Every finding on record at Goldwater Care Princeton

Based on observation, interview, and record review the facility failed to ensure hair nets contained all hair during food preparation; failed to ensure hands were washed and gloves were changed in a manner to prevent cross-contamination; failed to ensure the dishwasher sanitization levels were properly tested and maintained; and failed to ensure dishes were washed in a manner to prevent cross contamination. These failures have the potential to affect all 76 residents residing at the facility.The findings include:1. The CMS 671 dated 7/21/26 showed there were 76 residents residing in the facility.On 7/21/26 at 9:34 AM, V4 (Dietary Manager) was in the kitchen assisting with preparation of the noon meal. V4's had her bangs outside of the hair net. At 10:45 AM, V4 was preparing buns for the noon meal with her bangs out of the hair net. V4 obtained items from the oven and assisted with obtaining temperatures of the foods. V4 made peanut butter and jelly sandwiches, prepared grilled cheese, and assisted with plating of the noon meal. On 7/22/26 at 8:36 AM, V4 was in the kitchen with her bangs out of the hair net. At 10:32 AM, the surveyor returned to the kitchen V4's bangs remained out of the hair net as she continued to assist with noon meal prep. V4's bangs remained out of her hair net throughout the kitchen observations. At 10:41 AM, V9 (Dietary Aide) was preparing beverages for the noon meal in the kitchen. V9's hair net was not covering hair in the back of his head and neck. At 10:51 AM, V4 was interviewed regarding hair nets (V4's bangs were still outside the hair net). V4 said hair nets should be worn any time staff are in the kitchen. The surveyor asked if all hair should be contained in the hair net. V4 reached up and pulled her hair net over her bangs. V4 said all hair should be contained inside the hair net so hair doesn't fall in the food. The facility's Hair Restraints Policy dated 2020 showed hair restraints shall be worn by all dining services staff when in food production areas, dishwashing areas, or when serving food. Hair restraints shall be used to prevent hair from contacting exposed food. 2. On 7/21/26 at 10:45 AM, V4 (Dietary Manager) was wearing gloves, removed hamburger buns from packaging and placed them in a shallow pan. V4 used her gloved hands to open the lid to the trash can and throw away the packaging. V4 did not remove her gloves after touching the garbage can. V4 obtained a new package of buns from the bread rack, removed a bun with her contaminated gloves and placed in in the pan with the other buns. V4 closed the package and returned the packaged buns to the bread shelf. V4 took the temperature of a large pan of pizza. V4 placed the contaminated gloved hands into the potholders and returned the pizza to the oven. V4 left the oven door open, removed the potholders, obtained alcohol swabs, and obtained the temperature of the second pan of pizza cooking in the oven. V4 closed the oven. V4 used the contaminated gloves throughout this observation. On 7/22/26 at 10:51 AM, V4 said if kitchen staff are wearing gloves during food preparation and they touch the garbage can, they should remove the gloves and wash their hands to prevent cross-contamination. They shouldn't touch anything else in the kitchen until they remove their gloves and wash their hands.The facility's Proper Hand Washing and Glove Use Policy dated 2020 showed all employees will use proper handwashing procedures and glove usage in accordance with state and federal guidelines. All employees will wash their hands upon entering the kitchen, after all breaks, and between tasks. Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. 3. On 7/21/26 at 11:37 AM, V7 (Dietary Aide) was rinsing off dirty dishes and loading them into the dishwasher tray. The surveyor asked V7 to test the dishwasher during the next load of dishes. V7 used the thermometer to measure the temperature of the water during the rinse and wash cycles, then walked away. The surveyor asked V7 if he tests the sanitizer in the dishwasher. V7 replied, Oh yeah. V7 obtained a box containing test strips for chlorine (used in the dishwasher) and QAT (sanitizing agent used in the sanitizing buckets and 3 compartment sink). V7 obtained the QAT test strip and dipped it into the water. The test strip did not change color. The surveyor asked if that is the test strip he normally uses and he replied, Yes, it should be 200. The surveyor asked if he was testing chlorine and he pointed to a bucket of chlorine solution with a yellow lid. The surveyor asked V4 (Dietary Manager) what test strips should be used to test the dishwasher. V4 walked over to the container of test strips and obtained the chlorine test strips. V4 said V7 should know to use these test strips. V4 handed V7 the chlorine test strips. V7 dipped the white test strip into the water, and it turned a faint grey color (indicating a reading of 10 ppm (parts per million). The surveyor asked if that was an appropriate result. V7 said, No, it's too low. V7 said the level of chlorine was low and he needed to change the bucket. V7 changed the bucket of chlorine and removed the tray of dishes that were in the dishwasher. V7 placed a dirty tray of dishes into the dishwasher, ran the dishwasher and held the sanitize button, releasing a steady stream of chlorine into the dishwasher. A strong odor of chlorine was noted and the surveyor asked how long he holds the sanitize button. V7 released the button and ran the dishwasher. V7 tested the dishwasher, and the strip was a dark black/purple color (demonstrating 200 ppm of chlorine). At 11:50 PM, the surveyor asked V4 what the chlorine level should be. V4 said the dishwashing machine releases a set amount of chlorine. V7showed V4 the chlorine testing strip with the result of 200 ppm. V4 replied, Oh we're good. They told us if it's 200 we're good. There outside of the machine showed 50 ppm chlorine was required. The facility's Dishwasher monitoring log showed the desired chlorine range was 50 -100 ppm. V7 continued running dishes through the dishwasher. On 7/22/26 at 10:51 AM, V4 (Dietary Manager) said the staff should know how to properly test the dishwasher. They should be using chlorine test strips for this machine. The surveyor asked V4 what the chlorine level should be. V4 replied, I don't know. The machine is supposed to add it properly. The surveyor pointed to the facility's dishwasher log that showed the required ppm was 50-100. V4 replied, Thank you for pointing that out. I'm learning something. V4 said the staff need to know the proper chemicals to ensure we are properly sanitizing the dishes. The facility's Low Temp Dish Machine Log showed the required PPM was 50-100. The facility's Sanitizing Disinfectant Solutions Policy dated 2020 showed employees shall refer to the manufacturer guidelines for the proper use of sanitizer and disinfectant solutions. Bleach (chlorine) solution should be at a concentration of greater than or equal to 50 to 100 ppm. 4. On 7/21/26 at 11:54 AM, V7 (Dietary Aide) was rinsing dirty plate lids and trays and loading the dishwasher trays. V7 was not wearing gloves. V7 moved from the dirty side of the dishwashing area to the clean side to put clean plate lids and trays away. V7 did not wash his hands when moving from dirty dishes to clean dishes. V7 continued this process a minimum of four times. Moving from dirty dishes to putting away clean dishes without washing his hands. On 7/22/26 at 10:51 AM, V4 (Dietary Manager) said if one person is doing dishes, then they should wash their hands when moving from dirty dishes to putting away clean dishes. V4 said they should not move back and forth without washing their hands due to the risk of cross-contamination.The facility did not provide a dishwashing policy.

Failures at this level required more than one deficient practice statement: A. Based on observation, interview, and record review the facility failed to ensure the legionella water management program included a facility assessment, identified control measures, provided acceptable ranges for control measures, and established how to intervene if the control limits are not met. This failure has the potential to affect all 76 residents residing in the facility reviewed for infection control. B. Based on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions (EBP) signage was in place (R6, R10, R43, R60); and failed to ensure staff wore Personal Protective Equipment (PPE) while providing direct care activities (R10, R43 and R75) reviewed for infection control. The findings include: a. 1. The CMS 671 dated 7/21/26 showed there were 76 residents residing in the facility. On 7/22/26 at 2:15 PM, V5 (Maintenance Director) said the facility doesn't specifically test for legionella, but he does test the water temperatures. V5 said he has worked at he facility 41 years. V5 said he received training on legionella, but did not recall any meetings to discuss the facility's water management program. V5 said he did not have a building specific assessment of the plumbing system to determine any potential areas of growth. V5 said he just obtains temperatures of the water. V5 said he did not have any additional legionella water program documents. On 7/22/26 at 2:34 AM, V1 (Administrator) said the facility did not have any further documentation for the Legionella water management program. V1 said she provided what she had. V1 said there was no diagram or flow chart of the building's plumbing system and potential areas of concern had not been identified. V1 said the facility had a meeting a few years back when legionella started being looked at during the survey process, but there had been no recent meetings. V1 said the legionella water management program is important to prevent the risk of exposing residents to legionella. On 7/22/26 at 3:14 PM, V12 (Infection Preventionist) said she doesn't have anything to do with the legionella water management program unless a resident tests positive for legionella. V12 said V1 (Administrator) and V4 (Maintenance Director) manage the program. The facility's Water Management Program for Prevention of Legionella Growth revised 6/27/23 showed the purpose was to identify and reduce the risk of legionella growth and spread. This program does not contain a facility assessment of the building's plumbing and identification of potential areas of concern; identified control measures; provided acceptable ranges for control measures; and established how to intervene if the control limits are not met. b. 1. R6's admission record shows he was admitted to the facility on [DATE] with Parkinson's Disease and type 2 diabetes. The July 2026 order summary report shows an order on 3/29/26 for Enhanced barrier precautions (specify: left lower leg). On 7/21/26 at 10:29 AM, R6 was observed to have PPE hanging on the outside of his door. There was a bin with gowns and gloves outside the doorway. The door had no sign to indicate any isolation or precautions. V14 CNA said she did not know why R6 had the PPE on the door, and said she thought maybe he was on contact isolation but was not sure. V10 (Registered Nurse) said R6 was on enhanced barrier precautions because he sees the wound doctor. She said there should be a sign on the door. The sign is important because staff would need to know before they go into the room. On 7/21/26 between 9:40 AM-11:53 AM, on the dementia unit, there was no signage indicating Enhanced Barrier Precautions, or other precautions were in place for R43, R10, and R60's room. R10 and R60's rooms had personal protective equipment (PPE) hanging on the door, however there were no signs indicating if the residents in those rooms were on precautions. R43's room did not have any PPE supplies or signage on her door. R10's admission Record, provided by the facility on 7/23/26, showed he had diagnoses including, but not limited to Parkinson's disease, dementia, hallucinations and retention of urine. R10's Order Summary Report, provided by the facility on 7/23/26, showed an order dated 2/5/26 for a urinary drainage catheter. The report showed an order that was still active for Enhanced Barrier Precautions related to the urinary catheter dated 3/4/26. The report also showed R10 had orders for wound treatments to his left heel dated 7/10/26 and his right heel dated 6/12/26. R10's care plan initiated on 2/4/26 showed he had impaired cognitive function/dementia or impaired thought process related to dementia diagnosis. R10's care plan initiated 3/4/26 showed the need for enhanced barrier precautions related to the use of the urinary catheter. R10's 5/5/26 facility assessment showed he required substantial/maximum staff assistance for eating, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The assessment showed R10 was dependent on staff for toilet hygiene, bathing, bed mobility and transfers. R43's admission Record, provided by the facility on 7/23/26, showed she had diagnoses including, but not limited to Alzheimer's disease, dementia, restlessness and agitation, and squamous cell carcinoma of skin, other parts of face. R43's Order Summary Report, provided by the facility on 7/23/26 showed an order dated 3/4/26 for Enhanced Barrier Precautions related to cancer lesion on forehead. R43's care plan initiated 9/24/25 showed she had impaired cognitive function or impaired thought processes related to Alzheimer's disease, dementia. R43's care plan initiated 3/4/26 showed the need for enhanced barrier precautions related to presence of chronic wounds-chronic cancerous ulcer. The care plan showed staff should follow enhanced barrier precautions per protocol. R43's facility assessment dated [DATE] showed she had moderately impaired cognition, short-term, long-term memory problems and had an open lesion other than ulcers, rashes, cuts (e.g., cancer lesion). The assessment showed R43 was dependent on staff for bed mobility, transfers, lower body dressing and oral hygiene. Substantial/maximum staff assistance was needed for toilet hygiene, upper body dressing, personal hygiene, and putting on/taking off footwear. R60's admission Record, provided by the facility on 7/23/26, showed she had diagnoses including, but not limited to moderate dementia with other behavioral disturbance, schizoaffective disorder, recurrent major depressive disorder, epilepsy, malignant neoplasm of right breast, severe protein-calorie malnutrition, repeated falls, and psychosis. R60's Order Summary Report, provided by the facility on 7/23/26, showed an order dated 7/5/26 for Enhanced Barrier Precautions due to pressure ulcers. R60's facility assessment dated [DATE] showed she had severe cognitive impairment and was dependent on staff for all care needs. The assessment showed R60 had one or more unhealed pressure ulcers. On 7/21/2026 at 11:14 AM, V17 (Certified Nursing Assistant-CNA) was asked about the PPE on the doors to R10 and R60's rooms and if the CNAs have to wear anything when providing care to the residents in these rooms. V17 said We don't have to wear a gown when providing care for (R10), just gloves. He has open sores on his heels. The nurse takes care of the dressing change. We just have to wear gloves. V17 said the CNAs just have to wear gloves when providing care for R60. Even when providing care. On 7/21/26 at 11:53 AM, V18 (Certified Nursing Assistant-CNA) was asked about the PPE on the door to R10 and R60'a rooms and asked if the CNAs have to wear any of the PPE when providing care to the residents in those rooms. V18 said they just need to wear gloves when providing care for R10 and R60. V18 was asked what staff have to wear when providing care for R43. V18 said the CNAs only have to wear gloves when providing care for R43, no other PPE. 7/21/26 At 1:26 PM, Enhanced Barrier Precaution signs were placed on the doors to R10 and R60's rooms. No EBP signage or PPE supplies were on the door for R43's room at this time. On 7/21/26 at 2:10 PM, V13 (Registered Nurse-RN-agency nurse) and V16 (CNA) did the dressing change for the pressure injuries on R10's bilateral heels. V13 and V16 were only wearing gloves during the entire procedure. V16 was holding R10's legs up so V13 could clean the wounds and apply the treatments and dressings. V16's clothing was touching R10's bedding during the procedure. On 7/21/26 at 2:48 PM, V13 (agency RN) and V11 (agency Licensed Practical Nurse-LPN) performed the dressing change to R43's right forehead cancer wound) V11 got the supplies ready and took into R43's room. Set the supplies on the nightstand on towels, then placed the gloves she had in her hand inside her right pocket, washed her hands and pulled the gloves out of her pocket to do the dressing change. V13 helped hold R43's hands and arms during the procedure due to R43 trying to reach towards the open wound. V11 and V13 only wore gloves during the procedure. Both V11 and V13's clothing touched R43's bedding several times during the procedure. No Enhanced Barrier Precaution signage or PPE supplies were on R43's door. R43's wound started above her right eyebrow and extended over her right eye by her cheek bone. V11 and V13 said the wound was cancer. The wound looked like a raw hamburger patty that was placed over her right eye, right forehead area. At 2:59 PM, V11 was asked if a gown and gloves should be worn during R43's wound care, V11 said she did not think so since R43 did not have an active infection. This surveyor asked if R43 had an open wound that required a dressing change and V11 said yes. On 7/22/2026 at 10:32 AM, V21 (CNA) went into R60's room and pulled the curtain. V21 was replacing R60's pillowcase. R60's pillow and the pillowcase were resting up against V21's uniform while she was changing the pillowcase. V21 lifted R60's head and put the pillow under R60. V21 was not wearing a gown, only gloves. On 7/22/26 at 2:20 PM, V12 (Licensed Practical Nurse-LPN/wound nurse/infection control nurse) said if a resident has a catheter, a feeding tube, a pressure wound, or an open wound that requires dressing, staff should be wearing a gown and gloves when providing direct care for the resident. V12 said it is important to make sure the signage is on the doors so staff know what type of precautions are in place and know what should be worn when providing direct care. V12 said it is important to do this for infection control. to protect the staff, the residents that are on precautions, and other residents. To prevent spreading infection to others. V12 said R43 should be on Enhanced Barrier Precautions because she has an open wound that requires a dressing change. V12 said R10 is on Enhanced Barrier Precautions due to bilat heel wounds and a catheter. V12 said R60 is on Enhanced Barrier Precautions due to Pressure ulcer wounds. V12 said any hands-on-care for residents on EBP precautions requires a gown and gloves. On 7/22/26 at 3:15 PM, V22 (Hospice CNA) was in R43's room, V22 was leaning over R43, letting her know she was going to get her up into her wheelchair. V22 pulled R43's cover back, V22 was touching R43's leg to wake her up and touching R43's bedding. V22 did not have a gown or gloves on. There was still no signage indicating the need for Enhanced Barrier Precautions, or any PPE on R43's door. On 7/23/2026 at 9:35 AM PPE and EBP signage were on the door to R43's room. The facility's Enhanced Barrier Precaution signage that was placed on R10, R43, and R60's doors (after two surveyors on and off the memory care unit questioned staff about having no signage on the doors) showed STOP. Enhanced Barrier Precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use central line, urinary catheter, feeding tube, tracheostomy. Wound Care: Any sin opening requiring a dressing. On 7/23/26 at 9:37 AM, V21 (CNA) said she should have probably wore a gown and gloves when changing R60's pillowcase because she was touching the resident and her pillow. On 7/23/26 at 9:46 AM, V12 (Licensed Practical Nurse-LPN/wound nurse/infection control nurse) said V22 (Hospice CNA) should have been wearing a gown and gloves while touching R43 or her bedding. V12 said the EBP signage is up now. On 7/23/26 at 10:06 AM, V2 (Director of Nursing) said V11 (LPN) should not have used the gloves from her pocket. Clean gloves should have been used. R75's face sheet printed on 7/23/26 showed diagnoses including but not limited to fracture of right femur and routine healing, orthopedic aftercare, and right side hemiplegia. R75's facility assessment dated [DATE] showed no severe cognitive impairment. The same assessment showed substantial staff assistance needed for lower body dressing and footwear on/off. R75's July 2026 physician orders showed an active order for right heel daily dressing changes and prn (as needed). The treatment order stated to wash area to right heel with wound wash and pat dry. Apply alginate calcium with silver to wound bed and cover it with a gauze island. On 7/22/26 at 9:13 AM, an EBP (enhanced barrier precautions) sign was posted on the door of R75's room. The sign showed staff must wear gloves and gowns for high-contact resident care activities. The sign showed they were both needed for wound care or any skin opening requiring a dressing. R75 was seated in an upright chair in the room wearing shoes and socks. R75 stated she has a sore on her heel that the doctor sees weekly. The nurses change the dressing at various times during the day shift. At 9:38 AM, V15 (Certified Nurse Aide) wore gloves to remove R75's right foot shoe and sock. The right heel did not have any dressing on it. V15 confirmed the dressing was missing and left to alert the floor nurse. R75 was unable to say how long the dressing had been missing. At 9:48 AM, V13(Registered Nurse) entered the room wearing gloves. V13 donned gloves but no gown and cleansed the heel. V13 went to the hall treatment cart for more wound supplies. R75 was left seated in the chair, holding her leg up in the air. V13 went down the hall for more wound supplies. R75 was unable to hold her leg up in the air and laid her bare foot on the room floor. At 9:55 AM, V13 returned with the missing wound supplies. V13 donned gloves again, put a calcium alginate pad and island dressing on the heel. Staff did not wear a gown during any part of the wound care. On 7/23/26 at 9:26 AM, V12 (Wound Care Nurse/Infection Control Preventionist) stated R75 is on enhanced barrier precautions because of the heel wound. Staff need to wear gowns and gloves at direct care. It protects the residents and staff from spreading germs in the facility. R75's care plan showed a focus area related to a right heel pressure ulcer. Interventions included administer treatments as ordered and follow the facility protocols for prevention/treatment of skin breakdown. The facility's policy and procedure titled Enhanced Barrier Precautions, with a revision date of 5/7/2024, showed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following.Chronic wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Examples of chronic wounds include, but are not limited to pressure ulcers.Indwelling medical device examples include.urinary catheters.The policy showed for residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities, especially when care is being bundled.dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter.Wound care: any chronic skin opening requiring a dressing.

Based on observation, interview, and record review failed to ensure medications were prepared at the time of administration for 44 residents residing on the front hall and failed to ensure medications were not left at the resident's bedside for two (R31, R56) of 44 residents reviewed for medication administration in the sample of 51. The findings include: 1. On 7/21/26 at 2:15 PM, V11 (Agency Licensed Practical Nurse – LPN) used a key to open a locked compartment inside a locked cupboard in the front hall medication room. There were seven plastic cups filled with stacks of individual medication cups. There was a piece of paper tape over the top of the seven cups. Each medication cup contained various numbers of pills. V11 looked at the pre-prepared medications and stated, Oh, I don't even want to touch them. V11 said the larger cups had 8 PM, written on them. V11 said there was no date. V11 said it looks like the residents' names were written on the medication cups. The surveyor asked if nurses should pre-prepare medications. V11 replied, Never. It's nursing 101. That's not a practice you should ever do. V11 said what if a medication gets changed or discontinued. The wrong dose or medication could be given. The stacks were not moved at this time and V2 (Director of Nursing – DON) was called to the front medication room. On 7/21/26 at 2:21 PM, V2 (DON) came to the front medication room, the surveyor pointed to the stacks of pre-prepared medications and asked if this should happen. V2 had a surprised expression on her face and replied, I would never allow this. Every nurse should know not to do this. The surveyor asked V2 to remove the stacks of medications to review with the surveyor. V2 placed the medications on the counter of the nurses' station. V10 (RN) was at the nurses' station and said she didn't know who had pre-prepared the medications. There were six stacks of medications, inside the larger cup labeled 8 PM and one stack labeled 6 AM. The medication cups were labeled with a resident first name or last name. V2 and V10 used a report sheet to identify the residents, each cup had varying numbers of pills inside. V2 and V10 said the pills appear to be residents residing on the front hall. (The facility roster provided 7/21/26 showed there were 44 residents residing on the front hall). There were two medication cups, in two different 8 PM stacks labeled with R33's first name. V2 and V10 looked at the medications inside the cups and they were not the same medications or number of pills. They said there was no other resident by that first name and didn't know why R33 had two medication cups labeled 8 PM. V2 said this is why you don't do this; it's dangerous. V2 said she was so upset she was shaking. V2 and V10 identified 35 residents with a total of 179 pills contained in the six stacks of pre-prepared medication cups labeled 8 PM. The seventh large cup was labeled 6 AM and there were eleven medication cups stacked inside with no resident name or identifiers. V2 and V10 said there was no way to know who the medications belonged to. V3 (Assistant DON – ADON) came to the nurses' station during this interaction and stated, Who did this? They should know better. On 7/22/26 at 2:25 PM, V2 (DON) said she hadn't figured out what nurse had pre-prepared the medications. V2 said she spoke to the night nurses, and they did not admit to it. V2 said that's not something any nurse should be doing. There are so many ways it can go wrong. The nurses should be preparing the medications immediately before they give them to the residents. The facility's undated Medication Administration General Guidelines showed medications are administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). This policy showed medications are administered at the time they are prepared. They are not pre-poured either in advance of the medication pass or for more than one resident at a time. 2. On 7/21/26 during initial tour of the front hallway, R31 and F56 were found to have medication left on the bedside table. R56 said the nurse had left her medications and she was just getting ready to take them. She could not identify each of the pills. R31 said he did not want the pill that was sitting on his bedside table, the nurse had left it there for him. On 7/21/26 at 10:21 AM, V10 said R56's medication cup had an iron tablet, a multivitamin, Eliquis (blood thinner) Coreg (blood pressure medication), and another pill she would have to check. V10 reviewed R56's medication orders and said the last pill was Lasix (for water retention). V10 said R56 usually takes all her medication, but she should have stayed with her to ensure she took all of the pills. V10 said medications should not be left on the bedside table. V10 said she had not given R31 any medication. When given the pill in the medication cup, she stated it was a Prilosec and must have been left by the night shift nurse. V10 said the medication was scheduled for 6:00 AM and given on the night shift. R56s July 2026 medication administration record shows her 8:00 AM medications to include: Lasix 40 mg, Iron 325 mg, Multivitamin, Coreg 3.125 mg, Eliquis 5 mg. R31s July 2026 medication administration record shows his Prilosec 20 mg was scheduled at 6:00 AM. The record shows the dose for 7/21/26 as given by the nurse. On 7/23/2026 at10:54 AM, V2 stated medications should never be left at the bedside for a resident. The nurse should make sure the resident takes the medication before documenting.

Based on observation, interview, and record review the facility failed to properly store a controlled medication (R28) and failed to properly label insulin pens (R33) for 2 of 2 residents reviewed for medication storage and labeling in the sample of 51. The findings include: 1. On [DATE] at 2:00 PM, V10 (Registered Nurse - RN) was performing controlled medication counts with the surveyor. R28's Lorazepam 1 mg medication card was removed from the narcotic box. The medication card contained multiple blister packs. V10 said there were 13 pills remaining. The blister pack for slot 13 was punctured. When the surveyor turned the medication card over, there was tape over the punctured slot 13. There was an additional piece of tape noted over the slot 16, but there was a cut through it and no pill. The surveyor asked if tape should be placed on a punctured medication card. V10 replied, No. They should not place tape over the back (of the controlled medication package). You don't know what is in there if the package was tampered with. V10 said if the package is damaged or punctured, then the nurse must waste the medication with another nurse to witness. At 2:05 PM, V12 (Licensed Practical Nurse - LPN) was showed R28's Lorazepam card. V12 the nurses know they can't tape a medication back in. V12 said the nurse should waste the medication. V12 attempted to remove the tape to waste the medication and stated, I can't even get the tape off. V12 said there's no way to know if the medication was diverted and replaced with another pill that looks like it. R28's Facesheet dated [DATE] showed he had diagnoses to include, but not limited to chronic kidney failure, chronic obstructive pulmonary disease (COPD), generalized anxiety disorder, major depressive disorder, mesothelioma, and diabetes.R28's Physician Order Summary dated [DATE] showed an order for Lorazepam (controlled anti-anxiety medication) to be administered for anxiety as needed. On [DATE] at 2:55 PM, V2 (Director of Nursing) said controlled medications are delivered from pharmacy in cards. V2 said the nurses should be doing controlled medication counts between shifts. V2 said when the nurses are doing these counts, they should be looking at the front and the back of these medication cards to ensure they haven't been tampered with. V2 said if the blister pack for a pill is punctured, then the medication must be wasted with two nurses. The nurses should not place tape over it. V2 said it's too easy to switch out a pill for drug diversion. The facility's Medication Storage Policy revised [DATE] showed the purpose was to ensure proper storage, labeling, and expiration dates of medications, biologicals, syringes and needles. This policy showed the facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. The facility's Narcotic/Controlled Substances - Counting Policy revised [DATE] showed if medications are on a card, observe the integrity of the card to make certain it has not been tampered with. 2. On [DATE] at 1:26 PM, a front hall medication cart was checked with V10 (RN). R33 had a Lantus insulin pen with the date [DATE] written on the cap of the pen in black marker. R33 had an insulin aspart pen with the date [DATE] written on the cap of the pen in black marker. Both insulin pens had a white pharmacy label with R33's name and Open date, with a blank line after it. Neither label had the date written in the Open date. The dates written on the pen didn't have any other information to determine if it was the open date or the discard date. V10 said insulin pens should be dated with the opened date and the expiration date. V10 said the insulin pens are good for 28 days. V10 said R33's insulin pens were not labeled correctly. V10 said the handwritten date doesn't show if it's the date the pen was opened, or it expired. V10 said it's important to make sure insulin is labeled correctly and discarded after 28 days to maintain its efficiency. V2 said we want to make sure we are administering insulin that is good and working properly. R33's Facesheet dated [DATE] showed diagnoses to include, but not limited to diabetes, morbid obesity, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), obstructive sleep apnea, and peripheral vascular disease. R33's Physician Order Summary dated [DATE] showed he had Flasp Flex Touch Insulin Pen (aspart insulin), give 6 units before meals for diabetes. Lantus pen 40 units twice a day for diabetes. On [DATE] at 2:55 PM, V2 (DON) said insulin pens come with a pharmacy label. The nurse should label each pen with the open date and expiration date. V2 said it is important to label with an open date because insulin is only good for a certain number of days. This ensures that the resident isn't receiving insulin past its expiration date. V2 said the pharmacy label has an open date area on it. The nurse should write the open date on the label. V2 said if the pen just has one date written on it, then there is no way to know what the date means. The pharmacy's Storage of Medications Policy revised 8/2024 showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. This policy showed when a manufacturer has a specified duration after opening, the nurse shall place a date opened sticker on the medication and record the date opened and the new expiration date. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating.

Based on interview and record review the facility failed to follow physician orders for 2 of 2 residents (R8, R62) reviewed for professional standards in the sample of 51.The findings include:1. R8s admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to Type 2 diabetes mellitus with other diabetic ophthalmic complications, hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease, and a dependence on renal (kidney) dialysis. R8s physician order sheet shows a 7/7/26 order for blood sugars ac/hs (before meals and at bedtime) and to notify the physician if less than 90 or greater than 200. The orders show an insulin sliding scale order for 7/6/26 with units to be given for blood sugar results. The order shows if the result is 401-450, 20 units of insulin should be given and to notify the physician.R8s July 2026 Medication Administration Record (MAR) shows blood glucose levels four times a day beginning 7/6/26. The results show 37 results greater than 200, including four results of 400 or greater. R8s nursing progress notes including the eMAR notes, show only one result greater than 200 was reported to the provider. No notifications were documented for 36 of the elevated blood sugars.On 7/23/26 at 10:00 AM, V10 (Licensed Practical Nurse/LPN) said if there are 2 orders, always do the most current. With (R8) if there is an order to call for greater than 200, then the nurses should be doing as the order reads.On 7/23/26 at 10:57 AM, V2 (Director of Nursing/DON) said if the physician's order reads for the results to be called for greater than 200, the nurses should be calling the physician and documenting it in the notes.2. R62s admission record shows she was admitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia (elevated blood sugar).The July 2026 physician order sheet shows an 1/22/26 order for insulin on a sliding scale for blood sugars before meals and at bedtime. The order shows if any result is greater than 401, the nurse is to give 10 units of insulin and call the physician.R62s July 2026 MAR shows her blood sugar results show on 7/11/26, her blood sugar was 414 at 11:00 AM. The progress notes and eMAR notes do not show any notification of the elevated blood glucose reading to the physician as ordered.On 7/23/26 at 10:57 AM, V2 said if that is the order, to call for greater than 400, then it should be followed. V2 said if the blood sugar was that high, even without an order they should be calling the physician.The facility's 11/13/18 policy for physician notifications shows they are to ensure medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner.

Based on observation, interview, and record review the facility failed to ensure leg wraps were applied as ordered (R1) and failed to assess a resident with a change of condition prior to transfer to the hospital (R5) for 2 of 2 residents reviewed for quality of care in the sample of 51. The findings include: 1. R1's face sheet printed on 7/22/26 showed diagnoses including but not limited to respiratory failure, diabetes mellitus with diabetic neuropathy, hypertension, and edema (swelling in legs due to fluid build up.) R1's facility assessment dated [DATE] showed no severe cognitive impairment and substantial staff assistance with lower body dressing. R1's July 2026 physician order summary report showed an order start dated 5/21/26 for: Bilateral knee-high ted hose or ace wrap if teds hose too tight, Every day and night shift. On in am, off at hs (bedtime). R1's July 2026 treatment administration report showed the wraps scheduled for 7 AM on and 7 PM off. On 7/21/26 at 9:39 AM, R1 was lying on the bed, dressed for the day. Her lower legs were visible and were not elevated. There were no leg wraps or compression hose on her legs. R1 said she has leg wraps the staff put on her every day. R1 said it is done in the morning and she did not know why they had not been put on for the day. At 11:48 AM, R1 was seated in the group dining room eating lunch. Her lower legs were visible and were not wrapped. On 7/22/26 at 8:56 AM, R1 was wheeling herself out of the bathroom and both lower legs were not wrapped. R1 said the wraps help with her leg swelling. Staff do it whenever they want. Sometimes it is before lunch and sometimes it is after lunch. At 11:50 AM, R1 was seated in the group dining room eating lunch. Her lower legs were not wrapped. On 7/22/26 at 1:37 PM, V10 (Registered Nurse/RN) stated R1 has bad cellulitis in her lower legs. She needs her legs wrapped to reduce the swelling. She has had sores on her legs in the past so the doctor wants them wrapped. She is good about having it done and does not refuse. V10 said it should be done first thing in the morning, before she gets out of bed. Once she is up and moving the swelling can increase. On 7/22/26 at 1:51 PM, V2 (Director of Nurses/DON) said nurses should be following doctor instructions as ordered. V2 said the leg wraps are important to reduce swelling and help R1 with leg circulation. It should be done in the morning, before she gets out of bed for the day. The facility's undated Anti-Embolism-Elastic Stocking policy states: Apply in morning before swelling occurs and while resident is still in bed. 2. R5s admission record shows he was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease (COPD), diabetes and congestive heart failure. R5 nursing progress note shows on 4/12/26 at 6:24 PM, V13 (RN) documented R5 requested to be sent out to the emergency department due to bilateral lower extremity pain. All parties were notified. The progress notes do not include any assessments to include vital signs, range of motion, level of pain, any swelling or condition of the skin, how he left the facility, and who was all notified. R5s progress notes for 4/12/26 at 11:41 PM show he was admitted to the hospital for COPD exacerbation. He returned to the facility on 4/13/26. R5s progress notes show no assessment upon return. Then on 4/17/26, R5 requested to be sent out again for bilateral leg pain and shortness of breath. The notes show a report called to the emergency department, but no assessment of vital signs, lung sounds, or physical assessment was noted in the record. The notes show he was admitted to the hospital again for pneumonia. On 7/23/26 at 10:00 AM, V12 (Licensed Practical Nurse/LPN) said when a resident has any change of condition and is being sent out to the hospital the notes should reflect what is going on with that resident. The notes should include vital signs and description of the resident. The notes should include all the information sent with the resident. On 7/23/26 at 10:44 AM, V2 said if a resident has any change, there should be a note and assessment including if they have pain, swelling, tingling, any range of motion concerns, and the assessment should be as specific as possible including subjective details. There should be information regarding where they are going, their condition and who specifically was notified. V2 reviewed R5s record and said none of those details were documented and they should be noted. The facility policy for notice of transfer and discharge reads When a facility transfers or discharges a resident under any circumstances, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Based on observation, interview, and record review the facility failed to ensure wound orders were followed (R75) and failed to ensure pressure reducing interventions were in place (R60) for 2 of 5 residents reviewed for pressure ulcers in the sample of 51. The findings include: 1. R75's face sheet printed on 7/23/26 showed diagnoses including but not limited to fracture of right femur and routine healing, orthopedic aftercare, and right side hemiplegia. R75's facility assessment dated [DATE] showed no severe cognitive impairment. The same assessment showed substantial staff assistance needed for lower body dressing and footwear on/off. R75's pressure ulcer risk assessment date 7/20/26 showed at risk for pressure ulcer development. R75's July 2026 physician orders showed an active order for right heel daily dressing changes and prn (as needed). The treatment order stated to wash area to right heel with wound wash and pat dry. Apply alginate calcium with silver to wound bed and cover it with a gauze island. R75's Wound Evaluation and Management Summary report dated 7/17/26 showed a right heel pressure ulcer measuring 0.5 x 0.4 x 0.2 centimeters. The report showed to treat with alginate calcium with silver and cover with gauze island dressing once daily and as needed, if saturated, soiled, or dislodged. On 7/22/26 at 9:13 AM, an EBP (enhanced barrier precautions) sign was posted on the door of R75's room. The sign showed staff must wear gloves and gowns for high-contact resident care activities. The sign showed they were both needed for wound care or any skin opening requiring a dressing. R75 was seated in an upright chair in the room wearing shoes and socks. R75 stated she has a sore on her heel that the doctor sees weekly. The nurses change the dressing at various times during the day shift. At 9:38 AM, V15 (Certified Nurse Aide) wore gloves to remove R75's right foot shoe and sock. The right heel did not have any dressing on it. V15 confirmed the dressing was missing and left to alert the floor nurse. R75 was unable to say how long the dressing had been missing. At 9:48 AM, V13(Registered Nurse) entered the room wearing gloves. V13 said the heel dressing should always be in place to prevent the sore from getting worse. V13 donned gloves but no gown and cleansed the heel. V13 went to the hall treatment cart for more wound supplies. R75 was left seated in the chair, holding her leg up in the air. V13 went down the hall for more wound supplies. R75 was unable to hold her leg up in the air and laid her bare foot on the room floor. At 9:55 AM, V13 returned with the missing wound supplies. V13 donned gloves again, put a calcium alginate pad and island dressing on the heel. V13 did not cleanse the wound again before the treatment. Staff did not wear a gown during any part of the wound care. On 7/23/26 at 9:26 AM, V12 (Wound Care Nurse/Infection Control Preventionist) stated she sees R75 twice a week. She had a stage 4 pressure ulcer on her heel that is almost healed. The dressing should be on the area as ordered to give it protection. If the wound is left open it can get infected or increase in size. Nurses should be cleansing the area to ensure the old dressing is completely off. The wound cleanser also helps as a possible debridement solution to get the old tissue out. Nurses should ensure the area is clean before any calcium alginate is placed. It is a medication and won't serve the purpose if it can't get to the wound correctly. V12 said R75 is on enhanced barrier precautions because of the heel wound. Staff need to wear gowns and gloves at direct care. It protects the residents and staff from spreading germs in the facility. V12 said the aides should be telling a nurse right away if a dressing is missing. It is important for the same reasons already stated. R75's care plan showed a focus area related to a right heel pressure ulcer. Interventions included administer treatments as ordered and follow the facility protocols for prevention/treatment of skin breakdown. The facility's Pressure Injury and Skin Condition Assessment policy revision dated 1/17/18 states: Dressings will be checked daily for placement, cleanliness, and signs and symptoms of infection. 2. R60's admission Record, provided by the facility on 7/23/26, showed she had diagnoses including, but not limited to moderate dementia with other behavioral disturbance, schizoaffective disorder, recurrent major depressive disorder, epilepsy, malignant neoplasm of right breast, severe protein-calorie malnutrition, repeated falls, and psychosis. R60's Order Summary Report, provided by the facility on 7/23/26, showed an order dated 7/5/26 for Enhanced Barrier Precautions due to pressure ulcers. R60's care plan initiated on 10/24/24 showed she had the potential for pressure ulcers related to bladder incontinence and impaired bed mobility. One of the interventions listed on the care plan was pressure-reducing mattress. R60's activities of daily living (ADL) care plan, initiated on 2/11/25, showed she was dependent on staff for all care needs including bed mobility, transfers, dressing, bathing, and toilet hygiene. The facility's Weekly Wound Report, provided by the facility on 7/21/26, showed R60 had two pressure injuries. One on her left buttock and another on her sacrum. On 7/21/26 at 10:12 AM, R60 was in her room lying in bed on her right side. An air-loss mattress system at the foot of her bed showed it was set at 280 on the soft to firm dial. R60 appeared small in stature, frail and skinny. A mat was on the floor next to the right side of R60's low bed. On 7/22/26 at 10:00 AM, R60 was in her room lying in a low bed on her right side. A mat was on the floor next to the right side of her bed. The air-loss mattress system at the foot of her bed showed it was set at 280. On 7/22/26 at 3:20 PM, R60 was lying in bed in her room on her left side. The air-loss mattress was set at 280. R60's weights/vitals tab, in her electronic medical record, showed her weight on 7/7/26 was 75.6 pounds. On 7/23/26 between 9:37 AM-10:32 AM, V21 (Certified Nursing Assistant-CNA), V21 (Registered Nurse-RN), V19 (Licensed Practical Nurse-LPN, Wound nurse, Infection Control Nurse), and V2 (Director of Nursing) were asked if they knew what the numbers on the air-loss mattress system represented. None of them were able to provide an answer. V21 (RN) provided this surveyor with the contact number for the company that provided the air-loss mattress system. This surveyor called and requested a call from a technician that sets up the air-loss mattresses for the facility. At 11:01 AM, V23 (Operations Manager for the company's Warehouse that provided the air-loss system for R60) returned the call and said generally the setting is set to the patient's weight. V23 said if the resident weighs 75 pounds, The machine should not be set at 280. V23 said at that setting, it would not be providing as much pressure relieving benefits because it would be too firm. The facility's policy and procedure titled Pressure Ulcer Prevention, with a revision date of 1/15/2018, showed the purpose of the policy was to prevent and treat pressure sores/pressure injury. The policy showed 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple stage II wounds, or one or more stage III or stage IV wounds.

Based on observation, interview and record review, the facility failed to ensure a resident's safety by not making sure the bed was in a low position when staff were not in the room for 1 of 5 residents (R60) reviewed for safety and supervision in the sample of 51.The findings include:R60's admission Record, provided by the facility on 7/23/26, showed she had diagnoses including, but not limited to moderate dementia with other behavioral disturbance, schizoaffective disorder, recurrent major depressive disorder, epilepsy, malignant neoplasm of right breast, severe protein-calorie malnutrition, repeated falls, and psychosis. R60's activities of daily living (ADL) care plan, initiated on 2/11/25, showed she was dependent on staff for all care needs including bed mobility, transfers, dressing, bathing, and toilet hygiene. R60's care plan initiated 10/12/25, showed she had the potential to be physically aggressive with care related to dementia and poor impulse control. R60's care plan initiated on 6/5/23 showed she was at risk for falls related to gait/balance problems. R60's care plan initiated on 7/31/26 showed she had impaired cognitive function/impaired thought processes related to dementia and schizoaffective disorder. One of the interventions dated 5/17/25 showed staff to have all necessary items in sight/easy to reach so resident can be observed at all times. On 7/21/26 at 10:12 AM, R60 was in her room lying in bed on her right side. A mat was on the floor next to the right side of R60's low bed. On 7/22/2026 at 10:00 AM, V19 (Registered Nurse-RN) and V20 (Licensed Practical Nurse-LPN) were going to do wound care for the pressure injuries on R60's buttocks and sacrum. V19 entered R60's room, sanitized the bedside table and raised R60's bed to waist height. V20 and this surveyor were standing in the hall outside of R60's room. V19 exited R60's room and started gathering the supplies needed for wound care from the treatment cart in the hallway. V19 sanitized the scissors and opened several drawers on the cart to grab calcium alginate dressing, manuka honey, wound wash, gauze, and two foam dressings from the treatment cart. No staff were present in the room with R60 while V19 grabbed the supplies. R60's bed was waist height. R60's falls report from 4/1/26-7/23/26, showed she had three falls during that time. R60's incident report dated 4/1/26 showed she had an unwitnessed fall and was found in her room on the floor. R60's Fall IDT note dated 4/1/26 showed R60 had rolled out of bed onto the floor. R60's 4/1/26 Fall Risk Assessment showed she was at risk for falls. On 7/23/26 at 10:06 AM, V2 (Director of Nursing-DON) said R60 has a history of falls, she is at risk for falls. V2 said R60 had a fall out of bed on 4/1/26. V2 said R60 a diagnosis of epilepsy. It is not recommended to leave the bed waist high and go out to grab supplies due to safety concerns.The facility's policy and procedure titled Fall Prevention Program, with a revision date of 11/21/2017, showed To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The document showed A fall risk assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. Safety interventions will be implemented for each resident identified at risk.Fall/safety interventions may include but are not limited to.The bed will be maintained in a position appropriate for resident transfers.Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan.

Based on observation, interview, and record review the facility failed to provide dementia care for a resident with dementia and behaviors for 1 of 3 residents (R1) reviewed for dementia care in the sample of 5.The findings include:The Nurse's Notes dated 7/3/26 at 9:40 PM for R3 showed at this time R1 was in this resident's room and had this resident pinned against the wall and was confused over room. Certified Nursing Assistant - CNA observed R1 against R3 and he was easily redirected out of the room. R3 noted to have redness to forearm and redness to shoulders. No bruising at this time. Staff to monitor residents. Administrator and Director of Nursing aware.On 7/12/26 at 3:34 PM, V9 Licensed Practical Nurse - LPN stated it was around 10:00 PM and she was at the nurse's station and heard a noise. She heard R3 yelling but wasn't sure, so her and V8 CNA went to look for the noise. R3's room was dark, the bathroom light was on, R3 was against the wall by the window and R1 was there. R1 was holding her left forearm with one hand and the bottom of her shirt with the other hand. R1 was looking for his wife, her name is the same as R3's name. R1 was easily separated from R3 and was removed from the room. V9 stated she looked over R3, checked her vital signs and contacted the doctor. V9 stated R3 went to bed and just asked for staff to check on her. V9 stated R1 will wander looking for his wife and is exit seeking. V9 stated when R1 wanders they take turns watching him. V9 stated she thinks that since R1's wife and R3 have the same name that he went into that room looking for his wife. V9 stated residents behaviors are put in the care plans.On 7/12/26 at 4:36 PM, V12 (R3's power of attorney) stated the facility did not notify her of any incident between a male resident and R3. She stated the facility never called her but R3 did call her. She stated they talk on the phone every day and one day R3 told her that a man in a wheelchair came into her room, she got up and yelled. R3 told her she was backed up against a wall and she kicked him. V12 stated she feels the facility should have supervised the residents better so this kind of thing doesn't happen.On 7/12/26 at 4:53 PM, V2 Director of Nursing - DON stated for the incident between R1 and R3 she would have expected the staff to separate the residents and make sure they were safe. The administrator should be contacted right away. The doctor, family/POA should be notified of the incident as well. The residents should be assessed, and the assessments should be documented. V2 stated she is new to the facility and is not aware of all the policies yet. She stated she would have social services sit down with R3 and do a trauma assessment and then notify the doctor to see if an evaluation needed to be done. The care plan would be adjusted if necessary. V2 stated to make sure both residents were safe; monitoring would be done. V2 stated she was not aware that R3 had the same name as R1's wife. V2 stated that if the wandering was related to him seeking his wife or that he is looking at females as his wife and/or this name issue it should all be care planned. These would be triggers for him and should be care planned.On 7/12/26 at 5:05 PM, V1 Administrator stated she was not aware that the name of R3 and R1's wife are the same and that he was looking for his wife. V1 stated that should be care planned and a part of his dementia care. V1 stated they will need to do more 1:1 with him. V1 stated this was not handled as it should have been.The current Care Plan with a revised date of 12/29/25 and target date of 9/10/26 for R1 showed it was last updated on 4/4/26 for his elopement risk/wanderer, exit seeking problem. The care plan did not show that he is trying to find his wife when he is wandering and was not updated after the incident between R1 and R3 and his triggers/behaviors. R1's care plan showed he has the potential to be physically and verbally aggressive. R1's care plan did not show that it was reviewed and/or revised after the incident on 7/3/26 between him and R3. The Minimum Data Set, dated [DATE] for R1 showed severe cognitive impairment.The Face Sheet dated 7/12/26 for R1 showed diagnoses including chronic pulmonary embolism, hyperlipidemia, gastro-esophageal reflux disease, chronic kidney disease, localized edema, insomnia, dementia, low back pain, major depressive disorder, and vitamin D deficiency.The Minimum Data Set, dated [DATE] for R3 showed moderate cognitive impairment.The Face Sheet dated 7/12/26 for R3 showed diagnoses including St elevated myocardial infarction, cerebral infarction, asthma, dementia, insomnia, atrial fibrillation, osteoarthritis, obesity, gastroesophageal reflux disease, and hypertension.The facility's Dementia Unit Admission/Discharge Criteria and Program policy (10/2017) showed the goal of this program is to provide a safe environment for the individual, while offering activities that support the best quality of life possible. The program will offer a person-centered approach. Person centered care encompasses four major elements and these are identified as core values of this unit. An individualized approach, recognizing uniqueness. In order to assure the best possible outcome, a team.will work together to develop plans of care that allows the resident to experience the best quality of life as possible. R1's care plan showed he has impaired cognitive function/dementia. The intervention to Cue, reorient and supervise as needed has been in place since 9/15/25.

Based on interview, and record review the facility failed to prevent resident to resident abuse for 2 of 3 residents with dementia (R1 & R2) reviewed for abuse in the sample of 7.The findings include:The Nurse's Note dated 6/5/26 at 7:03 AM for R2 showed the nurse documented the next morning after the incident that the certified nursing assistant observed and reported that the resident was involved in a physical altercation with another resident (R1). Both residents were immediately separated. Assessment was initiated, and no injuries were noted as a result of the incident.The Final Abuse Investigation Report dated 6/8/26 showed in the Incident Description: V3 Registered Nurse - RN reported to V1 Administrator that there was a physical abuse allegation between two residents, R1 and R2. V3 stated that when the V4 certified nursing assistant - CNA looked up from her charting and observed R1 with both hands on R2's neck. V4 separated the two without incident and immediately told the nurse. The facility's conclusion was that abuse was unfounded.On 7/12/26 at 1:00 PM, V4 CNA stated she was charting when the incident between R1 and R2 occurred. V4 said R2 had been touching the medication cart, had grabbed the pill crusher and was redirected not to do that. R1 had told R2 to stop touching the cart. Right after this R2 was in his wheelchair and R1 had his hands around R2's neck. R1 had both of his hands around R2's neck and R2's neck was red. They were separated right away. V3 was the nurse, and she was notified and the administrator was told. R1 looked frustrated; R1 is confused. V4 stated she thinks R1 was trying to make R2 knock it off. V4 stated she thought what R2 was doing just set R1 off. V4 stated again that R1 had his hands around R2's neck. V4 stated she removed R1's hands from R2's neck and told the nurse. On 7/12/26 at 1:56 PM, V1 Administrator stated, for the June 2026 abuse allegation between R1 and R2 she stated she has problems deciding if an abuse allegation is founded or unfounded. V1 stated she decided this investigation was unfounded because there was no harm and staff had intervened before it resulted in harm. V1 stated the nurse never documented any injury and she was not aware of any red marks on the resident's neck; if she had known that the findings would have been different.The Face Sheet dated 7/12/26 for R1 showed diagnoses including chronic pulmonary embolism, hyperlipidemia, gastro-esophageal reflux disease, chronic kidney disease, localized edema, insomnia, dementia, low back pain, major depressive disorder, and vitamin D deficiency.The Minimum Data Set, dated [DATE] for R1 showed severe cognitive impairment.The Face Sheet dated 7/12/26 for R2 showed diagnoses including dementia without behavioral disturbance, rhabdomyolysis, atrial fibrillation, atherosclerotic heart disease, benign prostatic hyperplasia, palliative care, hyperlipidemia, abdominal aortic aneurysm, hypertension, and non pressure chronic ulcer.The Minimum Data Set, dated [DATE] for R2 showed severe cognitive impairment.The facility's Abuse Prevention and Reporting policy (10/24/22) showed abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review the facility failed to notify the power of attorney for a resident with dementia of an incident for 1 of 3 residents (R3) reviewed for notification in the sample of 5.The findings include:The Nurse's Notes dated 7/3/26 at 9:40 PM for R3 showed at this time R1 was in this resident's room and had this resident pinned against the wall and was confused over room. Certified Nursing Assistant - CNA observed R1 against R3 and he was easily redirected out of the room. R3 noted to have redness to forearm and redness to shoulders. No bruising at this time. Staff to monitor residents. Administrator and Director of Nursing aware. On 7/12/26 at 3:34 PM, V9 Licensed Practical Nurse - LPN stated it was around 10:00 PM and she was at the nurse's station and heard a noise. She heard R3 yelling but wasn't sure, so her and V8 CNA went to look for the noise. R3's room was dark, the bathroom light was on, R3 was against the wall by the window and R1 was there. R1 was holding her left forearm with one hand and the bottom of her shirt with the other hand. R1 was looking for his wife, her name is the same as R3's name. R1 was easily separated from R3 and was removed from the room. V9 stated she looked over R3, checked her vital signs and contacted the doctor. V9 stated R3 went to bed and just asked for staff to check on her.On 7/12/26 at 4:36 PM, V12 (R3's power of attorney) stated the facility did not notify her of any incident between a male resident and R3. She stated the facility never called her but R3 did call her. She stated they talk on the phone every day and one day R3 told her that a man in a wheelchair came into her room, she got up and yelled. R3 told her she was backed up against a wall and she kicked him. V12 stated the facility calls her for all kinds of silly things, but they did not call her about this, and they should have notified her.On 7/12/26 at 4:53 PM, V2 Director of Nursing - DON stated for the incident between R1 and R3 she would have expected the staff to separate the residents and make sure they were safe. The administrator should be contacted right away. The doctor, family/POA should be notified of the incident as well.On 7/12/26 at 5:05 PM, V1 Administrator stated the POA/family should be notified and care plan updated. This was not handled like it should have been.The Face Sheet dated 7/12/26 for R3 showed diagnoses including St elevated myocardia infarction, cerebral infarction, asthma, dementia, insomnia, atrial fibrillation, osteoarthritis, obesity, gastroesophageal reflux disease, and hypertension.The facility's Physician-Family Notification policy (10/1/15) showed the facility will inform the resident; consult with the resident's physician or authorized designee such as nurse practitioner; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental or psychosocial status.

Based on observation, interview and record review the Facility failed to staff a full-time Director of Nursing. This failure has the potential to affect all 76 Residents residing in the Facility.Findings include: The Facility Assessment Tool, dated 1/21/26, documents: V2 (former Director of Nursing/DON) as the Director of Nursing; and a Director of Nursing is needed to provide support and care for Residents; and the Director of Nursing will communicate verbally/in writing, the expectations of care provided to the Residents and will provide oversight to ensure these expectations are met.The Director of Nursing Job Description, created 5/2/17, documents the primary purpose of the position is to plan, organize, develop and direct the overall operation of our Nursing Department in accordance with current Federal, State and Local standards, guidelines and regulations that govern our Facility, to ensure the highest degree of quality care is maintained at all times.The Facility Resident Room Roster, dated 4/23/26, documents 76 Residents residing in the Facility.On 4/23/26 at 8:45 am, upon entry in the Facility, V7 (Human Resources Manager) stated, I would put you in the conference room, but I am doing a big orientation in there today, so I am going to put you in the Director of Nursing/ (DON) office since we do not have a DON right now. V7 also stated, We have not had a Director of Nursing for about three weeks now, our last one quit on 3/31/26.On 4/22/26 (during the hours of 8:45 am and 3:00 pm) and 4/23/25 (during the hours of 8:15 am through 1:30 pm) the Facility did not have a Director of Nursing available.On 4/22/26, V2's (former Director of Nursing) Employee File was reviewed and documents V2's hire date of 6/30/25. V2's Resignation Letter, dated 3/16/26, documents V2's termination of employment date on 3/31/26.On 4/22/26 at 10:58 am, R6 stated, We do not have a Director of Nursing right now, she quit. I am not sure who I would go to for my nursing stuff, I would probably to (V1/Administrator).On 4/22/26 at 10:31 am, V2 (former Director of Nursing) stated, I put my resignation in and my last day at the Facility was 3/31/26.On 4/22/26 at 1:10 pm, V1 (Administrator) stated, (V2/DON) put a resignation in and (V2's) last day was 3/31/26. I have not replaced (V2) yet, but I am currently interviewing for (V2's) replacement.

Based on observations, interviews and record review, the facility failed to assess each resident for risk of entrapment and only use bed rails after trying other alternatives for five of five residents (R4, R5, R9, R46, R64) and explain the risks and benefits to the resident or the resident's representative for one of five residents (R4) in a sample of 35.Findings include: The Side Rails/Bed Rails policy dated 10/24/22 documents examples of bed rails include side rails, bed side rails and safety rails. The facility shall ensure that prior to installation of bed rails the facility has attempted to use alternatives. If alternatives fail, the facility shall assess the resident for risks of entrapment and possible benefits of bed rails; shall ensure bed is appropriate for the resident and that bed rails are properly installed and maintained; determine if bed rails meet the individual needs of a resident via resident assessment: medical diagnosis, behaviors, size and weight, medications, ability to toilet self, cognition, communication, mobility and risk of falling; evaluate resident's risks and potential risks can be exacerbated by improper match of the bed rail to bed frame, improper installation and maintenance; after alternatives have been attempted and prior to installation, the facility shall obtain informed consent and document in the medical record; the Care Plan may include the medical need, how often the bed rail is applied, duration of use and the circumstances for when it is to be used, how monitoring is provided, identify potential complications such as physical and/or psychosocial changes related to the use of bed rails, interventions to minimize or eliminate the use of bed rails; and who monitors for the implementation of use, assesses to determine ongoing need for bed rails, if use should gradually decrease and if interventions are effective; and check bed rails regularly and ensure dimensions are appropriate, confirm proper installation.The Bed Rail Safety-Gap Measurements audit sheet documented gap measurements were conducted on 5/2/25.1. R4 was admitted on [DATE] with diagnoses of history of falling, fracture lower end of left femur, orthopedic aftercare, long term uses of anticoagulants and morbid obesity.R4's Care Plan documents on 4/28/25 R4 was assessed to need right and left quarter bedrail.R4's Side Rail Assessment conducted 3/28/25 and 6/5/25 documented R4 did not have siderails attached to the bed and the assessment was not completed.On 8/12/25, 8/13/24 and 8/14/25 R4's bed was observed to have right and left quarter bedrails attached to the bed and in the up position.R4's record did not contain an Acknowledgement of Restraint/Device Use (consent form).2. R5 was admitted on [DATE] with diagnoses of Cerebral Palsy, Stroke, Schizoaffective Disorder, Bipolar Type, Muscle Wasting and Atrophy, Cognitive Communication Deficit, Anticoagulant use and Osteoarthritis.R5's Care Plan documents on 2/25/25 R5 was assessed to need right and left halos (adjustable bed mobility device).The Initial Side Rail Assessments dated 1/15/25 did not document R5's diagnoses, behaviors, if the bed rail was attached to the bed, risks of rails, restrictions and benefits or bed mobility. The Quarterly Side Rail assessment dated [DATE] identified no conditions that posed a risk and that halos were utilized.On 8/12/25, 8/13/24 and 8/14/25 R5's bed was observed to have right and left quarter bedrails attached to the bed and in the up position.3. R9 was admitted on [DATE] with diagnoses of Acquired Absence of Left Leg Below Knee, Mood Disorder, Insomnia, Major Depressive Disorder, Osteoarthritis and Malaise.R9's Care Plan documents on 3/25/25 R9 was assessed to need right and left quarter bedrail.The Quarterly Side Rail assessment dated [DATE] did not document diagnoses, interventions attempted and no conditions that posed a risk of rails.4. R46 was admitted on [DATE] with diagnoses of Cognitive Impairments, Osteoarthritis, Diabetic Neuropathy, Major Depressive Disorder, Acquired Absence of Right Great Toe and Anxiety Disorder.R46's Care Plan documents on 2/25/25 R46 was assessed to need right and left quarter bedrail.The Quarterly Side Rail assessment dated [DATE] did not document diagnoses, prior interventions attempted and no conditions that posed a risk of rails.5. R64 was admitted on [DATE] with diagnoses of Osteomyelitis of Vertebra and Sacral Region, Severe Morbid Obesity and Osteoarthritis.R64's Care Plan documents on 2/24/25 R64 was assessed to need a right half bedrail.R64's Quarterly Side Rail Assessment conducted 6/5/25 documented R64 did not have siderails attached to the bed and the assessment was not completed.On 8/12/25, 8/13/24 and 8/14/25 R64's bed was observed to have right and left quarter bedrails attached to the bed and in the up position.On 8/14/25 at 1:10 PM, V1 (Administrator) and V13 (Maintenance Director) agreed R46's bed rails had spacers between the bed rail and mattress and the gap was measured at 5 inches. On 8/15/25 at 10:45 AM, R46's bed rails still had the spacers in place.On 8/14/25 at 1:00 PM, V13 (Maintenance Director) stated bed rails are checked annually. V13 stated R46's bed rails should not have a spacer and should be removed.On 8/14/25 at 1:05 PM, V1 (Administrator) stated the facility owns their beds, all beds have bed rails and verified bed rail inspections are conducted annually. V1 stated if bed rails are not approved for use, the rail is zip tied, although staff do break the zip ties off and use bed rails if needed. V1 stated specialty mattresses can replace the regular mattress on each bed and the nurses should be assessing if bed rails are appropriate and gaps are within acceptable limits, although the assessments are not documented. Bed rail assessments are conducted quarterly. V1 agreed bed assessments were not either completed and/or accurately completed, R4 did not have an Acknowledgement of Restraint/Device Use (consent form) and Nurse's nor Certified Nurse Aides document a gap assessment or bed rail condition was assessed. 1.

Based on observation, interview and record review, the facility failed to ensure oxygen was administered as ordered for one of three residents (R4) in a sample 35. Findings include:The Oxygen Concentrator policy dated 2013 documents the oxygen concentrator converts ambient air to a higher level of oxygen and is used to provide oxygen therapy. R4's Care Plan dated 7/11/25 documents R4 uses continuous oxygen related to Chronic Obstructive Pulmonary Disease (COPD) and Respiratory Failure. R4 will have no signs or symptoms of poor oxygen absorption through the review date. Interventions include If R4 is eating, oxygen still must be given to R4 but in a different manner (e.g., changing from mask to a nasal cannula). Return R4 to usual oxygen delivery method after the meal and monitor for signs and symptoms of respiratory distress and report to the physician as needed: respirations, pulse oximetry, increased heart rate (Tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage and skin color. R4's Physician Order dated 7/4/25 documents oxygen at 1-4 LPM (liters per minute) via nasal cannula continuously. On 08/12/2025 at 10:30 AM, R4's oxygen tubing was on the floor and not plugged into the concentrator. On 8/12/25 at 10:35 AM, V15 (Registered Nurse) was notified that R4's oxygen was not on and the oxygen tubing was on the floor. V15 did not assess R4 for respiratory distress. On 08/12/2025 at 1:10 PM, R4 was observed in the dining room with oxygen and an oxygen concentrator. V14 (Certified Nurse Aide) took the oxygen off R4, transported R4 to her room and returned R4 to bed without the oxygen. At 1:18 PM, V8 (Registered Nurse) entered R4's room with the concentrator and placed R4 back on the oxygen without an assessment for respiratory distress. R4 appeared to be anxious, short of breath and using accessory muscles to breathe. On 8/12/25 at 1:30 PM, V8 confirmed R4 was to be on continuous oxygen and R4 appeared to have signs of respiratory distress (during transport on 8/12/25 at 1:10 PM) and agreed oxygen levels were not assessed. On 8/12/25 at 2:00 PM, R4 stated she was short of breath without the oxygen on and felt afraid (during transport 8/12/25 at 1:10 PM). On 8/15/25 at 1:00 PM, V2 (Director of Nursing) stated the facility does not have portable oxygen tanks and staff have to push the oxygen concentrators down the hall to the dining room and then back to the resident's room.

Based on interview and record review, the facility failed to protect a resident from resident-to-resident physical abuse for two of three residents (R1, R2) reviewed for physical abuse in a sample of three. Findings include:The facility's Abuse Prevention and Reporting policy, revised 10/24/22, documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. This form documents that physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.R1's electronic face sheet documents the following diagnoses: Congested Heart Failure, Gastro-Esophageal Reflux Disease, Gout, Osteoarthritis, Chronic Kidney Disease, Amnesia, edema, Obesity, Falls, Vascular Dementia, Mood Disturbances, Anxiety.R1's Abuse/Neglect Screening, dated 5/12/25, documents a score of 4, indicating that R1 is a moderate risk for abuse and neglect.R1's current care plan documents that R1 is at risk for abuse/neglect related to Dementia diagnosis. R1's abuse interventions document that R1 will be cared for in a safe manner, and verbalize to staff any incidents of abuse or neglect through review date.R1's Progress Notes, dated 7/12/25 at 4:52am, documents that staff went to R1's room and noticed R2 hitting R1. This form documents that R1 had no complaints of pain. All the required parties were notified.R2's current electronic medical record documents the following diagnoses: Hydrocele, Strabismus, Restlessness and Agitation, Inguinal Hernia, Alzheimer's, Insomnia, Dementia severe with agitation, Hypertension, Hyperlipidemia, Atrial Fibrillation, Atherosclerotic Heart Disease, Coronary Artery Disease, Major Depression, Urinary Tract Infection, Chronic Obstructive Pulmonary Disease.R2's current Care Plan documents that R2 has the potential for aggressive behavior related to dementia. R2's goal is that he will not harm himself or others. This form also documents that R2 has the potential to be verbally aggressive related to dementia, ineffective coping skills, and poor impulse control. R2 can be physically aggressive, related to dementia, and poor impulse control.R2's Progress Notes, dated 7/12/25 at 4:50am, documents that staff witnessed R2 hitting R1. V3, Registered Nurse, asked R2 what happened, R2 stated He pulled me out of my bed. R2 was noted to have an increase in confusion.The facility's Initial Abuse Investigation Report, dated 7/12/25, documents a report of alleged physical contact between two residents (R1, R2).V5's, Certified Nursing Assistant, signed statement, dated 7/12/25, documents that someone was yelling help. (V5 and V4) ran into (R1 and R2's) room and witnessed (R2) swinging fists at (R1), while (R1) was lying in the bed. (R2) was standing over (R1). (R1) was removed away from (R2). (R1) stated He pulled me out of his bed.On 7/14/25 at 1:00pm, V4, Certified Nursing Assistant, stated that she heard yelling and went to R1 and R2's room. V4 stated that R2 was standing over and hitting R1 in the face with his fists. V4 stated that R1 was yelling to call the police. V4 stated that R2 stated that R1 pulled him out of his bed. V4 verified that R1 can not stand or transfer by himself. On 7/14/25 at 1:10PM, V3, Registered Nurse, stated that V4 and V5, Certified Nursing Assistant, told her that R2 was hitting R1, while he was in bed. V3 stated that R2 did not sustain any injuries during the altercation.

Based on interview and record review the facility failed to provide snacks at bedtime for all residents. This failure has the potential to affect all facility residents. The facility policy, Snacks, undated, documents Policy: Between meal snacks are available to residents per the planned menu or resident preference. Purpose: Too offer additional nourishment between meals. Procedure: 1. The Food and Nutrition Department will send snacks to the nursing stations at the appropriated times .3. Bedtime snacks will be sent to the nursing station(s) in bulk. These snack items are to be offered to each resident. Per facility policy, acceptance or refusals of snacks are to be documented. The facility's Certified Nursing Assistant (CNA) Job Description documents Essential Duties and Responsibilities: Provide assistance with serving meals and feeding; providing fresh water an nourishment between meals. On 6/11/24, at 9:57am, the survey Group Meeting, R11, R22, and R54 agreed they are not offered any bedtime snack. During this meeting, R60 stated I don't get any at bedtime. And the nurse told me I should have a snack at bedtime. I have not seen any snacks sitting out. On 6/11/24, at 1:03pm, V6 Dietary Manager/DM stated we send out snacks (animal crackers, grahams, wafers) with drinks around 7 or 7:30pm for bedtime snacks. My kitchen staff take trays to the halls and the CNAs are to pass them out. On 6/13/24, at 9:40am, V6 DM stated the kitchen provides bedtime snacks for all of the residents. On 6/11/24, at 3:10pm, V2 Director of Nursing/DON stated the CNAs are to offer and pass the bedtime snacks. They probably document it under tasks whether or not it was accepted or refused as per policy. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Center for Medicare and Medicaid/ Services/CMS form 671), dated 6/10/24, and signed by V16 Minimum Data Set Assessment Coordinator, documents 66 residents currently reside in the facility.

Based on observation, interview and record review the facility failed to implement a cleaning procedures and schedule for the kitchen and failed to use appropriate utensils while plating lunch. This has the potential to affect 66 residents residing in the facility. Findings include: The facility's Cleaning Procedures, undated, documents that food service equipment shall be washed, rinsed, and sanitized according to standard procedures. The facility's Cleaning Instructions Ceilings and Walls, dated 2020, documents ceiling and walls will be cleaned on a regular basis. This form documents that walls will be cleaned daily using hot, soapy water to remove dirt, spatters, and food stains, or as needed. Wall will be cleaned and sanitized monthly, or as needed. Use hot, soapy water to wash, then rinse with clean, warm water. In food preparation areas, wipe down with sanitizing solution and allow to air dry. On 06/10/24 at 9:30am, each oven and steamer in the kitchen had black burnt crumbs in the floor. A brown greasy like substance ran down the doors of each oven. The ventilation hood above the cooking area had a brown greasy build up on it. The wall behind the dishwasher had brown/black streaks running down the wall. There was a black crumbly substance on the floor and wall under the dishwasher. There was a brown fuzzy substance on the covering above the dishwasher. On 6/10/24 at 11:45am, V19, Cook, washed her hands and applied gloves. V19 then grabbed a plate dished up and covered the food. V19 grabbed a dinner roll with her gloved hand. V19 repeated this process several times. V19 stated that she should have used tongs to grab the dinner rolls, not her gloved hands. On 6/10/24 at 1:00pm, V5, Dietary Manager, stated that she does not know the last time the kitchen was cleaned. V5 was unable to supply a cleaning schedule. On 6/11/24 at 11:00am, V1, Administrator, stated that the kitchen did not have a cleaning schedule in place. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 6/10/24, documents that 66 residents reside in the facility.

Facility failures resulted in two deficient practices. A.) Based on record review and interviews the facility failed to follow their policy on Water Management Program for Prevention of Legionella Growth, and perform preventative maintenance to stop the growth and spread of Legionella. This has the potential to affect all 66 residents that reside at the facility. B.) Based on observation, interview, and record review, the facility failed to place signage in a location to clearly identify the category of transmission-based precautions, instructions for PPE (Personal Protective Equipment), to instruct visitors to see the nurse prior to entering the resident's room for one resident (R64) that required transmission-based precautions in a sample of 49 residents and failed to ensure Personal Protective Equipment was donned per policy, and non-contaminated supplies were safe for wound care for one residents (R32) observed for wound care in a sample of 49 residents. Findings include: A) The facility policy, Water Management Program for Prevention of Legionella Growth, revised (5/17/2024) documents the following: Purpose: To identify and reduce the risk of Legionella growth and spread. Preventative maintenance will be performed as applicable: The following will be verified and documented at least once weekly: 1.) The domestic hot water boiler storage tanks verified to be set between 140-160 degrees Fahrenheit. 2.) Thermostat indicating the temperature of water entering the circulating system at the mixing valve is at 120 Fahrenheit or above. 3.) Eye wash stations will be inspected and flushed weekly. 4.) Ice machines will be inspected and cleaned internally at least every 3 -6 months and as needed for leakages or contamination. 5.) Cooling tower (if applicable) will be inspected at least weekly to ensure proper functioning and chemical distribution. 6.) Weekly sanitizing of medical devices such as CPAP (continuous positive airway pressure). The facility was unable to provide a flow diagram of the buildings water system. On 6/12/2024 at 8:45AM V10 (Maintenance Director) stated, I do not have any other information to show that I have been doing any of the preventative maintenance protocols, according to the policy. I just started the eye wash weekly inspection on 5/29/2024. I have not done any temperatures for the water boiler or temperatures of the water entering the circulating system at the mixing valve. The ice machine should be inspected and cleaned every 3-6 months, but that has not been done. I am pretty sure that the weekly sanitizing of medical devices has not been done either. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 6/10/24, documents that 66 residents reside in the facility. B.) 1. R64's Physician Order Sheet, dated 6/1/24 through 6/30/24, documents Foley catheter 16 French with 10CC (centimeter) to drainage and gravity for a diagnosis of urine retention. And Enhanced Barrier Precautions- for an indwelling foley catheter every day and night shift. On 6/10/2024 at 1:30P.M., R64's entry door lacked signage to identify the category of transmission-based precautions, instructions for PPE (Personal Protective Equipment) and instructions to see the nurse prior to entering the resident's room. The Isolation Room Set Up policy, revised 5/30/14, documents It is the policy of this facility to set up isolation precautions. Procedure: 7. Place sign on door to resident's room for visitors to inquire at nurse's desk prior to entering room. On 6/13/2024 at 1:55 PM V1/Administrator stated, Yes, there needs to be signage on the door when Enhanced Barrier Precautions are in use. The sign was on the wrong door. It is fixed now. B) 2. The Dressing Change (Clean/Non-Sterile) policy, reviewed 1/9/18, documents 2. Prepare a clean, dry work area at bedside. 3. Bring supplies into resident's room. Individual resident supplies may be placed on the over bed table after it has been disinfected and/or a protective barrier placed on the table. 7. Prepare/open any necessary supplies and place on top of clean barrier. 17. In the event more than one wound is present, each wound site is considered a separate treatment. A new pair of non-sterile gloves will be used for the cleaning of each site. The Enhanced Barrier Precautions policy, effective 4/3/24, documents Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The Donning & Doffing PPE (Personal Protective Equipment) guidance, no date, documents 3. Put on isolation gown. Tie all of the ties on the gown. On 5/1/24, a Physician ordered Enhanced Barrier Precautions (chronic wound, indwelling catheter) every day and night related to multi-resistant organisms in the urine. On 5/10/24, a Physician ordered wound care for the sacral wound and for the right buttock wound. 06/11/24 at 1:10 PM, an open box of latex gloves was observed to be opened and lying open side down on the floor in R32's room. V6 (Certified Nurse Aide/CNA) was observed to be providing cares for R32 without having the Personal Protective Gown fully donned and ties were not tied. On 6/11/24 at 1:17 PM, V8 (Licensed Practical Nurse) was observed to pick the box of gloves up off the floor, placed the box of gloves on the clean surface with the dressing change supplies, donned the gloves from the opened box that had been on the floor and conducted wound care on R32.

Based on interview and record review, the facility failed to ensure residents have knowledge of who the Grievance Official is, how to file a Grievance and where the forms are located for four (R11, R22, R54, and R60) of four residents reviewed for Grievances in a sample of 49. Findings include: The facility's Grievances policy, revised 9/25/17, documents Purpose: To ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus .Guidelines: The resident has the right to voice grievances to this facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal .Grievances may be filed orally (meaning spoken), in writing, or anonymously. Grievances may also be filed anonymously through the Corporate Compliance Hotline .An appointed Grievance Official (usually Social Service Director) is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations and maintaining the confidentiality of all information associated with grievances. On 6/11/24, at 9:57am, the survey Group Meeting was held in the facility with four residents (R11, R22, R54, and R60) present. During this meeting all four residents agreed that they did not know who the Grievance Official is, how to file a grievance nor where the forms were kept. R11 asked Where do you get the forms? The facility's Resident Council Minutes dated from 6-29-23 to 5-30-24 do not include any discussion on how to file a grievance. 06/11/24 1:40 PM V4 Activity Director confirmed the Resident Council meeting minutes do not include any discussion of how to file a Grievance. On 6/11/24, at 12:52pm, V14 Social Service Director/SSD stated the following: I am the Grievance Officer. Any time a grievance occurs I go talk to the resident and bring a sheet. I let the new residents know about how to file a grievance. V14 is unaware there are residents who do not know how to file. I guess I need to round more. I have not discussed the topic at Resident Council but maybe that's what I should do.

Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled correctly. This failure has the potential to affect all 28 residents (R3, R10, R14-17, R26, R27, R29, R31, R33, R35, R36, R38-R40, R44, R46-R49, R52, R53, R57, R59, R65, R68 and R121) currently residing in the facility Safe Unit. Findings include: The (revised) 7/2/19 facility policy, Medication Storage directs staff, Purpose: To ensure proper storage, labeling and expiration dates of medications, biological's, syringes and needles. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines will respect to expiration dates for opened medications. Facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. Facility should ensure that medications are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Refrigeration: 36- 46 degrees. On 6/10/24 at 9:29 A.M., V15/Licensed Practical Nurse (LPN) opened the locked door to the (facility) Back Hall Medication Room. A refrigerator with no temperature log present contained a thermometer in an open freezer section, that was iced to the shelf. V15/LPN, wiggling the thermometer back and forth, was able to loosen and read the thermometer. At that time V15/LPN verified she did not check the temperature of the refrigerator today and had never been instructed to check and record the temperature. On a shelf a 5 ML (Milliliter) bottle of undated Tuberculin, Purified was opened with 1/2 of the contents missing. At that time, V15/LPN verified the undated bottle. A review of the facility Back Hall Medication Refrigerator for January, February, March, April, May and June 2024 documents missing refrigerator temperatures. On 6/13/24 at 9:41 A.M., V2/Director of Nurses verified the temperature of the medication storage refrigerator was to be checked once daily by the night shift nurse. At that time, V2/DON also verified the opened, undated Tuberculin solution and the missing temperatures for January, February, March, April, May, and June 2024. A facility Room Roster dated 6/10/24 and provided by V1/Administrator documents 28 residents currently reside on the facility Safe Unit.

Based on observation, interview and record review the facility failed to provide a lift sling for mechanical lift transfers for one resident (R11) of three residents reviewed for Activities of Daily Living in the sample of 15. This failure resulted in R39 experiencing increased feelings of isolation, disappointment and hopelessness related to inability to get out of bed. Findings include: Current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Weight Record indicates R11's weight on 3/5/21 was 472.6 pounds. Comprehensive Cognitive assessment dated [DATE] indicates R11 has no cognitive or memory impairments, understands and is understood. Current Care Plan indicates R11 has a psychosocial well-being problem related to loss of independence and prefers to watch television and use his computer. Care Plan indicates R11 is at Risk for Abuse/Neglect related to depression and passive personality. Care Plan indicates R11 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include Encourage visitation by family and friends and to monitor for feelings of hopelessness, seclusion from others, isolation and feelings of hopelessness. On 3/10/21 at 1:45pm R11 was lying in bed and stated he wanted to get up but couldn't get out of bed because there was no available sling for the mechanical lift which he needs to get out of bed. R11 stated that he bought three slings with his own money because the facility never consistently had slings big enough to get him out of bed. At that time V9, CNA (Certified Nurse Assistant) found one of R11's slings and explained that the sling was splitting at the seam. V9 stated that another sling was in laundry and that sling also starting to fray. V9 stated that the third sling is missing. On 3/10/21 at 2:00pm V10, Laundry stated that only one of R11's slings is in the laundry and it is also frayed and shouldn't be used. V10 stated that she didn't know that one of the slings was also missing. On 3/10/21 at 2:10pm V2, DON (Director of Nursing) stated that he was unaware that one of R11's slings was missing. No attempt was made to find a (facility) sling to get R11 out of bed. On 3/11/21 at 12:35pm R11 was in bed and stated they never found a sling to get him out of bed yesterday and has been in bed since then. At that time R11 stated I bought three slings months ago because staff could never consistently find a sling to fit me and get me out of bed. Sometimes I had to stay in bed for a week. R11 stated it's Just a fact of life. R11 stated that he has several siblings that he face times on the computer when he's able to get out of bed. R11 stated I'm able to stay connected with my family that way and it makes me feel real good. I'm really disappointed and feel isolated when I'm stuck in bed. R11 also stated he was an IT (Information Technology) worker before he was admitted to the facility and using his computer is most important to him. R11 states I just put my head phones on and lose myself when I can't get out of bed. R11's room was noted to have a large screen computer monitor and other computer equipment. R11 is able to control his motorized wheelchair when he is able to get out of bed and have access to all of his electronic equipment. R11 does not have access to his computer from his bed. On 3/11/21 at 10:45am V6, SSD (Social Service Director) stated that she was aware R11 bought his own lift slings. V6 stated that even if R11 buys his own supplies the facility should be able to provide those supplies at all times. On 3/12/21 at 10:40am V1, Administrator stated that she was unaware that staff were relying on R11's use of his own slings to get him out of bed and that We should always have the supplies needed for (R11). Facility assessment dated [DATE] documents: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The facility will ensure that all necessary equipment and supplies are available. The facility will provide physical resources such as mechanical lift slings.

Based on interview and record review the facility failed to supervise and ensure fall interventions implemented for one resident (R2) of three residents reviewed for falls. This failure resulted in R2 sustaining a pelvic fracture. Findings include: Current physician's orders [REDACTED]. Physician order [REDACTED]. Comprehensive assessment dated [DATE] indicates R2 was severely cognitively impaired and required extensive assist of two staff with mobility and personal care. Nurse Note dated 6/27/20 at 7:45am indicates R2 had an unwitnessed fall in her room - found lying on the floor by a housekeeper. Note indicates V6, RN (Registered Nurse) assessed R2 and initially only found a left elbow bruise before assisting R2 back to her chair. Nurse Note 6/27/20 at 10:15am indicates that 15 minutes after fall during a neurological check, R2 was noted to be again attempting to get out of her chair and noted R2's right leg appeared to be more painful when moved - R2 was then assisted into bed. Note indicates physician was notified and ordered R2 sent to hospital for evaluation due to recent right [MEDICAL CONDITION]. Nurse Note dated 6/27/20 at 3:06pm indicates R2 returned from the hospital with [DIAGNOSES REDACTED]. Hospital Records dated 6/27/20 confirm fracture of pubic fracture. On 9/11/20 at 10am V6, LPN (Licensed Practical Nurse) stated that R2 was in a recliner type chair in her room (alone) before breakfast when R2 fell out of the chair. V6 stated that R2 never tried to climb out of bed, but would frequently try to climb out of the chair and would throw her legs over the side of the chair. V6 stated that it was a very busy time of the morning, staff were trying to keep residents in their rooms as much as possible because of COVID and that staff would just make frequent rounds on residents. V6 did acknowledge that R2 was high risk for falls due to previous fall with fracture and severe Dementia - inability to follow direction and poor safety awareness. Care Plan Risk for falls related to Dementia and recent right [MEDICAL CONDITION] indicates interventions were initiated on 6/22/20: Ensure (R2) is wearing appropriate non-skid footwear. Fall Occurrence Report dated 6/27/20 indicates clothing/shoes were a predisposing factor to R2's fall and that (R2) was wearing socks instead of non-skid socks. Fall Risk Assessment - Post Fall dated 6/27/20 indicates R2 was high risk for falls. No fall assessment had been completed prior to 6/27/20. On 9/16/20 V1, Administrator stated a fall risk assessment should be done on admission - none was completed on R2. Facility Policy/Fall Prevention Program dated 11/21/17 documents: A fall risk Assessment will be performed by a license nurse at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Footwear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid.

Based on interview and record review, facility staff neglected to operationalize the facility's Wandering Resident policy to ensure that detailed monitoring plans were in place for four of seven residents (R1 to R4) assessed by the facility to be at risk for elopement in a sample of five. Facility nursing staff also neglected to implement any interventions when R1 was exhibiting wandering behaviors and document episodes of wandering and exit-seeking behaviors in R1's medical record, as required by the policy. This neglect resulted in R1 exiting the building without staff knowledge, falling outside the building and being diagnosed with [REDACTED]. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1/14/13, the facility remains out of compliance at a Severity Level 2. Additional time is needed to evaluate the implementation of revised policies and procedures and inservicing of staff to determine the effectiveness of these changes. Findings include: The facility's Alarm Listings sheet dated 12/27/12 identified seven residents (R1 to R7) who were equipped with electronic monitoring bracelets. The facility's Elopement Binder examined on 1/5/13 contained Elopement Risk Identification sheets which provided a physical description and picture for each of the residents R1 to R7. The facility's Wandering, Unsafe Resident policy last revised on 12/2008 listed seven directions for staff to follow to prevent "unsafe wandering" for residents at risk for elopement. Item five on this list stated, "Nursing staff will document circumstances related to unsafe actions , including wandering, by a resident." Item six on the list stated, "Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior." R1's Care Plan last updated on 11/28/12 listed a problem of "Elopement Potential for injury related to exit seeking, looking for something." for R1. The total approaches listed for this problem were: "1:1 time; Attempt to identify the antecedent to the behaviors (cause); Family/significant other visit; Implement a toileting schedule; Offer food/drink; Place resident picture in the Elopement binder at each desk; Redirect with activity; and Electronic Monitor Bracelet, check daily." The Care Plans for R2 (last updated on 11/21/12), R3 (last updated on 11/21/12) and R4 (last updated on 11/7/12) listed identically worded approaches for the elopement problem as in R1's Plan, with the following exceptions: R2's Plan lacked a toileting schedule approach; R3 and R4's plan also included an approach for decreasing environmental stimulation; and R4's Plan lacked the approach of 1:1 time. These Care Plans did not provide any further detailed instructions for staff to follow to ensure residents who were exhibiting exit-seeking behavior were consistently monitored. E2 (Director of Nursing) stated the following on 1/8/13 at 11:20 AM with regards to the approach of "1:1 time" listed in R1's Care Plan: "We don't do one to one time, that is, staff sitting with a resident at all times. One to one is meant at the time, for example, a Nurse would redirect a resident." E2 also stated with regards to facility procedure for elopement risk residents that an electronic monitor bracelet is to be placed on the resident as a precaution, but that the care for these residents "really isn't any different." E2 said that residents who become "exit seekers" need to be placed in another facility with a locked Dementia Unit. E2 said that the facility also does not admit residents with this behavior. A facility Incident Summary dated 1/4/13 indicated that R1 was found outside of the building's Southeast door lying on the left side at 7:10 AM that day. The Summary stated that R1 made no complaints of pain when immediately assessed outside, but complained of pain in the right hip once R1 was back in the building. The same Summary documented that on R1's initial assessment after the incident, R1 had a body temperature of 92.4 degrees Fahrenheit (F). The Summary indicated that R1 was transported to the local hospital at 8 AM on 1/4/13. R1's Emergency Department report dated 1/4/13 from the local hospital indicated that R1 was disoriented, had a body temperature of 96.2 degrees F, was cold to the touch, and complained of pain in the left foot, right hip and neck upon arrival at 8:35 AM. The report indicated that R1 was placed in a heated wrap for ten minutes at a high setting to raise R1's body temperature. The report listed [DIAGNOSES REDACTED]. elbow. Z1 (Emergency Department Physician) stated on 1/4/13 at 2:30 PM that R1 was diagnosed with [REDACTED]. Z1 said that it was very difficult to estimate the amount of time that R1 was exposed to the cold outside, because there are so many variables. Z1 said that outside temperature was about 10 degrees F with a wind chill of plus 1 degree F at around the time R1 was reported found out of the building. An x-ray report dated 1/4/13 at 8:57 AM from the local hospital for R1's left foot indicated a displaced acute [MEDICAL CONDITION] toe. An x-ray report dated 1/5/13 at 1:27 AM from the local hospital for R1's right hip indicated an impacted [MEDICAL CONDITION] hip. The National Weather Service website temperature information for the town where facility was located on 1/4/13 at 6:55 AM and also at 7:15 AM indicated that the outside temperature there was 14 degrees F with a windchill of plus 2 degrees F at those times. E9 (CNA) stated on 1/5/13 at 1 PM that E9 came to work at 5:30 AM on 1/4/13 and started R1's shower right away. E9 said that when the shower was finished around 6 AM, R1 left the shower room ambulating with her walker, and went into the East dining room. E9 said that R1 liked to wander in the facility, and sometime in the past, R1 would try to go out doors. E10 (CNA) reported on 1/7/13 at 12:55 AM that E10 was evidently the last staff person who saw R1 in the building before being found outside on 1/4/13. E10 said that E10 learned this as a result of management's investigation into the incident. E10 said that at about 6:50 to 6:55 AM on 1/4/13, E10 saw R1 walking with her walker in the center hall by room [ROOM NUMBER]. E10 said that E10 redirected R1 to go back to Northeast hall, where R1's room was located. E10 said that R1 then turned around in that direction, and E10 proceeded to enter another residents's room nearby. E4 (Licensed Practical Nurse (LPN)) stated on 1/5/13 at 8:25 AM that E4 reported to work on 1/4/13 at about 6:40 AM. E4 said that E4 had just started medication pass on the East wing at about 7:10 AM when Nurse Aide E6 reported that R1 was outside the Southeast exit door on the ground. E4 said that several staff responded, and that E4 saw R1 on the ground on her left side about three feet away from the door. E4 said that R1 was dressed with a long sleeved shirt, pants that were partially pulled down exposing R1's right hip and lower abdomen, socks and shoes. E4 said that R1 was not wearing anything else like a coat, hat or gloves. E4 said that R1 was alert to person, but did not respond to questions about pain or striking her head. E4 said that after R1 was brought inside, E4 took R1's vitals and gave R1 warm fluids. E4 said that E4 did not remember R1's exact body temperature at the time, but said that it was "low." E4 said that when Nurse Aides took R1 back to R1's room for toileting and dressing with warm clothing, R1 complained of pain in her right hip. E4 said that E4 reported the incident to R1's physician, who gave the order for R1 to be transferred to the hospital. E4 said on 1/5/13 at 8:25 AM that R1's normal daily routine was wandering throughout the facility using her walker. E4 stated that R1 wore an electronic monitoring bracelet and thought it was with regard to R1's state of confusion. E6 (Certified Nurse Aide (CNA)) stated on 1/10/13 at 1 PM that R1 generally would wander throughout the facility, sometimes going into other residents' rooms. E6 said in the past one to three months, E6 had seen R1 open the inner door of the set of double exit doors on the Northeast and Southeast halls on occasion. E7 (CNA) stated on 1/10/13 at 12:25 PM that E7 has seen R1 out walking on the facility patio when the weather has been nice in the past. E7 stated that this winter, R1 has still tried to go out on the patio on cold days. E7 said that E7 has had to redirect R1 from the patio door by telling R1 that the weather is too cold outside and that R1 does not have a coat on. E7 stated that E7 had observed R1 trying to go outside the patio door every day last week, probably two to three times a day. E7 stated that E7 thought this was just typical behavior for R1, so E7 did not report these occurrences to management. E10 (CNA) stated on 1/10/13 at 12:40 PM that E10 had observed R1 going outside through the facility's patio door into the large fenced area on nice days. E10 said that R1 has also tried to go out the patio door when it has been too cold outside. E10 stated that within the last two weeks, E10 saw R1 go out the patio door, and E10 had to redirect R1 back into the building. E10 said that staff watch elopement risk residents, and if they would try to go outdoors, "we would try to keep an eye on them." E10 also said that these residents can not be confined or watched constantly, because "it would take seven or eight Aides for those residents here." E12 (Activity Assistant) stated on 1/10/13 at 1:25 PM that about a week ago, a nurse asked E12 to sit and do an activity with R1, because R1 was wandering around so much of the time. R1's nursing note dated 1/4/13 at 7:10 AM documented the incident of R1 being found outside of the Southeast door. The last nursing note which documented R1's wandering and/or exit-seeking behavior before the 1/4/13 entry was dated 12/18/12 at 11 AM (seventeen days earlier): "Seen by front door on rounds." The Immediate Jeopardy was identified at 11:30 AM on 1/11/13. It began on 1/4/13 when R1 exited the building unnoticed and unattended by staff . E1 (Administrator) and E2 (Director of Nursing) were notified of the Immediate Jeopardy on 1/11/13 at 2:15 PM. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 was sent to the hospital on [DATE], diagnosed with [REDACTED]. R1 was placed on 15 minute monitoring for a 72 hour period and re-assessed at a high risk level for elopement. 2. Facility staff were instructed on 1/13/13 that doors with activated alarms must be physically and visually inspected. If a cause for the alarm is not determined, then a resident head count will be initiated. 3. On 1/13/13. licensed staff performed an assessment on all current residents for wandering and fall risk to ensure that care plans were appropriate, and interventions were in place. Newly admitted residents will be assessed on admission. 4. On 1/14/13, facility staff was inserviced on all updated wandering and elopement policies and procedures which include: a.) 15 minute checks on all residents assessed as a high risk for elopement for an assessment period of 72 hours, at which time the checks may be discontinued if no exit-seeking behavior is noted. b.) A list of all exit-seeking residents will be evaluated in the daily department head meeting and by the Charge Nurse on weekends. c.) In the event of an attempted elopement or elopement of a resident, that resident will be added to exit-seeking list and one on one observation of the resident will be done for 24 hours. One to one would be discontinued if no further attempts were noted. All staff, except for one Nurse who is out of the country at this time, were inserviced. Forty-eight staff were inserviced by telephone, and the remainder in person. The one Nurse will not be permitted to work, until the Director of Nursing instructs the person on the new policy and procedures. 5. On 1/14/13, the Director of Nursing audited the appropriateness of interventions in place for each wandering or fall risk resident.

Based on observation, interview and record review, the facility failed to supervise one of seven residents (R1) assessed by the facility as having elopement potential in a sample of five. The facility also failed to develop and implement effective, individualized care plan approaches to address the elopement potential for R1. As a result of these failures, R1's exited the building unnoticed, fell , and developed hypothermia. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1/14/13, the facility remains out of compliance at a Severity Level 2. Additional time is needed to evaluate the implementation of revised policies and procedures and inservicing of staff to determine the effectiveness of these changes. Findings include: A facility Incident Summary dated 1/4/13 indicated that R1 was found outside of the building's Southeast door lying on her left side at 7:10 AM that day. The Summary stated that R1 made no complaints of pain when immediately assessed outside, but complained of pain in the right hip once R1 was back in the building. The same Summary documented that on R1's initial assessment after the incident, R1 had a body temperature of 92.4 degrees Fahrenheit (F). The Summary indicated that R1 was transported to the local hospital at 8 AM on 1/4/13. R1's Emergency Department report dated 1/4/13 from the local hospital indicated that R1 was disoriented, had a body temperature of 96.2 degrees F, was cold to the touch, and complained of pain in the left foot, right hip and neck upon arrival at 8:35 AM. The report indicated that R1 was placed in a heated wrap for ten minutes at a high setting to raise R1's body temperature. The report listed [DIAGNOSES REDACTED]. elbow. Z1 (Emergency Department Physician) stated on 1/4/13 at 2:30 PM that R1 was diagnosed with [REDACTED]. Z1 said that it was very difficult to estimate the amount of time that R1 was exposed to the cold outside, because there are so many variables. Z1 said that outside temperature was about 10 degrees F with a wind chill of plus 1 degree F at around the time R1 was reported found out of the building. The National Weather Service website temperature information for the town where facility was located on 1/4/13 at 6:55 AM and also at 7:15 AM indicated that the outside temperature there was 14 degrees F with a windchill of plus 2 degrees F at those times. E4 (Licensed Practical Nurse (LPN)) stated on 1/5/13 at 8:25 AM that E4 reported to work on 1/4/13 at about 6:40 AM. E4 said that E4 had just started medication pass on the East wing at about 7:10 AM when Nurse Aide E6 reported that R1 was outside the Southeast exit door on the ground. E4 said that several staff responded, and that E4 saw R1 on the ground on her left side about three feet away from the door. E4 said that R1 was dressed with a long sleeved shirt, pants that were partially pulled down exposing R1's right hip and lower abdomen, socks and shoes. E4 said R1 was not wearing anything else like a coat, hat, or gloves. E4 said that R1 was alert to person, but did not respond to questions about pain or striking her head. E4 said that after R1 was brought inside, E4 took R1's vitals and gave R1 warm fluids. E4 said that E4 did not remember R1's exact body temperature at the time, but said that it was "low." E4 said that when Nurse Aides took R1 back to R1's room for toileting and dressing with warm clothing, R1 complained of pain in her right hip. E4 said that E4 reported the incident to R1's physician, who gave the order for R1 to be transferred to the hospital. E4 said that R1's normal daily routine was wandering throughout the facility using her walker. E4 stated that R1 wore an electronic monitoring bracelet and thought it was with regard to R1's state of confusion. E4 reported that on the morning of R1's fall outside, E4 heard no door alarms sound. E4 said that E4 did remember hearing the Southeast door alarm sound though when E4 went out that door to assist R1 lying on the ground. E2 (Director of Nursing) stated on 1/5/13 at 9:10 AM that R1 was not at the facility at that time, but was at hospital (other than the local hospital). E2 said that late last night, the facility sent R1 back to the local hospital for continued complaints of pain in R1's right hip. E2 said that the facility learned from the local hospital in the night that R1's right hip had never been x-rayed when R1 first came to that hospital in the morning. E2 stated that when the local hospital did the right hip x-ray late in the night, a fracture was detected. E2 said that R1 was then transferred form the local hospital to the other hospital, because no local orthopedic physician was available for R1's treatment. An x-ray report dated 1/4/13 at 8:57 AM from the local hospital for R1's left foot indicated a displaced acute fracture of the fifth toe. An x-ray report dated 1/5/13 at 1:27 AM from the local hospital for R1's right hip indicated an impacted right hip fracture. While at the other hospital awaiting right hip surgery on 1/7/13 at 9:35 AM, R1 stated to the surveyor that she had pain in her right hip and that she was going to have surgery. R1 was oriented to person only, and unable to correctly identify what town she was in. R1 said that a couple weeks ago she fell on ice at the courthouse in yet another town and broke her hip. R1 said that it was a nice day when she fell , and that the temperature outside was probably 70 degrees F. E13 (LPN) stated on 1/11/13 at 2:40 PM that when she reported to work at 10 AM on 1/4/13, R1 was at the local hospital. E13 said that sometime after lunch, R1's daughters brought R1 back to the facility in a wheelchair on 1/4/13. E13 said that R1 was in the dining room sipping coffee, but was "quiet and not very active." E13 said that when CNA's took R1 to R1's room for toileting, they reported to E13 that R1's transfer was more difficult than usual. E13 said that E13 observed the next transfer of R1 to the toilet after the supper meal, and found R1 to be "shaky" and not able to ambulate independently. E13 said that the next time she checked on R1, R1 had been put to bed. E2 (Director of Nurses) stated on 1/17/13 at 1:50 PM no elopement precautions were put in place when R1 came back from the hospital on the afternoon of 1/4/13. E2 stated that R1's daughters said R1 could not bear weight well and E6 had told E2 that R1 did not transfer well that afternoon. E14 (LPN) stated on 1/15/13 at 8:50 AM that E14 came to work at 7 PM on the evening of 1/4/13 and received report from E13 concerning R1's incident earlier in the day. E14 said that R1's neurological checks were due at 7 PM, 9 PM and 11 PM that night. E14 said that when E14 checked on R1 early that evening, R1 experienced pain in the right hip on movement. E14 said that she administered Tylenol to R1 at around 8:30 PM, but at 11 PM, R1 reported no relief of pain. Also at 11 PM, R1 was not able to move her right hip. E14 stated that E14 then checked R1's record for x-ray results done at the hospital early that same day, but found none for R1's right hip. E14 said that she called the local hospital and inquired about x-rays done on the right hip, learning from staff there that no x-rays were done for that hip. E14 said that after E14 called R1's physician and family members, R1 was then transferred to the local hospital. E6 (Certified Nurse Aide (CNA)) stated on 1/5/13 at 11:05 AM that E6 spotted R1 lying on the ground on her left side just outside the Southeast hallway door at about 7:15 AM on 1/4/13. E6 said that E6 heard no door alarms sound prior to the discovery of R1, and that R1's walker was sitting in the area between the outer and inner Southeast hall doors. E6 said that she called out for help to other staff, and that E6 and E8 (CNA) went out the door immediately to attend to R1. E6 said that E4 (Nurse) also followed them out to assess R1. E6 said R1 was wearing a sweatshirt, pants, socks and shoes at the time. E6 said that R1's pants were down partway, exposing R1's right buttock. E6 said R1 had had a shower that morning, so her hair was still damp, but stiff and frozen on the right side of R1's head. E6 said that when E6 asked R1 at the time what had happened, R1 just said she was "cold." E6 said that R1 later complained of pain in her right hip when E6 was helping R1 get into another set of clothes in the bathroom of R1's room. E6 stated on 1/7/13 at 12:30 PM that E6 was on her way down the Southeast hall to a room near the end of the hallway, when E6 first saw R1 out on the ground on 1/4/13 at about 7:15 AM. E6 stated that E6 was between the last two rooms on the left side of the hall (rooms 42 and 45) at the time. E6 said that the wood bottom panel of the inner end door blocked the view of the ground where R1 was lying, until E6 was almost at the end of the hall. E6 stated on 1/10/13 at 1 PM that R1 generally would wander throughout the facility, sometimes going into other residents' rooms. E6 said in the past one to three months, E6 had seen R1 open the inner door of the set of double exit doors on the Northeast and Southeast halls on occasion. E9 (CNA) stated on 1/5/13 at 1 PM that E9 came to work at 5:30 AM on1/4/13 and started R1's shower right away. E9 said that when the shower was finished around 6 AM, R1 left the shower room ambulating with her walker, and went into the East dining room. E9 said this was the last time she saw R1 prior to the incident. E9 said that R1 liked to wander in the facility, and sometime in the past, R1 would try to go out doors. E7 (CNA) stated on 1/10/13 at 12:25 PM that E7 has seen R1 out walking on the facility patio when the weather has been nice in the past. E7 stated that this winter, R1 has still tried to go out on the patio on cold days. E7 said that E7 has had to redirect R1 from the patio door by telling R1 that the weather is too cold outside and that R1 does not have a coat on. E7 stated that E7 had observed R1 trying to go outside the patio door every day last week, probably two to three times a day. E7 stated that E7 thought this was just typical behavior for R1, so E7 did not report these occurences to management. E10 (CNA) reported on 1/7/13 at 12:55 AM that E10 was evidently the last staff person who saw R1 in the building before being found outside on 1/4/13. E10 said that E10 learned this as a result of management's investigation into the incident. E10 said that at about 6:50 to 6:55 AM on 1/4/13, E10 saw R1 walking with her walker in the center hall by room 27. E10 said that E10 redirected R1 to go back to Northeast hall, where R1's room was located. E10 said that R1 then turned around in that direction, and E10 proceeded to enter another residents's room nearby. E10 said that R1 was a "walker" in the facility. E10 stated on 1/10/13 at 12:40 PM that E10 had observed R1 going outside through the facility's patio door, located off the center hallway in the building, into the large fenced area on nice days. E10 said that R1 has also tried to go out the patio door when it has been too cold outside. E10 stated that within the last two weeks, E10 saw R1 go out the patio door, and E10 had to redirect R1 back into the building. E12 (Activity Assistant) stated on 1/10/13 at 1:25 PM that about a week ago, a nurse asked E12 to sit and do an activity with R1, because R1 was wandering around so much of the time. E5 (Maintenance Director) stated on 1/5/13 at 10:15 AM that E5 checks all the exit door alarms every day, and that on 1/3/13 the Southeast door alarms worked as usual. E5 said that when he checked the alarms on that door at 8:30 AM on 1/4/13 after the incident, they both worked then as well. E5 said that E5 maintains a log book in which he checks off alarms for each exterior door in the building when the alarms work properly when tested . E5's door alarm test sheet for December 2012, inspected on 1/5/13, contained check marks for every exterior door alarm location, indicating that the alarms were functional. The January 2013 test sheet also indicated by check marks that all door alarms were functional when tested for the first four days of the month. The Southeast hall double exit doors were located at the far end of the hallway. The inner door was wood frame with a glass panel in the center, and the outer door was mostly glass with an aluminum frame. The outer door was equipped with both a built-in central alarm contact on the door jamb and a portable battery powered alarm unit attached to the face of the door. Both alarms were operating when the door was opened on 1/5/13 and again on 1/7/13. The outer door was locked from the outside when closed, so R1 could not have re-opened the door once outside. A sidewalk led from the door onto a larger asphalt walkway which extended around the South side of the building. The area outside the door was enclosed by a fence which also enclosed the facility's South patio area. Neither of the Southeast doors were equipped with hardware to detect a resident electronic monitor bracelet. This type of hardware was noted only on the facility's front door and two doors leading to the facility's main parking lot. The facility's patio door was located off the middle of the Center hallway which joined the East and West wings of the building. R1's [DIAGNOSES REDACTED]. R1's Elopement Risk Assessment sheet, which included assessments done on 12/5/12 and 1/4/13, indicated that R1 scored a "3" and a "4" on those dates, respectively. The sheet stated that a score of "4 or more indicates risk and requires interventions/care plan." R1's Care Plan last updated on 11/28/12 listed a problem of "Elopement Potential for injury R/T exit seeking, looking for something." for R1. The total approaches listed for this problem were: "1:1 time; Attempt to identify the antecedent to the behaviors (cause); Family/significant other visit; Implement a toileting schedule; Offer food/drink; Place resident picture in the Elopement binder at each desk; Redirect with activity; and Electronic Monitor Bracelet, check daily." E11 (Care Plan Coordinator) stated on 1/7/13 at 1:20 PM that a Dementia resident who is ambulatory and wanders meets the criteria for elopement precautions. E11 said that the facility would rather error on the side of safety for residents exhibiting this behavior. E11 said that elopement precautions are to place an electronic monitor bracelet on the resident, put the residents's picture in the "wander book" at the front and back nurses' stations, and have staff "watch these residents more." E11 stated that having staff "watch" the residents did not mean that these residents would be placed on a specific monitoring schedule though. E2 (Director of Nursing) stated the following on 1/8/13 at 11:20 AM with regards to the approach of "1:1 time" listed in R1's Care Plan: "We don't do one to one time, that is, staff sitting with a resident at all times. One to one is meant at the time, for example, a Nurse would redirect a resident." E2 also stated with regards to facility procedure for elopement risk residents that an electronic monitor bracelet is to be placed on the resident as a precaution, but that the care for these residents "really isn't any different." E2 said that residents who become "exit seekers" need to be placed in another facility with a locked Dementia Unit. E2 said that the facility also does not admit residents with this behavior. When the fact that the Southeast door had no electronic monitoring equipment present to detect R1's monitor bracelet at the time of R1's elopement, E2 stated on 1/8/13 at 11:20 AM that the area in which R1 was found outside was fenced. E2 said that R1 could not have left the area . The Immediate Jeopardy was identified at approximately 11:30 AM on 1/11/13. It began on 1/4/13 when R1 exited the building unnoticed and unattended by staff . E1 (Administrator) and E2 (Director of Nursing) were notified of the Immediate Jeopardy on 1/11/13 at 2:15 PM. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 was sent to the hospital on [DATE], diagnosed with [REDACTED]. R1 was placed on 15 minute monitoring for a 72 hour period and re-assessed at a high risk level for elopement. 2. Facility staff were instructed on 1/13/13 that doors with activated alarms must be physically and visually inspected. If a cause for the alarm is not determined, then a resident head count will be initiated. 3. On 1/13/13. licensed staff performed an assessment on all current residents for wandering and fall risk to ensure that care plans were appropriate, and interventions were in place. Newly admitted residents will be assessed on admission. 4. On 1/14/13, facility staff was inserviced on all updated wandering and elopement policies and procedures which include: a.) 15 minute checks on all residents assessed as a high risk for elopement for an assessment period of 72 hours, at which time the checks may be discontinued if no exit-seeking behavior is noted. b.) A list of all exit-seeking residents will be evaluated in the daily department head meeting and by the Charge Nurse on weekends. c.) In the event of an attempted elopement or elopement of a resident, that resident will be added to exit-seeking list and one on one observation of the resident will be done for 24 hours. One to one would be discontinued if no further attempts were noted. All staff, except for one Nurse who is out of the country at this time, were inserviced. Forty-eight staff were inserviced by telephone, and the remainder in person. The one Nurse will not be permitted to work, until the Director of Nursing instructs the person on the new policy and procedures. 5. On 1/14/13, the Director of Nursing audited the appropriateness of interventions in place for each wandering or fall risk resident.