Face Sheet reflected a [AGE] year old female, with an admission date of [DATE] and a readmission date of [DATE], with the following Diagnosis: [REDACTED]. Review of Resident # 3's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident # 3 had a Brief Interview for Mental Status (BIMS) of nine (9) indicating moderate cognitive impairment, and no current behavior problems. Review of Resident # 3's Plan of Care, last updated on 10/12/2015 reflected a problem with a [DIAGNOSES REDACTED]. Interventions included: Monitor for any increase agitation, verbal or physical, document episodes of behavior, remove resident from increased stimuli during behavioral episodes, monitor for delusions and hallucinations in the clinical record, notify MD of any behaviors and obtain a psychiatric consultation as needed. Review of a facility copy of a Complaint/Grievance Report dated 11/06/2015 reflected Resident # 3 had reported a pregnant girl and her boyfriend had been sleeping in her bed, and when she came into her room the female hit her and the male kicked her. Attached to the Complaint were typed interviews, with no date or time indicating when the interviews were obtained. The documentation reflected the ADON attempted three (3) interviews with Resident #3. In the first interview Resident # 3 stated she found the boy and the pregnant girl in her bed, then she hit the girl and told her to go away. Resident # 3 refused to talk to the ADON when a second interview was attempted. During a third interview Resident # 3 stated she went to the hospital on [DATE] to be cleansed because she got in a fight with the pregnant girl and both hit each other. In an interview on 11/17/2015 at 1:35 PM, the Social Worker stated she had received a complaint on 11/06/2015 from Resident # 3 regarding CMA K and her boyfriend being in her bed. The Social Worker stated Resident # 3 told her on 11/01/2015 when she refused to take her medication from CMA K, Resident # 3 was slapped in the face and kicked in the stomach by CMA K and her boyfriend. The Social Worker stated when she told the DON and ADON, they both stated Resident # 3 was not reliable due to her mental diagnosis. The Social Worker stated she gave the complaint to the Former Administrator to investigate and never heard anything else about the results of the investigation. In an interview on 11/17/2015 at 1:45 PM, Resident # 3 stated she did report that a pregnant medication aide (CMA K) and her boyfriend had been in her bed before she went to the hospital on [DATE]. She stated after she returned from the hospital she told the Social Worker that CMA K had slapped her in the face and kicked her in the stomach on the day the facility sent her to the hospital. Resident # 3 stated when she tried to defend herself CMA K started yelling and had hit her. Resident # 3 stated she does not trust the CMA K (concerned she might hit her again), but CMA K continues to bring her medications to her. In an interview on 11/18/2015 at 1:05 PM CMA K stated on 11/01/2015 Resident # 1 had refused her medications. CMA K stated her medication cart was outside Resident # 3's room. Resident # 3 came up to the medication cart, knocked a water pitcher on the cart over, and began hitting her and kicking her in the stomach. CMA K stated she yelled for other staff to help her and Resident # 3 was sent to the hospital. CMA K stated no one called her regarding the incident until two (2) or three (3) days later. CMA K stated since the incident she has continued to give Resident # 3 her medications. CMA K stated no administrative staff had instructed her to have one of the charge nurses administer Resident # 3's medications when she was working. In an interview on 11/19/2015 at 2:30 PM, the Former Administrator stated he did not feel any abuse had occurred since Resident # 3 told the ADON different stories during three separate interviews (although she refused to talk to the ADON on the second attempt). The Former Administrator stated he did not report Resident # 3's allegation of physical abuse since he did not think it had occurred. In an interview on 11/19/2015 at 10:00 AM, the DON stated she had been aware of the allegation made by Resident # 3 and that she had instructed CMA K to have one of the charge nurses give Resident # 3 her medications when CMA K worked. The DON stated she felt if Resident # 3's allegation of physical abuse had needed to be reported to State, the Former Administrator would have called the incident in. 5). Review of Resident # 9's Face Sheet reflected a [AGE] year old female with an admission date of [DATE] and a readmission date of [DATE] with the following Diagnosis: [REDACTED]. Review of Resident # 9's clinical record reflected she was transferred to another nursing home at her request on 09/16/2015. Review of Resident # 9's MDS Quarterly assessment dated [DATE] reflected Resident # 9 had a BIMS score of eight (8) indication moderate cognitive impairment, required extensive assistance of two (2) staff for bed mobility, transfer, dressing, toileting, and extensive assistance of one (1) staff for personal hygiene and bathing. The MDS Assessment also reflected Resident # 9 had exhibited verbal behavioral symptoms towards others less than daily, and other behavioral symptoms not directed towards others. Review for Resident # 9's Plan of Care last updated 09/02/2015 did not reflect Resident # 9's behavioral problems assessed in the MDS Quarterly assessment dated [DATE]. Review of Resident # 9's clinical record reflected she was transferred to another nursing home at her request on 09/16/2015. Review of a facility form, Complaint/ Grievance Report dated 08/27/15 reflected Resident # 9 had informed the SW that CNA L and CNA M do not want to assist her into and out of bed, and when Resident # 9 requires assistance they complain, holler and curse at her while providing care. In an interview on 11/18/2015 at 8:45 AM the ADON stated she had conducted the investigation regarding CNA L and CNA M refusing to assist Resident # 9 into and out of bed, and cursing/yelling at Resident # 9 when providing care. She stated she spoke with other alert residents on the same hall (could not remember who), interviewed their coworkers and the charge nurse. No one had witnessed any verbal abuse or known refusal of providing care to residents. The ADON stated both CNA's denied the allegations. She stated after completing the interviews she turned in the Complaint/Grievance Report form to the Former Administrator. The ADON stated she told the staff to only care for Resident # 9 with a witness. The ADON stated she never heard anything else about the complaints, but she did not suspend either CNA since she had completed her interviews before the 2-10 shift started and the Former Administrator had not informed her she needed to do so. In an interview on 11/19/2015 at 2:30 PM, the Former Administrator stated he was brought the complaints regarding CNA L and CNA M by Resident # 9. The Former Administrator stated he brought Resident # 9 to his office and she withdrew her complaints against CNA L and CMA M. The Former Administrator stated he did not think he needed to notify the State regarding the allegation of verbal abuse since Resident # 9 withdrew her complaint. Review of the facility policy, ABUSE, NEGLECT AND MISAPPRIATION OF PROPERTY,REVISED 02/24/2015 reflected, Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse, including seclusion and misappropriation of a patient's/resident's property and/or funds .3. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and /or state law . The facility provided a list of 29 cognitive impaired residents.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for two (2) of four (4) residents reviewed for falls when: 1. Resident # 7 reported a fall on 10/24/2015 which resulted in a non-displaced fracture to her second metacarpal base (finger) of the left hand. The facility failed to implement new interventions to prevent future falls. Resident # 7 fell on [DATE], which resulted in an acute Right Distal Radial and Ulnar Fractures (both bones of the forearm where they meet the wrist). 2. Resident # 2 has a history of falls. The facility failed to implement the planned interventions of having Resident # 2's call light in reach and the bed alarm in place and functioning when in bed. This deficient practice resulted in Resident # 7 sustaining additional fractures and puts 32 residents identified by the facility as being at risk of falls at risk for abrasions, bruising and fractures due to safety measures not being identified and in place. Findings include: 1). Review of Resident # 7's Face Sheet reflected a [AGE] year old female with an admission date of [DATE] and the following Diagnosis: [REDACTED]. Review of Resident # 7's Plan of Care dated 09/29/2015 reflected a risk for fall due to cognitive impairment and psychotropic medication therapy. Interventions included resident will spend the majority of time awake in common areas of the secure unit and vocalize needs, Staff will frequently walk around with resident and remind her of hazards and to be cautious, call light is in reach and answer promptly, and assure lighting is adequate and areas are free from clutter. A second problem in the Plan of Care dated 10/27/2015 was resident had a fracture to her second metacarpal base (finger) of the left hand. Interventions include Splint wrapped in place, and monitor for signs/symptoms of pain. Observation of Resident # 7 on 11/19/2015 at 9:05 AM reflected Resident # 7 was ambulating in the common area of the secured unit. She had a splint to her right arm and had small fading bruises to both upper arms. When asked what happened to her arm she stated, I fall. I fall. That's all I do . Review of Resident # 7's Incident and Accident Reports since her admission on 09/14/2015 reflected she had been found on the floor on 09/14/2015 at 1:45 PM, and on 09/16/2015 at 3:00 AM and 4:00 PM. Interventions documented on 09/14/2015 were continue close observation, on 09/16/2015 at 3:00 AM increase observation of resident and at 4:00 PM seatbelt to wheelchair which she can undo. In an interview on 11/19/2015 at 10:00 AM, the DON stated after Resident # 7 was found on the floor on 09/16/2015 other interventions were put in place including placing the bed in the lowest position and having a fall mat. Review of an Incident and Accident Report reflected Resident # 7 came out of her room on 10/24/2015 at 1:45 PM to report she had fallen the previous night. Resident # 7's hand was assessed as being swollen and bruised. An x-ray was obtained on 10/24/2015 which revealed Resident # 7 had a non-displaced fracture to her second metacarpal base (finger) of the left hand. Resident # 7's hand was splinted to stabilize and encourage healing. The only intervention was to monitor closely for injuries as is constantly bumping into doors etc. No new interventions were put in place to prevent future falls. Review of an Incident and Accident Report reflected Resident # 7 came out of her room on 11/16/2015 at 11:30 PM holding her right hand stating this hurts. Additional documentation on the Incident and Accident Report reflected the inner area of Resident # 7's right wrist is noted to be reddish purple in color and bruised, able to move her fingers, but complaining of pain to the wrist when touched. Resident # 7 was given Tylenol 325 milligrams, two (2) tablets for pain and the nurse elevated the right wrist on a pillow. An x-ray was obtained on 11/17/2015 which reflected an acute Right Distal Radial and Ulnar Fractures (both bones of the forearm where they meet the wrist). Resident # 7 was sent to the hospital emergency room for treatment and was returned to the facility on [DATE] at 2:25 AM. Interventions listed to prevent further falls included, already on a low bed with fall mat and continue to monitor closely (no new interventions). During an interview on 11/19/2015 at 10:00 AM, the DON stated she felt her staff are monitoring Resident # 7 one on one. The DON stated in addition to monitoring Resident # 7, the one CNA on the secured unit is responsible for the care of 12 other residents. Initially, the DON stated she did not know of any interventions to prevent additional falls other than to keep the bed low and have a fall mat (put in place prior to the 10/24/2015 fall that resulted in a fracture). Later in the interview the DON stated the facility could try a bed alarm so staff would know when Resident # 7 is out of bed and ambulating. During an interview on 11/19/2015 at 5:45 AM CNA O stated she worked the night shift on the secured unit. She stated Resident # 7 has always had a low bed and a fall mat since she was admitted to the facility. CNA O stated Resident # 7 has started primarily sleeping at night since she had the first fracture (10/24/2015). 2) Review of Resident # 2's Face Sheet reflected a [AGE] year old male with an admission date of [DATE], with the following Diagnosis: [REDACTED]. Review of Resident # 2's Quarterly MDS assessment dated [DATE] reflected a BIMS Score of 11 indicating minimal cognitive impairment, requires maximum assistance of one (1) staff member to perform Activities of Daily Living (ADL's) with the exception of eating. Resident # 2 was assessed with [REDACTED]. Review of Resident # 2's Plan of Care updated on 09/28/2015 reflected a history of falls prior to and since admission to the facility. Interventions included: Encourage to call for assist, ensure that call light is within reach and answered promptly, assess environmental factors that may contribute to fall, Assess need for low bed/chair and or a bed alarm and low bed with fall mat. Observation on 11/17/2015 at 4:45 PM reflected Resident # 2 was lying in bed. The call light was on the fall mat. When asked, Resident # 2 stated he could not reach his call light. The bed alarm appeared to be off. When the ADON entered the room she confirmed the call light was out of reach and the bed alarm was not functioning. The mat portion of the bed alarm was found on the night stand under some papers. The ADON placed the call light within reach of Resident # 2, and when she could not get the bed alarm to work, another staff member brought new bed alarm for Resident # 2. During an interview on 11/17/2015 at 4:55 AM, CNA L stated she has been working since 2:00 PM caring for Resident # 2. She stated she saw the alarm in place earlier on her shift. She stated she was not aware why the call light was out of reach and the bed alarm was not functioning with the mat on the nightstand. Observation 11/18/2015 at 9:15 AM reflected Resident # 2's bed alarm was on the floor mat with no clip to attach near Resident # 2. The Administrator was notified and a clip was applied to the call light with the call light within Resident # 2's reach. During an interview on 11/18/2015 at 9:25 AM CNA N stated she routinely cares for Resident # 2. She stated she has never had a problem with Resident # 2 trying to take off his bed alarm. During an interview on 11/19/2015 at 10:00 AM the DON stated Resident # 2 is to have his call light in reach at all times and the bed alarm in place when he is in bed due to his history of falls. During an interview on 11/19/2015 at 12:50 PM, the Administrator stated his date of hire was 11/09/2015, and he had just completed orientation and started as the Administrator for the facility on 11/16/2015. The Administrator stated he expected his administrative staff (including the DON) to discuss and come up with new interventions when resident's experience a fall in order to prevent future falls and injuries. Review of the facility policy, FALL MANAGEMENT, revised on 05/11/2015 reflected, Policy: 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls .Procedures: 4. If a fall occurs, qualified staff evaluates patient/resident for injury from the fall and initiates any immediate medical interventions necessary, investigates the potential reason for the fall, determines appropriate interventions to prevent future falls,and completes a Fall Investigation Worksheet . The DON stated they currently have identified 32 residents at risk of falls.

Based on interview and record review, the facility failed to ensure the resident environment remained free from accident hazards and received adequate supervision to prevent accidents for one of three residents reviewed for behaviors (Resident #1). Resident #1 was found unresponsive on [DATE] related to alcohol intoxication and hospitalized with a blood alcohol level of 324 milligrams (mg) per deciliter (dl) and aspiration pneumonia. The facility failed to supervise the resident environment and Resident #1 to prevent access to alcohol. This deficient practice had the potential to place three residents at risk of alcohol intoxication, alcohol poisoning and/or death. Finding include: Review of the Consolidated Physician orders [REDACTED]. Continued review of the physician orders [REDACTED]. All medications have a contraindication for the use of alcohol. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 has behaviors toward other, score of 15 on the cognition assessment, needs assistant with activities of daily living. Review of the Care plan corresponding to the MDS dated [DATE] reflects Resident #1 has possible aspiration pneumonia (from intoxication and hospitalized ), history of falls, potential for pain, assist with meals, self-releasing seat belt, depression, anxiety, dementia, manic depression with mood swings, verbally abusive to others, smoker, psychotropic medications, very demanding and get upset, refuses to eat with other residents needing assistance, and obsessive compulsive disorder. Review of the nurse ' s notes dated [DATE] at 4:00 PM Resident #1 had a visitor for the last hour, visitor now pushing resident in his wheelchair past the nurse ' s desk out to smoke and noted residents eyes are very red. At 6:00 PM a nurse aide told the charge nurse Resident #1 ' s room smelled of alcohol. The nurse expressed concerns to Resident #1 that his eyes were red, slurred speech and report of the smell of alcohol and that she was worried because of all the medications he was taking. Resident #1 asked if she was accusing him of drinking alcohol and she stated she was suspicious. She asked if he would submit to a blood alcohol test and allow his room to be searched. Resident #1 answered no and became angry. This was reported to the Administrator. At 6:10 PM Resident #1 left the dining room. At 7:25 PM Resident #1 was at the nurse desk for at least 40 minutes complaining about this nurse and the Administrator "question my integrity " . After multiple attempts to express concerns for his health and safety Resident #1 continued to complain. The physician was notified and the physician stated to ask for consent to search his room and a blood alcohol test. If he does not agree and the nurse felt he was intoxicated to hold his Clonazepam for that evening. The physician stated to tell Resident #1 he would talk with him when he came. The physician also stated if Resident #1 refuses the room search and consent for alcohol testing he could not continue to be his physician. At this time the resident consented to the room search. At 8:00 PM no bottles or evidence of alcohol was found in his room but the resident refused a search of his person. At 9:30 PM Resident #1 told the staff they were poor detectives, in so many words, as he had hide the bottles of liquor under his dresser. At this time the residents clothes is saturated with liquor. There are three bottles labeled Whiskey laying across his bed empty and the physician was notified. At 10:30 PM the night nurse noted Resident #1 ranting and raving about his " integrity " given to him by God. He continued to talk to another resident sounding as if he was preaching stated " that ' s by the Holy Spirit " then he would laugh and repeat himself. Eyes are red; speech slurred and smells strongly of alcohol. Monitoring resident propelling himself around and laughing while repeating himself. Refused transfer assistance by the staff. He stated he was not sick and don ' t you know Gods goodness. At 11:30 PM Resident was assisted to bed by the nurse aide and the charge nurse and he began to holler and punch at the air. On [DATE] At 1:15 AM resident asleep snoring loudly verbally responsive with mumbling "Whatcha want? " Head of bed up to prevent aspiration. At 3:00 AM Resident #1 is unresponsive to verbal or tactile stimuli, vomited moderate amount of foul smelling emesis. Notified the physician and Resident #1 was transported to the hospital via ambulance. Ambulance stated they had several emergencies and would be on their way. Ambulance arrived at 4:10 AM for transport to the nearest emergency room for treatment and evaluation of possible aspiration. In an interview on [DATE] at 3:15 PM Licensed Vocational Nurse (LVN) A stated she had not seen anything on the person who brought in the liquor that would make her suspicious. She stated she notice this person pushing Resident #1 past the nurses ' station and his eyes were red and she thought she would need to monitor. A nurse aide told her she smelled alcohol on Resident #1. She told the Administrator and both of them talked to the resident who became very upset and angry that his integrity was being questioned. When Resident #1 was asked about a room search he refused and went to his room. A few minutes later he returned to the nurse ' s desk chewing them out. She stated she called the physician who stated if resident #1 refused an alcohol test and an room search he was no longer going to be his physician. He told the nurse to hold Resident #1 ' s Lorazapam. The physician stated, if you cannot wake him, send him to the hospital. In an interview on [DATE] at 9:50 AM Resident #1 stated the name of the person who he had bought four pints of whiskey from for $5.00 a pint so the person could buy cigarettes. He stated the person had the whiskey in his boot that is why they call it "boot legging. " He stated he was one of four men buying liquor from the person. Resident #1 stated he nearly died as per his doctor at the hospital as his medication and liver did not like the liquor. He stated he drank 2 or 3 of the pints. He stated he spilled one on himself and one on the floor but he believed he drank part of them along with the other two pints. He stated he had a bad seizure at the hospital and had to be totally detoxed. The doctor told him if he did it again he would die because of the types of medications he was on. Review of the Laboratory Comparative Report from the local hospital dated [DATE] reflected Resident #1 ' s blood alcohol level collected on [DATE] at 5:20 a.m. was 324.0 mg/dl on (reference range is 0.0 - 5.0 mg/dl). Further review reflected the resident ' s blood alcohol level collected on [DATE] at 12:00 p.m. was 189.0 mg/dl. In an interview on [DATE] at 1:20 PM the lab tech at the local hospital stated a blood alcohol level of 324 mg/dl was equivalent to 3.24 blood alcohol level. He stated a level of 400 could be fatal for most people. The lab tech stated blood alcohol level of .8 is considered intoxicated. Review of Resident #1 ' s Discharge Summary from the local hospital on [DATE] reflected discharge [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:00 PM the attending physician for Resident #1 stated, "The resident was totally out of it for 12 hours. " He stated Resident #1' s level of alcohol was dangerous for him with the medications he was on. "I am stupid for drinking. " Resident #1 told the physician he got the liquor from a friend who visits him. In an interview on [DATE] at 9:20 AM the Administrator stated Resident #1 was intoxicated and was sent to the hospital. He stated he believes another residents family members brought in the liquor but Resident #1 would not tell him if he bought it or if the liquor was given to him. He stated he was going to call the police but had not as yet. In an interview on [DATE] at 12:00 p.m. the Administrator stated they had completed a room search of that hall and they found two residents with empty bottles in their rooms. Both denied knowing anything about the empty liquor bottles. Review of documentation by the Administrator dated [DATE], reflected that on [DATE] the housekeeping staff found an empty whiskey bottle in the waste basket over the weekend of one resident who denied drinking the alcohol. The Administrator ' s first suspicion of the person responsible for smuggling it into the facility was toward staff members. The resident in question denied drinking alcohol and refused to give up the name of the person who supplied it. Further review of this documentation reflected that on [DATE], the housekeeping staff found more empty liquor bottles of whiskey on the front porch of the facility and in another resident ' s room. This resident also denied drinking alcohol. At this time, a night nurse was suspicious of a family member of one resident. An aide stated she smelled alcohol when he came near her, nothing further was reported in regards to this person (the visitor). The document further stated on [DATE] a family member of another resident stopped by the facility and a staff member thought there were a couple of sizable objects on his person. The family member went straight to Resident #1 ' s room, they visited for about ,[DATE] minutes. At this point the Administrator knocked on Resident #1's door to speak with Resident #1. The situation was suspicious and the Administrator wanted to make his presence known. Around 5:50 p.m., the Administrator met Resident #1 in the hall way and his eyes were red and had slurring speech. The Administrator alerted the evening nurse to monitor Resident #1. After dinner Resident #1 was questioned by the Administrator and the evening Nurse. Resident #1 vehemently denied drinking alcohol and was offended that they asked. The Administrator asked if they could do a room search and Resident #1 became upset and refused a room search. Resident #1 proceeded to his room. About 15 to 20 minutes later Resident #1 came to the nursing station and began arguing with the evening nurse and the Administrator about them questioning his credibility. During the course of the argument Resident #1 agreed to a room search which did not produce any alcohol or bottles. Resident #1 refused to allow a body search or a search of his wheelchair. Resident #1 became upset and cursing. The Administrator decided not to peruse the matter further. The Administrator left at approximately 8:00 PM. In an interview on [DATE] at 3:00 PM the Administrator stated he had called the local police department and they are not making a report. They told him if he wanted a restraining order for the person selling the liquor they would do that. The Administrator stated they had not called in the incident to DADS as corporate office thought it only involved Resident #1 and they did not believe it was an issue until they found other empty bottles in the facility and determined other resident maybe involved. He stated the other bottles were found on [DATE] and it was decided to call DADS. He stated he was getting ready to call in the report to DADS when the investigator entered the building but he was waiting on the police to call him back to see what they were going to do. In an interview on [DATE] at 10:50 AM the Director of Nurses (DON) stated they did not identify any other resident in the facility who appeared intoxicated. She stated one of the medication aides owns a liquor store and she had been suspended pending the investigation to determine if she knew about the liquor. In an interview on [DATE] at 11:08 AM Medication Aide (MA) A stated she did not own the liquor store her husband did. She stated she works week ends at the nursing home. She stated she was unaware of any alcohol being sold to anyone that was bringing it to the nursing home. She stated she was very upset that she was being accused by others of selling the liquor to the person who brought the liquor to Resident #1. She stated she would report it immediately if she knew. She stated none of the resident had come to the liquor store to buy liquor. MA A stated they had camera in the store and none of the resident was seen. She stated she had asked the staff in the store if the person alleged to have brought liquor to the facility had been in the store and they had stated " no. " In an interview on [DATE] at 11:25 AM Registered Nurse (RN) A stated they had suspected something was going on with Resident #1 the week before and they did a drug test which was negative. He stated we were monitoring as we were suspicions of something. In an interview on [DATE] at 11:35 AM Certified Nures Aide (CNA) A stated she did not know anything until Resident #1 came back from the hospital. She stated she did not see anything suspicious. In an interview on [DATE] at 11:40 AM CNA B stated the person named by Resident #1 as bring him liquor comes to the facility with a big coat on and goes to Resident #1 ' s room. She stated he will stay a few minutes and leave if the resident is not in his room. Resident #1 returned from the hospital he stated to her he bought the liquor from this person and he drank it. She stated she never smelled alcohol. She stated all the aides were told by the nurse to monitor and report anything suspicious to her. She stated they found another empty bottle in another resident ' s room and they were to monitor him also. The census of 43 was provided by the Administrator.