Every finding on record at Fox Hollow Post Acute

Based on observation, interview and record review, the facility nursing staff failed to demonstrate competencies and skill-sets to care for residents' needs, as identified through resident assessment, and described in the plan of care, for 1 of 4 (Resident #1) residents reviewed. The facility failed to ensure CNA A continuously monitored and maintained proper positioning while sitting in her wheelchair for Resident #1. This deficient practice could place residents affect residents at risk of not receiving care and services to meet their needs. Findings included:Record review of Resident #1's admission record, dated 07/24/26, reflected a [AGE] year-old female re-admitted on [DATE] and originally admitted on [DATE]. Her relevant diagnoses included acute chronic systolic heart failure (a long-term stable weak heart pumping condition), dementia (a decline in mental ability severe enough to interfere with daily life), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter flood), and subsequent non-st elevation (NSTEMI) myocardial infarction (a heart attack that occurs within four weeks (28 days) of a previous one.Record review of Resident #1's significant change MDS assessment, dated 07/03/26, reflected a BIMS score of 03, which reflected her cognition was severely impaired.Record review of Resident #1's quarterly care plan, dated 06/27/26, reflected:Focus: 06/04/2026 [Resident #1] has impaired skin integrity as evidenced by skin abrasion (abrasion) to rt foot 1st, related to trauma. Date initiated 06/04/2026.Interventions/Tasks: See NP, x-rays 2 views R foot, administer treatments as ordered and monitor for effectiveness, notify the physician if signs or symptoms of infection occur, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date initiated 06/04/26.Record review of Resident #1's progress notes/change of condition, dated 06/04/26 at 3:13 p.m., authored by ADON C reflected: Situation: skin wound or ulcer.nursing observations: [Resident #1] sitting at nurse's station when this nurse observed bleeding from right foot. [Resident #1] does with abrasions and bleeding.Record review of Resident #1's Skin Issues assessment, dated 06/04/26 at 7:46 p.m., reflectedSkin issues: new issue, location: right dorsum (top surface of foot)1st digit, 2nd digit, 3rd digit, and 4th digit: Skin issue: abrasion, Progress: new wound, acquired: in-house acquired, .Presence of wound pain: no.During an observation and interview on 07/23/26 at 9:45 a.m., Resident #1 was observed lying in bed awake. Her right foot was observed wrapped in clean white gauze, covering her toes. Resident #1 was not interviewable.During a telephone interview on 07/24/26 at 1:43 p.m., CNA A said Resident #1 was non-verbal, was not ambulatory and relied on her specialized wheelchair for ambulation. CNA A said Resident #1 had no sensation to her left leg and feet. She said on 06/04/26, while she was exiting the employee's breakroom, Resident #1 was sitting in the dining room in her wheelchair and waved her over. CNA A said when she approached Resident #1, she asked her to take her outside to get fresh air. CNA A said she asked her charge nurse for permission and was told it was ok to take her outside. She said Resident #1 had both feet on the footrest, wearing socks, and had a blanket covering her legs and feet. CNA A said she proceeded to wheel Resident #1 outside through the front door. CNA A said once they were outside, Resident #1 requested to be taken around the facility and she agreed. CNA A said she wheeled Resident #1 around the building one time and then proceeded to take her back inside and parked her in front of the nurse's station. CNA A said about ten minutes after leaving her in the nurse's station, CNA B confronted her and asked her what had happened to Resident #1. CNA A said she had no idea what she was talking about and asked CNA B what she meant. CNA A said CNA B told her Resident #1's right toes were bleeding. She said she was called to the DON's office where she was questioned regarding what had happened. CNA A said she advised the DON and the Administrator that she had no idea what had happened to Resident #1. She said Resident #1 had not complained or had any facial grimacing while they were outside. CNA A said the Administrator started reviewing their surveillance camera and that's when they found out what happened. CNA A said she saw on the surveillance camera Resident #1's right foot had slipped off the footrest and dragged along the gravel as wheelchair moved. CNA A said she had failed to ensure Resident #1's feet were on her wheelchair's footrest periodically while she wheeled her around the building. CNA A said the fact that Resident #1 had a blanket covering her legs and feet might have caused her to overlook where her feet were. CNA A said she never saw blood, and Resident #1 never verbally complained or had facial grimacing. CNA A said that was the first time she had ever taken a resident outside the facility. CNA A said she had been in-serviced many times on transfer procedures, feet positioning while in the wheelchair, and safety. CNA A said a negative outcome to Resident #1 not having her feet on the wheelchair's footrest would be that she can get hurt. She said she had successfully completed her annual skill checks.During an interview on 07/24/26 at 2:09 p.m., CNA B said on 06/04/26 at around 2:30 p.m., she noticed Resident #1 sitting in her wheelchair in front of the nurse's station. She said when she proceeded to wheel her back to her room to lay her down, she noticed Resident #1's right foot was bleeding. She said Resident #1 did not have any facial grimacing or complained of pain. CNA B said she immediately called ADON C to go assess Resident #1. CNA B said ADON C helped her take Resident #1 back to her room. CNA B said when they got to Resident #1's room, the wound care nurse was also assisted in transferring Resident #1 back to bed. CNA B said once Resident #1 was in bed, she continued rounding other residents.During an interview on 07/24/26, at 2:18 p.m., ADON C said Resident #1 was non-verbal, non-ambulatory, and relied on her specialized wheelchair to get around. She said Resident #1 had no feeling to her right leg/foot. She said on 06/04/26, she had been called by CNA C to the nurse's station to assess Resident #1. She said she observed Resident #1's had abrasions to her 1st, 2nd, 3rd, and 4th toes and were bleeding. She said she Resident #1 was wearing socks so the blood had already absorbed. She said between her and CNA B took Resident #1 back to her room to lay her down. She said while in Resident #1's room, the wound care nurse arrived, and both assessed Resident #1. She said they notice Resident #1's 1st, 2nd, 3rd, and 4th, toes had abrasions and no deformities were observed. She said Resident #1's NP was notified and ordered x-rays of her foot, pain medication was administered, and family member was notified. ADON C said Resident #1 was seen by her podiatrist on 06/05/26 and no new orders were given. ADON C said Resident #1's x-rays were negative for fractures. She said wound care was initiated immediately after laying Resident #1 in bed and continued to this date. ADON C said Resident #1's wounds were healing and looked good. ADON C said she and the facility's DON regularly in-service staff on proper foot placement in wheelchairs and assuring footrest are in place.During an interview and observation on 07/24/26 at 2:25 p.m., the WCN said on 06/04/26, she had been called to Resident #1's room. She said when she arrived, ADON C and CNA B were with Resident #1. She said between all three, they transferred Resident #1 back to her bed. The WCN said Resident #1 had not voiced any pain, nor she had any facial grimacing during the transfer. The WCN said she immediately assessed Resident #1 and observed she had an abrasion to her right foot 1st, 2nd, 3rd, and 4th digits. She said she had immediately initiated wound care and as of today, her 2nd, 3rd, 4th abrasions were resolved. The WCN said Resident #1's 1st digit nail was still being treated. The WCN said she was later told Resident #1's right foot slipped off the wheelchair's footrest more than likely had contact with street. The WCN said Resident #1 had no sensation to her legs and feet.During an interview on 07/24/26 at 2:45 p.m., the DON said Resident #1 is non-verbal, was non-ambulatory, had a specialized wheelchair for transport, and relied on staff for all her ADLs. The DON said on 06/04/26, she was told Resident #1 was observed sitting in her wheelchair by the nurse's station. She said CNA B observed Resident #1's right foot bleeding and immediately notified ADON C. She said upon being assessed by the facility's WCN and ADON C, Resident #1 was observed with an abrasion on 1st, 2nd, 3rd, and 4th right toes. The DON said she was told that earlier that day CNA A had taken Resident #1 taken Resident #1 outside because she felt a bit anxious. She said she and the Administrator immediately interviewed CNA A but denied any incident occurred to Resident #1 while she wheeled her around the facility. The DON said the Administrator reviewed the surveillance camera and that's when they discovered what happened to Resident #1. She said what they saw was while Resident #1 was being wheeled, she had a blanket covering her legs and feet and only wearing socks. The DON said while CNA A wheeled Resident #1 around the facility, in one of the turns, her right foot slipped from the wheelchair's footrest and dragged along the street while she was being wheeled. The DON said she observed Resident #1 with no facial grimacing. The DON said CNA A was observed failing to ensure Resident #1's feet were properly positioned on the wheelchair footrests, which resulted in Resident #1's right foot dragging on the street while she was being wheeled. She said Resident #1's NP was immediately notified; x-rays were ordered with no acute findings. She said Resident #1 continues with wound care treatment and abrasions were almost healed. The DON said she and the facility's ADONs regularly in-serviced staff on wheelchair safety, which included proper placement of feet. The DON said CNA A was immediately terminated because of the fact that it happened. The DON said a negative outcome for CNA failure to ensure Resident #1 had her feet resting on the wheelchair's footrest at all times was the possibility of an injury.During an interview on 07/24/26 at 2:59 p.m., the Administrator said after reviewing the facility's CCTV that Resident #1's right foot abrasions occurred while she was being wheeled outside by CNA A. He said he initiated an investigation, in-services were conducted to all staff, nursing interventions were added as well, MD and family were made aware, police report made, skill checks were initiated on all direct contact staff. He said CNA A was terminated. The Administrator said all staff were in-serviced on the topic of ANE weekly and as needed. Record review of the facility's Staffing, Sufficient and Competent Nursing policy revised April 2025, reflected: The facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation:Competent Staff:1.Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles occupational functions successfully.3.Licensed staff must demonstrate the skills and techniques necessary to care for residents needs including.b. resident rights.g. person-centered care

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #2) reviewed for medications. Facility failed to administer physician ordered medications Lisinopril and Clopidogrel Bisulfate to Resident #2 on 07/12/26. This failure could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death.Finding included: Record review of Resident #2' admission record, dated 07/23/26, reflected a [AGE] year-old male admitted on [DATE] and discharged on 07/13/26. His relevant diagnoses included cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery (an ischemic attack where blood flow to the right side of the brain is reduced or blocked by a narrowed or closed vessel), toxic encephalopathy (a brain dysfunction caused by exposure to harmful substances (prescription drugs or heavy metal), diastolic heart failure (when the main pumping chamber of the heart becomes thick and stiff), and hypertension (when blood pushes too strongly against your artery walls at readings consistently at or above 130/80).Record review of Resident #2's MDS assessment was still in progress.Record review of Resident #2's initial care plan, dated 07/13/26, reflected:Focus: Hypertension: [Resident #2 has a diagnosis of hypertension and is at risk for elevated blood pressure. Date initiated: 07/13/26. His interventions included administer medication as ordered. Date initiated: 07/13/26.Record review of Resident #2's physician order summary, dated 07/23/26, reflected: Lisinopril Oral tablet 5 mg (Lisinopril) give 2 tablet by mouth two times a day for HTN. Order date 07/11/26 and start date 07/12/26. Clopidogrel Bisulfate tablet 75 mg. Give 1 tablet by mouth one time a day for blood clot prevention. Date ordered 07/11/26 and start date 07/12/26. Record review of Resident #2's July 2026 MAR reflected: Lisinopril Oral tablet 5 mg (Lisinopril) give 2 tablet by mouth two times a day for HTN, start date 07/12/26 had a code 9 (pending medication) on 07/12/26 at 8:00 a.m. Clopidogrel Bisulfate tablet 75 mg. Give 1 tablet by mouth one time a day for blood clot prevention, start date 07/12/26 had a code 9 (pending medication) on 07/12/26 at 8:00 a.m. Record review of the facility's emergency automated dispensing cabinet list of medications reflected that on 07/12/26 there were 6 Lisinopril Oral tablet 5 mg and 6 Clopidogrel Bisulfate tablet 75 mg. Record review of the Resident #2's Delivery Manifest Report, dated 07/12/26 at 4:57 p.m., reflected lisinopril and clopidogrel were delivered to the facility on [DATE] at 4:57 p.m. Record review of Resident #2's progress notes on 07/12/26 did not reflect LVN D's attempts to contact the pharmacy or NP regarding his orders for lisinopril and clopidogrel. During an interview on 07/23/26 at 3:28 p.m., LVN D said she was Resident #2's charge nurse on 07/12/26 from 6 a.m. to 6 p.m. She said Resident #2 was admitted the evening of 07/11/26 and since his admission he displayed aggressive behaviors towards staff and family members. She said Resident #2 refused all his over the counter medications (vitamins) during her shift. LVN D said Resident #2 had an order for lisinopril 2 tablets twice a day at 8:00 am and 8:00 pm and clopidogrel one time a day at 8:00 a.m. LVN D said she entered code 9 for both lisinopril and clopidogrel because they were pending for the pharmacy to deliver the medications. LVN D said she did not check the facility's emergency automated dispensing cabinet to see if lisinopril and clopidogrel were available. She said since Resident #2 refused the over the counter medications she figured he was going to refuse lisinopril and clopidogrel also. LVN D said sometime during her shift she notified Resident #2's NP that he was noncompliant with his over the counter medications but did not mention the facility had not yet received lisinopril and clopidogrel. She said she must have forgotten to mention it because she was too busy monitoring Resident #2 and continued thinking he would have also refused those two medications also. LVN D said there were no negative outcomes to Resident #2 not administered lisinopril and clopidogrel because she continued thinking he would refuse them also. LVN D said she had been in-serviced on medication administration and knew to check of the facility's emergency automated dispensing cabinet when a resident's order is pending to be delivered by the pharmacy to ensure residents don't skip medications. During a telephone interview on 07/24/26 at 11:25 a.m., the Dr. said he was called on 07/11/26 when Resident #1 was admitted to reconcile his medications. He said Resident #2 was admitted with altered mental status. The Dr. said Resident #2 started displaying noncompliance with medications and behavioral problems upon admission. He said on 07/12/26, a facility nurse called him to let him know Resident #2 was being non-compliant with his medications but was not told the pharmacy had not yet delivered lisinopril and clopidogrel. The Dr. said in my professional opinion, there were no negative outcomes to Resident #2 not being administered lisinopril and clopidogrel for one day (07/12/26). He said Resident #2 was sent out to the hospital the morning of 07/13/26 due to his altered mental status and remained hospitalized where he continued to refuse medication. During an interview on 07/24/26 at 10:18 a.m., the DON said Resident #2 was admitted the evening of 07/11/26 and discharged to the hospital on [DATE]. She said Resident #2 displayed verbal and physical aggression towards staff and family members since his he was admitted . The DON said LVN D should have checked the facility's emergency automated dispensing cabinet to see if lisinopril and clopidogrel were available. The DON said staff are continuously reminded to the facility's emergency automated dispensing cabinet to ensure medications were administered as ordered. The DON said if the medication(s) have not been delivered by the pharmacy, nursing staff should be calling the pharmacy to check on their status, notify the resident's NP, and ensure they document all their efforts. The DON said all nursing staff were regularly in-serviced on the topic of medication administration. The DON said there were no negative outcomes to Resident #2 because he had been non-compliant with his medications since he was admitted and the following day he was sent out to the hospital for altered mental status. Record review of the facility's Administration Medication policy, not dated reflected: Medications are administered in a safe, timely, and clinically appropriate manner in accordance with all prescriber orders and regulatory requirements.Any medication refusals, omissions, or errors must be documented and reported in accordance with facility policy and reviewed through the QAPI process. Staff are expected to follow all established procedures to ensure accountability and continuous quality improvement.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected he no longer used an air mattress. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.Findings included:Record review of Resident #1's face sheet, dated 06/26/26, reflected an [AGE] year-old male, admitted on [DATE], diagnoses included: encounter for orthopedic (bones or muscle) aftercare following surgical amputation, absence of left leg below knee, type 2 diabetes mellitus (insulin resistance and high blood sugar levels), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping), dysphagia (trouble swallowing), chronic kidney disease (condition that affects the kidneys' ability to filter waste from the blood), and muscle wasting and atrophy (reduction in muscle mass and strength). Record review of Resident #1's MDS assessment, dated 06/08/26, reflected a BIMS score of 06, indicating severe cognitive impairment. The MDS reflected Resident #1 required setup or clean up assistance (helper assists only prior to or following the activity) for roll left and right; and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for sit to lying and lying to sitting on side of bed. Record review of Resident #1's care plan, dated 06/26/26, reflected [Resident #1] had a pressure ulcer, unstageable, to sacrum and was at risk for further breakdown and/or slow, delayed healing related to impaired circulation, impaired nutrition, and incontinence of bladder. Date initiated: 05/02/26. Interventions included: administer treatment as ordered and air mattress. Record review of Resident #1's order summary, dated 06/27/26, reflected an order of air mattress to bed as tolerated. Start date of 05/01/26. Order was discontinued on 05/22/26. During an interview and observation, on 06/27/26 at 2:00 PM, Resident #1 stated he was doing well. Resident #1 stated he had another mattress before but he did not like it. Resident #1 stated it was not comfortable for him so the staff changed the mattress but he did not remember when. Resident #1 was observed with no visible injury. Resident #1 was observed to be laying supine on a regular mattress with no air mattress or pump. During an interview, on 06/27/26 at 2:25 PM, the ADON stated she was not sure if Resident #1 had an air mattress. The ADON stated the WC Nurse entered the order for the air mattress to help with wound healing and added the intervention to the care plan. The ADON stated if the air mattress was discontinued, Resident #1's care plan should have been updated by the WC Nurse to reflect he longer used an air mattress. The ADON stated there was no negative outcome for Resident #1 as staff followed his orders. The ADON stated it was important to ensure the care plans were revised as needed so that everyone was aware of how to care for the resident. During an observation, on 06/27/26 at 2:55 PM, Resident #1 was observed by the ADON and the ADON verified he was not using an air mattress. During an interview, on 06/27/26 at 3:00 PM, the WC Nurse stated she was responsible for updating care plans for wounds or skin changes and related interventions. The WC Nurse stated Resident #1 had an air mattress but it was discontinued on 05/22/26 because he did not like the way the air mattress felt. The WC Nurse stated if the air mattress was still on the care plan, it should have been resolved and removed. The WC Nurse stated there was no negative outcome for Resident #1 as staff followed his orders and he was able to move/reposition himself in bed. The WC Nurse stated it was important for the care plan to be updated accurately to ensure all staff were aware of the resident's current needs and how to care for him. During an interview, on 06/27/26 at 3:30 PM, the DON stated the WC Nurse was responsible for developing and revising care plans related to wounds and skin changes. The DON stated Resident #1 had an air mattress for the wound on his sacrum, but Resident #1 did not like the air mattress so it was discontinued on 05/22/26. The DON stated Resident #1 was mobile, moved around in bed, and the air mattress was going to cause more damage than good if he did not like the air mattress. The DON stated the care plan was not updated to reflect that the air mattress was discontinued. The DON stated there was no negative outcome or risk of injury for Resident #1 as staff followed his orders and the wound to his sacrum had improved. The DON stated it was important for the care plan to be revised and accurate to ensure everyone was aware of the correct information and to follow through with the interventions for the resident's current needs. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, undated, reflected - Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Residents #1) of 5 residents reviewed for accidents and supervision. The facility failed to ensure Resident #1 who had a previous history of elopement, received adequate supervision to prevent elopement. Resident #1 exited from the facility front entrance on 05/02/26 at around 8:40 PM. Resident was found roughly 2 miles from facility on a busy 2-way street that did not have a sidewalk and returned to the facility about 5 hours after he eloped. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 05/02/26 and ended on 05/04/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining serious injury, harm, and death. The findings included: Record review of Resident #1's face sheet with a date of 06/02/2026 was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of dementia (an umbrella term for a decline in mental ability that is severe enough to interfere with daily life). Record review of Resident #1's quarterly MDS dated [DATE] reflected a Brief Interview for Mental Status scored 5 (severe cognitive impairment). Record review of Resident #1's elopement/wander assessment completed at admission on [DATE] reflected a score of 10 indicating he was at risk for wandering or elopement. A follow-up assessment was done on 5/03/26 after the incident with a risk score of 28 indicating he was at risk for wandering or elopement. Record review of Resident #1's care plan reflected it had been started at time elopement on 05/02/26 but was not completed. Record review of Residents #1's chart reflected that he was admitted to the facility from home on [DATE] at around 3:30pm. Recorded review of Resident #1's medical chart reflected that after the elopement, the care plan for Resident #1was updated to reflect the elopement and interventions including the addition of a wander guard. During an interview on 06/02/26 at 11:00 a.m., Resident #1 said that he wanted to go home. Resident #1 said that he did not remember leaving the facility on 05/02/26. During an interview on 06/03/26 at 9:00 AM, CNA A revealed she was assigned to work with Resident #1 05/02/26 but stated she did not receive a report from the previous aide to inform her that Resident #1 was a new admission. CNA A stated she realized Resident #1 was a new resident when she was doing her documentation. CNA A stated she last saw Resident #1 at 06:30pm on 05/02/26 in his room. CNA A was not aware of any history or behaviors that Resident #1 had. During an interview on 06/02/2026 at 9:20 PM with CNA B revealed she did not know there was a new resident until 10:48 PM and went into Resident #1's room and she did not see him in his bed. CNA B went and informed LVN C on 05/02/26 at 10:48pm that Resident #1 was not in his room. CNA B stated the previous shift staff would inform them resident's needs, supervision, and risks. However CNA B stated with regards to Resident #1 she was not made aware on 05/02/26. During an interview and record review of the facilities front door alarm log on 06/02/26 at 9:37 AM with the Maintenance Director revealed the front door alarm system was functioning appropriately at time of Resident #1's elopement and when checked after his return. Front door alarm log documents reflected they were checked daily. The Maintenance Director stated the doors are locked at all times. The maintenance Director stated there was a receptionist every day from 08:00 AM to 05:00 PM . During an interview on 06/03/26 at 9:45am with LVN C revealed that she was the assigned nurse for Resident #1 and stated after she was notified by CNA B of Resident #1 missing, she immediately informed the Administrator and DON of Resident #1 missing and the facility began their procedures for a missing resident at 10:48pm. LVN C stated she got report that that their was a new resident when she started her shift at 7:00pm but stated she was not informed or aware of any behaviors, risks or supervision requirements. LVN C stated at time of Resident #1's elopement she had not yet gone to see Resident #1. During an interview on 06/03/2026 at 10:33 AM with the DON revealed that residents who were identified at risk for elopement did not necessarily need a wander guard unless the resident showed signs of exit seeking behaviors. The DON stated that she did not mention Resident #1's history of elopement to staff. The DON stated that when Resident #1 came back to the facility he was assessed by the ADON and did not have any injuries, he did complain of pain to his feet and pain medication was administered. During an interview on 06/02/26 at 3:45 PM with the Administrator revealed Resident #1 was seen on video surveillance exiting the facility through the front door on 05/02/26 at around 8:40pm behind a person who was not identified. The Administrator stated Resident #1 was returned to the facility at 1:40AM on 05/03/26 by police and had been found roughly 2 miles away from the facility. The Administrator stated he stated an investigation and that Resident #1 was assessed by the ADON and did not have any injuries, he did complain of pain to his feet and pain medication was administered. The Administrator stated that before admission he was informed about Resident#1's history of elopement from home. The Administrator stated that after the incident the facility On 05/03/26 Completed a head to toe assessment to ensure resident is safe, new wandering assessment done on all 5 residents who had wander guards on 05/03/26, the wandering binder was updated, staff was educated on rounding and wandering on 05/03/26, Resident #1's care plan was updated. During an review on 06/02/26 at 3:45 PM of still image revealed Resident #1 exiting front door and he was wearing dark clothing. During an interview with Resident #1's RP on 06/03/26 at 10:19 AM revealed that prior to admission she met with the admission Coordinator and informed her that Resident #1 had couple of incidents of elopement from home. RP stated that Resident #1 eloped from home 3 weeks prior to admission. RP stated that Resident #1 had Dementia and was confused. During an interview with the admission Coordinator on 06/03/26 at 10:30 AM revealed she had been made aware by Resident #1's RP of his previous incidents of elopement from home. The admission Coordinator stated that she informed the IDT team of Residents #1's history of elopement from home during a meeting prior to admission. During an interview with the DON 06/03/26 at 10:33am she stated she felt there was a system failure due to the staff not checking on Resident #1 for 4 hours, and stated the resident was exposed to danger due to being by himself and there was a potential risk for his own safety because it was a busy street. The DON said Resident #1 returned to facility complaining of foot pain, and further imaging revealed no negative findings. DON stated that staff should round every 2 hours. During an interview with the Administrator on 06/03/26 at 11:00am he stated that they did not consider Resident #1's history of elopement from home as an active behavior or risk because his last elopement from home occurred in March. The Administrator stated that Resident #1 was found by the police around 2 miles away from the facility. Observation completed on 06/03/26 at 12:00 p.m., of street where Resident #1 was found on 05/03/26 reflected that Resident #1 was located on a busy 2-way street that did not have a sidewalk. During an observation on 06/4/26 on 600 hall from 9:00 am to 3:00 pm of staff rounding reflected nursing staff rounded on residents every 1 hour and 40 minutes to 2 hours and 20 minutes. During an observation of the front door on 06/03/26 between 05:30pm and 06:30pm when no receptionist was present revealed 3 visitors input a code to unlock the door to exit. During an interview with the Administrator on 06/03/26 at 07:08pm revealed families had access to the door code to exit facility at all times but could only enter from the outside using the code from 5am-5pm; and if visiting after 5pm would need to have staff open the door. The Administrator stated the facility had changed the door code on 05/03/26 and sent out notifications to families on 05/03/26 regarding facility access procedures related to the front door code being changed monthly and as needed, hours the access code worked and procedures for visiting outside of those hours and signing in. The Administrator stated staff were in- serviced on ensuring the door closed behind them when exiting and entering. The Administrator stated that visitors were informed by a texting service on 05/03/26. Record review of facility's policy titled Wandering and Elopements with a revision date March 2019, reflected: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents Record review of facility's policy titled Safety and Supervision of Residents undated reflected: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 05/02/26 and ended on 05/04/26. The administrator was made aware of past non-compliance on 06/04/26 at 5:54 p.m. The facility had corrected the noncompliance before the survey began. On 05/02/26 Facility called a code pink, searched for Resident #1 in and around facility, called PD, called local hospitals. This was verified by interviews with staff who worked on 05/02/26 and with leadership staff. On 05/03/26 Completed a head-to-toe assessment to ensure resident is safe. Record review of head to toe assessment of Resident #1 on 05/03/26 was reviewed and indicated there were no injuries. [Psych provider] consultation for Resident #1 Record review reflected that Resident #1 had a psych consultation on 05/15/26. New wandering assessment done on all 5 residents who had wander guards on 05/03/26. These were reviewed on 06/03/26 and reflected they were updated on 05/03/26. Staff education on rounding and wandering on 05/03/26. Record review of facility's in-services reflected the staff was educated on rounding and wandering on 05/03/26. CNA G, CNA H, CNA H, CNA I, CNA M from 06:00 am to 02:00 pm shift. CNA A and CNA J from 02:00 pm to 10:00 pm shift. CNA B, and CNA K from 10:00pm to 06:00 am shift. LVN D, LVN L from 07:00 am to 07:00 pm shift. LVN C, LVN E, LVN F from 07:00 pm, to 07:00am shift, and ADON, DON and admission coordinator confirmed recent in-services and demonstrated understanding. Educated nurses on what steps to occur if elopement evaluation is greater than 10 on 05/03/26. Record review of inservice titled steps to occur if elopement evaluation is greater than 10 was done on 05/03/26. Updated elopement binder to include anyone which is at risk 05/03/26. Record review of elopement binder reflected it was updated. Updated care plan of Resident #1 on 05/03/26. Record review of Resident #1's care plan reflected it was updated on 05/03/26. Conducted an elopement drill on 05/03/36. Record review of Elopement drill log reflected that was conducted on 05/03/26. Resident family members were made aware of door access times and procedures for visiting which included having to sign in and wear a visitor sticker badge to identify who is a visitor. Staff were in-serviced over door safety and ensuring the door was closed behind them when entering or exiting the facility. Record review of inservice titled door safety and ensuring the door was closed behind them when entering or exiting the facility was done on 05/03/26. Completed wander guard evaluation and added one to the Resident #1 on 05/03/26. Record review of Resident #1 wander guard evaluation reflected it was done on 05/03/26. Educated staff on assessing clinical picture of new admissions between IDT and Admissions team on 05/04/26. Record review of inservice titled assessing clinical picture of new admissions between IDT and Admissions team reflected it was done on 05/04/26. CNA A, CNA B, LVN L and ADON were interviewed on 06/04/26 and confirmed they were in serviced on ensuring the door closed behind them when exiting and entering. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 05/02/26 and ended on 05/04/26. The administrator was made aware of past non-compliance on 06/04/26 at 5:54 p.m. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 Residents (Resident #1) reviewed for antibiotic medication. Facility failed to acquire and administer physician ordered antibiotics to treat Resident #1's identified UTI. On [DATE] R#1was sent to hospital, admitted with septic shock and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death.Findings included: Record review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old female with an admission date of [DATE] with pertinent diagnoses that included End Stage Renal Disease (is the final stage of chronic kidney disease (stage 5), where kidneys lose of function, causing kidney failure. It requires life-sustaining treatment, such as dialysis or a kidney transplant.) Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 which meant intact cognitive status. Resident #1 received dialysis while being a resident. Record review of Resident #1's comprehensive care plan dated date initiated [DATE] revealed she was on antibiotic therapy Blujepa related to infection Urinary tract infection/E. Coli (Escherichia coli are bacteria commonly found in the intestines of humans and animals), initiated on [DATE]. Interventions: administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 6:52 p.m., authored by LVN A reflected: Resident #1 complained of general weakness. LVN A called NP C and he ordered to draw Complete blood count (a common blood test that measures the cells circulating in your blood ) and comprehensive metabolic panel (a routine 14-test blood panel used to evaluate liver/kidney function, fluid balance, and metabolism). Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 9:41 a.m., authored by LVN B reflected Resident #1 complained of general weakness. LVN B called NP C and he ordered to ammonia level (measures the amount of ammonia in your blood to check for liver or metabolic issues) and urinalysis with culture (a two-part diagnostic test used to detect and identify urinary tract infections). Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 1:50 p.m., authored by LVN E reflected (HE/SHE) reported lab results and urinalysis to NP C. No new orders at that time. Record review of Resident #1's urinalysis results received on [DATE] revealed leukocytes 500 in the urine (ref range- Negative).Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 12:25 p.m., authored by LVN B reflected she notified the NP C on [DATE] of the urine culture results. NP C provided a new order for Blujepa [oral antibiotic to treat urinary tract infections] 750 mg twice per days for 5 days and a consult with infection preventionist NP D. Record review of Resident #1's on her electronic medication administration record dated [DATE], reflected no documentation that her order for Blujepa was administered. Record review of Resident #1's nurses notes on her electronic medical record showed no documentation regarding the delivery/acquisition status of the medication Blujepa and no documentation of follow up communication with the pharmacy or NP/MD. Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 6:53 p.m., authored by LVN A reflected NP D discontinued order for Blujepa and ordered Invanz 500 mg IV every night for 10 days. Record review of Resident #1's on her electronic medication administration record dated [DATE], reflected no documentation the order for Invanz [a broad spectrum antibiotic used to treat serious bacterial infection, including Urinary Tract Infections] was administered. Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 10:46 a.m., authored by LVN A reflected, while at dialysis, Resident#1 became lethargic, had low blood pressure, and Resident #1 was sent to the hospital via EMS. Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 4:52 p.m., authored by LVN A reflected she was admitted for septic shock (a life-threatening, advanced stage of sepsis where infection causes severe, widespread inflammation and dangerously low blood pressure), NSTEMI (a type of heart attack caused by a partial blockage of a coronary artery) and thrombocytopenia (a medical condition characterized by an abnormally low number of platelets in the blood). Record review of Resident #1's hospital record dated [DATE] reflected Resident #1 expired on [DATE] from cardiac arrest (a medical emergency where the heart suddenly and unexpectedly stops beating, causing it to stop pumping blood to the brain, lungs, and other organs.) During a phone interview on [DATE] at 2:27 p.m., NP C stated that he was notified on [DATE] regarding Resident #1, and he ordered a complete blood count and a comprehensive metabolic panel. NP C stated that on [DATE], he ordered a urinalysis with culture and an ammonia level. NP C stated that on [DATE], he was called and was notified on the urinalysis results and he did not give any orders. He stated he wanted to wait for the urine culture results because Resident #1 did not have any symptoms. NP C stated that on [DATE], he received the results on the urine culture and he ordered Blujepa and a consult with NP D. NP C stated that he was not called regarding the Blujepa antibiotic not arriving to the facility from the pharmacy until after 3 to 4 days. During a phone interview on [DATE] at 3:10 p.m., NP D stated that she went to the facility on [DATE] for a consultation with Resident #1. NP D stated that she discontinued the order for Blujepa, because it was a contraindication for residents with renal failure. NP D stated she ordered Invanz 500mg IV every night for 10 days for E coli in the urine. NP D stated it was a possibility that an untreated UTI could lead to septic shock and death. During a phone interview on [DATE] at 3:30 p.m., the Pharmacy staff stated that the pharmacy received the order for the Blujepa on [DATE]. Pharmacy staff stated that the blujepa medication was a new antibiotic, and it usually took 3 to 4 days to arrive to the facility. Pharmacy staff stated that the facility was aware of the delay of the medication. Pharmacy staff stated that, on [DATE], the facility had 4 vials of Invanz 500mg available in the emergency kit machine. During an interview on [DATE] at 4:00 p.m., LVN A stated that on [DATE], Resident #1 told him that she was feeling generalized weakness and that she was not feeling her normal self. LVN A stated that he called NP C and notified him. LVN A stated that NP C ordered a comprehensive complete panel and a complete blood count. LVN A stated, on [DATE], NP D came to the facility and she changed the antibiotic order to Invanz. LVN A stated that he did not recall if he called the pharmacy to follow up regarding the antibiotic status, or when the medication was going to arrive the facility. LVN A stated, on [DATE], he received a call from dialysis that the resident was sent out to the hospital due to lethargy and weakness. During an interview on [DATE] at 6:30 p.m., LVN F stated that on [DATE], when the dose for Invanz was due, he checked the emergency kit machines that were in the facility and that he did not find the Invanz antibiotic. LVN F stated that he did follow up with the pharmacy, and that the pharmacy told him that the Invanz antibiotic would get to the facility in the morning, but he forgot to document that in the Resident #1's electronic chart. During an interview on [DATE] at 9:58 a.m., with LVN B stated that, on [DATE], she reported the urine culture results to NP C, NP C ordered Blujepa, and she ordered the antibiotic from pharmacy. LVN B stated that she did follow up with the pharmacy, but she did not document on the Resident's electronic chart. LVN B stated that the pharmacy said that they had received the order for Blujepa on [DATE]. LVN B stated that she forgot to ask the estimated time of arrival. During an interview on [DATE] at 3:05 p.m., with the DON stated she was not aware Resident#1 had not received her antibiotics. DON stated staff should follow up on medication to ensure it was delivered and received, and if the medication was not available, they should be in communication with the NP to see what else they could do. DON stated that she was not aware that the antibiotic was going to be delayed. During an interview on [DATE] at 4:00pm, the Administrator stated that the facility did not have a policy for quality of care. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:48PM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 5:48pm and the POR was asked at this time. The following Plan of Removal (POR) submitted by the facility was accepted on [DATE] at 05:27 p.m.: Plan of RemovalName of Facility- [Facility]Date of Compliance: [DATE] F684- Quality of CareImmediately actions1. DON and/or designee will educate nursing staff on monitoring residents with identified UTI symptoms and confirmed UTIs and documentation on [DATE]. Staff not currently working will be educated prior to their next shift. 2. DON and/or designee will educate nurses on monitoring and following up with residents who had antibiotics ordered and documenting status updates on [DATE]. Staff not currently working will be educated prior to their next shift. 3. DON an/or designee will educate the nurses and med aids on monitoring the availability and acquisition of physician ordered medication along with verifying anticipated delivery date of medication and appropriately documenting it on [DATE]. Staff not currently working will be educated prior to their next shift. 4. DON and/or designee will educate nurses on following up and in communication with the NP/MD when an ordered medication is not available and ensuring the communication is reflected in the clinical record on [DATE]. Staff not currently working will be educated prior to their next shift. 5. DON and/or designee will educate nurses about reviewing the ekit for availability of ordered medication on [DATE]. Staff not currently working will be educated prior to their next shift. 6. IP and/or designee audited all residents with active orders for antibiotics to confirm that medication is available and administered on [DATE]. 7. ADONS and/or designee will audit all residents with antibiotics and infections to ensure that residents are being monitored and documented daily. 8. ADONs and/or designee will audit residents with active orders for antibiotics to confirm that medication is available and administered daily.9. ADONs and/or designee will review, during workday clinical meetings, new physician ordered medication to ensure that medication was delivered, or communication and documentation is reflected in the clinical record if there is a delay or med is not available.10. DON will perform a random review of 5 residents with antibiotics weekly to ensure compliance with antibiotic administration, monitoring, and documentation. 12. [SIC]If any discrepancies are found, they will be addressed immediately.13.[SIC] Findings and trends will be reported by the administrator to QAPI Committee. Monitoring and verification of the POR included the following: In-service attendance sheet was verified on [DATE] staff were inservice on monitoring residents with identified UTI symptoms and confirmed UTIs and documentation. Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were educated on signs and symptoms of UTIs and the monitoring and documentation of signs and symptoms. In-service attendance sheet was verified on [DATE] staff were inservice on monitoring and following up with residents who had antibiotics ordered and documenting status updates Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were educated on following up and documenting, the status updates of ordered antibiotics. In-service attendance sheet was verified on [DATE] staff were inservice on monitoring the availability and acquisition of physician ordered medication along with verifying anticipated delivery date of medication and appropriately documenting. Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were educated on calling the pharmacy to verify availability and anticipated delivery date of ordered medication and document in the resident's charts. In--service attendance sheet was verified on [DATE] staff were inservice on following up and in communication with the NP/MD when an ordered medication is not available and ensuring the communication is reflected in the clinical record Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were educated on notifying provider when a medication is not available and were aware of document the communication on the residents charts. In-service attendance sheet was verified on [DATE] staff were inservice on reviewing the ekit for availability of ordered medication. Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were aware to review the kit for any new order medication to check for availability. Record review on [DATE] of the 24 hours summary from [DATE] to [DATE] revealed all residents on antibiotics were monitored for any s/s. Record review of the Sampled residents, Resident #2, Resident #3, and Resident #4's, MAR revealed they all had orders for antibiotics, and the antibiotic was administered as prescribed. During an interviews with, the ADON clarified that whoever was assigned to work on weekends will verify medication was delivered, or communication and documentation is reflected in the clinical record if there is a delay, or med is not available. She stated, during the weekdays, the ADONs will verify. During interview with the DON, she verified random review of 5 residents with antibiotics weekly to ensure compliance with antibiotic administration, monitoring, and documentation, she also stated that any discrepancies will be addressed immediately. During an interview with the Administrator, he stated he did not identify any other residents with similar issues, however, any finding and trend will be reported to the QAPI committee. The Administrator was informed that the Immediate Jeopardy was removed on [DATE] at 5:27 p.m., however, The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered- care plan, and the resident's choices for 1 (Resident #1) of 3 residents reviewed for quality of care. The facility failed to treat a confirmed infection despite two provider orders, resulting in septic shock and death, with no evidence of clinical follow-up or intervention An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death. This failure resulted in Resident #1 being admitted to the hospital with septic shock on [DATE], and expiring on [DATE].Findings included: Record review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old female with an admission date of [DATE] with pertinent diagnoses that included End Stage Renal Disease (is the final stage of chronic kidney disease (stage 5), where kidneys lose of function, causing kidney failure. It requires life-sustaining treatment, such as dialysis or a kidney transplant.) Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 which meant intact cognitive status. Resident #1 received dialysis while being a resident. Record review of Resident #1's comprehensive care plan dated date initiated [DATE] revealed she was on antibiotic therapy Blujepa related to infection Urinary tract infection/E. Coli (Escherichia coli are bacteria commonly found in the intestines of humans and animals), initiated on [DATE]. Interventions: administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 6:52 p.m., authored by LVN A reflected: Resident #1 complained of general weakness. LVN A called NP C and he ordered to draw Complete blood count (a common blood test that measures the cells circulating in your blood ) and comprehensive metabolic panel (a routine 14-test blood panel used to evaluate liver/kidney function, fluid balance, and metabolism). Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 9:41 a.m., authored by LVN B reflected Resident #1 complained of general weakness. LVN B called NP C and he ordered to ammonia level (measures the amount of ammonia in your blood to check for liver or metabolic issues) and urinalysis with culture (a two-part diagnostic test used to detect and identify urinary tract infections). Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 1:50 p.m., authored by LVN E reflected (HE/SHE) reported lab results and urinalysis to NP C. No new orders at that time. Record review of Resident #1's urinalysis results received on [DATE] revealed leukocytes 500 in the urine (ref range- Negative).Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 12:25 p.m., authored by LVN B reflected she notified the NP C on [DATE] of the urine culture results. NP C provided a new order for Blujepa [oral antibiotic to treat urinary tract infections] 750 mg twice per days for 5 days and a consult with infection preventionist NP D. Record review of Resident #1's on her electronic medication administration record dated [DATE], reflected no documentation that her order for Blujepa was administered. Record review of Resident #1's nurses notes on her electronic medical record showed no documentation regarding the delivery/acquisition status of the medication Blujepa and no documentation of follow up communication with the pharmacy or NP/MD. Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 6:53 p.m., authored by LVN A reflected NP D discontinued order for Blujepa and ordered Invanz 500 mg IV every night for 10 days. Record review of Resident #1's on her electronic medication administration record dated [DATE], reflected no documentation the order for Invanz [a broad spectrum antibiotic used to treat serious bacterial infection, including Urinary Tract Infections] was administered. Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 10:46 a.m., authored by LVN A reflected, while at dialysis, Resident#1 became lethargic, had low blood pressure, and Resident #1 was sent to the hospital via EMS. Record review of Resident #1's nurses notes on her electronic medical record dated [DATE] at 4:52 p.m., authored by LVN A reflected she was admitted for septic shock (a life-threatening, advanced stage of sepsis where infection causes severe, widespread inflammation and dangerously low blood pressure), NSTEMI (a type of heart attack caused by a partial blockage of a coronary artery) and thrombocytopenia (a medical condition characterized by an abnormally low number of platelets in the blood). Record review of Resident #1's hospital record dated [DATE] reflected Resident #1 expired on [DATE] from cardiac arrest (a medical emergency where the heart suddenly and unexpectedly stops beating, causing it to stop pumping blood to the brain, lungs, and other organs.) During a phone interview on [DATE] at 2:27 p.m., NP C stated that he was notified on [DATE] regarding Resident #1, and he ordered a complete blood count and a comprehensive metabolic panel. NP C stated that on [DATE], he ordered a urinalysis with culture and an ammonia level. NP C stated that on [DATE], he was called and was notified on the urinalysis results and he did not give any orders. He stated he wanted to wait for the urine culture results because Resident #1 did not have any symptoms. NP C stated that on [DATE], he received the results on the urine culture and he ordered Blujepa and a consult with NP D. NP C stated that he was not called regarding the Blujepa antibiotic not arriving to the facility from the pharmacy until after 3 to 4 days. During a phone interview on [DATE] at 3:10 p.m., NP D stated that she went to the facility on [DATE] for a consultation with Resident #1. NP D stated that she discontinued the order for Blujepa, because it was a contraindication for residents with renal failure. NP D stated she ordered Invanz 500mg IV every night for 10 days for E coli in the urine. NP D stated it was a possibility that an untreated UTI could lead to septic shock and death. During a phone interview on [DATE] at 3:30 p.m., the Pharmacy staff stated that the pharmacy received the order for the Blujepa on [DATE]. Pharmacy staff stated that the blujepa medication was a new antibiotic, and it usually took 3 to 4 days to arrive to the facility. Pharmacy staff stated that the facility was aware of the delay of the medication. Pharmacy staff stated that, on [DATE], the facility had 4 vials of Invanz 500mg available in the emergency kit machine. During an interview on [DATE] at 4:00 p.m., LVN A stated that on [DATE], Resident #1 told him that she was feeling generalized weakness and that she was not feeling her normal self. LVN A stated that he called NP C and notified him. LVN A stated that NP C ordered a comprehensive complete panel and a complete blood count. LVN A stated, on [DATE], NP D came to the facility and she changed the antibiotic order to Invanz. LVN A stated that he did not recall if he called the pharmacy to follow up regarding the antibiotic status, or when the medication was going to arrive the facility. LVN A stated, on [DATE], he received a call from dialysis that the resident was sent out to the hospital due to lethargy and weakness. During an interview on [DATE] at 6:30 p.m., LVN F stated that on [DATE], when the dose for Invanz was due, he checked the emergency kit machines that were in the facility and that he did not find the Invanz antibiotic. LVN F stated that he did follow up with the pharmacy, and that the pharmacy told him that the Invanz antibiotic would get to the facility in the morning, but he forgot to document that in the Resident #1's electronic chart. During an interview on [DATE] at 9:58 a.m., with LVN B stated that, on [DATE], she reported the urine culture results to NP C, NP C ordered Blujepa, and she ordered the antibiotic from pharmacy. LVN B stated that she did follow up with the pharmacy, but she did not document on the Resident's electronic chart. LVN B stated that the pharmacy said that they had received the order for Blujepa on [DATE]. LVN B stated that she forgot to ask the estimated time of arrival. During an interview on [DATE] at 3:05 p.m., with the DON stated she was not aware Resident#1 had not received her antibiotics. DON stated staff should follow up on medication to ensure it was delivered and received, and if the medication was not available, they should be in communication with the NP to see what else they could do. DON stated that she was not aware that the antibiotic was going to be delayed. During an interview on [DATE] at 4:00pm, the Administrator stated that the facility did not have a policy for quality of care. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:48PM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 5:48pm and the POR was asked at this time. The following Plan of Removal (POR) submitted by the facility was accepted on [DATE] at 05:27 p.m.: Plan of RemovalName of Facility- [Facility]Date of Compliance: [DATE] F684- Quality of CareImmediately actions1. DON and/or designee will educate nursing staff on monitoring residents with identified UTI symptoms and confirmed UTIs and documentation on [DATE]. Staff not currently working will be educated prior to their next shift. 2. DON and/or designee will educate nurses on monitoring and following up with residents who had antibiotics ordered and documenting status updates on [DATE]. Staff not currently working will be educated prior to their next shift. 3. DON an/or designee will educate the nurses and med aids on monitoring the availability and acquisition of physician ordered medication along with verifying anticipated delivery date of medication and appropriately documenting it on [DATE]. Staff not currently working will be educated prior to their next shift. 4. DON and/or designee will educate nurses on following up and in communication with the NP/MD when an ordered medication is not available and ensuring the communication is reflected in the clinical record on [DATE]. Staff not currently working will be educated prior to their next shift. 5. DON and/or designee will educate nurses about reviewing the ekit for availability of ordered medication on [DATE]. Staff not currently working will be educated prior to their next shift. 6. IP and/or designee audited all residents with active orders for antibiotics to confirm that medication is available and administered on [DATE]. 7. ADONS and/or designee will audit all residents with antibiotics and infections to ensure that residents are being monitored and documented daily. 8. ADONs and/or designee will audit residents with active orders for antibiotics to confirm that medication is available and administered daily.9. ADONs and/or designee will review, during workday clinical meetings, new physician ordered medication to ensure that medication was delivered, or communication and documentation is reflected in the clinical record if there is a delay or med is not available.10. DON will perform a random review of 5 residents with antibiotics weekly to ensure compliance with antibiotic administration, monitoring, and documentation. 12. [SIC]If any discrepancies are found, they will be addressed immediately.13.[SIC] Findings and trends will be reported by the administrator to QAPI Committee. Monitoring and verification of the POR included the following: In-service attendance sheet was verified on [DATE] staff were inservice on monitoring residents with identified UTI symptoms and confirmed UTIs and documentation. Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were educated on signs and symptoms of UTIs and the monitoring and documentation of signs and symptoms. In-service attendance sheet was verified on [DATE] staff were inservice on monitoring and following up with residents who had antibiotics ordered and documenting status updates Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were educated on following up and documenting, the status updates of ordered antibiotics. In-service attendance sheet was verified on [DATE] staff were inservice on monitoring the availability and acquisition of physician ordered medication along with verifying anticipated delivery date of medication and appropriately documenting. Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were educated on calling the pharmacy to verify availability and anticipated delivery date of ordered medication and document in the resident's charts. In--service attendance sheet was verified on [DATE] staff were inservice on following up and in communication with the NP/MD when an ordered medication is not available and ensuring the communication is reflected in the clinical record Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were educated on notifying provider when a medication is not available and were aware of document the communication on the residents charts. In-service attendance sheet was verified on [DATE] staff were inservice on reviewing the ekit for availability of ordered medication. Interviews completed with staff members on [DATE] (LVN G, LVN H, MA I, LVN J, LVN K, LVN L, MA M, LVN N, LVN O, LVN P, ADON Q, ADON R, ADON S) reflected that all staff were aware to review the kit for any new order medication to check for availability. Record review on [DATE] of the 24 hours summary from [DATE] to [DATE] revealed all residents on antibiotics were monitored for any s/s. Record review of the Sampled residents, Resident #2, Resident #3, and Resident #4's, MAR revealed they all had orders for antibiotics, and the antibiotic was administered as prescribed. During an interviews with, the ADON clarified that whoever was assigned to work on weekends will verify medication was delivered, or communication and documentation is reflected in the clinical record if there is a delay, or med is not available. She stated, during the weekdays, the ADONs will verify. During interview with the DON, she verified random review of 5 residents with antibiotics weekly to ensure compliance with antibiotic administration, monitoring, and documentation, she also stated that any discrepancies will be addressed immediately. During an interview with the Administrator, he stated he did not identify any other residents with similar issues, however, any finding and trend will be reported to the QAPI committee. The Administrator was informed that the Immediate Jeopardy was removed on [DATE] at 5:27 p.m., however, The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 3 linen carts (600 hallway linen cart) reviewed for accidents and hazards: The facility failed to ensure 600 hallway linen cart did not have disposable razors in top of linen cart. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.The findings included: During an observation on 03/5/26 at 10:48 p.m., Surveyor was walking down the 600 hallway and observed a razor in top on the linen cart. During an interview 03/5/26 at 10:50 p.m., CNA A said she did not notice that the razor was in top of the linen cart. CNA A said that the razor was left there by the previous shift. CNA A said that the razor should have been dispose in the sharps container because any resident could grab it and get hurt. During an interview on 3/5/26 at 11:00 p.m., LVN B said that the razor should not have been in top of the linen cart because a resident could get hurt, and that the razor should have been disposed in the sharps container. During an interview on 03/6/25 at 3:42 p.m., the DON said razors should be kept under lock and key in supply room for cnas. The DON said a negative outcome could be that any resident could grab it and caused harm. Record review of facility's policy titled Safety and Supervision of Residents with a revised date of July 2017 revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly labeled and dated.The facility failed to clean the equipment properly.This failure placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.Findings Include:Observation of the juice machine on 01/20/26 at 8:27 AM revealed one of the spouts had a green substance around the entire rim.Observation of the walk-in refrigerator on 01/20/26 at 8:31 AM revealed a plastic container of tomatoes and a plastic container of oranges, not labeled or dated indicating when it was received.Observation of the walk-in pantry on 01/20/26 at 8:40 AM revealed a case of five coffee creamer bottles not labeled or dated indicating when it was received. In an interview on 01/20/26 at 8:47 AM, the DM stated that all staff were responsible for cleaning the juice machine. The DM stated that every morning after breakfast, staff cleaned all equipment used. The DM stated that she was responsible for checking that the kitchen and equipment was clean but forgot to look at the juice machine spout. The DM stated that she would be inspecting the spouts from now on. The DM stated it was important for equipment to be clean because equipment could have germs and make the residents sick. The DM stated she had a system for labeling food items; the morning shift labeled the refrigerated foods, and the afternoon shift labeled the dry foods. The DM stated that she or the cook was in charge of overseeing that all food items were labeled properly. The DM stated it was important for food to be labeled and dated because food needed to be disposed of when it expired. The DM stated it was also important that food was labeled and dated because expired food would be dangerous for residents; the residents could get sick. In an interview on 01/22/26 at 9:32 AM, the Administrator stated he did not know why the juice machine was not cleaned. The Administrator stated he had spoken to the DM to ensure all areas of the kitchen were cleaned properly. The Administrator stated that labels fell off from the plastic containers in the refrigerator because the refrigerator was cold. The Administrator stated he did not know why the coffee creamers were not labeled but after speaking with the DM, the DM ensured him that all food was going to be labeled and dated. Record review of the Sanitation policy dated April 2026 revealed:2. All utensils, counters, shelves and equipment shall be kept clean.10. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Record review of the Refrigerators and Freezers policy dated 2001 revealed:7. All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage.

Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 4 residents (Resident#132 and Resident #3) reviewed for oxygen in that: 1. Resident #132 received oxygen at 2 LPM via nasal cannula without a physician's order. 2. The facility failed to ensure Resident #3's oxygen was administered at the correct setting of 3 LPM on [DATE] as ordered by the physician. These deficient practices could affect the residents who received oxygen continuously and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.The findings were: 1. Record review of Resident #132's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] with pertinent diagnoses that included Pneumonia (a lung infection that inflames the air sacs, causing them to fill with fluid or pus, which makes it hard to breathe), Congestive Heart Failure (heart muscle weakens and can't pump enough blood, causing fluid backup), Moderate Persistent Asthma, and Dementia (an umbrella term for a decline in mental function - including memory, language, problem-solving, and reasoning - severe enough to interfere with daily life and independent functioning). Record review of Resident #132's care plan dated [DATE] reflected Resident #132 was at risk for complication with the respiratory system due to shortness of breath. Interventions -Oxygen therapy as ordered. Record review of Resident #132's electronic chart reflected there was no physician order for oxygen. During an observation on [DATE] at 3:10 p.m. Resident #132 was laying in bed with O2 via NC at 2LPM. No distress was noted. During an interview on [DATE] at 3:23 p.m., LVN Q confirmed that there was no physician order in place for Resident #132's oxygen. She stated that Resident #132 required continuous oxygen via NC. LVN Q stated that it was important to have a physician order in place to administer the adequate amount of oxygen to Resident #132. She stated that they were nurses who work on a as needed basis and knowing what the setting was supposed to be at was important. LVN Q stated that the negative outcome of not having a physician order in place would be that the nurse would then not realize that they need to be on oxygen and the resident can desaturate (blood oxygen drops) making it hard to breath and would have to perform CPR. During an interview on [DATE] at 3:25 p.m., LVN D stated that she was the ADON covering the 600 hall due to the assigned ADON was out today, [DATE]. She confirmed that there was no physician oxygen order in place for Resident #132. LVN D stated that the admitting nurse was responsible for entering the physician order right away. She stated the ADON audits physician orders daily. LVN D stated that it was important for the physician oxygen order to be in place to make sure that they were fulfilling the residents' medical needs. She stated that the resident can desaturate and get rehospitalized or cause death. During an interview on [DATE] at 2:15 p.m., the DON stated that the nurse who admitted the resident was responsible for entering the physician oxygen order. She stated that the nurses were responsible for following physician orders. The DON stated that she does not know how it got missed. She stated that it was their responsibility to check that it was in place. The DON stated that it was important to have a physician's order in place to make sure that they were following the physician orders and for patients' safety. She stated that they cannot administer oxygen without a physician order. 2. Record review of Resident #3's admission record dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE] and with an initial admission date of [DATE]. Pertinent diagnoses included Cerebral Infarction (brain tissue death caused by a blocked blood vessel), Congestive heart failure (heart muscle weakens and can't pump enough blood, causing fluid backup), Heart disease, Chronic Kidney Disease, Hypertension (high blood pressure), and Type 2 Diabetes Mellitus. Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed oxygen therapy. Record review of Resident #3's physician order dated [DATE], revealed oxygen at 3 LPM continuous via nasal cannula per concentrator. Record review of Resident #3's person-centered care plan initiated date [DATE] revealed Resident #3 used oxygen therapy related to Congestive heart failure and Shortness of breath. Intervention included, Administer oxygen as ordered. O2 at 3 LPM continuous via nasal cannula per concentrator. During an observation of Resident #3 on [DATE] at 9:25 am, the oxygen level on the oxygen concentration machine was at 2 LPM via nasal cannula. Observed Resident #3 in bed with head of the bed slightly elevated. No signs of respiratory distress were noted. In an interview on [DATE] at 9:27 am, Resident #3's family member stated the nurse had not checked the oxygen machine in the morning. In an interview on [DATE] at 9:34 am, LVN P stated she was the nurse for Resident #3. LVN P verified that the setting on the oxygen machine was set at 2 LPM. LVN P checked Resident #3's oxygen order and stated the doctor's order was for 3 LPM. LVN P stated she had not had a chance to go into Resident #3's room to check on the oxygen setting. She stated that the assigned ADON was in charge of checking oxygen settings once a day. LVN P stated she normally checked on resident's oxygen settings, but she had just not been able to get to Resident #3's room yet. LVN P stated if an oxygen setting was not correct, a resident could have had hypoxia (a serious condition where tissues don't get enough oxygen), shortness of breath or respiratory distress. In an interview on [DATE] at 1:32 pm, LVN C stated she was the ADON assigned for Resident #3's hall. LVN C stated that Resident #3 was a resident that needed to be constantly monitored. LVN C stated that the family tended to move the oxygen setting. LVN C stated she went in the morning to check the oxygen settings, and it was at 2 LPM and raised it to 3 LPM. LVN C stated she was not sure of what had happened or how the oxygen setting was changed. LVN C stated she had spoken with the family about no moving the setting. LVN C stated the floor nurse should have also checked the oxygen setting but did not know why it was not checked. LVN C stated if oxygen settings were wrong, the resident could have lost oxygen and desatted (slang term for decrease in oxygen saturation). LVN C stated Resident #3 had a history of pneumonia, and it was important for the oxygen settings to be as the doctor ordered them. In an interview on [DATE] at 1:44 pm the DON stated everyone was responsible for checking the oxygen settings. Every nurse that went into the room should have checked the oxygen settings to ensure the right setting and the right rate. DON stated if the family was indeed moving the settings, then the nurses should have checked on the resident more frequently. Record review of the facility's Oxygen Administration Policy with a revised date of [DATE] revealed, Preparation 1. Verify that there is a physician's order for this procedure. Review the physicians' orders or facility protocol for oxygen administration. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principle, and included the appropriate accessory and cautionary instructions and the expiration date when applicable for 2 of 6 medication carts (400 hallway nurse cart and 100 hallway cart). 1.The facility failed to ensure that the 400 hall nurses medication cart was locked and secured when LVN G left the medication cart unlocked and unsecured on [DATE]. 2.The OTC medication in the 100 hallway Medication Cart did not have an opened date written on the bottle. These failures could place residents at risk of injury if medications left unsecured were consumed, drug diversion, and not receiving the therapeutic effects of the medication or treatment.The findings included: 1.During an observation on [DATE] at 2:15 p.m., the 400 hall nurse's medication cart was left unlocked and unattended by LVN G. Observed LVN G get supplies out of the medication cart, leave it unlocked, and walk into the resident's room. LVN G then returned to the medication cart again, left the medication cart unlocked once again and walked into the resident's room to administer G-tube medication. During an interview on [DATE] at 2:31 p.m., LVN G stated that she was responsible for the nurse's medication cart that was left unlocked. She stated that she was nervous trying to get supplies for her G-tube medication observation that she forgot to lock it. She stated that if it was left unlocked then a resident or a family member could open it and take medications. During an interview on [DATE] at 2:35 p.m., LVN D stated that she was the ADON overseeing the 400 hall. She stated that it was the nurse's responsibility for her medication cart to be locked. LVN D stated that the nurse's medication cart was to be locked every time they step away from the cart. She stated that the medication carts have all types of medication and if left unlocked it endangers the residents. LVN D stated that the residents can get a hold of medications. During an interview on [DATE] at 2:15 p.m., the DON stated that the nurses were responsible for keeping the medication carts locked. She stated the medication carts should be locked immediately before they walk away from the cart. The DON stated that it was important for the medication carts to be locked to prevent anybody from going into the carts and getting medications. She stated that they would be conducting random checks to monitor that the medication carts are kept locked. Record review of the facility policy and procedure titled Administrating Medications with a revised date April, 2019 revealed: Policy Interpretation and Implementation 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. During an observation on [DATE] at 10:00 a.m., of the Medication Cart 100 hallway with LVN F, revealed one over the counter (OTC) medications which did not have an opened date written on the bottle (Melatonin 5 mg). During an interview on [DATE] at 10:05 a.m., LVN F stated the OTCs should have an open date written on them. He said that the bottle of medication was still within the expiration date but should have had an open date written on them. He said it was important to write the open date to know for how long the bottle had been opened. During an interview on [DATE] at 3:15 p.m., DON stated that she knew the medication bottle was still within the expiration date. DON stated that she would make sure the bottles found (without an open date written on them) were disposed of because they did not know when the bottles were opened and she did not want residents to get medication that they did not know when it was opened. DON stated that she did not think there was a negative outcome due to the bottle was not expired. Record review of the facility policy and procedure titled Storage of Medications with a revised date November, 2020 revealed: 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 residents (Resident#116) reviewed for indwelling catheters. The facility failed to prevent Resident#116's urinary catheter tubing (bag) from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections. Findings included: Record review of Resident#116's face sheet revealed an [AGE] year-old male originally admitted on [DATE]. Resident#116 admitted with diagnosis of other obstructive and reflux uropathy (when flow of urine is blocked in the bladder, ureter urethra). Record review of Resident #116's MDS dated [DATE], Section C-Cognitive patterns revealed Resident #116 had a BIMS score of 4 which indicated Resident #116 had severely impaired cognition. Section H-Bladder and bowel revealed Resident #116 had an indwelling catheter. Record review of Resident #116's care plan dated 12/1/2025 revealed Resident #116 has a foley catheter Obstructive and reflux uropathy Date initiated 11/4/25 and revised on 11/9/25, Intervention/tasks listed: the resident #116 has a 18 french 10 milliliters balloon, Intervention: indwelling position catheter bag and tubing below the level of the bladder and away from entrance room door. Record review of Resident #116's Order Summary printed 1/21/26 revealed an order to Change Foley Catheter 18 # French with 10milliliters balloon every 30 days and if plugged out or dislodged as needed. Order Foley catheter care every shift and as needed start dated 09/30/25. During an observation conducted on 01/20/26 at 10:15 AM, Resident #116's indwelling catheter bag was noted laying on the floor on the right side of Resident #116's bed. During interview with CNA I on 01/20/26 at 10:15 AM, CNA I was informed and shown the catheter bag laying on the floor. She stated the foley bag should not be touching the floor. CNA I put on gloves after sanitizing hands with hand sanitizer and hung the foley bag on Resident#116's bedframe. CNA I stated by the foley bag touching the floor, Resident #116 could be at risk for infection. During interview with LVN H on 01/20/26 at 10:18 AM, LVN H was informed of the catheter bag laying on the floor. She stated it should not be touching the floor. She replied that a negative outcome of a foley catheter bag being on the floor was the catheter wouldn't drain well and pick up bacteria from floor. LVN H stated that she receives infection control training very often, about once a month, which includes hand washing, enhanced barrier precautions, foley catheter care, nebulizer care and equipment sanitation and avoiding cross contamination. During interview with DON on 01/22/26 at 3:00 PM, she stated that for catheters they should be on the side of the bed, not on the part that goes up and down, so it does not fall, but on the frame. DON stated, no, it should not be touching the floor, if on the floor it could cause a urinary infection to the resident. She stated they would be thinking of ways to prevent bags from touching the floor on residents with low lying beds, perhaps putting another bag to serve as a barrier. Record Review of Policy Titled Catheter Care, Urinary with revised date September 2014, revealed: Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs, for 1 Resident (Resident#72) of 3 residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident#72's behaviors. These failures could place all 121 residents in the facility at risk for their mental and psychosocial needs not being met. The findings included: Record review of Resident#72's face sheet, dated 1/21/26, revealed Resident #72 was 66 years-old male and was initially admitted to the facility on [DATE]. Resident#72's diagnoses included: Muscle Weakness, unspecified lack of coordination, unsteadiness on feet. Record review of Resident#72's Quarterly MDS assessment, dated 11/30/25, revealed Resident#72:-had moderate cognitive impairment;-was able to make self understood;-was usually able to understand others;-was able to walk 10 feet with supervision of touching assistance;-was able to walk 50 feet with supervision of touching assistance;-was able to walk 150 feet with supervision of touching assistance;Record review of Resident #72's Comprehensive care plans dated 12/1/25 revealed no focus, goals or interventions/tasks related to Resident#72's behavioral issues, refusing using shoes or non-skid socks. During an observation on 1/20/26 at 12:30 p.m., Resident #72 was in the dining room without shoes or non-skid socks. During an interview on 1/20/26 at 12:41 p.m., CNA J stated that Resident #72 refused to wear shoes or non-skid socks. She stated nurses were aware of Resident #72 refusing to wear shoes or non-skid socks. During an interview on 1/20/26 at 12:45 p.m., LVN K stated Resident #72 refused to wear shoes or non-skid socks. LVN K said when Resident #72 refused to wear shoes or non-skid socks, nurses should have informed DON about the refusal. LVN K said that she was sure the refusal of the shoes was already care planned. LVN K said that the negative outcome for refusal to wear shoes or non-skid socks not being on the care plan was that staff would not know Resident#72 could fall. She said that by being care planned, staff could minimize the falls or prevent falls for Resident #72. During an interview on 1/20/26 at 1:00 p.m., Resident #72 said that he was offered to wear the shoes, but he left to the dining room without the shoes. During an interview on 1/22/26 at 3:00 p.m., the DON said Resident #72 had refused wearing shoes or non-skid socks. DON said that MDS nurse and all nurses were responsible for updating the care plan. DON said that when a resident refused wearing shoes it should have been care planned. DON said that the negative outcome would be not following the plan of care. Record review of the facility's policy on, Care Plans, Comprehensive Person-Centered, with revision date March, 2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The facility's Matrix for Providers revealed 121 residents in the facility.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs, for two residents (Resident #1 and Resident #2), of twenty-eight residents reviewed for call light access. Residents #1 and #2's call light was placed out of reach of Resident #1 and Resident #2 while in bed. This failure could place residents at risk for not being able to call for assistance from staff. The findings included: 1.Record review of Resident #1's admission Record, dated 01/20/26, revealed Resident #1 was a [AGE] year-old resident and was admitted to the facility on [DATE]. Resident #1's diagnoses included hypertension (high blood pressure), nontraumatic intracerebral hemorrhage (a serious stroke type, bleeding directly into the brain tissue), stroke, and speech and language deficits following stroke. Record review of Resident #1's Quarterly MDS assessment, dated 10/20/25, revealed Resident #1: -was usually understood by others, -was usually able to understand others, -BIMS was 03 which indicated he had severe cognitive impairment, -Resident was dependent on 2 or more staff for bed mobility, Eating, Shower/bath, and toileting. -was frequently incontinent of bowels and bladder. Record review of Resident #1's care plan, dated 11/10/25, revealed: FOCUS: Cognitive Impairment: Resident #1 exhibits cognitive loss related to altered cognitive performance with BIMS (Brief Interview for Mental Status) Score of:(SEVERE IMPAIRMENT 3.0) Date Initiated: 05/02/2025 Revision on: 05/02/2025 GOALS: Will avoid complications (i.e., falls, injury, impaired nutrition/hydration, decline in ADLs) related to cognitive deficits to extent possible. Date Initiated: 05/02/2025 Revision on: 11/05/2025 Target Date: 01/31/2026 INTERVENTIONS/TASKS: Anticipate needs and meet promptly. Date Initiated: 05/02/2025 CNA LPN LVN RN Discuss concerns regarding overall status/health with resident/family as needed. Date Initiated: 05/02/2025 LPN LVN SSD CM RN Encourage routine daily decision making as indicated. Date Initiated: 05/02/2025 CNA LPN LVN RN Explain all care before providing to reduce resident tension and promote a comfortable experience. Date Initiated: 05/02/2025 CNA LPN RN LVN Invite, encourage, remind, and escort to activity programs as desired. Date Initiated: 05/02/2025 ACTA ACTD CNA LPN LVN Medication as ordered. Date Initiated: 05/02/2025 LPN LVN RN Monitor for changes in cognitive status. Notify physician if observed. Date Initiated: 05/02/2025 LPN LVN RN. 2. Record review of Resident #2's admission Record, dated 01/20/26, revealed Resident #2 was an [AGE] year-old resident and was admitted to the facility on [DATE]. Resident #2's diagnoses included Alzheimer's Disease (a progressive, irreversible neurodegenerative brain disorder), dementia (an umbrella term for a decline in mental function - including memory, language, problem-solving, and reasoning - severe enough to interfere with daily life and independent functioning), white matter disease (conditions that damage the brain's white matter which causes symptoms like cognitive decline, memory loss, balance issues, and gait disturbances), and heart disease. Record review of Resident #2's Medicare 5-Day MDS assessment, dated 11/22/25, revealed Resident #2: -was usually understood by others, -was usually able to understand others, -BIMS was 05 which indicated he had severe cognitive impairment, -Resident required supervision or touching assistance for eating; -Resident was dependent on 2 or more staff for Shower/bath, and -Resident required partial to moderate assistance with toileting. -was occasionally incontinent of bowel and continence of bladder was not rated due to catheter. Record review of Resident #2's care plan, dated 01/14/26, revealed: FOCUS: Resident #2 has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, Dementia, WHITE MATTER DISEASE, UNSPECIFIED Date Initiated: 06/19/2024 Revision on: 06/19/2024 GOAL: [Resident #2] will be able to communicate basic needs on a daily basis through the review date. Date Initiated: 06/19/2024 Revision on: 11/07/2025 Target Date: 04/14/2026 INTERVENTIONS/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/19/2024 LPN RN Ask yes/no questions in order to determine the resident's needs. Date Initiated: 06/19/2024 ACTA CNA LPN RN SW Cue, reorient and supervise as needed. Date Initiated: 06/19/2024 CNA LPN RN Discuss concerns about confusion, disease process, NH placement with resident/family/caregivers). Date Initiated: 06/19/2024 LPN RN SW Monitor/document/report PRN 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, mental status. Date Initiated: 06/19/2024 LPN RN In an observation on 01/20/26 at 10:39 AM Resident #1 was lying in bed with the head of his bed inclined. There were fall mats on the floor at the sides of his bed. Resident #1's call light was not within reach. The call light was at the head of the bed to the side dangling toward the floor. Resident #1 closed his eyes and would not speak with surveyor. In an observation and interview on 01/20/26 at 10:40 AM Resident #2 was lying in bed with the head of his bed inclined. Resident #2's call light was not in reach. His call light was tucked between the mattress and the bedrail. Resident #2 stated he did not know where the button for the light was. He said he had not seen it. He said he did not know how he would call for the nurse if he needed anything. In an interview on 01/20/26 at 10:55 AM CNA A for Resident #1 and Resident #2 stated Resident #1 could not reach his call light because it was too far out of reach. CNA A stated the call lights were to always be in reach of residents. CNA A stated if the call light was not within reach of the resident, the residents would not be able to notify them if they needed help. CNA A stated they were in-serviced on call lights twice a week. She said the last in-service on call lights was on Friday (01/16/26). CNA A stated Resident #2's call light was right next to the bed and it was also supposed to be within his reach. CNA A stated it was mostly the CNAs responsibility to ensure the call light was within reach of the resident, but it was also everyone's responsibility. CNA A stated if the resident's call light was not within reach, they may fall trying to get up without assistance. In an interview on 01/20/26 at 10:59 AM CNA B for Resident #1 and Resident #2 stated Resident #1 could not reach his call light. She said he was supposed to be able to reach his call light. CNA B stated if Resident #1 had an emergency, he could scream to call them. CNA B stated they were in-serviced all the time on call lights. She said the last time she was in-serviced was two weeks ago. CNA B stated Resident #2's call light was also supposed to be within his reach. CNA B stated everyone was responsible for making sure the call lights were within reach of the residents. She said the residents may fall if their call light was not within reach because they would try to get up by themselves. In an interview on 01/22/26 at 01:50 PM LVN C stated everyone was responsible for call lights. She said the call light should be within reach of the residents whenever they are in their bed. She said if the resident did not have the call light within their reach, the resident may fall because they may attempt to get out of bed without assistance or they would not get help if it was wanted. In an interview on 01/22/26 at 02:00 PM LVN D stated everyone was responsible for call lights. She said the call light needed to be within the patient's reach. She said if the call light was not within the patient's reach and the patient needed assistance, they could fall or if they needed assistance immediately the assistance would be delayed. In an interview on 01/22/26 at 03:23 PM ADON E stated everybody was responsible for call lights and rounding. She said the call lights were to be within the resident's reach. She stated if the residents could not use their call light to call for assistance, they may try to get up from bed unassisted and fall. She said they are in-serviced on call lights 1 - 2 times a week. She said the last in-service they received on call lights was on Tuesday, 01/20/26. In an interview on 01/22/2026 at 04:05 PM the Administrator stated all staff were responsible for call lights and making sure the call light was readily available for the residents. He said if the residents could not reach or use their call light, that may cause a lapse in care. He said the staff were just in-serviced on call lights on Tuesday (01/20/26). In an interview on 01/22/2026 at 04:12 PM the DON stated everybody was responsible for making sure the call lights were within reach of the residents. She said the call lights are to be next to the resident so they could call for assistance when they need it. She said if the call light was not within reach, it could delay the need of the residents and ADL care they require. Record review of the facility's policy Answering the Call Light, 2001 Med-Pass, Inc. (Revised March 2021) revealed: Purpose The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines 4.Be sure that the call light is plugged in and functioning at all times. 5.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 6.Some residents may not be able to use their call light. Be sure you check these residents frequently.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5% for 27 medication administration opportunities with 3 errors resulting in a 11.11% medication error rate, for 2 of 5 residents (Resident #92 and Resident #56) reviewed for medication administration. 1. The MA failed to check Resident #92's pulse prior to the administration of his medications Amiodarone (used to regulate rapid and/or irregular heart rhythms) and Metoprolol (used to treat high blood pressure, chronic chest pain, and to improve survival following a heart attack) as ordered by the physician during medication pass observation on 01/21/2026 at 7:50 a.m. 2. The facility failed to ensure Resident #56 received medication Novolin R insulin (used to control high blood sugar) as ordered by the physician on 01/21/2026 at 4:00 p.m These failures could place residents at risk of low heart rate, dizziness, risk of falling, severe low blood pressure, hospitalization, and high blood sugars which can lead to death if not receiving the intended therapeutic benefits of the medication.The Findings included: 1.Record review of Resident #92's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] and original admit date on 03/14/2024 with the following pertinent diagnoses of Primary Hypertension (high blood pressure), Unspecified Atrial Fibrillation (irregular heartbeat), Peripheral Vascular Disease (poor blood flow to arms, legs or organs), Other Disorder of Circulatory System (issues with the heart, blood, or vessels that impair blood flow). Record review of Resident #92's quarterly MDS dated [DATE] reflected he was assessed to have a BIMS score of 13 indicating he was cognitively intact. Record review of Resident #92's comprehensive care plan dated 01/05/2026 reflected a problem Cardiac: At risk for impaired cardiac function and complications related to Atherosclerotic Heart Disease, Atrial Fibrillation, Hypertension, Diabetes. Interventions included Administer medications as ordered. Observe, document, and notify MD of adverse side effects. Review of Resident #92's physician order summary reflected an order dated 02/19/2025 for Amiodarone HCL oral tablet 200mg give 1 tablet by mouth one time a day for HTN, Hold if SBP less than 100, DBP less than 60 or PULSE less than 60, Notify MD. He also had an order dated 02/19/2025 for Metoprolol Tartrate oral tablet 50mg give 1 tablet by mouth two times a day for hypertension Hold if SBP less than 100, DBP less than 60 or PULSE less than 60, Notify MD. During an observation on 01/21/2026 at 7:50 a.m., the MA checked Resident #92's blood pressure manually. She stated that the blood pressure reading was 152/80 and that she did not get the pulse. MA proceeded to prepare and administer 11 medications for Resident #92. She then documented on each medication that was administered but when she got to Amiodarone, the system prompted her to enter the pulse reading. MA exited out of the computer and went back into the room to check Resident #92's pulse. She returned to the computer and documented pulse 88 for Amiodarone and Metoprolol. During an interview on 01/21/2026 at 8:15 a.m., the MA stated she was supposed to check Resident #92's pulse before administering Amiodarone and Metoprolol. She stated that it was important to check the pulse before administering medication because she needs to know if the reading was not low. If it was too low and not within the parameters, then she cannot administer it. She stated that she did not check the pulse before administering medications because she got nervous. The MA stated that the negative outcome would be that Resident #92's heart rate can drop and he can have a heart attack. During an interview on 01/21/2026 at 8:21 a.m., ADON E stated that both Metoprolol and Amiodarone have parameters to hold the medication if the pulse was less than 60. She stated that the pulse was to be checked before administering these medications to know if they would need to hold it and not administer. ADON E stated that the negative outcome would be that the resident can go into bradycardia (slow heart rate) and become unstable to where they would have to send them out to the hospital. During an interview on 01/22/2026 at 2:15 p.m., the DON stated that her expectation was that the blood pressure and pulse were to be checked prior to administering blood pressure medications. She stated the negative outcome for not checking prior to administering was that if the pulse was less than 60 the resident can have cardiac problems, low blood pressure, and could become unresponsive. 2.Record review of Resident #56's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and original admit date [DATE] with the following pertinent diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar), Chronic Kidney Disease, and Muscle Wasting and Atrophy (wasting or shrinkage of muscles). Record review of Resident #56's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 13 indicating she was cognitively intact. Record review of Resident #56's comprehensive care plan dated 12/12/2025 reflected a problem Diabetes: Resident #56 had a diagnosis of diabetes and was at risk for complications. Interventions included Give medications per order. Review of Resident #56's physician order dated 01/18/2026 reflected Novolin R Injection Solution 100unit/ml (insulin Regular Human) Inject as per sliding scale: if150-199=2250-299=6300-349=8350-499=10 call MD to report, subcutaneously before meals and at bedtime. Record review of Resident #56's Medication Administration Record for January 2026, dated 01/21/2026, reflected that Resident #56 blood sugars were checked 14 times from 01/18/2026 through 01/21/2026. 1 out of the 14 times that the blood sugar was checked since the order began, Resident #56 had one blood sugar reading of 206 and was not administered insulin. During an observation of medication administration on 01/21/2026 at 4:00 p.m. for Resident #56, LVN G was observed that insulin Novolin R was not administered. LVN G stated that the computer system would prompt her if insulin needed to be administered once she entered the blood sugar reading. LVN G entered the blood sugar reading of 233 and the system did not prompt her to administer insulin. She then stated that she would go to another resident since Resident #56 does not require insulin to be administered. LVN G documented in Resident #56's medication administration record that no insulin was administered. During an interview on 01/21/2026 at 4:10 p.m., LVN G reviewed the Novolin R insulin order along with surveyor. She stated that the insulin sliding scale order had been entered incorrectly. LVN G stated that the range in the insulin sliding scale that was omitted was 200-249=4 units. She stated that she was the nurse who had entered the insulin order on 01/18/2026. LVN G corrected the order and administered 4 units. LVN G stated that the negative outcome of not administering the insulin due to having a missing range would be that Resident #56 could have a hyperglycemic (condition in which the sugar level in the blood was higher than normal) episode, which could be critical. During an interview on 01/21/2026 at 4:26 p.m., LVN D stated that she was the ADON overseeing the 400 hall. She stated that the nurse responsible for entering the order was the nurse who takes the order from the doctor. LVN D stated that she prints a daily report and reviews the orders that were entered. She stated that she does not know how this error was missed and not caught. She stated that the standard insulin sliding scale was that any blood sugar reading of 150 would require insulin to be administered. LVN D stated that the negative outcome would be that the resident could have a hyperglycemic episode. During an interview on 01/22/2026 at 2:15 p.m., the DON stated that the nurse responsible for entering the order was the one who takes the order from the doctor. She stated that the orders were reviewed in their morning meetings. She does not know how it was missed. The DON stated that it was her responsibility to have caught it. She stated that the negative outcome of not entering the insulin sliding scale correctly was that the resident could have multiple doses missed. This would cause the resident to become hyperglycemic and cause more complications. Record review of the facility policy and procedure titled Administering Medications with a revised date April, 2019 revealed: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame. 11. The following information is checked/verified for each resident prior to administering medications:b. Vitals signs, if necessary

Based on interview and record review the facility failed to ensure before allowing an individual to serve as a nurse aide, registry verification was received that the individual had met competency evaluation requirements for 1 of 3 employees (CNA A) reviewed for nurse aide registry verification. The facility failed to ensure CNA A had a current nurse aide certification while employed at the facility, while actively providing care for residents.This failure could place residents at risk of not being provided the appropriate care. The findings include: Record review of application software used by the facility to manage employee documents revealed CNA A's nurse aide certification expired on [DATE]. Record review of Texas Unified Licensure Information Portal's Nurse Aide Public Registry, on [DATE] at 4:24 PM, revealed CNA A's nurse aide certification status was expired and listed her certification expiration date as [DATE].Record review of Texas Unified Licensure Information Portal's Nurse Aide Public Registry defined a nurse aide registry status of expired to indicate This nurse aide's registration is expired. The nurse aide is currently not employable as a nurse aide in a licensed nursing facility in the state of Texas.Record review of CNA A's timecard, from [DATE] till [DATE], revealed she worked a total of roughly 716 hours.Record review of CNA A's timecard for [DATE] revealed she last worked on [DATE] at 6:14 AM.During an interview with the Administrator on [DATE] at 6:15 PM, he stated he was not aware of CNA A having an expired certification prior to it being identified on [DATE]. The Administrator said staff members were responsible for renewing their certifications and verifying their certifications were active and HR was used as a failsafe. The Administrator stated he was not able to recall the exact date of expiration for CNA A's nurse aide certification but he did see it and confirmed it was expired. The Administrator stated CNA A had been working the floor and providing care to residents since the day of her expired certification (which at that time was thought to be [DATE]). The Administrator stated CNA A worked roughly 4 months and around 700 hours with an expired certification. The Administrator stated when they identified CNA A's certification was expired on [DATE], they removed her from the schedule and prompted her to complete her renewal. The Administrator stated prior to her certification expiring no one had sent any communication to CNA A regarding her upcoming expiration. The Administrator stated aside HR reviewing certifications it would also be him. The Administrator stated they did not catch CNA A's expired certification due to a failed system. The Administrator stated certifications were checked probably every 3 to 6 months and the last time it was checked prior to [DATE] was probably before [DATE]. The Administrator stated they previously did not run or receive any reports regarding certification status's and on [DATE] they set up a program that would run a monthly report and send an email of the upcoming licensures and certifications that would be expiring. The Administrator stated CNAs were not allowed to work with an expired certification. The Administrator stated as per facility policy staff needed to be in good standing with tier certifications and in this situation the facility policy was not followed. The Administrator stated he did not think there was any negative impact to the residents due to CNA A working with an expired certification, but being in compliance with the their licensure body was required. During an interview with the DON on [DATE] at 7:06 PM, she stated she was not aware of CNA A having an expired certification prior to it being identified on [DATE]. The DON stated the staff should remember when their expiration dates were but believed HR provided them with information of when their expiration was coming up. The DON stated HR was responsible for reviewing and verifying staff certifications were active and she did not know how they were reviewed, how often they were reviewed or when they were last reviewed prior to [DATE]. The DON stated she did not run or receive any reports or updates from HR on staff's certification statuses. The DON stated HR was the only person who reviewed certifications and did not know why CNA A's expired certification was not identified. The DON stated CNA A's nurse aide certification was currently expired when reviewed it on [DATE] and she had been working the floor and providing care to residents with an expired certification for about 4 months. The DON stated CNAs were not allowed to work with an expired certification because they were providing direct patient care. The DON stated they identified CNA A had an expired certification on [DATE] when they pulled personnel files, the DON stated in response they removed CNA A from the schedule. The DON stated, based on facility policy, certifications had to be kept up to date and active and in this situation staff did not follow this policy. The DON stated although it was a big oversight, staff were trained, had skill check offs and knew how to do their job, and stated the only negative impact would be a nurse aide not having an active certification would mean they were not in compliance with the regulation not that they didn't know how to provide care. During an interview with HR on [DATE] at 7:22 PM, she stated she was not aware CNA A's nurse aide certification was expired prior to identifying it on [DATE]. HR stated she helped staff with employment verification and it was the staff responsibility to upload their items in TULIP and verify their certification. HR stated both her and the staff were responsible for verifying their certifications were active and it should be checked every 3 to 4 months. HR stated she checked certifications upon hire and then yearly and employees were responsible for keeping up with their certifications. HR stated she checked staff certification on the nurse aide registry or would run it through another website registry. HR stated she would not send a report or updates to the DON or Administrator. HR stated she was the only person who reviewed certifications and did not know how or why she did not identify CNA A's expired certification. HR stated she had not sent any reminder to CNA A about her certification needing to be renewed. HR reviewed CNA A's certification status and confirmed it was expired. HR stated CNA A worked for about 4 months at a rate of about 40 hours per week providing care to residents with an expired certification. HR stated nurse aides were not able to work with an expired certification and they had to be certified due to providing patient care. HR stated when she identified CNA A had an expired certification she reached out to her and filled out her employee verification and told CNA A to submit it into TULIP and contact them. HR stated the facility policy stated staff had to be current with their certification and had to notify them about any expirations as it was part of their responsibility. When asked if the facility staff followed their policy in this situation HR did not answer question directly and stated, I should have checked. HR stated nurse aides not having an active certification could negatively impact residents because of them not following the proper patient care protocols and the liability added. During an interview with CNA A on [DATE] at 7:34 PM, she stated she had just found out the morning of [DATE] that her certification was expired when HR messaged her. CNA A stated she was not aware prior to this. CNA A stated her certification expired in June of 2025. CNA A stated she was used to the facility and HR letting her know before her certification expired, but it was her responsibility to make sure her certification was renewed and active and she should have checked and known, but she had not checked. CNA A stated she worked at the facility proving patient care since her certification expired about 3 to 4 months or longer. CNA A stated she worked with and provided care to a lot of residents during that time. CNA A stated you could not work as a nurse's aide with an expired license because you had to be certified to work with patients. CNA A stated in response to identifying her certification was expired the facility took her off the schedule on [DATE]. CNA A stated the facility policy stated they could not work without a certification. CNA A stated she did not follow the facility policy in this situation. CNA A stated not having an active nurse aide certification could negatively impact residents because the facility would have to find someone to replace her and pick up her shifts. Record review facility's policy titled, Licensure, Certification, and Registration of Personnel, with an updated date of 09/2018, stated, 3. A copy of recertifications (e.g., annual, bi-annual, etc., as applicable) must be presented to the Human Resources Director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record. 4. Our facility conducts employment background screening checks, reference checks, license verifications and criminal conviction investigation checks in accordance with current federal and state laws.s failure could place residents at risk of not being provided the appropriate care.

Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Residents #1) of 4 residents reviewed for accidents and supervision. On 8/29/25 Resident #1, while being transferred by CNA A and CNA B via mechanical lift from bed to wheelchair, hit her left foot against the mast of the mechanical lift. CNA A failed to protect Resident #1's feet during the mechanical lift transfer. Resident #1's x-ray results: acute third digit proximal phalanx shaft and neck fracture (The largest and longest phalanx bone, it is the base of the toe.) An Immediate Jeopardy was identified on 10/10/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 02:59 p.m. While the Immediate Jeopardy was removed on 10/11/2025 at 6:10 p.m. the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures. These failures placed residents at risk of injuries. The findings included: Record review of Resident #1's face sheet dated 10/9/2025 reflected an [AGE] year-old female with an admission date of 11/30/2024 with DX. cerebral infarction (stroke), spinal stenosis (spinal space surrounding the spinal cord becomes narrowed.) Record review of Resident #1's quarterly MDS dated [DATE] reflected a Brief Interview for Mental Status scored 14 (no cognitive impairment). Resident #1 had functional limitations in range of motion on upper and lower extremities. Resident#1 was totally dependent for transfers. Record review of Resident #1's comprehensive care plan dated 09/17/2025 revealed she required 2-person assistance for transfers and bed mobility. Record review of Resident #1's x-ray results: acute third digit proximal phalanx shaft and neck fracture (The largest and longest phalanx bone, it is the base of the toe.)Record review of facility policies indicated facility did not have a policy on mechanical lift.During an interview on 10/8/25 at 11:00 a.m. Resident #1 said that during a transfer she was on the mechanical lift and when the CNA turned her, her foot bumped to the mast of the mechanical lift. Resident#1 said that she told CNA A and B that she had felt pain in that instant. Resident #1 said she went to Occupational Therapy and voiced to Occupational Therapist Assistant (OTA) that she had severe pain to her left foot. During an interview on 10/8/25 at 3:11 p.m. OTA said Resident#1 went to therapy between 1:00pm - 2:30pm on 8/29/2025 and Resident#1 complained of pain to her left foot. OTA said she observed that Resident#1's left foot had a bruise. OTA said that she reported to the DOR and then DOR reported to LVN C. OTA said LVN C conducted an assessment and noted a purple discoloration to Resident#1's left foot. OTA said that LVN C immediately notified NP and got orders for x rays. During an interview on 10/8/25 at 3:20pm DOR said that OTA informed her that Resident#1 was complaining of pain to her left foot. DOR said that she went to notify LVN C on 8/29/2025. During an interview on 10/8/25 at 3:32 pm LVN C said she was informed on 8/29/25 by the DOR of Resident # 1 having had pain to her left foot. LVN C said she immediately assessed Resident #1 and she noted discoloration to her left foot and notified the nurse practitioner. LVN C said that the nurse practitioner ordered X-Rays. During a phone interview on 10/8/25 at 4:39 p.m. CNA A said she and CNA B around 8:30 AM were transferring Resident # 1 on 8/29/2025 from the bed to the wheelchair. CNA A said that during the transfer, CNA B moved the resident to the left which caused her to bump her foot against the mast of the mechanical lift. CNA A said, Resident # 1 did not complain of pain, we continued with the transfer and did not report to LVN C because I thought it was not significant. During an interview on 10/9/25 at 10:00 a.m. CNA B said while she and CNA A transferred Resident # 1 on 8/29/25 from bed to wheelchair via mechanical lift, she was in charge of guiding Resident # 1 to her wheelchair. CNA B said Resident #1 grunted at the moment her foot hit the mast of the mechanical lift. CNA B said after the transfer she and CNA A looked at her left foot and did not notice anything wrong. CNA B said she had failed to report the incident to LVN C. During an interview on 10/9/2025 at 11:00 a.m. DON said CNAs did not report the incident because it was only a tap against the mechanical lift and that Resident#1 did not complain of pain. DON said that investigation and assessments were initiated immediately after being notified by the Director of Rehabilitation. DON said that the facility does not have a policy on mechanical lifts. An Immediate Jeopardy was identified on 10/10/2025. The Immediate Jeopardy template was provided to the administrator's facility on 10/10/2025 at 02:59 p.m. Verification of IJ: Started on 10/11/2025 at 09:00 a.m. and included:Record review of an In-Service with subject of Change of Condition, dated 09/15/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Hoyer Transfer, dated 08/29/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Hoyer Transfer and training, dated 10/09/2025, indicated that working staff signed the in-service record.Record review of an In-Service with subject of Abuse, Neglect, and Exploitation, dated 08/29/2025, indicated that working staff signed the in-service record. Record review of Resident #1 pain assessment done on 10/10/2025. Record review of Resident #1 head to toe assessment done on 10/10/2025. Record review of QAPI with subject of notification of changes condition,, dated 10/11/2025, indicated that Director of Nurses, Director of Rehabilitation, Dietary Representative, Activities representative, and MDS participated in the QAPI meeting. Record Review of updated change in condition policy dated 10/10/25. Record review of 24 hour review and random mechanical lift transfer monitoring done on 10/10/2025. Record review of safety/abuse survey on random residents dated 10/10/25. During interviews on 10/11/2025 from 9:00 a.m., to 6:00 p.m. CNAs A, B, E, G, I, P, S were from the 6 am to 2 pm shift, CNAs F, H, J, K, L, M, Q, R, T from the 2 pm to 10 pm shift, CNAs N, O, and from the 10 pm to 6 am shifts revealed. were all knowledgeable of the expectation that if when providing care to a resident a change was noticed CNAs were to stop the care and inform the charge nurse verbally and with the stop and watch form. CNAs indicated where the stop and watch form was located at the nurses' station. LVNs C, U, and V from the 7 a.m. to 7 p.m. shift and RN W from the 7 a.m. to p.m. shift and DOR from the 8 am to 5 pm shift, revealed were knowledgeable of the procedure of that the CNAs should follow when a change was noted in a resident. LVNs interviews revealed LVNs should immediately assess resident after CNAs notified them of a change. A mechanical lift observation was done on 10/11/25 at 11:00 a.m., for Resident#1 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. A mechanical lift observation was done on 10/11/25 at 12:00 p.m., for Resident #2 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. A mechanical lift observation was done on 10/11/25 at 01:58 p.m., for Resident #3 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. A mechanical lift observation was done on 10/11/25 at 02:40 p.m., for Resident #4 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. A mechanical lift observation was done on 10/11/25 at 03:20 p.m., for Resident #5 assisted by CNAs A and B revealed CNAs follow procedure to transfer resident from wheelchair to bed using mechanical lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. The Administrator was informed that the Immediate Jeopardy was removed on 10/11/2025 at 6:10 p.m., however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system.

Based on interview and record review, the facility failed to provide the resident and resident representative written notice which specifies the duration of the bed-hold policy for 1 (Resident #1) of 2 resident reviewed for bed-holds. The facility failed to provide bed-hold notification to Resident #1 when she was discharged to the hospital. This failure could place residents at risk of being improperly discharged and placed in unsafe conditions. The findings included: Record review of Resident #1's admission record dated 12/15/24 revealed an [AGE] year-old female with an admitted [DATE] and diagnoses of Muscle Weakness (Generalized), Encephalopathy (brain disorder) Unspecified, Type 2 Diabetes Mellitus (body does not use insulin effectively or produce enough insulin) without complications, Alzheimer's Disease (brain disorder that causes gradual decline in memory, thinking and reasoning skills) unspecified, and other seizures. Record review of Resident #1's Hospital record dated 11/27/24 revealed Resident #1 was admitted to the hospital on 11/27/24. Record review of Resident #1's progress note dated 12/05/24 revealed Resident #1 was readmitted back to the facility on [DATE]. An attempt to interview Resident #1 on 12/14/24 at 11:15 a.m., was unsuccessful as Resident #1 was not interviewable. In an interview on 12/14/24 at 11:17 a.m. the RP stated Resident #1 had been sent to the hospital last month and stayed there for over a week. She said she was not given information or signed any papers about a bed-hold. She said Resident #1 was admitted back to the facility, however was not able to return to the same room. Record review of Resident #1's electronic records and chart on 12/15/24 at 11:05 a.m. revealed there was no bed-hold forms found in either. In an interview on 12/15/24 at 12:28 p.m. when asked about a bed hold notice for Resident #1, the DON said she could not find any bed-hold form or documentation of it being given. She said she was not in charge of that and did not believe that nursing was in charge of giving those. She said that residents who were discharged and were anticipating return have a room available, however, it would not necessarily be the same room depending on how long they were gone. In an interview on 12/15/24 at 1:23 p.m. the Administrator said the bed-hold form was in the admission agreement and it was signed when a resident was admitted to the facility. He said that his staff gave the resident and family the form to sign upon admission. He said that Business Office Manager was in charge of admission forms and was currently out of town. Record review of the facility's policy titled, Bed-Holds and Returns revealed: Policy Interpretation and Implementation 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 5 residents (Resident #79, Resident #260, and Resident #261) reviewed for respiratory care. 1. The facility failed to ensure Resident #260, and Resident #261 received oxygen at the prescribed rate. 2. The facility failed to ensure Resident #79 had appropriate orders to receive oxygen. These failures could place residents at risk for respiratory distress. The findings included: 1. Record review of Resident #260's face sheet dated 10/29/24 reflected the resident was a 75 -year-old female admitted to the facility on [DATE]. Resident #260 had diagnoses which included the following: chronic (long-standing) congestive heart failure (a long-term condition in which the heart weakens and causes fluid buildup in the feet, arms, lungs, and other organs), respiratory disorders, acute (severe and sudden in onset) respiratory failure with hypoxia (decrease in oxygen supply to the tissues), and dyspnea (shortness of breath). Record review of Resident #260's 5-Day scheduled MDS assessment, dated 10/15/24, reflected the resident had a BIMS score of 5 which suggests severe cognitive impairment. Self-care assessment reflected she was dependent on staff for all self-care except eating and oral hygiene which required partial/moderate assistance from staff. Special treatments, procedures, and programs reflected the resident received continuous oxygen therapy. Record review of the most recent Care Plan for Resident #260 reflected the resident required the use of continuous oxygen related to acute respiratory failure, congestive heart failure, and dyspnea. Interventions included administering oxygen at 2 LPM via nasal cannula continuous per concentrator. Date Initiated: 10/17/2024. Record review of the Doctor's Order Summary reflected Resident #260 was prescribed O2 at 2 LPM via nasal cannula continuous per concentrator. Start Date 10/15/2024. Record review of the MAR for October 2024 reflected Resident #260 was prescribed O2 at 2 LPM via nasal cannula continuous per concentrator every shift for SOB. Start Date 10/15/2024. Observation on 10/27/24 at 2:31 pm of Resident #260 revealed resident in bed with head of bed elevated. Resident #260 received O2 at 2.5 LPM via NC. In an interview on 10/27/24 at 2:38 pm with LVN I, she said she was the nurse assigned to Resident #260. She said she was responsible for ensuring the O2 rate was set accurately for Resident #260. She said that she checked the O2 rate every morning when she arrived on shift. The State Surveyor requested the LVN check the O2 rate, and she said the rate was at 2 LPM. She said that the concentrator must be looked at slanted because the machines are slanted and that the line was supposed to be in the middle of the ball. The State Surveyor asked Resident #260 how she was feeling, and she denied SOB, difficulty breathing, heart racing or dizziness. LVN checked Resident #260's O2 saturation, and it was at 98% with a heart rate of 72 bpm. LVN I said If a resident received more O2 than prescribed, they can experience hyperoxia or too much oxygen in the blood. Record review of Resident #261's face sheet dated 10/29/24 reflected the resident was an 82 -year-old female admitted to the facility on [DATE]. Resident #261 had diagnoses which included the following: acute (severe and sudden in onset) on chronic (long-standing) congestive heart failure (a long-term condition in which the heart weakens and causes fluid buildup in the feet, arms, lungs, and other organs) and acute (severe and sudden in onset) respiratory failure. Record review of Resident #261's Physician's Order Sheet/Routine Transfer Orders Summary, dated 10/9/24, reflected the resident had oxygen at 2 L via NC. Record review of the most recent Care Plan for Resident #261 reflected the resident required the use of continuous oxygen related to acute respiratory failure, congestive heart failure, and shortness of breath when lying flat. Interventions included administering oxygen at 2 LPM via nasal cannula. Date Initiated: 10/24/2024. Record review of the Doctor's Order Summary reflected Resident #261 was prescribed O2 at 2 LPM via nasal cannula continuous per concentrator. Start Date 10/23/2024. Record review of the MAR for October 2024 reflected Resident #261 was prescribed O2 at 2 LPM via nasal cannula continuous per concentrator every shift. Start Date 10/23/2024. Observation on 10/27/24 at 2:34 pm of Resident #261 revealed resident in bed with head of bed elevated. Resident #261 received O2 at 1.5 LPM via NC. In an interview on 10/27/24 at 2:38 pm with LVN I, she said she was the nurse assigned to Resident #261. She said she was responsible for ensuring the O2 rate was set accurately for Resident #261. She said that she checked the O2 rate every morning when she arrived on shift. The State Surveyor requested the LVN check the O2 rate, and she said the rate was at 2 LPM. She said that the concentrator must be looked at slanted because the machine was slanted and that the line was supposed to be in the middle of the ball. The State Surveyor asked Resident #261 how she was feeling, and she denied SOB, difficulty breathing, heart racing or dizziness. LVN checked Resident #261's O2 saturation, and it was at 96% with a heart rate of 88 bpm. LVN said If a resident received less O2 than prescribed, they can become short of breath, hypoxic (decreased perfusion of oxygen to tissues), or experience respiratory distress. In an interview on 10/30/24 at 4:12 pm ADON/LVN B said that the floor nurses assigned to the residents were responsible for ensuring oxygen concentrators were at the appropriate settings. She said the nurses should ensure the settings are correct when doing their rounds and when they first come on shift after getting report. She said when reading the O2 flow rate, the nurse must be at eye level to ensure the line was in the center of the ball. She said if it was looked at above or below eye level, the rate will appear to be at a higher or lower rate than it was. She said she was not aware of an oxygen concentrator that was not read at eye level. She said O2 was considered a medication, so must be given as ordered to prevent respiratory complications. In an interview on 10/30/24 at 5:16 pm DON said the floor nurse that worked with a resident who received O2 was responsible for ensuring the O2 was at the correct rate. She said the nurse should check the O2 rate settings throughout their shift and periodically when they go in to see their resident on O2. She said oxygen must be given as ordered to prevent respiratory distress. She said once they reviewed the situation, she would conduct further education with staff. 2. Record review of Resident #79's face sheet dated 10/29/24 reflected the resident was a 73 -year-old female admitted to the facility on [DATE]. Resident #79 had diagnoses which included the following: morbid obesity (chronic disease in which the body mass index was 40 or higher or 35 or higher and experiencing obesity-related health conditions), muscle wasting and atrophy (wasting of an organ or tissue), muscle weakness, and hypertension (the pressure in blood vessels was too high). Record review of Resident #79's Comprehensive MDS assessment, dated 10/2/24, reflected the resident had a BIMS score of 14 which suggests intact cognition. Self-care assessment reflected she was dependent on staff for all self-care except eating and oral hygiene which required partial/moderate assistance from staff. Special treatments, procedures, and programs reflected the resident received continuous oxygen therapy. Record review of the Care Plan completed on 9/27/24 for Resident #79 did not reflect the resident required the use of oxygen therapy. Record review of the most recent Care Plan on 10/15/24 for Resident #79 reflected the resident was at risk for complications with the respiratory system due to shortness of breath. Date initiated: 10/29/24 with intervention to administer medications as ordered. Monitor for side effects/adverse reactions and effectiveness. Date initiated 10/29/24. Record review of the Doctor's Order Summary reflected Resident #79 was prescribed O2 at 2 LPM via nasal cannula continuous per concentrator. Start Date 10/28/2024 at 4:30 pm. End Date 10/28/24 and O2 at 2 LPM via nasal cannula per concentrator PRN. Start Date 10/28/24 at 4:32 pm. Record review of the MAR for September 2024 reflected the medication reconciliation had been performed for Resident #79 with review of the prior care setting discharge medications one time only for medication reconciliation for 1 day. -Start Date- 09/26/2024. The MAR did not reflect oxygen therapy was administered. Record review of the MAR for October 2024 reflected Resident #79 was prescribed O2 @2 LPM via nasal cannula continuous per concentrator as needed for SOB. Start Date: 10/28/2024 at 4:30 pm DC Date: 10/28/2024 at 4:33 pm and O2 @2LPM via nasal cannula per concentrator PRN as needed for SOB Start Date: 10/28/2024 at 4:32 pm. Record review of Medication Reconciliation Report for Discharge for Resident #79 dated 9/26/24 reflected no orders for oxygen. Record review of O2 saturation log documented Resident #79 with oxygen via nasal cannula since 9/26/24. Record review of progress note dated 10/20/24 reflected Resident #79 continues oxygen via NC. Record review of progress note dated 10/28/24 at 4:29 pm for Resident #79 reflected new order received from MD for oxygen PRN at 2 LPM via nasal canula due to SOB. Observation and interview on 10/28/24 at 11:45 am revealed Resident #79 in bed with head of bed elevated. Resident #79 received O2 2LPM via NC. Resident stated she was on O2 because she becomes short of breath due to her edema (swelling caused by fluid buildup in the body's tissues and organs). Resident said that she had received oxygen since the first day she arrived at the facility. In an interview on 10/29/24 at 1:50 PM with CNA J, she said Resident #79 had always had O2 since she worked with her. She said sometimes the resident will not have it on because she took it off. She said the resident called the nurse to help get it back on. She said she had noted resident #79 with O2 on and off since she was admitted . In an interview on 10/29/24 at 02:10 pm with LVN K, she said Resident #79 came to facility from hospital via ambulance with O2. She said they immediately took her off the oxygen, once orders were verified, because the resident's oxygen saturations were fine. She said yesterday MD gave orders for chest x-ray, PRN O2, and a nebulizer treatment after he completed his rounds with resident due to noted edema and shortness of breath. LVN K said a nurse may use her judgement to provide O2 without an order if signs or symptoms of respiratory distress were noted. She said there were no progress notes showing Resident #79 was under respiratory distress prior to receiving orders for PRN O2 on 10/28/24. In an interview on 10/29/24 at 4:24 pm with ADON/LVN H, she said she does not recall how long Resident #79 has been receiving oxygen. She said there should be an order for O2 if a resident was receiving oxygen, unless the resident was under respiratory distress, then the nurse uses her judgement to start the resident on oxygen then receive orders from the MD. She said they have no standing orders for O2 used for PRN. ADON said that there were no progress notes showing Resident #79 with respiratory distress. In an interview on 10/30/24 at 4:12 pm with ADON/LVN B, she said If a resident was receiving O2, there should be orders prior to resident receiving the O2. She said a nurse can give oxygen to a resident if needed, but they must have a PRN order. She said O2 was considered a medication, so it must be given as ordered to prevent respiratory complications. In an interview on 10/30/24 at 5:16 pm with DON, she said if a resident was receiving oxygen, they must have an order. She said if a resident was in respiratory distress, nursing intervention will apply, they will complete a change in condition, and must follow up with the order, otherwise they should not be on O2. She said if oxygen was received on admission, they should have orders in PCC (a cloud-based healthcare software platform that long-term care providers use for clinical documentation) or on progress notes. She said if nothing was on PCC or progress notes, then they should not be administering O2. The DON said when Resident #79 arrived on admission, the nurse should have verified the O2 order. She said once everything was reviewed, they will need to re-educate staff. Record review of the Oxygen Administration policy, revised October 2010, reflected: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Steps in the Procedure . 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

49301 Based on observation, interview, and record review, the facility failed to establish 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 8 residents (Resident #79) observed for infection control issues in that: 1. Wound care LVN M did not put on PPE when she entered Resident #79's room who was on contact precautions. 2. The AD did not change gloves while handling food and then touched the handles of a resident's wheelchair before returning to the task of handling food again. This deficient practice could place residents at-risk for infection due to improper infection control practices. The findings included: 1. 1. Record review of Resident #79's face sheet dated 10/29/24 reflected the resident was a 73 -year-old female admitted to the facility on [DATE]. Resident #79 had diagnoses which included the following: morbid obesity (chronic disease in which the body mass index was40 or higher or 35 or higher and experiencing obesity-related health conditions), muscle wasting and atrophy (wasting of an organ or tissue), muscle weakness, and hypertension (the pressure in blood vessels was too high) and sebaceous cyst (nodules filled with keratin (a protein found in the body)). Record review of Resident #79's Comprehensive MDS assessment, dated 10/2/24, reflected the resident had a BIMS score of 14 which suggests intact cognition. Self-care assessment reflected she was dependent on staff for all self-care except eating and oral hygiene which required partial/moderate assistance from staff. Record review of the most recent Care Plan on 10/15/24 for Resident #79 reflected the resident had infection of the (UTI/ESBL) Date Initiated: 10/18/2024 Revision on: 10/24/2024. The resident was on antibiotic therapy (MACROBID 100MG BID X 10 DAYS) r/t infection (UTI/ESBL) Date Initiated: 10/18/2024 Revision on: 10/24/2024. Record review of the Doctor's Order Summary reflected Resident #79 had all services and meals to be rendered in single room due to contact isolation and single room Contact Isolation in Place: DX: Escherichia Coli (a gram-negative bacteria that can cause a variety of illnesses, such as UTI and diarrhea)/ ESBL Q shift. Start Date: 10/21/24. Observation on 10/29/24 at 1:40 pm revealed wound care LVN M entered Resident #79's room without donning gown and gloves. A red contact precaution sign was observed above the room number with the following instructions: All Healthcare Personnel must: wear gloves when entering room and remove before leaving room. Wear a gown when entering the room and remove before leaving room. In an interview on 10/29/24 at 1:45 pm with wound care LVN M, she said she only needed to use PPE if she provided care with actual contact with the resident, such as doing wound care. She said contact precautions required staff to wear a gown whenever they were having any type of contact with patients. She said if they did not follow the instructions on the precaution signs located outside of resident's rooms, they could spread infection. She said the last infection control in-service she attended was this morning. In an interview on 10/29/24 at 01:50 PM with CNA J, she said the last infection control in-service she attended was at hire approximately 4 months ago. She said they went over hand hygiene before entering rooms and when exiting rooms. She said when there was a contact precaution sign up, they cannot go into that room without applying the PPE required, which are gowns and gloves. In an interview on 10/29/24 at 1:58 PM with CNA L, she said the last infection control in-service she attended was upon hire approximately 4 weeks ago. She said they go over signs posted. She said if a resident had a yellow enhanced barrier protection sign, they must wear gowns and gloves while providing care and the resident had an indwelling device, such as a shunt for dialysis. If a resident had a red sign posted for contact precautions, they must wear gown and gloves when ever entering the room. She said they must sanitize their hands before and after entering and exiting all rooms. She said they must remove PPE before coming out of any room and wash their hands or sanitize. In an interview on 10/29/24 at 2:10 pm with LVN K, she said the last infection control in-service she attended was approximately a month or less ago. She said they go over types of PPE they must wear, and the signs posted on resident's rooms. She said for signs up showing EBP, they gown up if providing care and the resident had a foley catheter, IV, PEG tube, or was receiving dialysis. She said when a resident was on contact precautions, they must be careful with infection control and wear a gown and gloves anytime they enter the room. She said they must perform hand hygiene before entering the room and when exiting the room. She said they must doff PPE after care was completed and wash hands before exiting the room. In an interview on 10/30/24 at 4:12 pm with ADON/LVN B, she said staff had an in-service on infection control approximately every 1-2 weeks. She said the IP was responsible for those trainings. She said they went over all protocols for contact precautions, EBP, hand hygiene and how to don and doff PPE. She said if a resident was in contact isolation, staff must go in with gown and gloves to render care to the resident any time they enter the resident's room because they cannot be sure what the resident had touched. In an interview on 10/30/24 at 5:16 pm DON said that the IP usually trained on infection control, but she helped. She said in the training, they go over EBP and contact precautions. She said EBP had made things a little confusing, but they keep reminding staff of the differences because of it. She said if a resident was on contact precautions, staff must wear a gown and gloves prior to entering the resident's room. She said when wound care LVN M entered the resident's room without the appropriate PPE, it was not done intentionally. She said the LVN was very nervous. In an interview on 10/30/24 at 6:32 pm with the Administrator, he said for infection control, they have the IP and DON involved with training. He said they do admit residents with an array of infections and follow protocols for them. He said they are trained once a week. He said that he does not go to any of the trainings, but he was aware that for residents on precautions they must use appropriate PPE when providing care and remove PPE before exiting the rooms. He said for residents on EBP, they must gown up and wear gloves while providing direct care. He said for residents on contact precautions, they did not have a choice but to gown up before entering the room. Record review of the facility ' s Isolation - Categories of Transmission-Based Precautions, revised September 2022, revealed: Policy Statement Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Contact Precautions 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment. 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room. b. Gloves are removed, and hand hygiene performed before leaving the room. c. Staff avoid touching potentially contaminated environmental surfaces or items in the resident ' s room after gloves are removed. 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 2.Observation on 10/27/24 at 3:01 p.m. of the AD passing out cupcakes and coffee for residents during an activity. The AD had gloves on and was getting a napkin and picking up the cupcake a fork and placing it on the napkin. Surveyor observed the AD turn around and repositioned a female resident's wheelchair closer to the table. The AD then turned and resumed handing out the cupcakes without changing her gloves. In an interview on 10/27/24 at 03:05 p.m., the AD said she was not a CNA but did know that if she touches a resident or a chair, she needed to change gloves. Surveyor asked the AD if she should just put her gloves on, the AD said no she needs to wash her hands and then put on a pair of clean gloves before handling the food. In an interview on 10/27/24 at 03:10 p.m., Housekeeper E said they have in-services on infection control and hand hygiene often. Housekeeper E said if she is doing a task and then has to change tasks, she needs to change gloves. Housekeeper said she must wash her hands before she dons a clean pair of gloves. Housekeeper E said they must wash their hands for 30 seconds. Housekeeper E said they had an in-service on hand washing this month. In an interview on 10/28/24 at 9:30 a.m., the AD said the in-services on infection control were necessary so that they do not spread germs. The AD said if they touched a surface and then go in and touch a resident, they may spread germs and some residents do not have healthy immune systems. The AD said it is important to wash their hands before donning gloves to handle food and if they touch a surface such as a table or chair, they need to change gloves, they must wash or sanitize before donning a clean pair of gloves. In an interview on 10/28/24 at 10:52 a.m., CNA F said they have in-services every Monday and Thursday. CNA F said they had an in-service last Monday on abuse and neglect. The CNA said they also have in-services on infection control. CNA F said they would need to don PPE if a resident was on isolation, and they must wash their hands. CNA F said washing their hands was the best way to prevent transmission of germs. CNA F said if she was providing care and her gloves were dirty, she needed to doff the dirty gloves, wash her hands and don clean gloves. If she was feeding a resident in isolation, she needed to don gloves and then when she takes off the gloves, she needed to wash her hands before she left the room. In an interview on 10/28/24 at 4:15 p.m., LVN G said they get in-services on hand hygiene weekly. LVN G said the CNAs are in-serviced often by the Lead CNA. LVN G said the nurses are on the floor and can observe the CNAs to check if they are using hand sanitizer and washing their hands as needed. LVN G said they also check the non-nursing staff and family. They educated the family on the importance of hand hygiene. LVN G said that in-services on hand hygiene are for all staff because all staff are hands on. They do in-services with demand demonstration. LVN G said they do spot checks for CNAs, Housekeeping staff and the Activity Department. Interview on 10/29/24 at 10:59 a.m., ADON/LVN H said she did rounds daily. She made sure the staff are gowning up when going into an isolation room. ADON H said she did spot checks on staff and would go into a room to make sure they are washing their hands and checking the CNAs are cleaning the resident correctly. ADON/LVN H said she has not used the audit but would start soon. ADON/LVN H said she did hand hygiene in-services for the whole facility staff. ADON/LVN H said the reason they have infection control procedures is to prevent the spread of infection. In an interview on 10/30/24 at 4:35 p.m., the DON said they just had an in-service on hand hygiene last week. The DON said the AD was present for the in-service and she did well during the demand demonstration. The DON said hand hygiene is important to prevent transmission of infection. The DON said she would conduct another in-service for hand hygiene procedures with all staff immediately. Record review of policy for Handwashing/Hand Hygiene revised on October 2023 reflected: Policy Interpretation and Implementation Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol- based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. Indications for Hand Hygiene 1. Hand hygiene is indicated: 1. immediately before touching a resident; 2. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); 3. after contact with blood, body fluids, or contaminated surfaces; 4. after touching a resident; 5. after touching the resident's environment; 6. before moving from work on a soiled body site to a clean body site on the same resident; and 7. immediately after glove removal. 8. before aseptic procedures; 9. when anticipating contact with blood or body fluids; and 10. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 2. The use of gloves does not replace hand washing/hand hygiene. Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves.

Based on observation, interview, and record review the facility failed to ensure at the time a resident is admitted , the facility had physician orders for the resident's immediate care and needs for 1 of 8 residents (Resident #79) reviewed for complete and accurate medical records. The facility failed to obtain orders for oxygen for Resident #79. This failure placed the resident at risk for not receiving the appropriate physician ordered care. The findings included: Record review of Resident #79's face sheet dated 10/29/24 reflected the resident was a 73 -year-old female admitted to the facility on [DATE]. Resident #79 had diagnoses which included the following: morbid obesity (chronic disease in which the body mass index was 40 or higher or 35 or higher and experiencing obesity-related health conditions), muscle wasting and atrophy (wasting of an organ or tissue), muscle weakness, and hypertension (the pressure in blood vessels was too high). Record review of Resident #79's Comprehensive MDS assessment, dated 10/2/24, reflected the resident had a BIMS score of 14 which suggests intact cognition. Self-care assessment reflected she was dependent on staff for all self-care except eating and oral hygiene which required partial/moderate assistance from staff. Special treatments, procedures, and programs reflected the resident received continuous oxygen therapy. Record review of the Care Plan completed on 9/27/24 for Resident #79 did not reflect the resident required the use of oxygen therapy. Record review of the most recent Care Plan on 10/15/24 for Resident #79 reflected the resident was at risk for complications with the respiratory system due to shortness of breath. Date initiated: 10/29/24 with intervention to administer medications as ordered. Monitor for side effects/adverse reactions and effectiveness. Date initiated 10/29/24. Record review of the Doctor's Order Summary reflected Resident #79 was prescribed O2 at 2 LPM via nasal cannula continuous per concentrator. Start Date 10/28/2024 at 4:30 pm. End Date 10/28/24 and O2 at 2 LPM via nasal cannula per concentrator PRN. Start Date 10/28/24 at 4:32 pm. Record review of the MAR for September 2024 reflected the medication reconciliation had been performed for Resident #79 with review of the prior care setting discharge medications one time only for medication reconciliation for 1 day. -Start Date- 09/26/2024. The MAR did not reflect oxygen therapy was administered. Record review of the MAR for October 2024 reflected Resident #79 was prescribed O2 @2 LPM via nasal cannula continuous per concentrator as needed for SOB. Start Date: 10/28/2024 at 4:30 pm DC Date: 10/28/2024 at 4:33 pm and O2 @2LPM via nasal cannula per concentrator PRN as needed for SOB Start Date: 10/28/2024 at 4:32 pm. Record review of Medication Reconciliation Report for Discharge for Resident #79 dated 9/26/24 reflected no orders for oxygen. Record review of O2 saturation log documented Resident #79 with oxygen via nasal cannula since 9/26/24. Record review of progress note dated 10/20/24 reflected Resident #79 continues oxygen via NC. Record review of progress note dated 10/28/24 at 4:29 pm for Resident #79 reflected new order received from MD for oxygen PRN at 2 LPM via nasal canula due to SOB. Observation and interview on 10/28/24 at 11:45 am revealed Resident #79 in bed with head of bed elevated. Resident #79 received O2 2LPM via NC. Resident stated she was on O2 because she becomes short of breath due to her edema (swelling caused by fluid buildup in the body's tissues and organs). Resident said that she had received oxygen since the first day she arrived at the facility. In an interview on 10/29/24 at 1:50 PM with CNA J, she said Resident #79 had always had O2 since she worked with her. She said sometimes the resident will not have it on because she took it off. She said the resident called the nurse to help get it back on. She said she had noted resident #79 with O2 on and off since she was admitted . In an interview on 10/29/24 at 02:10 pm with LVN K, she said Resident #79 came to facility from hospital via ambulance with O2. She said they immediately took her off the oxygen, once orders were verified, because the resident's oxygen saturations were fine. She said yesterday MD gave orders for chest x-ray, PRN O2, and a nebulizer treatment after he completed his rounds with resident due to noted edema and shortness of breath. LVN K said a nurse may use her judgement to provide O2 without an order if signs or symptoms of respiratory distress were noted. She said there were no progress notes showing Resident #79 was under respiratory distress prior to receiving orders for PRN O2 on 10/28/24. In an interview on 10/29/24 at 4:24 pm with ADON/LVN H, she said she does not recall how long Resident #79 has been receiving oxygen. She said there should be an order for O2 if a resident was receiving oxygen, unless the resident was under respiratory distress, then the nurse uses her judgement to start the resident on oxygen then receive orders from the MD. She said they have no standing orders for O2 used for PRN. ADON said that there were no progress notes showing Resident #79 with respiratory distress. In an interview on 10/30/24 at 4:12 pm with ADON/LVN B, she said If a resident was receiving O2, there should be orders prior to resident receiving the O2. She said a nurse can give oxygen to a resident if needed, but they must have a PRN order. She said O2 was considered a medication, so it must be given as ordered to prevent respiratory complications. In an interview on 10/30/24 at 5:16 pm with DON, she said if a resident was receiving oxygen, they must have an order. She said if a resident was in respiratory distress, nursing intervention will apply, they will complete a change in condition, and must follow up with the order, otherwise they should not be on O2. She said if oxygen was received on admission, they should have orders in PCC (a cloud-based healthcare software platform that long-term care providers use for clinical documentation) or on progress notes. She said if nothing was on PCC or progress notes, then they should not be administering O2. The DON said when Resident #79 arrived on admission, the nurse should have verified the O2 order. She said once everything was reviewed, they will need to re-educate staff. Record review of the Oxygen Administration policy, revised October 2010, reflected: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Record review of the Medication Orders policy, revised November 2014, reflected: Purpose The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician authorized to practice medicine in this state and must be seen by the Physician at least every sixty (60) days. 2. A current list of orders must be maintained in the clinical record of each resident. Recording Orders 1. Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. A placebo is considered a medication and must also have specific orders. Example: Dilantin 100mg by mouth three times per day. 2. PRN Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. Example: Tylenol 500mg by mouth every 4 hours as needed for mild pain or temp greater than l01 F. 3. Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route and rationale. Example: oxygen 3L/min per nasal cannula as needed for shortness of breath.

Based on observation, record review, and interview, the facility failed to implement written policies to prevent neglect, for one Resident (R#1) of four residents reviewed for falls. R#1 had a history of [REDACTED].#1 while transporting R#1 in a shower chair. R#1 fell from the shower chair and sustained a C1 cervical fracture and a skull fracture. This failure resulted in actual harm to R#1 and could place all seven residents with a history of falls at risk for additional falls and injuries. The findings were: Record review of the facility's, Abuse and Neglect - Clinical Protocol, revised [DATE], revealed, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record review of the facility's policy on, Fall and Fall Risk, Managing, revised [DATE], revealed: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Record review of R#1's undated Face Sheet revealed R#1 was [AGE] years-old and was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed R#1: -was able to make himself understood, -was able to understand others, -had moderately impaired cognition, -required extensive assistance from staff for bed mobility, transfers, locomotion off unit, dressing, eating, toilet use and personal hygiene, -required total assistance from staff for locomotion on unit and bathing, -had no Range of Motion impairments, -was incontinent of bladder and of bowel, and -had falls with no injury since admission/reentry/prior assessment. Record review of R#1's care plan for Falls last edited on ,[DATE] revealed R#1 was at risk for falls due to anxiety, recently deceased spouse, poor safety awareness, generalized weakness, and unsteady balance and gait. The care plan indicated R#1 constantly yelled, Get me up, I want to get up and had increased movement in bed due to irritation of skin. Record review of R#1's care plan for Falls, last edited on [DATE], revealed R#1 had actual falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Care plan indicated R#1 had cognitive impairment due to a [DIAGNOSES REDACTED]. Interventions were: -fall mats, -attempt to identify cause of fall and alleviate problem to extent possible, -place resident on a fall prevention program if warranted, -provide proper, well maintained footwear, -update fall assessment upon admission, readmit, annual, significant change, quarterly and PRN (as needed), -keep bed in lowest position with brakes locked, -provide toileting assistance per round and p.m., and -instruct resident to call for help before out of bed or chair. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Notes section indicated R#1 was found lying on the gray mat on the floor, facing up, on [DATE]. No injuries were documented. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 was found lying on the floor. R#1 sustained a skin tear to the right shoulder blade. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 constantly yelled out, removed his oxygen, and attempted to get up from the chair. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 was found in a sitting position on top of the floor mat, with his right leg under his buttocks and his left leg bent to the side. No injuries were documented. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Notes section indicated R#1 slipped out of bed to the floor on [DATE]. No injuries were documented. Record review of R#1's Progress Notes, dated [DATE] at 9:15 p.m., revealed nursing staff was called from the office to assess R#1 after a fall. R#1 was found on the floor, on his right side, in between the bathroom door and the room door. R#1 had been in the shower chair on the way to shower room with a Certified Nurse Aide (CNA) when the fall occurred. R#1 had a laceration to the forehead. R#1 was alert times one, and able to move all extremities. R#1 was agitated and asking to go back to bed. R#1 was assisted up and into bed, and R#1's Physician and family member were called. Record review of R#1's Progress Notes, dated [DATE] at 10:31 a.m., revealed nursing staff was called to R#1's room and found R#1 lying on the floor. A CNA had transferred R#1 to the shower chair, enroute to the shower room. R#1, became agitated and fell off the chair and hit his head causing a laceration to the right side of forehead with bleeding. The Director of Nurses (DON) was present to assess R#1. R#1 was sent to the hospital via ambulance. Record review of R#1's, Facility Internal Investigation, dated [DATE], revealed CNA C said she and CNA E got R#1 out of bed, using the mechanical lift, and placed R#1 in a shower chair. CNA E then left the room with the mechanical lift. CNA C started to transport R#1 to the shower room. CNA C said that, as they got close to R#1's room door, CNA C used her left hand to move a privacy curtain, but kept her right hand on R#1's shoulder. CNA C said, When I moved the curtain, (R#1) moved his body to the right and fell forward. I heard a loud noise. I tried to catch him but it happened so fast, he was too heavy. We were by the door so I think he hit the door handle. CNA C said earlier R#1 had been in the Geri chair (rolling recliner) for dinner and had been restless, moving a lot, and yelling. CNA C said she had showered R#1 many times and R#1 had not moved a lot or tried to get up. Record review of R#1's Fall Scene Investigation Report, dated [DATE], revealed R#1 fell to the floor while being assisted by staff. R#1 mental status prior to fall was, Agitated, which was R#1's normal mental status. Record review of the hospital's, Emergency Provider Report, dated [DATE] at 2:00 a.m., revealed R#1 arrived via EMS (Emergency Medical Services) due to a fall episode, Patient was seen fall by CNA while being assisted . Impression was: 1. Small acute extra-axial hematoma over the right frontal lobe, likely subdural . 2. Right frontal scalp hematoma with underlying nondisplaced fracture involving the frontal bone including the anterior and posterior walls of the right frontal sinus . 3. C1 Jefferson (burst) fracture without significant distraction of fracture fragments. 4. Type II mildly displaced odontoid (neck) fracture . Record review of the hospital's, Consultation form, indicated a Primary Impression of Subdural Hematoma and Secondary Impressions which included C1 cervical fracture and Skull Fracture. In an interview on [DATE] at 11:20 a.m., CNA A said R#1 had a behavior of getting out of bed unassisted. CNA A said they had been told by the nurse to keep an eye on R#1. In an interview on [DATE] at 11:30 a.m., Licensed Vocational Nurse (LVN) B said R#1 had been alert to person only, and had used a Geri-chair. LVN B said R#1 had one fall during her shift. LVN B said R#1 was found on the floor, sitting on the floor mat, with no injury. LVN B said R#1 sometimes resisted care and got agitated. LVN B said R#1 had floor mats and bed at the lowest position as interventions to prevent falls. In an interview on [DATE] at 4:20 p.m., CNA C said she and CNA E transferred R#1 from bed to shower chair using a mechanical lift. CNA C said CNA E then left R#1's room and she (CNA C) stayed with R#1. CNA C said she was pushing R#1 in the shower chair to take R#1 to the shower, outside R#1's room. CNA C said she was holding R#1's shoulder. CNA C said that, before leaving the room, she stopped to open the privacy curtain from bed A (bed closest to the doorway). CNA C said she turned to move the privacy curtain while still holding onto R#1's shoulder with one hand. CNA C said that, when she turned, she heard a noise and saw R#1 on the floor. CNA C said the room door was open and R#1 probably hit his head on the door knob. CNA C said she could not hold R#1 to prevent the fall. CNA C said she called for assistance and LVN D and the DON came to the room. In an interview on [DATE] at 4:50 p.m., CNA E said she assisted CNA C with R#1's transfer from the bed to the shower chair via mechanical Lift. CNA E said after the transfer, she left R#1's room and continued with her duties. CNA E said the mechanical lift stayed inside R#1's room. In an interview on [DATE] at 8:35 a.m., LVN D said she was called by the CNA to R#1's room around 8:30 p.m., LVN D said she found R#1 at the room entrance, lying on his right side. LVN D said she saw blood on R#1's forehead. LVN D said she called the DON and the DON did a nursing assessment. LVN D said R#1 was then transferred via mechanical lift to his bed. LVN D said she called R#1's Physician, who gave an order to transfer R#1 to the hospital. LVN D said R#1 was still hospitalized at this time. In an interview on [DATE] at 9:00 a.m., the DON said she was called to R#1's room. The DON said R#1 was on the floor, lying on his right side, close to the room entrance. The DON said she did an assessment, and R#1 was transferred to the hospital via EMS. The DON said R#1 was not able to stand up by himself, however he was able to kick, or take his shoes off by moving his legs. The DON said R#1 had some trunk strength and sat in a Geri chair. In an interview on [DATE] at 9:50 a.m., LVN B said that, prior to the fall, R#1 had not been able to ambulate and had used a wheelchair, but R#1 was sliding down from the wheelchair, so he was placed in a Geri chair. In an interview on [DATE] at 10:00 a.m., CNA F said that, prior to the fall, R#1 was not able to stand and used to have a wheelchair, but he was sliding down, and was placed in a Geri chair. The facility's undated CMS Roster/Sample Matrix (802) form indicated there were seven residents with a history of falls, including falls with major injury.

Based on observation, record review, and interview, the facility failed to ensure each resident was free from neglect, for one Resident (R#1) of four residents reviewed for falls. R#1 had a history of [REDACTED].#1 while transporting R#1 in a shower chair. R#1 fell from the shower chair and sustained a C1 cervical fracture and a skull fracture. This failure resulted in actual harm to R#1 and could place all seven residents with a history of falls at risk for additional falls and injuries. The findings were: Record review of R#1's undated Face Sheet revealed R#1 was [AGE] years-old and was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed R#1: -was able to make himself understood, -was able to understand others, -had moderately impaired cognition, -required extensive assistance from staff for bed mobility, transfers, locomotion off unit, dressing, eating, toilet use and personal hygiene, -required total assistance from staff for locomotion on unit and bathing, -had no Range of Motion impairments, -was incontinent of bladder and of bowel, and -had falls with no injury since admission/reentry/prior assessment. Record review of R#1's care plan for Falls last edited on ,[DATE] revealed R#1 was at risk for falls due to anxiety, recently deceased spouse, poor safety awareness, generalized weakness, and unsteady balance and gait. The care plan indicated R#1 constantly yelled, Get me up, I want to get up and had increased movement in bed due to irritation of skin. Record review of R#1's care plan for Falls, last edited on [DATE], revealed R#1 had actual falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Care plan indicated R#1 had cognitive impairment due to a [DIAGNOSES REDACTED]. Interventions were: -fall mats, -attempt to identify cause of fall and alleviate problem to extent possible, -place resident on a fall prevention program if warranted, -provide proper, well maintained footwear, -update fall assessment upon admission, readmit, annual, significant change, quarterly and PRN (as needed), -keep bed in lowest position with brakes locked, -provide toileting assistance per round and p.m., and -instruct resident to call for help before out of bed or chair. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Notes section indicated R#1 was found lying on the gray mat on the floor, facing up, on [DATE]. No injuries were documented. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 was found lying on the floor. R#1 sustained a skin tear to the right shoulder blade. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 constantly yelled out, removed his oxygen, and attempted to get up from the chair. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 was found in a sitting position on top of the floor mat, with his right leg under his buttocks and his left leg bent to the side. No injuries were documented. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Notes section indicated R#1 slipped out of bed to the floor on [DATE]. No injuries were documented. Record review of R#1's Progress Notes, dated [DATE] at 9:15 p.m., revealed nursing staff was called from the office to assess R#1 after a fall. R#1 was found on the floor, on his right side, in between the bathroom door and the room door. R#1 had been in the shower chair on the way to shower room with a Certified Nurse Aide (CNA) when the fall occurred. R#1 had a laceration to the forehead. R#1 was alert times one, and able to move all extremities. R#1 was agitated and asking to go back to bed. R#1 was assisted up and into bed, and R#1's Physician and family member were called. Record review of R#1's Progress Notes, dated [DATE] at 10:31 a.m., revealed nursing staff was called to R#1's room and found R#1 lying on the floor. A CNA had transferred R#1 to the shower chair, enroute to the shower room. R#1, became agitated and fell off the chair and hit his head causing a laceration to the right side of forehead with bleeding. The Director of Nurses (DON) was present to assess R#1. R#1 was sent to the hospital via ambulance. Record review of R#1's, Facility Internal Investigation, dated [DATE], revealed CNA C said she and CNA E got R#1 out of bed, using the mechanical lift, and placed R#1 in a shower chair. CNA E then left the room with the mechanical lift. CNA C started to transport R#1 to the shower room. CNA C said that, as they got close to R#1's room door, CNA C used her left hand to move a privacy curtain, but kept her right hand on R#1's shoulder. CNA C said, When I moved the curtain, (R#1) moved his body to the right and fell forward. I heard a loud noise. I tried to catch him but it happened so fast, he was too heavy. We were by the door so I think he hit the door handle. CNA C said earlier R#1 had been in the Geri chair (rolling recliner) for dinner and had been restless, moving a lot, and yelling. CNA C said she had showered R#1 many times and R#1 had not moved a lot or tried to get up. Record review of R#1's Fall Scene Investigation Report, dated [DATE], revealed R#1 fell to the floor while being assisted by staff. R#1 mental status prior to fall was, Agitated, which was R#1's normal mental status. Record review of the hospital's, Emergency Provider Report, dated [DATE] at 2:00 a.m., revealed R#1 arrived via EMS (Emergency Medical Services) due to a fall episode, Patient was seen fall by CNA while being assisted . Impression was: 1. Small acute extra-axial hematoma over the right frontal lobe, likely subdural . 2. Right frontal scalp hematoma with underlying nondisplaced fracture involving the frontal bone including the anterior and posterior walls of the right frontal sinus . 3. C1 Jefferson (burst) fracture without significant distraction of fracture fragments. 4. Type II mildly displaced odontoid (neck) fracture . Record review of the hospital's, Consultation form, indicated a Primary Impression of Subdural Hematoma and Secondary Impressions which included C1 cervical fracture and Skull Fracture. In an interview on [DATE] at 11:20 a.m., CNA A said R#1 had a behavior of getting out of bed unassisted. CNA A said they had been told by the nurse to keep an eye on R#1. In an interview on [DATE] at 11:30 a.m., Licensed Vocational Nurse (LVN) B said R#1 had been alert to person only, and had used a Geri-chair. LVN B said R#1 had one fall during her shift. LVN B said R#1 was found on the floor, sitting on the floor mat, with no injury. LVN B said R#1 sometimes resisted care and got agitated. LVN B said R#1 had floor mats and bed at the lowest position as interventions to prevent falls. In an interview on [DATE] at 4:20 p.m., CNA C said she and CNA E transferred R#1 from bed to shower chair using a mechanical lift. CNA C said CNA E then left R#1's room and she (CNA C) stayed with R#1. CNA C said she was pushing R#1 in the shower chair to take R#1 to the shower, outside R#1's room. CNA C said she was holding R#1's shoulder. CNA C said that, before leaving the room, she stopped to open the privacy curtain from bed A (bed closest to the doorway). CNA C said she turned to move the privacy curtain while still holding onto R#1's shoulder with one hand. CNA C said that, when she turned, she heard a noise and saw R#1 on the floor. CNA C said the room door was open and R#1 probably hit his head on the door knob. CNA C said she could not hold R#1 to prevent the fall. CNA C said she called for assistance and LVN D and the DON came to the room. In an interview on [DATE] at 4:50 p.m., CNA E said she assisted CNA C with R#1's transfer from the bed to the shower chair via mechanical Lift. CNA E said after the transfer, she left R#1's room and continued with her duties. CNA E said the mechanical lift stayed inside R#1's room. In an interview on [DATE] at 8:35 a.m., LVN D said she was called by the CNA to R#1's room around 8:30 p.m., LVN D said she found R#1 at the room entrance, lying on his right side. LVN D said she saw blood on R#1's forehead. LVN D said she called the DON and the DON did a nursing assessment. LVN D said R#1 was then transferred via mechanical lift to his bed. LVN D said she called R#1's Physician, who gave an order to transfer R#1 to the hospital. LVN D said R#1 was still hospitalized at this time. In an interview on [DATE] at 9:00 a.m., the DON said she was called to R#1's room. The DON said R#1 was on the floor, lying on his right side, close to the room entrance. The DON said she did an assessment, and R#1 was transferred to the hospital via EMS. The DON said R#1 was not able to stand up by himself, however he was able to kick, or take his shoes off by moving his legs. The DON said R#1 had some trunk strength and sat in a Geri chair. In an interview on [DATE] at 9:50 a.m., LVN B said that, prior to the fall, R#1 had not been able to ambulate and had used a wheelchair, but R#1 was sliding down from the wheelchair, so he was placed in a Geri chair. In an interview on [DATE] at 10:00 a.m., CNA F said that, prior to the fall, R#1 was not able to stand and used to have a wheelchair, but he was sliding down, and was placed in a Geri chair. Record review of the facility's, Abuse and Neglect - Clinical Protocol, revised [DATE], revealed, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record review of the facility's policy on, Fall and Fall Risk, Managing, revised [DATE], revealed: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility's undated CMS Roster/Sample Matrix (802) form indicated there were seven residents with a history of falls, including falls with major injury.

Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision to prevent accidents, for one Resident (R#1) of four residents reviewed for falls. R#1 had a history of [REDACTED].#1 while transporting R#1 in a shower chair. R#1 fell from the shower chair and sustained a C1 cervical fracture and a skull fracture. This failure resulted in actual harm to R#1 and could place all seven residents with a history of falls at risk for additional falls and injuries. The findings were: Record review of R#1's undated Face Sheet revealed R#1 was [AGE] years-old and was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed R#1: -was able to make himself understood, -was able to understand others, -had moderately impaired cognition, -required extensive assistance from staff for bed mobility, transfers, locomotion off unit, dressing, eating, toilet use and personal hygiene, -required total assistance from staff for locomotion on unit and bathing, -had no Range of Motion impairments, -was incontinent of bladder and of bowel, and -had falls with no injury since admission/reentry/prior assessment. Record review of R#1's care plan for Falls last edited on ,[DATE] revealed R#1 was at risk for falls due to anxiety, recently deceased spouse, poor safety awareness, generalized weakness, and unsteady balance and gait. The care plan indicated R#1 constantly yelled, Get me up, I want to get up and had increased movement in bed due to irritation of skin. Record review of R#1's care plan for Falls, last edited on [DATE], revealed R#1 had actual falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Care plan indicated R#1 had cognitive impairment due to a [DIAGNOSES REDACTED]. Interventions were: -fall mats, -attempt to identify cause of fall and alleviate problem to extent possible, -place resident on a fall prevention program if warranted, -provide proper, well maintained footwear, -update fall assessment upon admission, readmit, annual, significant change, quarterly and PRN (as needed), -keep bed in lowest position with brakes locked, -provide toileting assistance per round and p.m., and -instruct resident to call for help before out of bed or chair. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Notes section indicated R#1 was found lying on the gray mat on the floor, facing up, on [DATE]. No injuries were documented. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 was found lying on the floor. R#1 sustained a skin tear to the right shoulder blade. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 constantly yelled out, removed his oxygen, and attempted to get up from the chair. Record review of R#1's Progress Notes, dated [DATE], revealed R#1 was found in a sitting position on top of the floor mat, with his right leg under his buttocks and his left leg bent to the side. No injuries were documented. Record review of R#1's Observation Report, dated [DATE] indicated R#1 had a history of [REDACTED].#1 was at risk for falls. Notes section indicated R#1 slipped out of bed to the floor on [DATE]. No injuries were documented. Record review of R#1's Progress Notes, dated [DATE] at 9:15 p.m., revealed nursing staff was called from the office to assess R#1 after a fall. R#1 was found on the floor, on his right side, in between the bathroom door and the room door. R#1 had been in the shower chair on the way to shower room with a Certified Nurse Aide (CNA) when the fall occurred. R#1 had a laceration to the forehead. R#1 was alert times one, and able to move all extremities. R#1 was agitated and asking to go back to bed. R#1 was assisted up and into bed, and R#1's Physician and family member were called. Record review of R#1's Progress Notes, dated [DATE] at 10:31 a.m., revealed nursing staff was called to R#1's room and found R#1 lying on the floor. A CNA had transferred R#1 to the shower chair, enroute to the shower room. R#1, became agitated and fell off the chair and hit his head causing a laceration to the right side of forehead with bleeding. The Director of Nurses (DON) was present to assess R#1. R#1 was sent to the hospital via ambulance. Record review of R#1's, Facility Internal Investigation, dated [DATE], revealed CNA C said she and CNA E got R#1 out of bed, using the mechanical lift, and placed R#1 in a shower chair. CNA E then left the room with the mechanical lift. CNA C started to transport R#1 to the shower room. CNA C said that, as they got close to R#1's room door, CNA C used her left hand to move a privacy curtain, but kept her right hand on R#1's shoulder. CNA C said, When I moved the curtain, (R#1) moved his body to the right and fell forward. I heard a loud noise. I tried to catch him but it happened so fast, he was too heavy. We were by the door so I think he hit the door handle. CNA C said earlier R#1 had been in the Geri chair (rolling recliner) for dinner and had been restless, moving a lot, and yelling. CNA C said she had showered R#1 many times and R#1 had not moved a lot or tried to get up. Record review of R#1's Fall Scene Investigation Report, dated [DATE], revealed R#1 fell to the floor while being assisted by staff. R#1 mental status prior to fall was, Agitated, which was R#1's normal mental status. Record review of the hospital's, Emergency Provider Report, dated [DATE] at 2:00 a.m., revealed R#1 arrived via EMS (Emergency Medical Services) due to a fall episode, Patient was seen fall by CNA while being assisted . Impression was: 1. Small acute extra-axial hematoma over the right frontal lobe, likely subdural . 2. Right frontal scalp hematoma with underlying nondisplaced fracture involving the frontal bone including the anterior and posterior walls of the right frontal sinus . 3. C1 Jefferson (burst) fracture without significant distraction of fracture fragments. 4. Type II mildly displaced odontoid (neck) fracture . Record review of the hospital's, Consultation form, indicated a Primary Impression of Subdural Hematoma and Secondary Impressions which included C1 cervical fracture and Skull Fracture. In an interview on [DATE] at 11:20 a.m., CNA A said R#1 had a behavior of getting out of bed unassisted. CNA A said they had been told by the nurse to keep an eye on R#1. In an interview on [DATE] at 11:30 a.m., Licensed Vocational Nurse (LVN) B said R#1 had been alert to person only, and had used a Geri-chair. LVN B said R#1 had one fall during her shift. LVN B said R#1 was found on the floor, sitting on the floor mat, with no injury. LVN B said R#1 sometimes resisted care and got agitated. LVN B said R#1 had floor mats and bed at the lowest position as interventions to prevent falls. In an interview on [DATE] at 4:20 p.m., CNA C said she and CNA E transferred R#1 from bed to shower chair using a mechanical lift. CNA C said CNA E then left R#1's room and she (CNA C) stayed with R#1. CNA C said she was pushing R#1 in the shower chair to take R#1 to the shower, outside R#1's room. CNA C said she was holding R#1's shoulder. CNA C said that, before leaving the room, she stopped to open the privacy curtain from bed A (bed closest to the doorway). CNA C said she turned to move the privacy curtain while still holding onto R#1's shoulder with one hand. CNA C said that, when she turned, she heard a noise and saw R#1 on the floor. CNA C said the room door was open and R#1 probably hit his head on the door knob. CNA C said she could not hold R#1 to prevent the fall. CNA C said she called for assistance and LVN D and the DON came to the room. In an interview on [DATE] at 4:50 p.m., CNA E said she assisted CNA C with R#1's transfer from the bed to the shower chair via mechanical Lift. CNA E said after the transfer, she left R#1's room and continued with her duties. CNA E said the mechanical lift stayed inside R#1's room. In an interview on [DATE] at 8:35 a.m., LVN D said she was called by the CNA to R#1's room around 8:30 p.m., LVN D said she found R#1 at the room entrance, lying on his right side. LVN D said she saw blood on R#1's forehead. LVN D said she called the DON and the DON did a nursing assessment. LVN D said R#1 was then transferred via mechanical lift to his bed. LVN D said she called R#1's Physician, who gave an order to transfer R#1 to the hospital. LVN D said R#1 was still hospitalized at this time. In an interview on [DATE] at 9:00 a.m., the DON said she was called to R#1's room. The DON said R#1 was on the floor, lying on his right side, close to the room entrance. The DON said she did an assessment, and R#1 was transferred to the hospital via EMS. The DON said R#1 was not able to stand up by himself, however he was able to kick, or take his shoes off by moving his legs. The DON said R#1 had some trunk strength and sat in a Geri chair. In an interview on [DATE] at 9:50 a.m., LVN B said that, prior to the fall, R#1 had not been able to ambulate and had used a wheelchair, but R#1 was sliding down from the wheelchair, so he was placed in a Geri chair. In an interview on [DATE] at 10:00 a.m., CNA F said that, prior to the fall, R#1 was not able to stand and used to have a wheelchair, but he was sliding down, and was placed in a Geri chair. Record review of the facility's policy on, Fall and Fall Risk, Managing, revised [DATE], revealed: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility's undated CMS Roster/Sample Matrix (802) form indicated there were seven residents with a history of falls, including falls with major injury.