Every finding on record at Castle Hills Rehabilitation and Care Center

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 1 kitchen reviewed for qualified staff. The facility failed to employ a qualified dietary food service manager for a period of 6 months. The acting DM had not completed a course of study in food safety and management since he assumed his position during February 2026. This deficient practice could place residents at risk of not receiving proper nutrition and hydration to meet the resident's needs. The findings were:Review of the dietary staff certifications (included all dietary staff's records on hand) revealed the DM did not have a certification reflecting that he completed a dietary manager or food and service manager course. Interview on 8/13/26 at 1:49 PM with the DM revealed he started working at the facility during February 2026. He stated he had worked as a Dietary Manager in a number of facilities but not in long-term care. He stated he worked at an assisted living facility for 3 years. The DM stated he never completed a dietary manager course and did not have a dietary manager certification. The DM stated the previous ADM hired him and the plan was he would enroll in a course but it did not work out. He stated the current ADM also knew he did not have his dietary manager certification and the plan was that he would complete a dietary manager course but had not yet enrolled in a course. He stated a new company bought out the facility and they were going to pay for the course but did not know when at this time. Interview on 8/13/26 at 5:45 PM with the ADM revealed he knew the DM had not completed a dietary manager course and did not have his certification. The ADM stated he had a dietary manager certification which he received through safe serve. He stated he believed his certification sufficed and the DM could work under his certification. The ADM stated he was not in charge of the operations of the kitchen and the DM was in charge of the kitchen functions. The ADM stated the new company that bought the facility on 8/1/26 offered a dietary manager's course and the DM would be expected to complete the course. as soon as the transition was completed. He stated he did not have a timeframe at this time. Review of a facility policy, 'Food and Nutrition Services Staff, dated October 2017, read The food services department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department.

Based on observations, interviews and record reviews the facility failed to ensure menus were followed and reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy for 1 of 4 days (8/13/26) by 1 of 1 Dietary Staff (Cook D) reviewed for menus. The facility did not have a dietician to provide and review menus. The DM was providing menus he put together on a daily basis including the lunch meal on 8/13/26. The lunch meal consisted of spaghetti with meal sauce, mixed vegetables and a fruit cup.Cook D did not follow the lunch menu on 8/13/26. He served spaghetti with meat sauce with a fruit cup or spaghetti with meat sauce and fried breaded cauliflower. These deficient practices could place residents at risk of not receiving meals according to a menu provided in advance and that met their nutritional needs. This could result in resident's not being satisfied with the meals they were served. The findings were: Review of resident council minutes from February 2026 to August 2026 revealed that on 7/2/26 residents complained they were not receiving food items based on the menu. Review of the menu board for the lunch meal on 8/13/26 read Spaghetti with meat sauce, mixed vegetables and fruit cup. Further observation revealed there was not a monthly menu posted anywhere in the dining room. Observation on 8/13/26 at 12:35 PM revealed some residents were served spaghetti with meat sauce, carrots and a fruit cup. Other residents were served spaghetti with meat sauce, fried breaded cauliflower and a fruit cup. Interview on 8/13/26 at 1:49 PM with the DM revealed he was previously able to access menus from their food distribution vendor. He stated the facility was bought out by a different company as of 8/1/26 and he no longer had access to the menus. He stated he would write the menu for each meal; breakfast, lunch and dinner on a daily basis and would provide dietary staff with a copy. The DM stated the lunch meal he provided dietary staff to prepare and serve on 8/13/26 was spaghetti with meat sauce, mixed vegetables and a fruit cup. He stated all food items were available and was not sure why [NAME] D did not follow the menu. The DM stated he had not completed his dietary manager course and was not certified. He stated he had the resident's therapeutic menus on file which he followed; however, he stated no one guided him when he was preparing the menus for the day. He stated they had not had a dietician for 1 month. The DM stated he was not sure how not having menus would affect the residents. Interview on 8/13/26 at 2:37 PM with [NAME] D revealed the DM provided a menu for 8/13/26 which included spaghetti with meat sauce, mixed vegetables and a fruit cup. However, the DM also instructed him to serve what was left of the breaded cauliflower and to fry it. He stated he also served carrots in case residents did not like the breaded cauliflower. [NAME] D stated he was not sure how this would affect the residents but understood the residents had expressed concerns about the lack of variety of food and alternatives not always being available. Interview on 8/13/26 at 5:45 PM with the ADM revealed another company had acquired the facility on 8/1/26 and they were still in transition. He stated there was a regional dietician but she was not providing menus. The ADM stated since the buy out they did not have access to the food distribution vendor's platform and they could not print out menus. He stated the DM was putting the menus together. The ADM stated they had a copy of the resident's therapeutic diets which the DM should follow. The ADM stated the goal was to have a smooth running kitchen so they could serve nutritional, appetizing and hot food. The ADM stated he did not believe the residents had been negatively impacted. Review of a facility policy, Menu, dated October 2017 read Menus are developed and prepared to meet the resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.Menus meet the nutritional needs of residents in accordance with recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 6 Residents (Resident #4) and for 2 of 4 days (8/13/26 and 8/14/26) reviewed for the food temperature. On 8/13/26 the lunch meal served consisted of spaghetti with meat sauce, fried breaded cauliflower and a fruit cup. Residents #4 stated his food cold and was not appetizing.The temperature of a test tray on 8/14/26 consisting of mini corn dogs, chicken tenders and french-fries revealed each item's temperature was 99 degrees. The mini corn dogs and french-fries were cold and not palatable. These deficient practices could place residents at risk of not receiving hot food and not enjoying their food. The findings were: Review of resident council minutes from February 2026 to August 2026 revealed on 2/6/26 residents complained the breakfast meal was cold. Review of Resident #4's face sheet, dated 8/15/26, revealed he was admitted to the facility on [DATE] with his primary diagnosis of Chronic Obstructive Pulmonary Disease (progressive lung diseases like emphysema and chronic bronchitis where the exact underlying type or specific cause is not detailed in the medical record), unspecified. Review of Resident #4's quarterly MDS assessment, dated 6/20/26, revealed his BIMS was 8 out of 15 reflective of moderate cognitive impairment. He required staff assistance with Setup or clean-up assistance. Review of Resident #4's Care Plan, dated 4/17/26 revealed he had an ADL/Self care deficit r/t activity intolerance, impaired balance, limited mobility and he required assistance: set up to supervision for eating. Int at 8/12/26 at 3:50 PM with the SW revealed she was the grievance officer and stated multiple residents had expressed various concerns about the food including that it was cold. She stated she wrote the grievances and reported and would present them during the morning meetings. She stated for cold food the DM would be responsible for addressing the concern. Interview on 8/12/26 at 6:38 PM with CNA B revealed multiple residents had complained about the food. Residents reported the food was cold and that the food did not taste good. CNA B stated she reported the concerns to the charge nurse. Observation and interview in the dining room on 8/13/26 at 1:20 PM with Resident #4 revealed he was eating his lunch meal. He was served spaghetti with meat sauce, fried breaded cauliflower and a fruit cup. Resident #4 stated the food was alright. He stated it was cold and it was edible. He stated he liked his food hot; the food tasted better when it was hot. Interview on 8/13/26 at 5:45 PM with the ADM revealed the goal was to have a kitchen that ran smoothly so they could provide residents with appetizing and hot food to the residents' satisfaction. The ADM stated it residents had not complained to him that the food was cold. Observation and interview on 8/15/26 at 11:55 AM revealed the lunch meal consisted of mini corn dogs and french-fries or chicken tenders and french-fries. Observation of the DM taking food temperature of the corn dogs, chicken tenders and french-fries were 99 degrees. Interview with the DM revealed he did not know what the holding temperature should be for the food. The food was tasted, the corn dog was cold and did not taste good. The french-fries were cold and hard and they did not taste good. Interview on 8/15/26 at 12:55 PM with the DM revealed the holding temperature should be 135 degrees to keep the food from developing bacteria so the residents did not get sick. He stated the residents would also enjoy the food more when it was hot which was important. He stated the residents would likely eat more and would be satisfied with the food if was hot and it tasted good. Review of a facility policy, Food Preparation and Service, dated November 2022, read Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.Food Preparation, Cooking and Holding Time/Temperatures1. The danger zone for food temperatures is above 41 F and below 135 F. This temperature rangepromotes the rapid growth of pathogenic microorganisms that cause foodborne illness.

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 grooming and personal hygiene for 2 of 7 Resident's (Resident #5 and Resident #7) reviewed for personal care. The facility failed to ensure Resident #5 received incontinent care on a regular basis and as needed; and failed to ensure nursing staff showered him on his scheduled days. Resident #5 smelled heavily of urine; his brief, sheet and gown were soaked. The sheet had brown stains. Resident #5 had not been showered.The facility failed to ensure Resident #7 received incontinent care on a regular basis and as needed. Resident #7's brief, her bed pad and gown were wet with urine. These deficient practices could place residents at risk of skin breakdown and could contribute to feelings of poor self-esteem. The findings were: 1.Review of Resident #5's face sheet, dated 8/14/26, revealed he was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (a long-lasting health condition where the body cannot process sugar properly), unspecified severe protein-calorie malnutrition (a serious medical condition where the body lacks enough food, energy, and protein) and adult failure to thrive (a complex syndrome of progressive physical, functional, and mental decline). Review of Resident #5's quarterly MDS assessment, dated 7/14/26, revealed his BIMS score was 6 out of 15 reflective of severe cognitive impairment. He required substantial to maximal assistance with personal hygiene and showers. Review of Resident #5's Care Plan, dated 4/22/26, revealed he was At risk for hypo-hyperglycemia, altered mental status, skin integrity, neuropathy r/t DM (Diabetes Mellitus) and one of the interventions included Weekly skin inspections per facility protocol. Observation and interview on 8/14/26 at 1:19 AM revealed Resident #5 was lying in bed asleep. Resident #5 woke up upon entering his room. Observation revealed Resident #5 smelled heavily of urine. Resident #5's hair looked dull and greasy. There were dry flakes on the right side of the head of the bed where Resident #5 laid his head. Resident #5 stated his brief was changed yesterday early morning and he was supposed to get a shower but was not showered. Resident #5 stated he felt wet and nasty. Observation and interview on 8/14/26 at 1:22 AM revealed Resident #5 was lying in bed. He smelled heavily of urine. Observation revealed CNA L drew Resident #5's linens down to his knees. Resident #5's brief, sheet and gown were soaked with urine. The sheet had brown stains. Interview with CNA L revealed she thought he had been changed. CNA L stated he looked bad and was soaking wet. She commented she imagined he felt bad lying wet in his brief, gown and sheet. She stated it looked like he had not been changed in a long while because there were brown stains on the sheets. CNA L commented, let me tell his CNA so she can hurry up and change him. CNA L stated she was assigned all rooms on that side of the hall except for two residents including Resident #5. Interview on 8/14/26 at 1:27 AM with LVN I revealed she had rounded on Resident #5 a couple of times since starting her shift at 6:00 PM. She observed Resident #5's condition and stated he was soaking wet through his brief, sheet and gown. She stated she thought CNA K had changed him but did not look like he had been changed in a long time. CNA K stated Resident #5 skin could break down lying in his urine for extended periods of time. LVN I stated Resident #5 was scheduled to receive showers on Tuesday's, Thursday's and Saturday's. She stated Resident #5 did not look like he had been shower and usually the aides would change the linen. LVN I stated by looking at Resident #5's linen, it did not look like his bedding had not been changed. It had brown stains. Interview on 8/14/26 at 7:28 PM with the DON revealed the CNA's should be rounding on the residents every 2 hours and as needed. She stated lying in urine for a long time could cause skin breakdown and the resident might feel helpless. She stated Resident #5's shower days were on Tuesday's, Thursday's and Saturday's. She stated in reviewing his shower sheet it reflected he was getting a bed bath but did not get a bed bath on 8/13/26 per his shower schedule. She stated LVN I and CNA K bathed him after LVN I and CNA K returned to change Resident #5 and they looked at his condition. The DON stated the charge nurse's should round and ensure that the CNA's were changing and showering the residents on their scheduled days. If a CNA did not bathe or shower the resident for whatever reason, she should report it to the charge nurse so she can address it. The DON stated it was important to receive showers for overall cleanliness and to maintain good hygiene. 2.Review of Resident #7's face sheet, dated 8/15/26, revealed she was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, moderate, with mood disturbance (involves a decline in thinking skills caused by reduced blood flow to the brain, paired with emotional and behavioral symptoms like depression, apathy, or sudden mood swings), and Major Depressive Disorder, recurrent, unspecified (a common and serious mood disorder. It causes ongoing and deep feelings of sadness, emptiness, and a loss of interest in normal activities that last for at least two weeks). Review of Resident #7's quarterly MDS assessment, dated 7/14/26, revealed her BIMS score was 3 out of 15 indicative of severe cognitive impairment. It reflected Resident #7 required set up or clean-up assistance for eating. Review of Resident #7's Care Plan, dated 4/27/26, revealed she had an ADL self-performance deficit r/t Vascular Dementia with mood disturbance. One of the interventions revealed she required substantial to maximal assistance with toileting. Observation and interview on 8/13/26 at 12:50 PM revealed Resident #7 lying in bed. The room smelled of urine. Observation revealed CNA K drew the linens back and she stated Resident #7's brief looked full, the bed pad was wet and the bottom of her gown was wet. CNA K stated she thought the CNA on the previous shift had changed Resident #7. She stated Resident #7 did not say anything to her about being wet. Interview with Resident #7 revealed she was wet and when asked how she felt about it she stated not good. Interview on 8/13/26 at 12:55 PM with Resident #7's roommate revealed the CNA on the previous shift changed her and Resident #7 at 9:00 PM. Interview on 8/14/26 at 7:28 PM with the DON revealed the CNA's should be rounding on the residents every 2 hours and as needed. She stated the charge nurse's should round and ensure that the CNA's were changing the residents on a regular basis. She stated lying in urine for a long time could cause skin breakdown and the resident might feel helpless. Interview on 8/14/26 at 8:41 PM with CNA K revealed during the overnight shift, she first passed out water at 10 PM and asked residents if they needed anything or to get changed. She stated she changed the residents who told her they needed their brief changed. CNA K stated during last night's observations on 8/13/26 at 12:50 PM Resident #7's brief was full, the bed pad and her gown were wet. She stated she made rounds at 12:00 AM, 2:00 AM and at 5:00 AM. She stated at 3:00 AM she would ask residents if they needed changing. CNA K stated the nurse's would assist with peri-care. CNA K stated the resident's have paid their money and we should provide the care they need. CNA K stated we should treat the resident's with dignity and respect. Review of a facility policy, Activities of Daily Living (ADL), Supporting, dated April 2025 read Resident's who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 5. Appropriate care and services are provided for resident's 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); c. elimination (toileting).

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 6 Residents (Resident #5 and Resident #7) reviewed for resident rights. LVN I failed to knock on the door before entering Resident #5's room. LVN I was rounding on Resident #5.CNA M failed to knock on the door before entering Resident #7's room. CNA M was delivering Resident #7's dinner tray. These deficient practices could place residents at risk of staff infringing on the resident's personal space. The findings were: Review of Resident #5's face sheet, dated 8/14/26, revealed he was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (a long-lasting health condition where the body cannot process sugar properly), unspecified severe protein-calorie malnutrition (a serious medical condition where the body lacks enough food, energy, and protein) and adult failure to thrive (a complex syndrome of progressive physical, functional, and mental decline). Review of Resident #5's quarterly MDS assessment, dated 7/14/26, revealed his BIMS score was 6 out of 15 reflective of severe cognitive impairment and he was dependent on staff for toileting. Review of Resident #5's Care Plan, dated 4/22/26, revealed he was Incontinent of bladder/bowel r/t neurogenicbladder. (a lack of bladder control caused by damage to the brain, spinal cord, or nerves).Observation and interview on 8/14/26 at 1:27 AM with LVN I revealed she entered Resident #5's room without knocking on the door or announcing herself. LVN I stated she was checking in on Resident #5 and forgot to knock. She stated she should knock because it was Resident #5's room and he had the right to accept or refuse her in his room. Interview on 8/14/26 at 1:30 AM with Resident #5 revealed he liked it when staff knocked on the door. He stated he felt like he could not say anything when staff just walked into his room. Interview on 8/14/26 at 1:11 PM with the DON revealed staff should knock on a resident's door because it was their room and the resident had the right to choose whether or not someone entered their room. She stated otherwise a resident might feel like they did not have a choice. 2. Review of Resident #7's face sheet, dated 8/15/26, revealed she was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, moderate, with mood disturbance (involves a decline in thinking skills caused by reduced blood flow to the brain, paired with emotional and behavioral symptoms like depression, apathy, or sudden mood swings), and Major Depressive Disorder, recurrent, unspecified (a common and serious mood disorder. It causes ongoing and deep feelings of sadness, emptiness, and a loss of interest in normal activities that last for at least two weeks). Review of Resident #7's quarterly MDS assessment, dated 7/14/26, revealed her BIMS score was 3 out of 15 indicative of severe cognitive impairment. It reflected Resident #7 required set up or clean-up assistance for eating. Review of Resident #7's Care Plan, dated 4/27/26, revealed she had an ADL self-performance deficit r/t Vascular Dementia with mood disturbance. One of the interventions included set up or clean-up assistance for eating. Observation and interview on 8/14/26 at 6:01 PM revealed CNA M walked into Resident #7's room with a dinner tray. Interview with CNA M revealed he did not knock on the door and stated he should have knocked on the door. CNA M stated he should respect Resident #7's privacy. Interview on 8/14/26 at 6:10 PM with RN N revealed he was standing in the hallway while CNA M was passing out dinner trays. RN N stated he did not notice that CNA M walked into Resident #7's room without knocking. RN N stated all staff should knock on a resident's door because it was the resident's personal space and staff should respect their privacy. He stated a resident might get upset or feel like they did not have a say about staff walking into their room. Attempted interview on 8/14/26 at 6:15 PM with Resident #7 revealed she presented as being confused. She stared off when asked her questions. A request was made for a copy of the facility resident's right's policy and it was not received.

Based on observation, interview and record review the facility failed to immediately inform the resident and consult with the resident's physician when there was a significant change in the resident's physical status for 1 of 6 Resident's (Resident #5) reviewed for change in condition. The facility failed to call Resident #5's physician to report skin changes and to obtain a new order for treatment. Resident #5 had built up white scales and flakes on the crown of his head, flakes throughout his scalp, around his beard line, on his forehead and neck. The affected areas caused itchiness and discomfort. This deficient practice could place residents at risk of declining physical health and result in discomfort for the resident. The findings were: Review of Resident #5's face sheet, dated 8/14/26, revealed he was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (a long-lasting health condition where the body cannot process sugar properly), unspecified severe protein-calorie malnutrition (a serious medical condition where the body lacks enough food, energy, and protein) and adult failure to thrive (a complex syndrome of progressive physical, functional, and mental decline). Review of Resident #5's quarterly MDS assessment, dated 5/6/26, revealed his BIMS score was 6 of 15 reflective of severe cognitive impairment. He required substantial to maximal assistance with personal hygiene and showers. Review of Resident #5's Care Plan, dated 4/22/26, revealed he was At risk for hypo-hyperglycemia, altered mental status, skin integrity, neuropathy r/t DM and one of the interventions included Weekly skin inspections per facility protocol. Review of Resident #5's physician orders for August 2026 revealed an order Weekly Skin Assessment, Skin Check. every night shift every Sat, dated 7/4/26. Review of Resident #5's weekly head to toe skin check for 8/1/26 and 8/8/26 revealed Resident #5 did not have any skin problems. Observation and interview on 8/14/26 at 1:19 AM revealed Resident #5 was lying in bed asleep. Resident #5 woke up upon entering his room. Observation revealed Resident #5 had built up white scales and flakes on the crown of his head, flakes throughout his scalp, around his beard line, on his forehead and neck. Resident #5 scratched his scalp and face during the entire interview. Resident #5 stated his scalp, face and neck itched and he felt very uncomfortable. Resident #5 was asked if he had said anything to anyone? Resident #5 stated he had not because he kept to himself. Resident #5 stated staff did not apply any type of ointment to his scalp, face and neck. Resident #5 stated his condition started awhile ago. Observation and interview on 8/14/26 at 1:27 AM with LVN I revealed she had rounded on Resident #5 a couple of times since starting her shift at 6:00 PM. She looked at Resident #5's scalp, head, face and neck and stated Resident #5 had very dry flaky skin and it looked worse than regular dandruff. She stated she did not notice his skin looked like it did. LVN I stated Resident #5 did not have an order for a topical ointment for his skin. LVN I stated she had not called Resident #5's physician because she did not know he had a skin problem. Interview on 8/14/26 at 1:08 PM with the DON revealed the protocols for addressing skin issues included: the charge nurse's would conduct weekly skin checks and report any skin issues to the treatment nurse. The treatment nurse would call the resident's physician and enter any new orders. The charge nurse's provided treatment, monitored the resident's condition and report back to the physician if there was no improvement. The DON stated LVN J told her Resident #5 had dry and flaky skin. She stated not following the protocols in place would result in Resident #5 not receiving treatment, his condition could worsen and was sure the affected areas itched Resident #5 and caused discomfort. Interview on 8/14/26 at 7:28 PM with treatment nurse, LVN J revealed she assessed Resident #5 earlier on this date, 8/15/26 and stated he had dry, flaky skin. She stated Resident #5 did not have a physician order for treatment. LVN J stated the nurse's completed the head to toe skin assessments and should let her know of any changes in a resident's skin. She stated she would then call the physician, report the changes and request an order for treatment. LVN J stated it was important to report changes in a resident's condition to the physician so that he could provide treatment orders. Otherwise the condition could worsen and Resident #5 would continue to experience itchiness. Interview on 8/14/26 at 8:41 PM with CNA K revealed she had noticed Resident #5's skin was very dry. She stated his scalp looked like he had caked on dandruff or psoriasis. CNA K stated she had been asking the nurse's for medicated shampoo for some time but had not received anything. CNA K stated she would advocate for the residents. Review of a facility policy, Change in a Resident's Condition or Status, dated December 2025 read The facility promptly notifies the resident, resident's attending physician or provider and the resident representative of changes of the resident's condition and/or status. 1. The nurse will notify the resident's attending physician, provider, or physician on call when there has beena(an):i. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease relatedclinical interventions (is not self-limiting).

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made for 1 of 7 Residents (Resident #1) reviewed for abuse. The facility failed to report an allegation of abuse, when Resident #1 alleged CNA A hurt his testicles during incontinent care. This deficient practice could place residents at risk for further abuse and could result in residents fearing nursing staff. The findings were: Review of Resident #1's face sheet, dated 8/15/26, revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery (an ischemic stroke affecting the right side of the brain) and Hemiplegia and Hemiparesis following Cerebral infarction affecting left non-dominant side (weakness or paralysis on the left, non-dominant side of the body after a stroke).Review of Resident #1's quarterly MDS assessment, dated 7/15/26, revealed his BIMS score was 7 out of 15 reflective of moderate cognitive impairment and he was dependent on staff for toileting. Review of Resident #1's Care Plan dated 7/29/26 revealed Resident #1 had an ADL/Self-care deficit r/t activity intolerance, hemiplegia, impaired balance and he required substantial to maximum assistance with toileting. Review of Resident #1's in-house census report revealed he was transferred on 7/21/26 to another room within the facility. Interview on 8/13/26 at 6:38 PM with CNA B regarding the facility process for reporting abuse and neglect. She stated Resident #1 reported to her that CNA A was pinching his testicles and it happened more than once. CNA B stated during care one day, Resident #1 spilled his drink and was very nervous. CNA B stated she told him she would clean it up and not to worry about it. He told her to please make sure it's clean because CNA A would get upset with him and pinch his testicles. CNA B stated she immediately told the DON about Resident #1's allegation. CNA B stated Resident #1 was moved to another room on a different hall and CNA A continued to work at the facility. CNA B stated she reported many incidents to the DON, and nothing seemed to get done. CNA B stated instead of doing something about CNA A the DON moved Resident #1 like he did something wrong, She stated the ADM was the abuse coordinator, but before that they did not have an ADM so they report allegations of abuse to the DON. CNA B stated she was used to going to the DON but should report allegations of abuse to the ADM. Interview on 8/13/26 at 6:55 PM with Resident #1 revealed he was moved to a different room a few weeks ago but was not sure why he moved. He reported when on the other hall, CNA A was mean to him and would get mad if he made a mess like when he spilled his drinks. He stated CNA A would get rough when changing his brief. Resident #1 stated CNA A would hang up his nut in the brief during care and she did it on more than one occasion. Resident #1 stated it hurt. He stated one time he told CNA A to stop, and she denied doing anything wrong. He stated he told another CNA what was going on. Resident #1 stated no one else talked to him about his reported concerns. Resident #1 stated he felt safe and felt better since moving rooms but commented he was scared of her. He stated he had not seen her again. Interview on 8/14/26 at 1:45 PM with CNA A revealed she and Resident #1 were like best friends. She stated she did not know what happened but suddenly the DON told her to stay away from Resident #1 and to not enter his room. CNA A stated the DON told her Resident #1 and his family member reported she was abusing him. CNA A stated the DON talked with her after she returned from her 2 days off and she learned Resident #1 had been moved, CNA A stated she was not suspended pending investigation. She stated the DON did not say anything else about the situation. She just knew to stay away from Resident #1. CNA A stated she never hurt Resident #1 or abuse him in any way. Interview on 8/14/26 at 9:05 PM with the ADM revealed he was abuse coordinator and stated he did not have any outstanding self-reports related to Resident Abuse. He stated no one had said anything to him recently about a resident making an allegation of abuse. Interview on 8/15/26 at 12:32 PM with the DON revealed the ADM confirmed with her, there were no other self-reports related to Resident Abuse. The DON stated she moved Resident #1 to another room because he and a family member reported concerns about being too close to the dining room and Resident #1 and his roommate were not getting along. The DON also stated Resident #1 and his family member expressed concerns about CNA A and they basically reported she had a bad attitude. The DON stated Resident #1 reported CNA A gave him attitude anytime he asked for help. The DON stated Resident #1 and the family member did not say anything about abuse. She stated she met with CNA A to discuss Resident #1's and the family member's concerns, and stated CNA A would not engage in the conversation. The DON stated she instructed CNA A not to enter Resident #1's room. The DON stated had Resident #1 or the family reported abuse, she would report it to the ADM immediately because they were obligated to report and investigate. She stated they were also responsible for ensuring the resident's safety so that they were not mistreated or abused. The DON stated not following the facility's policy could result in continued abuse. Interview on 8/15/26 at 1:56 PM with Resident #1's family member revealed she noted CNA A had distanced herself from her and Resident #1. She stated she saw in the camera that CNA A would get frustrated and was short with Resident #1 during care. The family member stated the DON talked with her and Resident #1 about moving him to another room and she was in agreement with the plan. She stated during their conversation, Resident #1 reported CNA A was mean to him, would yank him around and would mistreat him. He stated CNA A would get mad when he spilled his drink. The family member stated the DON did not mention anything about CNA A pinching his testicles but she heard it from another staff member. Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021 read 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 corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. 2. Develop and implement policies and protocols to prevent and identify; a. abuse or mistreatment of of residents.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations withing timeframes required by federal requirements.

Based on interview and record review the facility failed to, in response to allegations of abuse, ensure they had evidence that all alleged violations were thoroughly investigated for 1 of 6 Residents (Resident #1) reviewed for abuse. The facility failed to investigate an allegation of abuse after Resident #1 alleged CNA A was hurting his testicles during incontinent care. This deficient practice could place residents at risk for further abuse. The findings were:Review of Resident #1's face sheet, dated 8/15/26, revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery (an ischemic stroke affecting the right side of the brain) and Hemiplegia and Hemiparesis following Cerebral infarction affecting left non-dominant side (weakness or paralysis on the left, non-dominant side of the body after a stroke).Review of Resident #1's quarterly MDS assessment, dated 7/15/26, revealed his BIMS score was 7 out of 15 reflective of moderate cognitive impairment and he was dependent on staff for toileting. Review of Resident #1's Care Plan dated 7/29/26 revealed Resident #1 had an ADL/Self-care deficit r/t activity intolerance, hemiplegia, impaired balance and he required substantial to maximum assistance with toileting. Review of Resident #1's in-house census report revealed he was transferred on 7/21/26 to another room within the facility. Interview on 8/13/26 at 6:38 PM with CNA B regarding the facility process for reporting abuse and neglect. She stated Resident #1 reported to her that CNA A was pinching his testicles and it happened more than once. CNA B stated during care one day, Resident #1 spilled his drink and was very nervous. CNA B stated she told him she would clean it up and not to worry about it. He told her to please make sure it's clean because CNA A would get upset with him and pinch his testicles. CNA B stated she immediately told the DON about Resident #1's allegation. CNA B stated Resident #1 was moved to another room on a different hall and CNA A continued to work at the facility. CNA B stated she reported many incidents to the DON, and nothing seemed to get done. CNA B stated instead of doing something about CNA A the DON moved Resident #1 like he did something wrong, She stated the ADM was the abuse coordinator, but before that they did not have an ADM so they report allegations of abuse to the DON. CNA B stated she was used to going to the DON but should report allegations of abuse to the ADM. Interview on 8/13/26 at 6:55 PM with Resident #1 revealed he was moved to a different room a few weeks ago but was not sure why he moved. He reported when on the other hall, CNA A was mean to him and would get mad if he made a mess like when he spilled his drinks. He stated CNA A would get rough when changing his brief. Resident #1 stated CNA A would hang up his nut in the brief during care and she did it on more than one occasion. Resident #1 stated it hurt. He stated one time he told CNA A to stop, and she denied doing anything wrong. He stated he told another CNA what was going on. Resident #1 stated no one else talked to him about his reported concerns. Resident #1 stated he felt safe and felt better since moving rooms but commented he was scared of her. He stated he had not seen her again. Interview on 8/14/26 at 9:05 PM with the ADM revealed he was abuse coordinator and stated he did not have any outstanding self-reports related to Resident Abuse. He stated no one had said anything to him recently about a resident making an allegation of abuse. Interview on 8/15/26 at 12:30 PM with the DON revealed the ADM confirmed with her, there were no outstanding self-reports related to Resident Abuse. The DON stated she moved Resident #1 to another room because he and a family member reported concerns about CNA A. They basically reported CNA A had a bad attitude. The DON stated Resident #1 reported CNA A gave him attitude anytime he asked for help. The DON stated Resident #1 and the family member did not say anything about abuse. She stated she met with CNA A to discuss Resident #1's and the family member's concerns, and stated CNA A would not engage in the conversation. The DON stated she instructed CNA A not to enter Resident #1's room. The DON stated had Resident #1 or the family reported abuse, she would report it to the ADM immediately because they were obligated to report and investigate. She stated they were also responsible for ensuring the resident's safety so that they were not mistreated or abused. The DON stated not following the facility policy could result in continued abuse. Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021 read 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 corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. 2. Develop and implement policies and protocols to prevent and identify; a. abuse or mistreatment of of residents.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations withing timeframes required by federal requirements.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 2 outdoor Atrium's (Atrium #2). The facility failed to ensure the condensation from the air conditioner in Atrium #2 did not run onto the concrete slab. There was an area approximately 2-feet wide by 4-feet long underneath the air conditioner. It was black and slippery. The area was dimly lit. This deficient practice could place residents at risk of slipping or falling; having an avoidable accident. The findings were: Observation on 8/14/26 at 1:09 AM revealed an air conditioner mounted about 10 feet high along the wall to the right-side of the door upon entering Atrium #2. Observation revealed the condensation from the air conditioner was leaking water onto the concrete slab underneath. The area was about 2- feet wide and about 4 - feet long. It was black and slippery. Atrium #2 was dimly lit, and the only lighting was the lighting coming in from the hallways around it. Observation and interview on 8/14/26 at 1:35 AM with the ADM revealed he had not noticed the condensation from the air conditioner was leaking onto the slab. He stated he was also not sure if there were light fixtures inside but stated there was natural lighting from the halls providing light inside Atrium #2. He stated residents could definitely slip and fall on the wet area and could get hurt. Interview on 8/14/26 at 6:10 PM with the MS revealed he had worked at the facility for about 6 months. He stated he made daily rounds of the facility and made observations of any potential hazards but stated anyone could let him know if there were any environmental hazards. He stated he cleaned the slab in Atrium #2 maybe during June 2026 after a resident fell. He stated he had not really noticed or paid attention that the condensation from the air conditioner was leaking onto the concrete slab. He stated the area underneath the air conditioner was black and there was built-up algae covering the area. He stated it was a safety hazard for the residents. The MS stated a resident could slip, fall and get injured. He stated he was not sure if there were lights in the Atrium. Interview on 8/15/26 at 12:32 PM with the DON revealed she was not aware of any residents having a fall in Atrium #2. Review of facility policy, Hazardous Areas, Devices and Equipment, dated July 2017, read All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. The safety committee will consist of members from the interdisciplinary team, which will include a representative from the clinical leadership, maintenance, and environment services teams.Identification of Hazards:A hazard is defined as anything in the environment that has the potential to cause injury or illness.Equipment and devices that are left unattended or are mal-functioning.Devices and equipment that are improperly used or poorly maintained.Insufficient lighting or glare.

Based on observation, interview and record review the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 of 4 days (8/13/26) and for 1 of 6 Residents (Resident #4)reviewed for sufficient staff. The facility failed to ensure there were 2 dietary staff for meal preparation and service for the breakfast and lunch meals. There was 1 cook who prepared and plated the breakfast and lunch meals on 8/13/26 resulting in the meals being served late. This deficient practice could place residents at risk of receiving their food late and result in the resident's food being cold. The findings were:Review of resident council minutes from February 2026 to August 2026 revealed during a council meeting on 2/6/26 residents complained the breakfast meal was cold. Review of Resident #4's face sheet, dated 8/15/26, revealed he was admitted to the facility on [DATE] with his primary diagnosis of Chronic Obstructive Pulmonary Disease (progressive lung diseases like emphysema and chronic bronchitis where the exact underlying type or specific cause is not detailed in the medical record), unspecified. Review of Resident #4's quarterly MDS assessment, dated 6/20/26, revealed his BIMS was 8 out of 15 reflective of moderate cognitive impairment. He required staff assistance with Setup or clean-up assistance. Review of Resident #4's Care Plan, dated 4/17/26 revealed he had an ADL/Self care deficit r/t activity intolerance, impaired balance, limited mobility and he required assistance: set up to supervision for eating. Observation on 8/13/26 at 12:31 PM revealed the food cart with the resident's lunch meal trays were delivered to the north-hall. Observation and interview in the dining room on 8/13/26 at 1:20 PM with Resident #4 revealed he was eating his lunch meal. He was served spaghetti with meat sauce, breaded cauliflower and a fruit cup. Resident #4 stated the food was alright. He stated it was cold and it was edible. He stated he liked his food hot; tasted better when it was hot. Interview on 8/13/26 at 1:49 PM with the DM revealed he arrived at the facility at about 11:00 AM. He stated staff on duty were [NAME] D and DA E, but DA E had to leave because of an emergency. He stated he came in to help, but the food shipment was delivered from their provider and he had to put it away. He stated [NAME] D prepared and plated the food for breakfast and lunch. He stated the meals were late. The DM stated breakfast was normally served between 7:00 AM to 7:15 AM. He stated [NAME] D reported he served breakfast about 8:00 AM. The DM stated the lunch carts to the north and south halls were normally delivered between 11:15 AM to 11:30 AM. He stated lunch was served at 12:00 noon in the dining room. The DM stated both the breakfast and lunch meals were served late because they were short-staffed. He stated he did not talk to any of the residents to inquire about the lunch meals being served late; however, he imagined the residents were probably not happy about having to wait. He stated a lot of the residents were assisted to the dining room early for meals so they waited longer than usual. Interview on 8/13/26 at 2:37 PM with [NAME] D revealed he and DA E arrived to work about 5;00 AM but DA E left about 2 hours after arriving because of an emergency. He stated he was the only one working for the breakfast meal and the lunch meal. He stated the breakfast meal was usually served about 7:00 AM but he served it about 8:00 AM. He stated the lunch meal carts went out to the north and south halls between 11:30 and 11:45 AM and lunch was served in the dining room at 12:00 noon. He stated he prepared and plated the breakfast meal and and the lunch meal. [NAME] D stated both meals were late because he was the only one working. He stated the resident's had to wait and staff kept asking him about when the food would be ready. [NAME] D stated he imagined the residents were not happy about having to wait for their meals. Interview on 8/13/26 at 5:45 PM with the ADM revealed he assumed his position about 2 months ago. He stated he understood, DA E left because of an emergency. He stated he called the DM to come in to assist. The ADM stated he was not sure what time the DM arrived to the facility. The ADM stated the goal was to have a kitchen that ran smoothly so they could provide residents with appetizing and hot food for the resident's satisfaction. The ADM stated it was difficult to do that with limited staff. The ADM stated some residents might be unhappy about the meals being served late. Review of facility policy, 'Food and Nutrition Services Staff, dated October 2017, read The food services department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department. 2. The department will maintain staffing levels sufficient to meet the resident's nutrition and preferences, taking into consideration the acuity, diagnoses, of the residents as well as assessments and plans of care.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 6 Resident's (Resident #3) and in 1 of 1 dining room reviewed for pests. Resident #3 was eating her lunch meal on 8/13/26. There were 3 or 4 flies swarming around which were distracting for Resident #3There were several flies swarming around the dining room during the lunch meal on 8/13/26. This deficient practice could place residents at risk of their food being contaminated and unsatisfactory eating conditions. The findings were:Review of Resident #3's face sheet, dated 8/14/26, revealed she was admitted to the facility on [DATE] with diagnoses including Senile degeneration of brain (generalized brain shrinking (cortical atrophy) or age-related mental decline seen in older adults), not elsewhere classified and Cognitive communication deficit (a breakdown in communication caused by impaired thinking processes-such as attention, memory, and executive function-rather than a basic loss of speech or language mechanics). Review of Resident #3's annual MDS assessment, dated 5/26/26, revealed her BIMS score was 3 of 15 reflective of severe cognitive impairment and she required supervision or touching assistance with eating. Review of Resident #3's Care Plan, dated 4/20/26, revealed ADL/Self care deficit r/t activity intolerance, senile degeneration of brain and one of the interventions included Eating assistance: Set up to supervision. Review of a the pest control invoice, dated 8/13/26, revealed the facility was treated for all insects throughout the building. Observation and interview on 8/13/26 at 12:41 PM revealed Resident #3 was sitting in bed with the head of bed up at about a 45 degree angle. She was slouched down in the bed. The bedside table was over the bed and she was eating her lunch meal, spaghetti with meat sauce, carrots and ice cream. Observation revealed Resident #3 was using her left hand to eat the spaghetti. The clothing protector was not on correctly and was not covering her chest area. Resident #3 had spaghetti all over her chest, meat sauce around her mouth and on her left hand. There were flies swarming around her, landing on her face, bedside table and on the edge of her plate. Resident #3 attempted to swat the flies away, but she was slow. Attempted interview with Resident #3 revealed she was very confused. Observation on 8/13/26 at 12:45 PM revealed RN G and CNA F entered Resident #3's room. Interview with RN G revealed Resident #4 had spaghetti all over her chest. She stated the clothing protector was not tied in the back and had slid down. She stated it was not covering her chest. RN G also stated Resident #3 had the tendency to slide down in bed and stated she needed repositioning. Further interviews with RN G and CNA F revealed there were flies swarming around Resident #3 and on her plate of food. RN G stated the flies would come into the facility from Atrium #2 where the residents who smoked gathered. She stated the residents were in and out of Atrium#2. CNA F stated the flies could contaminate Resident #3's food and could spread infections and diseases. CNA F stayed with Resident #3 for the rest of her meal. Observation on 8/13/26 at 1:20 PM revealed there were flies swarming around while the residents ate their lunch meal. Interview on 8/13/26 at 1:25 PM with CNA H revealed she saw the flies in the dining room and had kept them away from the resident's tray while she fed the resident. She stated the flies could contaminate the food because they carried diseases. CNA H stated she thought the flies entered the facility through the front door while people came in and left the facility. Interview on 8/14/26 at 6:10 PM with the MS revealed they had a pest control vendor that would come out and service the building every month. He stated the vendor came in yesterday, 8/13/26. The MS stated it was difficult to control the flies because they flew in through the front door as people entered and exited the facility. He stated the flies also entered the facility through Atrium#2 where the residents smoked because the residents would gather there often. He stated the flies were a nuisance to residents and staff alike. He stated flies often were infected and had diseases that could be passed onto the residents. Requested a pest control policy from the MS but he did not provide one.

Based on record review and interview, the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility reviewed for RN coverage. The facility failed to have the services of an RN on 04/11/2026, 04/12/2026, and 05/10/2026. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. The findings included:Record review of the facility's resident roster, dated 05/18/2026, revealed a census of 54 residents. Record review of the facility's Time detail from April 2026 to May 2026 reflected the facility did not have an RN working for a total of 8 hours on [NAME] 11th, 12th and May 10th of 2026. During an interview on 05/20/2026 at 10:08 AM, the DON revealed there were days when 8 hours of RN staffing hours were missing. She revealed it was important to have RN staff because it's a regulation and it was a regulation because RNs provided a supervisory role to LVN and CNAs. She further revealed they were in the process of hiring more RNs. During an interview on 05/20/2026 at 11:45AM, the ADM revealed it was important to have an RN work 8 hours per day because the additional training that an RN received was important to bring to the facility. He further revealed they were in the process of hiring more RNs and his goal was to have an RN available 24/7 for resident care. Record review of facility's policy Nursing Services-Registered Nurse (RN), revised 02/2026, reflected . 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day. 7 days per week. (The requirement for 8 consecutive hours of RN services can be met by any RN or multiples of RNs. The hours worked by the DON would be considered applicable towards the requirement.) .

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in clinical complications) for 2 of 8 residents (Residents #1 and #2) reviewed for resident rights. The facility failed to notify Resident #1 and Resident #2's physician when they each drank 1 [NAME] on 04/17/26. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The findings included:Record review of Resident #1's admission record, dated 05/19/26, reflected Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses to include cognitive communication deficit. It further revealed he was his own responsible party (RP). Record review of Resident #1's quarterly MDS assessment, dated 03/31/26, reflected Resident #1 had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #1's Order Summary Report, dated 05/19/2026, reflected .Call [hospice company] with any questions or concerns, dated 07/07/2025, May participate in activities as tolerated, dated 07/07/2025, and The physician acknowledges the benefit vs risks for the use of medications listed with a Black Box Warning (highlights serious risks of medications, ensuring both healthcare providers and patients are aware of severe potential side effects), dated 07/07/2025. Record review of Resident #2's admission record, dated 05/19/26, reflected Resident #2 was a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include need for assistance with personal care. It further revealed she was her own RP. Record review of Resident #2's quarterly MDS assessment, dated 05/09/26, reflected Resident #2 had a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #1's and Resident #2's electronic medical record reflected no change in condition occurred on 04/17/26 and that no contact was made to the physician. Record review of the facility's April 2026 activities calendar reflected a fiesta event that took place at the facility on Friday 04/17/26. During an interview on 05/19/2026 at 04:08 PM, the Activities Director revealed there was a fiesta event in April 2026 that served alcohol to only a select few residents that the DOR oversaw. During an interview on 05/19/2026 at 04:48 PM, the DOR revealed at the fiesta event in April 2026 the activities director told him that he oversaw handing out alcoholic drinks. He revealed he used his discretion in allowing residents to have alcoholic drinks, for example if a resident was a fall risk he knew not to allow them to drink alcohol. He revealed the vendor said only a little bit of alcohol was in the margaritas, but the DOR had watered down the drinks even more. The DOR was unaware of the exact amount of alcohol that was in the drinks. He revealed Residents #1 and #2 were the only residents who were served alcohol that did not have a doctor's order to drink alcohol. During an interview on 05/20/2026 at 07:08 AM, the DON revealed there was alcohol given to certain residents at the facility's fiesta event in April 2026. She revealed they were not aware that alcohol was going to be served at the fiesta event and if they knew alcohol was going to be served to residents at this event, she would have gotten doctor's orders for select residents to drink alcoholic drinks. She revealed Residents #1 and #2 were the only residents who drank an alcoholic drink that did not have doctor's orders to drink alcohol. She was not aware of any other residents that drank alcohol other than another resident who had standing doctor's orders to have alcohol. She further revealed that they did not contact these residents' doctors after they drank alcoholic drinks because these residents did not exhibit a change in condition. During an interview on 05/20/2026 at 09:15 AM, Resident #1's [hospice company revealed they were not contacted when Resident #1 attended an event at the facility where he consumed alcohol and they should have been contacted. They revealed that Resident #1 had been educated on his disease process and medications and risks associated with that. They revealed Resident #1 was alert and oriented and able to make his own decisions. They revealed they would not recommend that he drink alcohol, but he had a right to make his own decisions. Their focus with hospice was to improve his quality of life, which would include making his own decisions. They further revealed that if Resident #1 experienced a change in condition after drinking alcohol, then they would expect to be contacted. During an interview on 05/20/2026 at 09:31AM, Resident #2's [physician's group] revealed they were not contacted when Resident #2 consumed alcohol at a facility event. They revealed they would have put a doctor's order in for Resident #2 to have an alcoholic drink. After they reviewed Resident #2's medical record, they revealed it was okay that Resident #2 had an alcoholic drink. Record review of the facility's policy, revised 05/13/2025, Notification of Changes, reflected The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstance requiring notification include: 3. Circumstances that require a need to alter treatment.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 8 residents (Residents #3, 4, and 5)) reviewed for pharmacy services. The facility failed to check Resident #3's and Resident #4's blood sugars to administer their respective insulins per doctor's orders on 05/10/26 at 6:30 AM.The facility failed to ensure Resident #5 had Methadone HCl available to her on 05/09/26 at 07:00 PM, 05/10/26 at 07:00 AM, and 05/10/26 at 07:00 PM. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. Findings included: Record review of Resident #3's admission record, dated 05/18/26, reflected Resident #3 was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include type 2 diabetes (a chronic metabolic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). Record review of Resident #3's quarterly MDS assessment, dated 03/07/26, reflected Resident #3 had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #3's care plan, last review completed 03/17/26, reflected a focus of At risk for hypo-hyperglycemia (low-high blood sugar level), altered skin integrity, neuropathy r/t [Diabetes], initiated 04/18/26, with intervention Medications/blood sugar check as ordered by physician and as needed, initiated 04/18/26. Record review of Resident #3's Order Summary Report, dated 05/20/26, reflected Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale (blood sugar scale): if [blood sugars] 70-149=0; 150-199=4; 200-249=6; 250-299=8; 300-349=10, subcutaneously before meals and at bedtime for Diabetes GIVE 12 UNITS IF BLOOD SUGAR IS GREATER THAN 349, with start date 03/01/25. Record review of Resident #3's Medication Administration Record, dated 05/18/26, reflected Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 70-149=0; 150-199=4; 200-249=6; 250-299=8; 300-349=10, subcutaneously before meals and at bedtime for Diabetes GIVE 12 UNITS IF BLOOD SUGAR IS GREATER THAN 349 had a chart code of 19=Other-See Progress Note and no blood sugar was documented by LVN A for 05/10/26 at 06:30 AM. Record review of Resident #3's progress note, dated 05/10/26 at 12:12 PM and documented by LVN A, reflected Insulin Lispro Injection Solution 100 UNIT/ML . NO NURSE ASSIGNED TO HALL.Record review of Resident #3's electronic medical record reflected no change in condition occurred on 05/10/26. Record review of Resident #4's admission record, dated 05/19/26, reflected Resident #4 was a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include type 2 diabetes (a chronic metabolic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). Record review of Resident #4's quarterly MDS assessment, dated 03/20/26, reflected Resident #4 had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #4's care plan, last review completed 03/10/26, reflected a focus of At risk for hypo-hyperglycemia (low-high blood sugar level), altered skin integrity, neuropathy r/t [Diabetes], initiated 04/20/26, with intervention Medications/blood sugar check as ordered by physician and as needed, initiated 04/20/26. Record review of Resident #4's Order Summary Report, dated 05/20/26, reflected Insulin Aspart-szjj Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Aspart-szjj) Inject as per sliding scale: if 150-199=2 UNITS; 200-249=4 UNITS; 250-299=6 UNITS; 300-349=8 UNITS; 350-399=10 UNITS >400 CALL md, subcutaneously before meals and at bedtime for diabetes, with start date 03/31/26. Record review of Resident #4's Medication Administration Record, dated 05/19/26, reflected Insulin Aspart-szjj Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Aspart-szjj) Inject as per sliding scale: if 150-199=2 UNITS; 200-249=4 UNITS; 250-299=6 UNITS; 300-349=8 UNITS; 350-399=10 UNITS >400 CALL md, subcutaneously before meals and at bedtime for diabetes had a chart code of 19=Other-See Progress Note and no blood sugar was documented by LVN A for 05/10/26 at 06:30 AM. Record review of Resident #4's progress note, dated 05/10/26 at 12:11 PM and documented by LVN A, reflected Insulin Aspart-szjj Subcutaneous Solution Pen-Injector 100 UNIT/ML . NO NURSE ASSIGNED TO HALL. During an interview on 05/18/2026 at 03:01PM, Resident #3 revealed he did not get medication in a timely manner but he would let the nursing staff know about needing his medication when they were not on time. He did not reveal a time when he was not given his insulin. During an interview on 05/19/2026 at 09:40 AM, Resident #4 revealed medication was administered in a timely manner to include getting her blood sugar check and receiving insulin. During an interview on 05/19/26 at 02:42 PM, LVN A revealed she wrote a progress note about no nurse being assigned to a hallway because she was not made aware that this hallway needed nurse coverage to administer insulin. She revealed she was monitoring Resident #3 and Resident #4 and they had no change in condition from not checking their blood sugar or giving them insulin had they needed it. Record review of Resident #5's admission record, dated 05/18/26, reflected Resident #5 was a [AGE] year-old female admitted on [DATE] with diagnoses to include osteoarthritis (degeneration of joint cartilage and the underlying bone) of the hip, other muscle spasm (sudden, involuntary contraction of a muscle, muscle weakness, and other abnormalities of gait (manner of moving on foot) and mobility. Record review of Resident #5's quarterly MDS assessment, dated 03/12/26, reflected Resident #5 had a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #5's care plan, last review completed 03/17/26, reflected a focus of Potential adverse side effects from opioid medication use, initiated 04/20/26, with intervention Administer medications as ordered by physician, initiated 04/20/26. Record review of Resident #5's Order Summary Report, dated 05/18/26, reflected Methadone HCl Oral Table 5 MG. Give 1 tablet by mouth two times a day for Pain, with start date 03/05/26. Record review of Resident #5's Medication Administration Record, dated 05/19/26, reflected Methadone HCl Oral Tablet 5 MG. Give 1 tablet by mouth two times a day for Pain had a chart code of: 19=Other-See Progress Note by RN B for 05/09/26 at 07:00 PM, 19=Other-See Progress Note by LVN A for 05/10/26 at 07:00 AM, and 19=Other-See Progress Note by LVN C for 05/10/26 at 07:00 PM. Record review of Resident #5's progress note, dated 05/09/26 at 08:16 PM and documented by RN B, reflected Methadone HCl Oral Tablet 5 MG. on order. Record review of Resident #5's progress note, dated 05/10/26 at 11:22 AM and documented by LVN A, reflected Methadone HCl Oral Tablet 5 MG. PENDING DELIVERY FROM PHARMACY. Record review of Resident #5's progress note, dated 05/10/26 at 08:55 PM and documented by LVN C, reflected Methadone HCl Oral Tablet 5 MG. Awaiting delivery of med. During an interview on 05/19/2026 at 02:36 PM, Resident #5 revealed she did not have her pain medications for 4 to 5 days last week. She revealed these medications were narcotics and the facility blamed the pharmacy for not sending medications or not having her medications. She revealed her pain was okay and she was fine but upset that the facility did not have her medication During an interview on 05/19/26 at 02:42 PM, LVN A revealed Resident #5 had no methadone last week. She revealed the doctor and pertinent parties were aware that the facility was just waiting for the medication to arrive because it had to have a triplicate (3 copy prescription form). She further revealed she monitored Resident #5 during this time and her pain was manageable. She said there was no uncontrolled pain otherwise she would have called the doctor. During a combined interview on 05/20/2026 at 05:05AM, RN B revealed Resident #5 did not have her pain medications for an unknown amount of time and was unsure if this was due to the facility or the doctor. RN B ensured that she monitored Resident #5's pain during this time. She revealed Resident #5 was not in pain and the resident was more annoyed than anything. LVN C revealed she did not recall when Resident #5 did not have Methadone. During an interview on 05/20/26 at 07:08 AM, the DON revealed there was a doctor's order for Resident #3 and Resident #4 to have their blood sugars checked by a [blood glucose monitoring tool] to monitor chronic illness and make sure their blood sugars were within normal limits and residents did not have adverse effects. She revealed Resident #4 and Resident #3 did not have a change in condition due to this missed Accu-check. She further revealed LVN A had misunderstood her assignment and did not check these residents' blood sugar levels to see if they needed insulin. She revealed this was corrected by explaining the nurse's duties that needed to be followed. The DON revealed Resident #5 did not have 3 doses of Methadone from 05/09/26 to 05/10/26. She revealed the facility should be proactively ordering refills. She revealed the pharmacy needed 3 to 4 days' notice to refill medications in a timely manner. She further revealed narcotics needed a triplicate which required a doctor signing a physical form. Record review of facility's policy Medication Administration, dated 05/09/25, reflected Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and #2) reviewed for care plans:1. The facility failed to ensure Resident #1's care plan reflected the resident's family members had been instructed/educated regarding the requirement that resident care be provided by facility staff rather than by family members.2. The facility failed to ensure Resident #2's care plan reflected he had been assessed to safely self-administer medications.These deficient practices could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.The findings included:1. Record review of Resident #1's face sheet dated 5/14/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included respiratory failure, morbid/severe obesity, urinary tract infection, and tracheostomy status (surgical procedure in which an opening is made in the front of the neck into the trachea [windpipe] to help a person breathe).Record review of Resident #1's Order Summary Report dated 5/14/26 reflected the following:- has indwelling (urinary) catheter indicated for neurogenic bladder (condition in which the bladder does not function normally because of problems with the nerves that control urination) order date 5/13/26 and no end date- monitor and record catheter output every shift with order date 5/8/26 and no end date- position catheter privacy bag and tubing below level of bladder every shift with order date 5/8/26 and no end dateRecord review of Resident #1's care plan with initiation date 5/11/26 reflected there was no focus, goal, or intervention that included family members had been instructed/educated regarding the requirement that resident care be provided by facility staff rather than by family members. During an interview on 5/14/26 at 12:37 p.m., Resident #1 was observed in the room and two family members at the bedside. Resident #1 stated he was admitted to the facility a week ago. Resident #1 was observed with an indwelling urinary catheter and sitting up in a wheelchair. Resident #1's family member stated she had been having to help the resident to the bathroom because nobody will come. During an interview on 5/14/26 at 1:07 p.m., RN B stated he had several discussions and provided education to Resident #1 and his family members about providing care to the resident. RN B stated, Resident #1's family member had requested disposable wipes and when asked why, the family member told RN B the wipes were needed to clean him. RN B stated he had educated the family not to provide care to Resident #1 and to call us for help.During an observation and interview on 5/15/26 at 8:52 a.m., Resident #1's family member was observed walking out of the resident's room and obtained a pair of gloves from the box mounted on the wall outside of the resident's room. Resident #1's family member stated he needed a pair of gloves because he had assisted Resident #1 to the bathroom and needed to put on gloves to clean him. RN B approached the State Surveyor and Resident #1's family member at the same time and stated he had educated Resident #1 and the resident's family members on numerous occasions regarding this behavior. During an interview on 5/15/26 at 11:40 a.m., the DON stated, she did not know Resident #1 well but was aware the resident's family members were at the resident's bedside all the time. The DON stated she was made aware of the resident's family members providing care to the resident a day earlier because RN B reported the behavior to her. The DON stated, it was a concern because there were safety concerns since the family members were providing care to Resident #1. The DON stated, as soon as a problem was identified, and if the family members were provided with education or any kind of feedback, the staff should be documenting it as soon as it happened. The DON stated RN B would be capable of revising or adding that problem to Resident #1's care plan and document that education was provided to the resident and the family members. During a follow up interview on 5/15/26 at 12:04 p.m., RN B stated he had worked with Resident #1 from the time of his admission on [DATE] and stated the family is almost always here and the resident's room is always packed with family. RN B stated the family members are not supposed to assist Resident #1 to get up because they did not know the strength of the resident, and the family members should be calling staff because the resident could have a fall or hit his head. RN B stated Resident #1's family member asked for disposable wipes that same morning and had educated the family about asking for help and they had acknowledged that they understood. RN B stated, the family members assisting the resident without asking for help has been since day one. RN B stated he had never put information in a care plan and believed management and the DON developed the care plan. RN B stated, if a behavior was exhibited consistently then it should be reported to the DON and the behavior would then need to be care planned. RN B stated he had not documented or kept a record of having had the discussion or education with Resident #1 and family members on what they are doing, but I will make it a point to document it today. 2. Record review of Resident #2's face sheet dated 5/14/26 reflected a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included factitious disorder imposed on self with combined psychological and physical signs and symptoms, need for assistance with personal care, muscle weakness, and obsessive-compulsive disorder.Record review of Resident #2's most recent quarterly MDS assessment dated [DATE] reflected that the resident was cognitively intact for daily decision-making skills and only required set-up or clean-up assistance with ADL's and mobility.Record review of Resident #2's comprehensive care plan with revision date 2/25/26 did not reflect the resident was able to self-administer medications.Record review of Resident #2's Self Administration of Medication Evaluation with effective date 7/3/25 and authored by LVN D reflected the resident was capable of independent self-administration of medications and the physician's orders stated the resident may self-administer. Record review of Resident #2's Order Details document dated 4/24/26 and time stamped 1:41 p.m. prescribed by the NP reflected the following:- Permethrin cream 5%, apply to body topically one time only; apply on body, neck down and leave on for 8 hours for 1 day and repeat in 7 daysRecord review of Resident #2's Order Summary Report dated 5/14/26 reflected there was no order that indicated the resident could self-administer medications.During an observation and interview on 5/14/26 at 9:07 a.m., Resident #2 stated he overheard of an outbreak of scabies in the facility and several residents were treated. Resident #2 walked over to the vanity in his room, opened the drawer and took out a tube of Permethrin 5% cream with the pharmacy label attached to it with the resident's name on it. Resident #2 stated an unidentified nursing staff provided him with the cream 3 weeks ago and applied the cream to his hands. Resident #2 stated he only applied the cream to his hands once and kept the tube. Resident #2 stated he was the most cognitive and most alert resident and was waiting for the doctor to approve being allowed to self-administer medications. During an interview on 5/14/26 at 10:12 a.m., the DON stated she had been employed at the facility since February 2026, and since that time there were no residents in the facility who had been assessed to self-administer medications, and she did not have any residents who requested to self-administer medications. The DON stated, per her expectation, that for a resident who wanted to self-administer medications, there would have to be an assessment, and if appropriate to self-administer, a physician's order, and it would have to be care planned. The DON stated she was not aware Resident #2 had been assessed to self-administer medications and the resident had never asked to be allowed to self-administer medications. During an interview on 5/15/26 at 8:52 a.m., RN C stated she was not aware of any of the residents in the facility who had been assessed and allowed to self-administer medications. RN C stated, if a resident had been assessed and determined to be able to safely self-administer medication, then an order would have to be obtained, and it absolutely, it should be care planned. During an interview on 5/15/26 at 10:00 a.m., the ADON stated she was aware there was an assessment involved that determined if a resident was able to self-administer medications. The ADON stated in addition to an assessment, the nurse would have to obtain orders for the residents to self-administer medications and it would have to be included in the care plan. The ADON stated, the care plan was important because it helped the staff know that the resident had the ability to safely self-administer medications. The ADON stated, care plans were revised by herself and the DON.During an interview on 5/15/26 at 10:21 a.m., LVN D stated she completed the Self Administration of Medication Evaluation with effective date 7/3/25 for Resident #2. LVN D stated the assessment was done during July 2025, because Resident #2 had requested to go out on pass and the resident wanted to take his medications with him. LVN D stated, Resident #2 was hospitalized shortly after that, so LVN D did not obtain a physician's order or update the care plan to reflect the resident could self-administer medications. LVN D stated, since Resident #2 often complained of symptoms and had been diagnosed with fictitious disorder, which made the resident focus on an illness he really didn't have, the resident would probably not be capable of self-administering medications. During an interview on 5/15/26 at 10:48 a.m., the Treatment Nurse stated, to determine if a resident was able to safely self-administer medications it would require an assessment, a physician's order and it would have to be care planned. The Treatment Nurse stated, everything needs to be care planned because it showed the resident was able to self-administer medications and she believed the care plan would be revised by the DON, but not sure.Record review of the facility document titled Comprehensive Care Plans with implementation date 2/2025 reflected in part, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.The comprehensive care plan will describe, at a minimum, the following.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 1 of 5 Residents (Resident #2) reviewed for medication storage:The facility failed to ensure Resident #2 did not have a tube of Permethrin 5% cream (a topical medication used to treat scabies; a contagious skin condition caused by tiny mites that burrow into the skin) inside a drawer in the resident's vanity.This deficient practice could affect residents who received medications in the facility and place them at risk for not receiving the correct medications, medication misuse or drug diversion.The findings included:Record review of Resident #2's face sheet dated 5/14/26 reflected a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included factitious disorder imposed on self with combined psychological and physical signs and symptoms (mental health diagnosis in which a person intentionally exaggerates, falsifies, or causes both physical and psychological symptoms in themselves, even though there is no obvious external reward such as money, avoiding work, or legal benefit), need for assistance with personal care, muscle weakness, and obsessive-compulsive disorder.Record review of Resident #2's most recent quarterly MDS assessment dated [DATE] reflected that the resident was cognitively intact for daily decision-making skills and only required set-up or clean-up assistance with ADL's and mobility.Record review of Resident #2's comprehensive care plan with revision date 2/25/26 did not reflect the resident was able to self-administer medications.Record review of Resident #2's Self Administration of Medication Evaluation with effective date 7/3/25 and authored by LVN D reflected the resident was capable of independent self-administration of medications and the physician's orders stated the resident may self-administer. Record review of Resident #2's Order Details document dated 4/24/26 and time stamped 1:41 p.m. prescribed by the NP reflected the following:- Permethrin cream 5%, apply to body topically one time only; apply on body, neck down and leave on for 8 hours for 1 day and repeat in 7 daysRecord review of Resident #2's Order Summary Report dated 5/14/26 reflected there was no order that indicated the resident could self-administer medications.During an observation and interview on 5/14/26 at 9:07 a.m., Resident #2 stated he overheard of an outbreak of scabies in the facility and several residents were treated. Resident #2 walked over to the vanity in his room, opened the drawer and took out a tube of Permethrin 5% cream with the pharmacy label attached to it with the resident's name on it. Resident #2 stated an unidentified nursing staff provided him with the cream 3 weeks ago and applied the cream to his hands. Resident #2 stated he only applied the cream to his hands once and kept the tube. Resident #2 stated he was the most cognitive and most alert resident and was waiting for the doctor to approve being allowed to self-administer medications. During an interview on 5/14/26 at 10:12 a.m., the DON stated she had been employed at the facility since February 2026, and since that time there were no residents in the facility who had been assessed to self-administer medications, and she did not have any residents who requested to self-administer medications. The DON stated, per her expectation, that for a resident who wanted to self-administer medications, there would have to be an assessment, and if appropriate to self-administer, a physician's order, and it would have to be care planned. The DON stated, medications could not be left with the resident because there could be a risk of somebody else having access to the medication and it could be used inappropriately, or it could be a risk for injury or adverse effects. The DON stated, Resident #2 was treated for scabies prophylactically at the resident's request because of his factitious disorder diagnosis which caused him to hyperfocus on a symptom or condition and would insist on treatment even when he didn't have an illness. The DON stated she was not aware Resident #2 had been assessed to self-administer medications and had never asked to be allowed to self-administer medications. During a telephone interview on 5/15/26 at 8:52 a.m., RN C stated she had been employed by the facility for 2 months and since that time did not have any residents in the facility who had physician's orders to self-administer medications. RN C stated she was aware Resident #2 had been prescribed Permethrin 5% cream used to treat scabies because the resident kept telling her about it. RN C stated she had seen the box of the Permethrin 5% cream in the medication cart, but tube was not in the box. RN C stated she recalled when the Permethrin 5% cream was delivered by the pharmacy and recalled the cream was applied to Resident #2 by another nurse but could not recall which nurse. RN C stated she believed the DON and the Administrator, as well as the nurse would have to know if a resident was cognitive and able to self-administer medications. RN C stated, for a resident to self-administer medications there would need to be an assessment, a physician's order, and it should be care planned. During an interview on 5/15/26 at 10:00 a.m., the ADON stated she had been employed by the facility as the ADON for the past 3 months. The ADON stated she had not done an assessment on residents in the facility to self-administer medications and was not aware of any residents in the facility who were allowed to self-administer medications. The ADON stated she was aware of an assessment to self-administer medications and if a resident was able to self-administer medications, then there should also be a physician's order. The ADON stated if a resident was determined to be able to self-medicate then she and the DON would have to revise the care plan. During an interview on 5/15/26 at 10:21 a.m., LVN D stated she completed the Self Administration of Medication Evaluation with effective date 7/3/25 for Resident #2. LVN D stated the assessment was done during July 2025, because Resident #2 had requested to go out on pass and the resident wanted to take his medications with him. LVN D stated, Resident #2 was hospitalized shortly after that, so LVN D did not obtain a physician's order or update the care plan to reflect the resident could self-administer medications. LVN D stated, since Resident #2 often complained of symptoms and had been diagnosed with fictitious disorder, which made the resident focus on an illness he really didn't have, the resident would probably not be capable of self-administering medications. During an interview on 5/15/26 at 10:48 a.m., the LVN Treatment Nurse stated, Resident #2 was convinced he had scabies and an order was obtained to treat him prophylactically. The LVN Treatment Nurse stated, Resident #2 had eczema on his hands but the resident was not allowed to have medications in his possession as there were no residents in the facility, including Resident #2 who had been cleared to self-administer medications. The LVN Treatment Nurse stated, for residents who were allowed to self-administer there should be an assessment, physician's orders, and the ability to self-administer medications would have to be care planned. If the resident was allowed to have medications in their possession, the facility would have to provide a lock box in the resident's room, and the resident would have to demonstrate he or she could lock the medications. Record review of the facility document titled Resident Self-Administration of Medication with revision date 5/2026 reflected in part, .It is the policy of this facility to support each resident's right to self-administer medications. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.Resident's preference will be documented on the appropriate form and placed in the medical record.The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is maintained in the resident's medical record.Record review of the facility document titled Medication Administration with revision date 5/7/25 reflected in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Record review of the facility document titled Medication Storage with revision date 6/15/25 reflected in part, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.All drugs and biologicals will be stored in locked compartments.Only authorized personnel will have access to the keys to locked compartments.medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #2) reviewed for accuracy of records:The facility failed to ensure nursing staff documented Resident #2 had been assessed to self-administer medications.This failure could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings included:Record review of Resident #2's face sheet dated 5/14/26 reflected a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included factitious disorder imposed on self with combined psychological and physical signs and symptoms (mental health diagnosis in which a person intentionally exaggerates, falsifies, or causes both physical and psychological symptoms in themselves, even though there is no obvious external reward such as money, avoiding work, or legal benefit), need for assistance with personal care, muscle weakness, and obsessive-compulsive disorder.Record review of Resident #2's most recent quarterly MDS assessment dated [DATE] reflected that the resident was cognitively intact for daily decision-making skills and only required set-up or clean-up assistance with ADL's and mobility.Record review of Resident #2's comprehensive care plan with revision date 2/25/26 did not reflect the resident was able to self-administer medications.Record review of Resident #2's Self Administration of Medication Evaluation with effective date 7/3/25 and authored by LVN D reflected the resident was capable of independent self-administration of medications and the physician's orders stated the resident may self-administer. Record review of Resident #2's Order Details document dated 4/14/26 and time stamped 1:41 p.m. prescribed by the NP reflected the following:- Permethrin cream 5%, apply to body topically one time only; apply on body, neck down and leave on for 8 hours for 1 day and repeat in 7 daysRecord review of Resident #2's Order Summary Report dated 5/14/26 reflected there was no order that indicated the resident could self-administer medications.During an observation and interview on 5/14/26 at 9:07 a.m., Resident #2 stated he overheard of an outbreak of scabies in the facility and several residents were treated. Resident #2 walked over to the vanity in his room, opened the drawer and took out a tube of Permethrin 5% cream with the pharmacy label attached to it with the resident's name on it. Resident #2 stated an unidentified nursing staff provided him with the cream 3 weeks ago and applied the cream to his hands. Resident #2 stated he only applied the cream to his hands once and kept the tube. Resident #2 stated he was the most cognitive and most alert resident and was waiting for the doctor to approve being allowed to self-administer medications. During an interview on 5/14/26 at 10:12 a.m., the DON stated she had been employed at the facility since February 2026, and since that time there were no residents in the facility who had been assessed to self-administer medications, and she did not have any residents who requested to self-administer medications. The DON stated, per her expectation, that for a resident who wanted to self-administer medications, there would have to be an assessment, and if appropriate to self-administer, a physician's order, and it would have to be care planned. The DON stated she was not aware Resident #2 had been assessed to self-administer medications and the resident had never asked to be allowed to self-administer medications. During an interview on 5/15/26 at 10:21 a.m., LVN D stated she completed the Self Administration of Medication Evaluation with effective date 7/3/25 for Resident #2. LVN D stated the assessment was done during July 2025, because Resident #2 had requested to go out on pass and the resident wanted to take his medications with him. LVN D stated, Resident #2 was hospitalized shortly after that, so LVN D did not obtain a physician's order or update the care plan to reflect the resident could self-administer medications. LVN D stated, since Resident #2 often complained of symptoms and had been diagnosed with fictitious disorder, which made the resident focus on an illness he really didn't have, the resident would probably not be capable of self-administering medications. Record review of the facility document titled Resident Self-Administration of Medication with revision date 5/2026 reflected in part, .It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.Resident's preference will be documented on the appropriate form and placed in the medical record.The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is maintained in the resident's medical record.Record review of the facility document titled Documentation in Medical Record with implementation date 4/2026 reflected in part, .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 4 residents (Resident #1) reviewed for infection control:The facility failed to ensure Resident #1's indwelling urinary catheter tubing was not touching the floor. This failure could place residents at risk of infection due to improper care practices.The findings included:Record review of Resident #1's face sheet dated 5/14/26 reflected a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, diabetes, urinary tract infection, heart failure, and tracheostomy status (a surgical procedure where a doctor makes an opening in front of the neck into the trachea [windpipe] to help a person breathe).Record review of Resident #1's Order Summary Report dated 5/14/26 reflected the following:- Change catheter drainage bag monthly and as needed for leaking or malfunction with order date 5/8/26 and no end date.- urinary catheter care every shift and as needed, cleanse with soap and water or peri-wash as needed with order date 5/8/26 and no end date.-Position urinary catheter privacy bag and tubing below level of the bladder with order date 5/8/26 and no end date.-Enhanced Barrier Precautions related to indwelling medical device; urinary catheter every shift with order date 5/8/26 and no end date.Record review of Resident #1's comprehensive care plan dated 5/11/26 did not address the resident's use of a urinary indwelling catheter.Record review of Resident #1's Clinical admission document with effective date 5/8/26 reflected the resident utilized a urinary catheter. During an observation on 5/14/26 at 12:37 p.m., Resident #1 was seen sitting up in a wheelchair, and the indwelling urinary catheter was draining via gravity on the resident's left side, and the tubing was touching the floor. Resident #1's indwelling urinary catheter tubing was touching the floor in front of the resident's feet and between his bedside table. Resident #1's family member was at the bedside and stated she had been having to help the resident to the bathroom because nobody will come. Resident #1 did not or would not answer the State Surveyor's questions regarding the urinary indwelling catheter.During an observation and interview on 5/14/26 at 12:54 p.m., CNA A stated he often worked the same unit Resident #1 resided on and made rounds of the resident at least every two hours. CNA A stated he and the charge nurse for the unit were responsible for the care of the urinary indwelling catheter. CNA A observed Resident #1's indwelling urinary catheter tubing touching the floor and stated it should not be touching the floor because it was cross contamination and an infection control issue. CNA A stated that the indwelling urinary catheter tubing observed between the resident's feet and the bedside table could potentially get tangled in the bedside tables wheels or the tubing could get stepped on which could cause injury to the resident. During an observation and interview on 5/14/26 at 1:07 p.m., RN B observed Resident #1's indwelling urinary catheter touching the floor between the resident's feet and the bedside table and stated the tubing should not be touching the floor because it was an infection control issue and could result in the resident developing an infection. RN B stated Resident #1 could also fall and trip on the indwelling urinary catheter tubing or the catheter could dislodge if stepped on. During an interview on 5/15/26 at 11:40 a.m., the DON stated, ensuring the indwelling urinary catheter bags and tubing were not touching the floor because keeping those items off the floor was considered an infection control standard of care and to maintain a closed drainage system and prevent infection. Record review of the facility document titled Catheter Care dated 11/25/25 reflected in part, .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.

Based on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one 1 of one 1 kitchen reviewed for food safety requirements. The facility failed to ensure: Dishes were kept clean and dry. Food in the walk-in refrigerator was fresh and dated. Food in the walk-in freezer was dated and stored properly. Storage bins and serving utensils were clean. These failures could place residents at risk for the spread of infections, food contamination, food-borne illnesses, and diminished quality of life. Findings included: 1. Observation of the kitchen on 4/22/26, beginning at 10:35 am, revealed a rack next to the handwashing sink. The rack contained trays with dishes stacked on top of the trays. Further observation revealed that when the DM washed her hands, water splashed on a tray with dessert bowls stacked on top of it and pooled on the tray. Further observation of revealed dessert bowls on a tray next to the handwashing sink that were stacked on top of each other. Two bowls were removed from the top of the stack by the investigator; those bowls were moist and had food particles on the inside bottom of the bowls. On the rack above the dessert bowls, there were saucers stacked on top of each other. Three saucers were removed from the top of the stack, and they had food particles on the bottom. On the rack on top of the saucers were cups stacked on top of each other. There was a brown substance on the rim of three cups on top of the stack. The DM confirmed the dishes observed were not dry and had food particles on them. 2. Observation of the walk-in refrigerator on 4/22/26 at 10:44 a.m., revealed a bag of celery that was brown in color, a small plastic bin with tomatoes, and another small plastic bin with red bell peppers that were not dated. 3. Observation of the walk-in freezer on 4/22/26 at 10:47 a.m. revealed breadsticks in a plastic bag that were not dated. Further observation revealed an open bag of frozen carrots that were open and not dated. 4. Observation and interview in the kitchen on 4/22/26 at 12:08 p.m., revealed two bins on a shelf with serving utensils inside, one of the bins had a ladle with food particles on it, the bottom of the bins also had food particles, visibly dirty, and sticky. The DM said the utensils in the bin were supposed to be clean and the bins were not supposed to be like that. During an interview on 4/22/26 at 1:18 p.m., the DM said she was responsible for ensuring that all foods were stored properly and labeled with the opened date, adding she must have missed a few items. The DM said that she did not believe having open and undated items could negatively affect the residents because before the food was served, she ensured that it was edible. The DM said it was important to ensure food items were dated so that prepared food was not served to residents after 3 days. And unprepared, unopened items after 6 days of being stored on the shelves. The DM further stated it was important frozen food items were dated so they were not used after 1 year of being stored in the freezer, adding it was important to ensure the packages were not left open while in the freezer to avoid freezer burn. The DM said it was not a good idea to have the shelf next to the hand-washing sink because water splashes on the tray with the clean dishes. The DM said the dishes should not be stacked on top of each other to dry because the condensation will still be there, he said this was important because the dishes could start growing mold. The DM further stated this could make the residents sick or upset their stomachs. The DM said dirty utensils and dishes could cause cross contamination and make the residents sick. The DM said everybody was responsible for ensuring the utensils and the bins were kept clean. Record review of the facility policy, titled Food Safety Requirements, dated 4/8/2026, revealed: .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.e. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food.3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage.Practices to maintain safe refrigerated storage include.Labeling, dating, and monitoring refrigerated food.Keeping foods covered or in tight containers.6. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. Record review of the facility's policy, titled Date Marking for Food Safety, dated 4/8/2026, revealed: .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.

Based on observations, interviews, and record reviews, the facility failed to 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 2 of 2 residents (Resident #3 and Resident #5) reviewed for infection control. The facility failed to ensure: CNA A performed hand hygiene according to facility policy and followed infection control procedures while providing care for Resident #5 on 4/14/26.CNA B followed EBP and infection control procedures while providing care for Resident #3 on 4/14/26. This deficient practice could affect all residents who receive care, placing them at risk of infection. Findings included: 1. Record review of Resident #5's admission Record, dated 4/14/26, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Need for assistance with personal care. Record review of Resident #5's Care Plan, dated 3/7/25, revealed the resident had impaired physical functioning related to mobility impairment and self-care impairment. Observation of peri-care for Resident #5, on 4/14/26 at 11:20 a.m., revealed CNA A washed his hands prior to providing care for 5 seconds. Further observation revealed CNA A removed his gloves and sanitized his hands for 2 seconds after cleaning Resident #5's genital area. Further observation revealed CNA A cleaned the resident's buttocks, disposed of trash and dirty linen, replaced the resident's pillows, blankets, positioned the bed, and handed the remote to the Resident #5 without changing his gloves or performing hand hygiene. During an interview on 4/14/26 at 11:31 a.m., Resident #5 said he was not sure about infection control but knew that staff washed their hands. During an interview on 4/14/26 at 1:10 p.m., CNA A said when he washed his hands, he usually sang the birthday song, which was about 10 seconds. CNA A further stated he did not know how long it was recommended to wash hands for. CNA A said when using hand sanitizer hands should be rubbed together until they were dry, about 5 seconds. CNA A said he was not aware that he only washed his hands for 5 seconds. CNA A said the sanitizer dried real fast. CNA A further stated he had not realized that he did not remove his gloves or perform hand hygiene after cleaning Resident #5's buttocks. CNA A further stated it was important to perform hand hygiene as recommended to avoid cross contamination because whatever bacteria that was on his hands could be transferred to the resident. During an interview on 4/20/26 at 4:31 p.m., the DON said the expectation was for staff to wash their hands for at least 20 seconds, to help prevent the spread of infections. The DON further stated this was important because not doing so could potentially cause infection. The DON said it was ultimately her responsibility to ensure staff performed hand hygiene as recommended, as the infection preventionist. 2. Record review of Resident #3's admission Record, dated 4/14/26, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: ESRD (kidneys can longer function due to permanent damage), Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar) , dependence on renal dialysis (treatment for kidney failure), need for assistance with personal care. Record review of Resident #3's Care Plan, dated 4/2/26, revealed the resident was incontinent of bowel and bladder, self-care deficit related to mobility impairment and self-care impairment, and was on enhanced barrier precautions related to permcath (a device placed under the skin to provide vascular access). Record review of Resident #3's Order Summary, dated 4/14/26, revealed an order for enhanced barrier precautions related to permcath, dated 3/1/26. Observation of peri-care for Resident #3 on 4/14/26, beginning at 1:33 pm, revealed CNA B did not donn PPE prior to entering the resident's room. Further observation revealed there was not an EBP sign outside the resident's door, there was PPE outside the resident's room. Further observation revealed CNA B, after cleaning feces, retrieved a clean washcloth to dry the resident's buttocks, retrieved barrier cream from the resident's side table and applied some to the resident's buttocks, held the resident's hands to assist her with turning on her left side, fastened the resident's brief, and removed the pillow from behind the resident's head without removing the dirty gloves or performing hand hygiene. During an interview on 4/14/26 at 2:00 p.m., Resident #3 said she could not say that staff followed infection control practices all the times. Resident #3 further stated that somebody wore a gown once the previous week but that was the only time. During an interview on 4/14/26 at 1:45 p.m., CNA B said she did not take her gloves off until she was done with everything. CNA B further stated that she put gloves on when she went into a resident's room and took them off when she left the room. CNA B said she did not know what the expectations were but knew that she could not go from room to room with gloves on and could not from resident to resident with the same gloves on. CNA B said that Resident #3 was not on EBP. During an interview on 4/20/26 at 4:31 p.m., the DON said the expectation for staff to change their gloves when they were going from a dirty area to a clean area. The DON further stated staff should assume their gloves were dirty when proving care and not touch other items in the room, such as pillows, remotes, or linen to avoid cross contamination. The DON said that Resident #3 was on EBP. The DON said Resident #3 had an order in place for EBP, but the sign was not on the door. The DON said staff were expected to follow EBP for any high contact resident care activities for residents with wounds and indwelling devices to help prevent the spread of Multi-drug-resistant organisms. Record review of the facility's policy titled Hand Hygiene, dated 4/11/2025, revealed: .4. Hand hygiene technique when using an alcohol-based hand rub.b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds. 5. Hand hygiene technique when using soap and water.Run hands together vigorously for at least 20 seconds. Record review of the facility's policy titled Perineal Care dated 5/2/2025, revealed: .Apply other personal protective equipment as appropriate.a. Cleanse buttocks and anus.Change gloves and continue with perineal care.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 15 residents (Resident#74) reviewed for accident hazards and supervision. Resident #74 eloped at night and crossed a busy 5-lane road before she was found at a bus stop by an off-duty CNA. This failure resulted in the identification of an IJ (Immediate Jeopardy) on 09/10/25. While the immediacy was removed on 09/12/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal This failure could place residents at risk for elopement, significant injury, and serious impairment or death.The Findings included:Observation on 9/9/25 from 8:50 AM to 10:15 AM of facility reflected: the inside door to the front lobby had a charm and keypad; the charm sounded when the door was opened. The door had an old wandering alert system not working and an electronic magnetic lock not working. The front door of the facility had no charm and/or keypad system or 15 second delay system; the front door was locked by a dead bolt. Receptionist desk was adjacent to the front door. Receptionist was present at the receptionist desk. Further observation of the path Resident #1 took during the elopement incident reflected the bus stop was about 150 feet from the facility. The bus stop was off the facility's ground and a 5-lane highway with busy traffic was adjacent to the bus stop. The resident had to cross the 5-lane road to get to the bus stop. Record review of Resident #74's face sheet, dated 9/10/25, reflected a 75 -year-old female who was admitted to the facility on [DATE] for respite care and discharged [DATE]. Resident #74 had diagnoses which included: HTN (hypertension), dementia (brain disorder resulting in decline in cognition), Alzheimer's disease (progressive disease that destroys memory), and breast cancer. The RP was listed as a family member. Record review of Resident's MDS, dated [DATE] in progress, reflected the resident's BIMS score was zero indicative of severe impairment in cognition. Resident was ambulatory. Record review of facility's incident report dated 9/6/25 titled Elopement Attempt Report, Resident #74, reflected: the timeline of elopement, namely between 8:59 PM and 10:08 PM. Further, the interview the Administrator had with the resident at 9/7/25 at 9:45 AM, the resident communicated to the Administrator she looked for an opportunity to elope and did not want to remain in the facility and wanted to visit her sister. The resident stated her work was done and she did not need to occupy a bed of another patient. Record review of Resident #74's Ambulation Assessment, dated 9/3/25, reflected resident was ambulatory. Record review of Care Plan dated 9/3/25 (baseline) read: .Assess for risk of elopement.Frequent rounding of resident. Record review of Resident #74 elopement score, dated 9/3/25 was 7 (moderate risk) [3-7score equaled moderate risk for elopement] Record review of Resident #74's Nurse Note, dated 9/6/25, at 8:58 PM authored by RN E reflected resident was seen wandering throughout the facility. Record revies of Resident #74's Nurse Note dated 9/6/25 at 10:33 PM authored by RN E read, .CNA [D] reports to this nurse [RN E], resident noted at bus stop across the street from facility. Brought resident back in with him. Resident confused; states she is trying to find her sister. Resident denies being hurt or any pain. Respiration even. Skin warm and dry. Skin assessment clear, no issues. [vitals]116/74 [blood pressure]62 [pulse] 18 [respiration] 97.8 [temperature] 96% [O2]Room Air Assisted to room and into bed. No acute distress noted. Call placed and message left for RP. Record review of facility's Elopement Binder, undated, found at the receptionist's desk reflected the presence of 15 face sheets with photographs. Resident #74 's face sheet and photo were in the binder. Record review of receptionist's written statement undated reflected she left the receptionist station around 9:40 PM to purchase dinner at a nearby restaurant. Receptionist stated she did not turn on the foyer alarm at 8:00 PM and she could not recall setting the alarm at 10:00 PM. During an interview on 9/9/25 at 10:10 AM the Maintenance Director, who accompanied the survey on Resident #74's route of elopement, stated he could not explain why the inside door charm was not heard and the keypad not set after 8:00 PM. The Maintenance Director stated the facility did not have a patient alert system. The Maintenance Director stated the distance to the bus stop was about 150 feet from the facility. The Maintenance Director stated it was a negative incident for a resident to wander to the bus stop because of the dangers of traffic, accidents and hazards, and stray dogs. The Maintenance Director stated the last time he checked the door alarm system was 8/25/25 and there were no concerns and he checked the alarm system weekly. During an interview on 9/9/25 at 11:05 AM, the DON stated Resident #74 was discharged on 9/8/25 around 5 PM because she needed to be in an environment that she was more comfortable in, and her family returned to town yesterday (9/8/25). The DON stated the resident was scheduled for respite care for 8 days at the time of admissions (9/3/25). The DON stated the resident's primary diagnoses included dementia, breast cancer, HTN, and pain; and the resident's BIMs was a zero (severe impairment). The DON stated Resident #74' elopement assessment on 9/3/25 scored was 07 indicative of at risk for elopement. The DON stated RN E documented that the resident was confused on 9/6/25 [date of elopement] and wandering throughout the facility and easily redirected. The DON stated that in RN E's statement she visibly saw the resident around 9:50 PM and the resident was following CNAs down the hall. The DON stated the last time Resident #74 was seen was at 10:08 PM by CNA D at the bus stop and brought back to the facility. The DON stated that Resident #74 communicated to CNA D she wanted to go home. DON stated the resident was assessed by RN E and the resident did not exhibit any adverse physical or psychosocial harm. The DON stated the RP, and the MD were notified. The DON stated a receptionist [Receptionist F] was not present between 9:50 PM and 10:08 PM (an 18-minute gap). The DON repeated there was no receptionist present at the timeframe of elopement. The DON stated she assumed the exit foyer door charm rang but not heard by any staff and the keypad was not set. The DON stated after the facility's investigation, it was determined the keypad was not set. The DON stated she was notified of the elopement on 9/8/25 around 10:10 PM. The DON stated it was not safe for Resident #74 to be outside the facility because she could be struck by a car or gotten lost. During an interview on 9/9/25 at 11:53 AM, CNA D stated he was off on 9/6/25 and passed the facility and, I glanced at the facility and saw the resident at the bus stop. CNA D stated he recognized the resident based on the fact he had seen the resident in the facility. CNA D stated he stopped, and the resident told him she wanted to go home; and she forgot where she was. CNA D stated the bus stop was across the street from the facility. CNA D stated he did not know how the resident crossed the street. CNA D stated the resident could have been harmed or struck by a car or a lot of things. CNA D stated he knew the resident had a diagnose of dementia. CNA D stated he had no explanation how the resident eloped. During a telephone interview on 9/9/25 at 1:35 PM, the RP stated she was called when the resident eloped. The RP described the resident as a person with dementia who was ambulatory and exit seeking. The RP stated she was concerned that the resident was able to elope without the facility noticing her absence and her crossing a busy road. The RP stated that the resident told her she left the facility during shift change. The RP stated the resident was safe in her home after being discharged from the facility on 9/8/25. During a telephone interview on 9/9/25 at 2:00 PM, RN E stated she physically saw Resident #74 following staff (CNAs and CMAs) asking them where her sister was. RN E stated the resident was a wanderer throughout the facility. RN E stated the resident eloped during night shift change (10:00 PM). RN E stated the door leading to the front door required the setting of the keypad at 8:00 PM when the receptionist ended her workday. RN E stated, staff forgot to set the keypad which was the root-cause of the resident eloping. RN E stated she assessed the resident when she returned to the facility and there was no physical or psychosocial harm. RN E stated the resident could have been hit by a car crossing the road near the facility. During a telephone interview on 2/9/25 at 2:15 PM, the MD stated the facility should have followed elopement protocols involving Resident #74. The MD stated the key to Resident #74's elopement should have been prevention. During a telephone interview on 9/10/25 at 10:53 AM RN H stated she saw Resident #74 wandering throughout the facility on 9/6/25 and she knew the resident had a diagnosis of dementia. RN H stated she was not called at 8:00 PM by the receptionist [Receptionist F] to set the foyer key lock alarm. RN H stated she was called by the receptionist [F] at 10:00 PM to set the alarm but she was too busy and did not set the alarm. RN H stated she was aware of the need to set the keypad alarm as per elopement protocol. RN H stated at shift change she was not present at the foyer location to hear the charm sounding. RC H stated she could not give an explanation how the resident eloped and why the resident was not monitored as a wanderer at risk for elopement by other nursing staff. During an interview on 9/9/25 at 3:04 PM, the Administrator stated Resident #74 was admitted for 5-7 days for respite care. The Administrator stated the timeline based on the self-report was the resident was admitted on [DATE] and was last seen on 9/6/25 at 9:50 PM by RN E; shift change occurred at 10:00 PM; and the resident was found across the street at a bus stop at 10:08 PM by CNA D who was not on duty. The Administrator stated the keypad had not been set at 8:00 PM by the RN H as requested by the receptionist [Receptionist F]. The Administrator stated RN H confirmed the keypad had not been set on 9/6/25 at 8:00 PM per protocol. The administrator stated the facility had a protocol for elopement and he did not explain why the protocol was not followed by the receptionist [F] and verified by the RN [H]. The Administrator stated the What apps [computer-based application for tracking setting of alarms] did not show that the keypad was armed/set on 9/6/25 at 8:00PM. The Administrator stated he assumed the keypad would be set at 8:00 PM. During an interview on 9/10/25 at 9:11 AM, the ADON stated based on nursing practice after a shift change at 10:00 PM the on-coming nursing staff would check on the resident population or at a minimum by midnight. The ADON stated that she could not give an explanation why the headcount of Resident #74 after shift change (average time was 15-20 minutes) was not done or documented by exception. During a telephone interview on 9/10/25 at 10:00 AM, Receptionist F stated she did not arm the foyer door at 8:00 PM on 9/6/25 because I got busy. The receptionist stated protocol called for the arming of the foyer door at 8:00 PM and verified by another staff member. The receptionist stated her shift was from 8 AM to 10:00 PM and she left duty on 9/6/25 at 10:01 PM. The receptionist stated she did not see Resident #74 throughout the day and there was an elopement binder at the receptionist desk which contained the face sheet and photo of Resident #74. The receptionist stated that RN H did not arm the foyer door at 8:00 PM. Record review of facility's investigation binder dated 9/6/25 reflected:---HHS self-report dated 9/6/25 with a finding of confirmed.---Written statement by CNA D dated 9/6/25 which documented while he was off-duty found Resident #74 across the facility at a bus stop.---Written statement by RN E dated 9/6/25 which documented she last saw Resident #74 in the facility on 9/6/25 at 9:50 PM.---The Facility's root -cause analysis which identified the root cause as the foyer alarm not being set and the receptionist not being at the front door receptionist desk.----The Disciplinary form entitled coaching given to the Receptionist F for not setting the alarm and giving false information.---The Sign-in sheet for the Ad-hoc QAPI meeting on 9/7/25 which addressed the root-cause analysis of Resident #74's elopement.---The In-service sign in sheets on elopement dated 9/7/25 given to 18 staff members [total paid staff was 89].----Resident #74's 15-minute monitoring sheet started 9/6/25 and ended 9/8/25.---Resident #74's one-on-one monitoring sheet initiated on 9/7/25 and ended 9/8/25. Record review of facility's Maintenance Log, undated, reflected the alarm system to the door leading to the front lobby was checked on 8/25/25. Record review of Receptionist F's Employee Coaching dated 9/7/25 reflected she provided inaccurate information to the Administrator that the foyer door was locked and keyed at 8:00 PM on 9/6/25. Receptionist was in-serviced on elopement policy, accurate reporting, and expectations. Record review of RN E's written statement dated 9/6/25 reflected she saw Resident #74 wandering the facility at 9:50 PM following a CNA. The next time RN E saw the resident was at 10:08 PM when she was returned to the facility by a CNA D. Record review of RN H's written statement date 9/7/25 reflected the RN H did not set the alarm (9/6/25 at 8:00 PM) when it was due to be set. Record review of facility's Alarm Check form, undated, read: .First door alarm to be turned on no later than 8:00 PM. Door will be checked every 2 hours to ensure it is functional. Record review of facility's Emergency Procedure-Missing Resident, dated August 2028, read: .Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. Record review of the facility's Wandering and Elopement policy, dated March 2029 read: .If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. This was determined to be an immediate jeopardy (IJ) on 09/10/25 at 4:25 PM. The Administrator was notified. The Administrator was provided with the template on 09/10/25 at 4:25 PM.The following Plan of Removal submitted by the facility was accepted on 09/11/25 at 10:32 AM. It was documented as follows: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes.On September 10, 2025, an investigation was initiated at [Nursing Facility] At approximately 4:41 pm on September 10, 2025, a surveyor provided written notification that Texas Health and Human Services had determined the conditions at [ Nursing Facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas:F-0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrections Implemented for Removal of Immediate Jeopardy.On September 6, 2025, at approximately 10:08pm resident #74, who was admitted on [DATE], for a short-term respite stay, was identified as having eloped from facility and returned safely at 10:10pm by a C.N.A. who was not on shift. Action: Resident #74 was immediately assessed by charge nurse on duty, RN [E] and found to be free of adverse effects related to elopement. Resident was placed on 15-minute checks while sleeping throughout the night, and on 1:1 care at 7:25am and remained on 1:1 supervision until safely discharging home with family on September 8, 2025, at 5:00pm. On September 10, 2025, at approximately 5:00 pm the following actions were taken:Action: Facility Administrator and Director of Nursing were educated by Regional Clinical Nurse and Area President on Abuse and Neglect, Wandering and Elopement, Emergency Procedure for Missing Persons, Elopement/Missing Person Protocol The sole responsibility was on the receptionist [Receptionist F] who didn't comply. The receptionist was coached (and placed on notice) by the Administrator and Director of Nursing (DON). She was also re-educated on the protocol. The RN [H] was re-educated on the protocol by the DON. Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Regional Clinical Nurse/Area President Action: Education initiated Abuse and Neglect, Residents Rights, Wandering and Elopement, Emergency Procedure for Missing Persons, Elopement/Missing Person Protocol, Process to secure front door. The Staff was in-serviced on resetting door code/keypad. The staff were also educated on the receptionist duty hours of 8:00 am to 10:00 pm by the DON, Administrator, Director of Nursing or Department Manager or designee. The staff has been in-serviced by the DON, Administrator, Director of Nursing or Department Manager or designee that the doors are locked at 8:00 pm. Education will be completed for all staff, including PRN employees or agency (if applicable). The facility does not utilize agency staff. New hires will be educated in orientation.Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Director of Nursing/designee Action: Administrator validated that exit doors are functioning as designed and intended. Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Administrator/Designee IDENTIFICATION OF OTHERS AFFECTED:All residents have the potential to be affected.Action: An audit was completed on Elopement and Wandering Risk Assessment on all residents and validated all residents at risk of elopement, score of 3 or greater, have appropriate interventions and plan of care in place per risk assessment.Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES:Action: In-service and education on Abuse and Neglect, Resident Rights, Wandering and Elopement, Emergency Procedure for Missing Persons, Elopement/Missing Person Protocol, and the process to secure front door.Start Date: 9/10/2025.Completion Date: 9/10/2025 and ongoing for all new hiresResponsible Party: Director of Nursing/Designee Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 9/10/2025.Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible: Administrator/Designee Action: A secondary alarm was installed on exterior front door. The secondary alarm will be secured at 8pm daily and validated by receptionist and a nurse employee. Once alarm has been secured, employees will send a secure message to department heads to confirm completion. A quote for exterior doors with magnetic lock and keypad release was obtained, reviewed, and submitted to corporate office for scheduling of installation.Start Date: 9/10/2025.Completion Date: 9/10/2025Responsible Party: Maintenance Director/Administrator or designee Tracking and Monitoring Director of Nursing/Designee will review residents with at risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 9/10/2025 Administrator/designee will complete random audit every shift for 7 days, beginning 9/11/205, for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week. Administrator/designee will complete audit of exits for proper functioning of doors, and alarms for proper functioning every shift for 7 days, beginning 9/10/2023 then will monitor random shifts, 5 times a week. The receptionist is on duty 7 days a week from 8:00 am to 10:00 pm including weekends Tracking and Monitoring will be reviewed with Quality Assurance Committee monthly, for three months and as needed thereafter. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review. Administrator Validation of the POR. Key Observations: Observation on 9/11/25 from 4:45 PM-4:50 PM reflected no door posed an elopement risk. The doors sounded with an alarm which allowed staff to respond in the event a resident attempted an elopement. Further observation reflected the foyer door where Resident #74 used to elope was armed and the keypad was operational. The front door to the facility had been modified with an alarm. Observation on 9/11/25 at 4:55 PM of facility's Elopement Risk binder contained 24 residents face sheets and photo. Also, the binder contained the elopement risk tool and the elopement protocol. Observation on 9/11/25 at 4:56 PM reflected the presence and functioning of a secondary alarm on the exterior front door. Also sign present for visitors was a posting on the foyer exit door that read: Attention. Please be observant. Do not allow residents to follow you out. Key Interviews:During a telephone interview on 9/9/25 at 1:35 PM, RP stated she was called when the resident eloped. The RP confirmed that the resident was at her home. During a joint interview on 9/11/25 at 4:20 PM with the Administrator and DON, the Administrator stated the highlight of the training on ANE was to utilize the elopement protocol to ensure safety and for staff/residents/visitors to report any allegation of ANE. The Administrator stated the highlight of the Wandering Inservice was not to make assumptions that staff followed elopement protocols. The DON stated the point stressed on Emergency Procedures was to know the whereabout of residents throughout the day. The DON stated the highlight of the Elopement/Missing Person Protocol was to thoroughly check the elopement risk score and put prevention measures in place. The Administrator stated: The sole responsibility was on the receptionist who did not comply. The receptionist was coached (and placed on notice) by the Administrator and Director of Nursing (DON). She was also re-educated on the protocol. During an interview on 9/11/25 at 4:35 PM, the DON stated the facility had 3 shifts (6:00 AM-2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00AM; and same shifts on weekends. During an interview on 9/11/25 at 4:37 PM, the Administrator stated he checked the exit doors every starting on 9/10/25 and would continue for 7 days and then for 5 days and then there would be a QAPI review. During an interview on 9/11/25 at 5:11 PM, CMA J(Medical Records, CMA) stated she attended the QAPI meeting on 9/10/25 and the highlight of the meeting was discussion of measures to prevent elopement and review of the elopement protocol. During an interview on 9/11/25 at 5:19 PM, CMA J stated when assigned the duty of receptionist would call a nurse to set the keypad at the foyer door at 8 PM, and wait until it was set, and test that the alarm triggered. Once the alarm was set the receptionist would send a message to department heads that the alarm was set at 8:00 PM. During an interview on 9/11/25 at 5:34 PM, the DON stated the facility had one new admission on [DATE] and the resident (Resident #1) scored a zero on elopement screen. [Record review of resident #1's elopement score on 9/11/25 reflected a score of zero.] During an interview on 9/11/25 at 5:44 PM stated the next QAPI meeting was scheduled for 9/29/25. In-service: During an interview on 9/11/25 at 6:00 PM, Receptionist L stated the highlights of his training included: ANE was to report immediately, for elopement to check on residents that wandered and check the elopement risk book if not certain, and to search for any missing residents. Also, Receptionist L stated to check on the setting of the alarm at 8:00 PM and if he had to take a break have another staff cover the reception desk. During an interview on 9/11/25 at 6:10 PM, RN M stated Abuse/Neglect/Exploitation [ANE [highlight was to report immediately. The main point on elopement to monitor wanders and start an immediate search when a resident; to check on residents every shift change and every 2 hours. The RN stated that the alarm had to be set at 8:00 PM and check the alarms every 2 hours. During an interview on 9/11/25 at 6:15 PM, CNA N stated ANE highlight was to report allegations of abuse to the Administrator who was the Abuse Coordinator. Regarding rights was to respect the resident rights. As for elopement to monitor, check on the whereabouts of residents, and listen for the door opening a closing. The CNA stated that at 8:00 PM to check that the exit door keypad was set. Likewise, when she arrived on duty to ensure assigned are in the facility. During an interview on 9/12/25 at 2:05 PM, LVN I stated she attended in-services, and the major highlights were report ANE to the Abuse Coordinator, respect resident rights, and to headcount the caseload. LVN stated that nursing staff needed to follow elopement and missing person protocols. During an interview on 9/12/25 at 2:09 PM, CMA O stated he attended in-services and the highlights were report ANE, respect resident rights, and ensure the doors were secured at 8:00 PM. The CNA stated that staff need to monitor wanderers and at shift change do a head count of the residents. The CNA commented that he had to participate in searching in the event a resident went missing. During an interview on 9/12/25 at 2:15 PM, CNA P stated she attended in-services and recalled the points made were to report ANE to the Abuse Coordinator, the Administrator, and to be alert for residents that were wanderers and exit seekers. She also was to check that doors were armed and secured at 8:00 PM and participate in the search of any missing resident. Night Shift (10 PM-6 AM) During a telephone interview on 9/11/25 at 10:05 PM, LVN Q stated: the highlight of the in-service on ANE was to report any suspicion of abuse to the Abuse Coordinator. As for Rights, LVN Q stated to respect the resident's right to participate in treatment. LVN Q stated the high point on the elopement training was to check on residents and to ensure the door key lock was properly set. During a telephone interview on 9/11/25 at 10:10 PM, LVN R stated the highlights of the in-services were report abuse, respect resident rights, know the whereabouts of residents, and properly set the door key lock at 8:00 PM. During a telephone interview on 9/11/25 at 10:15 PM, LVN S stated she attended in-service training and some of the highlights were: the abuse coordinator was the Administrator, respect resident rights, and check on residents during shift change and regularly throughout the shift. LVN added that a code had to be called when a resident was missing and to follow the elopement and missing person protocols. Day Shift (6:00 AM-2:00 PM) During an interview on 9/12/25 at 8:35 AM, LN A stated the highlights of her in-service trainings were report ANE to the abuse coordinator, respect resident rights to participate in care, and for elopement to search and know the whereabouts of residents; and set the alarm at night and check often that the alarm is set. During an interview on 9/12/25 at 8:47 AM, LVN T stated the key points of the in-services were: to report immediately any allegations of ANE; and to respect the resident rights make decisions on care. LVN stated that staff needed to know the whereabouts of residents and to immediately search for any missing resident per protocol. LVN stated to set alarm at night and to document the setting of the alarm. During an interview on 9/12/25 at 8:54 AM, RT [respiratory therapist] U stated the key points made in the in-services were to report ANE in a timely manner, and respect resident right around treatment and care. RT stated the highlight of the elopement in-service was to follow protocols and ensue the alarm was set. The RT U stated, to also know the whereabouts of residents. During an interview on 9/12/25 at 1:50 PM, Housekeeping V, stated she learned from her training to report any suspicion of ANE to nurse management. She added that as a housekeeper she was to monitor any resident exit seeking and to inform nurse management. Also, she was to participate in any search of missing residents. During an interview on 9/12/225 at 1:53 PM, Rehab Director W, stated he attended in-services, and the main points made were: follow elopement and missing person protocols; and report ANE to the Abuse Coordinator, the Administrator. During an interview on 9/12/25 at 1:55 PM, CNA X stated she attended in-services, and she recalled report ANE, check on doors and whereabouts of residents. Also, the CNA stated she was to check doors and ensure resident safety. During an interview on 9/12/25 at 1:58 PM, CNA Y stated she attended in-services and what stood out was to report ANE to the Administrator. As for elopement and missing persons she was to monitor wanders and know the whereabouts of her caseload. Weekend Coverage During an interview on 9/12/25 at 8:40 AM, CMA Z stated that he worked on weekends and had received in-service training. CMA stated he remembered from the training ANE to report immediately to the Abuse Coordinator, respect resident rights. As for elopement the CMA stated the highlights were: monitor residents always especially shift change and ensure that the alarm is set at 8 PM to 6 AM. CMA stated if a resident was missing to follow missing person protocol. During an interview on 9/12/25 at 9:05 AM, CMA J (Medical Records and Receptionist) stated she works as weekends. She stated that training was initiated after the incident of elopement of 9/6/25. She remembered from the training to report immediately to the Administrator any allegation of ANE. She commented that resident rights needed to be respected. Regarding elopement, she stated: to monitor movement of the exit door and check the elopement binder. Moreover, she stated the alarm was set at 8:00 PM and the receptionist evaluated the alarm system and then sent a notice to management on the What Apps that the alarm was set and secured. PRN Staff During telephone interview on 9/12/25 at 1:30 PM, Receptionist AA, stated the highlights of the in-services were: report abuse, respect resident rights, and for elopement check on the exit door and check the alarm was set. Receptionist stated that a elopement binder was at the receptionist desk and her training called for search for missing residents and reporting to management. During a telephone interview on 9/12/25 at 1:35 PM, LVN Q stated the key points of her in-services were: to report ANE and follow protocols on elopement and missing persons. LVN stated the training stressed to headcount residents during shift change and throughout the day. During a telephone interview on 9/12/25 at 1:38 PM, CNA BB stated, the in-services stressed to report ANE and respect resident rights. Also, the CNA stated she needed to headcount her residents and monitor the movement of wanders. The CNA stated she needed to ensure doors were armed and locked at 8:00 PM. In the event a resident went missing she was to follow the missing person checklist. During a telephone interview on 9/12/25 at 1:43 PM, CNA CC stated she attended in-services and remembered to report any allegations of ANE to the Abuse Coordinator, the Administrator. She stated that as a CNA she needed to headcount her caseload and check on the arming of doors after 8:00 PM. If a resident went missing, she would participate in the search of the resident. During an interview on 9/12/25 at 10:57 AM, the Administrator stated the 1:1 [for Resident #74] started on 9/7/25 at 7:00 AM by staff member CMA J and continued by CMA K and thereafter continued on a 24-hour basis until resident's discharge on [DATE] at 5:00 PM. Key Record Reviews: Record review of receptionist timecards [receptionist F, G and J] from 9/6/25 to 9/11/25 reflected a schedule of hours from 8:00 AM to 10:00 PM. Record revies of Resident #74's Nurse Note dated 9/6/25 at 10:33 PM authored by RN E read: .CNA [D] reports to this nurse [RN E], resident noted at bus stop across

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the residents that meets professional standards of quality of care within 48 hours of a resident's admission for one (Resident #1, of five residents reviewed for baseline care plans, in that: The facility failed to implement Resident #1's baseline care plan and failed to include Resident #1's current urinary tract infection and antibiotic use in the baseline care plan resulting in Resident #1's hospitilization with a diagnosis of sepsis. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life, infection, and hospitalization. An IJ was identified on 04/29/25. The IJ template was provided to the facility on [DATE] at 9:37 pm. While the IJ was removed on 05/02/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Findings Included: Review of Resident #1's face sheet reflected a [AGE] year old man who was admitted to the facility on [DATE] and discharged from the facility on 03/12/25 with diagnoses of Hemiplegia and hemiparesis (hemiplegia refers to complete paralysis on one side of the body, while hemiparesis refers to partial weakness on one side) following cerebral infarction (a condition where a blood clot or blockage in a blood vessel prevents oxygen and blood from reaching a part of the brain, causing brain tissue to die), and Wernicke's encephalopathy (a serious, acute neurological emergency cause by a deficiency of thiamine (vitamin B1) most often due to chronic alcohol use). Review of Resident #1's care plan reflected a focus dated 03/10/25 of impaired communication due to: and intervention dated 03/10/25 of use simple and direct communication to promote understanding. Care plan focus dated 03/10/25 of alteration in elimination of bowel and bladder with a goal dated 03/10/25 of will be free from signs and symptoms of incontinence through next review date and interventions dated 03/10/25 of if catheter in place, secure per protocol, cath q shift per protocol, monitor for drainage, out, s/s of UTI: changes in color, odor, or consistency of urine, dysuria (painful or burning urination) frequency, fever, pain and provide assistance to toilet as needed. Review of Resident #1's MDS, dated [DATE], did not reflect he had an indwelling catheter. Review of Resident #1's MDS BIMS dated 03/11/25 reflected a score of three suggesting severe cognitive impairment. Review of Resident #1's rehabilitation hospital discharge records dated 03/20/25 reflected Resident #1 was discharged with a foley catheter (a thin flexible tube inserted into the bladder to drain urine) with instructions, The most important thing you want to do is prevent infection. Discharge records reflected cognitive status A&O X2 (a person is alert and aware of their person and place), other comments reflected, confused. Review of Comprehensive Skilled assessment dated [DATE] signed by LVN B reflected wound care indwelling catheter (including suprapubic catheter (a medical device, a tube inserted into the bladder through a small incision in the lower abdomen, used to drain urine) and nephrostomy tube (a thin, flexible catheter inserted through the back into the kidney to drain urine when normal urine flow is blocked) and summary of head to toe assessment findings included a description of any progress toward goals or decline note reflected confusion noted. Review of Resident #1's orders did not reflect physician orders for an indwelling catheter or the care and monitoring of an indwelling catheter. Review of Resident #1's progress notes reflected 3 (three) notes referencing Resident #1 foley catheter 1. Skin/wound progress note dated 03/11/25 foley catheter in place 2. Skin/wound progress note dated 03/12/25 foley catheter 3. Note physician history and physical dated 03/12/25 foley catheter in place Review of Resident #1's EMR reflected no nurses' notes regarding skilled nurse assessments or urine output measurements for Resident #1's foley catheter. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/10/25 at 8:21 pm, late entry, reflected Resident #1 continued with antibiotics for UTI. Review of Resident #1 Nurses Note (identity of nurse unknown) dated 03/10/25 at 8:49 pm, late entry, reflected confusion noted. Review of admission & Baseline care plan/summary dated 03/10/25 signed by LVN B reflected GI/Bowel abdomen soft, non-tender, non-distended, urine normal color/consistency, catheter/nephrostomy tube indwelling catheter/suprapubic/nephrostomy, bowel and bladder care plan focus alteration of elimination of bowel and bladder, goal will be free from s/s of UTI or complications related to incontinence through next review dated, interventions call light within reach and remind to use call light as needed, intervention if catheter in place, secure per protocol, cath care q shift per protocol, monitor for drainage, output, s/s of infection and follow up with physician as needed, monitor and report s/s of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever pain. Comments: Resident #1 continues with antibiotics for UTI, confusion noted. Review of Resident #1's Comprehensive Skilled assessment dated [DATE] signed by LPN C reflected behavior problems verbal, other behaviors (socially inappropriate), rejects evaluation or cares, indwelling catheter, summary of Head-to-Toe Assessment/Findings including a description of any progress toward goals or decline noted - confusion noted. Review of Resident #1's Elopement Risk Assessment Tool dated 03/11/25, unsigned by staff, reflected Resident #1 had a diagnosis of Dementia, OBS (a condition characterized by cognitive impairment and behavioral changes caused by underlying brain damage), Alzheimer's, Intellectual/Developmental Disability, Hallucinations, Anxiety Disorder, Depression, Bipolar, and/or Schizophrenia, Resident #1 cognitively impaired with poor decision making skills (example disorientation, cognitive deficits, disorganized thinking). Review of Resident #1's Trauma Abbreviated PCL-C dated 03/11/25 signed by LPN C reflected, unable to obtain answers from resident due to impaired cognition/communication and representative is unable to answer. Review of Resident #1's Infection Surveillance Form dated 03/11/25, unsigned, reflected, confusion note. Review of Resident #1's Skin/Wound Progress Noted note dated 03/11/25 by LVN A wound care nurse, reflected Resident, Pt. arrived at facility with . Foley Catheter in place ., MD, DON and RP at bedside. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 reflected, resident was alert and oriented X1. Resident was not able to voice needs. MD notified of admission, orders verified, admission assessment completed, call button within reach will continue to monitor, resident came into facility with peg tube. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 at 5:43 am reflected redirected resident multiple times this shift, observed attempting to get out of bed, re-educated resident to call light, assigned CNA instructed to monitor resident frequently throughout shift, every effort made in making resident as comfortable as possible, as needed Tylenol administered as ordered for nonverbal indicator of discomfort, will monitor through the remainder of this shift Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 reflected witnessed fall resident observed crawling out of bed onto floor by floor mat, he stated he wanted to stand up. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 late entry reflected resident had behaviors; resident had restlessness and anxiety noted Review of Resident #1's Skilled Status Note 2 (identity of nurse unknown) dated 03/12/25 reflected confusion noted stable no new concerns. Review of Resident #1's Skilled Status Note 2 (identity of nurse unknown) dated 03/12/25 reflected resident on antibiotic for UTI for 5 days, call light was in reach, staff continued to monitor resident. Review of Resident #1's Skin and Wound Nurses Note (identity of nurse unknown) dated 03/12/25 reflected GU: urinary incontinence, foley catheter. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 at 1:40 pm reflected resident found on floor by physical therapy, resident confused and unable to express what happened, nurse conducted physical assessment, neurological checks, resident complained of generalized pain and was confused, but normal for baseline, continued to monitor. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 reflected DON and CNA made nurse aware that resident was on the floor, resident was complaining of pain to left wrist 3/10 (0 = no pain, and 10 = worst imaginable pain). Nurse assessed resident, resident was able to move right upper extremity, x-ray ordered to the left hand, pain medication given and was not effective, nurse monitored and updated provider with any changes. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 reflected resident was sent out to hospital for pain to left wrist, resident showing signs of restlessness and anxiety, medications were in place, resident was a fall risk, resident continued with antibiotics for UTI, no new concerns. Review of IDT Event Review progress note dated 03/12/25 witnessed fall from bed, no injuries noted, root cause analysis for event new admission, anxiety, impulsivity, diagnosis of UTI, dementia, difficulty expressing self, hepatic encephalopathy (a neuropsychiatric syndrome caused by impaired brain function due to liver disease, specifically when the liver fails to remove toxins from the blood), CVA (Cerebrovascular Accident), call light in reach, psych evaluation and treatment anxiety and restlessness. Review of Resident #1's Pain assessment - Post Incident dated 03/12/25 signed by LVN B reflected pain behavior - resistiveness to cares, restlessness, repetitive verbalizations or movements, verbal expression of distress/crying, sad, pained, worried facial expressions. Resident's current level of pain on a numeric scale of 1-10 (0 = no pain, and 10 = worst imaginable pain) 3. Review of Resident #1's Anxiolytic (medications, also called anti-anxiety agents, used to treat or prevent anxiety) Medication Informed Consent dated 03/12/25 signed by LVN B reflected anxiolytic medication & indication for use Xanax (treats anxiety) anxiety, potential contributing factors previously addressed - pain and infection or other change in condition, target behavior symptoms Resident #1 was showing [NAME] of anxiety and restlessness and came moving to the edge of bed and rolling off the bed. Review of Resident #1's Change of Condition Evaluation dated 03/12/25 signed by LVN B reflected, the change in condition, symptoms, or signs LVN B was calling about is/are: Falls, pain (uncontrolled), Behavioral symptoms (e.g. agitation, psychosis) started on: 03/12/25 Change of Condition Evaluation dated 03/12/25 signed by LVN B reflected: Since the change in condition occurred have the symptoms or signs gotten worse - medication given was not effective This condition, symptom or sign had occurred before: No. Other relevant information: Resident has had a past history of left wrist pain with no fractures noted. Summarize your observations, evaluation, and recommendations: Left wrist with pain noted. Pain scale is 5/10 (0 = no pain, and 10 = worst imaginable pain). No swelling. X-ray administered. Resident sent to the hospital per family request. Describe mental status of changes (compared to baseline; check all that you observe: increased confusion (e.g. disorientation), abrupt significant change in cognitive function form usual, with or without altered level of consciousness. Functional status evaluation: describe functions status changes - fall. Recommendation of primary clinician - send to the hospital, testing x-ray, interventions - new or change in medications Behavioral status evaluation - describe behavioral changes: resident is having signs and symptoms of anxiety and restlessness and symptoms or signs of pain. Is an abdominal/GI assessment relevant to the change in condition being reported - not clinically applicable to the change in condition being reported (distended abdomen box not checked) Genitourinary (refers to the urinary and genital organs, also known as the urogenital system. It encompasses both the reproductive organs and the urinary tract) Status Evaluation: not clinically applicable to the change in condition being reported. Pain Status Evaluation - is pain assessment relevant to the change in condition been reported: yes Does the resident/patient have pain: yes Is the resident/patient cognitively able to rate their pain scale: - No Negative vocalization: troubled - repeated trouble calling out, loud moaning or groaning, crying, facial expression - sad/frightened/frown Body language: tense, distressed pacing, fidgeting, Consolability: distracted or reassured by voice or touch Is the pain: acute Pain location: not applicable/not assessed Specify exact location of pain: left hand (palm) complaining of left hand with pain scale of 5/10 (0 = no pain, and 10 = worst imaginable pain) Tylenol given X-ray results: -no fracture noted. Review of Resident #1's Comprehensive Skilled assessment dated [DATE] signed by LVN B reflected evidenced of an acute change in mental status from the resident's baseline behavioral problems of verbal behavior (screaming, cursing, etc.), other behaviors (social inappropriate), and rejects evaluation or cares, indwelling catheter, [Resident #1] was sent out to [hospital] for pain to left wrist, falls . Resident showing signs of restlessness and anxiety. Medications are in place. Resident is a fall risk. Resident continues with abt's for UTI. Review of Resident #1's Skilled Nursing Facility Records to Hospital Transfer Form dated 03/12/25 reflected ADLs totally dependent, bladder function incontinent, last know bowel movement 03/12/25, urinary catheter in place left blank. Unusual mental status/cognition function before the change in condition - alert, disoriented but cannot follow simple instructions. Medications on antibiotics - Cephalexin oral capsule 500 MG for UTI treatment duration 03/16/25, treatment started 03/11/25. Devices - bladder (Foley) catheter - left blank. Risk alerts agitation with risk to harm self or others and high fall risk. Resident was showing signs and symptoms of anxiety and restlessness. Redirection given. Review of Resident #1 hospital history of present illness records dated 03/13/25 reflected male with history of CVA with outlet obstruction chronic foley (a persistent blockage in the urinary tract, preventing the bladder from emptying properly) presented to the ER with recurrent falls. Resident #1 had been complaining of left sided hip pain, left wrist pain, back pain, lower back pain, left lower quadrant pain, and left femur pain. Review of Resident #1's hospital X-ray of chest, abdomen and pelvis dated 03/13/25 reflected foley catheter was present within the urinary bladder. The bladder remained distended and recommended correlation for catheter dysfunction (mechanical issues like kinking, catheter malposition, or thrombotic complications such as intracatheter thrombosis and fibrin sheath formation). Review of Resident #1's hospital records dated 03/13/25 reflected Resident #1's general appearance, chronically ill appearing, confused . Review of Resident #1's hospital Diagnosis Assessment Plan dated 03/13/25 reflected UTI/Sepsis, change foley catheter - done in the ER. Interview on 04/29/25 with a family member by phone at 1:59 pm revealed Resident #1 had a foley catheter and the hospital told her it was placed wrong, pulled, or neglected and Resident #1 got sepsis. Interview on 04/30/25 with LVN B at 2:20 pm revealed she looked at care plans and care plans were the blueprint of the residents' care including what the resident needed, residents' goals, and how to take care of the resident. She said the negative effects of not following the catheter care plan were the resident could get a UTI or become septic if catheter care was not properly care planned and followed through for the resident. Interview on 04/30/25 with LVN F at 1:44 pm revealed everything about a resident should be care planned and of course the catheter care should be care planned. She revealed the negative effects of not having a resident centered care plan in place was that you don't have a plan in place to care for the resident and if you don't carry out catheter care planning, it means that the needs of the resident were not being meet. She said that all the nurses, not just the admitting nurse, were responsible to make that it was made known that Resident #1 had a foley catheter and to make sure it was care planned and the residents' catheter care needs were meet. Interview on 04/30/25 with the Administrator at 12:24 pm revealed the nurse who admits the resident into the facility can open the care plan. There was a care plan for the resident, but it was not specific to the information from the hospital discharge information. Resident #1 had a UTI, and he was on an antibiotic and that was not included in his care plan. The negative effect of not having a care plan that addressed the individual resident needs was that it was not resident centered and there was the opportunity for error in for the care or service to be provided to that resident. The Administrator said a care plan provided body of knowledge to be able to carry out the services or elements of the needs of the resident and was the template that allowed you and your staff meet the welfare of the resident. The administrator said the care plan was the responsibility admitting nurse because Resident #1 was at the facility less than 72 hour and the admitting nurse should have done the admitting orders for the foley catheter care. The negative effects of not having the order entered was the failure of not having Resident #1's needs meet. He stated if you don't take care of a catheter a resident could get an infection. He said he was not a nurse, but he did not feel like catheter care was carried out for this resident. Interview on 04/30/25 with the DON at 8:47 am revealed a care plan contained all the residents' information gathering in one central area for anything that is important to the residents' care, and it should be resident specific. She revealed the catheter care plan should be specific to the catheter size and include the reason the catheter was present, and the reason would be different from resident to resident. The care plan should include everything that should be included in a catheter order including monitoring urine output. She said the IDT team was responsible for the care plan, but it was a whole facility approach. She said the nurse who signed the baseline care plan should make sure that that all the information was in the care plan. She stated this was the responsibility of the previous DON. The current DON said the negative effect of not having a person-centered care plan was that you don't really know how to care for the resident, and everyone was different, so their care was different. She said she thought the care plan had everything that it needed to have for the care of Resident #1's catheter needs but based on the progress notes there was no indication that they carried out catheter care. She said she hoped that they carried out Resident #1's catheter care plan but the documentation was poor. She stated she subscribed to the idea that if care was not charted it did not happen. Review of facility Care Plans, Comprehensive Person-Centered dated 2022 reflected: Policy statement Measurable objectives and at timetables to meet the residence physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person centered plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The ADM was notified on 04/29/25 at 9:37 pm that an IJ had been identified and an IJ template was provided. An amended IJ template was provided on 04/30/25 at (I have to find the time). The following POR was approved on 04/30/25 at 4:36 pm: The POR included the following: CARE PLAN TAG F656 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On April 29, 2025, an investigation was initiated at the Rehabilitation and Care Center. At approximately 9:37 p.m. on April 29, 2025, a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at Rehabilitation and Care Center constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F656 - The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The facility failed to write a care plan for Resident #1's catheter care. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Resident #1 no longer resides at facility On April 29, 2025, at approximately 10:00pm the following actions were taken; Action: Director of nursing/Designee validated all residents with urinary catheters have comprehensive care plans with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in place for each identified resident. All identified residents with urinary catheters were validated to have comprehensive, person-centered care plans to incorporate care of catheter and identified risk factors associated with catheters. The DON was trained by Corporate Clinical Support. Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Director of Nursing/Designee Action: Ad Hoc QAPI with Administrator, Director of Nursing, and Medical Director was conducted to review citations and Plan of Correction for removal Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Administrator and Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents with urinary catheters have the potential to be affected. Action: Director of Nursing/designee completed a sweep of all residents to identify any resident with urinary catheter, and to validate residents with catheters have comprehensive plans of care in place addressing the following: Catheter care, monitoring and identification of signs and symptoms of infection, pain, monitoring of output urine, monitoring for appropriate drainage, and for signs of change of condition. Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: Director of Nursing/Designee completed education with all licensed nursing staff on the requirement and facility policy to ensure completion of comprehensive plan of care with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in place for each resident. Education included the need to ensure all residents with urinary catheters have comprehensive, person-centered care plans to incorporate care of catheters and identified risk factors associated with catheters. Start Date: 4/29/2025 Completion Date: Ongoing until all licensed staff have received education prior to their next scheduled shift. Responsible Party: Director of nursing/designee Action: Director of Nursing/designee will review all residents with foley catheters upon admission. Director of Nursing and/or designee will ensure monitoring orders and care plans are immediately updated upon admission and identification of resident admitted with a foley catheter. All residents with foley catheters will be added to facilities daily internal tracking tool and reviewed daily, Monday through Friday, by interdisciplinary team for compliance with facility policy and procedure related to foley catheter care and care planning requirements. Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible Party: Director of Nursing/Designee Tracking and Monitoring Director of nursing/designee will monitor all resident with new orders for catheters, or newly admitted with catheters, daily Monday through Friday, x 4 weeks, then weekly x 4 weeks, to include review of any new admissions from weekend on Mondays, to validate all residents with urinary catheters have comprehensive care plan with measurable objectives and timetables to ensure they have comprehensive, person-centered care plan to incorporate care of catheter and identified risk factors associated with catheter, including s/s of infection, cares of catheter, output, pain, drainage, and change in condition. Results will be supplied to the Quality Assurance Committee. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review Monitoring: Review on 05/01/25 of nurses note that Resident #1 was discharged to the hospital, review of skilled nursing facility to hospital form transferring Resident #1 to the hospital. A review of PCC reflected Resident #1 was discharged from the facility to the hospital on [DATE] and he is no longer a resident at the facility. Record review on 05/01/25 of statement from the DON that she performed a sweep of all residents by pulling the order listing report to identify any resident with a urinary catheter, and to validate residents with catheters have comprehensive plans of care in place to address catheter monitoring and care, monitoring and identifying signs and symptoms of infections, pain, monitoring output of urine, monitoring for appropriate drainage and for signs of change in condition. Review on 05/01/25 of the care plans for the three (3) residents in the facility with urinary catheters reflected comprehensive, person-centered care plans that incorporated the care of catheters and identified risk factors associated with catheters. Record review of statement on 05/01/25 from DON that as of 04/29/25 the facility had no new admissions of residents with foley catheters. Interview on 05/01/25 with the CNO at 4:08 pm revealed she in-serviced the DON on comprehensive care plans and discussed the importance of comprehensive care plans specific to catheters that on admission residents who have urinary catheters have comprehensive care plan with measurable objectives and timetables to ensure they have comprehensive, person-centered care plan to incorporate care of catheter and identified risk factors associated with catheter, including s/s of infection, cares of catheter, output, pain, drainage, and change in condition. Interview on 05/01/25 with the DON at 1:47 pm revealed she reviewed the facility care plan policy with the CNO and was in-serviced to make sure resident care plans are accurate and resident care plans will be audited. She was further in-serviced by the CNO regarding comprehensive care plans specific to catheters that on admission residents who have urinary catheters have comprehensive care plan with measurable objectives and timetables to ensure they have comprehensive, person-centered care plan to incorporate care of catheter and identified risk factors associated with catheter, including s/s of infection, cares of catheter, output, pain, drainage, and change in condition. Record review on 05/01/25 of Ad Hoc QAPI with Administrator, Director of Nursing, and Medical Director dated 04/29/25. Record review completed on 05/01/25 of log used to complete training for staff, indicated who was trained over the phone or in person. 100 percent of the nursing staff was in-serviced, this included PRN staff. During interviews on 05/01/25 from 10:15 am - 2:29 pm 2 RNs, 1 LPN, and 9 LVNs from different shifts all stated they were in-serviced before working their shift on the requirements and facility policy to ensure completion of comprehensive plan of care with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in place for each resident. The in-service included the need to ensure all residents with urinary catheters have comprehensive, person-centered care plans to incorporate care of catheters and identified risk factors associated with catheters. While the IJ was removed on 05/02/25 at 12:11 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure that residents with indwelling catheters received appropriate treatment and services for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to manage Resident #1's foley catheter by not having orders for catheter care, monitoring for signs/symptoms of infection, or monitoring the input/output, subsequently leading to hospitalization on 03/12/25 and a diagnosis of sepsis. These failures could place Residents with indwelling urinary catheters at risk of discomfort, infections, and a decreased quality of life, and hospitalization. An IJ was identified on 04/29/25. The IJ template was provided to the facility on [DATE] at 9:37 pm. While the IJ was removed on 05/02/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Findings Included: Review of Resident #1's face sheet reflected a [AGE] year old man who was admitted to the facility on [DATE] and discharged from the facility on 03/12/25 with diagnoses of Hemiplegia and hemiparesis (hemiplegia refers to complete paralysis on one side of the body, while hemiparesis refers to partial weakness on one side) following cerebral infarction (a condition where a blood clot or blockage in a blood vessel prevents oxygen and blood from reaching a part of the brain, causing brain tissue to die), and Wernicke's encephalopathy (a serious, acute neurological emergency cause by a deficiency of thiamine (vitamin B1) most often due to chronic alcohol use). Review of Resident #1's care plan reflected a focus dated 03/10/25 of impaired communication due to: and intervention dated 03/10/25 of use simple and direct communication to promote understanding. Care plan focus dated 03/10/25 of alteration in elimination of bowel and bladder with a goal dated 03/10/25 of will be free from signs and symptoms of incontinence through next review date and interventions dated 03/10/25 of if catheter in place, secure per protocol, cath q shift per protocol, monitor for drainage, out, s/s of UTI: changes in color, odor, or consistency of urine, dysuria (painful or burning urination) frequency, fever, pain and provide assistance to toilet as needed. Review of Resident #1's MDS, dated [DATE], did not reflect he had an indwelling catheter. Review of Resident #1's MDS BIMS dated 03/11/25 reflected a score of three suggesting severe cognitive impairment. Review of Resident #1's rehabilitation hospital discharge records dated 03/20/25 reflected Resident #1 was discharged with a foley catheter (a thin flexible tube inserted into the bladder to drain urine) with instructions, The most important thing you want to do is prevent infection. Discharge records reflected cognitive status A&O X2 (a person is alert and aware of their person and place), other comments reflected, confused. Review of Comprehensive Skilled assessment dated [DATE] signed by LVN B reflected wound care indwelling catheter (including suprapubic catheter (a medical device, a tube inserted into the bladder through a small incision in the lower abdomen, used to drain urine) and nephrostomy tube (a thin, flexible catheter inserted through the back into the kidney to drain urine when normal urine flow is blocked) and summary of head to toe assessment findings included a description of any progress toward goals or decline note reflected confusion noted. Review of Resident #1's orders did not reflect physician orders for an indwelling catheter or the care and monitoring of an indwelling catheter. Review of Resident #1's progress notes reflected 3 (three) notes referencing Resident #1 foley catheter 1. Skin/wound progress note dated 03/11/25 foley catheter in place 2. Skin/wound progress note dated 03/12/25 foley catheter 3. Note physician history and physical dated 03/12/25 foley catheter in place Review of Resident #1's EMR reflected no nurses' notes regarding skilled nurse assessments or urine output measurements for Resident #1's foley catheter. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/10/25 at 8:21 pm, late entry, reflected Resident #1 continued with antibiotics for UTI. Review of Resident #1 Nurses Note (identity of nurse unknown) dated 03/10/25 at 8:49 pm, late entry, reflected confusion noted. Review of admission & Baseline care plan/summary dated 03/10/25 signed by LVN B reflected GI/Bowel abdomen soft, non-tender, non-distended, urine normal color/consistency, catheter/nephrostomy tube indwelling catheter/suprapubic/nephrostomy, bowel and bladder care plan focus alteration of elimination of bowel and bladder, goal will be free from s/s of UTI or complications related to incontinence through next review dated, interventions call light within reach and remind to use call light as needed, intervention if catheter in place, secure per protocol, cath care q shift per protocol, monitor for drainage, output, s/s of infection and follow up with physician as needed, monitor and report s/s of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever pain. Comments: Resident #1 continues with antibiotics for UTI, confusion noted. Review of Resident #1's Comprehensive Skilled assessment dated [DATE] signed by LPN C reflected behavior problems verbal, other behaviors (socially inappropriate), rejects evaluation or cares, indwelling catheter, summary of Head-to-Toe Assessment/Findings including a description of any progress toward goals or decline noted - confusion noted. Review of Resident #1's Elopement Risk Assessment Tool dated 03/11/25, unsigned by staff, reflected Resident #1 had a diagnosis of Dementia, OBS (a condition characterized by cognitive impairment and behavioral changes caused by underlying brain damage), Alzheimer's, Intellectual/Developmental Disability, Hallucinations, Anxiety Disorder, Depression, Bipolar, and/or Schizophrenia, Resident #1 cognitively impaired with poor decision making skills (example disorientation, cognitive deficits, disorganized thinking). Review of Resident #1's Trauma Abbreviated PCL-C dated 03/11/25 signed by LPN C reflected, unable to obtain answers from resident due to impaired cognition/communication and representative is unable to answer. Review of Resident #1's Infection Surveillance Form dated 03/11/25, unsigned, reflected, confusion note. Review of Resident #1's Skin/Wound Progress Noted note dated 03/11/25 by LVN A wound care nurse, reflected Resident, Pt. arrived at facility with . Foley Catheter in place ., MD, DON and RP at bedside. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 reflected, resident was alert and oriented X1. Resident was not able to voice needs. MD notified of admission, orders verified, admission assessment completed, call button within reach will continue to monitor, resident came into facility with peg tube. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 at 5:43 am reflected redirected resident multiple times this shift, observed attempting to get out of bed, re-educated resident to call light, assigned CNA instructed to monitor resident frequently throughout shift, every effort made in making resident as comfortable as possible, as needed Tylenol administered as ordered for nonverbal indicator of discomfort, will monitor through the remainder of this shift Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 reflected witnessed fall resident observed crawling out of bed onto floor by floor mat, he stated he wanted to stand up Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/11/25 late entry reflected resident had behaviors; resident had restlessness and anxiety noted. Review of Resident #1's Skilled Status Note 2 (identity of nurse unknown) dated 03/12/25 reflected confusion noted stable no new concerns. Review of Resident #1's Skilled Status Note 2 (identity of nurse unknown) dated 03/12/25 reflected resident on antibiotic for UTI for 5 days, call light was in reach, staff continued to monitor resident. Review of Resident #1's Skin and Wound Nurses Note (identity of nurse unknown) dated 03/12/25 reflected GU: urinary incontinence, foley catheter. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 at 1:40 pm reflected resident found on floor by physical therapy, resident confused and unable to express what happened, nurse conducted physical assessment, neurological checks, resident complained of generalized pain and was confused, but normal for baseline, continued to monitor. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 reflected DON and CNA made nurse aware that resident was on the floor, resident was complaining of pain to left wrist 3/10 (0 = no pain, and 10 = worst imaginable pain). Nurse assessed resident, resident was able to move right upper extremity, x-ray ordered to the left hand, pain medication given and was not effective, nurse monitored and updated provider with any changes. Review of Resident #1's Nurses Note (identity of nurse unknown) dated 03/12/25 reflected resident was sent out to hospital for pain to left wrist, resident showing signs of restlessness and anxiety, medications were in place, resident was a fall risk, resident continued with antibiotics for UTI, no new concerns. Review of IDT Event Review progress note dated 03/12/25 witnessed fall from bed, no injuries noted, root cause analysis for event new admission, anxiety, impulsivity, diagnosis of UTI, dementia, difficulty expressing self, hepatic encephalopathy (a neuropsychiatric syndrome caused by impaired brain function due to liver disease, specifically when the liver fails to remove toxins from the blood), CVA (Cerebrovascular Accident), call light in reach, psych evaluation and treatment anxiety and restlessness. Review of Resident #1's Pain assessment - Post Incident dated 03/12/25 signed by LVN B reflected pain behavior - resistiveness to cares, restlessness, repetitive verbalizations or movements, verbal expression of distress/crying, sad, pained, worried facial expressions. Resident's current level of pain on a numeric scale of 1-10 (0 = no pain, and 10 = worst imaginable pain) 3. Review of Resident #1's Anxiolytic (medications, also called anti-anxiety agents, used to treat or prevent anxiety) Medication Informed Consent dated 03/12/25 signed by LVN B reflected anxiolytic medication & indication for use Xanax (treats anxiety) anxiety, potential contributing factors previously addressed - pain and infection or other change in condition, target behavior symptoms Resident #1 was showing [NAME] of anxiety and restlessness and came moving to the edge of bed and rolling off the bed. Review of Resident #1's Change of Condition Evaluation dated 03/12/25 signed by LVN B reflected, the change in condition, symptoms, or signs LVN B was calling about is/are: Falls, pain (uncontrolled), Behavioral symptoms (e.g. agitation, psychosis) started on: 03/12/25 Change of Condition Evaluation dated 03/12/25 signed by LVN B reflected: Since the change in condition occurred have the symptoms or signs gotten worse - medication given was not effective This condition, symptom or sign had occurred before: No. Other relevant information: Resident has had a past history of left wrist pain with no fractures noted. Summarize your observations, evaluation, and recommendations: Left wrist with pain noted. Pain scale is 5/10 (0 = no pain, and 10 = worst imaginable pain). No swelling. X-ray administered. Resident sent to the hospital per family request. Describe mental status of changes (compared to baseline; check all that you observe: increased confusion (e.g. disorientation), abrupt significant change in cognitive function form usual, with or without altered level of consciousness. Functional status evaluation: describe functions status changes - fall. Recommendation of primary clinician - send to the hospital, testing x-ray, interventions - new or change in medications Behavioral status evaluation - describe behavioral changes: resident is having signs and symptoms of anxiety and restlessness and symptoms or signs of pain. Is an abdominal/GI assessment relevant to the change in condition being reported - not clinically applicable to the change in condition being reported (distended abdomen box not checked) Genitourinary (refers to the urinary and genital organs, also known as the urogenital system. It encompasses both the reproductive organs and the urinary tract) Status Evaluation: not clinically applicable to the change in condition being reported. Pain Status Evaluation - is pain assessment relevant to the change in condition been reported: yes Does the resident/patient have pain: yes Is the resident/patient cognitively able to rate their pain scale: No Negative vocalization: troubled - repeated trouble calling out, loud moaning or groaning, crying, facial expression - sad/frightened/frown Body language: tense, distressed pacing, fidgeting, Consolability: distracted or reassured by voice or touch Is the pain: acute Pain location: not applicable/not assessed Specify exact location of pain: left hand (palm) complaining of left hand with pain scale of 5/10 (0 = no pain, and 10 = worst imaginable pain) Tylenol given X-ray results: -no fracture noted. Review of Resident #1's Comprehensive Skilled assessment dated [DATE] signed by LVN B reflected evidenced of an acute change in mental status from the resident's baseline behavioral problems of verbal behavior (screaming, cursing, etc.), other behaviors (social inappropriate), and rejects evaluation or cares, indwelling catheter, [Resident #1] was sent out to [hospital] for pain to left wrist, falls . Resident showing signs of restlessness and anxiety. Medications are in place. Resident is a fall risk. Resident continues with abt's for UTI. Review of Resident #1's Skilled Nursing Facility Records to Hospital Transfer Form dated 03/12/25 reflected ADLs totally dependent, bladder function incontinent, last know bowel movement 03/12/25, urinary catheter in place left blank. Unusual mental status/cognition function before the change in condition - alert, disoriented but cannot follow simple instructions. Medications on antibiotics - Cephalexin oral capsule 500 MG for UTI treatment duration 03/16/25, treatment started 03/11/25. Devices - bladder (Foley) catheter - left blank. Risk alerts agitation with risk to harm self or others and high fall risk. Resident was showing signs and symptoms of anxiety and restlessness. Redirection given. Review of Resident #1 hospital history of present illness records dated 03/13/25 reflected male with history of CVA with outlet obstruction chronic foley (a persistent blockage in the urinary tract, preventing the bladder from emptying properly) presented to the ER with recurrent falls. Resident #1 had been complaining of left sided hip pain, left wrist pain, back pain, lower back pain, left lower quadrant pain, and left femur pain. Review of Resident #1's hospital X-ray of chest, abdomen and pelvis dated 03/13/25 reflected foley catheter was present within the urinary bladder. The bladder remained distended and recommended correlation for catheter dysfunction (mechanical issues like kinking, catheter malposition, or thrombotic complications such as intracatheter thrombosis and fibrin sheath formation). Review of Resident #1's hospital records dated 03/13/25 reflected Resident #1's general appearance, chronically ill appearing, confused . Review of Resident #1's hospital Diagnosis Assessment Plan dated 03/13/25 reflected UTI/Sepsis, change foley catheter - done in the ER. Interview on 04/29/25 with a family member by phone at 1:59 pm revealed Resident #1 had a foley catheter and the hospital told her it was placed wrong, pulled, or neglected and Resident #1 got sepsis. Interview on 04/29/25 with CNA D by phone at 2:33 revealed he had worked at the facility for about a year. CNA D said he was responsible for emptying out the urine in catheters and measuring the amount of urine and telling the nurse the amount, but he said he did not remember Resident #1 except that his name was familiar. He said if the urine was not emptied from the catheter bag, it could go back into the bladder and cause an infection. Interview on 04/29/25 with CNA E at 2:25 pm revealed she worked at facility during the time frame Resident #1 was at the facility but could not recall helping Resident #1, but she did provide foley catheter care to residents. She said if a resident had a foley catheter, CNAs needed to check the bag to see if it needs to be emptied of urine and then do the peri care (cleaning the genitals and anal area to promote hygiene and prevent infections). She said if the catheter bag was full of urine, it hurt the resident. She said she emptied catheter bags of the urine, measured the amount of urine, then told the amount to the nurse. Interview on 04/29/25 with LVN B at 6:38 pm revealed she vaguely remembered the resident, but she did not remember him having a catheter. She said nurses were supposed to look at the catheters and chart when they had looked at it and what they saw. She said nurses looked at the residents' catheters to confirm that there was no trauma to the cite, that the color and consistency of the urine was not abnormal, that the output was measured, and there was no blood in the urine. LVN B said this information would have been charted by the nurse. She said if the urine was not emptied from the catheter bag, it could go back into the bladder and cause the bladder to become distended, and the person could get sick, develop sepsis, and possibly die. She did not remember Resident #1 being confused, she said this would have concerned her. She revealed she did not remember him, she said it was a crazy time and it was like a blur because the facility was changing ownership, and they were in-between 2 (two) nurse managers. Interview on 04/30/25 with LVN B at 2:20 pm revealed when Resident #1 was at the facility, either the ADON or the DON were putting in the orders in for catheter care. She said she would have taken report from the hospital, and she would do baseline admission and care plan admission assessment. She said the ADON and DON should have looked at the assessments and they were not looking at the assessments. She said catheter care required more immediacy. LVN B said she did not remember the names of any CNAs who would have helped Resident #1 with his catheter care. She said if there was not an order entered for catheter care, the EMR did not prompt for the catheter care needs for a resident who had a catheter. She said if you visually saw a resident had a catheter, and there were no orders for catheter care, you could manually enter the catheter care order into the EMR system to prompt the necessary care. LVN B did not know what happened to cause the catheter care order to be missed and it was a problem that the order was not placed because treatment was missed. Interview on 04/29/25 with LVN A by phone at 7:05 pm revealed she no longer worked at the facility, and she did not remember working with Resident #1. She revealed she was the wound care nurse, and the floor nurses did the catheters. Surveyor told LVN A there was a wound care progress note dated 03/11/25 with her name that discussed Resident #1's skin care and the note did not reflect that Resident #1's bladder was distended. LVN A revealed if Resident #1's bladder was distended, she would have reported it to the floor nurse and the floor nurse would have reported it to the MD. She said there were procedures to follow when a resident had a foley catheter. She said a residents' catheter needed to be checked and monitored to make sure everything was in place. She revealed if the foley catheter was not monitored, absolutely things could go wrong with the resident, a resident could go septic. She said it was the responsibility of the floor nurse to check the foley catheter every shift and monitor the output. She said if the monitoring was not charted, then the foley catheter was not monitored. Interview on 04/29/25 with LVN F at 1:44 pm revealed she remembered Resident #1 but did not remember if he had a catheter. She said she remembered him because he had a lot of falls. She said she did not remember anyone providing catheter care to him. She said she felt like he fell because he was restless, did not want to be at the facility, and he seemed confused. She said if she saw a resident who had a catheter, but did not have catheter orders, she would prompt them to be entered in the system so catheter care would be populated as a resident care task. LVN F said the lack of catheter care could have caused and infection and caused a distended bladder. She said that Resident #1 could have been restless because of the discomfort from the infection caused by the lack of catheter care. She said the admission nurse was responsible for entering the catheter orders. She said the negative effects of not providing catheter care were infection, sepsis, and possibly death. She said all nurses needed to check on the residents even if they were not the admitting nurse and confirm that the necessary catheter orders were in place. Interview on 04/30/25 with the previous DON by phone at 11:11 am revealed she recalled Resident #1, and she was aware that he had a catheter, but she did not assist with catheter care. She said the CNAs would have provided catheter care but she did not see anyone provide catheter care but that did not mean it had not been provided. She said if catheter care was done, it was in the nursing notes. She said usually there was an ordered entered for catheter care. She said the nurse who did Resident #1's assessment could have created his order for catheter care and the ADON and DON would have followed up. She said it was part of the nurses skilled notes to document a residents' catheter care. Interview on 04/30/25 with the Administrator at 12:24 pm revealed the nurse who admitted Resident #1 was at the facility less than 72 hour and the admitting nurse should have done the admitting orders for the foley catheter care. The negative effects of not having the order entered was the failure of not having Resident #1's needs meet. He stated if you don't take care of a catheter the resident could get an infection. He said he was not a nurse, but he did not feel like catheter care was carried out for this resident. Interview on 04/30/25 with the DON at 8:47 am reflected she began working at the facility on 04/10/25. The DON stated Resident #1 should have had standard foley catheter orders in place for measuring urine output, looking for s/s of infection, securing the catheter bag so the catheter bag was below the resident's bladder, Enhanced Barrier Protection (infection control measures that expand standard precautions by incorporating the use of gowns and gloves during high-contact resident care activities), and orders to change the bag once a month. She said all of these measures should have been in the nursing orders. She said the admitting nurse should have entered the orders. The DON said the negative effects of not entering the orders at admission was that if orders were not in place, necessary resident care would get missed. The DON said it was important to assess the catheter to confirm there was no obstruction or urinary retention and make sure catheter was flowing. She said if the catheter was not flowing well and emptied property it could cause bladder distention and pain. She said it was the responsibility of the nursing management team to double check and make sure orders were correctly entered. She said that it is important to trust but verify that orders were not missed and that Resident #1 did not have a catheter because there were no catheter ordered entered. She said the negative effect of not checking if a resident has a catheter and the resident did have a catheter was missing the s/s of infection. Interview on 04/29/25 with the MD by phone at 5:33 pm revealed if a resident was admitted to the facility with a catheter, the resident would have pre-set orders from the facility to address the necessary catheter care to prevent infection. She said that Resident #1's output should have been monitored, that was basic nursing 101 (refers to the introductory or fundamental level of a subject). She said if there was a change in condition related to the catheter care, she would have been notified, but if they are not monitoring the catheter and there were no skilled nursing notes regarding checking the catheter and notes documenting the urine output, it would be hard to notify of a change of condition of something that was not monitored. She said the facility was changing ownership at that time and staff both quit and walked out and documentation was not very good. Review of facility Catheter Care, Urinary dated 2018 reflected Input/Output - observe the resident's urine level for noticeable increases or decreases. If the level stays the same or increases rapidly, report it to the physical or supervisor. Maintain as accurate record of the resident's daily output, per facility policy and procedure. Check the resident to be sure he or she is not lying on the catheter and to keep the catheter and be free of kinks. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage back from flowing back into the urinary bladder. Documentation - The following information may be recorded in the resident's medical record: 1. The date and time that catheter care was given 2. The name and title of the individual(s) giving the catheter care. 3. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain 4. Any problems or complaints made by the resident related to the procedure 5. If the resident refused the procedure, the reason(s) why and the intervention taken 6. The signature and title of the person recording the date 7. Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. Reporting other information in accordance with facility policy and professional standards of practice. The ADM was notified on 04/29/25 at 9:37 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/30/25 at 4:36 pm: The POR included the following: FOLEY CATHETER TAG F690 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On April 29, 2025, an investigation was initiated at the Rehabilitation and Care Center, At approximately 9:37 p.m. on April 29, 2025, a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at Rehabilitation and Care Center constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F690 - The facility must ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The facility failed to manage Resident #1's foley catheter by not having orders for catheter care, monitoring for signs/symptoms of infection, or monitoring the input/output, subsequently leading to hospitalization and being diagnosed with sepsis. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Resident #1 no longer resides at facility On April 29, 2025, at approximately 10:00pm the following actions were taken; Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Director of Nursing Action: All nursing staff were immediately educated on foley catheter care. Education entailed: Appropriate catheter care and documentation of caring out orders on changes of condition, admission or propose of catheter use. Director of Nursing and/or designee will ensure monitoring orders and care plans are immediately updated upon admission or change of condition and identification of resident admitted with a foley catheter. The staff will retain if a discrepancy is discovered during review or audit. The current nursing staff has been in-service. Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Director of Nursing Action: Ad Hoc QAPI with Administrator, Director of Nursing, and Medical Director was conducted to review citations and Plan of Correction for removal Record review on 05/01/25 Start Date: 4/29/2025 Completion Date: 4/29/2025 Responsible: Administrator and Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents requiring assistance with incontinent care related to the use of a foley catheter have the potential to be affected. SYSTEMIC CHANGES AND/OR MEASURES: Action: Orders for all residents with foley catheters will be reviewed upon admission. Director of Nursing and/or designee will ensure monitoring orders and care plans are immediately updated upon admission and identification of resident admitted with a foley catheter. All residents with foley catheters will be added to facility's daily internal tracking tool and reviewed daily, Monday through Friday, by interdisciplinary team for compliance with facility policy and procedure related to foley catheter care. This process will be ongoing. Start Date: 4/29/2025 Completion Date: 4/29/25 Responsible Party: Director of Nursing, Assistant Director of Nursing and/or designee Action: Director of nursing/designee completed education with all nursing staff, including PRN employees and agency staff on care and competencies for urinary catheters. Education included review of facility policy on catheter cares, requirement to maintain an accurate record of resident's daily output, monitoring for problems such as drainage, s/s of infection, dysuria, redness, crusting, pain, distention and for any change in condition. Start Date: 4/29/2025 Completion Date: 4/29/25. All new employees will receive education upon hire and prior to start of their shift. Education entailed: Appropriate catheter care and documentation of caring out orders on changes of condition, admission or propose of catheter use. Director of Nursing and/or designee will ensure monitoring orders and care plans are immediately updated upon admission or change of condition and identification of resident admitted with a foley catheter. The staff will retain if a discrepancy is discovered during review or audit. The current nursing staff has been in-service. Responsible Party: Director of Nursing, Assistant Director of Nursing and/or designee Tracking and Monitoring The Director of Nursing will conduct a weekly audit, for four weeks, of all residents with orders for foley catheters to ensure compliance with facility policy and physician orders. Verification of findings will be documented and submitted to the administrator for tracking and trending. Results will be provided to the Quality Assurance Committee. Any trends or concerns were/will be

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision. The facility failed to supervise Resident #1 who eloped from the facility on 06/19/2024 and was found approximately 50 feet away from the facility at an intersection. This noncompliance was identified as past non-compliance. The past non-compliance IJ began on 06/19/2024 and ended on 06/23/2024. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: A record review of Resident #1's admission record dated 08/02/2024 revealed Resident #1 was admitted on [DATE] with diagnoses which included hemiplegia (left sided semi paralysis), vascular dementia (brain damage caused by multiple strokes), and general anxiety disorder. A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 09 out of a possible 15 which indicated moderate cognitive impairment. Resident was assessed as using a manual wheelchair and was assessed as, Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity . Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns A record review of Resident #1's care plan dated 08/02/2024 revealed Resident #1 was an elopement risk and had a history of elopement 06/19/2024 . monitor Resident #1 for indications of elopement seeking, cigarette seeking . redirect to next smoke break, offer activities television, music, magazines, snacks . is/has potential to be verbally aggressive to staff and other residents r/t mental/emotional illness . assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. assess resident's coping skills and support system . give the resident as many choices as possible about care and activities . provide positive feedback for good behavior . emphasize the positive aspects of compliance . psychiatric/psychogeriatric consult as indicated . when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later A record review of Resident #1's medical record from 09/01/2023 to 08/02/2024 revealed Resident #1 was assessed on 03/23/2024 as a low wander elopement risk and on 06/19/2024 had an elopement incident. A record review of Resident #1's nursing notes revealed LVN A documented on 06/19/2024 at 01:34 AM, Resident #1 was seen in the smoking courtyard at approximately 09:50 PM and by 10:45 PM could not be located. LVN A documented she initiated the facility's elopement procedure and began an all-facility search, notified the DON, the Administrator, and the local police department, accounted for all other residents, and expanded the search to outside of the facility. LVN A documented while on the telephone with the DON the local police department called the facility at 11:28 PM to report they were supervising Resident #1 nearby the facility. During an interview on 08/01/2024 at 04:58 PM the DON stated on 06/19/2024 at 09:50 PM Resident #1 was seen by LVN A in the facilities smoke break area hyper focused on receiving another cigarette. The DON stated he had already smoked his cigarette, the last allotted for the day, and staff redirected him to other activities to have the Resident continue with his activities of daily life and prepare for bed. The DON stated by 10:45 it was recognized by LVN A that Resident #1 was not in the facility. The DON stated she and LVN A initiated the facility's elopement protocol and assigned staff responsibilities to simultaneously account for all residents, search the entire facility, alert the local police department, alert the DON, the Administrator, and expand the search to the exterior of the facility. They organized a staff lead vehicle assisted search of the surrounding neighborhood when the local police department called the facility and stated they were supervising Resident #1 who was alongside of the road by the facility. The DON stated she and the Administrator met the police officers and assumed custody of Resident #1 at 11:58 PM on 06/19/2024. The DON stated Resident #1 was located across the street from the facility about a block down the road and described the location on an internet-based map. The DON stated Resident #1 was returned to the facility and assessed without any injuries. The DON stated Resident #1's physician ordered bilateral knee x-rays which resulted negative for injuries. The DON stated Resident #1 received enhanced monitoring from a 1 to 1 staff member every 15 minutes for 6 hours. The DON stated the Administrator initiated an investigation. A record review of an internet-based map accessed on 08/02/2024 as described by the DON revealed Resident #1 was located approximately 688 feet from the facility's front door. The Administrator was notified on 08/02/24 at 06:00 PM, a past non-compliance IJ situation had been identified due to the above failure. It was determined the failures placed Resident #1 in an IJ situation on 06/19/2024. The facility implemented the following interventions. During a joint interview on 08/02/2024 at 04:00 PM the Administrator and the DON stated the facility had 2 exit doors commonly utilized by staff to enter and exit the facility. The DON stated one door was the front door which was monitored by the facility's receptionist from 06:00 AM to 08:00 PM and the other door was the back door which was secured with an electromagnet and released by a numeric coded keypad. The DON stated the front door also had an electromagnet and was secured from the hours of 08:00 PM to 06:00 AM. The Administrator stated the front door was secured by the receptionist when she left for the day, and he would receive a daily message alerting him to the practice of securing the front door. The Administrator stated on 06/20/2024 immediately after Resident #1's elopement the facility initiated an investigation, reported the incident to the state agency, assessed Resident #1 and concluded he had no injuries, assessed peer residents for safety and revealed all were safe without injuries, interviewed all staff on duty, and interviewed residents who may have witnessed Resident #1. It was concluded Resident #1 may have eloped through the facility's front door either by exiting concurrently when a staff or visitor entered or exited the facility or Resident #1 may have covertly gained knowledge of the code. The Administrator stated the facility reviewed the elopement incident and developed and implemented quality improvement initiatives which included monitoring the secured front doors and back door every 2 hours from 08:00 PM to 06:00 AM, changing the door codes every month, and replacing the alarm batteries every month. The DON stated Resident #1's care plan was updated by the interdisciplinary team to include enhanced monitoring of Resident #1 especially when he was agitated and became focused on finding cigarettes. The Administrator stated all staff were in-serviced on Resident #1's care plan, ANE prevention, elopement prevention, reporting allegations of ANE, and/or elopement. The DON stated Resident #1 has been assessed an elopement risk and has been added to the elopement binder located at the receptionist desk. A record review of the facility's elopement binder located at the receptionist desk revealed Resident #1 was identified as a wander elopement risk, should be redirected per his care plan, and staff were to communicate with each other to redirect Resident and/or initiate the elopement protocol with attempts to re-direct Resident #1 to safety. During an interview on 08/02/2024 at 01:15 PM Receptionist E stated she was the receptionist from 06:00AM to 02:00 PM or sometimes from 08:00 PM to 06:00 PM. Receptionist E stated the front door was monitored from 06:00 AM to 08:00 PM and if she was not there, other staff (the BOM, the Administrator, etc.) would monitor the front door from 06:00 to 08:00 AM when she arrived or from 06:00 PM to 0:0 PM when she left. Receptionist E stated she had access to the facility elopement binder located at the desk and identified Resident #1 with specific interventions to re-direct Resident #1 away from the front door. A record review of the facility's daily front door and back door monitor logs revealed the doors had been checked every 2 hours from 08:00 PM to 06:00 PM since 06/21/2024. A record review of the facility's employee roster dated 08/01/2024 revealed 73 employees. A record review of the facility's in-service records dated 06/20/2024, 06/21/2024, and 06/23/2024 revealed 63 employees across all departments and work shifts had signed and documented they received the re-enforced trainings for elopement protocol and reporting, ANE prevention and reporting, and resident #1's care plan to include re-direction interventions when he was becoming agitated and cigarette seeking. During an interview on 08/01/2024 at 5:01 PM LVN A stated she had received the elopement protocol, Resident #1's care plan, and ANE prevention and reporting in-service sometime at the end of June 2024. LVN A stated she recalled the DON ensured everyone received the in-services. During an interview on 08/02/2024 at 01:45 PM LVN B stated she worked all shifts and usually worked the 06:00 AM to 02:00 PM shift. LVN B stated she recalled everyone received in-services regarding Resident #1's elopement in June 2024. LVN B stated she would and had redirected Resident #1 when he became fixated on receiving a cigarette and Resident #1 forgets he just had a smoke break. LVN B stated it was a group effort with staff coordinating and providing Resident #1 with alternatives such as an activity, he likes bingo. During an interview on 08/02/2024 at 02:10 PM LVN C stated she had just started and had received in-service training to include Resident #1's care plan and ANE and elopement prevention protocols. LVN C stated she usually worked the 02:00 PM to 06:00 PM shifts and has been assigned to ensure the front door has been secured after 08:00 PM and to check on Resident #1 often. During an interview on 07/31/2024 at 11:20 AM CNA D stated he has worked with Resident #1 and has received training to redirect Resident #1 when he becomes aggressive with cigarette seeking. CNA D stated he would offer the Resident with assistance with the toilet or offer clothing change. CNA D stated he usually does not work with Resident #1 but had provided care for the Resident occasionally. CNA D stated, if he's soiled, he lets me change him, and he forgets about the cigarette. A record review of the facility's in-service records dated 06/20 through 06/23/2024 revealed policies which included: Emergency Procedure - Missing Resident dated 2018, the policy statement resident elopement resulting in a missing resident is considered a facility emergency . residents at risk for wandering and for elopement will be monitored, and staff will take necessary precautions to ensure their safety . staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. Emergency procedure missing Resident . announce president missing using facility code, note the time the resident was discovered missing, notify the Administrator, director of maintenance, director of nursing. Initiate a thorough search by staff members to locate the Resident. Instruct staff members to search the entire facility, grounds and neighboring street. Assign each staff member an area to search to avoid overlap. Look under bed, furniture, clothing closet, and behind doors . staff will report search results to the Administrator . if the search is unsuccessful, the administrator will contact the police to report the missing result Wandering and elopement policy . 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. As at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the residence safety. If an employee observes a resident leaving the premises, he or she should: attempt to prevent the resident from leaving in a non-threatening courteous manner, request assistance from other staff members in the immediate vicinity as needed, instructed another staff member to alert the charge nurse, director of nursing and or administrator of the residents' intent to leave the premises . if a resident is missing, initiate the elopement missing resident emergency procedure:

Based on observations, interviews, and record reviews the facility failed to ensure resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 3 residents (Resident #2 and #1), in that: 1. Resident #2 was able to exit the building without staff knowing on 3/15/2024; staff were unaware Resident #2 had wheeled himself to a bus stop on a city sidewalk and was gone until he was brought back by police; staff were unaware that Resident #2 had exit seeking behavior although it was in his admission paperwork. 2. Resident #1 was able to exit the building without staff knowing on 3/19/2024; staff were unaware Resident #1 had exited the building and her whereabouts are still unknown. This failure could place resident at risk of neglect resulting in elopements that could have resulted in serious injury, harm, impairment or death. An IJ was identified on 03/22/2024. The IJ template was provided to the facility on [DATE] at 05:50 PM. While the IJ was removed on 03/23/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facilities need to evaluate the effectiveness of their corrective actions. The findings were: 1.Record review of Resident #2 Administration Record dated 3/24/2024, revealed Resident #2 was a [AGE] year-old male originally admitted on [DATE] with diagnosis listed as: unspecified heart failure. Other active diagnosis included deaf, non-speaking; functional quadriplegia [completely immobile due to severe disability or frailty]; schizoaffective disorder bipolar type [mental health disorder marked by a combination of symptoms such as hallucinations or delusions, mood disorder symptoms such as depression or mania]. Further review a discharge date of [DATE] to another nursing facility in the area. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #2 was coded as highly impaired [absence of useful] hearing with unclear speech; ability to express ideas and wants was coded as usually understood; ability to understand others was coded as sometimes understands in Section B - Hearing, Speech, and Vision. In Section C - Cognitive Patterns, Resident #2 was coded as No for Should BIMS be Conducted due to resident is rarely/never understood; with Disorganized Thinking continuously present, does not fluctuate. In Section D - Mood, Resident #2 was coded as being short-tempered, easily annoyed, rarely felt lonely or isolated from those around you; In Section E - Behavior, Resident #2 was coded as none of the above for indicators of psychosis [hallucinations, delusions]. In Section GG - Functional Abilities, Resident #2 was coded as normally utilizing a wheelchair. Resident #2 was coded as substantial/maximal assistance [helper does more than half the effort] for wheel 50 feet with two turns, and wheel 150 feet with a manual wheelchair. Record review of Resident # 2's All-Inclusive Admission with Baseline Care Plan, dated 11/09/2023, revealed the resident was at risk for wandering with a wandering risk score of 3. Under the subheading for vision, 4.) Residents' ability to see an adequate light and with glasses if used was coded as highly or severely impaired - sees only lights, colors, etcetera or no vision. Record review of referral documents from previous hospital admission, revealed under Emergency Department Medical Screen Exam on 11/03/2023 at 1:18, Resident #2 was deaf and communicates via sign language; does not want to go back to the group home .; wants to go into a nursing home. Reexamination on 11/03/2023 at 1:58 PM, presents to emergency department because he is unhappy with his living situation. At 11/03/2023 at 12:05 PM, documentation reveals, Informed that the patient [Resident #2] has been denied at multiple NH [nursing homes] because of behavioral issues he has had in the past. Under the History & Physical section dated 11/03/2023 at 3:28 PM, patient wanting a new placement and refusing to leave . Progress Note dated 11/05/2023 at 3:03 PM revealed, Resident #2 called 911 from group home .30 minutes after discharge from a hospital in [redacted] . upset due to circumstances. Record review of Behavior Note, dated 3/10/2024 at 5:57 AM, authored by LVN A revealed Resident #2, seen him going out the front door, wanting nurse to call 911. Record review of Behavior Note, dated 3/16/2024 at 2:03 AM, authored by LVN A revealed, Resident #2 found by police at bus stop, police was called by persons walking by for wellness check, policy finally got [Resident #2] to return to facility .EMS came, unable to take him since he is not critique [critical]. I had to station an aide at front door so resident wouldn't go back to bus stop. We need a inside lock on [front door] so this situation would not happen again. Record review of Internal Investigation Summary dated 3/16/2024, revealed Timeline of Event: 3/16/2024 at 12:48 AM Administrator received call from LVN A to inform the police have brought Resident #2 to the facility from the bus stop at the end of the parking lot on the city sidewalk. Resident #2 had wheeled himself to the bus stop without notifying a nurse or any other staff. Resident #2 told the police officer he wanted to go to the hospital. EMS was contacted at Resident #2's request; paramedics assessed the resident and declined to transfer to the hospital; resident declined head to toe assessment by DON at that time; resident uncooperative and upset; the next afternoon resident insisted that the doctor be called so he could be sent to the hospital; Attending physician was called and an order was obtained to transfer him to [Hospital]; Resident from [another major city] area originally where he had a habit of going to the hospital and then going to a different facility; Ended up in [this area] because he became hard to place in [another major city] area due to his behaviors; While inpatient at the hospital he requested another facility to be found and a social worker has been working to facilitate a transfer; Facility was willing to accept the resident back from the hospital; According to his mother, Resident #2 had past behaviors such as he will go to a hospital and not want to leave. Record review of handwritten statement dated 3/18/24, authored by LVN A revealed, statement, on 10-6 shift, while at the nurses' station north, vital check of Resident #2. Resident #2 was watching TV in the ding room between 10-11pm on 3/15/24. Record review of In-Servicing dated 3/16/24 included topics: Abuse and Neglect, and Resident Rights. The In-Servicing was signed by 18 staff. 2.Record review of Resident #1's Admission Record, dated 3/22/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included: type 2 diabetes mellitus with foot ulcer secondary to resistance to multiple antibiotics, and cellulitis [an infection whereas bacteria enter through a break in the skin that causes selling, pain, redness, warmth to the affected area, and requires antibiotic treatment]. Record review of Resident #1's baseline care plan, dated 3/19/2024 at 6:49 PM, revealed Resident #1 had a wandering risk score of 1 indicative of low risk for wandering. Record review of referral documents from previous hospital admission, revealed under the heading Chief Complaint, dated 3/15/2024 at 5:05 PM, [Resident #1] occasionally telling nurses she wants to leave AMA. Under the heading Pre-Procedure Diagnosis, drug abuse (methamphetamine). Under the heading History of Present Illness, [Resident #1], is homeless and unable to take care of feet/obtaining medication. Under the heading, History - Adult longitudinal, Resident #1 had drug use: Meth/amphetamines, drug screen positive at admission. Record review of skilled nursing notes gated 3/19/2024 at 9:26 PM, authored by LVN C, Resident #1 arrived at the facility at 6:30 PM . Resident #1 Found in dining room at about 8:30 PM about to light a cigarette . Resident #1 Redirected to smoking courtyard. Resident #1 last seen by staff walking towards smoking courtyard at about 8:30 PM wearing clothing that she arrived in from the hospital [disposable paper scrubs]. during last medication round at 9:00 PM Resident #1 was not observed in her room and subsequently could not be found in the building. Missing resident protocols initiated. Record review of handwritten note entitled hospitals called, dated 3/20/2024 at 3:48 PM revealed 10 different local hospitals contact information indicating they had been contacted regarding Resident #1. Record review of [hospital] Patient Visit Information documents, dated 3/20/2024, revealed under the heading medication dose and instructions included medication dose and instructions, Resident #1 had a prescription for Bactrim, an antibiotic, to be taken twice a day for 14 days. Documents included information on Food Resources in the area. In an interview on 3/20/2024 at 5:05 PM, the DON stated, with the current census being low [49 at the time of interview], current staffing was very good. The DON stated the facility staffed 3 CNAs on the morning [6a-2p] and afternoon [2p-10p] shifts, and 2 CNAs on overnights. The DON stated the facility staffed 2 nurses on all shifts. The DON stated the ADON came in early, that she [the DON] stayed late, and the Treatment Nurse usually worked in the middle, an 8a-5p shift. The DON stated that there is a MA on each of the morning and afternoon shifts. The DON stated the medical records clerk and the ADM both have active CNA certifications and will jump in to work the floor when necessary. The DON stated the front desk receptionist position is usually 8a-5p, but there is flexibility for her to flex her shift as she needs to. In an interview on 3/20/2024 at 5:55 PM, the DON stated Resident #1 left no personal belongs behind when she eloped. The DON stated that Resident #1 was homeless and a drug addict. The DON stated Resident #2 had a known behavior in another major metropolitan area of requesting to go to the hospital, where he would refuse to return to his previous facility, and request alternative placement be found. The DON stated this was how he ended up in this area and ultimately in the facility. The DON stated Resident #2 was now difficult to place in that area. The DON stated that she wanted to give people a chance which is why she took these two residents despite their predilections for problematic behaviors. The DON stated the facility typically does not take residents that pace or have exit seeking elopement behaviors. In an interview on 3/20/2024 at 6:20 PM, MA F stated on 3/19/2024 at around 8:30 PM, he had been standing at the medication cart position just outside of a resident's room in the process of preparing that residents medications when he saw Resident #1 was at dining room table in the process of lighting a cigarette. He notified a staff member closer to Resident #1 to redirect Resident #1 to the smoking courtyard. He stated he saw Resident #1 walking towards that smoking courtyard. He stated that around 9:00 PM he was notified by his nurse, LVN B that Resident #1 was not in her room and was needed for medication administration. MA F stated the two of them, MA F and LVN B, went to look for the Resident #1 in the smoking courtyard. MA F stated upon not finding her there they initiated the facilities missing persons protocol and began a facility wide search. In an interview on 3/20/24 at 6:35 PM LVN B stated Resident #1 had arrived to the facility around 6:30 PM on 3/19/2024; and had dinner. Another staff member, MA F, notified him that Resident #1 was attempting to smoke in the dining room, so MA F redirected Resident #1 to smoke in the courtyard. Around 9:00 PM LVN B realized Resident #1 was not in her room, and LVN B needed to give her evening meds. LVN B went down to the smoking courtyard and did not find Resident #1 there. LVN B initiated an all staff search of the facility an exterior of the building. LVN B notified the DON and the ADM that Resident #1 had eloped. LVN B stated the local Police Department was notified, and a report was filed; Local Police declined to initiate a missing person report due to Resident #1's previous drug seeking behaviors and homelessness. LVN B stated he thought there were cameras in the parking lot but was not sure if they actually worked. In an interview on 3/20/24 at 6:55 PM, Resident # 3 stated he did not actually see the lady [Resident #1] leave. Resident #3 stated he had a brief conversation along the lines of hi how are you in the vestibule /waiting area and Resident #1 replied she was waiting for someone. Resident #3 stated he went about looking for a book to read and later noticed Resident #1 was gone and assumed she was picked up by whoever she had been waiting for. Resident # 3 stated Resident #1 had a small red bag and was wearing the paper hospital top and bottom. Resident #3 stated she did not seem upset and was calm when he saw her. Resident # 3 stated he thought it was around 8:30 PM or 9:00 PM yesterday [3/19/2024] when this occurred. In an interview on 3/20/24 at 7:00 PM, the ADM stated the facility did not have cameras. The ADM stated the doors do not alarm or chime upon opening. The ADM stated after hours the doors automatically lock behind you but can be opened from the inside. In an interview on 3/21/24 at 2:00 PM, Ombudsman stated she had not yet been informed of any elopement at this facility; Ombudsman A stated she did not have any concerns about this facility or elopements knowing the type of residents housed at this facility; Ombudsman A stated that since the new administrator and DON started at this facility, things have really turned around - patient morale and outlook has improved and things have really gotten better at this facility. Ombudsman A stated for the census this facility has a very good staffing ratio. In an interview on 3/21/2024 at 3:45 PM, the DON stated this facility does not normally admit residents with elopement/exit seeking behaviors; DON stated the recent in services included enhanced observations of behaviors that might lead to elopement/exit seeking behaviors such as expressions of dissatisfaction, increased aggression or agitation or statements to that effect. The DON stated this facility was not equipped for residents with significant behaviors for elopement or wandering. The DON stated those residents are diverted to one of their sister facilities that has a locked unit. In an interview on 3/21/2024 at 5:30 PM with Charge Nurse RN E at the local emergency room for [Hospital], stated Resident #1 presented to the emergency roiagnom on [DATE] at 10:48 PM with anxiety and heel pain. Charge nurse RN E stated Resident # 1 was seen by [ER Physician]. Charge nurse RN E stated Resident #1 was not administered any medication while in the emergency room . Resident #1 was given paper prescriptions for medications to treat the infection and her regular maintenance medications. Resident #1 was also provided information on available food resources. Charge nurse RN E stated Resident #1 was alert and oriented times 4 [person, place, time, situation]. Resident #1 disposition was discharged home with medications. Charge nurse RN E stated while in the emergency room , Resident #1 did not reveal she was homeless or would have any difficulty obtaining the prescriptions. Charge nurse RN E stated while in the emergency room , Resident #1 did not reveal that she had eloped from the facility. In an interview and observation on 3/22/2024 at 2:15 PM with the ADM and the DON present, the ADM stated a new alarm system had been installed on the interior door to the vestibule area last night. The Administrator stated during the daytime hours a chime will sound anytime that door was opened. The Administrator further stated between the hours of 8:00 PM and 6:00 AM the nurses would enter a code that would switch the alarm from a chime to an alarm. The Administrator further stated after 8:00 PM, or when receptionist left for the day, an alarm would sound anytime that door was opened. The alarm required passcode be entered before the alarm would stop sounding. The Administrator stated the chime could be heard throughout the facility, even to the furthest points of resident occupied areas. and the alarm was louder and can be heard throughout the facility even to the furthest points of resident occupied areas. Record review of In-Service training report/attendance record dated 3/19/2024 included topics: Abuse Neglect, Resident Rights, Monitoring Signs of Possible Elopement Risk. It included 26 staff signatures. Record review of the facility's Wandering, And Elopement policy revised March 2019, revealed: if identified as at risk for wandering, elopement or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. 2.) if an employee observes a resident leaving . attempt to prevent; Request assistance from other staff; Instruct another staff member to alert management 3.) if a resident is missing, initiate the elopement/missing resident emergency procedure: a determine if the resident is out on an unauthorized leave of absence; b.) if the resident was not on an unauthorized leave, initiate a search of the facility, grounds and immediate area surrounding the building; c.) if the resident is not in any of the searched areas notify the administrator, director of nursing, family/responsible party and law enforcement officials. Record review of In-Service training report dated 3/20/2024 on the topic of Alerts and Meaning; Contents or summary of training . Code green - missing residents. This training was conducted by the DON and included signatures of 22 staff members. The facility's Plan of Removal was accepted on 03/23/2024 at 7:51 A.M. and included: F600- Immediate Action Notify The Medical Director of the Immediate Jeopardy status. Resident # 1 and Resident #2 are no longer residing at the facility. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 10 pm on 03/22/2024. Alarm was installed on the dining room door to the front office, which contains the outside exit door. The alarm is turned on nightly as the receptionist leaves at 8:00 pm by the Charge Nurse. The alarm will remain off during daytime hours when the front office area is monitored by the receptionist. The charge nurse will check the alarm and door every two hours to ensure they are on and functioning. The alarm will remain turned on throughout the weekend. The alarm checks will be documented on a log included with the abatement plan. Training on the door alarm will be completed by Sunday, 03/24/24, at noon. Inservice staff on elopement/missing resident protocols, which includes color-coded announcements and search areas. For new admissions, when staff conduct routine checks, they will discuss with residents the resident's comfort, orientation, and understanding of facility rules, such as the process to check out when going on pass. These conversations will be in addition to the orientation provided by the admitting charge nurse. The charge nurse will turn on the front door alarm after the receptionist leaves - no later than 8:00 p.m.-and document the action on a check log. Staff will be in service to answer door alarms after the start of the new process and quarterly thereafter. The Clinical Liaison and Marketer and the Admissions Director/designee will carefully scan records to ensure residents are appropriate for facility services and will make residents aware of efforts to assist resident's plan for discharge. The Admissions Director/designee will review the procedures for signing in and out for a pass. For after-business-hours admissions, the nurse admitting the resident will cover these steps during the assessment and orientation process for the resident. The administrator and DON will provide education on the Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy, with a focus on the need to monitor residents going in and out of the dining room front door and monitoring the front door alarm. The target date for training completion is Sunday, 03/24/24, by noon. New employees and agency nurses (if used) will be educated on the alarms and resident monitoring during orientation and before starting their initial shift. An interview with LVN A on 3/23/24 at 245 p.m. confirmed that she was in-serviced and educated on the alarms and resident monitoring. Before starting her shift on 3/22/23 at 9:30 P.M. by the DON. The Administrator and Director of Nurses will educate the Clinical Liaison and the Admissions Director on reviewing referral paperwork and on the importance of identifying information that may need to be reviewed by the Director of Nursing before acceptance. This will ensure that residents accepted for admission are appropriate for the facility and do not require a secured facility. Residents deemed unsafe for admission due to wandering behaviors will not be admitted . Training will be completed by Sunday, 03/24/24, at noon. Upon admission, the Admissions Director and/ or designee will discuss facility rules with the resident and responsible party regarding signing in and out to go on pass. The charge nurse admitting the resident will further discuss the facility rules for exiting the facility and will assess the elopement risk of the new resident. If it is determined at any time post-admission that a resident is no longer safe and needs a secured unit, the resident will have 1:1 monitoring until safely discharged to an appropriate facility. Education will be provided on this process to the Department Managers, including the Admission Director and Clinical Liaison, as well as the Charge Nurses and Nurse Managers. This training will be completed by the Administrator and the Director of Nurses by Sunday, 03/24/24, at noon. The DON and/ or designee will audit all new admissions and readmissions daily to ensure an elopement risk assessment has been completed and that the resident has been provided with orientation for the out-on-pass procedure. The Director of Nurses and/ or designee will complete and review elopement risk audits with each admission, readmission, and change of condition. Quarterly assessments and reviews will remain ongoing to ensure that an appropriate and personalized plan of care is in place for residents at risk and that compliance and standards are met. The administrator and director of nurses will provide the staff with training on Elopement Protocols by Sunday, 03/24/24, at noon. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a non-threatening, courteous manner. b. Request assistance from other staff member in the immediate vicinity as needed. c. Instruct another staff member to alert the charge nurse, Director of Nursing and/or Administrator of the resident's intent to leave the premises. If a resident is missing, initiate the elopement/missing resident emergency procedure: d. Determine if the resident is out on an unauthorized leave of absence. e. If the resident was not authorized to leave, initiate a search of the facility, grounds, and immediate areas surrounding the building. f. If the resident is not in the searched areas, notify the Administrator, the Director of Nursing, the family/responsible party, and law enforcement officials. When the resident returns to the facility, the director of nursing services or charge nurse shall: g. Notify staff and examine the resident for injuries. h. Notify the physician and medical director of the resident return and assessment findings. i. Notify the family/ responsible party. Verification included: Notify The Medical Director of the Immediate Jeopardy status. Verified via interview with Medical Director [Name of MD], on 3/23/24 at 1:12 PM, she was notified of the IJ at on 3/22/24 at 6:45 PM. Resident # 1 and Resident #2 are no longer residing at the facility. Verified, via interview with The DON on 3/23/24 at 1:24 P.M., that Resident # 1 was discharged from the facility on 3/20/24 at 107 P.M., and Resident # 2 was discharged from the facility on 3/19/24 at 10:00 P.M. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Verified, Elopement assessments completed on electronic medical records for 49 of 49 residents. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 10 pm on 03/22/2024. Verified, on 3/23/24 via Interview with DON, that none of the 49 current residents were identified as High Risk. Alarm was installed on the dining room door to the front office, which contains the outside exit door. Verified by surveyor on 3/23/24 at 10:45 a.m. upon entrance that dining room door to front office is present and functioning. The alarm is turned on nightly as the receptionist leaves at 8:00 pm by the Charge Nurse. The alarm will remain off during daytime hours when the front office area is monitored by the receptionist. Verified, via an interview with The Administrator on 3/23/24 at 120 p.m., that the alarm is turned on by the receptionist nightly at 8:00 P.M. Verified that the alarm is monitored during daytime hours by the receptionist. Verified, via logbook noted on south wing of [ name of Nursing Home] on 3/23/24 at 210 P.M that night shift nurses monitor alarm after 8:00 p.m. The charge nurse will check the alarm and door every two hours to ensure they are on and functioning. Verified, via log book signatures noted on south wing of [ Name of Nursing Home] on 3/23/24 at 210 P.M that night shift nurses monitor alarm after 8:00 p.m. The alarm will remain turned on throughout the weekend. Verified, by surveyor on 3/23/24 at 10:45 a.m. upon entrance that alarm is on and functioning. The alarm checks will be documented on a log included with the abatement plan. Verified, via log book signatures noted on south wing of [ name of Nursing Home ] on 3/23/24 at 210 P.M . Training on the door alarm will be completed by Sunday, 03/24/24, at noon. Verified, completed training for Door alarms was completed by 54/54 employees, noted with signatures acknowledging in-service. Inservice staff on elopement/missing resident protocols, which includes color-coded announcements and search areas. Verified, Inservice elopement/missing resident protocols staff signatures and interviews with the DON, ADON, and the Administrator revealed DON and ADON were trained step by step in elopement/missing resident protocols procedure on 03/22/23 to cover immediacy by the Administrator. DON and ADON were brought into the office, provided a copy of the procedure, and were able to verbalize understanding of the procedure. See the in-service sheets attached. For new admissions, when staff conduct routine checks, they will discuss with residents the resident's comfort, orientation, and understanding of facility rules, such as the process to check out when going on pass. These conversations will be in addition to the orientation provided by the admitting charge nurse. Verified, in-service elopement/missing resident protocols was completed via in-service elopement /missing resident protocols was completed by (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, and (2) 10 pm-0600 am LVN's. The charge nurse will turn on the front door alarm after the receptionist leaves - no later than 8:00 p.m.-and document the action on a check log. Staff will be in service to answer door alarms after the start of the new process and quarterly thereafter. Verified via in-service elopement /missing resident protocols was completed for: (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, (2) 10 pm-0600 am LVN's. and (2) receptionists. The Clinical Liaison and Marketer and the Admissions Director/designee will carefully scan records to ensure residents are appropriate for facility services and will make residents aware of efforts to assist resident's plan for discharge. The Admissions Director/designee will review the procedures for signing in and out for a pass. For after-business-hours admissions, the nurse admitting the resident will cover these steps during the assessment and orientation process for the resident. Verified, via in-service signature, elopement /missing resident protocols was completed by The Clinical Liaison, Marketer, and Admissions Director. Verified via in-service elopement /missing resident protocols was completed by (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, (2) 10 pm-0600 am LVN's. The administrator and DON will provide education on the Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy, with a focus on the need to monitor residents going in and out of the dining room front door and monitoring the front door alarm. The target date for training completion is Sunday, 03/24/24, by noon. Verified, via record review of the in-service sheet Titled Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy reflected 54 staff members' signatures. 11 LVNs, 2 RNs, 12 CMA's, 11 Administrative personnel, 10 Therapists, 3 housekeepers, and 6 dietary staff. 24 out of 54 staff members interviewed (8 LVN, 2 RN, 6 Therapy, 3 Administrative, 5 dietary) verified Inservice. New employees and agency nurses (if used) will be educated on the alarms and resident monitoring during orientation and before starting their initial shift. Verified via interview with the DON on 3/23/24 at 235 P.M. that no new licensed nurses have been hired since this IJ, and only one agency nurse has been used by the [ Name of Nursing home] since the IJ. An interview with LVN A on 3/23/24 at 245 p.m. confirmed that she was in-serviced and educated on the alarms and resident monitoring. Before starting her shift on 3/22/23 at 9:30 P.M. by the DON. The Administrator and Director of Nurses will educate the Clinical Liaison and the Admissions Director on reviewing referral paperwork and on the importance of identifying information that may need to be reviewed by the Director of Nursing before acceptance. This will ensure that residents accepted for admission are appropriate for the facility and do not require a secured facility. Residents deemed unsafe for admission due to wandering behaviors will not be admitted . Training will be completed by Sunday, 03/24/24, at noon. Verified via interview with Clinical Liaison and Admissions Director on 3/23/24 at 245 pm that they were in-serviced on referral paperwork that may need to be reviewed by the Administrator and the DON. Upon admission, the Admissions Director and/ or designee will discuss facility rules with the resident and responsible party regarding signing in and out to go on pass. The charge nurse admitting the resident will further discuss the facility rules for exiting the facility and will assess the elopement risk of the new resident. If it is determined at any time post-admission that a resident is no longer safe and needs a secured unit, the resident will have 1:1 monitoring until safely discharged to an appropriate facility. Education will be provided on this process to the Department Managers, including the Admission Director [TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to ensure resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 3 residents (Resident #2 and #1) reviewed for neglect., in that: 1. Resident #2 was able to exit the building without staff knowing on 3/15/2024; staff were unaware Resident #2 had wheeled himself to a bus stop on a city sidewalk and was gone until he was brought back by police; staff were unaware that Resident #2 had exit seeking behavior although it was in his admission paperwork. 2. Resident #1 was able to exit the building without staff knowing on 3/19/2024; staff were unaware Resident #1 had exited the building and her whereabouts are still unknown. This failure could place resident at risk of neglect resulting in elopements that could have resulted in serious injury, harm, impairment, or death. An IJ was identified on 03/22/2024. The IJ template was provided to the facility on [DATE] at 05:50 PM. While the IJ was removed on 03/23/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facilities need to evaluate the effectiveness of their corrective actions. The findings were: 1.Record review of Resident #2 Administration Record dated 3/24/2024, revealed Resident #2 was a [AGE] year-old male originally admitted on [DATE] with diagnosis listed as: unspecified heart failure. Other active diagnosis included deaf, non-speaking; functional quadriplegia [completely immobile due to severe disability or frailty]; schizoaffective disorder bipolar type [mental health disorder marked by a combination of symptoms such as hallucinations or delusions, mood disorder symptoms such as depression or mania]. Further review a discharge date of [DATE] to another nursing facility in the area. Record review of the quarterly MDS assessment dated [DATE], revealed Resident #2 was coded as highly impaired [absence of useful] hearing with unclear speech; ability to express ideas and wants was coded as usually understood; ability to understand others was coded as sometimes understands in Section B - Hearing, Speech, and Vision. In Section C - Cognitive Patterns, Resident #2 was coded as No for Should BIMS be Conducted due to resident is rarely/never understood; with Disorganized Thinking continuously present, does not fluctuate. In Section D - Mood, Resident #2 was coded as being short-tempered, easily annoyed, rarely felt lonely or isolated from those around you; In Section E - Behavior, Resident #2 was coded as none of the above for indicators of psychosis [hallucinations, delusions]. In Section GG - Functional Abilities, Resident #2 was coded as normally utilizing a wheelchair. Resident #2 was coded as substantial/maximal assistance [helper does more than half the effort] for wheel 50 feet with two turns, and wheel 150 feet with a manual wheelchair. Record review of Resident # 2's All-Inclusive Admission with Baseline Care Plan, dated 11/09/2023, revealed the resident was at risk for wandering with a wandering risk score of 3. Under the subheading for vision, 4.) Residents' ability to see an adequate light and with glasses if used was coded as highly or severely impaired - sees only lights, colors, etcetera or no vision. Record review of referral documents from previous hospital admission, revealed under Emergency Department Medical Screen Exam on 11/03/2023 at 1:18, Resident #2 was deaf and communicates via sign language; does not want to go back to the group home .; wants to go into a nursing home. Reexamination on 11/03/2023 at 1:58 PM, presents to emergency department because he is unhappy with his living situation. At 11/03/2023 at 12:05 PM, documentation reveals, Informed that the patient [Resident #2] has been denied at multiple NH [nursing homes] because of behavioral issues he has had in the past. Under the History & Physical section dated 11/03/2023 at 3:28 PM, patient wanting a new placement and refusing to leave . Progress Note dated 11/05/2023 at 3:03 PM revealed, Resident #2 called 911 from group home .30 minutes after discharge from a hospital in [redacted] . upset due to circumstances. Record review of Behavior Note, dated 3/10/2024 at 5:57 AM, authored by LVN A revealed Resident #2, seen him going out the front door, wanting nurse to call 911. Record review of Behavior Note, dated 3/16/2024 at 2:03 AM, authored by LVN A revealed, Resident #2 found by police at bus stop, police was called by persons walking by for wellness check, policy finally got [Resident #2] to return to facility .EMS came, unable to take him since he is not critique [critical]. I had to station an aide at front door so resident wouldn't go back to bus stop. We need a inside lock on [front door] so this situation would not happen again. Record review of Internal Investigation Summary dated 3/16/2024, revealed Timeline of Event: 3/16/2024 at 12:48 AM Administrator received call from LVN A to inform the police have brought Resident #2 to the facility from the bus stop at the end of the parking lot on the city sidewalk. Resident #2 had wheeled himself to the bus stop without notifying a nurse or any other staff. Resident #2 told the police officer he wanted to go to the hospital. EMS was contacted at Resident #2's request; paramedics assessed the resident and declined to transfer to the hospital; resident declined head to toe assessment by DON at that time; resident uncooperative and upset; the next afternoon resident insisted that the doctor be called so he could be sent to the hospital; Attending physician was called and an order was obtained to transfer him to [Hospital]; Resident from [another major city] area originally where he had a habit of going to the hospital and then going to a different facility; Ended up in [this area] because he became hard to place in [another major city] area due to his behaviors; While inpatient at the hospital he requested another facility to be found and a social worker has been working to facilitate a transfer; Facility was willing to accept the resident back from the hospital; According to his mother, Resident #2 had past behaviors such as he will go to a hospital and not want to leave. Record review of handwritten statement dated 3/18/24, authored by LVN A revealed, statement, on 10-6 shift, while at the nurses' station north, vital check of Resident #2. Resident #2 was watching TV in the ding room between 10-11pm on 3/15/24. Record review of In-Servicing dated 3/16/24 included topics: Abuse and Neglect, and Resident Rights. The In-Servicing was signed by 18 staff. 2.Record review of Resident #1's Admission Record, dated 3/22/2024, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included: type 2 diabetes mellitus with foot ulcer secondary to resistance to multiple antibiotics, and cellulitis [an infection whereas bacteria enter through a break in the skin that causes selling, pain, redness, warmth to the affected area, and requires antibiotic treatment]. Record review of Resident #1's baseline care plan, dated 3/19/2024 at 6:49 PM, revealed Resident #1 had a wandering risk score of 1 indicative of low risk for wandering. Record review of referral documents from previous hospital admission, revealed under the heading Chief Complaint, dated 3/15/2024 at 5:05 PM, [Resident #1] occasionally telling nurses she wants to leave AMA. Under the heading Pre-Procedure Diagnosis, drug abuse (methamphetamine). Under the heading History of Present Illness, [Resident #1], is homeless and unable to take care of feet/obtaining medication. Under the heading, History - Adult longitudinal, Resident #1 had drug use: Meth/amphetamines, drug screen positive at admission. Record review of skilled nursing notes gated 3/19/2024 at 9:26 PM, authored by LVN C, Resident #1 arrived at the facility at 6:30 PM . Resident #1 Found in dining room at about 8:30 PM about to light a cigarette . Resident #1 Redirected to smoking courtyard. Resident #1 last seen by staff walking towards smoking courtyard at about 8:30 PM wearing clothing that she arrived in from the hospital [disposable paper scrubs]. during last medication round at 9:00 PM Resident #1 was not observed in her room and subsequently could not be found in the building. Missing resident protocols initiated. Record review of handwritten note entitled hospitals called, dated 3/20/2024 at 3:48 PM revealed 10 different local hospitals contact information indicating they had been contacted regarding Resident #1. Record review of [hospital] Patient Visit Information documents, dated 3/20/2024, revealed under the heading medication dose and instructions included medication dose and instructions, Resident #1 had a prescription for Bactrim, an antibiotic, to be taken twice a day for 14 days. Documents included information on Food Resources in the area. In an interview on 3/20/2024 at 5:05 PM, the DON stated, with the current census being low [49 at the time of interview], current staffing was very good. The DON stated the facility staffed 3 CNAs on the morning [6a-2p] and afternoon [2p-10p] shifts, and 2 CNAs on overnights. The DON stated the facility staffed 2 nurses on all shifts. The DON stated the ADON came in early, that she [the DON] stayed late, and the Treatment Nurse usually worked in the middle, an 8a-5p shift. The DON stated that there is a MA on each of the morning and afternoon shifts. The DON stated the medical records clerk and the ADM both have active CNA certifications and will jump in to work the floor when necessary. The DON stated the front desk receptionist position is usually 8a-5p, but there is flexibility for her to flex her shift as she needs to. In an interview on 3/20/2024 at 5:55 PM, the DON stated Resident #1 left no personal belongs behind when she eloped. The DON stated that Resident #1 was homeless and a drug addict. The DON stated Resident #2 had a known behavior in another major metropolitan area of requesting to go to the hospital, where he would refuse to return to his previous facility, and request alternative placement be found. The DON stated this was how he ended up in this area and ultimately in the facility. The DON stated Resident #2 was now difficult to place in that area. The DON stated that she wanted to give people a chance which is why she took these two residents despite their predilections for problematic behaviors. The DON stated the facility typically does not take residents that pace or have exit seeking elopement behaviors. In an interview on 3/20/2024 at 6:20 PM, MA F stated on 3/19/2024 at around 8:30 PM, he had been standing at the medication cart position just outside of a resident's room in the process of preparing that residents medications when he saw Resident #1 was at dining room table in the process of lighting a cigarette. He notified a staff member closer to Resident #1 to redirect Resident #1 to the smoking courtyard. He stated he saw Resident #1 walking towards that smoking courtyard. He stated that around 9:00 PM he was notified by his nurse, LVN B that Resident #1 was not in her room and was needed for medication administration. MA F stated the two of them, MA F and LVN B, went to look for the Resident #1 in the smoking courtyard. MA F stated upon not finding her there they initiated the facilities missing persons protocol and began a facility wide search. In an interview on 3/20/24 at 6:35 PM LVN B stated Resident #1 had arrived to the facility around 6:30 PM on 3/19/2024; and had dinner. Another staff member, MA F, notified him that Resident #1 was attempting to smoke in the dining room, so MA F redirected Resident #1 to smoke in the courtyard. Around 9:00 PM LVN B realized Resident #1 was not in her room, and LVN B needed to give her evening meds. LVN B went down to the smoking courtyard and did not find Resident #1 there. LVN B initiated an all staff search of the facility an exterior of the building. LVN B notified the DON and the ADM that Resident #1 had eloped. LVN B stated the local Police Department was notified, and a report was filed; Local Police declined to initiate a missing person report due to Resident #1's previous drug seeking behaviors and homelessness. LVN B stated he thought there were cameras in the parking lot but was not sure if they actually worked. In an interview on 3/20/24 at 6:55 PM, Resident # 3 stated he did not actually see the lady [Resident #1] leave. Resident #3 stated he had a brief conversation along the lines of hi how are you in the vestibule /waiting area and Resident #1 replied she was waiting for someone. Resident #3 stated he went about looking for a book to read and later noticed Resident #1 was gone and assumed she was picked up by whoever she had been waiting for. Resident # 3 stated Resident #1 had a small red bag and was wearing the paper hospital top and bottom. Resident #3 stated she did not seem upset and was calm when he saw her. Resident # 3 stated he thought it was around 8:30 PM or 9:00 PM yesterday [3/19/2024] when this occurred. In an interview on 3/20/24 at 7:00 PM, the ADM stated the facility did not have cameras. The ADM stated the doors do not alarm or chime upon opening. The ADM stated after hours the doors automatically lock behind you but can be opened from the inside. In an interview on 3/21/24 at 2:00 PM, Ombudsman stated she had not yet been informed of any elopement at this facility; Ombudsman A stated she did not have any concerns about this facility or elopements knowing the type of residents housed at this facility; Ombudsman A stated that since the new administrator and DON started at this facility, things have really turned around - patient morale and outlook has improved and things have really gotten better at this facility. Ombudsman A stated for the census this facility has a very good staffing ratio. In an interview on 3/21/2024 at 3:45 PM, the DON stated this facility does not normally admit residents with elopement/exit seeking behaviors; DON stated the recent in services included enhanced observations of behaviors that might lead to elopement/exit seeking behaviors such as expressions of dissatisfaction, increased aggression or agitation or statements to that effect. The DON stated this facility was not equipped for residents with significant behaviors for elopement or wandering. The DON stated those residents are diverted to one of their sister facilities that has a locked unit. In an interview on 3/21/2024 at 5:30 PM with Charge Nurse RN E at the local emergency room for [Hospital], stated Resident #1 presented to the emergency roiagnom on [DATE] at 10:48 PM with anxiety and heel pain. Charge nurse RN E stated Resident # 1 was seen by [ER Physician]. Charge nurse RN E stated Resident #1 was not administered any medication while in the emergency room . Resident #1 was given paper prescriptions for medications to treat the infection and her regular maintenance medications. Resident #1 was also provided information on available food resources. Charge nurse RN E stated Resident #1 was alert and oriented times 4 [person, place, time, situation]. Resident #1 disposition was discharged home with medications. Charge nurse RN E stated while in the emergency room , Resident #1 did not reveal she was homeless or would have any difficulty obtaining the prescriptions. Charge nurse RN E stated while in the emergency room , Resident #1 did not reveal that she had eloped from the facility. In an interview and observation on 3/22/2024 at 2:15 PM with the ADM and the DON present, the ADM stated a new alarm system had been installed on the interior door to the vestibule area last night. The Administrator stated during the daytime hours a chime will sound anytime that door was opened. The Administrator further stated between the hours of 8:00 PM and 6:00 AM the nurses would enter a code that would switch the alarm from a chime to an alarm. The Administrator further stated after 8:00 PM, or when receptionist left for the day, an alarm would sound anytime that door was opened. The alarm required passcode be entered before the alarm would stop sounding. The Administrator stated the chime could be heard throughout the facility, even to the furthest points of resident occupied areas. and the alarm was louder and can be heard throughout the facility even to the furthest points of resident occupied areas. Record review of In-Service training report/attendance record dated 3/19/2024 included topics: Abuse Neglect, Resident Rights, Monitoring Signs of Possible Elopement Risk. It included 26 staff signatures. Record review of the facility's Wandering, And Elopement policy revised March 2019, revealed: if identified as at risk for wandering, elopement or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. 2.) if an employee observes a resident leaving . attempt to prevent; Request assistance from other staff; Instruct another staff member to alert management 3.) if a resident is missing, initiate the elopement/missing resident emergency procedure: a determine if the resident is out on an unauthorized leave of absence; b.) if the resident was not on an unauthorized leave, initiate a search of the facility, grounds and immediate area surrounding the building; c.) if the resident is not in any of the searched areas notify the administrator, director of nursing, family/responsible party and law enforcement officials. Record review of In-Service training report dated 3/20/2024 on the topic of Alerts and Meaning; Contents or summary of training . Code green - missing residents. This training was conducted by the DON and included signatures of 22 staff members. The facility's Plan of Removal was accepted on 03/23/2024 at 7:51 A.M. and included: F600- Immediate Action Notify The Medical Director of the Immediate Jeopardy status. Resident # 1 and Resident #2 are no longer residing at the facility. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 10 pm on 03/22/2024. Alarm was installed on the dining room door to the front office, which contains the outside exit door. The alarm is turned on nightly as the receptionist leaves at 8:00 pm by the Charge Nurse. The alarm will remain off during daytime hours when the front office area is monitored by the receptionist. The charge nurse will check the alarm and door every two hours to ensure they are on and functioning. The alarm will remain turned on throughout the weekend. The alarm checks will be documented on a log included with the abatement plan. Training on the door alarm will be completed by Sunday, 03/24/24, at noon. Inservice staff on elopement/missing resident protocols, which includes color-coded announcements and search areas. For new admissions, when staff conduct routine checks, they will discuss with residents the resident's comfort, orientation, and understanding of facility rules, such as the process to check out when going on pass. These conversations will be in addition to the orientation provided by the admitting charge nurse. The charge nurse will turn on the front door alarm after the receptionist leaves - no later than 8:00 p.m.-and document the action on a check log. Staff will be in service to answer door alarms after the start of the new process and quarterly thereafter. The Clinical Liaison and Marketer and the Admissions Director/designee will carefully scan records to ensure residents are appropriate for facility services and will make residents aware of efforts to assist resident's plan for discharge. The Admissions Director/designee will review the procedures for signing in and out for a pass. For after-business-hours admissions, the nurse admitting the resident will cover these steps during the assessment and orientation process for the resident. The administrator and DON will provide education on the Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy, with a focus on the need to monitor residents going in and out of the dining room front door and monitoring the front door alarm. The target date for training completion is Sunday, 03/24/24, by noon. New employees and agency nurses (if used) will be educated on the alarms and resident monitoring during orientation and before starting their initial shift. An interview with LVN A on 3/23/24 at 245 p.m. confirmed that she was in-serviced and educated on the alarms and resident monitoring. Before starting her shift on 3/22/23 at 9:30 P.M. by the DON. The Administrator and Director of Nurses will educate the Clinical Liaison and the Admissions Director on reviewing referral paperwork and on the importance of identifying information that may need to be reviewed by the Director of Nursing before acceptance. This will ensure that residents accepted for admission are appropriate for the facility and do not require a secured facility. Residents deemed unsafe for admission due to wandering behaviors will not be admitted . Training will be completed by Sunday, 03/24/24, at noon. Upon admission, the Admissions Director and/ or designee will discuss facility rules with the resident and responsible party regarding signing in and out to go on pass. The charge nurse admitting the resident will further discuss the facility rules for exiting the facility and will assess the elopement risk of the new resident. If it is determined at any time post-admission that a resident is no longer safe and needs a secured unit, the resident will have 1:1 monitoring until safely discharged to an appropriate facility. Education will be provided on this process to the Department Managers, including the Admission Director and Clinical Liaison, as well as the Charge Nurses and Nurse Managers. This training will be completed by the Administrator and the Director of Nurses by Sunday, 03/24/24, at noon. The DON and/ or designee will audit all new admissions and readmissions daily to ensure an elopement risk assessment has been completed and that the resident has been provided with orientation for the out-on-pass procedure. The Director of Nurses and/ or designee will complete and review elopement risk audits with each admission, readmission, and change of condition. Quarterly assessments and reviews will remain ongoing to ensure that an appropriate and personalized plan of care is in place for residents at risk and that compliance and standards are met. The administrator and director of nurses will provide the staff with training on Elopement Protocols by Sunday, 03/24/24, at noon. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a non-threatening, courteous manner. b. Request assistance from other staff member in the immediate vicinity as needed. c. Instruct another staff member to alert the charge nurse, Director of Nursing and/or Administrator of the resident's intent to leave the premises. If a resident is missing, initiate the elopement/missing resident emergency procedure: d. Determine if the resident is out on an unauthorized leave of absence. e. If the resident was not authorized to leave, initiate a search of the facility, grounds, and immediate areas surrounding the building. f. If the resident is not in the searched areas, notify the Administrator, the Director of Nursing, the family/responsible party, and law enforcement officials. When the resident returns to the facility, the director of nursing services or charge nurse shall: g. Notify staff and examine the resident for injuries. h. Notify the physician and medical director of the resident return and assessment findings. i. Notify the family/ responsible party. Verification included: Notify The Medical Director of the Immediate Jeopardy status. Verified via interview with Medical Director [Name of MD], on 3/23/24 at 1:12 PM, she was notified of the IJ at on 3/22/24 at 6:45 PM. Resident # 1 and Resident #2 are no longer residing at the facility. Verified, via interview with The DON on 3/23/24 at 1:24 P.M., that Resident # 1 was discharged from the facility on 3/20/24 at 107 P.M., and Resident # 2 was discharged from the facility on 3/19/24 at 10:00 P.M. The Director of Nurses and Assistant Director of Nurses are completing Elopement Assessments on all current residents to ensure the risk category is accurately identified. Verified, Elopement assessments completed on electronic medical records for 49 of 49 residents. Residents identified as high risk will be reported to the physician and IDT to determine appropriate action and interventions. This task will be completed by 10 pm on 03/22/2024. Verified, on 3/23/24 via Interview with DON, that none of the 49 current residents were identified as High Risk. Alarm was installed on the dining room door to the front office, which contains the outside exit door. Verified by surveyor on 3/23/24 at 10:45 a.m. upon entrance that dining room door to front office is present and functioning. The alarm is turned on nightly as the receptionist leaves at 8:00 pm by the Charge Nurse. The alarm will remain off during daytime hours when the front office area is monitored by the receptionist. Verified, via an interview with The Administrator on 3/23/24 at 120 p.m., that the alarm is turned on by the receptionist nightly at 8:00 P.M. Verified that the alarm is monitored during daytime hours by the receptionist. Verified, via logbook noted on south wing of [ name of Nursing Home] on 3/23/24 at 210 P.M that night shift nurses monitor alarm after 8:00 p.m. The charge nurse will check the alarm and door every two hours to ensure they are on and functioning. Verified, via log book signatures noted on south wing of [ Name of Nursing Home] on 3/23/24 at 210 P.M that night shift nurses monitor alarm after 8:00 p.m. The alarm will remain turned on throughout the weekend. Verified, by surveyor on 3/23/24 at 10:45 a.m. upon entrance that alarm is on and functioning. The alarm checks will be documented on a log included with the abatement plan. Verified, via log book signatures noted on south wing of [ name of Nursing Home ] on 3/23/24 at 210 P.M . Training on the door alarm will be completed by Sunday, 03/24/24, at noon. Verified, completed training for Door alarms was completed by 54/54 employees, noted with signatures acknowledging in-service. Inservice staff on elopement/missing resident protocols, which includes color-coded announcements and search areas. Verified, Inservice elopement/missing resident protocols staff signatures and interviews with the DON, ADON, and the Administrator revealed DON and ADON were trained step by step in elopement/missing resident protocols procedure on 03/22/23 to cover immediacy by the Administrator. DON and ADON were brought into the office, provided a copy of the procedure, and were able to verbalize understanding of the procedure. See the in-service sheets attached. For new admissions, when staff conduct routine checks, they will discuss with residents the resident's comfort, orientation, and understanding of facility rules, such as the process to check out when going on pass. These conversations will be in addition to the orientation provided by the admitting charge nurse. Verified, in-service elopement/missing resident protocols was completed via in-service elopement /missing resident protocols was completed by (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, and (2) 10 pm-0600 am LVN's. The charge nurse will turn on the front door alarm after the receptionist leaves - no later than 8:00 p.m.-and document the action on a check log. Staff will be in service to answer door alarms after the start of the new process and quarterly thereafter. Verified via in-service elopement /missing resident protocols was completed for: (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, (2) 10 pm-0600 am LVN's. and (2) receptionists. The Clinical Liaison and Marketer and the Admissions Director/designee will carefully scan records to ensure residents are appropriate for facility services and will make residents aware of efforts to assist resident's plan for discharge. The Admissions Director/designee will review the procedures for signing in and out for a pass. For after-business-hours admissions, the nurse admitting the resident will cover these steps during the assessment and orientation process for the resident. Verified, via in-service signature, elopement /missing resident protocols was completed by The Clinical Liaison, Marketer, and Admissions Director. Verified via in-service elopement /missing resident protocols was completed by (2) 6 am-2 pm LVN's, (2) 2 pm - 10 pm LVN's, (2) 10 pm-0600 am LVN's. The administrator and DON will provide education on the Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy, with a focus on the need to monitor residents going in and out of the dining room front door and monitoring the front door alarm. The target date for training completion is Sunday, 03/24/24, by noon. Verified, via record review of the in-service sheet Titled Wandering and Elopement Policy, Emergency Procedure-missing Resident Policy, and Abuse, Neglect, and Exploitation policy reflected 54 staff members' signatures. 11 LVNs, 2 RNs, 12 CMA's, 11 Administrative personnel, 10 Therapists, 3 housekeepers, and 6 dietary staff. 24 out of 54 staff members interviewed (8 LVN, 2 RN, 6 Therapy, 3 Administrative, 5 dietary) verified Inservice. New employees and agency nurses (if used) will be educated on the alarms and resident monitoring during orientation and before starting their initial shift. Verified via interview with the DON on 3/23/24 at 235 P.M. that no new licensed nurses have been hired since this IJ, and only one agency nurse has been used by the [ Name of Nursing home] since the IJ. An interview with LVN A on 3/23/24 at 245 p.m. confirmed that she was in-serviced and educated on the alarms and resident monitoring. Before starting her shift on 3/22/23 at 9:30 P.M. by the DON. The Administrator and Director of Nurses will educate the Clinical Liaison and the Admissions Director on reviewing referral paperwork and on the importance of identifying information that may need to be reviewed by the Director of Nursing before acceptance. This will ensure that residents accepted for admission are appropriate for the facility and do not require a secured facility. Residents deemed unsafe for admission due to wandering behaviors will not be admitted . Training will be completed by Sunday, 03/24/24, at noon. Verified via interview with Clinical Liaison and Admissions Director on 3/23/24 at 245 pm that they were in-serviced on referral paperwork that may need to be reviewed by the Administrator and the DON. Upon admission, the Admissions Director and/ or designee will discuss facility rules with the resident and responsible party regarding signing in and out to go on pass. The charge nurse admitting the resident will further discuss the facility rules for exiting the facility and will assess the elopement risk of the new resident. If it is determined at any time post-admission that a resident is no longer safe and needs a secured unit, the resident will have 1:1 monitoring until safely discharged to an appropriate facility. Education will be provided on this process to the Department Managers, includin [TRUNCATED]

42031 Based on interview and record review the facility failed to immediately consult with the resident's physician when there was a change in condition and a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 4 of 11 residents (Residents #1, #2, #3, #4), reviewed for physician notification, in that: Residents #1-#4 were administered blood pressure medications when their blood pressures were low and outside of the physician ordered parameters without physician notification prior to or after medication administration. This failure could result in decreased continuity of care, and a delay in needed treatment and services. An immediate jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:23 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm at a scope of pattern due to the facility's need to monitor the effectiveness of their plan of removal. The findings were: Closed record review of Resident #1's face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (diffuse disease of the brain that alters brain function or structure caused by metabolic changes due to underlying health conditions), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result in inadequate blood flow to the brain and other vital organs). Resident #1 was discharged to the hospital on [DATE]. Closed record review of Resident #1's care plan revealed a focus for the diagnosis of hypertension initiated on [DATE] with the resident at risk for hypertension and hypotension episodes and a goal for Resident #1 to have no side effects of medications. Interventions included to assess reports of hypotension and hypertension episodes, check B/P as ordered and notify the doctor of abnormal results, observe for signs and symptoms and to provide medications as ordered. Closed record review of Resident #1's physician orders revealed an order with a start date of [DATE] for Losartan potassium 100mg tablet (medication used to lower blood pressure) to be given once daily for hypertension at 8:00 p.m. with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #1's EMAR for [DATE] revealed on [DATE] at 8:00 p.m. Losartan potassium 100mg tab was administered by LVN A with a B/P of ,d+[DATE], P-78. Closed record review of Resident #1's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Losartan potassium medication outside of the ordered parameters on [DATE]. Record review of Resident #2's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: cellulitis of right lower limb, essential primary hypertension, and legal blindness. Record review of Resident #2's care plan, revised [DATE], revealed a focus, [Resident #2] has [diagnosis] of Hypertension. Is at risk for Hypo-/hypertensive episodes, and interventions, Check B/P as ordered and notify MD of abnormal results and Provide medications as ordered. Record review of Resident #2's physician orders revealed an order with a start date of [DATE] for Metoprolol Tartrate Oral Tablet 25mg tablet to be given once daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Record review of Resident #2's EMAR for February 2024 revealed on [DATE] at 8:00 p.m., Metoprolol Tartrate Oral Tablet 25mg tablet was administered by LVN B with a B/P of ,d+[DATE], P-79. Record review of Resident #2's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Metoprolol Tartrate medication outside of the ordered parameters on [DATE]. Record review of Resident #3's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with diagnoses including: unspecified dementia, essential primary hypertension, and heart failure. Record review of Resident #3's care plan, revised [DATE], revealed a focus, [Resident #3] has a [diagnosis] of Hyperlipidemia. Is at risk for complications related to [diagnosis] and adverse reaction to medications, and interventions, Provide medications as ordered. Further review revealed a focus, [Resident #3] is at risk for chest pains, irregular pulse and adverse reaction to medications due to [diagnosis] of Heart Failure, and interventions, Hold medications within parameters from MD and indicated (example: hold digoxin if pulse is below 60). Record review of Resident #3's physician orders revealed an order with a start date of [DATE] for Hydrochlorothiazide Tablet 25 mg. Give 1 tablet by mouth one time a day for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Record review of Resident #3's EMAR for February 2024 revealed on [DATE] Hydrochlorothiazide was administered by LVN B with a B/P of ,d+[DATE], P-56. Record review of Resident #3's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Hydrochlorothiazide medication outside of the ordered parameters on [DATE]. Closed record review of Resident #4's face sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included ESRD (End Stage Renal Disease- medical condition in which the kidneys cease functioning on a permanent basis leading to the need for long-term dialysis or a kidney transplant to maintain life), hypertensive heart disease with heart failure (constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation with the heart unable to pump enough blood to meet the body's needs for blood and oxygen), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result in inadequate blood flow to the brain and other vital organs). Resident #4 was discharged as expired on [DATE]. Closed record review of Resident #4's physician orders revealed an order with a start date of [DATE] and a DC date of [DATE] for Losartan potassium 25mg tablet to be given once daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #4's EMAR for [DATE] revealed losartan potassium 25mg was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of ,d+[DATE] P-77, and on [DATE] at 8:00 a.m. with a B/P of ,d+[DATE] P- 77. Closed record review of Resident #4's EMAR for February 2024 revealed losartan potassium 25mg was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of ,d+[DATE] P-86, and on [DATE] at 8:00 a.m. by LVN B with a B/P of ,d+[DATE] P-113. Closed record review of Resident #4's physician orders revealed an order with a start date of [DATE] for carvedilol 25mg tablet by mouth twice daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #4's EMAR for [DATE] revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of ,d+[DATE] P-77 and at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-77. On [DATE] at 8:00 a.m. it was administered by LVN A with a B/P of ,d+[DATE] P- 77. Closed record review of Resident #4's EMAR for February 2024 revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of ,d+[DATE] P-86 and at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-86. On [DATE] at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-68, on [DATE] at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-70. On [DATE] at 8:00 a.m. by LVN B with a B/P of ,d+[DATE] P-113. Closed record review of Resident #4's EMAR for [DATE] revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-78 Closed record review of Resident #4's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure readings and or the administration of the Losartan potassium or Carvedilol medications outside of the ordered parameters. In an interview on [DATE] at 12:05 p.m., LVN A stated she takes her own vital signs and if she administered any medications outside of the ordered parameters then she had contacted the physician and documented in the resident progress notes or through the EMAR documentation. LVN A further stated she does not know what happened and does not copy vital signs. LVN A was unable to state where else the documentation of the physician being notified would be. In an interview on [DATE] at 5:17 p.m., LVN B stated that he personally measures and accurately records vital signs including blood pressure and pulse each time the physician orders call for vital signs and stated that he does not administer medications outside of the parameters noted in the physician orders. LVN B stated he always follows physician orders, including notifying the physician if and when a resident's vital signs were outside of parameters noted in the orders. When asked why he had not notified the physician on [DATE] when Resident #2 received medication outside of parameters, and on [DATE] when Resident #3 received medication outside of parameters, LVN B stated that he always notifies the physician when needed and stated he did not know why there was no documentation of his notification. In an interview with the DON [DATE] at 5:15 p.m., the DON confirmed that accurately measuring and recording vital signs as per physician order and notifying the physician of a change in the resident's condition and/or a need to alter the resident's treatment were integral to assisting the residents to maintain good health. In a telephone interview on [DATE] at 1:02 p.m. the MD stated he was not aware and could not recall being notified specifically with vital sign issues but was driving and did not have his patient records in front of him. The MD further stated patient safety was a priority for him and his group of physicians. In a telephone interview on [DATE] at 2:40 p.m. the MD stated the vital sign issues brought to his attention by surveyor were concerning. The MD stated he and other physicians in his group were in the facility often, and at times even 2 to 3 times a week and he had not recalled seeing blood pressure or vital sign issues on what was displayed to the physician. The MD further stated the vital sign issues could make clinical decision making more difficult. The facility's Plan of Removal was accepted on [DATE] at 5:10 p.m. and included: Date: [DATE] F 726 Immediate action: The Medical Director was notified of the Immediate Jeopardy status on [DATE] at 7:35 pm. Resident Vital Signs were taken when the issue was identified on [DATE]. An audit was done to ensure parameters were ordered for all residents on cardiac medication and vitals were being recorded on the computer correctly. The cardiac medication and vitals were found to be within normal limits. No adverse reactions observed with any resident. VS are currently in progress for all residents to ensure they are within normal/ safe limits. The primary physician will be notified for any residents found with abnormal vital signs to determine if additional treatment is warranted. This task will be completed by 10 pm on [DATE]. The Director of Nurses completed an audit on administration parameters for all residents receiving cardiac medications on [DATE] once the issue was identified. An audit will be completed again to ensure that all parameters are in place and being followed for residents on cardiac medications. On [DATE], a complete audit was done which included checking the data on the computer, taking new vital signs for residents, ensuring the vitals were recorded correctly and calling the doctors to ensure parameters were correct. This task was completed before 11:59 pm on [DATE]. Parameters will be verified with the primary care physician and updated if appropriate by 11:59 pm [DATE]. All nursing staff involved in administration of medication were in serviced to ensure they were taking vital signs prior to administering cardiac medications to ensure parameters were correct and medication was either held or administered accordingly. The staff had to do return demonstration following the in-service. Agency staff will be in-serviced on this issue prior to their starting their shift. Education will be provided to all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. The EMR system (PCC) copy feature that allowed the utilization of the last set of vital signs taken for medication administration has been turned off as of [DATE] @ 12:45pm. Facilities Plan to ensure compliance quickly Education provided by the DON will include all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. Education was initiated on [DATE] by the Director of Nurses and will continue until all nurses and med aides have completed the education and skill check for Vital Sign competency. The DON or designee will educate all newly hired licensed nurses and medication aides on medication administration and reconciliation guidelines as well as the importance of following parameters, taking a new set of vital signs with each med pass, and alerting the physician if a medication is given outside of the parameters. The DON or designee will audit all new admission, readmission, and new/ changed orders to ensure accuracy and that appropriate parameters, based on the medication, are in place if warranted. Nurses and medication aides will have a skills check completed by the Director of Nurses for medication pass to ensure they are taking a new set of vital signs and following parameters as appropriate by [DATE] 11:59 pm. Nursing and medication aide staff members will not be allowed to work their oncoming shift until this education and skill check is completed. The Director of Nurses or designee will audit vital signs and bp parameters daily x 14 days, then weekly x 4 weeks to ensure compliance. Ongoing audits will be completed randomly thereafter to verify continued compliance and ensure standards are met. Re-education will be completed with the nurse(s) or medication aide(s) if any evidence of non-compliance is determined. The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. POR Verification The Medical Director was notified of the Immediate Jeopardy status on [DATE] at 7:35 pm. - Confirmed via interview with the Medical Director [DATE] at 5:37 pm Resident Vital Signs were taken when the issue was identified on [DATE]. An audit was done to ensure parameters were ordered for all residents on cardiac medication and vitals were being recorded on the computer correctly. The cardiac medication and vitals were found to be within normal limits. No adverse reactions observed with any resident. VS are currently in progress for all residents to ensure they are within normal/ safe limits. The primary physician will be notified for any residents found with abnormal vital signs to determine if additional treatment is warranted. This task will be completed by 10 pm on [DATE]. - Confirmed via interview with Medical Director [DATE] at 5:37 pm - Confirmed via record review of 15 resident clinical records The Director of Nurses completed an audit on administration parameters for all residents receiving cardiac medications on [DATE] once the issue was identified. An audit will be completed again to ensure that all parameters are in place and being followed for residents on cardiac medications. - Confirmed via interview with the DON [DATE] at 5:15 pm On [DATE], a complete audit was done which included checking the data on the computer, taking new vital signs for residents, ensuring the vitals were recorded correctly and calling the doctors to ensure parameters were correct. This task was completed before 11:59 pm on [DATE]. Parameters will be verified with the primary care physician and updated if appropriate by 11:59 pm [DATE]. - Confirmed via interview with the DON [DATE] at 5:15 pm - Confirmed via interview with the Medical Director [DATE] at 5:37 pm - Confirmed via record review of 15 resident clinical records All nursing staff involved in administration of medication were in serviced to ensure they were taking vital signs prior to administering cardiac medications to ensure parameters were correct and medication was either held or administered accordingly. The staff had to do return demonstration following the in-service. Agency staff will be in-serviced on this issue prior to their starting their shift. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Education will be provided to all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. The EMR system (PCC) copy feature that allowed the utilization of the last set of vital signs taken for medication administration has been turned off as of [DATE] at@ 12:45pm. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Facilities Plan to ensure compliance quickly Education provided by the DON will include all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. Education was initiated on [DATE] by the Director of Nurses and will continue until all nurses and med aides have completed the education and skill check for Vital Sign competency. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff The DON or designee will educate all newly hired licensed nurses and medication aides on medication administration and reconciliation guidelines as well as the importance of following parameters, taking a new set of vital signs with each med pass, and alerting the physician if a medication is given outside of the parameters. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff The DON or designee will audit all new admission, readmission, and new/ changed orders to ensure accuracy and that appropriate parameters, based on the medication, are in place if warranted. - Confirmed via interview with DON [DATE] at 7:12 pm Nurses and medication aides will have a skills check completed by the Director of Nurses for medication pass to ensure they are taking a new set of vital signs and following parameters as appropriate by [DATE] 11:59 pm. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Nursing and medication aide staff members will not be allowed to work their oncoming shift until this education and skill check is completed. The Director of Nurses or designee will audit vital signs and bp parameters daily x 14 days, then weekly x 4 weeks to ensure compliance. Ongoing audits will be completed randomly thereafter to verify continued compliance and ensure standards are met. - Confirmed via interview with DON [DATE] at 7:12 pm Re-education will be completed with the nurse(s) or medication aide(s) if any evidence of non-compliance is determined. - Confirmed via interview with DON [DATE] at 7:12 pm The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. - Confirmed via interview with DON [DATE] at 7:12 pm During an interview with the DON on [DATE] at 5:15 p.m., the DON stated that only nurses and medication aides measured vital signs and administered at the facility and there were 2 medication aides and 12 nurses employed by the facility. The DON stated that 11 of the 14 staff members who administered medications had both of two in-service trainings and completed both of two skills checks. Skills checks required staff to demonstrate how to assess blood pressure using two techniques. The DON stated that the three staff members who did not yet receive training will be required to do so before their next shift. During an interview with LVN B on [DATE] at 5:17 p.m., LVN B stated his work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN B further stated he had completed two demonstrative skills checks with the DON. During an interview with Medication Aide E on [DATE] at 5:22 p.m., Medication Aide E stated her work schedule was Monday through Friday from 6:00 a.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. Medication Aide E further stated she had completed two demonstrative skills checks with the DON. During an interview with LVN A on [DATE] at 5:26 p.m., LVN A stated her work schedule was Monday through Friday from 8:00 a.m. to 5:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN A further stated she had completed two demonstrative skills checks with the DON. During an interview with RN F on [DATE] at 5:32 p.m., RN F stated her work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. RN F further stated she had completed two demonstrative skills checks with the DON. During an interview with LVN G on [DATE] at 5:43 p.m., LVN G stated his work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN G further stated he had completed two demonstrative skills checks with the DON. During an interview with LVN H on [DATE] at 5:50 p.m., LVN H stated her work schedule was Monday through Friday from 2:00 p.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN H further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN I on [DATE] at 5:55 p.m., LVN I stated his work schedule was Monday through Friday from 2:00 p.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN I further stated he had completed two demonstrative skills checks with the DON. During a telephone interview with LVN J on [DATE] at 6:04 p.m., LVN J stated her work schedule was Monday through Friday from 8:00 a.m. to 5:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN J further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN K on [DATE] at 6:16 p.m., LVN K stated her work schedule was Monday through Friday from 6:00 a.m. to 2:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN K further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN L on [DATE] at 6:24 p.m., LVN L stated her work schedule was Monday through Friday from 10:00 a.m. to 6:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LN L further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN M on [DATE] at 6:16 p.m., LVN M stated his work schedule was Monday through Friday from 10:00 p.m. to 6:00 a.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN M further stated he had completed two demonstrative skills checks with the DON. Record review of the facility in-service training, Checklist Vital Signs: Assessing Blood Pressure, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility in-service training, Blood Pressure Measurement (Digital) Skills Checklist, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility skills check, Vital Signs Parameters/Blood Pressure/Pulse, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility skills check, Vital Signs Parameters, dated [DATE], revealed it had been signed as completed by eleven staff members. The Administrator was informed the Immediate Jeopardy was lifted on [DATE] at 8:12 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. No facility policy regarding physician notification was received prior to exit.

42031 Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 4 of 11 residents (Residents #1, #2, #3, #4), reviewed for significant medication errors, in that: Residents #1, #2, #3, and #4 were administered medications to lower blood pressures when their blood pressures or Pulse was already low and outside the physician ordered parameters. An immediate jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:23 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm at a scope of pattern due to the facility's need to monitor the effectiveness of their plan of removal. This failure could result in critically low blood pressures, inadequate blood flow, and could result in dizziness, fainting, hospitalization , and death. The findings were: Closed record review of Resident #1's face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (diffuse disease of the brain that alters brain function or structure caused by metabolic changes due to underlying health conditions), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result in inadequate blood flow to the brain and other vital organs). Resident #1 was discharged to the hospital on [DATE]. Closed record review of Resident #1's care plan revealed a focus for the diagnosis of hypertension initiated on [DATE] with the resident at risk for hypertension and hypotension episodes and a goal for Resident #1 to have no side effects of medications. Interventions included to assess reports of hypotension and hypertension episodes, check B/P as ordered and notify the doctor of abnormal results, observe for signs and symptoms and to provide medications as ordered. Closed record review of Resident #1's physician orders revealed an order with a start date of [DATE] for Losartan potassium 100mg tablet medication used to lower blood pressure) to be given once daily for hypertension at 8:00 p.m. with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of less than 60 beats per minute. Closed record review of Resident #1's EMAR for [DATE] revealed on [DATE] at 8:00 p.m. Losartan potassium 100mg tab was administered by LVN A with a B/P of ,d+[DATE], P-78. Closed record review of Resident #1's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Losartan potassium medication outside of the ordered parameters on [DATE]. Record review of Resident #2's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: cellulitis of right lower limb, essential primary hypertension, and legal blindness. Record review of Resident #2's care plan, revised [DATE], revealed a focus, [Resident #2] has [diagnosis] of Hypertension. Is at risk for Hypo-/hypertensive episodes, and interventions, Check B/P as ordered and notify MD of abnormal results and Provide medications as ordered. Record review of Resident #2's physician orders revealed an order with a start date of [DATE] for Metoprolol Tartrate Oral Tablet 25mg tablet to be given once daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Record review of Resident #2's EMAR for February 2024 revealed on [DATE] at 8:00 p.m., Metoprolol Tartrate Oral Tablet 25mg tablet was administered by LVN B with a B/P of ,d+[DATE], P-79. Record review of Resident #2's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Metoprolol Tartrate medication outside of the ordered parameters on [DATE]. Record review of Resident #3's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with diagnoses including: unspecified dementia, essential primary hypertension, and heart failure. Record review of Resident #3's care plan, revised [DATE], revealed a focus, [Resident #3] has a [diagnosis] of Hyperlipidemia. Is at risk for complications related to [diagnosis] and adverse reaction to medications, and interventions, Provide medications as ordered. Further review revealed a focus, [Resident #3] is at risk for chest pains, irregular pulse and adverse reaction to medications due to [diagnosis] of Heart Failure, and interventions, Hold medications within parameters from MD and indicated (example: hold digoxin if pulse is below 60). Record review of Resident #3's physician orders revealed an order with a start date of [DATE] for Hydrochlorothiazide Tablet 25 mg. Give 1 tablet by mouth one time a day for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Record review of Resident #3's EMAR for February 2024 revealed on [DATE] Hydrochlorothiazide was administered by LVN B with a B/P of ,d+[DATE], P-56. Record review of Resident #3's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure reading and or the administration of the Hydrochlorothiazide medication outside of the ordered parameters on [DATE]. Closed record review of Resident #4's face sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included ESRD (End Stage Renal Disease- medical condition in which the kidneys cease functioning on a permanent basis leading to the need for long-term dialysis or a kidney transplant to maintain life), hypertensive heart disease with heart failure (constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation with the heart unable to pump enough blood to meet the body's needs for blood and oxygen), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result in inadequate blood flow to the brain and other vital organs). Resident #4 was discharged as expired on [DATE]. Closed record review of Resident #4's physician orders revealed an order with a start date of [DATE] and a DC date of [DATE] for Losartan potassium 25mg tablet to be given once daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #4's EMAR for [DATE] revealed losartan potassium 25mg was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of ,d+[DATE] P-77, and on [DATE] at 8:00 a.m. with a B/P of ,d+[DATE] P- 77. Closed record review of Resident #4's EMAR for February 2024 revealed losartan potassium 25mg was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of ,d+[DATE] P-86, and on [DATE] at 8:00 a.m. by LVN B with a B/P of ,d+[DATE] P-113. Closed record review of Resident #4's physician orders revealed an order with a start date of [DATE] for carvedilol 25mg tablet by mouth twice daily for hypertension with parameters to hold the medication for a SBP (first/top number) of 110 or less or a pulse of 60 beats per minute or less. Closed record review of Resident #4's EMAR for [DATE] revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of ,d+[DATE] P-77 and at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-77. On [DATE] at 8:00 a.m. it was administered by LVN A with a B/P of ,d+[DATE] P- 77. Closed record review of Resident #4's EMAR for February 2024 revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 a.m. by LVN A with a B/P of ,d+[DATE] P-86 and at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-86. On [DATE] at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-68, on [DATE] at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-70. On [DATE] at 8:00 a.m. by LVN B with a B/P of ,d+[DATE] P-113. Closed record review of Resident #4's EMAR for [DATE] revealed Carvedilol 25mg tab was administered on [DATE] at 8:00 p.m. by LVN B with a B/P of ,d+[DATE] P-78. Closed record review of Resident #4's EHR progress notes revealed no documentation regarding the physician being notified of the low blood pressure readings and or the administration of the Losartan potassium or Carvedilol medications outside of the ordered parameters. In an observation and interview on [DATE] at 11:45 a.m. the DON stated she was unaware of a way to copy and paste vital signs and showed surveyor a resident's vital sign list that did not have repeat vital signs for the resident listed. And after reviewing the EMAR the repeat vital signs could be seen on the EMAR documentation only and not on the residents' vital sign list in the EHR. The DON stated she would investigate the repeat vital signs. In an interview on [DATE] at 10:30 a.m. the DON stated she contacted her corporate entity, and they removed the use last documented vital sign option from their computer system. In an observation and interview on [DATE] at 4:00 p.m. CMA D was passing medications and had just taken a resident's blood pressure and was entering it in the computer system. CMA D stated he did not copy vital signs and takes his own manually each time. CMA D stated there was not a way to copy and paste vital signs but there used to be a button that had used last documented but he never used it. CMA D showed surveyor the vital signs entry screen and where the button used to be but stated it was not an available option now. CMA D was unsure when it was no longer an option. In an interview on [DATE] at 12:05 p.m. LVN A stated she takes her own vital signs and if she administered any medications outside of the ordered parameters then she had contacted the physician and documented in the resident progress notes or through the EMAR documentation. LVN A further stated she does not know what happened and does not copy vital signs. LVN A stated there was a use last documented vital signs button, but she did not use it. LVN A was unable to state where else the documentation of the physician being notified would be. In an interview on [DATE] at 5:17 p.m., LVN B stated that he personally measures and accurately recorded vital signs including blood pressure and pulse each time the physician orders call for vital signs and stated that he does not administer medications outside of the parameters noted in the physician orders. LVN B stated he always follows physician orders, including notifying the physician if and when a resident's vital signs are outside of parameters noted in the orders. When asked why he had not notified the physician on [DATE] when Resident #2 received medication outside of parameters, and on [DATE] when Resident #3 received medication outside of parameters, LVN B stated that he always notifies the physician when needed and stated he did not know why there was no documentation of his notification. In an interview with the DON [DATE] at 5:15 p.m., the DON confirmed that accurately measuring and recording vital signs as per physician order and notifying the physician of a change in the resident's condition and/or a need to alter the resident's treatment were integral to assisting the residents to maintain good health. In a telephone interview on [DATE] at 1:02 p.m. the MD stated he was not aware and could not recall being notified specifically with vital sign issues but was driving and did not have his patient records in front of him. The MD further stated patient safety was a priority for him and his group of physicians. In a telephone interview on [DATE] at 2:40 p.m. the MD stated the vital sign issues (administration of medications outside of parameters and same vital signs documented) brought to his attention by surveyor were concerning. The MD stated he and other physicians in his group were in the facility often, and at times even 2 to 3 times a week and he had not recalled seeing blood pressure or vital sign issues on what was displayed to the physician. The MD further stated the vital sign issues could make clinical decision making more difficult. Review of https://www.ncbi.nlm.nih.gov/books/NBK526065/ last updated [DATE], for Losartan indicated . Losartan is FDA approved for the treatment of several medical conditions, which include the following: Hypertension . acute coronary syndrome, stable coronary artery disease . and treatment of heart failure . The onset of action of losartan is 6 hours, lasting for 24 hours . Reevaluate blood pressure (including orthostatic blood pressure), renal function, and serum potassium . Any clinician (MD, DO, NP, PA) can prescribe losartan for the treatment of hypertension and diabetic nephropathy. However, clinicians should follow the patients and regularly monitor their renal function and blood pressure. The drug is effective for hypertension and can be part of long-term therapy. However, it still requires the participation of an interprofessional team to optimize treatment. When initially prescribed, a pharmacist should verify appropriate dosing, perform medication reconciliation, and can counsel the patient about the drug. Nursing can also provide valuable patient counseling, as well as answer questions and assess therapeutic effectiveness on subsequent visits. If the pharmacist or nursing staff encounter any concerns, they should report these to the prescriber promptly so that therapeutic adjustments can take place. This interprofessional team approach to losartan therapy can optimize patient outcomes while minimizing potential adverse effects. Review of https://www.ncbi.nlm.nih.gov/books/NBK532923/ last updated [DATE], indicated . Metoprolol is FDA-approved to treat angina, heart failure, myocardial infarction, atrial fibrillation/flutter, and hypertension. Off-label uses include supraventricular tachycardia and thyroid storm . The primary adverse effects of metoprolol include heart failure exacerbation, fatigue, depression, bradycardia or heart block, hypotension, bronchospasm, cold extremities, dizziness, decreased libido, diarrhea, tinnitus, decreased exercise tolerance, glucose intolerance, and may mask hypoglycemia . Metoprolol is contraindicated in patients with sick sinus syndrome, second or third-degree heart block (in the absence of a pacemaker), decompensated heart failure, hypotension . Monitoring . Oral administration, heart rate rhythm, and blood pressure require monitoring. Review of https://www.ncbi.nlm.nih.gov/books/NBK430766/ last updated [DATE] indicated . Hydrochlorothiazide is a medication approved by the U.S. Food and Drug Administration (FDA) to treat hypertension and peripheral edema Patients undergoing hydrochlorothiazide treatment should be regularly monitored for electrolyte imbalances, including sodium, potassium, calcium, and magnesium levels . Blood pressure should be closely monitored to ensure patients on hydrochlorothiazide treatment achieve and maintain their target blood pressure, minimizing the risk of adverse effects associated with high or low blood pressure. Review of https://www.ncbi.nlm.nih.gov/books/NBK534868/ last updated [DATE], for carvedilol indicated . Screen patients for potential contraindications, such as severe hypotension, second or third-degree AV block, and other conditions that may necessitate caution or alternative therapies . The most prevalent adverse effect of carvedilol is undesired, excessive hypotension resulting from its vasodilating properties, leading to symptoms such as dizziness, lightheadedness, fatigue, and headaches . Vital signs, such as blood pressure and heart rate, should be monitored before initiation and at each dose titration. Individuals undergoing heart failure treatment necessitate vigilant monitoring for any indications of decompensation. The facility's Plan of Removal was accepted on [DATE] at 5:10 p.m. and included: Date: [DATE] F 726 Immediate action: The Medical Director was notified of the Immediate Jeopardy status on [DATE] at 7:35 pm. Resident Vital Signs were taken when the issue was identified on [DATE]. An audit was done to ensure parameters were ordered for all residents on cardiac medication and vitals were being recorded on the computer correctly. The cardiac medication and vitals were found to be within normal limits. No adverse reactions observed with any resident. VS are currently in progress for all residents to ensure they are within normal/ safe limits. The primary physician will be notified for any residents found with abnormal vital signs to determine if additional treatment is warranted. This task will be completed by 10 pm on [DATE]. The Director of Nurses completed an audit on administration parameters for all residents receiving cardiac medications on [DATE] once the issue was identified. An audit will be completed again to ensure that all parameters are in place and being followed for residents on cardiac medications. On [DATE], a complete audit was done which included checking the data on the computer, taking new vital signs for residents, ensuring the vitals were recorded correctly and calling the doctors to ensure parameters were correct. This task was completed before 11:59 pm on [DATE]. Parameters will be verified with the primary care physician and updated if appropriate by 11:59 pm [DATE]. All nursing staff involved in administration of medication were in serviced to ensure they were taking vital signs prior to administering cardiac medications to ensure parameters were correct and medication was either held or administered accordingly. The staff had to do return demonstration following the in-service. Agency staff will be in-serviced on this issue prior to their starting their shift. Education will be provided to all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. The EMR system (PCC) copy feature that allowed the utilization of the last set of vital signs taken for medication administration has been turned off as of [DATE] @ 12:45pm. Facilities Plan to ensure compliance quickly Education provided by the DON will include all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. Education was initiated on [DATE] by the Director of Nurses and will continue until all nurses and med aides have completed the education and skill check for Vital Sign competency. The DON or designee will educate all newly hired licensed nurses and medication aides on medication administration and reconciliation guidelines as well as the importance of following parameters, taking a new set of vital signs with each med pass, and alerting the physician if a medication is given outside of the parameters. The DON or designee will audit all new admission, readmission, and new/ changed orders to ensure accuracy and that appropriate parameters, based on the medication, are in place if warranted. Nurses and medication aides will have a skills check completed by the Director of Nurses for medication pass to ensure they are taking a new set of vital signs and following parameters as appropriate by [DATE] 11:59 pm. Nursing and medication aide staff members will not be allowed to work their oncoming shift until this education and skill check is completed. The Director of Nurses or designee will audit vital signs and bp parameters daily x 14 days, then weekly x 4 weeks to ensure compliance. Ongoing audits will be completed randomly thereafter to verify continued compliance and ensure standards are met. Re-education will be completed with the nurse(s) or medication aide(s) if any evidence of non-compliance is determined. The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. POR Verification The Medical Director was notified of the Immediate Jeopardy status on [DATE] at 7:35 pm. - Confirmed via interview with the Medical Director [DATE] at 5:37 pm Resident Vital Signs were taken when the issue was identified on [DATE]. An audit was done to ensure parameters were ordered for all residents on cardiac medication and vitals were being recorded on the computer correctly. The cardiac medication and vitals were found to be within normal limits. No adverse reactions observed with any resident. VS are currently in progress for all residents to ensure they are within normal/ safe limits. The primary physician will be notified for any residents found with abnormal vital signs to determine if additional treatment is warranted. This task will be completed by 10 pm on [DATE]. - Confirmed via interview with Medical Director [DATE] at 5:37 pm - Confirmed via record review of 15 resident clinical records The Director of Nurses completed an audit on administration parameters for all residents receiving cardiac medications on [DATE] once the issue was identified. An audit will be completed again to ensure that all parameters are in place and being followed for residents on cardiac medications. - Confirmed via interview with the DON [DATE] at 5:15 pm On [DATE], a complete audit was done which included checking the data on the computer, taking new vital signs for residents, ensuring the vitals were recorded correctly and calling the doctors to ensure parameters were correct. This task was completed before 11:59 pm on [DATE]. Parameters will be verified with the primary care physician and updated if appropriate by 11:59 pm [DATE]. - Confirmed via interview with the DON [DATE] at 5:15 pm - Confirmed via interview with the Medical Director [DATE] at 5:37 pm - Confirmed via record review of 15 resident clinical records All nursing staff involved in administration of medication were in serviced to ensure they were taking vital signs prior to administering cardiac medications to ensure parameters were correct and medication was either held or administered accordingly. The staff had to do return demonstration following the in-service. Agency staff will be in-serviced on this issue prior to their starting their shift. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Education will be provided to all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. The EMR system (PCC) copy feature that allowed the utilization of the last set of vital signs taken for medication administration has been turned off as of [DATE] at@ 12:45pm. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Facilities Plan to ensure compliance quickly Education provided by the DON will include all nurses and certified medication aides on the need to take a new set of vital signs with each medication pass, and the importance of following parameters to hold or give medications based on vital sign values obtained and to notify the physician if medication was given outside of the parameters provided. Education was initiated on [DATE] by the Director of Nurses and will continue until all nurses and med aides have completed the education and skill check for Vital Sign competency. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff The DON or designee will educate all newly hired licensed nurses and medication aides on medication administration and reconciliation guidelines as well as the importance of following parameters, taking a new set of vital signs with each med pass, and alerting the physician if a medication is given outside of the parameters. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff The DON or designee will audit all new admission, readmission, and new/ changed orders to ensure accuracy and that appropriate parameters, based on the medication, are in place if warranted. - Confirmed via interview with DON [DATE] at 7:12 pm Nurses and medication aides will have a skills check completed by the Director of Nurses for medication pass to ensure they are taking a new set of vital signs and following parameters as appropriate by [DATE] 11:59 pm. - Confirmed via interviews with 11 of 14 nursing staff members who administer medication - Confirmed via record review of two in-service trainings - Confirmed via record review of two skills check off lists for each 11 of 14 staff Nursing and medication aide staff members will not be allowed to work their oncoming shift until this education and skill check is completed. The Director of Nurses or designee will audit vital signs and bp parameters daily x 14 days, then weekly x 4 weeks to ensure compliance. Ongoing audits will be completed randomly thereafter to verify continued compliance and ensure standards are met. - Confirmed via interview with DON [DATE] at 7:12 pm Re-education will be completed with the nurse(s) or medication aide(s) if any evidence of non-compliance is determined. - Confirmed via interview with DON [DATE] at 7:12 pm The Director of Nurses will present audit findings to the QAPI committee each month until compliance achieved. - Confirmed via interview with DON [DATE] at 7:12 pm During an interview with the DON on [DATE] at 5:15 p.m., the DON stated that only nurses and medication aides measured vital signs and administered at the facility and there were 2 medication aides and 12 nurses employed by the facility. The DON stated that 11 of the 14 staff members who administered medications had both of two in-service trainings and completed both of two skills checks. Skills checks required staff to demonstrate how to assess blood pressure using two techniques. The DON stated that the three staff members who did not yet receive training will be required to do so before their next shift. During an interview with LVN B on [DATE] at 5:17 p.m., LVN B stated his work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN B further stated he had completed two demonstrative skills checks with the DON. During an interview with Medication Aide E on [DATE] at 5:22 p.m., Medication Aide E stated her work schedule was Monday through Friday from 6:00 a.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. Medication Aide E further stated she had completed two demonstrative skills checks with the DON. During an interview with LVN A on [DATE] at 5:26 p.m., LVN A stated her work schedule was Monday through Friday from 8:00 a.m. to 5:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN A further stated she had completed two demonstrative skills checks with the DON. During an interview with RN F on [DATE] at 5:32 p.m., RN F stated her work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. RN F further stated she had completed two demonstrative skills checks with the DON. During an interview with LVN G on [DATE] at 5:43 p.m., LVN G stated his work schedule was Saturday and Sunday from 6:00 a.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN G further stated he had completed two demonstrative skills checks with the DON. During an interview with LVN H on [DATE] at 5:50 p.m., LVN H stated her work schedule was Monday through Friday from 2:00 p.m. to 10:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN H further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN I on [DATE] at 5:55 p.m., LVN I stated his work schedule was Monday through Friday from 2:00 p.m. to 10:00 p.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN I further stated he had completed two demonstrative skills checks with the DON. During a telephone interview with LVN J on [DATE] at 6:04 p.m., LVN J stated her work schedule was Monday through Friday from 8:00 a.m. to 5:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN J further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN K on [DATE] at 6:16 p.m., LVN K stated her work schedule was Monday through Friday from 6:00 a.m. to 2:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LVN K further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN L on [DATE] at 6:24 p.m., LVN L stated her work schedule was Monday through Friday from 10:00 a.m. to 6:00 p.m., confirmed that she received two in-service trainings, and verbalized understanding of the trainings. LN L further stated she had completed two demonstrative skills checks with the DON. During a telephone interview with LVN M on [DATE] at 6:16 p.m., LVN M stated his work schedule was Monday through Friday from 10:00 p.m. to 6:00 a.m., confirmed that he received two in-service trainings, and verbalized understanding of the trainings. LVN M further stated he had completed two demonstrative skills checks with the DON. Record review of the facility in-service training, Checklist Vital Signs: Assessing Blood Pressure, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility in-service training, Blood Pressure Measurement (Digital) Skills Checklist, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility skills check, Vital Signs Parameters/Blood Pressure/Pulse, dated [DATE], revealed it had been signed as completed by eleven staff members. Record review of the facility skills check, Vital Signs Parameters,

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations of individual needs and preferences for 2 of 10 sampled residents (Resident #2 and #3) who requested siderails to assist with bed mobility as evidenced by: 1) Resident #2, who had siderails on her bed prior to receiving her new bed, requested to have siderails replaced and they were not installed until after she had fallen from her bed on 10/19/10 and fractured her femur. 2) Resident #3 who had siderails on her bed prior to receiving her new bed, requested to have siderails replaced and they were not installed until after she fell on [DATE] and fractured her left hand thumb. This deficient practice could affect 10 residents in the facility that used half or quarter side rails to enable them to move in bed. Failure to accommodate resident needs and preferences by not providing half side rails to enable transfers in bed, could affect the quality of life by feeling of loss of independence and self-worth. The findings were: A) Record review of Resident #2's Incident/Accident Report, dated 10/19/10, revealed she fell from her bed and was transported to the hospital for evaluation and treatment. Record review of Resident #2's post-operative report, dated 10/19/10, revealed she had a surgical repair of her left femur (thigh) fracture and had a rod inserted in the site. Record review of facility Incident/Accident Tracking & Trending Logs, dated August to October 2010, revealed Resident #2 had a fall on 10/19/10 from her bed. Further review revealed she had used the underside of the bed to turn when she overcompensated and fell . Record review of an Internet form, provided by the Interim-Administrator and printed on 10/28/10, revealed a hand-written-note indicating new beds were ordered in 4/10 and were delivered on 8/24/10. Continued review revealed assist rails and side rails were ordered on [DATE], shipped from the company on 9/30/10, and were delivered on 10/5/10. Interview on 10/28/10 at 2:50 P.M. with the DON, and ADON, both stated they had no prior knowledge about the type of beds or mattresses delivered to the facility. The DON stated there was no bed rails delivered when the beds arrived on 8/24/10 and that there had been a 2-day conversion of beds and on 8/24/10 one side of the building received their beds and on 8/25/10 the other side of the building received their new beds. She stated she was not aware of the reason why the rails were not ordered at the same time with the beds. She further stated the assist rails were ordered on [DATE] and delivered on 10/5/10. She confirmed there was approximately five weeks from the time the beds arrived to the time the rails were delivered. Observation of Resident #2 on 10/28/10 at 12:45 P.M. revealed she was bedfast and unable to position herself in bed without staff assistance. During an interview with Resident #2 on 10/28/10 at 12:45 P.M. she stated she recently had fallen between her new bed and the wall while CNA H was changing her diaper. Resident #2 stated she hung onto the bed frame to assist with positioning during incontinent care. She stated when CNA H gave a pull of the diaper to remove it from underneath her, she went over the side of the bed and landed on her left knee and now had a rod surgically placed from her left knee to her left hip. Resident #2 stated she did not like her new bed. She stated she had complete side rails on her old bed; they had been removed and were not placed on her new bed. She further stated she turned to her left side better than her right side and had used the left side rail to help with positioning. Resident #2 stated she had been asking for side rails to be placed on her new bed and did not receive them until after she had returned from the hospital with a fracture. She further stated she had spoken to the previous Administrator multiple times and had been told the facility had been working on getting them for her. Lastly, she stated she felt if she had her side rails on the bed she would not have fallen out of the bed. During an interview with the DON on 10/28/10 at 1:15 P.M. she stated Resident #2's family had spoken to the previous Administrator about her desire to get side rails for her new bed and that it had not gone any further than that. She further stated Resident #2 did not receive her side rails on her bed until she had returned from the hospital after her fall with fracture. During an interview with the ADON on 10/28/10 at 1:45 P.M. she stated Resident #2's side rails from her old bed did not fit her new bed and that it had been brought to the attention of the previous Administrator. The ADON stated a grab bar needed to be ordered for Resident #2. She stated Resident #2's old bed had one side rail positioned on Resident #2's left side. She further stated the old bed was close to the wall but there was enough space for someone to get through to assist with positioning if needed. The ADON then stated Resident #2's left side of her new bed was positioned against the wall. Record review of Resident #2's MDS Assessments, dated 1/9/10 and 7/9/10, revealed she was bedfast most of the time and used bedrails for bed mobility and transfer. Further review revealed she required extensive assistance with one person physical assistance with bed mobility and she had no falls. Resident #2 was further assessed to have no short-term or long-term memory loss and her cognitive skills for daily decision making indicated she had some difficulty in new situations only. Record review of the facility form titled Resident Order Listing, dated 10/13/10, revealed Resident #2 used half side rails on both sides of her bed at her request to assist with turning and positioning due to a past [MEDICAL CONDITION] (stroke) since 6/18/08. During an interview with the DON on 10/28/10 at 2:25 P.M. she stated Resident #2's Resident Order Listing was reviewed on 10/13/10 by the ADON, Interim Administrator, and herself. She further stated Resident #2 had been using the siderails and these orders had been in place prior to the new beds being delivered. Record review of the Restraint Reduction Committee Physical Restraint Reduction Tracking Log, dated 10/2010, revealed Resident #2 had been using half rails since 6/18/08 and they had been discontinued on 10/13/10. Record review of Resident #2's care plan, dated 10/15/10, revealed she had mobility problems related to transfers and positioning. Further review revealed she had been using side rails for bed mobility and they had been discontinued on 10/13/10. Record review of Resident #2's Acute Care Plan, dated 10/20/10, revealed she had a fall on 10/19/10 due to impaired safety judgment and the facility would assess for assistive devices after she returned from the hospital. During an interview with LVN F on 10/28/10 at 12:00 P.M. she stated Resident #2 used to have siderails on the left side of her bed and they had been removed one month prior. She further stated that everyone had their siderails removed at that time, but that some residents had ? and ? rails installed, but that she was not involved in that decision making process. She stated that Resident #2 required one person to assist with incontinent care prior to the fall and that now she required two people. Lastly she stated Resident #2's quarter siderails were installed after she had been readmitted from the hospital. During a telephone interview with the facility's previous Administrator on 10/28/10 at 3:52 P.M. she stated that the new beds were ordered for the facility by corporate and was done as part of their facility wide renovation project. She stated that the facility had been unaware of what type of beds they were going to be receiving and they had been delivered without siderails or assist bars. She further stated the siderails from the old beds did not fit the new beds. The previous Administrator stated Resident #2 was unhappy with her new bed and she had explained to her she ' d get used to it. She further stated a turning rail had to be ordered for Resident #2 because she wanted it for the left side of her bed and they had been delivered prior to her resignation. The previous Administrator stated she had no conversations about the new bed or siderails with Resident #2's family members. During an interview with the Rehab Director on 10/28/10 at 5:00 P.M. he stated the facility had not consulted the therapy department when the new beds came or when the nursing department evaluated who were able to use siderails for bed mobility and positioning. He further stated the company wanted to eliminate siderails, not reduce them. The Rehab Director stated that Resident #2 had requested siderails for her bed and prior to her fall she had been able to help with bed positioning and it was one of the few things she could do. He stated that Resident #2 participated in her care prior to her fall but did not tolerate being out of bed. Lastly he stated he knew of a few residents that did not feel safe in the new beds the facility had recently purchased. During an interview with Resident #2's family member on 10/28/10 at 8:34 P.M. he stated that Resident #2 used rails for positioning and the siderails on the old bed went from the head of the bed to the middle of the bed and was positioned on the Resident #2's left side. He further stated he felt that his mother's fall would not have happened if she had the siderail installed. He further stated he had reported it to a nursing assistant and that he could not remember which one he had told. Resident #2's family member stated her left siderail had not been installed until after she had fallen from the bed. During an interview with the Maintenance Director on 10/29/10 at 10:41 A.M. he stated when the new beds came they arrived without siderails. He further stated he had applied Resident #2's assist bars on either 10/22/10 or 10/25/10 and that he did not keep records of that information. During an interview with LVN F on 10/29/10 at 10:50 A.M. she stated she was unaware if the facility evaluated residents who used siderails for bed mobility and positioning prior to the new beds arriving. During an interview with the DON on 10/29/10 at 4:00 P.M. she stated the QAA Committee had not met to discuss Resident #2's fall yet because she had been readmitted the day the Committee had last met. She further stated falls were reviewed monthly and that the new beds had been discussed at the September 2010 meeting. B) Record review of the Incident and Accident Report, dated 9/2/10, and timed at 3:50 P.M. revealed Resident #3 was found lying on the floor on her belly next to her bed. The report further revealed the resident stated, "I was trying to turn over and I forgot there were no side rails". Interventions to prevent further falls revealed to remind resident there were no rails. Record review of the Safety Assessment Informed Consent dated 8/28/10 revealed the resident was placed on half side rails for mobility in bed. Observation on 10/28/10 at 9:30 P.M. revealed Resident #3 was watching T.V. in bed. Resident was lying on a scoop mattress. Resident #3's outer aspect of the right eye had a slight purplish circle around it. Her left thumb was slightly purple and in a splint. The front aspect of her left hand appeared slightly purple. Record review of Resident #3's Incident and Accident Report, dated 10/19/10, and timed at 3:00 P.M. revealed the resident was found on the floor, and bruised her right eye. She complained of head pain, and left hand thumb pain. Record review of the Radiology Report, dated 10/19/10 revealed an acute [MEDICAL CONDITION] 5th digit (thumb). In an interview on 10/28/10 at 9:30 P.M., with Resident #3, she stated she fell twice, and stated she had told the nurse that she wanted the side rails put back. She stated she does not want to have another "fight with the floor". She further stated that since her second fall, the facility had given her a new mattress, but she said it was too narrow. She stated that with the splint on her thumb, made it hard to hold onto anything. Record review of the Nursing Care Plan dated 8/28/10 revealed problems identified were mobility during transfers and potential for falls. Interventions for both problems revealed to use half side rails for bed mobility while in bed, and to keep the bed in a low position. Record review of the last quarterly MDS, dated [DATE] revealed the resident was assessed for half rail, or one side rail as a device for transfer. Observation and interview on 10/29/10 at 5:00 P.M. revealed CNAs "E" and "F" assisted Resident #3 into bed. Further observation revealed resident could not turn to her left or right side without assistance from staff. She attempted to anchor herself, but was unable. Resident stated that she could not reach anything to hold onto such as the dresser or the side of the bed. She further stated she was afraid to fall. When asked whether the side rails would help her, she stated that they would. Interview on 10/28/10 at 2:50 P.M. with the DON and ADON, the ADON stated she spoke with the resident, and offered her the scoop mattress after she fell on [DATE], since she did not have side rails. Interview on 10/28/10 at 8:15 P.M. with the DON she stated she had a meeting on 10/13/10 with her two ADON's, and her MDS Coordinator. The purpose of the meeting was to reassess the needs of the residents on side rails. It was at this time, she realized the physician's orders [REDACTED]. She stated she got feedback from the nursing staff and they determined Resident #3 was to remain on the scoop mattress, and the side rails were discontinued. Interview on 10/28/10 at 9:15 A.M. with LVN "A", she stated Resident #3 had half side rails which she used to help position and move herself in bed. She stated the resident had the side rails before the new beds. The resident fell again on 10/19/10, at which time the resident was then placed on a scoop mattress. After both incidents the resident had to be reminded that she did not have the side rails to grab onto any longer. She stated the resident could make her needs known. LVN "A" further stated the ADON was aware the resident wanted her side rails back, and the ADON spoke with the resident. She stated the resident was able to use the side rails, and helped herself more with the side rails on. Interview on 10/28/10 at 10 P.M. with the Interim Administrator, she stated her first day at work was on 10/11/10, and was not informed by the previous administrator of concerns voiced by residents, staff, or family that the beds or side rails were a problem. She stated the beds, frames and mattresses were delivered on 8/24/10 and were installed on 8/24/10 and 8/25/10 by the staff at the facility, and from the company. Interview on 10/29/10 at 10:30 A.M. with Rehabilitation Aide "B", she stated when a former ADON came back from a conference, it seemed like every resident had their side rails removed. She stated the facility was confused between a restraint and a rail to assist for mobility while in the bed. She stated that Resident #3 had difficulty turning herself because she did not have her rail to hold onto. She further stated the rehabilitation department was not involved in the discussion prior to when the new beds arrived. She stated the nursing staff did not ask her or the Rehabilitation Director about which residents should have their side rails or assist bars removed. Interview on 10/29/10 at 1:15 P.M. with Restorative Aide "D", she stated she worked with Resident #3 after her fall. She stated the resident could make her needs known. She stated she observed the resident turn with the scoop mattress. She further stated the resident told her that the scoop mattress was narrower. She stated the resident benefited and used the side rails when she had them on. She further stated the ADON was aware the resident wanted her side rails back. Interview on 10/29/10 at 5:20 P.M. with CNA " E ", he stated the Resident #3 needed two people to assist getting into the chair, but needed one person to assist while dressing, and incontinent care. He stated when the resident had side rails; she was able to do more. He further stated the Resident can't really turn in the scoop bed because she was large. Record review of the Nurse's Notes dated 10/20/10, and timed at 1:20 A.M. revealed the resident recalled to have fallen out of bed, and stated, "I thought there was a siderail". Further observation revealed the resident had further bruising and swelling of her left thumb. Information obtained by the DON, on 10/29/10 revealed there were 8 residents that were on half side rails, and 2 residents on quarter side rails to assist in bed mobility.

Based on observation, interview, and record review, the facility failed to ensure that each resident received assistance devices to prevent accidents in 2 of 10 sampled residents (Resident #2 and #3) with half side rails to assist themselves with mobility while in the bed as evidenced by: 1) Resident #2, who had siderails on her bed prior to receiving her new bed, requested to have siderails replaced and they were not installed until after she had fallen from her bed on 10/19/10 and fractured her femur. 2) Resident #3 who had siderails on her bed prior to receiving her new bed, requested to have siderails replaced and they were not installed until after she fell on [DATE] and fractured her left hand thumb. This deficient practice could affect 10 residents in the facility that used half or quarter side rails to enable them to move in bed. Failure to provide assistance devices could result in injury and decline in physical functioning. The findings were: A) Record review of Resident #2's Incident/Accident Report, dated 10/19/10, revealed she fell from her bed and was transported to the hospital for evaluation and treatment. Record review of Resident #2's post-operative report, dated 10/19/10, revealed she had a surgical repair of her left femur (thigh) fracture and had a rod inserted in the site. Record review of facility Incident/Accident Tracking & Trending Logs, dated August to October 2010, revealed Resident #2 had a fall on 10/19/10 from her bed. Further review revealed she had used the underside of the bed to turn when she overcompensated and fell . Record review of an Internet form, provided by the Interim-Administrator and printed on 10/28/10, revealed a hand-written-note indicating new beds were ordered in 4/10 and were delivered on 8/24/10. Continued review revealed assist rails and side rails were ordered on [DATE], shipped from the company on 9/30/10, and were delivered on 10/5/10. Interview on 10/28/10 at 2:50 P.M. with the DON, and ADON, both stated they had no prior knowledge about the type of beds or mattresses delivered to the facility. The DON stated there were no bed rails delivered when the beds arrived on 8/24/10 and that there had been a 2-day conversion of beds and on 8/24/10 one side of the building received their beds and on 8/25/10 the other side of the building received their new beds. She stated she was not aware of the reason why the rails were not ordered at the same time with the beds. She further stated the assist rails were ordered on [DATE] and delivered on 10/5/10. She confirmed there was approximately five weeks from the time the beds arrived to the time the rails were delivered. Observation of Resident #2 on 10/28/10 at 12:45 P.M. revealed she was bedfast and unable to position herself in bed without staff assistance. During an interview with Resident #2 on 10/28/10 at 12:45 P.M. she stated she recently had fallen between her new bed and the wall while CNA H was changing her diaper. Resident #2 stated she hung onto the bed frame to assist with positioning during incontinent care. She stated when CNA H gave a pull of the diaper to remove it from underneath her, she went over the side of the bed and landed on her left knee and now had a rod surgically placed from her left knee to her left hip. Resident #2 stated she did not like her new bed. She stated she had complete side rails on her old bed; they had been removed and were not placed on her new bed. She further stated she turned to her left side better than her right side and had used the left side rail to help with positioning. Resident #2 stated she had been asking for side rails to be placed on her new bed and did not receive them until after she had returned from the hospital with a fracture. She further stated she had spoken to the previous Administrator multiple times and had been told the facility had been working on getting them for her. Lastly, she stated she felt if she had her side rails on the bed she would not have fallen out of the bed. During an interview with the DON on 10/28/10 at 1:15 P.M. she stated Resident #2's family had spoken to the previous Administrator about her desire to get side rails for her new bed and that it had not gone any further than that. She further stated Resident #2 did not receive her side rails on her bed until she had returned from the hospital after her fall with fracture. During an interview with the ADON on 10/28/10 at 1:45 P.M. she stated Resident #2's side rails from her old bed did not fit her new bed and that it had been brought to the attention of the previous Administrator. The ADON stated a grab bar needed to be ordered for Resident #2. She stated Resident #2's old bed had one side rail positioned on Resident #2's left side. She further stated the old bed was close to the wall but there was enough space for someone to get through to assist with positioning if needed. The ADON then stated Resident #2's left side of her new bed was positioned against the wall. During an interview with the DON and ADON on 10/28/10 at 2:56 P.M. they stated Resident #2 was in her new bed when she fell on [DATE]. They further stated their corporate office had ordered new beds for the facility as part of a renovation process and they were not told ahead of time whether the new beds came with side rails or not. The ADON and DON stated even the regional nurse did not know what type of beds were being delivered. They stated when the beds were delivered they came with no side rails or assist bars. They further stated at that time they went through the facility to determine who needed side rails and who did not. Record review of Resident #2's MDS Assessments, dated 1/9/10 and 7/9/10, revealed she was bedfast most of the time and used bedrails for bed mobility and transfer. Further review revealed she required extensive assistance with one person physical assistance with bed mobility and she had no falls. Resident #2 was further assessed to have no short-term or long-term memory loss and her cognitive skills for daily decision making indicated she had some difficulty in new situations only. Record review of the facility form titled Resident Order Listing, dated 10/13/10, revealed Resident #2 used half side rails on both sides of her bed at her request to assist with turning and positioning due to a past cerebrovascular accident (stroke) since 6/18/08. During an interview with the DON on 10/28/10 at 2:25 P.M. she stated Resident #2's Resident Order Listing was reviewed on 10/13/10 by the ADON, Interim Administrator, and herself. She further stated Resident #2 had been using the siderails and these orders had been in place prior to the new beds being delivered. Record review of Resident #2's Safety Assessments, dated 4/10/10, revealed she used side rails for bed mobility purposes. Further review of her Safety Assessment, dated 10/15/10 and under the Quarterly/Significant Change Assessment Section, revealed the decline/changes in resident condition related to restraints had been left blank. Further review revealed her side rails had been discontinued 10/13/10. During an interview with the DON on 10/28/10 at 6:30 P.M. she stated Safety Assessments were done quarterly and that they talked to residents and family members to inform them of the results. Record review of the Restraint Reduction Committee Physical Restraint Reduction Tracking Log, dated 10/2010, revealed Resident #2 had been using half rails since 4/18/08 and they had been discontinued on 10/13/10. Record review of Resident #2's care plan, dated 10/15/10, revealed she had mobility problems related to transfers and positioning. Further review revealed she had been using side rails for bed mobility and they had been discontinued on 10/13/10. Record review of Resident #2's Acute Care Plan, dated 10/20/10, revealed she had a fall on 10/19/10 due to impaired safety judgment and the facility would assess for assistive devices after she returned from the hospital. During an interview with LVN F on 10/28/10 at 12:00 P.M. she stated Resident #2 used to have siderails on the left side of her bed and they had been removed one month prior. She further stated that everyone had their siderails removed at that time, but that some residents had ? and ? rails installed, but that she was not involved in that decision making process. She stated that Resident #2 required one person to assist with incontinent care prior to the fall and that now she required two people. Lastly she stated Resident #2's quarter siderails were installed after she had been readmitted from the hospital. During a telephone interview with the facility's previous Administrator on 10/28/10 at 3:52 P.M. she stated that the new beds were ordered for the facility by corporate and was done as part of their facility wide renovation project. She stated that the facility had been unaware of what type of beds they were going to be receiving and they had been delivered without siderails or assist bars. She further stated the siderails from the old beds did not fit the new beds. The previous Administrator stated Resident #2 was unhappy with her new bed and she had explained to her she ' d get used to it. She further stated a turning rail had to be ordered for Resident #2 because she wanted it for the left side of her bed and they had been delivered prior to her resignation. The previous Administrator stated she had no conversations about the new bed or siderails with Resident #2's family members. During an interview with the Rehab Director on 10/28/10 at 5:00 P.M. he stated the facility had not consulted the therapy department when the new beds came or when the nursing department evaluated who were able to use siderails for bed mobility and positioning. He further stated the company wanted to eliminate siderails, not reduce them. The Rehab Director stated that Resident #2 had requested siderails for her bed and prior to her fall she had been able to help with bed positioning and it was one of the few things she could do. He stated that Resident #2 participated in her care prior to her fall but did not tolerate being out of bed. Lastly he stated he knew of a few residents that did not feel safe in the new beds the facility had recently purchased. During an interview with Resident #2's family member on 10/28/10 at 8:34 P.M. he stated that Resident #2 used rails for positioning and the siderails on the old bed went from the head of the bed to the middle of the bed and was positioned on the Resident #2's left side. He further stated he felt that his mother's fall would not have happened if she had the siderails installed. He further stated he had reported it to a nursing assistant and that he could not remember which one he had told. Resident #2's family member stated her left siderail had not been installed until after she had fallen from the bed. During an interview with the Maintenance Director on 10/29/10 at 10:41 A.M. he stated when the new beds came they arrived without siderails. He further stated he had applied Resident #2's assist bars on either 10/22/10 or 10/25/10 and that he did not keep records of that information. During an interview with LVN F on 10/29/10 at 10:50 A.M. she stated she was unaware if the facility evaluated residents who used siderails for bed mobility and positioning prior to the new beds arriving. During an interview with the DON on 10/29/10 at 4:00 P.M. she stated the QAA Committee had not met to discuss Resident #2's fall yet because she had been readmitted the day the Committee had last met. She further stated falls were reviewed monthly and that the new beds had been discussed at the September 2010 meeting. B) Record review of the Incident and Accident Report, dated 9/2/10, and timed at 3:50 P.M. revealed the Resident #3 was found lying on the floor on her belly next to her bed. The report further revealed the resident stated, " I was trying to turn over and I forgot there were no side rails". Interventions to prevent further falls revealed to remind resident there were no rails. Record review of the Safety Assessment Informed Consent dated 8/28/10 revealed the resident was placed on half side rails for mobility in bed. Observation on 10/28/10 at 9:30 P.M. revealed Resident #3 was watching T.V. in bed. Resident was lying on a scoop mattress. Resident #3's right outer aspect of the eye had a slight purplish circle around it. Her left thumb was slightly purple and was in a splint. The front aspect of her left hand appeared slightly purple. Record review of the physician's orders [REDACTED]. Further record review of the Incident and Accident Report, dated 10/19/10, and timed at 3:00 P.M. revealed the resident was found on the floor, and bruised her right eye. She complained of head pain, and left hand thumb pain. Record review of the Radiology Report, dated 10/19/10 revealed an acute fracture of the left 5th digit (thumb). Interview on 10/28/10 at 9:30 P.M., with Resident #3, she stated she fell twice, and stated she had told the nurse that she wanted the side rails put back. She stated she does not want to have another "fight with the floor". She further stated that since her second fall, the facility had given her a new mattress, but she said it was too narrow. She stated that with the splint on her thumb, made it hard to hold onto anything. Record review of the Nursing Care Plan dated 8/28/10 revealed problems identified were mobility during transfers and potential for falls. Interventions for both problems revealed to use half side rails for bed mobility while in bed, and to keep the bed in a low position. Record review of the last quarterly MDS, dated [DATE] revealed the resident was assessed for half rail, or one side rail as a device for transfer. Observation and interview on 10/29/10 at 5:00 P.M. revealed CNAs "E" and "F" assisted Resident #3 into bed. Further observation revealed resident could not turn to her left or right side without assistance from staff. She attempted to anchor herself, but was unable. Resident stated that she could not reach anything to hold onto such as the dresser or the side of the bed. She further stated she was afraid to fall. When asked whether the side rails would help her, she stated that they would. Interview on 10/28/10 at 2:50 P.M. with the DON, and ADON, both stated they had no prior knowledge about the type of beds or mattresses delivered to the facility. The DON stated there was no bed rails delivered when the beds arrived on 8/24/10. She stated she was not aware of the reason why the rails were not ordered at the same time with the beds. She further stated the assist rails were ordered on [DATE] and were delivered on 10/5/10. She confirmed there was approximately five weeks from the time the beds arrived to the time the rails were delivered. The ADON stated she spoke with the resident, and offered her the scoop mattress after she fell on [DATE], since she did not have side rails. Interview on 10/28/10 at 8:15 P.M. with the DON she stated she had a meeting on 10/13/10 with her two ADON's, and her MDS Coordinator. The purpose of the meeting was to reassess the needs of the residents on side rails. It was at this time, she realized the physician's orders [REDACTED]. She stated she got feedback from the nursing staff and they determined Resident #13 was to remain on the scoop mattress, and the side rails were discontinued. Interview on 10/28/10 at 9:15 A.M. with LVN "A" , she stated Resident #3 had half side rails which she used to help position and move herself in bed. She stated the resident had the side rails before the new beds. The resident fell again on 10/19/10, at which time the resident was then placed on a scoop mattress. After both incidents the resident had to be reminded that she did not have the side rails to grab onto any longer. She stated the resident could make her needs known. LVN "A" further stated the ADON was aware the resident wanted her side rails back, and the ADON spoke with the resident. She stated the resident was able to use the side rails, and helped herself more with the side rails on. Interview on 10/28/10 at 10 P.M. with the Interim Administrator, she stated her first day at work was on 10/11/10, and was not informed by the previous administrator of concerns voiced by residents, staff, or family that the beds or side rails were a problem. She stated the beds, frames and mattresses were delivered on 8/24/10 and were installed on 8/24/10 and 8/25/10 by the staff at the facility, and from the company. Interview on 10/29/10 at 10:30 A.M. with Rehabilitation Aide "B", she stated when a former ADON came back from a conference, it seemed like every resident had their side rails removed. She stated the facility was confused between a restraint and a rail to assist for mobility while in the bed. She stated that Resident #3 had difficulty turning herself because she did not have her rail to hold onto. She further stated the rehabilitation department was not involved in the discussion prior to when the new beds arrived. She stated the nursing staff did not ask her or the Rehabilitation Director about which residents should have their side rails or assist bars removed. Interview on 10/29/10 at 1:15 P.M. with Restorative Aide "D", she stated she worked with Resident #3 after her fall. She stated the resident could make her needs known. She stated she observed the resident turn with the scoop mattress. She further stated the resident told her that the scoop mattress was narrower. She stated the resident benefited and used the side rails when she had them on. She further stated the ADON was aware the resident wanted her side rails back. Interview on 10/29/10 at 5:20 P.M. with CNA "E", he stated the Resident #3 needed two people to assist getting into the chair, but needed one person to assist while dressing, and incontinent care. He stated when the resident had side rails; she was able to do more. He further stated the Resident can't really turn in the scoop bed because she was large. Record review of the Nurse's Notes dated 10/20/10, and timed at 1:20 A.M. revealed the resident recalled to have fallen out of bed, and stated, "I thought there was a siderail". Further observation revealed the resident had further bruising and swelling of her left thumb. Record review of the Medication Administration Record dated 10/20/10 revealed resident received Vicodin 5/325 mg., 1 tablet, TID for left hand fracture till 10/28/10 (10 days). Information obtained by the DON, on 10/29/10 revealed there were 8 residents that were on half side rails, and 2 residents on quarter side rails to assist in bed mobility.