Every finding on record at Five Points Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including the procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 4 of 4 medication carts reviewed for pharmacy services. The facility failed to ensure the Controlled Drugs Count Record on 4 medication carts for shift-to-shift narcotic counts did not have multiple blanks which indicated the narcotic count was not completed at shift change. This failure could result in narcotics being misappropriated from the facility which could result in ineffective treatment resulting in exacerbation of residents' disease process. Findings included: Observations on 5/19/26 of the facility's shift-to-shift narcotic count books revealed the following: *Controlled Drugs - Count Record for May 2026 documented the following on every sheet: Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication corresponds to the quantity stated on each controlled drug accountability record. At 2:30 PM - Hall 100 narcotic controlled drug count sheet for May had 11 blank spaces. At 2:45 PM - Hall 200 narcotic controlled drug count sheet for May had 2 blank spaces. At 3:12 PM - Hall 300 narcotic controlled drug count sheet for May had 1 blank space. At 3:18 PM - Hall 400 narcotic controlled drug count sheet for May had 3 blank spaces. During an interview on 5/21/26 at 2:20 p.m., the Adm. stated shift to shift narcotic counts were to ensure that the count was correct and accurate. The Adm. stated she was going to in-service nursing staff to ensure narcotic counts were to be completed at shift change. During an interview on 5/21/26 at 8:40 a.m., the DON stated the negative outcome would be that the nurse couldn't be held accountable if they did not sign in or out on the narcotic shift to shift sign sheet. The DON stated if there was no signature, the nurses couldn't be held responsible. The DON stated he was going to check the narcotic sign in sheets every day and hold the nurses accountable. During an interview on 5/21/26 at 8:50 a.m., RN A stated she signed the narcotic sheet every time she came on duty and if there was no signature, she dd not accept the cart. RN A stated if the nurse did not read the bottom of the sign in sheet, it tells you to sign the sheet when you accept the cart. RN A stated the nurse leaving the shift and the nurse coming on shift count the narcotics and sign the sheet which ensured the narcotic counts were correct. RN A stated if the narcotic count was incorrect, she would stop what she was doing and call the DON with the problem. During an interview on 5/21/26 at 9:00 a.m., RN B stated when the nurses did shift to shift change and signed the narcotic sheet, they were verifying the contents of the medication cart that all narcotics were accounted for. RN B stated the nurse coming on shift and the nurse coming off shift both signed the narcotic sheet, so the count was correct at that time. During an interview on 5/21/26 at 9:07 a.m., MA C stated she counted the narcotics with the nurse or MA coming off shift to verify all the narcotics were accounted for. MA C stated if the count was wrong and/or there were missing medications, she would stop what she was doing and call the DON to get further directions. During an interview on 5/21/26 at 9:13 a.m., the ADON/RN, stated nurses signed the narcotic sheet when taking responsibility for the cart which assured the narcotic count was correct. The ADON/RN stated the nurses did it again when coming off shift assuring the narcotic count was correct at the end of the shift. The ADON/RN stated staff knew to do it, she felt they had just gotten lazy. During an interview on 5/21/26 at 9:21 a.m., LVN D stated when she signed the narcotic count sheet, it was to ensure the narcotic count was correct. LVN D stated if there were no signatures or the count was incorrect, she would not accept the cart until the DON was contacted to provide the proper direction to proceed. Record review of the bottom section of the Controlled Drugs - Audit Record for the month, documents the following: Signing is acknowledgement the nurse has counted the controlled drugs and have found that the quantity of each medication corresponds to the quantity stated on each controlled drug accountability record. Any discrepancies must be noted in the comment column, indicated on each drug accountability record, and the DON notified. Record review of the facility's policy, Controlled Medications - Administration, revised 4/6/26, revealed the following: Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedure:8. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit.

Based on interview and record review, the facility failed to ensure the resident had the right to and the facility made prompt efforts to resolve grievances the resident may have respond for 6 of 11 anonymous residents reviewed for resident rights. The facility failed to provide or demonstrate responses, actions, and rationale taken regarding resident concerns with laundry not being delivered, being delivered incorrectly, and missing items. This failure could place residents at risk of feeling unheard, experiencing feelings of anger and frustration, as well as a decreased quality of life. Findings included: In an interview at an undisclosed date at an undisclosed time 6 anonymous residents stated laundry was a big issue. The anonymous residents stated clothes went missing and were never replaced or clothes were delivered to the wrong rooms. The 6 anonymous residents stated they did not feel the issue was resolved. In an interview on 05/21/2026 at 9:02 AM, the LS indicated the issues usually happened because the facility could not keep a stable staff. The LS stated a negative outcome was that the residents could get upset. In an interview on 05/21/2026 at 9:36 AM, the AD stated a negative outcome with clothes not being returned was being upset if it was done in her home, it could turn into bigger problems, and the resident would not have clothes. In an interview on 05/21/2026 at 10:08 AM, the DON stated they in-serviced staff and went over all complaints. The DON stated they did not document any resolutions as it was resolved by usually finding the item. The DON stated a negative outcome would be the residents would feel like the grievance was invalid or we (facility) don't care. In an interview on 05/21/2026 at 10:13 AM, the ADM stated they resolved the concerns with in-services but didn't do a grievance. The ADM stated a negative outcome would be depending on the situation or depending on what it was. Record review of the Resident Advisory Council Minutes, dated 12/4/2025, under heading Old Business, 2nd sentence, Follow up on action on concerns from previous meeting minutes discussed with a Yes or No option, indicated neither Yes or No were marked. No documentation provided on responses, actions, and rational taken regarding resident concerns. Record review of the Resident Advisory Council Minutes, dated 01/08/2026, under heading Old Business, 2nd sentence, Follow up on action on concerns from previous meeting minutes discussed with a Yes or No option, indicated neither Yes or No were marked. No documentation provided on responses, actions, and rational taken regarding resident concerns. Record review of the Resident Advisory Council Minutes, dated 02/12/2026, Under heading Laundry and Housekeeping, stated clothing going missing/in other people's room. Putting roommate clothes mixed together. Under prompt Are there any concerns with laundry, items of clothing missing, it was answered with Yes. No documentation provided on responses, actions, and rational taken regarding resident concerns. Record review of the Resident Advisory Council Minutes, dated 03/12/2026, Under heading Laundry and Housekeeping, stated Clothes still missing Under prompt Are there any concerns with laundry, items of clothing missing, it was answered with Yes. No documentation provided on responses, actions, and rational taken regarding resident concerns. Record review of the Resident Advisory Council Minutes, dated 04/09/2026, Under heading Laundry and Housekeeping, stated Clothes missing Under prompt Are there any concerns with laundry, items of clothing missing, it was answered with Yes. No documentation provided on responses, actions, and rational taken regarding resident concerns Record review of Resident Rights, dated 11/28/2026, stated under heading Grievances- Line 2- The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. Record review of in-services of subject Response to Resident Council Concerns, dated 2/13/2026, stated the following: Line 15: Laundry should be returned to owner quickly and correctly. No additional in-services were provided on missing or incorrect delivered laundry. Record review of admission Packet -Company Policy and Required Notices, undated, stated under roman numeral V- Policy for Raising and Addressing Concerns, line 5- The administrator shall review the report and confirm that the appropriate action has been taken and ensure feedback is provided to the person making the complaint regarding the concern.

Based on observations, interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and was developed within 48 hours of a resident's admission for 1 of 18 residents (Resident #84) reviewed for baseline care plans. The facility failed to ensure Resident #84's baseline care plan reflected the resident's prescribed anticoagulant medication, Eliquis, including the need for monitoring related to anticoagulant use. This failure could result in staff not being aware of critical medication related risks and monitoring needs, placing residents at risk for delayed treatment and failure to provide necessary care and services. Findings included: Record review of Resident #84's face sheet, dated 05/19/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #84 had diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in the blood), mild protein-calorie malnutrition and chronic combined systolic (congestive) and diastolic (congestive) heart failure, and atrial fibrillation (irregular heart rhythm) Record review of Resident #84's MDS face sheet revealed the admission MDS was not yet completed. Record review of Resident #84's baseline care plan, initiated on 05/15/2026, revealed no interventions, monitoring, or care plan focus related to anticoagulant therapy. No additional care plan addressing anticoagulant use had been developed. Record review of Resident #84's admission documentation, completed on 05/15/2026, revealed question 17 asked whether the resident was prescribed medications including anticoagulants; the anticoagulant medication was not selected. Record review of Resident #84's active medication order listing from the hospital, dated 05/14/2026, revealed Resident #84 was prescribed Eliquis 5 mg by mouth twice daily for atrial fibrillation. Record review of Resident #84's active physician orders as of 05/19/2026 revealed the following:Eliquis Oral tablet 5mg give 5 mg by mouth two times a day for anticoagulant (order date 05/15/2026) During an observation and interview on 05/19/2026 at 8:55 AM, Resident #84 was lying in her bed, she stated she was in the facility for skilled care and she took an anticoagulant medication. During an interview on 05/20/2026 at 2:59 PM, the DON stated when a resident was admitted to the facility an admission assessment was completed by the nurse on duty with the resident, The DON stated the assessment auto populated the base line care plan. The DON stated if information was missing during the admission the interdisciplinary team (IDT) would update that information within the 48-hour time frame. During an interview on 05/21/2026 at 9:04 AM, the ADM stated nurses were responsible for ensuring resident information, which included medications, were entered into the baseline care plan upon admission. The ADM stated the IDT, consisted of the DON, ADON, the MDS Coordinator and herself reviewed admission information the following day to finalize the baseline care plan and any information missed would be addressed at that time. During an interview on 05/21/2026 at 9:15, the ADON LVN stated the IDT, consisted of the ADM, DON, MDS Coordinator and herself were responsible to ensure baseline care plans reflected the residents' status, and medication needs. The ADON LVN stated the team would meet within 24 hours or next business day after a resident was admitted , to complete the baseline care plan. The ADON LVN stated if the baseline care plan was not completed correctly staff would not be aware of the residents' current status. During an interview on 05/21/2026 at 11:00 AM, RN A stated the nurse on duty was responsible for ensuring care was put in the baseline care plan upon a resident's admission and a possible negative outcome for not having a correct care plan would be staff would not be aware what a resident may need. During an interview on 05/21/2026 at 11:12 AM, the MDS LVN stated the IDT which consisted of the ADM, DON, ADON and himself were responsible for completing the baseline care plans within the 48-hour time frame., The MDS LVN stated anticoagulant therapy was important to include in the care plan so staff could monitor bruising, bleeding and abnormal laboratory findings. Record review of a facility, undated, policy titled Baseline Care Plans revealed the following: This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standard of quality care. The baseline care plan will- Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to Initial goals based on admission orders including physician orders.The facility will provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: A summary of the resident's medications.

Based on interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for medication administration.The facility failed to ensure Resident #1's opioid pain medication was refilled timely.This failure could place residents at risk of increased pain and/or diminished quality of life.Findings Included:Record review of Resident #1's admission record dated 03/09/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 02/07/26. She had diagnoses that included, but were not limited to, chronic pain syndrome and angina pectoris unspecified (chest pain).Record review of Resident #1's annual MDS assessment completed on 01/19/26 revealed a BIMS of 15 which indicated intact cognition. Section J Health Conditions revealed Resident #1 had received scheduled pain medication during the look back period. She occasionally had pain that rarely affected her sleep or activities of daily living. Resident #1 rated her pain at 5 out of 10. Section N Medications revealed Resident #1 received opioid medication during the 7-day look back period.Record review of Resident #1's care plan initiated on 04/22/25 revealed the following: . The resident uses medications for Pain management. The resident has a potential for uncontrolled pain . Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.Record review of Resident #1's MAR dated November 2025 revealed 10 missed doses of oxycodone-acetaminophen oral tablet 5-325 MG. The MAR revealed she missed 3 doses on 11/01/25 at 12:00 PM, 04:00 PM, and 08:00 PM. The first 2 missed doses were labelled as unavailable. The last missed dose on this date was labelled as see nursing notes. Resident #1 missed the 08:00 AM, 12:00 PM, 04:00 PM, and 08:00 PM doses on 11/02/25. All four missed doses were labelled as see nursing notes. Resident #1 missed the 08:00 AM, 12:00 PM, and 04:00 PM doses on 11/03/25. All three missed doses were labelled as unavailable. The MAR revealed an order with start date of 11/01/25 for Acetaminophen-Codeine Oral Tablet 300-60 MG . Give 60 mg by mouth every 4 hours as needed for pain. Resident #1 took this medication once on 11/01/25, 4 times on 11/02/25, and twice on 11/03/25. The order ended for acetaminophen-codeine oral tablet 300-60 MG on 11/04/25.Record review of Resident #1's MAR dated January 2026 revealed 11 missed doses of oxycodone-acetaminophen oral tablet 5-325 MG. The MAR revealed she missed two doses on 01/03/26 at 04:00 PM and 08:00 PM. The 04:00 PM dose was labeled unavailable. The 08:00 PM dose was simply labelled as not given. The MAR revealed Resident #1 missed three doses on 01/04/26 at 08:00 AM, 12:00 PM, and 04:00 PM. All three missed doses were labelled as unavailable. The MAR revealed Resident #1 missed 4 doses on 01/05/26 at 08:00 AM, 12:00 PM, 04:00 PM, and 08:00 PM. The first three doses missed on 01/05/26 were labelled as unavailable. The last dose was labelled as see nursing notes. Resident #1 slept through her 12:00 PM dose on 01/24/26 and she was out of the facility for her 12:00 PM dose on 01/28/26. The MAR revealed an order with a start date of01/03/26 for traMADol HCI Oral Tablet 50 MG . Give 1 tablet by mouth four times a day for order is to be discontinued when oxycodone arrives. According to the MAR Resident #1 took this medication once on 01/03/26, four times on 01/04/26, and four times on 01/05/26. The order was discontinued on 01/06/26.Record review of Resident #1's progress notes dated 10/06/25 to 11/06/25 revealed a note dated 11/01/25 for a new order for Acetaminophen-Codeine Oral Tablet 300-60 MG.Give 60 mg by mouth every 4 hours as needed for pain.Record review of Resident #1's progress notes dated 12/07/25 to 01/07/25 revealed a note dated 01/03/25 for a new order for traMADol HCI Oral Tablet 50 MG . Give 1 tablet by mouth four times a day for order is to be discontinued when oxycodone arrives.During an interview on 03/09/26 at 08:15 AM Resident #1's FM stated Resident #1 told her about missing several doses of her pain medication. FM stated, It happened more than once. She stated she did not notice Resident #1 experiencing pain during the time the medication lapsed. FM stated she did not know if the facility gave Resident #1 alternate pain medication as she waited for her oxycodone prescription to get refilled.During an interview on 03/09/26 at 08:26 AM Resident #1 she stated she remembered the facility not getting her pain medications refilled timely. She stated her pain medication lapsed twice, once in October 2025 and once in January 2026. Resident #1 stated the facility gave her an alternate pain medication in January to cover the time her oxycodone prescription lapsed. She stated, They (nurses) kept blaming the doctor and the doctor kept blaming the pharmacist. Everybody blaming everybody. I just know I wasn't getting it (her oxycodone pain medication)!During an interview on 03/09/26 at 09:47 PM MD stated the process to get oxycodone refilled was lengthy. He stated the facility had to turn in a request when there were 2 days of medication left and his staff had to do several specific tasks to ensure they were in line with DEA. He stated, Sometimes the pharmacy runs out of stock, and they don't let us know right away. MD stated there was no reason Resident #1's medication should have lapsed between refills.During a group interview on 03/09/26 at 10:11 AM ADON B stated she depended on her nursing staff to request medication refills when necessary. She stated the administering nurse should request a refill when there were 1-5 days of medication left. ADON A stated she did not think Resident #1 was negatively impacted by her pain medication lapsing because Resident #1 was on several other types of pain medication including a fentanyl patch. When asked, neither ADON had an answer as to why Resident #1's pain medication lapsed. ADON A stated it might have been because the nurses did not realize it was regularly scheduled for 4 times a day which meant 8 pills remaining only covered 2 days.During an interview on 03/09/26 at 10:17 AM DON stated he did not think Resident #1 was negatively impacted by her pain medication lapsing because the facility ordered different pain medication to cover the period of the lapse. He stated he was not sure why her medication lapsed in November 2025 and in January 2026. DON stated he suspected it was because the nurses administering her medication did not take into consideration that 4 pills covered only 1 day.During an interview on 03/09/26 at 11:29 AM RN C stated a resident with regularly scheduled opioid pain medication could be negatively impacted if the medication lapsed. She stated the resident could have increased pain or it could cause them to act out. RN C stated, We should call and get an order for something different until it is filled.During an interview on 03/09/26 at 11:36 AM LVN D stated if a resident's regularly scheduled opioid medication lapsed it could result in breakthrough pain for the resident.Record review of facility policy titled Medication Administration and General Guidelines and dated 2025 revealed the following: . Medications are administered as prescribed in accordance with.good nursing principles and practices.Record review of facility policy titled Controlled Medication - Ordering & Receipt and dated 2025 revealed the following: . 8. Schedule II controlled substance medications are reordered when a 3-5-day supply remains to allow for transmittal of required valid prescription to the pharmacist.

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained free from accidents as was possible and each resident received adequate supervision and assistance devised to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents, hazards and supervision.The facility failed to ensure Resident #1 did not elope from the facility when Resident #1 left the facility in the middle of the night, without anyone knowledge, and ended up 0.4 miles from the facility trying to obtain a hotel room for the night.The noncompliance was identified as PNC. The IJ began on 12/10/25 when Resident #1 eloped from the facility. The facility had corrected the noncompliance before the investigator entered the facility.This failure could place residents at risk of serious injury or serious harm and placed residents at risk of heat or cold exposure, dehydration and /or other medical complications, of being struck by a motor vehicle.Findings included: Record review of Resident #1's Face Sheet, undated, documented a [AGE] year-old male was admitted to the facility on [DATE] with the following diagnoses: metabolic encephalopathy (a brain dysfunction from a chemical imbalance due to an underlying illness, causing confusion, memory issues, personality changes, or coma), enterocolitis due to clostridium difficile (a serious bacterial infection causing diarrhea, abdominal pain, and fever, often triggered by antibiotic use disrupting gut flora), protein-calorie malnutrition (a serious condition from not getting enough protein and/or calories, leading to poor growth, weight loss, weakened immunity and increased infections), hypertension (high blood pressure), acute pulmonary edema (a life-threatening emergency where fluid rapidly fills the lungs air sacs, causing sever shortness of breath), acute kidney failure (kidneys rapidly stop filtering waste and balancing fluids which leads to toxic buildup in the blood), intestinal obstruction - unspecified as to partial or complete obstruction (blockage - partial or complete - in the small or large intestine, preventing food, liquid, gas and stool from passing through) and cognitive communication deficit (difficulty with communication due to impaired thinking or neurological conditions affecting memory, attention, problem-solving and social cues, making it hard to organize thoughts, follow conversations, or understand instructions). Record review of Resident #1's initial Care Plan, dated 12/5/25, revealed the following:The resident has an alteration in neurological status related to metabolic encephalopathy. Interventions: cueing, reorientation as needed, pain management as needed, PT, OT and St evaluate and treat as needed.The resident has impaired cognitive function/dementia or impaired thought processes. Interventions: administer medications as ordered, engage the resident in simple, structured activities that avoid overly demanding tasks, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status.The resident is at risk for falls. Interventions: have residents' call light within reach and encourage residents to use. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing.Record review of Resident #1's Care Plan, updated on 12/10/25 after elopement, revealed the following:At risk for elopement as evidenced by: resident left the facility. Goal: will remain safe within facility unless accompanied by staff or other authorized person through review date. Interventions: resident placed one on one until family picked him up, assess/record/report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home or hospital, supervise closely and make regular compliance rounds whenever resident is in room, if the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.Record review of Resident #1's Medicare 5-day MDS resident assessment, dated 12/10/25, documented the resident scored 5 of 15 on a mini-mental exam for cognitive awareness and he was not capable of making informed decisions and he was independently ambulatory.Record review of Resident #1's nurses notes documented the following:12/10/25 at 2:08 a.m. - A local policeman called and asked if we had Resident #1 as a resident, I informed him that we did, they stated he was at a local hotel trying to get a room. The police brought Resident #1 back, spoke with Resident #1 and got him to his room. Resident #1 stated that he was being held hostage, I explained he was on contact isolation due to infection. Resident #1 stated he didn't want to be here. Called and spoke with Resident #1's family member and voiced understanding to what had happened and stated the family member would come and get him so he would not be confined, and it would please him. LVN spoke with the Administrator and explained what was going on, 400 door not shutting or locking.12/10/25 at 2:10 a.m. - Weekly Skin assessment: surgical incision present: yes, Location - 16 staples intact to center abdominal area, no redness, drainage or warmth noted.12/10/25 at 9:28 a.m. - Elopement Follow-up: currently: exit seeking, increase wandering, agitation, asking to leave or go elsewhere, 1 on 1 monitoring, patient to discharge by request.12/10/25 - Resident was interviewed at this time to determine resident can remain in facility, at this time, resident is one on one and wishes to go home with family member, Resident #1 states that he does not like being here because he must be isolated into his room. Family member is on their way from out of state and resident will discharge home with the family member. Currently, the resident is restless in room and remains one to one.12/10/25 at 10:38 a.m. - family member was here at this time to pick up resident, the family member understood that resident left facility last night and ended up in a hotel and was retuned by police. Family member was also given discharge instructions and medications. No further needs.12/10/25 at 12:44 p.m. - came in at 6:15 a.m. to sit with Resident, Resident was trying to leave the building. resident kept pacing from bed to bathroom to window, the resident kept wanting to leave. A family member picked resident up at 10:30 a.m. Record review of the Provider Investigation Report, dated 12/16/25, and filled out by the Administrator, reflected Resident #1 was last seen by staff at 12:20 a.m. during rounds. At approximately 1:10 a.m., the facility received a call from the local police department stating Resident #1 was at a local hotel approximately 0.4 miles away from the facility. It was 52 degrees outside, and Resident #1 was wearing a shirt, jeans, jacket and boots. Resident #1 stated he wanted to reserve a hotel room because he felt like a hostage at our facility because he was on contact isolation for C-diff. The local police department brought Resident #1 back to the facility, a skin assessment was conducted and there were no new injuries. Administrator arrived at facility and assessed all exit doors for function, initiated elopement in-service, interviewed staff, and verified Resident #1 was one on one. Resident noted to be asleep in his room. Staff posted at all exit doors until system cleaned by vendor. Staff reported that the door alarm did not function on hallway 400 and the door remained unlocked after several attempts to try to reset the lock. A nurse was able to get the door locked after a period of time. Maintenance checked all doors for proper function. Facility door vendor onsite to assess and repair doors that are malfunctioning. Resident #1 was discharged to a family member. Elopement in-service completed, elopement drills conducted per protocol, elopement assessments completed on all residents. Resident #1 had been in the facility for 5 days when the incident occurred. There was nothing in Resident #1 admission paperwork to indicate that he was an elopement risk. Record review of Resident #1's Weekly Skin Assessment, dated 12/10/25 at 2:10 a.m. documented the following:No bruises, skin tears, abrasions, lacerationsSurgical incision - yes Note Locations: 16 stables to center abdominal area - no redness, drainage or warmth noted. Record review of Resident #1's elopement evaluation sheet, dated 12/10/25 at 2:15 a.m., documented the following:Elopement:Note what door exited - 400 hallNote how long missing - missing within 30 minutes, CNA had checked on him 30 minutes beforeWhere was the resident discovered - at a local hotelOther information related to the elopement - was trying to get a roomAny injuries - NoCognition/Behavior at time of event - cognitive impairment, paces, exit seeking, restlessNursing description of the event - Local police department called and asked if we had Resident #1 residing in facility. Nurse informed him that we did, they stated he was at a local hotel trying to get a room. They brought Resident #1 back to the facility and spoke with Resident #1 when he got to his room. Resident #1 stated he was being held hostage. Nurse explained he was on contact due to infection. Resident stated he didn't want to be here.Resident statement related to event - I'm being held hostage, so I was getting a room.Interventions initiated by Nurse - 1 on 1 supervision During an interview on 1/7/26 at 11:16 p.m., LVN A stated he did take care of Resident #1 one night. LVN stated on 12/9/25, Resident #1 tried to elope on him, but he stopped him. LVN A stated he did not remember what Resident #1's BIMS score was but he seemed confused the night before he eloped (12/9/25) and kept saying he did not want to be in the nursing home and kept trying to get out the door at the end of the hallway. LVN A stated he remembered Resident #1 had some kind of abdominal surgery and he was at the facility for strength training. During a follow-up telephone interview on 1/8/26 at 12:00 p.m., LVN A stated he did not inform anyone of Resident #1's attempted elopement the night before because Resident #1 failed to get out of the facility so reporting it was not necessary. An observation on 1/7/26 at 11:31 p.m. of the route that Resident #1possibly took to a local hotel, was driven by the investigator. Reviewing the odometer, the hotel was approximately 0.4 miles away from the facility going straight down the road that was in front of the facility, to a four-lane divided highway at a busy intersection. During an interview on 1/8/26 at 8:20 a.m., the Administrator stated three nurses could not get that door to lock on the 400 hallway. The Administrator stated she had staff stand by each exit door and she stood at the nurses' station to monitor all the staff that she had stationed at the exit doors. The Administrator stated she called the facility door security vendor, the company that takes care of the locking systems and any issues with the doors. The Administrator stated the facility door security vendor got to the facility about 1:00 p.m. on 12/10/25 and that afternoon and the locks were fixed at that time. The Administrator stated she had reduced the time to 4 seconds so the locking mechanism will activate. The Administrator stated Resident #1 just did not want to be in the facility from the get-go. The Administrator stated they put signs up on all the exit doors on how to reset the alarm once the door was open more than 5 seconds. The Administrator stated she also put large red emergency only signs on all the exit doors. During an interview on 1/8/26 at 8:57 a.m., the ST stated she remembered trying to get a BIMS score on Resident #1, but he was so anxious and non-compliant and kept saying he did not want to be here. The ST stated on the first day, she could not finish the BIMs test as the interview went bad. The ST stated Resident #1 did not want to talk, he wanted to leave the facility. The ST stated that when she went to Resident #1's room on the second day, Resident #1 was fully dressed and had his boots on and told her that he was going home. The ST stated on the second day, Resident #1 answered a few questions, but she could not remember which ones. During an interview on 1/8/26 at 9:45 a.m., Resident #1's family member stated Resident #1's dementia was really getting bad, and he did not want to be in the facility. Resident #1's family member stated Resident #1 was declining mentally and had just lost his wallet and did not remember how to work his phone anymore. Resident #1's family member stated they had been trying to get POA or Guardianship or something so they could be of help to Resident #1. Resident #1's family member stated Resident #1 wants to live on his own, but something needed to be done to ensure his safety. Resident #1's family member stated staff gave Resident #1 a BIMS test the morning after he eloped, and he did not do very good as he was very confused. Resident #1's family member stated Resident #1 told him that he was on isolation and not allowed to leave his room and he was really upset about it and just wanted to leave. During an interview on 1/8/26 at 12:30 p.m., the Maintenance Supervisor stated the lock on the 400 door was working the day before the elopement. The Maintenance Supervisor stated he checks the locks daily at 9:00 a.m., Monday through Friday. The Maintenance Supervisor stated he had never had any trouble with the lock on the 400 hallway not working. The Maintenance Supervisor provided a check list of items that are checked daily on each door. On 1/8/26 at 1:55 p.m., the door on 400 hallway was checked and it was in proper working order and locked, with a large red sign that read, Emergency Exit Only.Record review of the checklist titled: Door, Locks and Alarms: Test operation of doors and locks, dated 1/1/26, revealed the following:Check operation of magnetic door locks:Inspect door lock mounting and operation and inspect panic hardwareVerify system code and keypad operations.Any magnetically locked doors must automatically unlock during a fire alarm (verify this during you normal fire drill)Check any advanced features (optional equipment)Check patient transmitter to make sure the door stays locked and alarm sounds.Check delayed egress operation.Push door release hard for a fraction of a second- door should not open and alarm should not sound.Apply pressure to the door release for the pre-determined nuisance period setting (normally 1 - 3 seconds)Door should go into irreversible unlocking sequence - door alarm will sound; door will automatically open within 15 to 3- seconds.Close door and reset the alarm.Ensure signs are placed on doors adjacent to the release device that read, 'Keep pushing. Door will unlock after 15 seconds.'Test doors and hardware for proper operation and condition.Check door for proper seal when closed so that no air gaps exist between smoke or fire barrier doors.Confirm all door labels are clearly visible for inspection and are readily legible.Document results of inspection in Comments and note any discrepancies. Record review on 1/8/26 at 12:50 p.m. of Maintenance Logs from 11/3/25 to present revealed the door locks and alarms were checked Monday through Friday consistently. Record review on 1/8/26 at 1:25 p.m. of an elopement drill, conducted on 11/28/25 prior to Resident #1's elopement, was started at 9:00 p.m. and ended at 9:30 p.m. Performance Rating for the drill was good. Actions: Called a code orange, identified resident and room number and time last seen. Verify resident is not signed out. Notify Administrator, DON, family and compliance nurse, provide information regarding resident to search teams, if resident is not found in 30 minutes or less - contact police. Time resident was found, post event documentation review: nurses notes, elopement risk assessment, follow-up elopement nurses notes every shift for 72 hours, care plan updated. Record review of the work order/receipt, dated 12/11/25, from the door security vendor revealed he reworked the front door mag lock wires and reinstalled the strike place. We were able to replace a timer at the rear and a keypad for the front doors. We also had to rework the timers to have a pot alarm at the door that was triggered. Record review of the Missing Resident/Elopement Monitoring documentation from 12/10/25 to present. All areas were checked on a daily basis since the elopement of Resident #1.Does the locking mechanism or alarm function properly on all exit doors of the facility? If no, describe corrective action on the back of this form.Conduct at least 3 elopement drills per week. 1 drill between 6am to 2 pm, 1 drill between 2 pm to 10 pm, and 1 drill between 10 pm to 6 am. Did staff respond appropriately? Yes or no. If no, note corrective action on the back of this form.Through daily rounds and duties at least 5 days per week, observe for visitors allowing residents to exit the facility unsupervised. In compliance? Yes or no.Has the door code been changed for this month? Yes or no; if no, state corrective action taken below. Record review for the In-Service Training Report, dated 12/10/25 and titled, Elopement Response and Prevention - Code Orange revealed the following:In case of a missing resident:Report to charge nurse immediately.Determine if resident is on authorized leave.Search the building and grounds including bathrooms, closets, etc.Notify Administrator and DON, responsible party, and physician.If not found in 30 minutes, report to the police, update responsible party.Upon return, the resident is to be assessed for injuries, physician notified of condition, and responsible party, appropriate staff, and police notified.Incident is to be documented in medical records.Elopement Prevention:Why is the resident wandering/exit seeking?Notify your charge nurse immediately when a resident is exit seeking.Do not leave the resident unattended until a resolution has been determined.Ask - does the resident need to use the bathroom, is he/she hungry, experiencing discomfort, boredom, wants to ambulate? Is the temperature uncomfortable?Is there an infection or is it worsening? Medication side effects? Increased confusion due to an underlying issue?Is the resident trying to find his/her room, bathroom, dining room, etc?Once a cause for wandering/exit seeking is identified, redirect the resident by providing ADL care, following new physician orders, decreasing sensory stimulation, providing the resident with familiar items, etc.Notify the on-call nurse of exit seeking behavior.When a door alarm sounds, staff must investigate and ensure all residents are accounted for. Do not silence the alarm without ensuring residents are safe.If the door releases after 15 seconds, the code must be entered to reset the door lock.The Elopement Binder (white binder) is located at the nurse's station with the Emergency Plan (red binder).This in-service was signed by 103 staff members. This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measure to prevent recurrence of the non-compliance. The facility had all doors and locking systems checked and repaired or replaced as needed, put up signs on all exit doors were to be used for emergency only, all staff were in-serviced on elopement and drills, and the facility held elopement drills three times a week with drills on three different shifts per week, with the last drill being conducted on 1/1/26. In addition, monitoring of visitors and staff were being conducted on a daily basis since 12/11/25, to ensure no one was allowing residents to exit the facility unsupervised.

Based on interview and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 7 residents reviewed for accuracy of medical records. The facility failed to ensure LVN A documented the correct time Resident #1 and his family were provided with copies of his baseline care plan. The facility failed to ensure LVN A documented the correct time Resident #1's family and doctor were notified of his fall on 05/21/25. The facility failed to ensure RN B documented the times correctly on 3 progress notes in Resident #1's chart on 05/23/25. These failures could place residents at risk of not receiving necessary care/treatment due to inaccurate medical records. Findings Included: Record review of Resident #1's admission record dated 06/04/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hemiplegia (paralysis) affecting right dominant side, cerebral infarction (stroke), difficulty in walking, and unsteadiness on feet. Resident #1 discharged from the facility on 05/23/25. The time listed for discharge was 04:30 PM. Record review of Resident #1's care plan revealed it was a baseline care plan initiated on 05/21/25. Resident #1 was noted to be at risk of falling. Record review of Resident #1's EHR in the MDS tab revealed no comprehensive MDS was completed due to the short duration of his stay in the facility. Record review of Resident #1's transfer form completed by DON on 05/23/25 revealed Resident #1's transfer to the hospital for altered mental state was effective on 05/23/25 at 03:10 PM. Record review of Resident #1's progress notes from 05/21/25 to 05/23/25 revealed the following: A note on 05/21/25 at 03:02 PM by LVN A which indicated Resident #1 was admitted to the facility on [DATE] at 03:02 PM. A note on 05/21/25 at 04:00 PM by LVN A which indicated a copy of Resident #1's baseline care plan was provided to Resident #1 and to his family member on 05/21/25 at 12:00 AM. A note on 05/21/25 at 05:29 PM by LVN A which indicated Resident #1 had a fall. The note further indicated Resident #1's doctor and family were notified of his fall on 05/21/25 at 12:00 AM. A note on 05/23/25 at 03:10 PM by DON which indicated Resident #1 was transferred to the hospital. A note on 05/23/25 at 04:47 PM by RN B which indicated a neuro assessment was completed on Resident #1. A note on 05/23/25 at 04:48 PM by RN B which indicated vital signs taken of Resident #1. A note on 05/23/25 at 04:51 PM by RN B which was a fall follow-up and indicated Resident #1 had continuous pain on his right side. During an interview on 06/04/25 at 11:21 AM DON was asked for actual family and physician notification times for Resident #1's fall on 05/21/25. He looked in the EHR and stated he would ask LVN A. During an interview on 06/04/25 at 11:26 AM DON stated LVN A notified Resident #1's family and physician at the time of the note in his EHR (05:29 PM) on 05/21/25. During an interview on 06/04/25 at 11:51 AM DON stated Resident #1 discharged from the facility on 05/23/25 at 03:00 PM. He stated Resident #1 did not return to the facility after that discharge. DON looked at progress notes in Resident #1's EHR and stated, I have no idea why RN B had documented assessments of Resident #1 at times later than the time of his discharge from the facility. During an interview on 06/04/25 at 11:57 AM RN B stated she noticed her notes had not been completed on Resident #1 and she completed the notes with information she had gathered prior to his discharge from the facility and did not change the time of her documentation. During an interview on 06/04/25 at 11:58 AM DON stated he was starting an in-service for nurses to address getting times right in documentation. During an interview on 06/04/25 at 12:12 PM RN B stated residents could be negatively impacted by inaccurate medical records. She stated she was not aware, prior to 06/04/25, of the expectation that assessments in the EHR be entered at the point of assessment. RN B stated it was possible to enter the assessment later and adjust the time of the assessment and that was what she should have done. During an interview on 06/04/25 at 02:45 PM LVN A stated residents might not receive needed care if their medical records are inaccurate. During an interview on 06/04/25 at 03:30 PM LVN C stated it was important to document times accurately in residents' medical records. She stated inaccurate medical records could negatively affect residents. During an interview on 06/04/25 at 03:40 PM LVN F stated residents could be negatively affected by inaccurate medical records. She said, If medical record is inaccurate, they (residents) wouldn't get proper care they (residents) need. During an interview on 06/04/25 at 03:47 PM ADON D stated a resident could be negatively impacted by inaccurate medical records, but it would depend on what is inaccurate. She stated the nurses in the facility were trained on documentation on the job and in nursing school. During an interview on 06/04/25 at 03:49 PM ADON E stated a resident could be negatively impacted by inaccurate medical records depending on what is inaccurate. Regarding training facility nurses on accurate documentation, she said, We do in-services, and we monitor documentation to make sure it is being done in a timely manner. During an interview on 06/04/25 at 03:55 PM DON stated it depends on what you're charting whether or not inaccurate medical records would negatively impact resident care. During an interview on 06/04/25 at 03:58 PM LVN A stated she did not accurately document the times Resident #1's family and physician were contacted on 05/21/25 regarding his fall because she did not realize they were inaccurate until she had signed the document. During an interview on 06/04/25 at 04:20 PM DON stated nurses were trained on documentation in nursing school and when something like this (inaccurate documentation in Resident #1's EHR by LVN A and RN B) happens. Record review of an undated facility policy titled Documentation revealed the following: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident . It has legal requirements regarding accuracy and completeness . 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 5. Each entry will be dated and timed.

Based on observation and record review; it was determined the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, and dispensing, and administration of all drugs and biologicals for 3 of 18 (Resident #39, Resident #65, and Resident #230) and 2 of 4 medication carts (Hall 300and Hall 400) under review. -Resident #39's Lispro had an open date on it of 02/17/2025. -Resident #230's Lantus Solostar Pen had an open date on it of 02/08/2025. -1 bottle of Naproxen 220mg that had an expiration date of 02/2025. -Resident #65's Insulin Lispro with an open date of 02/19/2025. The facility's failure 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 could place all residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. Findings include: During an observation on 03/24/25 at 10:52 AM revealed Medication cart for 400 Hall having Resident #39's Lispro had an open date on it of 02/17/2025, and Resident #230's Lantus Solostar Pen had an open date on it of 02/08/2025. During an interview on 03/24/25 at 11:05 AM LVN B stated that the negative outcome for having medications with no open dates on them was the medications not being effective. During an observation on 03/24/25 at 11:38 AM revealed the medication cart for Hall 300 revealed Resident #65's Insulin Lispro with an open date of 02/19/2025. 1 bottle of Naproxen 220mg had an expiration date of 02/2025. During an interview on 03/24/25 at 11:46 AM LVN D stated that a negative outcome for having medications with no expiration dates was a medication being used that is not going to be effective. During an interview on 03/25/25 at 07:32 AM DON stated that a negative outcome for giving expired medications is that the medications could lose their effectiveness. Record review of facility provided policy titled, Recommended Medication Storage, Revised 07/2012, revealed the following: Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened. Record review of facility provided policy titled, Recommended Medication Storage, Revised 07/2012, revealed the following: Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 4 of 4 medication carts (Hall 100, Hall 200, Hall 300, and Hall 400) and 6 of 18 residents (Resident #27, #32, #47, #176, #228. and #229) reviewed for medication storage. -Medication on bedside table of Resident #32. -Medication cart for Hall 200 revealed 25.5 unidentifiable loose pills in the medication cart drawers. -Medication cart for 400 Hall had 1.5 loose pills in the bottom of the medication cart drawers. -Resident #229's Stiolto Aer 2.5-2.5 had no open date. -Resident #228's Trelegy Ellipta had no open date. -Medication cart for 300 Hall had 1 bottle of Melatonin 3mg that did not have an expiration date on the bottle. -Medication Triamcinolone acetonide cream was on Resident #27's bed. -Medication cart for 100 Hall had 1 bottle of Aspirin 81mg with no expiration date on the bottle, and 1 Coreg pill was found in the bottom of the medication cart drawer -Resident #47 had a bottle of Aspirin 81mg on her bedside table. -Resident #176 had a tube of Neosporin ointment on her bedside table. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an observation on 03/24/25 at 09:21 AM revealed a nasal spray bottle was on Resident #32's bedside table, the medication was identified as fluticasone propionate. The medication bottle had no open date on it. Resident #32 stated that the medication was not supposed to be in there with her. During an observation on 03/24/25 at 09:53 AM revealed 25.5 loose pills were loose in the medication cart drawers of the medication cart for Hall 200. During an interview on 03/24/25 at 10:13 AM LVN A stated that a negative outcome of having loose pills was a resident missing a dose of medication. LVN A also stated that a negative outcome of leaving medication on a resident's bedside table was to another resident possibly taking the medication or the resident forgetting that they took the medicine and taking another dose. During an observation on 03/24/25 at 10:52 AM revealed Medication cart for 400 Hall having 1.5 loose pills in the bottom of the medication cart drawers. Resident #229's Stiolto Aer 2.5-2.5 had no open date on the medication, Resident #228's Trelegy Ellipta had no open date on the medication. Resident #39's Lispro had an open date on it of 02/17/2025, and Resident #230's Lantus Solostar Pen had an open date on it of 02/08/2025. During an interview on 03/24/25 at 11:05 AM LVN B stated that the negative outcome for having medications with no open dates on them was the medications not being effective, and the negative outcome of having loose pills was that you don't know what it is. During an observation on 03/24/25 at 11:21 AM revealed the medication cart for Hall 100 had 1 bottle of Aspirin 81mg with no expiration date on the bottle and 1 Coreg pill was found in the bottom of the medication cart drawer. This pill was identified by LVN B. During an interview on 03/24/25 at 11:32 AM LVN B stated that a negative outcome for not having an expiration date on a bottle of medication could lead to giving expired medications. LVN stated that having loose pills in the bottom of the medication cart is that you might not know what it is or who it belongs to. During an observation on 03/24/25 at 11:38 AM revealed 1 bottle of Melatonin 3mg did not have an expiration date on the bottle. During an interview on 03/24/25 at 11:46 AM LVN D stated that a negative outcome for having medications with no expiration dates was a medication being used that is not going to be effective. During an observation on 03/24/25 at 02:27 PM revealed Resident #176 had a tube of Neosporin on her bedside. During an observation on 03/25/25 at 07:10 AM revealed a bottle of chewable Aspirin 81mg was on Resident #47's bedside table. When Resident #47 stated that she chews them and puts them on her teeth which cause her pain. During an interview on 03/25/25 at 07:32 AM DON stated that a negative outcome for having loose pills in the medication cart drawers would be first of all a sanitation issue. I hope the nurses don't use them; it could possibly lead to a missed dose. Nurses are responsible for making sure that the carts are clean and orderly. DON stated that a possible negative outcome for giving expired medications is that the medications could lose their effectiveness. DON stated that a possible negative outcome for having medications on a bedside table was another resident taking the medication and having a negative outcome. Record review of facility provided policy titled, Recommended Medication Storage, Revised 07/2012, revealed the following: Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened. .Fluticasone-expires 6 weeks (50mcg strength) or 2 months (100-250mcg) after initial use. .Insulins (vials, cartridge, pens) . .Humalog Flex Pen 75/25 and 50/50 pens Insulin Glargine (Lantus) . .expires 28 days after initial use regardless of product storage (refrigerated or roo temperature). Record review of facility provided policy titled, Medication Carts, dated 2003, revealed the following: 1. Medication carts shall be maintained by the facility. .5. Carts should be clean. Record review of facility provided policy titled, Medication Administration Procedures, revised 10/25/2017, revealed the following: 1. All medications are administered by licensed medical or nursing personnel. 2. Medications are to poured, administered and charted by the same licensed person. Record review of facility provided policy titled, Recommended Medication Storage, Revised 07/2012, revealed the following: Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened. .Fluticasone-expires 6 weeks (50mcg strength) or 2 months (100-250mcg) after initial use. .Insulins (vials, cartridge, pens) . .Humalog Flex Pen 75/25 and 50/50 pens Insulin Glargine (Lantus) . .expires 28 days after initial use regardless of product storage (refrigerated or roo temperature). Record review of facility provided policy titled, Medication Carts, dated 2003, revealed the following: 1. Medication carts shall be maintained by the facility. .5. Carts should be clean. Record review of facility provided policy titled, Medication Administration Procedures, revised 10/25/2017, revealed the following: 1. All medications are administered by licensed medical or nursing personnel. 2. Medications are to poured, administered and charted by the same licensed person.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 Nourishment Room reviewed for sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerated foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the refrigerator in the Nourishment Room on [DATE] at 08:55 AM revealed the following: 1. (2) containers of Orange Juice, both opened. No date or label. 2. (1) 4-pack of yogurt smoothie drink, no date or label. 3. (14) cups on tray with unidentified liquid inside, no labels, dates of [DATE] on lids. 4. (1) chocolate milk container, opened, no date or label. Observation of the freezer in the Nourishment Room on [DATE] at 9:01 AM revealed the following: 1. (1) box of opened Outshine bars, no date or label. 2. (1) gallon of ice cream, opened and half gone, no date or label. 3. (2) loose popsicles, no date or label. In an interview on [DATE] at 9:01 AM, [NAME] J stated that that all dietary staff are responsible for the Nourishment Room to keep the refrigerator/freezer cleaned out and items labeled. [NAME] J stated that a possible negative outcome for not having labels and dates on items in the refrigerator/freezers could be that people could get sick if expired food was given to residents. In an interview on [DATE] at 9:18 AM, the DON stated that it was the dietary staff who were responsible for the nourishment room refrigerator/freezer. In an interview on [DATE] at 11:18 AM, the DM stated that dietary staff are responsible for labeling and dating food in the nourishment room refrigerator and freezer. She stated a possible negative outcome for not labeling/dating food could be that a resident could get some old or outdated food and it could make them sick. Record Review of facility policy dated 2012 titled Storage Refrigerators, revealed in part: 5. Food must be covered when stored, with a date label identifying what is in the container.

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 8 staff (MA E and CNA K) reviewed for resident care -MA E did not perform hand hygiene before donning gloves to administer medicated eye drops to Resident #5. -CNA K did not perform hand hygiene or glove change after performing perineal care and placing a clean brief on Resident #45. These failures could place residents at risk of cross-contamination and infections. Findings include: During an observation on 03/25/25 at 08:03 AM MA E did not perform hand hygiene before donning gloves to administer medicated eye drops to Resident #5. During an interview on 03/25/25 at 08:09 AM MA E stated that a possible negative outcome for not performing hand hygiene before administering eye drops was contamination. During an interview on 03/25/25 at 08:51 AM DON stated that not performing hand hygiene before medications administration, was cross contamination, as the nurses hands could be dirty and they are touching the residents face. During an observation on 03/25/25 at 10:47 AM CNA K was performing perineal care on Resident #45 and did not change gloves or perform hand hygiene after cleaning the resident. CNA K then proceeded to place a clean brief on Resident #45 with the same gloves she had just performed perineal care with. During an interview on 03/25/25 at 11:03 AM CNA K stated that not changing gloves and performing hand hygiene between the dirty and clean areas of perineal care could lead to the spread of bacteria and lead to an infection. Record review of facility provided policy titled Fundamentals of Infection Control Precautions, revised 03/2024, revealed the following: 1. Hand Hygiene Hand hygiene continues to the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . .Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . .Upon and after coming in contact with a resident's intact skin, . .after contact with a resident's mucous membranes and body fluids or excretions; .

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #31) of 3 residents reviewed for respiratory care. The facility failed to store Resident #31's nasal cannula properly. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings include: Record review of Resident #31's clinical record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include pleural effusion (the buildup of excess fluid in the pleural space, the area between the lungs and the chest wall), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), pneumonia (lung inflammation caused by a bacterial or viral infection), and anxiety (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #31's clinical record revealed her last MDS was a quarterly completed 3-7-2025 listing her with a BIMS score of 10 indicating she was moderately cognitively impaired, and she had a functionality of being dependent on staff for her activities of daily living such as dressing, bathing, and toileting. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #31 was marked as having oxygen While a Resident. Record review of Resident #31's Order Summary Report with Active Orders as of 3-18-2025 revealed the following order: - May use oxygen @_1-4___l/m via nasal canula every shift. Active 03-08-2025 Record review of Resident #31's clinical record revealed a care plan with the admitted [DATE], which revealed the following: Focus: Resident has oxygen therapy as needed. Date Initiated: 12-14-2022. Date Revised: 3-25-2024. -there were no interventions for respiratory equipment care to include nasal cannula storage. During an observation on 03/24/25 at 08:53 AM Resident #31 was not present in her room. Her oxygen concentrator was next to her bed with her nasal cannula on the floor behind the concentrator. There were white specks of discoloration on the nasal prongs from use. A storage bag tied to the machine for proper storage not being used. Noted a date on the hydration bottle that was 3-7-2025. During an observation on 03/24/25 at 10:57 AM Resident #31's nasal cannula continued to be on the floor behind her oxygen concentrator. The date on the hydration bottle was still 3-7-2025. No date was on the nasal cannula or tubing. There continued to be white specks on the nasal prongs from previous use. During an observation on 03/24/25 at 12:13 PM Resident #31's nasal cannula continued to be on the floor behind her oxygen concentrator. The date on the hydration bottle was still 3-7-2025. No date was on the nasal cannula or tubing. There continued to be white specks on the nasal prongs from previous use. During an observation on 03/24/25 02:09 PM Resident #31's nasal cannula continued to be on the floor behind her oxygen concentrator. The date on the hydration bottle was still 3-7-2025. No date was on the nasal cannula or tubing. There continued to be white specks on the nasal prongs from previous use. During an observation and interview on 03/25/25 at 06:28 AM Resident #31 was up in her wheelchair dressed for the day wearing her oxygen via NC. There were slight white discolored flecks to the nasal prongs. A date of 3-7-2025 was on the hydration bottle and no date on the nasal cannula or oxygen tubing. Resident #31 stated, Ya, the staff put my oxygen on me last night. Resident #31 did not know which staff member place the oxygen on her the previous evening. Resident #31 reported no issues with her care. During an interview on 03/25/25 at 08:46 AM CNA G (assisting with Hall 100 this shift) who reported that staff are to complete rounds every 2 hours. Staff are to check if the resident was on oxygen and if the resident is wearing it properly, the hydration chamber is full, and the equipment is on. If the resident does not need the oxygen, then staff need to make sure the tubing and nasal cannula were stored correctly. CNA G reported that if the nasal cannula was on the floor, then it needed to be replaced because contact with the floor will contaminate the cannula and that staff do not want to put it on the residents nose. CNA G reported that if a nasal cannula that has been on the floor is put on a resident, then that resident would be at risk for infection. During an interview on 03/25/25 at 08:54 AM LVN C reported that staff were supposed to make rounds every two hours or more frequently if the residents need it. LVN C reported that staff were supposed to check a resident's oxygen and if the resident is on oxygen, do they have the nasal cannula on correctly and was it working. If the resident was not wearing the nasal cannula, then it should be stored correctly in a plastic bag off the floor. LVN C reported that if a nasal cannula was on the floor, then it should be immediately replaced. LVN C reported that if a nasal cannula was on the floor and then put on a resident it will place that resident at risk for infection. During an interview on 03/26/25 at 09:50 AM the DON reported that staff should make rounds as often as possible and should check a resident's oxygen when in the room. If the resident oxygen is not in use, then the tubing and cannula should be stored in a plastic bag. The DON reported that if a resident's oxygen cannula was on the floor, then it should be thrown away. The DON reported that if a nasal cannula that has been on the floor was placed on a resident's face, then it places that resident at risk for infection. During an interview on 03/26/25 at 10:14 AM the DON reported that the Oxygen Administration policy was the only policy the facility had on respiratory equipment. The DON reported that the facility did not have a specific poly on storage of the respiratory equipment like the nasal cannula and tubing. The DON reported that the facility stores the respiratory equipment in a bag off the floor for infection control. Record review of the facility provided policy titled, Oxygen Administration revised 02/13/07, revealed no information of the storage of respiratory equipment to include oxygen tubing and nasal cannula.

Based on observation, interview, and record review the facility failed to ensure residents have the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 hallways (Hall 100) that were monitored for personal privacy. A resident information sheet was left in the family area of hallway 100 for a 2-hour period. This failure has the potential to affect residents receiving care in the facility by exposing their personal medical information. Finding include: During an observation on 03/24/25 at 10:00 AM a CNA assignment sheet dated 03/19/25 was observed on a round brown table with 4 chairs at the end of the 100 Hall. Also noted in the room were two large chars for visitors and the room was labeled as the Living Room. The room was open to the 100 Hall with no doors present. The CNA assignment sheet contained 16 resident's names with the following: 16 Residents had their primary diagnoses listed. 16 Residents were listed with dietary needs from mechanical soft diet to regular diet. 16 Residents were listed as a DNR or a Full Code for their Advanced Directive. 14 Resident were listed as incontinent or continent. 11 Residents had their vital signs listed. No staff were present. Two residents were in the hallway within eyesight of the table. During an observation on 03/24/25 at 10:59 AM the same CNA assignment sheet dated 03/19/25 was observed on the round brown table at the end of the 100 Hall. No staff were present. During an observation on 03/24/25 at 12:12 PM the same CNA assignment sheet dated 03/19/25 was observed on the round brown table at the end of the 100 Hall. No staff were present. During an interview on 03/25/25 at 08:48 AM CNA G (assisting with 100 Hall care this shift) reported that resident information should be stored in a way that maintains privacy. CNA G said that resident information should not be stored where someone could see it because that could be a HIPAA violation. CNA G reported that if a resident's information was left out then someone could steal it. CNA G denied that she was the staff member that left the CNA assignment sheet at the end of the 100 Hall. During an interview on 03/25/25 at 09:54 AM LVN C reported that a resident's information should be private and covered. LVN C said that if a resident's information was left out and could be accessed it would violate the residents' rights and that is why it should be kept private so no one can access it. LVN C reported that if a resident's information was left out then anyone could read it and they could give that information to other people. A family member could be in the hallway and could read the residents information and could give that information to someone else. LVN C reported that violating a resident's private information could lead to a resident feeling disappointed, upset, and embarrassed. During an interview on 03/26/25 at 10:22 AM the DON reported that the open areas at the end of each hallway were provided for family to visit with residents. The DON reported that a residents' personal information should be covered for privacy so that it could not be seen. The DON reported that if a residents' information was left for public view the someone could steal it. The DON reported that is a residents' information was exposed then the residents' confidentiality would be affected. Record review of the facility provided policy titled, Resident Rights revised 11/28/16, revealed the following: Privacy and Confidentiality - The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

Based on observations, interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #228) of 19 residents reviewed for baseline care plans. The facility failed to ensure Resident #228's baseline care plan included information related to her diabetes and spinal fracture. This failure could place residents at risk of not receiving correct and/or necessary care/treatment. Findings included: Record review of Resident #228's face sheet dated 03/24/2025 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of first lumbar vertebra subsequent encounter for fracture with routine healing (spinal fracture) and Type 2 diabetes Mellitus without complications, unspecified fall, subsequent encounter, acute kidney failure, unspecified protein-calorie malnutrition, and Chronic respiratory failure with hypoxia (not enough oxygen in the blood). Record review of Resident #228's MDS face sheet revealed her admission MDS was not yet completed. Record review of Resident #228's baseline care plan completed on 03/18/2025 revealed no mention of her Type 2 diabetes or spinal fracture. Record review of Resident #228's Admission assessment completed on 03/18/2025 reflected no mention of her Type 2 diabetes or spinal fracture. Record review of Resident #228's active orders dated 03/18/2025 revealed the following: Humalog Kwik Pen Subcutaneous Solution Pen-Injector 100 unit/ml -Inject subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus without complications. PT/OT to evaluate and treat as indicated for primary diagnosis of fracture of first lumbar vertebra subsequent encounter for fracture with routine healing. During an observation and interview on 03/24/2025 at 09:57 AM, Resident #228 was dressed for the day and seated in her wheelchair in her room. Resident #228 stated she was a diabetic and received insulin for her diabetes. Resident stated she was in the facility for skilled care due to hurting her back during a fall. During an observation and interview on 03/25/2025 at 11:00 AM, the DON stated when a resident was admitted to the facility an admission assessment was completed by the nurse on duty with the resident or resident's representative. The DON pulled the assessment up on his computer and demonstrated how the assessment auto populated the base line care plan. The DON stated that if something was missed or not available during the admission assessment the IDT would update that information when they met with the resident or resident's representative within 48 hours of admission. During an interview on 03/25/2025 at 1:45 PM, RN H stated the nurse on duty was responsible for ensuring care was put in the baseline care plan upon a resident's admission and a possible negative outcome for not having a correct care plan would be that staff would not be aware what a resident may need. RN H stated a base line care plan is to be completed within 48 hours. During an interview on 03/25/2025 at 1:52 PM, RN I stated the DON was responsible for ensuring care plans were completed timely and correctly because it revolved around patient safety. During an interview on 03/25/2025 at 3:07 PM, the Corp RN stated the nurses were responsible for ensuring care plans were put in the system timely and correctly but overall, it was the IDT's responsibility to ensure all care plans had resident's information in them. The Corp RN stated that if information was not in the care plan, then staff would not be aware how to care for a resident. The Corp RN stated that information during admission was not always available but said that it was the IDTs responsibility to get that information from the physician, the resident or their representative and put it in the base line care plan within 48 hours. Record review of a facility policy titled Baseline Care Plans (no date) revealed the following: This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standard of quality care. The baseline care plan will- Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to Initial goals based on admission orders. Physician orders. Therapy services.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #72) of 19 residents reviewed for DNR orders. Resident #72 had a Full Code Status in active medical orders and on Resident's Face Sheet as well as a Do Not Resuscitate (DNR) form in her health record. This failure could place residents at risk of having their end of life wishes dishonored. Findings: Record review of the face sheet for Resident #72 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified intracapsular fracture of right femur (upper leg bone), subsequent encounter for closed fracture with routine healing (break within the hip joint capsule), Alzheimer's disease (memory loss) with late onset, unspecified osteoarthritis (break down of joints causing pain related to age/wear and tear), unspecified site. The Advance Directive tab on the Face Sheet documented Resident #72 as a Full Code (a patient's request to receive all possible medical interventions, including CPR, in the event of a cardiac or respiratory arrest). Record review of the Admission MDS dated [DATE] for Resident #72 revealed a BIMS score of 0 out of 15 indicating her cognition was severely impaired. Record review of Resident #72's Electronic Health Record under the miscellaneous tab contained a Do Not Resuscitate form signed by family, 2 witnesses, and physician. Record review of Resident #72's care plan dated [DATE] documented Resident #72 as DNR. Record review of Resident #72's Active Orders as of [DATE] revealed an active order for Full Code dated [DATE]. During an interview on [DATE] at 8:45 AM, the ADON stated that the nursing staff is responsible for putting the code status of the resident in the electronic health record and the nursing staff are supposed to check the next day after admission to make sure the code status was put in correctly. The ADON was shown the Orders and Face Sheet for Resident #72 which revealed the resident was a Full Code, and then was shown the DNR and Care plan which showed Resident #72 was a DNR. The ADON stated this was inaccuracy of records and the negative outcome for inaccuracy for code status for a resident could be that they could perform CPR on someone who would not want to be resuscitated. During an interview on [DATE] at 9:04 AM, LVN F stated he had worked in the facility for 3 ,d+[DATE] years. He confirmed he was the nurse working on the hallway Resident #72 was currently residing on. LVN F stated that if he had a resident who coded (someone who has experienced a cardiac or respiratory arrest, triggering a code blue or similar emergency response, and requiring immediate life-saving measures) on his shift, he would check their chart under code status and if they were a full code, he would send someone to get the crash cart (a wheeled cart stocked with emergency medical equipment, supplies, and drugs, primarily used during medical emergencies, especially for cardiac arrest resuscitation efforts) and start CPR immediately and then call 911. LVN F stated if a resident had CPR performed on them, but they were a DNR, that would be a huge problem. He stated the negative outcome for performing CPR on a resident who had a DNR could be cracking ribs and possibly killing them. During an interview on [DATE] at 9:07 AM, the DON was shown the Face Sheet for Resident #72 being a Full Code and the resident's DNR. The DON stated that it was an inaccuracy of resident records and that a negative outcome for this could be that someone could possibly not see the DNR and perform CPR, which could upset the family because their wishes were not followed. The DON stated that it was the nurse's responsibility to put in code statuses for residents. During an interview on [DATE] at 10:02 AM, the DON stated that they do not have a policy regarding accuracy of records. Record review of facility policy titled, Physician's Orders and dated 2015 revealed: Purpose: To monitor and ensure the accuracy and completeness of all physician orders. 1. Physician's monthly consolidated orders must be reviewed by a licensed nurse to assure they reflect all current orders.

Based on interviews and record review, the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from verbal abuse when on 1/23/25, the ABOM yelled at Resident #2 to get the fuck out of my office. Resident #2, who has Alzheimer's disease, was in front of the ABOM's desk and stroking his penis while asking her if she wanted to fuck. This failure could place residents at risk of mental anguish or emotional distress. This was determined to be PNC as the facility had implemented corrective actions prior to entry. Findings included: Record review on Resident #2's clinical record indicated Resident #2 was an [AGE] year-old male, initially admitted on [DATE], with the following diagnoses: Diverticulitis of large intestine with perforation an abscess (an inflammation or infection in one or more small pouches in the digestive tract which caused contents to leak in the abdomen which formed an abscess), muscle wasting and atrophy (causes muscles to lose mass and strength), difficulty in walking, psychotic disorder with delusions (cause abnormal thinking and perception and cannot tell what's real from what's imagined), major depressive disorder (persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life), Alzheimer's disease with late on set (cognitive decline that typically develops after the age of 65), diabetes (too much sugar in the blood), protein-calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function), hypokalemia (low level of potassium in the blood which can result in fatigue, muscle cramps, and abnormal heart rhythms), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (the heart doesn't pump blood as well as it should), rheumatoid arthritis (chronic inflammatory disorder usually affecting small joints in the hands and feet), benign prostatic hyperplasia without lower urinary tract obstruction (prostate gland enlargement that can cause urination difficulty), spinal stenosis (spaces inside the bones of the spine get too small), repeated falls and a fracture of lateral malleolus of right fibula (a break in the bone of outer side of the right ankle joint). Record review of Resident #2's quarterly MDS resident assessment, dated 12/30/24, documented the resident scored 11 of 15 on a mini-mental exam for cognitive awareness, Acute change in mental status, inattention, disorganized thinking. Record review of Resident #2's quarterly MDS resident assessment, dated 2/21/25, documented the resident score 9 of 15 on a mini-mental exam for cognitive awareness, he was moderately impaired for daily decision making. Record review of the Provider Investigation Report, dated 1/28/25, documented the following. On 1/23/25 at 4:40 p.m., the ABOM said, in front of two witnesses, stated she was cornered in her office by Resident #2. The ABOM stated Resident #2 said to her, will you fuck me while he was stroking his penis. The ABOM yelled at Resident #2 to get the fuck out of her office three times. ABOM was suspended on 1/24/25 when she arrived for work. Resident #2 was referred to a behavior hospital for alleged sexually inappropriate behaviors. Quality of Life rounds on residents and in-serviced staff members on abuse/neglect, dementia behaviors. (The two witnesses to this conversation were the DON and SW) Review of the Provider Investigation Report included documentation of the inservices provided to staff to cover Abuse/Neglect, dementia training with 56 staff attending. In addition, quality of life rounds were conducted with resident after the incident to ensure all residents did not have any additional concerns. Record review on 2/20/24 of the nurses' notes for Resident #2 revealed the following: 1/23/25 at 5:03 p.m. - called doctor's office on inappropriate behaviors at this time. New order for Paxil 50 mg. Stop Cymbalta and Zoloft once Paxil is in. (Paxil - treats depression, anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder) (Cymbalta - treats depression, anxiety, diabetic peripheral neuropathy, fibromyalgia and chronic muscle or bone pain) (Zoloft - treats depression, obsessive-compulsive disorder, posttraumatic stress disorder, social anxiety disorder and panic disorder) 1/24/25 at 8:50 a.m. - location of event: ABOM office Condition/behavior at time of event: Cognitive impairment, wanders, requires cueing. No pain or injury Was told by the ABOM that Resident #2 cornered her in her office and asked her if she wanted to fuck while stoking his penis three times. Initial treatment/new orders: skin assessment done on resident. Resident Statement: resident had no recollection of event and stated, I think my care is wrecked. Physician and family member notified. 1/24/25 at 11:35 a.m. - Resident was sent to a behavioral hospital for psychiatric evaluation. Record review of the Inservice Training Reports reflected the facility conducted the following in-services on: 1/25/25 - Abuse/Neglect/Dementia Training 1. Any abuse or neglect noted needs to be reported to the Administrator, take immediate action to stop abuse and report to the Administrator. 2. Please see attached policy and procedure for Abuse/Neglect 3. When a resident with dementia approaches you inappropriately, ensure you remain calm and try to redirect resident. If resident tries to become aggressive or you cannot redirect, please try, and get away from the situation, and remember to always communicate these instances with a manager so situations can be followed up. 1/26/25 - Abuse/Neglect/Dementia Training 1. Any abuse or neglect noted needs to be reported to the Administrator, take immediate action to stop abuse and report to Administrator. 2. Please see attached policy and procedures for abuse/neglect. 3. Workplace burnout is a state of mental, physical, and emotional exhaustion that occurs when chronic workplace stress goes unmanaged. 4. Ensure we are notifying managers if you are feeling burnt out at work. If you see a staff member being short with you or not acting like themselves, this could be a sign of burnout and either charge nurse or manager needs to be notified in order to address the situation. 5. Signs of Burnout: Symptoms: Feeling tired, exhausted, or powerless Having trouble sleeping Experiencing headaches, muscle pain or stomach issues Feeling disconnected from work or uninterested in it Turning to substances like alcohol or drugs to cope Feeling helpless, hopeless, or resentful During an interview on 2/29/25 at 6:50 p.m., LVN B stated Resident #2 was confused and tends to wander in other rooms looking for his wife who had passed away several years ago. LVN B stated he had heard about the incident with the ABOM, but he had never witnessed him doing any kind of sexual behaviors before. During an interview on 2/20/25 at 8:25 a.m., the DON stated about 5:00 p.m. at the end of the day shift on 1/23/25, the ABOM came to the nurses' station and said Resident #2 was sexually inappropriate with her. The DON immediately placed Resident #2 one on one after the DON was made aware of the situation and the ABOM quicky left the facility. The DON stated he called the physician and he changed some of Resident #2's medications. The DON stated the next morning, the DON met with the ABOM and LVN A in his office. The DON stated The ABOM was suspended until the investigation was completed then she was terminated for verbally abusing a resident. The DON stated the ABOM admitted she yelled at Resident #2 to get the fuck out of my office three times. The DON stated Resident #2 was sent to a behavior hospital and was now on Hospice. The DON stated Resident #2 labs were out of [NAME], his medications were changed, the family decided to place him on Hospice, Resident #2 was currently back in the facility and had no further inappropriate behaviors. During an interview on 2/20/25 at 1:35 p.m., the ABOM stated she was in her office sitting at her desk with her back against the wall. The ABOM heard a noise and when she turned around, Resident #2 was six inches away from her. The ABOM stated she stood up immediately and hoped since she stood up, she was hoping Resident #2 would move back but he did not. The ABOM stated Resident #2 asked her several times, Are you going to fuck me or not and he started to roll forward towards her. The ABOM stated that she yelled very loudly for Resident #2 to get the fuck out of her office, but no one came. The ABOM stated she was up against the wall in her office. The ABOM stated she told Resident #2 to get the fuck out of her office. The ABOM stated she was loud and direct and hoping someone would come to her rescue. The ABOM stated Resident #2 blocked the doorway and said, Is this the place to fuck? The ABOM stated she ran to the nurses' station and the ADON was there and she told the ADON to get Resident #2 out of her office because he was still stroking himself. The ABOM stated they got Resident #2 out of her office, and she left the facility and did not say a word to anyone. The ABOM came back to the facility in the morning and Resident #2 came back to her office and she told him to get away from her office. The ABOM stated the Regional Director of Nurses suspended her and then she was terminated. Record review on 2/20/25 of a statement handwritten by SW, dated 1/28/25, documented the following: In regard to Resident #2 - ABOM was moved to my office so they shared an office. Resident #2 would wander around the halls and the ABOM had commented when Resident #2 passes by that he (Resident #2) gave her the ick vibes. I informed her that the situation was pure confusion and innocent, and she shrugged her shoulders. The day after her incident with Resident #2 (1/24/25), Resident #2 passed by the office around 8:20 a.m., and she yelled out, You need to get the fuck away from this office. Resident #2 kept rolling past and did not even glance in the direction of the office. Record review of the facility's policy on Abuse/Neglect, revised 3/29/18, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, 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, such as telling a resident that she will never be able to see her family again, etc. A. Screening: The facility will conduct criminal background checks of all personnel. B. Training: The facility will train through orientation and on=going in-services on issues related to abuse/neglect prohibition practices regularly. C. Prevention: The facility will provide the residents, families, and staff an environment free from abuse and neglect. D. Identification: The facility will identify and investigate events that may constitute abuse/neglect. E. Reporting: Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. F. Investigation: All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. G. Protection: The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation. Interviews conducted throughout this two day investigation revealed all staff had knowledge and understanding of the in-services they received covering abuse/neglect and dementia training and signs of staff burnout.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated. 2. The facility failed to ensure personal items were properly stored. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 2/11/24 at 8:05 AM revealed the following: 1. 2 bags of spinach, no label or date, not in the original box. 2. 1 bag of frozen hash brown patties, no label or date, not in the original box. 3. 2 bags of okra, no label or date, not in the original box. 4. 1 plastic baggie of frozen strawberries, no label or date, not in the original box. 5. 1 plastic baggie of eggrolls with frost inside the bag and on the eggrolls. In an observation and interview of the kitchen food preparation area on 2/11/24 at 8:10 am, a personal drink cup was noted on the kitchen prep table. Cook A picked up the personal drink cup and stated the cup was hers. Cook A stated she knew she was not supposed to have personal drinks in the kitchen preparation area and the drink should have been kept in the office and not on the prep table. She stated this could contaminate the resident foods that were prepared in the kitchen. Observation of the freezer on 2/12/24 @ 10:05 AM revealed the following: 1. 2 bags of spinach, no label or date, not in the original box. 2. 1 bag of frozen hash brown patties, no label or date, not in the original box. 3. 2 bags of okra, no label or date, not in the original box. 4. 1 plastic baggie of frozen strawberries, no label or date, not in the original box. 5. 1 plastic baggie of eggrolls with frost inside the bag and on the eggrolls. In an interview and a walk through with the DM on 2/12/24 at 2:15 pm, the DM stated of the issues with the food not being labeled and dated in the freezer was that it was just missed. The DM stated she trained staff and did in-services frequently on labeling and dating and keeping personal items out of the kitchen prep areas. The DM stated she expected all staff to label and date all food items after they use the package. The DM stated the consequences of not labeling and dating foods could cause residents to have food borne illnesses. The DM stated Cook A was just nervous when she left the personal cup on the kitchen preparation table. The DM stated Cook A knew she was supposed to keep personal items out of the kitchen preparation area. The DM stated she has a place in her office where staff are to store the personal items. Record Review of the policy titled, Work Conduct, in the Dietary Services Policies and Procedures Manual updated 10/23/23, documented all personal belongings must be kept out of the food preparation area. Record Review of the policy titled, Sanitation and Food Handling, in the Dietary Services Policies and Procedures Manual updated 10/23/23, documented all food items were to be labeled and dated as to their content. Store items in their original container unless otherwise directed to do so.

Based on observation, interview, and record review the facility failed to post the following information on a daily basis: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift--registered nurses, licensed practical nurses, or licensed vocational nurses (as defined under state law), certified nurse aides-and resident census for one of one facility reviewed for posted nurse staffing information. The facility failed to post nurse staffing data as required in that it did not include the current date on posting, posting was dated 01/30/2024. This failure could place residents and visitors at risk of not being informed regarding the current day's nurse staffing levels. Findings included: During an observation on 02/11/2024 at 08:23 AM the nurse staffing posting hanging on the wall hanging next to Nurses station in the center of the facility was dated 01/30/2024. Observation on 02/13/2024 at 08:03 AM revealed the nurse staff posting hanging on the wall next to Nurses station in the center of the facility was dated 12/12/2024. Observation on 02/13/2024 at 10:11AM revealed nursing staff posting hanging on the wall next to the Nurses station in the center of the facility was dated 12/13/2024. Interview on 02/13/2024 at 10:02 AM with ADON, stated that the schedule should be updated on a daily basis. ADON stated, My template that I use the date was not updated to show the correct date. I fixed it the day you guys came in. ADON stated there could be a negative outcome. Interview on 02/13/2024 at 10:07 AM with DON, stated that a negative outcome for not having an updated schedule could lead to staffing ratios not being correct. Interview on 02/13/2024 at 11:14 AM with ADM, stated We do not have a policy regarding schedule posting and that the facility will follow regulations. Record review of the code of Federal Regulations revealed the following guidelines: S 483.35(g) Nurse Staffing Information. S 483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #188) of 18 Residents reviewed for comprehensive care plans. -The facility failed to include care plans for Resident #188's use of oxygen therapy. This failure could affect residents receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Finding include: Record review of Resident #188's face sheet dated 2-12-2024 revealed she was a [AGE] year-old female resident admitted to the facility originally on 3-27-2019 and readmitted on [DATE] with diagnoses to include acute respiratory failure with hypoxia (sudden failure of lungs to deliver oxygen to the body), Influenza ) a common, sometimes deadly viral infection of the nose, throat, and lungs, also called the flu), major depression (mental illness causing sadness due to lack of chemicals in the brain that cause happiness), falls, anemia (low red blood cell count), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), hypertension (a condition in which the force of the blood against the artery walls is too high), and Rheumatoid Arthritis (autoimmune inflammation of the joints). Record review of Resident #188's clinical record revealed her last MDS assessment was a quarterly completed 1-10-2024 listing her with a BIMS of 15 indicating she was cognitively intact, and she required the use of a walker and partial/moderate assist with her activities of daily living. Record review of Resident #188's Orders form with active orders as of 2-12-2024 revealed the following orders: May use oxygen @ 2 l/m via nasal cannula every day and night shift- Active 1-11-2024. Record review of Resident #188's Oxygen saturation log from 2-1-2024 to 2-11-2024 revealed that Resident #188 was wearing her Oxygen 26 of the 32 times that her oxygen saturation was checked. Record review of Resident #188's care plan with admitted [DATE] revealed the following: There was no care plan for oxygen therapy. During an observation and interview on 02-12-2024 at 11:15 AM Resident #188 was noted to be wearing her O2 via NC with hydration set at 3L/min. Resident #188 reported that at one time she was down to needing only 1L/min of oxygen therapy but due to her recent hospitalization she was back to needing 3L/min. Resident #188 stated that she hopes that she can get stronger and wean herself from needing oxygen in the future. During an interview on 02-13-2024 at 09:19 AM with MDS B, MDS C, and MDS D all 3 MDS Nurses were asked that since Resident #188 had orders for oxygen therapy, had documentation for monitoring O2 saturations/oxygen therapy, and Resident #188's MDS was marked for O2 therapy why wasn't Resident #188 care planned for oxygen therapy. MDS C stated that if the oxygen therapy is acute the floor nurses will update the care plan and if the oxygen therapy comes across the MDS when the MDS assessment is due then the MDS nurses would update the care plan. All 3 MDS nurses were asked since it was in the MDS then why wasn't Resident #188's care plan updated, none of the MDS nurses responded. When asked what a negative outcome would be for not updating the care plan, MDS C stated that the residents wouldn't receive the care they are planned for. Record review of facility provided policy titled Comprehensive Care Planning, undated, revealed the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident 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 highest practicable physical, mental, and psychosocial well-being . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the residents medical, physical, and psychosocial needs. When developing a comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) .

Based on observations, interviews, and record reviews the facility failed to store food in accordance with professional standards for food service safety to prevent food borne illness in one of one kitchen observed for safe food storage in that: Food stored in the walk-in refrigerator, walk-in freezer, and dry storage area was not properly labeled, dated, and stored. These failures could place residents who eat food served by the kitchen at risk of food-borne illness. Findings included: An observation on [DATE] at 08:35 AM of the refrigerator revealed the following: 1. A small white bowl of what appeared to be collard greens covered with plastic wrap, unlabeled and undated; 2. Opaque square plastic tub with red lid labeled as gravy with only one date of ,d+[DATE]; 3. Orange slices in a steam table tray labeled and dated ,d+[DATE] and ,d+[DATE]; 4. Sausage in resealable plastic bag dated ,d+[DATE] and ,d+[DATE]; 5. Bologna in a resealable plastic bag with only one date of ,d+[DATE]; 6. BBQ Rib meat in a resealable plastic bag dated ,d+[DATE] and ,d+[DATE]; 7. Pot roast in a resealable plastic bag with only one date of ,d+[DATE]; 8. Flour tortillas in a resealable plastic bag with only one date of ,d+[DATE]; 9. Cooked spaghetti noodles in a resealable plastic bag with only one date of ,d+[DATE] An observation on [DATE] at 08:42 AM of the pantry revealed the following: 1. The lid to the plastic bucket of cornmeal was not sealed leaving the cornmeal open to air. 2. The lid to the plastic bucket of sugar was not sealed leaving the sugar open to air. 3. An almost empty plastic bottle of Hershey's chocolate syrup was sitting on a shelf with the lid partially open. The lid was unable to close due to a buildup of a gummy brown substance around the lid. The bottle was labeled and dated but the label and date were unreadable. The manufacturer's directions on the bottle indicated the bottle needed to be refrigerated after opening. An observation on [DATE] at 08:52 AM of the freezer revealed the following: 1. A resealable plastic bag of what appeared to be biscuits with no label or date. During an interview on [DATE] at 10:53 AM, Cook A stated leftover items in the refrigerator should be dated with two dates, the date we make and 6 days afterward. She stated items in the freezer should be dated, the day we got it. Cook A said whoever grab[sic] it was responsible for dating leftovers. When asked who was responsible for clearing expired food from the refrigerator she stated, whoever checks, me, her (gestured to the DM), the other cook. Cook A said a possible negative outcome of having food improperly labelled, dated, and stored would be, somebody can get sick. During an interview on [DATE] at 10:59 AM DM stated leftover food in the refrigerator should be dated, The day we use it and then from that day, 7 days out. She stated kitchen staff label freezer food the day it arrives at the facility. DM said she and the cooks are responsible for labeling and dating food as well as clearing expired food from the refrigerator. She said a possible negative outcome for improperly dated food was, it could make them (residents) sick. She said the same outcome could be true for items not refrigerated properly. When asked to provide a possible negative outcome for improperly sealed food in the pantry, DM said, I would think dust or bugs could get into it. During an interview on [DATE] at 11:46 AM ADM stated DM is responsible for labelling and dating food as well as removing expired food from the refrigerator and pantry. She said a possible negative outcome of food being improperly dated or stored was, You know, illness. Record review of the facility provided policy titled Left - Over Foods and dated 2012 revealed the following: 1. Left-over foods shall be refrigerated, dated, labeled, and properly covered promptly after meal service. 4. The guidelines from the 'Texas Food Establishment Rules' will be used when determining the shelf life of leftovers. Record review of the facility provided policy titled Cooling Methods Fact Sheet and dated [DATE] revealed the following: . Once the food item has been properly cooled, it should be stored properly - covered and labeled with the 7 day use by date, with the day of preparation being day one. Record review of the facility provided Record of Departmental In Service and Meetings given by DM and attended by 7 kitchen staff on [DATE] at 09:30 AM revealed the following: . Summary/Objectives .Date all left over food for 7 days the day it's cooled is day 1. We follow the Texas Food Establishment Rules for left over food storage. After 7 days food is thrown out. All food must have an in date and an out date and product name.

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 1 of 3 Residents (Resident #39) reviewed for incontinent care. -CNA D and E failed to use proper hand hygiene techniques when providing incontinent care to Resident #39. This failure had the potential to affect all residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Record review of Resident #39 face sheet dated 12/12/22 reviewed an [AGE] year-old female admitted to the facility on [DATE] with diagnose included, but were not limited to, Alzheimer's disease with late onset, metabolic encephalopathy, urinary tract infection site not specified. Record review of Resident #39 Quarterly MDS dated [DATE] revealed BIMS of 09 of 15 indicating moderately impaired cognition. MDS revealed resident is always incontinent of urine and frequently incontinent of bowel. Record review of Resident #39 care plan last reviewed 09/26/22 revealed the resident has bladder and bowel incontinence. During an observation of incontinent care on 12/11/22 at 02:45 pm for Resident #39, CNA E returned to the room with a bag of incontinent supplies for incontinent care for the resident. Both CNA D and CNA E proceeded to tell the resident what they were intending to do, however they did not wash their hands with soap and warm water or utilize ABHR prior to starting care. Both CNA D and CNA E placed gloves on and completed the incontinent care. No gloves or handwashing or use of ABHR was observed when the dirty brief was removed and prior to the new brief was picked up and placed on the resident. All dirty supplies were placed in a bag at the end of the care and both CNAs removed their gloves. CNA D washed her hands first and then CNA E washed her hands with warm water and soap from resident's sink. During an interview on 12/11/22 at 03:15 pm with CNA D, she was asked about not seeing her washing her hands prior to the incontinent care and was this appropriate. CNA D answered, she did not know she was supposed to do this. CNA D was asked about not changing gloves or washing her hands prior to putting on the resident's new brief and what the consequences of this could cause. CNA D responded that she was nervous and forgot to do this as a part of her procedure and that not doing this could cause contamination to the brief. During an interview on 12/11/22 at 03:25 pm with CNA E, she was asked not seeing her washing her hands prior to incontinent care was this appropriate. CNA E stated this could cause infection. CNA E was asked about not changing gloves or washing her hands prior to putting on the resident's new brief and what the consequences of this could cause. CNA E responded this could contaminate the clean material and that she did not learn this when she became certified. During an interview on 12/13/22 at 08:13 am with the DON, she was asked when do you expect hand hygiene to be completed during incontinent care. DON stated, before they start, after peri-care, from dirty to clean portion, at end and every time they touch the resident. She was asked what do you feel the consequences could be if hand hygiene is not performed. DON stated UTI's and infection control. Record review of facility provided policy titled, Perineal Care dated effective 5/11/22 revealed the following: . Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition Procedure Content . 10) Perform hand hygiene . 24) Doff gloves and PPE 25) Perform hand hygiene . Record review of facility provided competency titled, Nurse Aide Incontinence Care-Proficiency Assessment not dated, revealed the following: This is a supplement to the competencies listed in the competency verification form . Technical competence necessary for safe clinical practice . Complete visual observation and return demonstration . Demonstrates proficiency in performing technical procedures safely in accordance with division standards as evidences by unit-specific criteria. Washes hands before gathering supplies . Washes hands . Puts on gloves . Washes hands/changes gloves . Record review of facility provided policy titled, Fundamentals of Infection Control Precautions, dated 2018, revealed the following: .Hand Hygiene 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: .Before and after assisting a resident with toileting (hand washing with soap and water); .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. It is necessary for staff to have access to proper hand washing facilities with available soap (regular or anti-microbial), warm water, and disposable towels and/or heat/air drying methods. .Except for situations where hand washing is specifically required, antimicrobial agents such as ABHR are also appropriate for cleaning hands and can be used for direct resident care. .Gloving . Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves . Failure to change gloves between resident contacts is an infection control hazard

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) for accidents and hazards. The facility failed to ensure Resident #1 was properly transferred using two staff resulting in a laceration to her left lower leg requiring sutures. This failure could place residents that require two-person staff assistance with transfers at risk for falls, accidents or injuries. The findings included: Record review of Resident #1's face sheet, dated 09/12/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (group of symptoms that affects memory, thinking and interferes with daily life), type 2 diabetes, hereditary and idiopathic [CONDITION(S)] (disease affecting peripheral nerves that causes weakness, numbness and pain in feet and hands), heart failure, chronic embolism and [CONDITION(S)] of unspecified deep veins of left lower extremity (blood clot), [CONDITION(S)] (condition that results in swelling of the leg or arm) and [CONDITION(S)] disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement.) Record review of Resident #1's Quarterly MDS assessment, dated 08/16/22, revealed a BIMS score of 2 out of 15 which indicated her cognition was severely impaired. The MDS also revealed she required extensive, two-person assistance with transferring, bed mobility, dressing, and toilet use, and limited, one-person assistance with eating and personal hygiene. Record review of Resident #1's care plan, dated 09/01/22, revealed, in part The resident has an ADL Self Care Performance Deficit . TRANSFER: The resident has requires [sic] x2 staff participation with transfers. Record review of Resident #1's Kardex, dated as of 09/09/22 revealed, in part, TRANSFER: The resident has requires [sic] x2 staff participation with transfers. Record review of a document in Resident #1's chart titled, SBAR 3.0 - V2 [communication tool that helps provide essential, concise information, usually during crucial situations], documented by LVN B, revealed, in part, Situation .A. I am contacting you about the following (select all that apply) .8a. Skin Change (rash, injury, ulcer, etc.) .8b. Skin Evaluation .7. Laceration .8bb. Describe location and the symptoms or signs .Left lower leg .15. This started on and/or symptoms first appeared .09/07/2022 . Record review of a document in Resident #1's chart titled, eTransfer Form - V5, documented by LVN B, revealed, in part, .Describe the reason for transfer .Large laceration to left lower leg .2. Date and time of the transfer .09/07/2022 18:36 .3. Is this an emergency transfer (transferred to the hospital prior to MD, PA, or NP notification) .1. Yes . 3. Current Resident Status .a. Current Primary Diagnosis Dementia .1. Level of Consciousness .1. Alert .2. Orientation:(select all that apply) .5. None of the above .3. Communication (select all that apply) .1. Clear Speech . 10. Is the resident's current status different from their baseline? .1. No . 8. Devices Used by the Resident .1. Select all the devices normally used by the resident .11. Wheelchair . Record review of facility provided hospital document titled, AFTER VISIT SUMMARY, for Resident #1, dated 09/07/22, revealed, in part, Today's Visit .Reason for Visit .Leg Avulsion (injury in which a body structure is torn off by either trauma or surgery; most commonly refers to a surface trauma where all layers of the skin have been torn away, exposing the underlying structures) .Diagnosis .Laceration of the left lower leg .Done today .Laceration Repair .Read the attached information .Laceration Repair with Stitches Discharge Instructions . A medical records request was sent to the hospital on 09/08/22, but at the time of investigation, no additional documents had been received. Record review of Resident #1's electronic chart during the time of investigation on 09/09/22 and 09/12/22 revealed no incident note found, no progress note found and no mention of how laceration was received. During a confidential interview on 09/08/22 at 12:11 PM, Individual F stated they observed Resident #1's leg wound, and she had a very large wound to her left calf. They stated the wound was approximately 8x10 centimeters, full thickness (a wound that extends through all layers of skin including subcutaneous tissue and could reach muscle, tendons, or bone, depending on the wound stage). They stated it was a nasty, nasty wound. They stated Resident #1 was obviously in distress. They stated Resident #1 had dementia and [CONDITION(S)] but could tell Resident #1 knew it hurt. They stated Resident #1 could answer yes or no questions but was generally confused about who, what, when, where, or why. They reported they were not told how the wound happened, they were told, I don't know, she [Resident #1] was moving from the wheelchair to the bed and not sure when or where it happened. It was a very, very large wound and very obviously painful wound. During an observation and interview on 09/09/22 at 9:20 AM, Resident #1 was in her room, lying in her bed under a blanket. She appeared well-groomed and in no distress. Her left lower leg was observed with an ACE bandage wrapped from her ankle to just below her knee with a wound dressing underneath. Both of her legs appeared swollen, and her right leg had brown discoloration observed from the middle of her shin and down. There were two small areas of yellow-colored bruising observed to two areas of her left thigh. Resident #1 was able to state her name and birthday and that she was from another state. When asked where she was now, she was unable to name specifically but stated, half-way across the country. When asked if she was in the hospital recently, she stated, oh this [motioned to the identification bracelet on her wrist] is from where I was there helping with the program. When asked if she had fallen recently, she stated no but then stated, it was a combined effort with someone else here. When asked if her left leg hurt, Resident #1 began to talk about another topic. Resident #1 would rarely speak with her eyes open. She mumbled often and would often talk about another topic other than what was being asked. At the end of the interview, she stated she needed to get up and get dressed for work. During an interview on 09/09/22 at 11:41 AM, the DON stated the incident with Resident #1 happened right after shift change on 09/07/22. The DON stated she was still at the facility, at the nurse's station working on something, and the nurse working on the hall with Resident #1, LVN B, came to inform her about Resident #1's laceration. The DON stated Resident #1 had big legs, her skin was thin and fragile, and she had a lot of fluid. The DON stated the aide working that hall, CNA A who worked for an agency company and who had transferred the resident multiple times, had never had any problems transferring her before. The DON stated CNA A stood resident #1 up to transfer her from her wheelchair to her bed and she pivoted well. The DON stated after Resident #1 was transferred, CNA A noticed a big gash on her leg when he picked her legs up to put them on the bed and she was bleeding profusely. The DON stated emergency services were contacted and an ambulance arrived approximately 10 minutes later. The DON stated she believed the facility staff covered the wound to protect it while the ambulance was on its way. She stated when she arrived at the room, she observed dark red blood on Resident #1. The DON stated, when it popped open, it's like there was blood pooled right inside but it was not running out anymore. She stated the wound looked like when initially it let loose [opened], there was all this blood and then it kind of stopped. We all came down there and looked at it. What it looked like was like when something is under pressure and it hit something, it split open. The DON stated they immediately called the doctor and the resident's family member and completed an SBAR. The DON stated they knew Resident #1 was going to have to have stitches. The DON stated she thought it was weird because there were no sharp objects for Resident #1 to have hit to cause a laceration. The DON stated Resident #1 was not in pain though she was confused and hard to talk to. The DON stated Resident #1 would say no when asked if she was in pain. The DON stated Resident #1 had obtained skin tears before and her skin was papery thin. The DON stated the resident had leg wraps in the past before to reduce swelling due to [CONDITION(S)]. The DON stated the agency CNA A was by himself during the transfer of Resident #1. She stated LVN B was just outside the room, and it only took her a second to get in there when CNA A called for help. When asked what Resident #1's transfer assistance requirements were, the DON stated, It looks like she was a two-person transfer on her care plan. When asked if she knew why CNA A was transferring Resident #1 by himself, the DON stated she did not know why. She stated Resident #1's Kardex [tool used to provide a brief overview of a resident's needs and requirements] also revealed Resident #1 required two person assistance for transfers. When asked why CNA A transferred her by himself, the DON stated, My guess would be he didn't read the Kardex. I don't know of any other reason, there were two aides on that hall. The DON stated there should have been two staff members to transfer Resident #1. When asked what a negative resident outcome could have been when transferring a resident who required two-person assistance with only one person, the DON stated, things like this. When asked if agency staff were oriented to the facility when they arrived, the DON stated, Most all of them have PCC [electronic charting system used by the facility] experience, I have not had one that had not worked with PCC. There is no orientation process necessarily, but they do get shift to shift report. The DON stated when agency staff come to work at the facility, they were expected to be able to read a Kardex and properly chart their activities (using PCC) as long as they were oriented to the residents they were supposed to be taking care of that shift. The DON stated, apparently, we should do a better job. That is probably a failure on our part to make sure they understand [to look at PCC and the resident's chart[. We should make sure they have that understanding. During a telephone interview on 09/09/22 at 1:57 PM, CNA A stated he was familiar with Resident #1. He stated her legs were very swollen due to some underlying health issues he was not sure of. He stated he was working at the facility when she was transferred to the hospital on 09/07/22. He stated she was in her wheelchair in her room, and he went in to see how her day was and if she was finished with her supper and she said she was ready for bed. He stated he got her positioned where he could lay her down in her bed. CNA A stated Resident #1 could pivot well and stand well. He stated he made sure the side rail was down on her bed and, you lift with your legs and pivot her to the bed. I did that normally. The second I sat her on the side of the bed, I noticed her leg was bleeding real bad. He stated he then notified the nurse, she was right outside the door. He stated the nurse was LVN B. He stated LVN B alerted the DON and the other nurse, and they all assessed Resident #1. He stated, that has never before happened with me. I was freaking out when it happened. My first instinct was to see if there was anything sharp, like on the wheelchair or the bed, but nothing poked her. She pivoted really well. When she sat down, I noticed blood spewing out of her leg. He stated he used a gait belt to assist with the transfer. When asked what Resident #1's transfer requirements were, he stated she required extensive assistance with one-person. He stated Resident #1 was not a hard transfer, she stood well for herself and there was no resistance and she was not bearing her weight down. CNA A stated Resident #1 did not hit anything that he was aware of. He stated she was not grimacing in pain, nor did she appear to be in pain after the transfer. He stated she was still talking about her day and going on perfectly fine. He stated there was no struggle getting her into her bed. He stated before the transfer, her legs looked the same as he remembered them being before. CNA A stated when he was getting ready to transfer her, it was obvious that she did not have the wound before the transfer but did have it after the transfer. He stated he knew she was a one-person transfer due to his experience with her. He stated he would look at a resident's Kardex if he did not know about a particular resident, but he worked at that facility a lot and Resident #1's report was the same as it always had been. He stated he has not looked at Resident #1's Kardex in a while, he had known her for months and he usually transferred her by himself. During an interview on 09/09/22 at 2:10 PM, the DON stated she was not sure how Resident #1's injury occurred. She stated when she looked in Resident #1's room after the incident, she did not see anything sharp that would have caused her laceration. She stated, that's not saying she couldn't have hit something, we just couldn't figure it out. During a telephone interview on 09/09/22 at 2:43 PM, CNA A stated there was no blood on the floor around Resident #1's legs or wheelchair or any obvious leg injury prior to him transferring Resident #1. He stated he had seen her legs prior to the transfer, and they were darker in color than what he remembered but did not see anything noticeable otherwise. He stated after the transfer, the bleeding was coming from the outside of her left leg. He said, her leg was open in that area and leaking blood, it was all very fast for me. The second I made sure she was safe I got the nurse. He stated there was nothing obstructing her path from her wheelchair to her bed. He stated he moved her wheelchair close to her bed, she was in front of him, and the bed was to his left. He stated he used a gait belt and she stood and pivoted to her right, his left, and sat on the bed with no difficulty. He stated he bent down to pick up her feet to put them on the bed, and that is when he noticed the wound. He stated he was told by a wound care nurse afterwards that Resident #1's legs were so swollen, things like that could have happened. During attempted telephone interviews on 09/09/22 at 11:09 AM and 09/12/22 at 2:21 PM, LVN B was called to discuss the incident regarding Resident #1 that happened during her shift. There was no answer, and the voice mail was full and could not accept any more messages. During a telephone interview on 09/12/22 at 3:46 PM, Individual E, Resident #1's family member, stated he was notified when Resident #1 was being sent to the hospital on 09/07/22, they [facility staff] said they were putting her to bed and got her into bed and noticed on the outside of her left leg, there was a pretty strong laceration. He stated Resident #1 was on blood thinners and her skin was sensitive to impact to possible lacerations. He stated he was told the staff noticed it was open and bleeding and they were able to quickly get the bleeding stopped and called him and sent her to the hospital. He stated as the hospital staff later got ready to work on the laceration, it was a pretty good size laceration. He stated the wound was mainly between her knee and ankle, it was probably by 3 x 4 [did not specify inches or centimeters] with a couple of lacerations, one running up and one running down. He stated he had a number of pictures of the wound before the hospital started working on it and while they were working on it. He stated, as they got into it, it was definitely into the subcutaneous area, and it opened up to one point, it was all the way down to the muscle sheath that runs with the bone. He stated, you couldn't see the bone, but you could see the muscle. He stated it took about 80 stitches subcutaneously and around 20 stitches on the surface. He stated the facility was not sure in the process of getting her into bed what her leg hit. It's unfortunate. He stated Resident #1 was not able to tell him what happened, she has [CONDITION(S)] and also diabetes. He stated she had quite a bit of confusion. She has not been able to tell me. I don't know if she is going to be able to shed any light. He stated she was admitted to the facility in early April 2022 and he has had no concerns with the facility, of any big consequence. We are fairly pleased with how they are treating [Resident #1]. When asked if she has had problems with her legs being very swollen before, he stated, Oh yes. The [CONDITION(S)] was a huge problem, and she is diabetic, too. Back in 2021, she got a big blister. For [Resident #1], it was a 9-month process to heal. She has a history; it's been a tough road. We pray it will go well but we have been here before. During an observation and interview on 09/12/22 at 4:15 PM, Resident #1 was in her room, sitting in a wheelchair. Her left lower leg was observed with an ACE bandage wrapped from her ankle to just below her knee with a wound dressing underneath. Both of her legs appeared swollen, and her right leg had brown discoloration observed from the middle of her shin and down. She did not appear in any distress and was wearing a night gown and otherwise appeared well-groomed. When she was asked how she was feeling, she stated, not good and when asked to elaborate, her words could not be deciphered. She slowly began to move her left leg off the wheelchair footrest, as if she wanted to try to stand up. When asked if she wanted to get in her bed, she stated yes, and patted the bed next to her. When asked if her left leg was hurting, she stated, no. (Her left leg wound was not observed during the time of the investigation since when the surveyor was present in the facility, wound care was not scheduled to be completed on those days.) During an interview on 09/12/22 at 55:15 PM, a policy for preventing accidents and/or hazards was requested from the Regional Nurse however the facility did not have one. During a confidential interview on 09/14/22 at 12:15 PM, Individual G stated they observed Resident #1's leg and there was a huge laceration .measured about 15 to 20 centimeters both ways [vertical and horizontally]. They stated it took two hours to be repaired. They stated the injury was not something that happened by just scraping, It was a huge laceration. They stated they did not observe any other injuries to Resident #1. They stated Resident #1 had an altered mental status that was baseline for her. They stated Resident #1 said she was not hurting but they felt like Resident #1 probably was hurting with how big the laceration was. They reported the resident required stitches but was not able to report how many. Individual G stated they did not know how Resident #1 obtained the wound, they were told the person who transferred the resident felt like the resident transferred well and never saw anything until the person went to put her in bed and then saw the blood. Record review of a facility provided policy titled, Resident Rights, dated 11/28/16, revealed, in part, .Safe Environment - the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.