Every finding on record at Edgemere Estates

Based on, interview, and record review, the facility failed to ensure the comprehensive person-centered care plan was reviewed and revised timely to reflect a change in Resident #1s consistent with professional standards of practice for 1 (Resident #1) of 7 residents observed for person centered care plan.The facility failed to revise the comprehensive person-centered care plan for Resident #1 not being compliant with treatment and continuously removing/refusing mask for oxygen and upon returning from hospital stay.This failure could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed and revised timely to address their needs.Record review of Resident #1's admission sheet dated 12/08/2018 revealed a [AGE] year-old female with an initial admission date of 09/20/2017. With a Diagnosis of multiple complex chronic conditions including COPD with respiratory failure and low oxygen levels, heart failure, kidney disease, cognitive deficits, weakness, and impaired mobility, requiring ongoing individualized care and monitoringRecord review of Resident #1's quarterly MDS dated [DATE] revealed under section C - cognitive patterns the resident had a BIMS score of 0 with the significance being the resident had severely impaired cognition.Record review of Resident #1's care plan dated 06/24/2026 revealed the resident had a focus for oxygen therapy related to chronic respiratory failure with hypoxia. The care plan identified oxygen therapy and included interventions to provide oxygen as ordered and monitor the resident for signs and symptoms of respiratory distress. However, the care plan did not identify or address the resident's documented refusal of oxygen therapy, including the risks associated with refusing oxygen, education regarding those risks, or interventions to address the refusal.Record review of Resident #1's history and physical dated 04/02/2025 stated the resident had multiple ongoing health conditions, including Alzheimer's disease/dementia with memory and communication problems, chronic lung disease with low oxygen levels, heart failure, high blood pressure, underactive thyroid, glaucoma, poor circulation, difficulty swallowing, poor nutrition, chronic pain, muscle weakness, difficulty walking, and a history of falls. The resident also had a history of a right ankle fracture, bladder control problems, acid reflux, depression/anxiety, seizures, and skin/wound concerns. The physical examination stated the resident was awake and responsive. Lung sounds were decreased on both sides but no wheezing or abnormal lung sounds were noted. Heart rate and rhythm were regular. The provider's plan included monitoring oxygen levels, preventing aspiration and falls, providing wound care, addressing nutritional needs, managing bowel and bladder needs, and helping with daily care.Record review of progress notes stated on 07/23/2026 - The resident refused treatment and repeatedly removed the treatment mask; family member was notified. Later, labored breathing was documented with abdominal pain and distention. The family requested transfer to local hospital for further evaluation, and the NP provided the transfer order. 07/26/2026- Resident returned to the facility from UMC. 07/27/2026 - Respiratory Therapy documented that the resident was started on continuous oxygen at 2 L/min. SpO2 was 93%-94%. The nasal cannula and humidifier were dated. 07/29/2026 - The resident was documented as continuously removing a treatment mask. The NP later directed that nebulizer treatments be administered while the resident was awake to avoid waking her at night. At the responsible party's request, she was not to be awakened multiple times overnight, and nebulizer administration times were changed accordingly.07/30/2026 - The resident refused a breathing treatment and repeatedly removed the nebulizer mask. She was also documented as noncompliant with the oxygen nasal cannula. In an interview with the NP on 08/14/2026 at 2:01pm, she stated the resident#1 had been placed on continuous oxygen when she developed abdominal/accessory muscle breathing and had remained on oxygen much of the time after returning from the hospital. She clarified, however, that the oxygen order was PRN (as needed) and that oxygen was required when the resident's oxygen saturation was below 92%. The NP stated the resident frequently removed the nasal cannula herself due to dementia. She stated staff were expected to replace the oxygen when the resident's oxygen saturation was below 92%.In an interview with the Dr. on 08/14/2026 at 3:55pm stated that the resident#1 had COPD (chronic obstructive pulmonary disease, a long-term lung condition that makes breathing difficult), and dementia. Dr. explained that oxygen was made available for continuous use when needed; however, residents with dementia could remove the oxygen themselves. He recalled that the resident#1 would remove her oxygen and required redirection due to her dementia.In an interview with LVN C on 08/17/2026 at 11:37am, LVN C stated that after being notified of an oxygen refusal, the nurse was expected to assess the resident, confirm the refusal, notify the provider and family if the resident continued to refuse, and document the refusal and notifications in PCC. She stated that failure to report and document the refusal was not appropriate because there would be no way to determine whether the nurse, provider, or family had been informed. Follow-up interview with LVN C on 08/17/2026 at 12:44 PM, LVN C stated she did not recall receiving a report from the CNAs that Resident#1 had refused the nasal cannula. She stated that if notified, she would have immediately assessed the resident and attempted redirection/re-education regarding oxygen use. LVN C stated CNAs were expected to report oxygen refusals so the nurse could assess, document the refusal, interventions and outcome, and complete appropriate notifications. She stated that resident#1 had PRN oxygen and that the outcome could vary based on the resident's condition. In an interview with RN D on 08/17/2026 at 12:29pm RN D stated that when a resident receiving oxygen therapy refused to wear the nasal cannula, the CNA was expected to notify the nurse. She explained that the nurse should assess the resident, provide education, follow up on the refusal, and document the event in PCC. She stated that, in her practice, the refusal and follow-up should be documented even if the resident later agreed to wear the nasal cannula.RN D stated that no CNA had notified her that Resident #1 had refused oxygen that night. She explained that if a resident did not receive needed oxygen, the resident's oxygen level could drop and the resident could become hypoxic, meaning the body was not receiving enough oxygen. She stated the potential effect would depend on whether the resident's oxygen was ordered continuously or as needed.In an interview with CNA G on 08/17/2026 at 12:34 PM, CNA G stated that if Resident #1 removed or refused the oxygen, CNA G would ask the resident why and attempt to determine whether the oxygen was uncomfortable. CNA G stated that if the resident continued to refuse the oxygen, the nurse would be notified of the refusal. CNA G explained that the CNA's responsibility was to report the refusal to nursing staff so the nurse could assess the resident and determine the reason for the refusal. CNA G stated that it was important for nursing staff to be informed of the resident's condition and any changes because the resident required oxygen for a reason related to the resident's health and well-being. CNA G further stated that failure to report an oxygen refusal could result in adverse effects, including difficulty breathing and other signs of decreased oxygenation.In an interview with RN E on 8/17/2026 at 1:07pm stated she did not specifically recall a CNA reporting to her on 08/02/2026 that resident#1 had refused to wear her nasal cannula. She explained that CNAs generally reported to her when a resident's nasal cannula was off, at which time she would assess the resident and replace the nasal cannula.RN E confirmed that when a CNA was providing ADL care to a resident receiving oxygen therapy and the resident refused the nasal cannula, the CNA was expected to notify the charge nurse. RN E stated she was not fully aware of the facility's specific documentation requirements in PCC following an oxygen refusal. However, when asked what she would personally do after receiving such a report, assessing the resident, and having the resident subsequently comply with the oxygen therapy, RN E stated she believed she would enter a note documenting the event.In an interview with the DON on 08/17/2026 at 3:00pm stated that resident#1 had a history of refusal but wasn't sure if it was in the care plan and that she'll have to check. The DON stated CNAs have to report to the nurse, and yes that could be change in condition. DON stated wasn't sure of how long resident #1 was refusing she had to check , if resident kept refusing treatment even though treatment was PRN, it would have to be cared planned as a change in condition, the nurses would have been responsible to over see this. DON stated then an intervention would have been put in place.In an interview with the Administrator on 08/17/2026 at 3:30 PM, the Administrator stated that the resident #1 refusal had only occurred for two days and was not considered a change in condition. The administrator stated that the care plan should identify what was occurring with the resident and include interventions to address the residents refusals. The Administrator further stated that the refusal should have been addressed in the care plan and that the PRN intervention should have been included.In an interview with LVN C on 08/17/2026 at 3:45 PM, LVN C stated that the resident had the right to refuse oxygen therapy and did not believe the refusal constituted a change in condition. LVN C stated that nursing staff would be notified if the resident appeared to be in distress. LVN C stated CNAs were trained to recognize signs of distress and report them to nursing staff but would not administer the oxygen treatment.In an interview with CNA F on 08/17/2026 at 5:26pm stated she did report to nurses that the resident was refusing the nasal cannula, and it was their duty as CNAs to report anything that happens to the resident.Review of the facility's policy Care Plans, Comprehensive Person- Centered, revealed the facility requires an individualized, person-centered care plan with measurable objectives and interventions based on the resident's comprehensive assessment. The care plan is to be reviewed and updated when the residents' condition changes; outcomes are not met, or following a hospital stay, and at least quarterly.

Based on interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided with such care, consistent with professional standards of practice for 1 (Resident #1) of 7 residents observed for oxygen management. The facility failed to ensure nursing staff assessed and followed up after Resident #1 refused her nasal cannula, including making additional attempts as appropriate and documenting the resident's refusal, assessment, and follow-up in the medical record. This failure could place residents at risk for inadequate oxygen support and respiratory decline. Findings include:Record review of Resident #1's face sheet, dated 08/14/2026, revealed an admission date of 12/08/2018.Record review of Resident #1's History and Physical, dated 04/02/2025, revealed respiratory-related diagnoses of chronic respiratory failure with hypoxia (long-term breathing failure in which the lungs do not provide enough oxygen to the blood); shortness of breath (difficulty breathing or feeling unable to get enough air); chronic obstructive pulmonary disease (COPD), unspecified (chronic lung disease that limits airflow and can make breathing difficult); cough, unspecified (cough without a more specific cause identified); allergic rhinitis, unspecified (nasal allergy inflammation that can cause congestion, sneezing, or drainage); other seasonal allergic rhinitis (seasonal nasal allergies caused by environmental triggers); encounter for screening for respiratory tuberculosis (evaluation/testing for tuberculosis affecting the lungs). The physical examination documented diminished breath sounds in both lower lung areas. The treatment plan directed staff to monitor oxygen, maintain adequate oxygen saturation, and keep oxygen saturation above 90%. The History and Physical revealed hypertensive heart disease with heart failure (high blood pressure that has affected the heart and contributed to heart failure); unspecified dementia, severe, with agitation (severe loss of memory and thinking abilities accompanied by agitation), osteoarthritis (wear-and-tear arthritis causing joint pain and stiffness) muscle wasting and atrophy, multiple sites (loss of muscle size and strength in several areas), heart failure, unspecified (the heart is not pumping blood as effectively as it should); essential hypertension (high blood pressure).Record review of Resident #1's quarterly MDS dated [DATE] revealed under section C - cognitive patterns the resident had a BIMS score of 0 with the significance being the resident was severely impaired cognition.Record review of Resident #1's Care Plan, closed on 08/03/2026, revealed a focus initiated on 03/19/2025 for oxygen therapy related to chronic respiratory failure with hypoxia, with oxygen ordered PRN. The goal was for Resident #1 to have no signs or symptoms of poor oxygen absorption through the review date. Staff interventions included changing Resident #1's position frequently to facilitate movement and drainage of lung secretions; encouraging or assisting with ambulation as indicated; providing extension tubing or portable oxygen for ambulation when applicable; continuing oxygen during meals using an alternate delivery method such as a nasal cannula when needed and returning the resident to the usual oxygen delivery method after the meal; monitoring for signs and symptoms of respiratory distress, including respirations, pulse oximetry, increased heart rate, restlessness, sweating, headache, lethargy, confusion, atelectasis, coughing up blood, cough, pleuritic pain, accessory muscle use, and changes in skin color, and reporting to the physician as needed; and positioning Resident #1 to facilitate ventilation and perfusion, including an upright or high-Fowler's position whenever possible (meaning staff needed to keep the resident sitting upright or raise the head of the bed when possible). These interventions identified CNA, LPN, and RN staff as responsible for multiple aspects of the respiratory care plan, while monitoring for respiratory distress was assigned to LPN/RN staff. The Care Plan also contained a separate focus initiated on 05/30/2025 for emphysema/COPD, with interventions to elevate the head of the bed or place Resident #1 upright in a chair during episodes of difficulty breathing, administer aerosol or bronchodilator treatments as ordered and monitor/document their effectiveness and side effects, avoid respiratory irritants, and monitor for difficulty breathing with exertion.Record review of five-minute video surveillance footage from Resident #1's room revealed that at 4 minutes and 18 seconds, CNA F attempted to place the nasal cannula on Resident #1, and Resident #1 refused, stating, No, no, no. At 4 minutes and 27 seconds, CNA F pointed toward her own nostril and asked Resident #1, No? to clarify whether she was refusing the nasal cannula, and Resident #1 responded, No. At 4 minutes and 31 seconds, CNA F informed the other CNA in the room that Resident #1 was refusing the nasal cannula. At 4 minutes and 37 seconds, the nasal cannula/tubing was placed on top of the oxygen concentrator. At 4 minutes and 42 seconds, CNA F stated that she was going to inform other staff that Resident #1 was refusing the oxygen cannula by saying I will let them know she refused it. At 4 minutes and 45 seconds, CNA F turned off Resident #1's headlamp. At 4 minutes and 50 seconds, CNA F exited the room. The video ended at exactly 5 minutes with Resident #1 remaining in the room without the nasal cannula in place. There was no evidence of LVNs or RNs going back into Resident #1's room to follow up on her refusing to wear her nasal cannula.Record review of the oxygen administration order dated 05/29/2025 revealed Resident #1 was to be administered oxygen at two liters per minute via nasal cannula or mask as needed for shortness of breath or cyanosis. The order was signed and confirmed by the DON.During a phone interview on 08/14/2026 at 11:35 a.m., with Resident #1's family member, the family member stated they would be sending the investigator video surveillance footage from the night of 08/02/2026 revealing staff entering Resident #1's bedroom on that night at approximately 11:58 p.m., and the video showing the resident declining to have her nasal cannula placed on her. The family member stated that the available video footage provided did not have a visible date and time on the actual video and it was only visible on their personal cellular phone indicating the date and time. During an interview on 08/17/2026 at 11:37 a.m., LVN C stated that CNAs were expected to replace a resident's nasal cannula after providing ADL care when oxygen therapy was ordered. She stated that if a resident refused the nasal cannula after multiple attempts, the CNA was expected to immediately notify the nurse. LVN C stated that after being notified of an oxygen refusal, the nurse was expected to assess the resident, confirm the refusal, notify the provider and family if the resident continued to refuse, and document the refusal and notifications in PCC. LVN C stated that failure to report and document the refusal was not appropriate because there would be no way to determine whether the nurse, provider, or family had been informed. LVN C stated that failure to receive oxygen as ordered or needed could result in decreased oxygen levels and respiratory distress. During an interview on 08/17/2026 at 11:57 a.m., RN H stated that when a resident refused oxygen, CNAs were instructed to notify the nurse immediately. RN H stated that the nurse would then assess the resident and attempt to place the oxygen back on the resident. RN H stated that if a resident with PRN oxygen continued to refuse and the resident's vital signs were stable, the nurse would document the refusal in PCC. RN H stated that if the nurse did not document the event, it would be as though it never happened. RN H stated that if the CNA failed to notify the nurse, the resident's oxygen level could become low, and the nurse would not have the opportunity to assess or document the resident's condition. During an interview on 08/17/2026 at 12:17 p.m., CNA I stated that when a resident with PRN oxygen refused the nasal cannula, she would encourage the resident to use the oxygen and immediately notify the nurse if the resident continued to refuse. CNA I stated that notification was important because the nurse needed to know what was occurring with the resident and assess whether the resident required oxygen. CNA I stated that although a resident had the right to refuse, the CNA providing ADLs to the resident was still responsible for encouraging use of the oxygen and reporting the refusal to the nurse so that they followed up and continue to make attempts.During an interview on 08/17/2026 at 12:29 p.m., RN D stated that when a resident receiving oxygen therapy refused to wear the nasal cannula, the CNA was expected to notify the nurse. RN D stated that the nurse should assess the resident, provide education, follow up on the refusal, and document the event in PCC. RN D stated that the refusal and follow-up should be documented even if the resident later agreed to wear the nasal cannula. RN D stated that no CNA notified her that Resident #1 had refused oxygen that night of 8/02/2026. She stated that if a resident did not receive needed oxygen, the resident's oxygen level could decrease, and the resident could become hypoxic.During an interview on 08/17/2026 at 12:34 p.m., CNA G stated that when a resident removed or refused oxygen, she would ask why the resident was refusing and attempt to determine whether the resident was uncomfortable. CNA G stated that if the resident continued to refuse, she would notify the nurse because reporting the refusal was the CNA's responsibility. CNA G stated that the nurse needed to know what was occurring with the residents so nursing could follow up. CNA G stated that failure to report an oxygen refusal could result in adverse effects, including difficulty breathing and changes in skin color, and could require emergency medical intervention.During an interview on 08/17/2026 at 12:44 p.m., LVN A stated that she did not recall receiving any report from the CNAs that Resident #1 had refused to wear her nasal cannula and specifically stated that the CNA assigned to the resident did not report an oxygen refusal to her the night of 08/02/2026. LVN A stated that if the refusal had been reported, she would have immediately assessed the resident and attempted to redirect and reeducate the resident regarding use of the nasal cannula. LVN A stated that CNAs were expected to report when a resident refused oxygen therapy. She stated that after receiving such a report, the nurse was expected to assess the resident and document the refusal, interventions, outcome, and appropriate notifications in a progress note. LVN A stated that if a CNA failed to report an oxygen refusal, the nurse would not have the opportunity to follow up and assess the resident. LVN A stated that she had not received any report that Resident #1 had removed or refused her oxygen.During an interview on 08/17/2026 at 1:07 p.m., RN E stated that she did not specifically recall a CNA reporting to her on 08/02/2026 that Resident #1 had refused to wear her nasal cannula. RN E stated that CNAs generally reported to her when a resident's nasal cannula was off, at which time she would assess the resident and replace the nasal cannula. RN E stated that when a CNA was providing ADL care to a resident receiving oxygen therapy and the resident refused the nasal cannula, the CNA was expected to notify the charge nurse. RN E stated that after receiving such a report and assessing the resident, she would document the event in PCC.During an interview on 08/17/2026 at 2:23 p.m., the DON stated that Resident #1 had an oxygen order directing staff to administer oxygen when the resident's oxygen saturation was below the ordered parameter or when the resident demonstrated shortness of breath or cyanosis.The DON stated that when oxygen was administered, documentation in PCC should reflect the resident's oxygen saturation and the reason oxygen was applied. The DON stated that CNAs were expected to notify nurses of oxygen-related concerns so nursing staff could assess the resident. The DON acknowledged concern regarding the lack of documented oxygen-saturation monitoring and stated she could not identify similar oxygen-saturation documentation after 07/29/2026.During an interview on 08/17/2026 at 3:45 p.m., LVN B stated that a resident with PRN oxygen had the right to refuse the nasal cannula; however, the CNA was still expected to notify the nurse of the refusal. LVN B stated that CNAs did not administer the oxygen treatment and were expected to report the refusal so nursing staff could follow up with the resident. She stated that nursing staff would document the resident's refusal and that CNAs needed to notify the RNs or LVNs immediately after a resident refused their oxygen cannula.During an interview on 08/17/2026 at 5:26 p.m., CNA F stated that during the night shift she and CNA J provided ADL care and repositioned Resident #1. CNA F stated that Resident #1 was not wearing oxygen and refused when CNA F attempted to place the nasal cannula. CNA F stated that they left the room and she subsequently reported the refusal to two nurses at the nurses' station, including LVN A. CNA F stated that she did not know whether the nurses went back into Resident #1's room or what they did after she reported the refusal. CNA F stated that she returned to her assigned hallway after making the report. CNA F stated that she knew the CNAs were expected to report to the charge nurse any refusals from the residents so that they could follow up and make additional attempts and to document it in their progress notes. CNA F stated that not reporting an oxygen refusal could result in adverse effects, including difficulty breathing and could require emergency medical intervention or sending a resident to the hospital.Record review of the facility's policy titled Oxygen Administration, implemented 10/2025, revealed the policy stated in part: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists.3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy.4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to:a. The type of oxygen delivery system.b. When to administer, such as continuous or intermittent and/or when to discontinue.c. Equipment setting for the prescribed flow rates.d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.e. Monitoring for complications associated with the use of oxygen.11. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them. Possible risks and complications include, but are not limited to:b. Respiratory infections related to contaminated humidification systems12. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen.Record review of the facility's policy titled Documentation in Medical Record, implemented 11/01/2025, revealed the policy stated, 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.1. 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.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.4. Principles of documentation include, but are not limited to:a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.c. Documentation shall be timely and in chronological order.d. Write legibly in black ink or follow the facility's specific electronic medical record software for inputting information.e. Record date and time of entry.i. Only document conclusions that can be supported by data and avoid bias, labels, and value judgments.

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 4 of 7 residents (Resident #96, Resident #43, Resident #66, Resident #82) reviewed for infection control. The facility failed to ensure the urinary catheter bags for Resident #96, Resident #43, Resident #66, and Resident #82 was anchored and secured to prevent infection. This failure could place residents at risk of infection due to improper care practices.Resident #96 Record review of Resident #96's face sheet dated 06/03/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #96's diagnoses included Pneumonia, (inflammation and fluid buildup in the lungs) Parkinsons Disease (brain disorder that affects movement in the body), Kidney failure (Kidneys have stopped working), Gastrostomy (an opening in the stomach to place a feeding tube), altered mental status (sudden change in how the brain works), metabolic encephalopathy (the brain has trouble working due to a chemical or metabolic problem). Record review of Resident #96's MDS dated [DATE], reflected a BIMS score of 09, which indicated moderate cognitive impairment. Resident #96 had an indwelling catheter. Record review of Resident #96's Order Summary Report dated 06/03/2026, revealed Foley Catheter Care everyshift Foley catheter care every shift with soap and water or may use wipes as appropriate/ desired by patient. Record review of Resident #96's Care Plan dated 06/03/2026, revealed focus [Resident #96] has a focus point The resident has Catheter: Neurogenic bladder(A Person loses control of their bladder because of nerve damage), Benign Prostatic Hyperplasia (Prostate Gland becomes enlarged) with a goal The resident will be/remain free from catheter-related trauma through review date. Interventions CATHETER: The resident has catheter. Position catheter bag and tubing below thelevel of the bladder and away from entrance room door. Check tubing for kinks each shift. INDWELLING CATHETER: Change catheter Q monthly and prn. 16fr/30cc. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation and interview on 06/02/2026 at 02:44 PM, Resident #96 was observed lying in bed, asleep. Resident #96 was unable to verbalize or communicate. Member S was present at the bedside. She stated she did not routinely check whether the catheter bag was touching the floor and was unaware of standards of practice related to catheter bag placement. Observation revealed Resident #96's catheter drainage bag was touching the floor. The drainage bag was positioned below the bladder however, it was not secured with the designated clips to prevent contact with the floor. Resident #43 Record review of Resident #43's face sheet dated 06/03/2026, revealed a[AGE] year-old female who was admitted to the facility on [DATE]. Resident 43's diagnoses included Acute Pyelonephritis (Kidney Infection), Acute Respiratory Failure with Hypoxia (Sudden severe low blood oxygen), Unspecified Hydronephrosis (Swelling of the kidney), Type 2 Diabetes (body doesn't use insulin properly), Protein Calorie Malnutrition (not getting enough nutrients to maintain healthy body function), Anemia (body does not have enough red blood cells to carry oxygen), Hearing loss (cannot hear), Myocardial Infarction (heart attack), Hypertension (High Blood Pressure), Ischemic Heart disease (Heart muscle doesn't get enough blood and oxygen). Record review of Resident #43's MDS dated [DATE], reflected a BIMS score of 15, which indicated that cognition was intact. Resident #43 had an indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of Resident #43's Order Summary Report dated 06/03/2026, stated change Foley Catheter: 20F/10ML bulb every 15th of the month during night shift, every night shift starting on the 15th and ending on the 16th every month, Foley Catheter - Change anchor and drainage bag every night shift every 15 day(s), Foley Catheter - Check for Patency and Placement. Ensure that Privacy Bag is on at all Times to maintain Privacy. Record review of Resident #43's Care Plan dated 06/03/2026, revealed focus The resident has indwelling Catheter:Neurogenic bladder, with a goal The resident will be/remain free from catheter-related trauma through review date, with interventions CATHETER: last changed: 5/15/26. Change catheter 1 month and as needed 20fr/10cc, CATHETER: The resident has catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door, Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation and interview on 06/02/2026 at 02:44 PM, Resident # 43 was lying in bed, resident was AOx3. The resident's Foley bag was sitting straight up with the base of the bag touching the floor. Resident #43 stated she did not know how often staff came and checked on her catheter bag or knew the procedures on the catheter care. Resident #66 Record review of Resident #66's face sheet dated 06/03/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #66's diagnoses included Obstructive and Reflux Uropathy (blockage in the urinary system), chronic kidney disease (Kidney damage) stage 4 (severe), Type 2 Diabetes mellitus with diabetic chronic kidneys (high blood sugar and damaged kidneys), Vascular Dementia (reduce blood flow to the brain cells), End Stage Renal Disease (total kidney failure), Hypertension (high blood pressure). Record review of Resident #66's MDS dated [DATE], reflected a BIMS score of 15, which indicated that cognition is intact. Resident #66 had an indwelling catheter (including suprapubic catheter and nephrostomy tube (catheter inserted through the skin of the lower back directly into the kidney)). Record review of Resident #66's Order Summary Report dated 06/03/2026, stated CHANGE FOLEY Catheter: 16fr/10cc Change Catheter every month, Foley Catheter. Record review of Resident #66's Care Plan dated 06/03/2026, revealed focus The resident has indwelling Catheter:Obstructive Reflux Uropathy with a goal CATHETER: last changed: 5/19/26 Change catheter Q month, 16fr/10cc, Encourage increased activity level to promote bowel function as tolerated., Follow facility bowel protocol for bowel management., Increase fiber and fluid intake to provide more bulk in diet as tolerated and indicated, Monitor medications for side effects of constipation. Keep physician informed of any problems. Observation and interview on 06/03/2026 at 1:43 PM, Resident #66 was AOx4 and stated she hardly ever checked her catheter bag. Upon observation, Resident #66's catheter drainage bag was completely off the bed rail and lying on the floor. LVN M stated catheter drainage bags should not be lying on the floor or touching the floor. The risk was due to infection control and should be replaced right away. Resident #82 Record review of Resident #82's face sheet dated 06/03/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident 82's diagnoses included sequelae of cerebral infarction (problems or side effects that remain from a stroke), type 2 diabetes mellitus with hyperglycemia (body could not use or make enough insulin), vascular dementia (Brain damage caused by poor blood circulation), Behavioral Disturbance (behavioral issue/difficulties), Dysphagia (difficult swallowing), Neuromuscular Dysfunction of Bladder (muscles that hold or release urine have nerve damage), cardiac arrhythmia (irregular heartbeat), Hyperlipidemia (High Cholesterol), Hypertension (high blood pressure). Record review of Resident #82's MDS dated [DATE], did not reflect a BIMS score, study was not conducted and skipped due to resident is rarely/never understood. Record review of Resident #82's Order Summary Report dated 06/03/2026, stated Indwelling Catheter Careevery shift Indwelling catheter care every shift with soap and water or may use wipes as appropriate/ desired by patient, Urinary Catheter Care: Check for patency, Empty foley bag every shift Ensure that Privacy Bag is on at all Times to maintain Privacy, Foley Catheter: 16F 10cc bulb as needed for Occlusion or Leakage, Foley Catheter: Change Catheter Anchor as needed as needed. Record review of Resident #82's Care Plan dated 06/03/2026, revealed focus The resident has indwelling Catheter: Neurogenic bladder, Skin Breakdown with a goal The resident will show no s/sx of Urinary infection through review date and interventions CATHETER: Change catheter q month as needed. 16fr/10cc, CATHETER: The resident has catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door, Check tubing for kinks each shift., Monitor for s/sx of discomfort on urination and frequency, Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, ever, chills, altered mental status, change in behavior, change in eating patterns. Observation of Resident #82 on 06/02/2026 at 10:01 AM, revealed Resident #82 was seen asleep in bed, and the resident's catheter bag was seen hanging from the bed rail below the bladder in a privacy bag. The privacy bag was lying on the floor. The catheter was not hung with the designated clips making the drainage bag hang low and come in contact with the floor. Observation on 06/02/2026 at 11:11 AM, revealed Resident #82 catheter bag was seen hanging from the bed rail below the bladder in a privacy bag. The privacy bag was lying on the floor. The catheter was not hung with the designated clips making the bag hang low and come in contact with the floor. In an interview on 06/02/2026 at 11:12AM , CNA R stated that she had been employed with the facility for about a year now and stated training are provided for foley/catheter care by the facility. CNA R stated during training staff were instructed to ensure the catheter bags were hung by the designated clips and placed below the bladder on the bed rails and to ensure the catheter bag do not touch the floor. CNA R observed Resident #82's catheter bag and stated that the main catheter bag should not be touching the floor and did not believe there was any risk because the catheter bag was placed in a privacy bag and the privacy bag was the one touching the floor. CNA R stated that was what she recalled from training but would go grab a new privacy bag and replace it since it was touching the floor. Observation and interview on 06/03/2026 at 09:00 AM, Med Aide P, stated she had been employed at the facility for almost a year now, and reported that all med aides, CNAs and RNs are responsible for ensuring Foley catheter bags were not placed on the floor. Med Aide P explained and demonstrated the process and procedures while attending to a resident with a Foley catheter. Med aide P knocked on the door to Resident #82, sanitized her hands and donned gloves. She then explained the process to Resident #82 and advised that she was just observing the location of the catheter bag. Med Aide P lifted the covers and observed the privacy bag was touching the floor. She stated that the privacy bag should remain below the bladder to allow urine to drain properly and that the designated clips should be secured to the bed rail to prevent the bag from falling. She stated the bed needs to be in a low position and that the bed being observed was positioned too low, causing the privacy bag to touch the floor. Med Aide P stated she received training upon hire and believed in-services training was provided quarterly or as needed to ensure privacy bags are not touching. She stated the risk associated with a privacy bag touching the floor was contamination and indicated the bag would need to be replaced because it had been touching the floor. Observation and interview on 06/03/2026 at 11:02 AM, LVN C stated she had been employed at the facility for nine years. LVN C stated that Fole catheter care was important for infection prevention and that all nursing staff responsible for ensuring tubing was not pulling and catheter bags were positioned below the bladder. Resident #69's catheter bag was observed and LVN C explained that catheter bags were required to be covered with privacy bags to maintain resident privacy. LVN C explained that catheter bags should have been secured to the bed rail using the designated clips and maintained below the bladder, ensuring the bags were not touching the floor, it would have required replacement due to the risk of contamination and infection. LVN C stated staff received training upon hire and that training was conducted quarterly or as needed. In an interview on 06/03/2026 at 12:08 PM, the DON stated she had been employed with the facility for a year and 3 months. The DON stated that she and the ADONS trained nursing staff on Foley catheter care and the proper positioning of catheter bags and privacy bags. The DON stated the risk associated with a catheter bag or privacy bag touching the floor was infection control. The DON further stated it was the responsibility of all staff to ensure privacy bags and catheter bags were not touching the floor. The DON reported that if any privacy bags and catheter bags had been observed touching the floor, staff were required to notify a nurse so the bag could be changed. The DON stated the infection control risk was due to bacterial contamination. Record review of the facility's in-services for Foley/Catheter care revealed training was conducted on 01/29/2026 and 12/10/2025. Infection control training for all staff was conducted on 02/26/2026. In an interview on 06/03/2026 at 03:23 PM, The Administrator stated that all nursing staff are responsible for Foley catheter care but, all staff in general could ensure that resident catheter bags are not touching or lying on the floor. The Administrator stated that if the drainage bag were located in a privacy bag, he does not believe there would be a risk of contamination. He stated the facility's policy does not specify whether a privacy bag could be touching the floor or not. The Administrator stated that if the actual drainage bag was located on the floor, then it would be a risk, and he would expect his staff to change the drainage bag because it would be contaminated. Record review of facility's policy titled Catheter care, Urinary revised September 2014, revealed section titled Infection Control b.) Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 of 8 residents (Resident #64) reviewed for ADL care. The facility failed to ensure Resident #64's nails were trimmed and filed on 06/01/2026. This failure could place residents at risk of loss of dignity, risk for infections, and a decreased quality of life.Findings included: Record review of Resident # 64's admission record dated 06/03/2026 revealed an [AGE] year-old female with an original admission date on 3/24/2020 and a readmission date on 03/01/2024. Record review of Resident # 64's Physician's progress note dated 05/13/2026 reveled a diagnosis of Alzheimer's disease (a progressive neurological disorder that gradually destroys memory, thinking skills, and the ability to carry out simple daily tasks), and dementia (a loss of memory, language, and thinking abilities that are severe enough to interfere with daily life). Record review of Resident #64's Quarterly MDS dated [DATE] revealed no BIMS score. Section GG- Functional abilities revealed Resident #64 was dependent meaning helper did all of the effort. The resident did none of the effort to complete the activity; or the assistance of 2 or more helpers was required for the resident to complete the activity. Record review of Resident #64's care plan revised on 04/07/2026 revealed Resident #64 had an ADL self-care performance deficit related to Alzheimer's, impaired balance. Interventions included a one person assist with personal hygiene and oral care. An observation on 06/01/2026 at 11:39 AM revealed Resident #64's fingernails on both hands to be about 1.5cm from the nail bed. The resident was nonverbal; she could not answer questions. In interview on 06/03/2026 at 10:52 AM with CNA B, she stated that nails care was done every Sunday and as needed. She stated the importance for maintaining nail hygiene was to make sure there was no bacteria under the nails and to ensure nails were not too long where residents could scratch themselves or hurt themselves. She stated that it was the responsibility of the CNAs's and nurses to ensure that nails were kept trimmed and clean. In an interview on 06/03/2026 at 11:16 AM with LVN C, she stated nail care was performed on Sundays. She stated that nurses were responsible for ensuring CNAs were cutting the residents' nails. She stated the risk of residents having long nails was potential injuries to skin because they could scratch themselves. In an interview on 06/03/2026 at 11:47 AM with the DON, she stated nail care was done weekly and as needed. She stated that nurses and CNAs were responsible for ensuring nails were trimmed and clean. She stated that residents with long nails were at risk of injury such as skin breakage. In an interview on 06/03/2026 at 2:13PM with the Administrator, he stated that nail care was provided and monitored on an as needed basis. He stated that the beautician, CNAs, nurses, and activities director could all provide nail care to residents. He stated it was all the staff's responsibility to ensure residents' nails were trimmed and clean. He stated that a risk to the residents would be injury resulting from scratching.Review of facility policy titled Care of Fingernails/Toenails revised October 2010 read in part . The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.General Guidelines Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was as free from accident hazards as possible for 3 of 12 residents (Resident#32, #51 and Resident # 84) reviewed for accidents. The facility failed to properly dispose of a retractable lancet device (small, pen like tool that holds a lancet (a small needle) used to prick the skin for blood sampling) in sharps container in one room (Resident #32), a syringe in one room(Resident#51 and Resident #84) ,and blood-stained alcohol prep pads in two rooms (Resident #32, #51 and Resident #84). This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: Record review of Resident # 32's admission record dated 06/03/2026 revealed a [AGE] year old female with an original admission date on 01/25/2021 and a readmission date of 05/06/2024. Record review of Resident # 32's diagnosis list dated 06/03/2026 revealed a diagnosis of vascular dementia (a decline in thinking and memory skills caused by reduced blood flow to the brain, which deprives brain cells of vital oxygen and nutrients). Record review of Resident #32's Quarterly MDS assessment dated [DATE], revealed a BIMs score of 04 indicating severe cognitive impairment. Record review of Resident # 32's care plan revised 05/07/2026 revealed Resident # 32 had impaired cognitive function or impaired though process related to dementia. An observation of Resident #32's room on 06/03/2026 at 1:27PM revealed a blood stained alcohol prep pad, 2 lancets and a syringe in the slot of the sharp's container located on the wall of the bathroom. Record review of Resident # 51's admission record dated 06/03/2026 revealed an [AGE] year old female with an admission date on 05/04/2026. Record review of Resident # 51's History and Physical dated 05/04/2026 revealed a diagnosis of advanced Alzheimer's dementia (a progressive brain disorder and the most common type of dementia). Record review of Resident # 51's MDS assessment dated [DATE] revealed a BIMS score of 03 indicating severe cognitive impairment. Record review of Resident # 51's care plan revised on 06/02/2026 revealed Resident #51 had impaired cognitive function/impaired through process related to diagnosis of dementia, BIMS score of 03. Record review of Resident # 84's admission record dated 06/03/2026 revealed an [AGE] year-old female with an admission date on 11/11/2022. Record review of Resident # 84's physician's progress note dated 05/20/2026 revealed a diagnosis of unspecified dementia (cognitive decline or memory loss without exact underlying cause). Record review of Resident # 84's quarterly MDS dated [DATE] revealed a BIMS score of 05 indicating severe cognitive impairment. Record review of Resident # 84's care plan revised 05/28/2026 revealed Resident #84 had had impaired cognitive function/impaired through process related to diagnosis of dementia. An observation of Resident #51's and 84's room on 06/01/2026 at 11:27AM revealed a blood stained alcohol prep pad, and 3 lancets in the slot of the sharp's container located on the wall of the bathroom. In an interview on 06/03/2026 at 10:25 am with LVN A revealed that all contents were to be disposed of completely in the sharp's container. She stated that it was the responsibility of whoever was disposing of the items to make sure that it was placed all the way inside the container. She stated that if items were left in the reach of residents, they could be at risk for needle sticks and injury. In an interview on 06/03/2026 at 11:47 AM with the DON revealed that the purpose of the sharp's containers were to dispose of any biohazard/ sharp items. She stated contents were to be disposed of in the sharp's container were to be disposed of all the way inside the container. She stated that all staff were responsible for ensuring that there were no contents left sitting in the drop slot of the sharp container. She stated that when contents were left in the reach of residents, this could pose a risk for residents getting a hold of items and injuring themselves. In an interview on 06/03/2026 at 2:13 PM with Administrator revealed that the purpose of the sharps containers was to dispose of hazardous items. He stated that contents were supposed to be disposed of completely inside the container. He stated that if items were left in the reach of residents, it could pose a risk of injury to both residents and staff. Review of facility policy revised January 2012 and titled Sharps Disposal revealed in part The facility shall discard contaminated sharps into designated containers. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for garbage disposal. -The facility failed to ensure the dumpster was closed on 06/01/2026. -The facility failed to ensure refuse, including construction debris and organic food waste, was disposed of inside the dumpster and not left exposed in a trash cart on 06/01/2026.These failures could place residents, staff, and visitors at risk of infestation of rodents and insects.Findings included: During the initial kitchen tour, an observation and interview were conducted on 06/01/2026 at 11:16 a.m. with the Nutrition Supervisor at the rear of the facility. The dumpster was observed open on one side with multiple trash bags visible, including bags containing adult briefs. A strong foul odor was present throughout the dumpster area. Adjacent to the dumpster, a trash cart containing construction debris, discarded fast-food bags, and other organic refuse was observed uncovered and exposed to the environment. The Nutrition Supervisor stated it was not appropriate for the dumpster to remain open or for construction debris and organic waste to be left uncovered outside of the dumpster. She stated these conditions had the potential to attract insects, flies, cockroaches, rodents, stray animals, and other pests, which could gain access to the exposed refuse, scatter trash throughout the area, create unsanitary conditions, and contribute to foul odors around the facility. During an interview on 06/03/2026 at 10:04 a.m. Housekeeper D stated that staff were expected to ensure dumpster lids remained closed when dumpsters were not actively being used. Housekeeper D stated that open dumpsters could attract insects, rodents, and other pests to the facility grounds. Housekeeper D stated that exposed refuse could create unpleasant odors and negatively affect the cleanliness and appearance of the facility. Housekeeper D stated that maintaining dumpsters in a closed position helped promote a sanitary environment for residents, visitors, and staff. During an interview on 06/03/2026 at 10:11 a.m. Housekeeper E stated that dumpsters should remain closed after trash was disposed of. Housekeeper E stated that open dumpsters increased the risk of pest activity and could contribute to unsanitary conditions around the building. Housekeeper E stated that exposed trash could create offensive odors and detract from the overall cleanliness of the facility. Housekeeper E stated that all staff shared responsibility for maintaining a clean and safe environment. During an interview on 06/03/2026 at 11:31 a.m. the DON stated that dumpsters were expected to remain closed except during active use. The DON stated that open dumpsters could attract vermin, insects, and other pests which could present sanitation concerns. The DON stated that improperly secured dumpsters could create foul odors and environmental hazards that could impact residents and visitors. The DON stated that staff were expected to identify and report environmental concerns to the maintenance director of the Administrator for prompt correction. During an interview on 06/03/2026 at 11:37 a.m. the Maintenance Supervisor stated that part of his responsibilities included monitoring the exterior grounds and ensuring dumpsters remained in good condition and properly closed. He stated that leaving dumpsters open increased the likelihood of attracting pests and wildlife. He stated that open dumpsters could create odor concerns and negatively affect the facility's sanitary conditions. He stated that maintaining closed dumpsters was necessary to provide a clean, safe, and well-maintained environment. During an interview on 06/03/2026 at 1:30 p.m. LVN C stated that dumpsters should remain closed when not actively receiving trash. LVN C stated that open dumpsters could result in pest infestations, unpleasant odors, and sanitation concerns. LVN C stated that environmental hazards had the potential to affect resident health and quality of life. LVN C stated that staff were responsible for reporting observed concerns to management to ensure corrective action was taken. During an interview on 06/03/2026 at 3:12 p.m. the Administrator stated that he did not identify any potential negative outcomes associated with the dumpster being left open. He stated that he had not observed issues related to pests, odors, or sanitation concerns resulting from the open dumpster. He stated, however, that the facility's policy required dumpsters to remain closed when not actively in use. He acknowledged that staff were expected to follow the facility's policy regarding dumpster management and environmental services practices.Record review of the facility's policy titled Food-Related Garbage and Refuse Disposal revised in October 2017, revealed in part. Policy Statement Food-related garbage and refuse are disposed of in accordance with current state laws. Policy Interpretation and Implementation 1. All food waste shall be kept in containers. 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. 6. Storage areas will be kept clean at all times, and shall not constitute a nuisance. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on interviews and record review, the facility failed to ensure 4 of 11(LVN E, CNA L, CNA G, and Activities Director) employees whose in-service records were reviewed had not received the required minimum 1-hour annual in-service training for Dementia and Behavior Management. The facility failed to keep copies of documentation of the required annual Dementia and Behavior Management training for LVN E, CNA L, CNA G, and Activities Director before the change of ownership was completed on December 04, 2025. This failure placed residents at risk for unmet needs due to untrained staff. Findings included: During an interview and Record Review on 12/16/25 at 4:42 PM with HR Payroll Coordinator revealed they had a change of ownership on December 04, 2025, and she no longer had access to training records from the previous company to show Dementia/Behavior/Communication training was completed on an annual basis according to facility policies for the following employees. -LVN Charge Nurse E was hired on 05/18/25. Documentation revealed Dementia/Behavior/Communication training was completed on 04/07/25. No previous training records were available to review due to change of ownership. -CNA L was hired on 10/27/23. Documentation revealed Dementia/Behavior/Communication training was completed on 09/25/25. No previous training records were available to review due to change of ownership. -CNA G was hired on 05/31/24. Documentation revealed Dementia/Behavior/Communication training was completed on 08/05/25. -Activities Director was hired on 09/25/19. Documentation revealed Dementia/Behavior/Communication training was completed on 08/05/25. No previous training records were available to review due to change of ownership. -During an interview on 12/15/25 at 4:00 PM, revealed he was trained this year but could not recall what date he had completed the computer training on Dementia/Behavior/Communication. - During an interview on 12/16/25 at 1:30 PM revealed, she did not recall if she had received training on Dementia/Behavior/Communication. -During an interview on 12/16/25 at 2:27 PM with the Executive Director revealed they had a change of ownership on 12/04/25. He said, So everyone was considered to be a new hire. He said they had not made copies of training records for the facility staff prior to the change of ownership and did not have documentation of the last annual training on Dementia and Behavior Management for some of the staff. He said, Like I said all the staff are considered to be new hires due to change in ownership and we are in the process of completing the annual training on Dementia and Behavioral Management. Review of facility's Policy and Procedure on Dementia Care implemented 11/2017 revealed, Policy: It is a policy of this facility to provide the appropriate treatment and services to every resident who display signs of or is diagnosed with dementia to meet his or her highest practical, physical, mental and psychological well-being. Explanation and Compliance Guidelines. The care plan interventions will be related to each residence individual symptomology and rate of dementia (or related diseases) progression with end result being noted improvement or maintain of the expected stable rate were decline associated with dementia and dementia like illnesses. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. If needed, the environment will be modified to accommodate individual resident care needs. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. All staff will be trained in dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies, and skill sets to ensure resident's safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for 1 (Resident #2) of 4 residents reviewed for unnecessary medications. The facility failed to ensure Resident #2 had behavior monitoring documentation on the Treatment Administration for his prescribed Valproic Acid (an antipsychotic medication), Hydroxyzine (an antianxiety/anticholinergic medication used to treat anxiety) and Trazodone HCL (used to treat insomnia). This failure could put residents at risk of harm from adverse reactions or harmful side effects. Findings included:Closed Record review of Resident #2's admission Record revealed Original admission Date 02/16/2023 and re-admission Date 02/10/25. -Review of Hospital paperwork from Geriatric Behavioral Unit dated 12/05/25 for Resident #2 revealed, admission date 12/05/25 and discharge date [DATE]. History & Physical dated 12/05/25 revealed [AGE] year-old male transferred to Geriatric Behavioral Units from the ER, brought in via EMS, from nursing home for violent behavior and GBU evaluation. Reason for admission: danger to others, danger deterioration. History and Present Illness: According to ED notes: He was recently discharged on 12/01/25 after being admitted on [DATE] for similar reasons of aggression with staff and residents at the nursing facility. This is his 3rd admission this year, the first one in February of this year. Patient was confused, does not acknowledge behaviors that brought him here. Denies mood swings, hallucinations. The patient is unable to answer questions. Review of systems: no anxiety, no depression. Summary Statement and Safety Plan: Due to these chronic acute, protective factors, I do find this individual to be at a high risk of hurting themselves or others. Will remain in structured environment. On-going psychiatric assessment and close monitoring. Maintain inpatient care to ensure patient safety and stabilization. Estimated length of stay: 5 to 10 days. Record review of Resident #2's History & Physical dated 04/03/25 revealed [AGE] year-old male with past medical history of vascular dementia with mood disturbance (A condition where brain damage from poor blood flow causes issues with thinking and memory, along with significant emotional changes like depression, anxiety and extreme mood swings), recurrent depressive disorder (Repeated episodes of feeling deeply sad, lost interest in things, have no energy and experience other symptoms like sleep, appetite changes, and might have periods of normal moments in between the episodes before the next depressive episode comes back), generalized anxiety disorder (constantly feel anxious or on edge about everyday things. Even when there's little reason to and it's hard to turn now or control, leading to physical symptoms like muscle tension, fatigue and trouble sleeping, making daily life feel overwhelming), and impulse disorder (A struggle to stop one's self from doing things, you shouldn't, leading to sudden actions like anger outburst, stealing or binge eating, even when they cause problems to the individual or others). History of falls, status post intertrochanteric fracture of left femur (A break in the upper part of the thigh bone, right where it connects to the hip).Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed BIMS Score 3 (severe cognitive impairment), functional limitation in range of motion to upper and lower extremities, Mobility device - wheelchair; requires substantial/maximal assistance with toileting hygiene, lower body dressing and putting on/taking off footwear; dependent with showers; partial/moderate assistance with personal hygiene. Set up assistance with sit to lying, sit to stand, chair/bed transfer, and tub/shower transfer and once seated in wheelchair, the ability to wheel at least 150 feet in a corridor or similar space. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), anxiety, depression, vascular dementia with mood disturbance and recurrent depressive disorder. High-Risk Drug Use - antidepressant, and anticonvulsant. Record review of Resident #2's Care Plan revealed: -Care Plan revised on 12/05/25 reflected Resident #2 has potential to be physically aggressive, related to dementia and poor impulse control. Interventions: In service direct care staff on residence behaviors and how to detect escalation. Analyzed times of day, places, circumstances, triggers and what the escalates behavior and document. Administer medications and labs as ordered. Monitor for side effects and effectiveness and notify physician of effectiveness. Assess and address for contributing sensory triggers as they occur. The residence triggers for physical aggression are to be monitored and identified so they can be used to deescalate the situation. When the resident becomes agitated, intervene before agitation escalates.-Review of Physician Order Summary Dated 12/15/25 for Resident #2 revealed, Anti-Depressant SE Monitoring: Order Start Date: 12/01/25 Observe closely for significant side effects of Anti-Depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings. Start Date: 12/01/25 BHV - Monitor and document any side effects related to use of Antidepressant medication. Two times a day related to Depression, unspecified Start Date: 12/01/25 Behavior Management Provider to provide psychiatric and psychosocial services evaluate and treat as warranted. Start Date: 12/01/25 Hydroxyzine Pamoate Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 6 hours as needed for anxiety for 14 Days. Start Date: 12/02/25 Trazodone HCl Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth as needed for insomnia for 14 Days at HS. Start Date: 12/01/25 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 10 ml by mouth two times a day for behaviors. -Review of Pharmacy Consultant MMR documented for Recommendations created 12/03/2025 revealed for Resident #2, No DC Summary med list filed at time of review. Active Order reviewed. Add Q shift antianxiety side effect monitoring and targeted behavioral monitoring for Hydroxyzine. Add Q shift antipsychotic side effects monitoring and targeted behavioral monitoring for Valproic Acid. Follow-Through documented In hospital 12/05/25. -Review of Resident #2's Medication Record and TAR Record dated December 2025 revealed, he had received Hydroxyzine, Trazodone HCl, and Valproic Acid Oral Solution as ordered. The TAR reflected the resident was monitored for side effects of antidepressant every shift and documented no side effects were observed. The TAR documented BHV - Monitoring and document any side effects related to use of antidepressant. The TAR did not document resident's targeted behaviors and did not document non-pharmacological interventions. The TAR only documented the nurse's initials. The TAR did not document to monitor targeted behavioral monitoring Q shift for Hydroxyzine and Valproic Acid and did not document non-pharmacological interventions.During an interview and record review on 12/16/25 at 1:45 PM, with DON revealed, TARs dated September - December 2025 did not document specific behaviors exhibited by Resident #2 such as verbal/physical aggression, refusal of care, refusal of labs and propelling his wheelchair up and down the halls and into other resident rooms. She said the TAR dated December 2025, only documented Side Effect Monitoring for use of anti-depressant, antipsychotic and antianxiety medications and did not document monitoring of targeted behavior and/ non-pharmaceutical interventions. Review of the facility's Policy & Procedure on use of Psychotropic Medication Use dated July 2022 revealed, Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications. Anti-psychotics., Anti-depressants., Anti-anxiety medications and Hypnotics. Psychotropic medication management includes: Indication for use; dose (including duplicate therapy); duration, adequate monitoring for efficacy and adverse consequences; and preventing, identifying and responding to adverse consequences. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Nonpharmacological approaches are used (unless Contraindicated) To minimize the need for medications, Permit. The lowest possible dose and allow for discontinuation of medications when possible. Residents on psychotropic medications received gradual dose reductions, unless medically contraindicated, in an effort to discontinue these medications. Resident Evaluations: Situations which may prompt an evaluation or re-evaluation for the resident include: admission or re-admission; A clinically significant change in conditions/status; a new, persistent, or recurrent clinically significant symptom or problem; a worsening of an existing problem or condition; a new medication order or renewal of orders; or an irregularity identified in the pharmacist's medication regimen review.

Based on interview, and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents (Resident #2) reviewed for dementia care. -The facility failed to provide or address the customary routines, preferences, and choices to enhance Resident #2's well-being when he refused care, refused labs, and became physically and verbally aggressive from August 2025 - December 2025. -The facility failed to implement interventions related to behavioral issues related to dementia, when Resident #2 wandered into another resident's room, punched Resident #4 on the arm, attempted to strike and was cursing when Resident #4 told Resident #2 that he was in the wrong room. This failure could result in residents with dementia not receiving services focused on their dementia-related behaviors which placed him and other residents at risk of not receiving the necessary personal care and services and placed residents at risk of verbal and physical abuse related to wandering behavior. Findings included: Resident #4Record review of Resident #4's Closed Records reflected an admission Record admission Date 11/24/25. Resident was discharged [DATE]. Review of History and Physical dated 12/02/25 for Resident #4 revealed [AGE] year-old female with past medical history of CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), Diabetes Mellitus (a chronic condition where the body does not produce enough insulin or cannot use insulin effectively), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), Hypothyroidism - thyroid gland does not produce enough thyroid hormones, which control body's energy use causing many functions to slow down leading to fatigue, weight gain, feeling cold, and dry skin). Review of admission MDS dated [DATE] for Resident #4 revealed, clear speech, makes self-understood, understands others, BIMS Score 13 (cognitively intact). Independent with indoor mobility with walker. Review of Care Plan dated 12/05/25 for Resident #4 revealed, Resident to Resident altercation. Resident struck by another resident while in room. Aggressor removed immediately. No visible injuries. Interventions: Provide emotional reassurance and maintain therapeutic communication. Review of Progress Note dated 12/05/25 for Resident #4 written by Nurse Practitioner revealed, today patient has been seen and evaluated with the charge nurse in charge of the patient. During today's rounds, patient was heard calling out for help. Upon entering room, it was observed that another resident had entered her room unintentionally. The resident appeared confused and was reportedly looking for his own room. The patient stated that the other resident hit her in the left arm and attempted to kick her. Patient described feeling startled by the encounter. A full evaluation was conducted at bedside, alert oriented to person, place, and time. Upon physical exam left arm, now swelling, no redness, no bruising, no tenderness on palpation, full ROM without pain, no visible signs and symptoms of trauma or injury. Distress Assessment: Patient verbalized she was OK and denied ongoing pain or discomfort. She stated that she was primary startled by the incident. Record review of Resident #2's Closed Records reflected an admission Record with the Original admission Date as 02/16/2023 and re-admission Date as 02/10/25. Resident was discharged [DATE].Review of PASRR Level 1 Screening dated 12/01/2025 for Resident #2 revealed, Primary Diagnosis of Dementia, Mental Illness. Review of Hospital paperwork from Geriatric Behavioral Unit (GBU) dated 12/05/25 for Resident #2 reflected, admission date 12/05/25 and discharge date [DATE]. History & Physical dated 12/05/25 revealed [AGE] year-old male transferred to Geriatric Behavioral Units from the ER, brought in via EMS, from nursing home for violent behavior and GBU evaluation. Reason for admission: danger to others, danger deterioration. History and Present Illness: According to ED notes: He was recently discharged on 12/01/25 after being admitted on [DATE] for similar reasons of aggression with staff and residents at the nursing facility. This is his 3rd admission this year, the first one in February of this year. Patient was confused, does not acknowledge behaviors that brought him here. Denies mood swings, hallucinations. The patient is unable to answer questions. Review of systems: no anxiety, no depression. Summary Statement and Safety Plan: Due to these chronic acute, protective factors, I do find this individual to be at a high risk of hurting themselves or others. Will remain in structured environment. On-going psychiatric assessment and close monitoring. Maintain inpatient care to ensure patient safety and stabilization. Record review of Resident #2's History & Physical dated 04/03/25 revealed [AGE] year-old male with past medical history of vascular dementia with mood disturbance (A condition where brain damage from poor blood flow causes issues with thinking and memory, along with significant emotional changes like depression, anxiety and extreme mood swings), recurrent depressive disorder (Repeated episodes of feeling deeply sad, lost interest in things, have no energy and experience other symptoms like sleep, appetite changes, and might have periods of normal moments in between the episodes before the next depressive episode comes back), generalized anxiety disorder (constantly feel anxious or on edge about everyday things. Even when there's little reason to and it's hard to turn now or control, leading to physical symptoms like muscle tension, fatigue and trouble sleeping, making daily life feel overwhelming), and impulse disorder (A struggle to stop one's self from doing things, you shouldn't, leading to sudden actions like anger outburst, stealing or binge eating, even when they cause problems to the individual or others). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed BIMS Score 3 (severe cognitive impairment), functional limitation in range of motion to upper and lower extremities, Mobility device - wheelchair; requires substantial/maximal assistance with toileting hygiene, lower body dressing and putting on/taking off footwear; dependent with showers; partial/moderate assistance with personal hygiene. Set up assistance with sit to lying, sit to stand, chair/bed transfer, and tub/shower transfer and once seated in wheelchair, the ability to wheel at least 150 feet in a corridor or similar space. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), anxiety, depression, vascular dementia with mood disturbance and recurrent depressive disorder. High-Risk Drug Use - antidepressant, and anticonvulsant. Record review of Resident #2's Care Plan revealed: -Care Plan revised on 12/05/25 The resident has potential to be physically aggressive, related to dementia and poor impulse control. Interventions: In service direct care staff on residence behaviors and how to detect escalation. Analyzed times of day, places, circumstances, triggers and what the escalates behavior and document. Administer medications and labs as ordered. Monitor for side effects and effectiveness and notify physician of effectiveness. Assess and address for contributing sensory triggers as they occur. The residence triggers for physical aggression are to be monitored and identified so they can be used to deescalate the situation. When the resident becomes agitated, intervene before agitation escalates.-Care Plan revised on 11/04/25 Resident has a behavior problem related to smears, fecal matter and restroom and refuses to change dirty clothes. Interventions: Educate the resident on successful coping and interaction strategies. Assist the resident to develop more appropriate methods of coping and interacting. Encourage the residents to express feelings appropriately. Provide opportunity for positive interaction, attention. Administer medications as ordered. Monitoring document side effects and effectiveness. -Care Plan revised on 09/23/25 The resident is resistive to care r/t refuses showers. Interventions: If possible, negotiate a time for ADL's so the resident participates in the decision-making process. Return at the agreed time. Give clear explanations of all charities prior to. And as they occur during each contact. Allow the resident to make decisions about treatment regimen. To provide a sense of control. -Care Plan revised on 09/23/25 The resident has a mood problem r/t anxiety, agitation. Interventions: Assist the resident in developing/providing the resident a program of activities that are meaningful and of interest. Encourage and provide opportunity for exercise, physical activity. Behavioral health consults as needed. Administer medications as ordered. Monitor/document for side effects and effectiveness. -Care Plan revised on 06/19/25 The resident uses antidepressant medication r/t depression. Goal: Revised 11/04/25. Target Date: 02/02/26. The resident will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions: Monitor/document/report PRN Adverse reactions to antidepressant therapy, change in mood, behavior, cognition, hallucinations, delusions, social isolation, withdrawal, decline in ADLs, continence, gait changes, rigid muscles, balance problems, movement problems, tremors, falls, insomnia, dry mouth and dry yes. Educate the resident about risk and benefits and side effects of antidepressant. Administer antidepressant medications as ordered. Monitor and document side effects and effectiveness Q Shift.-Care Plan revised on 06/19/25. Resident is on anticonvulsant therapy r/t impulse disorder. Goal: Revised 11/04/25. Target Date: 02/02/26. Resident will be free of seizure activity through the next review. Interventions: Protect from injury if seizure occurs. Pad siderails as needed to prevent injury. Monitor for signs of warning prior to seizures. Give meds per order, monitored labs -report abn's to physician. Document seizure in clinical record.-Care Plan revised on 04/21/25. The resident has impaired cognition function or impaired thought processes r/t Dementia. Goal: Revised 11/04/25. Target Date: 02/02/26. The resident will be able to communicate basic needs on a daily basis through next review. Interventions: Discussed concerns about confusion, disease process, Nursing Home placement with resident and family. Communicate with resident and family regarding resident's capabilities and needs. Administer medications as ordered. Monitoring document side effects and effectiveness.-Care Plan revised on 04/02/25. The resident has potential to be verbally aggressive r/t Dementia. Goal: Revised: 11/04/25. Target Date: 02/02/26. The Resident will demonstrate effective coping skills by next review. Interventions: Assess resident's coping skills and support system. Assess and anticipate resident's needs: food, thirst, toilet needs, comfort level, body positioning, pain etc. Analysis of key times, places and circumstances, triggers and what deescalates behavior and comfort. Administer medications as ordered. Monitored document side effects and effectiveness.-Review of IDT - Multidisciplinary Care Conference dated 12/04/25 Type: Quarterly for Resident #2 revealed, discussed consequence of refusing treatment and concerns. Offer relevant alternatives if the Patient has refused treatment(s). Risk Factors/Prevention/Accidents/Incidents. New medication for aggressive behaviors. Found a few times with fecal matter all over the restroom or his bed. Resident refuse showers or change dirty clothes. Requested therapy for right hand weakness. -Review of IDT - Multidisciplinary Care Conference dated 11/04/25 Type: Quarterly for Resident #2 revealed, discussed consequence of refusing treatment and concerns. Offer relevant alternatives if the Patient has refused treatment(s). Risk Factors/Prevention/Accidents/Incidents. New medication for aggressive behaviors. Found a few times with fecal matter all over the restroom or his bed. Resident refuse showers or change dirty clothes. Requested therapy for right hand weakness. -Review of Physician Order Summary Dated 12/15/25 for Resident #2 revealed, Anti-Depressant SE Monitoring: Order Start Date: 12/01/25 Observe closely for significant side effects of Anti-Depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code Other/See Nurses Notes' and progress note findings. Start Date: 12/01/25 BHV - Monitor and document any side effects related to use of Antidepressant medication. Two times a day related to Depression, unspecified Start Date: 12/01/25 Behavior Management Provider to provide psychiatric and psychosocial services evaluate and treat as warranted. Pharmacy: Start Date: 12/01/25 Benzgalantamine Gluconate Oral Tablet Delayed Release 10 MG (Benzgalantamine Gluconate) Give 1 tablet by mouth two times a day for Dementia. Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for Dementia. Start Date: 12/01/25 Hydroxyzine Pamoate Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 6 hours as needed for anxiety for 14 Days. Memantine HCl Oral Tablet 10 MG give 1 tablet by mouth two times a day for Alzheimer's disease. Start Date: 12/02/25 trazodone HCl Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth as needed for insomnia for 14 Days at HS. Start Date: 12/01/25 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 10 ml by mouth two times a day for behaviors -Review of Physician Progress note written by Nurse Practitioner on 12/05/25 for Resident #2 revealed, Patient is being seen today s/p return to facility from GBU for an aggressive episode towards another resident in the facility. Today I witnessed patient in another resident's room noted with aggressive behavior, resident placed on 1:1 with facility staff and is pending to be sent out to GBU for reevaluation of aggression and his behavioral episode. Plan: Send to GBU for evaluation of aggressive behavior. Social Services for discharge planning. Review of contracted Behavior Health Clinical Treatment Plan dated 12/02/25 for Resident #2 revealed, Resident had cognitive ability to establish a verbal therapeutic relationship with therapist. Behavior and emotions improve in response to participation in therapy. Patient is an [AGE] year-old male who was admitted to the facility on [DATE] from the hospital. Medical records note vascular dementia. Patient referred for psych and Med management services due to anxiety, irritability, agitation, verbal physical aggression. Staff reports patient can be occasionally irritable and critical. Medical History: Alzheimer's Disease, Dementia. Resident has anxiety, depression, disorientation, emotional withdrawal. Moderate Cognitive Decline. -Review of Behavior Health Psychiatric Subsequent assessment dated [DATE] for Resident #2 revealed, Primary Treating Dx: Impulse Behavior. Secondary Treating Dx: recurrent depressive disorder. Insomnia, Delusional Disorder, Vascular Dementia, and unspecified dementia with other behavioral disturbance. Reason for Referral: Anxiety Disorder, Irritability, Anger, Verbal Aggression, Physical Aggression. Staff members were instructed to promptly inform the provider of any changes in the patient's mental status or the appearance of new or worsening symptoms, including confusion, mood alterations, anxiety, changes in appetite, or sleep issues. Oriented to person. Thought Content: Delusions. Insight: Poor. Judgement: Poor. Resident is non-verbal. Due to dementia, expectations are that the patient will most likely experience loss of function, refusal of care, behaviors (including wandering, agitation, aggression) changes in weight and further decline of cognition. Provider spoke with staff regarding the care/medication update and responses. Staff will notify provider if patient experiences changes in mental status, new or worsening symptoms of confusion, depression, anxiety, changes in appetite or sleep patterns. -Review of Behavior Health Psychiatric Subsequent assessment dated [DATE] for Resident #2 revealed, the patient voices no symptoms of depression, anxiety, changes in appetite, sleep disturbances, or psychosis but has dementia related agitation and psychosis. The patient recently was sent to GBU and returned with no change in orders. The writer made changes upon his return and is closely monitoring the changes and behaviors. Staff observed no aggression or agitation but is back at baseline in which the patient refuses showers and certain nursing care but does not get physical with redirection. Cognitive impairment. Oriented to person. Thought Content: Delusions. Labs reviewed: UTI. -Review Behavioral Health Progress Note dated 10/23/25 reveal Resident #2 was oriented to person, place, and time. Disorientation: Mild. Patient's Response to Intervention: Patient was encountered in lobby and agreed to talk. Patient was cooperative and easy to engage. Patient reported feeling tired and apologized in advance if he fell asleep. Patient reported that he has noticed that he has less energy and this worries him sometimes. Patient responded well to interventions and was able to re-orient himself and identify factors affecting his mood. Plan For Next Session: Encourage patient to continue engaging in self-soothing activities. -Review of Pharmacy Consultant MMR documented for Recommendations created 12/03/2025 revealed for Resident #2, No DC Summary med list filed at time of review. Active Order reviewed. Add Q shift antianxiety side effect monitoring and targeted behavioral monitoring for Hydroxyzine. Add Q shift antipsychotic side effects monitoring and targeted behavioral monitoring for Valproic Acid. Follow-Through documented In hospital 12/05/25. -Review of Nurse's IDT notes from August 2025 - December 2025 revealed, Resident #2 frequently refused showers, refused labs, propelled his wheelchair with his feet all over the facility and occasionally entered other resident rooms, pushed residents out of his way as he propelled himself up and down the resident halls. He was verbally and physically aggressive with other residents and facility staff attempts were made to provide shower and personal care. Resident refused x-ray of the right hand, after he had sustained a fall 10/17/25 that caused swelling to the right hand. -Review of Elopement assessment dated [DATE] for Resident #2 revealed, Category: Not risk for elope. No history of elopement. -Review of Elopement assessment dated [DATE] for Resident #2 revealed, Category: Not risk for elope. No history of elopement. -Review SBAR Communication Form dated 12/05/25 for Resident #2 revealed, Behavioral Symptoms started on 12/05/25 and have gotten worse. During an interview on 12/11/25 at 2:40 AM with DON revealed, Resident #2 was alert and oriented to person, was able to answer simple questions, used a wheelchair for mobility, propelled his wheelchair with his feet up and down the resident halls and constantly went into other resident rooms and resisted redirection to leave the room because he thought that it was his room. She said the resident required close supervision and redirection to keep him from going into other resident rooms. She said the resident had delusions, sundown, and would push the other residents out of his way when he wheeled himself in the resident halls, refused to shower, swearing at staff when attempts were made to provide daily care, at times suspicious of others, demanding, and anxiety. She said he never attempted to leave the facility. She said the resident could not have a roommate because he preferred to be by himself, would cuss, throw water at his roommates and would ask them to leave because it was his room. She said the resident spoke some English but preferred to speak in Spanish and was able to answer questions. She said the resident had multiple medication adjustments and was taking Valproic Acid for behaviors and several medications for his dementia. She said the resident was in the 100 Hall when he was sent to emergency room on [DATE] for altered mental status and was transferred from there to the GBU on 11/20/25 and had returned to the facility on [DATE] and was placed in the 200 Hall upon re-admission because his room in the 100 hall was not available. She said that in the last incident on 12/05/25, they heard Resident #4 yelling for help and upon entering the room, found Resident #2 in her room and she was telling him to leave because it was not his room. She said Resident #4 reported he had punched her in the arm and was resisting leaving the room. She said Resident #2 was placed on 1:1 to keep him from going into other resident rooms on that day, until he was sent to the GBU. The DON said the facility staff tried to provide close supervision and re-direction to Resident #2 while they provided care to the other residents. During an interview on 12/11/25 at 2:55 AM with LVN Charge Nurse B in the 200 Hall revealed, she had been employed for a couple of months and was assigned to Resident #2. She said Resident #2 was re-admitted from the hospital a couple of weeks ago to the 200 Hall. She said he was occasionally oriented to person and place, and he thought he was at home. She said the resident had limited range of motion to one arm, was incontinent of bowel & bladder, was able to stand up with assistance, and needed assistance with dressing. She said he constantly propelled his wheelchair with his feet up and down the halls looking for his room. She said that on the date of the incident on 12/05/25 she and the Nurse Practitioner had heard Resident #4 yelling for help. She said that when they had entered the room, Resident #2 had one hand in a fist, and she said he had hit her, and he was pulled away. She said Resident #4 had reported she was telling Resident #2 that he was in the wrong room, and he had started cursing and had punched her in her arm. She said the Nurse Practitioner had assessed Resident #4 and had no apparent injuries. She said, I have heard from other staff say that he goes into other resident rooms. I had never seen him go into other resident rooms until the day of the incident on 12/05/25.During an interview on 12/12/25 at 3:07 PM with RN ADON C revealed that on 12/05/25 she had been notified by LVN Charge Nurse B at approximately 12:50 PM, that Resident #2 had been placed on 1:1 to prevent Resident #2 from leaving the room and going into other resident rooms until he was transferred to the GBU for evaluation of aggressive behavior. She said Resident #2 had refused to allow the staff to assess him and did not allow the staff to get close to him. She said EMS was called and he was sent to the hospital for evaluation of his aggressive behavior. She said Resident #2 was oriented to person and at times to place, propelled his wheelchair with his feet all over the facility looking for his room. She said that at times he attempted to enter other resident rooms and required close supervision and redirection from the staff. She said Resident #2 used to be in the 100 Hall and had been placed in the 200 Hall upon readmission from the hospital. She said he would frequently go to the 100 Hall looking for his room. She said Resident #2 had a history of physical aggression towards other residents and staff when care was provided. She said he had punched one of his roommates on the chest and had not caused any apparent injuries. She said on another occasion he threw water at one of his roommates because he wanted him to leave the room. She said Resident #2 had been sent to the GBU for altercations with other residents, non-compliance with medications, refusing showers and labs. She said the resident toileted with assistance and ate in the main dining room. She said he was very particular to those who sat with him at the table in dining room and would leave the dining room if he did not like the residents. She said Resident #2 had a recent incident involving Resident #4. She said Resident #2 had wheeled himself into her room and when she was telling him he was in the wrong room, he had punched her in the arm and did not cause any apparent injuries. During an interview on 12/12/25 at 3:20 PM with LVN MDS Nurse D assigned to Resident #2 revealed, he was a loner, very particular who he talked to, was occasionally oriented to person and place. She said he was also very particular to the people who sat with him in the dining room and would leave the table and go to his room if he did not like the people that sat at the table with him. She said his BIMS score was 3, which meant he was severely cognitively impaired. She said he propelled his wheelchair with his feet all over the facility looking for his room and never attempted to leave the facility. She said he would at times wheeled himself into other resident rooms, thinking that it was his room. She said he needed assistance with Activities of Daily Living and was occasionally incontinent with bowel & bladder. She said he frequently resisted personal care and would push the staff away and/or hit the staff when they attempted to provide daily care. She said he would also yell at the staff when care was provided. She said she was not aware that the wander guard had been discontinued on 11/07/25 since resident was not exhibiting wandering behaviors. During an interview on 12/12/25 at 4:01 PM with Executive Director revealed, he had issued Resident #2 a Discharge Notice on 12/06/25 after he had been sent to the GBU, on 12/05/25 for evaluation of physical aggression. He said the reason for giving the resident a discharge notice was because he had assaulted a resident and was a threat to staff and other residents at the facility. He said Resident #2 had another incident either in January or February 2025 of this year where he kicked, punched the staff, was verbally abusive and resisted care. He said the resident also had wandering behavior and propelled his wheelchair with his feet all over the facility occasionally went into other resident rooms. He said the resident became verbally and physically aggressive when the staff attempted to redirect him. He said the resident required close supervision and redirection especially when he was around other residents. He said the resident ate his meals in the dining room and he was very particular of who sat at the table with him. He said that in the last incident on 12/05/25, Resident #2 wheeled himself into Resident #4's room, and when she had told the resident to leave because it was not his room, he had punched her in the arm. He said Resident #4 had not sustained any injuries on the day of the incident. He said that they had decided to readmit Resident #2 to the 200 Hall after he had returned from the GBU on 12/01/2025, so he could have a room to himself to prevent incidents because when they had attempted to place a roommate in his room, he would kick them or throw water at the roommates. He said that the interventions that they had attempted to keep him from being aggressive with residents and staff had been unsuccessful, and that is why the resident was issued a discharge notice because he was a threat to residents and staff. During an interview and record review on 12/15/25 at 11:44 AM, with DON revealed, she had followed up with the GBU today and was informed the Resident #2 had been discharged to a [NAME] Home. She said the Nurses IDT Notes only documented Resident #2 resisted care and did not document the resident propelled his wheelchair with his feet all over the facility and occasionally entered other resident rooms, thinking that it was his room, did not document resident required close supervision and redirection to help him find his room. She said they had started using the Wander Guard Bracelet in October 2025, she said the resident never attempted to leave the facility. However, the Wander Guard Bracelet had been discontinued due to the resident not exhibiting wandering behavior and had not been resolved in the current care plan. The DON said that she did not attend the Care Plan meetings and said that she attended care plan meetings only as needed. She said the facility had morning meetings with the nursing staff, nursing administration, and MDS Nurse to report changes in condition and behaviors exhibited by the residents. She said the MDS gathers information from the morning meetings and resident families to complete the MDS assessments. She said they had recently hired a new Social Worker. Review of the Treatment Administration Records revealed the TARs dated September 2025 through December 2025 did not document specific behaviors exhibited by Resident #2. She said the TARs did not document resident had episodes of verbal and physical aggression verbal and physical aggression towards staff when they attempted to provide care and re-direction, wandered up and down the halls looking for his room and pushed other residents out of his way, entered other resident rooms thinking it was his room and punched them and refused labs. She said the TAR did not document non-pharmatological approaches used to minimize the need for medications that addressed resident's behaviors. She said the staff had been trained in Dementia Care and Behavior Management but could not recall the dates. The state surveyor requested copies of in-service training on Dementia and Behavior Management and were not provided prior to exit. During an interview and record review on 12/15/25 at 12:30 PM, with LVN MDS Nurse D stated, they had morning meetings with the nurses and CNAs to report changes in condition, behaviors, changes in skin integrity. She said the staff had been trained to document behaviors in the Nurse's progress notes, CNA documentation sheets in the electronic clinical record. She said she was not aware if the nurses documented behaviors exhibited the resident and/or non-pharmacological interventions in the TARs. She said the care plan needed to be revised by the IDT after each comprehensive and quarterly MDS assessment. She did not know how changes to care plan were communicated to the staff. She said the facility did not have any documentation in the IDT notes of how often the IDT discussed resident behaviors and effect of care plan interventions. She said she had not changed the revision date on the care plan for the Risk for elopement/wandering since 4/21/25 and the interventions did not reflect the resident required close supervision and redirection to keep him from entering other resident rooms and prevent recurrence of physical aggression towards other residents. She confirmed the care plan did not document non-pharmacological interventions. She said the care plan did not address that he wheeled himself in his wheelchair up and down the halls and pushed residents out of his way. She said the facility did not have any documentation in the Care Plan dated 12/05/25 of resident triggers for physical aggression, of when and who monitored and identified triggers to de-escalate physical aggression towards other residents and staff. She confirmed the care plan interventions did not document non-pharmacological interventions to prevent physical aggression towards staff and other residents. Review of the care plan that addressed Resident #2 had mood problem r/t anxiety and agitation was last revised on 06/19/25 and did not document the resident preferred to be by himself in his room and did not like to interact with resident or staff due to easily becoming anxious and agitated. The care plan interventions did not document non-pharmacological interventions to prevent anxiety and agitation or what type of activities were provided to the resident. Review of the care plan that addressed Resident #2 was on antidepressant medication was last revised on 06/19/25. She confirmed the care plan interventions did n

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse for 1 (Residents #4) of 4 residents reviewed for abuse. The facility failed to ensure residents were free from physical abuse when Resident #2 wandered into another resident's room, punched Resident #4 on the arm, attempted to hit and started cursing when Resident #4 told Resident #2 that he was in the wrong room. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included:Resident #4Record review of Resident #4's Closed Records reflected an admission Record admission Date 11/24/25. Resident was discharged [DATE]. Review of History and Physical dated 12/02/25 for Resident #4 revealed [AGE] year-old female with past medical history of CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), Diabetes Mellitus (a chronic condition where the body does not produce enough insulin or cannot use insulin effectively), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), Hypothyroidism - thyroid gland does not produce enough thyroid hormones, which control body's energy use causing many functions to slow down leading to fatigue, weight gain, feeling cold, and dry skin). Review of admission MDS dated [DATE] for Resident #4 revealed, clear speech, makes self-understood, understands others, BIMS Score 13 (cognitively intact). Independent with indoor mobility with walker. Review of Care Plan dated 12/05/25 for Resident #4 revealed, Resident to Resident altercation. Resident struck by another resident while in room. Aggressor removed immediately. No visible injuries. Interventions: Provide emotional reassurance and maintain therapeutic communication. Review of Progress Note dated 12/05/25 for Resident #4 written by Nurse Practitioner revealed, today patient has been seen and evaluated with the charge nurse in charge of the patient. During today's rounds, patient was heard calling out for help. Upon entering room, it was observed that another resident had entered her room unintentionally. The resident appeared confused and was reportedly looking for his own room. The patient stated that the other resident hit her in the left arm and attempted to kick her. Patient described feeling startled by the encounter. A full evaluation was conducted at bedside, alert oriented to person, place, and time. Upon physical exam left arm, now swelling, no redness, no bruising, no tenderness on palpation, full ROM without pain, no visible signs and symptoms of trauma or injury. Distress Assessment: Patient verbalized she was OK and denied ongoing pain or discomfort. She stated that she was primary startled by the incident. Record review of Resident #2's Closed Records reflected an admission Record with the Original admission Date as 02/16/2023 and re-admission Date as 02/10/25. Resident was discharged [DATE].Review of Hospital paperwork from Geriatric Behavioral Unit (GBU) dated 12/05/25 for Resident #2 reflected, admission date 12/05/25 and discharge date [DATE]. History & Physical dated 12/05/25 revealed [AGE] year-old male transferred to Geriatric Behavioral Units from the ER, brought in via EMS, from nursing home for violent behavior and GBU evaluation. Reason for admission: danger to others, danger deterioration. History and Present Illness: According to ED notes: He was recently discharged on 12/01/25 after being admitted on [DATE] for similar reasons of aggression with staff and residents at the nursing facility. This is his 3rd admission this year, the first one in February of this year. Patient was confused, does not acknowledge behaviors that brought him here. Denies mood swings, hallucinations. The patient is unable to answer questions. Review of systems: no anxiety, no depression. Summary Statement and Safety Plan: Due to these chronic acute, protective factors, I do find this individual to be at a high risk of hurting themselves or others. Will remain in structured environment. On-going psychiatric assessment and close monitoring. Maintain inpatient care to ensure patient safety and stabilization. Record review of Resident #2's History & Physical dated 04/03/25 revealed [AGE] year-old male with past medical history of vascular dementia with mood disturbance (A condition where brain damage from poor blood flow causes issues with thinking and memory, along with significant emotional changes like depression, anxiety and extreme mood swings), recurrent depressive disorder (Repeated episodes of feeling deeply sad, lost interest in things, have no energy and experience other symptoms like sleep, appetite changes, and might have periods of normal moments in between the episodes before the next depressive episode comes back), generalized anxiety disorder (constantly feel anxious or on edge about everyday things. Even when there's little reason to and it's hard to turn now or control, leading to physical symptoms like muscle tension, fatigue and trouble sleeping, making daily life feel overwhelming), and impulse disorder (A struggle to stop one's self from doing things, you shouldn't, leading to sudden actions like anger outburst, stealing or binge eating, even when they cause problems to the individual or others). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed BIMS Score 3 (severe cognitive impairment), functional limitation in range of motion to upper and lower extremities, Mobility device - wheelchair; requires substantial/maximal assistance with toileting hygiene, lower body dressing and putting on/taking off footwear; dependent with showers; partial/moderate assistance with personal hygiene. Set up assistance with sit to lying, sit to stand, chair/bed transfer, and tub/shower transfer and once seated in wheelchair, the ability to wheel at least 150 feet in a corridor or similar space. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), anxiety, depression, vascular dementia with mood disturbance and recurrent depressive disorder. High-Risk Drug Use - antidepressant, and anticonvulsant. Record review of Resident #2's Care Plan revealed: -Care Plan revised on 12/05/25 The resident has potential to be physically aggressive, related to dementia and poor impulse control. Interventions: In service direct care staff on residence behaviors and how to detect escalation. Analyzed times of day, places, circumstances, triggers and what the escalates behavior and document. Administer medications and labs as ordered. Monitor for side effects and effectiveness and notify physician of effectiveness. Assess and address for contributing sensory triggers as they occur. The residence triggers for physical aggression are to be monitored and identified so they can be used to deescalate the situation. When the resident becomes agitated, intervene before agitation escalates. -Care Plan revised on 09/23/25 The resident has a mood problem r/t anxiety, agitation. Interventions: Assist the resident in developing/providing the resident a program of activities that are meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. Behavioral health consults as needed. Administer medications as ordered. Monitor/document for side effects and effectiveness. -Care Plan revised on 06/19/25. Resident is on anticonvulsant therapy r/t impulse disorder. Goal: Revised 11/04/25. Target Date: 02/02/26. Resident will be free of seizure activity through the next review. Interventions: Protect from injury if seizure occurs. Pad siderails as needed to prevent injury. Monitor for signs of warning prior to seizures. Give meds per order, monitored labs -report abn's to physician. Document seizure in clinical record.-Care Plan revised on 04/21/25. The resident has impaired cognition function or impaired thought processes r/t Dementia. Goal: Revised 11/04/25. Target Date: 02/02/26. The resident will be able to communicate basic needs on a daily basis through next review. Interventions: Discussed concerns about confusion, disease process, Nursing Home placement with resident and family. Communicate with resident and family regarding resident's capabilities and needs. Administer medications as ordered. Monitoring document side effects and effectiveness.-Care Plan revised on 04/02/25. The resident has potential to be verbally aggressive r/t Dementia. Goal: Revised: 11/04/25. Target Date: 02/02/26. The Resident will demonstrate effective coping skills by next review. Interventions: Assess resident's coping skills and support system. Assess and anticipate resident's needs: food, thirst, toilet needs, comfort level, body positioning, pain etc. Analysis of key times, places and circumstances, triggers and what deescalates behavior and comfort. Administer medications as ordered. Monitored document side effects and effectiveness.-Review of Physician Order Summary Dated 12/15/25 for Resident #2 revealed, 12/01/25 Behavior Management Provider to provide psychiatric and psychosocial services evaluate and treat as warranted. Pharmacy: Start Date: 12/01/25 Benzgalantamine Gluconate Oral Tablet Delayed Release 10 MG (Benzgalantamine Gluconate) Give 1 tablet by mouth two times a day for Dementia. Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for Dementia. Start Date: 12/01/25 Hydroxyzine Pamoate Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 6 hours as needed for anxiety for 14 Days. Memantine HCl Oral Tablet 10 MG give 1 tablet by mouth two times a day for Alzheimer's disease. Start Date: 12/01/25 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 10 ml by mouth two times a day for behaviors. -Review of Physician Progress note written by Nurse Practitioner on 12/05/25 for Resident #2 revealed, Patient is being seen today s/p return to facility from GBU for an aggressive episode towards another resident in the facility. Today I witnessed patient in another resident's room noted with aggressive behavior, resident placed on 1:1 with facility staff and is pending to be sent out to GBU for reevaluation of aggression and his behavioral episode. Plan: Send to GBU for evaluation of aggressive behavior. Social Services for discharge planning. Review of contracted Behavior Health Clinical Treatment Plan dated 12/02/25 for Resident #2 revealed, Resident had cognitive ability to establish a verbal therapeutic relationship with therapist. Behavior and emotions improve in response to participation in therapy. Patient is an [AGE] year-old male who was admitted to the facility on [DATE] from the hospital. Medical records note vascular dementia. Patient referred for psych and Med management services due to anxiety, irritability, agitation, verbal physical aggression. Staff reports patient can be occasionally irritable and critical. Medical History: Alzheimer's Disease, Dementia. Resident has anxiety, depression, disorientation, emotional withdrawal. Moderate Cognitive Decline. -Review of Behavior Health Psychiatric Subsequent assessment dated [DATE] for Resident #2 revealed, Primary Treating Dx: Impulse Behavior. Secondary Treating Dx: recurrent depressive disorder. Insomnia, Delusional Disorder, Vascular Dementia, and unspecified dementia with other behavioral disturbances. Reason for Referral: Anxiety Disorder, Irritability, Anger, Verbal Aggression, Physical Aggression. Staff members were instructed to promptly inform the provider of any changes in the patient's mental status or the appearance of new or worsening symptoms, including confusion, mood alterations, anxiety, changes in appetite, or sleep issues. Oriented to person. Thought Content: Delusions. Insight: Poor. Judgement: Poor. Resident is non-verbal. Due to dementia, expectations are that the patient will most likely experience loss of function, refusal of care, behaviors (including wandering, agitation, aggression) changes in weight and further decline of cognition. -Review of Behavior Health Psychiatric Subsequent assessment dated [DATE] for Resident #2 revealed, the patient voices no symptoms of depression, anxiety, changes in appetite, sleep disturbances, or psychosis but has dementia related agitation and psychosis. The patient was sent to GBU and returned with no change in orders. The writer made changes upon his return and is closely monitoring the changes and behaviors. Staff observed no aggression or agitation but is back at baseline in which the patient refuses showers and certain nursing care but does not get physical with redirection. Cognitive impairment. Oriented to person. Thought Content: Delusions. Labs reviewed: UTI. -Review of Nurse's IDT notes from August 2025 - December 2025 revealed, Resident #2 frequently propelled his wheelchair with his feet all over the facility and occasionally entered other resident rooms, pushed residents out of his way as he propelled himself up and down the resident halls. -Review SBAR Communication Form dated 12/05/25 for Resident #2 revealed, Behavioral Symptoms started on 12/05/25 and have gotten worse. During an interview on 12/11/25 at 2:40 AM with DON revealed, Resident #2 was alert and oriented to person, was able to answer simple questions, used a wheelchair for mobility, propelled his wheelchair with his feet up and down the resident halls and constantly went into other resident rooms and resisted redirection to leave the room because he thought that it was his room. She said the resident required close supervision and redirection to keep him from going into other resident rooms. She said the resident had delusions, sundown, and would push the other residents out of his way when he wheeled himself in the resident halls, refused to shower, swearing at staff when attempts were made to provide daily care, at times suspicious of others, demanding, and anxiety. She said the resident could not have a roommate because he preferred to be by himself, would cuss, throw water at his roommates and would ask them to leave because it was his room. She said the resident spoke some English but preferred to speak in Spanish and was able to answer questions. She said the resident had multiple medication adjustments and was taking Valproic Acid for behaviors and several medications for his dementia. She said that in the last incident on 12/05/25, they heard Resident #4 yelling for help and upon entering the room, found Resident #2 in her room and she was telling him to leave because it was not his room. She said Resident #4 reported he had punched her in the arm and was resisting leaving the room. She said Resident #2 was placed on 1:1 to keep him from going into other resident rooms on that day, until he was sent to the GBU. The DON said the facility staff tried to provide close supervision and re-direction to Resident #2 while they provided care to the other residents. During an interview on 12/11/25 at 2:55 AM with LVN Charge Nurse B in the 200 Hall revealed, Resident #2 was re-admitted from the hospital a couple of weeks ago to the 200 Hall. She said he was occasionally oriented to person and place, and he thought he was at home. She said the resident had limited range of motion to one arm, was incontinent of bowel & bladder, was able to stand up with assistance, and needed assistance with dressing. She said he constantly propelled his wheelchair with his feet up and down the halls looking for his room. She said that on the date of the incident on 12/05/25 she and the Nurse Practitioner had heard Resident #4 yelling for help. She said that when they had entered the room, Resident #2 had one hand in a fist, and she said he had hit her, and he was pulled away. She said Resident #4 had reported she was telling Resident #2 that he was in the wrong room, and he had started cursing and had punched her in her arm. She said the Nurse Practitioner had assessed Resident #4 and had no apparent injuries. She said, I have heard from other staff say that he goes into other resident rooms. I had never seen him go into other resident rooms until the day of the incident on 12/05/25. During an interview on 12/12/25 at 3:07 PM with RN ADON C revealed that on 12/05/25 she had been notified by LVN Charge Nurse B at approximately 12:50 PM, that Resident #2 had been placed on 1:1 to prevent Resident #2 from leaving the room and going into other resident rooms until he was transferred to the GBU for evaluation of aggressive behavior. She said Resident #2 had refused to allow the staff to assess him and did not allow the staff to get close to him. She said EMS was called and he was sent to the hospital for evaluation of his aggressive behavior. She said Resident #2 was oriented to person and at times to place, propelled his wheelchair with his feet all over the facility looking for his room. She said that at times he attempted to enter other resident rooms and required close supervision and redirection from the staff. She said Resident #2 used to be in the 100 Hall and had been placed in the 200 Hall upon readmission from the hospital. She said he would frequently go to the 100 Hall looking for his room. She said Resident #2 had a history of physical aggression towards other residents and staff when care was provided. She said he had punched one of his roommates on the chest and had not caused any apparent injuries. She said on another occasion he threw water at one of his roommates because he wanted him to leave the room. She said Resident #2 had been sent to the GBU for altercations with other residents, non-compliance with medications, refusing showers and labs. She said the resident toileted with assistance and ate in the main dining room. She said he was very particular to those who sat with him at the table in dining room and would leave the dining room if he did not like the residents. She said Resident #2 had a recent incident involving Resident #4. She said Resident #2 had wheeled himself into her room and when she was telling him he was in the wrong room, he had punched her in the arm and did not cause any apparent injuries. During an interview on 12/12/25 at 3:20 PM with LVN MDS Nurse D assigned to Resident #2 revealed, he was a loner, very particular who he talked to, was occasionally oriented to person and place. She said he was also very particular to the people who sat with him in the dining room and would leave the table and go to his room if he did not like the people that sat at the table with him. She said his BIMS score was 3, which meant he was severely cognitively impaired. She said he propelled his wheelchair with his feet all over the facility looking for his room and never attempted to leave the facility. She said he would at times wheeled himself into other resident rooms, thinking that it was his room. She said he frequently resisted personal care and would push the staff away and/or hit the staff when they attempted to provide daily care. She said he would also yell at the staff when care was provided. During an interview on 12/12/25 at 4:01 PM with Executive Director revealed, he had issued Resident #2 a Discharge Notice on 12/06/25 after he had been sent to the GBU, on 12/05/25 for evaluation of physical aggression. He said the reason for giving the resident a discharge notice was because he had assaulted a resident and was a threat to staff and other residents at the facility. He said Resident #2 had another incident either in January or February 2025 of this year where he kicked, punched the staff, was verbally abusive and resisted care. He said the resident also had wandering behavior and propelled his wheelchair with his feet all over the facility occasionally went into other resident rooms. He said the resident became verbally and physically aggressive when the staff attempted to redirect him. He said the resident required close supervision and redirection especially when he was around other residents. He said the resident ate his meals in the dining room and he was very particular of who sat at the table with him. He said that in the last incident on 12/05/25, Resident #2 wheeled himself into Resident #4's room, and when she had told the resident to leave because it was not his room, he had punched her in the arm. He said Resident #4 had not sustained any injuries on the day of the incident. He said that they had decided to readmit Resident #2 to the 200 Hall after he had returned from the GBU on 12/01/2025, so he could have a room to himself to prevent incidents because when they had attempted to place a roommate in his room, he would kick them or throw water at the roommates. He said that the interventions that they had attempted to keep him from being aggressive with residents and staff had been unsuccessful, and that is why the resident was issued a discharge notice because he was a threat to residents and staff. During an interview and record review on 12/15/25 at 11:44 AM, with DON revealed, she had followed up with the GBU today and was informed the Resident #2 had been discharged to a [NAME] Home. She said the Nurses IDT Notes only documented Resident #2 resisted care and did not document the resident propelled his wheelchair with his feet all over the facility and occasionally entered other resident rooms, thinking that it was his room, did not document resident required close supervision and redirection to help him find his room. Review of the Treatment Administration Records revealed the TARs dated September 2025 through December 2025 did not document specific behaviors exhibited by Resident #2. She said the TARs did not document resident had episodes of verbal and physical aggression verbal and physical aggression towards staff when they attempted to provide care and re-direction, wandered up and down the halls looking for his room and pushed other residents out of his way, entered other resident rooms thinking it was his room and punched them and refused labs. She said the TAR did not document non-pharmacological approaches used to minimize the need for medications that addressed resident's behaviors. During an interview and record review on 12/15/25 at 12:30 PM, with LVN MDS Nurse D stated, they had morning meetings with the nurses and CNAs to report changes in condition, behaviors, changes in skin integrity. She said the staff had been trained to document behaviors in the Nurse's progress notes, CNA documentation sheets in the electronic clinical record. She said she was not aware if the nurses documented behaviors exhibited the resident and/or non-pharmacological interventions in the TARs. She said the care plan needed to be revised by the IDT after each comprehensive and quarterly MDS assessment. She did not know how changes to care plan were communicated to the staff. She said the facility did not have any documentation in the IDT notes of how often the IDT discussed resident behaviors and effect of care plan interventions. She said she had not changed the revision date on the care plan for the Risk for elopement/wandering since 4/21/25 and the interventions did not reflect the resident required close supervision and redirection to keep him from entering other resident rooms and prevent recurrence of physical aggression towards other residents. She confirmed the care plan did not document non-pharmacological interventions. She said the care plan did not address that he wheeled himself in his wheelchair up and down the halls and pushed residents out of his way. She said the facility did not have any documentation in the Care Plan dated 12/05/25 of resident triggers for physical aggression, of when and who monitored and identified triggers to de-escalate physical aggression towards other residents and staff. She confirmed the care plan interventions did not document non-pharmacological interventions to prevent physical aggression towards staff and other residents. Review of the care plan that addressed Resident #2 had mood problem r/t anxiety and agitation was last revised on 06/19/25 and did not document the resident preferred to be by himself in his room and did not like to interact with resident or staff due to easily becoming anxious and agitated. The care plan interventions did not document non-pharmacological interventions to prevent anxiety and agitation or what type of activities were provided to the resident. Review of the care plan that addressed Resident #2 was on antidepressant medication was last revised on 06/19/25. She confirmed the care plan interventions did not document non-pharmacological interventions. Review of the care plan that addressed the resident is on anticonvulsant therapy r/t impulse behavior last revised on 06/19/25 and the Goal and Interventions written on the care plan were related to seizure disorder. The care plan did not document the residents' behaviors and non-pharmacological intervention. The care plan did not document the resident was receiving psychological and psychiatric services to manage impulse behavior. Review of the care plan that addressed the resident, had impaired cognitive function or impaired thought processes r/t Dementia. She confirmed the care plan interventions did not document non-pharmacological interventions. During an interview on 12/15/25 at 2:18 PM, with LVN Charge Nurse E revealed, Resident. #2 was only oriented to person, propelled his wheelchair with his feet, up and down the halls looking for his room. She said the resident, occasionally entered other resident rooms and lay in their beds. She said the resident also had verbal aggression and would swear and cuss the residents and staff when care was provided. She said the resident had a strong personality. Macho (a man who is aggressively or overly masculine, often showing an exaggerated sense of toughness, dominance, and self-assurance) and it was his way or the freeway. She said he preferred to speak in Spanish, was a loner, and get very upset if someone got in his way when he propelled himself up and down the halls. She said he was rude and short with the staff when they attempted to talk to him. She said he had been sent to the Geriatric Behavior Unit on several occasions due to punching and being confrontational with other residents and staff. She said the other residents were afraid of him and scared of being around him. She said she was not familiar with Care Plan and had never read the Care Plan interventions. She said she did not know if the CNAs were informed of the Care Plan interventions that addressed resident's behaviors. She said Resident #2 needed closed supervision, redirection and assistance to find his room. She said the resident never attempted to elope from the facility. She said, he wheeled himself up and down the halls looking for his room. During an interview on 12/15/25 at 2:35 PM, with LVN Charge Nurse F revealed, Resident #2 had been recently moved to the 200 Hall upon readmission from the hospital. She said the resident kept going to the 100 Hall looking for his room. She said the resident was only oriented to person, was confused and propelled his wheelchair with his feet up and down the halls, occasionally entered other resident rooms. She said the staff had to wheel him to his room as needed or had to remove him from other resident rooms. She said he was able to propel his wheelchair very fast and at times they could not keep up with him or keep an eye on him because they were busy doing their work. She said the resident was a loner and was territorial and did not like to have roommates. She said that when he was alone in his room and did not have a roommate, he would not have behaviors. She said he would kick and take things from his roommates. She said the resident would become verbally aggressive in the dining room if he did not like who sat at his table. He would ask the resident to move to another table, or he would leave the dining room and go to his room. She said the resident was receiving psychological services, had multiple medication changes. She said initially the medication changes work, then he will start with the same behaviors again. During an interview on 12/15/25 at 4:00 PM with CNA G, said Resident #2 was confused, oriented to person and at times was able to find his room. He said the resident propelled his wheelchair with his feet all over the facility and required close supervision and redirection because he went into other resident rooms. He said the resident mainly spoke Spanish but understood English. He said the resident was territorial, was a loner, and ate his meals in the dining room. He said he did not like to talk much to the staff, and he read the newspaper and watched TV in his room. He said resident rounds were made every two hours, and they tried to redirect Resident #2 as much as they could while they did their work. He said the resident did not like to attend group activities; he became anxious about being around people. He said the resident was Bossy and like to be in control. He said the resident refused showers. He said, With Resident #2, it's all in the approach and how you talk to him that makes him become agitated or how you ask him to assist with his personal care. He just wants to feel that he is in control. During telephone interview on 12/16/25 at 9:37 AM, CNA J said Resident #2 was confused, oriented to person. He said the resident had aggressive behavior, started yelling, swearing, and refused showers. He said the resident propelled his wheelchair with his feet all over the facility. During an interview on 12/16/25 at 1:30 PM with Activities Director revealed, Resident #2 was confused, liked to be by himself in his room and did not like to attend group activities. She said she provided him with books on economics, because he was an accountant and provided history books for him to read in his room. She said Resident #2 did not like to interact with others and did not like to participate in group activities. She said the resident propelled his wheelchair down the hallways and would motion with his hands for the other residents to get out of his way. She said she was not aware of residents' behaviors. During an interview and record review on 12/16/25 at 1:45 PM, with DON revealed, she said the TARs dated September - December 2025 did not document specific behaviors exhibited by Resident #2 such as verbal/physical aggression, refusal of care, refusal of labs and propelling his wheelchair up and down the halls and into other resident rooms. She said the TARs dated September - She said the facility did not have any documentation in the Care Plan dated 12/05/25 of resident triggers for physical aggression, of when and who monitored and identified triggers to de-escalate physical aggression towards other residents and staff. She confirmed the care plan interventions did not document non-pharmacological interventions to prevent physical aggression towards staff and other residents. Review of the care plan revealed MDS LVN D had not changed the revision date on the care plan that addressed Resident #2 had mood problem r/t anxiety and agitation was last revised on 06/19/25 and did not document the resident preferred to be by himself in his room and did not like to interact with resident or staff due to easily becoming anxious and agitated. The care plan interventions did not document non-pharmacological interventions to prevent anxiety and agitation or what type of activities were provided to the resident. The care plan did not document the residents' behaviors and non-pharmacological intervention. The care plan did not document the resident was receiving psychological and psychiatric services to manage impulse behavior. During an interview on 12/16/25 at 2:27 PM, the Executive Director revealed they had a change of ownership on 12/04/25. He said, So everyone was considered to be a new hire. He said they had not made copies of training records for the facility staff prior to the change of ownership and did not have documentation of the last annual training on Dementia and Behavior Management for some of the staff. He said they were in the process of completing the annual training on Dementia and Behavioral Management for the staff. He said he did not know about behaviors being addressed in care plans and nonpharmacological intervent

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 3 of 15 rooms from hallway 400. The facility failed to clean food and stains from the floor that looked like smeared fruit. The facility failed to clean the carpets of trash, debris, and food crumbs. The facility failed to clean an alcohol pad with dried blood from the floor. These failures placed residents and staff at risk of living, working, and visiting in an unsafe, unsanitary, and uncomfortable environment. The findings include: Resident# 5 Record review of Resident# 5's admission record dated 4/28/2025 revealed a [AGE] year-old female with an admitted [DATE]. Record review of Resident# 5's history and physical dated 1/7/25 revealed she had diagnoses of pulmonary disease, heart failure, type 2 diabetes, unspecified dementia, and major depressive disorder. Record review of Resident# 5's MDS assessment dated [DATE] revealed a BIMS of score of 12 indicating she had moderate cognitive impairment. The resident's functional abilities revealed she needed moderate assistance with oral and toileting hygiene, shower, lower body dressing and putting on or taking off footwear. Record review of Resident# 5's care plan revised on 4/22/25, revealed the resident wished to remain in the facility long term and resident and family members were encouraged to provide a home like environment. It indicated the resident had a communication problem and the facility was to anticipate and meet her needs. The care plan revealed Resident# 5 was at fall risk related to being unaware of safety needs. Resident# 46 Record review of Resident# 46's admission record dated 4/28/2025 revealed a [AGE] year-old male with an admitted [DATE]. Record review of Resident# 46's history and physical dated 3/14/25 revealed he had diagnoses of kidney failure, end of stage renal disease, abnormalities of gait and mobility, dementia, anxiety and depression unspecified. Record review of Resident# 46's MDS assessment dated [DATE] revealed a BIMS score of 13 indicating he was cognitively intact. It revealed he was impaired on one side to his upper extremities, and he needed moderate assistance with toileting and personal hygiene with substantial assistance for showers, lower body dressing and putting on or taking off footwear. Record review of Resident# 46's care plan revised on 3/14/25, revealed the resident expressed desire in activity involvement and encouraged visits from family, friends and clergy. It asked for staff to provide room visits two to three times per week to establish friendship and trust. Resident# 69 Record review of Resident# 69's admission record dated 4/28/2025 revealed a [AGE] year-old male with an admitted [DATE]. Record review of Resident# 69's history and physical dated 3/18/25 revealed he had diagnoses of Parkinson's disease, infection of the skin, cognitive communication deficit, muscle weakness, abnormalities of gait and mobility, unspecified intestinal obstruction and acute kidney failure. Record review of Resident# 69's MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. It revealed he needed moderate assistance with oral hygiene and eating, and substantial assistance with toileting, shower, upper and lower body dressing and with putting on or taking off footwear. Record review of Resident# 69's care plan revised on 4/1/25, revealed the resident expressed some desire in activity involvement and encouraged visits from family, friends and clergy. It asked for staff to provide room visits two to three times per week to establish friendship and trust. In an observation on 04/28/25 at 10:01 AM in Resident # 69's room, the carpet had stains and pieces of paper and trash. Side B of the room also had stains on the carpet and food particles that looked like pieces of chips on the floor. In an observation on 04/28/25 at 10:20 AM in Resident # 5, the floor was dirty and had stains that appeared to be fruit, which looked stepped on and smeared. The stains were yellow and green and looked dry, as if they had been there for a significant amount of time. During a second observation at 1:53 PM, the floor continued to be dirty with the same stains. In an observation and interview on 04/29/25 at 10:24 AM, Resident # 46 and 69's rooms had trash, pieces of paper, and food crumbs. Resident #46 said his carpet was stained and that he had told the facility multiple times, but they had not cleaned it. Resident #69 stated that staff went to his room from time to time to take out the trash, but it took the staff a long time to clean his floor and carpet, which he said was cleaned once a day in the mornings. In an Observation and interview on 04/29/25 at 10:34 AM in Resident# 5's room, she was sitting on her wheelchair. She said that sometimes the floors were dirty, and staff took a long time to clean them. Observations revealed there was an alcohol pad on the floor with dry blood on it. Resident #5 stated she did not know if the alcohol pad belonged to her or her roommate. In an interview on 04/30/25 at 08:53 AM with the Housekeeper, she stated it was important to keep the residents' rooms clean because it was their house and they worked for them. She said it was the responsibility of all staff members to clean or report when a room was dirty, for housekeeping to assist the residents with cleaning. The Housekeeper stated that having food debris on the carpet was not acceptable because it could attract pests or insects which could contaminate surfaces in the room and could make the residents sick. She said that it could also make residents and family members feel as if the facility did a poor job maintaining the rooms clean and sanitized. In an interview on 04/30/25 at 11:00 AM with the Housekeeping Supervisor, he stated that it was not acceptable to have trash, debris, or food residues on the floors or carpets of the residents' rooms. He said there was a risk of attracting insects such as roaches or ants, which could potentially make the residents and visitors uncomfortable and make them feel like the facility did not pay attention to hygiene. Regarding the stains on the floor of Resident # 5, the Housekeeping Supervisor stated they could be food residue, sputum, or another bodily fluid, and the alcohol swab with blood residue posed an infection control hazard and there was a risk of cross-contamination for the residents. In an interview on 04/30/25 at 11:57 AM with the DON, she stated the expectation was for the residents' rooms to be cleaned daily and as needed. The DON said there was a potential to attract insects such as roaches and ants by leaving food crumbs on the floors or carpets. The DON said the stains on the floor of Resident # 5 looked like food, and there was a potential fall hazard if a resident stepped and slipped on it, resulting in a fall or accident. The DON stated the alcohol swab with blood residues posed a hazard for infection control if the resident had a health condition in their blood. In an interview on 04/30/25 at 12:45 PM with LVN A, she explained that the expectation was that housekeeping cleaned the rooms, floors, and carpets of the residents' rooms on a daily basis or as needed. LVN A said the floors for Resident # 69 Resident # 5 looked dirty and unclean. LVN A said the potential outcome could be that residents with dementia could ingest trash or food crumbs found on the floors or carpet, and there was the potential for them choking or getting sick from eating something found on the floor. LVN A stated if the stains on the floor of Resident # 5 were mucus or spit, and the alcohol pad with dried blood was from a resident with a blood infection or disease, it could result in cross-contamination or infection. In an interview on 04/30/25 at 01:07 PM with CNA B, she stated that the carpet and floors looked dirty with trash and crumbs. CNA B said there was a risk of cross contamination and that the food residues could attract insects and potentially get the residents sick. She stated that it was all staff's responsibility to make sure the rooms were clean and if a CNA was to find a room in that state, it was expected for them to clean it or to contact maintenance to assist with cleaning. CNA B said the stains on the floor and the alcohol pad with blood found on Resident # 5 could result in contamination and making residents sick. Record Review of the facility's policy with a revision date of 02/21 titled Homelike Environment, stated in part: The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, these characteristics include clean, sanitary and orderly environment.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. The facility failed to store frozen vegetables, frozen cookie dough and sausage patties, in a closed box and sealed bag inside the freezer to prevent food contamination and freezer burn. The facility failed to keep a 1-gallon bottle of Worcestershire's sauce free of dry drippings and residues on the bottle. The facility failed to keep the ice machine and its filters clean and free of dust and lint. The facility failed to keep the deep fryer free of food particles, grease accumulation, and burnt oil, and the stove wall next to the fryer was not free of oil splatter and food particles. These failures could place residents at risk of food borne illnesses. Findings included: In an Observation of freezer #2 and Interview on 04/28/25 at 08:10 AM with the Nutrition Supervisor there was a box of mixed vegetables, oriental blend to the left side of the freezer and a box of chocolate chip frozen cookie dough to the right of the freezer. Neither box was closed and the bags containing the food were not sealed or tied with a knot. The Nutrition Supervisor stated that the bag containing the vegetables, and the cookie dough should not be unsealed and that it was expected for staff to tie close the bag to avoid the contents being exposed and contaminated, or for them to get freeze burn. She stated the potential outcome of the vegetables and cookie dough not being properly closed could expose them to cross contamination and potentially making the residents sick. In an Observation of refrigerator #3 and Interview on 04/28/25 at 08:16 AM with the Nutrition Supervisor there was an open box with an open bag containing sausage patties. The Nutrition Supervisor stated the bag should be sealed and the box should be closed. She said this could result in the patties being contaminated or getting spoiled and the potential outcome could be the residents getting sick if they consumed the contaminated patties. In an Observation and Interview on 04/28/25 at 08:21 AM with the Nutrition Supervisor in the dry storage room, on the first metal rack to the left of the entrance of the pantry a 1-gallon bottle of Worcestershire's sauce had dry drippings on the side. The Nutrition Supervisor stated this could attract insects, potentially contaminating other food in the pantry or kitchen. If insects contaminated ingredients, residents could get sick from consuming food prepared with those ingredients. In an Observation and Interview on 04/28/25 at 08:26 AM with the Nutrition Supervisor, the ice machine had dust and lint on its filters and top. The Nutrition Supervisor stated that the ice machine was expected to be clean and free of dust and lint. The potential problems were that the ice could get contaminated, making residents sick if they used it in their drinks, or the machine could malfunction and stop working due to dirty filters. In an Observation and Interview on 04/28/25 at 08:30 AM with the Nutrition Supervisor, the deep fryer was full of oil that looked burnt and black. Grease had built up on the top and sides, and food particles were on the outside of the fryer. The stove wall to the right of the fryer had oil splatter and food particles on it. The Nutrition Supervisor stated that the deep fryer and the stove looked dirty with oil and grease and that staff were expected to clean them after cooking and leaving the appliances dirty was not acceptable because it could lead to cross-contamination to the resident's food and potentially make them sick. In an interview on 04/30/25 at 10:02 AM with Nutrition Aide C, she said everyone in the kitchen oversaw cleaning their stations. Nutrition Aide C said she believed that maintenance oversaw cleaning of the ice machine She stated it was the cook's responsibility to clean the deep fryer and the stove, and she did not know if only the cook was responsible for cleaning these items. She stated that it was important for the kitchen utensils and equipment to be clean to avoid the residents getting sick. She also stated that food inside the fridges needed to be stored in sealed and labeled containers to avoid contamination and residents getting sick. Nutrition Aide C said that food and vegetables left uncovered and not sealed in the fridge was not acceptable because there was a risk of contamination that could potentially get the resident's sick. Nutrition Aide C stated the kitchen equipment was dirty and was not acceptable and could also get the residents sick by contaminating their food if it came in contact with the appliances' dirty surface. In an interview on 04/30/25 at 10:15 AM with Nutrition Aide D, she stated that food and vegetables needed to be inside a bag dated and sealed to avoid microbes getting into the food or odors from the fridge, and also to prevent spoilage. Nutrition Aide D said the risk of leaving food inside a bag unsealed or tied with just a knot was that the food could get contaminated or spoiled. She added that a resident could get sick or intoxicated if they were served food that got contaminated from being left open in the fridge. Regarding the dirty equipment such as the deep fryer, stove, and ice machine, Nutrition Aide D stated it was the responsibility of all staff members to ensure it was clean and sanitized because the potential outcome could be residents getting sick from contaminated food if the equipment was dirty. She stated that each staff member was in charge of cleaning their station once they were done working on it. In an interview on 04/30/25 at 10:28 AM with the Cook, she stated that vegetables and food such as the sausage patties needed to be stored in a container with a lid creating a seal. The [NAME] said If the vegetables were left in an opened bag, there was a risk of freezer burn or cross-contamination, and they had to be sealed either in a zip lock bag or by tying a knot on the bag after use. Regarding the dry drippings, The [NAME] stated they could potentially attract insects and potentially get the residents sick. She stated that the ice machine, the deep fryer, and stove were dirty and could potentially get the residents sick due to cross-contamination and bacteria. In an interview on 04/30/25 at 11:48 AM with the DON, she stated that the vegetables, cookie dough, and patties needed to be sealed inside of the fridge for infection prevention and control and there was a potential for residents to get sick if they got served a meal with contaminated or spoiled food. The DON said there was an expectation that the equipment in the kitchen be clean. Regarding the kitchen and the dirty ice machine, fryer, and stove, The DON explained there was a potential outcome of contaminating the food for the residents getting them sick from cooking and using dirty equipment. In an interview on 04/30/25 at 12:16 PM with the Administrator, he stated the bags in the fridge containing vegetables needed to be stored inside the bags and the bags needed to be properly sealed because if not, the food could get spoiled. For cleaning the kitchen, The Administrator said it was the expectation that the equipment was clean and without grease or crumbs. Record Review of the facility's policy dated revised on 3/2019, titled Food Storage, read in part: Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. All foods should be covered, labeled and dated. Record Review of the facility's policy dated 11/03/24, titled General Sanitation of Kitchen, read in part: The staff shall maintain the sanitation of the kitchen through compliance with written, comprehensive cleaning schedule. Tasks will be assigned to be the responsibility of specific positions. Record Review of the facility's policy dated 9/15/06, titled Cleaning Ice Machine, Scoop and Tray, read in part: The ice machine and equipment (scoops and trays) will be cleaned on a regular basis to maintain a clean, sanitary condition. Clean exterior of machine with detergent solution, Rinse and allow to dry.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was as free of accident hazards as possible for 4 of 22 residents (#36, #53, #68 and #70) reviewed for accidents. -The facility failed to properly dispose of a retractable lancet device (small, pen like tool that holds a lancet (a small needle) used to prick the skin for blood sampling) in sharps container in one room (resident# 36 and resident#53's room) -The facility failed to properly dispose of blood-stained alcohol prep pads in two rooms (resident#36,#53,#68 and #70 rooms) This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: Resident #36 Record review of Resident #36's face sheet dated 04/30/2025 revealed a [AGE] year-old female that was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #36's History and Physical dated 04/02/25 revealed, Resident #36 was diagnosed with Alzheimer's disease, unspecified dementia with agitation. Record review of Resident #36's Quarterly MDS dated [DATE] revealed no BIMS score. Record review of Resident #36's care plan dated 04/10/25 revealed the Resident has an ADL self-care performance deficit related to Alzheimer's, and the resident had impaired cognitive function/ dementia or impaired thought processes related to Alzheimer's. Resident # 53 Record review of Resident #53's face sheet dated 04/30/2025 revealed an [AGE] year-old female that was originally admitted to the facility on [DATE]. Record review of Resident #53's history and physical dated 04/22/25 revealed, Resident #53 was diagnosed with Unspecified dementia. Record review of Resident #53's quarterly MDS dated [DATE] revealed a BIMS score of 05 indicating severe cognitive impairment. Record review of Resident #53's care plan dated 04/30/25 revealed the Resident has impaired cognitive function or impaired thought processes related to dementia/ Alzheimer's. Resident #68 Record review of Resident #68's face sheet dated 04/30/2025 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Record review of Resident #68's History and Physical dated 04/02/2025 revealed, Resident #68 was diagnosed with dementia. Record review of Resident 68's annual MDS dated [DATE] revealed a BIMS score of 09 indicating moderate cognitive impairment. Record review of Resident #68's care plan reviewed on 03/04/25 revealed the Resident had impaired cognitive function/ dementia or impaired thought processes related to dementia. Resident #70 Record review of Resident #70's face sheet dated 04/30/2025 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Record review of Resident #70's History and Physical dated 04/02/2025 revealed, Resident #70 was diagnosed with unspecified dementia. Record review of Resident #70's Quarterly MDS dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. Record review of Resident #70's care plan dated 04/10/25 revealed the Resident had an ADL self-care performance deficit related to dementia. Observation of resident#36 and 53's room on 4/28/2025 at 10:20 am revealed a lancet device left sitting in the horizontal drop slot of the sharps container along with a blood soiled alcohol prep pad. Observation of resident #68 and 70's room on 04/28/2025 at 10:38 am revealed a blood-stained alcohol prep pad sitting in the horizontal drop slot of the sharp's container. In an interview on 04/30/2025 at 12:19 pm with DON she said that any contents that were to be disposed of in the sharp's container were to be disposed of all the way inside the container. She stated that all staff were responsible for ensuring that there were no contents left sitting in the drop slot of the sharp's container. She stated that when contents were left in the reach of residents, this could pose a risk for residents getting a hold of items and injuring themselves. She stated that there was an in-service done recently on properly disposing contents in the sharp's container. In an interview on 04/30/2025 at 12:50 pm with LVN A she said that all contents were to be disposed of completely in the sharp's container. She stated that it was the responsibility of whoever was disposing of the items to make sure that they were placed all the way inside the container. She stated that if items were left in the reach of residents, they could be at risk for needle sticks and ingestion. In an interview on 04/30/2025 at 1:30 pm with administrator he said that sharps containers are used to dispose of hazardous items. He stated that contents are supposed to be disposed of completely inside the container. He stated that if items were left in the reach of residents, residents could get injured. Review of facility policy revised January 2012 and titled Sharps Disposal read in part The facility shall discard contaminated sharps into designated containers. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, for 1 of 3 nurse carts checked for medication storage. The facility failed to ensure liquid medication stored in the medication cart in one hall (300 hall) did not have dried drippings on the sides of the bottles. This failure could affect residents that received medications at the facility by placing them at risk of not having prescribed medications and cross contamination. The findings include: In an observation on 04/29/2025 at 10:49 AM, dried drippings were revealed on a Lactulose Solution liquid bottle and a ProHeal Liquid Protein bottle in the medication cart for 300 halls. LVN E stated the bottles were to be clean and no dried drippings were to be on medications. She stated nurses and medication aides were responsible for maintaining the medication cart and everything it contained, clean and organized. In an observation on 04/29/2025 at 10:49 AM, dried drippings were revealed on a Lactulose Solution liquid bottle and a ProHeal Liquid Protein bottle in the medication cart for 300 halls. LVN E stated the bottles were to be clean and no dried drippings were to be on medications. She stated nurses and medication aides were responsible for maintaining the medication cart and everything it contained, clean and organized. In an interview on 04/30/2025 at 12:15 PM with the DON she said that medication aides and nurses were responsible for maintaining cleanliness of the medication carts. She stated that staff were to clean their medication carts on a daily basis which included making sure medication bottles are free from dried drippings. The DON stated she and the ADON monitor medication carts once a week to make sure medications are clean. She stated the liquid medication bottles were to be clean after each use or when observed dirty. The DON stated the risks of medications having dried drippings on the bottle was a cross-contamination concern that can affect the residents. She stated a possible risk included residents can become ill. In an interview on 04/30/2025 at 12:34 PM with LVN A she said nurses were responsible for keeping medications in the medication carts clean. She stated nurses were to monitor their medication cart and medications it contained, clean once a shift and throughout their shift. She stated the DON monitors medication carts daily for compliance. She stated the risks of medications having dried drippings on the bottle included infection control concerns since it is unknown what the dried drippings residue contained. She stated this can place residents at risk for illness. In an interview on 04/30/2025 at 2:03 PM with the ADON she said nurses and medication aides were responsible for the medication bottles' cleanliness. The ADON stated the afternoon and night shift nurses were given the task to review medication carts for cleanliness including medication bottles, since there were less medications to administer at those times. She stated the DON, and the Weekend Nurse Supervisor monitor medication carts and ensure medications were being cleaned properly on a weekly basis. The ADON stated the risk for the residents being administered medications with dried drippings is a possible infection control concern. Record review of facility's policy, Storage of Medications, dated with revision date April 2007, read in part: The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The policy did not specify about medication bottle maintenance.

Based on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 2 of 22 residents (Resident #16 and #178). The facility failed to ensure resident call lights were within reach for 2 residents (Resident #16 and #178). This failure placed residents at risk of having their needs unmet when they are unable to contact staff. Findings included: Resident #16 Record review of Resident #16's face sheet dated 04/30/2025 revealed Resident #16 was originally admitted to facility on 02/10/2016 and readmitted on [DATE]. Record review of Resident #16's History and physical dated 05/08/24 revealed a [AGE] year-old female diagnosed with vascular dementia. Record review of Resident #16's Quarterly MDS dated [DATE] revealed Resident #16's BIMS score was 02 indicating severe cognitive impairment. Resident needed Extensive assistance with bed mobility, transfers and toileting (resident involved in activity; staff provide weight bearing support). Record review of Resident #16's care plan reviewed on 04/05/24 revealed she was at risk for falls, and interventions included to ensure call light is available to resident. An observation on 04/28/25 at 10:15 a.m., revealed Resident #16's call light was pinned between two pillows that she was laying on top of. Resident #178 Record review of Resident #178's face sheet dated 04/30/2025 revealed a [AGE] year-old male that was admitted to facility on 04/03/2025. Record review of Resident #178's medical diagnosis list revealed, Resident #178 was diagnosed with cognitive communication deficit, and unspecified dementia. Record review of Resident #178's Quarterly MDS dated [DATE] revealed no BIMS score. Resident was dependent( helper does all the effort) for toileting , bed mobility and transfers Record review of Resident #178's care plan dated 04/05/2025 revealed he was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/ comprehension, unaware of safety needs. Interventions included to ensure call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. An observation on 4/28/25 at 10:05 a.m., revealed Resident #178's call light was on the floor next to the head of the bed, while he was sleeping in bed. In an interview on 04/30/2025 at 12:19 p.m., with the DON she said the call lights were for patients to be able to call for assistance. She stated call bells should be kept within residents' reach. She stated the CNA's, nurses and overall, all staff were responsible for ensuring residents call lights were within reach. She stated that if call lights were not kept within residents' reach, then residents could possibly not be able to call for help when needed. She stated that an Inservice for call lights was done recently. In an interview with LVN A on 04/30/2025 at 12:50 p.m.,she said that the call lights were supposed to be within reach of all residents. She stated that all staff were responsible for ensuring call lights were within reach of residents. She stated that residents were rounded every 2 hours and as needed. She stated that if the call lights were not within reach of the resident, residents could sustain a fall, or they would not be able to call for help. She stated that the facility was always providing in-services regarding call lights, and she stated that the most recent was at the beginning of April 2025. In an interview with CNA B on 4/30/25 at 1:00 p.m, she said that call lights were for residents to use to call for assistance and for staff to attend to them as soon as possible. She stated that call lights were to always be in reach of the resident. She stated that CNAs and nurses were responsible for ensuring call lights were always within reach for the residents. She stated that if call lights were not within reach, it could delay care and could result in a resident sustaining a fall. She stated that the facility was constantly conducting in-services on keeping call lights within reach and answering them in a timely manner, but she could not remember the most recent one. Review of facility policy dated September 2022 and titled Call System, Resident read in part Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

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, the comprehensive person-centered care plan for 3 (Resident #7, Resident #10 and Resident #11 ) of 5 residents reviewed for wounds. The facility failed to provide wound care for Resident #7's arterial wound (arterial ulcers, are painful injuries in your skin caused by poor circulation) of the right second toe. The facility failed to provide wound care for Resident #10's pressure wound to the right second toe. The facility failed to provide wound care for Resident #11's dehiscence wound right forefoot. This failure could affect others by placing them at risk of potential medical complications related to wounds. Findings included: Resident #7 Record review of Resident #7's face sheet dated 02/06/25, revealed, admission on 08/19/24 and re-admission on 01/23/25 to the facility. Record review of Resident #7's hospital history and physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with history of right big toe osteomyelitis (infection of the bone) and having it amputated, heart failure, and myocardial infarction (a condition where blood flow to the heart muscle is blocked, leading to damage or death of heart tissue). Record review of Resident #7's quarterly MDS dated [DATE], revealed, no BIMS score was taken to measure the cognition of the resident. Resident #7 was diagnosed with Diabetes Mellitus and Osteomyelitis. Resident #7 was coded for risk of pressure ulcers/injuries. Treatments coded were pressure reducing device for chair, reducing device for bed, and applications of ointments/medications. Record review of Resident #7's Order Recap dated 01/08/25, revealed, arterial wound of the right second toe. Cleanse wound with NS or wound cleanser. Pat dry with 4 by 4-inch gauze. Apply betadine (a topical antiseptic that provides infection protection against a variety of germs for minor cuts, scrapes, and burns) to eschar (a dry, black or brown crust of dead tissue that forms on the surface of a burn, ulcer, or other wound) area. Cover with kerlix (a brand of gauze bandage roll used to protect wounds) and secure with cloth tape. One time a day related to other acute osteomyelitis, other site. Record review of Resident #7's care plan dated 12/06/24, revealed, presented with arterial wound of the right second toe 1cm by 1 cm by 0.3 cm. Provide wound care per treatment order. Record review of Resident #7's Administration Report dated 01/01/25-01/31/25, revealed, wound care was not provided on 01/11/25 and 01/25/25. Review of the Administration Report dated 12/01/24-12/31/24, revealed, wound care was not provided on 12/02/24, 12/03/24, 12/07/24, 12/22/24, 12/27/24, 12/28/24, 12/29/24. Resident #10 Record review of Resident #10's face sheet dated 02/06/25, revealed, admission on 02/10/16 and re-admission on 02/01/22 to the facility. Record review of Resident #10's hospital history and physical (was in the facility system) dated 05/24/23, revealed, a [AGE] year-old female (age was updated to reflect 2025) diagnosed with Atherosclerosis (a chronic disease that affects the arteries, causing them to become narrowed and hardened) and hypertension (a condition where the blood pressure in the arteries is persistently elevated above normal levels). Record review of Resident #10's quarterly MDS dated [DATE], revealed, a BIMS score of 2 and severely impaired cognition to be able to recall or make daily decisions. Resident #10 was coded for risk of pressure ulcer/injuries. Treatments were pressure reducing device for chair, reducing device for bed, applications of ointments/medications. Record review of Resident #10's Order Recap dated 10/30/24, revealed, right second toe wound. Cleanse with NS. Apply collagen/silver sheet. Cover with 4 by 4-inch gauze. Secure with cloth tape one time a day related to abrasion to right lower leg. Record review of Resident #10's care plan dated 12/10/24, revealed, an arterial wound of the right second toe 1.2cm by 1.2cm. Measure ulcer on at regular intervals and monitor ulcer for signs of infection. Record review of Resident #10's Administration Report dated 12/01/24-12/31/24, revealed, wound care was not provided on 12/02/24, 12/03/24, 12/07/24, 12/08/24, 12/14/24, 12/22/24, 12/27/24, 12/28/24, 12/29/24. Review of the Administration Report dated 01/01/25-01/31/25, revealed, wound care not provided on 01/03/25, 01/11/25, 01/18/25, 01/19/25, 01/25/25. Review of the Administration Report dated 02/01/25-02/28/25, revealed, wound care not provided on 02/01/25. Resident #11 Record review of Resident #11's face sheet dated 02/06/25, revealed, a [AGE] year-old female diagnosed with traumatic amputation of one left lesser toe and right lesser toe disruption of wound, pressure chronic ulcer of other part of left foot, Atherosclerosis of native arteries of right leg with ulceration of other part of foot, open wound to right foot, pressure ulcer of elbow stage 3, Diabetes. admission on 03/30/21 and re-admission on 08/18/24 to the facility. Record review of Resident #11's quarterly MDS dated [DATE], revealed, there was no BIMS score conducted to measure the cognition for Resident #11. Resident #11 was coded for risk of pressure ulcer/injuries. Treatments were to use pressure reducing device for chair, reducing device for bed, and surgical wound care. Record review of Resident #11's Order Recap dated 01/29/25, revealed, right forefoot dehiscence wound. Cleanse with NS. Pat dry with 4 by 4-inch gauze. Apply betadine to the area and cover with kerlix. Secure with cloth tape. Record review of Resident #11's care plan dated 12/06/24, revealed, a post-surgical dehisced wound of the right second toe 1cm by 1cm by 1.5cm. Provide wound care per treatment order. Record review of Resident #11's Administration Report dated 12/01/24-12/31/24, revealed, wound care was not provided on 12/02/24, 12/03/24. Review of the Administration Report dated 01/01/25-01/31/25, revealed, wound care was not provided on 01/08/25, 01/09/25, 01/10/25, 01/11/25, 01/12/25. Review of the Administration Report dated 02/01/25-02/28/25, revealed, wound care was not provided on 02/02/25. Observation and interview on 02/05/25 at 2:45 PM, with the Treatment Nurse, she stated the facility had been having issues for several months with wound care not being provided on the weekends. The Treatment Nurse stated she, and the EX -DON were providing in-services and education on providing wound care. The Treatment Nurse stated she had created a binder with the residents who needed to have wound care done for each hallway nurse that was broken down to make it easy for them. The Treatment Nurse stated even with that they were still having issues with wound care. The Treatment Nurse stated she had reported it to the ADON and the Administrator who asked her for a list of residents and that they would follow up with those residents. The Treatment Nurse stated she had not seen anything being done by the Administrator and keeps reporting it in the morning meetings. The Treatment Nurse stated she had been letting them know every Monday and has to go back to re-check all the residents' wounds. The Treatment Nurse stated she had not seen any of the wounds from the residents getting worse. The Treatment Nurse stated on 02/01/25-02/02/25, wound care was not provided for Resident #7 and Resident #11 from 200 hall. The Treatment Nurse stated in the facility system it would let the nurse know when it was time to give the wound care as it comes up green and if it was not completed it would turn red. It was observed on the facility system that Resident #7 and Resident #11 were all red. During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated that yesterday (02/05/25) the facility did an audit and found the same concerning trend to be found with the residents in 400 hall. The ADON stated the only hall to provide wound care for the weekend (02/01/25-02/02/25) was 300 hall. The ADON stated it has been a battle for the pasted couple of months (3) with not having wound care being provided for the residents at the facility. The ADON stated the Treatment Nurse created a binder and divided it between the halls so it would make it easier for the assigned nurses to complete wound care. During an interview on 02/06/25 at 11:22 AM, with CNA C, she stated she did not observe wound care being conducted on the weekend (02/01/25-02/02/25). During an interview on 02/07/25 at 9:47 AM, with LVN G, she stated there have been times she was not able to complete all the wound cares for the residents. LVN G stated she had passed it on in report to the other oncoming nurse but did not verify later on to see if it had been completed. During an interview on 02/07/25 at 10:39 AM, with the Wound Care Doctor, he stated he was not informed of residents missing wound care. The Wound Care Doctor stated the Treatment Nurse has mentioned some issues but did not tell him the details of those issues. The Wound Care Doctor stated the nurses were to be providing wound care. The Wound Care Doctor stated these issues had not been brought to his attention especially major lapses with wound care. The Wound Care Doctor stated he should have been informed of any missed wound care or changes to significant changes. The Wound Care Doctor stated the risk of deterioration, infection, or necrosis(a type of cell death that occurs when cells are irreversibly damaged and lose their normal functions). During an interview on 02/10/25 at 11:45 AM, with Interim-DON, he stated the Treatment Nurse was to be providing wound care during the weekdays and the nurses on the weekends since there was no Treatment Nurse working. The Interim-DON stated not doing wound care could have a negative effect on the resident where the wound could get worse or infected. The Interim-DON stated he was not notified that wound care was not being provided on the weekends and if known he would have taken action immediately. The Interim-DON stated it should have been expected that the nurses notify him that wound care was not being done. Record review of the facility Skin policy dated 07/22, revealed, A Pressure Injury Prevention Care Plan will be completed by the Treatment Nurse or Charge nurse and interventions implemented for all Residents based upon the Braden Scale score in conjunction with clinical judgement and review of other risk factors. An updated Pressure Injury Prevention Care Plan will be completed upon a change in Braden Scale score or a change in condition. The Director of Nursing or designee will audit and verify system compliance weekly including prevention-focused rounding and education as appropriate. Rounding will be completed by the Charge Nurse, Treatment Nurse and Nurse Manager for observations of pressure sore prevention, including, but not limited to best practices such as off-loading, turning and repositioning. The Quality of Assurance and Performance Improvement Review will include the findings from random audits of documentation completion: Physician Orders, Pressure Injury Care Plan, Non-Pressure Injury Care Plan.

Based on observation, interview, and record review the facility failed to ensure a resident receives care to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 5 residents reviewed for pressure ulcers/wounds. The facility failed to provide wound care for Resident #3's pressure ulcer stage 3 to the left buttock on 02/01/25 and 02/02/25. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings include: Resident #3 Record review of Resident #3's face sheet dated 02/05/25, revealed, admission on 01/30/25 to the facility. Resident #3 discharged on [DATE] Record review of Resident #3's hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer. Record review of Resident #3's admission MDS dated [DATE], revealed, no impairment in cognition with a BIMS score of 13 and the resident was able to recall and make daily decisions. Resident #3 was coded for risk of pressure ulcers and unhealed pressure ulcers. Resident #3 was coded for stage 3 pressure ulcer. Resident #3 was to have pressure reducing devices for chair, for bed, turning/repositioning program, pressure/ulcer/injury care, applications of ointments/medications, and hydration interventions. Record review of Resident #3's Skin Issues Assessment generated by the Wound Care Nurse dated 01/30/25, revealed, left gluteus/ buttock pressure ulcer/ injury stage 3, 9 cm by 3.5 cm by 0.2 cm. Record review of Resident #3's Order Recap dated 01/30/25, revealed, left buttock stage 3 pressure wound. Cleanse with NS and pat dry with a 4 by 4-inch gauze. Apply collagen powder to the wound bed granulated tissue. Cover with foam border dressing. One time a day related to Pressure Ulcer of Other site, Unstageable. - Order dated 01/30/25, revealed nursing Intervention: Turn and reposition every hour every shift. Record review of Resident #3's Administration Report dated 02/01/25-02/28/25, revealed, wound care was not completed for 02/01/25 and 02/02/25 for Resident #3. Record review of Resident #3's progress notes for 02/01/25-02/02/25, revealed, there was no nursing note indicating if wound care was provided or not. During an interview on 02/05/25 at 1:18 PM, with Resident #3's Family member, she stated that wound care was not being done during the weekend as Resident #3 still had the same dressing on since his arrival to the facility. During an interview on 02/05/25 at 1:50 PM, with LVN B, she stated the family member had informed her that Resident #3 had a bad weekend. LVN B stated the family member had mentioned that Resident #3 did not have wound care done on the weekend (02/01/25-02/02/25). LVN B stated she checked if Resident #3 had wound care done on the weekend and confirmed it had not been done. LVN B stated that there was not a Wound Care Nurse on the weekend, but all nurses were able to provide wound care. LVN B stated the weekend nurses were responsible for providing wound care. LVN B stated the risk of not providing wound care could be the wound getting worse or infection. interview on 02/05/25 at 2:45 PM, with the Treatment Nurse, she stated she provided wound care during the weekdays and on the weekends, the nurses were to be providing the wound care. The Treatment Nurse stated the nurses on the weekend would be able to provide wound care for those residents needing wound care. The Treatment Nurse stated Resident #3 had not had his wound care done on 02/01/25 and on 02/02/25. The Treatment Nurse stated the negative outcome could be a delay in the wound in healing. During an interview on 02/05/25 at 3:09 PM, with the Social Worker, she stated the staff was not assisting as they should be with Resident #3. The Social Worker stated the family member felt Resident #3 was not getting the correct wound care treatment. During an interview on 02/05/25 at 3:29 PM, with LVN A, she stated wound care was being provided for Resident #3 on 02/01/25-02/02/25. LVN A stated she had forgotten to document that wound care was provided for Resident #3. LVN A stated she had looked at the MARs earlier that day for Resident #3's orders for wound care and remembered it. LVN A stated from what she remembered she went ahead and conducted the wound care later on in the day without looking at the wound care orders. LVN A stated she forgot to document it on the facility system. LVN A stated she was trained to look at the orders and would look at them earlier in the day and then would give treatment. LVN A stated the risk of not conducting wound care could be a risk of infection. During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated wound care was supposed to be done as ordered. The ADON stated during the weekday the Treatment Nurse conducts the wound care and on the weekend the nurses are able and have to do the wound care. The ADON stated that nurses are trained to look at the orders while gathering the supplies for the wound treatment and cannot be looking at the orders earlier in the day and doing the wound treatment without looking to verify the orders. The ADON stated the risk would be a decline in the resident's condition. During an interview on 02/06/25 at 8:42 PM, with LVN F, she stated she did not provide wound care when she worked the weekend because she was busy doing other things. LVN F stated there could be a negative outcome of not providing wound care which would depend on the situation of the resident. Observation and interview on 02/05/25 at 2:45 PM, with the Treatment Nurse, she stated the facility had been having issues for several months with wound care not being provided on the weekends. The Treatment Nurse stated she, and the EX-DON were providing in-services and education on providing wound care. The Treatment Nurse stated she had created a binder with the residents who needed to have wound care done for each hallway nurse that was broken down to make it easy for them. The Treatment Nurse stated even with that they were still having issues with wound care. The Treatment Nurse stated she had reported it to the ADON and the Administrator who asked her for a list of residents and that they would follow up with those residents. The Treatment Nurse stated she had not seen anything being done by the Administrator and keeps reporting it in the morning meetings. The Treatment Nurse stated she had been letting them know every Monday and has to go back to re-check all the residents' wounds. The Treatment Nurse stated she had not seen any of the wounds from the residents getting worse. The Treatment Nurse stated on 02/01/25-02/02/25, wound care was not provided for Resident #3 and other residents from 200 hall. The Treatment Nurse stated in the facility system it would let the nurse know when it was time to give the wound care as it comes up green and if it was not completed it would turn red. During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated that yesterday (02/05/25) the facility did an audit and found the same concerning trend to be found with the residents in 400 hall. The ADON stated the only hall to provide wound care for the weekend (02/01/25-02/02/25) was 300 hall. The ADON stated it has been a battle for the pasted couple of months (3) with not having wound care being provided for the residents at the facility. The ADON stated the Treatment Nurse created a binder and divided it between the halls so it would make it easier for the assigned nurses to complete wound care. During an interview on 02/06/25 at 11:22 AM, with CNA C, she stated she did not observe wound care being conducted on the weekend (02/01/25-02/02/25). During an interview on 02/07/25 at 9:47 AM, with LVN G, she stated there have been times she was not able to complete all the wound cares for the residents. LVN G stated she had passed it on in report to the other oncoming nurse but did not verify later on to see if it had been completed. During an interview on 02/07/25 at 10:39 AM, with the Wound Care Doctor, he stated he was not informed of residents missing wound care. The Wound Care Doctor stated the Treatment Nurse has mentioned some issues but did not tell him the details of those issues. The Wound Care Doctor stated the nurses were to be providing wound care. The Wound Care Doctor stated these issues had not been brought to his attention especially major lapses with wound care. The Wound Care Doctor stated he should have been informed of any missed wound care or changes to significant changes. The Wound Care Doctor stated the risk of deterioration, infection, or necrosis(a type of cell death that occurs when cells are irreversibly damaged and lose their normal functions). During an interview on 02/10/25 at 11:45 AM, with Interim-DON, he stated the Treatment Nurse was to be providing wound care during the weekdays and the nurses on the weekends since there was no Treatment Nurse working. The Interim-DON stated not doing wound care could have a negative effect on the resident where the wound could get worse or infected. The Interim-DON stated he was not notified that wound care was not being provided on the weekends and if known he would have taken action immediately. The Interim-DON stated it should have been expected that the nurses notify him that wound care was not being done. Record review of the facility Skin policy dated 07/22, revealed, A Pressure Injury Prevention Care Plan will be completed by the Treatment Nurse or Charge nurse and interventions implemented for all Residents based upon the Braden Scale score in conjunction with clinical judgement and review of other risk factors. An updated Pressure Injury Prevention Care Plan will be completed upon a change in Braden Scale score or a change in condition. The Director of Nursing or designee will audit and verify system compliance weekly including prevention-focused rounding and education as appropriate. Rounding will be completed by the Charge Nurse, Treatment Nurse and Nurse Manager for observations of pressure sore prevention, including, but not limited to best practices such as off-loading, turning and repositioning. The Quality of Assurance and Performance Improvement Review will include the findings from random audits of documentation completion: Physician Orders, Pressure Injury Care Plan, Non-Pressure Injury Care Plan.

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 resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 of 6 residents (Resident #3) reviewed for baseline care plan. Resident #3 did not have a baseline care plan developed within 48 hours of admission that addressed his services that were being provided. This failure could place newly admitted residents at risk of not receiving the care and services and continuity of care. Findings include: Record review of Resident #3's face sheet dated 02/05/25, revealed, admission on 01/30/25 to the facility. Record review of Resident #3's hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer. Record review of Resident #3's admission MDS dated [DATE], revealed, no impairment in cognition with a BIMS score of 13 and the resident was able to recall and make daily decisions. Resident #3 was coded for risk of pressure ulcers and unhealed pressure ulcers. Resident #3 was coded for stage 3 pressure ulcer. Resident #3 was to have pressure reducing devices for chair, for bed, turning/repositioning program, pressure/ulcer/injury care, applications of ointments/medications, and hydration interventions. Record review of Resident #3's Baseline Care Plan was reviewed on 02/05/25, revealed, Resident #3 did not have a baseline care plan generated nor a comprehensive care plan. During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated Resident #3 did not have a baseline care plan done and it should have been done on 01/31/25. The ADON stated she did not know why one was not done but it should have been done by the admitting nurse. The ADON stated the purpose of the baseline care plan was to instruct staff on how to care for the resident immediately on admission. The ADON stated the risk was the resident not getting the care and services needed. During an interview on 02/10/25 at 11:45 AM, with Interim-DON, he stated upon admission the admitting nurse should generate a baseline plan within 48 hours. The Interim-DON stated the nurse was responsible for creating the baseline care plan. The Interim-DON stated the purpose of a care plan was to better know how to take care of the resident. The Interim-DON stated it would have an impact on the care of the resident if a baseline care plan was not created. Record review of facility Assessments Policy dated 11/17, revealed, A baseline person center-care plan of care for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The baseline care plan must be initiated with 48 hours of admission (including re-admission). The care plan must include initial goals be based on admission orders, physician orders, dietary orders, therapy services, social services, and PASRR recommendations if applicable. The baseline care plan must be derived from the nursing assessment form, fall assessment, Braden assessment, bowel/bladder assessment, pain assessment and medication orders.

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 1 resident (Residents #3) of 4 reviewed for medication administration. The facility failed to administer on 02/01/25, to Resident #3's medication of Ciprofloxacin HCL oral tablet 500 mg which to given two times a day for infection and was not given in the morning. The facility failed to administer on 02/01/25, to Resident #3's medication of Sulfamethoxazole-Trimethoprim oral tablet 800-160 mg by mouth two times a day for infection and was not given in the morning. The facility failed to administer on 02/01/25 and on 02/02/25, to Resident #3's medication of Spironolactone oral tablet 25 mg by mouth one time a day for prophylaxis for both days. This deficient practice could place the residents at risk of not receiving medications as ordered by the physician. Findings included: Record review of Resident #3's face sheet dated 02/05/25, revealed, admission on 01/30/25 to the facility. Record review of Resident #3's hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer. Record review of Resident #3's admission MDS dated [DATE], revealed, no impairment in cognition with a BIMS score of 13 and the resident was able to recall and make daily decisions. Record review of Resident #3's Order Recap dated 01/30/25, revealed, Ciprofloxacin HCL oral tablet 500 mg to be given two times a day for infection. Review of order dated 01/30/25, revealed, Sulfamethoxazole-Trimethoprim oral tablet 800-160 mg by mouth two times a day for infection. Review of order dated 01/30/25, revealed, Spironolactone oral tablet 25 mg by mouth one time a day for prophylaxis. Record review of Resident #3's Administration Report dated 02/01/25-02/28/25, revealed, Ciprofloxacin was not given on 02/01/25. Sulfamethoxazole-Trimethoprim was not given on 02/01/25. On 02/01/25 and 02/02/25, Spironolactone was not given. Record review of Resident #3's Grievance/Complaint Report dated 02/03/25, revealed, Family member stated was not getting all his medications administered by the LVN A. Family member stated she had asked LVN A why and she did not give her an explanation as to why medications were not being given. During an interview on 02/05/25 at 1:18 PM, with Resident #3's Family member, she stated on the weekend she had asked LVN A if she was going to give Resident #3 his night medication and was told that the facility did not have his medications. The Family member stated that LVN B had told her on 02/03/25, that she had given Resident #3 his medication and that they had come from another city. During an interview on 02/05/25 at 1:50 PM, with LVN B, she stated that medications were not given for Resident #3 on 02/01/25-02/02/25 (weekend). LVN B stated she did not know why they were missed. LVN B stated it was expected for the nurses to be following physician orders. LVN B stated the nurses were responsible for ensuring the medications were given. LVN B stated the risk was infection or it was getting worse. During an interview on 02/05/25 at 3:29 PM, with LVN A, she stated Resident #3 was receiving his medications. LVN A stated if there were no medications available then the MA would have to let her know so that they could pull from the Nexus (a storage where extra medications are kept). LVN A stated not getting the medications could throw the body out of [NAME] (out of balance or unaligned in some way). During an interview on 02/06/25 at 8:56 AM, with the ADON, she stated it was not reported to her that medications were not being given. The ADON stated the MAs are to be reporting to the nurses if there are not medications and the nurses are to be reporting to the physician if there are not medications on hand. The ADON stated the risk would be a decline in the resident. During an interview on 02/06/25 at 8:08 PM, with MA D, she stated LVN A had told her they did not have access to the Nexus to pull medication from it. MA D stated that Resident #3 was given whatever medications they had on hand and whatever they did not have was not given. MA D stated she was unaware if the physician was notified due to the nurses handling it. MA D stated there could be a risk which depended on the situation. During an interview on 02/06/25 at 8:17 AM, with MA E, she stated Resident #3 did not have medications on the weekend (02/01/25-02/02/25) and had informed LVN A about the medication issue. MA E stated on 01/31/25 and 02/01/25 medications were being pulled from other residents to give to Resident #3. MA E stated she pulled from several residents from among the whole facility. MA E stated they were not able to borrow medications. MA E did not indicate what the risk would be. During an interview on 02/06/25 at 8:42 PM, with LVN F, she stated nursing staff should not be borrowing medication from other residents. LVN F stated the medications are prescribed to someone and giving it to someone else could have an effect on that resident receiving more medication. LVN F stated the risk for Resident #3 since he had blood pressure medications could be his blood pressure goes high. LVN F stated it would also be a medication error. During an interview on 02/07/25 at 9:47 AM, with LVN G, she stated she had not encountered any issues with medications. LVN G stated she has not borrowed any medications from other residents to give to a resident. LVN G stated the risk for borrowing medications was not knowing how a resident would respond and it could exhaust the medications from the residents they borrowed from. During an interview on 02/07/25 at 11:09 AM, with NP, he stated he had not received reports of medications not being available for the residents. The NP stated the nursing staff should not be borrowing medications from other residents to give. The NP stated if the resident had prescribed medications, then he was covering the cost of that medication. The NP stated everything must be properly documented. The NP stated residents should be receiving their pre-approved package of medications. The NP stated that it was concerning that this process was not being followed. The NP stated not giving the medication could have serious consequences. The NP stated if the facility had switched pharmacies and did not have the medication then they should have called them immediately. The NP stated in cases like this they could have provided an alternative medication or found a solution. During an interview on 02/08/25 at 10:04 AM, with LVN A, she stated that she had not instructed anyone to be borrowing medications from other residents. LVN A stated it was against the law and they could not do that. During an interview on 02/10/25 at 11:45 AM, with Interim-DON, he stated medications are to be taken as prescribed by the physician orders. The Interim-DON stated all orders have to be followed and not following the order could have a negative effect on the resident. The Interim-DON stated the risk would depend on the resident's situation and medication given. The Interim-DON stated it was not okay to be borrowing medications from other residents. The Interim-DON stated the risk of borrowing medications could be side-effects. Record review of the facility Administrating Medications Policy dated 04/19, revealed, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. The individual administrating medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. If a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for 1 (Resident #3) of 3 residents reviewed for discharges. The facility failed to ensure Resident #3 had a safe discharge when he left AMA to his home. This failure could place residents at risk of inappropriate transfers and diminished continuity of care. Findings included: Record review of Resident #3 ' s face sheet dated 02/05/25, revealed, admission on 01/30/25 to the facility. Record review of Resident #3 ' s hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer. Record review of Resident #3 ' s admission MDS dated [DATE], revealed no impairment in cognition with a BIMS score of 13 and the resident was able to recall and make daily decisions. Resident #3 was coded for risk of pressure ulcers and unhealed pressure ulcers. Resident #3 was coded for stage 3 pressure ulcer. Resident #3 was to have pressure reducing devices for chair, for bed, turning/repositioning program, pressure/ulcer/injury care, applications of ointments/medications, and hydration interventions. Resident #3 was occasionally urinary incontinent and frequently bowel incontinent. Record review of Resident #3 ' s Skin Issues Assessment generated by the Wound Care Nurse dated 01/30/25, revealed, left gluteus/ buttock pressure ulcer/ injury stage 3, 9 cm by 3.5 cm by 0.2 cm. Record review of Resident #3 ' s Order Recap dated 01/30/25, revealed, left buttock stage 3 pressure wound. Cleanse with NS and pat dry with a 4 by 4-inch gauze. Apply collagen powder to the wound bed granulated tissue. Cover with foam border dressing. One time a day related to Pressure Ulcer of Other site, Unstageable. Order dated 01/30/25, revealed nursing Intervention: Turn and reposition every hour every shift. Record review of Resident #3 ' s Grievance/Complaint Report dated 02/03/25, revealed, that the Admission Coordinator started the grievance/complaint report and then was passed to the Social Worker to follow up with. It was noted that No wound care had been given on bed sores, the family was having to conduct incontinence care, and medications were not being given. Review of the Grievance/Complaint Report revealed, there was no follow-up mentioned on the facility follow up or the resolution of what the facility was going to do with wound care not being provided for Resident #3, incontinence care, and medications not being given. During an interview on 02/05/25 at 1:50 PM, with LVN B, she stated she came in Monday morning (02/03/25) and was informed that Resident #3 wanted to be transferred to another facility. LVN B stated the family member had informed her that Resident #3 had a bad weekend. LVN B stated she was not informed by the family member nor Resident #3 on what the concerns were. LVN B stated on 02/04/25 that the family member went to the nurse ' s station and requested the AMA form and signed out Resident #3. LVN B stated she helped put Resident #3 in the car and off he went. LVN B stated she informed the NP who responded with what happened. During an interview on 2/5/25 at 4:03 pm, the ADON stated that the Social Worker knew that Resident #3 was going home, but they (nursing department) themselves had not been informed. The ADON stated that during this time, they had been trying to get in contact with the facility where Resident #3 was supposed to be discharged . The ADON stated that APS should have been called due to the home not being a safe discharge option, considering the clinical care Resident #3 required. During an interview on 02/05/25 at 4:36 PM, with the Social Worker, she stated that she would need to review the policy to determine whether the facility was required to call and confirm if the resident arrived at the facility or home safely. The Social Worker stated that it did not appear that the policy required such a call. The Social Worker stated that Resident #3 ' s family member had informed them that she was going to take him home. The Social Worker stated that if the resident required skilled services, particularly wound care, it would need to be assessed whether his home was a safe and appropriate environment for him. The SW stated that they would refer this matter to the nursing team. The Social Worker stated that it had been one day since Resident #3 ' s discharge, and they had not yet discussed the situation with the nurse. The SW stated that the reason for not discussing it with the nurse was that they had planned to ask whether the resident ' s wound required consideration for continued care. The SW stated that they were unsure if the wound care nurses were present at the time. The SW stated that a referral to Adult Protective Services (APS) would be made if necessary. The SW stated that they needed to consult with nursing staff to determine if a referral was required. The SW stated that, within the past 24 hours, there had been no discussion to determine whether the home was an appropriate setting for Resident #3 or if APS needed to be contacted. During an interview on 2/7/25 at 11:09 am, the NP stated when the resident left AMA, he was initially informed only that he had left. It wasn ' t until later that he was told the reasons behind his departure. The NP stated he should have been notified that Monday (2/3/25) when the facility became aware of issues such as wound care not being completed, medications not being administered, and incontinence care concerns. The NP stated he should have been informed the day the patient left AMA. At that point, they could have spoken with Resident #3, assessed the situation, and potentially found a resolution. The NP stated that waiting to notify him until after the fact limited the options for intervention. The NP stated when a resident leaves AMA, it is ultimately their decision. The NP stated he strongly believed that any resident choosing to leave against medical advice should have the opportunity to speak with their provider before signing the discharge form. The NP stated that conversation could help assess risks and explore alternatives. During an interview on 2/10/25 at 11:01 am, the Administrator stated that if a resident left Against Medical Advice (AMA), the decision to call APS would depend on the patient ' s situation. The Administrator stated that APS was contacted, but they did not know the exact date it was done but it had not been completed at the time of AMA. The Administrator stated that concerns about the SW ' s performance required a Performance Enhancement Plan (PEP). The Administrator stated that the concerns regarding the SW were consistent across various situations. Record review of the facility ' s Discharging a Resident without a Physician ' s Approval Policy dated 10/22, revealed, A physician ' s order was obtained for discharges, unless a resident or representative was discharging himself or herself against medical advice. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will: discuss with the resident, (and or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that was not equipped to meet his/her needs and attempt to ascertain why the resident was choosing that location. Determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect was necessary. The referral should be made at the time of discharge.

Based on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 2 (Resident #2 and #3) of 6 residents reviewed for vehicle safety. -Maintenance Director failed to ensure Resident #2 and #3 were secured in the vehicle on 06/17/2024, while transporting residents back to the facility from dialysis visit, which resulted in falls with injuries. The noncompliance was identified as PNC. The IJ began on 06/17/2024 and ended on 06/18/2024. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of accidents and potential harm. Findings include: Resident #2: Review of Resident #2's Face Sheet dated 07/10/2024, revealed a [AGE] year-old female, with an admitted [DATE]. Resident #2's diagnoses included: weakness, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), end stage renal diseases (ESRD) (condition in which the kidneys lose the ability to remove waste and balance fluids), neuromuscular dysfunction of bladder (nerves and muscles don't work together very well causing lack of bladder control), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), unsteadiness on feet, pain, and history of falling. Review of Resident #2's quarterly MDS assessment dated [DATE], revealed resident had a BIMS score of 10 indicating moderate cognitive impairment. Section on Functional Abilities and Goals revealed Resident #2 with impairment to one side of the upper and lower extremities. Resident was dependent on staff assistance for oral hygiene, toileting, bathing, dressing, personal hygiene, and transfers. Review of Resident #2's comprehensive care plan dated 07/10/2024, revealed the resident is at risk for falls with injury related to weakness. Part of the interventions included, Uses wheelchair for long distance mobility; fall precautions. Review of Resident #2's physician orders dated 07/10/2024, reads in part an order for dialysis: Hemodialysis (treatment to filter wastes and water from your blood) every Monday, Wednesday, and Friday with transport time to dialysis at 1:00 p.m. Review of Resident #2's progress note dated 06/17/2024 at 7:03 p.m., written by LVN K reads while receiving oncoming report, this nurse received a phone call from facility driver that Resident #2 fell out of her chair onto the van floor while being transported back to the facility from dialysis. Driver unsure of any injury and called 911. The ambulance took resident to the hospital. An attempt to contact resident's RP was made with no success. Second RP was called and informed. Dr. and DON also notified. Review of Resident #2's progress note dated 06/18/2024 at 2:26 a.m., written by LVN K, reads (Resident #2) arrived back to the facility at 11:24 p.m., Her FM who was following the ambulance arrived approximately 5 minutes prior. She comes with a diagnosis of scalp hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) and closed right fibula (outer and usually smaller of the two bones between the knee and the ankle in humans) fracture. A script for Tylenol 325 mg x 2 by mouth every 4 hours for fever and pain came with her. Upon assessment it was noted the hematoma to the back of her head, right side. No discoloration but pain to touch. She also has a cast on her right leg from her knee down to toes. When asked she stated a little pain to head. Tylenol given. It was effective. Review of Resident #2's progress noted dated 06/18/2024 at 12:07 p.m., written by SW, reads met with resident at bedside. FM also in room. SW inquired with resident about her recollection regarding the events that transpired the previous day. Resident verbalized not recalling what had occurred. SW inquired if she recalled being transferred and she stated she does not recall anything. SW asked if she was comfortable, and she verbalized she was. SW asked FM if he had any questions or concerns, and FM declined having any questions or concerns at the time. SW notified FM of on-going investigation. SW offered the number to the Complaint and Incident Intake number and Local Ombudsman and FM declined, stating he already had the information. Record review of EMS run record dated 06/17/2024 for Resident #2, reads R19 arrived with P24 already on scene to a 74 YOF who had suffered a fall from a sitting position. Patient was found lying supine on the floor of a transport van, alert and oriented, with (FM) present. Patient had stated that she had just finished her dialysis treatment and was being transported back home, when the van had taken a sharp left turn heading up [street name], and the patient fell out of her wheelchair and hit the back of her head on the floor of the van. Patient reported that she does not take any blood thinners or aspirin and that she did not lose consciousness. Patient was assisted by P24 and R19 crew members out of the van and onto the stretcher. Patient was placed onto R19 for further evaluation and treatment. Patient was placed on oxygen at 4LPM via nasal cannula, as reported she is on constant O2 and her SpO2 did drop to the high 80s when off oxygen. Patient was AO x4, a small bump to the back of her head was found, no bruising or bleeding present with no complaints of pain anywhere and vitals in normal range. Patient was transported code 1 to the hospital. Patient transfer was given to the hospital anursing staff and R19 departed the facility. Record review of hospital records for Resident #2 dated 06/17/2024, reads Patient completed dialysis and was in the back of the van when the van took a hard turn and patient fell from wheelchair. There are no complaints from her, but scalp hematoma was found. Patient is here for evaluation. Lab results interpretation: CT scan of cervical spine without contrast with no acute findings in head or cervical spine. CT of brain without contrast with no acute findings in the head or cervical spine. Radiology of right tibia/fibula revealed, Distal (situated away from the center of the body or from the point of attachment) tibial (large bone at the front of the lower leg) fracture associated with proximal (situated nearer to the center of the body or the point of attachment) and distal fractures of the fibula (outer and usually smaller of the two bones between the knee and the ankle in humans). Severe generalized demineralization of bones. During an interview on 07/03/2024 at 11:01 a.m., Resident #2 said she did not remember what happened on 06/17/2024 while in the facility vehicle. Resident #2 does not remember any details of the incident including who was driving the vehicle, who else was in the vehicle, was she secured to the vehicle, where the incident occurred, or what happened after the incident. During an interview on 07/03/2024 at 11:05 a.m., Resident #2's RP and FM said on the day of the incident he was with Resident #2 during her dialysis visit. RP said the facility Maintenance Director arrived sometime around 5:30 p.m., to pick up Resident #2 and #3 to transport back to the facility. RP said he wheeled Resident #2 to the lift ramp of the vehicle and walked away to go to his truck. RP said he did not see how the driver secured the residents in the vehicle prior to departure. RP said he followed the facility vehicle. RP said that while at the intersection of two streets he observed the facility vehicle making a protected left turn and that it seemed that the vehicle was experiencing mechanical issues and the driver pulled over to park. RP said when he got off the truck to see if they needed assistance, he saw inside the van that both residents were on the floor. RP said he did not see any cars cutting off the van during the turn and from his perspective the van was not going fast. RP said when he walked up to the vehicle, he did not see any seatbelts on the residents and the residents had fallen to their right side. The RP said he observed the wheelchairs were upright. RP said Resident #2's head was leaning towards her right side and right leg was bent and left leg up on the armrest. The RP said Resident #3 was smaller than Resident #2 and he observed that Resident #3 was out of the wheelchair and lying on right side of head on floor. RP said the driver called 911 and emergency services showed up and assisted the residents to reposition, and then took both residents in ambulances. RP said the driver did not tell him anything about what happened. RP said Resident #2 had been transported in the vehicle regularly without any incident prior to the incident on 06/17/2024. Resident #3: Review of Resident #3's Face Sheet dated 07/03/2024, revealed a [AGE] year-old female, with an admitted [DATE]. Resident #3's diagnoses included: abnormalities of gait and mobility, end stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis, anxiety disorder (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and lack of coordination. Review of Resident #3's quarterly MDS assessment dated [DATE], revealed resident had a BIMS score of 13 indicating she was intact cognitively. Section on Functional Abilities and Goals revealed Resident #3 was dependent on staff assistance for transfers and uses a manual wheelchair. Resident #3 had not had any other falls since admission. Review of Resident #3's comprehensive care plan dated 07/03/2024, revealed the resident is at risk for falls. Part of the interventions included, Uses wheelchair for long distance mobility; fall precautions. Review of Resident #3's physician orders dated 07/10/2024, reads in part an order for dialysis: Hemodialysis three times a week with transport time to dialysis at 1:00 p.m. Review of Resident #3's progress note dated 06/17/2024 at 7:05 p.m., written by LVN L, reads Driver contacted facility to advise that residents were on their way back from dialysis and informed nurses that on a turn that resident fell and tipped over. Driver contacted 911, as there was a hematoma to patient's head. EMS on scene and resident to be transported to the hospital. FM has been notified as well as MD and DON. Review of Resident #3's progress note dated 06/18/2024 at 1:35 a.m., written by LVN L, reads Resident returned from the hospital at 12:30 a.m., Resident alert and currently voice no pain. Resident with facial bruising to left eye, abrasion to left leg. RN at hospital said CT scan done and clear with no abnormalities. Review of Resident #3's progress note dated 06/18/2024 at 12:04 p.m., written by the SW, reads Met with resident at bedside, family present. Female FM stepped out and male FM and resident remained in the room. SW inquired with resident about her recollection of the events that transpired the previous day. Resident reports she was being brought back home when a turn was made, and she tilted to the right side. SW inquired with resident if she had any other recollection and male FM interjected and stated she was not buckled in. SW asked male FM to allow resident to provide information. Resident then stated that she recalls driver doing something at the bottom of her wheelchair but states she was not buckled from the top. DON and Administrator notified. Record review of EMS run record dated 06/17/2024 for Resident #3, reads Rescue 25 found the patient lying prone inside of a van. Patient was a [AGE] year-old female complaining of pain to the right wrist and face. She sustained a hematoma to the left eyebrow as well as an abrasion to the left knee. Patient had completed dialysis and was on her way to facility. Patient states that she was a passenger inside of the van when the driver took a sharp turn and knocked the patient off of her seat onto the floor of the van. Patient was moved to the stretcher and loaded into rescue 25. Her vitals were assessed while en route to the hospital. Patient was transported to the hospital code one level three trauma. Patient was transferred over to hospital staff and rescue 25 left without incident. Record review of hospital records for Resident #3 dated 06/17/2024, reads Patient completed dialysis and was on the van. The van took hard turn and patient on wheelchair fell . Patient has facial bruises and complaining of left knee pain and right-hand pain. Pain level is 5/10 pain. Patient did not lose consciousness. Lab results interpretation: Radiology right hand with no definitive areas of acute bony injuries. Radiology of left tibia fibula with no acute bony injuries were demonstrated. Minimal degenerative changes left knee joint. CT scan of facial bones without contrast: impression left anterior frontal scalp hematoma and left periorbital (eyelid or skin around the eye) soft tissue swelling. No maxillofacial fracture. CT scan of brain without contrast: No acute intracranial hemorrhage. During an interview on 07/03/2024 at 9:58 a.m., DON said the Maintenance Director was a designated driver for the facility's only transportation vehicle. DON said the Maintenance Director would pick up residents who were out of the facility at appointments after 4:00 p.m. before the 6/17/2024 incident. DON said she received a call on 06/17/2024 around 6:00 p.m. from the Maintenance Director who had contacted 911 prior to calling the DON. DON said the Maintenance Director reported that he picked up Residents #2 and #3 from dialysis, and while traveling back to the facility, while he was turning the facility vehicle, a car was crossing, and he had to brake hard. The DON said Residents #2 and #3 were on their wheelchairs and fell out of their wheelchairs and onto the floor. DON said the Maintenance Director pulled over and called 911. DON said the residents were transported to the hospital by ambulance. DON said Resident #2 had a left distal tibial fracture. Resident #3 did not sustain any fracture but had scratches and bruises to her face. DON said the Maintenance Director returned to the facility without any passengers and left for the day. DON said she and the former Administrator conducted the investigation. DON said they interviewed the Maintenance Director, who said that he strapped the wheelchairs of the residents and secured them with the vehicle seatbelts. DON said Residents #2 and #3 were interviewed. DON said Resident #2 said she did not remember the incident and that she only remembers flying. DON said Resident #3 FM were very upset. DON said the SW interviewed Resident #3 and FM was present during the interview saying that she was not strapped in. DON said Resident #3 then agreed that she was not strapped in. DON said Maintenance Director was suspended two days and given written disciplinary action. DON said all drivers had to re-do driver competency with return demonstration. DON said there is one Facility Driver and three other designated drivers. DON said a decision was made that only the Facility Driver will drive residents to outside appointments, or they will call for an ambulance transportation. During an interview on 07/08/2024 at 10:13 a.m., Resident #3 said she was being picked up from dialysis by the Maintenance Director. Resident #3 said the Maintenance Director did not put a seatbelt on her. Resident #3 said it was only she, Resident #2, and the Maintenance Director in the vehicle. Resident #3 said while turning a corner she fell from her wheelchair to right side and hit her head. Resident #3 said she fell on her arm and had a bruise to her leg. Resident #3 said she told the driver that her arm was hurting, and he told her the ambulance was on the way. Resident #3 said she sustained facial injuries of a bump on her left eyebrow and bruises. Resident #3 said she did not remember if her wheelchair was secured or if it moved. Resident #3 said Resident #2 was behind her and fell as well. During an interview on 07/03/2024 at 12:10 p.m., Facility Driver said he was not present for the incident that occurred on 06/17/2024. Facility Driver said following the incident where residents had fallen, he is the only person who was authorized to drive the vehicle. He said that he had been the Facility Driver for several years and conducts training of other designated drivers. He said the former Administrator did not want him to work overtime and he would work until 2-2:30 p.m. He said that he arrives at work at 5:00 a.m., to drive residents to outside appointments. He said that the facility is now working on scheduling outside appointments within the time that he was scheduled to work, or he flexes his schedule to accommodate late evening appointments and pickups. He said that he inspected the vehicle on 06/18/2024 and found no mechanical issues with the equipment in the vehicle. He said that it was the neglect of the Maintenance Director who did not put the seatbelt on the residents. He said he trained the three other designated drivers and required that they performed a return demonstration around 3 months ago. He said that he had not experienced any issues with the securement devices while he had been driving. During an observation on 07/03/2024 at 12:20 p.m., Facility Driver was observed individually lifting three residents on the vehicle and securing each resident to go to an outside appointment. Facility Driver secured the frames of the wheelchairs with four-point anchors to the floor rail. He then secured residents by running a seatbelt across the residents and pulled each piece of equipment to ensure all belts and attachments were secured. There were no defects, or any other issues noted with vehicle equipment. Facility Driver found to be proficient at use of safety equipment. During an interview on 07/03/2024 at 2:00 p.m., the Maintenance Director said he had been in his position at the facility for two years. The Maintenance Director said he was a designated transporter up to 06/17/2024, in case of evacuations or emergencies. The Maintenance Director said he had been driving the facility vehicle for about a year without incident. The Maintenance Director said he was in-serviced on safe transportation by the Facility Driver back in July 2023. The Maintenance Director said the in-service covered the importance of buckling up residents, seatbelts, and putting on manual brakes. The Maintenance Director said he was trained to use floor anchors to secure the wheels and use the seatbelt that goes over the chest of passengers. He said there are two anchors used in front and two in the back that are attached to the frame of a wheelchair and adjusted to size. He said he was trained to double check to make sure the passenger was secured and there was no movement. The Maintenance Director said on 06/17/2024 during the evening he picked up Resident #2 and #3 from a dialysis appointment. He said he was driving about 30-40 MPH. He said that he waited at the intersection of two streets and waited for the protected left green light. He said that Resident #2's RP was following the vehicle. The Maintenance Director said the green light came on and he started turning left onto the farthest right lane of the three-lane road. He said he saw a white sedan facing the opposite direction that appeared to possibly turn into his lane. The Maintenance Director said he hit the brake and turned more left. He said he heard a hit on the floor and noticed that both Resident #2 and #3 fell to the right side. He said he stopped in the non-passing lane and called 911. He said that both wheelchairs were anchored to the floor. He said he could not explain what happened. He said he did not see any defects in the seatbelts or anchors. He said the seatbelts were off and he did not know if it was because of the hard braking. He said he was not in any rush to be anywhere. He said an ambulance arrived and they had to wait for a second ambulance. He said Resident #3 complained of pain to her arm and had a bump/bruise to her forehead. He said Resident #2's FM was present at the scene and that Resident #2 had landed on her back on the floor and had one of her legs stuck in the seatbelt. The Maintenance Director said after the residents were transported to the hospital he drove back to the facility. He said the following day the Facility Driver checked the van to make sure nothing snapped and re-in-serviced the Maintenance Director on properly securing passengers during transport having to do a return demonstration. The Maintenance Director said he then had to leave because he was suspended on 06/18/2024. He said he came back to the facility on [DATE] and had not driven the vehicle anymore. Review of vehicle manufacturer operation manual undated, reads in part, Safety belts must be worn by all occupants. Passengers can dramatically reduce their risk of being killed or seriously injured by wearing their safety belts. Organizations that own vans and wagons should have a written safety belt use policy. Drivers should be responsible for enforcing the policy. Review of the facility provided Safe Transportation policy dated 05/2023, reads in part When transportation is the responsibility of the facility, staff will assist in transporting, handling, and transferring individuals. The purpose of this policy is to ensure the safety of individuals served as well as staff during transportation and include the provisions for handling emergency situations. Interpretation: 1. Vehicles must meet federal, state, local and manufacturer's safety and mechanical operating and maintenance standards for the vehicle. The Administrator and/or Director of Maintenance will ensure the safety of vehicles equipment, supplies, and materials owned or leased by the company and will maintain these in good condition during times of providing services. 5) Before allowing transportation staff to drive unsupervised, transportation staff must be trained and able to demonstrate the following: Operation of wheelchair lift, restraining devices and other special equipment; passenger assistance and securement; awareness and handling of unsafe conditions, emergencies, and security threats; and procedures for reporting abuse and neglect. 6) Transportation staff will receive training on each individual's transferring or handling requirements for the individual and/or equipment prior to transferring or transporting individuals. All transfers and handling of individuals served will be done in a manner that ensures safe transportation, dignity, and privacy. 12) In accordance with state laws, anyone riding in a moving vehicle must wear seatbelts and/or child safety restraints. To this end, every vehicle used to conduct facility business shall have a safety belt installed for each seating position. No vehicle shall be operated while carrying more passengers than available safety belts. Each motor vehicle operator and all occupants shall be secured with the safety belt or child safety seat whenever the motor vehicle is under power or in motion. The driver of the vehicle shall ensure that each occupant is properly restrained before beginning any trip, regardless of the length or duration, until the motor is shut off. Under no circumstances will any person be allowed to drive, ride, or otherwise be transported without such devices in use. 17) Residents using wheelchairs will be transported according to manufacturer's safety guidelines. This includes, but is not limited to, safe operation and regular maintenance of lift equipment, checks of straps to secure the wheelchair to the floor of the vehicle, and use of adaptive seating equipment when appropriate. Transportation staff who are transporting residents and who complete tie-downs of wheelchairs will receive training on how to do so and will be required to demonstrate competency prior to transporting individuals using wheelchairs. Review of employee records revealed Maintenance Director was hired on 09/28/2022. On 07/06/2023 the Maintenance Director received competency training on being a Van Driver-Transporter PRN. Maintenance Director was found to be competent in numerous tasks to include administrative functions which included reporting all incidents such as falls and change of condition to the DON immediately; personnel functions, transportation functions, staff development, safety and sanitation which included following established safety regulations in use of equipment; equipment and supply functions, and resident rights. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: On 6/18/2024 Facility Maintenance Director given disciplinary action of write up with two-day suspension. Review of employee timecard verified that employee was suspended 6/18/2024 and did not return to work until 6/24/2024. On 6/18/2024 Driver competencies were performed for one Facility Driver and three other staff members designated as drivers. On 6/18/2024 Facility restrictions put in place regarding who was able to drive residents on the vehicle allowing only the Facility Driver to drive residents. On 6/18/2024 Facility Driver verified functionality of seatbelt and safety straps finding no defects. On 6/18/2024 Facility in-service on teaching additional drivers properly how to strap residents on the wheelchairs to van when transporting. On 06/18/2024 Facility in-service on and abuse and neglect. After entry of investigator on 07/03/2024: Random sample residents (Resident #10, #12, #13, and #14) who had been transported by the facility vehicle were interviewed. Resident #10 was interviewed on 07/10/2024 at 8:59 a.m., Resident #12 as interviewed on 07/10/2024 at 8:54 a.m., Resident #13 was interviewed on 07/10/2024 at 9:02 a.m., and Resident #14 was interviewed on 07/10/2024 at 9:06 a.m. None of the residents reported any concerns with being secured when being transported in the vehicle. None of the residents reported any fall or near fall incidents in the vehicle. On 07/03/2024, observation made of Facility Driver performance on using securement safety devices in the vehicle. There was no evidence of any defects of safety equipment. Facility Driver found to be proficient at use of safety equipment.

Based on observation, interview and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 14 residents reviewed for neglect in that: Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A who was responsible for Resident #1 did not know the process and procedures that were to be followed when a full-code resident was found unresponsive, resulting in the resident not being provided CPR. An IJ was identified on [DATE] at 10:25 AM. The IJ template was provided to the facility on [DATE] at 10:25 AM. While the IJ was removed on [DATE] at 6:55 PM the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm, because all staff had not been trained on Emergency Response Procedure and Calling a Code. These failures could place residents at risk for serious injury, hospitalization and/or death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged on [DATE] due to death in the facility. The face sheet did not indicate his code status. Record review of Resident #1's history and physical dated [DATE] revealed he had diagnoses including coronary artery disease (damage or disease of the hearts major blood vessels), osteomyelitis (infection in the bone), Diabetes mellitus with hyperglycemia (Diabetes with high blood sugar), hypertension (high blood pressure, vascular dementia (dementia caused by blood clots in the brain) and hemiparesis affecting left side as late effect of cerebrovascular accident (Stroke affecting his left side). Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 8 (moderate cognitive impairment). He had symptoms of delirium including fluctuating periods of inattention and disorganized thinking. He had symptoms of psychosis including hallucinations (seeing something that is not actually there). He had no symptomatic behaviors. He was dependent on staff for toileting, bathing, dressing, personal hygiene, sitting up, and transferring between surfaces. Record review of Resident #1's care plan dated [DATE] revealed he was a full code status, that the facility would honor his wishes regarding code status and attempt to resuscitate him should arrest occur. His physician would be contacted, emergency services would be notified, and family would be notified. Record review of Resident #1's physician's orders dated [DATE] revealed no orders concerning his code status. Record review of Resident #1's Advance Directives information in his electronic record accessed [DATE] revealed his CPR (Resuscitation) Status was Attempt CPR. Record review of Resident #1's progress note dated [DATE] at 10:53 AM by RN A documented the following Resident found unresponsive by this nurse, initially attempted vitals but was unsuccessful, CPR initiated immediately, code cart brought to room, AED in place with commands initiated, 911 called, CPR continued till EMS arrived and took over. DON, Administrator, and MD notified. Family called and updated. All questions and concerns addressed. Record review of the fire department's Hospital Care Report for Resident #1 dated [DATE] beginning at 7:55:12 AM revealed that paramedics were dispatched to the facility at 7:56 AM and arrived at the resident's bedside at 8:07 AM. The resident was pale and cold, pulseless and apneic (not breathing) and facility staff were performing compressions. Facility staff reported to the paramedics they noticed the resident was not breathing at around 7:20 AM and had called 911 around 7:55 AM. The paramedics took over compressions, established IV (needle in a vein) access, placed oxygen on the resident and administered epinephrine (adrenaline) and normal saline. The patient (Resident #1) was found in asystole (without a heartbeat) and remained in the same cardiac rhythm. The paramedics contacted physician (unidentified) who gave permission to discontinue ALS (Advance Life Support) interventions. CPR was discontinued on [DATE] at 8:17 AM. The paramedics advised the nurse at the facility of the doctor's orders, and the paramedics left. The resident was not transported from the facility. Record review of the facility's self-report Intake Investigation Worksheet dated [DATE] revealed an allegation of neglect because RN A found Resident #1 unresponsive on [DATE] at 7:38 AM but did not initiate CPR until 16 minutes later at 7:55 AM. In an interview on [DATE] at 8:31 AM, the ADON revealed she received a telephone call at 7:40 AM on [DATE] from the DON that RN A had texted the DON at 7:38 AM that Resident #1 had expired. The DON asked the ADON to go to the facility to initiate CPR and call 911. The ADON stated she arrived at the facility at 7:54 AM and found RN A at the nurse's station at the front of the building. Per the ADON she asked RN A who was with Resident #1 and RN A said No one. The ADON stated she then ran to Resident #1's room with RN A and when she arrived the crash cart was in the resident's room but there were no staff members there. The ADON said she called 911 at 7:55 AM while RN A initiated CPR assisted by LVN D, and CNAs C and E who had arrived at the room by then. Per the ADON, CNA C had gone into Resident #1's room to get him up for breakfast, found him unresponsive, and notified RN A. The ADON stated she asked RN A why CPR was not initiated, and RN A said that he was already cold and grey, and that she (RN A) did not know what to do, that this type of situation was handled differently in the hospital where she had worked before. [RN A date of hire [DATE]]. The ADON stated that RN A had not alerted other nurses in the facility about Resident #1's condition. She said that an investigation was done, with RN A being suspended and later terminated in response to the investigation. In an interview on [DATE] at 12:39 PM, the DON revealed that when CNA C told RN A that Resident #1 was unresponsive and the RN found the resident unresponsive, the RN should have started the code. She said the Code Blue procedure involved the nurse getting help from other staff in announcing Code Blue on the intercom, taking the crash cart and AED to the resident's room, and calling 911 while responding nurses and other responding staff would place a back board under the resident, start chest compressions, place and use the ambu-bag (bag used to help a patient's breathing), place the AED pads on the patient's chest and follow instructions from the AED machine. The DON said that that these compressions, use of the ambu-bag and following instructions from the AED should continue until paramedics arrived to take over the situation. She said that RN A was suspended pending investigation of the incident, and later was terminated. In an interview on [DATE] at 4:59 PM the DON revealed that the facility had not done any training about how to respond to this type of emergency [an unresponsive patient who is full-code], because nothing like this had happened before. She stated that nurses learned about CPR in outside classes when they got their CPR cards renewed. Telephone attempts to reach RN A were made on [DATE] at 9:34 AM, and on [DATE] at 8:15 AM, 9:21 AM, and 11:24 AM with no response although requests for a return call were left in her digital mailbox. Record review of RN A's personnel file revealed she was hired on [DATE]. She initialed a New Hire Orientation Acknowledgement that included location and information about the AED on [DATE]. In an interview on [DATE] at 8:31 AM, LVN D said she became aware of the incident involving Resident #1 before breakfast on [DATE] when RN A came to her asking what the procedure was when a resident was found with no vital signs. LVN D said RN A was not sure if Resident #1 had a DNR order or had a full code status. LVN D said she went to the nurse's station and found a green sheet of paper in his file [denotes full code status] and then looked in his electronic chart which also showed he had a full code status. LVN D said when she discovered Resident #1 had a full-code status she ran to get the crash cart and AED, took them to Resident #1's room. LVN D stated when she arrived at Resident #1's room the room was empty. LVN D said she and RN A arrived at the resident's room together and put the board under his back, opened the AED and placed patches on the resident, started CPR. LVN D said the AED did not shock him. At some point the ADON arrived and was using the ambu-bag. LVN D was not able to state when the ADON arrived. In an interview on [DATE] at 8:56 CNA E revealed that the morning of [DATE] around 7:25 AM, she was walking down the 400 hall when CNA C came out of Resident #1's room and said he was not moving. CNA E said she looked at Resident #1 who looked grey and was cold to the touch. CNA E said she and CNA C stepped outside the room where RN A had her cart and told the RN that she needed to go into the room because Resident #1 was gone. CNA E said the RN went into Resident #1's room, touched the resident, and pulled the sheet over his head. CNA E said she told the RN Don't do that and the RN pulled the sheet back down. CNA E said the RN then left the room and once outside asked the CNA (CNA E) what the procedure was. CNA E said she did not respond to the RN's question but instead told CNA C what the CNAs did when told by a nurse that a resident had died (wash the body, change the linens, use a towel to close the mouth). In a telephone interview on [DATE] at 10:52 AM, CNA C revealed she arrived for work on [DATE] around 6:00 AM and began her work. After readying several residents for breakfast, she asked RN A what she needed to for Resident #1. RN A told her to get him up for breakfast, but when CNA C entered Resident #1's room to begin getting him ready, she saw that the resident's face and hands were discolored, and his mouth was wide open. The CNA said she looked at the resident's chest and did not see him breathing. CNA C said she walked out of room and told RN A something was wrong with Resident #1, that he was not breathing and was not ok. CNA C said she went with RN A into Resident #1's room and saw the RN check the resident's pulse and breathing. The CNA followed the RN out of the resident's room where RN A was heard asking CNA E what the procedure was because it was different in different states. CNA C stated she was later going to the dining room to help with breakfast when she saw the ADON, RN A and LVN D go to Resident #1's room with the crash cart. She followed them to the resident's room where she observed the three nurses place the back board, start chest compressions, attach the AED to the resident, and begin use of the ambu-bag. In an interview on [DATE] at 4:22 PM, LVN F revealed that on [DATE] before breakfast (was not able to give specific time) she heard unidentified staff members saying that Resident #1 had expired. LVN F said she was surprised because no one had called a Code Blue. LVN F said she went to Resident #1's room where LVN D, RN A and CNA C were beginning to place the back board under the resident and to start compressions. Record review of the facility's policy Emergency Procedure - Cardiopulmonary Resuscitation dated ,d+[DATE] revealed that if an individual is found unresponsive and not breathing normally a licensed staff member who is certified in CPR/BLS (cardiopulmonary resuscitation/Basic life support) shall initiate CPR unless it is know that a DNR order that specifically prohibits CPR and/or external defibrillation exists for the individual. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR order or a physician's order to not administer CPR. Record review of the facility's policy Abuse and Neglect - Clinical Protocol dated [DATE] revealed that the definition of neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The physician and staff will help identify risk factors for abuse within the facility such as those related to staffing such as poor preparation, training, and lack of knowledge or skills that might affect how the residents are being cared for. Staff and management will help identify situations that might constitute or could be construed as neglect such as inattention to advance directives. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:25 AM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 10:25 AM. The Plan of Removal was accepted on [DATE] at 12:12 PM: [DATE] Employee was interview and statement taken. This was completed by [DON name] RN, DON and [ADON name] LVN, ADON on [DATE]. Met with Administrator and decision was made to suspend employee same day on [DATE]. This was completed by [DON name] RN, DON and [Administrator name], Administrator on [DATE]. Investigation begin by interviewing staff members and taking written statements. This was completed by [DON name] RN, DON on [DATE]. [DATE] Full code and DNR audit were completed to ensure, physician order, code status icon and correct colored paper (green or red) is in chart for all residents. This was completed by [LVN B Name] LVN, Medical records on [DATE]. Continued to take statements from staff members. This was completed by [DON name] RN, DON on [DATE]. Audit CPR certification for nurses completed This was completed by [DON name] RN, DON on [DATE]. CPR certification class was scheduled for Thursday [DATE] at 1:30pm. This was completed by [ADON name] LVN, ADON on [DATE]. In-service on where to find a residents' code status provided to staff. This was completed by [DON name] RN, DON on [DATE]. [DATE] In-services on ''Emergency response procedure, calling a code'' provided to staff. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] In-services continued on ''Emergency response procedure, calling a code'' This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] In-serviced nurses about what to do when a patient is full code or DNR and found with no signs of life. This was completed by [DON name] RN, DON on [DATE]. Facilities Plan to ensure compliance quickly [DATE] Staff in-service on ''Abuse and neglect'' and ''Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support''. Staff members will not assume any job responsibilities until training has been received by DON/designee This was completed by [DON name] RN/DON on [DATE]. This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards to knowledge about abuse and neglect and how to reach/do in a code blue situation. DON/designee will report monthly to QAPI [DATE] and ongoing CPR certification class and emergency mock drill training provided on [DATE] at 1:30pm. Will be completed by [Business owner's name] (Owner of [Business name and location]). This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. DON/designee will report monthly to QAPI Ongoing Emergency mock drills training quarterly. Will be completed by [Business owner's name] (Owner of [Business name and location]). This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. DON/designee will report monthly to QAPI Plan of Removal was verified a follows: - Confirmed through interview and record review (DON, [DATE] 4:59 PM; HR Manager [DATE], 9:43 AM) that alleged perpetrator was interviewed, suspended and terminated. - Through interview with 3 LVNs from 6 AM to 6 PM shift and two LVNs from 6 PM to 6 AM shift confirmed understanding of training regarding response to resident without signs of life (LVN F, [DATE] 4:22 PM; LVNs - [DATE] 9:04AM, [DATE] 2:22 PM, 5:08 PM, 5:16 PM.) - Confirmed through interview (Medical Records Director, [DATE] at 3:11 PM) that an audit was performed on all resident records to ensure accuracy of resident code status; confirmed through record review of residents physical and electronic charts ([DATE] at 4:04 PM) the accuracy of resident code status for 12 sample residents (Census of 75). - Confirmed through record review (audit listing with nurse's names and CPR expiration dates) and interview (DON [DATE], 5:05 PM) that nurses' CPR training status was audited, and that the facility has taken action to train one nurse whose CPR training was expired. - Confirmed through observation (Group trainings observed [DATE], at 2:07 PM, 2:50 PM, 3:58 PM), interview (DON [DATE] at 5:05 PM) and documentation (Inservice sign-ins dated [DATE], [DATE], [DATE], [DATE]) that trainings regarding calling a code and regarding determining a resident's code status as identified in the plan of removal were provided. - Confirmed through interview (Administrator [DATE] 3:30 PM) and record review (Service Agreement dated [DATE]) that the facility entered into a service agreement with a provider of BLS and First aid/CPR/AED courses. - Confirmed through interview and record review that ANE training is provided to employees and through interviews with 13 staff (RN (DON [DATE] 5:05 PM; RN [DATE] 2:03 PM), LVN (LVN F, [DATE] 4:22 PM; LVNs [DATE], 5:08 PM, 5:16 PM, CNAs - [DATE] at 10:52, [DATE], 1:52 PM, 1:59 PM, 2:33 PM, 2:57 PM, 3:07 PM, 3:30 PM; 3:40 PM), Restorative Aide ([DATE], 2:11 PM), Activities Director ([DATE], 2:16 PM) understanding of the concept of neglect. - Confirmed through interview that employees (DON [DATE] 5:05 PM) who have not completed Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support training will not assume job responsibilities until training has been done. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:55 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 14 residents reviewed for physician's orders for provision of basic life support in that: Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A went to the resident's room and checked him for signs of life but did not know how to respond when she did not find a pulse, and did not immediately start CPR or other life-sustaining measures, resulting in Resident #1's wishes to be resuscitated not being honored. An IJ was identified on [DATE] at 10:25 AM. The IJ template was provided to the facility on [DATE] at 10:25 AM. While the IJ was removed on [DATE] at 6:55 PM the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm, because all staff had not been trained on Emergency Response Procedure and Calling a Code. These failures could place residents at risk for serious injury, hospitalization and/or death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged on [DATE] due to death in the facility. The face sheet did not indicate his code status. Record review of Resident #1's history and physical dated [DATE] revealed he had diagnoses including coronary artery disease (damage or disease of the hearts major blood vessels), osteomyelitis (infection in the bone), Diabetes mellitus with hyperglycemia (Diabetes with high blood sugar), hypertension (high blood pressure), vascular dementia (dementia caused by blood clots in the brain) and hemiparesis affecting left side as late effect of cerebrovascular accident (Stroke affecting his left side). Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 8 (moderate cognitive impairment). He had symptoms of delirium including fluctuating periods of inattention and disorganized thinking. He had symptoms of psychosis including hallucinations (seeing something that is not actually there). He had no symptomatic behaviors. He was dependent on staff for toileting, bathing, dressing, personal hygiene, sitting up, and transferring between surfaces. Record review of Resident #1's care plan dated [DATE] revealed he was a full code status, that the facility would honor his wishes regarding code status and attempt to resuscitate him should arrest occur. His physician would be contacted, emergency services would be notified, and family would be notified. Record review of Resident #1's physician's orders dated [DATE] revealed no orders concerning his code status. Record review of Resident #1's Advance Directives information in his electronic record accessed [DATE] revealed his CPR (Resuscitation) Status was Attempt CPR. Record review of Resident #1's progress note dated [DATE] at 10:53 AM by RN A documented the following Resident found unresponsive by this nurse, initially attempted vitals but was unsuccessful, CPR initiated immediately, code cart brought to room, AED in place with commands initiated, 911 called, CPR continued till EMS arrived and took over. DON, Administrator, and MD notified. Family called and updated. All questions and concerns addressed. Record review of the fire department's Hospital Care Report for Resident #1 dated [DATE] beginning at 7:55:12 AM revealed that paramedics were dispatched to the facility at 7:56 AM and arrived at the resident's bedside at 8:07 AM. The resident was pale and cold, pulseless and apneic (not breathing) and facility staff were performing compressions. Facility staff reported to the paramedics they noticed the resident was not breathing at around 7:20 AM and had called 911 around 7:55 AM. The paramedics took over compressions, established IV (needle in a vein) access, placed oxygen on the resident and administered epinephrine (adrenaline) and normal saline. The patient (Resident #1) was found in asystole (without a heartbeat) and remained in the same cardiac rhythm. The paramedics contacted physician (unidentified) who gave permission to discontinue ALS (Advance Life Support) interventions. CPR was discontinued on [DATE] at 8:17 AM. The paramedics advised the nurse at the facility of the doctor's orders, and the paramedics left. The resident was not transported from the facility. Record review of the facility's self-report Intake Investigation Worksheet dated [DATE] revealed an allegation of neglect because RN A found Resident #1 unresponsive on [DATE] at 7:38 AM but did not initiate CPR until 16 minutes later at 7:55 AM. In an interview on [DATE] at 8:31 AM, the ADON revealed she received a telephone call at 7:40 AM on [DATE] from the DON that RN A had texted the DON at 7:38 AM that Resident #1 had expired. The DON asked the ADON to go to the facility to initiate CPR and call 911. The ADON stated she arrived at the facility at 7:54 AM and found RN A at the nurse's station at the front of the building. Per the ADON she asked RN A who was with Resident #1 and RN A said No one. The ADON stated she then ran to Resident #1's room with RN A and when she arrived the crash cart was in the resident's room but there were no staff members there. The ADON said she called 911 at 7:55 AM while RN A initiated CPR assisted by LVN D, and CNAs C and E who had arrived at the room by then. Per the ADON, CNA C had gone into Resident #1's room to get him up for breakfast, found him unresponsive, and notified RN A. The ADON stated she asked RN A why CPR was not initiated, and RN A said that he was already cold and grey, and that she (RN A) did not know what to do, that this type of situation was handled differently in the hospital where she had worked before. [RN A date of hire [DATE]]. The ADON stated that RN A had not alerted other nurses in the facility about Resident #1's condition. She said that an investigation was done, with RN A being suspended and later terminated in response to the investigation. In an interview on [DATE] at 12:39 PM, the DON revealed that when CNA C told RN A that Resident #1 was unresponsive and the RN found the resident unresponsive, the RN should have started the code. She said the Code Blue procedure involved the nurse getting help from other staff in announcing Code Blue on the intercom, taking the crash cart and AED to the resident's room, and calling 911 while responding nurses and other responding staff would place a back board under the resident, start chest compressions, place and use the ambu-bag (bag used to help a patient's breathing), place the AED pads on the patient's chest and follow instructions from the AED machine. The DON said that that these compressions, use of the ambu-bag and following instructions from the AED should continue until paramedics arrived to take over the situation. She said that RN A was suspended pending investigation of the incident, and later was terminated. In an interview on [DATE] at 4:59 PM the DON revealed that the facility had not done any training about how to respond to this type of emergency [an unresponsive patient who is full-code], because nothing like this had happened before. She stated that nurses learned about CPR in outside classes when they got their CPR cards renewed. Telephone attempts to reach RN A were made on [DATE] at 9:34 AM, and on [DATE] at 8:15 AM, 9:21 AM, and 11:24 AM with no response although requests for a return call were left in her digital mailbox. Record review of RN A's personnel file revealed she was hired on [DATE]. She initialed a New Hire Orientation Acknowledgement that included location and information about the AED on [DATE]. In an interview on [DATE] at 8:31 AM, LVN D said she became aware of the incident involving Resident #1 before breakfast on [DATE] when RN A came to her asking what the procedure was when a resident was found with no vital signs. LVN D said RN A was not sure if Resident #1 had a DNR order or had a full code status. LVN D said she went to the nurse's station and found a green sheet of paper in his file [denotes full code status] and then looked in his electronic chart which also showed he had a full code status. LVN D said when she discovered Resident #1 had a full-code status she ran to get the crash cart and AED, took them to Resident #1's room. LVN D stated when she arrived at Resident #1's room the room was empty. LVN D said she and RN A arrived at the resident's room together and put the board under his back, opened the AED and placed patches on the resident, started CPR. LVN D said the AED did not shock him. At some point the ADON arrived and was using the ambu-bag. LVN D was not able to state when the ADON arrived. In an interview on [DATE] at 8:56 CNA E revealed that the morning of [DATE] around 7:25 AM, she was walking down the 400 hall when CNA C came out of Resident #1's room and said he was not moving. CNA E said she looked at Resident #1 who looked grey and was cold to the touch. CNA E said she and CNA C stepped outside the room where RN A had her cart and told the RN that she needed to go into the room because Resident #1 was gone. CNA E said the RN went into Resident #1's room, touched the resident, and pulled the sheet over his head. CNA E said she told the RN Don't do that and the RN pulled the sheet back down. CNA E said the RN then left the room and once outside asked the CNA (CNA E) what the procedure was. CNA E said she did not respond to the RN's question but instead told CNA C what the CNAs did when told by a nurse that a resident had died (wash the body, change the linens, use a towel to close the mouth). In a telephone interview on [DATE] at 10:52 AM, CNA C revealed she arrived for work on [DATE] around 6:00 AM and began her work. After readying several residents for breakfast, she asked RN A what she needed to for Resident #1. RN A told her to get him up for breakfast, but when CNA C entered Resident #1's room to begin getting him ready, she saw that the resident's face and hands were discolored, and his mouth was wide open. The CNA said she looked at the resident's chest and did not see him breathing. CNA C said she walked out of room and told RN A something was wrong with Resident #1, that he was not breathing and was not ok. CNA C said she went with RN A into Resident #1's room and saw the RN check the resident's pulse and breathing. The CNA followed the RN out of the resident's room where RN A was heard asking CNA E what the procedure was because it was different in different states. CNA C stated she was later going to the dining room to help with breakfast when she saw the ADON, RN A and LVN D go to Resident #1's room with the crash cart. She followed them to the resident's room where she observed the three nurses place the back board, start chest compressions, attach the AED to the resident, and begin use of the ambu-bag. In an interview on [DATE] at 4:22 PM, LVN F revealed that on [DATE] before breakfast (was not able to give specific time) she heard unidentified staff members saying that Resident #1 had expired. LVN F said she was surprised because no one had called a Code Blue. LVN F said she went to Resident #1's room where LVN D, RN A and CNA C were beginning to place the back board under the resident and to start compressions. In an interview and record review on [DATE] at 3:45 PM with the Administrator and the DON, the Administrator revealed that nurses are given a one-day orientation to the facility policies, and three days of orientation on the floor with experienced nurses regarding protocol to make sure nurses are ready to work the floor. The DON then signs the paperwork regarding orientation. The Administrator stated that that the orientation with experienced nurses on the floor included the AED, the Crash Cart and how to determine code status. When asked when the crash cart and determining code status were not included on the orientation check list, the Administrator stated that the AED is on the orientation check list, and the Crash Cart was in the same area as the AED. Record review of the facility's policy Emergency Procedure - Cardiopulmonary Resuscitation dated ,d+[DATE] revealed that if an individual is found unresponsive and not breathing normally a licensed staff member who is certified in CPR/BLS (cardiopulmonary resuscitation/Basic life support) shall initiate CPR unless it is know that a DNR order that specifically prohibits CPR and/or external defibrillation exists for the individual. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR order or a physician's order to not administer CPR. Record review of the facility's policy Abuse and Neglect - Clinical Protocol dated [DATE] revealed that the definition of neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The physician and staff will help identify risk factors for abuse within the facility such as those related to staffing such as poor preparation, training, and lack of knowledge or skills that might affect how the residents are being cared for. Staff and management will help identify situations that might constitute or could be construed as neglect such as inattention to advance directives. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:25 AM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 10:25 AM. The Plan of Removal was accepted on [DATE] at 12:12 PM: [DATE] Employee was interview and statement taken. This was completed by [DON name] RN, DON and [ADON name] LVN, ADON on [DATE]. Met with Administrator and decision was made to suspend employee same day on [DATE]. This was completed by [DON name] RN, DON and [Administrator name], Administrator on [DATE]. Investigation begin by interviewing staff members and taking written statements. This was completed by [DON name] RN, DON on [DATE]. [DATE] Full code and DNR audit were completed to ensure, physician order, code status icon and correct colored paper (green or red) is in chart for all residents. This was completed by [LVN B Name] LVN, Medical records on [DATE]. Continued to take statements from staff members. This was completed by [DON name] RN, DON on [DATE]. Audit CPR certification for nurses completed This was completed by [DON name] RN, DON on [DATE]. CPR certification class was scheduled for Thursday [DATE] at 1:30pm. This was completed by [ADON name] LVN, ADON on [DATE]. In-service on where to find a residents' code status provided to staff. This was completed by [DON name] RN, DON on [DATE]. [DATE] In-services on ''Emergency response procedure, calling a code'' provided to staff. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] In-services continued on ''Emergency response procedure, calling a code'' This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] Continue investigation by taking staff statements. This was completed by [DON name] RN, DON and [Corporate Staff Name] RN, EDCS on [DATE]. [DATE] In-serviced nurses about what to do when a patient is full code or DNR and found with no signs of life. This was completed by [DON name] RN, DON on [DATE]. Facilities Plan to ensure compliance quickly [DATE] Staff in-service on ''Abuse and neglect'' and ''Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support''. Staff members will not assume any job responsibilities until training has been received by DON/designee This was completed by [DON name] RN/DON on [DATE]. This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards to knowledge about abuse and neglect and how to reach/do in a code blue situation. DON/designee will report monthly to QAPI [DATE] and ongoing CPR certification class and emergency mock drill training provided on [DATE] at 1:30pm. Will be completed by [Business owner's name] (Owner of [Business name and location]). This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. DON/designee will report monthly to QAPI Ongoing Emergency mock drills training quarterly. Will be completed by [Business owner's name] (Owner of [Business name and location]). This will be monitor by DON/designee by conducting 5 random interviews x1 week with staff, record responses and document in regards how to react/do in a code blue situation. DON/designee will report monthly to QAPI Plan of Removal was verified a follows: - Confirmed through interview and record review (DON, [DATE] 4:59 PM; HR Manager [DATE], 9:43 AM) that alleged perpetrator was interviewed, suspended and terminated. - Through interview with 3 LVNs from 6 AM to 6 PM shift and two LVNs from 6 PM to 6 AM shift confirmed understanding of training regarding response to resident without signs of life (LVN F, [DATE] 4:22 PM; LVNs - [DATE] 9:04AM, [DATE] 2:22 PM, 5:08 PM, 5:16 PM.) - Confirmed through interview (Medical Records Director, [DATE] at 3:11 PM) that an audit was performed on all resident records to ensure accuracy of resident code status; confirmed through record review of residents physical and electronic charts ([DATE] at 4:04 PM) the accuracy of resident code status for 12 sample residents (Census of 75). - Confirmed through record review (audit listing with nurse's names and CPR expiration dates) and interview (DON [DATE], 5:05 PM) that nurses' CPR training status was audited, and that the facility has taken action to train one nurse whose CPR training was expired. - Confirmed through observation (Group trainings observed [DATE], at 2:07 PM, 2:50 PM, 3:58 PM), interview (DON [DATE] at 5:05 PM) and documentation (Inservice sign-ins dated [DATE], [DATE], [DATE], [DATE]) that trainings regarding calling a code and regarding determining a resident's code status as identified in the plan of removal were provided. - Confirmed through interview (Administrator [DATE] 3:30 PM) and record review (Service Agreement dated [DATE]) that the facility entered into a service agreement with a provider of BLS and First aid/CPR/AED courses. - Confirmed through interview and record review that ANE training is provided to employees and through interviews with 13 staff (RN (DON [DATE] 5:05 PM; RN [DATE] 2:03 PM), LVN (LVN F, [DATE] 4:22 PM; LVNs [DATE], 5:08 PM, 5:16 PM, CNAs - [DATE] at 10:52, [DATE], 1:52 PM, 1:59 PM, 2:33 PM, 2:57 PM, 3:07 PM, 3:30 PM; 3:40 PM), Restorative Aide ([DATE], 2:11 PM), Activities Director ([DATE], 2:16 PM) understanding of the concept of neglect. - Confirmed through interview that employees (DON [DATE] 5:05 PM) who have not completed Emergency response procedure, calling a code: verification of code status, instructing staff to activate emergency response system code, call 911, and initiate basic life support training will not assume job responsibilities until training has been done. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:55 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for1 (Resident #37) of 21 residents reviewed for an environment free of accident hazards as possible. The facility failed to ensure that the mechanical lift (Hoyer) sling used to transfer Resident #37 was in good working order, resulting in a sling strap tearing, and Resident #37 falling to the floor. This failure could result in residents fearing transfers using a mechanical lift, and serious injury, including fractures. Findings included: Record review of Resident #37 ' s face sheet dated 03/14/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #37 ' s quarterly MDS dated [DATE] revealed he had a BIMS score of 12 (moderate cognitive impairment). He was dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and personal hygiene. He was dependent on staff for bed to chair/ chair to bed transfers and tub/shower transfers. He was always incontinent of bowel and bladder. His diagnoses included end-stage renal disease (kidney failure), heart failure, morbid obesity, Record review of Resident #37 ' s care plan dated 03/07/2024 revealed he was at risk for falls, and the Maintenance department was to check all Hoyer lift nets and straps to make sure they were not torn or old and could be used safely. His care plan dated 06/20/2023 revealed he would receive assistance with ADLs. Record review of Resident #37 ' s Resident Incident Report dated 03/14/2024 revealed that on 03/06/2024 he was being transferred from a shower chair in a Hoyer sling when the Hoyer strap broke. He was observed to be on the floor on his left side and said he had pain on his left leg. His physician was notified and x-ways of his left hip and leg were ordered. Record review of Resident #37 ' s Nursing Progress Note dated 03/06/2024 revealed that at 2:45 PM a CNA (unidentified) called LVN I into his room and where the resident was observed laying on the floor on his left side. Per the CNAs (2) they were transferring the resident onto the bed after his shower when the Hoyer strap broke. The resident voiced pain to the left leg down to the ankle. The resident was able to move his left arm and denied any new pain except throbbing to his left leg. In an interview and observation on 03/11/24 at 10:58 AM Resident #37 revealed that on the past Wednesday [03/06/2024] staff members were transferring him in a Hoyer lift when the sling broke and he fell to the ground landing on his left side. Resident #37 was observed to have a bruise on his left wrist. Resident #37 said an x-ray machine was brought om and they did [his] whole left side and found nothing. He said that he hit his left foot on the lift and that his side under his left breast hurt. In an interview on 03/14/24 at 11:53 AM CNA J confirmed she had received prior training to check Hoyer slings to make sure they were in good condition In an interview on 03/14/24 11:28 AM CNA K confirmed she had received prior training to check Hoyer slings to make sure they were in good condition In an interview on 03/14/24 a 12:09 PM the Lead CNA confirmed she had received prior training to check Hoyer slings to make sure they were in good condition In an interview on 03/14/24 at 01:28 PM LaundryWorker M revealed she had been instructed and does inspect Hoyer nets for wear. She said that if there was a problem with the condition of the sling, she would tell the Maintenance/Housekeeping Manager. In an interview on 03/14/2024 at 2:55 PM the DON said that as a result of Resident #37 ' s fall staff had been in serviced to make sure to hook the Hoyer sling to the mechanical lift using two loops instead of one. Record review of the facility policy Safe Lifting and Movement of Residents revised 4/2007 revealed that the facility would use mechanical lifting devices to protect the safety and well-being of residents. Mechanical lift equipment shall undergo routine checks and maintenance by nursing and maintenance staff to ensure that equipment remains in good working order.

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibited neglect for 3 (Resident #1, Resident #26 and Resident #28) of 29 residents reviewed for neglect. The facility failed to adequately supervise those residents identified at risk of elopement; failed to check the wander guard bracelet and wander guard system for functionality according to manufacturing recommendations until after the incident involving Resident #1 on 7/2/17. On 7/02/17 at 7:38 AM, Resident #1, who was assessed to be at risk for elopement/wandering, wheeled herself out through the front entrance of the facility. Resident #1 had a wander guard bracelet in place, and the wander guard alarm on the front entrance was not activated when resident #1 exited the facility. The resident wheeled herself approximately half a mile along highly traffic streets in her wheelchair and was found lying on the ground in a driveway by a passerby. The facility staff were not aware resident #1 had eloped until the Police Department called the facility on 7/2/17 at 8:30 AM asking if they had a resident that was missing. Two other residents who were care planned for the use of wander guards were checked for wander guards and functionality of the guards on 8/10/17. Resident #26 did not have her wander guard on and #28's wander guard did not activate the system. On 8/10/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 8/12/17 the facility remained out of compliance at potential for more than minimal harm pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 19 residents identified by the facility as having elopement risk behaviors, placing them at risk of injury or death during an elopement. The findings include: Resident #1 Review of Face Sheet dated 8/10/17 revealed Resident #1 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. In an observation on 8/7/17 at 12:00 Noon, Resident #1 was observed eating in the dining room. She appeared clean and well groomed. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] documented in part: rarely/never made herself understood; sometimes was able to understand others; short and long term memory problems; severely impaired-never rarely made decisions; required extensive to total assistance of 1 person with all activities of daily living; balance from surface to surface was not steady only able to stabilize with staff assistance; and was incontinent of bowel and bladder. Review of Resident #1 Care Plan documented in part: Problem Onset: 6/21/17 :Wanders; Approaches: Wander guard to help prevent leaving of facility, Monitor resident's location as necessary, Redirect resident from leaving facility as necessary, Check wander guard placement every shift, wander guard in place to right lower extremity. Review of Risk of Elopement/Wandering assessment dated [DATE] for Resident #1 which was completed for a change in condition documented in part: resident was cognitively impaired with poor decision-making skills. She had a [DIAGNOSES REDACTED]. She verbally expressed the desire to go home, packed belongings to go home or stayed near exit door. Her family had verbalized concerns she had wandering tendencies. Resident #1 at Risk for elopement/wandering at this time: Yes. Appropriate intervention, initiated, placed wander guard on the resident ankle. Review of Incident/Accident Report dated 7/2/17, written by LVN H documented in part: received call from police department on 7/2/17 at 8:30 AM stating they have a person that might be a resident from facility. Upon arrival to location writer able to identify subject as Resident #1. Additional comments and or steps taken to prevent recurrence: Wander Guard system, 1 hour checks in place, nurse conducted full assessment. Review of the Provider Investigation Report dated 7/02/17, documented in part: At approximately 8:30 AM police officer notified facility that they had a person that ight be a resident of our facility and identified self as Resident #1. The police officer noted that resident was found approximately 0.4 miles from facility. Licensed Vocational Nurse (LVN) H spoke to the officer and asked the officer to bring person to facility to identify. Upon arrival LVN H identified resident as Resident #1. Resident stated I want to go to the bridge, I'm going to visit my family in(NAME) Mexico. At the time police officer called facility is when facility became aware resident #1 was missing. Review of facility's video camera system revealed on 7/02/17 at 7:38 AM, resident #1 in wheelchair, wheeling self through the front door entrance. The video shows no receptionist, staff or visitor present at that time. Abrasion noted to L (left) knee. Resident #1 exited facility on 7/02/17 at 7:38 AM, even though resident was wearing a wander guard bracelet, resident was able to prop door open. It is unclear if alarm sounded and disengaged because the receptionist arrives 4 minutes and stated the wander alarm was not on when she arrived on 7/02/17. Further, when resident returned to facility via Emergency Medical Services (EMS) and police department LVN F and Maintenance Worker checked wander guard system, bracelet And confirmed it functioned properly. In an observation and review on 7/12/17 at 2:30 PM, of the facility's video recording dated 7/02/17 at 7:30 AM with facility Administrator, revealed Resident #1 was sitting in her wheelchair in the front lobby unsupervised by the entrance doors. There was no receptionist, visitors, or other residents observed. At 7:38 AM, Resident #1 wheeled herself to the main doors, pushed the front door grab bar and exited the facility at that time. Resident #1 was observed leaving the facility, turned left into the driveway located in front of the main entrance to the facility. Review of (undated) Door Alarm Function Monitoring Tool attached to the Provider Investigation Report dated 7/2/17 documented in part: The facility had initiated Door Alarm Function Monitoring Tool to check the functionality of wander guard system on the front entrance door. In an interview on 8/10/17 at 5:00 PM Maintenance Manager stated they were not checking the functionality of the wander guard system until Resident #1 elopement from the facility on 7/2/17. In an interview on 08/09/2017 at 3:00 PM, Administrator confirmed the facility had started checking the functionality of the wander guard system until Resident #1 elopement from the facility on 7/2/17. Review of Physician Orders for Resident #1 dated July 2017 documented in part: Wander guard check placement and function QS (every shift). Interview and record review on 8/11/17 at 9:35 AM, with the Director of Nursing (DON) revealed that the Medication Administration Record (MAR) dated 7/2017 for Resident #1 did not have any written documentation for the Wander Guard checks for placement and function to be done every shift by the licensed staff on 7/01/17, 7/02/17, 7/03/17, and 7/04/17. The DON stated the nurses are responsible for checking the Wander Guard every shift as documented on the MAR and had been trained to initial the MAR when completed. DON stated There is no way to say if they checked the wander guard for placement and functionality checks were done on those days if there are blanks on the MAR for those days. In an interview on 8/11/17 at 2:00 PM, Passerby F, reported that on 7/2/17 at approximately 8:00 AM, he was going north, saw an empty wheelchair wheeling down a driveway into the street. He stopped and got out of his car, stopped the wheelchair from rolling into the street and noted Resident #1 crawling towards the wheelchair. I picked up the resident from the ground and sat her in the wheelchair. I noted that she had scrapes on her knees. She was grimacing and appeared to be in pain. She was wearing a night gown, a brief and noted that her pubic area and buttocks were exposed. I called 911. I also noted that her wheelchair had a number #116 on it and he thought it might belong to the nursing facility. Review of the Emergency Medical Service Transportation Event Information Report dated 7/2/17 documented in part: Elderly female /unaware of situation, wearing pink hoodie and light blue plaid shirt, no bottoms, in wheelchair, does not know where she lives or where she woke up. Problem: Fall, not alert, the reason for the fall is unknown. She is not completely alert (not responding appropriately). Contact with Nursing Facility to see if this might be one of their patients wearing baby blue pink night gown, pink slippers, in wheel chair with facility name. She is in good health, no medical emergency with patient, facility staff is on their way to identify the patient and stated she does have and ankle bracelet with ID, patient released to facility staff. In an interview on 8/10/17 at 4:45 PM Attending Physician stated when Resident #1 eloped from the facility on 7/02/17 she was in tremendous risk, of being injured because she is severely cognitively impaired and could have been run over by a car, was in danger of falling from the wheelchair when propelling the wheelchair down the streets that could have resulted in a neck fracture, or a brain bleed. Review of Nurses Notes written by Licensed Vocations Nurse (LVN) H dated 7/2/17 documented in part: Received call approximately 8:30 AM from police department stating they had located a person with a wheelchair that might be a resident of the facility. The person gave name of Resident #1. Upon arrival to location identified person as Resident #1 sitting in wheelchair. Emergency Medical Services (EMS) had attended call and checked person for any injury to which none was found, some scrapes to knees observed. Patient is confused and states is going to(NAME)Mexico since someone awaits for her. She was not able to state if she has fallen or how she got out of facility. Has working wander guard to right lower extremity. Responsible party made aware and physician notified. 1 to 1 monitoring. In an interview on 8/7/17 at 5:00 PM Certified Nursing Assistant (CNA) Q reported on 7/2/17 at approximately 7:00 AM she had been assigned to care for Resident #1 on the 6:00 AM -2:00 PM shift. CNA Q stated she had bathed that morning and had left Resident #1 in the 100 hallway where resident resides which is close to the main front entrance of the facility. In an interview on 8/8/17 at 8:45 AM, LVN H stated he was assigned to Resident #1 on 7/02/17 on the morning shift to the 100 hallway. LVN H reported that he had seen Resident #1 sitting in her wheelchair in the 100 hallway waiting for staff to wheel her to the dining room for breakfast. LVN H stated approximately, On that day 7/02/17 at 8:30 AM, I received a call from the police department saying Resident #1 had eloped. The Maintenance Worker and I drove over to where the resident was, picked her up and brought her back to the facility. In an interview on 8/11/17 at 3:17 PM LVN R stated The Wander Guard system in the front entrance doors of the facility sometimes works and sometimes it does not. That is why residents that are at risk of elopement are exiting the facility. Administration knows about this issue, it happens all the time. Review of (undated) ACCUTECH Wander Guard User Manufacturer Manual recommendations documented in part: The TAD (Tag Activator /Deactivator) and PTAD (Partial Tag Activator/Deactivator) are used to check the functionality of an Accutech Tag. Accutech Tags operate by internal battery. Over the course of normal operating, Tags eventually lose battery power and the Tags will need to be replaced. The TAD/PTAD is used to determine if a Tag has sufficient battery power to respond to an activating signal. In order to check the range capability of a Tag, you must take it to an active zone. Testing Tags: for maximum protection of residents or assets, Accutech recommends that Tags be tested on a weekly basis. Resident #26 Record Review of Resident Face Sheet (undated) documented in part: Resident #26 is an [AGE] year old female admitted to the facility on [DATE]. Record Review of History and Physical for Resident #26 dated 11/06/2016 documented in part: past medical history: [MEDICAL CONDITION], hypertension, dementia, decreased hearing, depression, paranoia, auditory hallucinations and [MEDICAL CONDITION]. Record Review of Minimum Data Set ((MDS) dated [DATE] for Resident #26 documented in part: Brief Interview of Mental Status (BIMS) score of 10. This score indicated Resident #26 is moderately cognitively impaired. Resident #26 has highly impaired hearing, clear speech and impaired vision. Resident #26 use a wheelchair as a mobility device. Record Review of Care Plan for Resident #26 dated 05/14/2013 documented in part: Problem Onset: wheels self and is at risk for inadvertent exit. Goal: resident will not exit facility without supervision. Approaches: wander guard to help prevent leaving facility, monitor location as necessary, check for placement and function of wander guard every shift and wander guard to wheelchair, check for function and placement every shift. Record Review of Risk of Elopement/Wandering assessment dated [DATE] for Resident #26 documented in part: Reason for Assessment: Quarterly. Potential Risk Factors: resident with cognitively impaired with poor decision-making skills, resident with [DIAGNOSES REDACTED]. Risk Factors: resident wanders aimlessly or non-goal directed. Resident is at risk for elopement. Intervention: continue with plan of care. Observation on 08/10/2017 at 4:04 PM, Activities Director wheeled Resident #26 to front lobby door. Front door could be opened and no alarm sounded. Resident #26 did not have a wander guard on self or wheelchair. Interview on 08/10/2017 at 4:12 PM, Licensed Vocational Nurse (LVN) Z stated Resident #26 did not have a wander guard on her ankle, they must have taken it off because her ankles are swollen. LVN Z stated wander guards are supposed to be checked every shift by the Charge Nurse. LVN Z stated she had not checked Resident 26s wander guard yet during the shift. Observation on 08/10/2017 at 4:26 PM, Licensed Vocation Nurse (LVN) Z placed new wander guard on Resident #26's left wrist. Resident #28 Review of Face Sheet (undated) for Resident #28 documented in part: an [AGE] year old male admitted to the facility on [DATE]. Resident #28 had a [DIAGNOSES REDACTED]. Review of Minimum Date Set ((MDS) dated [DATE] for Resident #28 documented in part: resident was able to be understood and understand others with clear comprehension. He has a Brief Interview of Mental Status (BIMS) score of 11. This score indicated Resident #28 is moderately cognitively impaired. Resident #28 required 1 person to assist in his activities of daily living. Review of Risk Elopement/Wandering assessment dated [DATE] documented in part: assessment completed due to change of condition. Resident #28 was cognitively impaired with poor decision-making skills and has a [DIAGNOSES REDACTED].#28 ambulated independently without assistive devices and has vision and communication problems. Resident #28 had verbally expressed the desire to go home. Review of Care Plan dated 07/11/2017 for Resident #28 documented in part: Resident wanders. Approaches: wander guard to help prevent leaving facility, monitor locations as necessary, redirect from leaving facility as necessary. Review of Physician Orders dated 07/2017 for Resident #28 documented in part: Wander guard to left ankle, check placement and function every shift. Observation on 08/10/2017 at 3:30 PM, Resident #28's wander guard bracelet did not activate wander guard alarm. Resident #28 was wheeled to front lobby door by Licensed Vocational Nurse (LVN) Y. Front door could be opened and no alarm sounded. Resident #28 had wander guard on his right ankle. LVN Y checked Resident #28's wander guard with wand. LVN Y replaced Resident 28's wander guard with new wander guard and confirmed it was working with wander guard wand. Interview on 08/10/2017 at 3:34 PM, LVN Y stated Resident 28's wander guard was not working when tested by the front door. LVN Y stated if the wander guard was working the door would have locked and the alarm above the door would have went off. LVN Y stated wander guard looked like it had water damage and stated it needed to be replaced. LVN Y stated wander guards are to be checked every shift by Charge Nurse. LVN Y stated she had not checked Resident #28's wander guards yet during her shift. In an interview on 08/09/2017 at 3:30 PM, Director of Nursing (DON) stated the facility did not have a formal protocol to check the physical locations of residents identified as elopement risk. She stated the nurses and nursing assistants check those resident's whereabouts in their 2 hour rounding, at meal times and during medication administration. Review of facility policy on Monitoring of Resident Location (undated) documented in part: A resident who is prone to wander, may be monitored frequently to confirm location. The decision to monitor a resident or monitor and document the monitoring of a resident will be the responsibility of the Administrator, Director of Nurses, Charge Nurse or as indicated by the Plan of Care. It will be the responsibility of their Charge Nurse or his/her designee to monitor residents who are prone to wander. Frequency of monitoring is to be determined by Charge Nurse or as indicated in the Plan of Care. A resident may be monitored: every 15 min (or every 15 minutes when awake), every 30 minutes, every hour. Then a resident on monitoring leaves the unit with staff from a department, that staff member must advise the nursing staff or resident's location. Review of facility policy (undated) on Safety and Supervision of Residents documented in part: Resident supervision is a core competence of the systems approach to safety. The type and frequency of resident supervision is determine by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. Review of the facility policy (undated) on Missing Resident documented in part: To ensure the health, safety and welfare of residents all times, each unit Charge Nurse during their respective tour of duty will be aware and responsible for knowing the location of their residents at all times. When residents are participating in various programs such as physical therapy, recreational activities, dining, etc. the staff in these program areas will exercise sound judgement and be aware and responsible for the health safety and welfare of their participants. Review of the facility policy (undated), on Wandering, Unsafe Resident documented in part: The facility will strive to prevent unsafe wandering while mainlining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. At-risk for wandering/elopement assessments will be conducted upon admission, quarterly and when there is a significant change in condition. The Resident's care plan will indicate the resident is at risk for elopement or another safety issues. Intervention to try to maintain safety, such as a detailed monitoring plan will be included. Review of the facility policy (undated) on Wander Guard documented in part: The facility recognize the need to provide a safe and secure environment for residents whose wandering may place them at risk for elopement. The system is a selective alarm system that is installed on exterior doors. The system alarms when residents wearing a bracelet signaling device attempts to pass through a monitored area. Residents identified at risk for elopement will have a bracelet signaling device' applied to their wrist. The Wander Guard computer system monitors location of of the resident and alarm when a resident passes through a monitored door to exit. The system only alarms for residents wearing the bracelet signaling device. Order is set in Blue Strata for wander guard Nurse will obtain an order for [REDACTED]. Review of the facility policy (undated) on Abuse Prevention Program documented in part: Policy Statement: Our residents have the right to be free from .neglect. Review of the facility (undated) Abuse and Neglect-Clinical Protocol documented in part: Along with other staff and management, the medical director will help identify situations that might constitute or could be construed as neglect. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. The medical director will advise facility management and staff about systems to ensure that basic medical, functional and psychosocial needs are being met and that potential preventable or treatable conditions affecting function and quality of life are address appropriately. An immediate Jeopardy was identified on 8/10/17 and the Nursing Home Administrator (NHA) was informed at 3:30 PM. On 8/11/17 at 3:16 PM, the Plan of Removal was accepted, which included: I. Interventions: -19 residents have been re-assessed for risk of elopement by 8/10/17 by the alleged deficient practice on 8/10/17. -All residents have been re-assessed for risk of elopement by 8/10/17 by completed elopement risk assessment. Any residents identified to be an elopement risk will have a wander guard applied, care plan updated, Medical Doctor (MD) responsible party notified and order obtained. No new residents identified for risk of elopement. -All licensed nursing staff will be in-services on ensuring wander guard bracelets are on residents, functioning properly and documented on MARS during each sift. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All Certified Nursing Assistant's (CNA's) will be in-serviced on monitoring if wander guard bracelet is physically on resident. If residents displays behavior of removing wander guard bracelet, notify charge nurses/Assistant Director of Nurses (ADON) /DON. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All licensed nursing staff and CNA's will be in-serviced on monitoring residents at risk of elopement at least every 1 hour. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All nursing management staff will be in-serviced to ensure care plans are updated, MD/Responsible Party (RP) are notified, MD order obtained and transcribed. Appropriate interventions will be implemented to prevent residents from removing wander guard bracelets/and or elopements. In-service to be completed by 8/11/17 and any staff that has not completed this in service will not be re-stated to their work schedule until completing in-service. -All staff will be in-serviced on facility elopement policy and procedures, and then need to observe the residents at risk of elopement during the activity they are responsible for, including what to do in the event of elopement, elopement preventing and location of elopement book. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -Maintenance staff will be in-serviced on testing wander guard boxes for functionality, following manufacturing guidelines, on a weekly basis. -Residents at risk of elopement will be observed during rounds every 1 hour by licensed nursing staff. II. Monitoring: -DON/ADON will randomly check MARS to ensure resident wander guards are documented and tested for functionality -Administrator will ensure DON/ADON are checking MARS for wander guard placement and functionality, and maintenance staff is testing wander guard boxes for functionality on a weekly basis for 3 months. -Any identified areas of concern identified during audits conducted by Administrator/DON/ADON/maintenance will be reviewed on a weekly basis for 30 days, then during monthly Quality Assurance Performance Improvement (QUAPI) meeting thereafter. Interviews done with Licensed Staff on all three shifts and on the weekend staff 10:00Am through 3:00 revealed they had been trained on ensuring wander guard bracelets are on residents, functioning properly and documented on MARS during each shift. All CNA's were trained on monitoring if wander guard bracelet is physically on resident, if not to notify ADON/DON. All licensed nursing staff and CNA's were in serviced on monitoring residents a risk of elopement at least every 1 hour. All nursing management staff were in-service to ensure care plan were updated, MD/RP notified, MD order obtained and transcribed. All staff was in-serviced on the elopement policy and procedures, and the need to observe the residents at risk of elopement during the activity they are responsible for, including what to do in the event of and elopement, elopement prevention and location of elopement book. Maintenance staff was in serviced on testing wander guard boxes for functionality following manufacturing guidelines on a weekly basis. The Plan of Removal was verified as having been implemented as follows: Interviews and record reviews done on 8/14/17 at 8:30 AM with DON revealed: -All available staff had been trained by 8/12/17 on the new protocols and were aware of the residents identified as elopement risk. -Residents identified as elopement risk who had a wander guard had been taken to the front door to test the efficacy of the wander guard bracelet -Residents identified as elopement risk were re-assessed for elopement and were monitored using the facility monitoring tool every 15 minutes. -Care plan were reviewed and updated for all elopement risk residents. -Maintenance staff was aware of the monitoring and maintenance of facility wander guard door alarms was conducted according to the manual guidelines. The Nursing Home Administrator was informed the IJ had been lifted on 8/12/17 at 10:00 PM. While the Immediate Jeopardy was lifted, the facility remained out of compliance at potential for more than minimal harm pattern due to the facility need to evaluate and monitor their corrective action system. Review of the Medical Device Report dated 8/10/17 revealed 19 residents were identified as an elopement risk and had a wander guard bracelet in place.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibited neglect for 3 (Resident #1, Resident #26 and Resident #28) of 29 residents reviewed for neglect. The facility failed to adequately supervise those residents identified at risk of elopement; failed to check the wander guard bracelet and wander guard system for functionality according to manufacturing recommendations until after the incident involving Resident #1 on 7/2/17. On 7/02/17 at 7:38 AM, Resident #1, who was assessed to be at risk for elopement/wandering, wheeled herself out through the front entrance of the facility. Resident #1 had a wander guard bracelet in place, and the wander guard alarm on the front entrance was not activated when resident #1 exited the facility. The resident wheeled herself approximately half a mile along highly traffic streets in her wheelchair and was found lying on the ground in a driveway by a passerby. The facility staff were not aware resident #1 had eloped until the Police Department called the facility on 7/2/17 at 8:30 AM asking if they had a resident that was missing. Two other residents who were care planned for the use of wander guards were checked for wander guards and functionality of the guards on 8/10/17. Resident #26 did not have her wander guard on and #28's wander guard did not activate the system. On 8/10/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 8/12/17 the facility remained out of compliance at potential for more than minimal harm pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 19 residents identified by the facility as having elopement risk behaviors, placing them at risk of injury or death during an elopement. The findings include: Review of the facility policy (undated) on Abuse Prevention Program documented in part: Policy Statement: Our residents have the right to be free from . neglect. Review of the facility (undated) Abuse and Neglect-Clinical Protocol documented in part: Along with other staff and management, the medical director will help identify situations that might constitute or could be construed as neglect. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. The medical director will advise facility management and staff about systems to ensure that basic medical, functional and psychosocial needs are being met and that potential preventable or treatable conditions affecting function and quality of life are address appropriately. Resident #1 Review of Face Sheet dated 8/10/17 revealed Resident #1 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. In an observation on 8/7/17 at 12:00 Noon, Resident #1 was observed eating in the dining room. She appeared clean and well groomed. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] documented in part: rarely/never made herself understood; sometimes was able to understand others; short and long term memory problems; severely impaired-never rarely made decisions; required extensive to total assistance of 1 person with all activities of daily living; balance from surface to surface was not steady only able to stabilize with staff assistance; and was incontinent of bowel and bladder. Review of Resident #1 Care Plan documented in part: Problem Onset: 6/21/17 :Wanders; Approaches: Wander guard to help prevent leaving of facility, Monitor resident's location as necessary, Redirect resident from leaving facility as necessary, Check wander guard placement every shift, wander guard in place to right lower extremity. Review of Risk of Elopement/Wandering assessment dated [DATE] for Resident #1 which was completed for a change in condition documented in part: resident was cognitively impaired with poor decision-making skills. She had a [DIAGNOSES REDACTED]. She verbally expressed the desire to go home, packed belongings to go home or stayed near exit door. Her family had verbalized concerns she had wandering tendencies. Resident #1 at Risk for elopement/wandering at this time: Yes. Appropriate intervention, initiated, placed wander guard on the resident ankle. Review of Incident/Accident Report dated 7/2/17, written by LVN H documented in part: received call from police department on 7/2/17 at 8:30 AM stating they have a person that might be a resident from facility. Upon arrival to location writer able to identify subject as Resident #1. Additional comments and or steps taken to prevent recurrence: Wander Guard system, 1 hour checks in place, nurse conducted full assessment. Review of the Provider Investigation Report dated 7/02/17, documented in part: At approximately 8:30 AM police officer notified facility that they had a person that ight be a resident of our facility and identified self as Resident #1. The police officer noted that resident was found approximately 0.4 miles from facility. Licensed Vocational Nurse (LVN) H spoke to the officer and asked the officer to bring person to facility to identify. Upon arrival LVN H identified resident as Resident #1. Resident stated I want to go to the bridge, I'm going to visit my family in(NAME) Mexico. At the time police officer called facility is when facility became aware resident #1 was missing. Review of facility's video camera system revealed on 7/02/17 at 7:38 AM, resident #1 in wheelchair, wheeling self through the front door entrance. The video shows no receptionist, staff or visitor present at that time. Abrasion noted to L (left) knee. Resident #1 exited facility on 7/02/17 at 7:38 AM, even though resident was wearing a wander guard bracelet, resident was able to prop door open. It is unclear if alarm sounded and disengaged because the receptionist arrives 4 minutes and stated the wander alarm was not on when she arrived on 7/02/17. Further, when resident returned to facility via Emergency Medical Services (EMS) and police department LVN F and Maintenance Worker checked wander guard system, bracelet And confirmed it functioned properly. In an observation and review on 7/12/17 at 2:30 PM, of the facility's video recording dated 7/02/17 at 7:30 AM with facility Administrator, revealed Resident #1 was sitting in her wheelchair in the front lobby unsupervised by the entrance doors. There was no receptionist, visitors, or other residents observed. At 7:38 AM, Resident #1 wheeled herself to the main doors, pushed the front door grab bar and exited the facility at that time. Resident #1 was observed leaving the facility, turned left into the driveway located in front of the main entrance to the facility. Review of (undated) Door Alarm Function Monitoring Tool attached to the Provider Investigation Report dated 7/2/17 documented in part: The facility had initiated Door Alarm Function Monitoring Tool to check the functionality of wander guard system on the front entrance door. In an interview on 8/10/17 at 5:00 PM Maintenance Manager stated they were not checking the functionality of the wander guard system until Resident #1 elopement from the facility on 7/2/17. In an interview on 08/09/2017 at 3:00 PM, Administrator confirmed the facility had started checking the functionality of the wander guard system until Resident #1 elopement from the facility on 7/2/17. Review of Physician Orders for Resident #1 dated July 2017 documented in part: Wander guard check placement and function QS (every shift). Interview and record review on 8/11/17 at 9:35 AM, with the Director of Nursing (DON) revealed that the Medication Administration Record (MAR) dated 7/2017 for Resident #1 did not have any written documentation for the Wander Guard checks for placement and function to be done every shift by the licensed staff on 7/01/17, 7/02/17, 7/03/17, and 7/04/17. The DON stated the nurses are responsible for checking the Wander Guard every shift as documented on the MAR and had been trained to initial the MAR when completed. DON stated There is no way to say if they checked the wander guard for placement and functionality checks were done on those days if there are blanks on the MAR for those days. In an interview on 8/11/17 at 2:00 PM, Passerby F, reported that on 7/2/17 at approximately 8:00 AM, he was going north, saw an empty wheelchair wheeling down a driveway into the street. He stopped and got out of his car, stopped the wheelchair from rolling into the street and noted Resident #1 crawling towards the wheelchair. I picked up the resident from the ground and sat her in the wheelchair. I noted that she had scrapes on her knees. She was grimacing and appeared to be in pain. She was wearing a night gown, a brief and noted that her pubic area and buttocks were exposed. I called 911. I also noted that her wheelchair had a number #116 on it and he thought it might belong to the nursing facility. Review of the Emergency Medical Service Transportation Event Information Report dated 7/2/17 documented in part: Elderly female /unaware of situation, wearing pink hoodie and light blue plaid shirt, no bottoms, in wheelchair, does not know where she lives or where she woke up. Problem: Fall, not alert, the reason for the fall is unknown. She is not completely alert (not responding appropriately). Contact with Nursing Facility to see if this might be one of their patients wearing baby blue pink night gown, pink slippers, in wheel chair with facility name. She is in good health, no medical emergency with patient, facility staff is on their way to identify the patient and stated she does have and ankle bracelet with ID, patient released to facility staff. In an interview on 8/10/17 at 4:45 PM Attending Physician stated when Resident #1 eloped from the facility on 7/02/17 she was in tremendous risk, of being injured because she is severely cognitively impaired and could have been run over by a car, was in danger of falling from the wheelchair when propelling the wheelchair down the streets that could have resulted in a neck fracture, or a brain bleed. Review of Nurses Notes written by Licensed Vocations Nurse (LVN) H dated 7/2/17 documented in part: Received call approximately 8:30 AM from police department stating they had located a person with a wheelchair that might be a resident of the facility. The person gave name of Resident #1. Upon arrival to location identified person as Resident #1 sitting in wheelchair. Emergency Medical Services (EMS) had attended call and checked person for any injury to which none was found, some scrapes to knees observed. Patient is confused and states is going to(NAME)Mexico since someone awaits for her. She was not able to state if she has fallen or to how she got out of facility. Has working wander guard to right lower extremity. Responsible party made aware and physician notified. 1 to 1 monitoring. In an interview on 8/7/17 at 5:00 PM Certified Nursing Assistant (CNA) Q reported on 7/2/17 at approximately 7:00 AM she had been assigned to care for Resident #1 on the 6:00 AM -2:00 PM shift. CNA Q stated she had bathed that morning and had left Resident #1 in the 100 hallway where resident resides which is close to the main front entrance of the facility. In an interview on 8/8/17 at 8:45 AM, LVN H stated he was assigned to Resident #1 on 7/02/17 on the morning shift to the 100 hallway. LVN H reported that he had seen Resident #1 sitting in her wheelchair in the 100 hallway waiting for staff to wheel her to the dining room for breakfast. LVN H stated approximately, On that day 7/02/17 at 8:30 AM, I received a call from the police department saying Resident #1 had eloped. The Maintenance Worker and I drove over to where the resident was, picked her up and brought her back to the facility. In an interview on 8/11/17 at 3:17 PM LVN R stated The Wander Guard system in the front entrance doors of the facility sometimes works and sometimes it does not. That is why residents that are at risk of elopement are exiting the facility. Administration knows about this issue, it happens all the time. Review of (undated) ACCUTECH Wander Guard User Manufacturer Manual recommendations documented in part: The TAD (Tag Activator /Deactivator) and PTAD (Partial Tag Activator/Deactivator) are used to check the functionality of an Accutech Tag. Accutech Tags operate by internal battery. Over the course of normal operating, Tags eventually lose battery power and the Tags will need to be replaced. The TAD/PTAD is used to determine if a Tag has sufficient battery power to respond to an activating signal. In order to check the range capability of a Tag, you must take it to an active zone. Testing Tags: for maximum protection of residents or assets, Accutech recommends that Tags be tested on a weekly basis. Resident #26 Record Review of Resident Face Sheet (undated) documented in part: Resident #26 is an [AGE] year old female admitted to the facility on [DATE]. Record Review of History and Physical for Resident #26 dated 11/06/2016 documented in part: past medical history: [MEDICAL CONDITION], hypertension, dementia, decreased hearing, depression, paranoia, auditory hallucinations and [MEDICAL CONDITION]. Record Review of Minimum Data Set ((MDS) dated [DATE] for Resident #26 documented in part: Brief Interview of Mental Status (BIMS) score of 10. This score indicated Resident #26 is moderately cognitively impaired. Resident #26 has highly impaired hearing, clear speech and impaired vision. Resident #26 use a wheelchair as a mobility device. Record Review of Care Plan for Resident #26 dated 05/14/2013 documented in part: Problem Onset: wheels self and is at risk for inadvertent exit. Goal: resident will not exit facility without supervision. Approaches: wander guard to help prevent leaving facility, monitor location as necessary, check for placement and function of wander guard every shift and wander guard to wheelchair, check for function and placement every shift. Record Review of Risk of Elopement/Wandering assessment dated [DATE] for Resident #26 documented in part: Reason for Assessment: Quarterly. Potential Risk Factors: resident with cognitively impaired with poor decision-making skills, resident with [DIAGNOSES REDACTED]. Risk Factors: resident wanders aimlessly or non-goal directed. Resident is at risk for elopement. Intervention: continue with plan of care. Observation on 08/10/2017 at 4:04 PM, Activities Director wheeled Resident #26 to front lobby door. Front door could be opened and no alarm sounded. Resident #26 did not have a wander guard on self or wheelchair. Interview on 08/10/2017 at 4:12 PM, Licensed Vocational Nurse (LVN) Z stated Resident #26 did not have a wander guard on her ankle, they must have taken it off because her ankles are swollen. LVN Z stated wander guards are supposed to be checked every shift by the Charge Nurse. LVN Z stated she had not checked Resident 26s wander guard yet during the shift. Observation on 08/10/2017 at 4:26 PM, Licensed Vocation Nurse (LVN) Z placed new wander guard on Resident #26's left wrist. Resident #28 Review of Face Sheet (undated) for Resident #28 documented in part: an [AGE] year old male admitted to the facility on [DATE]. Resident #28 had a [DIAGNOSES REDACTED]. Review of Minimum Date Set ((MDS) dated [DATE] for Resident #28 documented in part: resident was able to be understood and understand others with clear comprehension. He has a Brief Interview of Mental Status (BIMS) score of 11. This score indicated Resident #28 is moderately cognitively impaired. Resident #28 required 1 person to assist in his activities of daily living. Review of Risk Elopement/Wandering assessment dated [DATE] documented in part: assessment completed due to change of condition. Resident #28 was cognitively impaired with poor decision-making skills and has a [DIAGNOSES REDACTED].#28 ambulated independently without assistive devices and has vision and communication problems. Resident #28 had verbally expressed the desire to go home. Review of Care Plan dated 07/11/2017 for Resident #28 documented in part: Resident wanders. Approaches: wander guard to help prevent leaving facility, monitor locations as necessary, redirect from leaving facility as necessary. Review of Physician Orders dated 07/2017 for Resident #28 documented in part: Wander guard to left ankle, check placement and function every shift. Observation on 08/10/2017 at 3:30 PM, Resident #28's wander guard bracelet did not activate wander guard alarm. Resident #28 was wheeled to front lobby door by Licensed Vocational Nurse (LVN) Y. Front door could be opened and no alarm sounded. Resident #28 had wander guard on his right ankle. LVN Y checked Resident #28's wander guard with wand. LVN Y replaced Resident 28's wander guard with new wander guard and confirmed it was working with wander guard wand. Interview on 08/10/2017 at 3:34 PM, LVN Y stated Resident 28's wander guard was not working when tested by the front door. LVN Y stated if the wander guard was working the door would have locked and the alarm above the door would have went off. LVN Y stated wander guard looked like it had water damage and stated it needed to be replaced. LVN Y stated wander guards are to be checked every shift by Charge Nurse. LVN Y stated she had not checked Resident #28's wander guards yet during her shift. In an interview on 08/09/2017 at 3:30 PM, Director of Nursing (DON) stated the facility did not have a formal protocol to check the physical locations of residents identified as elopement risk. She stated the nurses and nursing assistants check those resident's whereabouts in their 2 hour rounding, at meal times and during medication administration. Review of facility policy on Monitoring of Resident Location (undated) documented in part: A resident who is prone to wander, may be monitored frequently to confirm location. The decision to monitor a resident or monitor and document the monitoring of a resident will be the responsibility of the Administrator, Director of Nurses, Charge Nurse or as indicated by the Plan of Care. It will be the responsibility of their Charge Nurse or his/her designee to monitor residents who are prone to wander. Frequency of monitoring is to be determined by Charge Nurse or as indicated in the Plan of Care. A resident may be monitored: every 15 min (or every 15 minutes when awake), every 30 minutes, every hour. Then a resident on monitoring leaves the unit with staff from a department, that staff member must advise the nursing staff or resident's location. Review of facility policy (undated) on Safety and Supervision of Residents documented in part: Resident supervision is a core competence of the systems approach to safety. The type and frequency of resident supervision is determine by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. Review of the facility policy (undated) on Missing Resident documented in part: To ensure the health, safety and welfare of residents all times, each unit Charge Nurse during their respective tour of duty will be aware and responsible for knowing the location of their residents at all times. When residents are participating in various programs such as physical therapy, recreational activities, dining, etc. the staff in these program areas will exercise sound judgement and be aware and responsible for the health safety and welfare of their participants. Review of the facility policy (undated), on Wandering, Unsafe Resident documented in part: The facility will strive to prevent unsafe wandering while mainlining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. At-risk for wandering/elopement assessments will be conducted upon admission, quarterly and when there is a significant change in condition. The Resident's care plan will indicate the resident is at risk for elopement or another safety issues. Intervention to try to maintain safety, such as a detailed monitoring plan will be included. Review of the facility policy (undated) on Wander Guard documented in part: The facility recognize the need to provide a safe and secure environment for residents who's wandering may place them at risk for elopement. The system is a selective alarm system that is installed on exterior doors. The system alarms when residents wearing a bracelet signaling device attempts to pass through a monitored area. Residents identified at risk for elopement will have a bracelet signaling device' applied to their wrist. The Wander Guard computer system monitors location of the resident and alarm when a resident passes through a monitored door to exit. The system only alarms for residents wearing the bracelet signaling device. Order is set in Blue Strata for wander guard Nurse will obtain an order for [REDACTED]. An immediate Jeopardy was identified on 8/10/17 and the Nursing Home Administrator (NHA) was informed at 3:30 PM. On 8/11/17 at 3:16 PM, the Plan of Removal was accepted, which included: I. Interventions: -19 residents have been re-assessed for risk of elopement by 8/10/17 by the alleged deficient practice on 8/10/17. -All residents have been re-assessed for risk of elopement by 8/10/17 by completed elopement risk assessment. Any residents identified to be an elopement risk will have a wander guard applied, care plan updated, Medical Doctor (MD) responsible party notified and order obtained. No new residents identified for risk of elopement. -All licensed nursing staff will be in-services on ensuring wander guard bracelets are on residents, functioning properly and documented on MARS during each sift. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All Certified Nursing Assistant's (CNA's) will be in-serviced on monitoring if wander guard bracelet is physically on resident. If residents displays behavior of removing wander guard bracelet, notify charge nurses/Assistant Director of Nurses (ADON) /DON. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All licensed nursing staff and CNA's will be in-serviced on monitoring residents at risk of elopement at least every 1 hour. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All nursing management staff will be in-serviced to ensure care plans are updated, MD/Responsible Party (RP) are notified, MD order obtained and transcribed. Appropriate interventions will be implemented to prevent residents from removing wander guard bracelets/and or elopements. In-service to be completed by 8/11/17 and any staff that has not completed this in service will not be re-stated to their work schedule until completing in-service. -All staff will be in-serviced on facility elopement policy and procedures, and then need to observe the residents at risk of elopement during the activity they are responsible for, including what to do in the event of elopement, elopement preventing and location of elopement book. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -Maintenance staff will be in-serviced on testing wander guard boxes for functionality, following manufacturing guidelines, on a weekly basis. -Residents at risk of elopement will be observed during rounds every 1 hour by licensed nursing staff. II. Monitoring: -DON/ADON will randomly check MARS to ensure resident wander guards are documented and tested for functionality -Administrator will ensure DON/ADON are checking MARS for wander guard placement and functionality, and maintenance staff is testing wander guard boxes for functionality on a weekly basis for 3 months. -Any identified areas of concern identified during audits conducted by Administrator/DON/ADON/maintenance will be reviewed on a weekly basis for 30 days, then during monthly Quality Assurance Performance Improvement (QUAPI) meeting thereafter. Interviews done with Licensed Staff on all three shifts and on the weekend staff 10:00Am through 3:00 revealed they had been trained on ensuring wander guard bracelets are on residents, functioning properly and documented on MARS during each shift. All CNA's were trained on monitoring if wander guard bracelet is physically on resident, if not to notify ADON/DON. All licensed nursing staff and CNA's were in serviced on monitoring residents a risk of elopement at least every 1 hour. All nursing management staff were in-service to ensure care plan were updated, MD/RP notified, MD order obtained and transcribed. All staff was in-serviced on the elopement policy and procedures, and the need to observe the residents at risk of elopement during the activity they are responsible for, including what to do in the event of and elopement, elopement prevention and location of elopement book. Maintenance staff was in serviced on testing wander guard boxes for functionality following manufacturing guidelines on a weekly basis. The Plan of Removal was verified as having been implemented as follows: Interviews and record reviews done on 8/14/17 at 8:30 AM with DON revealed: -All available staff had been trained by 8/12/17 on the new protocols and were aware of the residents identified as elopement risk. -Residents identified as elopement risk who had a wander guard had been taken to the front door to test the efficacy of the wander guard bracelet -Residents identified as elopement risk were re-assessed for elopement and were monitored using the facility monitoring tool every 15 minutes. -Care plan were reviewed and updated for all elopement risk residents. -Maintenance staff was aware of the monitoring and maintenance of facility wander guard door alarms was conducted according to the manual guidelines. The Nursing Home Administrator was informed the IJ had been lifted on 8/12/17 at 10:00 PM. While the Immediate Jeopardy was lifted, the facility remained out of compliance at potential for more than minimal harm pattern due to the facility need to evaluate and monitor their corrective action system. Review of the Medical Device Report dated 8/10/17 revealed 19 residents were identified as an elopement risk and had a wander guard bracelet in place.

Based on interview, and record review the facility failed to provide supervision to prevent accidents for three residents (Resident #1, Resident #26, and #28) of 29 residents reviewed for accidents and supervision. The facility failed to adequately supervise those residents identified at risk of elopement; failed to check the wander guard bracelet and wander guard system for functionality according to manufacturing recommendations until after the incident involving Resident #1 on 7/2/17. On 7/02/17 at 7:38 AM, Resident #1, who was assessed to be at risk for elopement/wandering, wheeled herself out through the front entrance of the facility. Resident #1 had a wander guard bracelet in place, and the wander guard alarm on the front entrance was not activated when resident #1 exited the facility. The resident wheeled herself approximately half a mile along highly traffic streets in her wheelchair and was found lying on the ground in a driveway by a passerby. The facility staff were not aware resident #1 had eloped until the Police Department called the facility on 7/2/17 at 8:30 AM asking if they had a resident that was missing. Two other residents who were care planned for the use of wander guards were checked for wander guards and functionality of the guards on 8/10/17. Resident #26 did not have her wander guard on and #28's wander guard did not activate the system. On 8/10/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 8/12/17 the facility remained out of compliance at potential for more than minimal harm pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 19 residents identified by the facility as having elopement risk behaviors, placing them at risk of injury or death during an elopement. The findings include: Resident #1 Review of Face Sheet dated 8/10/17 revealed Resident #1 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. In an observation on 8/7/17 at 12:00 Noon, Resident #1 was observed eating in the dining room. She appeared clean and well groomed. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] documented in part: rarely/never made herself understood; sometimes was able to understand others; short and long term memory problems; severely impaired-never rarely made decisions; required extensive to total assistance of 1 person with all activities of daily living; balance from surface to surface was not steady only able to stabilize with staff assistance; and was incontinent of bowel and bladder. Review of Resident #1 Care Plan documented in part: Problem Onset: 6/21/17 :Wanders; Approaches: Wander guard to help prevent leaving of facility, Monitor resident's location as necessary, Redirect resident from leaving facility as necessary, Check wander guard placement every shift, wander guard in place to right lower extremity. Review of Risk of Elopement/Wandering assessment dated [DATE] for Resident #1 which was completed for a change in condition documented in part: resident was cognitively impaired with poor decision-making skills. She had a [DIAGNOSES REDACTED]. She verbally expressed the desire to go home, packed belongings to go home or stayed near exit door. Her family had verbalized concerns she had wandering tendencies. Resident #1 at Risk for elopement/wandering at this time: Yes. Appropriate intervention, initiated, placed wander guard on the resident ankle. Review of Incident/Accident Report dated 7/2/17, written by LVN H documented in part: received call from police department on 7/2/17 at 8:30 AM stating they have a person that might be a resident from facility. Upon arrival to location writer able to identify subject as Resident #1. Additional comments and or steps taken to prevent recurrence: Wander Guard system, 1 hour checks in place, nurse conducted full assessment. Review of the Provider Investigation Report dated 7/02/17, documented in part: At approximately 8:30 AM police officer notified facility that they had a person that might be a resident of our facility and identified self as Resident #1. The police officer noted that resident was found approximately 0.4 miles from facility. Licensed Vocational Nurse (LVN) H spoke to the officer and asked the officer to bring person to facility to identify. Upon arrival LVN H identified resident as Resident #1. Resident stated I want to go to the bridge, I'm going to visit my family in Juarez, Mexico. At the time police officer called facility is when facility became aware resident #1 was missing. Review of facility's video camera system revealed on 7/02/17 at 7:38 AM, resident #1 in wheelchair, wheeling self through the front door entrance. The video shows no receptionist, staff or visitor present at that time. Abrasion noted to L (left) knee. Resident #1 exited facility on 7/02/17 at 7:38 AM, even though resident was wearing a wander guard bracelet, resident was able to prop door open. It is unclear if alarm sounded and disengaged because the receptionist arrives 4 minutes and stated the wander alarm was not on when she arrived on 7/02/17. Further, when resident returned to facility via Emergency Medical Services (EMS) and police department LVN F and Maintenance Worker checked wander guard system, bracelet And confirmed it functioned properly. In an observation and review on 7/12/17 at 2:30 PM, of the facility's video recording dated 7/02/17 at 7:30 AM with facility Administrator, revealed Resident #1 was sitting in her wheelchair in the front lobby unsupervised by the entrance doors. There was no receptionist, visitors, or other residents observed. At 7:38 AM, Resident #1 wheeled herself to the main doors, pushed the front door grab bar and exited the facility at that time. Resident #1 was observed leaving the facility, turned left into the driveway located in front of the main entrance to the facility. Review of (undated) Door Alarm Function Monitoring Tool attached to the Provider Investigation Report dated 7/2/17 documented in part: The facility had initiated Door Alarm Function Monitoring Tool to check the functionality of wander guard system on the front entrance door. In an interview on 8/10/17 at 5:00 PM Maintenance Manager stated they were not checking the functionality of the wander guard system until Resident #1 elopement from the facility on 7/2/17. In an interview on 08/09/2017 at 3:00 PM, Administrator confirmed the facility had started checking the functionality of the wander guard system until Resident #1 elopement from the facility on 7/2/17. Review of Physician Orders for Resident #1 dated July 2017 documented in part: Wander guard check placement and function QS (every shift). Interview and record review on 8/11/17 at 9:35 AM, with the Director of Nursing (DON) revealed that the Medication Administration Record (MAR) dated 7/2017 for Resident #1 did not have any written documentation for the Wander Guard checks for placement and function to be done every shift by the licensed staff on 7/01/17, 7/02/17, 7/03/17, and 7/04/17. The DON stated the nurses are responsible for checking the Wander Guard every shift as documented on the MAR and had been trained to initial the MAR when completed. DON stated There is no way to say if they checked the wander guard for placement and functionality checks were done on those days if there are blanks on the MAR for those days. In an interview on 8/11/17 at 2:00 PM, Passerby F, reported that on 7/2/17 at approximately 8:00 AM, he was going north, saw an empty wheelchair wheeling down a driveway into the street. He stopped and got out of his car, stopped the wheelchair from rolling into the street and noted Resident #1 crawling towards the wheelchair. I picked up the resident from the ground and sat her in the wheelchair. I noted that she had scrapes on her knees. She was grimacing and appeared to be in pain. She was wearing a night gown, a brief and noted that her pubic area and buttocks were exposed. I called 911. I also noted that her wheelchair had a number #116 on it and he thought it might belong to the nursing facility. Review of the Emergency Medical Service Transportation Event Information Report dated 7/2/17 documented in part: Elderly female /unaware of situation, wearing pink hoodie and light blue plaid shirt, no bottoms, in wheelchair, does not know where she lives or where she woke up. Problem: Fall, not alert, the reason for the fall is unknown. She is not completely alert (not responding appropriately). Contact with Nursing Facility to see if this might be one of their patients wearing baby blue pink night gown, pink slippers, in wheel chair with facility name. She is in good health, no medical emergency with patient, facility staff is on their way to identify the patient and stated she does have and ankle bracelet with ID, patient released to facility staff. In an interview on 8/10/17 at 4:45 PM Attending Physician stated when Resident #1 eloped from the facility on 7/02/17 she was in tremendous risk, of being injured because she is severely cognitively impaired and could have been run over by a car, was in danger of falling from the wheelchair when propelling the wheelchair down the streets that could have resulted in a neck fracture, or a brain bleed. Review of Nurses Notes written by Licensed Vocations Nurse (LVN) H dated 7/2/17 documented in part: Received call approximately 8:30 AM from police department stating they had located a person with a wheelchair that might be a resident of the facility. The person gave name of Resident #1. Upon arrival to location identified person as Resident #1 sitting in wheelchair. Emergency Medical Services (EMS) had attended call and checked person for any injury to which none was found, some scrapes to knees observed. Patient is confused and states is going to Juarez Mexico since someone awaits for her. She was not able to state if she has fallen or how she got out of facility. Has working wander guard to right lower extremity. Responsible party made aware and physician notified. 1 to 1 monitoring. In an interview on 8/7/17 at 5:00 PM Certified Nursing Assistant (CNA) Q reported on 7/2/17 at approximately 7:00 AM she had been assigned to care for Resident #1 on the 6:00 AM -2:00 PM shift. CNA Q stated she had bathed that morning and had left Resident #1 in the 100 hallway where resident resides which is close to the main front entrance of the facility. In an interview on 8/8/17 at 8:45 AM, LVN H stated he was assigned to Resident #1 on 7/02/17 on the morning shift to the 100 hallway. LVN H reported that he had seen Resident #1 sitting in her wheelchair in the 100 hallway waiting for staff to wheel her to the dining room for breakfast. LVN H stated approximately, On that day 7/02/17 at 8:30 AM, I received a call from the police department saying Resident #1 had eloped. The Maintenance Worker and I drove over to where the resident was, picked her up and brought her back to the facility. In an interview on 8/11/17 at 3:17 PM LVN R stated The Wander Guard system in the front entrance doors of the facility sometimes works and sometimes it does not. That is why residents that are at risk of elopement are exiting the facility. Administration knows about this issue, it happens all the time. Review of (undated) ACCUTECH Wander Guard User Manufacturer Manual recommendations documented in part: The TAD (Tag Activator /Deactivator) and PTAD (Partial Tag Activator/Deactivator) are used to check the functionality of an Accutech Tag. Accutech Tags operate by internal battery. Over the course of normal operating, Tags eventually lose battery power and the Tags will need to be replaced. The TAD/PTAD is used to determine if a Tag has sufficient battery power to respond to an activating signal. In order to check the range capability of a Tag, you must take it to an active zone. Testing Tags: for maximum protection of residents or assets, Accutech recommends that Tags be tested on a weekly basis. Resident #26 Record Review of Resident Face Sheet (undated) documented in part: Resident #26 is an [AGE] year old female admitted to the facility on [DATE]. Record Review of History and Physical for Resident #26 dated 11/06/2016 documented in part: past medical history: coronary artery disease, hypertension, dementia, decreased hearing, depression, paranoia, auditory hallucinations and psychosis. Record Review of Minimum Data Set ((MDS) dated [DATE] for Resident #26 documented in part: Brief Interview of Mental Status (BIMS) score of 10. This score indicated Resident #26 is moderately cognitively impaired. Resident #26 has highly impaired hearing, clear speech and impaired vision. Resident #26 use a wheelchair as a mobility device. Record Review of Care Plan for Resident #26 dated 05/14/2013 documented in part: Problem Onset: wheels self and is at risk for inadvertent exit. Goal: resident will not exit facility without supervision. Approaches: wander guard to help prevent leaving facility, monitor location as necessary, check for placement and function of wander guard every shift and wander guard to wheelchair, check for function and placement every shift. Record Review of Risk of Elopement/Wandering assessment dated [DATE] for Resident #26 documented in part: Reason for Assessment: Quarterly. Potential Risk Factors: resident with cognitively impaired with poor decision-making skills, resident with [DIAGNOSES REDACTED]. Risk Factors: resident wanders aimlessly or non-goal directed. Resident is at risk for elopement. Intervention: continue with plan of care. Observation on 08/10/2017 at 4:04 PM, Activities Director wheeled Resident #26 to front lobby door. Front door could be opened and no alarm sounded. Resident #26 did not have a wander guard on self or wheelchair. Interview on 08/10/2017 at 4:12 PM, Licensed Vocational Nurse (LVN) Z stated Resident #26 did not have a wander guard on her ankle, they must have taken it off because her ankles are swollen. LVN Z stated wander guards are supposed to be checked every shift by the Charge Nurse. LVN Z stated she had not checked Resident 26s wander guard yet during the shift. Observation on 08/10/2017 at 4:26 PM, Licensed Vocation Nurse (LVN) Z placed new wander guard on Resident #26's left wrist. Resident #28 Review of Face Sheet (undated) for Resident #28 documented in part: an [AGE] year old male admitted to the facility on [DATE]. Resident #28 had a [DIAGNOSES REDACTED]. Review of Minimum Date Set ((MDS) dated [DATE] for Resident #28 documented in part: resident was able to be understood and understand others with clear comprehension. He has a Brief Interview of Mental Status (BIMS) score of 11. This score indicated Resident #28 is moderately cognitively impaired. Resident #28 required 1 person to assist in his activities of daily living. Review of Risk Elopement/Wandering assessment dated [DATE] documented in part: assessment completed due to change of condition. Resident #28 was cognitively impaired with poor decision-making skills and has a [DIAGNOSES REDACTED].#28 ambulated independently without assistive devices and has vision and communication problems. Resident #28 had verbally expressed the desire to go home. Review of Care Plan dated 07/11/2017 for Resident #28 documented in part: Resident wanders. Approaches: wander guard to help prevent leaving facility, monitor locations as necessary, redirect from leaving facility as necessary. Review of Physician Orders dated 07/2017 for Resident #28 documented in part: Wander guard to left ankle, check placement and function every shift. Observation on 08/10/2017 at 3:30 PM, Resident #28's wander guard bracelet did not activate wander guard alarm. Resident #28 was wheeled to front lobby door by Licensed Vocational Nurse (LVN) Y. Front door could be opened and no alarm sounded. Resident #28 had wander guard on his right ankle. LVN Y checked Resident #28's wander guard with wand. LVN Y replaced Resident 28's wander guard with new wander guard and confirmed it was working with wander guard wand. Interview on 08/10/2017 at 3:34 PM, LVN Y stated Resident 28's wander guard was not working when tested by the front door. LVN Y stated if the wander guard was working the door would have locked and the alarm above the door would have went off. LVN Y stated wander guard looked like it had water damage and stated it needed to be replaced. LVN Y stated wander guards are to be checked every shift by Charge Nurse. LVN Y stated she had not checked Resident #28's wander guards yet during her shift. In an interview on 08/09/2017 at 3:30 PM, Director of Nursing (DON) stated the facility did not have a formal protocol to check the physical locations of residents identified as elopement risk. She stated the nurses and nursing assistants check those resident's whereabouts in their 2 hour rounding, at meal times and during medication administration. Review of facility policy on Monitoring of Resident Location (undated) documented in part: A resident who is prone to wander, may be monitored frequently to confirm location. The decision to monitor a resident or monitor and document the monitoring of a resident will be the responsibility of the Administrator, Director of Nurses, Charge Nurse or as indicated by the Plan of Care. It will be the responsibility of their Charge Nurse or his/her designee to monitor residents who are prone to wander. Frequency of monitoring is to be determined by Charge Nurse or as indicated in the Plan of Care. A resident may be monitored: every 15 min (or every 15 minutes when awake), every 30 minutes, every hour. Then a resident on monitoring leaves the unit with staff from a department, that staff member must advise the nursing staff or resident's location. Review of facility policy (undated) on Safety and Supervision of Residents documented in part: Resident supervision is a core competence of the systems approach to safety. The type and frequency of resident supervision is determine by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. Review of the facility policy (undated) on Missing Resident documented in part: To ensure the health, safety and welfare of residents all times, each unit Charge Nurse during their respective tour of duty will be aware and responsible for knowing the location of their residents at all times. When residents are participating in various programs such as physical therapy, recreational activities, dining, etc. the staff in these program areas will exercise sound judgement and be aware and responsible for the health safety and welfare of their participants. Review of the facility policy (undated), on Wandering, Unsafe Resident documented in part: The facility will strive to prevent unsafe wandering while mainlining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. At-risk for wandering/elopement assessments will be conducted upon admission, quarterly and when there is a significant change in condition. The Resident's care plan will indicate the resident is at risk for elopement or another safety issues. Intervention to try to maintain safety, such as a detailed monitoring plan will be included. Review of the facility policy (undated) on Wander Guard documented in part: The facility recognize the need to provide a safe and secure environment for residents who's wandering may place them at risk for elopement. The system is a selective alarm system that is installed on exterior doors. The system alarms when residents wearing a bracelet signaling device attempts to pass through a monitored area. Residents identified at risk for elopement will have a bracelet signaling device' applied to their wrist. The Wander Guard computer system monitors location of the resident and alarm when a resident passes through a monitored door to exit. The system only alarms for residents wearing the bracelet signaling device. Order is set in Blue Strata for wander guard Nurse will obtain an order for [REDACTED]. An immediate Jeopardy was identified on 8/10/17 and the Nursing Home Administrator (NHA) was informed at 3:30 PM. On 8/11/17 at 3:16 PM, the Plan of Removal was accepted, which included: I. Interventions: -19 residents have been re-assessed for risk of elopement by 8/10/17 by the alleged deficient practice on 8/10/17. -All residents have been re-assessed for risk of elopement by 8/10/17 by completed elopement risk assessment. Any residents identified to be an elopement risk will have a wander guard applied, care plan updated, Medical Doctor (MD) responsible party notified and order obtained. No new residents identified for risk of elopement. -All licensed nursing staff will be in-services on ensuring wander guard bracelets are on residents, functioning properly and documented on MARS during each sift. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All Certified Nursing Assistant's (CNA's) will be in-serviced on monitoring if wander guard bracelet is physically on resident. If residents displays behavior of removing wander guard bracelet, notify charge nurses/Assistant Director of Nurses (ADON) /DON. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All licensed nursing staff and CNA's will be in-serviced on monitoring residents at risk of elopement at least every 1 hour. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -All nursing management staff will be in-serviced to ensure care plans are updated, MD/Responsible Party (RP) are notified, MD order obtained and transcribed. Appropriate interventions will be implemented to prevent residents from removing wander guard bracelets/and or elopements. In-service to be completed by 8/11/17 and any staff that has not completed this in service will not be re-stated to their work schedule until completing in-service. -All staff will be in-serviced on facility elopement policy and procedures, and then need to observe the residents at risk of elopement during the activity they are responsible for, including what to do in the event of elopement, elopement preventing and location of elopement book. In-service to be completed by 8/11/17 and any staff that has not completed this in-service will not be re-instated to their work schedule until completing in-service. -Maintenance staff will be in-serviced on testing wander guard boxes for functionality, following manufacturing guidelines, on a weekly basis. -Residents at risk of elopement will be observed during rounds every 1 hour by licensed nursing staff. II. Monitoring: -DON/ADON will randomly check MARS to ensure resident wander guards are documented and tested for functionality -Administrator will ensure DON/ADON are checking MARS for wander guard placement and functionality, and maintenance staff is testing wander guard boxes for functionality on a weekly basis for 3 months. -Any identified areas of concern identified during audits conducted by Administrator/DON/ADON/maintenance will be reviewed on a weekly basis for 30 days, then during monthly Quality Assurance Performance Improvement (QUAPI) meeting thereafter. Interviews done with Licensed Staff on all three shifts and on the weekend staff 10:00Am through 3:00 revealed they had been trained on ensuring wander guard bracelets are on residents, functioning properly and documented on MARS during each shift. All CNA's were trained on monitoring if wander guard bracelet is physically on resident, if not to notify ADON/DON. All licensed nursing staff and CNA's were in serviced on monitoring residents a risk of elopement at least every 1 hour. All nursing management staff were in-service to ensure care plan were updated, MD/RP notified, MD order obtained and transcribed. All staff was in-serviced on the elopement policy and procedures, and the need to observe the residents at risk of elopement during the activity they are responsible for, including what to do in the event of and elopement, elopement prevention and location of elopement book. Maintenance staff was in serviced on testing wander guard boxes for functionality following manufacturing guidelines on a weekly basis. The Plan of Removal was verified as having been implemented as follows: Interviews and record reviews done on 8/14/17 at 8:30 AM with DON revealed: -All available staff had been trained by 8/12/17 on the new protocols and were aware of the residents identified as elopement risk. -Residents identified as elopement risk who had a wander guard had been taken to the front door to test the efficacy of the wander guard bracelet -Residents identified as elopement risk were re-assessed for elopement and were monitored using the facility monitoring tool every 15 minutes. -Care plan were reviewed and updated for all elopement risk residents. -Maintenance staff was aware of the monitoring and maintenance of facility wander guard door alarms was conducted according to the manual guidelines. The Nursing Home Administrator was informed the IJ had been lifted on 8/12/17 at 10:00 PM. While the Immediate Jeopardy was lifted, the facility remained out of compliance at potential for more than minimal harm pattern due to the facility need to evaluate and monitor their corrective action system. Review of the Medical Device Report dated 8/10/17 revealed 19 residents were identified as an elopement risk and had a wander guard bracelet in place.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food under sanitary conditions in one of one facility kitchens. A. The facility served unpasteurized eggs with runny yolks on 8/04/15 and 8/05/15 to 7 residents (Residents #3, #6, #25, #29, #30, #35 and #36) of 18 residents identified who request their eggs soft cooked. The deficient practice of serving undercooked, unpasteurized eggs resulted in an immediate jeopardy identified on 8/06/15. While the immediate jeopardy was removed on 8/07/15 at 10:24 AM, the facility remained out of compliance at a scope and severity at a pattern level with no actual harm that is not immediate jeopardy as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 18 residents at risk of food-borne illnesses. Additional deficiencies included: B. Frozen foods were not thawed appropriately C. Raw foods were adjacent to cooked foods D. Cooked foods were not cooled appropriately E. Foods storage containers were not clean F. Kitchen staff did not wear gloves when handling foods G. Clean flatware was not stored in a sanitary manner These failures could place 100 residents served food from the kitchen at risk of food-borne illnesses The findings include: A. Eggs Record review of residents' face sheets and History and Physicals revealed the following: a) Face sheet dated 7/30/15 documented Resident #3 was an [AGE] year old man admitted on [DATE]. The Medical History and Admission Examination dated 8/02/15 included [DIAGNOSES REDACTED]. b) Face sheet dated 5/07/15 documented Resident #6 was an [AGE] year old woman admitted on [DATE] with [DIAGNOSES REDACTED]. c) Face sheet dated 8/07/15 documented Resident #25 was an [AGE] year old woman admitted on [DATE]. The Medical History and Admission Examination dated 4/16/15 documented [DIAGNOSES REDACTED]. d) History and Admission Examination dated 5/04/15 documented Resident #29 was an [AGE] year old woman with [DIAGNOSES REDACTED]. e) Resident #30 was an [AGE] year old female with [DIAGNOSES REDACTED]. f) Resident #35 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. g) Face Sheet dated 8/07/15 documented Resident #36 was an [AGE] year old man readmitted on [DATE]. History and Admission Examination dated 4/06/15 documented [DIAGNOSES REDACTED]. [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]), debility, and [MEDICAL CONDITION]. On 8/4/15, review of the document titled (Facility) Weekly Menus: Summer/Fall 2014 Week 3 revealed that eggs were served every day for breakfast from 8/3/15 to 08/09/15. 18) On 8/6/15, review of invoices for facility food purchases revealed the following: a) On 7/30/15 three cases of large white pasteurized shell eggs were ordered, but none were delivered; b) On 7/31/15 two cases of large grade AA white shell eggs were delivered (unpasteurized); c) On 8/3/15 two cases of large white pasteurized shell eggs were ordered but none were delivered. Observation on 8/04/15 at 8:41 AM, Resident #3 was served and ate breakfast consisting of sausage, biscuit and an egg with a runny yolk. Observation of breakfast on 8/05/15 from 8:19 to 8:40 AM, Residents #3, #6, #25, #29, #30, #35, and #36 were served and ate eggs with runny yolks. Observations of the kitchen on 8/05/15 at 8:20 AM: a) The facility refrigerator contained one half-empty and one unopened case of eggs. Neither the cases nor the eggs had markings indicating that the eggs were pasteurized. b) Behind the serving line, a flat of eggs without pasteurized markings sat on the counter beside an electric griddle. The Cook broke six of the unpasteurized eggs onto the griddle, and then turned them over. c) The Cook uncovered a plate containing four fried eggs and slid them onto two different plates, leaving a trail of runny egg yolk on the plate. Observation 8/05/15 at 8:25 AM, Assistant Director of Nursing (ADON) J cut eggs on the plate of Resident #3. The yolks of the eggs were runny. ADON J said the egg yolks were runny. Observation on 8/05/15 at 8:30 AM, the Cook checked temperatures of 4 unpasteurized eggs with runny yolks held on the serving line by inserting a thermometer into the runny yolks. The temperature of the eggs checked was 133.5 degrees Fahrenheit. Interview on 8/4/15 at 9:50 AM, the Dietary Supervisor (DS) said the 1.5 cases of eggs in the refrigerator were unpasteurized. The DS said she had not been able to get pasteurized eggs from her suppliers because of the bird flu. In an interview on 8/05/15 at 8:20 AM, the Cook said he was going to cook them (eggs) through because they were not pasteurized. He said the temperature of cooked unpasteurized eggs should be 160 degrees and that unpasteurized eggs should be cooked through. He stated that he waits until they (eggs) are completely solid. The Cook said the yolks of unpasteurized eggs being held on the serving line were not cooked through, and should be thrown away. In an interview on 8/05/15 at 8:42 AM, the DS said the eggs that were being eaten by Resident #3 were not pasteurized and were not cooked through. She said eat eggs should be cooked until they reach 135 degrees and cooked solid. The DS said she has not been able to get pasteurized eggs from her supplier, but the residents demand over-easy or other undercooked forms of eggs, and would not eat eggs unless they were cooked to order. In an interview on 8/5/15 at 10:40 AM, the DS said the facility's 2 food suppliers were both short on pasteurized eggs. She said food orders were placed with suppliers on Tuesdays and Fridays, and that two cases of pasteurized eggs were ordered each time, arriving on Mondays and Thursdays. She said recently ordered pasteurized eggs were sometimes not delivered. The DS said the pasteurized eggs ordered on [DATE] were not delivered on 8/3/15 and the facility ran out of pasteurized eggs over the weekend. She said since the facility was not able to get pasteurized eggs they had started ordering unpasteurized eggs. The DS said she had talked to residents about not being able to serve them eggs with runny yolks, and she asked the nurses and aides to talk with residents about not asking for eggs with runny yolks, but that the nurses would still ask the cooks for eggs with runny yolks. She said she had talked to the Nursing Facility Administrator (NFA) about not being able to get pasteurized eggs and he indicated she should try to give the residents what they wanted. In an interview on 8/05/15 at 4:09 PM, the DS said the Cook knew the eggs used this morning were uncooked because the residents would not eat them if the yolk was hard. The DS said on 8/04/15 eggs were served cooked hard to the residents and some of the residents were angry and refused to eat them. The DS said there were no undercooked eggs served on 8/04/15, but when reminded Resident #3 had an egg with a runny yolk on 8/04/15, the DS said the Cook did make him an egg with a runny yolk because he wanted one. In an interview on 8/05/15 at 4:33 PM, the Nursing Facility Administrator (NFA) said the DS called him and told him she told the state surveyor she was serving unpasteurized eggs and the NFA was aware. The NFA said he was not aware this was occurring. The NFA denied telling the DS to go ahead and give the residents what they want. The NFA said the DS was responsible for ordering the facility food. The NFA said he only looks at food temperatures and refrigerator temperatures. The NFA said the DS made a decision to use unpasteurized eggs without consulting him. In an interview on 8/06/15 at 3:17 PM, the Registered Dietician (RD) said if unpasteurized eggs are not cooked to the proper temperature (160 - 165 degrees F) there is a risk of food-borne illness from Salmonella. Review of facility's policy entitled Dietary/Food Handling, revised April 2001, provided by the Director of Nurses on 8/06/15 stated in part: 6. Fresh eggs may be served only in the following manner: a. Baked; b. Hard-boiled; c. Fried; or d. Scrambled. 7. Under no circumstances may uncooked or undercooked eggs be served. Review of CMS letter 14-34 dated May 20, 2014 stated, in part, Skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritidis (SE). In accordance with the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) standards, skilled nursing and nursing facilities should not prepare nor serve soft-cooked, undercooked or sunny-side up eggs from unpasteurized eggs. Review of the Food and Drug Administration web site (www.fda.gov <http://www.fda.gov>) retrieved on 8/10/15: Egg Safety Final Rule Egg-associated illness caused by Salmonella is a serious public health problem. Infected individuals may suffer mild to severe gastrointestinal illness, short term or chronic arthritis, or even death. Implementing the preventive measures would reduce the number of Salmonella Enteritidis infections from eggs by nearly 60 percent. An immediate jeopardy was identified on 8/06/15 and the Nursing Facility Administrator was informed at 10:46 AM on 8/06/15. On 8/06/15 the facility submitted their corrective action plan of removal. The Plan of Action dated 8/6/15 documented the following: 1) Facility disposed of all non-pasteurized eggs, and discontinued all use of non-pasteurized eggs. 2) Corrective Actions for Specific Residents: 18 residents identified to have received non-pasteurized eggs over-easy were assessed and monitored for signs and symptoms of diarrhea and vomiting. 3) Corrective Actions for Other Residents: All residents will be served only pasteurized eggs. On 8/6/15 the DS and Registered Dietitian in-serviced staff on proper preparation of eggs per facility policy and procedure on food preparation. 4) Measures/System Changes Made: NFA notified food service vendor to no longer supply the facility with any non-pasteurized eggs. New employees will be in-serviced on proper preparation of eggs per facility policy and use of only pasteurized eggs. On 8/6/15 NFA in-serviced DS regarding what to order when vendor does not have pasteurized eggs. 5) Monitoring of Corrective Actions: During weekly visits Registered Dietitian will monitor food preparation to ensure eggs are prepared and served as per policy. Concerns arising during monitoring will be acted upon immediately and reported through Quality Assurance meetings Observations on 8/06/15 and 8/07/15 confirmed there were no unpasteurized eggs in the facility. Observations on 8/06/15 and 8/07/15 confirmed pasteurized eggs were being used for all undercooked egg dishes. Interviews on 8/07/15 with 4 Licensed Vocational Nurses, the DS, the Cook, and Dietary Aides T and U confirmed they were aware of the facility policy for the use of pasteurized eggs and when unpasteurized eggs could be used. The nursing staff said they were monitoring the residents who received undercooked unpasteurized eggs for gastrointestinal symptoms and fever for 72 hours. They will then watch resident meals for undercooked eggs on resident plates and be sure the eggs were made from pasteurized eggs. The NFA was informed the immediate jeopardy was lowered effective 8/07/15 at 10:24 AM. The facility remained out of compliance at a scope and severity at a pattern of no actual harm with potential for more than minimal harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. B. Observations on 8/05/15 at 4:01 PM, in the kitchen, revealed the following: a. In one side of a 2 compartment sink was a steam table insert contained 2 large bagged meats. They were sitting in bloody water. Next to them was a 10 pound log of hamburger meat that was under running water. b. On a counter across from the refrigerator was a large pan of eggs in warm water. Several of the eggs were cracked and there was cooked egg seeping out of some of the eggs. The DS told Dietary Aide F to put the eggs in the refrigerator in about an hour after they cool. c. In the refrigerator a large canister contained eggs marked with a P (pasteurized), many were cracked and were laying in a colorless fluid. Dietary Aide F took the container of eggs to pour out the liquid per the DS instructions. d. The DS placed the pot of cracked hard-boiled eggs in water in the other side of the 2 compartment sink opposite from the unthawing raw meat. She took a clean steam table insert and put the 2 bags of meat into it, the bags were leaky bloody water. She crossed over the eggs and placed the pan on the counter. She then turned the running water on to run into the pan of eggs. She took a baking sheet and placed the hamburger meat on the baking sheet and put in into the refrigerator. The DS then placed the meat, out of the package, into another clean steam table insert and put it into the refrigerator. She lifted the pan with the bloody water over the eggs and as she put it into the first side of the sink it slipped and bloody water sprayed across the eggs (including some that were cracked) and the counter on the other side of the sink. In an interview on 8/05/15 at 4:09 PM, the DS said the eggs in the large container were going to be used for salads. The DS said the eggs in the pot were hard-boiled and it was okay for them to sit there to cool. She said it was okay for the eggs to be in the sink with thawing raw meat on the other side. She said if the bloody water splashed on them it was okay because the running water would get that splashed water out of the pan with the eggs. Review of facility's policy titled Thawing Food Properly, dated 2006, provided by the DS on 8/06/15 stated in part: Here are four acceptable ways to thaw food safely: In a refrigerator. Thaw food in a refrigerator at 41 (degrees) F . or lower . Under running water. Thaw food submerged under running water at a temperature of 70 (degrees)F . or lower In a microwave oven . As part of the cooking process . C. Observation and interviews on 8/3/15 at 6:55 AM revealed the following: a. In the facility freezer there were 1 undated package of sweet rolls and five long plastic bags each containing 2 to 3 slices of bread or bread crusts. When asked why the sweet rolls were not dated the Cook stated these need to be thrown out and was observed to put the rolls in a garbage can. When asked what the bread and bread crusts were for the Cook stated that they were for bread pudding. b. 30 undated sandwich bags each containing a piece of sliced bread on a tray on the bottom of a cart. Dietary Aide M said the 30 undated sandwich bags each containing a piece of sliced bread were being saved to make bread pudding. c. On a cart with a built-in tray for silverware, the vinyl cover had an accumulation of debris such as bread crumbs, pepper seeds, salt or sugar and black granular material on it. Similar accumulations of debris were found in the bottoms of the tray wells which also contained forks and spoons with built up handles. d. A cart with large plastic bins lined with thin plastic bags that were worn away around the edges of the bins. The edges of the bins were observed to have an accumulation of smears of various colors. The bins were labels Flour 12/1/14 Sugar 12/1/14 and Rice 12/1/14. The Cook said the plastic bags lining the bins of flour, sugar and rice needed to be changed. e. A plastic bin containing toasted bread that had been sliced in half. The lid and sides of the bin were sticky from an accumulation of grease residue, and the lid of the bin had an accumulation of bread crumbs and other debris. The Cook said the bin contained toast for breakfast When asked if the bin was clean, Dietary Aide N did not reply but took the lid and began cleaning it with a paper towel. f. 3 foil-covered pans on top of an oven in the facility kitchen contained Chili Rellenos. The Cook said they had been placed on top of the oven about 20 or 30 minutes before the surveyor's arrival in the kitchen (6:55 AM) so they would thaw a little before he put them in the oven. Observation on 8/3/15 at 7:23 AM, in the facility pantry, a large rolling bin labeled Pinto Beans. The lid of the bin had an accumulation of debris such as bread crumbs, salt or sugar and what appeared to be coffee grounds. Upon lifting the lid off the bin, the bin was observed to be unlined and the rim was seen to have an accumulation of brown and yellow smears and of specks of various colored material. Observation on 08/3/15 at 9:00 AM, there was a pan of uncooked chicken thighs in a thin red sauce sitting on a counter of the kitchen. The DS said she did not want the chicken thighs chilled before cooking, and checked the temperature of the chicken, stating that it was 100 degrees. Observation and interview on 8/4/15 at 8:45 AM, the following was observed: a. Dietary Aide M wrapped toast in plastic wrap without gloves on her hands. She removed untoasted bread from a bread sleeve, sliced it and wrapped it in plastic wrap without wearing gloves on her hands. b. In the kitchen pantry was an unsealed plastic container containing a brown powdered substance with bread crumbs, salt or sugar and other residue on the container lid. c. There were 2 uncovered plastic containers placed on a shelf above a food preparation area that contained eggs and sausage that were being cooled down. The DS said the eggs and sausage were being saved in case there were residents needing a late breakfast or wanting additional food. When asked about the temperature of the eggs and sausage, DS said the eggs and sausage had been there too long and would be thrown out. Review of facility's policy titled Dietary/Food Handling, revised April 2001, provided by the DS on 8/06/15 stated in part: 3. All potentially hazardous food must be maintained at 40 (degrees) or less, or at 140 (degrees) or above except during preparation, cooking or cooling. Review of facility's policy entitled Food Temperature Control dated 8/5/2015, provided by the DS on 8/06/15 stated in part: Rapidly Cool Foods to 41 Degrees or Less . Rapidly Reheat to 165 Degrees or Greater . Cold Hold at 41 Degrees or Less . The list of 18 residents served eggs with runny yolks was received from the DS on 8/05/15 at 9:30 AM. The 100 residents who eat in food prepared in the kitchen was obtained form the CMS 672 dated 8/03/15.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision and assistance devices to prevent accidents for one (Resident # 15) of 14 reviewed residents at risk for falls. The facility failed to ensure Resident #15 had Dycem (A sticky, non-slip device used to prevent slips and falls from a wheelchair) in her wheelchair. Resident #15 fell out of her wheelchair on 7/26/13 and suffered a laceration over her eye, a subdural hematoma, a subarachnoid hematoma and a fractured sacrum. This deficient practice could have placed 106 residents identified at risk for falls for injuries. The findings include: Review of Medical History and Admission Examination dated 4/23/12 documented resident # 15 was an [AGE] year old female with [DIAGNOSES REDACTED]. Record review of the Face Sheet documented resident #15 was admitted on [DATE]. Review of Fall Risk Evaluation score dated 4/22/13 documented resident #15 was scored 13 and on 7/30/13 she was scored 15. A total score of 10 or above represents High Risk for falls. Record review of Incident/Accident Report dated 7/11/13 documented on 7/11/13 at 2:00 PM, resident #15 was observed sliding off of her wheelchair. Resident #15 stated she was trying to get something that was on the floor. Resident #15 suffered a hematoma (bruise) to the back of her head. On the report is stated the resident " has hi/low (bed) and beveled edged mats; will add Dycem to w/c (wheelchair) " . The report was signed by Licensed Vocational Nurse (LVN) A, Director of Nurses (DON) C, Medical Director D and Nursing Facility Administrator (NFA) E. The Incident Investigation stated resident #15 was " sliding off w/c " and the resident ' s state of mind was " oriented/no problem " . Review of Care Plan problem dated 7/11/13 documented CNA reports finding resident in a sliding position at wheelchair. The approach included in part Dycem ( a sticky, non-slip device) in wheelchair seat. In an interview on 8/9/13 at 11:20 AM Nurse Manager (NM) I said, After the morning meeting the Nurse Managers inform the charge nurses about the changes,such as the addition of Dycem, and then the charge nurse carries out the interventions and in-services the CNA's. I placed the Dycem in the wheelchair of Resident #15 myself on 7/11/13 because the charge nurse was busy. Review of 24-Hour Reports, a report used to communicate new patient information, dated 7/11/13, 7/12/13, 7/13/13 revealed Dycem was not documented. Record review of Skilled Nursing Notes, Medication Administration Record, Treatment Administration Record, Physician Orders, and Physical Therapy Notes for July 2013 revealed no documentation that Dycem was in use. Record review of Incident/Accident Report dated 7/26/13 documented Resident # 15 " attempted to get out of chair and fell to floor. CNA (Certified Nurse Aide) found resident on floor and alerted the nurse. The nurse went immediately to resident room and started assessment. Resident had laceration to left temple. MD (medical director) notified and sent out via EMS. " Resident #15 ' s level of consciousness was documented as " alert X 3 (alert and oriented to person, place and time.) " Record review of the following radiology reports for exams dated 7/26/13 revealed: a. CT (Computerized Tomography) Brain - Impression, focal hematoma in the right frontal lobe and small subdural hematoma in the left frontal region. A subarachnoid hematoma in the right bilateral frontal lobes, left parietal lobe (side lobe of the brain) and right quadrigeminal cistern (open space in the brain). ( A subdural hematoma is bleeding that is between the hard lining of the skull and the middle membrane around the brain. A subarachnoid hematoma is bleeding between the middle lining of the brain and the lining next to the brain.) b. CT Pelvis - Nondisplaced fracture through S5 (5th sacral vertebrae) with mild anterior angulation. The skeleton is osteopenic (weak bones). Record review of the Provider Investigation Report dated 7/26/13 resident #15 was interviewable and capable of making informed decisions. " She stated she was in her room and was either trying to stand and fell and/or reaching forward in the wheelchair for a piece of paper and fell forward. " The report stated resident #15 suffered a 1 inch laceration (cut) to the left side of the temple above the eyebrow, a left frontal subdural hematoma, a small left subarachnoid hematoma and a non-displaced fracture through the sacrum at the S5. The resident was on the floor in front of the wheelchair face down, left arm down under her, the right arm was holding tissues to the left side of her forehead and her legs were straight - not bent. At 7:00 PM, resident #15 was sent to the hospital. The Skin, Bruise, or Other Event Investigation dated 7/26/13 was checked resident #15 was oriented, but it was scribbled out and " confused/disoriented " was checked. The Incident Investigation stated resident #15 was confused/disoriented (the incident report stated she was alert and oriented X3). The Incident Investigation, Resident Specific Care Plan in Place, Followed and Documented had spaces to document "Yes", "No" or "NA". The spaces for "appropriate safety precautions and devices" and "positioning devices" were checked " N/A ". Indicating nothing being used. Review of Medical Record documented resident #15 was hosptalized on [DATE] after her fall and re-admitted on [DATE]. She had injuries recorded as Acute Fracture of the Coccyx, right frontal intraparenchymal hematoma, left frontal small subdural hemorrhage, bilateral frontal subarachnoid hemorrhage. In an interview on 8/08/13 at 2:50 PM, resident # 15 stated on 7/26/13 "I slid down from my wheelchair on my butt, hit my head on the over bed table and landed on the floor on my butt. I was sitting on the floor and my head was bleeding. I lay over onto the floor. I had to stay in the hospital for 5 days. I do not remember ever seeing Dycem in my wheelchair. " In an interview on 8/9/13 at 8:45 AM, CNA B stated, "I work 300 hall day shift and resident # 15 was my resident each day. Resident #15 never had Dycem on her chair or in her room and no one ever told me she was supposed to have it. In an interview on 8/9/13 at 9:40 AM, LVN A said she had no knowledge of Dycem ever being in resident #15 ' s wheelchair. If a resident has a new approach such as Dycem the staff is in-serviced by the Nurse Manager. "I was never in-serviced" that resident #15 had a new approach to have Dycem in her wheelchair. In an interview on 8/09/13 at 11:13 AM, Nursing Facility Administrator (NFA) F said incident reports are reviewed during the morning meeting held Monday through Friday. Interventions are put into place. The Nursing Managers will provide an Update Sheet with instructions for new interventions. The sheet is given to the charge nurse who is responsible to in-service the CNAs on any interventions, etc., that are put in place and to implement those interventions. If the charge nurse is busy, the Nursing Manager will implement. In an interview on 8/9/13 at 11:20 AM Nurse Manager (NM) I said, during morning meeting the team reviews the incidents from the day before and decide the interventions. The Care Plan Nurses complete the care plan status sheet and the Nurse Managers complete the Update for Nurses sheet. After the morning meeting the Nurse Managers inform the charge nurses about the changes and they carry out the interventions and in-service the CNA's. I placed the Dycem in the wheelchair of Resident #15 myself on 7/11/13 because the charge nurse was busy. We do not obtain physician orders [REDACTED]. Observation on 8/09/13 at 8:45 AM, revealed resident #15 did not have Dycem in or on her wheelchair. The 106 residents at risk for falls was obtained from the Alarm Monitor Report dated 8/05/13 provided by DON C.

Based on observation, interview, and record review the facility failed to promote care for residents in a manner that maintained or enhanced each resident's dignity by failing to ensure that each resident receive visual privacy in the shower rooms. 1) Resident #11 was wheeled backwards in a shower chair and the back right side including his right buttock were exposed. 2) Resident #24 was being showered in the shower room and the shower curtain was not drawn. Three facility staff members entered the shower room and resident was fully exposed. This failure could affect 111 residents' requiring assistance with bathing to affect thier self-esteem by not providing them with appropriate coverage of their bodies during showers and transfers to and from the shower rooms. Findings included: 1) Observation on 6/25/13 at 9:40 am revealed Certified Nurse Aide (CNA) N pulled Resident #11 out of his room backwards in a shower chair and pushed him into the 200 Hall shower room. Resident #11 was draped in a sheet with his back right side including right buttock uncovered and in plain view of staff, visitors, residents and anyone else in the hallway. 2) Observation on 06/26/13 at 9:48 am outside of the 200 Hall shower room, CNA F was in the shower room showering Resident #24. At 9:56 am, Housekeeper D knocked on the door, opened the door and rolled in a linen barrel. Two minutes later Housekeeper D came out of the shower room with another linen barrel. At 9:58am, surveryor knocked on door and entered the shower room. Resident #24 was in the sitting in shower chair without any clothing washing his hair. CNA F pulled the shower curtain closed. During an interview on 06/26/2013 at 9:59 am, housekeeping aide D stated that she has to pick up dirty laundry from the shower rooms because the barrels are easily filled up with dirty linen as the residents are being showered. She stated that she removes the full barrels of dirty linens and puts an empty barrel to be used. She stated this is done during shower times. Observation on 06/26/13 at 9:57 am, Staff H from Central Supply knocked on the shower door and entered the room without waiting for a response. When he came out he kept the door opened while talking to Licensed Vocational Nurse (LVN) A. Resident # 24 was sitting in the shower stall with soap on his body and wet hair. He was completely naked and the shower curtain was not drawn around him. Observation on 06/26/13 at 10:03 am, CNA E, walked up to the shower room, knocked, opened the door and walked in. One minute later CNA E walked out of the shower room carrying several folded towels. 3) Confidential resident interview on 6/25/13 at 12:40 pm and 06/26/13 at 9:00 am, stated, " I shower every day. The staff make me feel bad in the shower. The staff have me in the shower naked without the shower curtain being drawn. People come in and out and other residents are in the shower naked." The resident was unable to identify who was going in and out of the showers or why. The staff does not close the shower curtain. "I hate to take showers because I feel like an animal, a goat, but I am not an animal! I wish the owner or administrator would take a shower here so they can feel how humiliating and degrading it is." The resident reported feeling humiliated and degraded by the people constantly going into the shower room when the resident is sitting there naked taking a shower. The resident reported complaints about this before, but is just ignored. 4) Confidential resident interview on 06/27/13 at 11:33 am stated that the resident showers everyday and staff do not close the curtain during the shower. Staff go in and out and see the resident naked. "It's embarrassing." The census of 111 residents was obtained from the daily census dated 06/26/2013.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision and assistance devices to prevent accidents for one (Resident # 15) of 14 reviewed residents at risk for falls. The facility failed to ensure Resident #15 had Dycem (A sticky, non-slip device used to prevent slips and falls from a wheelchair) in her wheelchair. Resident #15 fell out of her wheelchair on 7/26/13 and suffered a laceration over her eye, a subdural hematoma, a subarachnoid hematoma and a fractured sacrum. This deficient practice could have placed 106 residents identified at risk for falls for injuries. The findings include: Review of Medical History and Admission Examination dated 4/23/12 documented resident # 15 was an [AGE] year old female with [DIAGNOSES REDACTED]. Record review of the Face Sheet documented resident #15 was admitted on [DATE]. Review of Fall Risk Evaluation score dated 4/22/13 documented resident #15 was scored 13 and on 7/30/13 she was scored 15. A total score of 10 or above represents High Risk for falls. Record review of Incident/Accident Report dated 7/11/13 documented on 7/11/13 at 2:00 PM, resident #15 was observed sliding off of her wheelchair. Resident #15 stated she was trying to get something that was on the floor. Resident #15 suffered a hematoma (bruise) to the back of her head. On the report is stated the resident " has hi/low (bed) and beveled edged mats; will add Dycem to w/c (wheelchair) " . The report was signed by Licensed Vocational Nurse (LVN) A, Director of Nurses (DON) C, Medical Director D and Nursing Facility Administrator (NFA) E. The Incident Investigation stated resident #15 was " sliding off w/c " and the resident ' s state of mind was " oriented/no problem " . Review of Care Plan problem dated 7/11/13 documented CNA reports finding resident in a sliding position at wheelchair. The approach included in part Dycem ( a sticky, non-slip device) in wheelchair seat. In an interview on 8/9/13 at 11:20 AM Nurse Manager (NM) I said, After the morning meeting the Nurse Managers inform the charge nurses about the changes,such as the addition of Dycem, and then the charge nurse carries out the interventions and in-services the CNA's. I placed the Dycem in the wheelchair of Resident #15 myself on 7/11/13 because the charge nurse was busy. Review of 24-Hour Reports, a report used to communicate new patient information, dated 7/11/13, 7/12/13, 7/13/13 revealed Dycem was not documented. Record review of Skilled Nursing Notes, Medication Administration Record, Treatment Administration Record, Physician Orders, and Physical Therapy Notes for July 2013 revealed no documentation that Dycem was in use. Record review of Incident/Accident Report dated 7/26/13 documented Resident # 15 " attempted to get out of chair and fell to floor. CNA (Certified Nurse Aide) found resident on floor and alerted the nurse. The nurse went immediately to resident room and started assessment. Resident had laceration to left temple. MD (medical director) notified and sent out via EMS. " Resident #15 ' s level of consciousness was documented as " alert X 3 (alert and oriented to person, place and time.) " Record review of the following radiology reports for exams dated 7/26/13 revealed: a. CT (Computerized Tomography) Brain - Impression, focal hematoma in the right frontal lobe and small subdural hematoma in the left frontal region. A subarachnoid hematoma in the right bilateral frontal lobes, left parietal lobe (side lobe of the brain) and right quadrigeminal cistern (open space in the brain). ( A subdural hematoma is bleeding that is between the hard lining of the skull and the middle membrane around the brain. A subarachnoid hematoma is bleeding between the middle lining of the brain and the lining next to the brain.) b. CT Pelvis - Nondisplaced fracture through S5 (5th sacral vertebrae) with mild anterior angulation. The skeleton is osteopenic (weak bones). Record review of the Provider Investigation Report dated 7/26/13 resident #15 was interviewable and capable of making informed decisions. " She stated she was in her room and was either trying to stand and fell and/or reaching forward in the wheelchair for a piece of paper and fell forward. " The report stated resident #15 suffered a 1 inch laceration (cut) to the left side of the temple above the eyebrow, a left frontal subdural hematoma, a small left subarachnoid hematoma and a non-displaced fracture through the sacrum at the S5. The resident was on the floor in front of the wheelchair face down, left arm down under her, the right arm was holding tissues to the left side of her forehead and her legs were straight - not bent. At 7:00 PM, resident #15 was sent to the hospital. The Skin, Bruise, or Other Event Investigation dated 7/26/13 was checked resident #15 was oriented, but it was scribbled out and " confused/disoriented " was checked. The Incident Investigation stated resident #15 was confused/disoriented (the incident report stated she was alert and oriented X3). The Incident Investigation, Resident Specific Care Plan in Place, Followed and Documented had spaces to document "Yes", "No" or "NA". The spaces for "appropriate safety precautions and devices" and "positioning devices" were checked " N/A ". Indicating nothing being used. Review of Medical Record documented resident #15 was hosptalized on [DATE] after her fall and re-admitted on [DATE]. She had injuries recorded as Acute Fracture of the Coccyx, right frontal intraparenchymal hematoma, left frontal small subdural hemorrhage, bilateral frontal subarachnoid hemorrhage. In an interview on 8/08/13 at 2:50 PM, resident # 15 stated on 7/26/13 "I slid down from my wheelchair on my butt, hit my head on the over bed table and landed on the floor on my butt. I was sitting on the floor and my head was bleeding. I lay over onto the floor. I had to stay in the hospital for 5 days. I do not remember ever seeing Dycem in my wheelchair. " In an interview on 8/9/13 at 8:45 AM, CNA B stated, "I work 300 hall day shift and resident # 15 was my resident each day. Resident #15 never had Dycem on her chair or in her room and no one ever told me she was supposed to have it. In an interview on 8/9/13 at 9:40 AM, LVN A said she had no knowledge of Dycem ever being in resident #15 ' s wheelchair. If a resident has a new approach such as Dycem the staff is in-serviced by the Nurse Manager. "I was never in-serviced" that resident #15 had a new approach to have Dycem in her wheelchair. In an interview on 8/09/13 at 11:13 AM, Nursing Facility Administrator (NFA) F said incident reports are reviewed during the morning meeting held Monday through Friday. Interventions are put into place. The Nursing Managers will provide an Update Sheet with instructions for new interventions. The sheet is given to the charge nurse who is responsible to in-service the CNAs on any interventions, etc., that are put in place and to implement those interventions. If the charge nurse is busy, the Nursing Manager will implement. In an interview on 8/9/13 at 11:20 AM Nurse Manager (NM) I said, during morning meeting the team reviews the incidents from the day before and decide the interventions. The Care Plan Nurses complete the care plan status sheet and the Nurse Managers complete the Update for Nurses sheet. After the morning meeting the Nurse Managers inform the charge nurses about the changes and they carry out the interventions and in-service the CNA's. I placed the Dycem in the wheelchair of Resident #15 myself on 7/11/13 because the charge nurse was busy. We do not obtain physician orders [REDACTED]. Observation on 8/09/13 at 8:45 AM, revealed resident #15 did not have Dycem in or on her wheelchair. The 106 residents at risk for falls was obtained from the Alarm Monitor Report dated 8/05/13 provided by DON C.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision and assistance devices to prevent accidents for one (Resident # 1) of 24 residents reviewed for quality of care. 1. Resident #1 was transferred by one person when the facility's Minimum Data Set (MDS) and Care Plan identified Resident #1 requiring two person to assist with transfers. Resident # 1 suffered a [MEDICAL CONDITION]. This deficient practice could affect 98 residents that are in need of assistance for transfers, placing them at risk of avoidable injuries. The findings include: Record review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was a two person physical assist for transfers. Review of the Care Plan dated 3-28-13 indicated Resident # 1 was a two person transfer. Review of Fall Risk Evaluation/Assessments dated 03-28-13 (Score of 20) and 05-01-13 (Score of 19) revealed resident was at high risk for falls (Total Score of 10 and above represents high risk). Review of Provider Investigation Report revealed that on 6-16-13 between 4:00 am and 6:15 am Resident # 1 began to experience an increase in behaviors which was yelling out and asking for coffee but denying pain until approximately 7:00 AM. Tylenol 325 mg, 2 tablets, were given at 7:00 am and was not effective. An x-ray of the leg was ordered by the physician which revealed a [MEDICAL CONDITION] hip. In a telephone interview on 6-27-13 at 8:30 am Certified Nurse Aide (CNA) J stated that on Saturday 6-15-13 she worked the evening shift 2 pm to 10 pm and had transferred Resident # 1 from the bed to her wheelchair by herself for dinner. " I wasn't supposed to do that because she is a two person transfer". She stated that everyone was busy so she transferred Resident #1 by herself. She stated that again she transferred Resident #1 from her wheelchair back to her bed by herself after dinner. When asked how are they aware of the number of staff to transfer a resident, she stated that there is a sign on the back of the bathroom door where it states that resident is a two person transfer. She said she saw the sign but continued. She reported resident did not complain of pain during her shift. In an Interview on 6-28-13 at 1:15 pm Licensed Vocational Nurse (LVN) K reported that she works at the facility PRN (as needed) . LVN K stated she worked the night shift 10 p-6am on 6-15-13 and at approximately 4 am she entered Resident # 1's room to provide care to the resident's roommate. Resident #1 asked her for coffee and she told her it was night time and coffee wasn't ready, the resident yelled out "Augh, Augh". LVN asked resident if she was in pain, she kept asking for coffee and yelling "Augh, Augh". LVN K reported "the yell was different". She assessed her and found no bruising. LVN stated the resident kept yelling out for coffee constantly during her shift after 4 am. She gave report to the oncoming nurse, LVN L, to keep an eye on resident because her "behavior was different". In a telephone interview on 6-28-13 at 1:55 pm LVN L stated he worked the morning shift 6 am to 2 pm and on 6-16-13 and between 6:30 am - 6:45 am, CNA Z and another CNA transferred Resident # 1 to her wheelchair. When they got her up, she cried out in pain saying "mi pierna, mi espalda, me duelen" (my leg, my back, they hurt). He stated that he and the CNAs put Resident #1 back to bed to assess her. He assessed Resident #1, did not find any bruising, swelling, or trauma. He stated the resident continued to complain of pain to her left leg at which time he gave her Tylenol. He called the physician and received orders for an x-ray. When the x-ray technician took the x-ray, he told him she had a fracture. LVN L received orders from physician to send resident to the hospital on 6-16-13 at 4:30 pm due to acute [MEDICAL CONDITION] femoral neck. The Centers for Medicare & Medicaid Services (CMS)Resident Census and Conditions of Residents (672) provided by Administrator Q on 6-25-13 identified 98 residents that needed assistance with transfer of one or two staff.

Based on observation, interview and record review the facility failed to provide supervision and assistance devices to prevent accidents for 1 (resident #1) of 7 residents reviewed for falls. The facility failed to: A. Accurately assess resident #1 for fall risks B. Provide interventions to reduce fall risks C. Assure interventions put into place were in working order, and D. Communicate behaviors that could increase the likelihood for falls On 2/09/13 resident #1 was found lying on the floor next to his bed bleeding from a head wound and from his nose. His right eye was swollen shut. A blood covered hospital gown was found wadded-up on the floor. Resident #1 was transported to the hospital where he was diagnosed with [REDACTED]. This failure placed 37 residents identified as recent admissions at risk for injury. The findings included: Review of clinical records documented resident #1 was an [AGE] year old man who was admitted on [DATE]. The Medical History and Admission Examination dated 1/15/13 documented [DIAGNOSES REDACTED]. The Admission Update dated 1/11/13 (prior to resident #1's admission) documented resident #1 was a fall risk, was incontinent of bowel and bladder and had dementia. Review of Admission Nursing assessment dated [DATE] and signed by LVN E documented resident #1 was admitted on [DATE] with left femur fracture, hypertension and congestive heart failure, had falls both 1 month prior to admission and also within 2-6 months prior to admission. Resident #1 required 2 person assist with both transfers and ambulation, had adequate vision with glasses and was incontinent of bowel and bladder. The spaces to check for orientation and disorientation were blank. Resident #1 had occasional pain that limited day-to-day activities within the past 5 days. Review of Daily Custodial/Skilled Nursing Notes dated 1/14/13 documented resident #1's orientation was alert, confused and disoriented. He was incontinent of bladder and bowel, required extensive assist of 2 persons for bed mobility and transfer, had [DIAGNOSES REDACTED]. Review of Fall Risk assessment dated [DATE] documented a fall risk score of 8. A score of 10 or higher represented a high risk for falls. Resident #1 was scored as follows: A. Level of Consciousness/Mental Status of "0" - alert (oriented X 3) or comatose; B. History of falls (past 3 months) "2", 1-2 falls in 3 months; C. Ambulation/Elimination Status of "2" - chair bound assist with elimination; D. Vision Status "0" - Adequate with or without glasses; E. Gait/Balance "2" - not able to perform function; F. Systolic Blood Pressure "0" - No Noted Drop between lying and standing G. Medications (Antipsychotics, AntianxietyAgents, Antidepressants, Hypnotics, Cardiovascular Medications, Diuretics, Narcotic Analgesics, Neuroleptics, Other Medications That Cause Lethargy or Confusion) "0" - None of these medications taken currently or within the last 7 days. H. Predisposing Diseases (Circulatory/Heart, Neuromuscular/Functional, Orthopedic, Perceptual, Psychiatric/Cognitive, Infection, Pain/Headache, Fatigue/Weakness/Weight Loss, Vitamin D Deficiency, History of Falls) "2", 1-2 present. In an interview on 2/12/13 at 11:10 AM, Director of Nurses (DON) D said, after reviewing the Fall Risk Evaluation dated 1/14/13 for resident #1, the fall risk assessment was scored too low and it was not an accurate assessment of resident #1's fall risk. The fall risk score should have been higher as resident #1 had intermittent confusion (score of "4" instead of "0"). Medications should have been scored "4" instead of "0" as resident #1 was on 2 blood pressure medications (cardiovascular medications) and 2 diuretics which would score as "4" not "0" and Predisposing Conditions was scored as "2" and not "4" as the resident had 3 or more predisposing conditions (circulatory/heart, orthopedic, psychiatric/cognitive, pain/headache and history of falls). The new score would have been "14". If it had been scored accurately, fall prevention interventions would have been initiated on admission which included a high-low bed and possibly alarms, a concave mattress and/or floor mats. Review of Incident/Accident Report dated 2/09/13 documented at 7:10 AM, resident #1 was "noted by CNA (Certified Nurse Aide) on floor by window. Attempting to get up with nursing, resident to bed, noticed laceration top of head, moves all extremities well, activated 9-1-1, called MD (doctor) and family, no alarms sounding." Additional comments and/or steps taken to prevent recurrence: "Obtaining high low bed and will place concave mattress as soon as available, changing to tab alarm." Incident Investigation stated in part that resident #1 was in bed prior to the incident and was confused/disoriented which was not a change in mental status. Resident Specific Care Plan in Place, followed and documented, contained a checklist ("yes", "no" or "NA") was blank for appropriate safety precautions and devices, positioning devices, toileting program, rehab/restorative, behavioral program, and other - list). Review of the Provider Investigation Report dated 2/11/13 documented resident #1 fell and sustained a fracture of the right maxillary sinus, right anterior zygomatic arch and nondisplaced right 11th rib fracture. Resident #1's functional ability was total dependence, required no special supervision, was not interviewable or able to make informed decisions and was verbally aggressive. "Per the facilities video surveillance, at 6:25 AM, the RN (Registered Nurse) supervisor checked on the resident lying quietly in his bed with no difficulty noted; per video surveillance the resident was checked on again by the CNA at 7:09 AM and she found him on the floor beside his bed; the RN was immediately called to the room and after the initial assessment called 911 with EMS staff present about 2 minutes after the 911 call was made; The hospital report documents the CAT scan showed no internal bleeding in the brain but there was a fracture of the right maxillary sinus and the right anterior zygomatic arch; also nondisplaced right 11th rib fracture. RN assessed the resident with a 2 inch laceration on top of head, swollen right eye orbit and bloody nose. The Provider Response as above with the addition that the local police were notified by unknown parties and they came (twice) and investigated the scene, took witness statements from the staff and viewed the facility video records from 6:06 AM to 7:10 AM (for the morning of Feb. 9, 2013) with the DON (Director of Nurses). Local police officers left the facility voicing no concerns after either of the 2 visits. The Investigation Summary stated the resident fell sometime between 6:25 AM and 7:09 AM, 911 was called, the bed pad alarm was on the bed but were unable to determine if the alarm was positioned under the resident that would sound as it normally would, the alarm was determined to be functioning as required and an in-service was begun on keeping alarms turned "on" at all times. The Provider Action Taken Post-Investigation stated, in part, when resident #1 returned to the facility they would change the resident's alarm from a bed alarm to a tab alarm to allow the alarm to sound sooner, change the bed to a high/low electronic bed, change the mattress to a concave mattress to reduce the chance for the resident to roll out of the bed and place beveled mats on the floor. Review of hospital imaging reports dated 2/09/13 documented the following: a. CT Brain (computerized tomography) documented facial bone fractures involving the anterior wall and posterior wall of the right maxillary sinus (nasal bone fractures) and anterior zygomatic arch on the right (cheekbone that forms the lower eye socket). b. CT Thorax (chest) with contrast documented a nondisplaced right 11th rib fracture (next to last rib on right side of the chest. Called a "floating rib" because it and rib 12 do not attach to the breast bone like the previous 10 ribs.) c. CT of Facial Bones documented the above facial fractures with an additional 2nd fracture of the right eye orbit. Observation on 2/10/13 at 10:20 AM, revealed resident #1's bedroom was part of a 2 bedroom suite that had a sitting area with a bathroom and then the 2 bedrooms. From the hallway door only the foot of resident #1's bed was visible. The middle and head of the bed were only visible upon standing in the bedroom doorway. There was a standard bed with manual cranks at the foot of the bed and a standard mattress was on the bed. There were no side rails, no linen and there was a bed pad alarm laid diagonally on the mattress on the left side of the bed. There were no floor mats seen, but the floor was carpeted. Next to the head of the bed between the bed and the outside wall was a stationery, wall-mounted night stand. On the floor in front of the night stand and extending under it was a dark, red-tinged stain. Observation on 2/12/13 at 5:10 AM, CNA A demonstrated with 2 residents how the pad alarm works. She asked resident #8 to turn to her side. When she did, the bed pad alarm immediately sounded until resident #8 returned to her back. Resident #9 also turned onto her side and the pad alarm took 2-3 seconds longer to sound but turned off when the resident turned onto her back. In interviews on 2/10/13 at 10:45 AM and by telephone on 2/213/13, RN B said he had made rounds on 2/9/13 at 6:20 AM and resident #1 was lying in bed. About 7:10 AM, CNA D motioned for him to come into resident #1's room. When he entered he found resident #1 on his knees and elbows on the floor between the bed and the outer wall. His head was partially under a wall-mounted, wooden nightstand. He was rocking back and forth trying to get up. RN B and CNA C got him up and sat resident #1 on the edge of the bed. His face was bloody and he had a cut on his head, a swollen-closed right eye and a bloody face. Emergency services were called and the resident was transported to a local hospital. RN B said there was a pad alarm on resident #1's bed, but he did not remember it alarming when he went into the room. RN B said he checked the alarm box and the alarm was turned "on". RN C said he and DON D lifted the bottom sheet on the bed and saw the alarm pad on the bed but did not remember if it was in the appropriate position. to alarm if resident #1 moved. RN B said resident #1 had dementia and was a fall risk RN B said resident #1 was "obtunded" (alertness or consciousness moderately reduced), he did not speak much and would not push (self-propel) his wheelchair. The week before resident #1 fell , he saw the resident sit on the side of the bed and use the urinal. RN B said "we run for those alarms" and he said he does not remember ever going to resident #1's room to answer an alarm. RN B said when a new alarm is initiated, the nurse gathers evidence for the need and calls the physician for an order. The alarm is obtained and placed. This is written on the 24 hour report to communicate to the other shifts of the alarm placement and the behaviors observed. Review of admission orders [REDACTED] a. Furosemide (a diuretic to treat blood pressure) 40 mg (milligrams) p.o. (by mouth) with breakfast b. Lisinopril (cardiovascular medication to treat blood pressure) 10 mg. p.o. q (every) day c. Metoprolol (cardiovascular medication to treat blood pressure) 50 mg. p.o. q day (give with food) d. Spirolactone (a diuretic to treat blood pressure) 25 mg p.o. with breakfast e. Ergocalciferol units (treats Vitamin D deficiency) on q week on Sunday f. Hydrocodone/APAP (narcotic pain medication) 7.5/325 1 tab every 4 hours as needed for pain g. Hydrocodone/APAP (narcotic pain medication) 7.5/325 2 tabs every 6 hours as needed for pain In review of resident #1's Medication Administration Record (MAR) for February 2013, both the medication aide and the nurses' MARs, there was no documentation resident #1 had any type of personal, wheelchair or bed alarm or that any alarms were checked for presence and functioning. Review of Behavior/Mood Record for February 2013 documented persistent anger with others and unpleasant mood in the morning for resident #1 from 2/04/13 through 2/08/13. "No mood or behaviors noted this shift" for evenings 2/04/13 through 2/08/13 and for nights 2/01/12 through 2/08/13. In review of the 24 hour reports for the 100 hallway, there was no communication written that resident #1 had bed or chair alarms, that he was sitting on his bed and using the urinal, or that he would get up without assistance and walk in his bedroom. In an interview on 2/10/13 at 11:27, DON D said at 6:25 AM resident #1 was fine and at 7:10 AM he was found on the floor. He had damage to his right orbit (the bony part of the eye socket), a bloody nose and a 2 inch laceration (cut) on top of his head. DON D said it appeared resident #1 attempted to get up and fell face forward into the wall-mounted night stand. His head was under the nightstand and he kept hitting his head trying to get up. The nurse manager at the hospital thought the injuries were from more than a fall so the police came to the facility. Resident #1's son also was there. The police investigated and reviewed video from the hallway surveillance camera that confirmed the time line given by the employees. The camera only shows the hallway, not inside the resident rooms. DON D said resident #1 had a history of [REDACTED]. DON D said resident #1 was on a standard bed, not a high-low bed (an electric bed where the height of the bed could be adjusted) and had a pad alarm on the bed that was turned "off". DON D said new alarms are discussed at the morning meetings and the supply clerk F is informed so he can add them to the alarm list. DON D said for any resident that scores a 10 or above on the fall risk assessment, the physician is informed and precautions are put into place. The physician order [REDACTED]. DON D said everyone knew resident #1 had a bed alarm. In a telephone interview on 2/11/13 at 9:52 AM, resident #1's Responsible Party (RP) said the night before, 2/08/13, resident #1 demonstrated how he could sit up without assistance. The RP said when he started to stand up he needed assistance to balance. RP said resident #1 was already walking with the help of a front wheeled walker and Physical Therapy at the hospital (he had broken his hip) before he was admitted to the facility. The RP said resident #1 was not able to make decisions and could only remember instructions for "5 minutes". The RP said when he left on the evening of 2/08/13, he made sure the pad alarm was turned on as it was off while he visited. He turned the alarm box on. He said resident #1 would not know how to turn the alarm box off. RP said he knew the alarm was on and working when he left because there was a little light that flashed when the alarm was turned on. RP said in the past he has come to visit resident #1 and the alarm was turned off. In an interview on 2/12/13 at 4:35 AM, CNA A said resident #1 could move side to side. CNA A said resident #1 sat on the edge of the bed 3 times during the early morning of 2/09/13 using the urinal. She said the bed alarm sounded every time resident #1 put his feet on the floor, but he did not stand up. CNA said resident #1 could not use a call light. When asked how often she checked on resident #1, CNA A said she checked on him every time the alarm sounded. CNA A said the last time she saw resident #1 was around 5:40 AM when she provided incontinent care and changed his linens. His bed alarm was on. In an interview on 2/12/13 at 11:40 AM, CNA C said said she first went into the suite area just before 6:00 AM to put her purse and jacket behind a chair in the common room. She again went into the suite area to take a resident from another room to shower in the suite's bathroom. CNA C said she did not look into resident #1's room. She did not go into resident #1's room until 7:10 AM when she went to get him up to the shower. She did not see him and as she turned to leave she heard a low moan and found resident #1 on the floor between the bed and the outside wall. There was no alarm sounding. CNA C said resident #1 was lying alongside the window side of the bed on the floor on his right side. CNA C said when she and RN B put resident #1 back in bed, she checked the bed pad alarm and it was turned off. If resident #1 had been situated on the alarm and he had moved, and the alarm was turned on, it would have sounded when he moved to the side of the bed. CNA C said the alarms are loud and can be heard for a distance. CNA C said resident #1 seemed to be a calm person and she never saw him try to get out of bed by himself. CNA C said resident #1 could not use the call light or a urinal. He was either taken to the bathroom or he voided in his brief. In an interview on 2/13/13 at 12:32 PM, CNA G said resident #1 is aggressive in the mornings with his bath. Afterwards he would ask to be taken to the bathroom and he would use a urinal with help from his family or the staff. He would not use a call light. CNA G said resident #1 did not have any wheelchair or bed alarms. She took care of him 5 days a week, showered him and changed his bed linens. There were no alarms and she never heard an alarm sound with resident #1. Resident #1 never tries to get up without assistance. In an interview on 2/11/13 at 3:34 PM, LVN H said resident #1 was calm and cooperative although he was aggressive and non-compliant with care in the mornings. LVN H said he did not know when alarms were started on resident #1 but said he was probably a fall risk because sometimes he was impulsive. LVN H said resident alarms were checked each shift and did not necessarily have to be documented. In an interview on 2/12/13 at 10:49 AM, LVN E said there was never a report that resident #1 attempted to get out of bed without assistance. LVN E said resident #1 never tried to get up, not even sit on the side of the bed. LVN E said she did not initiate the bed alarm. When an alarm is started the family is informed and the doctor is called for orders. Orders for the alarm are placed on the nurse's MAR to document they have been checked for placement and functioning each shift. Once a week an alarm audit is performed to check that the alarms are working and there are physician orders [REDACTED]. Also, if the hospital reports the resident has tried to get up or if he tries after he is admitted to the facility then the precautions are started. LVN E said there was no report that resident #1 was a fall risk while in the hospital and when he was admitted there was no high-low (adjustable height) bed available. Resident #1 was placed on a regular bed. In an interview on 2/12/13 at 12:44 PM, Assistant Director of Nurses (ADON) I said the only reported behaviors were from the day shift (in the mornings) and the wound care nurse. He was physically and verbally abusive with cares, but did not try to get out of bed. In the morning meetings there was no mention of resident #1 trying to get up from bed without assistance and there was nothing of this on the 24 hour report or nurse's notes. ADON I said no one had reported in any of their meetings that resident #1 was able to use a urinal. There was no communication. In a telephone interview on 2/12/13 at 2:25 PM, Attending Physician said she does not remember if anyone called her to report concerns about resident #1's risk for falling. Attending Physician said if the nurses assess the resident as a fall risk, they will initiate the appropriate alarm and write a telephone order which the doctor will sign. In an interview on 2/13/13 at 1:38 PM, LVN J said if a personal alarm is needed for a resident the physician is called for orders for fall prevention measures. A fall assessment is performed on all admissions and if the resident scores as a high risk for falls, it is brought up in the morning meeting. LVN J said sometimes the assessments are completed before the physician is called to verify the medication ordered on the admission orders [REDACTED]'s Fall Risk Assessment). In review with LVN J the Fall Risk Assessment for resident #2 (a [AGE] year old woman admitted on [DATE] with [DIAGNOSES REDACTED].#2 was on 2 blood pressure medications. LVN J said resident #2 was a high risk for falls, but since she was alert and oriented X 3 (person, place, time) she did not need the interventions recommended for high risk residents as she could understand and follow instructions to request assistance. In an interview on 2/13/13 at 2:22 PM, CNA K said resident #1 cannot use a call light. He started standing by himself and asking for the urinal. One day CNA K found resident #1 standing by his closet and pressing the wall mounted door guard trying to turn off the pad alarm that was sounding. CNA K said sometimes resident #1 tries to get up from his wheelchair so he has a wheelchair alarm. Review of the Silver Chair Training program titled Accident Prevention and Management 2007, Version 3.01 stated, Remember - Personal alarms don't eliminate the need for supervision. A resident who has an alarm should be checked regularly and offered opportunities to ambulate, toilet, and participate in activities according to his plan of care. Review of Falls and Fall Risk, Managing, revised August 2006, stated in part the following: Prioritizing Approaches to Managing Falls and Fall Risk; The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If the systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. Monitoring Subsequent Falls and Fall Risk; The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed in a problem that required the interventions (e.g. dizziness or weakness) has resolved. Review of Fall Reduction and Prevention Policy, dated July 2010, provided by Nursing Facility Administrator (FA) L, stated the following: Purpose: To reduce or prevent falls and to prevent serious injury resulting from falls Procedure: (1) Identify residents who are high-risk based on fall assessments with a history of multiple falls. (3) Assess what resident needs chair alarm, bed alarm, low bed, mats on the floor, pommel cushions. (6) In-service all staff on fall prevention programs, specifically what devices are being used on each resident. Review of Falls Risk Assessment revised August 2006, provided by DON D, stated in part: Policy Statement: Based on previous evaluations and current data, the nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff and others, will seek to identify resident risk factors for falls and will document the risk factors in the resident's medical record. Policy Interpretation and Implementation: (1) The nursing staff and the physician will review a resident's record and/or individual fall record for evidence of previous falls, especially falls in the last 90 days, and recurrent or periodic bouts of falling over time. (2) The nursing staff will ask the resident and/or his/her family about any history of the resident falling. (4) The Attending Physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairment (such as decreased vision and peripheral neuropathy) that may predispose to falls, and identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). (5) The nursing staff, Attending Physician, and Consultant Pharmacist, will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. (6) The staff, with the support of the Attending Physician, will evaluate functional and psychological factors including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence and cognition that may relate to fall risk. Review of Important Messages (payroll Distribution 8-15-11) provided by DON D stated in part the following: All Staff; Item One; "It is every employees responsibility to ensure all alarms are on all the time without exception." Licensed Staff and Certified Nurse Aides; Item One; Nurses who apply new alarms or change alarms, must obtain a Dr's Order for it, should update the master care plan in the nurse ADL books and copy it and replace it in the bathrooms. Indicate on alarm list and 24 hour report you have done this. Review of power point presentation dated 7/22/11 titled Stars, Flower & Falls provided by DON D on 2/12/13 stated: Responsibilities: CNAs - be aware of alarms listed in the Nurse Aide Care Plans on the Residents' Restroom doors Nurses - will verify residents with ordered alarms have them in place within the first hour of their shift. Reminders: If the Assessment indicates a fall risk requiring an alarm - get a Dr's order. Give the "green copy" of the Dr's order to the Central Supply clerk for her records. The universe of 37 residents who were new admissions was obtained from the Detail Admission/Discharge Report provided by DON D on 2/13/13.