Every finding on record at Brookhaven Nursing and Rehabilitation Center

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #10) of 6 residents, reviewed for infection control. 1. LVN A failed to don PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precaution. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of Resident #10's Comprehensive MDS Assessment, dated 04/23/26, reflected the resident was a [AGE] year-old female, had a BIMS score of 15 indicating her cognition was considered intact and functioning normally. The resident had diagnoses which included pressure ulcer of left buttock, malnutrition (refers to deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), multiple sclerosis (a chronic autoimmune disease of the central nervous system (brain, spinal cord, and optic nerves) and hypertension (condition where the force of blood pushing against your artery walls is consistently too high). Record review of Resident #10's Comprehensive Care Plan, initiated 04/28/26, reflected (Residents name) had stage 4 pressure ulcer of left buttock. Physician order dated 04/15/2026 had nursing intervention: implement and maintain enhanced barrier precautions when performing high contact care activities, related to wound care every shift. An observation on 05/27/2026 at 10:46 AM revealed Resident #10's room had an Enhanced Barrier Precaution sign outside of her room, and the cart set up with PPE. LVN A prepared Resident #10's wound care and incontinent care items. LVN A performed hand hygiene with sanitizer and entered the resident's room. He did wound care and incontinent care without PPE (gown).An interview on 05/27/26 at 11:00 AM revealed LVN A knew that Resident #10 was on enhanced barrier precaution, and he should have donned PPE before accessing Resident 10's wound. He stated that he forgot to wear the gown, and failure to use PPE could put the resident at risk for infection. He stated that he had been in-serviced on enhanced barrier precautions. An interview on 05/27/2026 at 1:41 PM with the DON revealed that her expectation was that the staff should use appropriate PPE while providing care to residents on enhanced barrier precautions. She stated a risk to the patient was infection. She stated that the staff had been in-serviced on infection control and enhance barrier precautions. Record review of the facility's policy titled Implementation of Standard and Transmission-Based Precautions dated March 2024, reflected: Enhanced Barrier Precautions (EBPs) - Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activitiesExamples of Enhanced-Based Precaution residents: Wounds - Includes chronic wounds, but are not limited to pressure ulcers, diabetic ulcers, unhealed surgical wounds and venous statis ulcers. Indwelling medical devices - Include central lines, urinary catheters, feeding tubes, and tracheostomies/vents.Enhanced-Based Precautions are indicated during: Dressing Bathing/showering in a shared/common shower room Transferring Providing hygiene Changing linens

Based on interviews and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort for 1 (Resident #1) of 3 residents reviewed for PASARR services and assessments. The facility failed to ensure Resident #1 received the Occupational Therapy that was recommended by the IDT meeting on 08/29/25. This failure placed residents at risk of not receiving needed specialized services that could impact their healing. Findings included: Review of Resident #1's Quarterly MDS Assessment, dated 10/04/25, reflected the resident had a BIMs score of 15 and was cognitively intact. She was admitted to the facility on [DATE]. Her diagnoses included seizure disorder, quadriplegia (inability to move extremities), anxiety, and depression. Review of Resident #1's Comprehensive Care Plan reflected there were no care plans for PASARR services. Review of Resident #1's PASARR Level 1 Screening, dated 06/27/25, reflected the resident tested positive for mental illness and developmental disability. Review of Resident #1's PASARR Comprehensive Service Plan Form reflected the initial interdisciplinary team meeting for the resident was held on 08/29/25 and Medicaid eligibility was confirmed. Review of Resident #1's Habilitation Service Plan dated, 08/29/25, reflected the initial IDT meeting was held on 08/29/25. Resident #1 was quadriplegic. Prior to her admission to the nursing facility, she was able to feed herself. Resident #1 wanted to be able to feed herself again. It was recommended that she receive occupational therapy to accomplish this goal. An interview on 12/03/25 at 12:40 PM with Resident #1 revealed she was not receiving all PASSAR services. She said she was supposed to receive occupational therapy. She said she did not know why she was not receiving the service. An interview on 12/03/25 at 2:48 PM with the MDS Coordinator revealed she was new to the position and was not familiar with Resident #1. She said she coordinated PASARR services. She said Resident #1 was not receiving occupational therapy but should have started receiving occupational therapy on 11/01/25, based on the Habilitation Service Plan and IDT meeting held on 08/29/25. She said she did not know why she was not receiving the therapy. The MDS Coordinator said the failures could result in a delay of care. An interview on 12/03/25 at 3:20 PM with the Rehabilitation Director revealed the occupational therapy was originally denied and another interdisciplinary team meeting was held. He said the new meeting was held on 11/19/25, (not reviewed), but the new request for occupational services was not sent by him, because the Physician was not available to sign the new request on 11/19/25. The Rehabilitation Director said on 12/05/25, the request would be sent again. He did not specify why he was waiting until 12/05/25 to re-send it. He said the risk to the resident would be a decline in functioning. An interview on 12/03/25 at 4:45 PM with the DON revealed the Physician was out on 11/19/25. She said he returned to the facility on [DATE] and the request for occupational therapy for Resident #1 should have been signed when the Physician returned. She said she did not know why the request was not signed and the MDS Coordinator was responsible for sending the request. The DON said she would have to review Resident #1's records to determine what the risk to Resident #1 would be. Review of the facility's policy, Preadmission and Screening Resident Review (PASRR) Rules, revised 03/15/23, reflected: .2. The facility will initiate the request for specialized services within 20 business days of the IDT. meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal .3. The Social Worker or designee will document the IDT. minutes and all specialized services into the on-line portal. within 3 business days after the IDT.meeting and annually thereafter.

Based on interview and record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay that included diagnoses, course of treatment, pertinent labs, a final summary of the resident's status and reconciliation of all pre-discharge medications with the resident's post-discharge medications for 1 of 5 residents (Resident #1) reviewed for closed records.The facility failed to ensure Resident #1 was discharged from the facility with a discharge summary that included an accurate and current description of the clinical status of the resident.The facility failed to provide the required notice to the Office of the long-term Care Ombudsman regarding the discharge of Resident#1.This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care.Findings Included: Record review of Resident #1's MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE]. Diagnoses included: Schizophrenia (a chronic mental health condition characterized by a combination of cognitive symptoms that significantly impair a person's daily functioning), anemia (a condition in which there is an abnormally low number of red blood cells (RBCs) or hemoglobin in the blood), hypertension (a condition in which the force of blood against the artery walls is consistently too high). Further review of the Resident #1's MDS, dated [DATE], revealed there was no documented BIMS score. Resident #1's MDS section E0200. Behavioral Symptom - Presence and Frequency reflected Resident#1 had Physical behavioral symptoms directed toward others (this behavior occurred once), Verbal behavioral symptoms directed toward others (this behavior occurred 4-6 times but less than daily). Record review of Resident #1's DISCHARGE - Recapitulation of Stay reflected one dated 10/02/2025 discharge to [hospital name 2]. There was no documented Discharge - Recapitulation of Stay for 10/03/2025 when Resident one went to the hospital. Record review of Resident #1's Physician orders dated 10/03/2025 revealed the following: Send to hospital for further evaluation and treatment. Interview with Ombudsman on 11/04/2025 at 10:09 AM revealed on 10/3/2025 the facility contacted her to get a list of suitable facilities for Resident#1's alternative placement. She stated SW B told her Resident#1 was going for treatment but did not specify the facility. She stated in immediate discharges the facility must provide clinical discharge summary of the residents to the receiving facility, and the notice of discharge to the Ombudsman manager which was not done. Attempted interview with FM 2 on 11/04/2025 at 1:43 PM was unsuccessful. A voicemail was left with a call back number. Attempted interview with FM1 on 11/04/2025 at 1:45 PM was unsuccessful. The surveyor left a voicemail with a call back number. Interview with LVN A on 11/04/2025 at 4:30PM revealed she was the nurse when Resident#1 was transferred to. She stated that she was not aware if he signed a discharge notice. Interview with SW B on 11/04/2025 at 4.45pm revealed that she did not send clinical documents or complete discharge summary because the former Administrator and the DON oversaw the transfer. Interview with SW C on 11/04/2025 at 2:10PM revealed she was the geriatric social worker at behavioral hospital. She stated the hospital was an acute stay behavioral hospital that stabilized behavior then discharged patients and it was not for long-term placement. She stated that Resident#1 was transferred to the hospital to evaluate and establish a medication regimen that would regulate his behavior and there was no clinical discharge summary provided. Interview with the DON on 11/04/2025 at 3:55pm revealed that she had been employed for a month. When asked if there was a clinical discharge summary or documentation dated 10/03/2025 the DON stated she could not find any documentation. She stated that the last week of October 2025 there was an email that SW C had gotten everything that she needed to find Resident#1 a new facility. She stated it was necessary to provide clinical discharge summary to the receiving hospital for continuum of care. Interview with LVN A on 11/04/2025 at 4:30PM revealed she was the nurse when Resident#1 was transferred to. She stated that she was not aware if he signed a discharge notice. She stated that she did not complete a discharge summary or the E-interact (a set of dashboard checklists, and automatic triggers designed to work together to assist care teams to reduce acute care transfers) because it was a busy day. She stated that failure to provide discharge summary to the admitting facility could result in the residents not receiving the care they deserve. Interview with MD on 11/04/2025 at 4.40pm revealed he called the ER and gave report to the ER Doctor and spoke with case management staff and notified them the resident would not be returning to the facility. He stated whenever a Resident transferred to the ER from the nursing home, the facility called and gave report to the receiving hospital. He stated that he did not make a discharge summary, because his duty was to call the hospital and give reports of what was going on with the residents. He stated that the nurse was responsible for the discharge summary. Interview with SW B on 11/04/2025 at 4.45pm revealed that she did not send clinical documents or complete discharge summary because the former Administrator and the DON oversaw the transfer. She stated it was important to provide the admitting facility with proper documentation such as clinical discharge summary so the residents can be cared for appropriately. Interview with Administrator on 11/04/2025 at 4:56PM revealed he was newly hired, and he was not part of the discharge and that he could not speak on how it was overseen. He stated even in an immediate transfer there is procedure and protocol to ensure the receiving facility had enough information to care for the resident. He stated that his expectation was there would be a time and record of when the resident signed and accepted the discharge notice. Record review of the facility's Transfer or Discharge, Emergency policy, latest revision dated 08/2018, stated the following: If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented.Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures:a. Notify the resident's Attending Physician.b. Notify the receiving facility that the transfer is being made.c. Prepare the resident for transfer.d. Prepare a transfer form to send with the resident.e. Notify the representative (sponsor) or other family members.f. Assist in obtaining transportation; andg. Others as appropriate or as necessary.5. Should it become necessary to transfer residents during emergency or disaster situations, transfer procedures outlined in our disaster plan will be implemented.6. The resident's medical record must be forwarded to the Medical Records office within twenty-four (24) hours of the transfer or discharge.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for three (Residents #1, #3, and #4) of five residents reviewed for abuse.The facility Administrator and DON failed to protect Resident #1, Resident #3, and Resident #4 from abuse by Resident #2.On 09/09/25, Resident #2 pushed the wheelchair of Resident #4. Resident #4 hit Resident #2. Resident #2 hit Resident #4 back.On 09/29/25 Resident #2 cursed at Resident #1 and Resident #3. He also pulled out a knife from his shoe and threatened them with it.On 10/02/25 Resident #2 threated to kill Resident #1 and chased after her on 10/02/25. Resident #1 suffered psychosocial harm. An IJ was identified on 10/02/25. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 10/03/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the Plan of Removal. This failure could place residents at risk of continued abuse and harm.Findings included: 1.Record review of Resident #1 's admission MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMs score was 15. Her cognitive skills for daily decision making were intact. Her diagnoses included anxiety, depression, post-traumatic stress disorder, schizophrenia, and arthritis. The resident used an electric wheelchair. Record review of Resident #1's Care Plan, dated 09/15/25, reflected:Trauma Informed Care: Resident had a previous/recent traumatic event.Facility interventions included:Identify triggers (any stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening) which may re-traumatize resident: (specify triggers such as physical touch, tone of voice, object, sound, smell, sight, violent movie/news, etc.) Review of Resident #1's Nurse notes reflected:10/01/25 2:54 PM Psychiatrist FNP saw the resident who was referred to her for medical management. Received order to continue Xanax (anti-anxiety medication) 0.5 milligrams orally every eight hours for 30 days for anxiety. The resident was informed. Written by ADON M An interview on 10/02/25 at 12:45 PM with Resident #1 revealed she was outside in the smoking area during smoke break. Resident #1 was upset and said she felt Resident #2 was causing her psychosocial harm. She said Resident #2 was mentally abusing her. Resident #1 said Resident #2 threatened to kill her many times. She said she usually did not go out to the smoke area, but the ADON N was with Resident #2 where he was smoking away from the other residents. An interview on 10/02/25 at 12:55 PM with Resident #1 revealed she was upset. She said she wanted to know how to get a restraining order against Resident #2. 2.Record review of Resident #2's admission MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 00. He sometimes understood sometimes and sometimes he understood others. The resident had delusions, physical behavioral symptoms directed toward others, and verbal behavioral symptoms directed toward others. His diagnoses included non-Alzheimer's dementia and schizophrenia. The resident used a manual wheelchair. Record review of Resident #2's Care Plan, dated 10/01/25, reflected:*Resident had episodes of verbal and physical behavioral symptoms as evidenced by poor impulse control with a diagnosis of schizophrenia.Facility interventions included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document.*Resident had a communication problem related to unclear speech and difficulty understanding and making self-understood.Facility interventions included: Be conscious of resident position when in groups, activities, and the dining room to promote proper communication with others. Record review of Resident #2's Notes written by RN A reflected:09/29/25 11:34 AM .Patient remain stable during this shift but continue to be non-compliant with care and verbally abusive to another resident this morning, the attention of this Nurse was called reporting patient was noted outside at the courtyard auguring with another resident and in the middle of the argument patient pull out a kitchen knife from his shoe, this Nurse immediately went outside at the courtyard and calmly assessed patient and ask patient if he have any knife on him, patient stated yes he has a knife and has taken it back to his room, this Nurse went straight to patient room and got the knife out of patient drawer in his room, this Nurse asked patient if he has any plans of hurting himself or others, patient replied NO this Nurse educate patient on safety precautions that must be observed at all time to keep him and other residents safe and that include not having any sharp object with him at any time and not getting close to any resident during an argument and to report any concerns he may have to the Nurse, supervisor or Administrator, patient verbalized understanding , patient refused his morning meds and bp check this morning, MD/DON notified, all safety and universal Precautions were observed, call light placed within patient reach, will continue to monitor patient. An observation and interview on 10/02/25 at 11:39 AM revealed Resident #2 was in the center of the main hallway. He was seated in his wheelchair with his leg extended out self-propelling in the hallway. The State Surveyor introduced self to Resident #2. Resident #2 started cursing at the State Surveyor and began wheeling himself away. The State Surveyor backed away from the resident. Resident #2 was yelling and cursing at everyone who walked by him. Resident #1 was in her electric wheelchair and propelled towards the State Surveyor. Resident #2 saw Resident #1 and started yelling, cursing and saying, calling the police and let the police come, and I will kill you. Resident #2 repeatedly screamed the sentences at Resident #1. Resident #1 yelled back at him and Resident #2 self-propelled himself towards Resident #1. There were multiple staff in the hallway observing and trying to redirect Resident #2. Resident #1 and the State Surveyor were pushed into the activity room to get away from Resident #2. There were 6 staff members who were trying to keep Resident #2 away from Resident #1. Resident #2 pulled out a lighter. Resident #1 was frantic and said she was afraid of Resident #2 and stayed in her room to get away from him. Resident #1 said Resident #2 had pulled a knife on her on 09/29/25 and she called the police. The police told her they could not do anything but would talk to Resident #2 and the staff. Resident #1 said she wanted to get out of the facility as fast as she could and she had to get her anxiety medication increased because of his behavior towards her. Resident #1 said she had reported the concerns to (unknown) facility staff, but nothing was done and that Resident #2 had the behaviors daily to others as well. Resident #1 said she did not file any grievances about Resident #2 because grievances did not work. An observation on 10/02/25 at 12:15 PM revealed Resident #2 was self-propelling himself in his wheelchair down the hall. At 12:20 PM, Resident #2 self-propelled himself into the dining room. Staff were assisting residents with their meals. Resident #2 passed by Resident #1 who was seated at a dining table. Resident #2 started yelling and cursing at Resident #1. Staff intervened and directed Resident #2 to his table to eat. 3. Record review of Resident #3's quarterly MDS assessment, dated 09/09/25 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included post-traumatic stress disorder and bipolar disorder. Record review of Resident #3's care plan, revised 05/08/25, reflected:The resident had a behavior problem related to suicidal ideations and multiple claims regarding suicide attempts with both staff and other residents.Facility interventions included: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, people involved, and situations. Document behavior and potential causes An interview on 10/02/25 at 11:15 AM with Resident #3 revealed he was awake, alert, and oriented to person, place, time, and situation. He said he did not feel safe at the facility. He said Resident #2 raised his anxiety and he wanted to move to a different facility. Resident #3 said he was not afraid of Resident #2 and could handle himself. A follow-up interview on 10/03/25 at 12:15 PM with Resident #3 revealed on 09/29/25 he was in the smoking area outside. He said Resident #2 was yelling and threatening Resident #1. Resident #2 reached into his tennis shoe and pulled out a butter knife. Resident #3 said Resident #2 threatened to kill him and Resident #1. Resident #3 said he grabbed his grabber stick and told Resident #2 it was bigger than his knife. Resident #2 said he would shoot Resident #1 and Resident #3. 4. Record review of Resident #4's quarterly MDS assessment, dated 10/01/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, bipolar type. Record review of Resident #4's Care Plans, dated 10/02/25, reflected:The resident had a mood problem related to history of schizoaffective disorder with bipolar and anxiety.Facility interventions reflected: monitor/record/report to medical doctor as needed for mood patterns, signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of the Provider Investigative Report dated 09/09/25 reflected:The Administrator and the DON concluded that Resident #2 saw his family member coming to visit and got excited to open the door. He then proceeded to move Resident #4 (who was in her wheelchair) out of the way. Resident #4 hit Resident #2 on the hands and Resident #2 hit Resident #4 back. No injuries noted. Staff would continue to redirect and monitor closely. Resident #2 was referred to psych for evaluation and treatment. An interview on 10/02/25 at 11:30 AM with Resident #4 revealed she was awake, alert, and oriented to time and situation. She said there was an incident between her and Resident #2 on 09/09/25. She said she was sitting in her wheelchair speaking to the Activity Director. Resident #2 told her to move. The Activity Director said she told Resident #2 to go around them. Resident #2 said no and pushed Resident #4's wheelchair out of the way. Resident #4 said she hit Resident #2 and he hit her back. She said she felt safe at the facility, but Resident #2 bothered Resident #1 also. Resident #4 said Resident #2 cursed at everyone. An interview on 10/02/25 at 12:35 PM with the DON revealed on 09/09/25, Resident #2 pushed Resident #4's wheelchair and Resident #4 hit Resident #2. Resident #2 hit Resident #4. The DON said the facility sent Resident #2 to a psychiatric hospital for one week . He said the police were called but could not do anything . The DON said Resident #2 was on enhanced supervision. The DON said Resident #2 was very loud. The DON said the facility was trying to send Resident #2 to a psychiatric facility after his actions towards Resident #1 on 10/02/25. The DON said Resident #2 would become abusive and abuse everyone around him. The DON said the staff had been very good about calming Resident #2 down. An observation and interview on 10/02/25 at 12:40 PM with the ADON N revealed he was sitting inside the facility. He was watching Resident #2 who was seated by himself in the smoking area outside. The ADON N said Resident #2 was placed on 1:1 monitoring at 11:45 AM. The ADON N said he did not know how Resident #2 got a lighter on 10/02/25. An interview on 10/02/25 at 1:45 PM with the Administrator revealed he had never observed Resident #2 have the behaviors of cursing and going after residents until 10/02/25. He said he self-reported the incident that occurred between Resident #2 and Resident #4 on 09/09/25 . He said Resident #2 was sent to a psychiatric facility and returned to the facility with medication changes. The Administrator said the resident had never threatened to kill any residents before 10/02/25. He said he had been trying to get Resident #2 admitted to a different facility following the incident on 09/09/25 and the SW had sent out many referrals. He said that Resident #2 was monitored closely, and staff would redirect him. The Administrator said he did not think Resident #2 was targeting Resident #1. He said Resident #2 had never threatened to kill Resident #1. The Administrator said he did not know of any incident that occurred on 09/29/25 of Resident #2 pulling a knife on Resident #1. He said he did not know how Resident #2 got a lighter on 10/02/25. A follow-up interview on 10/02/25 at 2:10 PM with the ADON N revealed Resident #2 had always been aggressive and some residents knew his temper and would poke the bear to get a reaction. The ADON N said Resident #2 did not threaten to kill residents prior to 10/02/25. The ADON N said to prevent Resident #2 from verbally abusing and going after residents, staff would re-direct them. He said he did not know why Resident #2 was targeting Resident #1 and said one day they would be good together and the next day they were not. He said Resident #2 had not threatened to kill Resident #1 until 10/02/25. The ADON N said on 09/29/25 he and the DON were in a meeting and were told Resident #2 had a knife in the smoking area, but they went outside and did not see a knife. He said he did not know Resident #1 called the police and he did not talk to them. He said he spoke to Resident #1 and Resident #2 about the incident on 09/29/25, but he never saw a knife. He said he did not know Resident #1 had her anxiety medication increased. The ADON N said the Administrator was notified about the incident on 09/29/25. A follow-up interview on 10/02/25 at 2:40 PM with the DON revealed he did not think Resident #2 was targeting Resident #1. The DON said he never heard Resident #2 threaten to kill residents. The DON said Resident #2 was on enhanced supervision to prevent him from verbally abusing and going after residents, but on 10/02/25 he was placed on 1:1 monitoring. The DON said on 09/29/25 Resident #1 and Resident #2 were outside smoking and talking. He said he was not aware of the police being called on 09/29/25 and the Administrator was notified about the incident. The DON said he thought RN A's documentation on 09/29/25 was incorrect because he never saw a knife. The DON said no one spoke to Resident #1 following the incident on 09/29/25. He said Resident #2 was not verbally abusing or threatening Resident #1. The DON said Resident #2 did not specifically curse at anyone. The DON said following the incident on 10/02/25, the facility was looking for another facility for Resident #2. The DON said he did not know that Resident #1 had her anxiety medications increased. An interview on 10/02/25 at 2:50 PM with RN A revealed on 09/29/25, the CNA told her that Resident #2 was in an argument with another resident and had pulled out a knife from his shoe. RN A said she took away the knife and told the DON. She said she did not know if Resident #2 threatened Resident #1. RN A said Resident #1 did call the police about the incident. RN A said all of her notes for 09/29/25 were correct. An interview on 10/02/25 at 3:55 PM with CNA B revealed Resident #2 was a bully to other residents and that the residents were not safe in the facility with him. An interview on 10/02/25 at 4:08 PM with CNA C revealed she was working on 09/29/25. She said Resident #2 had aggressive behaviors. She said the residents at the facility were not safe because there had been too many times when staff had to break up incidents between Resident #2 and other residents. She said on 09/29/25 Resident #1 and Resident #2 were outside smoking. Resident #1 and Resident #2 were bickering. CNA C said she was very scared, and she tried too re-direct him. Resident #2 said to Resident #1, I will cut you mother f***er and slice and dice you. CNA C said she searched and did not see the knife. An interview on 10/03/25 with an Anonymous person revealed Resident #2 had been threatening and going after residents since he was admitted . The Anonymous person said Resident #2 made specific threats including threatening to hit Resident #1 prior to 10/02/25. The Anonymous person said the DON did not address the issues of Resident #2. The Anonymous person said Resident #2 was not safe to be around other residents. An interview on 10/02/25 at 2:40 PM with the SW revealed she was told on 10/02/25 to find a facility for Resident #2 to go to. She said when Resident #2 returned from the psychiatric facility on 09/09/25, residents were very upset. The SW said she was told by the Administrator not to find him a different place to live, because he was their resident and they were going to make it work. Record review of the facility policy, Abuse Prevention Program, not dated, reflected:Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This was determined to be an IJ on 10/02/25 at 4:40 PM. The Administrator and the DON were notified. The Administrator was provided the IJ template on 10/02/25 at 4:50 PM. The following Plan of Removal was submitted by the facility and was accepted on 10/03/25 at 11:20 AM and reflected the following:Resident #2 was immediately placed on 1:1. Local law enforcement were called while alternative placement is being sought. At 3:45 PM Resident #2 was sent to the hospital for further evaluation and treatment. Resident # 2 returned to the facility at 10:00 PM and was placed on 1:1. Continue effort to find alternative placement. Discharge notice will be given after discussion with family. Will remain 1:1 until placement is found.Resident #1 was removed from Resident #2, and a head to toe was completed on Resident #1. The resident was found to be at their normal baseline, in addition had a trauma informed assessment was completed by the social worker and a psych referral was made for further assessment, Resident #1 was emotionally reassured of their safety and educated on the additional support. Facility Psych services contacted with no new order.The Ombudsmen were notified via email.The attending physician/Medical Director and family /responsible parties of both Residents #1 and # 2 were notified.On 10/02/25 safe surveys were initiated on all interviewable residents, no pattern or concerns were identified nor noted.Head-to-toe assessments were initiated on all nonverbal residents with no pattern or evidence of any deviation from all of the residents' normal baseline status.Resident #1 family/representative offered police intervention/reporting.State Self Report was initiated, intake # pending.Systematic ApproachOn 10/02/2025 An ad hoc QAPI meeting was held, in attendance were the: Medical Director (via TEAMS), Executive Director, DON and the Regional [NAME] President of Operations to review appropriate interventions and to review our present Policy and Procedures on: Abuse Prevention, Timely Reporting and Documentation. Review of the present policies was found to be sufficient and met state and federal requirements.EducationOn 10/02/25 The Abuse Prevention Coordinator was in re-serviced by the Regional [NAME] President of Operations, on the Abuse Prevention Protocol, to include a questionnaire and in service on abuse and neglect.Beginning on 10/02/25 - All staff were re-inserviced by the Administrator /Director of Nursing Services and/or Manager on Abuse Prevention Protocol/Reporting and Documentation.On 10/02/25 Additional Inservice's with competency were added for all staff: In addition, each staff member began inservicing with competency on Abuse Prevention/Timely Reporting and Documentation and Managing Residents with Behaviors.Any staff who were not present to complete the in-service by 10/02/25 would be required to complete the in-services at the start of their next shift before beginning work. New hires and PRN will also be in service prior to the start of their shift. The education will be conducted and monitored by the DON/Designee.MonitoringResident safe surveys and/or head to toe assessments will be conducted weekly x 4 weeks on all patients, then monthly x 3 months with oversite from the facility DON and Administrator.Employees will complete Abuse questionnaires / and in-servicing weekly x 4 weeks then monthly x 3 months with oversite and monitoring from the facility DON and Administrator.Quality AssuranceIn-servicing on Abuse and Neglect and any associated concerns will be included in the facility's monthly QAPI meeting for 3 months to include the Medical Director with oversight from the facility Administrator and DON. Monitoring the facility's Plan of Removal included the following: Record review of Resident #1's clinical records revealed the resident was assessed by the facility on 10/02/25. No injuries were noted. The Family Nurse Practitioner was notified. Record review of Resident #2's clinical records revealed the resident was sent to the hospital on [DATE] but returned to the facility the same night. The resident was placed on 1:1 monitoring. An observation on 10/03/25 at 12:20 PM revealed Resident #2 was sitting in his wheelchair in the hallway with the Administrator and transport drivers with a stretcher in the hall talking to the resident. On 10/03/25 at 12:35 PM Resident #2 got onto the stretcher and left the facility with the transport drivers. Interviews were conducted on 10/03/25 from 1:15 PM to 4:30 PM with staff from various shifts. The staff included LVN D, LVN E, CNA F, LVN G, CNA H, CNA I, CNA J, CNA K, CNA L, and the SW.All staff were able to identify:What abuse was and the different types of abuse. The staff understood abuse had to immediately be reported to the Administrator. An interview on 10/03/25 at 3:00 PM with the DON revealed his roles in the facility plan of removal included: Resident #2 was in a psychiatric hospital and when he returned, he would be placed on 1:1 monitoring. The DON said he spoke to Resident #1 and she was doing well. He said he completed a trauma and emotional assessment, and she was not fearful. The DON said he would ensure all assessments were completed and he would monitor residents for any signs and symptoms of distress, anxiety, or disturbance and ensure residents did not make threats to other residents. An interview on 10/03/25 at 3:20 PM with Resident #1 revealed she was upset. She said she was terrified about Resident #1 returning to the facility. She said the DON spoke to her and she told him she was still afraid of Resident #2. An interview on 10/03/25 at 3:55 PM with Resident #1 and the Corporate Nurse revealed prior to the conversation, Resident #1 did not feel safe. She was afraid Resident #1 would return to the facility, and she would be threatened by him or even discharged . The Corporate Nurse reassured the resident and told her Resident #1 would not be returning to the facility and she was not going to be kicked out. Resident #1 told the State Surveyor that after speaking with the Corporate Nurse she felt safe. An interview on 10/03/25 at 4:22 PM with the Administrator revealed he wanted to find Resident #2 a new placement. He said if the resident came back, he would be placed on 1:1 monitoring. He said Resident #2 was not appropriate to stay at the facility. He said he spoke to Resident #1 on 10/02/25 and she was fine. He said he had told the nurses to check with her every 1-2 hours and if anything was concerning at all to give him a call. He said his role in the Plan of Removal would be monitoring to ensure resident safe surveys and/or head-to-toe assessments would be conducted weekly x 4 weeks on all patients, then monthly x 3 months. Employees would also complete abuse questionnaires/and in-servicing weekly x 4 weeks then monthly x 3 months. An IJ was identified on 10/02/25. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 10/03/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 1 (Resident #1) of 9 residents reviewed for neglect. 1. The facility failed to ensure Resident #1 was not neglected when she fell from her bed and remained on the floor beside her bed for approximately 4 hours on 07/30/25. 2. The facility failed to ensure RN A and CNA B did Routine Resident Checks every 2 hours on Resident #1 during their shift on 07/30/25. The non-compliance was identified as past non-compliance. The facility corrected the non-compliance before surveyor's entrance. These failures could place residents at risk for humiliation, fear, shame, agitation, decreased quality of life and possibly death. Findings included:Record review of Resident #1's admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included: hypokalemia (condition where the potassium levels in the blood are lower than normal), cerebral infarction (occurs when blood flow to the brain is interrupted, leading to brain tissue damage), depression, hypertension (high blood pressure), gastro-esophageal reflux disease (GERD) without esophagitis (a condition where stomach acid flows back into the esophagus without causing inflammation or damage to the esophageal lining), constipation, osteoarthritis in the right knee (joint disease that causes pain, stiffness, and swelling in the joints), and age-related osteoporosis without current pathological fracture (a condition that weakens bones, making them more prone to fractures), and dementia. Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected she had severe cognitive impairment with a BIMS score of 2. Resident #1 used a wheelchair and walking cane for assistance with mobility and was independent and did not require any assistance with rolling left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, or toilet transfer. Resident #1 needed assistance with setup or clean-up with tub/shower transfer, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. Resident #1 did not have any falls prior to being admitted to the facility. Record review of Resident #1's Care Plan reflected the following entries:An entry dated 06/29/2025 and revised on 08/26/2025 reflected: Focus: [Resident #1] was at risk for falls related to impaired balance/gait, weakness and use of psychotropic medications.Goal: [Resident #1 will have decreased risk for serious injury or hospitalization as a result of falling through the next assessment review period. Date Initiated: 08/29/2025, Revision on: 08/17/2025, Target Date: 07/30/2025 .Interventions: Discuss/review fall(s) at morning meetings, IDT/QA meetings, and as indicated.Date Initiated: 06/29/2025 Encourage locking of brakes on Wheelchair.Date Initiated: 06/29/2025 Encourage resident to voice needs as well as to seek/await staff assist with transfers.Date Initiated: 06/29/2025 Encourage use of self-help devices as indicated.Date Initiated: 06/29/2025 Ensure glasses are clean, in good repair and worn appropriately.Date Initiated: 06/29/2025 Ensure resident wears appropriate, well-fitting footwear to minimize the risk ofSlipping.Date Initiated: 06/29/2025 Fall risk quarterly and prn per facility policy.Date Initiated: 06/29/2025 Keep call light within reach.Date Initiated: 06/29/2025 Keep environment clear of unnecessary objects. Keep bed locked and in lowest position unless otherwise ordered/indicated.Date Initiated: 06/29/2025 Nursing staff will monitor for side effects/adverse reactions to medications.Date Initiated: 06/29/2025 Refer to therapies and/or restorative, as indicated.Date Initiated: 06/29/2025 Safety training, retraining and education as needed.Date Initiated: 06/29/2025 An entry dated 08/26/2025 reflected: Focus: [Resident #1] was at risk for skin breakdown due to decreased mobility.Goal: [Resident #1] will have no skin breakdown in the next 90 days. Date Initiated: 08/26/2025 and Target Date: 07/30/2025. There were no Interventions in place. Record review of Resident #1's Skin Assessment for 07/30/25 at 5:00 AM due to an un-witnessed fall revealed, that Resident #1 had a small scrape on her upper right arm and denied pain. Record review of Resident #1's Neurological Check on 07/30/25 at 6:14 AM, revealed that she was complaining of vomiting and diarrhea. [Resident #1] denied any pain or discomfort or emotional distress. Record review of Resident #1's X-rays on 07/31/25 revealed that impressions were taken of the skull, hips, and chest and the findings revealed that there was no evidence of any fractures present in all areas. Record review of the facility's Admissions List for 02/01/25 to 08/26/25 revealed that Resident #1 was admitted to the facility from an acute care hospital on [DATE]. Record review of the facility's Incident Logs for 02/26/25 to 08/26/25 revealed on 07/30/25 at 5:00 PM, Resident #1 had an unwitnessed fall. Record review of the facility's In-service Training Log reflected that the staff's previous training on Resident Rights was conducted by Administrator on 07/23/25. The In-Service Training Logs reflected the staff were trained on the facility's policies and procedures on Resident Rights. The In-Service Training Attendance Roster reflected that the trainings were attended by all staff except RN A and CNA B. Record review of the facility's Staff Schedule for 07/29/25, revealed that RN A and CNA B were assigned to the evening shift on the 200 Hall where Resident #1 resided. Record review of the facility's In-service Training Log dated 07/30/25, reflected that the trainings were conducted by Administrator. The In-Service Training Logs reflected the staff were trained on the facility's policies and procedures on Abuse/Neglect, Resident Rights, Routine Round Checks, Call Lights, and Fall Preventions. The In-Service Training Attendance Roster reflected that the trainings were attended by all staff except RN A and CNA B. Record review of the employee files for RN A and CNA B revealed on 07/30/25 both staff members were suspended pending the facility's investigation of Resident #1's fall during the evening shift on 07/29/2025. Both staff members were terminated on 07/30/25 due to policy/procedure violation, prohibited conduct, safety violations, and unsatisfactory job performance which led to Resident #1's unwitnessed fall on 07/30/25. Both employee files did not reveal any other infractions or disciplinaries regarding resident neglect. Record review revealed on 07/30/25, the facility conducted Safe Surveys with the residents in the facility, and all stated that their needs were being met at the facility and did not have any concerns regarding abuse and neglect. Record review of the facility's Provider Investigation Report dated 08/06/25 revealed, RN A was the Charge Nurse on duty and CNA B was also on duty assigned to the 200 and 300 halls during the evening shift on 07/30/25, which was from 6 PM to 6 AM. On 07/30/25 at approximately 4:30 AM, [Resident #1] was observed by FM to have fallen and remained on the floor or an extended period of time. FM voiced concerns regarding the night shift doing routine checks during their shifts. [Resident #1] had a head-to-toe assessment which revealed a skin tear to her upper right arm. RN A and CNA B were immediately suspended and later terminated due to not following the facility's Routine Round Check Policy. The finding of Founded due to the neglect of RN A and CNA B. In a telephone interview with RN A on 08/26/25 at 4:25 PM revealed, that she was employed at the facility for 2 years as of 07/30/25. RN A stated that she worked the 6P-6A shift on 07/30/25. RN A stated that CNA B worked the 6P-6A shift on 07/30/25. RN A stated that herself and CNA B were assigned 2 hallways on 07/30/25. She stated at the beginning of her shift, she would do her rounds and check on residents to see how they were doing. RN A stated that Resident #1 was independent but needed some assistance with her ADL's due to her having some muscle weakness. RN A stated that Resident #1 appeared to be fine and did not appear to be in any distress or discomfort when she checked on her at the beginning of her shift. RN A stated that Resident #1 did not like to be awakened during the night and preferred to keep her door ajar or closed. RN A stated that if Resident #1's door was opened throughout the night, she would become disturbed in her sleep. RN A stated that during her shift on 07/30/25, Resident #1 had nausea and was vomiting due to her having some health issues. RN A stated that she did not Check-In with Resident #1 during her shift because she became busy with tasks such as assisting other residents and passing medications to residents. RN A stated that she was doing her rounds around 4:30 AM on 07/30/25, she heard some noise and observed Resident #1 on the floor beside her bed. She stated that Resident #1 stated that she had fallen on the floor after self-ambulating herself to the bathroom. RN A stated that Resident #1 did not know how long she remained on the floor after her fall. RN A stated that Resident #1 had a camera in her room that recorded the resident's fall on 07/30/25. RN A stated that after she observed Resident #1 on the floor, she contacted CNA B and told her that Resident #1 had fallen out of the bed and they picked up Resident #1 and placed her on her bed. RN A stated that Resident #1 complained of dizziness after the fall, and she was given a head-to-toe assessment. Resident #1's head-to-toe assessment revealed a small tear on Resident #1's right elbow. RN A stated that she took Resident #1's vital signs and everything looked good. RN A asked Resident #1 if she needed anything to drink and/or eat and she told her no, she wanted to go to sleep. RN A stated that after the fall, she did not observe any bruises on Resident #1. RN A stated that the x-ray technician came to the facility and gave Resident #1 an x-ray, which revealed no injuries. RN A stated that Resident #1 also received a Neurological Check, which revealed no concerns. She stated that after x-ray technician left Resident #1's room, she went to sleep. RN A stated that after Resident #1's fall, she notified the FM, physician and called the DON and she made an incident report. She stated that she called Resident #1's FM and left a voicemail message informing her about Resident #1's fall. RN A stated that prior to 07/30/25, Resident #1 did not have any history of falls. RN A stated that she could not remember the last In-Service she received on abuse, neglect, falls, and routine resident checks but she had taken the Trainings at least once or twice a week. RN A stated that neglect was when a resident has their Call Light on and the Call Light remains on for a long amount of time and no one answers the Call Light. RN A stated that she was told by the DON and Administrator that she would be suspended from working at the facility pending the facility's investigation on the incident. RN A stated that she was notified by the Administrator that her employment was terminated due to not following the facility's policy, Routine Resident Checks, which stated that Routine Resident Checks should be done on every shift at least every 2 hours. RN A stated that there was a potential risk of Resident #1 being on the floor for 4 hours without any assistance. RN A stated the Resident #1 could have been harmed by being unconscious, have serious injuries and fractures bones. Record review of CNA B's undated statement, Fall Incident Statement revealed, Upon the return from her 45-minute lunch break on 07/30/25 at approximately 4:00 AM, RN A called her to come to [Resident #1's] room because she needed assistance. CNA B stated that she entered the room and observed [Resident #1] on the floor. Resident #1 told CNA B that she went to the bathroom and became dizzy. RN A and CNA B assisted [Resident #1] by placing her into her bed. CNA B gave [Resident #1] the call light and advised her not to attempt to go to the bathroom without assistance. [Resident #1] told CNA B that she called for help verbally. CNA B stated that she told [Resident #1] that no one heard her and to use the call light for assistance. CNA B stated that [Resident #1] typically walked with the assistance of her walking cane and she was unsure if [Resident #1] used her walking cane when she walked to the bathroom. CNA B stated that [Resident #1's] cane was observed near her bed rail. CNA B stated that [Resident #1] asks for her door to remain shut at all times and she had not entered [Resident #1's] room for a couple of hours during her shift and was unsure how long [Resident #1] was on the floor. [sic] During an observation of Resident #1's room on 08/26/25 at 4:01 PM, revealed that the Call Light was operable and was in reach. Resident #1's wheelchair was observed beside her bed. Resident #1 was not in her room. In a telephone interview with [Resident #1's] FM on 08/26/25 at 4:50 PM, she stated that she was [Resident #1's] RP/FM. The FM stated that Resident #1 was admitted to the facility on [DATE] for Long Term Care. The FM stated that Resident #1 had a camera in her room. The FM stated on 07/30/25 at 5:09 AM, she received a voicemail from RN A stating that she was making rounds throughout the facility and found [Resident #1] sitting on the floor. RN A stated that when she asked [Resident #1] what happened, she said that she was going to the bathroom and she felt dizzy and decided to sit down on the floor. RN A stated that [Resident #1] had some bruising on her right hand and nowhere else. The FM stated that she was asleep when RN A telephoned her and left the voicemail message. The FM stated that she got up around 8:00 on 07/30/25, listened to the voicemail message and thought that it was weird that [Resident #1] would get out of her bed and just sit on the floor because she had never done anything like that in the past. The FM stated that she decided to look at the video camera footage on the day of the incident. The FM stated that the video camera footage revealed that [Resident #1] had a fall on 07/30/25 around 12:30 AM and remained on the floor until about 4:30 AM until RN A seen her and CNA B assisted [Resident #1] with getting back into her bed. The FM stated that she felt like the facility staff were negligent due to no one checking in on her mom for 4 hours. The FM stated that [Resident #1] initially sustained a tear on her right arm near her elbow after the fall. She stated that a couple of days later, Resident #1 had a bruise to her check, left lower leg. The FM stated that Resident #1 had not had any falls prior to being admitted to the facility. The FM stated that she did not want to get anyone at the facility into any trouble, but she felt like the staff were negligent by not checking in on [Resident #1] during the evening shift on 07/30/25. An observation of video footage sent to HHSC Surveyor from Resident #1's FM on 08/26/25 at 5:22 PM revealed the following: On 07/30/25 at 00:56 (12:56 AM) Resident #1 was observed sitting on the edge of her bed upright, with both of her feet on the floor. Resident #1 was observed leaning towards her headboard and grabbing her cane. Resident #1 was observed then standing up, Resident #1 appeared to be unbalanced and attempted to regain her balance. Resident #1 was then observed to take about 10 steps forward when she falls forward and out of view of the camera. The floor was free of any obstacles. Resident #1 did not vocalize anything such as pain or for help. Resident #1 was observed in the bottom corner of the camera getting on her knees then the video ends. On 07/30/25 at 4:38 AM Resident #1 was observed sitting on her buttocks near the middle/bottom half of her bed, her legs are not able to be seen as they are out of view of the camera. Resident #1's cane was observed near her pillow propped up against the bed. Audio can be heard of [RN A] stating she needs help another lady's voice [CNA B] asks, with what and [RN A] says she's on the floor. On 07/30/25 at 4:39 AM, [RN A and CNA B] were observed entering Resident #1's room. RN A was heard stating she's never done this before she can walk and then telling Resident #1 Okay we need to get you up and asks Resident #1 How you feeling? to which Resident #1 was heard saying Good, I think. Both staff members were observed assisting Resident #1 from the floor to the bed, Resident #1 was observed telling CNA B that she was going to the bathroom. On 07/30/25 at 4:41 AM, CNA B was observed placing the call light within reach of Resident #1 and both staff [RN A and CNA B] tell Resident #1 to call and to use her call light and they will come help her and Resident #1 replied, Yes I know. On 07/30/25 at 4:42 AM RN A was observed taking Resident #1's vital signs and noted that Resident #1 was hurt on her elbow and asked Resident #1 if she got hurt to which Resident #1 stated yes and CNA B asked her if she hit her head and Resident #1 stated No and shook her head. CNA B then tells Resident #1 that she will be back to clean her elbow. On 08/26/25 at 10:28 AM, an attempted telephone call to CNA B was unsuccessful. In an interview with CNA C on 08/27/25 at 11:50 AM, he stated that he had been employed at the facility for 14 years. CNA C stated that he was not on duty when Resident #1 had a fall on 07/30/25. CNA C stated that he had taken In-Service Trainings on Abuse, Neglect, Falls, Fall Prevention and Routine Resident Checks sometime last month. CNA C stated that In-Service Trainings were conducted by the Abuse Coordinator who is the Administrator. CNA C stated that In-Service Trainings are ongoing and are done every time an incident happened at the facility, such as an allegation of abuse, neglect and resident falls, and call lights. CNA C stated that Routine Resident Checks are to be done every 2 hours or as needed depending on the resident's needs. CNA C stated that if he observed a resident on the floor, he would make sure that the resident was safe and then he would notify his Nurse and inform him/her what happened. CNA C stated that if a resident was left alone on the floor for 4 hours it was resident neglect. He stated that residents should not be on the floor and left unattended for that amount of time, which was excessive. CNA C was able to define and provide examples of resident neglect and was able to provide a detailed understanding of each. CNA C stated that the risk of a resident remaining on the floor for a long period of time can affect a resident's psychological well-being and cause harm such as injuries and fractured bones. In an interview with the CNA D on 08/27/25 at 11:57 AM, she stated that she had been employed at the facility for 5 years. CNA D stated that she was not on duty when Resident #1 had a fall on 07/30/25. CNA D stated that she had taken several In-Service Trainings on Abuse, Neglect, Falls, Fall Prevention and Routine Resident Checks during her tenure at the facility. CNA D stated that In-Service Trainings were conducted by the Abuse Coordinator who is the Administrator, and the DON. CNA D stated that In-Service Trainings are always being done with all staff every time an incident happened at the facility, such as an allegation of abuse, neglect and resident falls, and call lights. CNA D stated that Routine Resident Checks are to be done every 2 hours or as needed, such as if a resident turns on their Call Light. CNA D stated that if she observed a resident on the floor, she would talk to the resident to ensure that the resident was safe and did not need any emergency medical attention. CNA D stated that she would then notify her Charge Nurse and inform him/her what happened. CNA D stated that if a resident is left alone on the floor for 4 hours it is resident neglect. CNA D stated that she was not aware of any residents being abused or neglected at the facility. CNA D stated that if she suspected that a resident was being abused or neglected, she would notify the Abuse Coordinator/Administrator. CNA D stated that a resident should not be on the floor and left unattended for 4 hours, which was too long. CNA D was able to define and provide examples of resident neglect and was able to provide a detailed understanding of each. CNA D stated that the risk of a resident remaining on the floor for a long period of time is that the resident could be seriously hurt or injured, which meant that the resident needed emergency services. In an interview with the Administrator on 08/27/25 at 1:49 PM, he stated that the DON was not available due to being ill and out on Leave. The Administrator stated that on 07/30/25, Resident #1 had a fall during the evening shift and was found on the floor by RN A. He stated that RN A and CNA B assisted Resident #1 back to her bed. He stated that RN A asked Resident #1 what happened and how did she fall? He stated that RN A stated that Resident #1 told both staff members [RN A and CNA B] that she got out of the bed and felt dizzy and had fallen on the floor. RN A checked the resident for s/s of any injuries, bruises and marks via a head-to-toe assessment. RN A stated that Resident #1 stated that she was dizzy and the head-to-toe assessment revealed that Resident #1 had a small skin tear on her upper right arm near her elbow. The Administrator stated that Neurological Checks, X-rays, and Skin Assessments were completed on 07/30/25, which revealed that the resident did not have any serious injuries including fractures. He stated that Resident #1's RP and physician were notified after the incident. The Administrator stated that he was informed by Resident #1's FM that a voicemail was received from RN A on the early morning of 07/30/25, which stated that resident had a fall. The FM notified the Administrator and DON and provided video camera footage that revealed that Resident #1 was on the floor for an excess of 4 hours. The Administrator stated that he suspended and later terminated both RN A and CNA B due to them not abiding by the facility's policy for Routine Resident Checks, which were to be done on residents every 2 hours. The Administrator stated that both staff members [RN A and CNA B] admitted that they did not perform routine resident checks during their shift on 07/30/25, which led to Resident #1 being left on the floor unattended. He stated that himself and the DON viewed the videos and stated that both staff members were negligent for leaving the resident on the floor after her fall on 07/30/25. The Administrator stated that he immediately began In-Service Trainings with all staff on Reporting Abuse, and Neglect, Abuse and Neglect, Falls, Falls Prevention, Call Lights, and Routine Resident Checks. The Administrator stated that he also conducted Safe Surveys with residents in the facility, which revealed that the sampled residents did not have any concerns regarding their safety and the care they were receiving at the facility. The Administrator stated that all the In-Service Trainings will be ongoing for all staff monthly. The Administrator stated there was a risk when a resident is left alone unattended on the floor for 4 hours, which meant that the staff did not perform routine resident checks while Resident was on the floor. He stated that there are risks included the resident not having their medical needs and concerns taken care of. The Administrator stated that harm included psychological and mental well-being and serious injuries. On 08/27/25 at 2:47 PM attempted Telephone Calls to RN A and CNA B were unsuccessful. During an observation on 08/27/25 at 2:51 PM, Resident #1 was observed in the Dining Room, sitting alone in a chair with a walking cane beside her. She was well-dressed and groomed and was participating in an activity with other residents. The activity was being conducted by the Activity Director. During an observation and interview with Resident #1 in the dining room on 08/27/25 at 3:15 PM, Resident #1 was observed sitting at a table by herself. There were approximately six residents still sitting in the Dining Room. Resident #1 stated that she had 1 fall since she had been admitted to the facility. Resident #1 stated that on the day of the incident in the middle of the night, she had to use the restroom and attempted to get out of her bed and her legs were weak and she had a fall. Resident #1 stated that she was unable to crawl to her bed to press the call light for help. She stated that she was on the floor for a long period of time, but she was unable to provide a timeframe of how long she was on floor. Resident #1 stated that she did not remember hitting her head on anything during or after her fall from the bed. Resident #1 reported that she had a scrape on her right arm and a bruise on her left leg after she fell. She stated that after she fell onto the floor, she did not yell for help and remained on the floor. She stated that she was not in any pain or distress after she fell on the floor. She stated that she keeps her door cracked throughout the day and night. She stated that RN A saw her on the floor and then CNA B assisted RN A with placing her onto her bed. Resident #1 stated prior to her fall on 07/30/25, she had not had any issues in the past getting out of her bed and self-ambulating to the restroom. She stated that she did not recall any staff coming into her room to check on her when she was sleeping. She stated that she does not like to be awakened at night. Resident #1 stated that she feels safe at the facility, and she did not have any concerns regarding the care she was receiving at the facility. An observation of Resident #1 and interview on 08/27/25 at 4:03 PM, revealed that there was a small approximately 1-inch scrape to her upper right forearm and a pink bruise on her left calf. Resident #1 stated that she did not have any other injuries on her body, including her face and head areas after the fall on 07/30/25. Resident #1 stated that she had not had any falls prior to being admitted to the facility. Resident #1 stated that she had not had any falls at the facility since her fall on 07/30/25. Record Review of the voicemail sent to HHSC Surveyor from Resident #1's FM on 08/27/25 at 4:41 PM revealed the following:[RN A] telephoned the FM and stated, Hi [FM} this is the Nurse from [the facility] and this is about [Resident #1]. RN A stated, while making rounds, she was found on the floor in a sitting position. When resident was asked what happened, resident stated that she was going to the bathroom, she felt dizzy so she sat down on the floor and she did not get hurt or anything, just a little bruise on her right hand and nothing else, it was not bleeding just a little scratch and I gave her two medications and I just wanted to let you know, thank you. The Timestamp on the voicemail recording was 07/30/25 at 5:09 AM. On 09/02/2025 at 2:48 PM, an email was received from the Administrator which included a Statement from the DON about Resident #1's fall on 07/30/25. The DON's Statement stated, [DON} was notified by the Nurse, [RN A] that [Resident #1] had fallen in her room. [RN A] was making her rounds when she had [sic] calling for help. [DON] instructed [RN A] to do head-to-toe assessment on [Resident #1] and note any injury, any complaint of pain, any skin swelling or skin breakdown. [DON] also instructed her to inform the family, inform MD and request for x-ray to any body part, and initiate neuro-checks on [Resident #1]. All of the above instructions were carried out by the Nurse [RN A]. In the IDT meeting the next morning, we reviewed the fall and noted that the resident ambulated independently using a cane and liked for her door to be closed when she was in her room, including at nighttime. The x-rays were done and were negative for any injuries for [Resident #1]. The Nurses on each shift were advised to continue monitoring [Resident #1] for pain and emotional distress. The DON's Statement of Fall incident Report on 07/30/20245 was signed by the DON. Record review of facility's policy for Resident Rights, undated, reflected, Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect.2. Staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents. Record review of facility's policy for Abuse Prevention Program, undated, reflected, Policy StatementOur residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from.involuntary seclusion, verbal, mental.Policy Interpretation and ImplementationAs part of the resident abuse prevention program, the administration will:1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff.or any other individual.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification andreporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.5. Implement measures to address factors that may lead to abusive situations, for example:a. Provide staff with opportunities to express challenges related to their job and work environment.6. Identify and assess all possible incidents of abuse;7. Investigate and report any allegations of abuse within timeframes as required by federal requirements;8. Protect residents during abuse investigations;9. Establish and implement a QAPI [VT15] review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. Record review of facility's policy for Routine Resident Checks, dated 2001, revised July 2013, reflected, Policy StatementStaff shall make routine resident checks to help maintain resident safety and well-being.Policy Interpretation and Implementation1.To ensure the safety and well-being of our residents, nursing staff shall make a routine check on each unit at least once every 2 hours and as needed.2.Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify and change in the resident's condition, identify if the resident has any concerns, and if the resident is sleeping, needs toileting assistance, etc.3.The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs.4.The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identify of the person making checks, and any outcomes of each check. (Note: CNA's may also record this information and provide it to the Nurse Supervisor/Charge Nurse).

Based on interviews and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 2 of 19 residents (Residents #7 and Resident #48) reviewed for quarterly assessments. 1. The facility did not ensure Resident #7's Quarterly MDS Assessment, dated 03/12/2025, was completed within 90 days of the previous assessment. 2. The facility did not ensure Resident #48's Quarterly MDS Assessment, dated 03/19/2025, was completed within 90 days of the previous assessment. These failures could place residents at risk of not having their assessments completed timely.Findings included:1. Record review of Resident #7's admission Record, dated 07/23/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #7's annual MDS assessment dated [DATE] revealed he had diagnoses including Hypertension (a condition in which the force of the blood against the artery wall is too high), Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Orthostatic Hypotension (form of low blood pressure that happens when standing after sitting or lying down), Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar, the body doesn't produce enough insulin or it resists insulin), Cerebral Palsy (a neurological disorder that affects movement and muscle coordination, caused by abnormal brain development or damage to the developing brain), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), Schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and Autistic Disorder (neurological and developmental disorder that affects how people interact with others, communicate, learn and behave).Record review of Resident #7's EHR revealed quarterly MDS assessment dated [DATE] reflected the status was In-Progress and had not been completed or transmitted to the CMS system. His most recent completed assessment was a Quarterly MDS assessment completed on 12/14/2024.2. Record review of Resident #48's admission Record dated 07/23/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE].Record review of Resident #48's quarterly MDS assessment dated [DATE] revealed she had diagnoses including Multiple Sclerosis (a chronic autoimmune disease that affects the central nervous system, leading to a range of neurological symptoms due to damage to the myelin sheath that insulates nerve fibers), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Psychotic Disorder (severe mental health conditions characterized by disruptions in thought processes, perceptions, and emotional responses, often leading to a loss of touch with reality), Arthritis (the swelling and tenderness of one or more joints), Osteoporosis (causes bones to become weak and brittle), and Muscle Weakness (a symptom of many conditions, ranging from muscle injuries to fatigue).Record review of Resident #48's EHR revealed her quarterly MDS assessment dated [DATE] reflected the status was In-progress and had not been completed or transmitted to the CMS system. Her most recent completed assessment was a quarterly MDS assessment dated [DATE].During an interview on 07/23/2025 at 1:30 PM, the DON stated the VP of Reimbursement is responsible for completing MDS assessments until an MDS coordinator is hired. The DON stated the risks for late assessments included not getting the most up-to-date information needed during their IDT meetings and it could also affect their reimbursement.During an interview on 07/23/2025 at 2:43 PM, the Administrator stated the VP of Reimbursement was responsible for completing MDS assessments until an MDS coordinator is hired. The Administrator stated he was aware some of MDS assessments were late, and they were working to resolve the matter. He stated risks for late assessments included the resident's information may not be updated timely and they could miss a change in condition. He stated the facility's reimbursement could be impacted as well. In an interview on 07/23/2025 at 3:00 PM, VP of Reimbursement stated the facility had not completed Resident #31 and Resident #48's quarterly MDS assessments due to the facility not having an MDS coordinator. VP of Reimbursement stated he was responsible for completing the assessments until an MDS coordinator is hired. VP of Reimbursement stated the risk of late or missed assessments could affect the residents plan of care, continuity of care, and affect reimbursement.Record review of the facility's undated policy and procedure titled Electronic Transmission of the MDS, identified as current by the Administrator, reflected the following: All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. MDS electronic submissions shall be conducted in accordance with current OBRA regulations governing the transmission of such data.

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/oral hygiene for one (Resident #67) of five residents reviewed for Activities of Daily Living (ADLs). The facility failed to ensure Resident #67 received personal hygiene care, in respect to facial hair across her chin. This failure could place residents who were dependent on staff for ADL care at risk for not having their care and treatment needs met.Findings included: Review of Resident #67's Face Sheet, dated 07/23/25, reflected she was a [AGE] year-old female, who most recently admitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness (decreased strength in the muscles), and lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements). Review of Resident #67's MDS Assessment, dated 05/05/25, reflected she required supervision or touching assistance for personal hygiene, including shaving. Review of Resident #67's Care Plan, dated 12/21/20, reflected Resident #67 required assistance from staff with ADLs. An associated goal was for Resident #67 to remain clean, comfortable, and well groomed. Associated interventions were for staff to encourage Resident #67 to participate in ADL care as she was able; staff were also to assist with/provide ADL care for Resident #67 as needed. During an observation of Resident #67 on 07/21/25 at 2:50PM, she was sitting up in her wheelchair. She was noted to have an excessive amount of thick, white facial hair across her chin, approximately 1/3 to 1/2 inches in length. During an interview with Resident #67 on 07/21/25 at 2:50PM, she stated she did not like the hair on her chin and wanted it removed; she could not recall if any staff members had previously asked her if she wanted her facial hair to be shaved. During an interview with LVN B on 07/21/25 at 2:58PM, she stated direct care staff were expected to check for facial hair on residents during routinely scheduled showers, several times per week. Upon observation of Resident #67's facial hair, she stated she would have expected for a staff member to have shaved her chin prior to it growing as long as it had. LVN B stated the risk of residents not being provided with proper grooming, such as shaving, included a lack of dignity. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, dated 03/2018, reflected, .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on observations, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one medication cart (200 hall) of the facility's' four medication carts reviewed for medication storage. The facility failed to ensure Residents #47 Basaglar Kwik pen 100unit/1ml, and Resident#11 Humulin 70/30 100 units/ml, were dated when opened.The facility failed to ensure that an opened bottle of Novolin 70/30 bottle was properly labeled and dated before storing in the 200-hall medication cart. This failure could affect residents by diminishing the effectiveness, and therapeutic benefits of the medications and/or result in medication error.The findings included: Review of Resident #47's Quarterly MDS Assessment, dated 03.28.2025 reflected the Resident #47 was a [AGE] year-old female and had a BIMs score of 2, indicating her cognitive function was severely impaired. The resident had diagnoses which included Diabetes Mellitus (a group of metabolic disorders characterized by high blood sugar levels, caused by either the body's inability to produce enough insulin or its inability to effectively use the insulin it produces), hypertension (high blood), Non-Alzheimer's Dementia, Renal insufficiency (a condition where the kidneys are unable to adequately filter waste and excess fluid from the blood). Review of Resident #47's Comprehensive Care Plan, dated [DATE], reflected the resident had Diabetes Mellitus and was taking Insulin at bedtime. Intervention included to give Diabetes medication as ordered by doctor.Review of Resident #47's active Physicians orders as of [DATE] basaglar Kwik pen 100unit/1ml insulin pen Inject 15 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Review of Resident #11's Quarterly MDS Assessment, dated [DATE], reflected the Resident #11 was a [AGE] year-old male with a BIMs score of 15 indicating she is cognitive function is intact. The resident had diagnoses of diabetes mellitus, Hypertension( high blood pressure), coronary artery disease (a condition where the arteries supplying blood to the heart narrow or become blocked due to plaque buildup, hindering blood flow and potentially leading to chest pain, shortness of breath, or even a heart attack), renal insufficiency (a condition where the kidneys are unable to adequately filter waste and excess fluid from the blood). Review of Resident #11's Comprehensive Care Plan, dated [DATE], reflected the resident had Diabetes Mellitus. Intervention included to give Diabetes medication as ordered by doctor. Review of Resident #11's active Physicians orders as of [DATE] reflected Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 101 - 150 = 0; 151- 200 = 2units; 201 - 250 = 3units; 251 - 300 = 4units;301 - 350 = 6units; 351 - 400 = 9units; 401+ = 12units call MD , subcutaneously before meals and at bedtime for diabetes. Observation on [DATE] at 1:37 PM with LVN A on the 200-hallway's medication cart revealed Basaglar Kwik pen 100unit/1ml for Residents #47, Humulin 70/30 100 units/ml for Resident#11, and an open vial of Novolin 70/30 with no label and no open date. In an interview on [DATE] at 1:42 PM with LVN A she stated that she did not realize that Resident #47's Basaglar Kwik pen 100unit/1ml, and Resident #11's Humulin 70/30 100 units/ml did not have open dates. She also stated that she did not realize that the opened bottle of Novolin 70/30 bottle was missing a label and the date it was open. She stated that it was important to date opened insulins because once opened insulins expire after 28 days. LVN A stated that the risk to the resident was receiving expired insulin that could cause negative drug effects that could harm the resident. She stated that having insulin in the medication cart that did not have the proper label could result in administering insulin to the wrong resident which may result in hospitalization. She stated that she knew that she was supposed to check and ensure all medications are within date before administering to the residents. LVN A stated that she had been in-serviced on medication storage and dating all opened insulins. An interview on 07.22.2025 at 1:47 PM with ADON A, revealed that all insulin pens and vials should be labeled, and they should have an open date. He stated it was the responsibility of every nurse to check the open date before the administering insulin to a resident. ADON A stated insulin was supposed to be dated because it expired 28 days after opening. He stated that failure to have open dates on insulin could result in administrating medication that was expired and could not be effective or that could have negative side effects to the resident. He stated that unit managers audited the medication carts as needed, but there was not set schedule. He stated that the pharmacist audited the medication carts monthly. In an interview on [DATE] at 10:57 AM with the DON, revealed that he was notified by LVN A of the undated insulin pens and the unlabeled insulin bottle in the 200-hall medication cart. He stated that after he was notified the facility audited all the medication carts and ensured that the undated insulins were disposed and all the insulin in the cart had open dates. The DON stated that he expected the charge nurses to check and make sure the insulin being administered had an open date and discarded after 28 days. The DON stated the pharmacist audited the carts monthly to make sure the insulins were dated. He stated that it was the responsibility of the nurses to make sure the insulins had an open date before administration of insulin. The DON stated that the unit managers completed random checks of the carts, and did not have a schedule. The DON stated that undated insulin could be expired which could decrease effectiveness of the insulin when administered to the resident. He stated that unlabeled insulin could be administered to the wrong patient resulting into adverse reaction and hospitalization. Review of the facility policy Storage of Medications revised on 01.07.2025 reflected: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing.5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interview and record review, the facility failed conduct a Comprehensive Assessment within 14 calendar days after admission for 1 of 5 residents (Resident #111) reviewed for Comprehensive Assessments and timing. The facility failed to ensure a Comprehensive MDS Assessment for Resident #111 was completed within 14 days after her admission to the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.Findings included: Review of Resident #111's Face Sheet, dated 07/22/25, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including history of falling (past instances of falling). Review of Resident #111's electronic medical record on 07/22/25 reflected no evidence that an MDS Assessment had been completed. During an interview with the [NAME] President of Reimbursement on 07/22/25 at 12:09PM, he stated the facility did not currently have a full-time MDS Coordinator. He said the facility had a couple of remote MDS Coordinators who were assisting the facility until the vacant position could be filled. The [NAME] President of Reimbursement confirmed Resident #111's Comprehensive (Admission) MDS Assessment had not been completed within the required timeframe. He stated the risk of MDS Assessments not being completed within the required timeframe included the potential for residents not receiving necessary services. Review of the facility's Electronic Transmission of the MDS policy, undated, reflected, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for two (Resident #4 and Resident #111) of six residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #4 and Resident #111 within 48 hours of their admissions. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.Findings included: Review of Resident #4's Face Sheet, dated 07/23/25, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #4's Baseline Care Plan, dated 05/13/25, reflected the ADON signed the document as completed on 05/13/25. Review of Resident #111's Face Sheet, dated 07/22/25, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including history of falling (past instances of falling). Review of Resident #111's Baseline Care Plan, dated 07/19/25, reflected the ADON signed the document as completed on 07/19/25. During an interview with ADON B on 07/22/25 at 12:44PM, she stated she completed the Baseline Care Plans for Resident #4 and Resident #111. She stated although the IDT Meetings were held within 48 hours of admission for both residents, the Baseline Care Plans were not completed within that required timeframe. She confirmed that Resident #4's Baseline Care Plan was completed on 05/13/25, and that Resident 111's Baseline Care Plan was completed on 7/19/25. ADON B stated there were times in which Baseline Care Plans were not completed within the required 48-hour timeframe following admission. She stated there was not a specific reason for this delay. ADON B stated the risk of Baseline Care Plans not being completed within the required timeframe included direct care staff members not having basic information about their newly admitted residents. Review of the facility's Care Plans - Baseline policy, dated 12/2016, reflected, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to maintain sanitary, clean, and safe medication storage and preparation.This failure placed residents at risk for healthcare associated cross contamination and blood borne infections.Findings included: An observation on 07/22/25 at 1:37PM revealed there was an unlabeled vial of insulin lispro with blood stains on the vial and box. The insulin vial and box were in the top drawer of hall 200 medication cart stored with other medications. An interview on 07/22/25 at 1:37PM with LVN A revealed that she did not realize the insulin box and vial had blood stains. She stated that nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. She stated that the blood on insulin bottle would put the residents and staff at risk for blood borne infections. She stated that the nurses were supposed to always check and ensure proper infection control. She stated that she had been in-serviced on infection control last month . An interview on 07.22.2025 at 1:47 PM with ADON A confirmed that the stain on the insulin box and vial were blood stains. He stated that the nurses were responsible for maintaining infection control and ensuring that the medication carts were clean and sanitary. He stated that the blood on insulin bottle would put the residents and staff at risk for cross contamination and blood borne infections. An interview on 07/23/25 at 1:41pm with DON revealed that he was notified by LVN A of the insulin vial with blood stain on the box and the vial. He stated that it was the nurses' responsibility to ensure that medications were stored and administered in clean, and sanitary environment. The DON stated that it was every staff members responsibility to always maintain infection control. He stated that after he was notified the unit managers conducted cart audits and removed and disposed the blood-stained insulin. He stated that the risk to the resident was blood borne infections. He stated that the staff was in-serviced in infection control 07.23.2025 Review of the facility policy Storage of Medications revised on 01.07.2025 reflected: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the Facility Monitoring Compliance with Infection Control policy revised on 1.7.25 Reflected the infection preventionist or designee shall monitor the effectiveness of our infection prevention and control work practices and protective equipment. This includes but is not necessarily limited to: Surveillance of the workplace to ensure that established infection prevention and control practices are observed, and protective clothing and equipment are provided and properly used; Investigation of known or suspected exposures to blood/body fluids to establish the conditions [NAME]-rounding the exposures.

Based on interview, observation, and record review, the facility failed to ensure the resident's responsible party had the right to exercise the resident's rights for one (Resident #1) of 4 residents reviewed for resident rights. The facility failed to ensure Resident #1's representative was involved in the decision making before providing a haircut and beard trim. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings Included: Record review of Resident #1's face sheet revealed Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] from a short-term care hospital. Also, Resident #1's face sheet identified his representative was a family member. Diagnosis included: Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions), Cerebrovascular Disease (conditions that affect blood flow to your brain), Unspecified Psychosis Unspecified Psychosis (a mental health diagnosis characterized by the presence of psychotic symptoms that do not meet the full criteria for any specific psychotic disorder, such as schizophrenia or schizoaffective disorder), Essential Hypertension (a condition in which the force of the blood against the artery walls is too high), Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block airflow and make it difficult to breath) and Major Depressive Disorder. Record Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed no BIMS score due to Resident #1's mental status being rarely/never understood which meant he had severe cognitive impairment. The MDS showed the Resident's ability to express ideas and wants and to understand verbal content was rarely/never understood. Also, Resident #1's Cognitive Skill for Daily decision making was never/rarely made decisions. Furthermore, Resident #1's mood was short-tempered, easily annoyed nearly every day. Record Review of Resident #1's Care Plan dated 2/28/25 showed resident had impaired cognitive function due to Alzheimer's and staff was to provide the resident with a homelike environment. Also, Resident #1 was on Hospice due to a terminal diagnosis of Cerebrovascular disease and had a goal that all needs will be met with dignity and respect, and Resident and families [sic] wishes will be honored and had staff encourage and allow resident to verbalize needs and concerns. Record review of Resident #1's progress notes from 2/13/2025 at 03:55 p.m. stated received a call from [family member] at 1535 who stated that she was not happy for not being notify [sic] before the dad getting a haircut. [family member] stated that she does not think the DON did anythingwith [sic] ill intended [sic], but the dad get a haircut every other month. She stated that the DON apologized for failing to notify the family.will [sic] continue to monitor closely. Interview on 3/4/25 at 9:54 a.m. with the Admin and DON, revealed the DON noticed Resident #1 needed a shave and assisted the hairdresser by holding Resident #1's head up for the haircut and beard trim. The Admin stated the family came to visit the next day and were upset about not being notified prior to the haircut and beard trim. He stated the family usually did Resident #1's haircut and beard trim themselves. The family notified the Veterans Affairs/VA case manager, and the facility had a care planning meeting last Thursday on 2/27/25. The Admin stated the family usually did Resident #1's hair themselves as he could be resistive to care at times and required two people to assist. The DON apologized to the family the next day when they came in for not contacting them for permission. The Admin stated he was notified of the incident by the VA case manager. Attempted interview on 3/4/24 at 10:45 a.m. with Resident #1, revealed he laughed and shook head yes when started talking to him. Surveyor asked if they took good care of him, he shook his head yes. Investigator asked if family took care of his beard and hair, he shook his head yes. Observed no concerning marks or bruises on Resident #1 but his beard was at least 1/2 inch long. Interview on 3/4/25 at 11:02 a.m. with CNA-A, revealed she had only worked at the facility for 3 weeks. She stated if a resident needed a shave or a haircut, she would let the charge nurse know. Interview on 3/4/25 at 11:06 a.m. with CNA-B, revealed she would let the charge nurse know if a resident needed a shave or a haircut. CNA-B stated the CNAs did not cut resident's nails or shave a resident unless a charge nurse approved it first. Interview on 3/4/25 at 11:09 a.m. with RN-C, revealed if a resident needed a haircut or a shave, she would tell the social worker or just talk to the family to get consent from them first. She stated one-time she called a family to get permission regarding a resident and the family stated the resident never cut the length of the beard, just trimmed the sides. RN-C stated that was an educational experience for her CNA because it would have been a problem if they had not talked to the family first. Interview by phone on 3/4/25 at 12:15 p.m. Resident #1's representative, revealed the facility cut her father's hair without permission. The last time the facility cut it was over a year ago. Her father was more interactive at that time and could sit up. At that time, she and her siblings decided they would cut his hair, shave his face, and cut his nails. Resident #1's representative stated she did let the facility know of the decision. She was not notified Resident #1 was shaved or had a haircut. She found out when she went into the facility on that Wednesday, 2/12/25. The nurse had asked her to shave him and give him a trim the day before and that was what she was going to do that day. She said she guessed the DON did not like the way her father was looking and went in with the hairdresser around 5 p.m. on 2/11/25. She stated she talked with the VA case manager about the situation. Interview by phone on 3/4/25 at 1:02 p.m. with the VA case manager stated Resident #1's representative reported the facility cut her father's hair, but she usually did it because her father was confused. She stated the DON felt her father needed a haircut. Resident #1's VA case manager stated they errored on the side of caution and requested the facility to self-report. She last saw Resident #1 in January and the VA nurse last saw him in February. Also, the VA case manager stated they suspended the facility from getting any new VA referrals. Interview by phone on 3/4/25 at 1:14 p.m. with the Hairdresser, revealed she had worked at the facility about 2 years. She stated the DON came and asked if she would be able to cut Resident #1's hair. She told him that was fine if he would go with her to help because she would need help. The hairdresser said they went into Resident #1's room and she asked if he was all right with getting his hair cut. She stated the resident looked at them kind of funny. She told him what she was going to do, and said he was fine. The hairdresser stated the DON touched Resident #1's head and the resident started wrestling a little. She stepped back and the DON talked to the resident to calm him down. Then, she finished with the haircut and beard trim. She had cut Resident #1's hair in the past about 1 1/2 year ago when they had asked her to. The hairdresser thought about checking to see if the family had been notified but thought the DON would have gotten approval. Record Review of the facility's Provider Initial Report (PIR) revealed the Admin had one on one education provided to the DON regarding communicating with families before making any decision regarding resident's care. Also, the facility's PIR investigation conclusion revealed the DON invited the hairstylist and paid so this resident can have a haircut forgetting to notify the family prior to this decision. Furthermore, the DON .apologized [to resident representative] for forgetting to notify . her. Record Review of the facility's In Service Training Attendance Roster dated 2/12/25, showed staff completed training for Customer Service. Also, on 2/13/25, staff completed training for Resident Rights. Record Review of the facility's policy, Resident Rights, undated revealed under Policy Statement that Employees shall treat all residents with kindness, respect and dignity. Also, under Policy Interpretation and Implementation, 1 a. a dignified existence, b. be treated with respect, kindness, and dignity; k. appoint a legal representative of his or her choice, in accordance with state law; s participate in decision-making regarding his or her care

Based on interviews and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services for one (Hospitality Aide A) of three employees reviewed for staff qualifications. 1. The facility failed to ensure Hospitality Aide A had a current nurse aide certification while employed at the facility while actively providing care for residents on 02/12/25: 6:00 AM - 2:00 PM shift, 02/10/25: 6:00 AM - 2:00 PM shift, 02/08/25: 6:00 AM - 2:00 PM shift, 02/07/25: 6:00 AM - 2:00 PM shift. This failure could result in residents being provided care by staff who do not have the training and competency needed for providing care. Findings include: Record review of Hospitality Aide A's personnel file revealed her date of hire was not listed. She did not have a CNA license. Record review of the facility's schedule revealed Hospitality Aide A was listed as a CNA and counted as a CNA in the numbers for the schedule on dates: 02/12/25: 6:00 AM - 2:00 PM shift 02/10/25: 6:00 AM - 2:00 PM shift 02/08/25: 6:00 AM - 2:00 PM shift 02/07/25: 6:00 AM - 2:00 PM shift An interview on 02/12/25 at 2:00 PM with Hospitality Aide A revealed she was working on Hall 300. She said her job duties included making beds and taking out the trash. She said she helped CNAs provide care to residents. She also said that when the facility was short of staff, she would feed residents, perform incontinence care, and work as the second staff for two person transfers. Hospitality Aide A said she had finished school to be a CNA but had not taken her CNA test. An interview on 02/12/25 at 2:35 PM with ADON revealed she assisted with staffing. She said Hospitality Aide A did not have a CNA license. The ADON said Hospitality Aide A was not supposed to work by herself. The ADON said Hospitality Aide A was not supposed to be counted in the schedule numbers and was supposed to work as an extra staff as a Hospitality Aide. The ADON said 7 CNAs were required for the 6:00 AM - 2:00 PM shift and 6 CNAs were required for the 2:00 PM - 10:00 PM shift. The ADON said when she made the schedule she included Hospitality Aide A in the numbers, but she was supposed to work with another CNA. An interview with the DON on 02/12/25 at 3:45 PM revealed he was aware that Hospitality Aide A did not have a CNA license. The DON said Hospitality Aide A was not allowed to provide care independently. The DON said there was no risk to the resident for Hospitality Aide A to work, because he would never allow her to work independently. The DON said he did not know Hospitality Aide A was counted as a CNA in the schedule numbers even though he reviewed the schedule every day. He said he never saw Hospitality Aide A work without another CNA. The Administrator was asked to provide a facility policy for competent nursing staff on 02/12/25 at 4:23 PM. The Administrator failed to provide the policy prior to exit on 02/12/25.

Based on observation, interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for 1 of 4 residents (Resident #27) reviewed for accidents and supervision. 1) The facility failed to ensure Resident #27 had adequate supervision when he eloped from the facility on 11/12/24 at 4:41 p.m. The resident left the building through a door which did not sound an alarm when he exited. On 11/13/24, the police found Resident #27 when he attempted to enter a school. The police returned Resident #27 to the facility at 8:24 a.m. Resident #27 was gone from the facility over 15 hours and his whereabouts during the time he was missing were unknown. 2) The facility failed to ensure all exit doors were armed to go off with an alarm sound to notify staff the door was opened. The noncompliance was identified as PNC, past non-compliance. The IJ, Immediate Jeopardy, began on 11/12/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization . Findings included: Record Review of Resident #27's face sheet revealed he was a [AGE] year-old male, admitted to the facility for respite care on 11/4/24 and was discharged on [DATE]. Resident #27's diagnoses included: Unspecified Dementia (loss of memory, language, problem solving and other thinking abilities that interfere with daily life), Behavioral Disturbance (can include changes in mood, perception, thoughts and behavior), Psychotic Disturbance (a mental illness that causes a person to lose touch with reality), Mood Disturbance (mental health condition affects your emotional state), Anxiety, Type 1 Diabetes Mellitus (condition where the pancreas make little or no insulin, which leads to high blood sugar levels), and Depression. Record Review of Resident #27's admissions Minimum Data Set/MDS assessment, dated 11/17/24 revealed a BIMS score of 00 which indicated severe cognitive impairment. The MDS showed the resident's wandering impact placed him at a significant risk of getting to a potentially dangerous place. Also, Resident #27 was frequently incontinent of bowel and bladder. Record Review of Resident #27's Care Plan dated 11/4/24, showed resident is an elopement risk .Disoriented to place, Resident wanders aimlessly and has wander guard, designed to support the safety and independence of residents by monitoring their movements and gently preventing them from unintentionally leaving the facility, to left leg. The facility was to intervene with these behaviors by distract resident from wandering by offering pleasant diversions .resident prefers and redirect from doorways and exits. Also, Resident #27 has impaired cognitive function/dementia or impaired thought processes .dementia . Furthermore, the Care Plan showed resident was at risk for falls. Record Review of Assessments revealed Resident #27 had a Wandering Risk Scale completed on 11/7/24 which showed the resident to be High Risk to Wander. Record Review of Progress Notes dated 11/17/24 by RN-E stated, Patient continues to receive one on one care after an elopement . Record Review of Frequent Observation Log every 15 minutes for Resident #27 reflected it started on 11/13/24 at 8:15 a.m. - 11/18/24 at 6 p.m. when resident was discharged . Interview on 12/18/24 at 8:51 a.m. with Administrator/Admin stated Resident #27 came to the facility for 2 or 3 weeks for respite care. He had a Wander guard placed on at admission. This was per family request as Resident #27 had attempted to leave family's home and would get lost. Admin stated resident was exit seeking, but never tried to exit the building. Admin stated on 11/12/24, around 5 p.m., RN-F noticed Resident #27 was not in the dining room for dinner as was his usual. Admin stated staff searched the facility and he had three people drive around to look for Resident #27 outside of the facility. Admin stated he looked at the cameras and saw Resident #27 left the building at 4:41 p.m. through the 200 hall doors where they were doing remodeling. He stated the door was usually alarmed and was on and working when they checked it with the police after Resident #27 eloped on 11/12/24. Admin stated they did not know why the alarm did not go off and they were unable to determine why the alarm did not sound. Admin stated the next morning on 11/13/24 at 8 a.m., the police found Resident #27 as he was trying to enter an elementary school 1.1 miles away from the facility. EMS, Emergency Medical Services, checked out Resident #27 and cleared him. Resident #27 refused to go to the hospital and family was notified. Admin stated Resident #27 did not have his Wander guard on when he returned to the facility. Admin stated the facility did one on one checks every 15-minutes on Resident #27 until he was discharged from the facility. Also, Admin stated they had staff do 15-minute door checks on the door Resident #27 went out of until a contractor came out the next day, on 11/13/24, to ensure the door was functioning correctly. Furthermore, Admin stated they in-serviced all staff on elopement procedures and had nurses check all doors for an alarm at the beginning of every shift. On 12/18/24 at 10:21 a.m. interview with CNA-A stated she was not working when Resident #27 eloped. CNA-A stated if she had a resident who was an elopement risk, she would sit with them, walk around with them, or redirect them with an activity. On 12/18/24 at 10:38 a.m. interview with LVN-B stated if she had a resident who was an elopement risk, she would do frequent checks on them and she would check the doors to see if the alarm was on. LVN-B stated she was not at work the day Resident #27 eloped. LVN-B stated Resident #27 would walk continuously throughout the building. She stated she always checked the doors at the beginning of every shift to ensure they were working. LVN-B stated she did complete elopement training after Resident #27 eloped. On 12/18/24 at 1:43 p.m. interview with Resident #27's family member was attempted. A voice mail was left but no response was received. Observation on 12/18/24 at 1:46 p.m. with Admin revealed that all the doors in the facility were armed, and alarms went off each time the doors were opened. Record Review of Work Acknowledgement with Contractor-C on 11/13/24 to test if door alarms were working with Contractor-D. Record Review of Frequent Observation Log for door checks on 200 halls reflected observation was conducted every 15 minutes from 11/12/24 at 6:30 p.m. through 11/13/24 at 12 a.m. Record Review of the facility's provider initial report, PIR, revealed the Admin interviewed LVN-B who worked 11/12/24, 6 a.m. - 6 p.m. and stated resident was up and walking all over the facility as usual. He is easy to be redirected to his room or dining room or the activity area. Also, the Admin interviewed RN-F who stated, I observed .all over the facility .I noticed that he was not in the dining room nor in the room and notified all staff of code pink (missing resident) and we initiated the search for the missing resident. Record Review of the facility's In Service Training Attendance Roster, dated 11/11/24 showed staff, including CNA-A, LVN-B and RN-A were trained on Missing Resident Policy, Code Pink. Record Review of the facility's Wandering and Elopements, undated, reflected under Policy Statement - The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Record Review of facility's Emergency Procedure - Missing Resident policy, undated, revealed under Policy Interpretation and Implementation. 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for 2 of 10 residents (Resident # 55 and Resident #12) reviewed for Accidents and Supervision. The facility did not provide supervision for Resident #55 and Resident #12 while smoking on 08/30/24. This failure could place residents at the facility at risk of injuries related to burns. The findings included: Record review of Resident #55's Face Sheet, dated 08/30/24, revealed that he was a [AGE] year old male with an initial admitted to the facility of 02/07/24. Resident #55's active diagnoses included: dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), major depressive disorder, seizures, hemiplegia (paralysis that affects one side of the body), unspecified affecting right dominant side, aphasia (loss of ability to understand or express speech, caused by brain damage) chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), muscle weakness (generalized), unsteadiness on feet, hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) following cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #55's MDS dated [DATE] revealed he had a BIMS score of 1/15 indicating a severe cognitive impairment. Record review of Resident #55's Care Plan, no date indicated, revealed the following: Focus - Resident #55 is a smoker and noncompliant with policies. I also smoke marijuana in the community despite numerous conversations from staff and education to stop. Date Initiated: 02/29/2024 Revision on: 08/15/2024 Goal - Resident #11 will not smoke without supervision through the review date. Date Initiated: 02/29/2024 Target Date: 10/28/2024 Interventions - -Assess resident's coping skills and support system. Date Initiated: 08/19/2024 -Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Date Initiated: 08/19/2024 -Monitor behaviors; aggressiveness and combativeness. Document observed behavior and attempted interventions. Date Initiated: 08/19/2024 Revision on: 08/19/2024 -Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 08/19/2024 Record review of Resident #55's Quarterly Care Plan Sheet dated 05/23/24 revealed that resident was a smoker and noncompliant. Record review of Resident #55's smoking assessment dated [DATE] and lock dated 07/01/24 indicated the resident can light his own cigarette but requires supervision while smoking. Resident #55 will need to store lighter and cigarettes. Resident #55 was deemed safe to smoke cigarettes at the facility. Record review of Resident #55's Psychiatric Note dated 08/16/2024 revealed that he was referred for depression, withdrawal, isolation, tearfulness, agitation, irritability, confusion and resistance to ADL /Medications. The Review of History revealed that Resident #55 denied drug usage and was a non-smoker. Record review of Resident #12's Face Sheet, dated 08/30/24, revealed that he was a [AGE] year old male with an initial admitted to the facility of 06/15/2016 and Re-entry admitted [DATE]. Resident #12's active diagnoses included essential (primary) hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause), Unspecified Psychosis not due to substance or known physiological condition ( a collection of symptoms that affect the mind, where there has been some loss of contact with reality ), major depressive disorder, schizoaffective disorder (mental health condition that is marked by a mix of hallucinations and delusions, and mood disorder symptoms, such as depression, mania), bipolar, insomnia (loss of sleep), deep veins of the lower extremity), falls, muscle weakness, lack of coordination, displaced intertrochanteric (broken hip) fracture of right femur), abnormalities of gait and mobility, dementia, psychotic disturbance, mood disturbance and anxiety, bipolar, dysphasia (difficulty swallowing), glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), aftercare following joint hip replacement. Record review of Resident #12's MDS dated [DATE] revealed he had a BIMS score of 15/15 indicating that his cognition is intact. Record review of Resident #12's Care Plan, no date indicated, revealed the following: Focus - Resident #12 is a smoker and noncompliant with smoking policies/procedures Date Initiated: 02/29/2024 Revision on: 03/07/2024 Goal - Resident #12 will not smoke without supervision through the review date. Date Initiated: 02/29/2024 Revision on: 05/30/2024 Target Date: 10/07/2024 Interventions - Instruct resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 02/29/2024 -Monitor oral hygiene. Date Initiated: 02/29/2024 -Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 02/29/2024 -Observe clothing and skin for signs of cigarette burns. Date Initiated: 02/29/2024 Record review of Resident #12's smoking assessment dated [DATE] indicated the resident can light his own cigarette, Supervision provided for residents in facility, but resident able to smoke without supervision. Resident #12 will need to store lighter and cigarettes. Resident #12 indicated was deemed safe to smoke cigarettes at the facility. Record review of Resident #12's smoking assessment dated [DATE] indicated the resident can light his own cigarette but requires Supervision while smoking for safety. Resident #12 will need to store lighter and cigarettes. Resident #12 indicated was deemed safe to smoke cigarettes at the facility. Record review of Resident #12's smoking assessment dated [DATE] indicated the resident can light his own cigarette but requires Supervision while smoking. Resident #12 will need to store lighter and cigarettes. Resident #12 indicated was deemed safe to smoke cigarettes at the facility. Record Review of the facility's posted Smoking Times revealed the following Smoking Times: 9 AM, 11 AM, 1 PM, 3 PM, 5 PM, 7 PM and 8 PM. These will be 15 minute breaks. Record Review of the facility's List of Smokers revealed that there were 10 residents in the facility that smoke cigarettes. The list included Resident #55 and Resident #12. In an interview with ADON H on 08/28/24 at 11:06 AM revealed that herself and staff are aware that Resident #55 and Resident #12 keep their cigarettes and lighters on their person. She stated that she has notified the DON and Administrator that both residents are not following the facility's Smoking Policy. She stated that both residents are Care Planned for being non-compliant with the facility's Smoking Policy. She reported that the Administrator and the DON have documented that Resident #12 is non-compliant, but they cannot do anything. ADON H was able to provide the red box that the residents cigarettes are located. The red box was locked and when opened revealed 3 sealed Ziploc bags with 3 resident names and inside of each Ziploc bag there were a box of cigarettes and lighters. She reported that the red box always remains locked, and the keys are always kept with a staff member. She stated that if residents keep lighters and cigarettes in their room, it has a potential to cause a fire, if a resident has fire near another resident that has oxygen, they can cause fire and harm to both residents and staff. In an interview with the DON on 08/30/24 at 11:35 AM, revealed that he was aware of Resident #55 and Resident #12 being non-compliant with the facility's Smoking Policy. He stated that both residents have a Smoking Assessments and are to be supervised by staff during scheduled smoking schedule. He stated that both residents have been observed by himself and staff smoking in the designated Smoking Area outside of the facility's smoking schedule. He confirmed that both residents have been observed with cigarettes and lighters in their possession. The DON stated that himself and staff have advised both residents that they are not to keep lighters and cigarettes in their possession, but both residents have been non-compliant, and he has documented their non-compliance in each residents Care Plan. The DON stated that himself and staff have observed cigarettes and lighters in Resident #55's room but have not observed any cigarettes or lighters in Resident #12's room. He stated that he has reeducated the residents that smoke and the staff on the risks of the residents having cigarettes and lighters in their possession. He stated that the risks of residents keeping lighters on their person and not in the designated lock box is that the resident can burn themselves or others, cause a fire and harm to themselves and other residents and staff. During an observation on 08/30/2024 at 12:14 PM, Resident #55 was in his room and sitting in a chair beside his bed, there was a box of [NAME] cigarettes on his wheelchair beside the bed. There were 3 cigarettes and 3 lighters observed in black container on the dresser underneath his television. Resident #55 has aphasia and is verbal, when asked if staff had told him that it was against the facility's policy to keep cigarettes and lighters in his room, he shook his head no. During an observation on 08/30/2024 at 1:50 PM, Resident #55 was not in his room, there were 2 cigarettes and 1 lighter observed in black container on the dresser underneath his television. During an attempted interview and observation of Resident #12 on 08/30/2024 at 1:57 PM, he was not in his room. There were not any cigarettes or lighters observed in the room. During an observation and interview on 08/30/24 at 2:12 PM, Resident #55 and Resident #12 were observed outside in the designated Smoking Area with cigarette lighters and smoking cigarettes. Resident #55 was observed from inside the facility sitting outside in the designated Smoking Area with a brown cigar on the table. Resident #55 was observed sitting at the table and began to place the brown cigar into a paper towel and rolled the paper towel several times. Resident #55 was asked to unroll the paper towel. Resident #55 stated that the brown cigar on the table was a blunt (which is a cigar that contains marijuana). Resident #12 stated that he keeps his cigarettes and lighter in his room. He stated that staff had advised him that he needs to keep his cigarettes and lighters in the locked box at the Nurses Station. Resident #12 stated that he does not want to keep his cigarettes and lighters in the locked box at the Nurses Station because he wants to smoke anytime, he wanted, and he does not want to smoke only during the facility's designated smoking times. He said he had been at the facility since December 2023. There were two lighters on his over bed table and a box of cigarettes. He said he was a smoker and he smoked after he ate, and staff were always with him when he went out to smoke. When asked if he could keep his smoking materials he did not answer. Resident #55 shook his head and stated that he felt the same way as Resident #12. In an interview with the Administrator on 08/30/24 at 4:25 PM, revealed that she was aware of Resident #55 and Resident #12 being non-compliant with the facility's Smoking Policy. The Administrator stated that herself, DON, staff and other residents have observed Resident #55 and Resident #12 smoking cigarettes in the designated Smoking Area outside of the facility's posted schedule smoking times. She stated that staff have observed Resident #55 with cigarettes and lighters on his person in the facility. She stated that staff would try to confiscate both items from Resident #55, but he would refuse to give the items to staff. She confirmed that both residents are violating the facility's Smoking Policy by keeping their cigarettes and lighters and not placing them in the lock box at the Nurses Station and by smoking outside of the facility's designated smoking times. She stated that the risk of both residents keeping their cigarettes and lighters on their person or in their room is that they can harm themselves by causing a fire, burning themselves and being injured. Record Review of the facility's, undated Smoking Policy - Residents, revealed the following: Policy Statement - This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation - 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 3. Oxygen use is prohibited in smoking areas. 4. Metal containers, with self-closing cover devices, are available in smoking areas. 5. Ashtrays are emptied only into designated receptacles. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. 7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns shall be noted in the medical record. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to smoke without supervision. Cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles are kept secured at the nurse's station. Matches are prohibited. 13. Residents are not permitted to give smoking articles to other residents. 14. Residents without independent smoking privileges may not have any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. 15. This facility maintains the right to confiscate smoking articles found in violation of our smoking policies.

Based on observation, interviews, and record review, the facility failed to resolve a grievance in a timely manner for 1 of 5 (Resident #44) residents reviewed for grievances. 1.The facility failed to make prompt efforts to ensure Resident #44's grievance was initiated, reported, and resolved in a timely manner. These failures could affect the Resident's ability to file a grievance without the fear of discrimination, reprisal or retribution and their right to have their grievances resolved in a timely manner. Findings Included: Record Review of Resident #44's Quarterly MDS with an ARD of 07/13/24 revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #44's active diagnoses included: Unspecified Dementia, Unsteadiness on feet, muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening) and unspecified glaucoma (progressive eye condition that can cause blindness). Resident #55 had a BIMS score of 9, indicating a moderately impaired cognition. Record Review of the facility's March 2024 Grievance Log revealed 3 logged grievances, none of which revealed a grievance filed for Resident #44. Record Review of the facility's April 2024 Grievance Log revealed 0 logged grievances. Record Review of the facility's June 2024 Grievance Log revealed 4 logged grievances, none of which revealed a grievance filed for Resident #44. Record Review of the facility's May 2024 Grievance Log revealed 1 logged grievances, none of which revealed a grievance filed for Resident #44. Record Review of the facility's July 2024 Grievance Log revealed 1 logged grievances, grievance filed was not filed by Resident #44. All grievances were dated as resolved. Record Review of the facility's August 2024 Grievance Log revealed 0 logged grievances. Interview with Resident #44 on 08/28/24 at 10:23AM revealed that her current wheelchair was not in working condition that was comfortable for her or met her needs . Resident #44 revealed that she filed a grievance with ADON A a few months ago and the Maintenance Assistant came by to fix the wheels, but the wheelchair was still not in working condition or comfortable for her. Resident #44 revealed that nobody came back from the facility to check and see if the wheelchair was working or comfortable for her after it was serviced by the facility Maintenance Assistant. Resident #44 revealed that she relies on the wheelchair to move around the facility and go out with her family. Resident #44 revealed her current wheelchair makes daily tasks harder for her such as coming and going from her room and attending activities. Observation of Resident #44's wheelchair on 08/28/24 at 10:30AM revealed a [Name of Wheelchair Brand] wheelchair next to Resident #44's bed. Wheelchair was observed with a broken left arm pad with padding exposed. Wheelchair was observed to be dusty and when Resident #44 transferred from the bed into her wheelchair, the wheelchair size narrowed causing difficulty for Resident #44 to maneuver the wheels. Interview with ADON A on 08/28/24 at 12:03PM revealed that Resident #44 did utilize the wheelchair on a daily basis. ADON A revealed that Resident #44 did report to him a few months back that her wheelchair was broken, and he reported the issue to the Maintenance Assistant. ADON A revealed that he was unaware that the complaint related to Resident #44's wheelchair should be constituted as a grievance and instead reported it to the maintenance department. ADON A revealed that he was unaware that Resident #44's complaint about her current wheelchair was still not resolved. ADON A revealed that the Social Worker is the facility grievance official and oversees the facility grievance procedures. ADON A revealed that if a resident had a grievance, he would fill out the facility grievance form, begin the investigation and alert the Social Worker and Administrator of the grievance. ADON A did not reveal a risk to residents for unresolved grievances. Interview with Maintenance Assistant on 08/28/24 at 12:37PM revealed that he did work on Resident #44's wheelchair a few months back per a work order he received for her wheelchair. The Maintenance Assistant revealed that the wheelchairs wheels were too loose at that time, and he tightened them. The Maintenance Assistant revealed that he was unaware, and it was not reported to him that Resident #44's wheelchair was broken still and needed servicing, or a new wheelchair was needed. The Maintenance Assistant revealed that he did not review grievances, but if a resident files a grievance related to needed maintenance, then it should have been transcribed into a work order. Interview with DON on 08/30/24 at 11:25AM revealed that the facility procedures on grievances was that the DON will receive all grievances from the resident or the staff member who received the grievance from the resident. The DON revealed that he would then either investigate the grievance or alert the appropriate department head to investigate. The DON revealed that the social worker is the facility grievance official, and she is responsible for ensuring that grievances are resolved in a timely manner. The DON revealed that residents are educated on the facility's grievance policy and procedures in resident council, on admission and through daily facility rounds conducted by all facility department heads. The DON revealed a risk to the resident for an unresolved grievance would be delay of care or concerns. Interview with Social Worker on 08/30/24 at 1:53PM revealed that she is the facility grievance official. The Social Worker revealed that the procedure for grievances is, if a resident at the facility had a grievance they could go to the front office or the social work office to get a grievance form to fill out and turn into any staff member. The Social Worker revealed that residents can also file grievances verbally to any staff member. Once the grievance was filed it will then be reported to the Administrator and allocated to the appropriate department head. The grievance should be resolved within 72 hours. The Social Worker revealed that residents are educated on facility grievance policies and procedures during care plans. The Social Worker revealed that Resident #44 filed a grievance with ADON A or that an official grievance was filed for Resident #44 related to her wheelchair. The Social Worker revealed that she was unaware that Resident #44 had a broken wheelchair or that her current wheelchair did not meet her needs. The Social Worker did not reveal a risk to residents for unresolved grievances. Interview with Administrator on 08/30/24 at 4:39PM revealed that the facility procedures on grievances was that residents can go to any facility department head to file a grievance. The Administrator revealed that then the grievance, after it is filed, will then be transcribed to the grievance log and assigned to the appropriate department head for resolution. The Administrator revealed that the facility social worker is the grievance official and oversees the grievance procedures. The Administrator revealed that she was unaware that Resident #44's grievance related to her wheelchair was not resolved or not transcribed to the grievance log. The Administrator did not reveal a risk to residents for unresolved grievances. The facility did not provide a policy related to grievances. A policy was requested to the Administrator on 08/29/24 at 5:44PM.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #55) out of 5 residents reviewed for care plans. The facility failed to ensure that Resident #55's comprehensive care plan included his diagnosis of Major Depressive Disorder. This failure could place residents at risk of having received inadequate interventions not individualized to their care needs and diagnoses. Findings Included: Record Review of Resident #55's Quarterly MDS with an ARD (Assessment Reference Date) of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Resident #55 had a BIMS score of 1 indicating a severe cognitive impairment. Record Review of the document titled, Psychiatric Subsequent Assessment, dated 04/24/2024, revealed Resident #55's primary treating diagnoses was, F33.9- Major Depressive Disorder, recurrent, unspecified. Reason for referral [for psychiatric services] indicated depression, withdrawal, isolation, tearfulness, agitation, irritability, confusion, and resistance to ADL/Medications. Record Review of Resident #55's comprehensive care plan, no date reflected, did not reveal Resident #55's current and active diagnosis of Major Depressive Disorder. Interview with Resident #55 on 08/27/24 at 11:15AM revealed Resident #55 was tearful and began crying during several times of the interview. Resident #55 expressed feelings of depression, sadness and frustration with his current nursing facility placement and his inability to effectively communicate his needs with staff due to his communication deficits. Resident #55 revealed he had been seeing a psychiatrist but could not reveal if he had been diagnosed with Major Depressive Disorder (he did not know all of his medical diagnoses) Interview with LVN I on 08/30/24 at 10:11AM revealed that she had been the nurse for Resident #55. LVN I revealed that she had witnessed crying episodes with Resident #55. LVN I revealed that she was unaware if Resident #55 was currently being treated for Major Depressive Disorder. LVN I revealed that she did have access to Resident #55's MDS and care plan but was unaware of his current and active diagnoses. LVN I revealed that Resident #55 was currently taking medications that treat depression. Interview with MDS Nurse G on 08/30/24 at 11:05AM revealed that herself and MDS Nurse Q were responsible for ensuring all residents comprehensive care plans were personalized and matched their current needs. MDS Nurse G revealed that if a resident had an active diagnosis with mental illness such as, Major Depressive Disorder, then it should have been included in the resident's comprehensive plan of care along with interventions. MDS Nurse G revealed a risk of not personalizing a resident's comprehensive plan of care that matched their current clinical status would be missed care opportunities. Interview with MDS Nurse Q on 08/30/24 at 11:15AM revealed that herself and MDS Nurse G were responsible for ensuring all residents comprehensive care plan were personalized and reflect the resident's current care needs. MDS Nursed Q revealed that she had just started at the facility a few weeks ago and was unaware Resident #55's comprehensive care plan did not reflect his current diagnosis of Major Depressive Disorder. MDS Nurse Q revealed a risk of not personalizing a resident's comprehensive plan of car would be missed care. Interview with DON on 08/30/24 at 2:50PM revealed that MDS Nurse G and MDS Nurse Q were responsible for ensuring that all resident's comprehensive care plans were up to date, personalized and reflected their current needs. The DON revealed that he was unaware that Resident #55's comprehensive care plan did not reflect his current diagnosis of Major Depressive Disorder. The DON revealed a risk of not having comprehensive care plans personalized for all resident's would be the opportunity for missed care by direct care staff. Interview with Administrator on 08/30/24 at 5:00PM revealed that MDS Nurse G and MDS Nurse Q were responsible for ensuring all comprehensive care plans are individualized and person-centered. The Administrator revealed that she was unaware that Resident #55's comprehensive care plan did not include his diagnosis of Major Depressive Disorder. The Administrator revealed a risk of not personalizing a resident's comprehensive plan of care would be the opportunity for missed care. Record Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered dated December 2016 revealed that the policy statement was, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the resident's status for 1 (Resident #55) of 5 resident's reviewed for MDS assessment accuracy. The facility failed to ensure Resident #55's Quarterly MDS assessment with an ARD (assessment reference date) of 05/14/2024, reflected his current diagnosis of Major Depressive Disorder (clinical depression). This failure could place residents at risk of not receiving care and services to meet their needs. Findings Included: Record Review of Resident #55's Quarterly MDS with an ARD (Assessment Reference Date) of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Record Review of the MDS Section I, Active Diagnoses revealed a sub-section titled, Psychiatric/Mood Disorder. The sub-section revealed an option titled, Depression (other than bipolar), this option was not checked, indicating no active diagnoses of depression. Resident #55 had a BIMS score of 1 indicating a severe cognitive impairment. Record Review of the document titled, New Patient Referral Form, dated 02/14/2024 revealed Resident #55 was referred to [Psych provider] for psychology and psychiatry services on 02/14/2024 for: Depression/Sadness, withdrawal, tearfulness, agitation, irritability, confusion, high risk behavior and resistance to ADL/Medications. Record Review of the document titled, Psychiatric Subsequent Assessment, dated 04/24/2024, revealed Resident #55's primary treating diagnoses was, F33.9- Major Depressive Disorder, recurrent, unspecified. Reason for referral [for psychiatric services] indicated depression, withdrawal, isolation, tearfulness, agitation, irritability, confusion, and resistance to ADL/Medications. Current Psychotropic Medications revealed the following: Medication- Trazodone (medication used to treat depression) Start Date- 02/07/2024 Quantity- 1 Dosage/Frequency- 100mg Tablet/BID Treating- F33.9 (Major Depressive Disorder) No stop date indicated. Record Review of the facility document for Resident #55 titled, Order Summary Report, dated 08/28/2024, revealed the following: Active Orders As of 08/28/24 for [Resident #55] Order Summary- Trazadone HCI Tablet 50MG (Trazodone HCI) Give 1 tablet by mouth two times a day for antidepressant Communication method- Phone Order Status- Active Interview with Resident #55 on 08/27/24 at 11:15AM revealed Resident #55 was tearful and began crying during several times of the interview. Resident #55 expressed feelings of depression, sadness and frustration with his current nursing facility placement and his inability to communicate effectively his needs with staff due to his communication deficits. Resident #55 revealed he had been seeing a psychiatrist but could not reveal if he had been diagnosed with Major Depressive Disorder. Interview with LVN I on 08/30/24 at 10:11AM revealed that she had been the nurse for Resident #55. LVN I revealed that she had witnessed crying episodes with Resident #55. LVN I revealed that she was unaware if Resident #55 was currently being treated for Major Depressive Disorder. LVN I revealed that she did have access to Resident #55's MDS and care plan but was unaware of his current and active diagnoses. LVN I revealed that Resident #55 was currently taking medications that treat depression. Interview with MDS Nurse G on 08/30/24 at 11:05AM revealed that she was unaware that Resident #55's MDS assessment did not reflect his current diagnosis of Major Depressive Disorder. MDS Nurse G revealed that she was the only person in the facility responsible for MDS assessments and their accuracy up until a few weeks ago. MDS Nurse G revealed that MDS Nurse Q recently started a few weeks ago and now is currently assisting with all assessments. MDS Nurse G revealed that she reviews all clinical documentation including psychiatry visit notes to ensure accuracy of the MDS assessment to ensure it reflects the resident's current clinical condition. MDS Nurse G revealed a risk to the resident for inaccurate MDS assessments would be the potential for missed care and care needs. Interview with MDS Nurse Q on 08/30/24 at 11:15AM revealed that revealed that she was unaware that Resident #55's MDS assessment did not reflect his current diagnosis of Major Depressive Disorder. MDS Nurse Q revealed that she had recently been hired at the facility and is responsibility for MDS assessments along with MDS Nurse G. MDS Nurse Q revealed she ensures MDS assessment accuracy by reviewing all clinical documentation along with staff and resident interviews. MDS Nurse Q revealed a risk to the resident for inaccurate MDS assessments would be the potential for missed care and care needs. Interview with DON on 08/30/24 at 2:50PM revealed that it was the responsibility of the MDS Nurses to ensure accuracy of all MDS assessments. The DON revealed that he was unaware that Resident #55's Quarterly MDS assessment did not reveal his active diagnosis of Major Depressive Disorder. The DON revealed that he has not seen Resident #55 tearful but was aware he was being treated for Major Depressive Disorder by the facility's psychiatrist. The DON revealed that a risk to the resident for inaccurate MDS assessments would be the missed care areas and interventions. Interview with Administrator on 08/30/24 at 5:00PM revealed that the MDS nurses are responsible for ensuring all MDS assessments are accurate and reflect the resident's diagnoses and care. The Administrator revealed that she was aware Resident #55 was currently on psychiatric services but was not aware he was currently being treated for Major Depressive Disorder. The Administrator revealed that a risk to the resident for inaccurate MDS assessments would be the potential for missed care. Record Review of the facility's policy titled, Electronic Transmission of the MDS, no date reflected, revealed that, The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data. Record Review of the facility's document titled, Job Description-MDS, no date reflected, revealed that, [The] Job Description [is to] conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment.

Based on interview and record review the facility failed to submit an accurate PL1 (PASARR Level 1) screening when residents admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 1 (Resident #55) out of 5 residents reviewed for PASARR screenings. The facility failed to submit a new PL1 screening when Resident #55 was diagnosed with Major Depressive Disorder after admission to the facility. These failures could affect residents by not receiving a Level II PASARR Evaluation to access for needed services. Findings Included: Record Review of Resident #55's Quarterly MDS with an ARD of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Resident #55 had a BIMS score of 1 indicating a severe cognitive impairment. Record Review of the document titled, Psychiatric Subsequent Assessment, dated 04/24/2024, revealed Resident #55's primary treating diagnoses was, F33.9- Major Depressive Disorder, recurrent, unspecified. Reason for referral [for psychiatric services] indicated depression, withdrawal, isolation, tearfulness, agitation, irritability, confusion, and resistance to ADL/Medications Record Review of the document titled, PASRR Level 1 Screening dated 02/07/2024 revealed that Resident #55's PL1 screening indicated that Resident #55 did not have evidence of mental illness, intellectual disability or developmental disability. Interview with Resident #55 08/27/24 at 11:30AM revealed that he had not received PASARR services. Resident #55 revealed that nobody at the facility had discussed PASARR services with him. Resident #55 revealed that he would like to be screened for potential PASARR services if he did qualify. Interview with MDS Nurse G 08/30/24 at 11:10AM revealed that she along with MDS Nurse Q were responsible for ensuring PASARR Level 1's were accurate and received on admission. MDS Nurse G revealed that she was unaware a new PASARR Level 1 was not submitted for Resident #55 after he was diagnoses with Major Depressive Disorder. MDS Nurse G revealed that if a resident is diagnosed with a new diagnosis of mental illness, developmental disability or intellectual disability a new PASARR Level 1 should be submitted. MDS Nurse G revealed that a risk for incorrect PASARR Level 1 evaluations would be missed care. Interview with the DON on 08/30/24 at 3:22PM revealed that MDS A and MDS Nurse Q were responsible for ensuring that the PASARR Level 1's were accurate and received on admission. The DON revealed that he was unaware that Resident #55 did not have a new PASARR Level 1 submitted after being diagnosed with Major Depressive Disorder. The DON revealed the facility procedure for PASARR's was that the facility would ensure the PASARR Level 1 is submitted to the LTC Online Portal on admission and if that PASARR Level 1 indicated yes for, mental illness, developmental disability or intellectual disability then that would trigger a PASARR Level II or evaluation to be completed. The DON revealed a risk for incorrect PASARR Level 1 evaluations would be missed care for the residents. Interview with Administrator on 08/30/24 at 5:10PM revealed that she was unaware that Resident #55 did not have a new PASARR Level 1 submitted after he was diagnosed with Major Depressive Disorder during his stay. The Administrator revealed that PASARR provided services for residents such as, therapy, case management and rehabilitation services. The Administrator revealed that it was the responsibility of MDS Nurse G and MDS Nurse Q to ensure accuracy of all PASARR assessments. The Administrator revealed a risk for incorrect PASARR Level 1 evaluations would be the opportunity for missed care needed for the residents. The facility did not provide a policy related to PASARR services or PASARR assessments. A policy was requested to the Administrator on 08/29/24 at 5:44PM.

Based on interview and record review, the facility failed to ensure that the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences of 1 (Resident #44) of 5 residents reviewed for accommodation of needs. 1. The facility failed to ensure that Resident #44 had a mobility device that was operable and comfortable to her that promoted independence, safety, and psychosocial need. This failure could place residents at risk of increased isolation, depression and increased risk of injury. Findings Include: Record Review of Resident #44's Quarterly MDS with an ARD of 07/13/24 revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #44's active diagnoses included: Unspecified Dementia, Unsteadiness on feet, muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening) and unspecified glaucoma (progressive eye condition that can cause blindness). Resident #55 had a BIMS score of 9, indicating a moderately impaired cognition. Record Review of the facility's document titled; Work Order Number 1173 revealed the work order was created by ADON A on 5/10. The Work Order revealed that resident [#44] complain[ed] that wheels to [her] wheelchair [are] making too much noise. Interview with Resident #44 on 08/28/24 at 10:23AM revealed that her current wheelchair was not in working condition that was comfortable for her or met her needs. Resident #44 revealed that she filed a grievance with ADON A a few months ago and the Maintenance Assistance came by to fix the wheels, but the wheelchair was still not in working condition or comfortable for her. Resident #44 revealed that nobody came back from the facility to check and see if the wheelchair was working or comfortable for her after it was serviced by the facility Maintenance Assistant. Resident #44 revealed that she relies on the wheelchair to move around the facility and go out with her family. Resident #44 revealed her current wheelchair makes daily tasks harder for her. Observation of Resident #44's wheelchair on 08/28/24 at 10:30AM revealed a [Name of Wheelchair Brand] wheelchair next to Resident #44's bed. Wheelchair was observed with a broken left arm pad with padding exposed. Wheelchair was observed to be dusty and when Resident #44 transferred from the bed into her wheelchair, the wheelchair size narrowed causing difficulty for Resident #44 to maneuver the wheels. Interview with the Maintenance Assistant on 08/28/24 at 12:37PM revealed that he did work on Resident #44's wheelchair a few months back per a work order he received for her wheelchair. The Maintenance Assistant revealed that the wheelchairs wheels were too loose at that time, and he tightened them. The Maintenance Assistant revealed that he was unaware, and it was not reported to him that Resident #44's wheelchair was broken still and needed servicing, or a new wheelchair was needed. The Maintenance Assistant revealed that he will work on getting Resident #44 a wheelchair right away. Interview with DON on 08/30/24 at 11:25AM revealed that all residents are assessed for mobility needs and preferences on admission by the admitting nursing and evaluating therapists. The DON revealed that for long-term care resident's, no specific person or department head in the facility was responsible for ensuring that the resident's equipment was working and met their needs. The DON revealed that it was the responsibility of all staff to ensure that all residents equipment was working and met their current needs. The DON revealed that he was unaware that Resident #44's wheelchair was broken and uncomfortable for her. The DON revealed that he was aware Resident #44 operated and utilized her current wheelchair on a daily basis and made no complaints to management that it was uncomfortable for her. The DON revealed that a risk to all residents if they had mobility devices that did not match their needs would be decreased involvement from those residents. Interview with Social Worker on 08/30/24 at 1:53PM revealed that she was unaware that Resident #44's wheelchair did not accommodate to her current needs. The Social Worker revealed that the responsibility of the nursing staff to ensure that all residents had mobility devices that met their needs. The Social Worker revealed that the facility was working on getting her a new wheelchair. Interview with Administrator on 08/30/24 at 4:39PM revealed that Resident #44 never addressed any issues with her current wheelchair to her or any other staff member. The Administrator revealed that every staff member is responsible for ensuring that their mobility devices, if needed, matched their current needs and was comfortable for them. Record Review of the facility policy titled, Quality of Life- Accommodation of Needs, dated August 2009 revealed that, the resident's individual needs and preferences, including the need for adaptive devices . shall be evaluated upon admission and reviewed on an ongoing basis.

Based on observations, record review, and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 11/28/23. 2. The facility failed to ensure an exterior door alarm was reset and functioning properly after allowing an outside vendor to utilize the door for a delivery. The facility concluded Resident #1 eloped through the facility's exit door that did not alarm when opened. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 11/28/23 and ended on 11/30/23. The facility corrected the non-compliance before surveyor's entrance. These failures placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's Face Sheet dated 12/28/23 revealed he was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including general anxiety disorder, fracture of metatarsal bones (bones in the foot), cerebral infarction (stroke), Type 2 diabetes, hypertensive urgency (high blood pressure), acute kidney failure, and cognitive communication deficit. Record review of Resident #1's MDS assessment dated [DATE] revealed he had a BIMS score of 0 indicating severe cognitive impairment. He was sometimes understood and sometimes able to understand others. The MDS Assessment indicated he performed walking with supervision or touching assistance. He had delusions and wandering behaviors were not exhibited. Record review of Resident #1's Care Plan dated Closed 12/6/23 revealed the following entry: Focus: The resident is an elopement risk/wanderer r/t disoriented to place, History of attempts to leave facility unattended, significantly intrudes on the privacy or activities [sic] Date initiated 11/8/23. Goal: Will be compliant with the use of Wander guard over next 90 days Interventions: Check placement of Wander guard and functioning Q shift; Distract Resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; .Encourage and allow resident to verbalize needs and concerns; If appropriate, assess and discuss with MD, resident, and family possible alternative placement in more secure environment Record review of Resident #1's Wandering Risk Scale dated 11/9/23 revealed he could follow instructions; was ambulatory; could communicate; had a history of wandering; had medical diagnosis of dementia/cognitive impairment and diagnosis impacting gating/mobility or strength; had wandered aimlessly within the home or off the grounds; and had wandered in the past month. Comments/Notes portion reflected, resident often wanders [throughout] facility opening exit doors. Resident #1's Wandering Risk Score was 15 indicating High risk to Wander. Review of the facility's Provider Investigation report dated 12/5/23 revealed the following: Incident Date: 11/28/23. Time of Incident 18:34 PM [6:45 PM]. Staff reported [Resident #1] was seen around [6:15 PM] ambulating back to his room and staff went to check on him around [6:45 PM], he was not in the room. The staff immediately started looking for him. Code Pink [missing resident code] and missing resident protocol was followed . The Search for [Resident #1] was initiated, code pink was called, facility followed missing resident protocol. A headcount of all the residents was completed, exterior doors was checked. When resident was not located the police was called resident responsible parties and MD was notified. All the exterior doors was [sic] checked. As soon as the police came, they informed the facility that the [Resident #1] was immediately located and taken to nearest available shelter, facility went and picked him up and immediately pace him on one on one. Head to toe assessment was completed, resident did not show any signs psychological distress when picked up .MD was notified, and he ordered labs. Incident was reported to state, in-service on missing resident, checking exit doors for safety and abuse/neglect was initiated with facility staff. The investigation Summary portion of the report reflected: .The facility searched internal and external, when resident was not located, police was called, and they came and reported that [Resident #1] was immediately located behind the facility neighborhood and taken to shelter. When resident came back to the facility, MD was notified, and he ordered labs which was negative for UTI. The facility had discussion with the family for additional care options. Due to a thorough and complete investigation, the incident was confirmed, it was noted that the exit door closed when the facility staff followed the steps to secure the door, turned the key and the door alarm did not fully activate after a vendor brought goods through the door. There was no willful intent that was noted. In-service on resetting door alarms, Missing residents, abuse and neglect was completed. Record review of Resident #1's progress notes revealed the following entries: *11/25/23 5:44 PM: Resident noted with wandering, redirection provided Signed by LVN A. *11/26/23 3:57 PM: Resident noted with wandering, redirection provided Signed by LVN A. *11/27/23 12:12 PM: A referral for transfer was sent out for res d/t wandering behaviors and safety concerns. SW heard back today that the facility did not have beds available. Was provided another facility to attempt transfer. S/W will f/u and provide a referral is possible. Signed by the Social Worker. *11/28/23 at 9:40 PM: Resident was observed walking towards his room at [6:15 PM]. Dinner was being served at the time. Staff went back to resident's room to check if he had completed his dinner but was not in the room. Staff started looking for the resident in his room and other resident's rooms. The incoming staff assisted in locating resident at [6:45 PM]. Code Pink was announced 30 minutes later when staff in the resident's unit could not locate the resident. Search then was initiated in and outside the building. Every room in the building and outside the building was searched with no success. Administrator, DON and ADON notified. Police were notified at [8:11 PM] and they arrived at the facility at [8:25 PM], Family was notified at [8:38 PM] and the Nurse Practitioner was notified as well. N/O [new order] for CBC, CMP, UA. Signed by LVN B. *11/28/23 at 11:15 PM: resident came back to the facility, accompanied by DON and ADON, resident alert and active. Head to toe assessment done, no physical injuries noted, skin looks clear and intact on all 4 extremities. Vital signs checked BP 144/68, Temp 98.2F, pulse 75/min, RR 18 bpm, O2 sat 98% on room air, blood sugar 118. Resident denies pain at this moment, evening meds given along with can of Ensure, resident refused for [sic] dinner. U/A sample collected, as per doctor's order. Resident resting in bed, will continue to monitor. Signed by RN C. *11/29/23 6:02 AM: resident stayed in his room on his bed, slept through the night. Signed by RN C. *11/29/23 1:12 PM: Resident in bed lying supine with eyes open. Talking in good spirits. Continue ADL care. Ate 100% of meal and snack. No respiratory or psychological distress noted. Continues 1:1 [one on one] care with staff. No pain noted. Resident visited with family today. MD visited as well, no new orders from lab results. Signed by DON. *12/1/23 1:11 AM: Resident discharged to [other facility], left building at [1:00 PM] via transport service. Patient is self ambulatory, alert/oriented x1, in stable condition, [vital] signs WNL, no s/s of pain, no sob noted, no skin issues at this time. Wander guard removed, medication list and medication sent with patient Signed by LVN A. During an interview on 12/28/23 at 10:25 AM, the Social Worker stated she was not present during the elopement incident with Resident #1. She stated the family found another facility for placement after the incident. During an interview on 12/28/23 at 2:00 PM, the Administrator stated the Wander guard system only covered two doors at the facility, the front door and the door leading to the hallway where maintenance offices and laundry were housed. She explained the other exit doors were set up with alarms and utilized a key to set the alarms. The Administrator stated a vendor from a dialysis company was provided access to the facility through an exterior door on the 300 Hall by the Maintenance Tech. She stated the Maintenance Tech failed to properly secure the door after the vendor left which allowed Resident #1 to leave the facility unnoticed. In an interview on 12/28/23 at 4:31 PM, CNA D stated he was very familiar with Resident #1 and was working on 11/28/23, the day of the incident. CNA D stated Resident #1 wore a Wander Guard device on his leg and would try to exit the facility 2-3 times on his shifts. He stated he was not assigned to Resident #1's hall on 11/28/23 but was assisting with passing dinner trays. He stated he took Resident #1's tray to his room and set it up for him. CNA D stated he saw Resident #1 in the hallway as he was still passing trays and redirected him to his room. He checked on him a short time later and saw him wearing a sweatshirt and putting on his shoes, he again redirected him to his dinner tray. CNA D stated he left and entered a room around the corner from Resident #1 to feed another resident. He stated he heard an emergency call on the overhead paging system. He learned Resident #1 was missing and began assisting with the search. He stated they searched all the rooms because Resident #1 would wander into other rooms. He stated he assisted with the outside search and stated it was just getting dark, he thought it was around 6:00 PM, but was not certain. He stated it was cool outside but not really cold and guessed the temperature at around 60 degrees. He stated he saw police at the facility around 7:30 PM. CNA D stated he was not aware if the family or physician had been notified as that was outside of his duties. He stated they stopped searching when they learned Resident #1 had been located. CNA D stated he received in-service training that night on abuse and neglect. They were trained on how to use the keys properly to reset the door alarms and had to demonstrate how to do it and listen for the beeps to be sure it's set. He stated that nursing staff or management should reset the doors, but they needed to know how to do it as well. He stated the exit doors should never be unattended if opened. During an interview and observation on 12/29/23 at 8:14 AM, the Maintenance Director stated he was not present at the time of Resident #1's elopement and could not state whether or not a door alarm sounded. He stated each door alarm was battery operated and those were changed twice a year. He stated they were last changed in July 2023, but he changed them all again immediately after the incident as a precaution. The Maintenance Director explained each exit door was equipped with an alarm that sounded whenever the handle was pushed to open the door. The alarm could only be reset using a key. The door keys were previously kept at the nurses' station on a ring with an individual key for each door. After the incident, he began installing boxes on all the exit doors that contained a key and could only be opened with keycode. He stated he also began re-keying all the doors so that the staff would not have to search for the correct key to reset the alarm. The maintenance director demonstrated the system at an exit door. He entered a code on a small box affixed to the door and retrieved a key. He pushed the door handle and an immediate alarm sounded which was very loud. He utilized the key to disable and reset the alarm. Three chirps could be heard when the key was turned to the right. The Maintenance Director explained those chirps indicated the alarm was set and staff must always listen for them to ensure the alarm would function properly. He stated there were two doors left waiting for installation and he anticipated they would be complete in the coming week. He stated the staff still had access to the keys for those doors in the interim. The Maintenance Director stated only himself, the Administrator and nursing management would have access to the box codes in order to ensure staff had to call them prior to resetting the door. He stated this was to ensure they knew exactly when the doors were used. He stated they would not allow vendors to use the doors for deliveries and they would be required to enter the front door. The Maintenance Director stated the facility Wander Guard system was checked weekly by the maintenance staff and every shift by the nurses. The Maintenance Director demonstrated the process on two additional doors including the one they felt Resident #1 had used to exit the building near rooms 316/317. That door was suspected because it was used earlier in the day to allow a vendor to deliver supplies to room [ROOM NUMBER]. During another interview with the Administrator on 12/29/23 at 9:20 AM, she stated she knew for a fact Resident #1 exited the building using the door near RM 316. She stated she had stayed a little late that day and was just leaving the parking lot when she received the call about Resident #1 and went right back in the building. She stated the search was already in progress when she got to the unit. She stated CNA E told her she noted right away that door did not alarm and did not appear to be latched closed when she walked out of it to search for Resident #1. The Administrator stated other staff reported the other doors alarms sounded normally as they used them during the search. She stated she was convinced that was the door. She stated all the exit doors were checked again to ensure they had been reset properly during the search. The Administrator stated she immediately sent staff to search the hospital and assisted living facilities located on either side of their building and she assisted searching the neighborhood behind them. She stated she notified the City A police. The Administrator stated the City A police arrived and, as she was speaking to the first officer, a second one entered and told her Resident #1 matched the description of a man the City B police had picked up a little earlier that evening from the neighborhood right behind the facility and taken to a shelter. [note: the city border runs directly behind the facility]. She stated she took an ADON and went to pick up Resident #1. She stated Resident #1 did not initially wish to leave the shelter but agreed to return with her. She stated he was assessed by nursing staff immediately upon return to the facility and no injuries or distress were noted. The Administrator stated she immediately began the investigation and learned a dialysis company had been there earlier that day and had requested to utilize the exit door near room [ROOM NUMBER] to deliver supplies as they were heavy and were being delivered to room [ROOM NUMBER]. The Maintenance Tech had disengaged the alarm and allowed them to use the entrance but had apparently failed to re-engage the lock and alarm properly after the company left. The Administrator stated she did not know the exact time the company was there but thought it was late in the afternoon. She stated they did not typically use that door for deliveries and no vendors would be allowed to use the exit doors in the future. The Administrator stated in-service training began immediately on 11/28/23 and most were completed on 11/29/23. She stated return demonstration was required so that staff knew how to properly reset the alarms. She stated any staff who were unavailable for the in-service training on those two days were not allowed to begin their shift until training was completed but she felt sure everyone had been trained. She stated the trainings were conducted by herself, the DON and ADON H. The Administrator stated CNA E was out of the country and the DON was out of town and both were unavailable for interview. In an interview on 12/29/23 at 9:39 AM, the Maintenance Tech stated he was not in the facility at the time Resident #1 eloped on 11/28/23. He stated he worked until 4:30 PM that day. The Maintenance Tech stated there was a delivery of dialysis supplies on the 300 Hall for room [ROOM NUMBER], and the driver had asked him to open the exit door for them so they would be closer to that room. He stated he did not recall them asking him to do that before. The Maintenance Tech stated he used a key to disable the alarm. He stated he hovered in the area while the door was open and the supplies were delivered and he tried to stay on that wing. The Maintenance Tech explained many of the residents knew him and would always approach him whenever he was on the hall to chat or make requests. He stated he was there when the delivery driver left and he recalled closing the door, removing the key, and leaving. The Maintenance Tech stated he could not recall whether or not he reset the alarm. He stated he had previous training regarding how to reset the alarms by turning the key and waiting to hear the chirps to indicate the alarm was set. He stated, with all the chaos on the hall and residents approaching him, he did not recall resetting the alarm, only closing the door and removing the key. He could not recall what time the delivery occurred, only that it was completed before the end of his shift which was 4:30PM. The Maintenance Tech stated he had received additional training since the incident with topics including resetting the alarm and Code Pink procedures. He stated he had to demonstrate the technique to the Administrator and Maintenance Director. He stated any issues with the door alarms should be reported to the Maintenance Supervisor and Administrator immediately. He stated risk of not resetting the alarm was residents could leave the building unnoticed and get hurt. In an interview on 10/29/23 at 10:01 AM, LVN G stated she was not working at the time Resident #1 eloped but had received in-service training. She stated if any door alarm sounded, they were to check the door immediately and the outside area before resetting the alarm. She stated the alarm was reset using a key and they must listen for the chirps to indicate the alarm was active. She stated they had to demonstrate they knew how to reset the alarm. She stated the Administrator or manager must be notified any time the door alarm was reset. In an interview on 12/29/23 at 10:22 AM, ADON H stated he worked late the day Resident #1 eloped but was not present at the time. He stated sometime around 6:15 PM, he had attended a quick stand-down meeting with the Administrator and left for the day. He stated he had not driven very far when he received the call about Resident #1 and immediately returned to the facility. He stated he did not recall hearing alarms before he left. ADON H stated, if they heard any alarm, they were to check the door immediately to determine what happened. He stated they were to retrieve a key, reset the door alarm and ensure it had been reset by hearing the beeps. He stated staff were supposed to perform a head count of all residents and report anyone missing right away and call a code pink. ADON H stated the new process included contacting the Administrator or Maintenance Director whenever the alarm was reset. The keys are in boxes that require a code, and they have to call management to get the code. He stated all staff were responsible for performing head counts and reporting the findings to the Charge Nurses and ADONs. ADON H stated, after the incident, they talked to everyone to determine the timeframe for when Resident #1 left and no one reported hearing an alarm sound. He stated he was unaware the dialysis company had requested to use the door near room [ROOM NUMBER] and did not recall them ever making that request before. He stated every door was checked during the investigation and found to be functioning properly. ADON H stated Resident #1 was wearing a Wander Guard but it was only set up for two doors in the facility, the front entrance and hallway with maintenance and laundry rooms, all other doors were emergency exits controlled by an alarm. ADON H stated he assisted the DON and Administrator in conducting in-service training beginning 11/28/23. On 12/29/23 at 11:00 AM attempt to interview LVN B via telephone was unsuccessful. In a telephone interview on 12/29/23 at 11:06 AM, RN C stated she was working as a Charge Nurse from 6:00 PM to 6:00 AM the day Resident #1 eloped from the facility. She stated she came on shift and received report. She stated she began making her rounds between 6:40 PM and 6:45 PM and noted Resident #1 was not in his room. She stated that was not unusual for him, but she looked for him at that time because of his wandering behaviors. She did not recall hearing any door alarms at that time. RN C stated she was unable to locate Resident #1 and called a Code Pink. She stated all staff stopped and began searching for him. RN C stated she went out the exit door close to his room, which was near room [ROOM NUMBER], and recalled hearing the alarm sound when she opened it. She did not see anyone outside and reset the door alarm. She stated she called the Administrator, who came right away and someone else had called 911. She stated the staff continued the search until they learned Resident #1 had been located. RN C stated the Administrator brought Resident #1 back to the facility and she assessed him right away and found no injuries. She stated he was placed on 1:1 monitoring . She checked his vital signs and called the physician who ordered labs to be done. RN C stated she collected lab samples and offered him dinner, which he refused. He accepted an Ensure drink with his medications. She stated Resident #1 never talked about where he had gone but that was not unusual for him. She stated he wandered frequently stating he was looking for his family member. RN C stated she received additional in-service training that evening including procedures for Code Pink and demonstrating she knew how to reset the door alarms. She stated the alarm was reset using the key and they must hear the chirps to confirm it was reset. She stated they needed to call the Administrator or manager any time the door alarms are reset. During an interview on 12/29/23 at 12:10 PM, ADON I stated she worked on 11/28/23 but had already gone home for the day when the incident occurred. She stated she had received in-service training following the elopement which included return demonstrations for all staff. She stated the maintenance department had installed boxes with keypads on each door which would contain the key to reset the alarm. ADON I stated if any door alarm sounded, they were to immediately check the area and surrounding area outside the door to try and determine the cause. A code for the key would be provided by the Maintenance Director or Administrator. She stated a head count should be done right away to ensure no residents were missing and a Code Pink should be called if any resident was unaccounted for. ADON I stated there were occasions when the alarms could be disabled such as for emergency responders. In that instance, the door should be manned at all times and alarm re-set immediately afterward. An interview on 12/29/23 at 12:30 PM with CNA J revealed he was working a double shift on 11/28/23 and was there the evening Resident #1 eloped from the facility. He stated he heard a Code Pink called right after dinner. He did not recall hearing a door alarm prior to the call but was working at another station. He stated everyone joined in the search checking room to room and outside the facility. CNA J stated he knew someone had called the Administrator because she had returned to the facility and he saw the police officers arrive. He stated he received in-services later that evening related to Code Pink procedures and how to properly reset the door alarms. He stated when a door alarm sounds, they are to immediately check the area, including outside. He stated anytime an exit door was opened, it must be monitored until a nurse or manager reset the alarm with a key. He also had to demonstrate how to set the alarm with a key and listen for the beeps for confirmation. During a telephone interview on 12/29/23 at 1:00 PM with a City A police dispatcher, she explained when they received the call about a missing resident, they broadcasted the call to neighboring cities and learned the resident had been picked up by a City B police officer. They relayed the information to the responding officers at the nursing facility. The Dispatcher was unable to provide the officers contact information or transfer the call and stated the information was likely all provided through the various dispatcher. She provided contact information for City B Police dispatch. A telephone interview on 12/29/23 at 1:05 PM with a City B Police dispatcher revealed she stated they received a call on 11/28/23 at 6:15 PM from [private home address] stating a male was knocking on their door looking for directions to a church and appeared very disoriented. She stated an officer arrived at the private home at 6:31 PM and later transported the man to a homeless shelter. She stated the information was relayed to the City A police. On 12/29/23 at 1:10 PM, a search via Google Maps accessed at Google.com/maps revealed the private home address where Resident #1 was found was approximately 0.7 miles away in the neighborhood directly behind the facility. The city border between City A and City B was also directly behind the facility property. This was determined to be a Past Non-Compliance Immediate Jeopardy on 12/29/23 at 3:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 12/29/23 at 3:58 PM. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of the following in-services dated 11/28/23 through 11/30/23 Ongoing checking exit doors and responding to door alarms; Missing Residents-Code Pink procedures, Abuse, Neglect, and Misappropriation. Attached sign-in sheets reflected staff from all shifts completed the trainings which included return-demonstrations for resetting door alarms. Interviews on 12/29/23 from 10:42 AM to 12:35 PM with LVN A, RN F, CNA K, CNA L, and CNA M, who worked multiple shifts, revealed they had received in-service training between 11/28/23 and 11/29/23. They stated the training had included return demonstrations of how to properly secure the exit doors and reset the alarms. They were able to accurately summarize how to secure the doors, report any alarm reactivations to management, and how to respond to a code pink alert for missing residents. Record review of the Maintenance Director's report Emergency Fire Doors dated 12/1/23 reflected the Area of Concern: Emergency Use Only, not for vendor use. Actions Taken: Batteries at all fire doors have been changed, keys located, plans made to mount keys at doors assigned. Persons responsible: All staff are responsible for keeping doors shut. Monitoring: 24/7 [24 hours per day/7 days per week]. Record review of the facility's Wandering and Elopements policy and procedure, undated and identified by the Administrator as current revealed: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents

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 infection for three (Halls 200, 300, and 400) of three halls reviewed and one out of one kitchen reviewed for infection control. 1. The facility failed to quarantine, Resident #2, #4, #5, and #7 who were exposed to COVID-19 and failed to ensure resident's onset of COVID-19 symptoms and quarantine dates were being tracked. 2. Facility failed to monitor Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11 for signs and symptoms of COVID-19. 3. The facility failed to ensure CNA A was wearing appropriate PPE while working on the COVID-19 300 Hall and ensure staff were wearing appropriate PPE throughout the facility. 4. The facility failed to ensure essential visitors were screened for fever and symptoms consistent with COVID-19 prior to entering the facility. An Immediate Jeopardy (IJ) was identified on 08/23/20 at 6:15 PM. The facility was provided with the IJ template on 06/15/20 at 6:15 PM. While the IJ was removed on 08/27/20, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk for exposure to COVID-19 which could result in serious illness and/or death. Findings Included: Review of Resident #1's MDS, dated [DATE], revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's lab results revealed, Resident #1's [DIAGNOSES REDACTED] COVID-19 swab was collected on 08/14/20 at 8:38 PM and the positive results were detected on 08/16/20 at 12:20 PM. Review of Resident #1's progress notes revealed she was sent to the hospital the evening of 08/14/20 due to a change in condition and returned to the facility on [DATE]. Upon her return to the facility she was placed on the COVID-19 isolation unit. Review of a handwritten chart created by ADON C revealed Resident #1's roommate was Resident #2. Resident #1 and Resident #2 were roommates prior to Resident #1 being sent to the hospital and testing positive for COVID-19. Review of Resident #2's MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Observations on 08/22/20 at 3:20 PM and on 08/23/20 at 2:44 PM revealed Resident #2 and Resident #4 was not quarantined. Observations revealed staff were not utilizing contact isolation after she was exposed to COVID-19 from her roommate, Resident #1 and Resident #3. There was no sign on the door that showed that residents were on contact isolation or to be directed to see the nurse before entering the room. Staff entered resident #4's room with dinner tray without wearing gown and face shield. Resident #2 handed the staff member a cup and television remote. The staff member did not practice hand hygiene and exited the room. The staff member delivered dinner trays to rooms 323 and Resident #2. The staff member did not practice hand hygiene until she finished delivering all hall trays. Interview with LVN G on 08/23/20 at 2:46 PM revealed she provided care for Resident #2. She stated Resident #2 was not being quarantined. LVN G stated she did not know residents were supposed to be quarantined due to exposure of COVID-19. LVN G stated Resident #1 and Resident #2 shared a room prior to Resident #1 being transferred to the hospital. Review of Resident #3's MDS, dated [DATE], revealed, she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Lab Report for Resident #3, dated 08/13/20, revealed Resident #3 was tested for COVID-19 on 08/10/20 and it was approved on 08/12/20. The lab results reflected she was [DIAGNOSES REDACTED]-COVID-19 positive. Review of a handwritten chart created by ADON C revealed Resident #3's roommate was Resident #4. Resident #3 and Resident #4 were roommates while Resident #3 was exhibiting signs and symptoms of COVID-19 and tested positive for COVID-19 prior to being moved to the COVID-19 isolation hall. Review of Resident #4's MDS, dated [DATE], revealed that she was an [AGE] year-old- female admitted to the facility on [DATE]. Interview with CNA H on 08/24/20 at 12:45 PM revealed he provided care to Resident #2 and Resident #4. He stated he did not take care of any residents who were quarantined. He stated he N95 mask, face shield, gown, and gloves out of precaution for himself but was not mandatory. Review of Resident #5's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #5's Progress Notes , dated 07/15/20 through 08/24/20, reflected no documentation related to being exposed to COVID-19 due to his roommate (Resident #11) testing positive and no documentation about being quarantined. Observations on 08/23/20 at 4:22 PM and 08/24/20 at 3:15 PM revealed Resident #5 was not quarantined. Observations revealed staff were not utilizing contact isolation procedures after Resident #5 was exposed to COVID-19 from his roommate, Resident #11 . Resident #5 was sleeping in his bed and was unable to be interviewed. There was no sign on the door that showed that residents were on contact isolation or to be directed to see the nurse before entering the room. There was no PPE in Resident #5's room. Review of Resident #8's MDS, dated [DATE], revealed that he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #8's physician progress notes [REDACTED]. Observation on 08/24/20 3:25 PM revealed Resident #8 was not being kept on droplet isolation, staff were not utilizing contact isolation precautions. Staff were not wearing PPE in the resident's room to provide care. Interview with ADON C on 08/24/20 at 1:20 PM revealed his role entailed overseeing the nursing staff on the 300 hall and half of the 200 hall. He stated Resident #1 was experiencing a change in condition; she was lethargic and had loss of appetite. ADON C stated Resident #1 continued to decline and ADON, DON, and Physician decided to send her to the hospital. He stated during the time she was experiencing signs and symptoms of COVID-19 Resident #1 continued to reside in the same room with Resident #2. He stated once they found out Resident #1 was COVID-19 positive, they started focusing on Resident #2 (Resident #1's roommate) by monitoring her for signs and symptoms of COVID-19 for 14 days and encouraged her to stay in her room. He stated she was currently being monitored but she was not on quarantine He stated when residents have been exposed to COVID-19 due to their roommate testing positive they did not place them on quarantine or use any special PPE because they would have to place everyone in the facility on a quarantine. ADON C stated Resident #3 had spiked a temperature and had diarrhea so they notified the doctor. He stated he did not remember when Resident #3 had a temperature and diarrhea. He stated a COVID-19 test was ordered. He stated Resident #3's test result came back positive. He stated once the positive COVID-19 test result was received Resident #3 was moved from her room to the 300 hall COVID-19 isolation unit. He stated they continued to monitor Resident #3's roommate, Resident #4, but they did not place Resident #4 on quarantine. ADON C stated Resident #3 was not isolated once she started exhibiting signs and symptoms, because at the time the staff did not know for sure that she had COVID-19, so they continued to monitor her until they got the test result back. ADON C stated once they got the labs back they moved Resident #3 immediately. He stated they did not initiate quarantine or isolation precautions for Residents #2 and #4 but would do whatever the doctor ordered them to do. ADON C stated if they had to quarantine every resident who was exposed to COVID-19, by their roommate, they would have to isolate everyone in the facility. ADON C stated it was a case by case basis regarding isolating residents who were experiencing signs and symptoms of COVID-19. ADON C stated if they knew for a fact a resident had COVID-19 they were placed on isolation. He stated when a resident was on quarantine they were observed and they ensured the resident stayed in their room. He stated if a resident's COVID-19 status was unknown, they would continuously monitor every day because they did not know if that resident was positive. ADON C stated he was trained by the DON and he was trained on the facility's policy regarding infection control and COVID-19. Interview with DON on 08/25/20 at 11:02 AM revealed COVID-19 was a [MEDICAL CONDITION] infection which the facility was currently dealing with. He stated signs and symptoms of COVID-19 consisted of elevated temperature, shortness of breath, difficulty breathing, and sore throat. He stated the meaning of isolation was to monitor residents for precautions regarding COVID -19. He stated residents showing signs and symptoms of COVID-19 were isolated. He stated staff had been trained on isolation precautions. He stated quarantine consisted of observation and keeping the resident in their room. The DON stated when a resident was quarantined they would be on close monitoring for signs and symptoms of COVID-19. He stated if a resident resided on a hall where another resident tested positive the whole hall was placed on quarantine. He stated when someone was on quarantine the direct care staff must wear full PPE which consisted of a N95 mask, gown, face shield or goggles, and gloves. The DON stated if a resident was exposed to COVID-19the physician would be contacted, the room would be cleaned and disinfected, resident closely monitored, isolated, and staff would use full PPE. He stated Resident #5 and Resident #2 were being monitored for exposure to COVID-19 by their roommates. He stated ADON C, ADON D, and he would implement full PPE to provide care to the residents. The DON stated staff would wear PPE in the room and take off the PPE in the room for the residents who had been exposed to COVID-19 by their roommate. He stated PPE was kept in the resident's bathroom. He stated after 10 days residents were not considered positive for COVID-19 and 10 days was how long residents were kept in quarantine. He stated full PPE was no longer required for Resident #4 (exposed to COVID-19 by roommate Resident #3) because it had been 10 days since expose to COVID-19. He stated Resident #4's quarantine ended on 08/23/20. The DON stated Resident #3 (Resident #4's roommate) was tested for COVID-19 because the doctor requested the test due to her being weak and having diarrhea. He stated Resident #3 was not exhibiting a fever and the resident was fine and there were no concerns regarding COVID-19. He stated diarrhea was a sign and symptom of COVID-19 but that it was an uncommon one. The DON stated Resident #3 was quarantined with her roommate, Resident #4, because she was not showing initial signs of COVID-19. He stated residents were isolated at the time of their COVID-19 test was conducted if they were symptomatic. He stated Resident #3 was isolated with her roommate, Resident #4, and then she was transferred to the 300 hall COVID-19 Unit once the positive result came back . The DON stated Resident #3 should have been moved when she started exhibiting signs and symptoms of COVID-19. He stated Resident #3 had exhibited unusual symptoms. The DON stated Resident # 1 received a COVID-19 test on 08/10/20 and the result was negative. He stated Resident #1 continued to show signs and symptoms of COVID-19 and was in the room with her roommate, Resident #2. He stated he had in-serviced his ADONs on the difference of quarantine and isolation constantly. He stated the ADONs report to him during the meetings regarding residents needing quarantine and isolation . He stated he dropped the ball regarding Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #7 regarding quarantine, isolation, and monitoring for signs and symptoms of COVID-19. Interview with the MD I on 08/25/20 at 2:51 PM revealed he expected the facility to place anyone who was starting to exhibit signs and symptoms of COVID-19 to be placed on isolation and removed from their roommate. Record Review of the Facility Infection Control Isolation tracking log, undated, revealed the facility was not currently tracking the six of the seven residents who were currently on isolation. The tracking log was provided on 08/24/20. Interview with the DON on 08/25/20 at 11:43 AM revealed he did not know why the new COVID-19 cases are not on the tracking log. He stated he would provide it. No additional tracking logs were provided prior to exit. Record Review of facility policy, Surveillance for Infections, dated 07/2017, revealed, The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. Review of U.S Department of Health and Human Services Commission public health and safety site, accessed on 09/02/20, from https://www.hhs.gov/answers/public-health-and-safety/what-is-the-difference-between-isolation-and-quarantine/index.html, titled, What is the difference between isolation and quarantine?, dated 07/22/20, revealed, Isolation and quarantine are public health practices used to protect the public by preventing exposure to people who have or may have a contagious disease. Isolation: separates sick people with a contagious disease from people who are not sick. Quarantine: separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. These people may have been exposed to a disease and do not know it, or they may have the disease but do not show symptoms. 2. Review of Resident #2's Progress Notes and TARs for August 2020 revealed the resident's temperature was checked routinely each shift, but there was no documentation the resident was monitored for any other signs or symptoms related to COVID-19. Resident #2's Progress Notes reflected no documented evidence she was exposed to COVID-19 due to her roommate Resident #1 testing positive for COVID-19 . Review of Resident #3's progress notes for 07/25/20 through 08/08/20 revealed no documentation the resident was monitored each shift for signs and symptoms of COVID-19. Resident #3 was moved to the COVID isolation unit on 08/13/20. Review of Resident #4's Progress Notes and TARs for 07/25/20 through 08/23/20 revealed the resident's temperature was checked routinely each shift, but there was no documentation the resident was monitored for any other signs or symptoms related to COVID-19. Resident #4's roommate, Resident #3, was moved to the COVID isolation unit on 08/13/20. Review of Resident #5's TAR and Progress Notes for 07/15/20 through 08/21/20 revealed Resident #5's temperature was monitored every shift, but there was no documentation of Resident #5 being monitored for other signs or symptoms of COVID-19. Resident #5's Progress Notes reflected no documentation related to being exposed to COCVID-19 due to his roommate (Resident #11) testing positive. Review of Resident #6's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #7's Progress Notes and TAR for 08/16/20 through 08/24/20, revealed the resident's temperature was monitored every shift, but there was no documentation of Resident #7 being monitored for other signs or symptoms of COVID-19. The progress notes did not contain any documentation regarding Resident #7 being exposed to COVID-19 through his roommate, Resident #6, who tested positive or about being placed on quarantine. Review of Resident #8's Progress Notes and TAR for 07/07/20 through 08/21/20, revealed the resident's temperature was monitored every shift, but there was no documentation of Resident #7 being monitored for other signs or symptoms of COVID-19. Review of Resident #9's MDS, dated [DATE], revealed that he was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #9's Progress Notes, dated 07/05/20 through 08/21/20, revealed there was no documentation regarding monitoring for signs and symptoms of COVID-19. Review of Resident #10's MDS, dated [DATE], revealed that he was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #10's Progress Notes for 07/03/20 through 08/21/20, revealed there was no documentation regarding monitoring for signs and symptoms of COVID-19 physician progress notes [REDACTED]. Review off Resident #11's MDS, dated [DATE], revealed that he was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #11's Progress Notes, dated 07/16/20 through 08/21/20, revealed there was documented monitoring for signs and symptoms of COVID-19 on 08/13/20 and 08/20/20 but for no other dates during the reviewed time frame. for signs and symptoms of COVID-19. Physician note, dated 08/14/20, reflected the physician wanted Resident #11 monitored for shortness of breath, cough/congestion, fatigue/muscles aches, and sore throat. Nurse note, dated 08/17/20, revealed Resident #11 tested positive for COVID-19. Interview with ADON C and ADON D on 08/23/20 at 2:01 PM revealed the staff should be monitoring all residents every shift for signs and symptoms of COVID-19 . They stated the ADONs and DON would follow up to ensure staff were conducting their monitoring once a shift. They stated nurses were to document in the resident's electronic chart. They stated they did not know when the last time nurses were trained on monitoring for signs and symptoms of COVID-19. They stated their expectation was that nurses should document and monitor every shift. They stated if they are not documenting and monitoring the residents for signs and symptoms of COVID-19, they could miss someone who is showing signs and symptoms, which could cause more residents to get sick. ADON C stated if the resident wass showing signs and symptoms of COVID-19 the nurse had been educated to document if residents were showing signs, and to document if they were not showing signs as well. ADON D stated monitoring is required for residents who were exposed to COVID-19 by their roommate. ADON D stated they would place COVID-19 positive residents on the 300 hall COVID-19 Unit, and clean and disinfect their prior room. ADON D stated both residents would be monitored for 14 days. ADON C and ADON D stated they were tracking quarantine periods on the tracking log, to ensure residents were being tracked for 14 days after quarantine . ADON D stated full PPE was required to be worn when caring for residents who were quarantined and had been exposed to COVID-19. Interview with DON on 08/23/20 at 4:11 PM revealed his expectation for monitoring residents for signs and symptoms of COVID-19 was that the nurses were to monitor, and if the resident was showing signs and symptoms of COVID-19 that was communicated to the DON, MD/NP, and POA. He stated staff were to document the monitoring even if the resident was not showing signs and symptoms. He stated monitoring was conducted every shift. The DON stated if there was no documentation of signs and symptoms it was because the resident did not have any signs and symptoms of COVID-19. He stated they monitored residents for signs and symptoms of COVID-19 but that it was not documented. The DON stated nurses were monitoring for signs and symptoms of COVID-19 even though they were not documenting the monitoring. He stated when the nurse took the resident's temperature they were screening for signs and symptoms of COVID-19 during that time. He stated he did not watch every nurse during that time to ensure they were doing the screening;he just knew they were doing it. The DON stated beginning 08/22/20 all staff would document the monitoring every shift even if the resident was not showing signs and symptoms of COVID-19. 3. Observation on 08/22/20 at 10:55 AM revealed CNA A was wearing a surgical mask on the 300 hall COVID-19 hall while providing resident care from room to room . She was also observed speaking to the DON. Interview with CNA A on 08/23/20 at 1:32 PM revealed she acknowledged she was wearing a surgical mask, gown, goggles, and gloves while working the 300 hall COVID-19 hall on 08/22/20 when she was observed. She stated she was providing care to all residents during that time. She stated she did not see a N95 mask in the PPE cart so she put on a surgical mask. She stated she did not ask LVN J for a N95 mask at the beginning of her shift, she stated that she did ask LVN J for a N95 in the middle of her shift and was given a mask. CNA A stated the risk of wearing any mask besides the N95 could cause herself to get infected or infect others. She stated facility policy regarding the type of mask to be worn on the COVID-19 isolation hall was a N95. She stated she was trained about a week ago on the proper PPE usage on the COVID-19 hall. Observation on 08/22/20 at 4:13 PM revealed the Hall 200 nurse, LVN M, was wearing a loose fitting KN95 mask on the hall. CNA N was observed wearing a N95 mask and full PPE. Observation of MA O was wearing a KN95 mask while passing medications to residents. Interview with LVN M on 08/22/20 at 4:15 PM revealed she was given the mask by the facility. She stated she was trained to wear the KN95 and N95 mask at the facility. LVN M stated she was not fit tested for her mask. LVN M stated her mask was loose due to weight-loss. Observation of the kitchen on 08/22/20 at 4:46 PM revealed three dietary aides, Dietary Aide K, Dietary Aide F, and Dietary Aide L, were preparing meal trays. The dietary aides were not wearing masks. Observation of the trays being loaded and put on the cart and moved out of the kitchen. Observation of the kitchen on 08/22/20 at 4:50 PM revealed Dietary Aide F, Dietary Aide K, and Dietary Aide L put on a surgical face mask, however, Dietary Aide F and Dietary Aide K were wearing their surgical masks below their nose. Interview and observation with Dietary Aide K on 08/23/20 at 5:54 PM revealed he was wearing an N95 mask and the bottom strap of the mask was dangling. He stated he was trained on how to wear a mask and that a mask must be worn while working in the kitchen. He stated he did not have the mask on during the observation made on 08/22/20 at 4:46 PM because it moved his beard restraint around. He stated that the correct way to wear a mask was that it covered the nose and mouth. He stated he did not know why he had his mask below his nose. He stated he was trained to wear any type of mask. Dietary Aide K stated he was trained by the DON. Interview with Dietary Aide L on 08/23/20 at 5:56 PM revealed the mask irritated the skin under her chin and she took it off for a second. She stated she was wearing a KN95 mask. She stated she could get a mask from the Administrator but brought her own to work. She stated the Administrator said they had to wear a KN95 mask and a surgical mask was no longer allowed since the COVID-19 outbreak. Dietary Aide L stated she received an in-service regarding masks on 8/18/20 and then again 8/23/20. She stated it was important to wear a mask during food preparation to prevent any type of germ spread. Interview with Dietary Aide F on 08/23/20 at 6:06PM revealed that she was wearing a N95 mask. She stated she was trained to wear the N95 mask. She stated she had the mask down below her nose because she had to speak to Dietary Aide L. She stated the facility policy was that they wear the mask and that it needed to cover their nose and mouth. Dietary Aide F stated she was trained by the DON on how to wear the mask and he provided her with the N95 mask. Observation and interview on 08/23/20 at 11:50 AM revealed that CNA P was observed wearing a KN95 mask. CNA P stated she was wearing a N95 mask and the mask was given to her by ADON C two to three days ago. She stated she was trained by the DON on the proper mask to wear at the facility. Observation and interview on 08/23/20 at 11:55 AM revealed CNA Q was wearing an KN95 mask and a surgical mask underneath. She stated she wore the surgical mask underneath the KN95 mask because the KN95 was loose on her face. She stated the facility policy was that she had to have the KN95 mask on before walking into the facility and starting work. She stated the facility would provide her with a KN95 or N95 mask. She stated that she was trained by the DON regarding the proper mask to wear at the facility. Observation and interview on 08/23/20 at 12:17 PM revealed LVN R was wearing a KN95 mask. He stated he got the mask from the front office that morning. He stated he was given the mask by his weekend supervisor, LVN E. LVN R stated it was the facility policy that he had to wear a KN95 or N95 mask. He stated that he was trained by the DON regarding masks. During an interview with ADON C and ADON D on 08/23/20 at 2:00 PM revealed since there was COVID-19 in the building everyone had to wear a N95 or KN95 mask. They stated they trained staff on how to properly wear the masks. They stated the DON trained staff, on a weekly basis, on masks and PPE usage. ADON C stated staff should not be wearing a surgical mask on the COVID unit because the risk for contracting COVID-19 from residents was high. ADON C and ADON D both stated the kitchen staff should be wearing a N95 mask. Interview with Weekend Supervisor, LVN E, on 08/23/20 at 2:57 PM revealed masks should be worn in the building and the preference was the N95 mask. She stated sometimes staff would wear surgical masks. LVN E stated there was no specific mask that needed to be worn. She stated staff had been trained on wearing a N95 mask. LVN E stated the purpose of the N95 mask was to mitigate the spread of [MEDICAL CONDITION]. She stated the risk of wearing a surgical mask on the COVID-19 unit was it could cause the staff to become infected and spread the illness. She stated that masks should be worn by all the staff in the building. Interview with DON on 08/23/20 at 4:11 PM revealed every employee in the facility should be wearing a mask. He stated facility staff were required to wear the N95 mask but that it was not mandatory. He stated that they recommended the N95 masks but they would accept the surgical mask. He stated on the 300 hall COVID-19 unit staff had to wear the N95 mask. He stated according to the CDC that staff could wear surgical masks throughout the facility. He stated the Administrator, ADON C, ADON D, and himself promote the N95 mask but staff could wear any type of face mask. He stated that for the COVID-19 unit it was mandatory for staff to wear the N95 mask. The DON stated his did not promote that staff wear a surgical mask on the COVID-19 unit. He stated when he was on the 300 hall COVID-19 Unit on 08/22/20 at 11:30 AM he did not notice CNA A was wearing a surgical mask and not a N95. He stated he trained the staff on the proper PPE to wear when working on the COVID-19 hall. He stated that everybody has been trained regarding masks including, Dietary, Therapy, Maintenance, Housekeeping, Nursing, and Administrative staff. He stated his last in-service on masks was 08/02/20. 4. Observation on 8/22/20 at 10:30 AM revealed the facility failed to properly screen the HHSC surveyor upon entering the facility. LVN AG only took the HHSC surveyor's temperature then proceeded to allow entrance into the facility. The HHSC surveyor toured the facility for two hours until temperature was re-checked and questionnaire was completed for COVID-19 by LVN E. Interview with Weekend Supervisor, LVN E, on 08/23/20 at 2:57PM revealed staff should conduct the screening on visitors. She stated she screened visitors on the weekend. LVN E stated she was not trained by administrative staff on how to screen visitors and staff. She stated HHSC surveyors are considered essential visitors and need to be screened too. She stated essential visitors need to be screened because you do not know where they have been on the outside or if they have been exposed. Interview with DON on 08/23/20 at 4:11 PM revealed on the weekends the LVN E was in charge of conducting the screenings of staff and any essential visitors who come into the building. He stated LVN E should have had the HHSC surveyor fill out the COVID-19 screening questionnaire because it helped them screen people who may have been exposed to COVID-19. He stated his expectation was when someone came into the facility they were screened; temperature taken and given the questionnaire. The DON stated the residents were put at risk because they had not screened someone who walked into the building. Review of facility policy, Coronavirus/COVID-19, 08/08/20, revealed, The facility follows current guidelines and recommendations for the prevention and control of [MEDICAL CONDITION]. The facility should contact their local health department if they have questions or suspect a resident of the nursing home has COVID-19. Per CDC, prompt detection, triage and isolation of potentially infectious residents are essential to prevent unnecessary exposure among residents, personnel, and visitors . 4. Source control, which involves having the infected person wear a cloth face covering or facemask over their mouth and nose to contain their respiratory secretions, might help reduce the risk of transmission of [DIAGNOSES REDACTED] CoV-2 from both symptomatic and asymptomatic people . Facilities may not allow entry unless the visitor meets the criteria of emergency personnel, necessary visits by the resident physician, or a state surveyor. Document name, reason for visit, job title, and temperature of each visitor. All persons that enter are to be screened for temperature and symptoms, and either given a mask or to provide their own mask . COVID-19 Control. 1. MD/PCP will notified of symptomatic residents and the resident will be required to take appropriate measures including Contact and Droplet Precautions and remaining in their room until assessed by PCP or orders are received for testing and test results are received . 2. Staff caring for a resident who is presumptive for COVID-19 will wear personal protective equipment while providing care. 3. If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED]. Temperature measurement may also be required to determine appropriateness of staff or visitors to be at the facility .15. All residents will have temperature monitored and recorded three times per shift Review of facility policy, Infection Control, dated 10/2018, revealed, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility . e. Maintain records of incidents and corrective actions rela (TRUNCATED)