Every finding on record at Five Points at Lake Highlands Nursing and Rehab

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 of 4 (Resident #1) residents reviewed for medication administration. The facility failed to ensure LVN A accurately documented Resident # 1's administration of Insulin Lispro on 8/16/26 at 8:00 a.m. The facility failed to ensure LVN A accurately documented Resident #1's blood sugar levels on 8/16/26. The facility failed to ensure LVN A administered Resident #1's Insulin Lispro on 8/16/26 at 12:00 p.m. as ordered by the physician. These failures could place residents at risk of not receiving treatments as ordered which could impact the residents' health and recovery. The findings included: Record review of Resident #1's face sheet dated 8/19/26 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had the following pertinent diagnoses: Type 2 diabetes (condition where the body cannot use the hormone insulin properly or does not make enough of it), Hypoglycemia (medical condition that happens when blood sugar drops below a healthy level), acute respiratory failure (a life threatening condition where the respiratory system rapidly fails to perform proper gas exchange, leading to dangerously low oxygen levels), dependence on renal dialysis (life sustaining medical status in which a person relies on artificial blood-filtering treatments because their kidneys no longer function well enough to keep them alive), and Type 1 diabetes (when the body's immune system mistakenly attacks and destroys the insulin-producing beta cells in the pancreas). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected Resident #1 had no impairment in cognition with a BIMS score of 14. Resident #1 received insulin 7 days per week. Record review of Resident #1's Care Plan revised 7/29/26 reflected .[Resident #1] has Diabetes Mellitus [a chronic metabolic condition where the body cannot properly regulate blood sugar or glucose] r/t ESRD [End Stage Renal Disease] Date Initiated: 07/23/2026 Revision on: 07/29/2026. Record review of Resident #1's Treatment Administration Record for August 2026 reflected Insulin Lispro Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Lispro) Inject 4 unit subcutaneously with meals for DM2 and on 8/16/26 at 8:00 a.m. and 12:00 p.m. the Insulin Lispro Subcutaneous Solution Cartridge 100 Unit/ML was not administered with a code of 3 which indicated Resident #1 was away from facility. The record did not reveal a blood sugar check for 8:00 a.m. and 12:00 p.m. Record review of Resident #1's progress notes on 8/16/26 at 6:44 p.m. written by LVN A revealed [Resident #1] transferred to nearest Emergency department, per family 911 call. [Resident #1] transferred via stretcher with no s/s (symptoms or signs) of distress noted. DON/ADON notified. MD (medical doctor) notified. Record review of Resident #1's Blood Sugar record reflected the following blood sugar readings:8/11/26 8:00 a.m. - 988/11/26 12:00 p.m. - 1058/11/26 5:00 p.m. - 1998/12/26 8:00 a.m. - 3778/12/26 12:00 p.m. - 2358/12/26 5:00 p.m. - 2698/13/26 8:00 a.m. - 3018/13/26 12:00 p.m. - 2658/13/26 5:00 p.m. - 2798/14/26 8:00 a.m. - 3518/14/26 12:00 p.m. - 2218/14/26 5:00 p.m. - 2238/15/26 8:00 a.m. - 4028/15/26 12:00 p.m. - 3968/15/26 5:00 p.m. - 463No Blood Sugar readings were recorded for 8/16/26. Record review of Resident #1's Order Summary Report dated 8/19/26 reflected the following active order Insulin Lispro Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Lispro) Inject 4 unit subcutaneously two times a day for DM2 [Diabetes Mellitus]. An interview with LVN A on 8/19/26 at 12:36 p.m. revealed she had worked with Resident #1 on 8/16/26. LVN A stated she took Resident #1's blood glucose level and vitals earlier in the morning when she administered her insulin at 8:00 a.m. LVN A stated she had administered the insulin at 8:00 a.m. and failed to document correctly on Resident #1's Treatment Administration Record for the 8:00 a.m. dose. LVN A stated she could not recall what Resident #1's glucose level was at the time of the insulin administration. LVN A stated between 7:00 a.m. and 3:00 p.m. Resident #1 should have administered insulin twice per the doctor's orders reflected on the Treatment Administration Record. LVN A stated she passed by Resident #1's room after lunch and had noted she had visitors that were unfamiliar. LVN A stated when she entered Resident #1's room she had not showed any symptoms of elevated blood sugar, she was responding to her appropriately and had not shown any signs of distress. LVN A stated she asked Resident #1 if she needed anything and whether she was okay and Resident #1 stated no I don't need anything, dismissed her from her room and Resident #1 continued to talk to her visitors. LVN A stated soon after checking on the resident EMS showed up at the facility and stated Resident #1 had called and wanted to go to the hospital. LVN A stated EMS had arrived around 3pm. LVN A stated she was able to take Resident #1's vitals prior to her leaving but had not administered her insulin that was due at 12:00 p.m. LVN A stated she was busy and had not gotten around to administering Resident #1's insulin. LVN A stated she observed Resident #1 waving from the gurney when exiting the facility with EMS. LVN A stated she inaccurately coded Resident #1's Treatment Administration Record with a #3 (indicating resident was away from the facility) for 8:00 a.m. and 12:00 p.m. because she charted late. LVN A stated she had administered Resident #1's insulin in the morning and should have documented it correctly to reflect the administration of the treatment and Resident #1's glucose level at 8:00 a.m. LVN A stated she should have left the box for 12:00 p.m. blank since she never administered the insulin and the resident was still at the facility at that time. LVN A stated the risk to the resident of not having received her insulin as prescribed was that she could have become hyperglycemic (high blood sugar). An interview with Resident #1 at the hospital on 8/19/26 at 2:30 p.m. revealed she could not remember whether she was given insulin the morning of her hospitalization. Resident #1 stated she waited a long time on 8/16/26 for her insulin and that was the reason her friends that were visiting called the ambulance. Resident #1 stated she was at the hospital due to her blood sugars. An interview with the Charge Nurse from the hospital on 8/19/26 at 2:40 p.m. revealed Resident #1 was admitted to the hospital for Hyperglycemia (high blood sugar) on 8/16/26. The Charge Nurse stated Resident #1 continued to be hospitalized because they were trying to stabilize her sugar levels. The Charge Nurse stated if they could stabilize Resident #1's blood sugar level the doctor would discharge Resident #1 the next day (8/20/26). An interview with Resident #1's Attending Physician on 8/20/26 at 10:37 a.m. revealed Resident #1's glucose fluctuated a lot due to her kidney disease and diabetes. The Attending Physician stated Resident #1 had Diabetes Type 1 which made it challenging to stabilize her blood sugars and therefore his expectation was that the nurses check Resident #1's blood sugar at least twice per day, administer her insulin as prescribed and accurately document everything. The Attending Physician stated a missed insulin administration would not have significantly affected Resident #1's blood sugar because of her kidney disease and the delayed effect insulin has on the resident. The Attending Physician stated it was important to administer Resident #1's insulin as prescribed because failure to consistently administer the insulin could have caused Diabetic Ketoacidosis (a life-threatening medical emergency where the body breaks down fat too fast causing dangerous acids called ketones to build up in the blood). The Attending Physician stated he would have been curious to know if the hospital was able to stabilize Resident #1's glucose because she had been admitted to the facility from the hospital about a month ago with Ketoacidosis and he had been struggling to stabilize her blood sugar due to her kidney disease. An interview with LVN B on 8/20/26 at 11:02 a.m. revealed the expectation was that she documents every time she took blood sugar and administered insulin in the Treatment Administration Record. LVN B stated it was important to follow the prescription for insulin administration because improper administration of insulin or failure to administer insulin could result in the resident going into a diabetic coma. An interview with RN C on 8/20/26 at 11:06 a.m. revealed it was important to administer insulin and all medications as prescribed. RN C stated he records any medication given to a resident in the Medication Administration Record and insulin was documented in the Treatment Administration Record. RN C stated the risk to the residents of not getting insulin as prescribed was Ketoacidosis (a life-threatening medical emergency where the body breaks down fat too fast causing dangerous acids called ketones to build up in the blood). An interview with the DON on 8/20/26 at 12:34 p.m. revealed the expectation was that the nurses needed to follow all doctor's orders related to administration of medications and treatments. The DON stated the administration of insulin should have been documented in the Treatment Administration Record and should have been done in real time and not later. The DON stated all medications should be administered timely. The DON stated the risk to the residents of not appropriately documenting the residents blood sugars and administration of the medication was that there was no proof the medication was given and was unknown if the resident still needed the medication. The DON stated missed medications could have severe consequences to a resident's health. An interview with the Administrator on 8/20/26 at 12:47 p.m. revealed nurses should have been following all doctors' orders. The Administrator stated medications should not have been skipped and if they were skipped the doctor should have been notified. The Administrator stated that the expectation was nurses should have been documenting administration of treatments or medications immediately and not at the end of the shift. The Administrator stated the risk to the resident of not accurately documenting administration of medication or non-administration was it would have been unknown if a resident needed medication or not. The Administrator stated it was the responsibility of the DON to ensure the nurses were following doctor's orders and administering medications and treatments timely. Record review of the facility's policy Administering Medications revised April 2019 reflected Medication are administered in a safe and timely manner and as prescribed.medications are administered in accordance with prescriber's orders, including any required time frames. Medication administration times are determined by resident need and benefit, not staff convenience.Medication errors are documented, reported and reviewed.Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 4 residents (Resident#1) reviewed for ADLs. The facility failed to ensure Resident #1 had her fingernails cleaned and trimmed on 05/26/26. This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. A record review of Resident #1's annual MDS assessment, dated 02/21/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnosis which included: hypertension (elevated blood pressure), type 2 diabetes mellitus (elevated blood sugar), non-Alzheimer's dementia (brain disorders causing cognitive decline due to factors other than Alzheimer's), and multiple sclerosis (a chronic autoimmune disease of the central nervous system in which the immune system mistakenly attacks myelin). Resident#1 BIMS score was 7/15, which indicated severe cognitive impairment. The resident was dependent with ADL's (activity of daily living). A record review of Resident #1's Comprehensive Care Plan, dated 03/04/26, reflected Focus: [Resident#1] has an ADL self-care performance deficit r/t disease process. Goal: [Resident#1] will maintain current level of function through the review date. Intervention: personal hygiene: The resident requires assistance by (X1) staff with personal hygiene and oral care. An observation and interview on 05/26/26 at 08:02 AM revealed Resident #1 was up in a wheelchair in the TV area. Both of Resident #1's hands were severely contracted with supportive devices (Contracted hands sponge pads). Resident #1 had a long fingernail approximately 0.6 centimeter on both hands, with a brown matter underneath the left-hand thumb Resident#1 was asked if she wanted her fingernails trimmed and cleaned, she replied yes. In an observation and interview on 05/26/26 at 10:52 AM revealed CNA A physically assessed Resident #1's fingernails and stated they needed trimming and the left thumb needed to be cleaned due to brown matter underneath. CNA A stated nail care for the residents was performed by CNAs on shower days and it was the responsibility of the nurses and CNAs to ensure the resident's nails kept clean and trimmed to prevent infection, and skin injury through scratching. CNA A stated the risk to Resident #1 could be infection development, skin integrity, and dignity issues. In an interview on 05/26/26 at 10:55 AM, LVN B stated the CNAs were responsible for nail care on the residents, unless they were diabetic, and the LVNs were responsible for the diabetics. She stated CNAs, and nurses were supposed to do rounds on the residents daily and checked their nails to make sure they were cleaned and trimmed, to the residents liking. She stated long dirty nails could pose a risk for infections, or skin tears. Interview and observation on 05/26/26 at 1:22 PM, the DON stated, she expected resident nail care to be provided during the shower days, and if the resident was diabetic the nurses had to trim the nails. The DON stated the resident was at risk of infection development and skin break down if she scratched herself. Record review of the facility's, undated, policy titled, Nursing Policy & Procedure Manual-Nail Care reflected, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails . It includes cleansing, trimming, smoothing, and cuticles are and is usually done during the bath.

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for the facility's only kitchen in that:The facility failed to ensure food items in the kitchen were appropriately covered and food item discarded after the expiry date on 3/29/2026.These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, if consumed and food contamination. Findings included:Observation on 03/29/2026 at 9:11 AM revealed approximately one half pitcher labeled as nectar thick water with a use by date of 03/26/26 was left in the walk in refrigerator.Observation on 03/29/2026 at 9:15 AM revealed multiple frozen sweet roll dough items and frozen beef steak fritters were stored in open cardboard boxes and left exposed to frigid air in the walk in freezer.In an interview and observation on 3/29/26 at 9:20 AM with Dietary Aide E, she stated that everyone in the kitchen was responsible for covering food items. She stated that usually dietary aides were responsible for making thickened water for service and should be discarded after expiration date. She stated the risk of not appropriately covering food items and discarding expired items was food contamination and possible food borne illness in residents.In an interview on 3/30/26 at 1:30 PM, the Dietary Manager stated that her expectation was that all food items in the kitchen be covered at all times. She stated that while some frozen food items may have small slits in the packaging to prevent ice crystal formation, leaving frozen food items exposed to frigid air by not completely closing the cardboard box was not acceptable. She stated that everyone working in the kitchen, including cooks, dietary aides, and herself, was responsible for ensuring food items were properly covered. She further stated that expired food should be promptly discarded once it has reached its expiration date to prevent foodborne illness in residents if consumed. She stated that the risk of not appropriately covering food items included cross contamination of food and decreased food quality. She further stated that, as the Dietary Manager, she provided frequent in services to all kitchen staff on appropriate food storage practices.In an interview on 03/30/26 at 2:13 PM, [NAME] A stated that everyone working in the kitchen was responsible for ensuring that food items were properly covered at all times and not exposed to air. She stated that failure to cover food items could result in cross contamination and could cause residents to become ill. [NAME] A further stated that dietary aides were responsible for preparing and dating nectar thickened water and that any expired thickened water should be discarded and not served to residents, as consumption could cause residents to become sick.Record review of facility policy titled, Food Storage and Supplies, undated reflected, . 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Any product with a stamped expiration date will be discarded once that date passes.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 7 residents (Resident #2, #12, #24, #91, #126, #144, and #156) of 10 residents reviewed for ADLs. The facility failed to ensure: Resident #24, Resident #91, Resident #144 had their fingernails trimmed on 03/29/2026.Resident #126 had her fingernails trimmed and cleaned and facial hair trimmed on 03/29/2026.Resident #156 had his fingernails cleaned and trimmed on 03/29/2026.Resident #2 had her fingernails trimmed and cleaned on 03/29/2026.Resident #12 had his fingernails trimmed and cleaned on 03/29/2026 These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life.1. Record Review of Resident #2's Quarterly MDS assessment dated [DATE] as a [AGE] year-old female with initial admission date of 11/25/2025 to the facility. Her pertinent diagnoses included: Diabetes mellitus (elevated blood glucose levels), cerebral infarction (is a condition caused by a blockage in blood vessels supplying the brain, resulting in tissue death). Her BIMS score was 12, which indicated Resident #2's cognition was moderately impaired. Resident #2 was dependent on staff for her personal hygiene. Review of Resident #2 's Comprehensive Care Plan, revised 11/26/2025 reflected, Focus: [Resident #2] has an ADL self-care performance deficit . Interventions: Assist with personal hygiene as required. In an observation on 03/29/2026 at 10:35 AM, revealed Resident #2 had long nails on both hands, they were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #2 was confused unable to answer questions. 2. Review of Resident #12 Quarterly MDS assessment, dated 02/17/2026, reflected Resident #12 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included need for assistance with personal care, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and muscle wasting. Resident #12 had a BIMS of 04 which indicated Resident #12's cognition was severely impaired. Resident#12 extensive assistance with transfer, and personal hygiene. Review of Resident #12's Comprehensive Care Plan dated 08/11/25 reflected the following: Focus: resident#12 has an ADL self-care performance deficit. Interventions: Bathing requires staff for assistance. In an observation on 03/29/2026 at 10:49 AM, revealed Resident #12 was lying in his bed. The nails on both hands were approximately 0.4cm in length extending from the tip of his fingers. The nails were discolored tan. Resident #12 had communication deficit. He did not answer questions. In an interview on 03/29/2026 at 11:51 AM, LVN B stated that Nurses and CNAs were responsible for clipping residents' fingernails. She stated that for residents with diabetes, Nurses were responsible for trimming fingernails as needed. LVN B stated the risks of long, dirty fingernails included skin tears, increased risk of infection and decreased quality of life. LVN B stated she would trim and clean both Resident #2 and #12's nails. 3. Record Review of Resident #24's MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admission date of 12/21/2018, diagnoses included Need for assistance with personal care, Schizophrenia (a chronic, severe mental disorder affecting thoughts, perceptions and emotions), Drug induced subacute Dyskinesia (Involuntary muscle movements). Resident #24 had a BIMS score of 00 indicating severe cognitive impairment. Record Review of Resident #24's Care Plan with revision date 07/08/2025 reflected . at times Resident #24 can be aggressive and hit or bite the staff. An interview and observation on 03/29/2026 at 02:57 PM, Resident #24 was sitting in her room, she had long fingernails and toenails measuring approximately 0.3-0.5 inches in length extending from the tip of her fingers and toes. Resident #24 stated she would like them to be trimmed by the facility staff. 4. Record Review of Resident #91's MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admission date of 06/11/2021, diagnoses included Unspecified Dementia (Memory loss), Category 5 Blindness on both eyes. Resident #91 had a BIMS score of 04 indicating severe cognitive impairment. Resident #91 was dependent on facility staff for toileting hygiene. Record Review of Resident #91's Care Plan with initiated date 11/12/2019 and revision date 06/18/2025 reflected Resident #91 had potential to be physically aggressive related to Dementia and Paranoid Schizophrenia. Goal: Resident #91 will not harm self or others. An interview and observation on 03/29/2026 at 11:34 AM, with Resident #91 revealed she was sitting in the TV area. Resident #91 had long fingernails on her left hand measuring approximately 0.4-0.5 inches in length extending from the tip of her fingers. Resident #91 stated she would like them to be trimmed. 5. Record Review of Resident #126's Annual MDS assessment dated [DATE] as a [AGE] year-old female with initial admission date of 8/11/2007 to the facility. Her pertinent diagnoses included: Hypertension (high blood pressure), Diabetes mellitus (elevated blood glucose levels), Hyperlipidemia (elevated lipid levels in blood), Contractures of muscles (long-lasting shortening of muscles leading to stiff joints and reduced mobility), Multiple sclerosis (disease that causes breakdown of the protective covering of nerves). Her BIMS score was 7, which indicated Resident #126 had severe cognitive impairment. Resident #126 was dependent on staff for her personal hygiene. Review of Resident #126 's Comprehensive Care Plan, revised 3/29/2026 reflected, Category: [Resident #126] has an ADL self-care performance deficit related to Multiple Sclerosis.Interventions: PERSONAL HYGIENE: [Resident #126] requires assistance by staff with personal hygiene and oral care. In an interview and observation on 03/29/2026 at 2:23 PM, Resident #126 had multiple chin hairs and long and jagged fingers nails on both hands measuring approximately 0.2 - 0.4 inches in length extending from the tip of her fingers. Resident #126 stated that she may have her nails cut later. She stated that she would like her fingernails and facial hair trimmed due to concerns about her appearance. 6. Record Review of Resident #144's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 12/14/2024, diagnoses included Unspecified Dementia (Memory loss), Need for assistance with personal care. Resident #144 had a BIMS score of 02 indicating severe cognitive impairment. Resident #144 needed supervision with self-care such as toileting hygiene. Record Review of Resident #144's Care Plan dated 05/19/2022 with revision date 12/06/2023 reflected Resident #144 had ADL self-care performance deficit. Interventions:.requires skin inspection weekly observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. (Revision 09/09/2025). Care Plan with revision date 03/21/2026 reflected Resident #144 had an open abscess wound to the left chest. Interventions: Educate Resident #144 that prevention of abscess starts with good hygiene. An interview and observation on 03/29/2026 at 12:19 AM, Resident #144 was sitting in the dining area, he had long fingernails on both hands measuring approximately 0.4-0.5 inches in length extending from the tip of his fingers. Resident #144 stated he would like them to be trimmed. 7. Record Review of Resident #156's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 03/04/2026, diagnoses included Hemiplegia and Hemiparesis following cerebral infraction affecting right dominant side (Paralysis and weakness affecting the right dominant side following a stroke), Aphasia following cerebral infraction (Acquired language disorder caused by damage to the brain followed by stroke), Type 2 diabetes mellitus (Elevated blood sugar levels). Resident #156 had BIMS score of 00 indicating severe cognitive impairment. Resident #156 needed moderate assistance with toileting hygiene and showers. Record Review of Resident #156's Care Plan with an initiation date of 03/25/2026 and revision date of 03/29/2026 reflected he had Diabetes Mellitus. Interventions. Encourage Resident #156 to practice good general health practices.good hygiene. Resident #156 had an ADL self-care performance deficit.Goal: Resident #156 will improve current level of function in . Personal Hygiene. Interventions: Toilet use: Resident #156 requires assistance hand washing. Bathing: Check nail length and trim and clean on batch day and as necessary. If diabetic, the nurse will provide toenail care. An interview and observation on 03/29/2026 at 11:02 AM, Resident #156 was sitting in the TV area, he had long and dirty fingernails on both hands measuring approximately 0.3-0.4 inches in length extending from the tip of his fingers. Resident #156 stated his fingernails were too long and he would like them to be trimmed. An interview on 03/29/2026 12:27 PM, CNA M revealed she has worked at the facility for 8 years. CNA M stated the CNAs were responsible for cleaning and trimming resident fingernails, the nurses completed the nail care for residents who were diagnosed with Diabetes. She stated several residents residing in the secured unit refused fingernail care, but they would go back later to reattempt, she would notify the nurse if the resident still refused fingernail care. She stated long and dirty fingernails put residents at risk for infections and skin tears. She stated the most recent in-service training she received on fingernail care was a month ago. CNA M stated she started providing fingernail care to some of the residents that morning and she will continue to do so, once the interview was over. In an interview and observation on 03/30/2026 at 11:21 AM, CNA F stated Resident #126 had long, dirty fingernails and facial hair that required trimming. CNA F stated CNAs were responsible for providing nail care, including trimming and cleaning fingernails, as well as trimming facial hair, unless the resident had diabetes. She stated nail care should be provided on shower days and as needed. CNA F stated the risks of long, dirty fingernails included potential skin tears, and failure to trim facial hair in a female resident could result in loss of dignity. She stated that she will provide nail care to the resident after the interview was completed. In an interview on 03/30/2026 at 3:45 PM, LVN G stated that Nurses and CNAs were responsible for clipping residents' fingernails. He stated that for residents with diabetes, Nurses were responsible for trimming fingernails. He stated that CNAs were responsible for trimming facial hair for female residents on shower days. He stated that the expectation was CNAs provide ADL care to residents on shower days and as needed. LVN G stated the risks of long, dirty fingernails included skin tears and increased risk of infection. He added that failure to trim facial hair in female residents could result in decreased quality of life. In an interview on 03/30/2026 at 3:51 PM, ADON H stated her expectation was that ADL care be provided as needed, particularly during shower days. She stated that CNAs were responsible for providing nail care, including trimming fingernails and facial hair, unless the resident had a diagnosis of diabetes. She stated that charge nurses were responsible for monitoring this care. ADON H stated that residents having long, dirty fingernails and untrimmed facial hair in female residents could result in lapses in infection control and dignity concerns. An interview on 03/30/2026 3:55 PM, CNA J revealed she was working at the facility for 8 years, she stated the CNAs were responsible to clean and trim resident's fingernails, the nurses were responsible to do so if the resident was diabetic. CNA J stated the residents who stayed in the secured unit could not take care of their personal hygiene, even if a resident refused fingernail care, she would reattempt and if they still refuse then report to her charge nurse. CNA J stated not cleaning and trimming fingernails could cause skin tears, infections. An interview on 03/30/2026 4:24 PM, RN O revealed she was working at the facility for a month, she stated the Charge nurse was responsible to clean and trim resident's fingernails. She stated not cleaning and trimming fingernails put residents at risk for skin scratches, injury and infections. She stated she had received training on fingernail care as a new hire. An interview on 03/30/2026 4:40 PM, CNA N revealed she was working at the facility for two years, she stated the CNAs were responsible for cleaning and trimming resident fingernails, nurses were responsible to do fingernail care if the resident was diabetic. She stated that not cleaning/trimming resident fingernails could lead to injuries and infections. She stated she received in-service on fingernail care a week ago. On 3/31/2026 at 11:53 AM, a request was made for the facility's general ADL policy. The Administrator stated the facility did not have a general ADL policy. An interview on 03/31/2026 12:48 PM, the DON revealed she was working at the facility for a month. She stated that the CNAs and the nurses were responsible for keeping the resident's fingernails clean and trimmed. The DON stated either the nurse, or CNAs could trim the fingernails of residents who were diagnosed with diabetes. The DON stated that not cleaning and trimming resident's fingernails could lead to the risk for skin tear, harming self or others and infections. The DON stated she was new to the facility, and she would set up training for staff on fingernail care. Record Review of undated facility policy titled Nail Care, nursing Policy and Procedure [NAME] ADL HG 03-10.0 reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails all occur in the elderly with some frequency. NAIL CARE, ESPECIALLY TRIMMING, IS PERFORMED BY A PODIATRIST IN THOSE WITH DIABETES AND PERIPHERAL VASCULAR DISEASE.Goals1. Nail care will be performed regularly and safely.2. The resident will free from abnormal nail conditions3. The resident will be free from infection.Procedure. When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident.

Based on interviews and record reviews, the facility failed to review and revise the person-centered comprehensive care plan for 1 (Resident #55) of 7 residents reviewed for comprehensive care plan revisions.The facility failed to revise Resident #55's comprehensive care plan to include a diagnosis of dementia.This failure could place residents at risk of not receiving appropriate interventions to meet their current health needs.Record review of Resident #55's face sheet, printed 03/31/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (decline in mental function) developed 03/20/24, acute kidney failure (sudden loss of kidney function), heart failure (heart muscle doesn't pump blood and oxygen to support other organs), chronic obstructive pulmonary disease (progressive, treatable lung disease), and age-related osteoporosis (brittle and fragile bones due to loss of bone density).Record review of Resident #55's quarterly MDS assessment, dated 03/09/26, reflected a BIMS score of 12, which indicated mild to moderate cognitive impairment. Section I - Active Diagnoses revealed I4800, Non-Alzheimer's Dementia was checked.Record review of Resident #55's comprehensive care plan, last reviewed 01/09/2026, revealed there was no focus area, goals, or interventions for Resident #55's dementia diagnosis.During an interview on 03/31/2026 at 12:14 p.m., the MDS Coordinator stated the nurse or ADON on the unit updated care plans. He stated the care plan triggered every 3 months at which time MDS reviewed it. He stated the review included the residents' diagnosis, in relation to goals and interventions in the care plan, to ensure the care plan was personalized. He stated if a diagnosis was missed, staff would not know the targeted behaviors and interventions. He stated he did not know why the diagnosis was missing.During an interview on 03/31/2026 at 12:32 p.m., LVN J stated she was unaware of Resident #55's dementia diagnosis. She stated nurses were not responsible for updating care plans. She stated if care plans were not accurate, residents may not receive medications and appropriate care. During an interview on 03/31/2026 at 12:32 p.m., the DON stated nurses were responsible for updating the care plan for any acute changes. She stated updated care plans gave CNAs and nurses knowledge and education of the care needed for residents. She stated there were quarterly care plans and she was unsure why the care plan failed to address the dementia diagnosis. She stated the expectation was for nurses to learn and know the policy and procedures related to revising care plans.Review of the facility's undated Comprehensive Care Planning policy reflected in part, Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to provide food prepared that conserved nutritive value, flavor, and appearance for 6 residents (Resident #s 11,29,72,87,129, and 133) of 6 residents on pureed diet.Cook A failed to follow the recipe for the pureed potato salad served for lunch service on 03/30/26.This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included:Record Review of the facility's recipes to scale document for Monday, March 30, 2026, Lunch reflected, . Potato Salad,Yield :6 Serving Size: 1 # 8 Scoop . Instructions: .Place in a blender or food processor. Add liquid, if needed (example reserved juice, reserved liquid, or milk) to assist with pureeing. Puree with a blender or food processor until smooth. NOTE: Water should not be used as a liquid to puree foods. If needed, gradually add thickener. Serve: #8 scoop .Record Review of Resident diet roster dated 3/29/26 Lunch meal reflected, Resident #s 11, 29, 72, 87, 129, and 133 were on pureed texture diet.During an observation on 03/30/2026 at 11:27 AM, [NAME] A was observed preparing pureed (pureed food is cooked food that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) potato salad. [NAME] A added an unmeasured amount of water from a steel pot located next to the pureeing machine to the prepared potato salad prior to pureeing. The amount of water added was not measured, and no standardized recipe was referenced during preparation. [NAME] a then added about 1 tablespoon of thickener to the mixture. [NAME] A then pureed the potato salad and mixed the pureed mixture using a spatula. Using the same spatula, [NAME] A portioned the pureed potato salad into six individual plastic cups. Portions were not measured, and [NAME] A was observed estimating portion sizes, filling each cup to approximately one-half cup. She then placed the six cups on a bed of ice in preparation for service. During an interview on 3/30/26 at 1:30 PM with the Dietary Manager, she stated that when preparing pureed foods, liquids such as gravy, milk, or sauces should be added to the original food rather than water, as the use of water can dilute both flavor and nutritive value. She further stated that the expectation was that a standardized scoop be used to portion pureed foods. However, the cook used a spatula instead, which could result in inaccurate portion sizes. The Dietary Manager stated that this practice could cause residents to miss required portions, leading to decreased food intake, compromised nutritional value, and potential weight loss. She confirmed that water was not included as an ingredient in the standardized recipe. She stated that there was no specific policy addressing standardized recipes; however, staff were expected to follow standardized recipes designed for the facility and use appropriate portion sizes when serving food.During an interview on 03/30/26 at 2:13 PM, [NAME] A reported that she did not review the standardized recipe prior to food preparation. She stated that she added water instead of the liquid specified in the standardized recipe to adjust the consistency of the pureed potato salad. She acknowledged that not following the standardized recipe could decrease the nutritional content of the meal. [NAME] A further stated that after pureeing the food, she used a spatula to thoroughly mix the contents. She then used the spatula to portion the pureed salad into small individual cups, estimating each portion to be approximately one-half cup. She stated that she should have used a #8 scoop, which equals 1/2 cup (4 oz), to ensure accurate portion control.

Based on observations, record reviews and interviews, the facility failed to provide each resident with at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 1 of 5 halls ( A1) reviewed for designated meal service times.The facility failed to provide lunch according to the designated meal service schedules on multiple occasions.This deficient practice could place residents at risk of low blood sugar levels, increased stress levels, slowed metabolism rates, weakened immune systems, malnutrition, weakened hearts, and organ failures.Record review of the facility's undated posted meal service reflected breakfast mealtime was 7:30 a.m., lunch mealtime was 12:30 p.m., and dinner mealtime was 5:30 p.m.During an observation on 03/29/2026 at 12:30 p.m., in the facility's dining room on hall A1, residents sat at tables for the lunch meal service. Observation revealed food trays arrived by staff at 1:25 p.m. and distributed. During an observation on 03/30/2026 at 12:30 p.m., in the facility's dining room on hall A1, residents were seated in the dining room at the tables. Observation revealed food trays arrived by staff at 1:20 p.m. and served. During an interview on 03/29/2026 at 2:25 p.m., CNA K stated lunch trays arrived daily 45-60 minutes after the 12:30 p.m. scheduled lunch time. She stated kitchen staff brought the lunch trays into the dining room, the nurse checked the tickets for accuracy before being distributed by CNAs. She stated hall A1 was served last.During an interview on 03/29/2026 at 2:38 p.m., CNA L stated meal trays arrived late because C1 hall was served first, then halls C2, B2, A2, and A1 was served last.During an interview on 03/30/2026 at 1:13 p.m., CNA J stated lunch arrived at A1 Hall 45 minutes after the scheduled lunch time. She stated the serving time depended on who was in the kitchen.During an interview on 03/30/2026 at 1:47 p.m., the Dietary Manager stated once meals were prepared in the kitchen, kitchen staff walked the trays to the different hall dining rooms, and the nurses and CNAs distributed the trays once on the hall. She stated the expectation was for residents to receive their trays within 40 minutes after the scheduled mealtime. She stated the halls that contained more residents took more time. She stated 40 minutes after scheduled mealtime was a reasonable timeframe. She stated staffing was sufficient to provide meals in the scheduled time frame.Record review of the facility's undated Resident Meal Service policy, indicated in part, We strive to provide meals and HS snacks to all residents in a timely manner.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes the services that attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 32 residents (Resident #87) who were reviewed for care planning. The facility failed to create a comprehensive care plan to maintain the placement of Resident #87's Scopolamine Base Patch (used to manage excessive drooling) as ordered by his physician. This failure could affect residents by placing them at risk by not having their physician orders followed, choking on his saliva, and loss of dignity. Record review of the MDS assessment dated [DATE] revealed Resident #87 as a [AGE] year-old male initially admitted to the facility on [DATE]. Resident #87's diagnoses included: non-Alzheimer's dementia, hypertension, chronic kidney disease, and lack of coordination. Review revealed Resident #87 had 0 for a BIMS score, which meant that he had severe cognition issues and was rarely/never understood. Resident #87 required partial to moderate assistance with ADLS. The resident was incontinent of bowel and bladder. Record review of Resident #87's care plan dated 1/6/2026 showed Resident #87 required extensive one person assistance with ADLS. Review of the care plan revealed no documentation to ensure the Scopolamine Base Patch was still in place. Record review of physician orders dated March 31, 2026, indicated Resident #87 was prescribed Scopolamine Base Patch 72 Hour 1.5 MG on 1/12/2026 to manage Sialorrhea (excessive drooling). Record review of the resident's MAR for March 2026 showed the Scopolamine patch administered on 3/29/2026 in the AM, exact time was not indicated. In an observation on 03/29/2026 at 2:07 PM Resident #87 was observed in the activity room of the secured unit with other residents in a manual wheelchair, his nails and hair were groomed, he was observed to be drooling, the front of his red t-shirt was soaked with drool from chest to waist, and there was towel on his lap. The resident was greeted; an interview was attempted but he was found to be non-interviewable. In an observation and interview on 03/29/2026 at 2:08 PM, LVN S reported the physician prescribed a patch for Resident #87 to wear behind either ear to reduce drooling. Observation revealed LVN S inspecting the resident and LVN S found the patch stuck to the resident's shirt. LVN S reported the patch must have fallen off. In an observation on 03/30/2026 at 3:31 PM, Resident #87 was observed on the secured unit. He was sitting alone in his wheelchair at the end of the hall without the Scopolamine Base Patch behind either ear. He was observed wearing a gray polo style shirt that was wet with drool from chest to belly. In an interview with RN O on 03/30/2026 at 3:33 PM. she stated she was scheduled as the charge nurse on the secured unit. RN O reported to have been employed at the facility for approximately a month. RN O reported the resident had a patch to address drooling and she did not know why Resident #87 did not have the patch on. She reported no one told her that the patch was missing. RN O stated she was not sure if the previous nurse was informed. RN O stated her shift started at 3:00 PM today (03/30/36). She reported the Intervention for the missing patch was to replace the patch. She reported that the resident could choke on his saliva without wearing the patch. In an interview with CNA N on 03/30/2026 at 3:38 PM, she reported she was supposed to check for the Scopolamine Base Patch when changing his shirt. CNA N stated she last changed his shirt around 1 pm and stated the patch was there. CNA N stated the expectation was to notify the charge nurse that Resident # 87's patch was off or missing. In an interview with the MDS coordinator administrator on 03/31/2026 at 11:27 AM it was revealed that ADON updates the care plan and the MDS will review it after. The care plan review triggers every three months. If there was a change or update before the three-month review, ADON will make the MDS coordinator aware of the change so that the care plan can be updated. He reported that he was not aware that Resident #87 was taking off his patch. He reported the impact to the resident of not care planning could result in the resident not getting his medications. In an interview with ADON T on 03/31/2026 at 12:14 PM it was revealed that ADON, nurses, and the MDS coordinator were all responsible for updating the care plan. If the update was acute the MDS coordinator was to make the update. He stated that the nurse documents resident needs in progress notes, CNAs notify the nurse of concerns, and the nurse or ADON updates the care plan through communication with MDS via text or morning meetings. ADON T said the impact was that Resident #87 secretes a lot and messes up his shirt and impact dignity. The health implication to the resident was excessive secretions. In an interview on 03/31/2026 at 12:48 PM with the DON, she stated that she has been employed at the facility for a little over a month and believes nurses can update care plans. She reported the charge nurse or ADON can make any acute changes to the care plan. She stated that she was still confused about who should update the care plans. She reported that the MDS coordinator should put in any diagnosis into the care plan. She stated that the health implication of Resident #87's unmanaged drooling could result in skin issues because of the excessive wetness of his shirt, she added that it also impacts the resident's dignity to not be in a clean and dry shirt. She stated she was made aware this day of concern for Resident #87's ability to maintain his patch. She reported her expectation was for the nurse on the unit to check in with the residents at minimum every three hours in addition to a CNA providing care to ensure that physician's orders were followed and the resident's patch was on. She reported that she has now planned an intervention for the resident and staff will call his physician to determine if there were other medical options. She stated it was care planned now that staff will check for the patch throughout the day. Review of the undated facility policy, Comprehensive Care Planning revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #89) of one resident reviewed for tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care. The facility failed to ensure RN D followed the procedure for tracheostomy care for Resident #89 on 03/30/26 by:Changing his gloves and performing hand hygiene before applying a clean trach drainage spongeUsing sterile technique when inserting the inner cannula into the resident's trach. These failures could place residents at risk for respiratory infections.Review of Resident #89's Comprehensive MDS assessment, dated 03/16/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS was 99 which meant Resident #89 was unable to complete the assessment interview. Her active diagnoses included acute respiratory failure with hypoxia (absence of oxygen), tracheostomy status (a surgical procedure creating an opening in the neck to provide a direct airway). In Section O-Special Treatments, Procedures, and Programs it revealed he required tracheostomy (trach) care during the 14 days look back period. Review of Resident #89 's care plan dated 03/11/2026, reflected, Focus: [Resident #89] has tracheostomy. Goal: . resident will have no signs/symptoms of infection . Interventions: . Use universal precautions . Review of Resident #89's Consolidated Physician's orders dated March 2026, reflected, .Tracheostomy care every shift and as needed.In an observation on 03/30/26 at 8:26 AM revealed RN D washed his hands; he donned gown and clean gloves. He cleaned the bedside table, and he put supplies on it. Without changing gloves, RN D removed and discarded the tracheostomy stoma dressing. RN D removed and discarded dirty gloves; he donned clean gloves without performing hand hygiene. He opened the tracheostomy kit and placed it on a bedside table. RN D removed and discarded the dirty gloves and donned sterile gloves from the tracheostomy kit without performing hand hygiene. RN D attached the suction to the resident's in-line suction line and inserted the suction line into the trach 2 times. RN D then cleared the line and turned off the suction machine. He discarded the suctioning catheter. Without changing gloves RN D wet the gauze with normal saline and wiped the stoma site with the wet gauze. RN D then picked up the stoma drainage sponge and placed it around the tracheostomy tube while wearing the same gloves. RN D then changed his gloves without performing any kind of hand hygiene. He then removed the disposable inner cannula from inside the resident's tracheostomy, he discarded it. RN D changed gloves without performing hand hygiene and then picked up a new inner cannula and inserted it into the trach and locked it. He removed his gloves, his gown, and sanitized his hands. In an interview with RN D on 03/30/26 at 8:52 AM he stated he was supposed to perform hand hygiene before and after trach care. He stated he knew the procedure was supposed to be a sterile procedure to reduce the risk of cross contamination and stated he supposed to wear a sterile glove to insert the inner cannula. Review of RN D's Competency checks for tracheostomy care reflected he was skills checked on 11/07/25 and deemed competent in trach care. In an interview with the DON on 03/30/26 at 8:52 AM revealed hand hygiene was to be performed anytime a staff member went from a dirty procedure to a clean procedure. She stated that trach care was to be an aseptic/sterile technique. She stated failure of staff to follow proper procedures could result in infections. Review of the facility's policy, Tracheostomy Care dated August 2024, reflected, The purpose: To maintain patency of the airway. To prevent infection of the airways and the area around the tracheostomy tube. To prevent excoriation of the area around the tracheostomy tube. Process . 10. Suction tracheostomy, if necessary. 11. When suctioning is complete, remove gloves and cleanse hands. Put on clean gloves. 12. Remove soiled dressing and inner cannula (if using a disposable cannula) and discard in waste bag. 13. Remove gloves. Discard in waste bag and cleanse hands.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 22 (Resident #112) residents observed for pharmacy services. CMA R failed to ensure Resident #112's medications were administered by leaving a cup containing medications on her bedside table for the resident to take later without supervision. This failure could place residents who received medications from CMA A by placing them at risk for medication errors and receiving less than therapeutic benefits from medications.Review of Resident #112's MDS assessment, dated 02/29/26, revealed a [AGE] year-old female admitted to facility on 02/29/26 with diagnoses included: Atrial Fibrillation or Other Dysrhythmias (Atrial fibrillation (AFib) is the most common form of arrhythmia), hypertension (high blood pressure), Diabetes Mellitus (elevated blood sugar), depression (a serious, common mood disorder causing persistent sadness, loss of interest, and functional impairment), Thyroid Disorder (occur when the butterfly-shaped gland in the neck produces too much (hyperthyroidism) or too little (hypothyroidism) hormone, disrupting metabolism), Seizure Disorder or Epilepsy (A seizure is a single, temporary disruption of brain electrical activity, while epilepsy is a chronic neurological condition characterized by recurrent, unprovoked seizures), and Anxiety Disorder (excessive, persistent fear or worry that interferes with daily life) . The BIMs score was 07 indicating the Resident #112's cognition was severely impaired. Review of Resident #112's March 2026 physician's orders included morning medication of Gabapentin (for neuropathy), Amiodarone (for heart rhythm problems), Potassium Chloride (for hypokalemia), Sertraline (for depression), Apixaban (for Atrial Fibrillation), Divalproex Sodium (for Seizure), Buspirone (for Anxiety), and Levothyroxine Sodium (for Hypothyroidism). Review of Resident#112's physician's order on 03/30/26 revealed: 1-Levothyroxine Sodium Oral Tablet 50 MCG (Levothyroxine Sodium) Give 1 tablet by mouth in the morning for Hypothyroidism. 2-Potassium Chloride ER Tablet Extended Release 20 MEQ Give 1 tablet by mouth in the morning for hypokalemia. 3-Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 3 tablet by mouth in the morning for depression GIVE 3 TABS TO EQUAL TO 150MG. 4-Apixaban Oral Tablet 2.5 MG(Apixaban) Give 1 tablet by mouth two times a day for Atrial Fibrillation. 5-Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for Seizure. 6-busPIRone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth three times a day for Anxiety. 7-Gabapentin Oral Tablet 100 MG (Gabapentin) Give 1 tablet by mouth one time a day for neuropathic pain. Observation of Resident #112's room on 03/29/26 at 12:11 PM, revealed a medication cup located on the bedside table contained medications in tablets form (one big oblong white tablet, one big oblong orange tablet, three medium clear blue oblong tablets, one round yellow tablet, one medium oblong white tablet, two round white tablets, and one white capsule). The resident was confused and talking about worms under her skin, fingernails, and all over her cover (no worms were noticed by this surveyor). Resident#112 stated that her medications were in the cup and she would take it. In an observation and interview on 03/29/26 at 12:25 PM, CMA R confirmed that she dispensed Resident #112's medications that morning and left them on the bedside table and left the room, she said it had been about 30 minutes since. CMA R was unable to give any explanation for leaving the medications at the bed side and note watching Resident#112 take her medications. CMA R stated that medications were to be administered to the residents, and she should stay with the resident to make sure the resident took the medication. CMA R stated that there was no excuse for not monitoring Resident #112 to make sure she took the medication. CMA R stated the risk of not watching the resident take her medications and keeping it unattended at bedside could be the resident may not take her medication, she may drop it, and if another resident walked into the room and took the medication, he/she may have an allergic reaction. An interview on 03/31/26 at 1:05 PM, the DON stated her expectations were for the nurses and CMAs to visually observe the resident taking their medication (ingest, inhale, apply) unless specifically ordered otherwise. The DON stated medications must never be left unattended in a resident's room, as this poses a safety risk, could lead to missed doses, wrong dosages, or potential overdoses. Review of the facility's policy dated 10/25/2017 Medication Administration Procedure revealed, 1. All medications are administered by licensed medical or nursing personnel. 2. Medications are to be poured, administered and charted by the same licensed person. 4. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. 5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record.

Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 6 medication carts observed for medications labeling and. The Hall C2 medication cart contained an insulin bottle of Lispro injection 100 unit/ml with no open date. This failure could place residents at risk for not receiving the therapeutic benefit of the medication or adverse reaction to expired medication. During observation and interview on 03/30/26 at 1:47 PM, the medication cart for Hall C2 with LVN J, observation of top-drawer holding insulin, found an insulin bottle of Lispro insulin with no open date. LVN J stated she used the insulin bottle and gave Resident #2 her insulin doses at breakfast and lunch time administration. LVN J stated insulin expired 28 days after opening it and a negative outcome could be the medication loses potency and could be ineffective. During an interview on 03/31/26 at 1:05 PM, the DON stated daily the charge nurses were supposed to check for any expired medications in the medication carts and the pharmacists checked the medication carts monthly. The DON stated Lispro insulin was good for 28 days after opening, and she expected the nurses to label and date all insulin in the cart with open date. The DON stated this was supposed to be completed to prevent side effects like being ineffective if they were expired, also chemical composition of the medications could change if the medication was expired. Record review of policy review titled Medication Storage in the Facility 2025 reflected, .13. Outdated, contaminated, or deteriorated medications. are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exits.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #140 and Resident #190) of 5 residents observed for infection control. The facility failed to ensure:CNA C changed gloves and completed hand hygiene during incontinent care for Resident #140 on 3/29/26.CNA Q performed hand hygiene while providing incontinence care to Resident #190 on 03/29/26. CNA P and CNA Q wore proper PPE while performing incontinent care for Resident#190 ,who was in enhanced barrier precautions for indwelling medical devices on 03/29/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness.Resident # 140Record review of the Quarterly MDS assessment dated [DATE] reflected Resident #140 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (a condition caused by a blockage in blood vessels supplying the brain, resulting in tissue death), hemiplegia (paralysis that affects one entire side of the body causing severe loss of muscle function, strength, and control) affecting left side, and elevated blood pressure. Resident #140's BIMS score of 14, which indicated Resident #140's cognition was intact. The MDS assessment indicated Resident #140 required maximal assistance with toileting hygiene. Observation on 03/29/26 at 10:20 AM revealed CNA C and CNA V entered Resident #140's room to provide incontinence care. Both CNAs washed their hands and donned gloves, CNAC unfastened Resident #140's brief, she then provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. She rolled resident on her side, CNA V supported resident when she was on her side. CNA C wiped the resident's buttock area with peri-wipes, front to back, then removed the soiled brief and with soiled gloves, placed the clean brief under the resident. She rolled the resident on her back onto the clean brief. Once finished, she fastened the resident's brief. Without changing gloves CNA C covered resident and she lowered the resident's bed to low position. Both CNAs removed and discarded gloves and washed their hands. In an interview on 03/29/26 at 11:32 AM, CNA C stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA C stated failing to provide proper care and exposed the residents to infections. Resident #190Record Review of Resident #190's quarterly MDS assessment, dated 03/25/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's BIMs score was 03 indicating the resident's cognition was severely impaired. His diagnoses included cerebral infarction(a type of ischemic stroke caused by a blockage in brain blood vessels, resulting in a lack of oxygen and brain cell death), end stage renal disease (permanent kidney failure where function falls below 10-15%, making it impossible to survive without dialysis or a transplant) dependent on renal dialysis (a life-sustaining treatment for kidney failure), sever sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to tissue damage and organ failure), acute embolism (a sudden blockage of an artery, typically caused by a traveling blood clot (thrombus), fat globule, air bubble, or other foreign material, resulting in restricted blood flow and tissue damage) and thrombosis (the dangerous formation of a blood clot (thrombus) inside a vessel, obstructing blood flow, often causing pain, swelling, and redness (typically in legs) or serious emergencies like heart attacks, strokes, or pulmonary embolisms) of right internal jugular vein. Record review of Resident #190's Care Plans dated 03/26/26, reflected focus: Resident is on enhanced barrier Precautions. Goal: There will not be any transmission of infection from or to the resident. Intervention: Gloves and gown should be donned if any of the following activities are to occur linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Perform hand sanitation before entering the room and prior to leaving the room Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. Therapy should use gown and gloves, when transfer training, mobility training, or other high-contact activity. Focus: The resident has an ADL Self Care Performance Deficit. Goal: The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. Interventions: Assist with personal hygiene as required. Observation on 03/29/26 at 10:59 AM revealed Resident #190 was on Enhanced barriers precautions related to indwelling foley catheter and feeding tube. There was signage on the left side of the door that informed visitors/staff he was on enhanced barrier precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. CNA P and CNA Q entered Resident #190's room without any form of PPE, there was PPE cart inside the Resident#190 room on the right side of the entrance. Both CNAs washed hands, donned gloves and procced to do incontinent care for Resident#190 without wearing gowns. CNA Q on the right side of the bed uncovered Resident#190, unfastened his brief, and pushed it between Resident#190 legs. CNA Q using wipe on per stroke cleaned Resident#190 front area including the foley catheter tube. CNA Q with the help of CNA P turned Resident#190 to his right side, Resident#190 brief was wet and had smear of bowel movement. CNA Q removed dirty gloves, washed hands and put on clean gloves. CNA Q removed the dirty brief put it in a plastic bag, got clean brief put it under Resident#190. CNA Q using wipes on at a time cleaned Resident#190 buttocks area and finished putting the clean brief on Resident#190 without changing gloves or performing any kind of hands hygiene (Sanitizing or washing). Both CNAs adjusted Resident#190 in his bed and covered him. CNA P removed gloves, washed hands, gathered linen and trash bag, and exited the room. CNA Q removed gloves and washed hands before exiting the room. Interview with CNA Q on 03/29/26 at 11:18 AM revealed she knew that she was supposed to wear gown for the resident peri care, because he was in EBP, but she forgot. She stated she was nervous. She stated she was in-serviced regarding different types of infection control including proper hands hygiene and wearing appropriate PPE. She stated she knew that she was supposed to change gloves with hands hygiene going from dirty to clean tasks during residents' incontinent care. She stated the risk of not following proper hands hygiene and wearing proper PPE to residents' cross contamination and development of infection. Interview with CNA P on 03/29/26 at 11:22 AM revealed he knew that he was supposed to wear gown for any high contact with residents in EBP, but he forgot. He stated he was nervous. He stated he was in-serviced regarding different types of infection control. He stated the risk of not wearing proper PPE in enhanced barriers precautions residents' rooms was exposing himself and others to the development of infection and spreading germs from one resident to another resident. Interview with the DON on 03/31/26 at 1:05 PM revealed staff were to sanitize their hands before caring for the residents when going from clean to dirty and after-caring. She stated CNAs where trained to perform hand hygiene between change of gloves. She stated the staff should follow proper infection control policies, and wear gowns before they touch any resident that had a port of entry. The DON stated the risk was spreading infection to residents. She further stated to protect residents from anything staff may harbor in their body. She stated she would educate all nursing staff, and she would do random rounds for monitoring. Record review of the facility's policy, Fundamentals of Infection Control Precautions, updated March 2024, reflected, .Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . After removing gloves or aprons.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. On 09/29/25, Resident #1 eloped out of the facility and was found in a nearby hospital about 12 hours later. Resident #1 retuned back to the facility and continued on one-to-one supervision. The noncompliance was identified as Past Non-compliance (PNC). The Immediate jeopardy (IJ) began on 09/29/25 and ended on 09/30/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm, or death.Findings include: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male with an initial admission date of 8/18/2025. Resident #1 had a BIMS of 5 indicating he was severely cognitively impaired. He required partial assistance with walking and ADLs. His pertinent diagnoses included non-Alzheimer's dementia (forms of cognitive decline not caused by Alzheimer's disease), anxiety, hypertensive heart disease (refers to heart problems from long-term high blood pressure ), osteoarthritis ( a degenerative joint disease especially in hands, hips, knees, and spine), and psychotic disorder (a mental health condition causing a break from reality, characterized by symptoms like hallucinations and delusions, accompanied by disorganized thinking, speech, and behavior), Intervertebral disc degeneration (breakdown of discs that separate the bones of the spine). Resident #1's height was 72 inches and weight was 283 pounds. Record review of Resident #1's comprehensive care plan with revised date of 8/20/25 reflected, Focus: [Resident #1] is at risk for elopement as evidenced by: Lack of safety awareness and cognition impairment. Goal: [Resident #1] Will remain safe within facility unless accompanied by staff or other authorized person through review date. Intervention: [Resident #1] Assess/record/report to MD risk factors for potential elopement such as: Wandering, Repeated requests to leave facility, statements such as I am leaving I am going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital will not leave facility unattended through the review date. Distract [Resident #1] from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books . Record review of Resident #1's comprehensive care plan with initiation date of 09/29/25 and revised date of 10/28/25 reflected, Focus: Actual elopement: [Resident #1] left the facility unattended. Goal: To find [Resident #1] without harm and return him to the facility. Intervention: [Resident #1] Will remain safe in the facility, with no further elopements or elopement attempts, unless accompanied by staff or other authorized person through review date.Assess/record/report to MD risk factors for potential elopement such as: [Resident #1's] elopement or attempted elopement, Wandering, Repeated requests to leave facility, statements such as I am leaving I am going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital. Staff to provide 1 on 1 Supervision, until discharge from facility. Record review of Resident #1's initial elopement risk assessment dated [DATE] reflected, [Resident #1] was placed on secured unit. [Resident #1] exhibits wandering behavior and is frequently exit-seeking. Resident identified as high risk for elopement. Safety measures in place and staff will continue close monitoring . Record review of Resident #1's progress notes by RN A dated 09/29/25 at 7:20 AM reflected At 11PM shift rounds, [Resident #1] was in his room. [At] 12.58 AM, [Resident #1] sat at the TV room. Rounds and checks were done. [At] 04:37 AM, [Resident #1] refused blood draw. At 06:30 AM, nurse saw [Resident #1] sitting in the TV room, Nurse went to administer medication to a resident, and on coming back, [Resident #1] was not on his seat. Rooms were searched. Code orange ([NAME]) was called MD, ADON, Administrator notified. At 0655 AM, [Resident #1's] responsible party was notified that resident left the building without letting anyone know. Police were notified. Record review of Resident #1's progress notes by the Administrator dated 9/29/25 at 8:49 PM reflected, Notified Responsible Party that [Resident #1] is in the hospital and being evaluated. Medical director (MD) and Nurse Practitioner (NP) notified. Record review of Resident #1's progress notes by LVN K dated 9/30/25 at 1:47 AM reflected, [Resident#1] returned to the facility from the hospital in stable condition via ambulance. Upon arrival, resident was alert and oriented to baseline. Vital signs were obtained and remained within normal limits . No signs or symptoms of distress, discomfort, or pain noted. Resident was assisted to his/her room safely by the Emergency Medical Technician (EMT) and the nurse on duty. All discharge instructions and hospital documentation were received, reviewed, and placed in the medical chart. Medications were reconciled and orders updated as indicated. Responsible party and attending physician were notified of resident's return. Ongoing monitoring and plan of care continue. One-on-One monitoring/head count has been initiated. Bilateral dressings present to the posterior lower legs. Record review of Resident #1's Hospital notes dated 9/29/25 - 9/30/25 revealed [Resident #1] was found screaming for help while lying on an embankment by EMS (Emergency Medical Service) and transported to the nearby hospital. Resident # 1 sustained bilateral superficial abrasions to his lower extremities, right hip and shoulder pain, and a compression fracture of the lumbar region of his spine. Record review of the Provider Investigation Report (PIR) dated 10/6/2025 reflected, Assessment: Once the [Resident #1] was located, he was transported to the hospital for evaluation and treatment as needed. The resident returned to the facility with a hospital report indicating that everything was stable and no concerns were identified.Upon review of the hospital records the X-ray results indicated a compression fracture in the lumbar region.Provider response: When resident was nowhere to be located staff-initiated code orange missing resident. A head count of all resident was completed and accounted all residents except the missing resident. A thorough search was conducted inside of the facility and outside, staff extended their search throughout the community and informed law enforcement, Responsible party/family and Physician. Staff in service. The Administrator arrived at 7:40 AM, initiated an investigation, and confirmed all doors, windows, and alarms were functioning. At 8:00 AM, Maintenance repaired a damaged window. At 8:30 AM, staff searched the resident's listed address while the Marketer contacted local hospitals and continued follow-ups every 30 minutes; police also arrived on-site.Search efforts continued throughout the afternoon. and Maintenance securing all windows with new locks at 2:00 PM. The administrator re-tested all security systems at 3:10 PM, confirming no issues. Throughout the day, the Administrator remained in contact with police, and ADONs updated elopement risk assessments and care plans for all residents, ensuring accuracy and compliance with policy. At 6:15 PM, Hospital confirmed the resident had arrived and was undergoing evaluation, with labs and X-rays completed. By 8:00 PM, the hospital reported all findings were stable and the resident was cleared for discharge. On 9/30/25 at 1:40 AM, the resident returned safely to the facility, where one-to-one monitoring was initiated and continued until further notice. Provider action taken post Investigation: in service staff: Abuse and Neglect, Elopement protocol and elopement prevention. Elopement assessment on all residents. Skin assessment and Pain assessment completed when resident returned back. One-on-one with resident when returned back to the facility until further notice. Monitoring checks in the Secure Unit. Reenforce windows in the secure unit. Record review of Progress notes for Resident #1 from 09/30/25 through 12/11/25 reflected the resident remained on every 15-minute checks. Record review of facility's incident Log from 9/30/25 to 11/30/2025 revealed Resident #1 had attempted elopement on 10/18/25. In an observation on 12/09/25 at 9:11 AM of the secured unit revealed the entrance door to the unit was locked. It had a doorbell. Signage on the entry door revealed high elopement risk -please make sure the door is closed and locked behind you. A staff member, came from the secured unit, and opened the door by keying in the door code, let the surveyor inside the secured unit, and made sure the door was closed behind us. In an interview and observation on 12/9/25 at 9:31 AM, the Maintenance supervisor, within the secured unit, revealed that there were 3 exit doors to the facility from the secured unit. All exit doors were secured, and alarmed. Observed room [ROOM NUMBER], was diagonally opposite and the closest room to the TV area in the secured unit. There was no resident in room [ROOM NUMBER] at the time of observation. Observed that the window in room [ROOM NUMBER] had a hole on the bottom track where the initial bolt was in place. The window in room [ROOM NUMBER] chimed as soon as the maintenance supervisor opened the window. The window only opened about 6 inches. The window was reinforced with bolt and additional clamp that acted as a stopper to prevent the window from opening fully, both on the top and bottom frame. The height of the windowsill from the base of the window to the ground was about 37 inches. The maintenance supervisor stated that after investigation it was revealed that Resident #1 eloped by jumping out form the window of room [ROOM NUMBER] in the secured unit. He stated that when he reported to work on 09/28/25, around 8 AM, and headed to the secured unit, he saw that the window in room [ROOM NUMBER] was off track and opened. The mesh outside the window was broken as well. He stated that the bolt that acts as a [NAME] was bolted out and the window was half open. He stated that this could have happened because Resident #1 applied so much force that it likely caused the mechanical device (Stopper) to be pressed down and put the window off track. He stated that the window opened outside to the facility premises that led to a double lane street of a residential area. He stated that he repaired the broken window in room [ROOM NUMBER] soon after. He stated that all windows and doors in the secured unit were checked daily. He stated that all windows in the secured unit were reinforced with additional bolsters on top and bottom window frames as well as alarms was placed on all windows the same day of elopement, 9/29/25. He added he had received in services on elopement protocol and elopement prevention as well as abuse and neglect. He was able to verbalize forms of abuse and the reporting requirements. In an observation on 12/9/25 between 9:45 AM - 9:50 AM, in the secured unit revealed windows in room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] had stopping devices on both the top and bottom of the window frame. The windows opened about 6 inches and alarmed. The windows in all three rooms chimed as soon as the surveyor opened them. Facility staff quickly came to the rooms as soon as they heard the alarm on all three instances. In an observation and interview on 12/9/25 at 9:53 AM, Resident #1 was observed to be sleeping in his room. There was a sitter at his bedside. He later woke up and stated that he did not remember anything about the elopement incident. He stated he was doing well. Observed wheelchair in his room , to which he stated , its used for seating purposes only. He added he was able to walk independently. In an interview on 12/9/25 at 10:00 AM, CNA I revealed she had been working in the facility for more than two years. She stated that she worked in the secured unit as a CNA on 09/29/25 on the 7AM - 3 PM shift. She stated that when she reported to work on 9/29/25, she was alerted about code orange (code for elopement). She stated that she joined other staff to find Resident #1 looking from room to room in the secured unit. She stated that all doors and windows in the secured unit were secured and alarmed. She added that she had received in-services on elopement protocol and elopement prevention as well as abuse and neglect. She was able to verbalize forms of abuse and the reporting requirements. She stated that Resident #1 continued to be on one-to-one supervision since he came back to the facility after elopement. In an interview on 12/9/25 at 10:06 AM, CNA G revealed she had been working in the facility for 20+ years. She stated that she worked in the secured unit as a CNA on 09/29/25, 7AM - 3 PM shift. She stated Resident # 1 was very strong and can be confused at times. When she came to work on 9/29/25, she was alerted about code orange (code for elopement). She stated that she joined other staff to find Resident #1 looking room to room and in the facility. She stated that she heard later that Resident #1 broke the window in room [ROOM NUMBER] and eloped. She stated that all doors and windows in the secured unit are now secured and alarmed. She added that she had received in services on elopement protocol and elopement prevention as well as abuse and neglect. She was able to verbalize forms of abuse and the reporting requirements. She stated that Resident #1 continued to be on one-to-one supervision since he came back to the facility after elopement. In an interview on 12/9/25 at 10:23 AM, Med Tech H revealed he worked on the secured unit as medication aide. He stated that he was familiar with Resident #1's care needs. He stated Resident #1 did not have any exit seeking behaviors in the past except for the elopement incident in September 2025. He stated in the secured unit, all doors and windows are locked and secured at all times. He stated window alarms were put in after the elopement incident. He stated he had received in services on elopement protocol and elopement prevention as well as abuse and neglect. He was able to verbalize forms of abuse and the reporting requirements. He stated that he was not aware of any other residents that were at elevated risk of elopement. ,Attempted phone interview on 12/9/25 at 10:51 AM, with RN A left voice message for RN A to call back the surveyor. Attempted phone interview on 12/19/25 at 11:50 AM with ADON F, was not in the facility and not available for interview. In an interview on 12/9/25 at 2:35 PM, CNA N revealed she worked as a CNA on the secured unit on 09/28/25 on 11 PM to 7 AM shift. She stated she was in the secured unit when Resident #1 eloped from the facility. Stated she had seen Resident #1 around 5 AM on 9/29/25 sitting in the TV room with other residents while making her round. She stated Resident #1 was a very strong resident. He was able to walk independently and only used his wheelchair for sitting purpose. She stated that Resident #1 used to wander within the secured unit upon admission but did not show any signs of elopement. She stated that Resident #1 needed moderate assistance with ADLs. She added around 6:30 AM, she was getting ready to take other residents to dining room for breakfast, when she heard RN A asking about Resident #1 whereabouts. She stated she looked into Resident #1's room and could not find him. She stated they started looking for Resident #1 from room to room, including bathrooms and closets within the secured area. She stated that RN A called, code Orange (code for elopement) since they could not locate Resident #1. She stated that it was busy hour in the secured area, since staff busy with assisting residents with breakfast / providing ADL care and did not hear any noise from room [ROOM NUMBER]. She stated that she was provided training and in-services on abuse, neglect and elopement protocols. She was able to verbalize forms of abuse and the reporting requirements. She stated that Resident #1 was on One-on-One monitoring after he was back in the facility until this time. In an interview with LVN K on 12/9/25 at 3:11 PM, revealed she was the Charge Nurse on the secured unit working 11PM - 7 AM Shift, when Resident #1 returned from the hospital on 9/30/25. She stated that she assessed Resident #1, he looked confused and thanked the paramedics for getting him back. She stated he complained of his legs hurting, there were bilateral dressings present to the posterior lower legs. She stated that Resident #1 was being treated for venous ulcer on right posterior leg previously in the facility. Resident #1 was administered his PRN pain medication. She stated she mostly worked on weekends in the facility. Resident #1 did not show any signs of eloping in the past. She stated that Resident #1 was started on one-on-one monitoring as soon as he came back to the facility. In an interview on 12/9/25 at 3:23 PM, CNA O revealed he worked as a CNA on the secured unit on 09/28/25 on 11 PM to 7 AM shift. He stated she was in the secured unit when Resident #1 eloped from the facility. He stated that he had seen Resident #1 sitting in the TV room, near the nurse's station, around 6:00 AM on 09/29/25. He stated that resident #1 is a tall man and very strong. He stated that he walked independently. He added between about 6:30 AM on 09/29/25, RN A started looking for Resident #1. She asked CNA N to look for Resident #1 in his room since she could not see him at the TV room anymore. He stated CNA N could not find Resident #1 in his room. He stated soon after the code Orange (code for elopement) was called, Staff members from the facility started searching for Resident #1 room to room throughout the facility and outside the facility. He stated that he noted Window of room [ROOM NUMBER] was open and broken during his search and notified RN A. He stated that Resident #1 was on One-on-One monitoring after he was back in the facility until this time. He stated that she was provided training and in-services on abuse, neglect and elopement prevention and protocols. He was able to verbalize forms of abuse and the reporting requirements. In an interview on 12/9/25 at 4:05 AM, the Administrator revealed Resident #1 did not have any prior elopement attempts from the facility. He added that he was at risk of wandering and hence was on secured unit from the time of admission to the facility. He stated that Resident #1 ambulated independently. He stated that between 6:30-7:00 AM on 09/29/25, Staff working in the secured unit noted that Resident #1 was missing. They immediately called Code Orange for elopement and started elopement procedure. He stated that ADON F immediately notified him about the incident, around 7:30 AM on 09/29/25 and he was in the facility by 7:40 AM. As soon as he arrived , he confirmed all doors, windows, and alarms were functioning. He noted that the window in room [ROOM NUMBER] was open and mesh broken, he stated that the maintenance supervisor repaired the broken window the same day. He stated that Resident #1 eloped from the window in room [ROOM NUMBER], closest to the TV room. He added that Resident #1 is a big guy, weighing close to 300 pounds, post investigation it was concluded that Resident #1 applied force on the sliding window and jammed it enough that it got out of track and opened the window. Resident #1 eloped by jumping out of the window. He stated that the bushes outside the window were broken and footprints were seen on the ground closer to the window. He stated that there were no cameras in the inside or outside of the facility. He added Police report was made and law enforcement officer soon arrived in the facility. He stated that search efforts continued throughout the afternoon. Maintenance supervisor added new locking and alarming devices on all windows in the secured unit on the same day of elopement. He stated that he assisted with search and was in touch with the law enforcement officers regarding the investigation. He added Resident #1 was found by EMS in the nearby area and taken to the hospital around on 09/29/25 around 6:15 PM. He added Resident #1 underwent evaluation, with lab work and X-rays in the hospital, they reported all findings were stable and [Resident#1] was cleared for discharge with arrival to the facility on 9/30/25 at 1:40 AM. Resident #1 was started on one-to-one monitoring upon his arrival to the facility and was in place until now. He stated that the acting DON read in the hospital records that Resident #1 had sustained compression fracture of the lumbar region of his spine per the hospital documentation. He stated that the physician was notified about the same. The Administration stated that he had interventions in place after the incident. He stated all windows and doors were reinforced in the secured unit. Maintenance Supervisor added additional stopping device on both top and bottom window frame and alarming device for all windows in the secured unit. Door and Window monitoring checks in the secured unit were continued daily. All residents in the facility were reassessed for elopement risk and no new residents were found with elevated risk. All staff were re-inserviced on elopement protocol and elopement prevention as well as abuse and neglect. He stated that Resident #1 continues on one-on-one until now. He added that Resident #1 had another elopement attempt on 10/18/25 and the facility was able to successfully provide interventions. The Administrator stated Resident #1's Responsible Party lived out of state and was making arrangements to move Resident #1 closer to her. In second interview on 12/9/25 at 4:12 PM, LVN K stated she was the charge nurse on the secured unit on 10/18/25. She stated that after Resident #1 came back from the hospital after the elopement incident on 09/29/25, he spent most of his time in the room. On 10/18/25, Resident #1 was up and stated he did not want anyone to come near him. He had one-on-one aide that continued watching him from outside his room. She stated that Resident #1 paced through the halls within the secured unit, he went to the exit door one time, however, did not push the door. She stated Resident #1 did not try opening any windows on her shift. LVN K stated she was able to calm down Resident #1 and redirect him back to his room after some time. She stated that she was provided training and in-services on abuse, neglect and re-inserviced on elopement prevention and protocols. She was able to verbalize forms of abuse and the reporting requirements. In an observation on 12/09/25 at 4:35 PM, Resident #1 was sitting outside his room near the TV area. He was engaged in a conversation with one-to-one sitter, who was next to him. An attempt was made to interview on 12/10/25 at 8:05AM, Resident #1 Responsible party. Left voice message to return the writer's call. Call was not retuned until exit from the facility. In a phone interview on 12/10/25 at 8:08 AM, RN A revealed she worked as a charge nurse in the secured unit on 9/28/25 11PM - 7AM shift on the day of the incident. She stated she last saw Resident #1 around 6:30 AM on 9/29/5 in the TV area that was close to the nurse's station. Resident #1 did not show any signs of elopement; he was calm all through the night and sat at the TV area for a long time. She was in the process of administering meds and getting other residents ready for breakfast. She noted that she went to administer medication for one of the other residents and after coming back to the nurses station, did not see Resident #1 in the TV area. She asked CNA N to check Resident #1's room and started checking other rooms in the meantime. Around 7 AM on 09/29/25, she called ADON F to report Resident #1 was missing and started code Orange (elopement code). After some time, a staff noted room [ROOM NUMBER]'s window was broken, and the bushes near the window had some indentations. She stated that police came and she provided all the information regarding elopement. She stated she did not hear any noises from room [ROOM NUMBER] that morning because it was very busy during that time. Residents were pushed in wheelchairs to be taken to the dining room for breakfast, some residents needed their morning medications and some others needed to be changed. She stated that Resident #1 was wearing long pants and shoes. She stated that resident had swelling on both lower extremities and was provided wound care by wound nurse. She stated that window alarms were not present prior to the elopement incident. She stated that maintenance comes in very frequently to check on all windows/ doors for secured units. She added that there were no concerns with any windows or doors prior to elopement that needed attention. She stated that Resident #1 continued on One-on-One monitoring at this time. She stated that she was provided training and in-services on abuse, neglect and re-inserviced on elopement prevention and elopement protocols. She was able to verbalize forms of abuse and the reporting requirements. In an interview on 12/10/25 at 8:52 AM, ADON F, revealed that he was the ADON of the secured unit. He stated Resident #1 was in secured unit on initial admission to the facility, with cognitive deficit and confusion. He added Resident #1 was very strong, weighing close to 300 pounds and 6 feet tall. He stated that Resident #1 was ambulatory, he presented with edema on his lower legs and some wounds on his posterior legs on admission. He stated he was alerted by RN A regarding Resident #1 missing while he was driving to the facility around 7:00 AM on 9/29/25. He stated that once he reached the facility, RN A had called code orange and the staff was already looking for the resident, when he joined in search. He stated he asked staff to search outside of the facility in the nearby vicinity. He stated that through their investigations, it was revealed that Resident #1 had eloped form the window in room [ROOM NUMBER] in the secured unit. He stated that he observed the metal bolt (placed in the bottom window frame to prevent the window from opening all the way) was sheared and one side of the sliding window was open all the way. He stated there were no alarms on the window before the elopement incident. He stated that the bush outside the window had some indentations. He stated Resident #1 was found in the hospital and X-rays revealed Resident #1 had compression fracture of the lumbar region and some superficial bruise on his lower posterior legs. He stated that after Resident #1 returned back on 9/30/25, he stayed in bed for a few days. He was treated for pain per physician order. ADON F stated, we did and continue to do everything to keep him [Resident #1] safe, his strength was underestimated. He stated all facility staff were re-inserviced on elopement protocol and elopement prevention as well as abuse and neglect. He was able to verbalize forms of abuse and the reporting requirements. He stated that Resident #1 continues on one-on-one until now. In an observation on 12/10/25 at 9:52 AM, Resident #1 was seen sitting on his bed in his room. The sitter (CNA P) was outside the room with direct sight on the resident. In an observation on 12/10/25 at 9:55 AM, with CNA P revealed Resident #1 ate breakfast in the morning of the interview. She stated that Resident #1 was watching something on the TV in his room and soon got agitated. She stated he turned the bedside table upside down. CNA P was able to redirect the resident and continued her one on one with him. She stated that she was not assigned to work on the secured unit on 9/29/25. She stated that when she came to work on 9/29/25, she was alerted about Code Orange (code for elopement) in the secured unit. She stated she was provided training and in-services on abuse, neglect, and elopement prevention and protocols. She was able to verbalize forms of abuse and the reporting requirements. In an interview on 12/10/25 at 9:39 AM, the DON revealed he was the Regional Compliance RN and was acting as the DON for the facility. He stated that he was notified about the elopement incidence for Resident #1 on the same day. He stated he helped with the search for Resident #1. He stated that after reviewing hospital records on 9/30/25, Resident #1 had sustained compression fracture of the lumbar region of his spine per the hospital documentation. He stated that the physician was notified about the same. The DON stated that he provided in services to the Administrator on Elopement prevention / Elopement protocols as well as Abuse and Neglect. He stated all facility staff have been re-inserviced on Abuse, Neglect and Elopement protocols and preventions. He stated that all residents in the facility were reassessed for elopement risk and no new residents were found with elevated risk. He stated that Resident #1 continues on one-on-one until now. Interview on 12/10/25 at 10:03AM, the Wound Nurse revealed Resident #1 had superficial scrapping on the posterior left side and noted no additional wounds after the elopement incident. She stated that they were already treating Resident#1 for venous ulcer on right posterior leg. She also added that Resident #1 was not compliant with his wound care and would not keep wound dressing on his feet at times. She stated that Resident #1 did not complain of any pain. She stated she was provided training and in-services on abuse, neglect, and elopement prevention and protocols. She was able to verbalize forms of abuse and the reporting requirements. Interview on 12/10/25 at 10:28 AM, the Medical Doctor revealed he was aware Resident #1 had sustained a compression fracture after the elopement incident. He stated that it was common in residents who were elderly. He added that Resident #1 had history of Intervertebral disc degeneration and the compression fractures often heal naturally. Interview on 12/9/25 at 10:31 AM, LVN L revealed he had worked in the facility for last 4 months. He stated that he worked on 9/29/25 and 9/30/25 in the secured unit, 7AM - 3PM shift. He stated that on 9/29/25, when he arrived at work, he was informed about after Resident #1's elopement and code Orange (code for elopement) was called. He stated he helped the staff with the search for some time until the administrator took over and went back to assist other residents in the secured unit. He stated that on 9/30/25 on 7 AM - 3 PM Shift, Resident #1 did not complain of any pain and was calm. He stated Resident #1 was very strong and needed moderate assistance with ADLS. He stated he was aware of Resident #1's care needs and did not display any elopement behavior in the past prior to the elopement incident. He added that he was not aware of any other resident in the secured unit that was at an elevated risk of elopement. He stated that Residents in the secured unit should be checked upon every 2 hours. He stated that he was provided training and re-inserviced on abuse, neglect and elopement prevention and protocols. He was able to verbalize forms of abuse and the reporting requirements. He stated that Resident #1 continues on one-on-one until now. He added Resident #1 had not tried opening any windows or doors after the elopement incident. Record review of facility's policy titled Elopement Prevention undated reflected, .Physical Plant .Function of the alarm system will be verified each week and documented in a maintenance log, Keypad exit magnetic locks. Secured Unit Or a combination of the above.All other exits not considered fire exits will be locked when not occupied by staff members. All exit devices will be maintained by the manufactures recommendations and function of each door device will be verified weekly and a log maintained.Staff Training Staff will receive training during their orientation process and then annually regarding: Elopement prevention, Operation of all exit devices and Actions to take if elopement occurs. Review of facility's policy titled Elopement Response undated reflected, Policy Statement : Nursing personnel must report and investigate all reports of missing residents.

Based on observation, interview and record review, the facility failed to immediately notify the resident representative and the resident's physician, when there was significant change in resident's physical, mental, or psychosocial status for one of eight (Resident #2) reviewed for resident rights. The facility failed to ensure LVN K notified the RP and the physician when Residents #2 was hit with the door. On 11/24/25 LVN K entered Resident #2's room hitting him with the door, she failed to complete an incident report, document assessments completed, and any required ongoing monitoring for delay in injury and failed to notify the resident's responsible representative of the resident's broken dentures. This failure could place residents at risk of not having their responsible party, physician and oncoming staff notified of changes, which could result in a delay in medical intervention and a decline in health. Findings included: Record review of Resident #2's Face Sheet dated 12/12/25 reflected an [AGE] year-old female with an admission date of 11/22/25. Her diagnoses included Alzheimer's disease. Record review of Resident #2's admission Nurses notes dated 11/22/25 and completed by LVN K, reflected the resident was ambulatory without assistive device, required minimal assistance with dressing, was able to toilet herself, required a secured unit, was alert to person but had short term memory impairments and difficulty in decision making when faced with new tasks or situations and had wandering behaviors. Resident was on anticoagulant (blood thinner) medication. Review of Resident #2's base line care plan initiated on 11/23/25 reflected that the resident was at risk of falls with interventions that included, anticipate and meet the resident's needs, call light within reach and educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Record review of Resident #2's Physician order summary report dated 12/10/25 reflected, . Admit to secure unit with active exit seeking behavior. with a start date of 11/23/25. Record review of Resident #2's Nurse Progress note dated 11/24/25 at 14:30 (02:30 p.m.) by LVN K, reflected Resident continues to frequently remove her upper dentures and wrap them in paper towels. This nurse has re-educated the resident on the importance of keeping dentures in a safe and designated container. Resident acknowledges understanding but continues the behavior. This nurse is concerned that the dentures may become misplaced or accidentally discarded. Denture cup placed at bedside and reinforced use. Will continue to monitor and reinforce education Record review of Resident #2's Nurse Progress note dated 11/26/25 by LNV K reflected, Effective date 22:24 (10:24 p.m.) Late Entry.This nurse was making rounds and when opening the residents room door she was standing behind it and the door bumped the resident. In an interview on 12/09/25 at 3:00 p.m. with resident #2's Representative they stated the resident was receiving hospice services at home and a brief respite request had been made to provide a break for Resident #2's familymember. They stated Hospice Agency J arranged with the facility for the resident to be admitted on [DATE] for a five day stay. The Representatives stated when they picked Resident #2 up on 11/26/25 they noticed bruises on both of the resident's arms and on the left side of her forehead above her left eye and her dentures were broken. Both stated they asked the facility about the bruises and were told the bruise on her right arm was from a blood draw and then they were told about the incident with the nurse hitting the resident with the door. They stated they were told no one knew about the broken dentures. Both stated they were never notified about the resident receiving lab work or about the incident with the door or her broken dentures and felt they should have been contacted. In an interview with LVN K on 12/09/25 at 03:45 p.m., she normally worked double weekends and was on duty the weekend of 11/22/25 and did the admission on Resident #2. She stated the resident would wander throughout the unit and had wandered into a few other residents' room. She stated she was making round on 11/24/25 around 10:00 p.m. and knocked on Resident #2's door and then opened it. She stated the resident was standing behind the door and when she opened the door and contacted the resident. She stated the resident said ouch but stated she did not fall. She stated she assessed the resident and did not notice any bruises, cuts or injury and the resident denied any pain. She stated she should have documented the incident and put on the report but stated she just failed to do so. She stated she was going to tell the family when they came in the next day but stated she did not see them. She stated she had also noticed Resident #2 was taking her upper denture in and out and had wrapped it up in a napkin one day. She stated they placed the denture in a cup and would put them back in for her to eat but had not noticed they were broken. She stated the day the Speech Therapist came to evaluate her on 11/24/25 the Speech Therapist had brought the dentures to her and told her they were broken. She stated she placed the dentures in a cup and locked them in the medication cart. She stated she reported to ADON F about the broken dentures. She stated when the Resident's family came to pick Resident #2 up on 11/26/25 she was asked by ADON F about the bruise on her forehead and that was when she told him about the door incident. She stated she filled out an incident report which was what triggered the late entry in the progress notes about the incident. She stated she knew she was supposed to document any incident so they could observe for any delayed injury. She stated the resident did not appear to be injured in any way, but since she is on blood thinners it would not be unusual for a bruise to occur a few days later. She stated she also had a bruise on her right arm due to the routine lab draw that was ordered upon her admission. She stated that was their standing protocol for base line labs upon admission. In an interview with ADON F on 12/10/25 at 08:35 a.m., he stated he was notified by the Administrator about Resident #2's concerns when they came in on 11/26/25 to take her home. He stated he went and assessed the resident and noted a slight discoloration on her left eye lid but did not see anything on her arms or legs. He stated he immediately started asking the staff if she had fallen and was told by LVN K about the incident with the door on 11/24/25. He stated she should have completed an incident report and notified the family and the MD at the time of the incident. He stated it was nursing judgement on notifying immediately or could it wait until the next day if it was something that had occurred in the night. He stated since there was no apparent injury it would have been acceptable to notify them both the next day but stated it should have been documented at the time of the incident. He stated he was made aware of the dentures the same day he was told about the door incident. He stated the family should have been called when they first noticed the broken dentures. In an interview with Resident #2's MD on 12/11/25 at 09:06 a.m., he stated his expectation was to be notified of any incident that required monitoring or follow up. He stated hitting the resident with a door would need to be monitored for delayed injuries. He stated he had heard about the incident but was not certain if he was notified at the time of the incident or after it was brought to the facility's attention. He stated he does order routine labs on all new admission to obtain a base line but stated since she was a respite only resident the labs should not have been ordered. He stated it was simply oversight when they put in the orders. In an interview with the DON on 12/11/25 at 11:00 a.m., it was revealed the staff was always to complete an incident report, notify family, physician and Administration so any incident could be evaluated to determine if it was a reportable event and to ensure timely monitoring and follow-up. He stated this was not typical of the staff failing to document and report an incident. He stated they had spoken to the Nurse, who admitted that she had failed to complete the necessary documentation and notifications. He stated she had been counseled. He stated this failure could result in delayed injury of resident with an unknown cause and it was their protocol to document all incidents and report as required. Record review of the facility's policy titled, Notifying the Physician of change in Status, dated March 2013, reflected, The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary.The facility utilized the INTERACT tool, Change in Condition-When to notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician.The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise.The nurse will monitor and reassess the resident's status and response to interventions.The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 of 7 residents (Resident #3). The facility failed to ensure Resident #3's room was free from hazards. This deficient practice could place residents at risk of living in an unsafe environment which could lead to falls and injuries.Findings include: Record review of Resident #3's Face Sheet, dated 12/09/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and difficulty walking. Record review of Resident #3's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 15, an intact cognitive response. For ADL care, it reflected the resident required substantial assistance. Record review of Resident #3's Comprehensive Care Plan, dated 12/09/2025, reflected the resident was a risk for falls. In an observation on 12/09/25 at 11:40 AM, Resident #3 had a large extension cord running across the floor from her television on the wall to the outlet next to the side of her bed. The television did have an outlet on the same wall. Resident #3 had another extension cord connected to two fans located next to a wall in the room. The bed adjuster sitting on top of the resident's bed had exposed wires. In an interview and observation on 12/09/25 at 1:00 PM, the Maintenance Supervisor observed the extension cords connected in Resident #3's room and stated she should not have the extension cords because the resident could trip and fall from them. He stated he did not know who placed the extension cords in the resident's room. He stated the resident should have had American Power Conversion cords to connect the devices, instead of the extension cords. He stated he was going to get the APC cords for the resident's room. He also observed the exposed wires for the bed adjuster and stated it was a low shock but should not be exposed. In an interview on 12/10/25 at 9:42 AM, the Administrator was advised of Resident #1's room having the extension cords and exposed wires in the room. He stated he was not aware of this. He stated it was a team effort, and everyone should be paying attention to this, including maintenance. He stated the main risk to the resident was a fire could start and the resident could fall. Record review of the facility's policy on Resident Rights, undated, revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on interviews and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #5) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #5 received any of her scheduled showers based on records reviewed for November and December 2025. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings Included: Record review of Resident #5's Face Sheet, dated 12/09/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Cerebral Infarction impacting left dominant side (stroke) and reduced mobility. Record review of Resident #5's Quarterly MDS assessment, dated 9/16/25, reflected a BIMS score of 14, an intact cognitive response. For ADL care, it reflected the resident required total assistance. Record review of Resident #5's Comprehensive Care Plan, dated 12/02/2025, reflected the resident was at risk for impairment of skin integrity and an intervention included keeping her skin clean and dry. In an interview on 12/09/25 at 12:05 PM, Resident #5 stated she did not receive her three scheduled showers a week and would be lucky if she got a bed bath. She stated she had not had a shower in over 5 weeks, prior to the shower she had received on 12/08/25. She stated she had to complain to leadership about not getting a shower and she was able to get one on 12/08/25. She stated she wanted her showers but was told by staff they did not have time. She stated the CNAs also told her the shower bed was broken. Record review of Resident #5's shower sheets for the month of November and December 2025 reflected the following:11/03/25: No indication of whether a bed bath or shower was provided.11/07/25: Refused11/19/25: Bed Bath12/04/25: Bed Bath12/05/25: Bed Bath12/08/25: Shower In an interview on 12/09/25 at 2:00 PM, LVN B was advised of Resident #5, only having shower/bath sheets for the dates previously stated. She stated CNAs rotated to different halls daily and the resident hall did not have a dedicated CNA. She stated the CNAs scheduled to work the A-hall, should check the shower schedule to see what residents were scheduled for showers for that day. She stated CNAs were supposed to turn in shower sheets at the end of their shift and the nurse assigned to the hall should check with the resident to confirm they had received their shower, and if they had refused, they were to attempt to persuade the resident to take one and contact the RP if they still refused. She stated if the resident did not receive their scheduled showers, they could have skin break down and stink. In an interview on 12/10/25 at 9:03 AM, LVN C stated he covered the hall of Resident #5. He stated the resident should receive a shower or bed bath at least three times a week. He stated sometimes the resident may refuse. He stated the resident should still have a shower sheet stating the resident refused and he attempts to talk them into getting a shower. He was advised of Resident #5 not receiving her scheduled showers and he stated the resident should receive her showers from the 3:00 PM to 11:00 PM shift. He stated he did not review the shower sheets to ensure the resident was not getting showers. He stated this was the ADON's responsibility. He stated the risk of the resident not receiving showers could result in skin breakdown and infections. In an interview on 12/10/25 at 9:48 AM, ADON E stated she managed the hall of Resident #5. She stated the resident should receive showers three times a week. She was advised of the shower sheets reviewed for November and December 2025, and the dates indicated a shower or bed bad was given. She stated the CNAs checked the shower scheduled to see who should receive the shower that day. The Nurses should check the shower sheets to ensure the resident was provided their shower. She stated she checked the shower sheet book weekly to see if showers were being given and she collected all of the shower sheets monthly. She stated she had not collected November's shower sheet yet to see if residents were getting her shower, so she was not aware of this. She stated the resident had not mentioned to her that she was not getting her showers. She stated the risk of residents not getting their shower was they could get sick, get an infection, and develop wounds. She stated all CNAs completed showers, and it was based on whoever CNA was assigned to the Hall during their shower schedule. Record review of the facility's policy on Bath, Tub/Shower, undated, revealed Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation. The resident will receive assistance with bathing according to their resident centered plan of care.

Based on interview and record review the facility failed to obtain from hospice the hospice election form, hospice plan care, and physician certification and recertification of the terminal illness specific to the patient and failed to designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care to the resident for one of three (Resident #2) residents reviewed for hospice services. The facility failed to coordinate care between the facility and Hospice Agency J for Resident #2 at the time of her Respite stay from 11/22/25 through 11/26/25 which resulted in her not receiving her Hospice aide services from 11/24/25 through 11/26/25. These failures could place residents on hospice at risk of not having services coordinated between service providers.Findings included:Record review of Resident #2's Face Sheet dated 12/12/25 reflected an [AGE] year-old female with an admission date of 11/22/25. Her diagnoses included Alzheimer's disease. Record review of Resident #2's Hospice Agency J Face sheet/staff assignments dated 10/17/25 reflected, Hospice Aide 5 visits weekly, Record review of Resident #2's admission Nurses notes dated 11/22/25 and completed by LVN K, reflected the resident was ambulatory without assistive device, required minimal assistance with dressing, was able to toilet herself, required a secured unit, was alert to person but had short term memory impairments and difficulty in decision making when faced with new tasks or situations and had wandering behaviors. Resident was on anticoagulant (blood thinner) medication. Review of Resident #2's base line care plan initiated on 11/23/25 reflected, [Resident #2] has a terminal prognosis and/or is receiving hospice services.Interventions.work cooperatively with hospice team to ensure the resident's. physical and social needs are met. Record review of Resident #2's Physician order Summary dated 12/10/25 reflected, .Resident receives care from Hospice Agency J. with a start date of 11/24/25. In an interview on 12/09/25 at 3:00 p.m. with Resident #2's Representative they stated the resident was receiving hospice services at home and a brief respite request had been made to provide a break for Resident #2's Family member. They stated Hospice Agency J arranged with the facility for the resident to be admitted on [DATE] for a five day stay. The stated they did not think the resident had received a shower during her stay at the facility. In an interview with LVN K on 12/09/25 at 03:45 p.m., she normally worked double weekends and was on duty on the weekend of 11/22/25 and did the admission on Resident #2.In an interview with LVN K on 12/09/25 at 03:45 p.m., she normally worked double weekends and was on duty on the weekend of 11/22/25 and did the admission on Resident #2. She stated this was the first respite admission she had completed. She stated ADON F had sent her a message about the upcoming admission and stated she had received the Hospice faces sheet but stated she had not noticed the staff assignments. She stated she did her admission assessments and stated one of the family members was present during the assessment. She stated the family member stated the resident might be hesitant about allowing them to assist her a lot with changing her clothes and showering but stated she told them if they laid her clothes out the resident could dress herself. She stated a nurse from Hospice came on the day of admission and left her a phone number to call if they needed anything and stated she saw one other person from the Hospice agency come later in the week but was not sure if she was a nurse or caregiver. In an interview with ADON F on 12/10/25 at 8:35 a.m., he stated he had received a message on 11/21/25 that they were receiving Resident #2 on 11/22/25 for respite services for 5 days. He stated he had let LVN K know about the new admission. He stated at that time he was not aware of what services the Hospice agency would provide. He stated when he came in Monday he found out they were missing some documents and had reached out to the hospice agency but stated he did not ask about the hospice aide. He stated this was a new hospice agency they had not worked with before and it was the first respite case he had handled, so he was not sure what was being provided. He stated regardless they still scheduled the resident for showers and provided what care she would allow them to do. In an interview with CNA G on 12/10/25 at 9:05 a.m., she stated Resident #2 was here for 4 or 5 days. She stated she was very independent and required limited assistance. She stated she was scheduled for showers on Monday, Wednesday and Fridays but stated they had offered and she declined. She stated they had assisted her with changing her clothes. She stated she knew she was on hospice services but stated she was not aware of when the Hospice aide was coming. She stated she saw one caregiver come one day but was not sure if she was the hospice aide. She stated they usually know when the hospice aides are coming and how often they are coming. In an interview with Hospice Agency J's Social Worker on 12/10/25 at 11:37 a.m., she stated she assisted with setting up the respite services for Resident #2. She stated they scheduled a nurse to come out on the day of admission to ensure the resident was settled in and the facility had what they needed. She stated the resident's hospice plan of care should have continued at the facility which included sending the hospice aide 5 days a week. She stated it appeared this did not happen. She stated they would look into what happened on their end but stated the facility did not reach out and let them know the aide was not coming.In an interview with Hospice Agency J's Case manager for Resident #2 on 12/10/25 at 1:15 p.m., she stated their Social Worker had set the respite services up for Resident #2. She stated it was all at the very last minute. She stated she did not see Resident #2 the week she was at the facility but stated the after-hours nurse saw her on admission and another nurse saw her on 11/25/25. She stated the hospice aide should have come Monday through Wednesday and was not sure what happened. In an interview with the DON on 12/11/25 at 11:00 a.m., he stated they have long standing relationships with the hospice agency they have contracted with, and everyone knows the routine. He stated the Hospice Nurse's and aides all communicate with the staff when they have arrived and what their schedules will be. He stated this was a new Hospice agency and they all dropped the ball, and not all of those pieces were in place prior to the resident's admission. He stated that going forward each unit's ADON will be responsible for coordinating with the hospice agency to ensure they have the Hospice agency's care plan and schedule and then communicate and coordinate with the facility staff. He stated the facility was ultimately responsible for the resident, but they had to communicate effectively between the two. He stated ultimately the facility's comprehensive care plan, and the hospice care plan should be combined into one comprehensive care plan to best serve the resident. He stated communication was key between the facility, the hospice and the family to ensure the residents' needs were met. Record review of the facility's policy titled, Hospice Services, dated February 2007, reflected, .The nursing facility and hospice provider must ensure that a coordinated plan of care reflects the participation of the hospice, nursing facility, the resident, and legal representative to the extent possible.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 4 residents (Resident #4) reviewed for dignity. The facility failed to ensure Resident #4 had a privacy curtain. This deficient practice could place the resident at risk of not feeling as if they were being treated with dignity and respect while being fed.Findings include:Record review of Resident #4's Face Sheet, dated 12/09/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included major depressive disorder and anxiety. Record review of Resident #4's Quarterly MDS assessment, dated 11/19/25, reflected a BIMS score of 8, a moderate impairment. For ADL care, it reflected the resident required supervision or touching assistance. Record review of Resident #4's Comprehensive Care Plan, dated 12/02/2025, reflected the resident had an impaired cognitive impairment and an intervention included providing the resident a homelike environment. In an interview and observation on 12/09/25 at 12:10 PM, Resident #4 stated she had been in the room for 4 weeks and she did not have a privacy curtain since residing in the room. She stated she needed to change her clothes but had to go into the bathroom because she was concerned about someone walking in on her. The resident was observed to not have a privacy curtain. In an interview on 12/09/25 at 12:30 PM, LVN B stated Resident #4 did not have a privacy curtain and she was supposed to have one for her privacy. She stated she just started working the A-hall and was not sure why the resident did not have a privacy curtain. In an interview on 12/10/25 at 9:48 AM, ADON E and the Administrator was told about Resident #4 not having a privacy curtain in her room, and they stated they were not aware of this. ADON E stated laundry may have removed the curtain to have it cleaned. ADON E stated the resident's roommate had a privacy curtain, this did not help Resident #4 for when anyone came into the room and she was trying the change. They both stated the resident needed a privacy curtain for her privacy and dignity. Record review of the facility's policy on Resident Rights, undated, revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

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 resident (Resident #3) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #3 had his fingernails cleaned and trimmed on 11/06/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Record review of Resident #3's admission MDS assessment dated [DATE] reflected Resident #3 was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dehydration (occurs when the body loses more fluids than it takes in, leading to a depletion of water and electrolytes), coronary artery disease (a condition where the arteries that supply blood to the heart [coronary arteries] become narrowed or blocked), and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland, a walnut-sized organ located below the bladder in men). Resident #3's had a BIMS score of 05 out of 15, which indicated severe cognitive impairment. The MDS assessment indicated Resident #3 required maximum assistance with personal hygiene. Record review of Resident #3's Care Plan dated 10/01/25, reflected the following: Focus: [Resident #3] has an ADL selfcare performance deficit. Goal: [Resident#3] will maintain current level of function . Personal hygiene. Interventions: Assist with personal hygiene as required . BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.Record review of Resident #3's Shower sheets on 11/06/2025 revealed Resident #3's last bed bath was on 11/04/2025, and shower was on 10/30/2025.An observation and interview on 11/06/25 at 09:01 AM revealed Resident #3 was lying in his bed. Resident #3's nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers. The nails were discolored tan with brown matter underneath. Resident #3 stated he would like his fingernails trimmed and cleaned. In an interview on 10/06/25 at 10:27 AM, CNA B looked at Resident #3's fingernails and stated she would clean and trim them today after Resident #3's shower. CNA B stated that both CNAs and Nurses were responsible for nailcare. She said that if the resident has diabetes, then nurses trimmed their fingernails. She stated that if nails were long and dirty, residents may be at risk of infection. In an interview and observation on 11/06/25 at 10:33 AM, LVN C stated that both nurses and CNAs were responsible for doing nail care for the residents. He stated that fingernails should be trimmed and cleaned on shower days and as needed. He stated that Resident #3 had dirty, untrimmed nails, and will provide nail care to the Resident today. He stated that dirty nails could lead to a risk in infections. In an interview on 11/06/25 at 2:47 PM, the ADON stated nail care should be completed as needed and every time aides washed the residents' hands. The ADON stated nails should be observed daily. The ADON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The ADON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The ADON stated she would do the routine rounds to monitor. The ADON stated residents having long and dirty nails could be an infection control issue. Record review of the facility's policy titled, Nursing Policy & Procedure Manual-Nail Care undated reflected, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails . It includes cleansing, trimming, smoothing, and cuticles are and is usually done during the bath.

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 diseases and infections for 2 of 6 residents (Resident #1, Resident #2) observed for infection control. The facility failed to ensure CMA A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and Resident #2 during a medication pass on 11/06/25. These failures could place residents at-risk of cross contamination which could result in infections or illness.Observations on 11/06/25 between 09:24 AM and 07:43AM revealed CMA A took a blood pressure cuff from the top of the medication cart, entered Resident #1's room, checked his blood pressure and put the blood pressure cuff back on the top of the medication carts without sanitizing it. CMA A gave Resident #1 his morning medications. CMA A moved the medication cart to the front of Resident #2's room. CMA A retrieved the blood pressure cuff from the top of the medication cart and checked Resident #2's blood pressure. CMA A returned to the medication cart and placed the blood pressure cuff on top of the medication cart, and again did not sanitize the cuff. CMA A gave Resident #2 her morning medications. In an interview with CMA A on 11/06/25 at 09:44 AM, she stated she cleaned the blood pressure cuff at the start of her shift this morning. She stated she cleaned the blood pressure cuff twice during her shift and added that she sanitized the blood pressure cuff between two residents' use. CMA A stated the risk of not cleaning the cuff between each resident was cross-contamination, spread of germs, and it could harm residents who were immunocompromised [low immune system]. In an interview with the Regional Nurse on 11/06/25 at 1:25 PM, he stated the staff were trained to disinfect the reusable equipment between residents' use. He stated the risk to the resident was the development of infection.In an interview with the ADON on 11/06/25 at 2:47 PM, she stated all staff were expected to follow infection control policy when in the building. She stated all equipment should be cleaned between patient-use according to the infection control policy. She stated there was an infection control policy specifically for equipment. The ADON stated the risk to the residents was cross contamination. Record review of the facility's policy titled Infection Control Policy & Procedure Manual 2019 UPDATED March 2023 reflected The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.6. Resident care equipment and articles. 3. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with approved disinfectant by the nursing assistant.

Based on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident to ensure safe and orderly transfer or discharge from the facility and ensure the orientation was provided in a form and manner that the resident could understand for one (Resident #1) of five residents reviewed for discharge. The facility failed on 8/21/2025 to ensure Resident #1's post-discharge destination and continued care provider could meet Resident #1's needs in that Resident #1 did not go to the Resident Representative's (RP) home, Resident #1 was taken to another family members residence because Resident #1 RP couldn't care for her due to work schedule and on or about 25 or 26 August 2025 Resident #1's RP obtained an order of protective custody for Resident #1 and Resident #1 was arrested and taken to a psychiatric hospital.This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for their needs not being met.This failure resulted in an Immediate Jeopardy situation on 9/16/2025. While the IJ was removed on 9/18/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm due to staff needing more time to monitor the effectiveness for the plan of removal for inappropriate discharge. Findings included:Record review of Resident #1's Discharge summary, dated [DATE], revealed a [AGE] year-old female originally admitted on [DATE], re-admitted on [DATE], and discharged on 08/21/2025. Resident #1 had diagnoses which included: Cellulitis of left lower limb (bacterial infection of the skin and underlying tissues), acute respiratory failure with hypercapnia (inability of the lungs to effectively remove carbon dioxide), morbid (severe) obesity with alveolar hypoventilation (breathing disorder), diabetes mellitus (high blood sugar) without complications, unsteadiness on feet, lack oof coordination, generalized anxiety disorder (mental health conditions), dementia in other diseases classified elsewhere (a type of dementia that occurs as a secondary symptoms of another underlying medical condition), severe with mood disturbance, pain unspecified, reduced mobility, difficulty in walking, deficiency of other vitamins, unspecified intellectual disabilities, schizoaffective disorder (mental condition that combines symptoms of schizophrenia and a mood disorder), bipolar (manic depression), fluid overload, unspecified pyuria (high levels of white blood cells in urine), lymphedema (swelling in the body), iron deficiency anemia, pulmonary hypertension (blood pressure in the arteries of the lungs is abnormally high), acute on chronic diastolic (congestive) heart failure, acute embolism and thrombosis of deep veins of unspecified lower extremity (blood clot in the deep veins of the lower leg), acute embolism and thrombosis of superficial veins of left upper extremity (new blood clot forming in a superficial vein in the left arm, or shoulder, which may involve a clot traveling through the bloodstream), muscle weakness, need for assistance with personal care, cognitive communication deficit person's ability to communicate effectively due to underlying impairments), acute cystitis without hematuria (inflammation of the bladder (cystitis) that does not involve blood in the urine (hematuria). The reason for the discharge reflected an incident with another resident causing bodily harm. The discharge effective date was 8/21/2025. Brief history for Resident #1 reflected an increase in unsafe behaviors towards residents. The course of treatment for Resident #1 reflected interventions of increased activities and time in a calming environment. The condition Resident #1 discharged reflected was good. Rehabilitative Potential for Resident #1 reflected fair. The follow-up and discharge medications (instructions to resident) revealed the following medications were sent home for Resident #1: Depakote ER Oral Tablet, Seroquel Calcium Carbonate Tablet Chewable 500 MG, Maalox Regular Strength Suspension Potassium Chloride ER Lasix Oral Tablet 20 MG, Multivitamin-Minerals Oral Tablet, Tylenol Extra Strength Oral Tablet 500 MG, Vitamin B12, Ergocalciferol Capsule 50000 UNIT, Zoloft Oral Tablet, Anoro Ellipta Inhalation Aerosol Powder Breath Eucerin, External Lotion Metformin Gentamicin Sulfate External Ointment 0.1 % Albuterol Sulfate HFA Inhalation Aerosol Solution. Resident #1 was discharged home with no home health. The list of reconciled medications sent with the representative reflected yes. How was the list of reconciled medication sent reflected verbal. Digitally signed by the physician. Record review of Resident #1's quarterly MDS assessment, dated 06/04/2025, revealed Resident #1 did not perform an interview for mental status due to the resident rarely/never understood. Resident #1's behavior revealed no exhibited physical behavioral symptoms directed toward others, no exhibited verbal behavioral symptoms director toward others and no exhibited other behavioral symptoms directed toward others. Record review of Resident #1's Care Plan, dated 02/21/2025, revealed Resident #1 would remain in the facility for long term as she required 24-hour licensed nursing care. Resident #1 required anti-psychotic and anticonvulsant medications for diagnoses of schizophrenia, psychosis, and bipolar disorder could show aggressive behavior during periods of frustration or agitation. Record review of Resident #1's referral from the hospital to Five Points at Highlands, dated 7/28/2023, revealed Resident #1's RP stated she could not care for Resident #1 any longer, and would need somewhere long-term, possibly with a secured unit to prevent Resident #1 from trying to leave. Record review of the NP progress note, dated 08/21/2025, revealed when the NP arrived on the secured unit and there were two officers conversing with the ADON and SW. Resident #1 was in the dining room with the sitter. Police informed staff that they cannot arrest Resident #1 due to her mental capacity, nor could they detain her with OPC because she was in a facility where she could receive medical care. Resident #1's RP was informed that Resident #1 was a danger to others and was receiving immediate discharge notice. The SW explained to Resident #1's RP that she could take Resident #1 to psych hospital, but the officers could not take her. The NP stated Resident #1's RP wanted police to take Resident #1 because she could not force Resident #1 to do anything. The NP encouraged her to call family members to assist her, Resident #1 had an immediate family member, but RP told NP that he will make things worse. Record review of the SW progress note, dated 8/22/2025, revealed the SW notified of the altercation between Resident #1 and another resident. SW contacted Resident #1's RP to notify her of the altercation and the order for immediate discharge. Resident #1's RP came to the facility to pick up Resident #1 and take her home with medication, a rollator, instructions, and community referrals for medical PCP and discharge from the facility. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation of request and/or referral for psych observation for Resident #1. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation that Resident #1's RP declined alternate placement for Resident #1. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation that Resident #1's RP received the facility Ombudsman's contact information to assist discharge to the community. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation of verbal or written notice of intent to leave the facility. In a confidential staff interview on an undisclosed date, it was revealed that Resident #1's was not a safe discharge, and the RP could not properly care for Resident #1 because she had dementia, the resident was obese and had mood disorders and the RP was a small petite elderly woman who Resident #1 could potentially harm. During an interview on 8/28/2025 at 9:10 a.m., with the Administrator revealed there was an unwitnessed incident on the secured unit and when he and the SW notified Resident #1's RP to inform her they were going to send Resident #1 out to the hospital for behavior observation, the RP stated she would just pick Resident #1 up and take her home. The Administrator stated they conducted the discharge process for Resident #1 and the RP was provided with all Resident #1's medications, but her belongings were still in the facility due to the RP stating she could not fit them in the car. During an interview on 08/28/2025 at 09:39 a.m., with Resident #1's RP she revealed that she had received a phone call on 08/21/2025 from the facility SW who stated she had to pick up Resident #1 from the facility immediately because Resident #1 could no longer stay at the facility due to an unwitnessed incident that happened and she was being discharge immediately. The RP told the SW that she had nowhere to take Resident #1 and asked if she could get Resident #1 sent to another facility, because Resident #1 gave up her apartment when she admitted to the facility and would be homeless. She stated the SW insisted the RP pick up Resident #1. The RP stated when she arrived at the facility, they gave her some papers as she put Resident #1 in the car. The RP stated she would never have picked up Resident #1 voluntarily because the RP could not care for Resident #1 properly as Resident #1 required round-the-clock care and the RP stated she worked two part-time jobs. RP revealed Resident #1 never went to her home the RP took her to another family members home until she was able to obtain an order of protective custody and police arrested Resident #1 and took her to a psychiatric hospital. During an interview with the SW on 8/28/2025 at 12:45 p.m., the SW stated Resident #1 discharged on 8/21/2025. The SW stated she informed Resident #1's RP that she could refer Resident #1 to another facility, but Resident #1's RP declined and picked up Resident #1 and took Resident #1 home. The SW stated it was a safe discharge because she had attempted to offer to find placement for Resident #1, but it was declined verbally, and Resident #1 went home with a family member who was provided with referrals for community resources, a walker, and medications. In an interview on 8/28/2025 at 217 pm, with the Administrator revealed Resident #1's RP came and picked up Resident #1 that it was a safe discharge as the RP was responsible for making decisions for Resident #1 care. The Administrator stated if the RP could not take care of Resident #1 the RP would have elected someone who could. The Administrator stated that if the RP couldn't find Resident #1 placement at another facility, he would have to consult with his superiors on Resident #1's return to the facility as days had passed so Resident #1 would have to go through the referral process and start the admission process again. Record review of facility Discharge or Transfer policy dated 12/2017 revised 2/12/2025 under Resident Discharge to the Community states For resident who want to be discharged o the community, this nursing home must determine if appropriate and adequate supports are in place, including capacity and capability for the resident's caregivers home. Family members, significant others or the resident's representative should be involved in this determination, with the resident's permission, unless the resident is unable to participate in the discharge process. A referral to the Local Contact Agency may be appropriate for many individuals, who could be transitioned to a community setting of their choice. The nursing home staff is responsible for making referrals to the LCA, if appropriate, under the process that the State has established. Nursing home staff should also make the resident and if applicable, the resident representative, aware that the local ombudsman is available to provide information and assist with and traditions from the nursing home. For residents who have been in the facility for a longer time, it is still important to inquire, as needed, whether the resident would like to talk with LCA experts about returning to the community. If the resident is unable to communicate their preference or is unable to participate in discharge planning, the information should be obtained from the resident's representative. Discharge planning must include procedures for: -Documentation of referrals to local contact agencies, the local ombudsman, or other appropriate entities made for this purpose. -Documentation of the response to referrals; and -For residents for whom discharge to the community has been determined to not be feasible, the medical record must contain information about who made that decision and rational for that decision. Discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs, as well as preferences. 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 must treat this situation similarly to refusal of care, and must: -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 is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; -Document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; -Document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; -Determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge. An Immediate Jeopardy was identified on 9/16/25 and the Administrator was notified of the Immediate Jeopardy on 9/16/25 at 6:28 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's POR for Immediate Jeopardy was accepted on 9/18/25 at 3:11 p.m. and reflected the following: . Interventions: 1. Resident #1 currently does not reside in the facility as of 8/21/25. The SW, and Administrator reached out to the RP of Resident #1 to discuss alternative placement due to increased behaviors. Resident #1's RP came to the facility to pick up the resident and take her home with medications, rollator, community resources for medical PCP. 2. All residents discharged in the past 30 days had their charts audited by the RCN, DON, and ADONs to ensure that all residents were discharged safely to their destination. 18 residents were discharged to the hospital. 3 residents discharged home. Initiated 9/16/25 and Completion Date 9/17/25. 3. The Administrator, DON, ADONs, and SWs were in-serviced 1:1 by ADO, RCN on 9/16/25 on the following topics. Initiated 9/16/25 and Completion Date 9/17/25. A. Discharge or Transfer to Another Facility Policy: New Process: Initiated 9/16/25 and Completion Date 9/17/25. In the future, if there is an emergency discharge scenario- all listed IDT members and PCP/MD will have a meeting to plan a safe discharge with all necessary community services. The charge nurses will report to DON and ADON if any part of the discharge process is overlooked or not completed. When a resident is discharged home, the following IDT members will perform the following: DON: Collaborate with IDT in the planning and ensure residents have all necessary post discharge providers in place for continuity of care. The DON's last day is 9/19/25. ADON A will be trained to follow the DON responsibilities on 9/17/25 and will resume the responsibilities for the discharge process on 9/19/25. ADONs: Family members will be educated on the care of the residents, including medications and psychology/psychiatry services to facilitate a safe discharge to a safe destination. The resident's attending physician and psych MD will be notified for the order and approval to discharge. ADONs A, B, and C are responsible for educating the PCP and psych services on upcoming discharges home as well as the community services for continuity of care. Social Workers: Ensure location and discharge address to Home Health Care if needed, order DME if needed. The SW will get in contact with resident and/or RP/family within 48 hours to ensure the resident is doing well and adjusting well in discharge location. The SW will document in Point Click Care ( PCC) in progress notes. The Administrator will check on all 48-hour discharge follow-ups during facility morning and end of day meetings on PCC. Administrator: Will ensure that every discharge has an IDT meeting completed and all providers for care are involved, and community resources are set up for discharge. The Administrator will ensure that all medications, DME and home health services are in place prior to discharge home. The SWs will document in PCC under progress notes the discharge location, post discharge services, home health services and caregiver support as needed. The Administrator is responsible for training the IDT on the discharge process and will check for every planned/unplanned discharge to ensure the process is followed for all discharges home by reviewing the documentation in PCC under progress notes and d/c summary. The Administrator will inquire about upcoming and unplanned discharges 5 days a week during morning facility and end-of-day meetings. The Administrator will report to the ADO weekly on the Operations Call for all home discharges. The ADO will audit all home discharges on PCC and verify with the facility IDT. Resident Rights Policy: All residents have the right to safely discharge with education provided for care, services, and medication. Behavioral Management Policy: Residents with behavioral or psychology diagnosis will have the appropriate care and services during admission and upon discharge. The SW will ensure that psychology services are in place when discharging a resident home. The MD was notified of the immediate jeopardy on 9/16/25 by the Administrator. An AD HOC (as needed) QAPI meeting was completed with interdisciplinary team which included the MD, Administrator, DON, Admissions, and BOM to discuss the citations and plan of removal. Initiated 9/16/25 and Completion Date 9/17/25. The Administrator/designee will test the IDT and charge nurses on the discharge process. Return demonstration via testing will need to be 100% prior to their shift. If 100% is not achieved- re-education will be provided until 100% compliance is achieved. Initiated 9/16/25 and Completion Date 9/17/25. Residents who have increased behaviors will be monitored every shift for safety by the nurse charge and will report daily to the DON and ADONs and notify the MD. There are 3 residents that are currently be monitored for behaviors (see attached). Training: ADON A will be responsible for educating and testing PRN and staff that are on vacation during this time period. ADON A will update the Administrator on the progress with education and testing 5 days a week until completed. Initiated 9/16/25 and Completion Date 9/17/25. For all immediate discharges: the Administrator will notify the Area Director of Operations prior to discharge. The ADO will verify the discharge process was followed correctly for a safe discharge. Initiated 9/18/25 and Completion Date 9/18/25. In-services: All charge nurses were in-serviced on the following topics by the Administrator, DON, ADONs. All nurses not present and PRN staff will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. Initiated 9/16/25 and Completion Date 9/17/25. Discharge or Transfer to Another Facility Policy: New Process: The charge nurse will educate the resident RP/family on medication review, count narcotics if any, and complete the DC summary in PCC at the time of discharge. The Charge Nurses will report to the DON and ADONs if any part of the discharge process is overlooked or not completed. Monitoring of the plan of removal included:Record review of facility in-services titled Behavior Management and documentation, Discharge Planning Process and Documentation, Discharge Planning Process policy, and Resident Rights, dated 9/16/25 though 9/18/25, reflected staff were educated by the Administrator, DON, and ADONs.Record review of a one-on-one in-service titled Resident Rights, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO. Record review of a one-on-one in-service titled Discharge Plannings Process and Documentation, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO.Record review of a one-on-one in-service titled Behavior Management and Documentation, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO. Record review of a one-on-one in-service titled Notify ADO of any Immediate Discharge, dated 9/18/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO.Record review of 30-Day Discharges identified two additional residents had discharged from the facility Resident, Resident #2 left against medical advice and resident #3 discharged back home after five days of respite care. Record review of the Administrator, DON, ADONs, SWs and Charge Nurses test on discharge process reflected they had 100% accuracy. Record review of the AD HOC QA meeting held on 9/16/25 reflected the meeting consisted of Administrator, DON, MDS, Medical Director, and Business Office Manager.Record review of ,residents identified for monitoring for behaviors, Resident #4, Resident #5 and Resident #6's electronic health records from 9/18/25 to 9/19/25 reflected they were monitored for behaviors. Interview with the ADO on 9/18/23 at 3:15 p.m. He stated he trained the Administrator and DON on the notification to ADO of any immediate discharge. Additionally, re-trained the Administrator, DON, and SWs on the discharge planning process and documentation, resident rights, Behavior management and documentation. Verified via record review signed by the Administrator, DON and both social workers. Interview with Administrator on 9/18/25 at 3:30 p.m., the Administrator stated the ADO re-educated him on the discharge planning process and documentation, resident rights, behavior management and documentation and the ADO trained him on the notification to ADO of any immediate discharge Interview with the DON, on 9/18/25 at 3:45 p.m., the Administrator was asked, what was the facility's monitoring or oversight process for ensuring residents were discharged safely. He responded his plan was for this to be a continuous quality measure; that started with the IDT team which consist of the resident and/or their resident representative, medical director, social worker, nursing, therapy, DON and Administrator which will ensure the resident is prepared, educated and discharged safely. The medical director approved the discharge, the social worker ensured medical equipment was ordered, referrals were placed and community services were set up and documented in PCC, the follow up 48 hours post discharge to make sure discharge was smooth and document response in PCC. The ADONs and/or charge nurse would review and educate resident and/or resident representative on medication and document in PCC. The Administrator would ensure all discharge process were followed. To ensure each steps where completed the Administrator would review the documentation was completed in PCC. The Administrator stated that the steps were the same for an immediate discharge except he had to contact the ADO and inform him of the immediate discharged resident. During an interview on 9/18/25 at 5:00 pm with ADON A revealed that she had been trained by the DON on her duty to sit in fill in as interim DON in the IDT planning and ensure residents have all necessary post discharge providers in place for continuity of care. Verified via record review of Resident #5 who resided on the secured unit showed increased behaviors and charge nurses documented Resident #5 increased behaviors in PCC. Charge nurse contacted ADON A, ADON A contacted the MD, the MD put in a psych evaluation order, Resident #5 RP contacted and Resident #5 discharged to the hospital. Interviews held on 9/18/25 from 3:15 p.m., to 6:00 p.m., and 09/19/25 from 6:00 a.m., to 5:40p.m., which covered staff who work morning, day, night shifts, PRN staff and double weekend staff conducted with the Administrator, DON, ADON A (1st shift/weekdays), ADON B(1st shift/weekdays), ADON C (1st shift/weekdays), RN D (weekdays), RN E (PRN), RN F (overnight/morning), RN G (overnight/morning), RN H (double weekends), LVN I (Overnight), LVN J (morning), LVN K (overnight), LVN L (second shift), LVN M (double weekends) and SW N, SW O indicated they all participated in in-services on resident rights, discharge process and documentation and proficiency test prior to starting their shifts. All staff knew their responsibilities. All staff were knowledgeable, who were a part of the IDT. All staff were able to state that the facility's discharge process to ensure all residents' discharges were safe, all know what was required to be documented and who was responsible for each task and understand that the Administrator would oversee the entire process to make sure it was complete, and he would report any immediate discharges to the ADO. The Administrator was informed that the Immediate Jeopardy was removed on 9/18/2025 at 3:11 p.m. The facility remained out of compliance at a severity level of that was not Immediate Jeopardy and a scope of isolated, due to staff needing more time to monitor the effectiveness of the plan of removal for inappropriate discharge.

Based on observation, interviews and records review the facility failed to ensure each resident received adequate supervision and transferred in a safe manner to prevent an accident for one (Resident #1) of four residents reviewed for accidents and hazards, in that: The facility failed to provide Resident #1 with adequate supervision and assistance with transfers to prevent an accident. On 05/14/25, Resident #1 had an unexpected or unintentional incident, which resulted in an injury to her left knee when transferred by two CNAs from the bed to a dialysis chair. On 05/19/25, the facility sent Resident #1 to the hospital after an x-ray of the bilateral (both) knees, dated 05/16/25 , revealed a possible acute nondisplaced fracture (the bone did not move when the fracture occurred) . follow-up x-rays or CT scan is recommended. On 05/19/25, Resident #1 had surgery to her left distal femur (lower part of thighbone, located just above the knee joint) to repair the fracture. An IJ was identified on 06/20/2025 at 1:30PM. The IJ template was provided to the facility on at 1:30 PM. While the IJ was removed on 06/20/2025 at 9:45PM, the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed residents at considerable risk of significant injury, harm, and/or impairment. Findings included: Record review of Resident #1's 5-day MDS Assessment, dated 05/29/25 reflected an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had an admission history and diagnoses of CHF ([congestive heart failure] a chronic condition where the heart is unable to pump blood effectively, leading to a buildup of fluid in the lungs and legs); seizure disorder; CKD dependent on dialysis; and age-related physical debility. A BIMS score of 11 suggested Resident #1 had a moderate cognitive decline. Resident #1 had no behavioral symptoms or rejection of care behavior during the MDS review period. Resident #1 was dependent of staff assistance with ADLs and was frequently incontinent of bladder and always incontinent of bowel. Resident #1 was at risk for pressure ulcers/injuries. Record review of Resident #1s comprehensive care plan, printed 06/09/25, reflected the following: [Resident #1] has surgical site to the left knee and left thigh (Date Initiated: 05/23/25). Interventions included Observe for s/s of infection and Observe for s/s of pain during treatment and medicate PRN per physician's orders. [Resident #1] has an ADL Self Care Performance Deficit (Date Initiated: 03/31/25). Interventions included Bed mobility: requires staff x1 for assistance; Encourage the resident to use bell to call for assistance; and Transfer: require a Mechanical Lift as a Mechanical Aid and 2 staff members to assist in transfers (Date Initiated: 05/20/25 by DON); [Resident #1] has a history of making false accusations/fabrications on staff, refusal of care, and refusal of medications (Date Initiated: 03/31/25; Revision on: 05/27/25). Interventions included Educate [Resident #1/RP/CG] of causative factors and measures to prevent false accusations; and Monitor/document/report and Psych Services to eval and treat as needed. Record review of Resident #1's active physician orders reflected:- Order date 03/28/25: Acetaminophen Oral Tablet 325 mg. Give 2 tablets by mouth three times a day for Pain. Give 2 tablets to equal 650 mg, not to exceed 3000 mg a day. [Discontinued 05/19/25] - Order date 03/28/25: Resident to have pain consult with pain management NP to assess for pain medication needs and /or modifications. [Discontinued 05/19/25] - Order date 03/28/25: DIALYSIS DAYS MONDAY-WED-FRI [Discontinued 05/19/25] - Order date 03/28/25: NO BP/BLOOD DRAW OR FINGER STICK TO RIGHT ARM [Discontinued 05/19/25] - Order date 03/31/25: Anticoagulant Monitoring: monitor for signs and symptoms of adverse reaction: . rash . tissue necrosis . hemorrhage . purple toe syndrome, Increased fracture risk with long term use. Every shift. [Discontinued 05/19/25] - Order date 05/16/25: Xray of left Femur 2V (two views), Bilateral (both sides) Hip 2V, and Left Tibia & Fibula (the bones that make up the lower leg) 2V. - Order date 05/15/25: Tylenol Extra Strength Oral Tablet 500 mg. Give 2 tablets orally every 8 hours as needed for Pain. Two tablets to equal 1000 mg. - Order date 05/22/25: Norco tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for Pain. - Order date 05/23/25: Cleanse left knee surgical site with wound cleanser, pat dry apply Betadine then cover with protective dressing change every Tuesday - Thursday and as needed. Every day shift every Tuesday, Thursday for wound care. - Order date 05/23/25: Cleanse left thigh surgical site with wound cleanser, pat dry apply Betadine then cover with protective dressing change every Tuesday - Thursday and as needed. Every day shift every Tuesday, Thursday for wound care. - Order date 05/23/25: PT to eval and treat. - Order date 05/23/25: PT to eval and treat as indicated. PT Clarification: Patient to receive skilled PT services 3x/week for 60 days. - Order date 05/27/25: [Provider Name] may provide psychiatric services. - Order date 05/23/25: Acetaminophen Oral Tablet 325 mg. Give 2 tablets by mouth three times a day for Pain. Give 2 tablets to equal 650 mg, not to exceed 3000 mg a day. - Order date 05/23/25: Resident to have pain consult with pain management NP to assess for pain medication needs and /or modifications. Record review of Resident #1's May 2025 MAR did not reflect a nurse initial that indicated Tylenol Extra Strength Oral Tablet 500 mg. Give 2 tablets orally every 8 hours as needed for Pain. Two tablets to equal 1000 mg were administered to Resident #1 on 05/15/25 for pain as needed. The MAR revealed that Resident #1 received Acetaminophen Oral Tablet 325 mg. Give 2 tablets by mouth three times a day (9AM, 1PM, 5PM) for Pain as ordered; except on Mondays at 9:00 AM when Resident #1 was at dialysis. On 05/14/25, Resident #1 did not receive the Acetaminophen dose on Wednesday, 05/14/25 at 9:00 AM or 1:00 PM. A comment was not entered in the comment section to explain why the doses were not administered. Record review of Resident #1's admission Fall Risk assessment dated [DATE], completed by ADON B, reflected a score of 12 that suggested Resident #1 was a High Risk for falls. Record review of Resident #1's progress notes indicated the following:- 05/15/25 at 9:20 PM, RN E documented [Resident #1] complained of pain to the left leg when turned/repositioned. pain started today. Assessed resident for injury. No injury noted. Resident moaned when left leg is moved. notified NP. Received order for x-ray, 1000 mg Tylenol . Administered Tylenol . - 05/16/25 at 8:12 AM, RN E documented X-ray results for left tibia/fibula, right femur received and relayed to NP. All results were negative. No new orders received. - LATE ENTRY (entered on 05/20/25 at 5:34 PM) effective date 05/16/25 at 4:28 PM, ADON B entered an Event Note: Level of pain 7 out of 10; Resident c/o (complained of) pain. X-ray of left femur (thigh), bilateral (both) hips, and left tibia and fibula (the two bones that make up the lower leg). - 05/17/25 at 2:33 PM, RN F documented New order STAT of x-ray of bilateral knees. [Resident #1] complained of pain to knee. - 05/19/25 at 12:00 AM (midnight), RN F documented Received bilateral knees x-ray result with impression that there is possible acute nondisplaced fracture of the distal left femur and relayed it to NP (on call for PCP), new order received to transfer to hospital for evaluation and treatment. Non-emergency transportation called. Night nurse to follow up. Limited movement initiated and maintained to left leg. - 05/19/25 at 1:25 AM, RN P documented [Resident #1] was transferred to hospital by [non-emergency transportation] for abnormal x-ray result. - LATE ENTRY (entered on 05/27/25 at 3:03 PM) effective date 05/20/25 at 5:17 PM, DON entered Received report at 1:31 PM from [hospital] that [Resident #1] has a nondisplaced fracture of distal femur and would be having surgery to repair. Record review of Incident Report #805, dated 05/15 /25 3:46 PM, completed by RN E indicated the incident occurred in the Resident's Room Incident description: Resident complained of pain in left lower leg when turned/repositioned. Resident description: Resident stated that the pain started today. When asked if she fell, she stated No. When asked if anyone hurt her she said No. When asked what happened her reply was that she didn't know her knee just started hurting. Immediate Action Taken: Assessed resident for injury. No injury noted. Resident moaned when left leg is moved. No s/sx of distress noted. Notified NP. Received order for x-ray bilateral hips, left femur, tibia, fibula. 1000 mg Tylenol every 8 hours PRN. Administered Tylenol 1000 mg to relieve pain. Level of Pain: 5. Record review of Resident #1's x-ray results dated 05/15/25 at 8:16 PM reflected examination of the left tibia/fibula, right femur, and bilateral hips had no evidence of an acute fracture. The reading physician (physician responsible for reading x-ray results and report impression of findings) read the results on 05/15/25 at 9:30 PM. Record review of Resident #1's x-ray results dated 05/16/25 at 1:46 PM reflected examination of bilateral knees that revealed a possible acute nondisplaced fracture of the distal left femur seen. The reading physician (physician responsible for reading x-ray results and report impression of findings) read the results on 05/16/25 at 3:25 PM. Record review of Resident #1's hospital visit summary (05/19/25 - 05/22/25) revealed Resident #1 admitted on [DATE] at 1:33 AM. The admission diagnosis reflected femur fracture. The admitting physician documented that [Resident #1] chief complaint was severe left leg pain. The admitting physician's history and physical summary indicated [Resident #1] . landed on her left knee 5 days ago. She had left knee x-ray done 2 days ago that showed possible knee fracture and acute nondisplaced fracture of left distal femur. [Resident #1] has persistent and worsening left lower extremity pain prompting them to send her to our ED for further evaluation. CT left lower extremity showed nondisplaced distal femoral fracture [Final Result time 05/19/25 at 2:22 AM]. Orthopedic surgery was consulted with plan to proceed with surgery at this morning [05/19/25]. Record review of a facility submitted SRI dated 05/20/25 and a 5-day PIR (Provider Incident Report)dated 05/27/25 reflected the internal investigation was UNFOUNDED. The 5-day PIR included written and signed witness statements from RN F, Resident #1 signed by ADON A, and TT C. The facility conducted In-services dated 05/20/25 on ANE, Resident Rights, and Change of Condition Notification. Record review of a written statement dated 05/19/25, RN F wrote On 05/14/25, [Resident #1] went to dialysis, came back and did not tell (RN F) about having pain. At 3:30 PM, the assigned CNA (CNA G) informed (RN F) and RN E at the nurse's station that [Resident #1] was complaining about pain to her left (knee) leg. RN E and (RN F) quickly went to see (Resident #1), assessed her. [Resident #1] said that she had pain to her left (knee) leg. RN E had already assumed his afternoon shift and he acknowledged to call the doctor and (RN F) left for home. RN F signed and dated (05/19/25) the statement. Record review of an undated written statement, ADON A wrote [Resident #1] stated that her leg started to hurt last Wednesday when 1 male and 1 female picked her up under her arms to put her in the chair for dialysis. She said her leg dropped and she told them it hurt. She went to dialysis and when she came back the nurse gave her pain medicine. Resident #1 and ADON A signed the statement. ADON A wrote Writer next to her name. Record review of an undated written statement, TT C wrote On Wednesday, 14th May 2025, (TT C) was called to assist to transport [Resident #1] to dialysis den (facility area where in house dialysis is given)for her dialysis schedule. (TT C) and a female aid transferred her from bed in the transport chair without moaning or groaning or complaint of pain, neither did any of her body part was dropped or rub against any hard surface. She was successfully and comfortably transported to dialysis den. TT C signed the statement. During an interview and record review on 06/08/25 at 1:44 PM, the NFA stated that he assisted the former administrator with completing self-reports before her last day worked for the facility. The NFA said that he was not the administrator over the facility at the time of the incident. The NFA said that he called in the self-report on 05/20/25 and completed the 5-day provider investigation report (PIR) on 05/27/25. Record review of the 5-day PIR reflected . An x-ray was ordered; no confirmed injuries were found initially, but the resident was sent to the hospital for further evaluation. The hospital determined the resident had a non-displaced distal femur fracture and will undergo surgery. The NFA said that he was unaware that the x-rays that resulted no confirmed injuries were of the hips, the right thigh, and the left lower leg. The NFA said that he did not know that there was a second set of x-rays done STAT on 05/16/25 of Resident #1's knees and the findings determined the possible non-displaced fracture and that was why Resident #1 was sent to the hospital but not until 05/19/25. The NFA said that he reported the investigation the way the DON informed him. During observation and interview on 06/08/25 at 3:42 PM, Resident #1 was lying in a left lateral position in bed. Resident #1 was oriented to self, situation, and time of day (with prompts). Resident #1 with fair recall of immediate and past events. Resident #1 stated two (unidentified) staff dropped her on her (left) knee when transferred from bed to dialysis chair prior to going to dialysis. Resident #1 said that the staff transferred her from the bed by lifting her under her arms to the dialysis chair. Resident #1 said she told the staff that they hit her knee on the floor and her knee hurt. Resident #1 said that the nurse administered pain medicine when she returned from dialysis. Resident #1 said that the male staff pushed her to dialysis in the dialysis chair. Resident #1 said she had to go to the hospital and had surgery to her knee. Resident #1 said that she still had stitches in her knee and had an appointment to follow up with the surgeon to remove the stitches. There were no fall mats noted on the bedside floor or in the room. Resident #1 denied she had a fall and restated that staff dropped her on her (left) knee during a transfer. During an interview and record review on 06/09/25 at 2:06 PM, the DON said that she learned about the x-ray results of Resident #1's knees that indicated a possible acute fracture during the morning meeting on 05/19/25. The DON said that there were previous x-ray results that were negative. The DON said that she told the staff to send Resident #1 to the hospital by non-emergency transport to get a second opinion of the x-ray results and she immediately implemented an internal investigation. The DON said that Resident #1 never told staff how she hurt her knee. The DON said that staff did not report a fall and Resident #1 never told staff that she fell or that someone hurt her. The DON said that Resident #1 was wheelchair bound and needed staff assistance to transfer. Record review of the 5-day PIR reflected [Resident #1] initially reported left leg pain during repositioning by staff. When asked what happened, [Resident #1] was unsure and denied any fall. With further questioning, she mentioned a fall at dialysis. When asked the dialysis staff they denied any fall. [Resident #1] stated she had been dropped in her room, but staff involved in her care denied any fall. When asked her again [Resident #1] changed her story and said there was no fall in the room and that it might have occurred while being transferred to a chair at dialysis. She eventually retracted this as well stating she had not fallen but her leg dropped a little . The DON said that she sent ADON A to the hospital to interview Resident #1 (on 05/19/25) after the hospital informed Resident #1 would have surgery to repair the fracture of the left knee. The DON said that ADON A reported that Resident #1 said that two staff members dropped her knee to the floor when transferred from the bed to the dialysis chair. The DON said that Resident #1 just had surgery and was still under the influence of anesthesia and had ADON A return to the hospital the next day (05/20/25) to interview Resident #1 again and [Resident #1] told a different story. Continued record review of the undated written statement signed by Resident #1, written and signed by ADON A, reflected . 1 male and 1 female picked her up under her arms to put her in the chair for dialysis. She said her leg dropped and she told them it hurt. She went to dialysis . The DON said that ADON A obtained the statement from Resident #1 at the hospital on [DATE], but Resident #1 changed her story. When asked if staff should pick a resident up under her arms to transfer, the DON replied, absolutely not. The DON demonstrated how the staff transferred Resident #1 from the bed to the dialysis chair. The DON said that TT C and CNA D clasped each other's arms like a bridge underneath Resident #1's legs and to support Resident #1's back, lifted her up off the bed and placed in the dialysis chair. The DON said that TT C was very tall, and CNA D was short. The DON said that the only thing she can figure that happened was CNA D may have bumped Resident #1's leg on the floor because the transfer was uneven, but it could not cause a fracture. The DON said that she consulted with the PCP (also the Medical Director) and he told her that he reviewed some old medical records and found that Resident #1 had brittle bones from osteoarthritis. Record review of Resident #1's admission record and admission MDS did not reflect an admission history or diagnosis of osteoarthritis. The diagnosis of Unilateral osteoarthritis resulting from hip dysplasia, right hip, entered during stay and the onset date reflected 05/15/25. The DON said that TT C was a CNA but was employed as the van driver. She could not think of the name of the female CNA (CNA D), but a statement was provided with the 5-day PIR. The investigator verified there was not a statement by a female CNA. During an interview on 06/10/2025 2:13 PM, the DOR said that she was familiar with Resident #1 who received physical therapy services effective 05/23/25. The investigator explained to the DOR the transfer technique used for Resident #1 the DON described and demonstrated. The DOR replied that she never heard of a 2-person transfer technique by clasping arms together to lift someone in a seated position. The DOR said that the therapy department educated staff on supervision with assisted devices and transfers whenever a resident received physical therapy services to ensure understanding on how to assist the resident. The DOR said the only transfer techniques are 1- and 2-person transfer with a gait belt and a mechanical lift. During an interview on 06/10/25 at 2:30 PM, RN F said that he worked 7A - 3P during the week. RN F said that he was familiar with Resident #1 as he was always her assigned nurse. RN F said that Resident #1 was weight-bearing during transfer. RN F said that Resident #1 required a gait belt for transfer and could stand from a seated position on the bed and step then pivot to sit in a wheelchair or dialysis chair. RN F stated that a CNA would bring the dialysis chair from the dialysis den (a room where residents go to receive dialysis by a third-party dialysis provider) to the resident's room, transfer the resident to the dialysis chair, and then push the resident to the dialysis den in the dialysis chair. RN F said that he assisted Resident #1 to bed when she returned from dialysis (Wednesday, 05/14/25) and she did not complain of pain to the left knee. RN F said that Resident #1 usually received dialysis in the morning and returned to her room shortly before or sometimes after his shift ended. RN F said on 05/15/25, CNA G approached the nurses' station and reported Resident #1 complained of pain of her left leg. RN F said that it was shift change and he had given hand-off report to RN E. RN F said that he accompanied RN E to Resident #1's room and observed RN E assess Resident #1. RN F said that RN E said that he would notify the doctor and RN F left. RN F said that he received hand-off report on 05/16/25 that Resident #1 had x-rays done for complaint of pain. RN F said on 05/16/25, he reviewed the x-rays and saw that they were of the right and left hips, the left lower leg, and the right thigh. RN F said that he called the x-ray company and asked where the results for Resident #1's left knee were. RN F said that the x-ray representative said that the results were of the areas ordered. RN F said that he was sure that Resident #1 complained of knee pain, obtained an order for a STAT x-ray of Resident #1's right and left knees and notified the x-ray company. RN F said that the x-ray company came out on 05/16/25 to do the x-rays. RN F said on 05/17/25 the facility did not receive Resident #1's x-ray results before the end of his shift at 3:00 PM. RN F said that he worked on Sunday, 05/19/25 from 7:00 AM to 11:00 PM. RN F said that he checked for Resident #1's x-ray results that morning and the facility still had not received the x-ray results. RN F said that he followed up with the x-ray company. RN F said that he checked the x-ray company site for the results at the end of his shift, 05/19/25 at 11:00 PM, and the results were posted in the portal. RN F said he saw that Resident #1 had a fracture, called the PCP to obtain an order to send Resident #1 to the hospital for further evaluation. RN F said that he contacted the non-emergency transport company and gave hand-off report to the on-coming nurse (RN P). During an interview on 06/10/25 at 2:51 PM, the Medical Director said that the DON notified him that she initiated an internal investigation of an unknown injury for Resident #1. The Medical Director said that the DON inquired how could [Resident #1] sustain a fracture if the staff denied there was a fall. The Medical Director said that he reviewed Resident #1 past medical history and discovered that she received injections to increase bone formation for osteoporosis back in 2014. The Medical Director said that he provided the health information to the facility to determine factors that could cause the injury if Resident #1 did not fall. The Medical Director emphasized that Resident #1's past health history was not his viewpoint or his determination for the fracture. The Medical Director said that Resident #1's osteoporosis was stable and was not of concern to her left lower extremity. The Medical Director said that it would require force to sustain the non-displaced fracture to Resident #1's distal femur. The Medical Director stated it was probable when asked by the Investigator if an inappropriate and/or unsafe transfer technique could cause the fracture. On 06/10/25 at 4:30 PM, the DON handed the investigator a copy of an email received from the x-ray company dated 06/10/25 at 4:25 PM and a copy of the staffing schedule dated 05/14/25. The DON said that she remembered who the female aide (CNA D) was and that was her name and phone number written on the schedule. The DON said that CNA D was no longer employed at the facility. The DON said that CNA D called off because she had a family emergency and never returned so the facility had to terminate her. Record review of the email received from the x-ray company revealed that the x-ray order of Resident #1's knees was placed on 05/16/25 at 8:32 AM; the order was confirmed 05/16/25 at 9:32 AM; the x-ray tech performed the x-ray on 05/16/25 at 1:32 PM; and the images were sent to the physician who reads the x-ray results on 05/16/25 at 1:56 PM. The email indicated that the results were not uploaded to the facility because of an error and was manually uploaded to the facility on [DATE] as a significant finding after notified that the results were not received. Record review of the schedule dated 05/14/25 reflected CNA D assignment was on a different hall than Resident #1 resided. The schedule reflected a code next to CNA D's name that indicated she was out due to emergency and did not work that day. During an interview on 06/10/25 at 5:25 PM, TT C said that he was the van driver for the facility and did not interact with residents from day-to-day except to transport to and from appointments. TT C said that he heard his name called out in the hallway (05/14/25) while he was getting a resident from their room to take to an appointment. TT C said a female (did not know who the female was) asked him to assist CNA D to transfer Resident #1 to dialysis. TT C said that he entered Resident #1's room and CNA D was standing beside Resident #1 (on the left side) who was sitting on the edge of the bed. TT C said that Resident #1 had on a (facility provided) gown. TT C said that CNA D placed a gait belt around Resident #1's waist and he grabbed the front and the back of the gait belt to lift Resident #1 up and placed her in the dialysis chair. TT C replied no when asked if he reached under Resident #1's arms to lift her when he assisted CNA D to transfer Resident #1 to the dialysis chair. TT C said that he was not sure if the gait belt slipped up under Resident #1's arms when he lifted her up because the belt was too loose. When asked if Resident #1 stepped or walked to the dialysis chair, TT C said no, we lifted her and placed her in the dialysis chair. When asked if Resident #1's feet raised off the floor when he and CNA D lifted Resident #1 to transfer from the bed to the dialysis chair, TT C said that he did not recall. TT C said that he did not know the female aide (CNA D) or her name. During an interview on 06/10/25 at 5:56 PM, RN E said that he was the charge nurse for Resident #1 on the 3PM - 11PM shift. RN E said that CNA G notified him of Resident #1's leg pain on 05/15/25 during shift change around 3:30 PM. RN E said that Resident #1 was in bed when he entered the room to assess Resident #1. RN E said that he assessed Resident #1 thighs and hips for bruising, swelling, or any signs of trauma from a fall and there were no signs of injury. RN E said whenever he tried to reposition Resident #1 or touch the left leg, she cried out and asked not to move her. RN E said that Resident #1 demonstrated decreased mobility of the left leg and she did not usually complain of pain. RN E said that he asked Resident #1 if she fell or if anyone hurt her and she denied. RN E said he asked staff if anyone saw her fall and staff replied that she was bed all day. RN E said that he asked Resident #1 when did the pain start and she replied today (05/15/25). RN E said that he did not remember if he asked what [Resident #1] was doing when the pain started or asked what could have caused the pain. RN E said that he completed an incident report after he spoke with his supervisor (could not recall exactly who he spoke to) about Resident #1 pain. RN E said that it was decided to complete an incident report because Resident #1's complain of pain was unusual. An outbound call on 06/10/25 at 5:00 PM and at 6:30 PM to CNA D was unanswered. The investigator left a message on the voicemail to return call. CNA D did not return the call before the Investigator exited the facility on 06/10/25 at 8:00 PM. Record review of the facility's Safe Patient Handling/Transfer undated policy reflected in its entirety the following: The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safe transfer, repositioning and resident movement.1. Nurses will identify residents in need of transfer, repositioning or movement assistance.2. Nurses will assess the risks associated with lifting, transferring, repositioning or movement assistance.3. nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling.4. Resident will be evaluated on admission and as needed for alternative means of lifting.5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury.6. Facility staff will report to supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff.7. Nursing will request therapy disciplines to evaluate resident ability to assist and amount of assistance needed with lifting, repositioning, transferring or mobility.8. Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. The NFA was notified of an Immediate Jeopardy (IJ) on 06/20/2025 at 3:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 06/20/2025 at 7:11PM and included: Plan of Removal for 6/20/25 Problem: F689 Free from Accidents/Hazards The facility failed to provide adequate supervision and assistance to prevent accidents. Interventions: As of 6/10/25, CNA A was in-serviced 1:1 by the DON. All other nursing staff were in-serviced on the same topics by the DON/ADON/Director of Rehab. Completion date will 6/10/25. CNA B is no longer employed with the facility. In-serviced Admin / DON by regional nurse and Area director of operations on gait belt transfers, abuse/neglect, notification of change of condition, and resident rights. Resident #1 was assessed for any additional injuries by DON/ADON on 6/10/25. No additional injuries noted. All other residents that require assistance with transfers were assessed for injuries on 6/10/25 by DON/ADON/Charge nurse. No additional injuries noted. Following the Kardex in Point Click Care for all transfer status and assistance required with return demonstration from staff. Gait belt transfers with return demonstration. Abuse and Neglect (Improper transfers) education Notification of change of condition education Resident Rights education completed 6/10/25 Fall Prevention Policy will be completed 1:1 with CNA A as of 6/10/25 by the Regional Compliance Nurse. This in-service will include reporting to the charge nurse immediately if a resident suffers a fall, has an accident, or is found on the floor. If the charge nurse is not available, staff will report to DON immediately. Staff will not assist a resident off the floor until a charge nurse has been notified and assessed the resident. As of 6/10/25 audits were completed. All residents in the facility received head-to-toe assessment/ pain assessment by the DON/ADON/Tx Nurse for any injuries and/or fractures. No additional issues were found. On 6/10/25, all resident care plans were reviewed and audited for accuracy of transfer status and assistance by DON and ADON and if there is any change of condition- care plans will be updated accordingly. No issues were identified. On 6/10/25, DOR/designee initiated gait belt (1 to 2 person) and mechanical lift training and check offs with return demonstration. All nursing staff will be checked off prior to the start of their next shift. Training and checkoffs will be completed by DON/ADON/and Director of Rehab. The medical director was notified the immediate jeopardy potential by the administrator on 6/10/25. ADHOC QAPI was held with the Medical Director and facility inte

Based on observations, record reviews, and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) of four resident reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised to prevent her from leaving the facility unsupervised. There was a door near the secure unit that did not have an audible alarm. It was determined the noncompliance was identified as a Past Noncompliance Immediate Jeopardy (IJ). The IJ began on 06/01/2024 and ended on 06/02/2024. The facility corrected the noncompliance before the investigations began. This failure placed residents at risk for harm and/or serious injury. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/22/2024, reflected the resident was a [AGE] year-old-female who admitted to the facility on [DATE]. The resident had diagnoses which included: Heart Failure (disease that affects the heart muscle), Schizophrenia (mental illness), cognitive impairment (confusion) end stage renal disease (kidneys have stopped working) and, dependent on dialysis (a machine that cleanses the blood). The MDS reflected she had a BIMS score of 10, which indicated moderate cognitive impairment. The resident was ambulatory with an unsteady gait, used a wheelchair as a walker, and required assist of one staff for activities of daily living. The MDS did not reflect any wandering behavior. Record review of Resident #1's care plan, dated with a review date of 03/30/2024, addressed the resident's impaired cognition due to schizophrenia loss, dialysis, wandering behavior on secured unit, and assistance required for activities of daily living. Record review of Resident #1's clinical record revealed two Elopement Risk Assessments, quarterly elopement risk assessment dated [DATE] reflected she was score of 13 (high risk for elopement). An elopement or attempt risk assessment dated [DATE] reflected she was a score of 26 (high risk for elopement). Record review of the Provider Investigation Report completed by the Administrator, dated 06/02/2024, revealed Resident #1 was independently ambulatory using her wheelchair as a walker, and her own responsible party. There was a family member as the #1 contact in case of emergency contact. Resident #1 could not make decisions for herself but was alert and usually understood. Resident #1 had left the faciity on [DATE] sometime between 9:00 p.m. and 10:00 p.m. The resident had been located at the hospital in theER on [DATE] at approximately 7:30 p.m. The resident was last seen sitting by one of the exits of the secured unit at some time before 10:00 p.m. on 06/01/2024. The family was notified, and the police were called. The facility staff searched for Resident #1, calling a Code Orange at 10:15 p.m. after observation that Resident #1 was missing. The family was contacted multiple times on 06/01/2024 and returned the call on 06/02/2024 at 11:45 a.m. The family stated they would call around and gave the administrator the Resident #1's last known address. The police used dog and picked up a scent at the local bus stop. The police reviewed the local bus company camera footage and the location of exit. The police contacted the administrator and informed the facility a secondary scent was picked up at the bus station in a city 4 miles away. The Provider Investigation Report reflected a finding of confirmed (for other). The facility started in-service at 12:00 a.m. on 06/02/23 on the elopement procedure policy and procedures with all staff. The facility's DON reassessed all the resident for elopement risk and updated and checked all care plans on 06/02/24. Review of Provider Investigation Report dated 06/02/2024 reflected a finding of confirmed for Other. Review of the External/Internal/Systemic Approach Investigation Summary dated 06/02/2024 completed on 06/02/2024 reflected: . An emergency QAPI meeting was held on 06/02/2024 with Medical Director in attendance . all residents had a new elopement assessment to identify any current patients that are imminent risk for elopement (no other residents were found to be at imminent risk of elopement) . (who was responsible: Nurse Management . who will monitor: Director of Nursing.elopement assessment will be completed upon admission and quarterly by the charge nurse and/or nurse managers and for any resident that triggers an imminent risk for elopement, the elopement response protocol will be initiated Any patient that triggers elopement risk will be placed on 1:1 monitoring until no longer deemed necessary. DON will monitor for compliance for daily times 5 days and weekly times 4 weeks until 06/30/2024 and then monthly on an ongoing basis .Who will monitor: Administrator and or designee tested the functionality of all doors (closure and alarm) and outside gates on the facility property for proper functioning and no issues were identified. Maintenance director or designee to monitor facility doors and gates checked to validate proper functioning daily times 5 days, weekly times 4 weeks , then as needed thereafter. The Director of Nursing During this interview the logs were requested form maintenance department and/or Nurse Manager will monitor weekly for compliance by completing an audit of the elopement assessments. Audits will be completed weekly for 3 weeks until 06/30/2024 and monthly on an ongoing basis Monitoring .Starting 06/01/2024 Director of Nursing and/or Nurse Managers will receive in hand, the resident monitoring/every 2-hour body check documentation at the end of each shift for the first 72 hours, each day for one week, then weekly for 4 weeks. The Administrator will review the documentation each week for compliance Facility staff to monitor and validation for proper functioning of all doors, and gates when interruption in electricity are identified daily [NAME] 5 days, weekly times weeks then as needed thereafter when interruptions occur .Facility receptionist to conduct visitor observation for attempting to allow residents to exit facility unsupervised daily times 5 days , weekly times 4 weeks, then as needed thereafter . QAPI committee will review monthly for 3 months and adjust he plan of corrections and processes as needed. The Administrator will monitor daily to ensure compliance for four weeks and will review . Further review of the Providers Investigation Report reflected monitoring and audits by the designated staff (DON Nurse Managers) had occurred. Record review of Resident #1's nursing progress notes from 05/01/2024 until 06/01/2024 reflected Resident #1 was on the secured unit and was only signed out three times a week on Tuesday, Thursday and Saturday for pass by facility staff when she would agree to go to dialysis. The resident was ambulatory on the secured unit utilizing a wheelchair as a walker for mobility. Further review reflected without the wheelchair the resident could only mobilize safely for about 20 feet. Further review reflected Resident #1 was not exit seeking. She would go to the doors but just look out the window and never touch the door, to set off the system. Record review of Resident #1's progress notes reflected dated 06/01/2023 at 10:15 p.m., LVN A noted CNA B was coming back from break and then informed LVN A that she could not locate Resident #1. LVN A stated, after being informed by the CNA, conducted an additional search, and then informed the nurse manager on duty and a code orange meaning elopement was called. The code included notification of the administrative staff, responsible party, police, and the physician. Record Review of the elopement risk assessments reflected the DON had assessed all resident for elopement as part of the plan of correction. Review of the in-service dated 06/01/2024 reflected all staff attended and the subject matter was regarding Facility policy on elopement and reducing the risk for elopement: initiating a frequent monitoring form, elopement forms for new admission, and quarterly or condition change, intervention, put in place immediately with reporting to the nurse in charge, ensuring all doors are closed after exiting the unit and all doors that lead to the outside, all alarms that have been placed on doors are independently functioning and the staff knows to report and how to reset the panel for the system, and the individual alarms. During a power outage (even flickering of power) staff are to check all doors to ensure they are secured, the doors will need to be manually reset (instructions on the manually reset). Further review reflected the staff was also in-serviced on abuse, neglect, and exploitation (types of abuse and who the abuse coordinator is). There were handouts given and a test to ensure competency . The staff was instructed they could not return to work until they had the training and had passed the test. Review of the in-service dated 06/01/2024 was reviewed and reflected abuse and neglect test that was given to the employee after the training. The test including five question concerning abuse and neglect: (questions what identifies abuse & neglect, what are you supposed to do when you observed it or told about it, who do you report, and what so you do if nothing appears to be done about the report.) In an interview on 06/03/24 at 9:20 a.m. with LVN H revealed the LVN had worked at the facility for seven years. LVN H stated Resident #1 was always looking out all the exit doors or sitting in a chair in the hallway. Resident #1 would sometimes talk about how she needed to check on her family. LVN H stated Resident #1 had no change in condition and was not any different after the two days off for LVN H. LVN H works Monday through Friday. LVN H stated Resident #1 never mentioned leaving and had the same behaviors, attending the activities then going back to walking with the wheelchair or sitting in the chair looking at the door or window. LVN H stated all employees got a mass text on Saturday night about Resident #1's elopement. LVN H came and helped but Resident #1 was not found. All staff had in-services on the elopement process and the alarm system for the facility and the secured unit. All staff were re-educated on how to reset the alarm manually. LVN H stated there had not been any problems with the facility alarm system working since the storm the previous week. The LVN stated a company came out and checked it, and everything has been fine. LVN H stated there had been no other elopements. An interview on 06/03/24 at 9:30 a.m. with CNA I revealed the CNA had been in-serviced on the alarm system for the secured unit, if there is no power, staff must protect all the exits. CNA I stated she had been in-serviced on Saturday in person on how to reset the system; the nurse usually does do that, but the Administrator wanted everyone to know. An interview on 06/03/24 at 9:45 a.m. with CNA J revealed Resident #1 would sit by the doors and look out while sitting in her wheelchair. CNA J stated Resident #1 was a pleasant resident. CNA J stated Resident #1 never caused any trouble. Resident #1 would talk about checking on her daughter, never tried to leave the unit. CNA J stated Resident #1 would be taken to the receptionist to take money from her trust fund. Resident #1 wanted to get snacks from the vending machines. CNA J came and helped look for the resident when the facility sent out the mass text. The facility in-serviced CNA J on the elopement process and the new alarms on the doors and how to reset the system and if an alarm sound staff is to react immediately. An interview on 06/03/24 at 9:00 a.m. with the Administrator revealed had been informed by the facility of the elopement around 10:30 p.m. on 06/01/2024, arrived at facility at 10:50 p.m. The Administrator began looking for Resident #1 and had been informed the staff was divided up into internal and the external search parties. The Administrator stated the facility had sent out a mass text and a lot of staff showed up to help. There were already staff driving around the area and the neighborhood, the police had been notified. The Administrator stated police arrived just before 11:00 p.m. and the DON arrived shortly after. The Administrator stated the police had a search helicopter looking for Resident #1 and search dogs, due to area being wooded, dense, close to busy streets and the bus stop. The Administrator stated the DON started trying to contact the family. The Administrator stated when information had been provided of an address in the area where Resident #1 used to live, the facility provided the address to the police; Resident #1 was not there. The Administrator stated the facility staff, drove at different times to the address to check; Resident #1 was not there. All residents had been accounted for, except Resident #1. The police stayed in contact and informed the Administrator of the scent the search dogs had picked up at the bus stop. The police told the Administrator there was a review camera footage and the location of Resident #1's exit. The police were able to determine Resident #1 had traveled to another city near the facility and the search dogs had picked up the scent at that bus station. The search dogs could not pick up Resident #1's scent again after located the scent multiple times at the bus station. The Administrator contacted all the local hospital, called the local news station, provided a picture and details of Resident #1's elopement. The Administrator stated the in-services on the night of the elopement (06/01/24) covering the elopement process, the security alarm system for the units. The Administrator stated the staff was in-serviced on how to conduct a search, and how to manually reset the system on the secured unit, if there was a power outage or power surges. The facility staff had to come in person to in-service on the topics, including abuse and neglect. The staff had to be checked off competency before were allowed to return to work. The Administrator stated the entire staff (160) had been in-serviced. The Administrator stated there was one staff member that phone was broken and would be in-serviced on tomorrow (06/04/24) when the staff returned to work before, the staff went to work. The Administrator informed the surveyor, one of the hospitals had contacted, the facility. Resident #1 had shown up at the hospital around 7:30 p.m. (06/02/24), walked into the emergency room requesting to see a physician because of a cough. Further interview revealed later in the day on 06/03/24, the Administrator had been contacted by the hospital again. The Administrator was told Resident #1 was not injured, the doctor had run some lab work and was going to dialyze Resident #1 (even though the resident was not due until tomorrow, Tuesday) just to be on the safe side, then return the resident to the facility after completed dialysis. An interview on 06/03/24 with MA G at 9:15 a.m. revealed MA G only worked Monday through Friday was not working when Resident #1 eloped. MA G stated Resident #1 was a pleasant lady, but was everywhere on the secured unit, and used a wheelchair for mobility like a walker. MA G had been in-serviced on elopement. MA G had to come up to the facility on Sunday. The MA had been shown how to reset the security system manually and how the alarms on the doors functioned. An interview on 06/03/2024 with Floor Tech at 10:00 a.m. revealed the Floor Tech had been cleaning the floors in the ding room of the secure unit at 7:30 p.m. The Floor Tech noticed Resident #1 sitting in the television room. The Floor Tech stated Resident #1 wanted the Floor Tech to buy a bag of chips and a soda from the vending machine. The Floor Tech had reported to the nurse Resident #1 wanted a snack. The floor tech left the unit around 8:45 p.m. Resident #1 was sitting in the doorway of room, in the wheelchair. The Floor Tech came back when the facility sent out the mass text and tried to look for Resident #1 but did not find the resident. The Floor Tech had been in-serviced on elopement process and the security system on the secured unit and the alarms on the doors and how to reset the system. An interview on 06/03/2024 with LVN E at 11:00 a.m. revealed Resident #1 was very pleasant, unsteady on the feet at times, walked all the time, except when was sitting at an exit and used wheelchair as a walker. LVN E stated Resident #1 was not always alert and oriented. Resident #1 required assistance of the staff to help change clothing and be reminded of when to eat. LVN E stated LVN A was working on the secured unit that night. LVN E had been contacted by phone by LVN A that Resident #1 was missing, a code orange had been called and the whole facility began a head count and started looking for Resident #1 inside and outside the facility, just like the staff had been trained to do. LVN E informed the administrative staff and the police for LVN A. LVN E stated the police had brought search dogs and the police informed the facility the dogs had picked up Resident #1's scent at the bus stop. Resident #1 had taken a bus to another area. LVN E stated on (06/02/24) the hospital had called the facility. Resident #1 had come into the ER and needed to see a doctor. LVN E stated there was no idea how she got out. LVN E had not heard any alarms go off on the unit and alarms were loud. LVN E stated the weather that night was good; it was not raining or storming. LVN E had been in-serviced on the secured unit system, how to check the doors and validate the system, how to manually reset it just in case it was needed, and the process of elopement before leaving the facility that night. In an observation and interview on 06/03/24 at 11:00 a.m. with Maintenance Supervisor revealed the security unit functionality of all doors (closure and alarm) and outside gates on the old unit and new unit were working appropriately. The Maintenance Supervisor had placed all new audible alarms on the doors in the old unit and the new unit. The surveyor observed those working with demonstration from the Maintenance Supervisor on the old unit and the new unit. During this interview the documents were provided for the logs on the checks of the system for the secured unit, old and new, starting on 06/02/24 and was to continue daily for 5 days a week times four weeks. The Maintenance Supervisor stated the facility had just placed an alarm on the door between the two dining rooms on 06/02/24 and explained the door was hooked up to the system and is able to reset , but that it was the only door that did not have an audible alarm on it. In an interview on 06/03/2024 with CNA C at 12:30 p.m. revealed Resident #1 was very pleasant, unsteady on feet at times, but used a wheelchair as a walker. CNA C stated Resident #1 was not always alert and oriented. Resident #1 required assistance of the staff to help change clothing. CNA C had observed Resident #1 on 06/01/24 around 10:00 p.m. sitting at the exit doors, looking out the window eating chips and drinking a coke. CNA C stated Resident #1 never touched the doors and does not set off the alarms. CNA B recalled what Resident #1 was wearing, when the other CNAs came and asked if CNA C had seen Resident #1. CNA C informed CNA B, Resident #1 had not been seen and CNAs began looking. CNA C went to the new unopened secured unit and back around past the vending machines to the other side of the facility that was called A2 (a new memory care unit that has not been licensed yet for usage). There was a door between both dining areas leading off the old unit into the new dining room area. CNA C thought maybe Resident #1 had gotten through the door somehow, CNA C did not find Resident #1. CNA C looked all over the new secure unit that had not been opened. CNA C did not check the doors on the new secured unit to see it any of the doors had been left open. CNA C had been in-serviced on the secured unit system, how to check the doors and validate the system, how to manually reset it just in case it was needed, and the process of elopement before she left the facility that night. An interview on 06/02/24 at 12:45 p.m. with LVN D revealed LVN D had been in-serviced on the elopement process and knew what to do. LVN D did not work on the secured unit, LVN D was still shown how to check all the doors and reset the system manually. An interview on 06/30/24 at 1:45 p.m. with CNA F had been in-serviced on code orange and what to do when a resident elopes. CNA F was shown how the alarms work on the doors in the facility, including the secured unit doors. An interview on 06/03/24 at 2:30 p.m. with LVN A revealed CNA B had taken a break. After the break CNA B could not locate Resident #1 to assist her to go to bed. LVN A stated CNA B reported Resident #1 was missing around 10:15 a.m. the LVN looked for Resident #1 and could not find the resident. LVN A informed the nurse manager on duty, who was LVN E and a Code Orange was called. LVN A stated the staff all looked inside and outside, the police, administration, and responsible party were contacted. LVN A stayed with the residents on the secured unit, until the relief nurse came, then started looking again. LVN A stated the resident never verbalized anything about leaving, Resident #1 would sit and look out the window on the doors or out the window in the room. LVN A stated Resident #1 never touched the doors to set the alarms off. LVN A had been in-serviced on the alarm system and how to check the doors and validate the system, and how to manually reset, just in case it was needed and the process of elopement before leaving the facility that night. An interview on 06/03/2024 with CNA B at 4:00 p.m. revealed CNA B had worked at the facility off and on for the past 7 years. CNA B recalled Resident #1 she was very pleasant, unsteady walking at times, but used a wheelchair as a walker. CNA B stated Resident #1 was not always alert and oriented. Resident #1 required assistance of the staff to help change clothing, and shower. CNA B had observed Resident #1 many times sitting at the exit doors or in the room looking out the window. CNA B stated Resident #1 never touched the doors and did not set off the alarms. CNA B stated Resident #1 would talk about checking on her child but would not talk was leaving. CNA B had been in-serviced on the secured alarm system on the doors. CNA B had been shown how to check the doors and validate the system. CNA B was shown how to manually reset the alarms, and the process of elopement before she left the facility that night. An interview on 06/03/2024 at 2:00 p.m. with the DON revealed that if a resident had left the facility, which should not be leaving, the staff should notify the DON and the Administrator immediately. The staff was supposed to call a code orange immediately start looking for the resident and call the police. The police and the responsible party should be notified. An interview on 06/03/2024 at 2:15 p.m. with the Administrator revealed there had been cooperate intervention, when he requested, when the elopement occurred. An observation on 06/03/24 at 8:30 a.m. revealed the surrounding outside area, the parking lot, and streets adjacent to the facility. The facility was in an industrial/residential area with multiple stores, and multiple businesses. The street in front of the facility was very busy. There was a popular conversion between two street approximately one to two miles away, where the bus stop was, as well as a very busy main four lane street that led to residential areas, and large shopping centers, that has heavy traffic on the road all times of the day and night. Where the resident's scent was picked up at the other bus terminal, was four miles away. The hospital that the resident entered was twenty two miles away. An interview on 06/03/2024 at 3:00 p.m. with the Medical Director revealed, was made aware of Resident #1's elopement from the secured unit. The Medical Director stated there was an emergency QAPI meeting on the morning of 06/02/2024. The committee discussed that the system needed to be updated with new interventions, which was the placement of the green alarm boxes . The Medical Director stated there was corporate assistance in the QAPI meeting. Record review of the facility's Policy and Procedure Elopement Prevention, dated January 2023, reflected Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission .The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, new exit seeking behavior, and upon change of condition 6. Should an elopement episode occur, the contributing factors, as well as interventions tried, will be documented in the nurses' notes . 7. If a resident is discovered to be missing, a search shall begin immediately Record review of the facility's Policy and Procedure Elopement Response, dated January 2023, reflected, Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented .1. It is the responsibility of all personnel to report any resident attempting to leave the premise, or suspected of being missing, to the charge nurse as soon as practical . 2. Determination of missing resident either by routine nursing rounds or door alarms: 4. Should an employee discover the resident is missing from the facility (Code Orange), he/she should charge nurse, . C. Make a thorough search of the building and premises . D. notify the Administrator and the Director of Nursing . E. Notify the responsible party . F Notify the attending physician .H. if necessary, notify . agency . J. make and extensive search of the surrounding area.5. A. Charge nurse on each unit send staff down each hall to check each room, including bathroom, closet, and bed for correct resident 6. A. Charge nurse designates one CNA per hall to remain on unit along with him/herself and sends remaining staff to affected area. B. Charge Nurse assigns staff to specific outside areas to ensure that all surrounding areas are searched C. after 30 minutes , if the resident had not been found, the following call must be made: report missing resident to the police .update all administrative staff Secured Unit. Fire exit doors on the secure unit will meet the following criteria: lock must be electro-magnetic, the lock must release when one of the following occurs: the fire alarm or sprinkler system are activated, power failure to the facility, activation of a switch or button located at the monitoring station and the main nurse's station

Based on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of four residents reviewed for pressure ulcers. The facility failed to appropriately identify the Resident #1's pressure ulcers, obtain and provide appropriate treatment, monitor the wounds, and provide interventions to prevent further deterioration of the wounds. Resident #1 was hospitalized and had sugery for osteomyelitis (bacterial infection in the bone) of the bone/joint of the right hip. This failure could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new pressure ulcers, worsening of existing pressure ulcers and infection. Findings include: Review of Resident #1's face sheet dated 9/28/2023 revealed a [AGE] year-old female admitted to the facility 08/24/2012 with a readmission on 03/10/2021. Resident was discharged to acute care facility on 09/19/2023 at 1:38 PM. Resident #1's diagnoses included: a disease present at birth causing chronic joint pain and limited mobility; and generalized muscle weakness. Review of hospital document: Wound Care Consultation dated 09/20/2023 at 6:07 PM, HWCP wrote Resident #1 was admitted to the hospital for altered mental status and worsening right hip wound. Resident #1 was found to have bilateral hip wounds. The family was unaware of how long she had the hip wounds. HWCP wrote large extensive left hip decubitus (injury to the skin caused by pressure) ulcer (open sore) with eschar (dead tissue) loosened at the edges with slough (yellowish/white tissue on the wound bed) and scant serosanguineous (thin pinkish) drainage. Right hip decubitus ulcer with fair quality viable tissue, slough, with loosening eschar with bone palpable (felt w fingers) at the base. There is moderate serosanguineous drainage. Very faint redness noted in the surrounding skin, no foul odor noted. Review of Hospital document - Operative/Procedure Notes dated 09/28/2023 Resident #1 had surgery on 9/26/2023 related to osteomyelitis (bacterial infection in the bone) of the bone/joint of the right hip. Review of Resident #1's significant change MDS dated [DATE] Resident #1 was cognitively intact as evidence by a BIMS score of 15, no behavioral issues identified. Resident #1 was dependent on facility staff for all ADL care, bathing and required the assistance of 2 people for mobility and transfers. Resident #1 required the assistance of 1 person for dressing, eating, toilet use and personal hygiene. Resident #1 had a tube in her bladder which drained urine into a bag and had bowel incontinence. Resident #1 developed 1 stage 4 (loss of tissue with exposed bone or muscle caused by pressure to a bony region) pressure ulcer on the left elbow. Review of Resident #1's care plan, reflected as of 7/31/2023 Resident #1 had an abscess to the right hip, goals of care was that resident would remain on palliative (non-aggressive) wound care. Interventions included assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Review of Resident #1's progress notes revealed an entry dated 7/31/2023 at 1:10 PM WCN A identified Resident #1 had developed an abscess with multiple heads to the right hip. WCN A wrote wound care is palliative wound due to resident overall significantly declining condition, non-compliance and significant weight loss. Resident will continue to have skin breakdown due to her condition physician notified. Review of Resident #1's Order Summary Report Printed 9/27/2023 reflected: as of 7/31/2023 cleanse right hip wound with wound cleanser, pat dry apply Dakin (wound cleanser) half strength solution soaked in gauze then cover with protective dressing change every Monday-Wednesday-Friday, every day shift (added 8/2/2023) and as needed. Review of Resident #1's Wound Administration Record dated August 2023 revealed Resident #1 refused treatment to the right hip 8/23/2023, otherwise it was documented as provided as prescribed. Review of Resident #1's Wound Administration Record dated September 2023 revealed Resident #1's treatment to the right hip was documented as provided as prescribed. Review of Resident #1's weekly ulcer assessment of the Stage 4 wound on the left elbow, dated 8/24/2023 WCN A noted in the section marked additional information .will continue with palliative wound care to .right hip wound. No documentation found in the EHR regarding the condition/description of the wound on the right hip. Review of Resident #1's weekly ulcer assessment of the Stage 4 wound on the left elbow, dated 8/30/2023 WCN A noted in the section marked other Resident is declining significantly, continue with hospice care. Refusing dressing change per order. refused to change her hip dressing on 8/30/2023. No documentation found in the EHR regarding the condition/description of the wounds on the hips. Review of Resident #1's weekly skin assessment dated [DATE] completed by WCN A revealed under other skin findings - .and right hip. Review of Resident #1's weekly ulcer assessment of the Stage 4 wound on the left elbow, dated 9/07/2023 WCN A noted in the section marked other Resident on hospice with palliative care. Not eating much. Resident continue to non-compliance with turning and repositioning. Resident hip wound will continue with Dakin half strength solution soak. Resident is high risk for skin breakdown due to her declining condition and non-compliance with turning and repositioning. No documentation found in the EHR regarding the condition/description of the wounds on the hips. Review of Resident #1's weekly ulcer assessment of the Stage 4 wound on the left elbow, dated 9/14/2023 WCN A noted in the section marked other, Resident continue to decline and refusing wound care more noted. Continue to refuse for turning and reposition per protocol. Continue to have skin breakdown. No documentation found the EHR regarding the condition/description of the wounds on the hips. Review of Resident #1's progress notes revealed, an entry dated 09/19/2023 at 4:14 PM, WCN A wrote, Resident dressing change was done, Resident continue to have bilateral hip wound . Resident is declining with significantly with unavoidable wounds. Family had a meeting with hospice nurse and ultimately sent Resident #1 to the hospital. No documentation found in the EHR regarding the condition/description of the wounds on both hips. Review of an addendum to 9/19/2023 progress notes dated 09/27/2023, WCN A described Resident #1's right hip as showing evidence of skin failure; within the wound bed was black eschar with some drainage with exposed bone. The left hip was described as having a deep tissue injury noted size about 5.2x6.2cm skin intact, surrounding skin normal, irregular edges and no drainage. This injury was not documented in the EHR prior to the day of discharge 9/19/2023. In an interview on 09/26/2023 at 2:43 PM, WCN A stated Resident #1 was non-compliant regarding her care. Resident #1 was known to not turn, refuse bed baths and refused dressing changes. Resident #1 has lost weight and developed unavoidable pressure sores in recent months. Resident was placed on hospice 8/22/2023 for pain management and remained a full code. The facility was to provide wound care. In an interview on 09/27/2023 at 10:59 AM, FM stated they knew Resident #1 had wounds on her legs and had no knowledge of wounds on her hips. When having conversations with the facility, FM thought the facility was talking about the chronic wounds on Resident #1's legs. In an interview on 09/27/2023 at 4:33 PM, the DON reviewed Resident #1's EHR and found no weekly ulcer/wound assessment specific to the hips. On 9/19/2023 Resident #1 was described as having skin failure on the right hip the affected area was measured by WCN A as 8x9.6cm no other description was provided. The DON stated that given the size of the injury she would have expected a description of what was measured and what was observed. This information would allow for the proper care and treatment of the wound. In an interview on 09/28/2023 at 11:22 AM with WCN A, believed the missing documentation was the result of computer glitches. WCN stated on 8/29/2023 time unknown, Resident #1 was noted to have an abscess with a small opening on the right hip, the surrounding tissue was discolored. WCN A measured the discolored area, measurements were not found documented in the EHR corresponding to the date of 8/29/2023. In an interview on 09/28/2023 at 12:52 PM, PP stated that Resident #1 had been in declining health for the past couple of months. PP was aware of an abscess on the right hip; was not certain if the abscess had opened prior to Resident #1's discharge to the hospital. PP did not recall knowing that the Right hip had an open sore that measured 8x9.6cm with exposed bone. PP was not aware that the left hip had a deep tissue injury that measured 5.2x6.2cm with intact skin. In an interview on 09/28/2023 at 2:30 PM, the Adm stated he was not aware that Resident #1 had developed wounds on the hips. The DON would provide the expectations for documentation. In an interview on 10/11/2023 at 11:33 AM, LVN C stated Resident #1's health was in decline for the past several months. Resident #1 was resistant to care, showers and turning r/t chronic pain caused by the disease present since birth. Resident #1 developed a poor appetite and would drink small amounts of fluids. LVN C stated that WC provided the treatments for Resident #1's wounds. LVN C had not recently visualized Resident #1's right hip because it usually had a dressing on it. In an interview on 10/11/2023 at 11:51 AM, WCN B stated she provided wound care to Resident #1 on Monday 9/18/2023 and it was checked off in the TAR. WCN B said there was no need to document anything as checking off on the TAR was sufficient to indicate that wound care was performed. WNC B described the right hip as having an open area about the size of her palm, the wound bed was red, with yellowish white and dead tissue. WCN B did not recall seeing exposed bone. WCN B described Residents #1 decline in health in recent months and her refusal to reposition and eat, which would impact her skin. In an interview on 10/11/2023 at 12:17 PM, WCN A stated that skin failure occurs when a person is dying they stop eating, depriving cells of nourishment, circulation is diverted to the major organs. Resident #1 was eating and drinking very little and would refuse to reposition all contributed to an unavoidable deterioration of her skin. WCN A said when a resident has all interventions i.e. air mattress, protein supplements, vitamins, repositioning in place and adequate nutrition and hydration and the skin breaks down that's skin failure. WCN A did not refer to the wound on Resident #1's right hip as a pressure related injury. In an interview on 10/11/2023 at 12:51 PM, DON stated that Resident #1 had an open wound on the right hip that was being treated by WC. DON described skin failure as the result of not eating, drinking or moving. Not getting the nutrients and staying in one position led to decreased circulation, the tissue/skin begins to die in a short period of time depending on the overall health of the person. In an interview on 10/11/2023 at 1:07 PM, ADM stated that on the day Resident #1 was discharged to the hospital, the family was present during wound care and verbalized no questions or concerns regarding the wound on the right hip. ADM stated the family had been present at other times during WC and had not verbalized concerns or questions. In an interview on 10/11/1023 at 6:04 PM, PP stated that he met with WCN A every week and he was not informed of any concerns or changes in the wound on Resident #1's right hip. PP described the wound was stable (measurements unchanged) and the current treatment was appropriate. PP described Resident #1 was experiencing a decline in health, she was known to refuse repositioning, eating and drinking resulting in poor healing of wounds including the right hip. PP stated that he had not visualized the wound himself, his decisions were based on the information provided to him from WCN A. Review of facility policy, undated Wound Treatment and Management, #5 treatment decisions will be based on: a. Etiology of the wound b. Characteristics of the wound

Based on interview and record review; the facility failed to ensure an alleged violation of abuse was reported immediately, but not later than 2 hours after the allegation was made if the events that cause the allegation involve abuse to the State Survey Agency for one (Resident #83) of 41 residents reviewed for abuse. The facility failed to report Resident #83's allegation of abuse by her daughter to the State Survey Agency. This failure affected one resident, Resident #83 and had the potential to affect all 187 residents by placing them as risk of abuse and neglect. Findings included: Resident #83's Face Sheet, dated 10/05/18, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Resident #83's MDS, dated [DATE], reflected the resident had moderately impaired cognitive skills. Review of Resident #83's Department Notes entered by LVN H dated 03/20/18 at 11:46 PM, reflected Resident daughter visited her mom, 3:37 PM . Resident called loudly for help, this nurse went into the resident room and found the resident alone, water wet all over her body, wallet and water pitcher on the floor, resident panting and furiously verbalized my daughter assaulted me, call the police she needs to go to jail, this writer on several attempt tried to calm the resident down in order to obtained information on what went wrong between the resident and the resident daughter but resident was agitated and insisted on calling the police this nurse immediately notified social worker who showed up with staffing coordinator and found the resident in an extremely angry manner they both tried to calm the resident down after several attempt but to no avail, resident was able to verbalized furiously my daughter assaulted me and poured water on me I don't want her here again. Review of Resident #83's Department Notes entered by Social Worker B dated 03/21/18 at 11:11 AM, reflected .03/ 21/ (YEAR) late entry for 03/20/18 called to resident's room by staff that resident and her daughter had been in the room and an argument issued and daughter left building. Resident then began screaming and demanding help that she had been assaulted her daughter and wanted to call the police to file a report. Upon entering the room Resident #83 was sitting in her wheelchair by her bed, she had her O2 and glasses off and was breathing heavily. This SW and Staffing Coordinator immediately asked what happened. Resident #83 was so short of breath she was unable to talk, O2 was applied and deep breathing ensued. Nurse came to the room and assessed her vitals. After a few moments the resident relayed to us that the daughter had come to visit and an argument over numerous issues ensued. Resident #83 relays that she threw the cell phone on the floor because she no longer wanted it and told her daughter to take it home. She then relayed that she picked up her water pitcher and attempted to toss the contents at her daughter but as the lid was on nothing happened. The resident stated that her daughter then reached for the pitcher, took the lid off and said let me show you how its done after that she tossed the water at her mother who had wet clothing from the waist down resident stated I want to file a report with police she assaulted me and I want her to go to jail. The resident then said she does not want her daughter backer (sic) in her room ever, staff agreed they would honor her request. This information then reported to the DNS and the Administrator . Interview with Resident #83 on 10/03/2018 at 11:40 AM revealed her daughter bought her a specific type of phone with her money and like a fool she put her in charge of everything and her daughter brought her back a phone she did not know how to operate. The resident stated, I told her I wanted a different type of phone from an organization. The resident stated she was in her wheelchair and her daughter snatched the cup from her and poured water over her head. Resident #83 revealed she tried to drown me. Resident #83 also stated she was insulted, and the staff did not do anything. She stated they kept saying the way they saw it was that her daughter did not assault her and just poured water on her. Resident #83 continued to insist her daughter physically assaulted her and as far as she knew the daughter was not supposed to come back to the facility but does not find comfort that the nursing facility will protect her. Interview with Social Worker B on 10/03/18 at 01:58 PM revealed Resident #83 had a visit by her daughter one afternoon and the staff heard yelling and the daughter had left the room and the resident was left there with water dripping from her head, with water all over the floor. The SW stated the resident said her daughter threw water in her face and they got into an argument. SW stated she did call the daughter and told her the resident did not want her as her RP anymore. The SW revealed the resident called the police, but she did not know what came of it because she had given her the number to the police department and left her alone to call on her own. The SW stated there were no incident or grievance reports completed. The SW also stated the resident wanted to file assault charges and that she did not want the daughter back in the building. Interview with the Administrator on 10/04/18 at 05:48 PM revealed in order for a resident to allege abuse there has to be an allegation or even if a family or an employee, on the resident's behalf to allege an allegation of abuse. The Administrator revealed an allegation of abuse exist is if a resident alleges that it is abuse then and only then can it be an allegation of abuse. The Administrator reported, the staff must notify him immediately if there is an allegation if abuse. The Administrator revealed if there was an allegation of abuse the following things would take place; the alleged person would be taken out of the facility and facility, safe surveys on the incident took place hall, abuse /neglect in-service, statements collected and witness statements. When surveyor asked why there was no record of an incident report, self-report and or grievance, he stated, the resident calmed down at first and she did not want the police called. Surveyor asked the Administrator if the police came to the facility for this incident, he stated the police didn't come (the DNS interjected and stated yes they did come out for this incident), oh well they did, no I wasn't aware of the police coming. The facility's policy titled, Abuse Policy , revised (MONTH) (YEAR), reflected, .Definitions Abuse means the willful ( the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish., Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend , or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient, such as telling a resident/ patient that he/ she will never be able to see his/ her family again . Mental abuse includes but is not limited to, humiliation . Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress . Policy Statement . It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/ patient property and to ensure all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident/ patient property (alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center. Such violations will also be reported to state agencies and law enforcement in accordance with existing state law. The Administrator/ Director of Nursing will direct a through investigation of each such alleged violation. The Administrator/ Director of Nursing is responsible to report the results of all investigation to the state agencies as required by the state and federal law Reporting . All alleged violations involving mistreatment, neglect, abuse, or exploitation including injuries of unknown source and misappropriation of resident/ patient property are reported immediately to the Administrator/ Director and to other officials in accordance with the State law through established procedures (including to the State survey and certification agency). Immediately means as soon as possible: 1. Any allegation of abuse within two hours and . 2. Any neglect, mistreatment, exploitation or injuries of unknown source resulting in serious injury within 2 hours and .

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two of six residents (Residents #1 and #2) reviewed when: 1. Resident #1 experienced an unwitnessed fall on 05/30/15, CNA A and CNA B assisted her off the floor and failed to notify the charge nurse. As a result the resident was not assessed until 06/01/15 and the x-ray revealed a fracture. This was determined to be past noncompliance due to the facility having implemented actions that corrected non-compliance prior to the beginning of the survey. 2. Resident #2 was not timely assessed for pain caused by her constipation until 33 minutes after pressing her call light for the second time. These failures placed an additional 165 residents at risk of not being timely assessed for change of condition. The findings include: 1. Resident #1's quarterly MDS assessment, dated 05/09/15, reflected she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had moderate cognitive impairment and required extensive assistance of one person for transfer. She required limited assistance of one person for bed mobility and to walk in her room. She had range of motion impairment on both sides of her lower extremities and used a walker and a wheelchair. Resident #1's Care Plan, reviewed 05/12/15, reflected she had a history of [REDACTED]. The goal was for Resident #1 to not have unidentified complications related to history of falling for the next 90 days. The approaches included for staff to observe for changes in condition. Review of Resident #1's Nurses Notes revealed no evidence of any documentation on 05/30/15 and 05/31/15. Review of a 24 hour report, dated 05/30/15 and 05/31/15, revealed no evidence the incident was reported or that Resident #1 was assessed for injury. Review of a Resident #1's Nurses Note, dated and signed by LVN on 06/01/15 at 1:42 PM, LVN C revealed Resident #1 has bruising to left upper arm with c/o pain when touched, resident was unable to inform nurse on what happened, resident is unable to raise hand adequately nurse will call and nurse practitioner and received x-rays. Review of Resident #1's Body Audit, dated 06/01/15 and completed and signed by LVN C, reflected bruises and [MEDICAL CONDITION] on upper left arm. Review of Resident #1's Physician Telephone order, dated 06/01/15, revealed orders for an x-ray of the left shoulder. Review of a Resident #1's Nurses Note, dated and signed by LVN E on 06/02/15 at 12:25 AM, revealed Resident #1 awake and alert during shift, still with bruising to left arm, unable to lift left arm at all, states pain 4/10. X-ray completed this evening, pending results. Resident resting this evening, respirations even and unlabored, no additional or delayed injuries noted. No distress noted. Will continue to monitor. Review of a Resident #1's Nurses Note, dated and signed by LVN C on 06/02/15 at 1:42 PM, revealed mobile x-ray results were back, acute humeral neck fracture, notified nurse practitioner and informed nurse to send resident out to doctors hospital including nephrology information, nurse spoke to resident to see if memory would recall what happened to receive bruises and [MEDICAL CONDITION] in shoulder and neck, resident stated she thought she fell , nurse asked was a nurse notified at time of fall resident stated, yes, but did not know which nurse, nurse asked evening nurse which was not informed of incident, accident may have happened over weekend, resident cleaned and dressed by CNA and an ambulance service was notified to pick up resident with stretcher due to injury location, daughter, responsible party has been called but number did not work. Review of Resident #1's Radiology Report, signed 06/02/15, reflected there was a fracture involving humeral neck with medial displacement. Conclusion: Acute left humeral neck fracture. Reference from the Sports Injury Clinic: The Humerus is the bone at the top of the arm which fits into the glenoid or socket of the shoulder to form the glenohumeral joint. The neck of the humerus is at the top of the bone. A fracture is a break in the bone. http://www.sportsinjuryclinic.net/sport-injuries/shoulder-pain/fracture-of-the-neck-of-the-humerus Review of Resident #1 Medication Administration Record, [REDACTED]. Interview with the DON on 06/18/15 at 10:20 AM revealed an injury of unknown origin was identified on 06/01/15 by LVN C. She stated x-rays were ordered and revealed a humeral fracture on 06/02/15. Resident #1 was transported to the hospital for further evaluation and treatment. The facility began an internal investigation and learned CNA A witnessed Resident #1 kneeling on the floor on 05/30/15 and assisted her up with the help of CNA B. The DON stated CNA A and CNA B did not report the incident to anyone. She stated Resident #1 stayed in bed as usual but did not complain of pain on 05/30/15 and 05/31/15, the only sign and symptom of an injury was the bruising discovered on 06/01/15. The DON stated Resident #1 would have been assessed for injury sooner if CNA A and CNA B reported what they witnessed. Interview with CNA A on 06/18/15 12:10 PM revealed she picked up hall trays after lunch on 05/30/15 and noticed Resident #1 kneeled down on the floor in her room. She stated she was not sure if she fell and called CNA B to assist with transferring Resident #1 from the floor to her recliner chair. She stated she asked Resident #1 is she was hurt and Resident #1 replied, no. CNA A stated she did not observe any injury; Resident #1 appeared fine, did not complain of pain or discomfort, and stayed in her recliner chair as usual. Review of CNA A's written statement dated, 06/16/15, reflected she cared for Resident #1 on 05/30/15. She wrote at lunch time she noticed Resident #1 kneeling on the floor in her room from across the hallway but she did not see her fall. She wrote Resident #1 kneeling was kneeling in front of her chair on her right knee and trying to get up with her left knee as if trying to get up. CNA A asked CNA B to assist transfer Resident #1 to her chair. CNA A asked Resident #1 if she was hurt, Resident #1 replied no . CNA A observed for any injuries and did not see anything. Interview with CNA B on 06/18/15 at 12:50 PM revealed CNA A approached her after lunch and asked for assistance with transferring Resident #1 from the floor to her recliner chair. CNA B stated Resident #1 did not complain of any pain and she did not observe any injury. When CNA B asked Resident #1 if she fell , Resident #1 replied I did not fall, I slid. CNA B stated she repeated her question several times and got the same response. CNA B stated We (CNA A and CNA B) did not report to a nurse, but should have reported it because the Resident #1 was on the floor. Interview with CNA F on 06/18/15 at 12:55 PM revealed she worked with Resident #1 on 05/30/15 from 3:00 PM to 11:00 PM. CNA F stated Resident #1 seemed her normal self. She stated Resident #1 declined a shower but she did not ask why in order to avoid Resident #1 getting agitated. Interview with LVN C on 06/18/15 at 1:45 PM revealed she did her morning rounds at 10:00 AM on 06/01/15, and conducted a routine assessment on Resident #1 and noticed the top of her left arm was bruised. She stated Resident #1 did not complain of pain and did not know how she obtained the injury. LVN C stated no one on duty at that time knew the origin of the injury, and there was no documentation regarding an incident. LVN C notified the unit manager then the physician, and mobile x-rays were ordered. LVN C obtained the x-ray results the following morning at 10:00 AM on 06/02/15 which revealed the humeral fracture, she notified the physician and received orders to send Resident #1 to the hospital. Review of a facility document, signed by the DON and ADM on 06/11/15, reflected an internal investigation report was initiated immediately after the incident was identified. In order to identify all residents potentially affected the facility conducted safe surveys and review of incident reports for the previous 60 days to determine if there were other injuries of unknown origin. The facility implemented a system change to collect stop and watch reports from the CNAs' one hour before the end of each shift so the nurses and unit manager to review for incidents and changes of conditions. Review of facility in-service records, dated 06/11/15 to 06/12/15, reflected 47 facility employees representing all shifts were trained regarding timely and accurate reporting of incidents, documentation, prevention and recognition of abuse and neglect, incident investigations, and post fall assessments. Review of CNA A and CNA B's timesheets, dated May and June 2015, revealed they had not worked since being identified as involved in the incident. Interview with the ADM at 3:30 PM on 06/18/15 revealed CNA A and CNA B would not work until they received in-service training regarding the incident. Interviews on 06/18/15 with six facility employees representing all three shifts; the DON at 10:20 AM, the ADM at 10:45 AM, LVN C at 12:25 PM, CNA F at 12:45 PM, LVN M at 12:55 PM, and CNA N at 2:20 PM revealed they were knowledgeable about identifying and reporting incidents of abuse and neglect. This was determined to be past noncompliance due to the facility having implemented actions that corrected non-compliance prior to the beginning of the survey. 2. Review of Resident #2's quarterly MDS assessment, dated 04/05/15, reflected she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was cognitively intact, did not walk, always incontinent of bowel and bladder, required total physical assistance of two people to transfer, extensive assistance of two people for dressing, toileting, and personal hygiene. Resident #2's Care Plan, reviewed 04/10/15, reflected she was at risk for constipation and the goal was to maintain normal bowl function over the next 90 days. The facility approaches to the problem were to assess Resident #2 for constipation as needed. Resident #2's care planned further reflected she had potential for pain and the goal was to have no unidentified complications related to medication usage or side effects over the next 90 days. The facility approaches to the problem were to evaluate Resident #2's pain daily using 1-10 scale, administer pain medications as ordered, assist to change positions slowly, and observe for worsening of pain symptoms and report to physician. Review of Resident #2's consolidated physician's orders [REDACTED]. Resident #2 also had a two pain medications ordered as need; Tylenol 325 mg two tablets by mouth every four hours as needed and [MEDICATION NAME] Extended Release 100 mg by mouth every six hours as needed. Observation at 1:48 PM on 06/18/15 revealed Resident 2's call light was already activated. LVN G and MA H were at the nursing station and a CNA was picking up lunch trays but no one entered Resident #2's room to provide assistance. Observation at 1:50 PM on 06/18/15 revealed Resident #2 was grimacing, teary eyed, grunting, and holding her stomach. CNA K was outside Resident #2's room but she did not answer the call light. Interview at 1:50 PM on 06/18/15 revealed Resident #2 needed assistance with a bowel movement that was causing her extreme pain, she scaled the pain at the highest level 10 out of 10. Resident #2 stated this was her second attempt to get assistance for the same issue by pressing her call light. She revealed she first called for assistance before lunch and CNA J answered but stated she would have to tell the nurse to come assess her. Resident #2 stated no one came back to assess her pain so she pressed her call light after lunch but it was not answered yet. She revealed it usually took 30 to 45 minutes for someone to answer her call light and she did not feel that was fair. She stated I was taught to treat others the way you want to be treated. I would like for them to know what it feels like to wait in bed for assistance. Observation at 2:08 PM on 06/18/15 revealed, 20 minutes after initial observation of the call light on, a student nurse came into to Resident #2's room and asked Do you need something? Let me go tell the nurse. Interview at 2:16 PM on 06/18/15 revealed Resident #2 asked Has it been 30 minutes yet? The student nurse did not do anything for me. Let's see how long it takes for the nurse to come, I thought she would be here by now. Observation at 2:21 PM on 06/18/15 revealed, 33 minutes after the initial observation of the call light on, LVN L answered the call light to provide assistance to Resident #2. Interview with LVN L at 2:21 PM on 06/18/15 revealed she was held up in another resident's room then the student nurse told her Resident #2 needed assistance. Interview with MA H at 2:24 PM on 06/18/15 revealed she did not notice Resident #2's call light and if she saw it she would have answered it. Interview with CNA J at 2:25 PM on 06/18/15 revealed she answered Resident #2 first call light request and told LVN G. CNA J stated LVN G went into Resident #2's room adjusted her foot and said she could not give medications because MA H was on a lunch break. Interview with LVN G at 2:30 PM on 06/18/15 revealed she was not the nurse assigned to Resident #2. She stated CNA J reported to her Resident #2's pain the first time she pressed her call light so she went to check on her but Resident #2 was asleep. There was no intervention done in regards to her pain. LVN G stated Resident #2 pressed her call light again and someone else assisted her. Review of Resident #2's Medication Administration Record, [REDACTED]. Interview with LVN L at 2:30 PM on 06/18/15 revealed Resident #2 had a bowel movement which relieved her pain and declined a pain medication. Interview with the DON at 3:16 PM on 06/18/15 revealed no one should wait that long for a call light to be answered and she expected any staff member nearby to assist residents not just those assigned to that resident. Interview with Resident #2 at 3:30 PM on 06/18/15 revealed she felt much better after she had a bowel movement. She stated in the past when she complained of pain she got medications that were ordered as need. She stated that if she would have gotten assessed for pain the first time she pressed her call light or even faster the second time, she believed the problem would have been taken care of sooner. The facility's resident roster, dated 06/18/15, revealed the facility had 165 residents.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for six (Residents #11, #41, #10, #33, #34 and #43) of six residents, who resided on the secured unit A-1, reviewed for scabies after one resident had scabies on the unit in February 2014. 1. The facility failed to re-assess Resident #10's skin for the effectiveness of the treatment after he was treated for [REDACTED]. Resident #10 continued to have multiple circular red raised bumps on his arms, legs, back and rib areas. 2. The facility failed to re-assess Resident #11's skin for the effectiveness of her treatment after she was treated for [REDACTED]. 3. Residents #33 and #34 currently had signs/symptoms of scabies. 5. Resident #43's was treated for [REDACTED]. These failures could affect all 170 residents by placing them at risk for scabies by contact with infected residents and/or facility staff who cared for these residents, including dietary staff, housekeeping staff, laundry staff, activities staff and central supply staff, who serviced all five units of the facility. Findings included: 1. Resident #10 was observed during the initial tour on 10/29/14 at approximately 8:50 AM on Unit A-1, sitting in the residents' lounge area. LVN C stated Resident #10 was alert and oriented to name only, was mobile with his wheelchair, required total care with his activities of daily living, and was incontinent. Resident #10 was observed scratching the top of his left hand and left arm. Review of Resident #10's MDS assessment dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The assessment also reflected he was severely cognitively impaired, had unclear speech, was never understood, totally dependent on staff to meet all of his activities of daily living, incontinent of bowel and bladder, and non-ambulatory, but could self-propel his wheelchair. Review of Resident # 10's physician's orders [REDACTED]. This order was signed and dated 10/15/14, by NP E. On 10/15/14, six days later, an order to treat Resident #10 with [MEDICATION NAME] from the neck down and to leave on for eight hours was received. The order also reflected to repeat the treatment in one week and was signed and dated by NP E. Further review of Resident #10's clinical record on 10/29/14 at 9:55 AM, revealed no documentation of the resident's skin to determine the effectiveness of the treatment. At this same time, LVN A, the Unit Manager for Unit A-1, was asked to locate evidence the skin condition for Resident #10 was documented. LVN A stated she was unable to find any documentation. An observation of Resident #10's skin on 10/31/14 at 2:35 PM revealed multiple circular red raised bumps all over is anterior and posterior arms, both of his legs and thighs, his back, and rib areas. There were multiple scratch marks on the surface of his back, legs, thighs, and arms. There were multiple dark brown scabs over some of the circular areas. 2. Resident # 11 was observed during the initial tour on 10/29/14 at 8:45 AM on Unit A-1, scratching the underside of the right arm. LVN C stated Resident #11 was alert and oriented to name only, ambulated in the facility without assistance, required total assistance with her ADLs, and she was incontinent. Review of Resident #11's MDS assessment dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment also reflected she was severely cognitively impaired, had unclear speech, was sometimes understood, totally dependent on staff to meet all of her activities of daily living, incontinent of bowel and bladder, was ambulatory, and frequently wandered on a daily basis. Review of Resident #11's physician's orders [REDACTED]. Review of Resident #11's Physician's Progress notes dated 08/05/14, revealed: "Skin: scabies, cont(continue) with [MEDICAL CONDITION] and pruritis." This note was signed by NP-D and electronically signed by MD F, the Medical Director for the facility. Review of Resident #11's nurses' notes dated 08/05/14 revealed, "New order for [MEDICATION NAME] 5% cream topical to all areas including scalp at bed time and wash off in shower in the morning; and scrape under nails. Ivermectin, 9 mg tablet by mouth, one time dose." Further review of Resident #11's clinical record revealed no assessment of the resident's skin to determine the effectiveness of the treatment. LVN C, Charge Nurse on A-1, was questioned on 10/29/14 at 12:45 PM, about the lack of skin documentation. LVN C replied she did not chart the condition of Resident #11's skin as NP-E had seen the resident. When asked for any documentation by nursing of Resident #11's skin condition, LVN C was unable to find any documentation of an assessment. 3. On 10/29/14 at appropriately 12:45 PM, LVN A was asked how many of the 36 residents on the unit had scabies. LVN A replied, "We don't have any residents with scabies." When asked the reason for Resident #10's physician's orders [REDACTED]. We have to say what we see. Like if it is a rash, we say rash because that is what we see when we look at the resident's skin." When asked how LVN A described the rash when she notified the Physician, LVN A replied, "Red raised small bumps on the trunk and arms and the resident is scratching." 4. http://www.cdc.gov/parasites/scabies/index.html reflected, "Human scabies is caused by an infestation of the skin by the human itch mite...The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies...Scabies can spread rapidly under crowded conditions where close body contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks." (Retrieved on 11/18/14). 5. An observation on 10/31/14 at 2:28 PM of Resident #33 revealed her right and left posterior arms had circular red raised bumps, some were open red [MEDICAL CONDITION] and some had dark brown scabs over the site area. She also had circular red raised bumps around her waist and waist line. 6. An observation on 10/31/14 at 2:40 PM of Resident #34's skin revealed multiple circular red raised bumps along her back at the waistline, under the right and left posterior arms, and breast. 7. Review of Resident #41's nurses' notes dated 08/26/14, revealed NP-D was notified of a rash to Resident #41's body. This note reflected new orders were given for [MEDICATION NAME] Cream to entire body and scalp at bedtime, scrape under nails, and to shower off in the AM. The note further reflected to clean all linens and clothes in hot water, and to terminal clean the entire room and bed. This note was signed by LVN G, Charge Nurse who worked on Unit A-1. No assessment or description of the skin condition was noted in the notes. Review of Resident #41's physician's orders [REDACTED]. Clean all linens and clothes in hot water, terminal clean entire room and bed." This order was signed and dated on 10/13/14 by NP-D. 8. Review of Resident #43's nurse's notes, dated 05/28/14, revealed NP-E was in the facility and wrote a new order for [MEDICATION NAME] 1% Cream to rash every 4 hours, and [MEDICATION NAME] Cream from neck down, leave on for 8 hours, then shower off. This note reflected the treatment was to be repeated in one week and 18 milligrams of Invermectin was to be administered to Resident #43. No skin description or assessments were documented in the notes. Review of Resident #43's physician's orders [REDACTED]." A second order on the same date reflected NP E ordered a one-time dose of 18 milligrams. This note was signed by NP-E Review of Resident #43's progress notes dated 05/28/14, revealed, "Papular rash waistline and thighs." This note was signed and dated by NP-E. 9. Review of the Infection Control Monthly Report provided by RN B on 10/29/14 at appropriately 1:20 PM, revealed the infection surveillance was incomplete as there were no entries for August 2014 when the surveyor already had identified Resident #11 and #41 as having been treated for [REDACTED]. Further review of the Infection Control Monthly Report revealed the following: February 2014, Resident #38 was treated with [MEDICATION NAME] and Ivermectin. May 2014, Resident #43 was treated with [MEDICATION NAME] and Ivermectin. June 2014, Resident #42 was treated with [MEDICATION NAME] (a topical scabidal agent for the treatment of [REDACTED]. July 2014, Residents #44, #45, #46, #47, and #48 were treated with [MEDICATION NAME]. October 2014, Residents #10, #34, and #40 were treated with [MEDICATION NAME] and/or Ivermectin. There were no entries on skin conditions for the months of January, March, or April, 2014. 10. http://www.cdc.gov/parasites/scabies/health_professionals/control.html reflected, "A scabies outbreak suggests that transmission has been occurring within the institution for several weeks to months - thus increasing the likelihood that some infested staff or patients may have had time to spread scabies elsewhere in the community, including to other facilities. Measures to control scabies in an institution depend on factors such as how many cases are diagnosed or suspected, how long infested persons have been at the institution while undiagnosed and/or unsuccessfully treated, and whether any of the cases are crusted (Norwegian) scabies. Because it is so highly transmissible, crusted scabies requires rapid and aggressive detection, diagnosis, infection control, and treatment measures to prevent and control spread....." (Retrieved on 11/18/14). 11. LVN A, Unit Manager for A-1, was interviewed on 10/30/14 at appropriately 7:40 AM, regarding procedures on notification of the Infection Control Nurse when an infection occurred on her unit. LVN A stated each Unit Manager was responsible for their own Monthly Infection Report. Review of LVN A's Infection Control Log for A-1 revealed no skin infections/rashes were documented on the report sheets from January 2014 to the current month, October 2014. When asked why there was no skin infection/rash on the report, she stated "I am not responsible for skin assessments or skin treatments." The Infection Control Nurse, RN-B was responsible for skin infection/rashes. When asked how the Unit Manager communicated with the Infection Control Nurse, LVN A stated "we have a stand up meeting every morning and we discuss all of the new orders for the previous day. When asked if scabies /rashes were discussed in the morning meetings, she stated "yes, I think it was back in July 2014 when we had several residents that had the rash and had received the cream." When asked if she thought the protocol was effective, LVN A replied, "Yes, initially it was because the residents that had been identified were being treated and no employee's reported having a rash, so we thought it was controlled until there was a new case in July 2014." LVN A continued, she thought it was in the cloth furniture that all of the residents sat on. LVN A stated, she thought that was the source of the scabies and therefore, all of the furniture from the residents' lounge was removed. 12. The DON was interviewed on 10/29/14 at appropriately 3:10 PM. When asked if she was aware Resident #10 had been treated for [REDACTED].#10's Physician Order, dated 10/09/14, regarding Scabies treatment. In addition Residents #11's and #41's physician's orders [REDACTED]. The DON stated at this point, she was not aware of these orders. When asked if the facility had a current protocol for scabies she stated "yes." When asked if she felt like the facility's protocol had been effective to prevent further spread of scabies in the A-1 Unit, she stated, "I thought so because I was not aware of the orders to treat (Resident #10) in October and we did not have any new cases in September." The DON stated she was unaware of the scabies cases for August and October 2014. When asked if the facility used CDC (Centers for Disease Control) guidelines for control and treatment for [REDACTED]." Further interview with the DON on 10/31/14 at 4:00 PM revealed when asked what communication systems were in place regarding tracking and trending infections, she replied each Charge Nurse was supposed to complete an infection control form for each infection, and the physician's treatment orders were then stapled to the infection form. The Unit Managers then presented that information during the daily stand up meetings and then the form was given to her. She stated she gave the form to RN B for tracking and trending. At that point, the DON was made aware that LVN A was unaware she needed to complete an Infection Control report form for skin infections for Unit A-1. The DON stated that might have been the reason she and the Infection Control Nurse were unaware of the scabies in August and October 2014. She also revealed she thought the linens were not bagged for 72 hours before being sent back into the unit. The DON stated the facility did not use the CDC guidelines. 13. The facility's current policy, Scabies, dated 03/01/10, reflected procedures only for individual cases. The policy also reflected, " ... Incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure. Persons who have been previously infected develop more rapid symptoms, 1-4 days after re-exposure. Symptoms sometimes include severe itching which worsens at night. Scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. Prevention is possible with good hygiene and forbidding the lending of clothing...Procedures for Individual Cases a. Establish contact isolation immediately, including gown with gloves tightly covering cuff of gown. Procedure: ...2) Remove all washable clothes from closet and place in contamination bag. 3) Place all remaining resident clothing in contamination bag, fasten tightly and label "Do no open until_____(two weeks.) This can be sent home or placed in storage for two weeks...5) Place clean linen on bed and clean utensils on stand (after housekeeping cleans room). Housekeeper: ...2) thoroughly wash and disinfect inside of closet, dresser, window sills, bedside tables (inside and out) and other furniture near bed 3) Washes down bed and mattress...6) Remove and bag cloth chairs to be stored for two weeks or ask family to pick up and replace with vinyl chairs. 7) Remove privacy curtains and bag for laundry...Laundry Departments Responsibilities: Before Day 1: 1) Clean the room for storing clean clothes. 2) Wash a gown and one set of street clothes for each resident. Clothes may not be returned to the resident room until the twenty four (24) hour process has been completed. 3) Wash two full sets of bed linen before day 1 of treatment and set aside a clean cart with disinfected cover. Keep it in separate area. One set should be held until after the resident has had [MEDICATION NAME] applied and room has been disinfected. The second set is to be used after the [MEDICATION NAME] has been washed off and the room disinfected again. 4) Gloves and gown should be worn by laundry during this process. These should be changed between washing, drying and folding...7) All privacy curtains must be washed, dried, and rehung...." 14. During an interview with LVN C on 10/29/14 at 12:50 PM when asked what the protocol was for the treatment of [REDACTED]." When asked if any of the residents with skin rashes had skin assessments done, she stated "No." When asked if all residents on the unit had been treated all at one time, she stated "No." LVN C then continued, "At first, in February 2014 only the resident that had been identified with a rash was treated (Resident #38)." Then in July 2014, the residents that were identified with rashes and their roommates were treated. LVN C stated sometime in the month of July 2014, the cloth furniture was removed from the residents' lounge area. The facility policy was shared with LVN C who stated the residents on this Unit cannot be placed in isolation. 15. The DON approached the surveyor on 10/30/14 at 7:20 AM, and stated the facility would now, effective 10/30/14 start using the CDC's Treatment Guidelines for Scabies. The DON stated the CDC guidelines were different from their policy in that "all persons should be treated at the same time to prevent re-infestation." The DON further stated all residents residing on A-1 unit would have a skin assessment completed and would be treated that day (10/30/14) with [MEDICATION NAME] Cream. All personal clothing, stuffed animals and personal belongings would be put in plastic bags and put outside for 3 days. All linen would be put in plastic bags, and then put into linen barrels lined with plastic bags and would be stored outside for three days, separated from the main facility laundry. All of the cloth chairs would be removed from the unit and different ones would be brought in for the residents to use. The DON stated the facility did not take these universal measures prior to this time, which was crucial as contact isolation measures were very difficult to enforce given the population who resided on the Memory Care Unit. 16. During an interview on 10/31/14 at 7:50 AM with RN B, the Infection Control Nurse, she was asked how infections in the facility were communicated to her for tracking and trending. She replied "We have a morning meeting every day and go over all of the physician's orders [REDACTED]. "What each Unit Manager usually does is staple the physician's orders [REDACTED]." RN B then enters the information on the Monthly Surveillance Form. RN B was asked when she became aware that the residents in the A-1 unit had rashes and were being treated for [REDACTED]." RN B stated in July 2014, the Unit had about seven residents who had rashes that were being treated. Then in the QA meeting in July 2014, MD-F and NP-D suggested to remove all of the furniture and deep clean all residents' rooms two times a day. When asked if she thought the facility's policy and procedures used during that period were effective, RN B stated, no, as the facility continued to have rashes from month to month. RN B stated the facility had an unusual number of residents with rashes than normal on Unit A-1. She stated she was not aware of the residents who had rashes in August and October of 2014. 17. In an interview on 10/31/14 at 12:00 PM, NP-D stated the facility had known that the rashes were scabies and not just a rash for some time now. She stated she had been giving orders to treat scabies for the A-1 Unit for about eight or nine months. She stated she had instructed the facility during the QA meeting in July 2014, to remove all of the cloth furniture, but they did not as the furniture was still in the dining area. NP-D stated, "I don't think we have ever eliminated scabies. The skin condition gets better with treatment, then it re-occurs." 18. In an interview on 10/31/14 at approximately 12:30 PM, MD-F, the facility's Medical Director, stated, "I don't understand why they are calling scabies a rash. A rash is a rash, and there are many types of rashes. Scabies is scabies and not a rash. If there is an order written [REDACTED]." 19. An interview with the Administrator on 10/31/14 at 4:45 PM revealed during the August 2014 QA meeting, the Medical Director discussed the issue of scabies and recommended removal of the cloth sofa in the unit. The Administrator stated the facility did this. The Medical Director also stated there was no need to do skin scrapings, and she was definite the rashes were scabies. 20. An interview on 11/01/14 at 1:26 PM with the District Manager of Housekeeping and Laundry revealed all linen and personal clothing except for a few changes for each resident had been collected, placed in plastic bags and put outside for 72 hours. The nurses assisted as they were treating all the residents for scabies. The 72 hours will be over by around 10:00 AM on 11/02/14. The District Manager of Housekeeping further stated "at that point the laundering of those clothes will begin and the clothes will be exposed: to three kills zones. The 24 dining room chairs that NP D recommended removal of for disinfection since July 2014, were removed and placed in sealed liners and put outside. After 72 hours, these chairs would be treated with a bleach germicidal cleaner, then extracted with and extraction machine. This machine used 170 degree water. 21. A facility document, dated 10/29/14, reflected head to toe assessments were conducted on the A-1 unit. 12 residents, including Residents #33, #34, and #10, had rashes. The Medical Director was notified of the rashes for the residents, and orders were received for [MEDICATION NAME] cream for treatment of [REDACTED]. On 10/29/14, the Medical Director also gave orders for [MEDICATION NAME] treatment for [REDACTED]. 22. The Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the DON on 10/29/14, revealed there were 170 residents in the facility.

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to prevent the transmission of scabies, when one resident on the secured unit had scabies in February 2014 for six (Residents #11, #41, #10, #33, #34 and #43) of six residents reviewed for scabies. 1. The Infection Control Nurse and the DON were not aware Residents #11 and #41 had scabies in August 2014. 2. The Infection Control Nurse and the DON were not aware Resident #10 was treated for [REDACTED]. Resident #10 continued to have multiple circular red raised bumps on his arms, legs, back and rib areas. 3. LVN A failed to complete the Infection Control form, which should have been submitted to the Infection Control Nurse for tracking and trending, when Residents #11, #41, and #10 were treated for [REDACTED]. 4. Residents #33 and #34 had signs/symptoms of scabies. 5. Resident #43 was treated for [REDACTED]. These failures could affect all 170 residents by placing them at risk for scabies by contact with infected residents and/or facility staff who cared for these residents, including dietary staff, housekeeping staff, laundry staff, activities staff and central supply staff, who serviced all five units of the facility. Findings included: 1. Resident #10 was observed during the initial tour on 10/29/14 at approximately 8:50 AM on Unit A-1, sitting in the residents' lounge area. LVN C stated Resident #10 was alert and oriented to name only, was mobile with his wheelchair, required total care with his activities of daily living, and was incontinent. Resident #10 was observed scratching the top of his left hand and left arm. Review of Resident #10's MDS assessment dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The assessment also reflected he was severely cognitively impaired, had unclear speech, was never understood, totally dependent on staff to meet all of his activities of daily living, incontinent of bowel and bladder, and non-ambulatory, but could self-propel his wheelchair. Review of Resident # 10's physician's orders [REDACTED]. This order was signed and dated 10/15/14, by NP E. On 10/15/14, six days later, an order to treat Resident #10 with [MEDICATION NAME] from the neck down and to leave on for eight hours was received. The order also reflected to repeat the treatment in one week and was signed and dated by NP E. Further review of Resident #10's clinical record on 10/29/14 at 9:55 AM, revealed no documentation of the resident's skin to determine the effectiveness of the treatment. At this same time, LVN A, the Unit Manager for Unit A-1, was asked to locate evidence the skin condition for Resident #10 was documented. LVN A stated she was unable to find any documentation. An observation of Resident #10's skin on 10/31/14 at 2:35 PM revealed multiple circular red raised bumps all over is anterior and posterior arms, both of his legs and thighs, his back, and rib areas. There were multiple scratch marks on the surface of his back, legs, thighs, and arms. There were multiple dark brown scabs over some of the circular areas. 2. Resident # 11 was observed during the initial tour on 10/29/14 at 8:45 AM on Unit A-1, scratching the underside of the right arm. LVN C stated Resident #11 was alert and oriented to name only, ambulated in the facility without assistance, required total assistance with her ADLs, and she was incontinent. Review of Resident #11's MDS assessment dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment also reflected she was severely cognitively impaired, had unclear speech, was sometimes understood, totally dependent on staff to meet all of her activities of daily living, incontinent of bowel and bladder, was ambulatory, and frequently wandered on a daily basis. Review of Resident #11's physician's orders [REDACTED]. Also ordered was Ivermectin (anti-parasite), 9 mg by mouth, a one- time dose. Review of Resident #11's Physician's Progress notes dated 08/05/14, revealed: "Skin: scabies, cont(continue) with lesions and pruritis." This note was signed by NP-D and electronically signed by MD F, the Medical Director for the facility. Review of Resident #11's nurses' notes dated 08/05/14 revealed, "New order for [MEDICATION NAME] 5% cream topical to all areas including scalp at bed time and wash off in shower in the morning; and scrape under nails. Ivermectin, 9 mg tablet by mouth, one time dose." Further review of Resident #11's clinical record revealed no assessment of the resident's skin to determine the effectiveness of the treatment. LVN C, Charge Nurse on A-1, was questioned on 10/29/14 at 12:45 PM, about the lack of skin documentation. LVN C replied she did not chart the condition of Resident #11's skin as NP-E had seen the resident. When asked for any documentation by nursing of Resident #11's skin condition, LVN C was unable to find any documentation of an assessment. 3. On 10/29/14 at appropriately 12:45 PM, LVN A was asked how many of the 36 residents on the unit had scabies. LVN A replied, "We don't have any residents with scabies." When asked the reason for Resident #10's physician's orders [REDACTED]. We have to say what we see. Like if it is a rash, we say rash because that is what we see when we look at the resident's skin." When asked how LVN A described the rash when she notified the Physician, LVN A replied, "Red raised small bumps on the trunk and arms and the resident is scratching." 4. http://www.cdc.gov/parasites/scabies/index.html reflected, "Human scabies is caused by an infestation of the skin by the human itch mite...The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies...Scabies can spread rapidly under crowded conditions where close body contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks." (Retrieved on 11/18/14). 5. An observation on 10/31/14 at 2:28 PM of Resident #33 revealed her right and left posterior arms had circular red raised bumps, some were open red lesions and some had dark brown scabs over the site area. She also had circular red raised bumps around her waist and waist line. 6. An observation on 10/31/14 at 2:40 PM of Resident #34's skin revealed multiple circular red raised bumps along her back at the waistline, under the right and left posterior arms, and breast. 7. Review of Resident #41's nurses' notes dated 08/26/14, revealed NP-D was notified of a rash to Resident #41's body. This note reflected new orders were given for [MEDICATION NAME] Cream to entire body and scalp at bedtime, scrape under nails, and to shower off in the AM. The note further reflected to clean all linens and clothes in hot water, and to terminal clean the entire room and bed. This note was signed by LVN G, Charge Nurse who worked on Unit A-1. No assessment or description of the skin condition was noted in the notes. Review of Resident #41's physician's orders [REDACTED]. Clean all linens and clothes in hot water, terminal clean entire room and bed." This order was signed and dated on 10/13/14 by NP-D. 8. Review of Resident #43's nurse's notes, dated 05/28/14, revealed NP-E was in the facility and wrote a new order for [MEDICATION NAME] 1% Cream to rash every 4 hours, and [MEDICATION NAME] Cream from neck down, leave on for 8 hours, then shower off. This note reflected the treatment was to be repeated in one week and 18 milligrams of Invermectin was to be administered to Resident #43. No skin description or assessments were documented in the notes. Review of Resident #43's physician's orders [REDACTED]." A second order on the same date reflected NP E ordered a one-time dose of 18 milligrams. This note was signed by NP-E Review of Resident #43's progress notes dated 05/28/14, revealed, "Papular rash waistline and thighs." This note was signed and dated by NP-E. 9. Review of the Infection Control Monthly Report provided by RN B on 10/29/14 at appropriately 1:20 PM, revealed the infection surveillance was incomplete as there were no entries for August 2014 when the surveyor already had identified Resident #11 and #41 as having been treated for [REDACTED]. Further review of the Infection Control Monthly Report revealed the following: February 2014, Resident #38 was treated with [MEDICATION NAME] and Ivermectin. May 2014, Resident #43 was treated with [MEDICATION NAME] and Ivermectin. June 2014, Resident #42 was treated with [MEDICATION NAME] (a topical scabidal agent for the treatment of [REDACTED]. July 2014, Residents #44, #45, #46, #47, and #48 were treated with [MEDICATION NAME]. October 2014, Residents #10, #34, and #40 were treated with [MEDICATION NAME] and/or Ivermectin. There were no entries on skin conditions for the months of January, March, or April, 2014. 10. http://www.cdc.gov/parasites/scabies/health_professionals/control.html reflected, "A scabies outbreak suggests that transmission has been occurring within the institution for several weeks to months - thus increasing the likelihood that some infested staff or patients may have had time to spread scabies elsewhere in the community, including to other facilities. Measures to control scabies in an institution depend on factors such as how many cases are diagnosed or suspected, how long infested persons have been at the institution while undiagnosed and/or unsuccessfully treated, and whether any of the cases are crusted (Norwegian) scabies. Because it is so highly transmissible, crusted scabies requires rapid and aggressive detection, diagnosis, infection control, and treatment measures to prevent and control spread....." (Retrieved on 11/18/14). 11. LVN A, Unit Manager for A-1, was interviewed on 10/30/14 at appropriately 7:40 AM, regarding procedures on notification of the Infection Control Nurse when an infection occurred on her unit. LVN A stated each Unit Manager was responsible for their own Monthly Infection Report. Review of LVN A's Infection Control Log for A-1 revealed no skin infections/rashes were documented on the report sheets from January 2014 to the current month, October 2014. When asked why there was no skin infection/rash on the report, she stated "I am not responsible for skin assessments or skin treatments." The Infection Control Nurse, RN-B was responsible for skin infection/rashes. When asked how the Unit Manager communicated with the Infection Control Nurse, LVN A stated "we have a stand up meeting every morning and we discuss all of the new orders for the previous day. When asked if scabies /rashes were discussed in the morning meetings, she stated "yes, I think it was back in July 2014 when we had several residents that had the rash and had received the cream." When asked if she thought the protocol was effective, LVN A replied, "Yes, initially it was because the residents that had been identified were being treated and no employee's reported having a rash, so we thought it was controlled until there was a new case in July 2014." LVN A continued, she thought it was in the cloth furniture that all of the residents sat on. LVN A stated, she thought that was the source of the scabies and therefore, all of the furniture from the residents' lounge was removed. 12. The DON was interviewed on 10/29/14 at appropriately 3:10 PM. When asked if she was aware Resident #10 had been treated for [REDACTED].#10's Physician Order, dated 10/09/14, regarding Scabies treatment. In addition Residents #11's and #41's physician's orders [REDACTED]. The DON stated at this point, she was not aware of these orders. When asked if the facility had a current protocol for scabies she stated "yes." When asked if she felt like the facility's protocol had been effective to prevent further spread of scabies in the A-1 Unit, she stated, "I thought so because I was not aware of the orders to treat (Resident #10) in October and we did not have any new cases in September." The DON stated she was unaware of the scabies cases for August and October 2014. When asked if the facility used CDC (Centers for Disease Control) guidelines for control and treatment for [REDACTED]." Further interview with the DON on 10/31/14 at 4:00 PM revealed when asked what communication systems were in place regarding tracking and trending infections, she replied each Charge Nurse was supposed to complete an infection control form for each infection, and the physician's treatment orders were then stapled to the infection form. The Unit Managers then presented that information during the daily stand up meetings and then the form was given to her. She stated she gave the form to RN B for tracking and trending. At that point, the DON was made aware that LVN A was unaware she needed to complete an Infection Control report form for skin infections for Unit A-1. The DON stated that might have been the reason she and the Infection Control Nurse were unaware of the scabies in August and October 2014. She also revealed she thought the linens were not bagged for 72 hours before being sent back into the unit. The DON stated the facility did not use the CDC guidelines. 13. The facility's current policy, Scabies, dated 03/01/10, reflected procedures only for individual cases. The policy also reflected, " ... Incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure. Persons who have been previously infected develop more rapid symptoms, 1-4 days after re-exposure. Symptoms sometimes include severe itching which worsens at night. Scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. Prevention is possible with good hygiene and forbidding the lending of clothing...Procedures for Individual Cases a. Establish contact isolation immediately, including gown with gloves tightly covering cuff of gown. Procedure: ...2) Remove all washable clothes from closet and place in contamination bag. 3) Place all remaining resident clothing in contamination bag, fasten tightly and label "Do no open until_____(two weeks.) This can be sent home or placed in storage for two weeks...5) Place clean linen on bed and clean utensils on stand (after housekeeping cleans room). Housekeeper: ...2) thoroughly wash and disinfect inside of closet, dresser, window sills, bedside tables (inside and out) and other furniture near bed 3) Washes down bed and mattress...6) Remove and bag cloth chairs to be stored for two weeks or ask family to pick up and replace with vinyl chairs. 7) Remove privacy curtains and bag for laundry...Laundry Departments Responsibilities: Before Day 1: 1) Clean the room for storing clean clothes. 2) Wash a gown and one set of street clothes for each resident. Clothes may not be returned to the resident room until the twenty four (24) hour process has been completed. 3) Wash two full sets of bed linen before day 1 of treatment and set aside a clean cart with disinfected cover. Keep it in separate area. One set should be held until after the resident has had [MEDICATION NAME] applied and room has been disinfected. The second set is to be used after the [MEDICATION NAME] has been washed off and the room disinfected again. 4) Gloves and gown should be worn by laundry during this process. These should be changed between washing, drying and folding...7) All privacy curtains must be washed, dried, and rehung...." 14. During an interview with LVN C on 10/29/14 at 12:50 PM when asked what the protocol was for the treatment of [REDACTED]." When asked if any of the residents with skin rashes had skin assessments done, she stated "No." When asked if all residents on the unit had been treated all at one time, she stated "No." LVN C then continued, "At first, in February 2014 only the resident that had been identified with a rash was treated (Resident #38)." Then in July 2014, the residents that were identified with rashes and their roommates were treated. LVN C stated sometime in the month of July 2014, the cloth furniture was removed from the residents' lounge area. The facility policy was shared with LVN C who stated the residents on this Unit cannot be placed in isolation. 15. The DON approached the surveyor on 10/30/14 at 7:20 AM, and stated the facility would now, effective 10/30/14 start using the CDC's Treatment Guidelines for Scabies. The DON stated the CDC guidelines were different from their policy in that "all persons should be treated at the same time to prevent re-infestation." The DON further stated all residents residing on A-1 unit would have a skin assessment completed and would be treated that day (10/30/14) with [MEDICATION NAME] Cream. All personal clothing, stuffed animals and personal belongings would be put in plastic bags and put outside for 3 days. All linen would be put in plastic bags, and then put into linen barrels lined with plastic bags and would be stored outside for three days, separated from the main facility laundry. All of the cloth chairs would be removed from the unit and different ones would be brought in for the residents to use. The DON stated the facility did not take these universal measures prior to this time, which was crucial as contact isolation measures were very difficult to enforce given the population who resided on the Memory Care Unit. 16. During an interview on 10/31/14 at 7:50 AM with RN B, the Infection Control Nurse, she was asked how infections in the facility were communicated to her for tracking and trending. She replied "We have a morning meeting every day and go over all of the physician's orders [REDACTED]. "What each Unit Manager usually does is staple the physician's orders [REDACTED]." RN B then enters the information on the Monthly Surveillance Form. RN B was asked when she became aware that the residents in the A-1 unit had rashes and were being treated for [REDACTED]." RN B stated in July 2014, the Unit had about seven residents who had rashes that were being treated. Then in the QA meeting in July 2014, MD-F and NP-D suggested to remove all of the furniture and deep clean all residents' rooms two times a day. When asked if she thought the facility's policy and procedures used during that period were effective, RN B stated, no, as the facility continued to have rashes from month to month. RN B stated the facility had an unusual number of residents with rashes than normal on Unit A-1. She stated she was not aware of the residents who had rashes in August and October of 2014. 17. In an interview on 10/31/14 at 12:00 PM, NP-D stated the facility had known that the rashes were scabies and not just a rash for some time now. She stated she had been giving orders to treat scabies for the A-1 Unit for about eight or nine months. She stated she had instructed the facility during the QA meeting in July 2014, to remove all of the cloth furniture, but they did not as the furniture was still in the dining area. NP-D stated, "I don't think we have ever eliminated scabies. The skin condition gets better with treatment, then it re-occurs." 18. In an interview on 10/31/14 at approximately 12:30 PM, MD-F, the facility's Medical Director, stated, "I don't understand why they are calling scabies a rash. A rash is a rash, and there are many types of rashes. Scabies is scabies and not a rash. If there is an order written [REDACTED]." 19. An interview with the Administrator on 10/31/14 at 4:45 PM revealed during the August 2014 QA meeting, the Medical Director discussed the issue of scabies and recommended removal of the cloth sofa in the unit. The Administrator stated the facility did this. The Medical Director also stated there was no need to do skin scrapings, and she was definite the rashes were scabies. 20. An interview on 11/01/14 at 1:26 PM with the District Manager of Housekeeping and Laundry revealed all linen and personal clothing except for a few changes for each resident had been collected, placed in plastic bags and put outside for 72 hours. The nurses assisted as they were treating all the residents for scabies. The 72 hours will be over by around 10:00 AM on 11/02/14. The District Manager of Housekeeping further stated "at that point the laundering of those clothes will begin and the clothes will be exposed: to three kills zones. The 24 dining room chairs that NP D recommended removal of for disinfection since July 2014, were removed and placed in sealed liners and put outside. After 72 hours, these chairs would be treated with a bleach germicidal cleaner, then extracted with and extraction machine. This machine used 170 degree water. 21. A facility document, dated 10/29/14, reflected head to toe assessments were conducted on the A-1 unit. 12 residents, including Residents #33, #34, and #10, had rashes. The Medical Director was notified of the rashes for the residents, and orders were received for [MEDICATION NAME] cream for treatment of [REDACTED]. On 10/29/14, the Medical Director also gave orders for [MEDICATION NAME] treatment for [REDACTED]. 22. The Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the DON on 10/29/14, revealed there were 170 residents in the facility.

Based on observation, interview, and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident for six (Residents #11, #41, #10, #33, #34 and #43) of six residents reviewed for scabies and resided on the secured unit A-1, after one resident was treated for [REDACTED]. 1. The Administrator and DON failed to develop an effective policy for preventing the spread of scabies. 2. The DON failed to monitor and supervise LVN A, who was the Unit Manager for the secured unit A-1, to ensure the Unit Manager was completing the Infection Control form to communicate infections on the unit. 3. LVN A failed to complete the Infection Control form, which should have been submitted to the Infection Control Nurse for tracking and trending, when Residents #11, #41, and #10 were treated for [REDACTED]. Resident #10 continued to have multiple circular red raised bumps on his arms, legs, back and rib areas. Residents #33 and #34 currently had signs/symptoms of scabies and Resident #43 was treated for [REDACTED]. These failures could affect all 170 residents by placing them at risk for scabies by contact with infected residents and/or facility staff who cared for these residents, including dietary staff, housekeeping staff, laundry staff, activities staff and central supply staff, who serviced all five units of the facility. Findings included: 1. Resident #10 was observed during the initial tour on 10/29/14 at approximately 8:50 AM on Unit A-1, sitting in the residents' lounge area. LVN C stated Resident #10 was alert and oriented to name only, was mobile with his wheelchair, required total care with his activities of daily living, and was incontinent. Resident #10 was observed scratching the top of his left hand and left arm. Review of Resident #10's MDS assessment dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The assessment also reflected he was severely cognitively impaired, had unclear speech, was never understood, totally dependent on staff to meet all of his activities of daily living, incontinent of bowel and bladder, and non-ambulatory, but could self-propel his wheelchair. Review of Resident # 10's physician's orders [REDACTED]. This order was signed and dated 10/15/14, by NP E. On 10/15/14, six days later, an order to treat Resident #10 with [MEDICATION NAME] from the neck down and to leave on for eight hours was received. The order also reflected to repeat the treatment in one week and was signed and dated by NP E. Further review of Resident #10's clinical record on 10/29/14 at 9:55 AM, revealed no documentation of the resident's skin to determine the effectiveness of the treatment. At this same time, LVN A, the Unit Manager for Unit A-1, was asked to locate evidence the skin condition for Resident #10 was documented. LVN A stated she was unable to find any documentation. An observation of Resident #10's skin on 10/31/14 at 2:35 PM revealed multiple circular red raised bumps all over is anterior and posterior arms, both of his legs and thighs, his back, and rib areas. There were multiple scratch marks on the surface of his back, legs, thighs, and arms. There were multiple dark brown scabs over some of the circular areas. 2. Resident # 11 was observed during the initial tour on 10/29/14 at 8:45 AM on Unit A-1, scratching the underside of the right arm. LVN C stated Resident #11 was alert and oriented to name only, ambulated in the facility without assistance, required total assistance with her ADLs, and she was incontinent. Review of Resident #11's MDS assessment dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment also reflected she was severely cognitively impaired, had unclear speech, was sometimes understood, totally dependent on staff to meet all of her activities of daily living, incontinent of bowel and bladder, was ambulatory, and frequently wandered on a daily basis. Review of Resident #11's physician's orders [REDACTED]. Review of Resident #11's Physician's Progress notes dated 08/05/14, revealed: "Skin: scabies, cont(continue) with [MEDICAL CONDITION] and pruritis." This note was signed by NP-D and electronically signed by MD F, the Medical Director for the facility. Review of Resident #11's nurses' notes dated 08/05/14 revealed, "New order for [MEDICATION NAME] 5% cream topical to all areas including scalp at bed time and wash off in shower in the morning; and scrape under nails. Ivermectin, 9 mg tablet by mouth, one time dose." Further review of Resident #11's clinical record revealed no assessment of the resident's skin to determine the effectiveness of the treatment. LVN C, Charge Nurse on A-1, was questioned on 10/29/14 at 12:45 PM, about the lack of skin documentation. LVN C replied she did not chart the condition of Resident #11's skin as NP-E had seen the resident. When asked for any documentation by nursing of Resident #11's skin condition, LVN C was unable to find any documentation of an assessment. 3. On 10/29/14 at appropriately 12:45 PM, LVN A was asked how many of the 36 residents on the unit had scabies. LVN A replied, "We don't have any residents with scabies." When asked the reason for Resident #10's physician's orders [REDACTED]. We have to say what we see. Like if it is a rash, we say rash because that is what we see when we look at the resident's skin." When asked how LVN A described the rash when she notified the Physician, LVN A replied, "Red raised small bumps on the trunk and arms and the resident is scratching." 4. http://www.cdc.gov/parasites/scabies/index.html reflected, "Human scabies is caused by an infestation of the skin by the human itch mite...The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies...Scabies can spread rapidly under crowded conditions where close body contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks." (Retrieved on 11/18/14). 5. An observation on 10/31/14 at 2:28 PM of Resident #33 revealed her right and left posterior arms had circular red raised bumps, some were open red [MEDICAL CONDITION] and some had dark brown scabs over the site area. She also had circular red raised bumps around her waist and waist line. 6. An observation on 10/31/14 at 2:40 PM of Resident #34's skin revealed multiple circular red raised bumps along her back at the waistline, under the right and left posterior arms, and breast. 7. Review of Resident #41's nurses' notes dated 08/26/14, revealed NP-D was notified of a rash to Resident #41's body. This note reflected new orders were given for [MEDICATION NAME] Cream to entire body and scalp at bedtime, scrape under nails, and to shower off in the AM. The note further reflected to clean all linens and clothes in hot water, and to terminal clean the entire room and bed. This note was signed by LVN G, Charge Nurse who worked on Unit A-1. No assessment or description of the skin condition was noted in the notes. Review of Resident #41's physician's orders [REDACTED]. Clean all linens and clothes in hot water, terminal clean entire room and bed." This order was signed and dated on 10/13/14 by NP-D. 8. Review of Resident #43's nurse's notes, dated 05/28/14, revealed NP-E was in the facility and wrote a new order for [MEDICATION NAME] 1% Cream to rash every 4 hours, and [MEDICATION NAME] Cream from neck down, leave on for 8 hours, then shower off. This note reflected the treatment was to be repeated in one week and 18 milligrams of Invermectin was to be administered to Resident #43. No skin description or assessments were documented in the notes. Review of Resident #43's physician's orders [REDACTED]." A second order on the same date reflected NP E ordered a one-time dose of 18 milligrams. This note was signed by NP-E Review of Resident #43's progress notes dated 05/28/14, revealed, "Papular rash waistline and thighs." This note was signed and dated by NP-E. 9. Review of the Infection Control Monthly Report provided by RN B on 10/29/14 at appropriately 1:20 PM, revealed the infection surveillance was incomplete as there were no entries for August 2014 when the surveyor already had identified Resident #11 and #41 as having been treated for [REDACTED]. Further review of the Infection Control Monthly Report revealed the following: February 2014, Resident #38 was treated with [MEDICATION NAME] and Ivermectin. May 2014, Resident #43 was treated with [MEDICATION NAME] and Ivermectin. June 2014, Resident #42 was treated with [MEDICATION NAME] (a topical scabidal agent for the treatment of [REDACTED]. July 2014, Residents #44, #45, #46, #47, and #48 were treated with [MEDICATION NAME]. October 2014, Residents #10, #34, and #40 were treated with [MEDICATION NAME] and/or Ivermectin. There were no entries on skin conditions for the months of January, March, or April, 2014. 10. http://www.cdc.gov/parasites/scabies/health_professionals/control.html reflected, "A scabies outbreak suggests that transmission has been occurring within the institution for several weeks to months - thus increasing the likelihood that some infested staff or patients may have had time to spread scabies elsewhere in the community, including to other facilities. Measures to control scabies in an institution depend on factors such as how many cases are diagnosed or suspected, how long infested persons have been at the institution while undiagnosed and/or unsuccessfully treated, and whether any of the cases are crusted (Norwegian) scabies. Because it is so highly transmissible, crusted scabies requires rapid and aggressive detection, diagnosis, infection control, and treatment measures to prevent and control spread....." (Retrieved on 11/18/14). 11. LVN A, Unit Manager for A-1, was interviewed on 10/30/14 at appropriately 7:40 AM, regarding procedures on notification of the Infection Control Nurse when an infection occurred on her unit. LVN A stated each Unit Manager was responsible for their own Monthly Infection Report. Review of LVN A's Infection Control Log for A-1 revealed no skin infections/rashes were documented on the report sheets from January 2014 to the current month, October 2014. When asked why there was no skin infection/rash on the report, she stated "I am not responsible for skin assessments or skin treatments." The Infection Control Nurse, RN-B was responsible for skin infection/rashes. When asked how the Unit Manager communicated with the Infection Control Nurse, LVN A stated "we have a stand up meeting every morning and we discuss all of the new orders for the previous day. When asked if scabies /rashes were discussed in the morning meetings, she stated "yes, I think it was back in July 2014 when we had several residents that had the rash and had received the cream." When asked if she thought the protocol was effective, LVN A replied, "Yes, initially it was because the residents that had been identified were being treated and no employee's reported having a rash, so we thought it was controlled until there was a new case in July 2014." LVN A continued, she thought it was in the cloth furniture that all of the residents sat on. LVN A stated, she thought that was the source of the scabies and therefore, all of the furniture from the residents' lounge was removed. 12. The DON was interviewed on 10/29/14 at appropriately 3:10 PM. When asked if she was aware Resident #10 had been treated for [REDACTED].#10's Physician Order, dated 10/09/14, regarding Scabies treatment. In addition Residents #11's and #41's physician's orders [REDACTED]. The DON stated at this point, she was not aware of these orders. When asked if the facility had a current protocol for scabies she stated "yes." When asked if she felt like the facility's protocol had been effective to prevent further spread of scabies in the A-1 Unit, she stated, "I thought so because I was not aware of the orders to treat (Resident #10) in October and we did not have any new cases in September." The DON stated she was unaware of the scabies cases for August and October 2014. When asked if the facility used CDC (Centers for Disease Control) guidelines for control and treatment for [REDACTED]." Further interview with the DON on 10/31/14 at 4:00 PM revealed when asked what communication systems were in place regarding tracking and trending infections, she replied each Charge Nurse was supposed to complete an infection control form for each infection, and the physician's treatment orders were then stapled to the infection form. The Unit Managers then presented that information during the daily stand up meetings and then the form was given to her. She stated she gave the form to RN B for tracking and trending. At that point, the DON was made aware that LVN A was unaware she needed to complete an Infection Control report form for skin infections for Unit A-1. The DON stated that might have been the reason she and the Infection Control Nurse were unaware of the scabies in August and October 2014. She also revealed she thought the linens were not bagged for 72 hours before being sent back into the unit. The DON stated the facility did not use the CDC guidelines. 13. The facility's current policy, Scabies, dated 03/01/10, reflected procedures only for individual cases. The policy also reflected, " ... Incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure. Persons who have been previously infected develop more rapid symptoms, 1-4 days after re-exposure. Symptoms sometimes include severe itching which worsens at night. Scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. Prevention is possible with good hygiene and forbidding the lending of clothing...Procedures for Individual Cases a. Establish contact isolation immediately, including gown with gloves tightly covering cuff of gown. Procedure: ...2) Remove all washable clothes from closet and place in contamination bag. 3) Place all remaining resident clothing in contamination bag, fasten tightly and label "Do no open until_____(two weeks.) This can be sent home or placed in storage for two weeks...5) Place clean linen on bed and clean utensils on stand (after housekeeping cleans room). Housekeeper: ...2) thoroughly wash and disinfect inside of closet, dresser, window sills, bedside tables (inside and out) and other furniture near bed 3) Washes down bed and mattress...6) Remove and bag cloth chairs to be stored for two weeks or ask family to pick up and replace with vinyl chairs. 7) Remove privacy curtains and bag for laundry...Laundry Departments Responsibilities: Before Day 1: 1) Clean the room for storing clean clothes. 2) Wash a gown and one set of street clothes for each resident. Clothes may not be returned to the resident room until the twenty four (24) hour process has been completed. 3) Wash two full sets of bed linen before day 1 of treatment and set aside a clean cart with disinfected cover. Keep it in separate area. One set should be held until after the resident has had [MEDICATION NAME] applied and room has been disinfected. The second set is to be used after the [MEDICATION NAME] has been washed off and the room disinfected again. 4) Gloves and gown should be worn by laundry during this process. These should be changed between washing, drying and folding...7) All privacy curtains must be washed, dried, and rehung...." 14. During an interview with LVN C on 10/29/14 at 12:50 PM when asked what the protocol was for the treatment of [REDACTED]." When asked if any of the residents with skin rashes had skin assessments done, she stated "No." When asked if all residents on the unit had been treated all at one time, she stated " No." LVN C then continued, "At first, in February 2014 only the resident that had been identified with a rash was treated (Resident #38)." Then in July 2014, the residents that were identified with rashes and their roommates were treated. LVN C stated sometime in the month of July 2014, the cloth furniture was removed from the residents' lounge area. The facility policy was shared with LVN C who stated the residents on this Unit cannot be placed in isolation. 15. The DON approached the surveyor on 10/30/14 at 7:20 AM, and stated the facility would now, effective 10/30/14 start using the CDC's Treatment Guidelines for Scabies. The DON stated the CDC guidelines were different from their policy in that "all persons should be treated at the same time to prevent re-infestation." The DON further stated all residents residing on A-1 unit would have a skin assessment completed and would be treated that day (10/30/14) with [MEDICATION NAME] Cream. All personal clothing, stuffed animals and personal belongings would be put in plastic bags and put outside for 3 days. All linen would be put in plastic bags, and then put into linen barrels lined with plastic bags and would be stored outside for three days, separated from the main facility laundry. All of the cloth chairs would be removed from the unit and different ones would be brought in for the residents to use. The DON stated the facility did not take these universal measures prior to this time, which was crucial as contact isolation measures were very difficult to enforce given the population who resided on the Memory Care Unit. 16. During an interview on 10/31/14 at 7:50 AM with RN B, the Infection Control Nurse, she was asked how infections in the facility were communicated to her for tracking and trending. She replied "We have a morning meeting every day and go over all of the physician's orders [REDACTED]. "What each Unit Manager usually does is staple the physician's orders [REDACTED]." RN B then enters the information on the Monthly Surveillance Form. RN B was asked when she became aware that the residents in the A-1 unit had rashes and were being treated for [REDACTED]." RN B stated in July 2014, the Unit had about seven residents who had rashes that were being treated. Then in the QA meeting in July 2014, MD-F and NP-D suggested to remove all of the furniture and deep clean all residents' rooms two times a day. When asked if she thought the facility's policy and procedures used during that period were effective, RN B stated, no, as the facility continued to have rashes from month to month. RN B stated the facility had an unusual number of residents with rashes than normal on Unit A-1. She stated she was not aware of the residents who had rashes in August and October of 2014. 17. In an interview on 10/31/14 at 12:00 PM, NP-D stated the facility had known that the rashes were scabies and not just a rash for some time now. She stated she had been giving orders to treat scabies for the A-1 Unit for about eight or nine months. She stated she had instructed the facility during the QA meeting in July 2014, to remove all of the cloth furniture, but they did not as the furniture was still in the dining area. NP-D stated, "I don't think we have ever eliminated scabies. The skin condition gets better with treatment, then it re-occurs." 18. In an interview on 10/31/14 at approximately 12:30 PM, MD-F, the facility's Medical Director, stated, "I don't understand why they are calling scabies a rash. A rash is a rash, and there are many types of rashes. Scabies is scabies and not a rash. If there is an order written [REDACTED]." 19. An interview with the Administrator on 10/31/14 at 4:45 PM revealed during the August 2014 QA meeting, the Medical Director discussed the issue of scabies and recommended removal of the cloth sofa in the unit. The Administrator stated the facility did this. The Medical Director also stated there was no need to do skin scrapings, and she was definite the rashes were scabies. 20. An interview on 11/01/14 at 1:26 PM with the District Manager of Housekeeping and Laundry revealed all linen and personal clothing except for a few changes for each resident had been collected, placed in plastic bags and put outside for 72 hours. The nurses assisted as they were treating all the residents for scabies. The 72 hours will be over by around 10:00 AM on 11/02/14. The District Manager of Housekeeping further stated "at that point the laundering of those clothes will begin and the clothes will be exposed: to three kills zones. The 24 dining room chairs that NP D recommended removal of for disinfection since July 2014, were removed and placed in sealed liners and put outside. After 72 hours, these chairs would be treated with a bleach germicidal cleaner, then extracted with and extraction machine. This machine used 170 degree water. 21. A facility document, dated 10/29/14, reflected head to toe assessments were conducted on the A-1 unit. 12 residents, including Residents #33, #34, and #10, had rashes. The Medical Director was notified of the rashes for the residents, and orders were received for [MEDICATION NAME] cream for treatment of [REDACTED]. On 10/29/14, the Medical Director also gave orders for [MEDICATION NAME] treatment for [REDACTED]. 22. The Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the DON on 10/29/14, revealed there were 170 residents in the facility.