Every finding on record at Glenview Wellness & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure injuries.The facility failed to ensure that dressing changes were completed for Resident #1's wound on 08/10/26, as ordered, and failed to ensure that the Wound Care Nurse cleaned Resident #1's wound prior to applying a clean dressing on 08/11/26. These failures could place residents at risk of improper wound management, deterioration in existing pressure injuries, infection, and pain.Findings included:Record review of Resident #1's Face Sheet, dated 08/11/26 revealed a [AGE] year-old female who admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had the following diagnoses: COPD (ongoing lunch condition caused by damage to the lungs), Hypertension (high blood pressure), and PVD (poor blood circulation). The MDS revealed that Resident #1 had a BIMS of 15, indicating she was cognitively intact. Record review of Resident #1's Care Plan, revised 07/31/26, revealed that she was at risk for impaired skin integrity and received the following treatment: Cleanse sacrum with N/S, pat dry, apply dry dressing every day shift every Mon, Wed, Fri for skin treatment AND every 8 hours as needed for skin treatment.Record review of Resident #1's Order Summary Report, dated 07/11/26 revealed the following orders with an order date of 07/20/26: Cleanse sacrum with N/S ,pat dry, apply dry dressing every 8 hours as needed for skin treatmentCleanse sacrum with N/S ,pat dry, apply dry dressing every day shift every Mon, Wed, Fri for skin treatmentProgress notes from wound care nurse on 08/11/26 at 1:14 PM revealed, Note Text : Resident verbalized that her fam called 911 and [NP name] N P and ordered to sent to be evaluated. Wound care to eval and treat. Dr. [Dr. name] was called and recommended to use collagen /barrier cream , cover with dressing. Resident sacrum has redness and a small area opened. [NP name] NP agreed with recommendation. Will re-assess the area when resident come back to facility if need the treatment change. [sis] Record review of Resident #1's August 2026 MAR/TAR revealed an order to, Cleanse sacrum with N/S, pat dry, apply dry dressing every day shift every Mon, Wed, Fri for skin treatment. The order was initialed as completed on 08/10/26 by RN A. During an observation on 08/11/26 at 12:00 PM, the DON and RN A performed incontinent care on Resident #1. Resident #1 was positioned on her right side. Observation of Resident #1's buttocks revealed a bandage dated 08/09/26 (Sunday). The bandage was soiled with a brown substance and the initials on the bandage were illegible. After incontinent care, the DON removed the soiled dressing and stated she was going to get the Wound Care Nurse. During an observation on 08/11/26 at 12:27 PM, The Wound Care Nurse applied PPE and washed her hands before entering Resident #1's room. The supplies were prepared on a clean barrier. Observation of Resident #1's sacral area revealed redness, with a small open area. The Wound Care Nurse performed hand hygiene, applied clean gloves, and cleansed the wound with normal saline. After cleaning, the Wound Care Nurse stated she had forgotten her marker to label the bandage and exited the room. During this time, no staff member was observed assisting Resident #1 to remain on her right side. Resident #1 was subsequently observed leaning onto her back, causing the wound area to come into contact with the brief and bed linens. The wound care nurse re-entered the room and applied a clean dressing to the wound. The wound was not observed to be re-cleaned prior to the new dressing. During the observation, the Wound Care Nurse educated Resident #1 on repositioning and turning while in bed. Resident #1 stated she would not be turned, sleep on her side, or utilize the wedges or pillows due to it being uncomfortable. During an interview on 08/11/26 at 11:53 AM, Resident #1 stated she might have a sore on her bottom, but it was getting better. She stated the staff were putting a dressing on it. She stated she did not like to turn or sleep on her side. Resident #1 stated the staff do try and turn her with wedges and pillows, but it was not comfortable, so she preferred to be positioned on her back. Resident #1 stated she wanted a new mattress and the facility had gotten her 2 new ones, but she still did not like them. During an interview on 08/11/26 at 1:20 PM, the Wound Care Nurse stated she has worked as the wound care nurse and ADON for 1 year. She stated Resident #1 was at the facility off and on and was constantly calling to go to the hospital. She stated her original wound care order was a dry dressing for protection because she had redness and did not turn in bed. The Wound Care Nurse stated the dressing helped to protect the area but there was an open area that she observed during the wound care on 08/11/26. The Wound Care Nurse stated that Resident #1 will not turn in bed. She stated the staff position her with wedges and she requested that they move them after a few minutes. The Wound Care Nurse stated they were reeducating her and would try to get her a new air mattress. The Wound Care Nurse stated she had cleaned the wound and then had to get her marker. She stated she did not realize that Resident #1's wound had touched the brief again. The Wound Care Nurse stated she should have cleaned the wound again for infection control. She stated not cleaning the wound could put Resident #1 at risk of infection and the wound worsening. During an interview on 08/11/26 at 1:48 PM, RN A stated she has worked at the facility for 2 weeks. She stated she had worked with Resident #1 on 08/10/26. RN A stated she assisted Resident #1 on 08/10/26 and had seen the redness on her sacrum. She stated she saw there was a bandage and peeled it back to visualize the skin. RN A stated she did not replace the dressing or clean it. During the interview, she observed Resident #1's TAR and stated she must had marked the wound care off as completed by accident. RN A stated the risk of not completing the wound care as ordered was the wound could worsen. RN A stated the wound looked the same on 08/11/26 as the previous day. She stated she should have done the wound care but did not have time and thought she left it red for the following shift to complete. During an interview on 08/11/26 at 3:04 PM with ADON B, she stated if the wound touched the brief or linen after cleaning, she expected the Wound Care Nurse to reclean and restart the process. ADON B stated it was an infection control issue, and the risk was further skin breakdown or infection. ADON B stated missing a skin treatment order caused an old dressing to remain and the skin to not be cleaned. She stated the risk was low if it was just one missed day, but it was possible for the wound to worsen. ADON B stated the wound care nurse, and nurses were responsible for completing the wound care and properly documenting their treatment. ADON B stated she was starting in-services to educate the staff. During an interview on 08/11/26 at 3:36 PM with the DON, she stated she had worked at the facility since February 2026. The DON stated if the wound was cleaned and then decontaminated on a different surface, she expected her staff to clean the wound again. She stated not properly cleaning the wound, put Resident #1 at risk of infection and cross contamination. The DON stated missing a skin treatment order put the resident at risk of wound maceration (softening and breakdown of skin around a wound). She stated the nurses were responsible for ensuring wound care was properly completed. Record review of the facility's policy Wound Management revised 2020 reflected the following: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing.Record review of the facility's Skin Integrity and Wound Management Skills Checklist dated July 2017 reflected the following: Wound Treatment: .Complete dressing application/ treatment according to ordersMaintains aseptic technique (clean technique).

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 1 of 3 residents (Resident #1) reviewed for clinical records regarding wound care.The facility failed to ensure nursing staff accurately documented the physician treatment orders for Resident #1, as the medical record indicated the wound care was completed on 08/10/26 when the ordered treatment was not provided. This failure could place residents at risk for inaccurately documented medical records that included their progress treatment, services, and interventions. Findings included: Record review of Resident #1's Face Sheet, dated 08/11/26 revealed a [AGE] year-old female who admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had the following diagnoses: COPD (ongoing lunch condition caused by damage to the lungs), Hypertension (high blood pressure), and PVD (poor blood circulation). The MDS revealed that Resident #1 had a BIMS of 15, indicating she was cognitively intact. Record review of Resident #1's Care Plan, revised 07/31/26, revealed that she was at risk for impaired skin integrity and received the following treatment: Cleanse sacrum with N/S, pat dry, apply dry dressing every day shift every Mon, Wed, Fri[BH1.1][KD1.2] for skin treatment AND every 8 hours as needed for skin treatment.Record review of Resident #1's Order Summary Report, dated 07/11/26 revealed the following orders with an order date of 07/20/26: Cleanse sacrum with N/S ,pat dry, apply dry dressing every 8 hours as needed for skin treatmentCleanse sacrum with N/S ,pat dry, apply dry dressing every day shift every Mon, Wed, Fri for skin treatmentRecord review of Resident #1's August 2026 MAR/TAR revealed an order to, Cleanse sacrum with N/S, pat dry, apply dry dressing every day shift every Mon, Wed, Fri for skin treatment. The order was initialed as completed on 08/10/26 by RN ADuring an observation on 08/11/26 at 12:00 PM, the DON and RN A performed incontinent care on Resident #1. Resident #1 was positioned on her right side. Observation of Resident #1's buttocks revealed a bandage dated 08/09/26 (Sunday). The bandage was soiled with a brown substance and the initials on the bandage were illegible. After incontinent care, the DON removed the soiled dressing and stated she was going to get the Wound Care Nurse. During an interview on 08/11/26 at 1:48 PM, RN A stated she has worked at the facility for 2 weeks. She stated she had worked with Resident #1 on 08/10/26. RN A stated she assisted Resident #1 on 08/10/26 and had seen the redness on her sacrum. She stated she saw there was a bandage and peeled it back to visualize the skin. RN A stated she did not replace the dressing or clean it. During the interview, she observed Resident #1's TAR and stated she must had marked the wound care off as completed by accident. RN A stated the risk of marking the order as completed was the oncoming shift would assume it had been completed and the wound could worsenDuring an interview on 08/11/26 at 3:04 PM with ADON B, she stated she expected staff to accurately document their treatments. She stated it was unethical to falsely mark an order as completed and the following shift would think the wound care was completed, so the risk was the wound care not being completed. ADON B stated missing a skin treatment order caused an old dressing to remain and the skin to not be cleaned. ADON B stated the nurses were responsible for ensuring their documentation was accurate and the treatment was completed according to the orders and policy. ADON B stated she was starting in-services to educate the staff. During an interview on 08/11/26 at 3:36 PM with the DON, she stated she had worked at the facility since February 2026. The DON stated she expected the staff to document once the order had been completed. She stated the risk of charting something the staff did not complete was the next shift would not be aware that the order still needs completed, and it would get missed. She stated the nurses were responsible for ensuring wound care was properly completed and accurately documented.Record review of the facility's Skin Integrity and Wound Management Skills Checklist dated July 2017 reflected the following: Wound Treatment: .Complete dressing application/ treatment according to ordersMaintains aseptic technique (clean technique). Documents procedure on the treatment record.

Based on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is to commence a new form of treatment for 1 of 5 residents (Resident #1) reviewed for resident rights. On 06/29/26, LVN B failed to notify Resident#1's legal representative about a new order for intravenous Vancomycin (glycopeptide antibiotic used to treat severe bacterial infections) to treat leukocytosis (an increase in the number of white blood cells in the bloodstream). This failure placed residents at risk of not making an informed decision about treatment, and risking side effects and allergic reactions. Findings included:Record review of Resident #1's face sheet, dated 07/08/26 reflected, she was a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE]. Resident#1 was diagnosed with acute kidney failure unspecified (sudden loss of kidney function), calculus of gallbladder with acute cholecystitis(gallstones) without obstruction, altered mental status (a change in a person's mental function) and cognitive communication deficit (A condition where cognitive impairments disrupt a person's ability to communicate effectively, despite. Face sheet reflected the legal representative was the first emergency contact. Record review of Resident #1's undated care plan reflected, dependent on staff for activities, cognitive stimulation, and social interaction. Resident goal reflected: attend/participation activities of choice.[Resident #1] interventions reflected invite [Resident #1] to activities. Record review of Resident #1's MPOA, dated 04/27/26 reflected, she had a legal representative. Record review of Resident#1 order summary reflected, Premixed Tyzavan (Vancomycin) 100MG in 200 ML water. Infuse intravenously at 133ML/HR over 90 minutes once daily for Leukocytosis for 7 days created by LVN B on 06/29/26. Record review of Resident#1 progress notes reflected no notation of family being contacted on 06/29/26. Late entry written by DON on 06/29/26 reflected: Vancomycin Intravenous Solution Reconstituted 1 GM (Vancomycin HCl). Use 1 gram intravenously one time a day for Leukocytosis for 7 day Record review of an in-service training record, dated 06/20/26, reflected that nursing staff were trained on resident right, customer service, medication administration (pain), abuse, neglect and exploitation. During an interview on 07/08/26 at 9:45 a.m., Resident #1's Family Member #1 stated when he visited Resident#1 at the facility, she was getting a IV line put in for antibiotics. Family Member #1 stated he was not notified, and he checked with Resident#1's legal representative, who also had not been notified either of the treatment. During an interview on 07/08/26 at 10:15 a.m., Resident #1's Legal Representative stated he was not notified of Resident#1's new treatment. During an interview on 07/08/26 at 12:20 p.m., the ADON stated Family Member #1 wanted to send Resident #1 to the hospital because she looked pale, and he wanted the hospital to do the PICC instead of the third party at the facility. The ADON stated she educated Family Member #1, and he decided to send Resident #1 to the hospital. The ADON stated the family should have been notified as soon as the order was received. During an interview on 07/08/26 at 12:50 p.m., the DON stated the family should have been notified when a new order came in from the NP, so the family knew what was going on and could say yes or no to treatment. The DON stated it was important to contact and educate the residents' families. During an interview on 07/08/26 at 1:54 p.m., over the phone, the NP stated on Sunday (06/29/26) evening, she called in the order for IV antibiotics for leukocytosis. During an interview on 07/08/26 at 2:08 p.m., RN A stated she received shift report from LVN B about Resident #1's order for IV antibiotics. RN A stated she was told by LVN B that family had been notified. An attempt was made to interview RN C on 07/08/26 at 2:16 p.m. via telephone; however, there was no answer. During an interview on 07/08/26 at 2:19 p.m., the Administrator stated that the family should be notified of any change in the resident and treatment. The Administrator stated families were at risk of not knowing what was provided to resident for their care. During an interview on 07/08/26 at 2:20 p.m., the DON stated the nurse, who put in the order, was responsible for notifying the family. The DON stated she was responsible for in-service with nursing staff. The DON stated families were at risk of not assisting and being aware of treatment and care provided to the residents. On 07/08/26 at 2:34 p.m., an interview was attempted with LVN B via telephone. Although she answered, she stated she could not talk and would call back; however, she did not call back. Record review of the facility's Change of Condition Notification policy reflected: to ensure residents, family legal representatives, and physicians are informed of changes in the residents condition in a timely manner.policy.C. A significant change in treatment.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #1 and Resident #2) of 6 residents observed for infection control. The facility failed to clean up blood on the door frame of Resident #1 and Resident #2 bathroom. This failure could place residents at risk for healthcare associated cross contamination and blood borne infections.Findings included: Record review of Resident #1 quarterly MDS assessment, dated 05/03/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. BIMS was not indicated. Her diagnoses included Unspecified Dementia with behavioral disturbance (changes in the brain that can cause forgetfulness, limited social skills, impaired thinking, irritability, and extreme mood swings), Hypertension (a condition in which the blood against the artery wall is too high), and (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1 Care Plan, dated 03/09/2026, reflected:03/15/2026 The resident has actual impairment to skin integrity (scab nose, healing/scab over bilateral arms). Resident will be free from injury.03/28/2026 The resident requires enhanced barrier precautions r/t dialysis. Resident will reduce transmission of pathogens. Observation on 05/10/2026 at 12:30pm of Resident #1 and Resident #2 bathroom, revealed dried blood on the door, the substance appeared dark red brown in color and was located on the right side of the door frame with no signage or indication of ongoing cleaning or isolation precaution observed at the time. Interview on 5/10/2026 at 1:15pm with Housekeeper A revealed he was unaware of blood on the door frame and confirmed that high touch surfaces including door frames were expected to be cleaned daily. Housekeeper A stated the risk of anyone coming in contact with blood or bodily fluids was bloodborne pathogens. During an interview on 5/10/2026 at 2:15pm with Housekeeper B revealed he was unaware of blood on the door frame and stated rooms were to be cleaned daily and wiped down. Housekeeper B stated the risk of encountering blood or bodily fluids was infections. Record review of Resident #2 quarterly MDS assessment, dated 05/04/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident had a BIMS of 15 indicating the resident had intact cognition. Her diagnoses included Adjustment Disorder with Mixed Anxiety and Depressed Mood (a strong reaction to stress or trauma), Unspecified Lack of Coordination (a condition that impairs the body's ability to coordinate movements, affecting balance, walking, and fine motor skills), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities). Record review of Resident #2 Care Plan, dated 02/17/2025, reflected:03/28/2026 The resident is at increased risk for impaired skin integrity and additional skin breakdown due to impaired ability to move and the resident being mostly incontinent of bowel and bladder. Interview on 05/10/2026 at 3:05pm with Resident #2 family member revealed the blood on the door frame had been there for 2 days and not cleaned by staff. Interview on 05/10 2026 at 3:10pm with Resident #2 revealed she and Resident #1 had been roommates since March 2026. Resident #2 stated their room does not get cleaned on the weekends. Resident #2 stated she had been able to use the bathroom but would be careful not to touch the door frame with the blood on it. Resident #2 stated she did not notify staff that blood was on the door. Interview on 05/10/2026 at 3:20pm with the DON revealed Resident #2's family had not voiced concerns about Resident #1 and Resident #2 being roommates. The DON stated Resident #2 or family members did not report to anyone about cleanliness of bathroom until today. The DON stated Resident #1 picks at her skin which causes bleeding and has sores on her body. The DON stated that the risk of coming in contact with blood depends on what that blood contains, but there's always a risk of infection. The DON stated in-services on infection control were done weekly. Interview on 05/10/2026 at 3:50pm with the Administrator revealed she was not aware of blood on the door frame of Resident #1 and Resident #2 bathroom prior to today. The Administrator stated Resident #2 had not voiced any concerns about Resident #1 or issues with room. The Administrator stated in-services on infection control had been completed and Resident #1 and Resident #2's room had been cleaned and disinfected. Review of the Infection Prevention and Control Program policy revised 10/24/2025 reflected:Infection Control Committee C. Duties and Responsibilities xi. Provide guidance for maintaining the Facility in a sanitary condition.xviii. Help housekeeping staff review cleaning procedures, agents, and schedules and recommend any major changes in cleaning products or techniques.xix. Monitor findings from any resident care quality assessment activities that relate to infection control. Infection Control Policies and ProceduresC. Objectivesi. Prevent, detect, investigate, and control infections in the Facilityii. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.iii. Identify an individual to whom possible incidents of communicable disease or infections can be reported.iv. Establish guidelines for implementing isolation precautions, including standard and transmission-based precautions.vii. Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment.

Based on observations, interviews and record reviews, the facility failed to treat the residents with respect and dignity for 1 (Resident #1) of 3 residents reviewed. 1. The facility failed to place Resident #1's name on the nameplate outside her room. 2. CNA A failed to wear her name tag when she provided care to Resident #1 .This failure placed residents at risk of needs not being met and not having their rights and dignity respected.Findings Included:Record Review of Resident #1's admission Record revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Acute and Chronic Respiratory Failure with Hypoxia (a life-threatening, sudden worsening of gas exchange in patients with pre-existing, long-term lung disease) Record Review of Resident#1's Care Plan revision date 03/20/2025 revealed; Focus for Resident #1 is at increased dependence on staff for activities, cognitive stimulation, social interaction r/t previous condition. Interventions included introduce Resident #1 to residents with similar background encourage/facilitate interaction. Focus for Resident #1 communication problem as she is hard of hearing and required longer time to process. Goal; Resident #1 was able to make basic needs known on a daily basis through the review date. Interventions: Encourage resident to continue speaking even if resident was having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express. Record review of Resident #1's Minimum Data Set Nursing Home Quarterly Item Set dated 02/01/2026 revealed; Resident #1 had a BIMS score of 14, which indicated the resident was cognitively intact. Section GG-Functional Abilities (Self-Care); Resident #1 was Dependent -Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or. The assistance of 2 or more helpers is required for the resident to complete the activity. Resident #1 required assistance for Eating, Oral hygiene, Toileting hygiene, Shower/bathe self, Upper body dressing, Lower body dressing, putting on/taking off footwear, and Personal hygiene. Observation on 02/18/2026 at 11:23 AM revealed the nameplate outside Resident #1's room was not present even when there was a resident in that room. The door was closed and when it opened, two staff members, one of them being CNA A, were observed walking out of the room. CNA A walked out of Resident #1's room without a nametag on her uniform. Interview on 02/18/2026 at 11:28 AM with Resident #1 revealed not all the staff wear their name tags or identify themselves when she asks them their names. She stated she wanted to know their names because she would like to know who was providing care. Interview on 02/18/2026 at 1:02 p.m. with ADON B revealed Resident #1 was moved from a room on the isolation hall to current. She stated it was important to have a name on the nameplate, so staff knew whom they were providing care. When the resident moved rooms, her name should be placed on the nameplate. ADON B stated the risk was not identifying the right person. Interview on 02/18/2026 at 1:58 PM with CNA C revealed staff were trained to knock on the resident's door and identify themselves when they enter the room. CNA C stated the risk was if staff were to go into a resident's room and they do not know who the staff was, the staff may scare the residents. She stated that when a resident's property was moved it was important that the name was placed outside the new room because staff need to know who was in that room for documentation and care purposes. Interview on 02/18/2026 at 2:17 PM with CNA A revealed; she forgot her name tag in her car. She stated it was important to have name tags on to identify themselves to the residents and let them know what care they will be performing. CNA A stated the residents had the right to proper care, the right to dignity and respect and the right to a safe space and safe area. Interview on 02/18/2026 at 2:33 PM with DON revealed the residents had a right to dignity and their room was their home. DON stated staff were to knock and identify themselves before they enter and provide care. The expectation was staff come to work in their uniform which included wearing a name tag. Interview on 02/18/2026 at 2:38 PM with ADMIN revealed residents have a right to safe place and safe care. Staff were expected to provide a homelike environment. ADMIN stated the expectation was to knock and introduce themselves to the resident before they provide care. The expectation was that staff wear their name tag. The risk was that residents may not know which staff member was in their room. Staff were given a name badge as part of their uniform and if they did not have one, they were to go to HR to receive a replacement. Review of Resident Rights policy date revised: 8/2020 revealed; Employees are to treat all residents with kindness,respect, and dignity and honor the exercise of residents' rights. D. Be fully informed and participate in his/her treatment including being fully informed in alanguage that he or she can understand of his/her total health status including his/her medical condition.Review of Dress Code policy titled Dress Code and Personal Appearance not dated revealed; Employees are required to wear a nametag unless the facility has a specific policy stating otherwise (e.g. IDD facilities). This identifies you and prevents unauthorized people from being in the location.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) reviewed for infection control. The facility failed to identify on the exterior of Resident #1's room that contact precautions were required before entering and did not provide the appropriate PPE at or near the door for Resident #1. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Findings Included: A record review of Resident #1's MDS, dated [DATE], reflected that she was a [AGE] year-old female that admitted to the facility on [DATE] and she had a BIMS score of 14, which indicated intact cognitive function. She was incontinent of bowel and bladder, and she required a wheelchair for mobility. A record review of Resident #1's face sheet, dated 12/28/2025, revealed her primary diagnosis was enterocolitis due to clostridium difficile (severe inflammation of the intestines, usually the colon, triggered by C. diff bacteria overgrowth after antibiotics disrupt gut flora, causing watery diarrhea, cramping, fever, and potentially life-threatening complications like sepsis or toxic megacolon). A record review of Resident #1's physician orders revealed an order for an infectious disease consult dated 12/19/2025. An observation of the exterior of Resident #1's door on 12/28/2025 at 10:05am revealed there were not any signs posted on the exterior of the room indicating the resident was on enhanced barrier precautions and/or contact precautions. Additionally, there was not any PPE outside the room in a cart nor hanging on the exterior of the door. No staff were observed to enter the room between 10:10am and 10:30am. During an interview with Resident #1 on 12/28/2025 at 10:10am, she stated she still had diarrhea sometimes and her stomach was not the best. Resident #1 stated she received antibiotics twice a day. Resident #1 stated she cannot leave the room because she was in isolation for her infection, but she wants to go back to her room and be able to go to the dining room. During an interview with the DON on 12/28/2025 at 11:30am, she stated there was one resident in the facility that was on contact precautions due to a C. diff infection. She further stated that resident was previously on enhanced barrier precautions due to a wound on her bottom that she had taken antibiotics for. The DON further stated that resident returned from the hospital about a week ago where she was not in isolation because her hospital lab tests came back negative for C. diff, but the facility tests resulted in a negative and then positive result, so they have implemented contact precautions and placed the resident on isolation, in accordance with their policy. The DON stated a referral has been requested for infectious disease to evaluate Resident #1 to determine if she still needs to be in isolation or not. When told that there was not any indication on the door that contact precautions were required and there was not any PPE outside the room, she stated there should be a sign on the door and she did not know why it was not. The DON further stated the PPE cart had been taken by the staff to the supply closet to be refilled and was placed back by the door. The DON stated that staff knew they needed to wear the appropriate PPE (gowns and gloves) to provide care to Resident #1 and all residents identified to require enhanced barrier precautions. The DON stated the risk of not identifying contact precautions were in place is that the infection could spread. A record review of the facility's Infection Prevention and Control Program, dated 10/24/2022, did not directly address the need to have signs posted on the door for infection control, but reflected the following: The facility must establish an Infection Prevention and Control Program under which it: Infection Control Committee:iii. Develop isolation precaution protocols when control of an infectious or communicable disease or disease risk is required in accordance with current Centers of Disease Control (CDC) guidelines and recommendations including but not limited to: The type and duration of the isolation depending on the infectious agent organism involved, and a requirement that the isolation should be the least restrictive possible for the resident under the circumstances. iv. Identify situations that may result in the employee's exposure to blood, body fluids, or other potentially infectious materials. Duties and Responsibilities: iv. Review food handling practices, laundry practices, waste disposal, pest control, traffic control, visiting rules for high-risk areas, and sources of airborne infection. xv. Reviews isolation precaution techniques and procedures and helps ensure that Facility staff, residents and visitors follow established procedures/precautions. xxi. Help assure that an adequate amount of protective supplies (i.e., gowns, gloves, masks, etc.) are on hand and readily accessible for handling infectious wastes, blood and/or body fluids.

Based on interviews and record reviews, the facility failed to ensure the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident. for 4 (Resident #1, Resident #2, Resident #3 and Anonymous Person) of 5 residents reviewed.The facility failed to protect and promote the rights of Resident #1, Resident #2, Resident #3 and Anonymous Person who wanted to continue to be able to sit in the front patio.This failure could place residents at risk of a diminished quality of life.Findings included:Record review of Resident #1's face sheet, dated 12/03/25 reflected he was an [AGE] year-old male who was admitted on [DATE] and diagnosed with but, not limited to Alzheimer's disease with late onset (characterized by progressive memory loss, confusion, and changes in mood, stemming from a mix of genetic)- onset 04/24/24, other viral Pneumonia( inflammation of the lungs caused by a virus )- onset 09/27/25, unspecified abnormalities with mixed disturbance of emotions and conduct (where a person has intense emotional reactions (anxiety, sadness) and behavioral problems (rule-breaking, aggression, withdrawal) following a stressful life event)- onset 05/23/24, unspecified Dementia, moderate, with other behavioral disturbance (describes a stage of dementia where memory/cognitive issues are significant -moderate )-onset 05/13/24, cognitive communication deficit (a difficulty in expressing or understanding messages due to impaired thinking skills like attention, memory, problem-solving, or organization)-onset 04/24/24, unspecified lack of coordination (difficulty controlling body movements (ataxia), causing clumsiness, unsteady gait, )-onset 04/24/24 and acute respiratory failure with hypoxia (a life-threatening condition where the lungs can't get enough oxygen into the blood (severe low oxygen, or hypoxemia) due to sudden lung injury from things like pneumonia, ARDS, or heart failure)-onset 04/24/24. Record review of Resident #1's MDS, dated [DATE] reflected his BIMS score was 06 which indicated severe cognitive impairment. Record review of Resident #2's face sheet, dated 12/03/25 reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with but not limited to cerebral infraction unspecified (happens when a blood clot blocks an artery in the brain, cutting off oxygen and nutrients, leading to brain tissue death) onset 12/04/24, chronic respiratory failure unspecified whether with hypoxia or hypercapnia (when the lungs gradually fail to get enough oxygen (hypoxia) or remove enough carbon dioxide (hypercapnia) )- onset 11/11/25, and unspecified lack of coordination (difficulty controlling body movements (ataxia), causing clumsiness, unsteady gait, or jerky motions)-onset 12/06/24. Record review of Resident #2's MDS, dated [DATE] reflected his BIMS score was 11 which indicated moderate cognitive impairment. Record review of Resident #3's face sheet, dated 12/03/25 reflected she was a [AGE] year-old female who was admitted on [DATE]. She was diagnosed with but not limited to schizoaffective disorder, bipolar type (a complex mental illness blending symptoms of schizophrenia (psychosis like hallucinations/delusions) with those of a mood disorder (major depression or bipolar disorder) )- onset 06/07/23, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, and cognitive communication deficit (a slight decline in thinking/memory (Mild Neurocognitive Disorder) from a known medical cause (like TBI, alcoholism, sleep apnea) without major behavioral issues, specifically showing difficulty with communication (language/expression) but still managing daily life independently) - onset 06/09/23. Record review of Resident #3's MDS, dated [DATE] reflected her BIMS score was 11 which indicated moderate cognitive impairment. During an interview on 12/04/25 at 5:50 am, RN A stated it was the residents' right to be able to go outside and sit on the front patio. RN A stated a staff member would have to let them out the front door. During an interview on 12/04/25 at 6:30 am Resident #1 stated he used to be able to go outside in the front for as long as he wanted to and as many times as he wanted to. Resident #1 stated now he can only go outside for 30 minutes when [MA B] goes outside. Resident #1 stated he felt upset, and he was suffering because another resident wheeled herself away from the facility, went to the hospital and got lost. Resident #1 stated it was not fair and since then the residents cannot go outside in front by themselves. During a confidential interview at an undisclosed date and time, Anonymous person stated another resident left the facility and since then the residents cannot go outside by themselves. Anonymous Person did not recall how long ago the incident happen. Anonymous Person would like to go back outside more because Anonymous Person felt trapped. During an interview on 12/04/25 at 6:40 am Resident #3 stated Resident #4 left the facility, got lost and Resident #3 believed the police brought her back. Resident #3 stated after that happened the residents could not go outside and sit on the patio. Resident #3 stated Resident #1, Resident #2 did not have any problems sitting outside on the front patio. Resident #3 stated the only time the residents can go outside in front was when MA B went outside for 30 minutes. Resident #3 stated it was not fair they are being treated this way and being punished because of Resident #4. During an interview on 12/04/25 at 6:53 am Resident #2 stated he goes outside now with a nurse. Resident #2 stated he would like to go outside more like before. During an interview on 12/04/25 at 8:45 am, LVN C (with the DON present) stated Resident #4 signed out and left the patio without letting staff know. The facility got a call from the hospital and stated Resident #4 was there and wanted x-rays. Resident #4 was transported back to the facility. LVN C stated it was common for residents to be outside on the front patio by themselves. During an interview on 12/04/25 at 9:04 am, the DON stated Resident #4 signed herself out, did not have to tell the facility where she went. The DON stated Resident #4 had a BIMS of 14 and was able to sign out. The DON stated MA B took the residents out for 30 minutes after her lunch break. The DON stated that residents with BIMS less than 13 could not go outside by themselves. During an interview on 12/04/25 at 9:30 am, the Administrator and the DON stated residents with a BIMS score of less than 13 must go outside with staff. The Administrator stated the temperature change limited the residents from going outside. The Administrator stated staff went outside with the residents and she would watch residents from her window. The DON stated Resident #1 was now on continuous oxygen and needed supervision to prevent him from running out of oxygen. The DON stated Resident #1 used to be a truck driver and liked the outdoors. The DON stated that Resident #2 had a change in condition with his asthma which was bad and needed to have staff with him. The DON stated Resident #3 did not like to sit outside by herself and liked to go outside with staff or other residents. The DON stated Resident #1, Resident #2 did not have to sign out/in because they were not able to go outside by themselves. The DON stated residents could not go outside unsupervised because of their BIMS scores, weather conditions and for the residents' safety they did not feel comfortable leaving the residents outside by themselves. Record review of Resident #4's progress notes dated 10/01/25 reflected, [local hospital nurse] stated [Resident #4] was at the ER. [Resident #4] asked if she could sit outside and get some fresh air but decide to wheel herself to the hospital.[Resident #4] checked herself in and stated nobody knows that she is at the ER, she was released to go back to the facility, but she got lost and was taken back to [local hospital] by a passerby.[LVN C] called family . Family member stated Resident #4 called while she was in the facility, and he told the resident she could go outside and get some fresh air [sic] written by LVN CRecord review of Resident #4's sign in and out sheet revealed she signed out on 10/01/25 at 12:00pm and signed herself back in at 1:57 pm.During an interview on 12/04/25 at 9:54am RA D stated Resident #1, and Resident #3 had complained about not being able to go outside. RA D stated that when it started getting too hot or too cold MA B would take the residents out on the front patio. During an interview on 12/04/25 at 9:55 am, MA B stated she took residents out to the front patio after her break and sometimes during her break for about 30 minutes. MA B stated she started taking residents out to the front patio with the weather change. During an interview on 12/04/25 at 11:30 am, Resident #1 stated that he wanted to leave the facility because he wanted to go outside and he was not a little kid. During an interview over the phone on 12/04/25 at 1:13pm the NP stated Resident #1, Resident #2, and Resident #3 were not exit seeking residents and she did not see a concern for the residents to sit out front at the patio. During an interview on 12/04/25 at 1:20pm, the Administrator (in-person), the DON (in-person) and the Regional Director (over the phone) were present at the exit conference. The Administrator stated the residents had always gone outside with staff. The Administrator stated Resident#1, Resident#2, Resident#3 did not have the cognition to go outside by themselves because their BIMS was less than 13. The Regional Director stated he received an IJ 2 1/2 years ago because a resident left the facility and got sunburn. The Regional Director stated in the past he was told by a surveyor that residents with a BIMS score less than 13 were not cognitive enough to go outside by themselves. The surveyor asked what assessments the facility used to determine that the residents could not sit outside unsupervised. The Administrator and DON stated the assessment that they complete to determine if the residents were able to be unsupervised was the residents' BIMS. The DON stated she was going to check with Resident #1, Resident #2 and Resident #3 to see what was said. Surveyor observed the DON exit from the office. During an interview on 12/04/25 at 3:30 pm, family member #5 returned phone calls and stated Resident #1 used to be able to go outside anytime on the front patio. Family member #5 stated the only activity he liked to do was sit outside. During an interview on 12/05/25 at 11:10 am, family member #6 returned phone call and stated Resident #3 was always complaining about something. Family member #6 stated Resident #3 wanted to go outside more and went outside for 30 minutes every day. During an interview on 12/08/25 at 8:10 am family member #7 returned phone calls and stated Resident #2 liked to go outside. Family member #7 stated she had not been to the facility for two weeks. Family member #7 stated he would be on the front patio without staff, and she did not have any concerns with him being outside unsupervised. Record review of facility policy titled out on pass, revised 08/2020 revealed, To provide residents with the opportunity to participate in family and community life in ways that support well- being and optimal functioning.It is the policy of the Facility to meet residents' physical and psychosocial needs to go out on pass. The facility will make reasonable efforts to ensure the resident safety and uphold resident rights.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 2 residents (Residents #1 and #2), reviewed for abuse, neglect, and exploitation.The facility failed to report an incident of resident to resident abuse between Resident #1 and Resident #2 that occurred on 10/10/2025.This failure could place residents at risk of abuse, neglect and exploitation.Findings included:Resident #1Record review of Resident #1's admission record, dated 10/21/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of vascular dementia (a type of dementia caused by reduced blood flow to the brain). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Record review of Resident #1's care plan initiated 10/10/25, revealed Resident #1 was the receiver of aggression from another resident and sustained injury to the skin as noted in skin injury care plan. Interventions included the following: - Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document.- Assess and address for contributing sensory deficits- Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.- Monitor resident frequently. Document observed behavior and attempted interventions in behavior log.- Separate from potential resident to resident incidents. Take to another area away from resident or residents to calm down and keep safe. If needed, [Health Company Name] eval/treat.Record review of Resident #1's nursing notes, dated 10/10/2025 at 6:57 pm, revealed ADON was notified by attending nurse that [Resident #1] was bleeding. She would not tell him how it happened. This nurse went to the unit with nurse to see if she would tell me and she did. She stated that her roommate [Resident #2] hit her with a hairbrush. She held out her left arm, and you can see the marks made up and down her arm from the bristles of the brush. ADON advised to do incident reports and contact RP for both residents. Residents were separated to avoid further conflict.Record review of Resident #1's nursing notes, dated 7:34 pm, revealed ADON called [RP name] to advise of small marks and [family member] was ok with. She states that she knows her [family member's] skin is fragile. Thanked for calling, no other questions or concerns.Record review of Resident #1's nursing notes, dated 10/10/2025 at 11:13 pm, revealed Pt walking down the hallway from her room holding her left forearm. Nurse noticed skin tear to back of right hand and bruise to left forearm. Pt denies pain or discomfort.Record review of Resident #1's nursing notes, dated 10/11/2025 at 6:55 am, revealed bruise remains to left forearm, denied pain.Record review of Resident #1's nursing notes, dated 10/12/2025 at 10:00 pm, revealed Resident continues with fading bruise to left forearm. Refuses to take wrap off. No concerns voiced all day. Will continue with plan of care in place.Record review of Resident #1's nursing notes, dated 10/13/2025 at 9:20 pm, revealed Resident assisted to another room temporary for tonight due to previous roommate separation and room mate noted to attempt to wander into previous room, notified RP of resident having room change for tonight to ensure separation .Record review of Resident #1's nursing notes, dated 10/13/2025 at 11:28 pm, revealed No behaviors noted on shift.Record review of Resident #1's nursing notes, dated 10/13/2025 at 11:33 pm, revealed skin noted injured with bleeding, non-intact. When asked what happened pt states; 'She did it point at the other pt.Record review of Resident #1's nursing notes, dated 10/14/2025 at 7:41 am, revealed bruise on the left forearm is fading, no behavior observed last night.Record review of Resident #1's nursing notes, dated 10/14/2025 at 3:03 pm, revealed, Resident alert/verbal, no s/sx pain or discomfort, area to right forearm appears dry, no discomfort per resident.Record review of Resident #1's nursing notes, dated 10/14/25 at 4:35 pm, revealed, Spoke to [RP name] regarding resident room change to [room number].Record review of Resident #1's nursing notes, dated 10/14/2025 at 4:35 pm, revealed Verbalized understanding also discussed wound care to left forearm. Discussed about the healing and improvement of area and area is has scabbed over no sign or symptoms of infection.Record review of Resident #1's nursing notes, dated 10/15/2025 at 6:08 am, revealed Resident slept in the new room [number] with no behavior noted.Resident #2Record review of Resident #2's admission record, dated 10/22/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia (dementia without a specified type or cause).Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment. Further review of the MDS revealed no physical, verbal or behavioral symptoms directed towards others occurred and Resident #2 wandered daily. Record review of Resident #2's care plan, date initiated 10/10/2025 revealed Resident #2 had potential to demonstrate physical behaviors r/t Dementia. Initiated a door slapping on another resident. Resident #2 appears upset walking behind roommate cursing. Unable to communicate why agitated. Initiated Aggression with another resident. Interventions included the following: - Cognitive Assessment- Assess and address for contributing sensory deficits- COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated.- Escorted to DR to calm [Resident #2] down. [Health Company Name] referral for medication review. Labs and U/A to be obtained. Separate residents.- Give [Resident #2] as many choices as possible about care and activities.- Medication review per [Health Company Name].-Monitor frequently document observed behavior and attempted interventions in behavior log.-Monitor/document/report to MD of danger to self and others.-Psychiatric/Psychogeriatric consult as indicated.-When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.Record review of Resident #2's nursing notes, dated 10/10/2025 at 8:03 PM, revealed. ADON was called to look over another resident that may have had contact with [Resident #2]. [Resident #2] observed walking up and down the hallway with blood stains on the upper sleeves of the t-shirt that she was wearing. Roommate states that they had an incident with a hairbrush and that [Resident #2] struck her with the brush to her left arm. No bruises, cuts lacerations noted on [Resident #2]. Attending nurse to completed an incident report and call RP to advise of situation. Resident were separated to avoid further conflict. [Resident #2] moved to room [number].Record review of Resident #2's nursing notes, dated 10/10/2025 at 8:15 PM, revealed, Pt following behind the other pt cursing out with some blood stains on her t-shirt. Pt appears upset. She was separated from the other pt. Rp's for both parties notified and advised of the situation. NP notified and no new order was given. This nurse updated behavior monitoring. Put in new order for [Health Care Company Name] to eval and treat for new behaviors, also to do the GDR.Record review of Resident #2's nursing notes, dated 10/10/25 at 9:19 PM revealed, Psych consult as indicated by Dr [Name], pt moved to another room.Record review of Resident #2's nursing notes, dated 10/14/2025 at 7:15 AM, revealed Resident refused to move into the new room and slept in her old room. The original resident also refused to welcome the new resident when approached. The resident originally assigned to the room stated that she did not want anyone else in her room. Situation will be followed up in AM.Record review of Resident #2's nursing notes, dated 10/16/2025, revealed Depakote increased to 250 mg BID x 10 days from Depakote 125 mg BID. Notified spouse [Name].Interview on 10/21/2025 at 9:06 AM, the Administrator stated there was an incident with Resident #1 and Resident #2. She stated Resident #2 was nonverbal but could say cuss words. She said Resident #2 hit Resident #1 on the arm with a hairbrush, but she could not say what happened. The Administrator stated she did not report this incident to the state agency because Resident #2's BIMS was 0 and there was no intent. She stated she reported based on the provider letter. Observation on 10/21/2025 at 10:10 am, revealed Resident #2 in the memory care unit, walking up and down the hall. Resident #2 appeared well groomed and dressed. Resident #2 was not able to answer surveyor questions. Observation and interview on 10/21/2025 at 10:29 am, revealed Resident #1 in her room, lying in bed. Resident #1 appeared well groomed and dressed. A small scab was observed on the Resident's right hand. Resident #1 stated she did not have a roommate anymore. Resident #1 said they got into a fight and her roommate took a brush and hit her on the arm and also this at the same time. Resident #1 then showed surveyor her right upper arm and 2 circular bruises were observed. The bruises measured approximately 3 inches by 3 inches, and had a slight yellow color around the outside and a purple color in the middle. Resident #1 stated it happened in their room when Resident #2 hit her before. Resident #1 stated she did not fall. Resident #1 stated she told staff, but was not able to tell surveyor who the staff was. Interview on 10/21/2025 at 11:16 am, LVN A stated Resident #1 had an altercation with Resident #2 and had some bruising on her right arm. LVN A stated he did not witness the incident and it happened on second shift. He stated they (staff) was currently monitoring the residents, to keep them from crossing paths, and monitoring their behaviors. Interview on 10/21/25 at 2:33 pm, ADON C stated she was here the evening of the altercation between Resident #1 and Resident #2 but did not witness the incident. She said right after the incident, LVN B wanted her to look at Resident #1's arm. ADON C stated Resident #1's arm had what looked like dots from a brush bristle. She said Resident #1 told her My roommate came in a whacked me. ADON C stated she did not do a full skin assessment just at the lower arms and asked the resident if she was hit anywhere else, which Resident #1 denied. ADON C stated Resident #2 did not answer when she asked about the incident. ADON C stated she did a trauma assessment on both residents, ensured both residents were separated and Resident #2 moved rooms immediately.Interview on 10/21/2025 at 3:30 PM, LVN B stated on 10/10/2025 he was by the nurses station when he saw Resident #1 holding her left arm and saw an indentation on the skin. He said Resident #1 did not want him to look at it, so he got ADON C. LVN B stated Resident #1 and Resident #2 were separated, and Resident #2 did not have any injuries. LVN B stated he did a full skin assessment on Resident #1 and an incident report later that night after she had calmed down. He stated he did not see any bruises on the upper right arm when he assessed her. LVN B stated he was not aware of any current bruises on Resident #1's upper right arm. When asked who was supposed to do the next skin assessment LVN B did not know. LVN B stated it just pops up in the system and it will prompt you. LVN B did not give a reason why the weekly skin assessment was not completed. LVN B stated they were making sure Resident #1 and Resident #2 did not have another altercation by keeping an eye on them and keeping them separated if they were too close. LVN B stated he had been in serviced on Abuse and Neglect. Interview on 10/21/2024 at 4:32 pm, the Administrator stated she did not report based on the provider letter and because Resident #2's BIMS was 0, she had no intent. The Administrator stated there was no risk for not reporting. When asked why abuse was reported the Administrator stated to make sure the facility is doing its due diligence by the residents. Record review of facility policy, titled Abuse Prevention and Prohibition Program dated 10/24/2022, revealed the following: .VI. Investigation.H. Resident-to-resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain.i. The presence of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate on non-accidental behavior.ii. Assessing psychosocial outcome of the victim of abuse may be difficult to determine or incongruent with what would be expected. In these situations, the Investigator should consider how a reasonable person in the resident's circumstances would be impacted by the incident.IX. Reporting/Response.D. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime.i. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).ii. No later than 24 hours after forming the suspicion - if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).iii. Reporting requirements are based on real (clock) time, not business hours.iv. The Administrator will provide the state survey agency, law enforcement and the Ombudsman (if applicable per state regulation) with a copy of the investigative report within 5 days of the incident.Record review of Long-Term Care Regulation Provider Letter, date issued 10/29/2024, revealed the following: Abuse:HHSC rules define abuse as:'The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault.'14CMS defines abuse as:'The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.'15Note: Allegations or incidents of resident-to-resident behavior may or may not meet the definition of abuse depending on whether a resident acted willfully. As the CFR states: 'Willful, as used in the definition of 'abuse,' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.'16

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for quality of care.The facility failed to ensure Resident #1's weekly skin assessment was completed on 10/17/2025. This failure could place residents at risk of not identifying skin breakdown or injuries, and delayed treatment and monitoring. Findings included:Record review of Resident #1's admission record, dated 10/21/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of vascular dementia (a type of dementia caused by reduced blood flow to the brain). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Record review of Resident #1's care plan, dated initiated 10/10/25, revealed Resident #1 was the receiver of aggression from another resident and sustained injury to the skin as noted in skin injury care plan. Interventions included the following: - Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document.- Assess and address for contributing sensory deficits- Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.- Monitor resident frequently. Document observed behavior and attempted interventions in behavior log.- Separate from potential resident to resident incidents. Take to another area away from resident or residents to calm down and keep safe. If needed, [Health Company Name] eval/treat.Record review of Resident #1's weekly skin check, dated 10/10/2025 at 11:04 PM, revealed bruise to left forearm / skin tear to back of right hand.Record review of Resident #1's EHR revealed no weekly skin checks completed since 10/10/2025 . Record review of MAR and TAR for October 2025 revealed the following:- Cleanse left arm with normal saline, pat dry, apply TAO, LOTA every day shift for skin treatment for 10 Days -Order Date-10/14/2025 - D/C Date-10/21/2025- Monitor bruise to left forearm until resolved every shift for Infection prevention -Order Date-10/10/2025 - D/C Date-10/21/2025- Monitor skin to right hand until resolved every shift for Infection prevention - Order Date-10/10/2025 Record review of Resident #1's incident report, dated 10/10/2025 at 8:00 PM, completed by LVN B, revealed Incident Description.Pt walking down the hallway from her room holding her left forearm with blood noted on shirt, skin tear to right hand and nonintact skin noted to left forearm. Resident unable to give description. Unwitnessed. Immediate Action Taken.head to toe skin assessment, pain assessments, trauma assessed. Notified MD, RP, separated resident from roommate.Injuries observed at Time of Incident: Injury type Abrasion on left forearm and Bruise right hand (back). Level of Pain: 0.Interview on 10/21/2025 at 3:30 PM, LVN B stated he did a full skin assessment on Resident #1 and an incident report later that night after she had calmed down on 10/10/2025. He stated he did not see any bruises on the upper right arm when he assessed her. LVN B stated he was not aware of any current bruises on Resident #1's upper right arm. When asked who was supposed to do the next skin assessment LVN B did not know. LVN B stated it just pops up in the system and it will prompt you. LVN B did not give a reason why the weekly skin assessment was not completed on 10/17/25. Interview on 10/21/2025 at 3:53 pm, ADON C stated she was not aware of the bruises on Resident #2's right upper arm. She stated LVN B would have been responsible to complete Resident #1's skin assessment on 10/17/2025. Interview on 10/21/2025 at 4:32 pm, the Administrator stated skin assessments should be completed weekly, depending on the resident. She stated the nurse was responsible for completing assessments and the ADON and DON were responsible for monitoring they were completed. She stated the risk to residents if not done was they were left unmonitored, they could have an adverse injury, or reaction. Interview on 10/22/2025 at 9:14 am, the Corporate Nurse stated they did not have a weekly skin assessment policy. She stated skin assessments should be completed weekly and if the resident refused, then documentation of the refusal. Interview on 10/22/2025 at 10:17 am, the DON stated Resident #1's skin assessment should have been completed on 10/17/2025 by LVN B. She stated the risk to residents was missing or preventing skin breakdown and safety. She stated they would need to be aware of the bruise and monitor, make sure it was not getting bigger or not resolved.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the state Agency) and the administrator of the facility for 1 of 1 resident reviewed for reporting abuse. CNA A failed to notify the ADM and DON about an accident/hazard regarding Resident #1 that happened on 08/27/25. This failure could place residents at risk for abuse and neglect. Findings included:Record Review of Resident #1's face sheet, dated 09/09/25, reflected a [AGE] year-old female with an initial admission date of 03/24/25 and a re-admission date of 09/03/25. Resident #1 had diagnoses of Paraplegia (loss of voluntary movement and sensation in the lower half of the body), Personality Disorder (mental health conditions characterized by long-term patterns of thinking, feeling, and behaving that deviate significantly from societal expectations and cause distress or impairment in various aspects of life), Anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease), Post-Traumatic Stress Disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as a natural disaster, violent crime, or serious accident), Paralytic Syndrome (a medical condition characterized by muscle weakness or paralysis), Tobacco Use, Neuromuscular Dysfunction of Bladder (a condition where the nerves and muscles that control bladder function are impaired)Lack of Coordination (the inability to perform smooth, precise, and controlled movements).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], reflected: Section B Hearing, Speech, and Vision reflected that Resident #1 had clear speech and Vision, had the ability to make herself understood and had the ability to understand others. Section C Brief Interview for Mental Status score reflected a score of 15, which indicated the resident's cognition was normal. Record review of Resident #1's Care Plan, dated 09/09/25, reflected the following:'Focus'Resident #1 utilizes a motorized wheelchair to move around in the room/facility. Resident #1 has been evaluated by Therapy in the usage of a power wheelchair.'Goal'Safe use daily of the electric wheelchair by Resident #1.'Interventions/Tasks'Transfer: The resident is able to transfer self but should use x1 staff for participation in safety.Resident#1 educated on safe use of electric wheelchair, not to allow other residents to hold on to the back on her wheelchair while in operation. In an interview on 09/09/25 at 9:54 AM, Resident #1 stated on 08/27/25 CNA A came in her room pissed off that she had work the 300 hall. Resident #1 stated she was soaked in urine and CNA A changed her diaper, but her bed was soaked in urine. Resident #1 stated she had asked CNA A if she was going to change the bed sheets, and CNA A responded she would change the sheets when Resident #1 got out of bed. Resident #1 stated she told CNA A that she was ready to get out of bed and that's when CNA A started transferring her to the motorized wheelchair. Resident #1 stated CNA A then pushed a button on the motorized wheelchair and the wheelchair ran into the wall and hit Resident #1's foot when the wheelchair hit the wall. Resident #1 stated that her foot was in pain at the time of the incident, but it was no longer in pain at the time of the interview. In an interview on 09/09/25 at 10:44 AM, CNA A stated she was getting Resident #1 ready to go outside for her smoke break. CNA A said she had gotten the motorized wheelchair next to the bed so Resident #1 could transfer from the bed to the wheelchair. CNA A stated that she pressed the joystick on the motorized wheelchair and the wheelchair zoomed off fast and hit the wall and Resident #1's right foot. CNA A told Resident #1 that she was going to get the nurse and Resident #1 stopped CNA A and stated she was fine and not in any pain and that it was not a big deal. CNA A stated that she was unsure why she did not report the incident immediately to a nurse. She stated that she meant to report it to a nurse when the incident happened, but she had forgot to report it because she was doing multiple things at once. She stated the risk of not reporting incident/accidents in a timely manner can prolong care and it is bad to not report. CNA A stated she was inserviced on how to properly use the motorized wheelchair by unlocking the wheelchair from the bottom and pushing it manually next time. In an interview on 09/09/25 at 2:03 PM, the DON stated that the incident happened on 08/27/25. The DON stated she did not find out about the incident until the next day on 08/28/25 when Resident #1 went to the DON and voiced that she was going to make a complaint to the state and that's when Resident #1 told her that her foot was hurting because of the motorized wheelchair hitting her foot and she requested some pain medicine. The DON stated that she immediately assessed Resident #1's foot, and orders were submitted for x-rays on 08/29/25. The DON stated x-ray results returned on 08/30 were negative, which indicated no injuries. The DON stated she expects staff to report all incidents to a nurse. The DON stated if a nurse was not available then she expects staff to report all incidents to her immediately. She stated the risk of staff not reporting incidents in a timely manner can cause care to be delayed. The DON stated if they would have known about the incident when it first occurred staff could have implemented the next steps right away. In an interview on 09/09/25 at 3:06 PM, the ADM stated that she had found out about the wheelchair hitting Resident #1's foot when the DON came to her on 08/28/2025. ADM stated that she immediately made an incident report to the state. She stated that Resident #1 knows how to adjust the speed on the motorized wheelchair, and she increases the speed on the wheelchair all the time. The ADM stated that when she was made aware of the incident she immediately went and had the wheelchair assessed by therapy to be sure the wheelchair was set to a safe speed. ADM stated the CNA has been in service on how to properly use the motorized wheelchair. ADM stated the risk of a CNA not knowing how to properly operate a motorized wheelchair can cause residents to get hurt. ADM stated her expectations of the CNA are to get assistance from therapy before operating the motorized wheelchair. Review of the facility policy, Abuse & Neglect, date revised 08/20 reflected: I. The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. The administrator is responsible for coordinating and implementing the Facility' abuse prevention policies, ii. Facility Staff will report known or suspected instances of abuse to the administrator, and his/her designee. A. Reporting Requirements i. If the reportable event does not result in serious bodily injury, the administrator, and his/her designee, will make a telephone report to the local law enforcement agency within 24 hours of the observation, knowledge, or suspicion of physical/sexual abuse.

Based on interview, and record review, the facility failed to ensure that each resident received adequate supervision for one (Resident #1) of three residents reviewed for supervision and ensured the environment remained free of accidents hazards. The facility failed to ensure CNA A appropriately transferred Resident #1 from the bed to the motorized wheelchair to ensure accidents did not occur. This failure could place residents at risk of being in an unsafe environment and at risk of accidents and injury. Findings included: Record Review of Resident #1's face sheet, dated 09/09/25, reflected a [AGE] year-old female with an initial admission date of 03/24/25 and a re-admission date of 09/03/2025. Resident #1 had diagnoses of Paraplegia (loss of voluntary movement and sensation in the lower half of the body), Personality Disorder (mental health conditions characterized by long-term patterns of thinking, feeling, and behaving that deviate significantly from societal expectations and cause distress or impairment in various aspects of life), Anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease), Post-Traumatic Stress Disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as a natural disaster, violent crime, or serious accident), Paralytic Syndrome (a medical condition characterized by muscle weakness or paralysis), Tobacco Use, Neuromuscular Dysfunction of Bladder (a condition where the nerves and muscles that control bladder function are impaired), Lack of Coordination (the inability to perform smooth, precise, and controlled movements).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], reflected: Section B Hearing, Speech, and Vision reflected that Resident #1 had clear speech and Vision, had the ability to make herself understood and had the ability to understand others. Section C Brief Interview for Mental Status score reflected a score of 15, which indicated the resident's cognition was normal. Record review of Resident #1's Care Plan, dated 09/09/25, reflected the following:'Focus'Resident #1 utilizes a motorized wheelchair to move around in the room/facility. Resident #1 has been evaluated by Therapy in the usage of a power wheelchair.'Goal'Safe use daily of the electric wheelchair by Resident #1.'Interventions/Tasks'Transfer: The resident is able to transfer self but should use x1 staff for participation in safety.Resident#1 educated on safe use of electric wheelchair, not to allow other residents to hold on to the back on her wheelchair while in operation. In an interview on 09/09/25 at 9:54 AM, Resident #1 stated on 08/27/25 CNA A came in her room pissed off that she had work the 300 hall. Resident #1 stated she was soaked in urine and CNA A changed her diaper, but her bed was soaked in urine. Resident #1 stated she had asked CNA A if she was going to change the bed sheets, and CNA A responded she would change the sheets when Resident #1 got out of bed. Resident #1 stated she told CNA A that she was ready to get out of bed and that's when CNA A started transferring her to the motorized wheelchair. Resident #1 stated CNA A then pushed a button on the motorized wheelchair and the wheelchair ran into the wall and hit Resident #1's foot when the wheelchair hit the wall. Resident #1 stated that her foot was in pain at the time of the incident, but it was no longer in pain at the time of the interview. In an interview on 09/09/25 at 10:44 AM, CNA A stated she was getting Resident #1 ready to go outside for her smoke break. CNA A said she had gotten the motorized wheelchair next to the bed so Resident #1 could transfer from the bed to the wheelchair. CNA A stated that she pressed the joystick on the motorized wheelchair and the wheelchair zoomed off fast and hit the wall and Resident #1's right foot. CNA A told Resident #1 that she was going to get the nurse and Resident #1 stopped CNA A and stated she was fine and not in any pain and that it was not a big deal. CNA A stated that she was unsure why she did not report the incident immediately to a nurse. She stated that she meant to report it to a nurse when the incident happened, but she had forgotten to report it because she was doing multiple things at once. She stated the risk of not reporting incidents in a timely manner can prolong care and it is bad to not report. CNA A stated she was inserviced on how to properly use the motorized wheelchair by unlocking the wheelchair from the bottom and pushing it manually next time. In an interview on 09/09/25 at 2:03 PM, the DON stated that the incident happened on 08/27/25. The DON stated she did not find out about the incident until the next day on 08/28/25 when Resident #1 went to the DON and voiced that she was going to make a complaint to the state and that's when Resident #1 told her that her foot was hurting because of the motorized wheelchair hitting her foot and she requested some pain medicine. The DON stated that she immediately assessed Resident #1's foot, and orders were submitted for x-rays on 08/29/25. The DON stated x-ray results returned on 08/30 were negative, which indicated no injuries. The DON stated she expects staff to report all incidents to a nurse. The DON stated if a nurse was not available then she expects staff to report all incidents to her immediately. She stated the risk of staff not reporting incidents in a timely manner can cause care to be delayed. The DON stated if they would have known about the incident when it first occurred staff could have implemented the next steps right away. In an interview on 09/09/25 at 3:06 PM, the ADM stated that she had found out about the wheelchair hitting Resident #1's foot when the DON came to her on 08/28/2025. ADM stated that she immediately made an incident report to the state. She stated that Resident #1 knows how to adjust the speed on the motorized wheelchair, and she increases the speed on the wheelchair all the time. The ADM stated that when she was made aware of the incident she immediately went and had the wheelchair assessed by therapy to be sure the wheelchair was set to a safe speed. ADM stated the CNA has been in service on how to properly use the motorized wheelchair. ADM stated the risk of a CNA not knowing how to properly operate a motorized wheelchair can cause residents to get hurt. The ADM stated her expectations of the CNA are to get assistance from therapy before operating the motorized wheelchair. On 09/09/25 at 4:04 PM, surveyor requested a policy for accidents/hazards, but the ADM stated that they did not have a policy on accidents/hazards.

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) and refer all level II residents and all residents with possible serious mental disorder, intellectual disability, or a related condition for one (Resident #8) of one residents reviewed for PASRR screenings. The facility failed to ensure Resident #8's PASRR Level One screening accurately reflected their diagnosis of mental illness. This failure placed residents at risk of not receiving specialized therapy and equipment services they may benefit from. Findings included: Review of Resident #8's admission Record, dated 08/19/25, reflected he was a [AGE] year-old male, admitted on [DATE], and having diagnoses of cerebral infarction (stroke), unspecified dementia, severe with mood disturbance, delirium due to known physiological condition (occurring as an effect of a diagnosed disease process), bi-polar disorder current episode mixed, moderate (individual experiences both moderate manic and depressive symptoms simultaneously), and anxiety disorder. Review of Resident #8's quarterly MDS assessment, dated 05/16/25, reflected he was admitted to the facility from a short-term hospital stay. Resident #8 was usually able to understand others and be understood by others. His BIMs score was seven, indicating severe cognitive impairment. He displayed no signs of delirium or psychosis, no behavioral problems, and had no indicators of a mood problem during the assessment period. Resident #8 had impaired range of motion on one side of his upper body, and both sides of his lower body. He was able to feed himself but was dependent on staff for movement and ADL care. Review of Resident #8's care plans reflected the following: - A care plan created on 05/04/24, for of psychotropic medications for depression (sertraline and Depakote) - A care plan created on 05/22/24 for a history of trauma - A care plan created on 05/24/24 for impaired cognitive function or dementia, or impaired thought processes related to his stroke - A care plan created on 05/24/24 for depression and antidepressant medication Review of a psychiatry progress note, dated 08/04/25, reflected Resident #8's primary treating diagnosis was bipolar disorder, current episode mixed, moderate, and was on two medications which were each being used to treat multiple psychiatric diagnoses, including his primary diagnosis. Review of Resident #8's PASRR Level 1 Screening reflected the screening was done on 08/17/24, the day before Resident #8 was admitted to the facility, at an acute care hospital. Section C of the document reflected Resident #8 did not have a primary diagnosis of dementia, did not have mental illness, developmental disability, or intellectual disability. An interview on 08/19/25 at 5:37 PM with Regional MDS revealed if Resident #8 came from the hospital with a diagnosis of bi-polar, and the hospital marked it negative, she would have to enter the information as-is, as a draft, and try to get a new, correct form from the hospital. She said the admissions person, who received the form from the hospital when someone was admitted , did not review the form, and just scanned it in, and she (MDS) would be the one to review the form. She said she had a form she consulted with the diagnoses, because she could not remember them all. The surveyor asked for a copy of this list at that time, but did not receive one prior to exit. An interview on 08/19/25 at 6:11 PM with Regional MDS revealed the physician had moved Resident #8's dementia diagnosis to the primary spot, but she realized it was not there when the survey began. She said if a resident had mental illness when admitted , and the form was incorrect, MDS was to ask the admissions person to get a correct one from the hospital. She said it was important for the forms to be correct so that residents would have access to services available to them, but Resident #8 would not qualify for services, and his mental health needs were being addressed by the facility. Review of the facility policy Pre-admission Screening Resident Review (PASRR), revised 06/2020, reflected Purpose: To ensure that all Facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated. Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. (.)I. The Facility, as a medicaid certified nursing facility, ensures that Level I of the Preadmission Screening Resident Review (PASRR) is completed prior to admission of all applicants, regardless of payor, to determine if they are have a Mental Disorder ( MD) or Intellectually Disabled ( ID). A. All applicants to the Facility, whether or not they receive or are eligible for Medicaid, receive the Level I screening. (.) V. A negative Level I screen permits admission to proceed and ends the PASARR process, unless a possible serious mental disorder or intellectual disability arises later. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. (.) VII. Failure to pre-screen residents prior to admission to the facility may result in the failure to identify residents who have or may have MD, ID or a related condition. (.) Procedure: I. Procedure for New Applicants A. PASRR Level I screening is to be completed before the individual is admitted to the Facility. If it is not completed by the sending institution, it should be completed byNursing Staff prior to admission.B. All first-time applicants to the Facility, regardless of Medicaid status or payer, must undergo a Level I PASRR screening before being admitted to the Facility, or on the first day in which Medicaid reimbursement is requested. (.) C. If the Level I screening reveals no sign of mental illness or intellectual disability, the applicant may be admitted to the Facility without further review. III. Screening Results A. If the Level I screening results indicate that the applicant should receive the Level II screening, the Facility shall contact the appropriate state agency for additional screening. i. The state agency will arrange for Level II screening and determine whether the individual should be admitted to the Facility and, if so, what services the individual will need. The Level II screening must be completed prior to admission. (.) iii. Recommendations from the Level II screening will be incorporated into the residents' care plan.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 8 residents, and 1 of 1 laundry room reviewed for infection control in that: 1. ADON B did not wear PPE during wound care for Resident #2 who was on Enhanced Barrier Precautions for wounds. 2. The facility failed to prevent cross contamination of three racks of clean residents' clothing by placing the racks in front of two washing machines in the soiled area of the laundry room. 3. The Laundry Aide failed to keep the clean laundry folding table clean, when she placed her shoes on the table next to residents' clean clothing. These failures could place residents at risk for infections due to lack of separation between clean and soiled laundry and by not following Enhancement Based Precautions.The findings included: Record review of Resident #2's face sheet dated 08/18/25 revealed a [AGE] year-old female who was admitted to the facility with pressure ulcer of the sacral region, stage 4 (this is a wound with full thickness tissue lose with exposed bone, tendon or muscle. Slough or eschar may be present on some parts), unspecified wrist fracture and urinary tract infection. Record review of Resident #2's [NAME] MDS dated [DATE] revealed Resident #2 had a BIM's score of 14, indicating cognitively intact. Further review of MDS revealed Resident #2 had skin and ulcer treatment plans of pressure reducing device for bed, nutrition or hydration interventions to manage skin problem and pressure ulcer care. Review of Resident #2's physician orders dated 08/18/25 reflected resident was on Enhanced Barrier Precautions r/t wound: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tube, tracheostomy/ ventilator. every shift for Standard Precautions, order start date 04/28/25. Review of Resident #2's care plan, initiated 08/05/25, revealed: Focus: On Enhanced Barrier Precautions for wounds.Goal: Enhanced Barrier Precautions will be followed through review period. Interventions: Enhanced Barrier Precautions r/t sacrum wound requires dressing: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tube, tracheostomy/ventilator During wound care observation on 08/18/25 at 1:30 PM, revealed door signage for Resident #2 for Enhanced Barrier Precautions. ADON B did not put on a gown during wound care for Resident #2. In an interview on 08/18/25 at 1:50 PM, ADON B said that she forgot to wear a gown. She said that she did not know why she forgot to wear a gown. She said she was usually very careful to make sure that she followed all PPE precautions. She said the risk of not following EBP was spread of infection. Observation and interview of laundry room on 08/19/25 at 11:00 AM, revealed the laundry room had a clean area and a dirty area that were separated by a partial wall. Further in the laundry room revealed three racks of clothing placed a few feet in front of two washing machines on the soiled area of the laundry room next to a sink. Further observation on the clean area of laundry room on the folding table revealed a pair of black shoes placed on top of clothing facing upwards with the soles of the shoes up. The Housekeeping Supervisor stated that the Laundry Aide had placed the two racks of clean residents clothing in the area (dirty area) after sorting them from the dryer before transporting them out to residents. She said the third rack was for missing residents' items or items that could be donated to residents that had no clothing. She said the laundry room was small, and they tried to use the areas as best as they could. She said that the laundry aide should have placed the clean clothing racks on the clean area to avoid cross contamination. In an interview with the Laundry Aide on 08/19/25 at 11:10 AM, she said that the shoes were hers. She did not say why she put her shoes on top of the table that was used to fold residents clothing when she was asked by housekeeping supervisor. The Laundry Aide said she would move her shoes and that the risk of placing shoes in an area used for folding residents clothing was contamination of laundry items. The Laundry Aide said that it was easier for her to have the racks of clothing in the area by the washing machines because it was closer to the sorting table after taking the cloths out of the dryer. She said she could see how mixing dirty and clean could cause a risk of cross contamination. In an interview with the DON on 08/19/25 at 5:04 PM, she said the expectation during wound care was for the nurses to wear a gown and gloves and to follow EBP. She said EBP was put in place as an extra layer of protection for staff and residents to prevent the spread of MDRO's infection. She said she and ADON were responsible for monitoring infection control policies and procedures that were being followed. The DON said she had in-serviced on infection control and how to handle linens but other than that she was not familiar with the laundry room. She said that the expectation was for all staff to follow infection control policies and procedures. In an interview with the ADM on 08/19/25 at 6:57 PM, it was revealed that she expected all staff to follow the infection control policy and to follow EBP. The ADM said that laundry room should follow the infection control by separating clean areas from soiled areas to prevent cross contamination. ADM said that she would bring up the incidents during the meeting and have OAPI team involved, and she would make sure that in-services for laundry department for infection control was completed by all staff. Record review of facility policy titled Standard and Enhanced Precautions dated April 1, 2024, revealed .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO .Wounds and/or indwelling medical devices even if a resident is not known to be infected or colonized with a MDRO .post signage .high-contact resident care activities requiring gown and glove use . Record review of facility policy titled Laundry-Route & Process, revision date 08/2020 reflected: K. A clean and safe environment is always maintained.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for 3 of 18 residents (Resident #81, Resident #5, and Resident #18) reviewed for maintenance services. The facility failed to ensure Resident #81's ceiling tile was repaired and maintained around the air vent. The facility failed to ensure Resident #5's air vent was cleaned and free of debris. The facility failed to ensure a hole in the wall of Resident #18's room was repaired. The facility failed to ensure resident #18 had sufficient lighting in the bathroom. These failures could place residents at risk of living in an unclean, unsanitary, and accident-free environment which could lead to a decreased quality of life.Findings included: Record Review of Resident #81's Face Sheet, not dated, indicated a [AGE] year-old female with an initial admission date of 03/29/24 and a re-admission date of 05/13/24. Resident #81 had diagnoses of Senile Degeneration of the brain (a progressive decline in thinking, memory, and daily function), Dysphagia (difficulty swallowing), Atherosclerosis of Native Arteries (the buildup of plaque within the body's arteries), Adjustment Disorder (a mental health condition where someone experiences excessive emotional or behavioral symptoms in response to a stressful life event or change), Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or not feeling rested after sleep, which disrupts daily activities), Lack of Coordination (difficulty in controlling and coordinating movements), Cognitive Communication Deficit (Attention and concentration difficulties), Dementia (a progressive loss of mental functions, such as memory, language, and reasoning), Delirium (a change in a person's mental state), Muscle Weakness, Anemia (a condition where the blood has a reduced ability to carry oxygen), and Hyperlipidemia (a condition in which there are abnormally high levels of lipids (fats) in the bloodstream). Record Review of Resident #5's Face sheet, not dated, indicated a [AGE] year-old with an admission date of 07/08/25. Resident #5 had diagnoses of Dementia (a progressive loss of mental functions, such as memory, language, and reasoning, Muscle weakness), Lack of Coordination (difficulty in controlling and coordinating movements), Type 2 Diabetes (when the body cannot use insulin correctly and sugar builds up in the blood), Hyperlipidemia (a condition in which there are abnormally high levels of lipids (fats) in the bloodstream), Bipolar Disorder a (mental health condition that causes extreme mood swings), Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or not feeling rested after sleep, Chronic Pain, Visual loss, Hearing loss, Hypertension (where the force of blood against the artery walls is consistently too high), Vascular Disease (conditions that affect the body's blood vessels, including arteries and veins), and Chronic Kidney Disease (where the kidneys are damaged and cannot filter blood effectively). Record Review of Resident of #18's Face sheet, not dated, indicated a [AGE] year-old with an admission date of 03/25/25. Resident #18 had diagnoses of Traumatic Subarachnoid Hemorrhage (bleeding into the space between the brain and its surrounding membranes), Lack of Coordination, Cataracts (clouding of the eye's natural lens), Convulsions (where muscles contract and relax rapidly, causing uncontrolled shaking of the body), Psychotic Disorder (a mental health condition that causes a person to lose touch with reality), Adjustment Disorder (a mental health condition where someone experiences excessive emotional or behavioral symptoms in response to a stressful life event or change), Muscle Weakness, Communication Deficit (a difficulty or impairment in the ability to effectively receive, send, process, or comprehend information), Aphasia (a language disorder that affects a person's ability to communicate), and Hypokalemia (low potassium levels in the blood), Depression. An observation on 08/17/25 at 1:51 PM, of Resident #81's room reflected brown water stains on the ceiling tile around the air vent that had condensation on the vent. An observation on 08/17/25 at 2:26 PM, of Resident #5's room reflected gray flakes that covered the air vent. An observation on 08/18/25 at 10:30 AM, of Resident #18's room reflected a hole in the wall behind the door. In an observation and interview on 08/18/25 at 10:35 AM, Resident #5's bathroom light was dim. Resident #5 stated the light was so dim she could not see when she entered the bathroom. In an interview on 08/19/2025 at 1:15 PM, the Maintenance Director stated he was responsible for changing the ceiling tiles, cleaning the air vents, repairing holes in the walls, and changing out the light bulbs in the facility. He stated the risk of the brown stains on the ceiling tile with condensation on the air vent could cause internal black mold. He stated the risk of not repairing the hole in the wall could cause a resident to get their arm stuck in the wall or they could cut themselves. He stated the risk of the dim light in the resident's bathroom could cause a fall. In an interview on 08/19/2025 at 6:30 PM, the ADM stated she expected the Maintenance Director to patch all holes. She stated the risk of the hole not being patched could cause pests to come through the wall. She stated she expected the Maintenance Director to change out light bulbs when there is little to no light, and the risk of failing to do so could cause a fall. She stated she also expected for the Maintenance Director to repair the ceiling tile that contained the brown stain with condensation on the vent and clean the debris off of the other vent as soon as they received the work order, and she stated the risk was the condensation, or debris could drop onto the resident. Record Review of the facility policy, revised 08/2020, titled Resident Rooms and Environment stated: Purpose: To provide residents with a safe, clean, comfortable and homelike environment. Policy: The facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk. To this end, the facility encourages residents to use their personal belongings to the extent possible. Procedure: l. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order; C. Lighting that is comfortable (minimum glare) yet adequate (suitable to the task) F. Comfortable levels of ventilation. Vlll. The Facility provides comfortable and adequate lighting throughout the Facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes: Sufficient general lighting in all areas; Task lighting as needed; Even light levels.

Based on observation, interview, and record review, the facility failed to ensure medication was stored in locked compartments for 1 of 7 Medication Carts (Cart A) and 1 of 2 Treatment Carts (Cart B) reviewed for drug security. 1. A medication cart (Cart A) was left unlocked when not in use, unattended, and out of nurse's view while Resident #15 sat across from medication Cart A on 08/17/25. 2. A treatment cart (Cart B) was left unlocked when not in use and unattended on 08/17/25. These deficiencies could place residents at risk of medications loss, drug diversion, or harm due to accidental ingestion of unprescribed medications.Findings included: Record review of Resident #15's face sheet dated 08/18/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia (this is a brain disease that alters brain function and causes a cognitive decline). In an observation on 08/17/25 at 08:20 AM and at 08:45 AM, it was revealed a medication cart (Cart A) was unlocked and unattended with the lock mechanism out (indicating it was unlocked) against the nursing station facing the foyer with Resident #15 seated across from the unlocked and unattended medication cart (Cart A). There was no staff in sight of the unlocked Cart A. In an observation on 08/17/25 at 08:45 AM, it was revealed that the Treatment cart (Cart B) was unlocked and unattended with the lock mechanism out (indicating it was unlocked) outside the secure unit double doors against the wall facing outwards to the nursing station. There were no staff close or working from the unlocked treatment cart (Cart B). In an interview on 08/17/25 at 08:50 AM with LVN A it was revealed she was responsible for Cart A. She said she forgot to lock Cart A when unattended and out of sight. She stated the expectation was to lock and secure the medication cart when not in use. LVN A stated treatment cart (Cart B) was not left unlocked by her. She said the treatment nurse may have left it unlocked when she went to do wound care in a resident's room. She said all nursing staff were responsible for securing medication carts when not in use. She said the potential risk was a resident may get into the cart and grab something. In an interview with the DON on 08/17/25 at 10:56 AM, she revealed LVN A told her that she left the medication cart (Cart A) and treatment cart (Cart B) unlocked because she was in a hurry to go and stop the bleeding for a resident. She said LVN A said it was the urgent situation that lead to her quickly grabbing bandages and rushing to a resident's room leaving the carts unlocked. DON said Cart A and Cart B should not be left unlocked when not in nurse's view and not actively working in it. The DON said the actual treatment cart was locked inside the wound care nurse's office and Cart B was just overflow stock for weekend nurses to have access to bandages and creams and wound items that may not be on the medication carts. She said the expectation for all staff was that they would follow policy and procedure and lock and secure the medication carts and treatment carts when not in use. She said the risk was unauthorized access to the carts. DON stated she would do an in-service with LVN A. In an interview with ADON B on 08/18/25 at 1:00 PM, it was revealed she was the treatment nurse and did not leave Cart B unlocked when unattended. She stated Cart B was an overflow treatment cart for nurses. She said Cart B was an extra treatment cart for the nursing staff to use when she was not in the building and for PRN treatments by nurses. She said all the nurses have access to Cart B and were responsible for locking it up after use. She said it was a safety risk to the residents especially with betadine on the treatment cart could burn the eyes if accidentally exposed to the hands and into the eyes. Interview on 08/19/25 at 3:49 PM with Administrator it was revealed, the medication carts and treatment carts should be locked when they were out of sight and staff were not actively working in the carts. She said the expectation was that all staff would follow company policies and procedures and the expectation for all staff was to keep the residents safe. Record review of in-service one on one titled Corrective Action Memo completed by LVN A on 08/17/25 lead by DON revealed education to ensure medication/treatment carts are secured and locked when unattended to prevent unauthorized access and ensure resident safety. Record review of facility policy Administering Medication revised 08-2020 reflected 15. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering the medication, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy is always maintained for all resident information by closing the MAR when not in use.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives showers to maintain grooming and personal hygiene for 1 (Resident #1) of 3 residents reviewed for ADL care. The facility did not provide showers or baths to Resident #1 as scheduled. This failure can affect residents by decreasing their quality of life. Findings include: Record Review of Resident #1 face sheet dated 06/10/2025, revealed an [AGE] year-old woman who was admitted to the facility on [DATE] with primary diagnoses of transient cerebral ischemic attack (brief blockage of blood flow to the brain) and sepsis (infection in the blood stream), with secondary diagnoses of acute kidney failure (kidneys unable to filter waste products out of blood), dependence on renal dialysis, unsteadiness on feet, unspecified abnormalities of gait and mobility (change in walking pattern as a result of issues with the legs or feet), unspecified lack of coordination, muscle weakness (generalized), and cognitive communication deficit (trouble with communicating). Record Review of Resident #1's MDS dated [DATE] reflected a BIMS score of 15, indicating cognitively intact. Resident #1 required extensive assistance with 3 ADLs (bed mobility, transfer, and toilet use). Resident #1's care plan, date initiated 05/13/2023, reflected: Problem: Resident #1 has an ADL Self Care Performance Deficit r/t recent weakness. The resident needs assistance performing ADLs. Interventions: BATHING: The resident requires total dependence from one person staff participation with bathing. Goal: The resident will maintain current level of functioning in late loss ADLs thought the next review date; Problem: Resident#1 has a behavior problem r/t refusal of all showers. Resident#1 will not take a shower and does not get out of bed other than to go to Dialysis. Tells staff that therapy is the only people that can get her out of bed and back into bed. Interventions: Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; Explain all procedures to (resident) before starting. Goals: Will understand that (nursing) staff can get her out of bed; Resident#1 will have fewer episodes of refusal by review date. Record review of Resident #1's care plan, initiated date 05/13/2023, did not address the resident not being able to take a shower and how that need was going to be addressed. Observation and interview with Resident #1 on 06/10/2025 at 12:03PM revealed resident dressed in hospital gown and the roots of her hair appeared greasy. The resident stated she had been receiving dialysis treatment 3 days a week. She had a dialysis port on the right side of her chest. The resident stated she did wear briefs and received incontinent care. The resident stated she would like to receive showers, but she receives bed baths, and she was told she cannot have showers. The resident further stated she was told it was because of her dialysis port. Resident #1 said she did not receive bed baths often and that the last bed bath was around 2 months ago. Record Review of Resident #1's bathing task sheet of baths given the last 30 days (from 06/10/2025) reflected that the resident has had 4 baths, 05/17/2025, 05/26/2025, 05/29/2025 and 5/30/2025. Record Review of Resident #1's progress note written by LVN A, dated 05/26/2025 revealed patient refused shower even after this writer tried to advise patient the need for shower . Record review of Resident #1's progress note dated 04/09/25, reflected Skin assessment completed, no skin issues noted. Interview with CNA B on 06/10/2025 at 1:55PM revealed that CNA B provides showers to residents in the mornings. She explained that residents are on a schedule for every other day of the week. The surveyor asked CNA B if she provided Resident #1 with showers; she stated she normally did bed baths with the resident, but she previously got her up for showers. She stated that Resident #1 told her that dialysis said she (Resident #1) cannot get showers but could get bed baths, so she gets bed baths on Monday, Wednesday, and Fridays . CNA B said she gave Resident #1 one (bed bath) yesterday (06/09/2025). CNA B then stated that Resident #1 refused a bed bath on 06/09/2025 because she wanted to get up for therapy. This surveyor asked if CNA B covered the resident's dialysis port for previous showers, CNA B stated she did not cover the port or watched it get covered. She said the nurse covered it, but she could not recall which nurse covered the dialysis port. She said she was not trained to cover the dialysis port because it was not in her scope as a CNA. She said only nurses covered the dialysis port. CNA B described the port cover as plastic and sticky, and hard to get off the resident. After the shower, CNA B said, a nurse (she could not recall name of nurse) told her that dialysis said the port was infected (indicating the resident could only further receive bed baths). Record review of Resident #1's bathing task sheet of baths given the last 30 days (from 05/10/2025) reflected no record of if the resident received or denied a bed bath or shower. Interview with the Nurse Practitioner on 06/10/2025 at 2:01PM revealed that Resident #1 should be able to receive showers and the dialysis port can be covered up. She said she was not aware of the issue, but she will make sure that she educates the nursing staff. Interview with the Regional Compliance Nurse on 06/10/2025 at 3:12PM revealed that initial refusal of showers was to be charted and care planned. She stated the residents have the right to refuse the shower, but staff can keep encouraging the residents. She said that just because they refuse doesn't mean they won't change their mind. The Regional Compliance Nurse stated she had not heard of a dialysis port being why a resident cannot have a shower. The Regional Compliance Nurse said staff can cover the access port; saying that may be a way to make someone have bed baths. The Regional Compliance Nurse stated she has had dialysis patients her whole career and never had that a situation where residents could only have bed baths due to their dialysis port and did not think nephrology would say that. The Regional Compliance Nurse explained dialysis did dressing changes on the ports and facility nurses monitor the sites. Interview with the ADM on 06/10/2025 at 4:34PM revealed the expectation for ADL care and showers was that they were resident rights and residents were to be asked if they want a shower. If residents refuse, staff were to put a note in their care plan or chart. The ADM stated that residents who were on dialysis do get showers. She named another resident who was on dialysis and took showers. The ADM stated dialysis ports need to be covered and taped for showers. Record review of facility in-service titled showers dated 05/07/25, revealed LVN A and CNA B had completed the training. Record review of the facility's Dialysis Care policy and procedure, revised 06/2020, reflected .IV. Care Plan A. The Interdisciplinary Team (IDT) will ensure that the resident's Care Plan includes documentation of the resident's renal condition and necessary precautions. Record review of the facility Resident Rights policy and procedure, revised 8/2020, reflected .II. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: A. Sleeping, eating, exercise and bathing schedules; B. Personal care needs, such as bathing methods, grooming styles and dress; and C. Health care scheduling, such as times of day for therapies and certain treatments.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for treatment of pressure ulcers. The facility failed to follow their Wound Care management protocol when they failed to refer Resident #1 to the Wound care consultant at the time of her re-admission to the facility when she was admitted with a sacral pressure ulcer. Resident #1 was readmitted on [DATE] and facility did not refer the resident to the Wound Care consultant until 03/25/25. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 03/17/25 and ended on 03/25/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for worsening wounds, infection, and hospitalization . Findings included: Record review of Resident #1's Face sheet dated 04/07/25 revealed she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses of unspecified displaced fracture of cervical vertebrae (neck region), fusion of spine-cervical region, osteoporosis (condition where bones become weak and brittle) with current pathological fractures (a bone break caused by underlying disease that weakens the bone structure) and severe protein-calorie malnutrition, Record review of Resident #1's 5-day MDS assessment dated [DATE] reflected the resident had a BIMS of 14 which indicated she was cognitively intact, required substantial to maximum assistance with ADLs, was always incontinent of bowel and urine, was at risk of developing pressure ulcers and had one stage III pressure (exposing the underlying fatty tissue, but not reaching muscle or bone) and one surgical wound. She had received Speech therapy, physical therapy, and occupation therapy with a start date of 03/18/25. Record Review of Resident #1's Physician order summary dated 04/07/25 reflected, Pressure relieving mattress and Pressure relieving chair cushion with a start date of 03/17/25 .Wound care for coccyx stage 2 pressure injury. Cleanse with wound cleanser. Apply Mepilex padded dressings every day and PRN .with a start date of 03/07/25 . Record review of Resident #1's care plan with an initiation date of 03/17/25, reflected, [Resident #1] is at increased risk for impaired skin integrity and additional skin breakdown due to impaired ability to move and the resident being mostly incontinent of bowel and bladder. Resident with pressure injury to coccyx (the small bone at the bottom of the spine)upon admission .Goal .Resident's pressure injury will resolve or show improvement by review date .the resident will not have any additional skin breakdown through the next review period .Interventions .Educate resident/representative about the proper usage of pressure reducing devices .The resident has a low-air-loss mattress due to admitting with pressure injuries .Wound care to coccyx as ordered by the physician . Record review of Resident #1's skin assessments: 03/18/25- Pressure Injury to buttocks 03/21/25- Pressure injury to coccyx 2x3x.5 on admission 03/28/25- open wound to coccyx Record Review of Resident #1 Physician Telephone order dated 03/25/25 reflected, Wound Care Consult. Record review of Resident #1's Progress Note dated 03/27/25 at 11:22 am by ADON A, reflected, NP ordered Medi honey (supports the removal of necrotic tissue), calcium alginate (dressing used to absorb wound drainage) to cover with foam dressing. [Family member] aware of the order . Record Review of Resident #1's Wound care Physician's report dated 03/31/25, Location: Sacrum Measurement: 1.5 cm length 3.0 cm width Depth 0.50 cm Etiology: Pressure Stage/Severity: Stage 4 Date Wound Acquired: 03/17/25. Wound Status: Present on Admission %Slough (by product of the inflammatory phase of wound healing comparison of dead and living cells): 100% Treatment- daily wound cleanser, apply Santyl, Calcium alginate and cover with dry dressing. Record Review of Resident #1's Wound Care consult report dated 04/07/25, Location: Sacrum Measurement: 1.5 cm length 3.0 cm width Depth 0.50 cm Etiology: Pressure Stage/Severity: Stage 4 Date Wound Acquired: 03/17/25. Wound Status: Subsequent- Stable Undermining: From 5 o'clock to 7 o'clock 2.5 cm %Granulation (health new tissue) 50% %Slough: 50% Treatment: Treatment- daily wound cleanser, apply Santyl, Calcium alginate and cover with dry dressing. In an interview and observation with Resident #1 on 04/07/25 at 08:30 a.m. revealed resident in her room lying on an alternating pressure mattress. Resident was turned on her side with pillows supporting her arms and a pillow between her legs. Resident's family member was at bedside. Family member stated the Resident had been living at home when she suffered a fall and was taken to the hospital around the first of February. She stated she was transferred to this facility around the end of February. Family stated the resident was not progressing and getting weaker, so she requested an MRI to be completed since the resident was having decreased sensation in her arms. She stated the facility transferred her to the hospital for the MRI on 03/07/25 where it was determined she had C1 fracture. She stated the resident underwent cervical neck fusion of the C1 through C7 (neck vertebrae) and she had done remarkable through the surgery. She stated she knew she had a wound while at the hospital and requested the hospital order an alternating pressure mattress for her when she returned to the facility on [DATE]. She stated the pressure mattress the facility provided was not working properly and it took them 4 days to get another pressure mattress. She stated the wound care they were providing in the beginning was not effective and she requested the wound care physician be consulted. She stated she was told the Wound Care physician only came once a week to the facility. She stated she asked if they could call the physician and let her know the condition of the wound. She stated later that week the NP came by and ordered a new treatment for the wound. She stated the wound care physician came last week on 03/31/25 and is due to return today (04/07/25). She stated she just wanted to make sure they were doing everything they could for Resident #1 to aide in her healing. She stated she was going to discuss with the wound care physician about a wound vac to see if that would aide in the healing of the wound. In an interview with the Wound Care Physician on 04/07/25 at 09:15 a.m. she stated she had received a referral on 03/27/25 for Resident #1. She stated she saw her on 03/31/25 which was her normal scheduled day at the facility. She stated she staged the wound at a stage 4 (involves full-thickness tissue loss where muscle, tendon or bone is exposed), but stated it was going to take time to be able to determine its true size until all of the slough had been removed. She stated she had debrided (removing non-viable tissue) the wound some on her first visit. She stated the facility had the resident on an alternating pressure mattress and were off loading and turning her. She stated she would visit with the Family member today about the possibility of a wound vac but stated it would depend on the progression of the wound. She stated the facility would usually obtain a consent for a wound care consult on any admission or any resident who acquired a wound, and she would evaluate them on her next onsite visit. She stated the facility would usually continue the hospital wound care orders if they came with orders or would have the primary physician give wound care orders until she evaluated the resident. She stated had they referred her when she admitted she would have seen her on 03/24/25, but instead saw her on 03/31/25. She stated she can't really say the delay caused any harm, since she was receiving wound care and did have interventions in place. An observation of the Wound Care Physician's evaluation of Resident #1 on 04/07/25 at 09:35 a.m. revealed the Physician measuring and assessing the wound. The Wound Care Physician spoke with the resident and the family member and explained the wound had made some progression with 50 % less slough than last week, but stated it was difficult to tell how deep the wound was until all the slough was removed. She told the Family member the wound was most likely going to get larger due to the removal of the devitalized tissue. The wound care physician told the Family member she would consider a wound vac in the future, but the wound was not at the point that it would benefit from a wound vac at this time. She stated she wanted to continue with the current wound care orders, turning side to side, continue with the alternating pressure mattress and limit her out of bed to an hour 3 times a day. ADON A proceeded with the prescribed wound care and covered the wound with a border gauze. In an interview with Medical Records clerk on 04/07/25 at 11:00 a.m. she stated she had received a request to order an alternating pressure mattress for Resident #1 on 03/25/25. She stated she ordered it that day and it was delivered the same day and was placed on the bed for the resident. She stated she was not aware of any problems with the previous air loss mattress, she was just told to order a new one. In in an interview with CNA C on 04/07/25 at 11:00 a.m. she stated she had been assigned to Resident #1 since her return to the facility. She stated they were turning her every 2 hours. She stated the resident had an alternating pressure mattress since her admission. She stated the wound on the resident's bottom had a small opening. She stated the nurses were putting a dressing over the wound. In an interview with the RA D on 04/07/25 at 11:05 a.m. she stated Resident #1 had an alternating pressure mattress on her bed as soon as she came into the facility. She stated the family member did not like the one the facility had and had brought in an egg crate mattress to put over the bed. She stated then she got a different alternating pressure mattress. She stated she had never seen the wound uncovered, stating it always had a dressing over it. In an interview with LVN E on 04/07/25 at 11:10 a.m. she stated she works the 6 a.m. to 2 p.m. shift Monday through Friday. She stated Resident #1 admitted with a wound to her sacral area. She stated they were providing wound care to the wound on the days the Treatment Nurse did not. She stated the Treatment nurse was the one who made the referrals for the Wound Care Consult. She stated any time a resident had a wound the Treatment Nurse would refer them to the Wound Care physician. She stated she had assumed the Treatment Nurse had referred Resident #1 to the wound care physician. She stated Resident #1 had an alternating pressure mattress, but stated it was not working properly, so they ordered another mattress. She stated the Treatment Nurse had resigned a few weeks ago. She stated when they were looking back to see if the referral had been made, she did not find a consent form for them to refer the resident, so she obtained the consent from the family and placed it in the Wound Care Physician's folder. She stated they had an Inservice a few weeks back and stated all the nurses would be responsible for wound care, obtaining the consents and treatment orders until a new Treatment Nurse could be put in place. In an interview with the DON on 04/07/25 at 11:30 a.m. she stated she had started for the facility around the first of March 2025. She stated the Treatment Nursed quit on 03/20/25 with no notice. She stated she had assumed all the weekly treatments, wound measurements and referrals were current and up to date. She stated she worked the floor on 03/22/25 and 03/23/25 and had done Resident #1's treatments. She stated when she saw the wound she would have staged it as unstageable due to the amount of slough. She stated the hospital had it staged as a Stage 2 but stated that was not where she would have staged it. She stated the family was very upset about the wound care treatment that was being provided and stated the Treatment Nurse had informed the family that the Wound Care Physician would be seeing her. She stated she offered to send the resident to the hospital for wound care management, but stated the family declined and wanted to wait to be seen in house. She stated after this they did a complete skin sweep of the building and an audit of the records and referrals and that was when they discovered the consent had not been obtained for the wound care consult. She stated they did obtain the consent, update the physician, and make the referral to the wound care physician. She stated the resident was provided an alternating pressure mattress upon the family members request, and when the family was not happy with the one, they provided, they ordered a replacement mattress the same day. She stated they had made an offer for ADON A to take the full-time position as ADON/Treatment nurse. She stated she had a background in wound care. She stated in addition she met with the staff and reviewed the process for all residents with wounds. She stated the admitting nurse is responsible for documenting the location and a description of the wound. She stated only the Wound Care Physician, the Treatment Nurse or ADON will stage the wounds. She stated the admitting nurse will obtain the signed consent for the Wound Care referral. She stated if the resident comes with treatment orders, they will review those orders with the physician upon admission. She stated herself and the ADONs will perform a chart audit after the admission to ensure all the orders had been obtained as well as any consents required or interventions. She stated the Treatment Nurse will provide weekly updates with the progress and measurements of all pressure and non-pressure wounds. In an interview with ADON B on 04/07/25 at 12:54 a.m. she stated the previous ADON/Treatment nurse was responsible for the Rehab Hall and for the wound care management. She stated the previous ADON/Treatment Nurse was still working when Resident #1 readmitted . She stated they were aware the resident was admitting with a wound, and she had told her to make sure she went and assessed the wound. She stated she knew the family had requested an alternating pressure mattress and she stated one was provided. She stated they were not aware there was a problem with the mattress until 03/25/25, and that was when they ordered a new mattress for her. She stated the protocol had always been to refer anyone admitted with a wound or even a surgical wound for the Wound Care physician to evaluate and treat if necessary. She stated she was surprised the previous Treatment nurse had not made the referral. She stated as soon as the lapse was discovered they obtained the necessary consent, and the Wound Care physician was notified. An attempt to contact the previous Treatment Nurse by phone was made on 04/07/25 at 01:13 p.m. Message was left, with no return call received prior to survey exit. In an interview with the NP on 04/07/25 at 01:02 p.m. she stated the staff had informed her at the time of Resident #1's admission that she had a sacral wound, and they wanted an air mattress for her. She stated the facility always referred any resident with a wound to the Wound Care physician, so she had assumed they would be obtaining any treatment orders needed from the Wound Care physician. She stated the Family member reached out to her on 03/27/25 and sent her a picture of the wound and was requesting a different treatment for the wound care. She stated she gave a new order for wound care and started the resident on Antibiotics as a precaution, until the Wound Care Physician could see her. She stated the wound did not appear to be infected. She stated the Wound care Physician saw the resident on 03/31/25. In an interview with the Administrator on 04/07/25 at 2:15 p.m. stated she the non-compliance was the result of the sudden departure of the Previous/Treatment nurse who had failed to complete her responsibilities. She stated the nursing staff had been re-educated on the process. She stated through the audits and skin sweeps it was determined no other oversight had occurred. She stated going forward chart audits will be conducted on all new admission to ensure any resident admitted with a wound received the necessary referrals, treatments and interventions required to promote wound healing and prevention for further decline. Record review of the facility's policy, Wound Management, dated June 2020, reflected, Purpose: To provide a system for the treatment and management of resident with wounds including pressure and non-pressure injury. A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing .An assessment of care needs for pressure injury and wound management will be made with emphasis on, but not limited to .Treatment .Mechanical offloading and pressure reducing devices .Evaluating and modifying interventions for a resident with an existing Pressure ulcer/Pressure injury .The Attending Physician will be notified to advise on appropriate treatment promptly . Record Review of Resident #1's consent for Wound Care Treatment reflected consent was provided by Resident #1's Family member on 03/25/25. Record Review of the Facility's Mandatory staff meeting dated 03/26/25 reflected the nursing staff would be responsible for all aspects of wound care until a Treatment Nurse could be hired. In addition, the staff were re-educated on the facility's wound care protocol. In an interview with the DON, ADON A and ADON B on 04/07/25 at 2:20 p.m. they stated they had been in serviced on the wound care protocol and knew they were responsible for ensuring the wound care consent and referral were made on any wound upon admission or any new wound acquired while in the facility going forward. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 03/17/25 and ended on 03/25/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure the facility's only garbage storage dumpster, and surrounding area, was maintained in a sanitary condition to prevent the harborage and feeding of pest. 1. The facility failed to ensure the trash dumpster's door, located outside the facility's building, was closed., 2. The facility failed to ensure trash was not left outside of the dumpster on the ground. This failure could place residents at risk of contracting disease by attracting pest, disease carrying rodents, and having debris dangerous to residents. Findings included: 1. During an observation on 7-9-2024 at 9:15 AM, the facility's only trash dumpster was observed to be 3/4 full of trash with its door open. The area surrounding the trash dumpster was observed to have used latex gloves, a pack of metal screws, a chicken bone, an uncovered rolling cart with a large trash bag full of trash (unsealed), a piece of broken glass, various trash debris, a metal rolling cart with a yellowish/brownish liquid substance with a strong odor, and a 3-tier plastic rolling cart. 2. In the dock area, next to a back door, observation was made on 7-9-2024 at 9:20 AM of stacked pallets having trash debris in-between a few pallets. In an interview on 7-10-2024 at 1:10 PM, with the Dietary Manager, it was revealed the Dietary Manager, Housekeeping Supervisor, and Maintenance Director were responsible to keep the outside trash dumpster secure and the surrounding area clean. The expectation of the Dietary Manager was for staff to keep the trash dumpster door closed, ensure sure trash was put in the trash dumpster, ensure there was no trash left on the surrounding ground by the trash dumpster, and to ensure the trash between the pallets, by the back door, was put in the trash dumpster. The Dietary Manager stated the potential risk to residents, by not properly disposing of trash, was it could attract rodents or insects. In an interview on 7-10-2024 at 1:30 PM, the Housekeeping Supervisor stated the Housekeeping Supervisor, Kitchen Supervisor, and Maintenance Director were responsible for ensuring trash was properly disposed of and kept off the ground. The Housekeeping Supervisor expected staff, who were disposing of trash, to use a cart with a lid when transporting trash from the facility building to the outside dumpster. He expected the staff member to put the trash in the dumpster and close the dumpster door. The Housekeeping Supervisor stated he did not expect staff to leave a trash bag full of trash, sitting in an open cart next to the dumpster and not put the trash bag into the dumpster; closing the door when finished. The Housekeeping Supervisor expected staff to not leave trash debris on the ground surrounding the dumpster area. His concerns for not properly disposing of trash by leaving a piece of broken glass on the ground, a metal pack of screws on the ground, leaving use nitrile gloves on the ground, and other debris was a resident could get cut, it could attract rodents and/or insects, and it was an infection control issue. In an interview on 7-10-2024 at 2:15 PM, the Maintenance Director revealed the Maintenance Director, Housekeeping Supervisor, and the Dietary Manager were all responsible for ensuring the proper disposal of trash for the facility. After showing the Maintenance Director photos of the trash dumpster that was observed on 7-10-2024 at 9:15 AM which included used latex gloves, a pack of metal screws, a chicken bone, an uncovered rolling cart with a large trash bag full of trash (unsealed), a piece of broken glass, various trash debris, a metal rolling cart with a yellowish/brownish liquid substance having a strong odor, and a 3-tier plastic rolling cart, surrounding the trash dumpster, he stated it was all trash and belonged in the trash dumpster. The Maintenance Director stated if staff were not physically able to put the trash into the dumpster, staff should have contacted the Housekeeping Supervisor, Kitchen Supervisor, or Maintenance Director so one of them would have been able to dispose of the trash properly. The Maintenance Director stated if the trash dumpster was full, staff should have contacted one of the three managers so they could have pushed the trash down lower, creating more room or they could make other arrangements. The Maintenance Director stated the potential risk to residents, for not properly disposing of trash debris, was it could cause injury, contamination, and roaches could get into the building. Record review of the facility's Operational Manual - Physical Environment Maintenance Services Policy, dated 8-2020, states: Purpose: To protect the health and safety of residents, visitors, and Facility Staff. Policy: The Maintenance Department maintains all areas of the building, grounds, and equipment. Procedure: I. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. II. Functions of the Maintenance Department may include, but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; B. Maintaining the building free from hazards . I. Maintaining the grounds, sidewalks, parking lots, etc., in good order . III. The Director of Maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. IV. As part of their duties, Maintenance Staff will comply with established infection control Precautions . IX. Maintenance Staff follow established safety regulations to ensure the safety and well-being of all concerned. Record review of the Texas Food Establishment Rules dated 3-15-2006 stated: S229.166(k) (4) Receptacles. (A) Except as specified in subparagraph (B) of this paragraph, receptacles and waste handling units for refuse, recyclables, and returnables and for use with materials containing food residue shall be durable, cleanable, insect and rodent-resistant, leakproof, and nonabsorbent. (B) Plastic bags and wet strength paper bags may be used to line receptacles for storage inside the food establishment, or within closed outside receptacles . (6) Outside receptacles. (A) Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for refuse and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized, and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit.

Based on observation, interview and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 7 residents (#1, #2, #3, #4, #5, #7, #8) of 8 residents reviewed for resident call system in that: The facility failed to ensure 7 out of 8 Resident's (#1, #2, #3, #4, #5, #7, #8) call buttons were accessible on 4/9/24 to residents on the secured unit. This failure could have placed 20 residents on the secured unit at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: 1. Record Review of the face sheet for Resident #1 showed a [AGE] year-old female who was admitted [DATE] and readmitted on [DATE]. Resident diagnoses included: Muscle Wasting (a weakening, shrinking and loss of muscle), Unspecified abnormalities of gait and mobility (a change to your walking pattern), Muscle weakness (decreased strength in muscles), Lack of Coordination (not able to move different parts of the body together well or easily), Dementia (progressive loss of intellectual functioning), Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), Unsteadiness on Feet (a pattern of walking that is unstable), Anxiety Disorder (Intense, excessive and persistent worry and fear about everyday situations), Insomnia (persistent problems falling and staying asleep), Chronic Pulmonary Disease (COPD; a group of lung diseases that block airflow and make it difficult to breath), and a History of Falling. Record review of Resident #1's MDS dated [DATE] reflected a BIMS score of 02, which indicated she was severely cognitively impaired. Resident #1's Care Plan dated 2/10/24 revealed resident was care planned for falls. Also, the resident's care plan stated to Encourage the resident to use call bell for assistance. Record review revealed resident had a fall with no injuries on 3/5/24. Observation on 4/9/24 at 9:54 a.m. of Resident #1 revealed she was sleeping, and her call light was not in her reach. The call light was on the wall behind her bed which was a foot away from the wall. 2. Record Review of the face sheet for Resident #2 revealed an [AGE] year-old female initially admitted on [DATE] and a readmission on 1/25/22. Resident diagnoses included: Anxiety, Dementia, Difficulty Walking, Unspecified Abnormal Gait and Mobility, Cognitive Communication Deficit (difficulty with any aspect of communication that is affected by disruption of cognition), Lack of Coordination, Muscle Weakness, Depressive Episodes, Need Assistance for Personal Care, Unsteadiness and History of Falls. Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 02, which indicated she was severely cognitively impaired. Resident #2's care plan dated 1/11/24 showed she was care planned for Elopement Risk and Falls which stated, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Record review revealed Resident #2 had a fall with no injuries on 1/17/24. Interview and observation on 4/9/24 at 9:54 a.m. of Resident #2 said she could not reach the call light. Observation revealed the call light was out of reach of resident. The call light was on the wall behind her bed which was 1 foot away from the wall. 3. Record Review of the face sheet for Resident #3 revealed an [AGE] year-old woman who was initially admitted on [DATE] and readmitted on [DATE]. Resident diagnoses included: Alzheimer's Disease (progressive mental deterioration due to generalized degeneration of the brain; common cause of senility), Dementia, Major Depressive Disorder, Muscle Wasting and Atrophy, Unsteadiness on Feet, Lack of Coordination, Anxiety, Insomnia and Need Assistance for Personal Care. Record Review of Resident #3's MDS dated [DATE] revealed a BIMS score of 01, which indicated she was severely cognitively impaired. Resident #3's care plan dated 3/6/24 showed she was care planned for her communication deficit. Resident was to develop communication abilities by staff anticipating her needs and to Ensure/provide a safe environment: Call light in reach. Observation on 4/9/24 at 10:04 a.m. revealed Resident #3 was sleeping, and the call light was out of her reach. The call light could not been seen anywhere around the resident's bed. 4. Record Review of the face sheet for Resident #4 revealed a [AGE] year-old woman who was admitted on [DATE]. Resident diagnoses included: Dementia, Abnormality of gait and mobility, Lack of Coordination, Unsteadiness on Feet, Muscle Wasting and Atrophy, Depressive Episodes, Anxiety, Difficulty in Walking, Cognitive Communication Deficit, and Needs Assistance with Personal Care. Record review of Resident #4's MDS dated [DATE] revealed a BIMS score of 00, which indicated she was severely cognitively impaired. Observation on 4/9/24 at 10:04 a.m. of Resident #4 revealed she was sleeping, and her call light was out of reach. The call light was not observed anywhere around her bed. 5. Record Review of the face sheet for Resident #5 revealed an [AGE] year-old man who was initially admitted on [DATE] and readmitted on [DATE]. Resident's diagnoses included: Dementia, Anxiety, Dysphagia Oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), Difficulty Walking, Unspecified Lack of Coordination, Abnormal Gait and Mobility, Major Depressive Disorder, History of falling, Coagulation Defect, Muscle Wasting and Atrophy, Unsteadiness on Feet, Repeated Falls, Cognitive Communication Defect, and History of Sudden Cardiac Arrest (sudden unexpected loss of heart function, breathing and consciousness). Record review of Resident #5's MDS dated [DATE], revealed a BIMS score of 03, which indicated he was severely cognitively impaired. Resident #5's Care Plan dated 1/24/24 showed he was care planned for aggressive behaviors and falls. Record Review showed resident had a fall with no injury on 5/20/23, on 6/13/23 and slid out of bed with no injury on 7/20/23. Observation on 4/9/24 at 10:06 a.m. of Resident #5 revealed he was sleeping with pillow partially over his head and the call light was out of his reach. The call light was lying on the floor next to the bed. 6. Record Review of the face sheet for Resident #7 revealed a [AGE] year-old woman who was initially admitted on [DATE] with a readmitted on 1/21/22. Resident Diagnoses included: Dementia, Unspecified Lack of Coordination, Major Depressive Disorder, Muscle Weakness, Anxiety, Muscle Wasting and Atrophy, Unsteadiness on Feet, and Iron Deficiency Anemia (too few healthy red blood cells which could cause extreme tiredness, weakness headache, dizziness, and shortness of breath). Record review of Resident #7's MDS dated [DATE] revealed a BIMS score of 8, which indicated she was moderately cognitively impaired. Resident #7's care plan dated 3/11/24 revealed she was care planned for falls, elopement risk, refusing showers and fighting staff. Also, care plan stated resident had an ADL (Activities of Daily Living) self-care performance deficit with interventions to Encourage the resident to use bell to call for assistance. Record review revealed a fall on 1/09/23 with no injuries. Observation on 4/9/24 at 10:26 a.m. revealed Resident #7 to be sleeping and her call light was out of her reach. The call light was not observed anywhere around the resident's bed. 7. Record Review of the face sheet for Resident #8 revealed an [AGE] year-old woman who was initially admitted on [DATE] and readmitted on [DATE]. Resident Diagnosis included: Alzheimer's Disease, Delirium (a disturbed state of mind/consciousness), Primary Insomnia, Anemia, Major Depressive Disorder, Atrial Fibrillation (irregular, often rapid heart rate that causes poor blood flow), Chronic Systolic Congestive Heart Failure (specific type of heart failure that occurs in the heart's left ventricle), Muscle Wasting and Atrophy, Unsteadiness on Feet, Repeated Falls and Lack of Coordination. Resident #8's MDS dated [DATE] revealed a BIMS score of 00, which indicated she was severely cognitively impaired. Resident #8's Care Plan dated 3/9/24 showed she was care planned for a risk of falls due to gait/balance problems, unaware of safety needs, Alzheimer's and history of falls with the interventions as Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation on 4/9/24 at 10:29 a.m. of Resident #8's room revealed her call light was not in reach of her bed area. The call light was not observed anywhere around her bed. Interview on 4/9/24 at 10:33 a.m. with CNA (Clinical Nurse Assistant) A stated she answers the call light as soon as it came on. She stated she checks the call light on rounds to make sure it is within reach of the resident. Interview on 4/9/24 at 10:39 a.m. with CNA B stated she did her rounds every two hours and checked to make sure the call light was in reach of the resident, and she would put the call light on the bed if it was not in reach. CNA B said a lot of things could happen if the call light was not in reach of a resident. Interview on 4/9/24 at 10:58 a.m. with RN (Registered Nurse) C stated if a call light goes off, she just goes and answers it as her CNA's may be busy with another resident. She stated she would check if call light was in reach when she checked on residents. RN C said it would be a problem if a resident's call button was not in reach if they had a fall or had gotten hurt. Interview on 4/9/24 at 2:20 p.m. with DON (director of nursing) stated the call lights should be answered as soon as they came on. Her expectation was for staff to check to see if call lights were in reach of residents when they did their rounds. DON said some residents on the secured unit had pads if they could not use the call light which would also be care planned. DON stated she was retraining some staff on call lights. Interview on 4/9/24 at 2:39 p.m. with Admin/Administrator who stated call lights should be answered in 10-15 minutes and depended on what the CNA was doing at the time. She expected staff to check on call lights on the secured unit to make sure they were in resident's reach during rounds. She stated the call lights should be specifically care planned for each resident. The facility resident roster dated 4/9/24 revealed 20 residents resided on the secured unit. Record review of facility's Fall Procedures revealed under Universal Fall Prevention Measures: A. Environmental - ii. Position call bell, urinal if applicable, and bedside stand within reach.

48122 48177 Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of seven residents (Resident #2) reviewed for accidents and supervision . The facility failed to ensure Resident #2 was transferred by two staff, which resulted in a fall with fracture of her distal left Femur (a distal femur is a fracture of the thighbone that occurs just above the knee joint) on 01/19/24 . The noncompliance was identified as PNC. The IJ began on 01/19/24 and ended on 01/22/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury due to unsafe transfers. Findings included: Review of the Admission Record for Resident #2. A discharged resident, dated 03/06/24 reflected a [AGE] year-old female who was admitted to facility on 10/15/20. Her diagnoses included unspecified dementia, Senile degeneration of the brain, glaucoma (a vision problem), lack of coordination, muscle weakness, cognitive communication deficit (difficulty with thinking in regard to language use), unsteadiness on feet, neuropathy (nerve pain), need for assistance with personal care, repeated falls and high blood pressure. Review of Resident #2's annual MDS assessment, dated 12/02/23, reflected Resident #2 had a BIMs score of 2, which indicated severe cognitive impairment, and showed no behavioral issues or psychosis. Resident #2 was dependent on staff for movement in bed, and for transfers from chair to bed/ bed to chair. Dependent defined in the MDS assessment was Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The document reflected Resident #2 had no prior falls. Review of Resident #2's care plan undated due to discharge status printed on 03/06/24 reflected Focus: The resident has had an actual fall with no injury on 2/17/2021, 6/7/21, 7/31/21, Fall with injury (pain) at a later date 1/20/24, Goal: The resident will resume usual activities without further incident through the review date, Interventions: Anti-skid mat placed on W/C [wheel chair] o Bed in low position o Call for assistance before you fall LVN o Continue interventions on the at-risk plan.o Fracture left femur sent to Hospital The Care Plan further reflected Focus: The resident has an ADL Self Care Performance Deficit r/t Activity Intolerance, Fatigue. Goal: The resident will maintain current level of function in Transfers, Eating, Dressing, Toilet Use through the review date. Interventions/tasks o Hoyer Lift for transfers, o Toilet Use: The resident requires assistance to adjust clothing, transfer onto toilet, transfer off toilet. o Transfer: Two-person Hoyer post fall 1/19/24. o Encourage the resident to participate to the fullest extent possible with each interaction. o Encourage the resident to use bell to call for assistance. o Bathing: The resident requires (1) staff participation with bathing. o Dressing: Assist the resident to choose simple comfortable clothing that maximizes the president's ability to dress self. o Dressing: The resident requires (1) staff participation to dress. CNAo Eating: The resident is able to feed self . Review of Resident #2's Transfer/Discharge, dated 03/06/24, reflected Resident #1 was discharged to an acute care hospital on 01/21/24. Review of Resident #2's progress notes, dated 01/19/24 at 9:05 PM by LVN B, reflected CNA A called him to report Resident #1 had an assisted fall while transferring from the Geri chair to bed. LVN B said Resident #1 was alert and confused to base line, Blood Pressure 121/62, Heart rate 65, Temperature 97.7, Oxygen saturation 94 %, Respiration Rate 17. He wrote skin was intact. Hospice, daughter and DON were notified. Review of the ambulance run sheet, dated 01/20/2024, reflected Resident #2 was transported to a nearby hospital due to pain in her lower extremity caused by a fall from the bed, and her level of distress was mild. Review of Resident #1's emergency room admission documentation, dated 01/21/2024, reflected she was admitted on [DATE] for a fractured left femur in a nursing home. It reflected [AGE] year-old female with a history of hypertension, hypothyroidism, colon cancer, dementia, CVA with left sided weakness presenting to the ED via EMS from her facility for a fall that happened 2 days ago. Per EMS, patient reportedly had an x-ray at the facility which showed a left nondisplaced fracture which prompted them to send her to the ER. History obtained from prior record reviews. Patient has a history of dementia and there is no family member at bedside. Patient was tender to palpation over the left female close to the knee. No active bleeding, no obvious dislocation noted. Was given 75 mcg fentanyl IV x 1 for her pain Control. The document reflected Pertinent imaging interpreted ( .) X-ray of the left femur shows periprosthetic (fractures that occur in association with an implant) fracture involving the distal femoral metadiaphysis (wide portion of a long bone). No abnormalities noted on the anterolateral (outside front) pelvis. Medications ordered the ED: 75 mcg IV fentanyl x 1. The document included a Supervising Physician note, which reflected [AGE] year-old female history of dementia advanced requires help with all ADLs here with the left knee pain found to have left periprosthetic fracture occurred during transfer from chair to bed; Had a long discuss ion with orthopedics given age and current baseline status low likely to improve quality of Iife surgery agree posterior long leg and can outpatient follow up. Review of the radiology report included in the emergency room documentation for Resident #2, dated 01/21/2024, reflected Radiology - [NAME] Femur Min 2 Views Lt 01/21 1258 * * * Report Impress Ion - Status: Signed Entered: 01/21/2024 1355 (1:55 PM) Im Pression: Left total knee arthroplasty in place with a nondisplaced periprosthetic fracture involving the distal femoral metadiaphysis . Adjacent soft tissue swelling and knee joint effusion. Review of Resident #2's Hospice Combined Disciplinary Comprehensive Assessment, dated 01/09/2024, reflected Musculo/ Skeletal- Nurse; Mobility Score:3 on a scale of 10 (Full range of activity) to 0 (Immobile); Ambulation: Mainly sit/lie; Uses device; Two person assist; Strength: Weak; Grips: Weak; Conditions: Joint stiffness; Foot drop left; Foot drop right Needs assistance with: Bathing; Ambulation; Dressing; Continence; Transfer Interview with LVN B on 03/06/24 at 4:08 PM revealed CNA A was transferring Resident #2 by herself from the Geri chair to bed around 8 or 9 PM. He said CNA A reported to him Resident #2 began to fall and CNA A assisted her to the floor in a seated position. LVN B said when he entered Resident #2's room, the resident was sitting on the floor with one of her arms holding onto the bed rail. LVN B said CNA A did not ask him for help during transfer. He said he did a full assessment of Resident #2. After Resident #2 denied pain, CNA A and LVN B lifted Resident #2 into her bed. LVN B said he monitored Resident #2 and asked her roommate if anything had changed. LVN B said he notified the family, physician, hospice company and the DON. He said he entered a change in condition in the MAR. He said it was important for the physician, family and the DON to be aware of what was going on with residents . Interview with the DON on 03/06/24 at 02:07 PM, revealed the DON was aware Resident #2 had a fall on 01/19/24. She said the hospice nurse came to assess Resident #2 on 01/20/24 and the resident denied pain. The DON said on 01/21/24 when physical therapy assessed Resident #2 and moved her left leg, was when Resident #2 screamed in pain. She said the hospice physician ordered x-rays and after results showed a femur fracture, Resident #2 was sent to the hospital. An interview on 03/28/2024 at 12:47 PM with the DON revealed Resident #2 was care planned as a one-person transfer prior to the incident on 01/19/2024, and he believed she was care planned appropriately. He said he thought the care plan was adjusted after that, and he was not aware of the resident ever falling prior to that incident. He said if the MDS said two-person assistance, there would need to be two people there for the transfer. The DOR said therapy was not working with Resident #2 on transfers, but they were working on more positioning-based issues, like seated balance. An interview on 03/28/2024 at 1:29 PM with MDS revealed she was the person who coded Resident #2's MDS assessment. She said in the seven-day lookback period, if a CNA happened to chart a resident was a limited two-person transfer three times, she had to code it that way in the MDS. She said she could have changed the care plan to say Resident #2 needed one to two staff assist for transfers, but the problem with that was transferring someone three times in a seven-day period did not mean the person always needed to be transferred by two people. If they care planned a two-person transfer, then two staff would have to go transfer that resident all the time, even if the resident did not need two people. She said sometimes a resident needed more assistance early in the morning, or in the evening when they were sleepy, but not any other time, and that was the case with Resident #2. Resident #2 was normally a one-person transfer. She said because she did not transfer the resident herself, she went by the documentation the staff entered. She said one MDS where a CNA happened to use limited two-person transfer three times was not enough of a change to have an IDT meeting . The IDT meetings were where they would normally discuss a change in someone's functional needs and make changes to the care plans . An interview on 03/28/2024 at 2:04 PM with the ADON revealed Resident #2 was a one-person gait belt the majority of the time, but required the assistance of two people if she was sleepy, in the morning, or at night. She said the resident was not cognitively able to tell staff if she needed more help, so the staff had to judge for themselves. (Progress notes from 01/19/24 indicated CNA A transferred Resident #2 at night by herself ). An interview on 03/28/2024 at 4:50 PM with the Administrator, DON and RNC revealed when informed of the Past Non-Compliance Immediate Jeopardy, the RNC stated she did not agree that it was an IJ. She said the facility and hospice documentation reflected Resident #2 was a one-person transfer, and that was safe and appropriate for her. The DON stated the staff were all aware they had residents who had changing conditions throughout the day. The DON said the staff based whether a one-to-two-person transfer was done by one or two by considering what the resident needed at the time, and the skill and strength of the CNA doing the transfer. She said her male CNAs or larger, stronger female CNAs, for example, might be able to do a one-person transfer when it might not be recommended for a smaller female CNA. The RNC stated the facility initiated an ad hoc QAPI and were auditing each chart to make sure all transfer status for residents were correct. She stated the MDS should have changed the care plan to one-to-two assist, instead of one-person, when she coded the MDS that way, but the resident was safe to be a one-to-two person assist, and the RAI manual supported this. The Administrator stated they started in-servicing staff after Resident #2's fall, and in-serviced all of the staff in the building, and the ADON went to the building on all shifts, and made sure every nurse and CNA was in-serviced and signed competencies before they worked a shift. Interview on 03/28/24 at 6:20 PM with CNA A revealed when she transferred Resident #1 on 01/19/24, the resident was unable to stand and hold herself up. CNA A stated she yelled for help and LVN B was in the hallway but not close to the room. While CNA A was waiting for LVN B, CNA A let the resident down to the ground. She stated it was not a fall and the use of the gait belt was to let Resident #1 down slowly. LVN B came in to assess. CNA A stated Resident #1 was a one-person transfer. She stated no one told her Resident #1 required two people to transfer. CNA A stated Resident #1 did not have a Hoyer lift sling or anything in the room. She stated Resident #1 was in a reclining chair and not a regular wheelchair. CNA A stated she was trained on transfers and had not worked with Resident #1 before until that day (01/19/24 ), and everyone had received training after that. Interviews on 03/28/2024 between 8:00 AM and 6:30 PM with CNA A, LVN A, ADON, LVN J, CNA K, CNA L, RA M, LVN N, and CNA O , staff who covered all shifts, revealed they received additional training on transfers after Resident #2's fall, which included how to know how a resident needed to be transferred, what to do if a resident appeared to need more assistance than usual or the information they received about the transfer did not seem correct, and included competency demonstrations for all types of transfer. All staff interviewed stated therapy staff were accessible at any time if they had any questions or concerns concerning a resident's transfer. All staff interviewed stated they were always able to get assistance when needed for resident transfers. Review of the hospice IDT assessment, Combined Disciplinary Comprehensive Assessment, dated 01/23/24, reflected, .mobility score: 3 on scale of 10 .ambulation: Mainly sit/lie; Uses device; Two person assist . Review of the facility's In-service Training Report .Falls, revised 06/2020, reflected nursing staff were in-serviced on falls involving procedures to proper transfers such as checking the care plan, body mechanics, transfer techniques and different transfer types. Review of the facility's In-service Training Report .Transfers, dated 01/22/24, reflected nursing staff were in-serviced on transfers involving fall management, resident assessment, care plan, universal fall precautions, documentation, and quality assurance. Review of the facility's transfer competency checklist, dated 01/22/24, reflected staff were tested for transfer competency in: Demonstrating how to correctly perform a pivot transfer with a resident Demonstrating how to correctly perform a pivot disk transfer with a resident Demonstrating how to correctly utilize a gait belt during transfer Demonstrating how to correctly utilize a slide board during transfer Demonstrating how to correctly use a mechanical lift during transfer Demonstrating knowledge of proper body mechanics for safe transfers Review of a list of residents who required two-person assistance with transfers, provided by the Administrator on 03/28/2024, reflected seven current residents . Observations on 03/28/24 between 8:00 AM and 6:30 PM of transfers included a two-person gait belt transfer, and a mechanical lift transfer, by CNAs . Both transfers were done correctly. Review of Employee files for CNA A reflected she was provided Abuse and neglect policy and reporting requirements upon hire on 04/13/23. Review of Employee file for LVN B reflected he was provided Abuse and neglect policy and reporting requirements upon hire on 03/07/23. Review of the facility's Transfer, revised 06/2020, reflected, ( .)check the care plan( .) The noncompliance was identified as PNC. The IJ began on 01/19/24 and ended on 01/22/24. The facility had corrected the noncompliance before the survey began .

42971 Based on interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of 6 residents reviewed for neglect. The facility failed to provide necessary x-ray services in a timely manner and failed to follow up to get results in a timely manner for Resident #1. The facility failed to provide education and training for nursing staff on how to carry out carry out physician orders for x-rays and follow up on the results in a timely manner. The facility failed to follow their policies for laboratory, diagnostic and radiology services and physician orders. Resident #1 fell on [DATE] at 2:00 PM and sustained an injury, the order for an x-ray was obtained on 9/28/2023 at 5pm. The x-ray was completed on 9/29/2023 at 1:15 PM (20 hours delay). The facility was notified of results at 8:00 PM on 9/29/2023. Thirty hours after the fall with fracture, the resident was sent to the hospital for treatment. Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/02/2023 at 5:00 PM. While the IJ was removed on 10/05/2023 at 4:15 PM, the facility remained out of compliance at actual harm with a scope identified as isolated. This failure resulted in delayed diagnosis, medical treatment, and hospitalization . Findings include: Record review of Resident #1's Quarterly MDS assessment, dated 08/13/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness, lack of coordination, unsteadiness on feet, generalized osteoarthritis, and history of falling. He had a BIMS score of 10 indicated his cognition was moderately impaired. Resident #1 required extensive assistance of one-person for physical assistance with bed mobility, dressing, and toilet use. Review of Resident #1's Comprehensive Care Plan, dated 04/23/23, reflected the following: Focus: Resident is at high risk for falls related to gait/balance problems due to Parkinson's with falls recorded on 2/14/23, 8/17/23, and 9/28/23 resulting in skin tear and intertrochanteric fracture of right hip. Record review of nurses note dated 9/28/23 completed by LVN A at 2:31 PM reflected Resident #1 was found laying on the floor, on his right side, in his room. Resident #1 complained of pain to his right leg. Record review of nurses note dated 9/28/23 completed by LVN B at 5:14 PM reflected the hospice nurse and LVN B assessed Resident #1. PCP gave an order to obtain x-ray to right shoulder, right hip, and right leg. Record review of physician order for Resident #1, dated 9/28/20223 at 5:09 PM, stated to obtain x-ray to right shoulder, right hip, and right leg due to fall and complaint of pain. Review of the record revealed Resident # 1 had pain and received pain medication routinely every 4 hours and he received break through pain medication as needed on 9/28/23 at 2:05 PM and on 9/29/23 at 9:35 AM. Record review of client coordination note report dated 9/28/23 completed by hospice nurse reflected the hospice nurse called LVN B to notify him to call in the x-ray and to call hospice with the results of the x-ray. Record review of nurses note dated 9/29/23 completed by LVN A at 11:06 AM reflected LVN A called the x-ray company to place a STAT x-ray to right shoulder, right hip, and right leg. Record review of radiology results report dated 9/29/23 reflected an x-ray was done to Resident #1's right hip, right leg, and right shoulder on 9/29/23 at 1:15 PM. The x-ray company sent the report to the facility on [DATE] at 2:01 PM. The radiology results report reflected Resident #1 had facture to the right hip. Record review of a nurses note dated 9/29/2023 completed by LVN B reflected Resident #1 was sent to the emergency room at 8:20 PM. Record review of hospital records dated 10/05/2023 reflected Resident #1 was admitted to the emergency room (ER) on 9/29/23 at 8:50 PM. Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. In an interview on 10/01/2023 at 2:23 PM, LVN A stated Resident #1 had a fall on 09/28/2023 at 2:00 PM. LVN A stated she assessed Resident #1; he complained of pain to the right leg. She medicated resident for pain. LVN A stated on 9/29/2023 around 11:00 AM, the ADON told her to follow up if the x-ray was done. She checked Resident#1's records; the x-ray was not done. She called the x-ray company for a STAT x-ray. The x-ray technician came on 09/29/23 at 1:15 PM. In an interview on 10/03/2023 at 1:22 PM, MA E stated on 9/28/2023 around 2:30 PM, her and LVN A assisted Resident #1 to change his pants. MA E stated she observed swollen area at the right hip of Resident #1. In an interview on 10/01/2023 at 3:02 PM, LVN B stated he was aware of an order received from Resident #1's PCP for x-ray to right shoulder, right hip, and right leg due to fall and complain of pain. LVN B stated since the hospice nurse was in the building, he assumed the Hospice Nurse would follow up and carry out the x-ray order. In an interview on 10/01/2023 at 5:01 PM, the Hospice Nurse stated on 09/28/2023 around 5:00 PM she assessed Resident #1 after the fall, he complained of pain to the right hip and right leg. She received an order for x-ray to right shoulder, right hip and right leg. Hospice nurse stated she gave the order to LVN B to call the x-ray company. In a follow up interview on 10/03/23 at 12:32 PM, the Hospice Nurse stated she contacted LVN B on 09/28/2023 around 7:00 PM, she told him to call in the x-ray and to inform hospice about the findings. In an interview on 10/01/2023 at 3:45 PM, RN C stated on 09/28/2023, on the change of the shift, LVN B reported to her that Resident #1 had a fall, and an order for x-ray was received. She stated she did not follow-up with the x-ray order. In an interview on 10/02/2023 at 2:00 PM, the Hospice Physician stated he expected the facility to get the x-ray ordered as soon as possible. He stated waiting 20 hours was too long. In an interview on 10/01/2023 at 3:50 PM, the ADON stated on 09/29/2023 around 9:00 AM, in the morning meeting, she learned Resident #1 had a fall on 09/28/2023. The ADON stated she told LVN A to follow up with the x-ray order. The ADON stated she did not know when the x-ray was done, and she did not know when the results of the x-ray were received by the facility. The ADON stated the nurses were responsible to follow up with the x-ray orders and the x-ray results. In an interview on 10/01/2023 at 3:59 PM, the DON stated on the afternoon of 09/28/2023, LVN A notified her about the fall. The DON stated she expected the LVN to follow up the x-ray order and to follow up to get the results in a timely manner. The DON stated she had been working in the facility for about a month and she was still in training. In a follow up interview on 10/02/2023 at 3:16 PM, the DON stated LVN A called in the STAT x-ray on 10/29/2023. The DON stated no documentation showing that the x-ray was called in to the x-ray company on 10/28/2023. The DON stated delay in x-ray would potentially prolong pain and would delay the implementation of appropriate interventions. The DON stated the nurses were responsible for implementing the order of x-ray for Resident #1. In a phone interview on 10/03/23 at 12:19 PM, Resident #1's RP stated a nurse notified her, on 09/28/2023 that Resident #1 had a fall. The RP stated on 09/29/2023, in the morning, she asked LVN A about the x-ray. LVN A told the RP that she ordered the x-ray. The RP stated on 09/29/2023, Resident #1's other family member was in the facility around 7:30 PM, and she insisted Resident #1 go to the hospital or she would call 911. The RP stated Resident #1 was sent to the hospital on 09/29/2023, in the evening and he had a hip surgery on 09/30/2023. In an interview on 10/03/2023 at 4:30 PM, The x-ray company representative stated the x-ray's final reported for Resident#1 was sent to the facility on [DATE] at 2:04 PM via fax to the facility. In an interview on 10/03/2023 at 5:00 PM, the Regional Director of Operations and Nurse Consultant I stated the phone number provided by the x-ray company was an electronic fax where the critical labs and x-ray results were sent to the facility. The Regional Director of Operations and Nurse Consultant I stated they could not find when the x-ray result was sent on 9/29/2023 to the facility for Resident #1. In an interview on 10/02/23 at 4:48 PM, the Corporate Administrator stated he expected nursing management to follow up to ensure x-ray services were provided to residents. Record review of the facility policy titled Laboratory, Diagnostic and Radiology Services, revised June 2020 reflected . II. The facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider . Record review of the facility's policy, Physician Orders revised June 2020, revealed . IV. Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order . Review of facility's policy Abuse Prevention and Prohibition Program last revised October 2022 reflected Each resident has the right to be free from .neglect This policy statement also includes .deprivation by any individual, including caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. The Administrator is responsible for coordinating and implementing the facility's abuse prevention polices, procedures, training programs, and systems . The Corporate Administrator was notified on 10/02/2023 at 5:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 10/04/2023 at 3:54 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Identify residents who could be affected. All residents have the potential to be affected. Identify responsible staff/ what action taken. 1. Abuse Coordinator (Corporate Administrator) reeducated on abuse/neglect by Regional Nurse Consultant on 10/2/23. New Administrator/ Abuse Coordinator educated on abuse/ neglect by Director Clinical Education on 10/3/2023. 2. Director of Nurses and ADON re-educated by the Regional Clinical Nurse on the facility fall evaluation and prevention policy. X-ray ordering and follow up. Education on laboratory, diagnostic and radiology services and educated on carrying out physician orders immediately no greater than 30mins of receiving order from physician on all patients including hospice patients Completed 10/1/23. Reeducated on abuse/neglect by Regional Nurse Consultant on 10/2/23. 3. All licensed nurses Registered Nurses and Licensed Vocational Nurses educated on carrying out orders for x-rays and Education on laboratory, diagnostic and radiology services on all patients immediately no greater than 30mins of receiving order from physician including hospice patients by Director of Nursing initiated on 10/1/2023 with completion date of 10/2/23. 4. All licensed nurses and LVN were re-educated on abuse/neglect by Director of Nursing initiated 10/2/23 with a completion date of 10/3/23. 5. Training for all licensed nurses RN and LVN's, follow up on x-ray results in a timely manner initiated on 10/1/2023 by the Director of Nursing. with the completion date of 10/2/23. 6. Licensed Nurses RN and LVN's in serviced by the DON on the facility policy and procedure regarding facility fall prevention policy, assessment, and notify the physician regarding change of condition. Training was initiated on 10/1/2023 with the completion date of 10/2/23. 7. Licensed Nurses RN and LVN's educated on carrying out orders on hospice patients immediately no greater than 30mins of receiving order from physician. Initiated by Director of Nursing on 10/1/2023. with the completion date of 10/2/23. 8. Director of Nursing, Assistant Director of Nursing and Weekend supervisor educated on procedure to pull report on New X-rays ordered and Falls. Completed on 10/2/23 by Regional Nurse Consultant. 9. An audit on all patients receiving x-ray in last 7 days to assure follow up completed, initiated on 10/1/2023 and completed by the Regional Nurse Consultant with no adverse findings. 10. Self-Report on Neglect made to Health and Human Services on 10/3/2023 by the Administrator. Abuse and Neglect Inservice initiated by the Regional Nurse Consultant on 10/3/2023 with a completion date of 10/4/2023. Abuse and Neglect investigation in process. Resident Safe Survey completed by the director of social services on 10/3/2023 with no negative outcome noted. 11. The licensed Nurse that didn't follow up with the X-ray was suspended on 10/1/2023 and termination of employment effective 10/3/2023. 12. New Licensed Nursing Home Administrator- Abuse Coordinator started at the facility on 10/2/2023. 13. Training and Education on Abuse and Neglect started by the Regional Nurse Consultant on 10/3/2023. In-Service conducted. 1. Abuse Coordinator reeducated on abuse/neglect by Regional Nurse Consultant on 10/2/23. The New Abuse Coordinator was reeducated on abuse/ neglect by the Director of Clinical Education on 10/3/2023. 2. Director of Nurses and ADON re-educated by the Regional Clinical Nurse on facility fall evaluation and prevention policy. X-ray ordering and follow up and. Education on laboratory, diagnostic and radiology services, and educated on carrying out physician orders on all patients including hospice patients completed 10/1/23. Re-educated on abuse/neglect policy by Regional nurse consultant on 10/2/23. 3. Director of Nursing, Assistant Director of Nursing and Weekend supervisor educated on procedure to pull report on New X-rays ordered and Falls. Completed on 10/2/23 by Regional Nurse Consultant. 4. All licensed nurses RN and LVN educated on carrying out orders for x-rays and. Education on laboratory, diagnostic and radiology services on all patients including hospice patients by Director of Nursing initiated on 10/1/2023 with completion date of 10/2/23. 5. Training for all licensed nurses RN and LVN's, follow up on x-ray results in a timely manner initiated on 10/1/2023 by the Director of Nursing with completion date of 10/2/23. 6. Licensed Nurses RN and LVN's in serviced by the DON on the facility policy and procedure regarding facility fall prevention policy, assessment, and notify the physician regarding change of condition. Training was initiated on 10/1/2023 with a completion date of 10/2/23. 7. Licensed Nurses RN and LVN's educated on carrying out orders on hospice patients immediately no greater than 30mins of receiving order from physician. Initiated by Director of Nursing on 10/1/2023 with completion date of 10/2/23. 8. All licensed nurses and LVN were re-educated on abuse/neglect by Director of Nursing initiated 10/2/23 with a completion date of 10/3/23. 9. An audit on all patients including hospice patients receiving x-ray in last 7 days to assure follow up initiated and completed on 10/1/2023 by the Regional Nurse Consultant with no adverse findings. 10. Staff Training and Education on Abuse and Neglect Policy and Process initiated by the Regional Nurse Consultant on 10/3/2023 with completion date of 10/4/2023. Any staff member that doesn't go through the training will not be allowed to work in the facility. All new hires will be trained in Abuse and Neglect policy and Process. 11. The licensed Nurse that didn't follow up with the X-ray was suspended on 10/1/2023 and termination of employment effective 10/3/2023. Implementation of Changes Abuse Coordinator reeducated on abuse/neglect by Regional Nurse Consultant on 10/2/23. New Administrator and Abuse Coordinator reeducated on abuse/neglect by the Director of Clinical Education on 10/3/2023. Director of Nurses re-educated by the Regional Clinical Nurse on facility fall prevention and evaluation, X-ray ordering and follow up Education on laboratory, diagnostic and radiology services. and educated on carrying out physician orders on all patients including hospice patients. Abuse and Neglect policy. Completed 10/2/23. Director of Nursing, Assistant Director of Nursing and Weekend supervisor educated on procedure to pull report on New X-rays ordered and Falls. Completed on 10/2/23 by Regional Nurse Consultant. Licensed nurse's RN's and LVN's re-educated on abuse/neglect policy by Director of Nursing. Initiated on 10/2/23 with completion date of 10/3/23. Licensed staff RN, LVN will review daily Monday through Friday with IDT (Therapy, Nurse managers, social worker, administrator.) all falls, and any patient receiving an X-ray. Weekend Supervisor RN to review all falls and X rays on weekends. The Director of Nursing, Assistant Director of Nursing or designee will run a daily report to identify any resident with fall or new order for X-ray. The changes were started by the Regional Nurse Consultant. The changes were implemented effective on 10/1/2023 and training was completed on 10/2/2023. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on fall policy, ordering x-rays and follow-up results, Education on laboratory, diagnostic and radiology services prior to working the floor. The Director of Nursing will ensure competency through signing of in service, verbalization of understanding and completion of returned questionnaire. Director of Nursing will complete audit of falls, x-rays with results daily x 30 days then weekly thereafter. The X-ray company contacted by facility leadership Director of Nursing/Administrator, beginning 10/2/23 all adverse/negative Xray results will be texted to both DON/Administrator phones for notification. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will be responsible for monitoring the implementation and effectiveness of in-service on 10/1/2023. The Abuse Coordinator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review all falls, new Xray orders and follow up results daily x4 weeks, then weekly thereafter and report any adverse finding during QAPI. Director of Nursing/Assistant Director of Nursing will conduct a daily audit of falls, Xray and result follow up x4 weeks, then weekly thereafter and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 10/2/2023 and conducted an Ad HOC QAPI regarding the facility allegedly failing to provide services, facility failed to provide necessary x-ray services in a timely manner for a hospice resident, who sustained an injury/pain with fall. The facility failed to follow up to get results in a timely manner. The facility failed to follow their policy for x-rays with residents who sustain an injury/pain with fall. The Medical Director was notified about the immediate Jeopardy on 10/2/2023, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 10/2/2023. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 10/2/2023. The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 10/02/23 reflected nursing and nursing administration (ADON, Weekend RN Supervisor and DON) was in-serviced on pulling x-ray and fall reports for residents, nursing documentation, change of condition notification, pain management, physician orders, fall evaluation/prevention and laboratory, diagnostic and radiology services and abuse/neglect policy. On 10/04/2023 between 4:41 PM and 5:54 PM and on 10/05/2023 between 10:13 AM and 12:31 PM eight (8) licensed vocational nurses and 2 registered nurses including Weekend RN Supervisor, were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of hospice residents orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. They were all knowledgeable of abuse/neglect policy on reporting, neglect definition including a delay in treatment and to report any allegations immediately. In an interview on 10/05/23 at 10:14 AM, RN C stated she received in-service training regarding obtaining x-ray orders including hospice residents facility responsible for ensuring x-ray ordered obtained and followed up in a timely manner. She stated a delay in obtaining and getting results of an x-ray was neglect. RN C stated she would contact physician, DON, and Administrator if a delay in resident x-ray order being completed or getting results. She was knowledgeable of abuse/neglect policy, definition of neglect and reporting requirements for abuse/neglect. In an interview on 10/05/23 at 11:25 AM, LVN A stated she received in-service training regarding x-ray orders to be obtained from physician and contact x-ray company for STAT x-ray for a resident who had unwitnessed fall and complained of pain requiring pain medication. She stated if there was a delay in obtaining x-ray or getting x-ray results for residents she would contact physician, DON and Administrator of the delay. She stated a delay in obtaining and following up on x-ray results was neglect and must be reported immediately to Administrator Review of the clinical record for Resident #7 who had a fall and x-ray ordered revealed x-ray ordered on 10/01/23 with no issues of lack timeliness of x-ray result for Resident #7. X-ray result revealed negative for fracture. Review of clinical record revealed appropriate notifications to RP, physician and DON. Review of LVN B's employee file revealed facility terminated employee as of 10/03/23. In an interview on 10/05/23 at 12:15 PM the ADON stated as of yesterday (10/04/23) she will be the Interim DON for the facility. She stated x-ray company had been contacted and will be alerting her, Administrator and Nurse Consultant of critical x-ray results so they will be able to follow-up to ensure charge nurses follow up on x-ray results for residents. She stated each morning she will review the log on new labs or x-ray resident orders and check to ensure x-rays were obtained in a timely manner. She stated she expected nurses to contact her and keep her apprised of residents status with x-ray orders and results. ADON stated she expected all nurses to notify her and the Administrator of abuse/neglect allegations immediately. She was knowledgeable of neglect definition of failure to provide services for a resident. She was knowledgeable of facility's abuse/neglect policy and reporting guidelines. In an interview on 10/05/2023 at 1:25 PM, the Administrator stated she was the abuse coordinator for the facility and any allegations of abuse/neglect must be reported to the state. She was knowledgeable of definition of neglect of failure to provide goods or services for a resident. She stated she just started on Monday as the new Administrator. She stated she expected all staff to report any allegations of abuse/neglect to her immediately. She stated she was responsible for reporting neglect to the state within 2 hours, initiate investigation, and must send in the provider investigation report within 5 days. On 10/05/2023 at 4:15 PM, the Regional Director of Operations and the Administrator were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering acuity of the facility residents for 4 ( LVN A, LVN B, LVN C, and ADON) of 6 nurses reviewed for competency, in that : The facility failed to ensure: - LVN B carried out an x-ray for Resident #1. - RN C followed up with the x-ray order for Resident #1. - LVN A followed up with the x-ray order in timely manner and to get results for Resident #1. - ADON monitored that the nurses followed up with the x-ray order and received the x-ray results in timely manner for Resident #1 Resident #1 fell on [DATE] at 2:00 PM and sustained an injury, the order for an x-ray was obtained on 9/28/2023 at 5pm. The x-ray was completed on 9/29/2023 at 1:15 PM (20 hours delay). The facility was notified of results at 8:00 PM on 9/29/2023. Thirty hours after the fall with fracture, the resident was sent to the hospital for treatment. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/02/2023 at 5:00 PM. While the IJ was removed on 10/05/2023 at 4:15 PM, the facility remained out of compliance at actual harm with a scope identified as isolated. These failures resulted in delayed diagnosis, medical treatment, and hospitalization . Findings include: Record review of Resident #1's Quarterly MDS assessment, dated 08/13/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness, lack of coordination, unsteadiness on feet, generalized osteoarthritis, and history of falling. He had a BIMS score of 10 indicated his cognition was moderately impaired. Resident #1 required extensive assistance of one-person for physical assistance with bed mobility, dressing, and toilet use. Review of Resident #1's Comprehensive Care Plan, dated 04/23/23, reflected the following: Focus: Resident is at high risk for falls related to gait/balance problems due to Parkinson's with falls recorded on 2/14/23, 8/17/23, and 9/28/23 resulting in skin tear and intertrochanteric fracture of right hip. Record review of nurses note dated 9/28/23 completed by LVN A at 2:31 PM reflected Resident #1 was found laying on the floor, on his right side, in his room. Resident #1 complained of pain to his right leg. Record review of nurses note dated 9/28/23 completed by LVN B at 5:14 PM reflected the hospice nurse and LVN B assessed Resident #1. PCP gave an order to obtain x-ray to right shoulder, right hip, and right leg. Record review of physician order for Resident #1, dated 9/28/20223 at 5:09 PM, stated to obtain x-ray to right shoulder, right hip, and right leg due to fall and complaint of pain. Record review of client coordination note report dated 9/28/23 completed by hospice nurse reflected the hospice nurse called LVN B to notify him to call in the x-ray and to call hospice with the results of the x-ray. Record review of nurses note dated 9/29/23 completed by LVN A at 11:06 AM reflected LVN A called the x-ray company to place a STAT x-ray to right shoulder, right hip, and right leg. Record review of radiology results report dated 9/29/23 reflected an x-ray was done to Resident #1's right hip, right leg, and right shoulder on 9/29/23 at 1:15 PM. The x-ray company sent the report to the facility on [DATE] at 2:01 PM. The radiology results report reflected Resident #1 had facture to the right hip. Record review of a nurses note dated 9/29/2023 completed by LVN B reflected Resident #1 was sent to the emergency room at 8:20 PM. Record review of hospital records dated 10/05/2023 reflected Resident #1 was admitted to the emergency room (ER) on 9/29/23 at 8:50 PM. Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. In an interview on 10/01/2023 at 2:23 PM, LVN A stated Resident #1 had a fall on 09/28/2023 at 2:00 PM. LVN A stated she assessed Resident #1; he complained of pain to the right leg. She medicated resident for pain. LVN A stated on 9/29/2023 around 11:00 AM, the ADON told her to follow up if the x-ray was done. She checked Resident#1's records; the x-ray was not done. She called the x-ray company for a STAT x-ray. The x-ray technician came on 09/29/23 at 1:15 PM. In an interview on 10/03/2023 at 1:22 PM, MA E stated on 9/28/2023 around 2:30 PM, her and LVN A assisted Resident #1 to change his pants. MA E stated she observed swollen area at the right hip of Resident #1. In an interview on 10/01/2023 at 3:02 PM, LVN B stated he was aware of an order received from Resident #1's PCP for x-ray to right shoulder, right hip, and right leg due to fall and complain of pain. LVN B stated since the hospice nurse was in the building, he assumed the Hospice Nurse would follow up and carry out the x-ray order. In an interview on 10/01/2023 at 5:01 PM, the Hospice Nurse stated on 09/28/2023 around 5:00 PM she assessed Resident #1 after the fall, he complained of pain to the right hip and right leg. She received an order for x-ray to right shoulder, right hip and right leg. Hospice nurse stated she gave the order to LVN B to call the x-ray company. In a follow up interview on 10/03/23 at 12:32 PM, the Hospice Nurse stated she contacted LVN B on 09/28/2023 around 7:00 PM, she told him to call in the x-ray and to inform hospice about the findings. In an interview on 10/01/2023 at 3:45 PM, RN C stated on 09/28/2023, on the change of the shift, LVN B reported to her that Resident #1 had a fall, and an order for x-ray was received. She stated she did not follow-up with the x-ray order. In an interview on 10/02/2023 at 2:00 PM, the Hospice Physician stated he expected the facility to get the x-ray ordered as soon as possible. He stated waiting 20 hours was too long. In an interview on 10/01/2023 at 3:50 PM, the ADON stated on 09/29/2023 around 9:00 AM, in the morning meeting, she learned Resident #1 had a fall on 09/28/2023. The ADON stated she told LVN A to follow up with the x-ray order. The ADON stated she did not know when the x-ray was done, and she did not know when the results of the x-ray were received by the facility. The ADON stated the nurses were responsible to follow up with the x-ray orders and the x-ray results. In an interview on 10/01/2023 at 3:59 PM, the DON stated on the afternoon of 09/28/2023, LVN A notified her about the fall. The DON stated she expected the LVN to follow up the x-ray order and to follow up to get the results in a timely manner. The DON stated she had been working in the facility for about a month and she was still in training. In a follow up interview on 10/02/2023 at 3:16 PM, the DON stated LVN A called in the STAT x-ray on 10/29/2023. The DON stated no documentation showing that the x-ray was called in to the x-ray company on 10/28/2023. The DON stated delay in x-ray would potentially prolong pain and would delay the implementation of appropriate interventions. The DON stated the nurses were responsible for implementing the order of x-ray for Resident #1. In a phone interview on 10/03/23 at 12:19 PM, Resident #1's RP stated a nurse notified her, on 09/28/2023 that Resident #1 had a fall. The RP stated on 09/29/2023, in the morning, she asked LVN A about the x-ray. LVN A told the RP that she ordered the x-ray. The RP stated on 09/29/2023, Resident #1's other family member was in the facility around 7:30 PM, and she insisted Resident #1 go to the hospital or she would call 911. The RP stated Resident #1 was sent to the hospital on 09/29/2023, in the evening and he had a hip surgery on 09/30/2023. In an interview on 10/03/2023 at 4:30 PM, The x-ray company representative stated the x-ray's final reported for Resident#1 was sent to the facility on [DATE] at 2:04 PM via fax to the facility. In an interview on 10/03/2023 at 5:00 PM, the Regional Director of Operations and Nurse Consultant I stated the phone number provided by the x-ray company was an electronic fax where the critical labs and x-ray results were sent to the facility. The Regional Director of Operations and Nurse Consultant I stated they could not find when the x-ray result was sent on 9/29/2023 to the facility for Resident #1. In an interview on 10/02/23 at 4:48 PM, the Corporate Administrator stated he expected nursing management to follow up to ensure x-ray services were provided to residents. Record review of the facility's policy titled Laboratory, Diagnostic and Radiology Services, revised 06/2020 reflected . II. The facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider . The Corporate Administrator was notified on 10/02/2023 at 5:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 10/04/2023 at 3:54 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Plan to remove immediate jeopardy. The resident is no longer in the facility and is now at the hospital. LVN B was terminated on 10/03/2023. On 10/01/2023 LVN A and RN C were educated on carrying out orders for x-rays immediately no greater than 30mins of receiving order from physician and Education on laboratory, diagnostic and radiology services on all patients including hospice residents. LVN A and RN C were also trained on carrying out physician orders on all residents including hospice patients. On 10/02/2023 ADON was educated on procedure on how to generate a report on new x-ray orders, falls and to notify the physician of any adverse findings no greater than 30min after receiving results. 10/01/2023 the nurse consultant conducted an audit on all residents receiving x-ray in last 7 days to ensure follow up were completed. No concern has been identified at this time. 10/01/2023 to 10/02/2023 the DON educated all licensed nurses RNs and LVNs on carrying out orders for x-rays immediately no greater than 30mins of receiving order from physician and Education on laboratory, diagnostic and radiology services on all residents including hospice residents. RNs and LVNs were also educated if STAT x-ray was not received within 2hours of x-ray completion, the licensed nurse should call the x-ray company for the reason of delay. The licensed nurse will notify the physician and DON immediately of the delay and seek further guidance. On 10/02/2023 x-ray company was contacted by the DON and the Administrator, beginning 10/2/23 all adverse and negative x-ray results will be texted to both DON, ADON, and Administrator phones, and an alert of x-rays added in the EMAR system. The Director of Nursing, Assistant Director of Nursing or designee will run a daily report to identify any resident with fall or new order for X-ray and immediately report any adverse findings to physician. 10/01/2023 a QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal. The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 10/02/23 reflected nursing and nursing administration (ADON, Weekend RN Supervisor and DON) was in-serviced on pulling x-ray and fall reports for residents, nursing documentation, change of condition notification, pain management, physician orders, fall evaluation/prevention and laboratory, diagnostic and radiology services and abuse/neglect policy. On 10/04/2023 between 4:41 PM and 5:54 PM and on 10/05/2023 between 10:13 AM and 12:31 PM eight (8) licensed vocational nurses and 2 registered nurses including Weekend RN Supervisor, were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of hospice residents orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. In an interview on 10/05/23 at 10:14 AM, RN C stated she received in-service training regarding obtaining x-ray orders including hospice residents facility responsible for ensuring x-ray ordered obtained and followed up in a timely manner. She stated when she received order for x-ray for a resident who had complaints of pain after an unwitnessed fall she would ask physician if STAT x-ray can be ordered. RN C stated she would contact x-ray company by phone for STAT x-ray and it should be completed within 4 hours. She stated after x-ray obtained by x-ray company, she would follow-up within 2 hours if x-ray results not received. She stated she would contact physician and DON if have any issues with x-ray order not being completed or not receiving x-ray results. In an interview on 10/05/23 at 11:25 AM, LVN A stated she received in-service training regarding x-ray orders to be obtained from physician and contact x-ray company for STAT x-ray for a resident who had unwitnessed fall and complained of pain requiring pain medication. She stated STAT x-ray orders were to be completed within 4 hours of contacting x-ray company and should follow up with x-ray company within 2 hours after x-ray technician came out to facility if not received results of x-ray. She stated if there was a delay in obtaining x-ray or getting x-ray results, she would contact physician and the DON for guidance. Review of the clinical record for Resident #7 who had a fall and x-ray ordered revealed x-ray ordered on 10/01/23 with no issues of lack timeliness of x-ray result for Resident #7. X-ray result revealed negative for fracture. Review of clinical record revealed appropriate notifications to RP, physician and DON. Review of LVN B's employee file revealed facility terminated employee as of 10/03/23. In an interview on 10/05/23 at 12:15 PM the ADON stated as of yesterday (10/04/23) she would be the Interim DON for the facility. She stated x-ray company had been contacted and will be alerting her, Administrator and Nurse Consultant of critical x-ray results so they will be able to follow-up to ensure charge nurses follow up on x-ray results for residents. She stated each morning she will review the log on new labs or x-ray resident orders and check to ensure x-rays were obtained in a timely manner. She stated she expected nurses to contact her and keep her apprised of residents' status with x-ray orders and results. In an interview on 10/05/2023 at 1:25 PM, the Administrator stated herself, ADON, and nurse consultant would get critical labs and x-ray results from the x-ray company along with nurses. She stated they would get alerts on their phones. On 10/05/2023 at 4:15 PM, the Regional Director of Operations and the Administrator were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 1 (Resident #1) of 6 residents reviewed for radiology services. 1. The facility failed to ensure that an x-ray was completed in a timely manner for Resident #1 2. The facility failed to follow up to get Resident #1's x-ray results in a timely manner. Resident #1 had an unwitnessed fall on 9/28/23 at 2pm and sustained an injury, The order for an x-ray was obtained on 9/28/23 at 5pm. The x-ray was completed on 9/29/23 at 1:15pm (20 hours delay). The facility was aware of results on 9/29/23 at 8:00 PM. Resident #1 had a fracture to the right hip. Thirty hours after the fall with fracture, the resident was sent to the hospital for treatment. Hospital Records indicated Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/02/2023 at 10:38 AM. While the IJ was removed on 10/05/2023 at 4:15 PM, the facility remained out of compliance at actual harm with a scope identified as isolated. These failures resulted in delayed diagnosis, medical treatment, and hospitalization . Findings included: Record review of Resident #1's Quarterly MDS assessment, dated 08/13/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness, lack of coordination, unsteadiness on feet, generalized osteoarthritis, and history of falling. He had a BIMS score of 10 indicated his cognition was moderately impaired. Resident #1 required extensive assistance of one-person for physical assistance with bed mobility, dressing, and toilet use. Review of Resident #1's Comprehensive Care Plan, dated 04/23/23, reflected the following: Focus: Resident is at high risk for falls related to gait/balance problems due to Parkinson's with falls recorded on 2/14/23, 8/17/23, and 9/28/23 resulting in skin tear and intertrochanteric fracture of right hip. Record review of nurses note dated 9/28/23 completed by LVN A at 2:31 PM reflected Resident #1 was found laying on the floor, on his right side, in his room. Resident #1 complained of pain to his right leg. Record review of nurses note dated 9/28/23 completed by LVN B at 5:14 PM reflected the hospice nurse and LVN B assessed Resident #1. PCP gave an order to obtain x-ray to right shoulder, right hip, and right leg. Record review of physician order for Resident #1, dated 9/28/20223 at 5:09 PM, stated to obtain x-ray to right shoulder, right hip, and right leg due to fall and complaint of pain. Record review of client coordination note report dated 9/28/23 completed by hospice nurse reflected the hospice nurse called LVN B to notify him to call in the x-ray and to call hospice with the results of the x-ray. Record review of nurses note dated 9/29/23 completed by LVN A at 11:06 AM reflected LVN A called the x-ray company to place a STAT x-ray to right shoulder, right hip, and right leg. Record review of radiology results report dated 9/29/23 reflected an x-ray was done to Resident #1's right hip, right leg, and right shoulder on 9/29/23 at 1:15 PM. The x-ray company sent the report to the facility on [DATE] at 2:01 PM. The radiology results report reflected Resident #1 had facture to the right hip. Record review of a nurses note dated 9/29/2023 completed by LVN B reflected Resident #1 was sent to the emergency room at 8:20 PM. Record review of hospital records dated 10/05/2023 reflected Resident #1 was admitted to the emergency room (ER) on 9/29/23 at 8:50 PM. Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. In an interview on 10/01/2023 at 2:23 PM, LVN A stated Resident #1 had a fall on 09/28/2023 at 2:00 PM. LVN A stated she assessed Resident #1; he complained of pain to the right leg. She medicated resident for pain. LVN A stated on 9/29/2023 around 11:00 AM, the ADON told her to follow up if the x-ray was done. She checked Resident#1's records; the x-ray was not done. She called the x-ray company for a STAT x-ray. The x-ray technician came on 09/29/23 at 1:15 PM. In an interview on 10/03/2023 at 1:22 PM, MA E stated on 9/28/2023 around 2:30 PM, her and LVN A assisted Resident #1 to change his pants. MA E stated she observed swollen area at the right hip of Resident #1. In an interview on 10/01/2023 at 3:02 PM, LVN B stated he was aware of an order received from Resident #1's PCP for x-ray to right shoulder, right hip, and right leg due to fall and complain of pain. LVN B stated since the hospice nurse was in the building, he assumed the Hospice Nurse would follow up and carry out the x-ray order. In an interview on 10/01/2023 at 5:01 PM, the Hospice Nurse stated on 09/28/2023 around 5:00 PM she assessed Resident #1 after the fall, he complained of pain to the right hip and right leg. She received an order for x-ray to right shoulder, right hip and right leg. Hospice nurse stated she gave the order to LVN B to call the x-ray company. In a follow up interview on 10/03/23 at 12:32 PM, the Hospice Nurse stated she contacted LVN B on 09/28/2023 around 7:00 PM, she told him to call in the x-ray and to inform hospice about the findings. In an interview on 10/01/2023 at 3:45 PM, RN C stated on 09/28/2023, on the change of the shift, LVN B reported to her that Resident #1 had a fall, and an order for x-ray was received. She stated she did not follow-up with the x-ray order. In an interview on 10/02/2023 at 2:00 PM, the Hospice Physician stated he expected the facility to get the x-ray ordered as soon as possible. He stated waiting 20 hours was too long. In an interview on 10/01/2023 at 3:50 PM, the ADON stated on 09/29/2023 around 9:00 AM, in the morning meeting, she learned Resident #1 had a fall on 09/28/2023. The ADON stated she told LVN A to follow up with the x-ray order. The ADON stated she did not know when the x-ray was done, and she did not know when the results of the x-ray were received by the facility. The ADON stated the nurses were responsible to follow up with the x-ray orders and the x-ray results. In an interview on 10/01/2023 at 3:59 PM, the DON stated on the afternoon of 09/28/2023, LVN A notified her about the fall. The DON stated she expected the LVN to follow up the x-ray order and to follow up to get the results in a timely manner. The DON stated she had been working in the facility for about a month and she was still in training. In a follow up interview on 10/02/2023 at 3:16 PM, the DON stated LVN A called in the STAT x-ray on 10/29/2023. The DON stated no documentation showing that the x-ray was called in to the x-ray company on 10/28/2023. The DON stated delay in x-ray would potentially prolong pain and would delay the implementation of appropriate interventions. The DON stated the nurses were responsible for implementing the order of x-ray for Resident #1. In a phone interview on 10/03/23 at 12:19 PM, Resident #1's RP stated a nurse notified her, on 09/28/2023 that Resident #1 had a fall. The RP stated on 09/29/2023, in the morning, she asked LVN A about the x-ray. LVN A told the RP that she ordered the x-ray. The RP stated on 09/29/2023, Resident #1's other family member was in the facility around 7:30 PM, and she insisted Resident #1 go to the hospital or she would call 911. The RP stated Resident #1 was sent to the hospital on 09/29/2023, in the evening and he had a hip surgery on 09/30/2023. In an interview on 10/03/2023 at 4:30 PM, The x-ray company representative stated the x-ray's final reported for Resident#1 was sent to the facility on [DATE] at 2:04 PM via fax to the facility. In an interview on 10/03/2023 at 5:00 PM, the Regional Director of Operations and Nurse Consultant I stated the phone number provided by the x-ray company was an electronic fax where the critical labs and x-ray results were sent to the facility. The Regional Director of Operations and Nurse Consultant I stated they could not find when the x-ray result was sent on 9/29/2023 to the facility for Resident #1. In an interview on 10/02/23 at 4:48 PM, the Corporate Administrator stated he expected nursing management to follow up to ensure x-ray services were provided to residents. Record review of the facility's policy titled Laboratory, Diagnostic and Radiology Services, revised June 2020 reflected . II. The facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider . An Immediate Jeopardy was identified on 10/02/23. The corporate administrator was notified on 10/02/2023 at 10:38 AM of the Immediate Jeopardy. IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 10/04/2023 at 3:54 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Plan to remove immediate jeopardy. The resident is no longer in the facility and is now at the hospital. LVN B was terminated on 10/03/2023. [Facility's name] submits the following Plan of Removal for the alleged failure to provide diagnostic services. By submitting this plan of removal [facility name] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified resident(s)? Resident with alleged deficient practice was discharged to hospital on 9/29/23. How were other residents at risk to be affected by this deficient practice identified? An audit on all patients receiving x-ray in last 7 days to assure follow up completed, initiated on 10/1/2023 and completed by the Nurse Consultant H with no adverse findings. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? On 10/01/2023 Nurse Consultant H re-educated the DON and the ADON on the facility fall evaluation and prevention policy. X-ray ordering and follow up. She educated them on laboratory, diagnostic and radiology services and educated on carrying out physician orders on all residents including hospice residents. On 10/01/2023 and 10/02/2023 the DON educated all licensed nurses RNs and LVNs on carrying out orders for x-rays and educated them also on laboratory, diagnostic and radiology services on all residents including hospice residents. The DON also educated them on follow up on x-ray results in a timely manner and on the facility policy and procedure regarding facility fall prevention policy, assessment, and notify the physician regarding change of condition. On 10/2/23 by Nurse Consultant H educated the DON, ADON, and weekend supervisor on procedure to pull report on new x-rays ordered and falls. The DON and the Administrator contacted the x-ray company, beginning 10/2/23 all adverse and negative x-ray results will be texted to both DON's and Administrator's phones for notification. LVN B was suspended on 10/1/2023 and termination of employment effective 10/3/2023. How will the system be monitored to ensure compliance? The Administrator, DON, ADON, and Nurse Consultant H will be responsible for monitoring the implementation and effectiveness of in-service on 10/1/2023. The DON, ADON, and Nurse Consultant H will monitor and review all falls, new x-ray orders and follow up results daily for 4 weeks, then weekly thereafter and report any adverse finding during QAPI. The DON and ADON will conduct a daily audit of falls, x-ray and result follow up for 4 weeks, then weekly thereafter and report any adverse findings during QAPI. Quality Assurance A QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 10/1/2023. The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 10/02/23 reflected nursing and nursing administration (ADON, Weekend RN Supervisor and DON) was in-serviced on pulling x-ray and fall reports for residents, nursing documentation, change of condition notification, pain management, physician orders, fall evaluation/prevention and laboratory, diagnostic and radiology services and abuse/neglect policy. On 10/04/2023 between 4:41 PM and 5:54 PM and on 10/05/2023 between 10:13 AM and 12:31 PM eight (8) licensed vocational nurses and 2 registered nurses including Weekend RN Supervisor, were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of hospice residents' orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. In an interview on 10/05/23 at 10:14 AM, RN C stated she received in-service training regarding obtaining x-ray orders including hospice residents facility responsible for ensuring x-ray ordered obtained and followed up in a timely manner. She stated when she received order for x-ray for a resident who had complaints of pain after an unwitnessed fall she would ask physician if STAT x-ray can be ordered. RN C stated she would contact x-ray company by phone for STAT x-ray and it should be completed within 4 hours. She stated after x-ray obtained by x-ray company she would follow-up within 2 hours if x-ray results not received. She stated she would contact physician and DON if have any issues with x-ray order not being completed or not receiving x-ray results. In an interview on 10/05/23 at 11:25 AM, LVN A stated she received in-service training regarding x-ray orders to be obtained from physician and contact x-ray company for STAT x-ray for a resident who had unwitnessed fall and complained of pain requiring pain medication. She stated STAT x-ray orders were to be completed within 4 hours of contacting x-ray company and should follow up with x-ray company within 2 hours after x-ray technician came out to facility if not received results of x-ray. She stated if there was a delay in obtaining x-ray or getting x-ray results she would contact physician and the DON for guidance. Review of the clinical record for Resident #7 who had a fall and x-ray ordered revealed x-ray ordered on 10/02/23 with no issues of lack timeliness of x-ray result for Resident #7. X-ray result revealed negative for fracture. Review of clinical record revealed appropriate notifications to RP, physician and DON. Review of LVN B's employee file revealed facility terminated employee as of 10/03/23. In an interview on 10/05/23 at 12:15 PM the ADON stated as of yesterday (10/04/23) she will be the Interim DON for the facility. She stated x-ray company had been contacted and will be alerting her, Administrator and Nurse Consultant of critical x-ray results so they will be able to follow-up to ensure charge nurses follow up on x-ray results for residents. She stated each morning she will review the log on new labs or x-ray resident orders and check to ensure x-rays were obtained in a timely manner. She stated she expected nurses to contact her and keep her apprised of residents status with x-ray orders and results. In an interview on 10/05/2023 at 1:25 PM, the Administrator stated herself, ADON, and nurse consultant would get critical labs and x-ray results from the x-ray company along with nurses. She stated they would get alerts on their phones. On 10/05/2023 at 4:15 PM, the Regional Director of Operations and the Administrator were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents and elopements for one (Resident #1) of seven residents reviewed for supervision. The facility failed to provide Resident #1 adequate supervision to prevent elopement after he displayed exit seeking behavior and elopement attempts. Resident #1 eloped on [DATE] and was found by the police. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. The administrator was provided the IJ Template on [DATE]. This failure could place residents at risk of elopement, resulting in physical harm, injury, emotional distress, or even death. The findings included: Review of Resident #1's admission record dated [DATE] revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #1 BIMS assessment, dated [DATE], revealed his BIMS was a 6 indicating severe cognitive impairment. Review of Resident #1 Elopement Risk Evaluation, dated [DATE] revealed he scored a 16 indicating he was high risk for elopements. The evaluation also reflected that Resident#1 did not reside on a secured unit. Resident #1 was able to ambulate independently, had verbalized anger and frustration related to placement and his cognitive skills for decision making were moderately impaired. The evaluation also revealed that Resident #1 could not recognize stop lights, did not know precautions when crossing streets, and did not know the location of his current residence. Review of Resident #1's Care Plan, review start date of [DATE], revealed the following: Focus: The resident is an elopement risk/wanderer r/t cognition. Goals: The resident will not leave facility unattended through the review date. Interventions included, assess for fall risk; distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; wander alert bracelet in place. Review of Resident #1 Clinical Record revealed the following note from LVN E on [DATE]: Resident continues to attempt to elope very often. Has asked how to get out of facility multiple times. Ambulates with no difficulty. Resident says he 'wants to go home.' Staff continues to monitor resident. N/c discomfort noted or voiced. In an interview on [DATE] at 10:58 AM with LVN E revealed that on Thursday, [DATE], he was Resident #1's nurse. He stated that on [DATE], Resident #1 was very restless and attempting to elope from the facility. He stated that a CNA found the resident outside in a courtyard at the facility and brought Resident #1 back inside to LVN E. He stated that he noted Resident #1's wanderguard was on him. He stated he asked the CNA if the wanderguard alerted the door and that the CNA had told him that the alarm did not go off since it was not a main door. He stated that he checked the lock on the courtyard fence and it was noted to be locked. He stated he completed an elopement risk evaluation after this incident. LVN E did not state that he reported this elopement attempt to the DON or to the maintenance director. Review of Resident #1 Elopement Risk Evaluation dated [DATE] revealed he scored a 0 indicating he was low risk for elopements. LVN E marked yes for section A, question 2, that asked the following: Resident is on a secured unit?. The evaluation stated, if yes to question A1 or A2, the assessment is complete. In an interview on [DATE] at 10:58 AM, LVN E stated that on the elopement risk evaluation dated [DATE], he notated that Resident #1 was in a secured unit. He stated that the facility had a secured unit, but stated that the unit was no longer in service. He stated that he believed the facility was a secured unit, because it was the most secure place he had worked, with these systems in place which is why he notated Resident #1 was in a secured unit. Review of the facility's list of incidents and accidents for the months of January, February and [DATE] revealed no elopements were documented. There were no elopement incidents for the dates of: [DATE] and [DATE]. Review of Resident #1 clinical record revealed there was no incident or accident related to his incident on [DATE] with LVN E. In an interview on [DATE] at 8:42 AM with the Administrator and DON revealed that on [DATE], around 7:15 PM the charge nurse had noted the Resident #1 was in his doorway. They stated that Resident #1 was found later by an officer at a bowling alley. The Administrator stated he drove the path to the bowling alley and he noted it was an 18-minute walk from the facility. The Administrator stated that the officer noted the wanderguard on the resident's right leg and took him to the hospital. The Administrator stated that the hospital called the facility to tell them they had Resident #1. They stated that the facility did have a secured unit, but due to COVID they had closed the secured unit around mid-December. Administrator stated that Resident #1 did not return to the facility as he needed a secured unit. Review of intake worksheet, revealed that Resident #1 was [DIAGNOSES REDACTED]. Review also revealed that the hospital was calling facilities within vicinity of the hospital to find where Resident #1 was living. In an interview on [DATE] at 10:16 AM with LVN B revealed he was the staff member who answered the telephone call from the hospital on [DATE]. He stated that the hospital had called and stated that they may have had one of the facilities residents. He stated he looked up the resident to confirm he resided at the facility. He stated when he discovered it was Resident #1 he told RN Weekend Supervisor and RN A since RN A was Resident #1's nurse. He stated that then a code pink (indicating a missing resident) was called, he called the NP and did not participate any further. LVN B stated that he could not even point out what Resident #1 looked like. He also stated that the facility did have a secured unit, but it was no longer functioning. He stated to say the facility as a whole was a secured unit, would be false. He stated he did not hear the door alarm alert at any time during his shift. In an interview on [DATE] at 11:06 AM with RN Weekend Supervisor revealed that she was speaking to a resident's family when she was notified that Resident #1 could not be found in the facility. She stated that she was told the hospital had called and informed that Resident #1 had been dropped off at the hospital by EMS. She stated that the facility initiated and completed a code pink and she completed all the required paperwork. She stated the all other residents were accounted for, besides Resident #1 who was in the hospital. She stated that she did not recall hearing the wanderguard alarm ever sound off and that she would have heard the alarm because it is very annoying. She stated that she suspected Resident #1 walked out when the funeral home and a hospice agency where coming and going, because a resident had expired around the same time. She stated she did see Resident #1 earlier in the day, pacing up and down the hallway. In an interview of [DATE] at 12:10 PM with CNA D revealed she was Resident #1's aide on [DATE]. She stated that when she arrived at work, Resident #1 appeared to be okay and acting normal. She stated that he had not voiced anything about wanting to leave the facility. She stated she passed out dinner trays and Resident #1 was observed sitting in his recliner around 5:30 PM. She stated that around 6:00 PM she had picked up Resident #1 dinner tray and asked him if he needed anything before she was to go around and get resident's ready for bed. CNA D stated around 7:30 PM, closer to 8:00 PM, RN A had asked her if she had seen Resident #1 and that was when CNA D told her she had been giving patient care. She stated this was when RN A told her that Resident #1 was not in his room. CNA D stated that she was not amazed Resident #1 was not in his room and stated that Resident #1 enjoyed sitting in the dining room located in the middle of the building. CNA D stated that staff searched for Resident #1 and called a code pink. She stated that Resident #1 never vocalized anything about leaving other than when he was first admitted about a week ago. CNA D stated that Resident #1 had stated he was going home, and she thought he would be at the facility for long term care. In an interview on [DATE] at 1:00 PM, RN A stated that on [DATE] she was Resident #1's nurse. She stated that around dinner time, she observed Resident #1 eating his dinner. She stated this was around 4:30 PM to 5:00 PM. She stated that then around 6:30 PM she had observed Resident #1 standing at his doorway. She stated at this time, she had given Resident #1 a medication for cholesterol and told Resident #1 to go sit in his recliner, so he would not fall. She stated that after this she did not observe Resident #1 the rest of the evening, but she didn't pay attention. She stated that during her last med pass, a nurse had called her and asked if Resident #1 was in his room. RN A stated when she went to Resident #1's room, he was not there. She stated she checked the bathroom and he wasn't there either. She stated that at this moment, the facility called a code pink , since a resident was missing. RN A stated she overheard LVN B speaking to the hospital . She stated that when she heard that Resident #1 was in the hospital, she was amazed because the door alarm did not alert as it was supposed to. RN A stated that she honestly did not know Resident #1 had a wanderguard, and that she does not know which residents have wanderguards and which resident don't. She stated that if Resident #1 had a wanderguard, then the door alarm should have alerted. RN A again , stated that the last time she saw Resident #1 was around 6:30 PM on [DATE]. She stated that around the same time this happened, a funeral home and hospice company was coming in and out and she suspected Resident #1 had left when the resident's remains were being transferred. Review of Resident #1's physician orders revealed the following orders: 1. May have wanderguard due to potential for elopement, no directions specified for order. Active: [DATE] 2. Monitor placement of wanderguard bracelet q shift, every shift for safety. Active [DATE] 15:15 3. Monitor for function of wanderguard QD and prn. No directions specified for order. Active: [DATE] Review of Resident #1 TAR for the month of March (2021) revealed that his wanderguard was not checked once a shift, every shift on the following days and shifts: - [DATE] the evening shift did not check for placement of his wanderguard. Review of Resident #1 TAR for the month of March (2021) revealed that his wanderguard was not monitored for function once a day and PRN for the entire month of [DATE]. Review of the TAR indicated that X's were on all days from [DATE] through [DATE]. Review of the facility's Missing Patient Locator Form dated [DATE] completed by RN Weekend Supervisor for Resident #1 reflected the following: 2. The staff member immediately notified the program director, director of nursing or nurse supervisor of the possibility that a patient is missing .If an alarm has sounded an immediate face-to-face head count of all patients in the center is conducted .Comments: No alarm, can't be done . 3. the search coordinator organizes a thorough simultaneous search of both the interior and immediate exterior area of the center Comments: hospital called to state they have patient. In an interview on [DATE] at 11:31 AM with Resident #1 responsible party (RP) revealed that she received a call from the facility at 8:39 PM on [DATE]. She stated that the staff member had asked her if she had a few moments to speak and told her that Resident #1 had escaped from the building. She stated she had asked RN Weekend Supervisor how it could have happened, and that RN Weekend Supervisor told her that there must have been a default in the facility system so the wanderguard did not work. She stated that she had asked if the facility had found Resident #1 and they explained to her that he was in the hospital and that the hospital would not discharge the resident unless she went up there. She stated as she pulled into the hospital parking lot, the hospital called her. She stated that the hospital had told her that Resident #1 was found in a parking lot, picking up trash near a bowling alley. She stated that the hospital had told her that bowling alley where he was found was over a mile away from the nursing facility. She stated that the hospital had told her the nursing facility stated they had given Resident #1 medication at 7:30 PM but Resident #1 was picked up by law enforcement around 7:45 PM. Resident #1's RP stated that the nursing facility had told her, that Resident #1 had been missing for about ,[DATE] minutes. She stated when she arrived at the hospital, Resident #1 was wearing a black wind coat, jeans and house shoes. She stated that she walked the paths that Resident #1 potentially walked to get to the bowling alley and that one of them required him to cross a ravine, and another path required him to cross a busy roadway then walk near a highway. She stated that she is glad that Resident #1 did not fall in general and not in the ravine. She stated while at the hospital with Resident #1 she had asked him how he had gotten out of the building, and he stated that he knew it was a 3-button code to get out. She stated she was confused how Resident #1 knew the code to exit the building. Resident #1 RP stated that when she admitted Resident #1, she was told it was a locked facility and it was the facility's fault that Resident #1 eloped. She stated that she had noted the wanderguard on Resident #1's ankle earlier in the day when she went to visit him around 10:00 AM. She stated she asked Resident #1 about the wanderguard and he had explained to her that they put it on him the day he was admitted and that it was to help them know where he is in case he ever goes missing. Review of google maps accessed on [DATE], revealed the bowling alley that Resident #1 was found at, following his elopement was 0.8 miles to 1.0 miles walking distance, which was an 18 to 21-minute walk depending on the route taken. Route A required Resident #1 to walk 0.4 miles down a busy roadway with 4 lanes of traffic (2 going east and 2 going west), then crossing an intersection where the 4-lane than expands to 5 lanes going east and 3 going west. This roadway meets with the off ramp of a major highway and the on ramp for the same highway. Route B required Resident #1 to walk down a two-lane road (one lane going North and one lane going South) for 0.6 miles, then another two-lane road for 0.3 miles then down the access road of a highway for 0.1 miles. Review of facility's PIR related to Resident#1's elopement dated [DATE] revealed staff reported Resident #1 was missing and that he was located by law enforcement, who later transported Resident #1 to the hospital for evaluation. Provider response revealed that Resident #1 was observed during med pass around 7:00 PM and at 8:15 PM the facility was unable to locate Resident #1 and called a code pink. Resident #1 was wearing a wanderguard at the time of elopement. 8:25 PM the hospital called stating they had a resident with a wanderguard in the ER. Family and physician were notified. Maintenance checked the functioning of all electronic doors and found they were functioning correctly. Review of an in-service titled Elopements: dated [DATE] revealed that 76 of 107 staff attended the in-service. A list of residents' with wanderguards was provided by the facility on [DATE]. This list identified 8 additional residents with wanderguards. - 1 resident lived on the 100 hallway - 2 residents lived on the 200 hallway - 2 residents lived on the 300 hallway - 3 residents lived on the 400 hallway - No residents lived on the 500 hallway, which was the facility's secured unit. During an observation and interview on [DATE] at 2:43 PM with Resident #6 revealed that he was wearing a wanderguard on his left ankle. He stated that he didn't know why he had the wanderguard on. He stated that he just wanted to go home and was able to give the directions to where he lived prior to admission to the facility. He stated that he knew he could walk right out those doors and pointed at the front and back doors of the building, if he wanted to go home. Review of the Logbook Documentation Task Name: Check operation of door monitors and patient wandering system revealed that on [DATE] the back and front door passed the check and on [DATE] the front and back door passed the check. Interview and observation on [DATE] at 9:11 AM with Maintenance Director revealed that brand new wanderguard were put on to each resident on their ankles or wrist, sometimes wheelchairs, upon admission. He stated that staff does check for function of the wanderguard prior to placement on the resident. He then demonstrated how the alarm will alert when the wanderguard gets close to the door sensor. The door sensor alerted when the new wanderguard was placed within 3 feet of the sensor. Maintenance then demonstrated how to check the wanderguard for function with the door sensor and with the box that was that located in the ADON's office. Review of the facility policy titled Electronic Monitoring Device System effective date ,[DATE] reflected: a. Licensed nurse visual checks of the sensor every shift. An area is available for ,[DATE] shift ,[DATE] shift, ,[DATE] shift observations are documented on the T.A.R. b. Licensed nurse will conduct a daily sensor check . The administrator was informed of the immediate jeopardy on [DATE] at 3:42 PM and was provided with the IJ template. A Plan of Removal was also requested at that time. The following Plan of Removal was accepted on [DATE]: Date: [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes On 03.30.2021, an abbreviated survey was initiated at (Facility Name and Address). A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: 1. The Facility failed to adequately supervise and to prevent accidents for one resident. The facility failed to adequately monitor as ordered by the physician for placement of functioning for 1 of 8 residents. Resident is of severely impaired cognition and was found on an access road near a major highway. On [DATE] the resident was found wandering on the side of the road picking up garbage by a local police officer at approximately 7:45pm after eloping from the facility without the knowledge of the staff or administration. The resident was transported to a nearby emergency room for evaluation and treatment. 2. A serious adverse outcome such as being struck by vehicles on the access road or busy freeway where he was found was possible due to his severely impaired cognitive status. The resident was not able to give his name or identify his surroundings when found. 3. The facility also has 7 other resident who were identified as elopement risks in the facility. Of these, 1 additional resident was identified as high risk on [DATE] but did not receive the wander guard until [DATE]. The facility needs to perform an audit of the residents in the facility, correctly assess and identify resident at risk of elopement. The facility needs to correctly assess, supervise and document wander guard placement and function to prevent further instances of elopement. Identify residents who could be affected All Residents that are assessed to be high risk for elopement could be affected. All residents in the facility with Census of 59 on [DATE] were assessed by the Nurse manager and Assistant Director of Nursing. All residents assessed and identified as elopement risk (10 residents) were transferred to the secured unit on [DATE] at 4:15pm by the Director of Staff Development, Director of Maintenance, Discharge Planner and MDS Nurse. The responsible parties for these 10 residents identified as elopement risk were notified and consents obtained to transfer them to the secured unit on [DATE] by the Director of Social Services. Physicians for these 10 residents identified as elopement risk were notified and orders obtained to transfer them to the secured unit on [DATE]by the nurse manager. Identify responsible staff/ what action taken A head count was completed by Director of Nursing and Assistant Director of Nursing for all residents in house and all the residents were accounted for on [DATE]. All doors were checked and were functioning properly on [DATE] by the Director of Maintenance. All residents with wander guards were checked for placement and functioning by the Nurse Manager and Assistant Director of Nursing. All residents assessed and identified as elopement risk (10 residents) were transferred to the secured unit on [DATE] at 4:15pm by the Director of Staff Development, Director of Maintenance, Discharge Planner and MDS Nurse. The responsible parties for these 10 residents were notified and consents obtained to transfer them to the secured unit on [DATE] by the Director of Social Services. Physicians for these 10 residents were notified and orders obtained to transfer them to the secured unit on [DATE] by the nurse manager. In-Service conducted In-service staff on adequately monitoring of residents who have been identified as elopement risk. Assessment for placement of Wander guard every shift and function daily by the Charge Nurse. Residents identified as elopement risk will receive a wander guard and be placed in the secured unit as ordered by physician. In-service was conducted by Senior Vice President of Operations, Director of Nursing and Director of Staff Development started on [DATE]. The in-service was attended by licensed nurses which include Registered Nurse and Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide and Licensed Therapists which include Physical Therapist, Occupational Therapist and Speech therapist, House Keeping, Laundry, Maintenance and Dietary staff. For staff who are unavailable for training on this date, they will not be allowed to return to work until training is completed by the Director of Staff Development. All new employees will not be allowed to work until they have completed the training by the Director of Staff Development. The in-service for the Licensed Nurses, Certified Nursing Assistance and other staff will be completed on 03.31.2021 Implementation of Changes The changes were initiated by the Director of Nursing. The changes will be implemented by the Director of Nursing. The changes will be implemented effective on 03.30.21 and completed on 03.31.21. The Director of Nursing will ensure competency through verbalization of understanding by staff. Monitoring The Director of Nursing/ Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of the changes. This will start on 03.30.2021 The Licensed Nurse on every shift will round on all the residents that are at risk for elopement. The resident would be assessed for placement of Wander guard every shift and functioning every day. Any concerns identified will be addressed immediately with the Director of Nursing/ Assistant Director of Nursing for correction. The Director of Nursing/ Assistant Director of Nursing will audit all new admission and readmission to the facility to ensure that residents identified as elopement risk are correctly assessed, supervised and wander guard placed and functioning to prevent instances of elopement. Any concerns will be addressed immediately by the Director of Nursing who will be overseen by the Administrator. Involvement of Medical Director The Medical Director, (Doctor's Name) was notified about the immediate Jeopardy on 03.30.2021. The Medical Director will be meeting with the Interdisciplinary team on 03.31.2021 to discuss more about the immediate Jeopardy and ways to address the alleged deficient practice. Involvement of QA An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Who is responsible for implementation of process? The Director of Nursing will be responsible for implementation of New Process. The New Process/ system will be completely in place on 03.30.2021. The Director of Nursing will be overseen by the Administrator. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 03.30.2021. Monitoring of the facility plan of removal is as follows: An observation on [DATE] at 4:53 PM revealed that the secured unit, Arcadia, was back open and functioning. 10 residents were observed on this hallway along with the MDS nurse, an aide and another staff member. All residents had their name tags and some of their belongings in private rooms. Interviews with Maintenance Director, MDS Nurse and D/C Planner revealed that on [DATE] they moved all 10 residents to the Arcadia unit. Rooms were already moved in ready, but staff moved the residents and some of their belongings and printed name tags for doors. They also stated that they were in-serviced on how residents must be assessed for elopement risk upon admission, quarterly and as needed; residents who are elopement risk must be given a wanderguard and taken to the secured unit, notification of family and physician. In an interview with LVN F on [DATE] at 10:40 AM revealed she was in-serviced when she arrived at work about the elopement protocols. She stated she was instructed that when a patient is coming on admission from a hospital, home etc. staff must do an assessment for the elopement risk of the resident. She stated that if a resident has a history of eloping, staff would need to interview the family or resident to see if they qualified for elopement. She stated some indicators of exit seeking behavior may be that the resident will say I don't want to be here, I want to get out of here, call my family to get me out, I don't know why I'm here. She stated that the secured unit is for the wanderers. She stated that the wanderguard is for those that are truly going to exit, and they know this is how I get out. She stated that when a resident with a wanderguard on, gets close to an exit door, the door flash and make an alarm sound and you'll know somebody is by the door trying to get out. She stated at that time she did not have any patients with a wanderguard. She stated that resident with wanderguards will have an order to check for placement and staff must say where it is, like left ankle, right ankle, arm what not and that you must function with the box every day and all the documentation goes under the resident TAR. In an interview on [DATE] at 10:40 AM with Housekeeper revealed she was in-serviced when she arrived at work. She said that when somebody (a resident) comes in, they (staff) must monitor them to see if they are a person who likes to wander. She stated that if they do like to wander, then staff must put the ankle guards on. She stated she was also taught to not let anybody follow you out the door and she stated, if we see somebody trying to leave then we are to tell somebody as soon as possible. She stated she knew somebody was a wander because the resident would have the ankle guard on. In an interview on [DATE] at 11:02 AM with CNA G revealed yesterday she had an in-service. She stated the in-service was about the eloping behaviors such as residents will be pushing the door, talking about getting out of here. She stated if the resident is consistently having the behavior she needs to report to her charge nurse. She stated she would know if somebody is a wander because they may be the wearing an ankle bracelet. She stated that the purpose of the wanderguard is if the resident goes through the door, the alarm would go, and staff would hear and would run off to the exit doors. She stated that Arcadia is open as of [DATE], she stated that Arcadia was supposed to open last week. She stated she would check on her residents with a wanderguard several times on her shift. In an interview on [DATE] at 11:14 AM with CNA H revealed she was in-serviced on how a patient is admitted they are to be assessed for elopement risk. She stated if they are an elopement risk, the resident will have a wanderguard placed and are sent to the secured unit. In an interview on [DATE] at 11:21 AM with LVN I revealed that Arcadia was reopened. She stated that it was supposed to have been open since last week. She stated she had an in-service that morning, she stated that she was instructed about elopements; we are to assess at admission, quarterly and as needed. She stated if based on the assessment a resident is an elopement risk, staff should notify family, doctor and get an wanderguard order and place the resident in the arcadia unit. She stated staff is to monitor placement every shift and function daily. She stated that there is a box in the ADON office that they use to monitor function. She was able to recite how to use the wanderguard and the box to ensure function. She stated that she would enter all her information for monitoring and placement into the TAR. In an interview on [DATE] at 11:32 AM with Director of Nutrition revealed he did have an in-service. He stated the in-service was about wanderguards, and elopements. He stated that when a new patient comes in the first thing is staff will assess for elopeability and whether they are elopement risk or not. He stated if the resident is an elopement risk, they are going to check whit he physician, put a wanderguard on and they will go to the secure unit. He stated that each shift, every day must check the wanderguards are functional and to document the findings of the assessment. He stated if the wanderguard is not working, to go straight to the DON or somebody can correct that action and document on the TAR. In an interview on [DATE] at 11:32 AM with LVN J revealed the in-service she attended was about elopement assessments and they are to be done upon admission quarterly and PRN. She stated if a resident is an elopement risk, you are to put a wanderguard on, notify MD, RP and DON and put them on the arcadia unit. She stated for the wanderguard, ensure staff charts where the guard is located and that they work. When asked how she checks the function of the wanderguard, LVN J stated, that's a good question and asked to get back. She stated its important to chart where she saw the wanderguard, because residents are Houdini's, they will slip out one way or other. In an interview on [DATE] at 12:10 PM with CNA K revealed the unit was now opened. She stated the in-service she received that morning was about elopements and how staff are to suppose to let the nurse know if a patient is showing signs of elopement and as soon as they tell the nurse, the nur (TRUNCATED)

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection; maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors; follow accepted national standards; follow a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility; follow standard and transmission-based precautions to prevent spread of infections, including when and how isolation should be used for four (Residents #1, #2, #3, and #4) of six residents observed for influenza and isolation precautions and for two (Residents #5 and Resident #6) of two residents observed for incontinence care. 1. The facility failed to follow facility policy and procedure and the CDC guidelines related to the influenza by failing to: - implement and maintain droplet precautions for: Resident #1 when the resident was diagnosed with [REDACTED].#2 who was tested for possible influenza on 01/16/18, Resident #3 who exhibited signs and symptoms of influenza on 01/13/18 and was diagnosed with [REDACTED].#4 who remained in the same room as Resident #3 from 01/13/18 through 01/17/18 resulting in Resident #4 contracting influenza with a confirmed [DIAGNOSES REDACTED]. - track and trend influenza infections in the facility to prevent the spread of the infection, which placed all residents at risk for development of influenza and influenza-related complications; - manage an influenza outbreak after the facility developed a sudden increase of acute, febrile respiratory illness cases by not [MEDICATION NAME] treating residents with [MEDICATION NAME] ([MEDICAL CONDITION] medication) when they were symptomatic per CDC guidelines. An Immediate Jeopardy was identified on 01/18/18. While the Immediate Jeopardy was removed on 01/20/18, the facility remained out of compliance at a scope of pattern and a severity level of harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures placed the 87 residents residing in the facility at risk for the development of influenza and influenza related complications. 2. CNA V and CNA F failed to perform hand hygiene when providing Residents #5 and #6 with incontinence care. These failures could affect the 8 incontinent residents on Hall 200 that CNA F was responsible for and the 8 incontinent residents on Hall 300 and Hall 400 where CNA V was responsible for by placing them at risk for infection and skin breakdown. Findings included: 1. Resident #1's MDS assessment, dated 01/09/18, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's Lab Report, influenza swab test, dated 01/13/18, revealed he had Influenza Type A. Resident #1's Physician Orders, dated 01/13/18, reflected the resident was ordered to be on droplet precautions and [MEDICATION NAME] for influenza for five days. An additional physician's orders [REDACTED]. Resident #1's Progress Notes, dated 01/18/18 at 1:36 p.m. by LVN A, reflected: Resident administered last dose of [MEDICATION NAME] this AM .Resident is currently on droplet precautions . The CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated (MONTH) (YEAR), reflected the following: III.B.2. Droplet precautions. Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions .Infectious agents for which Droplet Precautions are indicated .include .[MEDICAL CONDITION] .A single patient room is preferred for patients who require Droplet Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). Spatial separation of .3 feet and drawing the curtain between patient beds is especially important for patients in multi-bed rooms with infections transmitted by the droplet route. Healthcare personnel wear a mask (a respirator is not necessary) for close contact with infectious patient; the mask is generally donned upon room entry. Patients on Droplet Precautions who must be transported outside of the room should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette. An observation of Resident #1, who resided on Hall 100, on 01/18/18 at 11:00 a.m. revealed the resident's call light was activated. A clear, plastic container with Personal Protective Equipment (PPE) in it was positioned outside the door to the resident's room. A sign was posted to see the nurse before entering the room. Without donning a gown or face mask, LVN A entered the resident's room. She then applied gloves, emptied the resident's urinal, washed her hands, and stayed in the room for approximately two minutes to speak to the resident. An interview with LVN A on 01/18/18 at 11:05 a.m. revealed she was aware Resident #1 was supposed to be on droplet precautions for an influenza infection, but she thought his isolation might have been discontinued. LVN A walked to the nurses' station to check and then returned to report the droplet precautions had been continued. She stated she should have worn a face mask, gown, and gloves to enter the resident's room and empty the urinal. An interview with the DON on 01/18/18 at 9:45 a.m. revealed there were three or four residents in the facility with influenza, but he did not provide an exact number of residents with [MEDICAL CONDITION] nor which residents. Resident #2's MDS assessment, dated 12/09/17, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2's Nurse Notes, dated 01/14/18, reflected: Resident continues to present with cough during shift. On-call physician notified. New order: Influenza swab test . Resident #2's Physician Orders, dated 01/16/18, reflected the resident was ordered to be on droplet precautions. Resident #2's Nurse Notes, dated 01/16/18, reflected: Per institutional infections control protocol, resident has been placed on Droplet Precaution pending the availability of the result of a diagnostic evaluation initiated on 01/13/18. Presently, resident does not present with any symptoms of active [MEDICAL CONDITION]. She is noted with intermittent wet but nonproductive cough. She denies sneezing and remains afebrile. Will continue to monitor. Assessed vital signs were noted as follows: T (Temperature)-98.7, HR (Heart Rate)-58, RR (Respiratory Rate)-16, and B/P (Blood Pressure) 124/81. Resident #2's Physician Orders, dated 01/18/18, reflected a chest x-ray to rule out pneumonia. Resident #2's Nurse Notes, dated 01/19/18, reflected: Note resident has been ordered Z-Pak (antibiotic) related to chest x-ray indicating [MEDICATION NAME] changes. Resident #2's Nurse Notes, dated 01/20/18, reflected: Continues on Z-Pak orally for upper respiratory infection . The CDC National Center for Immunization and Respiratory Diseases, released the following information last reviewed 10/20/17, at https://www.cdc.gov/flu/consumer/symptoms.htm: Flu Symptoms Influenza (also known as the flu) is a contagious respiratory illness caused by flu viruses. It can cause mild to severe illness, and at times can lead to death. The flu is different from a cold. The flu usually comes on suddenly. People who have the flu often feel some or all of these symptoms: · Fever* or feeling feverish/chills · Cough · Sore throat · Runny or stuffy nose · Muscle or body aches · Headaches · Fatigue (tiredness) · Some people may have vomiting and diarrhea, though this is more common in children than adults. An observation on 01/18/18 at 11:20 a.m. revealed Resident #2 in her wheelchair in the hallway. The resident had a productive cough and was wearing a face mask that covered her mouth and not her nose. Her face was flushed, and she appeared ill. An interview with the resident at this time revealed she was sick and had been coughing, but she did not know if she had influenza. She stated she was going to her room. The resident resided on Hall 300. An observation on 01/18/18 at 11:25 a.m. revealed CNA D entered Resident #2's room and donned only gloves. The resident was in the room. There was not an isolation sign posted and no PPE equipment available outside of the room. CNA D shut the resident's door. An observation and interview on 01/18/18 at 11:27 a.m. revealed the LVN Staffing Coordinator was walking down the hall. When asked if she was aware Resident #2 had orders to be on droplet precautions, the LVN Staffing Coordinator stated she did not know the resident had orders for droplet precautions. She stated she would get the necessary PPE immediately. She left briefly and returned with the PPE equipment and isolation sign. She put on gloves, a mask, and a gown and entered Resident #2's room. She also took in PPE for CNA D. An interview with CNA D on 01/18/18 at 11:30 a.m. revealed she was not aware Resident #2 had orders to be on droplet precautions. An interview with LVN C on 01/18/18 at 11:35 a.m. revealed he had placed Resident #2 on droplet precautions on 01/16/18 due to the resident having signs and symptoms of influenza. He stated she had been tested on [DATE], and they did not have the lab results back yet. LVN C stated the protocol for droplet precautions was for staff to wear a mask when they were in the resident's room, and the resident had to wear a mask if she left the room. LVN C stated a chest x-ray had also been ordered. He stated he did not know why PPE and an isolation sign were not posted outside of her door on 01/16/18. An interview with the DON on 01/18/18 at 12:00 p.m. revealed he was aware Resident #2 was on droplet precautions and wearing a mask, but he did not know she had orders for droplet precautions that was ordered on [DATE]. The DON stated staff were supposed to follow droplet precautions and wear the required PPE when it was ordered, but the facility did not know if Resident #2 even had the flu. Resident #2's Nurse Notes, dated 01/19/18, reflected: .Continue on droplet and contact precautions for flu-like symptoms . Resident #2's Nurse Notes, dated 01/19/18 at 3:55 p.m., reflected: .Per institutional infections control policy in accordance with CDC's influenza guidelines, MD had ordered to start [MEDICATION NAME] . Resident #2's Lab Report, Influenza swab test, collected 01/14/18 and resulted 01/19/18 revealed she did not have influenza. A follow-up interview with LVN C on 01/19/18 at 11:30 a.m. revealed droplet precautions for Resident #2 were discontinued on 01/19/18. However, since receiving an in-service on CDC guidelines, he had gotten orders to start Resident #2 on [MEDICATION NAME], as well as, an antibiotic to treat [MEDICAL CONDITION]. An interview with the Infection Preventionist (IP) on 01/18/18 at 12:15 p.m. revealed he knew there were residents in the facility with influenza and residents on droplet precautions, but he did not know which residents. The IP stated he knew Resident #1 had finished his [MEDICATION NAME] that morning and was asymptomatic, so he had discontinued the droplet precautions. The IP stated he realized residents were supposed to stay on droplet precautions for at least seven days, so he re-ordered the droplet precautions. The IP stated the facility was trying to follow droplet precautions for Resident #2, but he did not know if she had tested positive for influenza. The IP stated he only worked in the Rehabilitation Unit, and the Director of Long Term Care took care of issues in the rest of the building. The IP stated he did not know if the facility had any resident deaths related to influenza. The IP stated his job was to update the infection control log in the computer monthly with all infections and that he followed emails and updates regarding influenza infection control. The IP stated the facility had an infection control policy related to influenza, but he had not completed any in-services with staff related to influenza infection control. He stated he thought the LVN Staffing Coordinator had likely in-serviced staff. The IP stated when a resident was placed on droplet precautions, he was responsible for notifying staff and getting the appropriate PPE for the resident on the rehabilitation hall and the Director of Long Term Care was responsible for notifying staff and getting the appropriate PPE for the resident for the rest of the building. The IP stated staff and therapy had been notified regarding residents with influenza and on droplet precautions. The IP stated he knew it was taking a while to get influenza test swab results, and in the meantime, residents were put in droplet isolation pending the results. Resident #3's MDS assessment, dated 12/23/17, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #3's Nurse Notes, dated 01/13/18, reflected: Resident continues to sleep during shift. Physician called and notified of resident being lethargic .Influenza swab, STAT. Resident #3's Physician Orders, dated 01/16/18, reflected the resident was ordered to be on droplet precautions. Resident #3's Nurse Notes, dated 01/16/18, reflected: Per institutional infections control protocol, the resident has been placed on Droplet Precautions pending availability of the result of a diagnostic evaluation initiated on 01/13/18. Presently, resident does not present with any symptoms of active [MEDICAL CONDITION] . Resident #3's Lab Report, Influenza swab test, collected 01/13/18 and resulted 01/17/18 revealed he had influenza type A. Resident #3's Nurse Notes, dated 01/18/18, reflected: Resident's flu evaluation result has been received with indicating FLU A .MD was notified and new orders given as follows: 1. Start [MEDICATION NAME] .2. Initiate isolation precautions . Resident #3's physician order, dated 01/18/18, reflected he was ordered to start [MEDICATION NAME]. Resident #4's MDS assessment, dated 12/26/17, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #4's Nurse Notes, dated 01/17/18, reflected: As a precautionary measure, (physician) has ordered to have the resident evaluated for the [MEDICAL CONDITION] . Resident #4's Lab Report, Influenza swab test, collected 01/17/18 and resulted 01/18/18 revealed he had influenza type A. Resident #4's Physician Orders, dated 01/18/18, reflected the resident was ordered to be on droplet precautions. His physician order, dated 01/18/18, reflected he was ordered to start [MEDICATION NAME]. Resident #4's Nurse Notes, dated 01/18/18, reflected: Resident's flu evaluation result has been received indicating FLU A was verified .MD was notified and new orders give as follows: 1. Start [MEDICATION NAME] .2. Initiate isolation precautions. Resident does not present with influenza associated symptoms . An interview and observation on 01/18/18 at 12:30 p.m. with the Director of Long Term Care revealed she collected the infection control information for the long term care side of the building and would give the information to the DON. The Director of Long Term Care stated there were five residents in the building with influenza with one additional resident still pending test results. The Director of Long Term Care revealed she had to separate two residents, who were roommates (Residents #3 and #4), on 01/17/18 after Resident #3's influenza swab test results tested positive. She stated currently both residents had influenza. She stated Resident #3 was placed on droplet precautions on 01/16/18 but remained in the room with Resident #4 until 01/17/18. The Director of Long Term Care revealed Resident #3 tested positive of influenza on 01/17/18 and Resident #4 had tested positive for influenza on the morning of 01/18/18. Observation of Hall 200 with the Director of Long Term Care revealed Residents #3 and #4 resided on the hall. Resident #4 was in his room, sitting in his wheelchair, with his door opened. There was no PPE available outside of his door and no sign indicating he was on droplet precautions. Staff were passing out hall lunch trays. Resident #3 was in a private room with PPE outside of his opened door. The Director of Long Term Care stated the plan was to move the residents back in together because they both had influenza. The Director of Long Term Care went to the nurses' station and did not place PPE or a sign outside of Resident #4's room after it was noted that these were not immediately available. An observation and interview on 01/18/18 at 12:45 p.m. with CNA D revealed she did not know Resident #4 had influenza and was on droplet precautions. There was still no isolation sign or PPE outside of Resident #4's door. CNA D stated she was going to tell CNA F because she was working on Hall 200 and did not know the resident had influenza and was ordered to be on droplet precautions either. An observation on 01/18/18 at 1:00 p.m. revealed there was still no isolation sign or PPE outside of Resident #4's door and the Director of Long Term Care was still at the nurse's station. At this time, the Administrator was asked to go to Hall 200 with the investigator. Observation with the Administrator revealed Resident #3 had PPE outside of his door, but Resident #4 still did not. The Administrator stated the DON, IP, and the Director of Long Term Care worked together to ensure they were aware of who had influenza, who was on [MEDICATION NAME], who was on droplet isolation, and ensuring PPE was placed as ordered. The investigator informed the Administrator that neither the DON, IP, nor the Director of Long Term Care knew the information. The Administrator stated there must have been some sort of disconnect or breakdown in communication and he would go talk to them. The Administrator stated the health department had been notified regarding the influenza diagnoses. The Administrator walked to the nurse's station and spoke to the Director of Long Term Care. An interview with CNA F on 01/19/18 at 11:10 a.m. revealed she was assigned to Hall 200 on 01/18/18 and was not aware Resident #4 had been diagnosed with [REDACTED]. She stated she had been to his room to assist him multiple times without PPE, because PPE was not available and she did not know he was on droplet precautions. CNA F stated PPE was not made available for Resident #4 until after 1:00 p.m. on 01/18/18 when Resident #3 was moved back into the room with him. CNA F stated it was the nurse's responsibility to notify her of changes with her residents, but they usually did not. A subsequent interview with LVN C on 01/19/18 at 11:30 a.m. revealed the nurse was supposed to notify staff and place PPE when isolation precautions were ordered. He stated he informed the CNA working on Hall 200 about Resident #4's influenza infection when Resident #3 and Resident #4 were moved back into the same room on 01/18/18 sometime after 1:00 p.m. An interview was conducted on 01/18/18 at 1:30 p.m. with the DON, IP, LVN Staffing Coordinator, and the Director of Long Term Care after they spoke with the Administrator. The interview revealed the LVN Staffing Coordinator was responsible for conducting in-services with staff when a resident was placed on droplet precautions. The LVN Staffing Coordinator stated she thought a computer based in-service for influenza had been completed in (MONTH) (YEAR) or possibly (MONTH) (YEAR), but no other in-services had been completed. The Investigator requested a copy of the in-service that was completed, but it was never received. The DON stated the nurse getting the order for isolation was responsible for placing the PPE. The DON stated the nurse was also responsible for putting the information on the 24 hour report, Kardex, and progress notes so the CNAs would be aware. The DON stated pending influenza test swabs were discussed in a meeting every morning. The DON stated he believed LVN A was not fully aware of Resident #1's continued isolation because she was not the routine nurse for the hall and was filling in for another nurse. The DON, IP, LVN Staffing Coordinator, and the Director of Long Term Care stated they did not know why there was a breakdown in communication for Resident #2. The DON stated the facility was working to correct the situation by having the MDS Coordinator tell staff who was droplet precautions, who had influenza, and putting out PPE for staff use. An interview with the MDS Coordinator on 01/18/18 at 1:55 p.m. revealed she had completed an in-service with the staff on 01/18/18 regarding residents who had influenza, residents on [MEDICATION NAME], and residents on droplet precautions. She stated the facility did not have any influenza-related resident deaths. An interview with the Medical Director on 01/18/18 at 2:25 p.m. revealed he was not aware of any facility issues with influenza and thought there were five residents with the infection in the facility. He stated influenza was deadly and the facility had to take the illness seriously and he was recommending the facility place residents with symptoms on droplet precautions immediately. The Medical Director stated he would contact the IP to ensure he had an accurate count of residents with influenza. An interview with the Medical Director, Administrator, and DON on 01/18/18 at 3:10 p.m. revealed the DON notified the health department about influenza in the facility on 01/02/18 or 01/03/18 and they had recommended the facility keep residents isolated in a private room or cohorted with residents with the same strain of influenza. The DON stated he was also instructed to refer to the CDC website. The DON and Administrator were aware multiple staff were observed wearing face masks outside of resident rooms, but did not know if any of the staff members had influenza, and did not say why they were wearing the masks. The DON stated the influenza vaccine had been offered to all staff and residents and influenza trending and analysis would be completed at the end of (MONTH) (YEAR). The DON also stated he would make sure the outbreak investigation tool had been completed. Review of CDC's Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities retrieved on 01/19/18 at https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm, on 01/19/18, reflected: Surveillance When there is influenza activity in the local community, active daily surveillance (defined below) for influenza illness should be conducted among all new and current residents, staff, and visitors of long-term care facilities, and continued until the end of influenza season. Ill residents, personnel, and visitors should be excluded from the facility until illness has resolved. .Confirmed or suspected influenza outbreak (2 or more ill residents) If there is one laboratory-confirmed influenza positive case along with other cases of respiratory infection in a unit of a long-term care facility, an influenza outbreak might be occurring .influenza testing should occur when any resident has signs and symptoms that could be due to influenza, and especially when two residents or more develop respiratory illness within 72 hours of each other . Once an outbreak has been identified, outbreak prevention, and control measures should be implemented immediately . Implement daily active surveillance for respiratory illness among ill residents, health care personnel and visitors to the facility. · During an outbreak, once a single laboratory-confirmed case of influenza has been identified, it is likely there are other cases among exposed persons. · Conduct daily active surveillance until at least 1 week after the last confirmed influenza case occurred. · Test for influenza in the following: - Ill persons who are in the affected unit as well as previously unaffected units in the facility - Persons who develop acute respiratory illness symptoms more than 72 hours after beginning [MEDICAL CONDITION] - Note that elderly persons and other long-term care residents, including those who are medically fragile and those with neurological or neurocognitive conditions, may manifest atypical signs and symptoms with [MEDICAL CONDITION] infection, and may not have fever. · Ensure that the laboratory performing the tests notifies the facility of tests results promptly. · The local health and state health departments should be notified of every suspected or confirmed influenza outbreak in a long-term care facility, especially if a resident develops influenza while on or after receiving [MEDICAL CONDITION]. Implement Standard and Droplet Precautions for all residents with suspected or confirmed influenza. Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a health care facility. Examples of Droplet Precautions include: · Placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza residents with one another; · Wear a facemask (e.g., surgical or procedure mask) upon entering the resident ' s room. Remove the facemask when leaving the resident ' s room and dispose of the facemask in a waste container. · If resident movement or transport is necessary, have the resident wear a facemask (e.g., surgical or procedure mask), if possible. · Communicate information about patients with suspected, probable, or confirmed influenza to appropriate personnel before transferring them to other departments. These Precautions are part of the overall infection control strategy to protect against influenza in health care settings and should be used along with other infection control measures, such as isolation or cohorting of ill residents, screening employees and visitors for illness, furloughing ill health care personnel, and discouraging ill visitors from entering the facility. .Because residents with influenza may continue to shed [MEDICAL CONDITION] while on [MEDICAL CONDITION] treatment, infection control measures to reduce transmission, including following Standard and Droplet Precautions, should continue while the resident is taking [MEDICAL CONDITION] therapy. This will also reduce transmission of viruses that may have become resistant to [MEDICAL CONDITION] drugs during therapy. All long-term care facility residents who have confirmed or suspected influenza should receive [MEDICAL CONDITION] treatment immediately. Treatment should not wait for laboratory confirmation of influenza. All eligible residents in the entire long-term care facility should receive [MEDICAL CONDITION] as soon as an influenza outbreak is determined .[MEDICAL CONDITION] is recommended for all non-ill residents, regardless of their influenza vaccination status, in long-term care facilities that are experiencing outbreaks . CDC recommends [MEDICAL CONDITION] for a minimum of 2 weeks, and continuing for at least 7 days after the last known case was identified. An email from the Health Department, dated 01/05/18 and provided by the DON on 01/18/18, reflected: .Thank you for calling to report your influenza concerns for your facility. I have included the recommendations list, the health advisory, and line list template that we would like for you to complete and return to us. -Epidemiology Disease Surveillance Coordinator. The ongoing facility Employee Illness Log, dated (MONTH) (YEAR), and received from the DON on 01/18/18 revealed ten staff members had been ill from 01/02/18-01/15/18. 9 of the staff were ill with respiratory symptoms and three staff members had fever. Three staff members did not have dates of recovery from their illness listed. The log did not reflect who had filled it out. Facility list of Residents on [MEDICATION NAME], List of Residents on Droplet Precautions, and List of Residents Confirmed with Flu, requested by the Investigator and provided by the DON, dated 01/18/18, revealed the facility had four residents confirmed with influenza, however Resident #1 was not on the list. The facility had eight residents on droplet precautions, and five residents taking [MEDICATION NAME]. Facility list of Residents on [MEDICATION NAME], List of Residents on Droplet Precautions, and List of Residents Confirmed with Flu, requested by the Investigator and provided by the DON, dated 01/19/18, revealed the facility had two additional residents confirmed with influenza. One of the residents was a new admit, and Resident #1 was added. The facility added four new residents to the droplet precautions list, and added eight new residents to the taking [MEDICATION NAME] list. Facility list of Residents on [MEDICATION NAME], List of Residents on Droplet Precautions, and List of Residents Confirmed with Flu, requested by the Investigator and provided by the DON, dated 01/20/18, revealed the facility had no new residents confirmed with influenza, however Resident #1 was not on the list. The facility added one new resident to the droplet precautions list, and added all residents to the taking [MEDICATION NAME] list. The Outbreak Investigation Tool with Facility Map, provided by the DON on 01/19/18 at 9:15 a.m. reflected: No information regarding staff symptoms or treatment. 12/28/17 to 01/04/18 - six residents developed influenza symptoms and were treated with [MEDICATION NAME]. 01/13/18-01/19/18 - twelve residents developed influenza symptoms and were treated with [MEDICATION NAME]. No residents on Hall 500, the secure unit, were diagnosed with [REDACTED]. An observation on 01/18/18 at 10:45 a.m. revealed three staff members were required, including the LVN Staffing Coordinator, to assist a resident back to the secure unit after the resident had a possible [MEDICAL CONDITION] in the beauty salon of the facility. An interview with the DON on 01/19/18 at 9:15 a.m. revealed the facility had admitted a new resident with influenza to the facility on [DATE] and placed them on droplet precautions. The DON stated he identified two additional residents with influenza symptoms on 01/18/18. The DON stated prior to 01/18/18, residents were not being treated with [MEDICATION NAME] until the influenza test swab was received. The DON stated the facility was going to start treating residents [MEDICATION NAME] when they were symptomatic per CDC guidelines. The facility's current Facility Infection Control Policy, dated (MONTH) 2013, reflected: Transmission Based Precautions: Initiation- A nurse may initiate transmission based precautions when there is reason to believe that a patient may suffer from an infectious or communicable disease. When precautionary measures are initiated, the nurse notifies the patient's attending physician, the legal representative, infection preventionist, and .Employees, patients, families, and visitors are responsible f (TRUNCATED)