Every finding on record at Heritage Specialty Care

Based on observations, staff interviews, and facility policy review, the facility failed to prepare food in accordance with professional standards for food safety to reduce the risk of food borne illness. The facility reported a census of 127 residents.Findings include:During continuous observation on 5/6/25 from 11:00 AM to 11:24 AM, Staff C, Dietary [NAME] washed her hands and used two towels to remove a steam pan of rice and then a steam pan of pork stir fry from the convection oven. The two towels were placed on the preparation table surface. Staff C scooped the proper amount of rice and pork stir fry for 7 pureed meals. Staff C wiped her hand on one of the towels on the preparation table. Staff C opened a bread bag and donned gloves. Staff C (with gloved hands) used tongs to place 5 slices of bread on a cutting board. Staff C operated the robo coupe with gloved hand used a scoop to add more of the liquid from the pork stir fry. With the same gloved hands, Staff C operated the robo coupe. With the same gloved hands, Staff C used tongs to remove 2 additional slices of bread from the bread bag. Staff C, placed her gloved hands on the sides of the stacked bread slices to straighten the stack of bread slices. Staff C held a knife in her right hand placing it in the middle on the stack of bread slices. Staff C placed her left gloved hand with her palm on the top slices and fingers around the edges. Staff C applied pressure to the top of the stack of bread as she pushed the knife down the stack. Staff C, sliced two additional times through the stack of bread while holding the stack of bread with her gloved left hand. Staff C turned off the robo coup and measured out 3 cups of the pureed rice and pork stir fry and left the remaining pureed mixture in the bowl of the robo coupe. Staff C replaced the bowl of the robo coupe back on the base and pushed on the blade touching the pureed mixture with right gloved hand. Staff C removed her right-hand glove and donned a clean glove. Staff C added the bread to the robo coupe using tong. Staff C with gloved hand stopped the robo coupe and measured out an additional 3 cups of the mixture to a second measuring cup. Staff C replaced the bowl to the base of the robo coupe and again pushed the blade down touching the pureed mixture with her gloved hand. Staff C removed her right glove. Staff C donned a glove on her right hand. Staff C used a rubber spatula and scraped the sides of the bowl of the robo coupe. Staff C held the rubber spatula in her right hand used her left hand to scrape off the rubber end of the spatula and again scraped the pureed mixture in the robo coupe. On 5/6/25 at 11:24 AM, Staff C, didn't recall touching the bread or the pureed mixture with gloved hands that touched multiple nonfood surfaces.On 5/6/25 at 11:25 AM, Staff E, Dietary [NAME] reported she observed the staff member cutting bread slices with gloved hands that came in contact with other surfaces. On 5/6/26 at 11:27 AM, the Regional Dietician reported Staff C shouldn't have touched the bread, pushed the robo coupe blade down or scrape off a rubber spatula with gloved hands that had touched nonfood surfaces when preparing pureed meals. Review of the employee file for Staff C contained a Job Description for the position of Cook, which listed Staff C's date of hire as 1/26/26. The Job Description directed staff to handle and prepare food in a sanitary manner, and to maintain strict compliance with established policy/practices/standards for food preparation and storage. Staff C signed the Job Description on 5/6/26. Review of the Order Listing Report with a date of 5/5/26 listed 6 residents with pureed diet texture.Review of the Food Preparation and Service facility policy revised April 2019 directed staff to adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness.

Based on clinical record review, facility document review, and staff interview, the facility failed to notify the Long-Term Care Ombudsman of a discharge for 3 of 6 residents reviewed (Resident #13, Resident #122, and Resident #126). The facility reported a census of 127 residents.Findings include:1. Review of the electronic health record (EHR) Clinical Census information for Resident #13 revealed an entry of hospital paid leave effective 3/28/26. A Progress Note dated 3/29/26 at 6:34 AM documented Resident #13 had been admitted to the hospital. Review of the Notice of Transfer Form to Long Term Care Ombudsman lacked Resident #13's 3/28/26 hospitalization. 2. Review of the EHR Clinical Census information for Resident #126 revealed an entry of hospital paid leave effective 2/24/26 and an entry of stop billing effective 2/28/26. A Progress Note dated 2/24/26 at 1:56 PM documented Resident #126 had been sent to the emergency room for surgical opinion. The Progress Notes lacked documentation Resident #126 had been admitted to the hospital. A Progress Note dated 2/27/26 at 12:00 PM documented Resident #126 was being discharged . Review of the Notice of Transfer Form to Long Term Care Ombudsman lacked Resident #126's 2/24/26 hospitalization and the 2/28/26 discharge. During an interview on 5/6/26 at 9:42 AM, Staff A, Interim Social Services reported Resident #13 and Resident #126 had not been included on the Notice of Transfer Form to Long Term Care Ombudsman. During an interview on 5/6/26 at 12:05 PM, the Administrator revealed the facility lacked a policy and acknowledged Resident #13 and #126 should have been included in the notifications to the LTC Ombudsman. 3. Review of the EHR Clinical Census information for Resident #122 revealed an entry of hospital unpaid leave effective 3/26/26. A Progress Note dated 3/26/26 at 6:50 PM documented Resident #122 had been admitted to the hospital. The Notice of Transfer Form to Long Term Care Ombudsman lacked Resident #122's 3/26/26 hospitalization.

Based on clinical record review, staff interviews, and facility policy review the facility failed to complete the Minimum Data Set (MDS) assessments to accurately reflect resident condition for a feeding tube, and to accurately reflect Preadmission Screening and Resident Review Level II for 2 of 4 residents reviewed (Resident #3 and Resident #105). The facility reported a census of 127 residents.Findings Include:1. The Minimum Data Set (MDS) assessment for Resident #3 dated 8/23/25 showed Resident #3 was not considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. The MDS listed diagnoses of depression and Post Traumatic Stress Disorder (PTSD). Resident #3's chart held the Notice of PASRR Level Il Outcome dated 3/27/25. The Level II directed Resident #3 needed the level of services provided in a nursing facility and needed specialized services for behavioral health and/or developmental condition. On 5/07/26 at 12:10 PM, Staff G, MDS Coordinator confirmed according to the MDS dated [DATE] for Resident #3, not considered by the state level II Preadmission Screening and Resident Review (PASRR). Staff G confirmed the MDS failed to show serious mental illness, intellectual disability or other related conditions. Staff G confirmed the assessment failed to show the completion of the Level II. Staff G opened the Level II dated 3/27/25. Staff G reported the facility expected the MDS accurate. 2. The Care Plan Report for Resident #105 with a revision date of 2/27/26 identified a Focus Area for tube feeding. Staff were directed to check for placement and gastric contents/residual volume per facility protocol and record (initiated 2/26/26). Resident #105's MDS assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) of 5 out of 15, indicating severe cognitive impairment. MDS Section K Swallowing/Nutritional Status for Resident #105 lacked documentation of a feeding tube. MDS Section Z Assessment Administration documented, in part, [staff who completed the assessment] certified the accompanying information accurately reflects resident assessment information for this resident. Staff B, Registered Nurse (RN) signed the completed Section K Swallowing/Nutritional Status on 4/9/26. Review of the Hospital Progress to Discharge summary dated [DATE], documented Resident #105 had a Left PEG tube (a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly) with site c/d/i (clean, dry, intact). The Order Review History Report electronically signed by the Physician on 4/1/26 included the following: a. Enteral Feed Order every shift Flush feeding tube with at 50ML of water before and after administration of feedings on hold from 04/06/2026 11:08 AM to 04/06/2026 4:51 PMb. Enteral Feed Order five times a day Formula Type / Strength: 1.5 Osmolyte 290 ML 5 times dailyc. Enteral Feed Order three times a day Check Residual every shift if less than 30ML note in progress note. On hold from 04/06/2026 11:08 AM to 04/06/2026 16:51 During an observation on 5/6/26 at 9:57 AM, Staff C, Registered Nurse (RN) provided Resident #105 with 50 ML of water before and after administration of feeding and 290 ML of Osmolyte feeding. Staff C acknowledged Resident #105 had the feeding tube since admission. On 5/6/26 at 1:16 PM, Staff B, MDS Coordinator Registered Nurse (RN) verbalized she was responsible for completing the MDS. Staff B acknowledged Resident #105 has had a feeding tube since his original admission on [DATE]. Staff B verbalized the MDS assessment dated [DATE] was inaccurately coded. On 5/6/26 at 1:21 PM, the Administrator voiced the expectation was the MDS should accurately reflect the resident condition. The MDS Completion and Submission Timeframes facility policy revised July 2017 revealed the Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to [redacted] system in accordance with current Federal and State Guidelines.

Based on observation, interview, and record review, the facility failed to ensure post dialysis assessments and fistula assessments were consistently completed in accordance with physician orders, facility policy, and the comprehensive care plan for 1 of 2 residents reviewed for dialysis (Resident #84). The facility reported a census of 127 residents.Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #84 dated 2/27/26 revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. Per this assessment, the resident had a diagnosis of dependence on renal dialysis, and received dialysis while a resident. Review of Resident #84's Care Plan focus area dated 5/6/25 revealed the resident received hemodialysis related to end stage renal disease (ESRD), and had an arteriovenous (AV) fistula to the left upper extremity (LUE). The Intervention dated 5/6/25 revealed staff to listen to and feel the dialysis site (the fistula) to ensure it was functioning correctly. This was required before dialysis, after dialysis, and on days without dialysis.During an observation and interview on 5/5/2026 at 8:17 AM, Resident #84 explained that while nurses checked her vital signs before she left for dialysis, they often failed to check her afterward or on days when she didn't have an appointment. Resident #84 pulled up her left sleeve and showed the fistula site. She expressed that this worried her because she was afraid of medical complications. In a follow-up interview the next day on 5/6/2026 at 8:32 AM, she noted that no one had checked her dialysis access site at all the previous day. She felt ignored.Review of Resident #84's electronic medical records showed the following present on the resident's April 2026 Supplemental Documentation Record: a. Complete the Dialysis Evaluation prior to dialysis, post dialysis and on non-dialysis days. every day shift every Tues, Thurs, Sat, Sun.b. Complete the Dialysis Evaluation prior to dialysis, post dialysis and on non-dialysis days. two times a day every Mon, Wed, Fri. Records revealed the following: On 4/16/2026 and 4/26/2026 (non-dialysis days), nurses signed off the assessment was done, but the actual evaluation data was missing. On 4/17/2026 (dialysis day), the facility failed to perform the required check after the resident returned from treatment.During an interview on 5/06/2026 at 9:11 AM Staff F, LPN (Licensed Practical Nurse) confirmed that staff were expected to evaluate dialysis residents every day. This included checking the dialysis site for a thrill and bruit (the vibration and sound that indicate the site was working properly) and vital signs. Staff F stated that these checks were supposed to happen before and after every dialysis appointment.During an interview on 5/06/2026 at 12:25 PM, the Director of Nursing (DON) stated that all staff had received online training for dialysis care. The DON acknowledged that while nurses were supposed to assess residents both before and after their appointments, the post-dialysis checks did not always happen. The DON also mentioned that daily checks on non-dialysis days only occurred if a doctor specifically ordered them, and any missed checks should have been documented as refused or noted if the resident was out of the buildingReview of the facility policy titled End-Stage Renal Disease, Care of a Resident with last revised September 2010 revealed staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis.

Based on observation, clinical record review, and interviews the facility failed to address trauma history, PTSD triggers, signs of distress, non-pharmacological interventions, or medication in assessments and care plans for 1 of 1 residents reviewed for Post Traumatic Stress Disorder (PTSD) (Resident #112). The facility reported a census of 127 residents.Findings include:admission paperwork for Resident #112 scanned to the facility on 2/20/2026 documented the resident took 1 milligram (mg) of prazosin at bedtime for chronic PTSD with trauma related nightmares. Resident #112's care plan with an admission date of 3/02/2026 did not include focus areas, goals, or interventions for PTSD, nightmares, trauma, or prazosin.The Minimum Data Set (MDS) for Resident #112 dated 3/08/2026 documented a Brief Interview for Mental Status score of 3/15 which indicated severe cognitive impairment. MDS diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. The box for PTSD was not checked.A document titled Progress Notes dated 4/07/2026 revealed the resident's provider conducted a regulatory visit at the facility. The past medical history did not include PTSD.The task section of the Electronic Health Record (EHR) included monitoring behavior symptoms. A 30 day look back revealed that on 4/13/2026 the resident was documented crying, yelling, pushing, and grabbing. On 04/16/2026 the facility documented the resident yelled/screamed.The resident's Medication Administration Record (MAR) for May 2026 retrieved 5/04/2026 at 1:47 PM documented the resident received prazosin HCl oral capsule 1 mg by mouth one time a day for chronic PTSD with night terrors. The MAR did not include behavior monitoring.On 5/04/2026 at 11:04 AM observed the resident call out from her bed with the sound ah ah ah ah ah ah. Her speech was mostly garbled then she clearly stated her head hurt. The resident closed her eyes and called out again in a higher pitch. Her head moved back and forth on the pillow.On 5/06/26 at 7:42 AM heard resident hum then call out with a loud, repetitive sound. After about a minute she yelled, ahhhhhhhh.At 9:12 AM on 5/07/2026 Staff I, Licensed Practical Nurse (LPN) indicated staff monitor for agitation, aggressive behavior, and residents seeking a lot of attention. She reported Resident #112 yelled and screamed sometimes when she was out of her room and called out when she was in bed, and she didn't really know what caused it. She stated it was addressed with scheduled and as needed medications. She was not aware of a PTSD diagnosis or nightmares/night terrors. She would address it by sitting with a resident and reassure them if she knew it was happening.During an interview on 5/07/2026 at 9:23 AM Staff J, Certified Nurses Aide (CNA) stated she watched residents for threatening, combative, sexual, emotional, and health changes and reported them to the nurse. Staff J reported it was normal for this resident to call out. She wasn't sure what caused it. When asked if she was aware of the resident's PTSD diagnosis or night terrors, she stated she didn't know about that because she didn't work at night. She didn't think it happened during the day, only when she did that 'screaming out thing' maybe.On 5/07/2026 at 10:04 AM Staff K, Assistant Director of Nursing (ADON) confirmed the resident's EHR did not include a diagnosis of PTSD. Because the resident was on a medication for PTSD, the ADON stated she would expect it to show on the list of diagnoses, the care plan, the MDS, and hospice information. She thought the facility would be responsible for identifying triggers, monitoring mood and behaviors, would have regular behavior documentation, should know what led to the PTSD diagnosis, and have a plan for non-pharmacological interventions. She was unable to find that in the resident's EHR.On 5/07/2026 at 10:38 AM the DON confirmed the resident was on prazosin for chronic PTSD with night terrors. She reported the resident admitted to the facility from home and coordination could be difficult. She wasn't sure about the cause of the PTSD or triggers, and stated the social worker who would have addressed that was no longer there. At 12:22 PM, she stated they did locate the diagnosis on the admission orders and confirmed it did not get transferred to the resident's EHR.

Based on interviews, record review, and policy review the facility failed to maintain documentation of staff screening and education regarding COVID vaccination, or maintain records of staff vaccination status. The facility reported a census of 127 residents.Findings include:On 5/07/2026 at 10:16 AM Staff K, Assistant Director of Nursing (ADON), stated she was the facility's infection preventionist. When asked when staff received education regarding COVID testing and vaccination, she stated the same provider who vaccinated residents could give the education to staff. Staff K did not have documentation of who received that education. She indicated she would have to see if there was COVID training in (redacted) their training platform or during orientation because she wasn't involved in all of that. During an interview on 5/07/2026 at 10:38 AM the Director of Nursing (DON) reported the staff received COVID education through (redacted) their training provider. The DON directed back to Staff K for documentation regarding COVID based on her role as infection preventionist. A document titled 2026 Annual CNA (Certified Nurses Aide) Training Schedule updated 02/16/2026 documented staff training by quarter. The list did not include COVID education. An email from the Administrator, dated 05/07/2026 at 11:39 AM included a COVID-19 fact sheet dated 1/31/2025. She indicated that was their COVID education. She did not include information about when staff were provided the education, who received it, how often, or how staff were screened. During an interview on 5/07/2026 at 12:19 PM Staff H, Certified Medication Aide (CMA) stated she had worked at the facility for about 2 years. She reported she was not asked by the facility for her vaccination status, was not offered the COVID vaccine or told where to get one, and the facility did not provide COVID education to her on paper or in person. She thought there might have been a training online but she couldn't remember when. During a follow up interview with Staff K on 5/07/2026 at 12:23 PM she stated she couldn't say if they had any additional documentation that staff were screened for vaccination eligibility, provided COVID education, were offered the vaccine or told where to get it, or if the facility administered the vaccine to any staff through their vaccination partner. A policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents and Staff dated February 2021 indicated staff eligible to receive the COVID-19 vaccine were strongly encouraged to do so. Staff consent would be documented in the employee health record. Staff would be provided a fact sheet specific to the vaccine he or she will receive that explained risks and benefits, contraindications, and potential side effects or adverse reactions.

Based on clinical record review, facility policy review, staff and resident interviews, the facility failed to provide baths for 3 of 9 residents sampled (Resident #2, Resident #3, and Resident #4). The facility reported a census of 123. Findings include: 1. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #4 list of diagnoses included heart failure, chronic kidney disease, type 2 diabetes, chronic obstructive pulmonary disease and a left diabetic foot ulcer. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated the resident had intact cognition. The MDS assessed the resident required moderate assistance of 1 staff for bathing. Resident #4's Care Plan dated 6/27/25, directed the moderate assistance of 1 staff for bathing. During an interview with the resident on 2/23/26 at 10:52 am, he stated he did not get a shower at all last week, he is to have his showers on Wednesday and Saturdays. The resident stated staff told him they did not have enough staff to give him his shower and we don't do baths on Sundays. Review of the bathing records revealed the following: a. In December 2025 the staff failed to provide a shower on December 3 and 31st.b. In January 2026, the staff failed to provide showers on 1/24, 1/28 and 1/31. c. In February 2026, the staff failed to provide showers on 2/4, 2/7, 2/11, 2/14, 2/18 and 2/21. 2. Review of the MDS for Resident #2, dated 1/9/26, revealed a list of diagnoses which included hemiplegia, right side affected. The BIMS score of score of 15/15 indicated intact cognition. The MDS assessed the resident required the assistance of 1 staff for bathing. Resident #2's Care Plan, dated 7/8/24, directed she required assistance of 1 staff for bathing. During an interview on 2/24/26 at 8:33 am, Resident #2 stated she did not receive twice weekly baths. Review of the bathing records revealed the following: a. In December 2025 the staff failed to provide a shower on December 9.b. In January 2026 the staff failed to provide a shower on January 13, 16 and 30th.c. In February 2026 the staff failed to provide a shower on February 10th. 2. Review of the MDS dated [DATE], revealed Resident #3 list of diagnoses included stroke with left side hemiplegia and epilepsy. The BIMS score of 15/15 indicated intact cognition. The MDS assessed the resident required the assistance of 1 staff for bathing. Resident #3's Care Plan, dated 11/21/23 directed he required assistance of 1 staff for bathing. During an interview on 2/24/26 at 11:45 am, Resident #3 stated he takes his bath/shower on Tuesday and Fridays.Review of the bathing records revealed the following: a. In January 2026 the staff failed to provide a shower on January 13.During an interview on 2/25/26 at 10:45 am, Staff B, Certified Nursing Assistant (CNA) stated the residents are not getting their baths as they should because staff are pulled to work other units when a staff member does not show up for work, which leaves units short. Review of a facility policy titled Activities of Daily Living (ADL's), Supporting, revised March 2028) revealed a Policy statement which declared Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observations, clinical record reviews, facility policy review, provider interview, staff and resident interviews, the facility failed to complete wound care as ordered, and failed to assure a resident attended schedule appointments for 1 of 9 sampled residents (Resident #4). The facility reported a census of 123 residents.Findings include: Review of Resident #4's Minimum Data Set (MDS) dated [DATE], revealed a list of diagnoses which included heart failure, chronic kidney disease, type 2 diabetes, and a left diabetic foot ulcer. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. The MDS assessed Resident #4 alert, oriented and could give accurate information. The MDS identified the resident required moderate assistance of 1 staff for dressing, toileting, bathing and walking. The resident utilized a walker in their room and a wheelchair outside of their room.Review of Care Plan, revised 11/12/25, revealed a Focus area to address I am at increased risk for skin impairments/pressure ulcers due to catheter use, diabetes and impaired mobility. Interventions included, in part:a. Monitor and document location, size and treatments of skin injury and to report abnormalities, failure to heal, signs and symptoms of infection to the physician. Initiated: 6/25/25.b. Weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudate (drainage), and any other notable changes or observations. Initiated: 6/25/25c. Wound Vac (a device used to promote healing) on at all times to left heel. Initiated: 6/25/25.Review of the Order Summary Report (the summary includes the resident's current orders), revealed the following orders: a. Apply Iodoflex iodine pad to left lateral heel ulcer and cover with dry gauze. Secure the gauze wrap and change every other day, to follow up in 1 week or sooner if need. Start Date: 1/10/26.b. Iodoflex External Pad (Cadexomer iodine) apply to left lateral heel topically in the morning every 2 days for diabetic ulcer. Once out of Iodoflex may use betadine gauze. Start Date: 1/23/26. Review of the January and February 2026 Treatment Administration Records (TAR) revealed:a. Apply Iodoflex iodine pad to left lateral heel ulcer and cover with dry gauze. Secure the gauze wrap and change every other day, to follow up in 1 week or sooner if need. Start Date: 1/10/26. Review of the TARS revealed the treatment not completed as scheduled on 1/26/26, 2/3/26, and 2/9/26. b. Iodoflex External Pad (Cadexomer iodine) apply to left lateral heel topically in the morning every 2 days for diabetic ulcer. Once out of Iodoflex may use betadine gauze. Start Date: 1/23/26. Review of the TARS revealed the treatment not completed as scheduled on 1/23/26, 1/27/26, and 2/8/26. During an interview on 2/24/26 at 7:45 am, the Podiatry wound clinic provider stated Resident #4 received services for wound follow up. The provider stated Resident #4 confides in her and she is concerned with his wound care needs not being met. The provider explained her concerns are with missed appointments at the wound clinic and the infectious disease provider. She stated wanted to see the resident every week. She stated Resident #4 had his first appointment 9/19/25, and then she did not see him again until 10/21/25. She stated the resident did have hospitalizations during this time. She added the resident was a no show for the following wound care appointments: 10/28/25, 10/31/25, 11/4/25; and a no show for the following infectious disease appointments: 10/30/25, 11/24/25. The provider added Resident #4 missed appointments on 12/9/25 and 1/14/26 due to a lack of transportation. The provider stated there has also been concerns with the facility being able to get the supplies for wound care treatments She stated she gives supplies if able, and makes changes to the orders as needed. The provider stated the resident has also reported the facility has not completed wound care treatments every other day, instead they do them every 2 to 4 days. Review of the electronic health record (EHR) revealed a provider note dated 1/9/26 with an order for the resident to return in one week (1/16/26). The EHR review revealed Resident #4 did not attend a wound clinic appointment on 1/16/26. The resident returned to the clinic on 1/21/26. During an observation and interview on 2/23/26 at 10:45 am, Resident #4 sat in his recliner with his feet down. Resident #4 reported he has appointments at the wound clinic every other week. Resident #4 stated he has missed appointments as the facility forgot to set up a ride for him or they do not have a staff to drive the van. Resident #4 observed to have a white gauze bandage with light blue tape applied to anchor the dressing in place. The dressing lacked a date. At 11:25 am Staff A, Licensed Practical Nurse entered the resident's room. Resident #4 asked Staff A if she was going to change the dressing on his foot. Staff A informed the resident the dressing change had already been done for the day. Review of the February 2026 Treatment Record indicated the morning left lateral heel wound treatment on 2/23/26 was signed off by a Staff B, Certified Medication Aide (CMA). During an interview on 2/24/26 at 12:15 pm, Staff B-CMA stated she accidently signed off all treatments for Resident #4 by mistake the morning of 2/23/26. During an observation on 2/24/26 at 9:10 am, Resident #4 sitting in his recliner. The residents rested on the floor, with a white Kerlix wrap on his left foot anchored by light blue tape. The resident stated it is the same dressing that he had on yesterday. Staff C, LPN and Assistant Director of Nursing donned a gown and completed a wound dressing change to Resident #4 left lateral foot wound. Staff C stated the dressings she removed was not dated to indicate when it was last completed. During an interview on 3/2/26 at 11:00 am, Staff C, LPN, stated when a resident goes out to a wound clinic appointment the staff are to receive the paperwork from the resident upon return, review for new orders and schedule the next appointment if appropriate. Staff C indicated Resident #4 usually goes to the wound clinic on Wednesday and that he does not refuse these appointments. She stated he is able to voice his ideas and knows the wound treatments that are ordered. Review of an undated Wound Care procedure. The procedure states the purpose of wound care is to promote healing. When a staff member does the treatment, they are to prepare items needed to complete the wound treatment, the staff should verify there is a physicians' order. They are to review the resident's care plan to assess for any special needs the resident may have and then assemble the equipment. The procedure directs the staff if the resident refuses the treatment, they are to document the reason why and notify the resident's physician.

Based on observations, clinical record review, review of food temperature logs, resident and staff interviews, the facility failed to provide food that is palatable for 1 of 9 sampled residents (Resident #4). The facility reported a census of 123 residents. Findings include: Review of Resident #4's Minimum Data Set (MDS) dated [DATE], revealed a list of diagnoses which included heart failure, chronic kidney disease, type 2 diabetes, and a left diabetic foot ulcer. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated the resident's cognition intact. The MDS assessed Resident #4 alert, oriented and could give accurate information. Review of Resident #4's care plan initiated on 6/25/25, the care plan directed staff to provide a diet low in sodium, regular texture and thin liquids as the resident is at a risk due to his chronic obstructive pulmonary disease, heart failure and kidney disease and to monitor his tolerance of the diet that is ordered. During an interview with Resident #4 on 2/23/26 at 10:52 am, he stated he eats all of his meals in his room and reports the food is cold almost every meal. Resident #4 stated the staff frequently serve the food later than scheduled and it doesn't feel it taste very good. An observation on 2/23/26 started at 12:45 pm of the meal service provided at Station 3 revealed: a. At 12:45 pm there are 12 residents seated in Station 3 dining room waiting for lunch. b. At 12:46 pm the dietary aide wheeled out the beverages and started to pass beverages.c. At 12:58 pm the dietary staff wheeled the hot food cart out to the dining room and begin to serve the residents. At this time the residents are asking for forks. Staff D-Food Service Supervisors present and attempted to find a plug in for the hot cart. The hot cart had to be moved close to the dietary door as the food cart plug in cord was too short to reach. Residents asked for forks to eat their meal but were told they did not have any forks for them to use. d. At 1:08 pm the dietary staff prepared Resident #4's tray of food directly from the food cart and Staff D-Food Service Supervisor took it directly to the resident. e. At 1:09 pm Staff D, Food Service Supervisor set the food tray on the residents over the bed table, and took the temperature of the food items. Temperature (in Fahrenheit) Results included: Pork chop - 101.8 F degrees, potatoes - 121.8 F degrees and the white milk - 45.4 F degrees. Staff D left the resident's room, went to the kitchen and prepared a fresh tray of food for the resident. f. The dietary staff served the last tray of food to Station 3 residents at 1:27 pm.Review of the temperature logs for the noon meal on 2/23/26 revealed prior to serving the meat the temperature was 189 degrees and after serving the meal was 171 degrees, the potatoes/starch was not temped before or after the meal and the milk temperature before serving was 34 and after serving the milk was 39 degrees. During an interview on 3/2/26 at 10:20 am, Staff-D Food Service Supervisor stated they are working on ways to keep the food hotter and the beverages colder when they are served. Review of the facility policy titled Food Preparation and Service, revised April 2019 directed, in part Food Service/Distribution #1. Proper hot and cold temperatures are maintained during food service. Foods that are held in the temperature danger zone are discarded after 4 hours.

Based on clinical record review, observations, staff and resident interview and facility policy review the facility failed to provide safe transfers for 3 of 4 residents reviewed (Residents #1, #6, #7). The facility reported a census of 115 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident#1 dated 8/1/25, listed diagnoses of stroke, high blood pressure (HTN), heart failure, non-Alzheimer's Dementia, Bipolar disorder, seizure disorder. The MDS reflected the Brief Interview for Mental Status (BIMS) score of 15 out of 15 intact cognition. The MDS identified Resident #1 dependent on staff for transfers, dressing, toileting, and hygiene. The Care Plan for Resident#1 reflected a revision date of 5/8/25, directed she needed the assistance of two staff and the stand lift to transfer. The Nurse Progress Note dated 8/19/2025 at 3:30 PM revealed an Incident, Accident, Unusual Occurrence Note Provider notified on call aware situation and laceration to left side head. New order to send to Emergency Department (ED) for further eval. The Progress Note dated 8/19/2025 at 3:41 PM, identified a Communication from Nursing to Therapy a change in condition or an area with a deficit that may warrant therapy: A fall from full body lift, sustained laceration to back of head. Assist of two staff with stand lift. The Encounter Note dated 8/21/25, revealed nursing reported on 8/19/25 Resident#1 was mid transfer with full body lift when she slipped out of the sling and fell to the ground from approximately sitting height. She struck her head and sustained a laceration. As she is anticoagulated due to medication, Resident#1 sent to the emergency room (ER) for immediate evaluation. Head Cat scan unremarkable, she received five staples to the laceration on her left side of her scalp and discharged back to the facility in stable condition. The Disciplinary Action Form dated 8/29/25, revealed on 8/19/25 the facility terminated the employment of Staff D, Certified Nurse Aid (CNA) because he failed to adhere to safety protocols and the Individualized Care Plan. The resident's Care Plan directed two-person transfer utilizing the stand lift, the employee attempted the transfer independently, selected the incorrect (full body) lift. The resident fell from the lift, sustained a laceration that required staples in the ER. The Encounter Note dated 10/24/25 at 7:23 AM reflected Resident#1 developed new or worsening pain. The note reported skin discoloration, the Provider ordered her to the hospital for ultrasound of the breast. The Nurse Progress Note dated 10/24/2025 at 8:29 described Resident#1 with abnormal bruising on right breast and right upper arm, she denied any recent injury or fall. No other areas of bruising or open skin noted. The Nurse Progress Note dated 10/24/2025 at 9:28 AM reflected a new order from the Provider to hold the blood thinning medication for 72 hours and ultrasound right breast for unexplained mass/bleeding internal. The Nurse Progress Note dated 10/24/2025 at 1:28 PM Resident assessed immediately, pain assessment 8 out of 10. Alert and oriented, unable to describe what happened. No open area, bleeding, signs or symptoms (s/s) of infection noted. Her skin warm to touch. No visible other injuries noted. Sent the resident to hospital for further evaluation, related to mass, internal bleeding. The Ultra Sound (US) of Right Breast dated 10/24/25, revealed diffuse (spread) edema within the breast with no drainable fluid collection. This may represent mastitis (inflammation of the breast tissue) or hematoma (is a collection of blood outside of blood vessels, likely resulting from trauma or potentially an underlying condition). Clinical follow -up is recommended to ensure resolution and no underlying pathology. The History and Physical dated 10/28/25, showed Resident#1's extensive ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) over body. The note identified Resident #1 stated this is not a new lift at facility, she felt they are not properly placing her and lift before they moved her which is caused bruising. The Physical Exam described the breasts: Extensive dark red/purple/black ecchymosis over bilateral breasts. Some areas of ecchymosis with mild yellowing indicating age. Tender to touch. A photograph included in the document showed dark purple and yellow edges to both breasts, the top of her abdomen and three quarters of her right arm. The Physician's Progress Note last updated 11/2/25, identified multiple bruises mostly on right arm, left side of abdomen, lateral side of legs, both exposed breast area not extending to skin covered under the breast. The Cat scan of the chest showed hyperdensity and asymmetric enlargement of the right pectoralis major and minor musculature with adjacent edema and stranding extending into the right breast. This is concerning for a hematoma. On 11/3/25 at 3:05 PM a transport driver wheeled Resident#1 back inside the facility and Staff C, CNA pushed her to her room. Staff B, CNA and Staff C transferred Resident #1 to her wheelchair (w/c) with the full body lift. Resident #1 leaned to the left significantly during the transfer from the transport wheelchair to her personal w/c, the lift sling failed to hold her right buttock and leg. After staff sat her in her personal w/c staff readjusted the positioning of the full body sling under Resident #1 lifted her for the second time to improve her positioning in her w/c. On 11/4/25 at 8:59 AM Resident #1 reported she continued to have pain in her breasts. On 11/5/25 at 8:52 AM the Provider reported he watched the nursing staff transfer Resident#1 on 10/24/25 to assess the process and look for the cause of the injury to her breast. He revealed he could see how ill positioning of the right breast could fall into her right armpit and with the squeezing of the sling when she is lifted that resulted in breast tissue injury. On 11/5/25 at 2:49 Staff E, Assistant Director of Nursing (ADON) stated Resident #1 positioning created a challenge for her transfers at times. On 11/6/25 at 11:15 AM the Director of Nursing (DON) reported she felt the bruising to Resident#1 resulted from a combination of the breast placement with transfers and the mass found in each breast after the CT as well as the blood thinning medication. 2. The MDS for Resident #6 dated 10/17/25 listed diagnoses of Atrial Fibrillation, non-Alzheimer's dementia, and Multiple Sclerosis (MS). The MDS identified a BIMS of 12 out of 15 Mild cognitive impairments. The MDS reflected Resident#6 dependent on staff for transfer chair to bed. The Care Plan for Resident #6 dated 9/27/23, directed she needed assist 2 staff and a full body lift to transfer. The Weight Summary for Resident #6 dated 11/5/2025 [NAME] a weight of 240.6 Lbs. On 11/5/25 at 2:15 PM Staff A, CNA and Staff B used the full body lift to transfer Resident #6 from the w/c into the bed. The sling covered Resident #6 during the transfer. Staff A reported she needed a big one due to her size. Staff A looked at the size it reflected XXL on the tag. The Staff E, Assistant Director of Nursing (ADON) asked the CNAs about the lift sizing chart. Staff E reported she expected the chart hung on all the lifts so the CNA knew the correct size of sling they needed to use for each resident. 3. The MDS for Resident #7 dated 7/25/25 listed diagnoses of coronary artery disease (CAD), non-Alzheimer's dementia. The BIMS for Resdient#7 reflected a score of 3 out of 15, severe cognitive impairments. The MDS reflected her dependency on staff for transfers from bed of chair. The Care Plan for Resident #7 dated 10/2/23 directed she required assistance of 2 staff and the full body lift. The Weight Summary for Resident #7 dated 11/5/2025 listed a weight of 210.8 Lbs. On 11/5/25 at 2:46 PM Resident #7 sat in the w/c in the lobby at the table with the full body lift sling under her, the tag read XXL. Staff B reported Resident #7's weight in the morning on 11/5/25 reflected 210 pounds. The Transfer Lift chart read that lift weight for an XXL is expected for 280 pounds +. On 11/5/25 at 2:49 PM Staff E, confirmed the staff used the wrong sling for R#6 & #7 transfers. On 11/6/25 at 8:12 AM Staff E reported the staff needed education of the lift sizing per the resident's weight. On 11/6/25 at 11:15 the DON reported she felt the staff can use a larger sling based on the fact she has upper body girth. She said the CNA's make a judgement on the size of the sling they use. The Sling Color Sizing Code System, undated, identified large, Burgundy- 190-320 pounds, extra-large- 280-450 pounds, extra extra large 400-600 pounds.The NOTE! The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. A proper fit will involve the judgment of the caregiver.*It is important to evaluate the width of a patient in relation to the width of the sling.**It is important that no portion of the patient overlap the sides of the sling.Color Coding is used on the binding of slings. It is not used with specialty slings.It is important that the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of neck). The facility provided a policy titled Safe Lifting and Movement of Residents dated 7/2017, nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include:a. Resident's preferences for assistance;b. Resident's mobility (degree of dependency);c. Resident's size;d. Weight-bearing ability;e. Cognitive status;f. Whether the resident is usually cooperative with staff; andg. The resident's goals for rehabilitation, including restoring or maintaining functional abilities.Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings.

Based on observation, clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure each resident had the call light accessible for Resident #3, Resident #6, and for multiple residents observed in resident rooms. The facility reported a census of 118 residents. Findings include: 1.The MDS (Minimum Data Set) dated 7/24/2025 revealed Resident #6 had no cognitive impairment, required moderate assistance of staff to transfer from bed to chair and had a history of falls. The resident had diagnoses including heart failure and neoplasm of the pelvis. The resident's care plan reported the resident had a history of falls. It directed staff to encourage the resident to use the call light. Observation on 8/18/2025 at 8:25 am revealed the resident sat up in bed eating breakfast. The resident's soft touch call light sat on the bedside stand out of reach, and the bed control sat on the floor. The resident indicated she could not reach the call light and stated she would yell for help if needed. 2.The MDS dated [DATE] revealed Resident #3 had no memory impairment, required partial assistance for transfers from one surface to another and had diagnoses including stroke and hemiplegia. The Care Plan revealed the resident had a fall risk dated 10/12/2024, and it directed staff to encourage the use of a call light and ensure it is within reach. On 7/30/2025, Staff B, CNA (Certified Nursing Assistant) reported when she arrived to work, she heard the resident calling out for assistance and rattling the bed rail. Staff B observed the resident's call light on the wall and out of reach. The resident had been incontinent of bowel and bladder. The Facility Incident Report dated 7/30/2025 included the resident reported the third shift aide failed to check and change him and he could not call for help since the call light was out of reach. Staff assessed the resident and failed to identify a skin issue. The facility educated staff and disciplined the night shift aide assigned to the resident. On 8/18/2025 at 10:00 a.m. the resident verified the incident occurred one time.The facility policy titled Answering the Call Light revised March 2021 included: .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.3. Observations on 8/18/25 during a facility wide call light audit at 8:35 am-8:54 am revealed the following: a. At 8:35 am, the call light in room [ROOM NUMBER] C 27 noted to be hanging on the wall, the resident in bed without access to her call light. b. At 8:37 am, the call light in room [ROOM NUMBER] C 26 not assessable to the resident, the resident in bed, the call light on the floor next to the resident's bed.c. At 8:43 am, the call light in room [ROOM NUMBER] B 43 the call light in the top drawer not accessible to the resident as the resident rested in bed.d. At 8:45 am, the call light in room [ROOM NUMBER] B 16 noted on the floor. The resident in bed eating breakfast, the resident asked where the call light was, she stated she had no idea.e. At 8:47 am, the call light is noted to be hanging on the wall, the resident in his wheelchair. The call light not assessable to the resident. f. At 8:47 am, the call light noted to be hanging on the wall. The resident is sitting in his wheelchair watching TV. The call light was not assessable to the resident.

Based on observation, maintenance record review, staff interviews, and facility policy review, the facility failed to provide a clean and homelike environment. The facility reported a census of 118 residents. Findings include: Observation on 8/18/25 at 8:00 am revealed a large, blackened area on the carpet in the main lobby area, located between the conference room and Administrator's office. The blackened area measured approximately 15 feet long by 6 feet wide. Observation on 8/19/25 at 8:46 am revealed the carpet at the entrance of the skilled unit coming from Station 3 had a darkened area which measured approximately 13 feet long by 3 feet in width. On 8/20/2025 at 10:25 a.m., Staff C, DON (Director of Nursing) reported when she first started in June, the facility had a resident who had a visitor who brought some things in from home, and they discovered bed bugs. They isolated the belongings, bagged them up, and treated the room. On 8/20/2025 at 11:25 am, Staff D, the Corporate Director of Facilities manager, revealed the facility had the carpet cleaned two times in the last six months, two months ago and then within the last six weeks. When they found bed bugs in a room, they followed facility policy and procedure. The facility notified him, and staff removed the resident from his room and provided a shower. They bagged and laundered his clothing and relocated the resident to another room for that night. They bagged everything in the room, and laundered and dried it at 160 degrees. The facility had a contract to pests. They pulled light and plug covers, and removed furniture from the room. If the facility owned the chair in the room, it was put in the dumpster. If the family owned the chair they worked with the family and treated the chair. Room was left empty for 24 hours and rechecked by the contracted company. On 8/20/2025 at 11:41 am, Staff E, Maintenance reported station 4 had bed bugs in a room. Staff took the resident to the shower room, bagged the clothing, moved him to another room, and the contracted company came. They had not had further issues. The resident had bed bugs at home and family came into the building and brought clothing from home. They asked family to refrain from bringing in clothing and they took care of the issue at home. [Contracted company name redacted] came quarterly and as needed. Housekeeping has control of the carpet cleaning. On 8/20/2025 at 12:05 pm, Staff F, Housekeeping Supervisor reported the facility had a commercial company clean the facility carpet. At this point, the carpet was worn down and cleaning was not very effective. They were working on replacing the carpet, but they had not identified when it would get completed. The most recently provided service on August 7. They planned to remove the carpet and install laminate flooring. The facility had four housekeepers during the day and two on the evening shift. Daily housekeeping tasks included the cleaning of each bathroom, wiping down handrails, toilets, and everything a resident touched. Housekeeping staff deep cleaned one room every day, stripped and wax floors in the fall, and buffed floors every Tuesday. During an interview with Staff A, Maintenance Supervisor at 8:10 am, Staff A stated the corporation had a plan to replace the dirty carpet but it won't probably happen until next year.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies form, the facility Quality Assurance and Performance Improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 118 residents. Findings include:The CMS 2567, dated June 12, 2025 reflected deficiencies identified for medication administration. The current complaint survey, conducted 8/18/2025 - 8/26/2025 also identified the above concern. In an interview on 8/20/2025 at 2:00 pm, the Administrator explained the QAPI team met monthly to discuss the Performance Improvement Projects (PIP) and quarterly with the full team. Data was collected via an online program, suggestion boxes, grievance forms, and when the [State Agency] found a deficiency. The facility prioritized the issues that impinged on residents' quality of life or rights. She explained there was a PIP in place for the previous survey deficiency but they were still struggling.On 8/20/2025 at 10:30 a.m., the DON (Director of Nursing) reported the QAPI team reviewed medication administration rights, reports of refusals and missed medications, and continue to do audits for the last survey ending in June. The facility QAPI Plan received from the administrator on 8/25/2025 included: Our companies written QAPI Plan provides guidance for our overall quality improvement program. QAPI activities and outcomes will be on the agenda of every staff meeting. The QAA (Quality Assessment and Assurance) committee will report all activities to the governing body during their regularly scheduled meetings. The QAA committee will have responsibility for reviewing data, suggestions, and input from residents, staff, family members and other stakeholders. The QAA committee will prioritize opportunities for improvement and determine which performance improvement projects will be initiated. When an issue or problem is identified that is not systemic and does not require a performance improvement project, the QAA committee will decide how to correct the issue or problem. These corrections may include an easy decision, corrective action plan, or rapid improvement cycle.

Based on clinical record review, staff and resident interviews, observations and policy review the facility failed to administer medications as ordered for one of three residents reviewed (Resident #8). The facility reported a census of 118 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had an admission date of 8/12/25. The resident had a Brief Interview for Mental Status score of 9 out of 15, which revealed moderate cognitive impairment. The resident had diagnoses which included Non-Alzheimer's Dementia, Traumatic Brain Injury and anxiety. The resident required partial/moderate assistance with activities of daily living. Review of the Facility Incident Report dated 8/12/25 at 11:53 am revealed the following: Resident #8 received another's medication in error on 8/13/25 during morning medication pass. The Incident Report revealed the facility received a phone call from the pharmacy provider reporting they sent the wrong medications for Resident #8. The pharmacy placed another resident's medications (a resident not at the facility) into the medication bubble pack with Resident #8's name on the bubble pack. The pharmacy sent 4 medication bubble packs for Resident #8 which included: Diltiazem ER (extended release) 360 milligrams (anti-hypertensive), Furosemide 20 milligrams (diuretic), Lisinopril 10 milligrams (anti-hypertensive) and Potassium ER 20 milligrams (supplement to treat low potassium). Review of the resident's physician orders dated 8/12/25 revealed the resident had the following medication orders: Amlodipine 10 milligrams one time daily (anti-hypertensive)Aspirin EC (enteric coated) 81 milligrams daily (blood thinner)Fluoxetine HCL 10 milligrams daily (anti anxiety) Lisinopril 20 milligrams 2 tablets daily (anti-hypertensive)Pravastatin Sodium 40 milligrams daily (high cholesterol)A review of the Facility's Progress Notes revealed the following notation regarding the medication error dated 8/13/25 at 12:00am: The Medical Provider notified of the medications. Hourly vitals initiated from the time the medication was given per medical provider. The daughter became aware. During an interview with Staff G-LPN (Licensed Practical Nurse) on 8/20/25 at 12:45 pm, the staff stated he worked on the day shift of 8/13/25 on Resident #8's unit. He went into her room and offered her the morning medications. He reported she took the medications whole with water. The process he did to pass her medications; he checked each medication he gave against the medication administration record for the resident, compared them to make sure he gave the correct medications. He said the medications in the card matched the [Electronic Health Record] medication administration record. He stated at about 10:00 am Staff H-LPN/Assistant Director of Nurses (ADON) approached him and asked if he gave Resident #8 her medications earlier, he said he had. Staff G stated Staff H told him he gave the resident the wrong medications. Staff G pulled up the resident's medication administration record at that time, Staff G stated it was a different one from the one he saw earlier. Staff G stated he knew that [Electronic administration record] had made some errors recently. He stated he gave Resident #8 her medications between 7:30-8:00 am that morning. He stated he had no idea how the electronic medication record got changed. During an interview with Staff H at 8/19/25 at 2:30 pm., Staff H stated she got a call from their pharmacy provider pharmacist, and they reported they sent the resident the wrong medications to the facility which was discovered at the pharmacy level. Staff G gave the incorrect medications to the resident on 8/13/25 at 8:13 am. When Staff H asked the nurse about the medications, he had already given the medications. He said he looked at the meds and claimed the medications in the card with Resident #8's on them matched the medication administration record. The resident was given Lasix, diltiazem, lisinopril and potassium in error. Staff H stated she examined the medication cards for Resident #8 prior to sending them back to the pharmacy and stated each card was missing 1 pill. She stated the medication cards had Resident #8's name on them but they were not the resident's medications. If Staff G would have compared the medication cards to the electronic medication administration record he would have recognized the error prior to giving the resident the wrong medications. During an interview with a Pharmacy Representative on August 25, 2025 at 8:40 regarding Resident #8's medication error. The Pharmacist stated they sent the wrong medication to the facility on 8/12/25. They discovered the error the following morning at about 10:00 am and alerted the facility. The Pharmacist spoke to Staff H and reported the error. Staff H removed 4 medication bubble packs to return to the pharmacy. The 4 bubble packs were each missing 1 pill which he indicated were given to Resident #8 that morning. A review of the Facility Policy titled Administering Medications dated as last revised April 2019 had documentation of the following: a. As required or indicated for a medication, the individual administering the medication records in the resident's medical record. aa. The date and time the medication was administered;bb. The dosage;cc. The route of administration;dd. The injection site (if applicable);ee. Any complaints or symptoms for which the drug was administered;ff. Any results achieved and when those results were observed;gg. The signature and tile of the person administering the drug;b. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy and approved by the Director of Nursing Services.

Based on observation, staff and resident interviews, and clinical record review the facility failed to offer toileting assistance for one of three residents reviewed. (Resident #3). The facility reported a census of 118 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had no memory impairment, required partial assistance for transfers from one surface to another and had diagnoses including stroke and hemiplegia. The Care Plan revealed the resident had a fall risk dated 10/12/2024, and it directed staff to encourage the use of a call light and ensure it is within reach.On 7/30/2025, Staff B, CNA (Certified Nursing Assistant) reported when she arrived to work, she heard the resident calling out for assistance and rattling the bed rail. Staff B observed the resident's call light on the wall and out of reach. The resident had been incontinent of bowel and bladder. The Facility Incident Report dated 7/30/2025 included the resident reported the third shift aide failed to provide assistance when he had incontinent bowel and bladder. He could not call for help since the call light was out of reach. Staff assessed the resident and failed to identify a skin issue.On 8/18/2025 at 10:00 am the resident reported the incident occurred one time. He had no recall of the staff involved and no further concerns.On 8/20/2025 at 10:28 am, Staff C, DON (Director of Nursing) reported the morning Resident #3 did not have his call light within reach and called out for help, he had incontinent bowel. He reported to staff the night shift aide failed to place his call light within reach after she had been in there previously. She placed the call light on the box, on the wall. The resident was independent in his room and at times staff put it out of his way so he didn't roll over it. They re-educated staff and focused on what defines abuse and customer service.On 8/20/2025 at approximately 11 am, Staff B, CNA reported working at the facility since February, 2025, full time on the day shift from 6 am - 2 pm. Normally, staff did a room to room report with the night shift, however on July 30th, they did not do a room to room report. She entered the front door and walked down the hall to the nurse's station when she heard Resident #3 shaking his bed rail, and calling hey. That was what he did if he dropped his call light or cannot get to it. Staff B observed the resident with incontinent bowel and bladder. She asked him what was going on since he was normally continent. He reported someone put him into bed and took his call light. Staff B observed the call light on the wall, on top of the call light box. Staff B provided cares, transferred him to his chair and asked Staff G, ADON (Assistant Director of Nursing) to speak to him. The facility Activities of Daily Living (ADLs), Supporting, revised March 2018 included: Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: . c. Elimination (toileting).

Based on observation, record review, resident, family and staff interview, the facility failed to administer medications as ordered for two of three residents reviewed (Residents #2 and #3). The facility reported a census of 118 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 and had the following diagnoses: Heart Failure, Coronary Artery Disease, Wound Infection, and Diabetes Mellitus. The MDS also identified Resident #2 to be totally dependent on staff assistance for oral hygiene, toileting hygiene, lower body dressing, and transfers from bed to chair or toilet. A review of the Facility Incident Report dated 5/23/25 at 6:30 AM, had documentation of the following: Resident #2 received Resident #7's medications in error. Resident #2 did not have a profile picture on file, no name tag on door, and was responding to the name for Resident #7 during conversation that morning. Resident #2 was given Resident #7's medications as follows: Tylenol, Buspirone, Cetirizine, Lamotrigine, Magnesium Oxide, Meloxicam, Mupirocin, Prednisolone Acetate eye drops, Risperidone, Sertraline, Topiramate, and Vitamin D3. Resident #2 became lethargic afterward. A review of Resident #7's Medication Administration Record revealed the following scheduled medications were ordered: a. Cetirizine HCl Oral Tablet 10 mg (milligrams) Give 1 tablet by mouth one time a day for runny nose/congestion. b. Meloxicam Oral Tablet 15 mg Give 1 tablet by mouth one time a day for Inflammation. c. Sertraline HCl Oral Tablet 50 mg Give 1 tablet by mouth one time a day related to Anxiety Disorder (side effects can include feeling sleepy or tired). d. Vitamin D3 Oral Tablet 125 mcg (micrograms) Give 1 tablet by mouth one time a day related to Vitamin D Deficiency. e. Lamotrigine Oral Tablet Give 100 mg by mouth two times a day related to Epilepsy. (Side effects can include dizziness, difficulty with balance, coordination). f. Magnesium Oxide Oral Tablet Give 400 mg by mouth two times a day for Supplementation (Side effects can include dizziness, heart arrhythmia - abnormal heart rhythm). g. Prednisolone Acetate Ophthalmic Suspension 1% Instill 1 drop in both eyes two times a day for Inflammation. h. Risperdal Oral Tablet 4 mg Give 4 mg by mouth two times a day related to Schizoaffective Disorder. (Side effects can include: drowsiness, dizziness). i. Topiramate Oral Tablet 100 Give 1 tablet by mouth two times a day related to Epilepsy (Side effects can include: dizziness, tiredness and fatigue). j. Buspirone HCl Oral Tablet 15 mg Give 1 tablet by mouth three times a day related to Anxiety Disorder (Side effects can include: dizziness and fatigue). k. Acetaminophen Tablet 325 mg Give 2 tablets by mouth four times a day for elevated temperature; pain. A review of Resident #2's MARs revealed Resident #2 also received the following: a. Amlodipine Besylate Oral Tablet 10 mg Give 1 tablet by mouth one time a day related to Essential Hypertension. b. Ascorbic Acid Tablet 500 mg Give 1 tablet by mouth one time a day related to unspecified severe protein-calorie malnutrition. c. Aspirin 81 Oral Tablet Chewable 81 mg Give 1 tablet by mouth one time a day related to Peripheral Vascular Disease. d. Bupropion HCl Oral Tablet Give 300 mg by mouth one time a day related to Major Depressive Disorder. e. Cholecalciferol Oral Tablet 50 mcg (2000 UT) Give 1 tablet by mouth one time a day related to unspecified severe protein-calorie malnutrition. f. Clopidogrel Bisulfate Oral Tablet 75 mg Give 1 tablet by mouth one time a day related to Peripheral Vascular Disease. g. Ferrous Sulfate Tablet 325 mg Give 1 tablet by mouth one time a day for supplementation Iron Deficiency. h. Fluconazole Oral Tablet 100 mg Give 5 tablets by mouth one time a day for infection. i. Furosemide Oral Tablet 20 mg Give 1 tablet by mouth one time a day related to Chronic Systolic Congestive Heart Failure. j. Lactobacillus Rhamnosus Oral Capsule Give 1 capsule by mouth one time a day for at high risk for diarrhea. l. Pantoprazole Sodium Oral Tablet Delayed Release 40 mg Give 1 tablet by mouth one time a day related to GERD (Gastro-Esophageal Reflux Disease). m. Polyethylene Glycol 3350 Powder Give 17 grams by mouth one time a day for constipation. n. Sennosides-Docusate Sodium Tablet 8.6-50 mg Give 1 tablet by mouth one time a day for Constipation. o. Tamsulosin HCl Oral Capsule 0.4 mg Give 2 capsules by mouth one time a day for urinary retention. p. Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 150 mg Give 1 capsule by mouth one time a day related to Anxiety Disorder. q. Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 mcg/act 2 puffs inhale Orally two times a day related to COPD (Chronic Obstructive Pulmonary Disease). r. Levetiracetam Oral Tablet 250 mg Give 1 tablet by mouth two times a day for seizure. s. Magnesium Oxide Oral Tablet 400 mg Give 1 tablet by mouth two times a day for hypomagnesemia. t. Metoprolol Tartrate Oral Tablet 50 mg Give 1 tablet by mouth two times a day related to Essential Hypertension. u. Ziprasidone HCl Oral Capsule 40 mg Give 1 capsule by mouth two times a day related to Anxiety Disorder. v. Gabapentin Capsule 300 mg Give 1 capsule by mouth three times a day for phantom limb syndrome. w. Acetaminophen Tablet 325 mg Give 2 tablets by mouth every 4 hours as needed for Elevated Temperature; Pain. Do not exceed maximum dose of 3000 mg daily. (had already received Resident #7's 650 mg of Acetaminophen). A review of the Facility Progress Notes revealed the following: 5/23/25 at 9:05 AM Medication error occurred. Resident notified of medication error. No known allergies to medicine given. Vital signs taken at 9:00 AM 110/60, temperature 98.2, heart rate 70, respiratory rate 14, oxygen saturation 90% on room air. Resident alert. 5/23/25 at 10:00 AM Reassessed during bladder scan. Alert, lethargic, but able to arouse. Able to communicate back to nurse that he understands he is getting a bladder scan. Oral fluids offered. Physician Assistant notified of medication error and ordered to monitor and send to the hospital if level of consciousness becomes worse. 5/23/25 at 12:00 PM Increased lethargy, blood pressure 99/54, heart rate 66, respiratory rate 12 and oxygen saturation 88% on room air. Pupils constricted with increased confusion noted when he spoke. Sent to the hospital per ambulance. Family notified of resident being sent to the hospital. A review of the Hospitalist Note dated 5/23/25 had documentation of the following: Presented on 5/23/25 with a recent bilateral BKA (below the knee amputation) with unintentional medication ingestion. Per report he received both his home medications in the morning as well as medications that are supposed to be given to another resident. Management included: a. ICU for close hemodynamic monitoring b. Telemetry, monitor QTC and QRS. c. Received sodium bicarb in Emergency Department, per discussion with nursing and poison control, poison control recommended sodium bicarb infusion as well as potassium, target Magnesium greater than 2, Potassium level greater than 4. d. Will review with pharmacy and hold home offending medications until safe to resume. On 5/28/25, The Care Plan identified Resident #2 with the problem of being at risk for adverse reaction related to polypharmacy. He takes multiple medications with black box warnings. He had a recent accidental medication administration episode. The Care Plan had the following interventions: a. Monitor for possible signs and symptoms of adverse drug reaction: falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, agitation, depression, poor appetite, constipation, gastric upset. b. Review pharmacy consult recommendations, and follow up as indicated. In an interview on 6/9/25 at 11:38 AM, Resident #2's Family Member reported the following: a. The nursing home did call her to report that he had received another resident's medications. They let the doctor know, he said to keep an eye on him. b. Later he developed a rash and had trouble breathing. c. He was later admitted to the hospital and stayed for four days. In an interview and observation on 6/10/25 at 7:50 AM, Resident #2 reported he had been given someone else's medication. The pills looked identical, but they gave him the wrong ones. The nurse asked him what his name was and called him by the right name. They sent him to the hospital and kept him for 4 days. After he received those other medications, he got more sleepy and the nurse said his pupils were pinpoint. Resident #2 sat up in bed and appeared to be awake and alert, wearing a clean hospital gown with a wound vac in place to the left stump (he had bilateral amputations below the knee) and an indwelling catheter in a dignity bag below the bladder level. He was properly positioned and appeared comfortable. In an interview on 6/10/25 at 2:04 PM, Staff E, RN reported the following: a. Before administering meds to a resident, the nurse or CMA (Certified Medication Aide) should make sure you have the right resident, use identifying data such as birth date, picture, and have them verbally confirm their information is correct if they are able to do that, check right dose, route, medicine, time and reason they are taking it and right documentation. b. On 5/23/25 at 9:05 AM she recalled Staff G, RN reported she made a medication error. Staff G called the physician assistant right away. He told her to continue to monitor him, take his vitals and if he has increasing lethargy or stupor or difficult to arouse. Call him if worsening. c. When Staff E entered the room after lunch, for a dressing change, Resident #2 was difficult to arouse. His color was normal, respirations were a little lower than his usual, but not alarmingly low. He was in the hospital for at least 5 or 6 days. d. The error could have been prevented by slowing down and double checking and making sure you have the right person to start with. She would take the card and compare to the MAR (Medication Administration Record) and do each med that way twice. e. Typically, when assigned to give meds on the skilled unit, at the most there are 30 residents. Recently we have 15 to 18 residents in the skilled unit. In an interview on 6/10/25 at 1:50 PM, Staff F, CNA reported the following: on 5/23/25 after lunch, Resident #2 looked sleepy. She was not sure what caused that. He wasn't really responding to us when we would call out his name. She reported it to the nurses right away. In an interview on 6/10/25 at 2:42 PM, Staff G, RN reported the following: a. Before administering medications to a resident, the nurse/CMA should follow the 5 rights of administration, right dose, time, route, patient, medications. b. In May 2025 (she could not recall the exact date, but remembered she wrote it on her statement for the incident report), she accidentally gave Resident #2 another resident's (Resident #7's) medications before breakfast. c. She had to give medications to 13 residents that day. d. There were a lot of call lights on, there was only one nurse (Staff G) and one CNA and the second nurse did not arrive until 8:00 AM. She wanted to catch up with med pass and give pain meds when she arrived. e. At 8:30 AM, she went to do a bladder scan on him and noticed he was pretty lethargic, we did a sternal rub, he was talking, he said when EMS (Emergency Medical Services) came to pick him up, he didn't want to go to the hospital, but he had trouble staying awake. Then I notified the provider, the physician assistant who was on call. The EMTs (Emergency Medical Technicians) arrived before lunch and took him to the hospital. f. The error could have been prevented if she did not let all the distractions overwhelm her. She should have gone through the 5 rights and she should have notified the provider immediately when she made the mistake. If you are the nurse on the floor, you are considered the charge nurse. In an interview on 6/12/25 at 9:57 AM, the Director Of Nursing reported he felt the cause of the above medication error was due to human error, complicated by the failure to properly identify the correct resident prior to administration of medication. 2. The Minimum Data Set, dated [DATE] identified Resident #3 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 and had the following diagnoses: Coronary Artery Disease, Heart Failure, and Diabetes Mellitus. The MDS also identified Resident #3 as independent with all activities of daily living. On 6/6/25, the Care Plan identified Resident #3 with the problem of having Diabetes Mellitus and provided signs and symptoms of hypo/hyperglycemia, however, it failed to direct staff to double check the amount of insulin to be administered. During an observation of a medication pass, Resident #3 received the wrong dose of insulin. On 6/10/25 at 12:45 PM, Staff J, RN drew up Aspart Insulin 12 units. Upon entering Resident #3's room, she informed her that her blood glucose was 213 and she had insulin for that. Staff J administered 12 units of Aspart insulin to Resident #3. A review of the June 2025 Medication Administration Record revealed an order for Novolog (Aspart) Insulin Inject 15 units subcutaneously in the afternoon related to Type 2 Diabetes Mellitus with lunch. Hold if lunch is not eaten. Novolog (Aspart) Insulin Inject as per sliding scale: Inject as per sliding scale: if 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300+ Notify provider, subcutaneously three times a day for Diabetes. Administer even if the patient is NPO (Add to pre-meal insulin) In an interview on 6/12/25 at 10:25 AM, Staff J, RN reported the following: a. She did admit she drew up 13 units b. She could not recall if the order was supposed to be for 15 units. c. She worked the dementia wing that morning and had to work long term care in the afternoon. This makes it difficult when they switch halls in the middle of the shift. In an interview on 6/12/25 at 11:00 AM, the DON verified the correct amount of insulin that Resident #3 should have received on 6/10/25 at 12:45 PM should have been Aspart a total of 15 units for the scheduled dose and an additional 2 units for the sliding scale. The total amount that should have been given should have been 17 units. A review of the Facility Policy titled: Administering Medications dated as last revised April 2019 had documentation of the following: a. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: aa. The date and time the medication was administered; bb. The dosage; cc. The route of administration; dd. The injection site (if applicable); ee. Any complaints or symptoms for which the drug was administered; ff. Any results achieved and when those results were observed; and gg. The signature and title of the person administering the drug. b. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services.

Based on record review, family and staff interview, and facility policy review, the facility failed to properly assess and intervene after administration of a rapid acting insulin (without consuming the meal) to 1 of 3 residents reviewed with orders for insulin (Resident #1). This resulted in the resident becoming unresponsive with a blood glucose of 25 and being sent to the hospital. The facility reported a census of 118 residents. Findings include: The Minimum Data Set, dated [DATE] identified Resident #1 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 0 and had the following diagnoses: Heart Failure, Urinary Tract Infection, and Diabetes Mellitus. The MDS identified Resident #1 was dependent on staff assistance for most activities of daily living with the exception of eating and oral hygiene. Observations of Resident #1 could not be completed as she was still hospitalized during the investigation. On 5/17/25, the Care Plan identified Resident #1 with the problem of using insulin/hypoglycemic medications related to diabetes and directed staff to monitor blood glucose as ordered. The Care Plan failed to direct staff on the need to observe for signs of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), or list actions to take if the resident presented signs of either one. A review of the Incident Report dated 6/4/25 at 3:30 PM revealed the following: Incident Description: Resident had her lunch at bedside table, the Nurse asked the resident to eat and uncovered her food for her then proceeded to administer her ordered insulin and SSI (sliding scale insulin) prior to the resident eating. Resident later found to be hypoglycemic with a blood sugar ranging from 25-35 prior to EMS arrival. Facility notified of allegation of abuse made by the Hospital for Neglect related to hypoglycemic occurrence. Level of Consciousness: Comatose (Un-arousable to verbal or physical stimuli) Statements by staff: Staff I, CNA (written 6/9/25) I brought the residents tray in her room. I know she will only eat if she is sitting up but the resident kept refusing to get up stating she needed a minute and she just woke up. I helped readjust her in bed and helped sit her up. I place the food in front of her and verbally prompted the resident. Staff B, RN (written 6/9/25) I reported for my shift and began preparing for it and someone called to us to check on Resident #1. We walked in and she was not responding, checked her vital signs and were stable but not waking up so I told Staff A, RN to get the glucometer to check her blood sugar, it was 25. I sent the CMA for Staff C,LPN/ADON and she got the Glucagon for me and I administered it. Follow up blood sugar was 35. Staff A, RN (written 6/9/25) I first saw the resident in the daytime, she was talkative and responded to questions. I administered her AM insulin. Around lunch time when she was due to get more insulin I gave her the insulin when she had her tray in front of her. I verbally told her to eat and opened the plate for her, I also told Staff I, CNA to make sure she ate and that they did not pick up her tray to give her more time to eat. I was not able to check on the resident again myself due to assisting other residents. I followed after Staff B, RN into Resident #1's room as I was gathering the supplies to check blood sugar. The blood sugar was 25 and Staff B administered the Glucagon. EMS came and assisted taking the resident. A review of the Progress Notes revealed the following: 6/4/25 at 2:51 PM Vital signs completed and within normal limits. No significant changes noted or reported. The resident resting in bed with eyes closed. 6/4/25 at 4:09 PM Unresponsive. Vital signs documented were dated and timed 6/4/25 at 9:17 AM. Blood glucose at 3:30 PM was 35. The Progress Note did not have documentation of the initial blood glucose of 25 as identified in the Incident Report, or what time the ambulance arrived and transported the resident to the hospital. There was no documentation on 6/4/25 from 3:53 AM until 2:51 PM. A review of the June 2025 Medication Administration Records and Physician Orders had documentation of the following: a. Insulin Lispro Injection Solution Inject 5 unit subcutaneously three times a day, scheduled as AM, Mid Morning, and PM. b. On 6/4/25, doses for AM and Mid morning were signed out as given c. Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale: if blood glucose 150 - 200 = give 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units > 450 Notify provider., subcutaneously three times a day for diabetes. d. On 6/4/25 AM blood glucose was 205 and received 4 units . On 6/4/25 the mid morning blood glucose was 192 and received 2 units. e. There was no documentation to show Glucagon was given. A review of the Hospitalist note dated 6/4/25 at 7:24 PM had documentation of the following: Today patient received 17 units Humalog around 11:30 AM upon receiving her lunch meal. She did not eat any of this meal. Her son came in around 3:30 PM and noted she was minimally responsive. Blood sugar was found to be 25. Brought to the ER per EMS. Glucose 37. In an interview on 6/10/25 at 11:24 AM, Staff A, LPN reported the following: a. On 6/4/25, before Resident #1 was sent to the hospital, Staff A administered 5 units of her scheduled insulin and an additional 2 units for sliding scale (for a total of 7 units). b. She administered the insulin at 12:30 PM. Lunch was served at 12:00 and when she administered the insulin, her lunch was still untouched. Staff A reminded Resident #1 that her lunch was there and she needed to eat. She was awake and alert at that time. c. Staff A did not see Resident #1 after she administered the above insulin. d. Staff A had already given report to the oncoming shift, Staff B, RN when another staff member reported Staff A should check on Resident #1. Staff A went to the room after 3:00 PM. Staff B was in the room checking her vital signs. e. She could not recall if Resident #1 was alert or lethargic. When Staff A checked her blood sugar, it was 26. She asked Staff C, ADON if she could find some Glucagon. Staff B gave Resident #1 the Glucagon. f. Afterward, Staff A left the room to call 911 while Staff B and Staff C stayed with the Resident #1 until the ambulance arrived. In an interview 6/10/25 at 11:40 AM, Staff B, RN reported the following: a. The process at the facility is to administer insulin with or after the meals. b. When a resident has a blood glucose below 50 and if non-responsive, the nurse should give Glucagon, check the blood sugar again after 15 minutes. c. If the resident is still unresponsive after Glucagon, the nurse should call the ambulance. d. She could not recall if Resident #1 had a history of refusing meals. e. On 6/4/25, Staff B was scheduled to work second shift. When she arrived to Resident #1's room, she was non-responsive. She grabbed her stethoscope and checked her vitals which were all normal. When she checked her blood sugar it was 25. After that she gave her Glucagon and she called the ambulance. Her color was pale pink and her skin was clammy. She tried calling out her name, rubbed her chest and she was still unresponsive. f. After she gave the Glucagon, the ambulance was already at the facility. g. If a resident does not eat after insulin was given, she would check her again after 20 minutes. She could not recall when Staff A gave the insulin or when Resident #1 was checked again. h. Staff B saw Resident #1 last at 3:10 PM. In an interview on 6/10/25 at 11:58 AM, Staff C, LPN/ADON reported the following: a. The process at the facility is to administer insulin normally with meals, unless the doctor orders it differently. b. She could not recall when Resident #1's insulin was ordered to be given. c. If a resident has a blood glucose below 50 and is unresponsive, the nurse should give Glucagon IM (intramuscularly). d. Resident #1 did have a history of refusing to eat, but she does better if the staff help her sit up in the chair. e. Before Resident #1 was sent to the hospital on 6/4/25, Staff C was in her office when Staff A reported Resident #1's blood sugar was 27. They both ran to Resident #1's room and she was unresponsive with her son at the bedside. Her skin was clammy. f. Staff B tried to rub her chest to wake her up. She moved her head, but never opened her eyes. Staff C then ran to get the Glucagon which she gave to Staff B to administer. They rechecked her blood sugar afterward and it was only 30. g. Staff C ran to get another Glucagon from Station 1's E-kit, however, by the time she arrived to the room, the paramedics were already there. h. If she knew the resident did not eat lunch after she gave the insulin, she would expect the nurse to recheck Resident #1 within 15 to 30 minutes. She was not sure if Staff A had rechecked Resident #1 after she gave the insulin. i. The nurse should have checked the resident's blood sugar before giving the insulin, recheck the resident after giving the insulin within 15 to 20 minutes. If the blood sugar is still low and the resident is awake, give the resident some snacks or milk. This should be documented in the nurse's notes. In an interview on 6/10/25 at 10:04 AM, the resident's family member reported the following: a. When he came to visit Resident #1, she was incoherent, she did not open her eyes, she was cold to the touch. Her left arm and face was cold. She was unresponsive and had agonal breathing. (he is a CPR instructor). She had no concept of anything. She was lying on her back which is unusual, she likes to sleep on her side. There was no color to her at all. When he came in it was about 3:20 PM. b. When he arrived, the nurses said they couldn't get her to wake up after they gave her insulin before she ate her lunch. They said it was given at 11:38 AM. And her orders were to give the insulin after her meal because they're supposed to count carbs. This is the standard for her. c. When the nurses arrived, all they did was check her blood sugar, no one checked her vital signs or checked her pupils. He performed a sternal rub to arouse her and had asked Staff D to clear her airway. Staff D left the room and did not return until 10 to 15 minutes later. d. He could not understand why she wasn't sitting up in the chair for lunch. She rarely refuses to eat when she's up in the chair. e. The nurses admitted that they didn't check on her for 4 hours. They did not do a post check on her. On 6/10/25 10:37 AM, in an attempt to contact the Medical Director, the Physician's Assistant answered the call. When asked if the above incident could have been prevented, he responded his interaction with Resident #1 was that she was decisional and cognitively intact enough that she should have eaten after she was given her insulin. If the lunch tray was in front of her and she was cognitively intact, she would have been able to eat. He did not have any reason to suspect that she was cognitively compromised that time. In an interview on 6/10/25 at 3:08 PM, Staff D, CNA/CMA reported the following: a. When asked what are signs that she would need to report to the nurse if a resident has a low blood sugar would be pale skin, unresponsive, fruity breath, clammy skin. b. On 6/4/25, Resident #1 had been in bed all day, she received insulin before she had lunch and at 3:10 PM, Staff B and Staff D checked her blood sugar because she was unresponsive. They checked her vitals and they were fine, then we checked her blood sugar. Her blood sugar was 26. They gave her some type of shot for diabetic people when they have low blood sugar. Staff B tried calling her name, touching her arm, but she was not able to open her eyes or respond. She looked like she was in a deep sleep. She was pale, clammy. c. Resident #1 usually will eat her meals when she sits up in her wheelchair. In an interview on 6/10/25 at 3:18 PM, Staff H, CNA reported the following: a. When asked what are signs that she would need to report to the nurse if a resident has a low blood sugar would be the resident would be sweating, dizzy, unresponsive. b. On 6/4/25, she recalled that the CMA/nurse gave Resident #1 her medications. Staff H brought in her lunch tray and Resident #1 said she did not want to eat. The next thing she remembered was they took her to the hospital. c. After she served her lunch tray, she did not see Resident #1 afterward as she was sent to work in another unit. d. Resident #1 usually does better and will eat if she's sitting up in a chair. In an interview on 6/11/25 at 8:46 AM, Staff I, CNA reported the following: a. When asked what are signs that she would need to report to the nurse if a resident has a low blood sugar, the resident would be unresponsive, not acting like usual, words sluggish, not moving how they should be, if food and drinks haven't been touched, skin pale and dry, drowsy. b. Before Resident #1 was sent to the hospital on 6/4/25, she recalled she brought in her lunch tray between 11:00 AM to 12:00 PM. She was sitting up in bed. Her right arm was very swollen and she reported this to Staff A, RN. c. After she brings in a resident's room tray, she would usually check the resident within 30 minutes to an hour. She checked on Resident #1 again between 12:00 and 1:00 PM and she was sleeping again. She did not touch anything off her tray. She woke her up and asked if she was going to eat anything and told her she needs to eat because she's diabetic. She kept saying she was tired and was trying to get up. She was told you can't force the residents to do anything they didn't want to. She offered her multiple times to have her eat. I left her tray in her room and I helped dietary pick up the rest of the room trays. d. She did not go in there again after she picked up her room tray because there were a lot of call lights going off. When she left for the day, it was 2:20 PM, Resident #1 was still in her room sleeping. e. Resident #1 does better if she sits up in the chair. Staff I admitted she should have sat her up in the chair, maybe she would have eaten more. She did not think that was addressed on her Care Plan. In an interview on 6/11/25 at 12:03 PM, the Director of Nursing reported the following: a. On 6/4/25, Staff A, RN gave Resident #1 scheduled Lispro 5 units and sliding scale Lispro 2 units and the amount she received after 11:30 was a total of 7 units of Lispro. For the entire day, she received a total of 16 units. b. Resident #1 did not eat her lunch after she was given the noon insulin. c. The order did not specify when to give the insulin, nursing judgement would be to administer it with meals. d. He was notified about the incident and arrived to her room at 3:30 PM and Staff B, RN had already given her Glucagon. e. He would have expected the nurse to recheck Resident #1 after giving insulin within 15 to 30 minutes afterward and would have expected her to chart that in the progress notes. f. When asked what he felt the cause of the error was, he reported, he did not think there was an error. The resident had requested her tray, she said she was going to eat, she had the food in front of her. She didn't eat. He would have expected the nurse to recheck the resident within 20 or 30 minutes. g. When asked if he thought the error could have been avoided, he reported he did not think the nurse had sufficient reasoning to believe Resident #1 would refuse to eat her food. The facility policy titled: Management of Hypoglycemia dated as last revised November 2020 had documentation of the following: 1. For hypoglycemia (<54 mg/dL): a. Administer Glucagon (intranasal, intramuscular, or as provided); b. Notify the provider immediately; c. Remain with the resident; d. Place resident in a comfortable and safe place (bed or chair); e. Monitor vital signs; and f. Recheck blood glucose in 15 minutes (as above). 2. If a resident has hypoglycemia and is unresponsive: a. Administer Glucagon (intranasal, intramuscular if order to do so); b. Notify the provider immediately. c. Remain with the resident. d. Place resident in a comfortable and safe place (bed or chair); and e. Monitor vital signs. 3. Documentation Document the resident's blood glucose before intervention. Note blood sugar after each administration of rapid-acting glucose and the follow-up blood sugar. Record the resident's level of consciousness before and after intervention. Document provider instructions.

Based on observation, record review, resident, family and staff interview, the facility failed to administer medications as ordered for two of three residents reviewed (Residents #2 and #3). The facility reported a census of 118 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 and had the following diagnoses: Heart Failure, Coronary Artery Disease, Wound Infection, and Diabetes Mellitus. The MDS also identified Resident #2 to be totally dependent on staff assistance for oral hygiene, toileting hygiene, lower body dressing, and transfers from bed to chair or toilet.A review of the Facility Incident Report dated 5/23/25 at 6:30 AM, had documentation of the following:Resident #2 received Resident #7's medications in error.Resident #2 did not have a profile picture on file, no name tag on door, and was responding to the name for Resident #7 during conversation that morning. Resident #2 was given Resident #7's medications as follows: Tylenol, Buspirone, Cetirizine, Lamotrigine, Magnesium Oxide, Meloxicam, Mupirocin, Prednisolone Acetate eye drops, Risperidone, Sertraline, Topiramate, and Vitamin D3. Resident #2 became lethargic afterward.A review of Resident #7's Medication Administration Record revealed the following scheduled medications were ordered:a. Cetirizine HCl Oral Tablet 10 mg (milligrams) Give 1 tablet by mouth one time a day for runny nose/congestion.b. Meloxicam Oral Tablet 15 mg Give 1 tablet by mouth one time a day for Inflammation.c. Sertraline HCl Oral Tablet 50 mg Give 1 tablet by mouth one time a day related to Anxiety Disorder (side effects can include feeling sleepy or tired).d. Vitamin D3 Oral Tablet 125 mcg (micrograms) Give 1 tablet by mouth one time a day related to Vitamin D Deficiency.e. Lamotrigine Oral Tablet Give 100 mg by mouth two times a day related to Epilepsy. (Side effects can include dizziness, difficulty with balance, coordination).f. Magnesium Oxide Oral Tablet Give 400 mg by mouth two times a day for Supplementation (Side effects can include dizziness, heart arrhythmia - abnormal heart rhythm).g. Prednisolone Acetate Ophthalmic Suspension 1% Instill 1 drop in both eyes two times a day for Inflammation.h. Risperdal Oral Tablet 4 mg Give 4 mg by mouth two times a day related to Schizoaffective Disorder. (Side effects can include: drowsiness, dizziness).i. Topiramate Oral Tablet 100 Give 1 tablet by mouth two times a day related to Epilepsy (Side effects can include: dizziness, tiredness and fatigue).j. Buspirone HCl Oral Tablet 15 mg Give 1 tablet by mouth three times a day related to Anxiety Disorder (Side effects can include: dizziness and fatigue).k. Acetaminophen Tablet 325 mg Give 2 tablets by mouth four times a day for elevated temperature; pain.A review of Resident #2's MARs revealed Resident #2 also received the following:a. Amlodipine Besylate Oral Tablet 10 mg Give 1 tablet by mouth one time a day related to Essential Hypertension.b. Ascorbic Acid Tablet 500 mg Give 1 tablet by mouth one time a day related to unspecified severe protein-calorie malnutrition.c. Aspirin 81 Oral Tablet Chewable 81 mg Give 1 tablet by mouth one time a day related to Peripheral Vascular Disease.d. Bupropion HCl Oral Tablet Give 300 mg by mouth one time a day related to Major Depressive Disorder.e. Cholecalciferol Oral Tablet 50 mcg (2000 UT) Give 1 tablet by mouth one time a day related to unspecified severe protein-calorie malnutrition.f. Clopidogrel Bisulfate Oral Tablet 75 mg Give 1 tablet by mouth one time a day related to Peripheral Vascular Disease.g. Ferrous Sulfate Tablet 325 mg Give 1 tablet by mouth one time a day for supplementation Iron Deficiency.h. Fluconazole Oral Tablet 100 mg Give 5 tablets by mouth one time a day for infection.i. Furosemide Oral Tablet 20 mg Give 1 tablet by mouth one time a day related to Chronic Systolic Congestive Heart Failure.j. Lactobacillus Rhamnosus Oral Capsule Give 1 capsule by mouth one time a day for at high risk for diarrhea.l. Pantoprazole Sodium Oral Tablet Delayed Release 40 mg Give 1 tablet by mouth one time a day related to GERD (Gastro-Esophageal Reflux Disease).m. Polyethylene Glycol 3350 Powder Give 17 grams by mouth one time a day for constipation.n. Sennosides-Docusate Sodium Tablet 8.6-50 mg Give 1 tablet by mouth one time a day for Constipation.o. Tamsulosin HCl Oral Capsule 0.4 mg Give 2 capsules by mouth one time a day for urinary retention.p. Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 150 mg Give 1 capsule by mouth one time a day related to Anxiety Disorder.q. Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 mcg/act 2 puffs inhale Orally two times a day related to COPD (Chronic Obstructive Pulmonary Disease).r. Levetiracetam Oral Tablet 250 mg Give 1 tablet by mouth two times a day for seizure.s. Magnesium Oxide Oral Tablet 400 mg Give 1 tablet by mouth two times a day for hypomagnesemia.t. Metoprolol Tartrate Oral Tablet 50 mg Give 1 tablet by mouth two times a day related to Essential Hypertension.u. Ziprasidone HCl Oral Capsule 40 mg Give 1 capsule by mouth two times a day related to Anxiety Disorder.v. Gabapentin Capsule 300 mg Give 1 capsule by mouth three times a day for phantom limb syndrome.w. Acetaminophen Tablet 325 mg Give 2 tablets by mouth every 4 hours as needed for Elevated Temperature; Pain. Do not exceed maximum dose of 3000 mg daily. (had already received Resident #7's 650 mg of Acetaminophen).A review of the Facility Progress Notes revealed the following:5/23/25 at 9:05 AMMedication error occurred. Resident notified of medication error. No known allergies to medicine given. Vital signs taken at 9:00 AM 110/60, temperature 98.2, heart rate 70, respiratory rate 14, oxygen saturation 90% on room air. Resident alert.5/23/25 at 10:00 AMReassessed during bladder scan. Alert, lethargic, but able to arouse. Able to communicate back to nurse that he understands he is getting a bladder scan. Oral fluids offered. Physician Assistant notified of medication error and ordered to monitor and send to the hospital if level of consciousness becomes worse.5/23/25 at 12:00 PMIncreased lethargy, blood pressure 99/54, heart rate 66, respiratory rate 12 and oxygen saturation 88% on room air. Pupils constricted with increased confusion noted when he spoke. Sent to the hospital per ambulance. Family notified of resident being sent to the hospital.A review of the Hospitalist Note dated 5/23/25 had documentation of the following:Presented on 5/23/25 with a recent bilateral BKA (below the knee amputation) with unintentional medication ingestion. Per report he received both his home medications in the morning as well as medications that are supposed to be given to another resident.Management included:a. ICU for close hemodynamic monitoringb. Telemetry, monitor QTC and QRS.c. Received sodium bicarb in Emergency Department, per discussion with nursing and poison control, poison control recommended sodium bicarb infusion as well as potassium, target Magnesium greater than 2, Potassium level greater than 4.d. Will review with pharmacy and hold home offending medications until safe to resume.On 5/28/25, The Care Plan identified Resident #2 with the problem of being at risk for adverse reaction related to polypharmacy. He takes multiple medications with black box warnings. He had a recent accidental medication administration episode. The Care Plan had the following interventions:a. Monitor for possible signs and symptoms of adverse drug reaction: falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, agitation, depression, poor appetite, constipation, gastric upset.b. Review pharmacy consult recommendations, and follow up as indicated.In an interview on 6/9/25 at 11:38 AM, Resident #2's Family Member reported the following:a. The nursing home did call her to report that he had received another resident's medications. They let the doctor know, he said to keep an eye on him.b. Later he developed a rash and had trouble breathing.c. He was later admitted to the hospital and stayed for four days.In an interview and observation on 6/10/25 at 7:50 AM, Resident #2 reported he had been given someone else's medication. The pills looked identical, but they gave him the wrong ones. The nurse asked him what his name was and called him by the right name. They sent him to the hospital and kept him for 4 days. After he received those other medications, he got more sleepy and the nurse said his pupils were pinpoint. Resident #2 sat up in bed and appeared to be awake and alert, wearing a clean hospital gown with a wound vac in place to the left stump (he had bilateral amputations below the knee) and an indwelling catheter in a dignity bag below the bladder level. He was properly positioned and appeared comfortable.In an interview on 6/10/25 at 2:04 PM, Staff E, RN reported the following:a. Before administering meds to a resident, the nurse or CMA (Certified Medication Aide) should make sure you have the right resident, use identifying data such as birth date, picture, and have them verbally confirm their information is correct if they are able to do that, check right dose, route, medicine, time and reason they are taking it and right documentation.b. On 5/23/25 at 9:05 AM she recalled Staff G, RN reported she made a medication error. Staff G called the physician assistant right away. He told her to continue to monitor him, take his vitals and if he has increasing lethargy or stupor or difficult to arouse. Call him if worsening.c. When Staff E entered the room after lunch, for a dressing change, Resident #2 was difficult to arouse. His color was normal, respirations were a little lower than his usual, but not alarmingly low. He was in the hospital for at least 5 or 6 days.d. The error could have been prevented by slowing down and double checking and making sure you have the right person to start with. She would take the card and compare to the MAR (Medication Administration Record) and do each med that way twice.e. Typically, when assigned to give meds on the skilled unit, at the most there are 30 residents. Recently we have 15 to 18 residents in the skilled unit.In an interview on 6/10/25 at 1:50 PM, Staff F, CNA reported the following: on 5/23/25 after lunch, Resident #2 looked sleepy. She was not sure what caused that. He wasn't really responding to us when we would call out his name. She reported it to the nurses right away.In an interview on 6/10/25 at 2:42 PM, Staff G, RN reported the following:a. Before administering medications to a resident, the nurse/CMA should follow the 5 rights of administration, right dose, time, route, patient, medications.b. In May 2025 (she could not recall the exact date, but remembered she wrote it on her statement for the incident report), she accidentally gave Resident #2 another resident's (Resident #7's) medications before breakfast.c. She had to give medications to 13 residents that day.d. There were a lot of call lights on, there was only one nurse (Staff G) and one CNA and the secondnurse did not arrive until 8:00 AM. She wanted to catch up with med pass and give pain meds when she arrived.e. At 8:30 AM, she went to do a bladder scan on him and noticed he was pretty lethargic, we did a sternal rub, he was talking, he said when EMS (Emergency Medical Services) came to pick him up, he didn't want to go to the hospital, but he had trouble staying awake. Then I notified the provider, the physician assistant who was on call. The EMTs (Emergency Medical Technicians) arrived before lunch and took him to the hospital.f. The error could have been prevented if she did not let all the distractions overwhelm her. She should have gone through the 5 rights and she should have notified the provider immediately when she made the mistake. If you are the nurse on the floor, you are considered the charge nurse.In an interview on 6/12/25 at 9:57 AM, the Director Of Nursing reported he felt the cause of the above medication error was due to human error, complicated by the failure to properly identify the correct resident prior to administration of medication.2. The Minimum Data Set, dated [DATE] identified Resident #3 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 and had the following diagnoses: Coronary Artery Disease, Heart Failure, and Diabetes Mellitus. The MDS also identified Resident #3 as independent with all activities of daily living.On 6/6/25, the Care Plan identified Resident #3 with the problem of having Diabetes Mellitus and provided signs and symptoms of hypo/hyperglycemia, however, it failed to direct staff to double check the amount of insulin to be administered.During an observation of a medication pass, Resident #3 received the wrong dose of insulin. On 6/10/25 at 12:45 PM, Staff J, RN drew up Aspart Insulin 12 units. Upon entering Resident #3's room, she informed her that her blood glucose was 213 and she had insulin for that. Staff J administered 12 units of Aspart insulin to Resident #3.A review of the June 2025 Medication Administration Record revealed an order for Novolog (Aspart) Insulin Inject 15 units subcutaneously in the afternoon related to Type 2 Diabetes Mellitus with lunch. Hold if lunch is not eaten.Novolog (Aspart) Insulin Inject as per sliding scale:Inject as per sliding scale: if 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300+ Notify provider, subcutaneously three times a day for Diabetes. Administer even if the patient is NPO (Add to pre-meal insulin)In an interview on 6/12/25 at 10:25 AM, Staff J, RN reported the following:a. She did admit she drew up 13 unitsb. She could not recall if the order was supposed to be for 15 units.c. She worked the dementia wing that morning and had to work long term care in the afternoon. This makes it difficult when they switch halls in the middle of the shift.In an interview on 6/12/25 at 11:00 AM, the DON verified the correct amount of insulin that Resident #3 should have received on 6/10/25 at 12:45 PM should have been Aspart a total of 15 units for the scheduled dose and an additional 2 units for the sliding scale. The total amount that should have been given should have been 17 units.A review of the Facility Policy titled: Administering Medications dated as last revised April 2019 had documentation of the following:a. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:aa. The date and time the medication was administered;bb. The dosage;cc. The route of administration;dd. The injection site (if applicable);ee. Any complaints or symptoms for which the drug was administered;ff. Any results achieved and when those results were observed; andgg. The signature and title of the person administering the drug.b. Medications ordered for a particular resident may not be administered to another resident, unlesspermitted by State law and facility policy, and approved by the Director of Nursing Services.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to consistently monitor the functioning of the dishwasher and failed to ensure adequate kitchen sanitation for 2 of 2 kitchen observations. The facility reported a census of 118 residents. Findings include: 1. The initial kitchen tour on 5/19/25 at 10:05 a.m. revealed the following concerns: a. A fan above the hand washing sink was covered with mesh and a thick layer of dust covered the mesh and the fan blades. The fan blew toward the left hand side of the dishwasher where clean dishes emerged. b. Staff B, Dietary Staff washed dishes and when requested to test the functioning of the dishwasher she obtained a strip but then stated she did not know how to complete the test. Staff B stated she did not test the machine that morning before doing breakfast dishes. The Dietary Manager was present and could not locate a log of dishwasher function tests. c. The top of the dishwasher was covered with yellow chunks of debris. d. The fire suppression system spigots had dust particles hanging from them. The Dish Machine Temperature Log for May 2025 directed staff to check the wash and rinse temperatures and parts per million (PPM) sanitizer concentration prior to each meal. The log lacked documentation staff carried this out for breakfast, lunch, and dinner from 5/15/25 to 5/17/25, for lunch and dinner on 5/18/25, and for breakfast on 5/19/25. A follow-up up visit to the kitchen on 5/20/25 at 12:57 p.m. revealed the following concerns. a. Dust remained on the fire suppression system spigots. b. Dust remained on the fan which blew toward the clean side of the dishwasher. The facility policy Sanitization, revised October 2008, stated the facility would maintain food service areas in a clean and sanitary manner and directed staff to wash all equipment to remove debris using hot water or chemical sanitizing solutions. The facility policy Dishwashing Machine Use, revised March 2010, stated the operator would check temperatures with each dishwashing cycle. On 5/21/25 at 1:17 p.m., the Dietary Manager stated moving forward, staff would check the dishwasher every day. He stated they would train all staff regarding this. He said he did not like the fans blowing toward the clean side of the dishwasher and agreed this was not a good set up.

Based on observation, record review, and staff interview the facility failed to change oxygen tubing on 1 out of 1 concentrator for residents with physician orders for oxygen (Resident #14). The facility reported a census of 118 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #14 indicated a Brief Interview for Mental Status (BIMS) score of 15 which indicates no cognitive impairment. It further indicated diagnoses including: chronic obstructive pulmonary disease (COPD), respiratory failure, and anxiety. The MDS indicated Resident #14 required moderate assist from staff for transfers, bathing, dressing, and personal hygiene. Review of the Care Plan dated 4/22/24 revealed Resident #14 altered respiratory status and utilizes oxygen. Observed Resident #14 on 05/20/25 at 10:36 AM with oxygen on in their wheelchair at 1.5 liter per nasal cannula from a tank. The tubing did not have a label with date tubing was changed. The oxygen concentrator in residents room had a label with the date 5/5/25 tubing was changed. On 05/21/25 at 11:26 AM the oxygen concentrator tubing in Resident #14 room date labeled 5/5/25 and the tubing on the tank on the wheelchair still did not have a date. On 05/21/25 at 12:42 PM Staff E, Registered Nurse (RN) stated the oxygen tubing should be changed but unsure how often, I know we have a policy for that. We mark the tubing with the date, time, and initial it has been changed. The concentrator and tank tubing on the wheelchair should be changed. On 05/21/25 at 1:17 PM Staff E, RN clarified the tubing for oxygen should be changed every week. She reviewed the policy and it directs the staff to change it weekly. On 05/22/25 at 11:01 AM the Director of Nursing (DON) states the tanks and the concentrator tubing for oxygen should be changed weekly and it should be labeled with the date and initials. The facility provided a policy titled Departmental (Respiratory Therapy) - Prevention of Infection revised 2011 which directed to change the oxygen cannula and tubing every seven (7) days, or as needed.

Based on observations, interviews, and record review, the facility failed to provide pain medication when scheduled for 1 of 1 residents that wore a Fentanyl patch (opioid medication) (Resident #109), resulting in this resident reporting being in severe pain. This resident was to have a Fentanyl patch applied on 8/19/24 at 1800. It was not applied until the morning of 8/21/24. The facility reported a census of 140 residents. Findings include: A Minimum Data Set (MDS) dated [DATE] documented Resident #109's diagnoses included Malignant Neoplasm of tongue (cancer), hip fracture, and depression. A Brief Interview for Mental Status score was documented as 12 out of 15, which indicated moderately impaired cognition. This MDS documented that Resident #109 experienced pain almost constantly in the prior 5 days. On 08/19/24 at 10:55 a.m., Resident #109 was sitting on her bed in a private room. This resident stated she was in pain. Stated her mouth hurt and she had a broken hip. A Progress Note dated 8/19/24 at 2:17 p.m., documented that a call was received from the pharmacy concerning the Fentanyl patch order denial by the provider, and the provider wanted to talk with the facility. The ADON (Assistant Director of Nursing) was informed. A Doctor's Order dated 8/19/24 at 7:06 p.m., directed staff to hold the Fentanyl patch for 3 days until 8/22/24. The reason for this hold was documented as the pharmacy would like to speak with physician prior to next order being sent. This Order was written by Staff K, Licensed Practical Nurse (LPN). On 8/21/24 10:06 a.m., Staff G, ADON stated she was not told that pharmacy wanted to talk to the provider regarding the Fentanyl patch. She acknowledged the Progress Note stated that the ADON was notified but stated she was not. This ADON stated she did not know the Fentanyl patch was being held. She looked up the order and verified that it was being held. This ADON said if she would have known about the pharmacy wanting to talk with the provider, she would have called the Hospice physician and not the facility's provider as the Hospice physician manages Resident #109's medications. When told that this resident had complained of pain on 8/19/24, this ADON acknowledged the concern that Resident #109 did not receive her Fentanyl patch at the scheduled time on 8/19/24 at 6:00 p.m., and still had not received the patch. On 8/21/24 at 10:21 a.m., the facility's Physician's Assistant (PA) stated he became aware of the pharmacy sending a request to talk to a physician yesterday morning. He stated he sent a new script for the Fentanyl yesterday morning, 8/20/24. Hospice wanted me to manage Resident #109's Fentanyl patch. This PA stated what happened was the pharmacy had requested the Hospice physician for a new script for the Fentanyl patch, but since this PA is the one who manages the Fentanyl patch he needed to put the new script in. This PA stated he was managing her Fentanyl patch and Hospice was managing her morphine and Haldol, pretty much everything else. He stated the pharmacy called him on the morning of 8/20/24 and that is when he sent the script for the Fentanyl patch to be filled. On 8/21/24 at 10:45 a.m., Staff L, Hospice Social Worker, stated she was in a lot of pain and the nurse came in and gave her some morphine and then put on her regularly scheduled patch. Staff L stated she overheard staff saying something about Resident #109 not having her patch on so they got an order to restart it again today. On 8/21/24 at 11:00 a.m., Resident #109 rated her pain at an 8 out of 10 with 0 being no pain and 10 being the worst pain. She stated the pain was in her mouth and her hip and leg. She had facial grimacing and rubbed her leg. On 8/21/24 at 11:15 a.m., the Nurse Consultant, acknowledged the concern regarding this resident going without her Fentanyl patch from 8/19/24 at 6:00 p.m. to 8/21/24 at 10:30 a.m. She also acknowledged that the facility's provider wrote a prescription for the Fentanyl patch yesterday morning 8/20/24, and it wasn't put in until 10:20 a.m. on this day 8/21/24. On 8/21/24 at 12:14 p.m., Staff K stated the pharmacist sent an electronic request. She stated she did write the order to hold the Fentanyl patch. Staff K stated she did not call the provider. Staff K stated another nurse wrote a fax or a note on the provider's clipboard. Staff K stated she wrote the order to hold the Fentanyl because it showed up in the medication administration record to apply the patch and she did not have the Fentanyl patch to apply. So she wrote the order to hold it until the provider could see the note from the other nurse. When asked if Resident #109 appeared to be in pain that night, Staff K stated that Resident #109 said she was in severe pain that night. Staff K stated she did give her the scheduled morphine but did not give her any PRN (as needed) morphine. Staff K stated Resident #109 has had a lot of pain, since she had fallen and broken her hip. She said her pain had worsened and since she was in Hospice they don't want to fix the fracture. A Pain policy revised on 9/2017 directed the following: Physicians shall help manage individuals with pain, including identification and management of causes. Outcomes 1. Pain will be identified and managed appropriately. 2. Factors that cause or exacerbate pain or increase the risks of having pain will be identified and addressed, to the extent possible. 3. Pain medications will be ordered and used appropriately. Recognition 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes. It also includes a review of any current treatments for pain, including any complementary and non-pharmacologic treatments. 2. The staff and physician will identify the characteristics (severity, location, intensity, frequency, duration, etc.) of pain. Staff should use a consistent pain assessment approach appropriate to the resident/patient's cognitive level. 3. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and quality of life, as well as contributing to complications such as deconditioning, gait disturbances, social isolation, and falls. Diagnosis/Cause Identification 4. The physician will help identify causes of pain; for example, by reviewing the patient's history, examining the patient directly, and having a sufficiently detailed discussion with the patient and staff. 5. The physician will help identify the extent to which underlying causes of pain can be addressed or reversed. 6. The physician will order appropriate tests as needed to help clarify aspects of pain (location, cause, etc.). For example, an x-ray may help to identify the cause of joint pain. Treatment/Management 7. With input from the resident/patient to the extent possible, the physician and staff will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. 8. The physician will order appropriate non-pharmacologic interventions and medications to address the individual's pain, consistent with recognized protocols and guidelines. Generally, and to the extent possible, an analgesic regimen should utilize the simplest regimen and lowest risk medications before using more problematic or higher risk approaches. Opioid use-especially, but not solely, related to the management of chronic non-cancer pain-should be consistent with relevant information about the limitations and risks of such medications. 9. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, and massage. 10. For the individual who is receiving opioid analgesics, the physician will order measures to prevent constipation. Monitoring 11. The staff will reassess the individual's pain and its consequences at regular intervals; for example, at least each shift for unstable or increasing pain or significant changes in levels of chronic pain, and at least weekly for stable chronic pain. Review should include frequency, duration, and intensity of pain; ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. 12. The staff will evaluate and report the resident / patient's use of standing and PRN analgesics. Depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain. If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding non-pharmacological measures. 13. Periodically the physician will evaluate and summarize the status of an individual with pain, including active conditions that exacerbate pain, consequences or complications of pain, and effectiveness of current interventions for pain. 14. The staff and physician will monitor for adverse effects of pain medications such as gastrointestinal bleeding from non-steroidal anti-inflammatory drugs (NSAIDs), or anorexia, confusion, lethargy or severe constipation related to opioids. The physician will adjust medications accordingly, based on effectiveness and side effects. 15. If the resident/patient's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support. If a consultant is involved in managing pain, the attending physician will maintain an active role by reviewing the consultant's recommendations, addressing medical issues that affect pain, monitoring for complications related to treatment, and evaluating subsequent progress. The physician should not simply defer to the consultant for all pain-related issues. 16. If pain is stable and the underlying cause is resolved or it is unclear whether a source of pain remains, the physician will consider a trial reduction or elimination of analgesic medication; for example, reduce the standing dose of an analgesic and see if there is any increase in pain-related symptoms or increased use of PRN analgesics. Reductions in opioid analgesics are especially important in light of their limited efficacy in the treatment of chronic non-cancer pain and their many diverse significant side effects. Based on results of attempted dose reductions, the physician should document a clinically significant rationale for not attempting further analgesic reduction. It should not just be assumed that the absence of pain symptoms implies the need for indefinite analgesic administration. Sometimes a trial tapering or discontinuation of analgesics is indicated to determine if current medications or doses are still needed.

Based on clinical record review, staff interviews, family interviews, resident interviews, policy review, and observations the facility failed to provide adequate supervision for 2 of 5 residents reviewed for adequate supervision (Resident #21 and #26). The facility failed to ensure the resident's safety by allowing Resident #21 to leave the facility with a male friend without the consent and knowledge of the resident's Guardian and failed to ensure a resident's safety by failing to complete a thorough search of the premises after a Wander guard alert system sounded. These failures resulted in possible endangerment for both residents, therefore causing an Immediate Jeopardy (IJ) to the health, safety and security of two residents. The facility reported a census of 152 residents. On August 1, 2023 at 1:39 pm, the State Survey Agency (SA) informed the facility of the staff's failure to ensure a cognitively impaired resident's Guardian gave permission for their loved one to leave the locked Dementia unit with a male visitor creating an Immediate Jeopardy situation, which began on July 22, 2023. The SA informed the facility they removed the immediacy on August 2, 2023 at 10:26 am. when the facility staff implemented the following Corrective Actions: a. Education completed with nursing staff and agency staff on the Leave of Absence procedure. Education where to find the resident representative in Point Click Care. Education on discharging a resident with medications when placed on a leave status. b. Resident log to be implemented on each unit for resident's going on a leave of absence. c. Report run on current residents with low BIMS' scores and ensured primary contact listed in clinical record. d. Visitors log implemented and visitors to sign in and out of the facility. e. Signs placed on main entrances doors for all visitors to sign in and out of the building when visiting. On August 15, 2023 at 3:15 pm, the State Survey Agency informed the facility of the staff's failure to ensure a cognitively impaired resident did not elope from the facility due to facility staff shutting off the Wander guard alert system without a thorough search of the premises which began on August 10, 2023. The SA informed the facility they removed the immediacy on August 15, 2023 when the facility implemented the following Corrective Actions: a. Employee involved in incident received corrective action. b. Resident was assisted back into the facility immediately after he was seen by a staff member. c. Risk management completed, resident assessment completed with no injuries including a skin assessment. d. Family and MD notified of incident. e. Wander guard was in place and functioning. f. Verified orders to assure order in place to replace Wander guard every 90 days, and check placement/functioning of monitoring device was being completed every shift. g. Door that resident went out was checked and the door alarm and Wander guard alarm checked and was functioning. h. Resident BIMS evaluation current and scored a 12 (moderately impaired). i. Internal investigation initiated, witness statements gathered. j. Staff education initiated regarding wandering/elopement policy and responding to door alarms on 8/14/23. k. Elopement drills conducted. Findings include: 1. According to Resident #21's face sheet upon admission to the facility, the resident had diagnoses which included Dementia with behavioral disturbances, Chronic Obstructive Pulmonary Disease, dysphagia-pharyngoesphageal phase (swallowing problems), suicidal ideation's, alcohol abuse, and major depressive disorder. The face sheet revealed the resident had an admitted [DATE] and directly admitted to the secure locked unit. The resident's daughter is the emergency contact person as well as her appointed Guardian. According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #21 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive ability. The resident moved about the unit independently and completed Activities of Daily living independently with oversight from the staff. The resident experienced 1 fall since admission without injury and receives antidepressant and antipsychotic medications daily. Review of a Care Plan dated 3/2/22 indicated the resident resisted cares and refuses to allow staff to help her at times. The Care Plan informed the staff Resident #21's daughter is her Guardian and emergency contact. The Care Plan alerted the staff that on 7/22/23 the resident went out with a family member, she and the family member did not have a clear return plan and the local police department was notified. Review of a Progress Note by Staff A-RN dated 7/22/23 indicated at approximately 1:00 pm the resident had a visitor arrive at the facility. Resident #21 told the staff her former brother-in-law was coming to the facility to see her. The front desk contacted Station 2 nurses station to alert staff the visitor had arrived. When the visitor arrived to the unit, the resident had her purse and a bag in hand. The male visitor carried the bags and they left the unit together. The nurse indicated she was unaware the resident had not signed out of the unit either at Station 2 or at the front desk. At approximately 9:50 pm Staff A-RN contacted the charge nurse to report Resident #21 had not yet returned from her visit and they do not have any contact information of the male visitor who took the resident out of the facility. Review of a Progress Note by Staff B-LPN/Assistant Director of Nurses dated 7/22/23 at 10:34 pm revealed she received a phone call from Resident #21's responsible nurse who reported the resident left the facility today and has not yet returned. Staff B-LPN placed a phone call to the resident's guardian to request a phone number for the male visitor who took the resident out of the facility on the day shift. The guardian stated she did not have the telephone number but possibly her brother did. Staff B requested the guardian call her brother to get the telephone number. Review of a Progress Note by Staff B-LPN/ADON dated 7/22/23 at 11:40 pm, the guardian stated her brother contacted the male visitor who indicated he would have the resident back at the facility by midnight. Review of a Progress Note dated 7/23/23 at 6:08 am, Staff B-LPN alerted the local police department, informing them of Resident #21's failure to return to the facility. Review of a Progress Note by Staff C-RN dated 7/23/23 at 10:49 am, Resident #21 returned to the facility today at 10:30 am. The note indicated the resident refused to have an assessment completed upon return to the facility. Staff C-RN falsely documented Resident #21 did have permission from her son to go out of the facility with the male visitor the day prior. Review of a Progress Note dated 7/23/23 at 12:10 pm by Staff C-RN, the staff nurse indicated several hours after the resident returned to the facility at 10:30 am, she made a comment she wanted to die. The staff placed the resident on 15 minute checks for closer supervision. Staff C-RN stated she contacted the Primary Care Physician regarding the comment on 7/23/23 at 12:05 pm. During an interview with Resident #21's Son on 7/31/23 at 4:00 pm revealed the son did not give permission for his mother to leave the facility with her former Brother-in-law on 7/22/23. The Son stated he was made aware his mother failed to return to the facility on ,d+[DATE], he called her the following morning at the former Brother-in-law's home and informed her she had to return to the facility that morning. During an interview with Resident #21's guardian and contact person on 7/31/23 at 2:00 pm, the guardian stated she received a phone call from Staff B-LPN/ADON on 7/22 at 10:15 pm, she was informed her mother hadn't returned from a off grounds visit with her former Brother-In-Law. The guardian made Staff B aware that she had no knowledge her mother went anywhere off the unit nor did she give permission for her to leave the facility. She stated she then received a call the following day to inform her that they placed her mother on 15 minute checks for suicidal ideation's. The guardian stated she spoke to the Administrator and Director of Nurses on Monday, 7/24/23 asking them if they reported the incident to the Department of Inspections and Appeals, they made the comment they thought this was an authorized visit. The guardian informed them this was not an authorized visit, she did not approve the visit. She voiced frustration with the lack of communication with her regarding the details of the incident with her mother. During an interview with the Primary Care Provider on 8/2/23 at 11:06 am, the PCP stated she was on call the weekend of the incident and did not receive any notification that the resident left the building with her former Brother-in-law on 7/22/23 and failed to return until the following morning. She stated the resident would have missed several doses of her antidepressant and antipsychotic medications which would not make her feel well. The PCP also stated the resident is on a pureed diet and is a choking hazard. The PCP continued to say she is sure the resident's guardian would not have been okay with her mother going out of the building with the male visitor due to her history of alcohol and drug misuse. During an interview with Staff D-Registered Dietician (RD) on 8/2/23 at 1:07 pm, the RD stated the resident is on a physician ordered pureed diet and is at risk of choking. During an interview with Staff C-RN on 8/2/23 at 8:20 am, the RN stated she worked on the locked Dementia Unit with an Agency RN on dayshift, 7/22/23. Staff C stated she was the primary nurse on A Hall and not responsible for Resident #21's care that day. Staff C stated earlier in the morning of 7/22 she witnessed Staff A-RN assist Resident #21 with a phone call. Later in the morning (time unknown by Staff C) the receptionist called back to the unit, alerting them Resident #21 had a visitor at the front entrance. Staff C asked an aide to take the resident to greet the visitor at the entrance. Staff E-Certified Nurses Aide (CNA) walked the resident to the entrance to greet her visitor and they all returned to the locked unit. The male visitor approached Staff C-RN and informed her he was taking Resident #21 out of the facility. Staff C stated she inquired if the resident could leave the unit with the male. Staff A-RN told Staff C-RN that yes the resident could go out of facility. Staff C stated she assumed everything was taken care of and the resident could go with the male visitor. When the resident and male visitor left the unit, the resident had her purse and bags of personal belongings. Staff C handed the sign out log to the male visitor who put his name and address on the form. The Resident and the male visitor left the unit together. Staff C-RN stated she did not send any medications or give the resident and male friend any instructions, stating she was not the primary nurse for Resident #21. Staff C-RN stated she worked on the locked Dementia Unit the following day (7/23), when she arrived on the unit the next morning a local police officer was on the unit speaking with Staff B-Assistant Director of Nurses. Staff C learned at that time the resident failed to return to the facility on [DATE]. The police officer informed the staff he was going to put out a missing persons report if she did not return soon. Staff C indicated the resident returned back to the facility at approximately 10:30 am, upset about having to return to the facility. Staff C-RN stated she was terminated from her employment at the facility on 7/25/23 but does not understand the reason. Staff C did admit the failure was partially because she did not call the resident's guardian to get permission for the leave. Staff C-RN stated Staff A-RN was an agency nurse but thought she had taken care of everything prior to the resident leaving the facility. Staff C-RN admitted she knew the resident had a guardian prior to this incident but again stated she was not the resident's primary nurse and she figured the other nurse took care of everything. During an interview with Staff E-CNA on 8/1/23 at 9:00 am, Staff E stated she was working the day shift (7/22) on the locked Dementia Unit. She was in the hall when she was approached by the resident and a male visitor. Both the resident and the male visitor had plastic bags with the resident's belongings, she indicated about 6 bags of belongings between both of them. The male visitor approached Staff E and asked her for the door code. Staff E did not give them the code but opened the door herself after asking both nurses, is it okay to let them out, they have a lot of bags. Both of the nurses replied yes, Staff E clarified the answer a second time and again they replied yes. Staff E entered the code and the resident and male visitor left the unit together. Staff C-RN informed Staff E they said they would be back before midnight. Staff E stated why would they have a lot of bags, it looked like they were moving out. Staff E finished her shift that day at 10:30 pm, the resident had not yet returned to the facility when she went home. Staff E returned to work the following day at 6:00 am and learned the resident had not returned to the facility as she said she would. Staff E stated the resident returned the morning of 7/23, she appeared like herself but very upset about having to return to the facility. Staff E-CNA was glad to see her back as she was worried she was dead somewhere, that she may have choked on regular food stating the resident receives a pureed diet or that maybe she drank alcohol or took some street drugs. During an interview with Staff A-RN on 8/2/23 at 9:00 am, Staff A stated she was an agency nurse assigned to work the dayshift on 7/22/23 in the locked Dementia Unit. She indicated on 7/22 Resident #21 was talking about getting a visit from her former Brother-in-Law that day and excited to see him. At approximately 12:30 pm, the Charge Nurse Staff C-RN informed Staff A she was going to take Resident #21 up to the front entrance to greet a male visitor, but at the last minute she asked a CNA to escort her. The aide escorted the resident to the entrance and shortly returned with the resident and male visitor to the unit. Staff A indicated she heard the male visitor say to Staff C-RN that he was taking the resident out. The two left the unit, the male visitor noted to be carrying several bags of the resident's belongings. Staff A overheard the male visitor state to Staff C-RN that he would have the resident back in several hours. Staff A stated she assumed since Staff C-RN worked at the facility full time she took care of the arrangements for the leave. Staff A-RN stated Staff C-RN ended her shift at 2:00 pm leaving Staff A-RN to work the unit alone until the end of the evening shift. Staff A passed medications to other residents but kept watching the clock, awaiting the return of Resident #21. At approximately 6:45 pm the resident still had not returned to the facility and hoped she would return soon as she did not have any of her medications for lunch or evening. Staff A-RN stated she pulled up the resident's face sheet and noted the male visitor was not listed on the form, so she did not have any contact information to call the visitor to inquire about the whereabouts of the resident. Staff A checked the sign out sheet and the resident did not sign out prior to leaving the building. Staff A called Staff F-LPN/Charge Nurse and alerted her of the situation and the resident was seen leaving with several bags of belongings. Staff A voiced her concern to Staff F concerned that the resident had not yet returned. Staff F directed Staff A to call Staff B-LPN/Assistant Director of Nurses to alert her of the situation. Staff A indicated at the end of her shift she gave report to the on-coming nurse and informed her if the resident did not return by morning they are to alert the local police department. Staff A-RN stated Staff C-RN was responsible to verify if the resident had the appropriate approval to leave the unit because she was the Charge Nurse. During an interview with Staff E-LPN/Charge Nurse on 7/22/23 evening shift. Staff E stated she received a phone call from Staff A-RN informing her we have a problem. She informed Staff E Resident #21 left on the day shift and had not yet returned to the facility. Staff E directed the RN to call Staff B-LPN/Assistant Director of Nurse. Staff A notified Staff B at 9:52 pm. Staff E stated Staff B asked her who took out the resident? replied a male visitor. Staff B asked who gave them permission to leave, Staff E replied Staff C-RN gave permission. Staff E stated she came back to the unit that day about 1:00 pm for another reason and met Resident #21 and a male visitor at the door trying to leave. Staff E asked Staff C-RN if it was alright for them to leave, Staff C stated yes. Staff E stated she had never seen this male visitor before and has never known the resident to leave the building with anyone before today. Staff C stated the resident and male visitor indicated they would return before midnight on 7/22. During an interview with Staff G-RN/Director of Nurses on 8/1/23 at 8:30 am, the DON revealed she received a phone call from Staff B-LPN/ADON on 7/22/23 at 10:00 pm, she informed the DON a male visitor took Resident #21 out of the facility without family approval or knowledge and had not yet returned. The DON stated the male visitor was not on the resident's face sheet to visit and should have not been allowed to leave the facility without the guardian's permission or knowledge. Staff G stated she spoke to the resident's guardian about the situation on 7/22/23, the guardian stated she should have been notified and she would not allowed her Mother to leave with the male visitor. During an interview with Staff B-LPN/ADON on 7/31/23 at 1:30 pm, the staff stated she worked on Saturday, 7/22/23 in her office, directly next door to the locked Dementia Unit. Staff B stated she knew the resident could only leave the unit with her daughter/guardian or her son. The policy for allowing residents off the unit is the facility staff must check the resident's face sheet to see if the person is on the approved list of visitors and if able to take the resident out of the unit. If the name of the visitor is not on the face sheet the staff must call the resident's responsible person to get permission. Staff B-LPN stated the resident resides on the locked unit and a reasonable staff person should have checked to assure they have permission to visit off the unit. Staff B shared she received a phone call the night of 7/22 at about 9:50 pm alerting her to the situation, the resident left the facility with a male visitor and had not yet returned. Staff B contacted the residents guardian in an attempt to get a contact number for the male visitor who took the resident out, the guardian did not have it but thought possibly her brother did. The resident's son alerted of the situation, texted the male visitor and confirmed the resident was with the male friend. The facility made aware the location of the resident. The local police were contacted early in morning of 7/23 and arrived to the facility at approximately 5:50 am to take the report. During an interview with Staff H-Certified Medication Aide on 7/31/23 at 3:00 pm, Staff H stated on 7/22/23 at about 1:30 pm he witnessed Resident #21 and a male visitor walking down the hall with several bags of clothing. He reported he did not see her leave but worked until 8:00 pm that night on the locked unit and she did not return while he was working that day. Staff H reported coming to work the next morning (7/23) and was told in morning report she failed to return yesterday. At about 10:30 am Staff H made phone contact with the resident, the resident stated she was at a friends house and was not returning to the facility. The resident gave Staff H the address of the male friend. Staff H asked to speak to the resident's friend, Staff H informed the male friend the resident needed to return to the facility. The resident's male friend kept saying she refuses to return, Staff H stated if she does not return the facility the police will get involved. Staff H reported the resident returned approximately about 11:00 the morning of 7/23. The male visitor dropped the resident off at the front door, gave her a kiss and quickly ran away. Staff H shared the resident kept verbalizing she was not going to stay at the facility and repeatedly packed her bags to leave again. Monday morning (7/24) Staff H asked Staff C-RN how the resident was allowed to leave the facility, Staff C stated it was Staff A-RN's fault, she approved her leaving. Review of a police report dated 8/23/23 revealed that at 1:00 pm on 7/22/23 a staff nurse allowed Resident #21 to leave the building with a male friend. The male friend was not on the approved list of visitors. Staff B-LPN/ADON informed the officer the facility had standard procedure that if someone was not on the list they need to contact the guardian or emergency contact person listed and get approval. The nurse informed the officer no one contacted the guardian. The officer told the guardian if her mother is not returned back to the facility by noon 7/23 he will file a missing persons report. Review of a policy dated 9/2017 titled Orders Related to Leaves of Absence from the Facility, the policy informs staff that nursing staff shall authorize leaves of absence appropriately, including medications, equipment or services that the resident may required during their absence from the facility. The policy states the residents will be able to have appropriate leaves, once the resident's responsible party, power of attorney has been verified. Residents will not experience problems due to the lack of medications while on leave. 2. According to Resident #26's Minimum Data Set (MDS) dated [DATE], the resident had diagnoses which included fractures, coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, functional quadriplegia, and falls with injuries. The Resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicates moderate cognitive impairment. The resident had total dependence of 2 staff for transfers and extensive assistance of 2 staff for dressing and personal hygiene, impairment of both lower limbs and utilizes a wheelchair for moving about the facility. The resident did not walk. Review of the Care Plan dated 3/27/23 with a revision noted on 8/15/23, informed the staff Resident #26 is an elopement risk and likes to go outside. The Care Plan indicated the resident sometimes leaves the facility unattended and directed the staff to be alert to his wandering behaviors and distract him from wandering by offering him diversions. The Care Plan indicated the resident wore a Wander guard alert system and directed staff to change the Wander guard every 90 days or as needed. Review of an Incident Report dated 8/14/23 Resident #26 eloped from the facility on 8/10/23. The report indicated the resident noted to be exit seeking and went out the Station 4 door. At the time of the elopement, information relayed from a staff member revealed they did not feel the incident was an elopement because staff were with him. The Administrator reviewed the incident on 8/14/23 and determined it was an elopement, the facility began a correction action plan, which included all staff elopement re-education initiated, an internal investigation initiated, elopement drills conducted, review of the resident's Care Plan, the residents family and Primary Care Physician notified of the elopement on 8/14/23 at 7:10 pm. During staff interviews the resident stated at the time of the incident he wanted to go outside for some fresh air. Staff identified a predisposing situation factor was the resident had active exit seeking behaviors. During an interview with Resident #26 on 8/15/23 at 1:00 pm, the resident questioned about the day he recently left the building, he stated he cannot remember the date but does remember going outside. When asked how he got out of the building he stated he left the building with a family member but does not know who they were and could not identify them if he saw them again. He stated he sat outside alone and liked being outside. Review of a Progress Noted dated 8/14/23 at 7:09 pm revealed the following entry: On 8/10/23 Resident #26 noted to be exit seeking and went out the facility door on station 4. Information obtained at the time of the alleged incident it was not felt to be an elopement and no injury was noted to resident. No further investigation was identified as necessary at that time. It was brought up to the administrator as an alleged elopement during a complaint survey on 8/14/23. The residents Primary Care Physician and wife were notified. During an interview with Staff L, Traveling Administrator on 8/16/23 at 7:00 am, the Administrator stated the incident with Resident #26 eloping from the building occurred on 8/10/23. She stated she became aware on 8/14/23 at 1 pm of a different version regarding the elopement. She was initially told on 8/10/23 by Staff G-RN the resident went outside the building but had a staff member with him, so she felt at that time no further investigation needed to be done. She stated on 8/14/23 she learned of another story, the resident noted alone outside in his wheelchair, without staff present. Staff L began another investigation and interviewed Staff G-RN again, during the second interview on 8/14/23, Staff G-RN admitted she turned off the Wander guard alarm without going outside to see if any residents were outside. During an interview with Staff G-RN on 8/14/23 at 12:00 pm, Staff G stated she was working on Station 4 on 8/10/23. She was in a resident room when she came out finding a group of people standing at the Station 4 entrance. She indicated the Wander guard alarm was sounding. She went to the door and attempted to shut off the alarm but did not know the Wander guard alarm code to deactivate the alarm. Staff M-Physical Therapist gave her the Wander guard code and at that time she shut off the sounding alarm. Staff G stated she did not go thru the vestibule and out the outside door to check to see if any residents were in the area. She stated she only glanced out the interior door while shutting off the alarm. She left the area and continued working. She went toward the nurses station and noted Staff N-RN running down the hall. Staff N stated Resident #26 is outside alone in the parking lot. Staff asked Resident #26 who let him outside, he stated a family member but doesn't know who. During a second interview with Staff G-RN on 8/14/23 at 1:20 pm, Staff G stated she shut off the Wander guard alarm using the key pad on the left side of the 1st door. She stated it was approximately 20 minutes later when she noted Staff N-RN running down the hall, stating Resident #26 is outside alone. Staff G stated the incident happened on 8/10/23 at approximately 11:00 am. Review of Staff G-RN personal file revealed a Corrective Action Form dated 8/15/23, review of the corrective action form revealed the staff received disciplinary action due to the following: On 8/10/23 Staff G-RN did not follow elopement wandering policy. She disengaged the alarm and did not complete a full investigation. During an interview with Staff N-RN on 8/15/23 at 11:00 am, Staff N stated she was making rounds on 8/10/23 with Housekeeping Supervisor on the south west hall on Station 4. She looked out the window and saw Resident #26 sitting outside alone in his wheelchair. The resident noted to be sitting at the south end of the parking lot, no one around him while there. She ran down the hall and outside to retrieve the resident. When she approached the exit door the alarms were not sounding. She brought the resident back into the building, at the time they entered thru the Station 4 doors the Wander guard alarm sounded. The resident has a Wander guard placed on the bottom of his wheelchair. Staff N inquired who wheeled him out, the resident replied he did not know. During an interview with Staff O-Housekeeping Supervisor on 8/15/23 at 1:40 pm, Staff O stated she was making rounds with Staff N-RN on 8/10/23 sometime late morning. They were on the B Hall of Station 4 when they looked out the window. Staff O asked Staff N if that was Resident #26 sitting out in the parking lot, Staff N confirmed it was the resident. Staff N and Staff O ran to the parking lot and noted the resident sitting in his wheelchair alone, without his oxygen on. Staff N and O returned the resident to the building. When they left the building to retrieve the resident the door alarms were silent, upon return into the building the Wander guard alarm sounded. Staff O stated about 10 minutes prior to seeing the resident outside she heard the Wander guard alarm sound but was quickly silenced. During an interview with Staff M-PT on 8/14/23 at 2:00 pm, Staff M stated he was walking down the hall and heard the Wander guard alarm sounding. He stated someone was by the door so he thought the situation was handled and he proceeded to the PT room. He stated Staff G-RN stood by the door and asked him for the Wander guard code to enable her to shut off the alarm, he gave her the code and walked off. Staff M stated there had been several times lately he noticed the resident wheel himself towards the exit door but staff intervene and bring him back to the day room. Review of a Wandering and Elopements Policy dated March 2019. The policy statement included the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy directs the staff to check resident's Wander guard devices daily for proper functioning. If a resident is missing, the staff are to initiated the elopement/missing resident emergency procedure: determine if the resident is out on an unauthorized leave, if resident not authorized to leave, initiate a search of the building and premises and if not located, notify the appropriate people. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse will examine the resident for injuries, contact the attending physician and report findings and condition of the resident, notice to the resident's legal representative, notify search teams the resident was found, complete an incident report and document relevant information in the resident's medical record.

Based on observation, interview, and record review the facility failed to ensure residents remained free from resident to resident physical altercations for 2 of 15 residents reviewed for abuse (Resident #15, Resident #16), resulting in Resident #15's transfer to the hospital and fracture of the right radius following a resident to resident incident. The facility reported a census of 148 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #15 dated 5/12/23 revealed the resident had moderately impaired cognitive skills for daily decision making. The Care Plan dated 3/28/23 documented, I am an elopement risk/wanderer related to being disoriented to place. I have dementia and do not recognize the need to be here. I have tried to push my way into other residents rooms and made them mad. I have been pushed by another resident. I have been struck by another resident when trying to enter their room. I pound on the exit doors at times and can be difficult to redirect. Interventions per the Care Plan documented the following: a. Initiated 11/24/20: Observe for the potential that I may wander. Redirect me away from other residents room and exits b. Initiated 6/15/22: Observe the potential that I may not choose to walk on opposite sides of the hall of other residents, resulting in me walking straight towards them, redirect me as needed. c. Initiated 11/24/20: Offer me distractions when I think that I need to leave such as a snack or activity to do. d. Initiated 11/24/20: Place a Wanderguard on me as needed. Check and change it per facility policy e. Initiated 5/24/21: Provide a safe environment for me to wander in. f. Initiated 11/24/20: Provide reassurance that my family knows where I am when I am looking for them g. Initiated 1/25/22: Redirect me away from other residents rooms as needed. Remind me why I should not enter them. Provide a distraction as needed. h. Initiated 11/11/22: Redirect me away from other residents who appear upset with me. i. Initiated 3/28/23: Try to redirect me away from exit doors when I am pounding on them or hitting them with my walker. The Care Plan dated 5/19/23 documented, I may have been pushed down by another resident, unwitnessed. I sustained a major injury. The Social Services Note dated 3/16/23 at 1:12 PM documented, in part, [Resident #15] remains alert and oriented to her name and can locate her room at times. She is disoriented to time scoring 4 on the BIMS (Brief Interview of Mental Status) for this assessment. She does not retain reality orientation when given. [Resident #15] voiced several mood concerns, when asked, but may not have fully understood the questions. She wanders about the memory care unit much of the day attempting to open the exit doors. She will pound on them at times. The Orders-Administration Note dated 3/17/23 at 11:48 PM documented, [Resident #15] is pacing and exit seeking, showed aggressive behaviors towards other residents. Review of a summary for a Facility Reported Incident (FRI), undated, which involved Resident #15 and Resident #16 documented the following: On 3/25/2023 at 1930 (7:30 PM), [Resident #16] was noted to push [Resident #15] away from her door resulting in [Resident #15] falling. The Nurses Note dated 3/25/23 at 8:51 PM documented, Saw the resident who initiated the physical aggression pushed down the resident who received the physical aggression and fell on the floor in the hallway via CCTV camera. Went to the resident and found her assisted by 2 CNA's (Certified Nursing Assistants) to stand her up with a walker. The resident is confused. Unable to describe the incident and situation. She is alert and oriented x 1. Denies hitting her head on hard objects. No skin injury and physical injury noted. The Nurses Note dated 5/4/23 at 9:24 AM documented, Called [Family Member, Name Redacted] which is her POA (power of attorney) and voiced concerns about [Resident #15's] behavior the last couple of days with her trying to elope and her aggressive behavior towards staff and other patients. [Family Member Name Redacted] said she would come visit [Resident #15] and maybe call the doctor to look at a med review due to the medications she's on doesn't seem to be working. The Encounter Note dated 5/5/23 at 12:00 AM documented, Faculty states that patient has mostly compliant with recommendations for brain rest and she is returning more back to her baseline. They do note however that they have underlying concerns for her worsening behavioral expressions especially with regard to aggression agitation and verbal assault. She is starting to work more toward physical aggression as well. Discussion with patient's [Family Member, Name Redacted] Today reveals she has had some concerns along this line as well for some time now. The Encounter Note dated 5/8/23 at 12:00 AM documented, She has also had persistent increasing agitation and aggressive behaviors over the last few weeks and months. The Nurses Note dated 5/8/23 at 8:17 PM documented, I was doing my documentation at the Nurses station when I heard a commotion at the lounge area and when I looked at CCT camera, I saw one Resident on the floor. I went there and Resident [Resident #15] was lying down and touching the back of her head. her walker is just near her. Another Resident ([Matching first name of Resident #16])was standing in front of her and saying I Did not pushed her. Resident was assessed from head to toe, she has a bump at the back of her head. She said it is very painful. Also her tailbone hurts. Vital signs taken and recorded, stable. She was assisted x 2 using a gaitbelt back to her bed. ROM (Range of motion) are intact. Informed Dr. [Name Redacted] and got an order to send her to [Hospital Name Redacted] ER for further evaluation because of her head bump .Ambulance picked her up at 20:00 (8:00 PM) to go to [Hospital Name Redacted] ER. The Nurses Note dated 5/9/23 at 1:49 AM documented, Resident comes from [Hospital Name Redacted] center after a fall that led her to ER for evaluation. As this nurse is getting a report the resident was already back from hospital. Neurological assessments are normal, a small bump on back back head is still present. The Encounter Note dated 5/12/23 at 12:00 AM documented, in part, the following: she continues to demonstrate intermittently violent and aggressive behavior with agitation. She is a wander and exit seeker at baseline with lifelong history of anxiety and underlying drive to be continuously moving which needs to be factored into the observation of the dementia related behavioral expressions. The Orders-Administration Note dated 5/16/23 at 2:55 AM noted Resident #15 had been exit seeking. The SPN-Focused Evaluation note dated 5/16/23 at 4:17 AM documented, in part, Moves all extremities per self, ambulating in hallway with walker at beginning of shift, banging on exit doors. Difficult to redirect at that time. The Encounter Note dated 5/17/23 at 12:00 AM documented, in part, the following; [age redacted]-year-old female seen today at [Name Redacted] nursing facility for close follow-up after initiation of antipsychotic Seroquel for intervention of significant agitation and aggression in setting of severe Alzheimer's dementia. Per nursing report patient has had positive response after initiation of the above pharmacological intervention and has been less aggressive and combative toward other residents and staff. She continues to demonstrate wandering and exit seeking behavior however per her family discussion she has always been a bit like this and they are not concerned with that behavior necessarily. The Nurses Note dated 5/17/23 at 1:20 PM documented, Resident observed in upright seated position on the floor in unit 2, hallway B by the end of the hallway/exit door. Resident reports that another resident ([Initials Redacted, match those of Resident #16]) knocked her down. Resident reported pain in her left hip, left elbow and right dorsal hand. Resident assessed and found to have swelling et pain in her left elbow, shortening of her left leg and pain. Resident noted to have small skin tear to right hand with a hematoma to top of right hand. Upon c/o (complained of) pain in hip during assessment, CNA (Certified Nursing Assistant) instructed to remain with resident and RN went to phone PCP (Primary Care Physician) for further instruction. VORB to send resident to ER for further evaluation of c/o pain. Resident transferred to [Hospital Name Redacted] ER via [Ambulance Company Name Redacted]. Review of a FRI summary for a second incident between Resident #15 and Resident #16, undated, revealed the following: At approximately 1330 (1:30 PM) hours [Resident #15] was sitting at the nurse's station with nurse [Staff P, Assistant Director of Nursing (ADON) ] when resident [Name redacted other resident] walked by without his walker. When nurse [Staff P] went to intervene with [Name redacted other resident], [Resident #15] wandered to hallway B and began pounding on doors. According to resident [Another resident name redacted], [Resident #16] reported that [Resident #15] was driving her crazy, so she pushed her. As a result of the fall and the resident reporting pain in her left hip, left elbow and right dorsal hand and swelling in her left elbow, physician ordered she be sent to the ER (emergency room ]. ER assessed resident and returned with no injuries. Both residents remain in the [specific area of facility redacted] unit. [Resident #15] is on 1:1 line of sight intervention until IDT (interdisciplinary team) has a chance to review other more appropriate interventions. Social worker at hospital told the DON (Director of Nursing that there were no new injuries and that they were sending her back to the facility. In fact, she came back to the facility with her [family member] with a splint on her Rt (right) wrist as a result of a fracture to the Rt. wrist. Nurse contacted the hospital to determine the diagnosis and orders. Hospital advised that they X-rayed: bilateral hips, bilateral knees, pelvic and right wrist. All X-rays were negative except for a closed Colles fracture of the right radius. The Witness Statement signed by Staff P, ADON for an incident date of 5/17/23 documented, On 5/17/23 at 1320 (1:20 PM), a resident came to me and states: [Resident #15] is on the floor by the door. I went to the exit door on B hall, found the resident lying on the floor by the wall, the walker on the other side of the hallway. [Resident #16] came out of her room this nurse asked: what happened here? [Resident #15] replied pointing at [Resident #16]: She pushed me. [Resident #16] states: you are too much, you make a lot of noise, you came to me that's why I pushed you. This nurse told [Resident #16]: you can not put your hands on anybody. Prior to the incident, [Resident #15] was wandering, pushing on doors, wanted to go home. This nurse redirected [Resident #15] several times, ambulated with resident, offered the resident to sit down, the resident refused, states: I have to go home, resident offered to use the bathroom, she refused. The Nurses Note dated 5/17/23 at 4:40 PM documented, Resident came back from the Hospital accompanied by her [Family Member]. She has a split on the right wrist and with diagnosis of Closed Colles Fracture of right radius. She needs to wear the Velcro wrist splint up and about for the next 1 month. The Encounter Note dated 5/19/23 at 12:00 AM documented, in part, the following: [age redacted]-year-old female seen today at [Facility Name] nursing facility for close follow-up after recent ER visit. 2 days ago, after our last visit, patient had an altercation with another resident and was pushed to the floor. She suffered a right wrist fracture at that time. Review of X-Ray results for x-ray of the right wrist minimum three views exam end date 5/17/23 at 3:16 PM, documented the following impression: a. A nondisplaced impacted fracture of the distal radius is strongly suspected. b. Probable fracture through the base of the ulnar styloid process. The Clinician's History per the X-Ray report documented, pain and <sic> [NAME] following a fall. The History Reported to Technologist section of the report documented, pain and swelling post fall per ED. pt has hematoma ulnar aspect of posterior wrist. Observation on 5/31/23 at 12:25 PM revealed Resident #15 laying in their room in bed. When queried about how others treated her who lived or stayed at the facility, whether she had been pushed, or recently being hurt, the resident responded she was treated ok, and denied being pushed or hurt recently. 2. The MDS for Resident #16 dated 4/27/23 revealed the resident scored 14 out of 15, which indicated intact cognition. Per this assessment, the resident had verbal behaviors directed towards others. The Care Plan initiated 2/8/23 documented the following for Resident #16: I have the potential for a poor mood state. I have a diagnosis of anxiety, depression, OCD (Obsessive Compulsive Disorder) and schizophrenia. I have a history of smoking. 1/22 I have been poked by another resident and poked her back. I have pushed another resident who was trying to enter my room to redirect them. I was hit by another resident on 9.8.22 in the dining room. I cuss and yell at times. I pushed a resident who was making noise near my room twice. I may have pushed another resident to the floor and caused them a major injury. The Nurses Note dated 3/25/23 at 9:24 PM documented, Saw the incident via CCTV camera, the resident who initiated the physical aggression pushed down the resident who received the physical aggression and fell on the floor in the hallway. Went to the resident who initiated the physical aggression and found her inside her room. She stated the resident who received the physical aggression banging the door in her room with a walker, so she open the door and pushed down the other resident. The resident is alert and oriented x 2. No injuries noted. Separated the resident who initiated the physical aggression from the resident who received the physical aggression. The Nurses Note dated 3/27/23 at 8:34 PM documented,[Name Redacted] ARNP (Advanced Registered Nurse Practitioner) was informed of [Resident # 16's] altercation with another Resident. No new orders made. The Incident Report for Resident #16 dated 5/17/23 at 1:20 PM documented, [Resident #16] admitted to RN (Registered Nurse) that she got mad at [Resident #15's initials] (another resident) for making banging noises with the exit door handle so she shoved her down. Attempted to educate resident that physical aggression is not appropriate and she stated she should've knocked her out and then upon RN assessing [Resident #15] for injury, [Resident #16] reported that [Resident #15] was probably just faking it anyways. Unable to redirect [Resident #16] or assess vitals at time of incident. [Resident #16] denies any injury rec'd other than she was annoyed with [Resident #15] making noise. Immediate intervention: separated residents. Residents normally don't share a living space/bathroom or interact on a routine basis. On 5/31/23 at 12:47 PM, observation revealed Resident #16 in her room seated on her bed. Resident #16 explained there was one resident she didn't get along with, mentioned the first name of Resident #15, and explained the lady would come and pound on the back door. Per Resident #16, some of the incidents had been pretty bad. Resident #16 described pounding on the backdoor with a walker, she (Resident #16) had told her don't do that anymore, and person had fallen back and hurt themselves. When queried about prior situations, Resident #16 said there had been nothing before that. Resident #16 explained the other person came to her hall and she didn't know what to do about it. On 6/1/23 at 10:05 AM, Staff Q, RN, had been queried about Resident #16's behaviors. Per Staff Q, the resident kept to herself and her roommate for the most part, and had some behaviors and got irritated easily. Staff Q explained she had been at the facility when she had shoved the other resident. When queried as to which date she had been referring to, Staff Q responded May 17th. Per Staff Q, an aide had called down the hallway and said she had shoved another resident down. Staff Q acknowledged it was difficult redirecting the resident's behaviors. Per Staff Q, she asked Resident #16 what did she do to shove her down, and the response given had been rattling the door, and Resident #16 said she should have shoved her harder. Staff Q identified Resident #15 as the resident who had been pushed. Per Staff Q, she had not seen the incident, and there was an aide when it happened. Per Staff Q, Resident #15 had been sent out. When queried what the hospital had found, Staff Q responded a right wrist fracture on Resident #15. When queried if she had been aware of previous incidents since she had been at the facility between the two residents, Staff Q explained she was not aware. On 6/1/23 at approximately 12:15 PM, Staff P had been queried about incidents between Resident #15 and Resident #16. Staff P explained she had been approached by Resident #16's roommate who had come to her and said someone was on the floor. Staff P asked where, a response had been given over there, and Resident #15 had been on the floor by the exit door, and a worker had been standing by the last room. Resident #15 had been in the floor in the middle of the hallway on her back. Staff P explained she had asked the CNA to get the nurse, and the nurse came to start assessing the resident. Per Staff P, Resident #16 came out, and had stood at the doorway. Per Staff P she had asked Resident #16 what had happened, and Resident #16 said she came to my room banging, banging, bang. Staff P explained per Resident #16 she was just too much. Staff P explained the following information provided by Resident #16: Resident #16 acknowledged shoving the other resident, but did not push the resident hard and had just pushed her to go away from the door. Staff P explained Resident #15 bumped on the door with sundowning, and explained Resident #15 wanted to go home bumping on the doors and wanted to exit and go. When queried about prior incidents between the residents, Staff P explained she knew she had pushed her and [Resident #15] had fallen. Per Staff P, this had occurred in the hallway, she did not recall how it happened, and confirmed Resident #15 had been pushed by Resident #16 prior to the current incident (noted to be 5/17/23). On 6/1/23 at 12:48 PM, Staff R, RN, had been queried about the incident which occurred 5/8 for Resident #15. When queried if she knew how the resident had fallen, Staff R responded no. Staff R explained she did not witness it, and could not assume the resident had been pushed or something. Staff R explained Resident #16 had been in front of the resident standing and holding the walker, and Resident #15 had been on the floor. When queried about other incidents, Staff R explained Resident #15 banging the door, and explained Resident #16 had been very irritated with that and shouting at her. Staff R explained they had not worked at the time of the last altercation. The Facility Policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/21 documented, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on clinical record review, staff and resident interviews and observations the facility failed to provide appropriate supervision to prevent 5 falls which resulted in 3 fractures for 1 of 7 residents sampled (Resident #7). The facility reported a census of 147. Findings include: According to the admission Minimum Data Set (MDS) dated [DATE], Resident #7 had diagnoses which included; diabetes-type 2, dementia, chronic kidney disease, thyroid disorder and arthritis. The resident ambulated about the unit independently without assistive devices, could toilet themselves and perform hygiene tasks independently. The Resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The resident resided on the locked CCDI unit (Chronic Confusion and Dementing Illness Unit). Review of the Care Plan initiated on 10/7/2022 informed the staff Resident #7 had a risk for falls upon admission. The Care Plan directed the staff to encourage the resident to use his call light and obtain a Physical and Occupational Therapy consultation and treat as necessary. Further review of the Care Plan noted the following changes: On 11/2/2022 the care plan indicated staff should encourage wearing appropriate footwear and review for antiemetic use (anti nausea medications), on 11/15 the care plan directed the staff to assist the resident to the bathroom before laying down in bed and on 12/4/22 the care plan directed staff to add auto locking brakes to the residents' wheelchair. Review of an undated care plan obtained from Staff A-RN on 2/8/2023 indicated on 1/18/2023 the staff moved the resident closer to the nurses station but failed to indicate which unit. Review of the Progress Notes revealed Resident #7 had an admitted [DATE] to the CCDI unit within the facility. Review of the Progress Notes revealed the resident had the following falls: a. On 11/2/2022 the resident had 2 unwitnessed falls, the second fall of the day, the resident lost his balance in the bathroom, fell to the floor and complained of severe left hip pain. The staff called Emergency Medical Services (EMS) and transported resident to a local hospital. The resident sustained a left greater trochanter fracture of left hip (hip fracture) and admitted to the hospital. The resident returned to the facility on [DATE]. b. On 11/10/2022 the resident returned from the local hospital after being treated for a hip fracture, within 45 minutes of his return the resident had an unwitnessed fall and complained of left hip pain. EMS summoned and transported the resident to a local emergency room for evaluation. The resident sustained an extension to the greater trochanteric fracture, which involved the intertrochanteric region extending toward the less trochanter fracture. The resident admitted to the hospital and had surgical repair of the fractured left hip. c. On 12/4/2022 the resident had an unwitnessed fall, complaining of left hip pain. d. On 12/15/2022 the resident had an unwitnessed fall in his room. The resident complained of severe left hip pain. EMS summoned and transferred the resident to a local emergency room . Upon assessment the resident found to have a new, acute fracture of the left proximal femur in the subtrochanteric region and further distally in the proximal 3rd of the femoral diaphysic near the distal portion of the hardware. The resident had surgical repair of fracture on 12/16/2022 and returned to the facility on [DATE]. The resident returned to the facility on a no weight bear status and used a wheelchair to move about the unit. e. On 12/27/2022 the resident had an unwitnessed fall and complained of severe left hip pain. EMS personal summoned and transferred the resident to a local emergency room . The emergency room x-rays revealed a nondisplaced oblique fracture of the medical mid left femoral shaft that could be acute and the resident is noted to have stable mild osteoarthritis of both hips. The resident returned to the facility the same day with an order for a orthopedic consultation as soon as possible. The resident stated to staff he had been up walking and fell on to the floor. Review of the Primary Care Provider note dated 1/10/2023 indicated Resident #7 has a history of left femur fracture on 11/2/22, worsened after a fall on 11/10/22 which required surgical repair. The resident again hospitalized on [DATE] with a new acute fracture and underwent another surgical repair. The resident discharged back to the facility for therapies and fell again on 12/27/22. The images of 12/27 showed a concern for another acute fracture, the resident discharged back to the facility with a follow up visit ordered with an orthopedic specialist. The resident remains no weight bear on the left leg and requires assistance of 2 staff for transfers. During an interview with Staff A-RN/MDS Coordinator on 2/8/23 at 10:15 am, Staff A stated she is responsible for the care plan changes and interventions for Resident #7. She stated he has had a lot of falls with fractures. Review of the residents falls and interventions completed with Staff A-RN, she stated the resident has had a total of 6 falls since admission. The following interventions were added to the resident's care plan: a. The resident had a fall on 11/2/22 which resulted in a fracture. The intervention put in place for the resident included a medication review for nausea. b. The resident had a fall on 11/10/22 which resulted in a fracture. The intervention put in place is to offer him to use the bathroom prior to laying down in bed. c. The resident had a fall on 12/4/22, the intervention put in place included adding auto lock breaks on his wheelchair. d. The resident had a fall on 12/15/22 which resulted in a fracture, the staff failed to put additional interventions in place. e. The resident had a fall on 12/27/22, the intervention included to move the resident to a different room in the facility. During the interview regarding the lack of interventions after the 12/15/2022 fall, Staff A stated she didn't put any new interventions in place for the resident, she guessed she missed that. During an interview with Staff B-Director of Nurses on 2/8/23 at 11:00 am, Staff B stated the care plan interventions were not effective as the resident continued to fall. The D.O.N. stated she does not think offering a resident to go to the toilet prior to laying down is an effective interventions as the staff should have already been doing this. During an interview with Staff C-LPN Unit Manager on 2/8/23 at 8:30 am, Staff C stated Resident #7 had frequent falls. He has fallen many times and has had 3 fractures as a result of the falls. She stated the resident was independent prior to this first fracture and has not walked independently since. She stated the resident has dementia, is impulsive and cannot remember to ask for help as per a care plan intervention. Observation on 2/7/23 at 11:50 am revealed the resident sitting on his bed in his room. The resident stated he cannot remember his falls but did state he cannot get up any more by himself and said his legs are not any good anymore. Review of a facility generated list of falls from 11/1/2022 thru 2/3/2023 revealed the facility had a total of 135 falls during this time frame, 42 were witnessed falls and 93 unwitnessed falls reported. Review of a Falls and Fall Risk policy dated 2017 directed staff to assess the resident to identify and implement pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

Based on observations, clinical record review, staff and resident interviews, the facility failed to supervise two residents adequately to prevent elopements from the facility for two of seven residents reviewed with elopement/wandering risks (Residents #1 and #3) and also failed to take immediate and appropriate action on 9/26/2022 to a hazard in the environment when a staff member pulled a gun out of her purse, waived it in the air and stated she would take matters into her own hands if the facility did not take care of it. This failure resulted in an Immediate Jeopardy (IJ) to the health, safety, and security of the residents. The facility reported a census of 151 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 with severely impaired cognitive skills for daily decision making, required limited assistance of two staff for transfers and ambulation, and had no wandering behaviors. The resident had diagnoses including dementia, major depressive disorder and weakness. The Care Plan initiated 5/23/22 revealed the resident had a risk for falls, required assistance of one staff for transfers and used a wheel chair for mobility. On 9/11/2022 the Care Plan added the resident had an elopement/wanderer risk related to disoriented to place and history of attempt to leave the facility unattended. It directed staff to distract the resident, place a monitoring device that sounds when leaving the building and resident transferred to the Memory Unit. The Wandering Evaluation dated 8/18/2022 revealed the resident had a low risk for wandering. The Facility Investigation Report included: On Sunday, 9/11/2022, staff observed Resident #1 outside of the building on the sidewalk of the parking lot near the front entrance, unsupervised and in his wheel chair. Staff failed to hear alarms at the time of the incident. The resident had no monitoring device. Staff A, Housekeeping Supervisor, observed the resident at approximately 3:05 p.m. and wheeled him/her back into the building. The climatologist reported the temperature on 9/11/2022 at 3:00 p.m. was 79 degrees. On 10/25/2022 at 9:15 a.m., Staff A reported the resident seemed to be enjoying the outdoors, and she brought the resident back inside the building. Staff A had never witnessed the resident attempt to exit the building prior. On 10/24/2022 at 2:30 p.m., Staff B, Registered Nurse (RN) reported the resident's family visited the resident around lunch time, and they usually take the resident outside. Around 2:00 p.m. - 3:00 p.m., Staff A wheeled the resident to the Nurse's Station. The resident did not have a wander-guard device on at the time. Staff B completed a wandering evaluation and found the resident at high risk, and the resident moved to the Memory Unit. Staff B indicated the resident had no prior attempts to exit the facility unsupervised. Observation on 10/24/2022 at 12:25 p.m., revealed the resident sat in a wheel chair with a wander guard bracelet on his left wrist. The resident reported he had been outside recently with his walker. On 10/25/2022 at 8:20 a.m., the resident sat at the side of his bed eating his breakfast. A family member sat in the chair near the resident and reported the resident did not have a wander guard prior to his elopement, and family usually takes him outside when they visit. Family knew how to enter the code to silence the alarm. The resident verbalized he knew to go outside through the door and he would have to put numbers in but did not know the code. 2. The MDS dated [DATE] revealed Resident #3 with severely impaired cognitive skills for daily decision making, transferred and ambulated independently with a walker, had wandering behaviors, and diagnosis included Alzheimer's disease. The Care Plan documented the resident had an elopement risk/wanderer risk related to being disoriented to place, and a lack of understanding regarding the need to be at the facility. It directed staff to assist the resident to locate her room and offer diversion activities. The Care Plan directed staff to redirect from other resident's rooms as needed and if wanders away from unit, stay with the resident and gently persuade her to walk back to the designated area. On 10/26/2017 staff placed a wander guard on the resident. On 9/7/2022 the Care Plan documented the resident moved to the Memory Unit. The Order Summary Report included an order for staff to place a wander guard and change every three months and as needed, dated 12/7/2017. The Treatment Administration Record dated 9/6/2022 revealed staff signed off check placement and function of wander guard on all three shifts. Staff changed the wander guard on 8/16/2022. Progress Notes dated 9/5/2022 at 1:12 p.m., revealed the resident attempted to exit the facility times two. Staff had visual contact with the resident the entire time, and easily redirected her. Family reported they had a conference scheduled for September 20, 2022 to discuss plan of care. Staff discussed possible relocation to the Memory Unit for safety, but family was unsure if the unit would be an appropriate placement. Resident is aware this is her home but does not understand why it is unsafe for her to leave. The Checklist for Wander guard Monitors revealed maintenance checked the wander guard on the Service Entrance Door on 9/6/2022. The Facility Investigation Report revealed on 9/6/2022 at 5:05 p.m., staff observed Resident #3 outside, unsupervised behind the building by a staff member who was on station four, through a window, attempting to enter the building through a different door. Staff immediately went out and assisted the resident inside, and the wander guard sounded. On 9/7/2022, maintenance increased the volume on the service entrance door, changed the door so it latches and requires a key to get back into the building, and alarm panel changed so staff is required to cancel the alarm at the door versus the Nurse's Station. The Incident Report included the resident stated she only wanted to go outside. On 10/25/2022 at 8:50 a.m., Resident #3 sat in a recliner in her room, in the Memory Unit. The resident reported no concerns with staff treatment as she dressed herself. She appeared pleasant and calm. On 10/25/2022 at 10:30 a.m., Staff D, Certified Nursing Assistant (CNA) indicated on 9/6/2022, the resident walked up to her and Staff E, Business Office Manager and said she wanted to go outside. They told the resident they would take her out later, gave her a piece of candy and she seemed satisfied. Staff D immediately went to Station Four to weigh a resident and she heard knocking, and saw the resident standing by the door. Staff D ran and assisted the resident inside through the service entrance door. The resident's walker sat on the inside of the door and the wander guard alarm sounded after they were about four feet inside the door. About four to five minutes passed from when Staff D last saw the resident. The facility fixed the latch on the door so sit required a key to enter the door. On 10/25/2022 at 2:00 p.m., Staff E reported on 9/6/2022, the resident came to the office door and said she wanted to go outside. The resident went down the hall and must have returned. Staff E failed to hear the alarm. The Business Office door is near the service entrance door. On 10/25/2022 at 5:10 p.m., Staff F, RN (Registered Nurse) reported working on 9/6/2022 and at the time Resident #3 exited the building she would have heard the alarm if it sounded since she was in a nearby room. Staff F interviewed the CNA's and nobody heard the alarm sound. Now, that alarm cannot be turned off at the Nurse's Station, staff have to physically go to the door and turn off the alarm. The Wandering and Elopements Policy revised March 2019 included: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 3. During an interview on 10/25/2026 at 3:15 p.m., Staff G, Scheduling Coordinator, reported an incident occurred on 9/26/2022 that involved a firearm in the facility. Staff I, CNA came to the facility around 9:30 - 10: 00 a.m., and came to Staff H, Human Resources (HR) and Staff G's office to complete a written statement related to an argument with another staff member that occurred the evening prior. During the conversation with Staff G and Staff H, Staff I removed a small firearm from her purse, and waived it in the air without aiming at anyone, and eventually placed the gun back into her purse. Staff G and Staff H left Staff I in their office, went to a meeting and when they returned Staff I remained in the office. When they left for lunch, Staff I exited the building. After lunch, Staff G notified the Administrator and the facility went into lock down with police presence for a week. Staff G and Staff H received verbal education regarding the necessity of reporting a firearm immediately. On 10/26/2022 at 9:30 a.m., Staff G indicated after she reported the incident, police arrived, and she gave a verbal statement. The Administrator printed off a sheet of paper listing the different emergency codes. The Administrator never directed Staff G to write a witness statement. The facility layout revealed the HR office is adjacent to the Station Four Skilled Unit. During a phone interview on 10/25/2022 at 5:30 p.m., Staff H, HR reported she resigned from the facility and last worked on 10/19/2022. Staff H recounted what occurred on 9/26/2022, Staff I, CNA came to her office around 9:30 a.m. and wrote a statement and also called compliance. Staff G, Scheduling Coordinator and Staff H left the office around 10:30 a.m. to attend a meeting and when they returned Staff I was still in the office. During the conversation, Staff I pulled a gun out of her bag and said if you don't handle it, I'll take care of it myself. Staff H never felt threatened, though she had concern for residents. Staff I never pointed the gun at anyone, she just wanted to tell her side of the story. Staff I felt she was being treated unfairly. Around 11:30 a.m., Staff G and Staff H left the building for lunch and Staff H assumed Staff I also left. During lunch, Staff G communicated with Staff H and decided they should report the incident. After lunch, Police arrived and she gave them a verbal statement. Staff H never received re-education or discipline from the facility regarding reporting a firearm. The Administrator never directed Staff H to write a witness statement. During a phone interview on 10/26/2022 at 10:30 a.m., Staff J, Interim Administrator revealed Staff K, Interim Director of Nursing (DON) came to his office on 9/26/2022 after a morning meeting and indicated there had been a gun in the building an hour or two before they were told. Staff J notified the police, they arrived and interviewed Staff G and Staff H. Staff J contracted the police to provide twenty-four hour surveillance for a week following the incident. The facility had an elopement one week prior to this, and they printed off the emergency codes and did various drills. Staff were not to allow Staff I back in the building. During a phone interview 10/26/2027 at 11:42 a.m., Staff K, Interim DON reported Staff E, Business Office Manager (BOM) called her into the office with Staff G. Staff G revealed Staff I had a gun earlier, not an active shooter, and she made no threats. Staff K told the Staff J and the police were called. They gathered Department Heads, put the building into lock down and nobody was allowed in. The police interviewed Staff G and Staff H, and then indicated they could not charge anyone because Staff I did not threaten anyone, and came to the facility to write a statement. Staff G and Staff H left Staff I alone in their office when they attended a meeting, and Staff I left the building around 11:30 a.m. Staff K reported Staff G and Staff H both received verbal education. They did not get statements, the police did. Staff K reported the facility never completed an Investigation that included an Incident Report and Witness Statements. During an interview on 10/25/2022 at 4:30 p.m., Staff L, Corporate RN reported Staff G and Staff H should have reported the firearm immediately, they had Emergency Preparedness training on Relias, a computer based training program. During an interview on 10/26/2022 at 11:30 a.m., Staff M, Licensed Practical Nurse (LPN) indicated she observed Staff I prior to her leaving the building on 9/26/2022. Staff I gave Staff M a hug as she passed noon medications. After lunch they went into lock down. She did not recall receiving re-education on what to do if they observed someone with a firearm, however she would have immediately reported it. They did a lot of elopement drills and were highly educated on that. During an interview on 10/25/2022 at 5:00 p.m., Staff F, RN reported she spoke with Staff I about 30-40 minutes before they went into lock down. Staff I walked around, talked to staff and said her good-[NAME]. Staff were not re-educated on what to do if they observed someone with a gun, but she knew to notify a supervisor immediately and call 911. The Corrective Action Form dated 9/26/2022 documented the facility terminated Staff I on 9/26/2022 because she brought a firearm into the facility and showed the weapon to multiple staff. Police were called. Corrective Action: The facility Corporation does not allow firearms on the property. Per policy, possession of a weapon is immediate termination. Staff I is not allowed on the property. Review of the local Police Investigation Report dated 9/26/2022 included: a. Date/Time found: 11:15 a.m. b. Date/Time reported: 1:15 p.m. c. Upon officer's arrival, Staff J, Administrator advised they had an employee come in who had a firearm and the building had to go into lock-down as a result of this. Two witnesses, Staff G and Staff H were interviewed. Staff H stated Staff I came to the office to give a statement about an incident that occurred between her and another employee the day before. Staff I was very upset that she had been suspended and during the course of the conversation, Staff I reached into her purse and pulled out a small black handgun, showed it and made a statement that was along the lines of she would defend herself and that she would handle her own problems. Staff I never pointed the handgun at Staff H or the other witness and she did not threaten anyone. She simply showed it to them and placed it back into her purse. Staff H did not personally feel threatened but was worried for the safety of the people in the Nursing Home. d. Staff G stated Staff I came in, upset about the fight she was involved in the day before, and upset she was the one suspended and had to leave at that time. Staff I came in with her hood up and sunglasses on, presumably because she did not want to be seen. Staff G stated Staff I is not very stable, meaning she is quick to get angry, emotional, is very irrational and does not handle certain situations very well. Staff I made a statement about how she was not one to mess with and around this time is when she took the firearm out of her purse which Staff G described as a small black handgun and showed it to Staff G and Staff H and did not threaten them with it and did not point it in their direction, but simply pulled it out of her purse, showed it to them, and then put it away. Staff G also advised there have been other issues with Staff I in the past with her anger and aggression. e. The officer went to Staff I's residence and attempted to make contact with her, get a statement and possibly look at her firearm but there was no car in the driveway and no answer at the door. She did call the officer back and gave a statement about what happened. She stated that she went to work to speak with HR about the incident that happened and she was trying to tell them her side of the story. She felt very unsafe and worried she may get jumped in the parking lot and that is why she had her handgun on her. She felt safe enough with HR that she could reveal to them that she carried a firearm. This was simply to show how scared she had been at work and would defend herself if necessary. She did not threaten anyone with the gun. She was advised she was not welcome back on the property. Review of the Firearms and Other Weapons Policy revised April, 2007 included: a. Policy Statement: Our facility prohibits employees, residents, visitors, vendors or others from possessing firearms or other weapons while in/on our facility's premises. b. Policy Interpretation and Implementation: An employee who suspects an individual of carrying a weapon should not confront the individual, but should immediately contact the security officer or supervisor and inform him/her suspicions. (Note: Should these staff members not be available, contact the local police department for assistance). Page 29 of the Employee Handbook updated 5/2022 included: Safety Rules: All safety incidents (no matter how minor) must be immediately reported to the supervisor. Employees are then required to complete an Employee Incident Report and Employee Statement before the end of their shift. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 10/27/2022 at 9:15 a.m. The facility removed the Immediate Jeopardy on 10/27/2022 through the following actions: a. A facility wide staff re-education on how to recognize an emergency and when/what to report to facility leadership immediately. b. Emergency management codes and procedures were hung throughout the facility. c. When leadership is aware of the hazard to the environment, immediate actions will be taken to ensure facility residents are protected from possible harm, such as placing the building on lock-down, notifying the police, determine if outside security is needed, and issuing any warrants as necessary. d. All current in facility agency staff have been educated and new agency staff will be educated via the Agency Staff Orientation Checklist. e. All new facility staff are educated via the handbook and Relias training. f. Signage is posted outside all doors throughout the building relative to the facilities policies governing the possession of firearms or other weapons while in or on the facility's premises. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures.

Based on observation, record review, staff, and resident interviews the facility failed to ensure a residents safety for 1 of 3 residents reviewed for a fall (Resident #88). The resident obtained a fracture from a fall, when a staff person turned away from the resident, requiring hospitalization . The facility identified a census of 128 residents. Findings include: 1. Resident #88's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a score of 14 out of 15, indicating good memory skills. The resident required 1 staff for limited assistance with ambulation in the room and in the facility. The MDS showed the resident had unsteadiness with walking but able to stabilize without staff assistance. The MDS also showed the resident had heart failure, [MEDICAL CONDITIONS] (dizziness) and collapse, and diabetes. The Care Plan revised on 3/28/19 showed the resident required staff assistance with mobility related to impaired mobility, shortness of breath, weakness and fatigue post hospitalization for pneumonia with [MEDICAL CONDITIONS], and a history of [MEDICAL CONDITION] episodes with falls. An intervention included to provide assistance of 1 staff with transfers and ambulation and to use a walker while ambulating. The Physician order [REDACTED]. The normal range of oxygen saturation for adults is 94 to 99 percent. Low blood oxygen levels can result in abnormal circulation and cause the following symptoms: shortness of breath, headache, restlessness, dizziness, rapid breathing, chest pain, confusion, and high blood pressure.) A Physical Therapy Evaluation and Plan of Treatment dated 3/20/19 identified the resident will have therapy for 3 times a week for 4 weeks. A long term goal identified for the resident is to ambulate safely on level surfaces for 150 feet, using a wheeled walker. Observation on 4/22/19 at 11:16 a.m. (initial tour) revealed the resident in her recliner with the oxygen running at 1 liter per minute per nasal cannula. The resident reported she fell while at home and had no falls since being here. The resident reported having fractured some bones in the back and had pain in her right shoulder. She reported she is receiving pain medications and felt her pain was under control. A Hospitalist History and Physical report dated 4/8/19 revealed the resident had a fall while working with therapy while at the care facility. According to the resident and family the therapist left her to grab a chair and in the meantime the resident lost her balance and fell backwards, landing on the buttocks. The resident started to have severe pain in the right hip and hit her head. The fall resulted in the resident being transferred to a local hospital for evaluation. The report revealed the resident had a CT (computerized tomography) scan without contrast of the pelvis which revealed an oblique nondisplaced fracture through the right ilium and nondisplaced right superior and inferior pubic rami fracture (fractured pelvis). The Orthopedic surgeon on call was consulted and recommended non-operative management with pain control, PT and OT therapy and weight bearing as tolerated. The resident admitted to the hospital for further management and evaluation. Review of an x-ray report of both hips dated 4/8/19 revealed the resident had an oblique nondisplaced fracture through the right ilium/iliac wing and a non displaced right superior and inferior pubic rami fractures. A Nurses Note dated 4/8/19 showed the resident walked with therapy to the dining room with use of a walker and gait belt. The therapist left the resident's side, walked over to get a chair for her to sit in and the resident fell , hitting her head on the wall near the nurse's station. A nurse's assessment revealed the resident responded appropriately and had full range of motion without pain but sustained a skin tear to the right forearm. The physician ordered the resident to be sent to the hospital for evaluation due to hitting her head and currently receiving anticoagulant medication. An Online Abuse or Incident Reporting form dated 4/9/19 sent to Department of Inspections and Appeals reported an incident resulting in hospitalization for Resident #88. The incident summary showed the resident had [DIAGNOSES REDACTED]. The resident has a BIMS of 14 out of 15 BIMS (Brief Interview for Memory Skills) and an assist of one with a front wheeled walker for transfers and ambulation. On 4/8/19 at 2:30 p.m. therapy worked with the resident for ambulation to see if the resident could safely be independent with ambulation in the facility. The resident walked 130 feet with a gait belt, needed stand by assist and occasional contact assist (holding on to the gait belt). The resident then walked 20 feet and 56 feet, with minimal contact assist. The therapist noted the resident's pace going slower. The therapist asked the resident if she wanted to sit down. The therapist turned to get a chair and as the therapist turned back, she saw the resident falling away from her. The resident fell against the wall with the shoulder, hit her head on the wall, and slid down onto the floor, landing on the buttocks. The Corrective Action Description of the Online Report 4/12/19 showed the resident went to the emergency room . The resident received an anticoagulant (blood thinner) and had hit the head which required an evaluation. The hospital reported a nondisplaced [MEDICAL CONDITION] iliac wing superior and inferior pubic rami which required hospitalization . The resident had an extensive history of dizziness and collapse of unknown injury. The resident wore Ted hose (compression stockings) and an abdominal binder while ambulating and denied dizziness at the time of the fall. The initial post fall nursing assessment and the initial Emergency Medical Service assessment identified an oxygen saturation of 85 % to 92%, indication the resident likely de-saturated (low oxygen) due to exertion while ambulation with therapy. The facility believed a combination of muscle fatigue and mild [MEDICAL CONDITION] (low oxygen) played a significant role in the resident's fall. The resident's care plan was updated to include the use of oxygen with ambulation. A witnessed Fall Report by the facility dated 4/8/19 showed while the resident walked with therapy staff to the dining area using a walker and gait belt, the resident became tired, the therapist walked over to get a chair for the resident to sit down. The resident fell , hitting her head on the wall near the nurse's station. After staff completed an assessment, the resident went by ambulance to the hospital. The resident received a skin tear to the right forearm. The Report showed the resident ambulated with assistance, was alert and orientated, used a walker. The resident ambulated long distance with Physical Therapy and became overly tired. The fall occurred as the therapist went to get a chair for the resident to rest. The Physical Therapist Assistant (PTA), Staff B wrote a statement: I was walking the resident to practice longer distances. While walking the resident to Station 1's dining room, turned away to get a chair for the resident to sit in and the resident fell back hitting the head on the wall near the nurse's station. Additional Notes on 4/9/19 on this Witnessed Fall Report included the resident assessment revealed a lower oxygen saturation after ambulation. The Patient Incident Reporting Form (by Rehabilitation) dated 4/8/19 showed the PTA (Physical Therapist Aide-Staff B), account of the fall: The patient participated in therapy. The patient met goal of walking to the nurse's station with the front wheeled walker and stand by assist (SBA-walking next to the resident). This therapist turned to pull a chair up for the resident and the resident fell to the right and could not reach the resident to recover the resident's balance. The resident hit the shoulder and her head on the wall and continued to fall onto the floor. A Physical Therapy Treatment Encounter Note dated 4/3/19 showed the resident with precautions and a fall risk. The therapist set up an oxygen bag on the walker to support an oxygen tank for the resident while ambulating. Gait training performed with contact guard and/or close stand by assist with a wheelchair to follow. The resident's oxygen level monitored throughout ambulation. The note indicated the resident's oxygen level dropped to 82 % with the resident on 2 liters of oxygen. The resident instructed to slow the pace for safety and ambulated up to 150 feet prior to rest break. A Physical Therapy Treatment Encounter Note dated 4/4/19 showed the resident ambulated 150 feet plus 100 feet. The resident's oxygen level dropped as low as 85% but increased to 95% while sitting and cued to use pursed lip breathing. A second interview with the resident on 4/23/19 at 11:27 a.m. the resident reported she did have a fall here at the facility. The resident reported not remembering if a gait belt around her waist at that time, or if oxygen applied. The resident reported walking with a therapist down to station 1. An interview on 4/23/18 at 12:15 p.m. Staff B, Physical Therapist Aide (PTA) reported walking the resident from Station 3 dining room to the resident's room, after a rest period, walked 130 feet and then another 20 feet. The resident's walker had a large oxygen tank in a bag on the resident's front wheeled walker which distributed oxygen to the resident during ambulation. Returning to the resident's room, Staff B switched the oxygen tank to the oxygen concentrator in the room. Staff B requested the resident to walk down the hall to Station 1, to get medication. When they got outside the resident's room, the PTA noted the oxygen tubing didn't go any further, so she removed the oxygen from the resident. The PTA walked with the resident down the hall, approximately 45 to 56 feet without oxygen. At the station, the PTA, noted the resident slower in pace and turned to get a chair for the resident. As the PTA turned back towards the resident she fell . The PTA reported Occupational Services (OT) were ready to determine the resident as independent that day and said she did not agree or disagree. The PTA reported the resident had on the gait belt, compression socks and abdominal binder. The PTA reported she did not hold onto the gait belt and used stand by assist the entire last walk. The PTA stated by using stand by assistance this would help determine if the resident's functions could be deemed independent. The PTA thought therapy services were going to make the resident independent that day, but then the fall occurred. The PTA also noted she did not check the resident's oxygen level during the entire session that day. An interview on 4/23/19 at 1:50 p.m. Staff C, Physical Therapist (PT) reported PT usually determines if a resident is deemed independent. All services will get together to discuss the matter. The PT replied they usually do a few sessions with the resident to determine if the resident is safe. The PT reported it was this Rehabilitation's Policy to always have a gait belt on a resident when working with the resident, whether they require one or not. The PTA noted staff usually use contact guard (CGA) in testing the resident, which means we hold onto the resident's gait belt while ambulating. A person can get the feeling of the residents balance, gait, and steadiness with the use of the gait belt. He noted stand by assist (SBA) means we just stand by them as they ambulate. An interview on 4/23/19 at 2:15 p.m. the Director of Rehabilitation Services reported all services will meet and discuss the determination to declare a resident independent with ambulation. The Director agreed the PT and TO notes did not report they were planning on making the resident independent on 4/8/19. An interview on 4/2319 at 2:35 p.m. Staff E, Licensed Practical Nurse (LPN) reported she saw the PTA walking the resident down the hall towards Station 1. The resident had on a gait belt, compression stockings, abdominal binder, using a walker. Staff E saw the PTA holding onto the gait belt. When they got to the entrance of the dining room, Staff E heard the PTA say to the resident it looked like she needed to rest. The PTA let go of the gait belt and stepped over to the opposite side of the resident to retrieve a chair. The resident fell into the wall. Staff E noted there were other staff persons in the dining room that the PTA could have asked for assistance to get the chair. Staff E commented staff do not let go of the gait belt until the resident was in a safe place. An interview on 4/25/19 at 8:23 a.m. Staff AA, LPN, reported working the day the resident fell . It occurred between 2 p.m. and 2:30 p.m., at shift change. Staff AA entered the dining room and found the resident on the floor by the wall, by the entrance to the dining room next to the medication carts. Staff AA asked the PTA what happened, the PTA told Staff AA, she ambulated the resident on a longer distance to see if the resident could be independent with ambulation. The PTA said she let go of the resident to get a chair and the resident fell . Staff AA reported there were 4 or 5 people in the same area and the PTA could have asked for some help. Staff AA assessed the resident, noted a skin tear, asked if the resident had pain, which the resident answered no. The resident covered her face and began to cry. Due to the resident hitting the head and being on an anticoagulant, the staff transferred the resident to a local hospital for evaluation. The resident stated twice to the medics that she had pain. An interview on 4/25/19 at 11:30 a.m., Staff C reported they usually make resident's independent in the room first and then independent in the halls. He noted the PTA may have been trying to determine if the resident could be independent in the hall on the day the resident fell . An interview on 4/15/19 at 12:10 p.m. the Acting Administrator (former Director of Nursing) reported all she knew of the resident's fall was second hand. She commented not knowing how the gait belt should be used for the resident that day, stand by assist or contact guard, because the Therapy Department have their own scope of practice. The facility's Falls Protocol Quick Reference dated 1/2015 reported identifying residents at risk which included: - completed a fall risk assessment for each resident at the time of admission and quarterly. - for those residents identified at risk of falls initiate/implement preventive interventions via care plan. The Facility's Policy for Functional Assist Level Scale dated 9/5/17 showed the Policy for Rehabilitation Services that all therapy personnel will document following an uniform system of measurement for disability by using the functional assist level scales within the clinical documentation systems. These scales indicate how much assistance is required for this individual to carry out a task. The Procedure for this Policy showed the following scales included: - Standby Assist (SBA) = No physical contact needed however close enough to reach if help is needed. - Contact Guard (CGA)= Occasional contact is needed-protective safeguarding.

Based on clinical record review, staff and resident interviews, the facility failed to provide adequate supervision to prevent accidents and failed to revise the Care Plan in order to provide interventions for safety (Resident #4). The sample consisted of 4 residents and the facility reported a census of 132 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 12/14/15. The MDS identified the resident had [DIAGNOSES REDACTED]. A score of 3 identified the resident had a severe cognitive impairment. The MDS assessment documented the resident required limited assistance for transfers, walking in their room and supervision in the hallway. The resident had balance problems and needed staff assistance when moving from a seated to standing position and standing from a seated position. The MDS identified the resident as not steady but able to stabilize self without staff assistance when walking and turning. A Fall Risk Evaluation form dated 12/17/15, documented the resident scored 20 and the 1/26/16 fall assessment documented a score of 18. The form indicated a total score of 10 and over identified the resident at high risk for falls. Review of the Incident/Accident Occurrence Forms identified the resident experienced three falls since admission to the facility. On 10/14/15 at 6:00 a.m., the staff found the resident on the floor by the bed and lying on right side. The resident had a small bump on the right side of head. The resident voiced complaints of a headache. The orthostatic blood pressures were lying 140/70, sitting 130/70 and standing 120/60 (orthostatic blood pressure problems). The nurse notified the ARNP (Advanced Registered Nurse Practitioner) at 6:10 a.m. On 1/16/16 at 5:15 p.m., staff witnessed the resident leave his/her walker and then fell on his/her back in the hallway (by lounge) floor. The resident hit his/her head on the floor. The orthostatic blood pressure identified orthostatic changes with values of lying, 142/80, sitting 110/64 and standing 122/72. The resident voiced complaints of a headache and the nurse administered APAP (analgesic) at 5:30 p.m. The report reflected the APAP was effective at 7:30 p.m. On 1/23/16 at 8:30 p.m., the staff found the resident on the floor in the bedroom. The report indicated the resident reported to the staff she/he went to close the bedroom door and slipped on the floor. The resident did not utilize the walker. The resident voiced complaints of right upper extremity arm/wrist pain and landed on right side of body on floor with right arm under body. The orthostatic blood pressures registered at lying 138/80, sitting, 140/60, and 128/68 standing. The Care Plan identified the resident had a problem with impaired mobility and needed assistive device use with a potential for elopement and injury from falls. The Care Plan approaches included and directed staff to monitor the resident for unsteadiness/instability and provide assistance as needed. The intervention identified the resident as typically independent and to monitor for correct assistive device usage and cue and assist the resident. The approach dated 10/14/15 directed staff to monitor orthostatic blood pressures for 3 days (after the fall). The Care Plan identified the resident had a fall on 1/16/16 and the approach directed staff to obtain a urine specimen and labs (blood for laboratory tests). The Care Plan identified the resident experienced a fall on 1/23/16, and sustained a closed skull fracture and closed displaced oblique fracture of his/her right arm. The approaches directed staff to provide assistance of 2 staff, use a gait belt and platform walker for ambulating and follow the Physical Therapy recommendations. Nurse Notes dated 1/16/16 at 6:25 p.m., documented the resident had a witnessed fall, hitting head on the floor with a raised area noted to the forehead. The Nurse ' s Notes dated 1/17/16 at 12:10 p.m. identified the staff obtained a urine specimen and sent it to a local laboratory for an evaluation. Nurse Notes dated 1/20/16 at 1:00 p.m. indicated the ARNP ordered Bactrim DS, one tablet twice a day for 7 days for urinary tract infection. The resident received the first dose of the antibiotic on 1/20/16 at 9:40 p.m. Nurse Notes dated 1/23/16 at 8:30 p.m., documented the resident returned from a family outing and staff assisted the resident to get ready for bed. Staff left the room, the resident got out of bed and attempted to close the door and fell to the floor. Staff found the resident on the floor with complaints of right arm and right wrist pain. The nurse sent the resident to a local emergency room for evaluation and treatment. The Nurse ' s Notes indicated the resident was admitted to a local hospital and returned from the hospital on [DATE]. The re-admittance assessment dated [DATE] identified the resident had bruises to the right hand with a cast on the right wrist with edema noted. The local hospital emergency notes dated 1/23/16, reflected the resident had [DIAGNOSES REDACTED]. On 2/15/16 at 10:50 a.m., the Assistant Director of Nursing reviewed the resident's falls and stated the intervention after the fall on 1/16/16 included to obtain a urinalysis and laboratory work. No other interventions were put in place. The interventions for the fall on 1/23/16 included a referral to Physical/Occupational Therapy for an evaluation and treatment since the resident returned using a platform walker and required assistance of 2 staff. A Falls Protocol Quick Reference dated 1/2015, directed staff to complete a fall risk assessment for each admission and quarterly and for residents at risk for falls staff should initiate preventative interventions. After a resident fall, staff should revise the resident's care plan with additional interventions identified.

Based on observation, clinical record review, interviews, and Wanderguard operating instructions, the facility failed to implement care plan intervention to ensure residents received adequate supervision from hazards in the environment for 9 of 9 residents reviewed. Resident #1 left the nursing home in his/her wheelchair without the facility staff knowing his/her whereabouts for approximately 25 minutes. The resident's Wanderguard device did not alarm when the resident exited the home. The resident had fallen out of his/her wheelchair when a passerby found him/her on the sidewalk near a telephone pole. Staff interviews determined no staff heard the Wanderguard alarm sounding plus the alternative alarm system had been turned off. Record review identified Resident #1 had a [DIAGNOSES REDACTED]. The findings constitute an immediate jeopardy to the resident's health and safety. The facility also failed to provide supervision related to Wanderguard (door alarm devices) for 3 additional residents (Residents #34, #35, and #36). In addition, the facility failed to implement care plan interventions to ensure residents received adequate supervision from hazards regarding falls for Residents #23, #22, #10, #4, Resident #1; and safety/supervision concerns for Resident #2. The facility reported a census of 130 residents. Findings include: 1. A History and Physical (H & P)dated 8/22/13 documented Resident#1 had [DIAGNOSES REDACTED]. Resident#1 resided at an assisted living facility and had been admitted to the hospital for behavioral disturbance. While in the assisted living the resident had 11 falls in the last 30 days even after being treated for [REDACTED]. The H&P reported the resident had been irritable last night, yelled out that he/she needed to leave to go to work, and cussed at a staff. The resident transferred to the nursing home on 8/29/13. A Resident Assessment/Data Collection Form/Initial Care Plan dated 8/29/13 documented that Resident#1 required assistance of two staff members for transfers, and cares, and use of wheel chair for ambulation but could bear full weight, and described the resident as alert, friendly, talkative, hyperactive, disoriented to time, and place. The Elopement Risk assessment dated [DATE] indicated the resident had been independent with wheelchair usage. Nurses Note dated 8/29/13 at 6:30 p.m. documented resident had been agitated attempting to stand up multiple times without assistance from wheelchair, and the resident stated he/she was looking for his/her spouse. A Fall Investigation form dated 8/30/13 documented the resident had been found on one knee looking for a fire to put out in another residents drawer. The Fall investigation form indicated the immediate action taken to prevent another episode had been to keep the resident near the nurses ' station. The resident did not have an injury. Nurses Note dated 9/01/13 at 4:00 a.m. documented the resident had been up and propelling self in the wheelchair wandering around the unit. Nurses Note dated 9/01/13 at 4:00 p.m. documented the resident set off the door alarm down station one BHall by opening up the door, the resident stated he/she had been trying to find his/her spouse and catch a train, the nursing intervention to this had been to take the resident to 2B (locked secured unit) for safety and provide one to one with a C.N.A, resident noted to have increased confusion, the family and physician had been notified, and monitoring continued. Nurses Note dated 9/3/13 at 1:00 p.m. documented the resident needs a lot of one on one the resident had been always looking for his/her spouse and wanted to go home and find his/her spouse, staff members were able to visit with the resident for distraction, and the resident did calm down. Nurses Note dated 9/04/13 at 9:15 p.m. documented the resident refused to have assessment completed, and resident noted with wandering behaviors this evening. Nurses Note dated 9/05/13 11:00 a.m. documented the resident propelled himself/herself in the wheelchair and continued to wander aimlessly. Nurses Note dated 9/06/13 at 8:00 p.m. documented the resident continued to wander, the resident had been able to self-propel his/her wheelchair independently. Nurses Note dated 9/08/13 at 8:00 p.m. documented a C.N.A reported to the nursing staff that Resident #1 had been observed outside of the facility. According to the C.N.A the resident had been found on the sidewalk outside by a passerby. (The passerby ' s spouse came into the facility to report the resident had been outside.) When the staff went outside she observed the resident sitting on the ground and observed the passerby assisted the resident up from the ground back into the wheelchair, then staff escorted the resident into the building. The resident appeared with the C.N.A who gave report, the resident sat in the wheelchair without signs or symptoms of pain. The resident ' s speech had been clear and the resident denied injuries. The resident appeared calm, and without signs of injuries upon visual assessment, neurological checks initiated, and 15 minutes checks continued, responsible party had been contacted, and fax sent to the physician. Nurses Note dated 9/08/13 at 10:00 p.m. documented the resident ' s range of motion had been within normal range, and the resident had no complaints of pain on palpation of the hips, and lower extremities. The resident remained at the nurses' station for the remainder of the shift. Nurses Note dated 9/09/13 at 10:30 a.m. documented the resident and belongings had been transferred to the secured unit. During an interview on 9/17/13 at 10:40 a.m. a male passerby reported that on 9/08/13 at about 6:30 p.m. he had driven on first avenue north of the nursing home and found a resident (Resident #1) on the ground on the west side of the telephone pole on his/her back. The passerby stopped to assist the resident, and noticed the resident ' s wheelchair went off the sidewalk and his/her feet were towards the street and his/her head towards the building. The wheelchair was nearby with a white plastic device and cord that had been making a beeping sound. The male passerby reported the resident wore a light blue sweater, and the resident did not have any bleeding. Then the male passerby assisted the resident to sit up, and then three ladies in uniforms arrived and appeared very concerned about the resident. The male passerby reported he had not been sure who the staffs names were. The male passerby reported the staff then assisted the resident back into the facility. A typed documented (undated) with the Director of Nursing (DON) ' s name explained the nursing home alarm systems as follows. The main entrance is equipped with 2 alarms. The first alarm is the actual door alarm and sounds when someone attempts to open the door without putting in the alarm delay code ...The alarm sounds at the door and at station three (3) nurse ' s desk. If the alarm panel when turned off does not sound at the nurse ' s desk. The doors are held by a magnet. When the doors have been opened without entering the code the magnet lights on the doors will change from double green to none green and one red, indicating that they must be reset at the door. To reset the magnets, the code must be entered and the doors open to full then closed. On 9/8/13, staff found the doors with the double green (lights) indicating that they had not been opened without the code being entered correctly. The second alarm is the Wanderguard and it sounds when a resident with a Wanderguard opens the door and attempts to go through the doors. The Wanderguard is not a part of the alarm panel and staff are not able to turn off the Wanderguard in anyway. The facility tested the Wanderguard on the night of 9/8/13 after the incident and the Wanderguard did not sound in the center of the 2 doors but did sound to the left and right of the center. The maintenance department made adjustments to Wanderguard system on the night of the elopement. The alarm panel at the station three nurse ' s desk had modifications made. The main control switch to the panel has now been covered so staff will no longer be able to switch it in the off position and staff were retrained on the use of the alarm panel. A typed document dated 9/8/13 with the Administrator ' s name revealed the Wanderguard on the main door did not sound when Resident #1 passed with his/her ankle bracelet in his/her wheelchair. The Administrator tested the front doors and the Wanderguard did not function correctly and did not sound the alarm. Staff Interviews: During an interview on 9/12/13 at 1:30 p.m. Staff EE, C.N.A described Resident#1 as nice, confused, always wanting to go to work, wandered a lot, could self propel his/her own wheelchair pretty fast. Staff EE reported that on 9/08/13 the resident reported he/she had pushed the front door open with his/her foot. Staff EE reported the resident easily pushed open the main entrance door with his/her foot, which the resident identified the main entrance door as the exit he/she took. Staff EE reported that she last saw the resident at about 7:25 p.m. in the dining room prior to his/her elopement on 9/08/13. The next time she saw the resident Staff BB, C.N.A from station#4 had brought the resident to station#1, and reported that the resident had been found outside the building sitting on the ground. Staff EE reported that she did not hear the WG alarm go off prior to the elopement, and a WG needs to be reset at the door that it goes off at. Staff EE reported when Resident#1 returned to the building assessments were started right away, then Staff EE, Staff FF R.N, and Staff A, LPN escorted the resident around the building to see which door the resident identified as his/her exit door, and to check the WG system. Staff EE reported no WG alarm went off. Staff EE reported that the WG system did not work when tested on [DATE] with Resident#1 going through the door. Staff EE reported the resident had on a blue sweater with long sleeves, tan shoes, eyeglasses, long pants, a shirt, and a WG bracelet on the ankle. Staff EE reported that the resident had been known to self transfer, but had been a one assist for transfers. Staff EE reported she could not recall if a head count of the residents had been done, but usually a head count is done if alarms go off with an elopement. Staff EE reported that she had previous WG training and a control panel tells you which door is activated with lights. Staff EE reported that education had been given on the control panel for station#3. Staff EE reported that Resident#1 had been moved from station#1 to 2B (the locked unit) the next day after the elopement. During an interview on 9/17/13 at 10:00 p.m. Staff NN, Registered Nurse (RN) reported she had been working on station#4 on 9/08/13 when, a lady entered the building at about 7:30 p.m. and told her that a resident was outside the building, Staff NN sent two C.N.As to respond, then the resident entered back into the building at about 7:45 p.m., and no WanderGuard alarms had sounded prior to that. During an interview on 9/18/13 at 3:45 p.m. Staff BB, C.N.A reported that she worked on station#4 on 9/08/13, when a lady came into the building by station#4 and told staff that a resident was in a wheelchair outside. Staff BB and Staff Y, C.N.A headed towards the station#4 exit, and saw that people had helped Resident#1 into the wheelchair. Staff BB reported the resident had been wearing long pants, and the resident was calm. Staff BB reported the time had to be after 7:00 p.m. because the sun had started to go down. Staff BB and Staff Y brought the resident back to the facility, then Staff BB took the resident to station#1. Staff BB reported that a head count had been completed on station#4. Staff BB reported that the staff did get education about the new door for station#4 and the main entrance, which included to be alert to the lights above the door, that green means locked and red means unlocked. Staff BB reported the main entrance to the building opened in August. During an interview on 9/17/13 at 9:42 p.m. Staff Y, C.N.A reported working on station#4 on 9/08/13 when a lady came into the facility at the station #4 entrance and reported that a man was outside trying to stand up. Staff Y reported that she and Staff BB, C.N.A had found Resident#1 by an electrical pole, and a passersby assisted the resident into the wheelchair. Staff Y reported that it had been about 8:00 p.m., and the resident had on a blue sweater, long pants, and that the resident had been in a good mood, and the resident stated he/she had been trying to go home, then Staff BB and Staff Y brought the resident back in the building, and then Staff BB took the resident to the station#1 nurse Staff FF. Staff Y reported that no Wanderguard alarms had sounded. Staff Y reported that Resident#1 is very strong and can propel his/her wheelchair quickly and independently. During an interview on 9/12/13 at 2:00 p.m. Staff CC, C.N.A reported that Resident#1 could be described as nice, cheerful, and could self propel his/her own wheelchair quickly. Staff CC reported she usually worked on station#1. Staff CC reported that on 9/08/13 at about 7:00 p.m. Resident#1 had been headed towards nurses' station#1, wearing a blue collar shirt, and long pants. Staff CC reported the next time she saw him/her was at about 7:40 p.m., when resident came back into the building. Staff CC reported she took the resident to the bathroom at 8:00 p.m., and then took the resident back to the station#1 dining room, the resident did not complain of pain, the resident had good balance, and had normal behavior. Staff CC reported the staff kept an eye on the resident did vitals and every 15 minute checks. Staff CC reported that each hallway has a panel that shows where a Wanderguard (WG) alarm had been set off, and then the door should be checked, and then the WG is reset by use of a pen or by putting in a code. Staff CC reported all staff had been provided with door alarm and WG education, and the front lobby had been open since August. Staff CC reported that Resident#1 could be fast enough to get out the front door with the reset time delay function of the front door. Staff CC had a WG bracelet on his/her right or left ankle since admit. Staff CC reported that no WG alarm went off prior to the resident's elopement. During an interview on 9/17/13 at 9:30 p.m. Staff I, R.N reported that on 9/08/13 staff C.N.A ' s reported to her that Resident#1 had been found outside the facility by the street. Staff I reported that no WG had went off. A head count had been completed on station#2. Staff I reported that the resident had been moved to station#2 the next day after his/her elopement. Staff I reported the WG alarms should have been heard throughout the building, and there are alarm stations in every hallway. Staff I reported the night shift staff are responsible to check the WG bracelets on the residents' body, and chart it on the treatment sheets. During an interview on 9/12/13 at 1:10 p.m. Staff DD, C.N.A described Resident#1 as a nice guy, easily redirected, propelled own wheelchair fast, and had short term memory loss. Staff DD reported that on 9/08/13 at about 7:15 p.m. she and Staff EE, C.N.A helped another resident to the bathroom when Resident#1 had been asleep in the station#1 dining room, then at 7:25 p.m. she saw Resident#1 awake in the station#1 dining room, and the next time she saw Resident#1 had been about 7:45 p.m. when the resident had been brought back into the building, the resident had on long pants, long sleeve shirt, sweater, socks, shoes. Staff EE reported the resident had one on one monitoring after his/her elopement. Staff EE reported resident received one on one sometimes from staff who was on light duty prior to his/her elopement or sometimes the resident would hang out in the hallway that the staff were working on, for instance when the staff were putting other residents to bed. Staff EE reported that from the beginning of the residents stay the resident could have used one on one monitoring. Staff EE could not remember if a head count had been done after the elopement. Staff EE reported the resident had a WG bracelet on his/her left ankle. During an interview on 9/18/13 at 2:54 p.m. Staff AA, C.N.A , certified preceptor, reported that she had seen Resident#1 after dinner at about 7:00 p.m. on 9/08/13 in the hallway headed towards station3B, the resident propelled his/her own wheelchair. Staff AA reported that Staff Z told her that the alarm panel was off for the nurse ' s station#3, then Staff AA alerted other staff, and told the nurse, then Staff AA and Staff Z went outside, then saw a resident with other staff members, and the resident had been brought through to the nurse's station#4 doors. Staff AA reported the resident had been wearing a blue sweater, and the resident did not appear distressed, and then a head count was completed on nurse's station#3. Staff AA reported that the main door had been opened up in late August after it was remodeled and staff had received education on the doors at that time, and also more after the elopement. Staff AA reported that she had been unsure of who shut off the alarm panel. During an interview on 9/18/13 at 12:05 p.m. Staff Z, Cook reported that he entered the facility on 9/08/13 at about 7:29 p.m. at the main entrance on the east side of the building. He walked toward nurse ' s station #1 to punch in at the time clock, then headed to the kitchen up to nurse ' s station#3 and noticed the lights were off on the station#3 alarm panel. Staff Z then found Staff AA, C.N.A and told her that the alarm switch had been turned off, and they needed to start doing a head count. Staff Z then turned to go to the kitchen and found the charge nurse and told him that the alarm panel was off and a head count needed to be done. Staff Z reported that the Station#3 alarm panel would affect north and south doors, the main front entrance, 3AHall, and the service door to the back of the kitchen. Staff Z reported that now the off switch to the alarm panel is covered, which was fixed on 9/09/13 or 9/10/13, and all staff were educated on the doors. Staff Z reported a guy came in the station#3 south door and informed him that a resident was out on First Avenue. Staff Z found Staff AA and told her that a resident was outside on the sidewalk, then Staff Z and Staff AA headed out the station#3 south door, and took a route along the front of the building towards first avenue, then a passersby's wife had come up the hill towards the facility and stated that the facility staff got the resident up and headed towards the station#4 entrance, which both Staff Z and Staff AA could visualize from their location. Staff Z reported the Wanderguard (WG) alarm can be easily heard in the building even in the break room. Staff Z reported that no alarms had been going off when he entered the building on 9/08/13. Staff Z reported that staff were educated to do visual checks of doors, and educated that two separate buttons need to be pushed to reset the alarm, staff also had to sign a safety in-service attendance sheet. During an interview on 9/18/13 at 3:15 p.m. Staff W, C.N.A reported she usually worked on station#1, and you had to keep a close eye on Resident#1 because he/she may try to self-transfer and resident had been a fall risk, and could move pretty good. Staff W reported that on third shift the resident had been taken back to the locked unit because it was hard to keep tabs on the resident. Staff W reported the resident had a WG bracelet on his/her ankle. During an interview on 9/17/13 at 12:15 p.m. Staff F, LPN reported that Resident#1 had a WG on the ankle, and could self propel his/her own wheelchair at a moderate pace, and staff would provide one on one monitoring at times, and light duty staff would spend time with the resident sometimes, and the resident loved chocolate. Staff F did reported that training for the front had been given to the staff that if the light on the front door was red the door needed to be reset to a green light. During an interview on 9/18/13 at 10:10 a.m. Staff II, C.N.A reported she usually worked third shift. Staff II reported that Resident#1 could be very determined, moved pretty quickly in the wheelchair, and could read. Staff II reported that the resident had been taken back to the locked unit to be monitored at times before the elopement and used one to one monitoring help as well. Staff II reported she worked the night shift and the evening shift that the resident got out of the building and had been instructed to keep an eye on the resident and to do every one hour head count checks. During an interview on 9/12/13 at 10:00 a.m. Staff FF, LPN he had worked on 9/08/13 and at 7:05 p.m. he came back from break and started medication pass on BHall station one. Staff FF reported that on 9/08/13 at about 7:45 p.m. Staff BB, C.N.A brought Resident #1 in a wheelchair from station#4, and notified him that the resident had been found sitting on the ground outside by a passerby and helped the resident back into the wheelchair. Staff FF reported the resident had been assessed with [REDACTED]. Staff FF reported he informed Staff BB to write up a statement, and then called the Administrator, the director of nursing, and the resident ' s responsible person. Staff FF reported the Administrator came in promptly, and then Staff FF proceeded to test alarms on all the doors with Staff A, LPN and with the resident. Staff FF reported the resident had a WG on his/her ankle. Staff FF reported that the resident identified the main entrance door as the exit door he/she used to get out of the building. Staff FF reported that he tested the front door WG system four times and it did not go off. The Administrator called the maintenance staff right away. Staff FF reported that he did not do a head count of the residents, but he should have. Staff FF reported that upon reenactment of opening the front door it took 40 seconds for the door to relock, and that it would have easily given the resident enough time for the resident to get out of the building. Staff FF reported that he checked the door alarms and WG system at midnight prior to going home at the end of his shift on 9/08/13. During an interview on 9/12/13 at 8:20 a.m. the Director of Nursing (DON) reported that the front door camera capability had not been available due to it not being turned back on after the remodeling had been completed. During an interview on 9/12/13 at 8:30 a.m. the facility Administrator reported there had not been any front door camera capability due to it being disabled had been a work in progress related to wire work. The Administrator reported that the front main entrance opened on 8/12/13. The Administrator reported that the WG alarms had been checked the morning of 9/08/13 by Staff X, Maintenance Staff, and checked by the Maintenance Supervisor and by himself post elopement. The main entrance WG system had been functioning on 9/08/13 but at a knee or hip range, the range had been extended to cover the range from the chest to the ankle range when an individual is in the standing position. The Administrator and Maintenance Supervisor both reported that all the exits were checked for the ranges daily. The Administrator educated Staff X, Maintenance staff on the importance to get all levels checks accurately. The Administrator reported that Staff FF, LPN had called him at about 8:00 p.m. on 9/08/13. The Administrator reported that staff interviews did not establish who had turned off the door alarms on station#3. During an observation on 9/12/13 at 8:00 a.m. the Administrator and the Maintenance Supervisor checked all the doors in the building for alarm status, and all alarms and WG systems were working correctly. The alarm range or the WGs spanned from the chest to below five (5) inches from the floor on all WG exits. The doors are checked every day to include the weekends. During an interview on 9/12/13 at 10:55 a.m. Staff X, Maintenance Staff reported on 9/09/13 that he had been notified and instructed to check the WG system at three different ranges, and before he had checked three ranges, but now the WG bracelet is lowered to the ground, so he needed to be checking the WG even lower. Staff X reported that he did do the WG checks the morning that Resident#1 got out of the building. Staff X reported that the weekend manager also checks the WG ' s daily. During an interview on 9/19/13 at 10:15 a.m. the Director of Nursing (DON) reported that the Administrator handled the 9/08/13 elopement, but did assist with staff education about door safety and assisted with the investigation process. The DON reported that the resident had been witnessed exiting a door before and Resident#1 had been easily redirected. The DON reported Resident#1 wandered frequently, and could go back to the locked unit for safety. The DON reported that the resident had been moved back to the locked unit the day after the elopement. Wanderguard System Operation-Bracelet Activation and Use document without a date labeled page 17 directs facilities to place the bracelets on the resident's dominant wrist. The metal in a wheelchair (or any other metal items) may interfere with the bracelet's signal to the door modules. Before proceeding with alternate placement you must contact technical service for further instructions. Page 18 Wheelchair Placement revealed the following directions for facilities; Facilities often ask about attaching the bracelet to a wheelchair. If attempts to use wrist placement have failed, mount the bracelet away from the metal frame of a wheelchair at a height of approximately three feet from the floor (in the center of the back of the wheelchair). The Director of Nursing provided the survey team a document titled Heritage Nursing and Rehab with a date of 9/09/13 with the 33 names of residents highlighted that are confused, and independently mobile, that do not reside in the locked unit. Observations on 9/17/13 at 8:20 a.m. revealed Resident#1 propelled himself/herself in a wheelchair down the hallway independently at a moderate pass. During an interview on 9/23/13 at 2:50 p.m. the Administrator reported the Residents #34, #35 and #36 did not reside in the locked unit of the facility. The Administrator reported that the five doors affected by the station#3 alarm panels would be the back kitchen entrance, the furthermost north door on station#3 hallway, the two doors in the station#3 dining room, and the main entrance. The Administrator pointed out the affected doors on the facility map. During an interview on 9/12/13 at 2:00 p.m. Staff CC, C.N.A reported that Resident#1 could be described as nice, cheerful, and could self propel his/her own wheelchair quickly. Staff CC reported she usually worked on station#1. Staff CC reported that on 9/08/13 at about 7:00 p.m. Resident#1 had been headed towards nurses' station#1, wearing a blue collar shirt, and long pants. Staff CC reported the next time she saw him/her was at about 7:40 p.m., when resident came back into the building. Staff CC reported she took the resident to the bathroom at 8:00 p.m., and then took the resident back to the station#1 dining room, the resident did not complain of pain, the resident had good balance, and had normal behavior. Staff CC reported the staff kept an eye on the resident did vitals and every 15 minute checks. Staff CC reported that each hallway has a panel that shows where a Wanderguard (WG) alarm had been set off, and then the door should be checked, and then the WG is reset by use of a pen or by putting in a code. Staff CC reported all staff had been provided with door alarm and WG education, and the front lobby had been open since August. Staff CC reported that Resident#1 could be fast enough to get out the front door with the reset time delay function of the front door. Staff CC had a WG bracelet on his/her right or left ankle since admit. Staff CC reported that no WG alarm went off prior to the resident's elopement. During an interview on 9/17/13 at 9:30 p.m. Staff I, R.N reported that on 9/08/13 staff C.N.A ' s reported to her that Resident#1 had been found outside the facility by the street. Staff I reported that no WG had went off. A head count had been completed on station#2. Staff I reported that the resident had been moved to station#2 the next day after his/her elopement. Staff I reported the WG alarms should have been heard throughout the building, and there are alarm stations in every hallway. Staff I reported the night shift staff are responsible to check the WG bracelets on the residents' body, and chart it on the treatment sheets. 2. A Minimum Data Set (MDS) with reference date of 6/12/13 documented Resident#34 had a brief interview for mental status score of 12 out of 15, which indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS revealed the resident had the [DIAGNOSES REDACTED]. The MDS documented the resident had a history of [REDACTED]. The Care Plan directed staff to remind the resident why the resident needed to stay at the facility when the resident talked of going home. The Care Plan identified a problem for the resident as impaired mobility with potential for elopement and injury related to brain injury trauma due to a motor vehicle accident. The Care Plan directed staff to provide a WG for the resident, and monitor for its placement routinely and as needed. The Care Plan also directed staff to monitor the resident for elopement type attempts, and provide the resident with redirection. Observation on 9/23/13 at 3:00 p.m. the resident sat in a wheelchair in the station #1 dining room with a WG bracelet attached to the metal bar under the resident's wheelchair about 24 inches from the floor. 3. A MDS with reference date of 7/23/13 documented Resident#35 had a brief interview for mental status score of 6 out of 15, which indicated severely impaired cognitive skills for daily decision making. The MDS revealed the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had a fall history. The Care Plan with admitted date of 4/24/13 documented an approach with a date of 5/17/13 that directed staff to implement a WG, and to monitor routinely for placement, and to monitor for elopement type attempts and to provide the resident with redirection and reassurance. The Care Plan documented the resident's primary form of locomotion had been a wheelchair and directed staff to provide as needed propulsion Observation on 9/23/13 at 3:00 p.m. revealed the resident sitting in a wheelchair in the resident ' s room, the WG bracelet had been attached to the metal frame of the wheelchair close to the right wheel. 4. A MDS with reference date of 8/05/13 for Resident#36 documented the resident had moderately impaired cognitive skills for daily decision making. The MDS documented the resident had potential indicators of psychosis listed as hallucinations, and delusions. The MDS documented the resident had [DIAGNOSES REDACTED]. The MDS revealed the resident had a history of [REDACTED]. The Care Plan identified a problem for the resident related to exit seeking behaviors, and directed staff to observe for the potential that the residents may wander and redirect the resident from the exits, and to keep a WG on the resident and check per facility policy. The Care Plan indicated the resident had been propelling the residents ' wheelchair independently. Observation on 9/23/13 at 3:05 p.m. revealed the resident sitting in the hallway in a wheelchair with a WG bracelet attached to the posterior metal portion of the right armrest of the wheelchair. The resident propelled the wheelchair without difficulty. Falls: 5. A MDS with reference date of 9/06/13 documented Resident#23 had a score of 10 out 15 for a brief interview for mental status, which indi