Every finding on record at Matthews Memorial Health Care Center

Based on record review and interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 (Resident #3) of 3 sampled residents. Findings:Review of the facility's policy titled, Care Plan Process with a revision date of 12/2024 read in part. The facility shall develop and implement a baseline care plan and summary for each resident that includes the instructions needed to provide effective and person centered care of the resident that meets professional standards of quality care. The baseline care plan shall:1. Be developed within 48 hours of a resident's admission. Review of Resident #3's medical record revealed an admit date of 04/06/2026 with the following diagnoses in part.Acute and Subacute Endocarditis, Pruritus, Generalized Edema, Tachycardia, Hypothyroidism, Hypotension, Moderate Protein-Calorie Malnutrition, and Major Depressive Disorder. Review of Resident #3's medical record revealed no documentation that a baseline care plan had been developed and implemented within 48 hours of admission. Review of Resident #3's admission MDS with an ARD of 04/16/2026 revealed a BIMS score of 15, which indicated intact cognition. Resident #3 required supervision/ touching assistance with toileting, showering, dressing, and transfers. Interview with S3MDS/LPN on 07/08/2026 at 10:45 a.m. revealed all newly admitted residents were required to have a baseline care plan completed within 48 hours of admission. S3MDS/LPN confirmed Resident #3 did not have a baseline care plan completed within 48 hours of admission and should have. Interview with S2DON 07/08/2026 at 10:52 a.m. confirmed all newly admitted residents were required to have a baseline care plan completed within 48 hours of admission. S2DON confirmed Resident #3 did not have a baseline care plan completed within 48 hours of admission and should have.

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #3) of 3 sampled residents. The facility failed to develop a comprehensive care plan that addressed Resident #3's medical, physical, mental, and psychosocial needs. Findings:Review of the facility's policy titled, Care Plan Process with a revision date of 12/2024 read in part.Regulations require facilities to complete a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to several specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care. Review of Resident #3's medical record revealed an admit date of 04/06/2026 with the following diagnoses in part.Acute and Subacute Endocarditis, Pruritus, Generalized Edema, Tachycardia, Hypothyroidism, Hypotension, Moderate Protein-Calorie Malnutrition, and Major Depressive Disorder. Review of Resident #3's admission MDS with an ARD of 04/16/2026 revealed a BIMS score of 15, which indicated intact cognition. Resident #3 required supervision/ touching assistance with toileting, showering, dressing, and transfers. Review of Resident #3's medical record revealed no documentation that an individualized comprehensive care plan had been developed. Interview with S3MDS/LPN on 07/08/2026 at 10:45 a.m. revealed residents were required to have a comprehensive care plan completed within 14 days of admission. S3MDS/LPN confirmed Resident #3 did not have a comprehensive care plan completed within 14 days of admission and should have. Interview with S2DON 07/08/2026 at 10:52 a.m. confirmed all residents were required to have a comprehensive care plan completed within 14 days of admission. S2DON confirmed Resident #3 did not have a comprehensive care plan completed within 14 days of admission and should have.

Based on observation, record review, and interview, the facility failed to provide care and services that met professional standards of quality by failing to obtain and document blood pressure measurements in accordance with physician orders and prior to administering medications with prescribed blood pressure parameters for 1 (Resident #3) of 3 sampled residents. Findings:Review of the facility's policy titled Vital Signs with a revision date of 05/2014 read in part.3. Vitals signs will be taken per physician's orders8. Vital signs will be recorded electronically in the Medical Record. Review of Resident #3's medical record revealed an admit date of 04/06/2026 with the following diagnoses in part.Acute and Subacute Endocarditis, Pruritus, Generalized Edema, Tachycardia, Hypothyroidism, Hypotension, Moderate Protein-Calorie Malnutrition, and Major Depressive Disorder. Review of Resident #3's admission MDS with an ARD of 04/16/2026 revealed a BIMS score of 15, which indicated intact cognition. Resident #3 required supervision/ touching assistance with toileting, showering, dressing, and transfers. Review of a physician's order dated 04/20/2026 read in part. administer Midodrine HCL tablet 5mg, one tablet by mouth three times daily for Hypotension, with instructions to hold the medication if Resident #3's systolic blood pressure exceeded 160mmHg. Review of a physician's order dated 05/05/2026 read in part. monitor blood pressure daily related to hypotension. Review of Resident #3's blood pressure records revealed blood pressure measurements were not obtained or documented on the following dates: 05/05/2026, 05/06/2026, 05/07/2026, 05/08/2026, 05/09/2026, 05/10/2026, 05/13/2026, 05/14/2026, 05/15/2026, 05/16/2026, 05/17/2026, 05/20/2026, 05/21/2026, 05/22/2026, 05/23/2026, 05/24/2026, 05/26/2026, 05/27/2026, 05/28/2026, 05/29/2026, 05/30/2026, 05/31/2026, 06/02/2026, 06/03/2026, 06/04/2026, 06/05/2026, 06/06/2026, 06/07/2026, 06/08/2026, 06/10/2026, 06/11/2026, 06/12/2026, 06/13/2026, 06/14/2026, 06/17/2026, 06/18/2026, 06/19/2026, 06/20/2026, 06/21/2026, 06/22/2026, 06/24/2026, 06/25/2026, 06/26/2026, 06/27/2026, 06/28/2026, 07/01/2026, 07/02/2026, 07/03/2026, 07/04/2026, 07/05/2026, 07/07/2026, and 07/08/2026. On 07/08/2026 at 10:52 a.m., an interview with S2DON confirmed Resident #3 had physician orders for daily blood pressure monitoring and for blood pressure to be obtained prior to administration of Midodrine HCL 5mg three times daily. S2DON confirmed that blood pressure measurements were not obtained or documented on the above listed dates, but should have been.

Based on interview and record review, the facility failed to accurately assess acute pain consistent with professional standards of practice for 1 (Resident #1) of 3 sampled residents. Findings:Review of the facility's policy titled, Pain Screen and Management, with a revision date of 05/2026 read in part.4. Acute onset of pain:a. A pain screening shall be completed when a resident experiences a new onset of pain.b. Documentation related to pain shall include the following elements: date and time of onset, location of the pain, characteristics/description of the pain, alleviation factors, exacerbating factors, treatments/ medications administered, and resident response to interventions.c. Documentation of a new type of pain, changes in pain mediation, and/or treatment interventions shall be completed every shift using an approved pain scale. Review of Resident #1's medical record revealed an admission date of 04/24/2026, with diagnoses that included in part.Disruption or Dehiscence of Gastrointestinal Tract Anastomosis, Persistent Postprocedural Fistula, Encounter for Surgical Aftercare following Surgery on the Digestive System, Fistula of the Intestine, Moderate Protein Calorie Malnutrition, Hypertension, and Endocarditis. Review of Resident #1's admission MDS with an ARD of 04/30/2026 revealed Resident #1 had a BIMS score of 14, indicating intact cognition. Review of Resident #1's care plan, initiated 04/29/2026, read in part.Resident #1 had the potential for pain related to bowel dehiscence with recurrent fistulas. Review of the nursing progress note dated 06/06/2026 at 10:00 a.m., documented by S4LPN, revealed Resident #1 declined breakfast and stated, I have a little stomach ache. There was no documentation that a comprehensive pain assessment was completed following Resident #1's report of pain. On 07/06/2026 at 1:59 p.m., an interview with Resident #1's family member revealed that on 06/06/2026, at approximately 2:30 p.m., she arrived at the facility and observed Resident #1 lying in a fetal position while complaining of abdominal pain. Resident #1's family member stated she requested that Resident #1 be transferred to the hospital immediately for further evaluation. On 07/07/2026 at 4:05 p.m., S4LPN stated that on 06/06/2026, Resident #1 reported abdominal discomfort, describing it as a little belly ache. S4LPN confirmed that a comprehensive pain assessment was not completed following Resident #1's complaint of abdominal pain. S4LPN confirmed Resident #1's pain severity utilizing the facility's approved pain scale, date and time of onset, pain location, pain characteristics, alleviating factors, or aggravating factors were not assessed or documented, but should have been. On 7/08/2026 at 4:00 p.m., S1Corporate RN reported the facility utilizes a standardized pain assessment tool that includes a numeric pain rating scale (0-10) for residents who are cognitively intact. S1Corporate RN reported that a comprehensive pain assessment should include, at a minimum, the type and severity of pain, the date and time of onset, and provider notification. S1Corportate RN confirmed there was no documentation of a comprehensive pain assessment in the medical record following Resident #1's complaint of abdominal pain. S1CorporateRN confirmed Resident #1's pain should have been assessed and documented, but was not.

Based on record review and an interview, the facility failed to ensure a resident's medical record was accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 sampled residents. The facility failed to ensure Resident #1's pain level and meal intake was accurately documented in the electronic medical record. Findings:Review of the facility's policy titled Documentation with a revision date of 03/2026 read in part.Clinical Record Accuracy: It is the policy of this facility to maintain accurate, complete and timely clinical records in accordance with the regulatory requirements. Review of Resident #1's medical record revealed an admission date of 04/24/2026, with diagnoses that included in part.Disruption or Dehiscence of Gastrointestinal Tract Anastomosis, Persistent Postprocedural Fistula, Encounter for Surgical Aftercare following Surgery on the Digestive System, Fistula of the Intestine, Moderate Protein Calorie Malnutrition, Hypertension, and Endocarditis. Review of Resident #1's admission MDS with an ARD of 04/30/2026 revealed Resident #1 had a BIMS score of 14, indicating intact cognition. Resident #1 required partial/moderate assistance with ADLs. Review of a nursing progress note dated 06/06/2026 at 10:00 a.m., documented by S4LPN, revealed Resident #1 did not eat breakfast and stated, No, I don't want it. I have a little stomach ache. Review of the facility's meal intake documentation revealed that, for breakfast on 06/06/2026, Resident #1 was documented as having consumed 100% of the meal. Review of the pain assessment documentation dated 06/06/2026 at 10:48 a.m. revealed Resident #1's pain level was documented as 0, indicating no pain. On 07/07/2026 at 4:05 p.m., S4LPN confirmed that on 06/06/2026, Resident #1 did not eat breakfast due to abdominal discomfort. S4LPN confirmed that the documentation on 06/06/2026 indicating resident consumed 100% of breakfast and the documentation of a pain score of 0 was inaccurate. On 07/08/2026 at 4:00 p.m., S1Corporate RN confirmed that the documentation dated 06/06/2026 indicating Resident #1 had a pain score of 0 and consumed 100% of breakfast was inaccurate. S1Corporate RN confirmed that the medical record should have accurately reflected Resident #1's pain assessment and actual meal intake on 06/06/2026, but did not.

Based on record review and interview, the facility failed to provide care and services that met professional standards of quality by failing to ensure physician orders for blood glucose monitoring were implemented for 2 (Resident #1 and Resident #2) of 3 residents sampled. Findings:Resident #1 Review of Resident #1's medical record revealed an admission date of 02/12/2026 with the following diagnoses in part. Chronic Kidney Disease, Type 2 Diabetes Mellitus with Hyperglycemia, Dementia, Essential Hypertension, Cognitive Communication Deficit, and Generalized Muscle Weakness. Review of Resident #1's admission MDS with an ARD of 02/13/2026 revealed a BIMS score of 6, which indicated severe cognitive impairment. Review of an admission progress note dated 02/12/2026 at 12:25 p.m. revealed Resident #1 was admitted to the facility on [DATE] following hospitalization. Hospital discharge diagnoses included Diabetic Ketoacidosis and Hyperkalemia. Review of Resident #1's physician order, with a start date of 02/12/2026, revealed an order for blood glucose monitoring before meals and at bedtime. Review of the February 2026 Medication Administration record (MAR) revealed no documented blood glucose results for Resident #1 on 02/12/2026 at 4:00 p.m. and 8:00 p.m. On 06/01/2026 at 3:45 p.m., an interview with S2LPN revealed she worked the 3:00 p.m. - 11:00 p.m. shift on 02/12/2026. S2LPN confirmed Resident #1 had a physician order for blood glucose monitoring before meals and at bedtime. S2LPN confirmed there was no documentation blood glucose monitoring was performed for Resident #1 at 4:00 p.m. or 8:00 p.m. on 02/12/2026. Resident #2Review of Resident #2's medical record revealed an admit date of 05/11/2026 with the following diagnoses in part. Pneumonia, Acute on Chronic Systolic Heart Failure, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Dementia, Long Term Use of Oral Hypoglycemic Drugs, and Hypertension. Review of Resident #2's admission MDS with an ARD of 05/18/2026 revealed a BIMS score of 6, which indicated severe cognitive impairment. Review of Resident #2's physician order, with a start date of 05/12/2026, revealed an order for blood glucose monitoring twice a day. Review of the May 2026 MAR revealed no documented blood glucose results for Resident #2 on 05/12/2026 or 05/13/2026. On 06/03/2026 at 2:47 p.m., an interview with S1DON confirmed Resident #1 and Resident #2 had physician orders for blood glucose monitoring upon admission. S1DON acknowledged blood glucose monitoring was not performed for Resident #1 on 02/12/2026 and for Resident #2 on 05/12/2026 and 05/13/2026, but should have been.

Based on record review and interview the facility failed to provide pharmaceutical services to ensure procedures that assure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of each resident. The facility failed to provide medications and/or biologicals to meet the needs of residents for 2 (Resident #1 & Resident #3) of 3 residents sampled. FindingsResident #1Review of Resident #1's medical record revealed an admit date of 02/12/2026 with the following diagnoses in part. Chronic Kidney Disease, Type 2 Diabetes Mellitus with Hyperglycemia, Dementia, Essential Hypertension, Cognitive Communication Deficit, and Generalized Muscle Weakness. Review of Resident #1's admission MDS with an ARD of 02/13/2026 revealed a BIMS score of 6, which indicated severe cognitive impairment. Review of Resident #1's physician orders revealed that the following medications were ordered to be administered on 02/12/2026:Rosuvastatin Calcium 10mg- administer 1 tablet orally at 9:00 p.m.Seroquel 100mg- administer 1 tablet orally at 9:00 p.m.Singulair 10mg- administer 1 tablet orally at 9:00 p.m.Sodium Bicarbonate 650mg- administer 1 tablet orally at 5:00 p.m.Tresiba FlexTouch 100 units/ml- administer 15 units subcutaneously at 9:00 p.m.Carvedilol 25mg- administer 1 tablet orally at 9:00 p.m.Humalog Kwikpen 100 units/ml- administer 2 units subcutaneously before meals at 4:00 p.m.Humalog Kwikpen 100 units/ml- administer per sliding scale at 4:00 p.m. and 8:00 p.m.Hydralazine 50mg- administer 1 tablet orally at 9:00 p.m.Revatio 20mg- administer 1 tablet orally at 9:00 p.m. Review of the February 2026 Medication Administration record (MAR) revealed code 5 was documented for each of the medications listed above on 02/12/2026. Review of facility's MAR legend revealed code 5 indicated medication was not administered and directed staff to refer to the progress notes. Review of an admission progress note dated 02/12/2026 at 12:25 p.m. revealed Resident #1 was admitted to the facility on [DATE] following hospitalization. Hospital discharge diagnoses included Diabetic Ketoacidosis and Hyperkalemia. Review of a progress note dated 02/12/2026 at 10:29 p.m. revealed Resident #1's medications were on hold pending delivery from the pharmacy. On 06/01/2026 at 12:34 p.m., an interview with Resident #1's family member revealed Resident #1 did not receive her scheduled medications on 02/12/2026 after admission to the facility. On 06/01/2026 at 3:45 p.m., an interview with S2LPN confirmed Resident #1 did not receive the medications listed above on 02/12/2026 because the medications had not been delivered by the pharmacy. On 06/02/2026 at 8:29 a.m., an interview with the pharmacist servicing the facility revealed the pharmacy did not receive Resident #1's medication orders until 9:07 p.m. on 02/12/2026. The pharmacist confirmed that if the medication orders had been faxed to the pharmacy at the time of Resident #1's admission on [DATE] at 12:25 p.m., the medications would have been delivered that same afternoon. Resident #3Review of Resident #3's medical record revealed an admit date of 03/10/2026 with the following diagnoses in part. Heart Failure, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes with Hyperglycemia, Chronic Kidney Disease, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Atherosclerotic Heart Disease, and Essential Hypertension. Review of Resident #3's admission MDS with an ARD of 03/16/2026 revealed a BIMS score of 13, which indicated intact condition. Review of Resident #3's physician orders revealed that the following medications were ordered to be administered on 03/11/2026:Amlodipine 10 mg- administer 1 tablet orally at 8:00 a.m.Cholecalciferol 5000 unit- administer 1 tablet orally at 8:00 a.m.Clopidogrel 75mg- administer 1 tablet orally at 8:00 a.m.Farxiga 5mg- administer 1 tablet orally at 8:00 a.m.Furosemide 20mg- administer 1 tablet orally at 8:00 a.m.Tamsulosin 0.4 mg- administer 1 tablet orally at 8:00 a.m.Lisinopril 40mg- administer 1 tablet orally at 8:00 a.m.Pantoprazole Sodium 40mg- administer 1 tablet orally at 2:00 p.m.Plaquenil 200mg- administer 1 tablet orally at 8:00 a.m. Review of the March 2026 MAR revealed code 5 was documented for each of the medications listed above on 03/11/2026. Review of facility's MAR legend revealed code 5 indicated medication was not administered and directed staff to refer to the progress notes. Review of an admission progress note dated 03/10/2026 at 5:25 p.m. revealed Resident #3 was admitted to the facility on [DATE] with a primary diagnosis of Heart Failure. Review of a progress note dated 03/11/2026 at 11:23 a.m. revealed Resident #3's medications were on hold pending delivery from the pharmacy. On 06/02/2026 at 1:14 p.m., an interview with the pharmacist servicing the facility revealed the pharmacy did not receive Resident #3's medication orders until 10:09 p.m. on 03/10/2026. The pharmacist stated the pharmacy maintains an on-call pharmacist for after hours; however, the facility did not contact the on-call pharmacist, resulting in a delay in medication delivery. The pharmacist confirmed that if the medication orders had been faxed to the pharmacy at the time of Resident #3's admission on [DATE] at 5:25 p.m., the medications would have been delivered that same afternoon. On 06/02/2026 at 3:46 p.m., S1DON acknowledged that the facility experienced delays in obtaining Resident #1 and Resident #3's medications from the pharmacy. S1DON confirmed medications should have been available for administration in accordance with physician orders, but were not.

Based on observation, interview, and record review, the facility failed to ensure residents received services and resources in the facility with reasonable accommodation of resident needs by failing to:Ensure 1 (#2) of 5 residents reviewed had a call light in place that accommodated his/her needs; and Ensure a call light was within reach in order to call for assistance for 4 (R5, R6, R7, and R8) of 5 residents reviewed for accommodation of needs. Resident #2 Review of Resident #2's medical record revealed an admission date of 09/11/2020 with diagnoses that included, in part. Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting the Left Non-Dominant Side, Type 2 Diabetes Mellitus, Aphasia, Dysphagia, Functional Quadriplegia. Review of Resident #2's annual MDS with ARD 1/15/2026 revealed a BIMS score of 3, indicating severe cognition impairment. Resident #2 had a functional range of motion Impairment to the upper and lower extremity on one side. Resident #2 was dependent for oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene, rolling left to right, and all transfers. Review of Resident #2's care plan with initiation date 08/29/2024 and next review date of 04/21/2026 revealed Resident #2 has a history of falls with potential for further falls related to history of poor sitting balance and regaining positioning, impaired mobility, right hemiparesis, and unable to turn or reposition self in bed with intervention that included in part. Place the call bell within reach. On 04/07/2026 at 11:18 a.m. Observation of Resident #2 revealed the resident in bed, awake, alert, and nonverbal. Resident #2 call bell cord observed wrapped on the right half side rail, with call bell button observed between mattress and side rail, not within reach of the resident. On 04/07/2026 at 2:39 p.m., Observation of Resident #2 revealed the resident in bed awake, alert, and nonverbal. Resident #2 call bell cord observed wrapped on the right half side rail, with call bell button observed between mattress and side rail, not within reach of the resident. On 04/08/2026 at 10:10 a.m. Observation of Resident #2 with S7 CNA and S8 CNA revealed Resident #2's call bell cord observed wrapped on the right half side rail, with the call bell button observed between the mattress and side rail, not within reach of the resident. S7 CNA and S8 CNA confirmed the call bell was out of reach for the resident. At this time, the call bell was placed in Resident #2's left hand. Resident #2 shook the call bell when verbally prompted to press the call bell button. Resident #2 was further instructed on how to press the call bell at this time. The resident continuously shook the call bell and was unable to press the button to trigger the need for assistance. On 04/08/2026 at 10:45 a.m. Interview with S1 DON revealed she was familiar with Resident #2 and her functional limitations. S1 DON revealed the resident has paralysis on one side. S1 DON revealed she believes the resident could use the call bell if she had the pad call bell, which is triggered by tapping. S1 DON stated she did not know whether the resident had a padded call bell. On 04/08/2026 at 10:47 a.m., observation of Resident #2's room with S1 DON. S1 DON confirmed that Resident #2 did not have a call bell in place that accommodated her functional needs and should. On 04/09/2026 at 08:31 a.m., observation of Resident #2 revealed a padded call bell on the resident's bed placed at the resident's chest level. Resident reached her left arm over to demonstrate she could reach and use the call bell. Resident shook her head No when asked if she could use the traditional call bell before it was switched out for the padded call bell. Resident #R5 Observation on 04/08/2026 at 8:20 a.m., revealed Resident #R5 was lying in bed asleep, and the call light was lying on the floor at the foot of the bed and was not within the resident's reach. Observation on 04/08/2026 at 4:00 p.m., revealed Resident #R5's call bell lying on the floor at the foot of the bed and not within the resident's reach. Interview on 04/08/2026 at 4:00 p.m. with S3 CNA confirmed Resident #R5's call light was not within reach, and it should have been. S3 CNA revealed that the distance of the call light on the wall to the head of the bed prevented the call bell from being within reach. She stated the call bell cord needed a clamp attached so it could be clamped to Resident #R5's bed to ensure that it was within her reach. Interview on 04/08/2026 at 4:05 p.m. with S1 DON, confirmed Resident #R5's call light should have been within her reach and it was not. Review of Resident #R5's medical record revealed an admit date of 01/08/2026 with diagnoses that included in part: Diabetes Mellitus with Ketoacidosis Without Coma, Essential Hypertension, Unspecified Dementia, Depression, Unspecified Psychosis, and other Symbolic Dysfunction. Review of Resident #R5's admission MDS with an ARD of 01/20/2026 revealed Resident #R5 required partial/moderate assistance with toileting hygiene, substantial/maximal assistance with shower/bathing self, and partial/moderate assistance for dressing and personal hygiene. Resident #R5 required supervision or touching assistance for bed mobility and walking less than 150 feet. Review of Resident #R5's Care Plan initiated 01/12/2026 read in part.Resident #R5 was at risk for falls. Interventions included call light within reach. Resident #R6 Observation on 04/08/2026 at 9:35 a.m., revealed Resident #R6 was lying in bed, and his call light was lying on top of the mini fridge at the foot of his bed. Resident #R6 stated that he cannot get to his call light. He stated when he needed to call for assistance he had his roommate press the call light for him. Observation on 4/09/2026 at 9:05 a.m., revealed Resident #R6 was lying in bed and his call light was lying on top of the mini fridge located at the foot of his bed, and not within his reach. Interview on 04/09/2026 at 9:05 a.m., with S4 LPN confirmed Resident #R6's call light was not within reach and it should have been. Review of Resident #R6's medical record revealed an admit date of 08/20/2025 with diagnoses that included in part: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side, Aphasia following Cerebral Infarction, Major Depressive Disorder, Anxiety Disorder, Essential Hypertension, and need for assistance with personal care. Review of Resident #R6's quarterly MDS with an ARD of 02/12/2026 revealed Resident #R6 was dependent with toileting hygiene, and required substantial/maximal assistance with shower/bathing self, dressing and personal hygiene. Resident #R6 was dependent with tub/shower transfers and with chair/bed-to-chair transfer, and walking did not occur. Review of Resident #R6's Care Plan initiated 03/10/2026 and revised on 04/09/2026 read in part.Resident #R6 was at risk for falls. Interventions included call light within reach. Resident #R7 Observation on 04/08/2026 at 3:45 p.m., of Resident #R7 revealed she was sitting up on the side of her bed. The call light was observed to be on an opposite and it was not within reach of the resident. Interview on 04/08/2026 at 3:45 p.m., with S5 LPN confirmed Resident #R7's call light was not within reach of the resident and it should be. She stated her bed was too far away from the call light for it to be within reach. Interview on 04/09/2026 at 10:25 a.m., with S6 LPN confirmed the call light in Resident #R7's room was not within her reach and it should be. Review of Resident #R7's medical record revealed an admit date of 03/03/2026 with diagnoses that included in part: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Unspecified Dementia, Unspecified Severity, with Mood Disturbance, Heart Failure, Essential Hypertension, Major Depressive Disorder, Insomnia, and Chronic Kidney Disease, Stage 3B Review of Resident #R7's Comprehensive assessment dated [DATE] revealed Resident #R7 required a cane/crutch for mobility. Setup or clean-up assistance was required with toileting hygiene, shower/bathing self, dressing, personal hygiene, bed mobility and transfers. Supervision or touching assistance required for walking. Review of Resident #R7's Care Plan initiated 03/10/2026 read in part.Resident #R7 was at risk for falls. Interventions included call light within reach. Resident #R8 Observation on 04/08/2026 at 4:20 p.m., of Resident #R8 revealed he was lying in bed and his call bell was hanging on the wall, not within his reach. Interview on 04/08/2026 at 4:20 p.m. with S5 LPN confirmed Resident #R8's call bell was not within his reach and it should have been. Review of Resident #R8's medical record revealed an admit date of 10/01/2025 with diagnoses that included in part: Other Seizures, Chronic Diastolic Congestive Heart Failure, Chronic Kidney Disease, Stage 3, Age-Related Physical Debility, Muscle Weakness (Generalized), Essential Hypertension, and Acquired Absence of Left Leg Above Knee. Review of Resident #R8's MDS with an ARD of 01/26/2026 revealed Resident #R8 required partial/moderate assistance with upper body dressing and personal hygiene. He required substantial/maximal assistance with toileting hygiene, shower/bathing self, lower body dressing, sitting to lying, and lying to sitting on side of bed. Resident #R8 was dependent with sitting to stand, chair/bed-chair transfer, toilet transfer, and tub/shower transfer. Walking did not occur. Review of Resident #R8's Care Plan initiated 11/03/2025 read in part.Resident #R8 was at risk for falls. Interventions included call light within reach. Interview on 04/09/2026 at 3:30 p.m. with S1 DON, and S2 Corporate RN confirmed each resident should have a call light that was within reach.

Based on observation, interview, and record review, the facility failed to ensure that 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents received services and treatments necessary to promote wound healing.Review of facility policy titled Prevention and Treatment of Skin Issues, revised 09/2025, revealed in part. Policy: It is the policy to properly identify and assess residents whose clinical conditions increase risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care.Resident #1Review of Resident #1's clinical record revealed an admission date of 03/07/2024, with diagnoses that included, in part,. Squamous Cell Carcinoma of Skin, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Benign Neoplasm of the Brain, history of Pulmonary Embolism, Atherosclerosis of Native Arteries of Extremities with Intermittent Claudication to Bilateral Legs.Review of Resident #1's Quarterly MDS with an ARD of 12/24/2025 revealed Resident #1 had a BIMS score of 99, indicating the resident was unable to complete the interview. Resident #1 was dependent on putting on/taking off footwear and Rolling left to right. Resident #1 was at risk for pressure ulcer/injury.Review of Resident #1's wound assessment dated [DATE], revealed the resident had a Stage 2 pressure ulcer to her right heel.Review of Resident #1's care plan with an initiation date of 08/30/2024 and next review date of 02/24/2026 revealed, in part, that Resident #1 had a care plan focus: Current Safety Devices and Special Equipment. Goal: Maintain optimal level of functioning. Intervention included in part.: heel protectors.On 02/09/2026 at 10:00 a.m., observation revealed Resident #1 was lying in her bed with her eyes closed. The resident was positioned on her back, without any positioning supports in place. Observation further revealed signage posted on the wall that read, Resident is to wear heel protectors. Two heel protectors were observed on top of Resident #1's clothes closet next to the bed and not on the resident's heels.On 02/09/2026 at 2:00 p.m., observation revealed Resident #1 sitting up in specialized wheelchair in her room with a family member. Two heel protectors were observed on top of Resident #1's clothes closet next to the bed and not on the resident's heels. A family member revealed that she has never observed heel protectors placed on Resident #1.On 02/10/2026 at 9:26 a.m., observation revealed Resident #1 lying in bed with her eyes closed. Resident #1 was positioned on her back. Resident #1's heels were positioned on the mattress without any positioning supports in place. Two heel protectors were observed on top of Resident #1's clothes closet next to the bed and not on the resident's heels.On 02/10/2026 at 11:04 p.m., S5TreatmentNurse revealed Resident #1 had a Stage 2 pressure ulcer to the right heel that was previously a deep tissue injury (DTI). Interventions in place to promote wound healing for Resident #1's right heel, in part, included pressure reduction.On 02/10/2026 at 11:33 a.m., observation revealed Resident #1 sitting up in a specialized wheelchair in the dining room with a family member. Resident #1 was not wearing heel protectors.On 02/11/2026 at 07:44 a.m., observation revealed Resident #1 lying in bed with eyes closed. Resident #1 was positioned on her back. Two heel protectors were observed on top of Resident #1's clothes closet next to the bed and not on the resident's heels.On 02/11/2026 at 07:58 a.m. S3LPN was present at Resident #1's bedside. S3LPN confirmed Resident #1 had a wound to her right heel. S3LPN revealed that interventions to aid in Resident #1's wound healing included routine turning and repositioning and heel protectors. S3LPN confirmed Resident #1's heel protectors were located on top of the clothes closet not on Resident #1's heels, but should have been.Resident #3Review of Resident #3's clinical record revealed an admission date of 11/31/2021 with diagnoses that included Paraplegia, Neuromuscular Dysfunction of the Bladder, acquired absence of left leg above the knee, acquired absence of right leg above the knee, Pressure Ulcer of Right Buttock Stage 4, and Pressure Ulcer of Left Buttock Stage 4.Review of Resident #3's Quarterly MDS with an ARD of 11/20/2025 revealed a BIMS score of 15, indicating intact cognition. Resident #3 was dependent for personal hygiene, rolling left to right, and all transfers.Review of Resident #3's care plan, initiated on 08/29/2024, with next review on 02/18/2026, revealed that Resident #3 was dependent for bed mobility and was care planned for the facility's Turn and Repositioning Program.Review of Resident #3's clinical record skin evaluation dated 02/05/2026 revealed Resident #3 had two skin issues: Stage 4 Pressure Ulcer to the right gluteus with measurements: Length (cm): 1.23, Width (cm): 1.61, Depth (cm): 0 Area (cm2): 2.32. Resident #3 had a Stage 4 Pressure Ulcer to the left gluteus with measurements: Length (cm): 1.22, Width (cm): 2.96, Depth (cm): 0, Area (cm2): 2.79.On 02/09/2026 at 12:25 p.m., observation revealed Resident #3 sitting up in bed with the head of the bed elevated. Resident #3 was positioned on his back. In an interview at this time, Resident #3 revealed he had a bilateral above-the-knee amputation (AKA) and required full assistance with turning and repositioning. The resident revealed that staff do not turn and reposition him or offer to do so every 2 hours. The resident stated he does not refuse to be turned.On 02/09/2026 at 12:25 p.m., observation of the turn schedule located on Resident #3's wall at this time revealed the resident's turn schedule was as follows: 12 o'clock- right, 2 o'clock- left, 4 o'clock- right, 6 o'clock- left, 8 o'clock- right, 10 o'clock- left.On 02/10/2026 at 08:37 a.m., observation revealed Resident #3 sitting up in bed with the head of the bed elevated. Resident #3 was positioned on his back without any supportive equipment in place. On 02/10/2026 at 10:20 a.m. observation/interview with Resident #3 at this time revealed the resident sitting up in bed with the head of the bed elevated. The resident was positioned on his back without any supportive equipment in place. According to his turn schedule, the resident should have been positioned on his left side. The resident stated he would like to be turned and had not been repositioned in several hours. Resident #3 stated he had two wedges for his repositioning and pointed to the corner of his room, where two wedges were observed in a box.On 02/10/2026 at 11:37 a.m., observation of Resident #3 revealed the resident sitting up in bed with the head of the bed elevated. Resident #3 was positioned on his back without any supportive equipment in place. Two position wedges were observed in a box in the corner of Resident #3's room.On 02/10/2026 at 12:45 p.m., observation of Resident #3 revealed the resident sitting up in bed with the head of the bed elevated. Resident #3 was positioned on his back without any supportive equipment in place. Two position wedges were observed in a box in the corner of Resident #3's room.On 02/10/2026 at 12:47 p.m., an interview with Resident #3 revealed no staff member had offered to turn or reposition him at any point that day.On 02/10/2026 at 1:05 p.m., an interview with S4CNA revealed she was assigned to Resident #3 that day and was familiar with the care he required. S4CNA revealed that Resident #3 required total care and was unable to reposition himself in the bed. S4CNA stated that Resident #3 was not on a turn schedule and that she had not turned or repositioned him that day. S4CNA revealed she had not offered to turn or reposition Resident #3 at any point during her shift that day.On 02/10/2026 at 1:10 p.m., observation of the turn schedule posted in Resident #3's room with S4CNA at this time. S4CNA confirmed she should have offered to turn Resident #3 every 2 hours, and did not.On 02/10/2026 at 1:30 p.m., the above findings discussed related to Resident #3 with S1DON. S1DON acknowledged Resident #3 should have been turned and repositioned or offered to be turned and repositioned every 2 hours, and was not.

Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment by not ensuring systems were in place to protect residents' personal belongings, resulting in missing items for 2 ( Resident #34 and Resident #55) of 34 sampled residents. Findings: Resident #34Review of Resident # 34's Clinical Record revealed an admit date of 07/10/2025 with diagnoses which included: Type 2 Diabetes Mellitus with Hyperglycemia, Hypertension, Acute Kidney Failure, Metabolic Encephalopathy, and Gastro-Esophageal Reflux Disease.Review of Resident # 34's admission MDS with an ARD of 07/22/2025, revealed Resident #34 had a BIMS score of 15, which indicated cognition was intact. Resident #34 required supervision/ touching assistance for bed mobility, transfers, and toileting. Resident #55 Review of Resident # 55's Clinical Record revealed an admit date of 01/30/2025 with diagnoses which included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominate Side, Hyperlipidemia, Major Depressive Disorder, and Anxiety. Review of Resident # 55's Quarterly MDS with an ARD of 11/04/2025, revealed Resident #55 had a BIMS score of 14, which indicated cognition was intact. Resident #55 required moderate/substantial assistance for bed mobility, transfers, and toileting. On 12/02/2025 at 01:18 p.m., an interview with Resident #34 revealed she was missing a blanket and two shirts since September 2025. Resident #34 stated she expressed her concerns during Resident Council meetings and that her missing items had not been replaced as of this date. A review of Resident Council Minutes revealed that Resident #34 and Resident #55 reported missing personal items during the months of September and October 2025. On 12/02/2025 at 10:48 a.m., an interview with S16Activity Director revealed that during September 2025 Resident Council meeting, Resident #34 reported missing clothing items. The Activity Director further reported that during the October 2025 Resident Council meeting, Resident #55 reporting missing clothing items. S16Activity Director stated she informed the supervisors of the appropriate departments following each resident council meeting. On 12/03/2025 at 3:45 p.m., an interview with Resident #55 revealed she was missing two pairs of pants since October 2025. Resident #55 stated she expressed her concerns during Resident Council meetings and that her missing items had not been replaced as of this date. On 12/04/2025 at 9:30 a.m., an interview was conducted with the S1ADM, who stated that staff are expected to notify her when items are missing and cannot be located after searching. The S1ADM reported that she reviews Resident Council Minutes monthly and addresses concerns raised during those meetings. S1ADM confirmed that Resident #34's and Resident #55's complaints regarding missing clothing items had not been addressed, despite staff being aware of the missing items. S1ADM acknowledged that staff should have reported the missing items and that items should have been replaced, but were not.

Based on interviews and record reviews, the facility failed to ensure individuals with a mental disorder were referred for a PASRR Level II review for 2 (Resident #26 and Resident #56) of 2 residents sampled for PASRR.Findings: Resident #26 Review of Resident #26's EMR revealed an admission date of 11/30/2023 with diagnoses including Major Depression Disorder and Anxiety Disorder. Review of Resident #26's EMR revealed a PASRR Level I was completed on 11/27/2023 and indicated Resident #26 had not been diagnosed with a mental illness. Record review revealed Resident #26 was not referred for a PASRR Level II review prior to admission, Further review revealed a diagnosis of Delusional Disorder was entered for Resident #26 on 02/09/2024. Review of Resident #26's EMR failed to reveal referral for a PASRR Level II review after diagnosed with Delusional Disorder. Resident #56 Review of Resident #56's EMR revealed an admission date of 02/11/2022 with diagnoses including Cognitive Communication Deficit, Gastrostomy Status, Cerebral Infarction, Hemiplegia, Major Depression Disorder and Epilepsy. Review of Resident #56's EMR revealed a PASRR Level I was completed on 03/10/2022 and indicated Resident #56 had not been diagnosed with a mental illness. Record review revealed Resident #56 was not referred for a PASRR Level II review prior to admission. Interview with S4SSD on 12/03/2025 at 9:00 a.m. revealed Resident #26 and Resident #56 were diagnosed with a mental illness, and were not referred for a PASRR Level II review. Interview with S12Admissions on 12/03/2025 at 10:21 a.m. confirmed Resident #26 and Resident #56 were diagnosed with a mental illness, and were not referred for a PASRR Level II review, but should have been.

Based on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for 2 (Resident #16 and Resident #57) of 34 sampled residents. The facility failed to ensure Resident #16 wore a fire resistant apron while smoking and failed to ensure EBP were implemented for Resident #57. Findings:Resident #57 Review of Resident #57's medical record revealed and admission date of 10/02/2024, with diagnoses that included in part .Pressure Ulcer of Right Heel, Un-stageable; Pressure-Induced Deep Tissue Damage of Left Heel; and Pressure Ulcer of Sacral Region, Un-stageable. Review of Resident #57's MDS revealed Resident #57 had a BIMS summary score of 8, which indicated moderate cognitive impairment. Resident #57 required substantial/maximal assistance with toileting hygiene and had unhealed/un-stageable pressure ulcers. Review of Resident #57's care plan revealed in part .At risk for complication related to Right Heel Deep Tissue: At risk for complication related to Left Medial Heel Deep Tissue Injury. Intervention: Enhanced Barrier Precautions in place (initiated: 11/18/2025). At risk for complications related to Un-stageable to Sacrum, 11/26/2025 Right Ischium Pinrose Drain Surgical Site. Interventions: Apply Wound-vac; Enhanced Barrier Precautions in place (initiated: 11/18/2025). Observation on 12/01/2025 at 10:20 a.m. revealed no EBP signage or PPE upon entrance into Resident #57's bedroom. Observations throughout the facility during survey revealed EBP signage and PPE stations located on resident doors for those residents whom required EBP. Observation and interview on 12/01/2025 at 1:31 p.m. revealed no EBP signage or PPE upon entrance into Resident #57's bedroom. Interview with Resident #57 revealed she had an IV (intravenous) in her arm. Observation of right upper arm midline IV. Observation of Resident #57's room revealed no PPE. Observation and interview on 12/02/2025 at 9:10 a.m. revealed no EBP signage or PPE upon entrance into Resident #57's bedroom. Interview with Resident #57 revealed staff does not wear gowns when providing care to her. In an interview on 12/02/2025 at 10:42 a.m., S14 LPN revealed Resident #57 had a wound on her back and a midline IV (intravenous) to her right upper arm for antibiotic treatment. S14 LPN confirmed Resident #57 was on EBP and should have had EBP signage and PPE on her door but did not. In an interview on 12/02/2025 at 10:52 a.m., S13 CNA Supervisor confirmed Resident #57 was on EBP according to her care plan and that there was no EBP signage or PPE on her door. S13 CAN Supervisor confirmed Resident #57 should have had EBP implemented, but did not. Review of the facility's 12/2024 policy titled Care Plan Process read in part. The facility shall use the results of the assessment to develop, review, and revise the resident's comprehensive plan of care. The facility staff shall follow the care plan. Resident #16 Review of Resident #16's medical record revealed an admit date of 01/25/20 with diagnoses that included: Nicotine Dependence, Major Depressive Disorder, and Cerebral Infarction. Review of Resident #16's Quarterly MDS with an ARD of 09/18/2025 revealed a BIMS score of 11, indicating moderately intact cognition. Review of Resident #16's Care Plan with a review date of 12/22/2025 read in part.Resident is an unsafe smoker. 09/11/2025 offer smoking apron. Review of Resident #16's Smokers assessment dated [DATE] read in part.Resident requires 1:1 supervision while smoking. Resident required fire-resistant smoking apron while smoking. Lighter and matches must be kept at the nurses station. An observation on 12/02/2025 at 9:18 a.m. Resident #16 was observed sitting in the smokers lounge with a staff member, smoking a cigarette, without a smoker's apron being worn. An interview on 12/03/2025 at 1:20 p.m. with S1ADM confirmed that Resident #16 should have had a smoker's apron on while smoking on 12/02/2025, but did not.

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 2 ( #59, and #76) of 4 (#1, #59, and #76, and #86) residents reviewed for ADL care. The facility failed to ensure:11. Resident #59 was provided nail care and was shaved; and 2. Resident #76 was provided proper hair care. Findings:Review of the facility's policy dated 08/2024 titled Resident Quality of Care read in part.Each resident shall receive optimal care to attain and/or maintain the highest possible mental and physical function. The facility will ensure that the resident's abilities to perform activities of daily living do not diminish unless it is clinically unavoidable. At the time of the bath, all residents shall also receive, if applicable, nail care and hair shampoo as needed, shave and oral hygiene. Resident #59 Review of Resident #59's medical record revealed an admission date of 09/09/2025 with diagnoses that included: Rhabdomyolysis and Major Depressive Disorder. Review of Resident #59's Quarterly MDS with ARD of 06/18/2025 revealed a BIMS of 15, indicating intact cognition. Resident #59 required partial/moderate assistance with personal hygiene. Review of Resident #59's care plan with a review date of 12/18/2025 read in part The resident has limited physical mobility weakness. Assistance needed with activities of daily living. An observation on 12/01/2025 at 9:50 a.m., Resident #59 was sitting in chair in room with 1/4 inch long facial hair to chin and 1/4 inch long jagged fingernails. Resident #59 stated that she does not like rock the boat and if they offer to cut her nails and long facial hair she lets them but staff don't often offer. Resident #59 stated that she likes to keep hair facial hair and nails cut. An observation and interview on 12/02/2025 at 8:51 a.m. Resident #59 continues with long facial hair to chin and long jagged nails. Resident stated that she came to the facility months ago and has only had her nails cut once. An interview on 12/02/2025 at 9:45 a.m., S16LPN confirmed Resident #59's long facial hair and long jagged nail and stated that she would get staff to take care of it today. Resident # 76 Review of Resident #76's medical record revealed an admit date of 01/25/2022 with the following diagnoses: Alzheimer's, Dementia, Hypothyroidism, and Anxiety Disorder. Review of Resident #76's Care Plan with a review date of 02/04/2026 read in part.Resident needs assistance with all activities of daily living. Review of Resident #76's Quarterly MDS with an ARD of 11/06/2025 revealed a BIMS score of 99 indicating resident is unable to be interviewed. Resident is dependent on staff for personal hygiene. An observation on 12/01/2025 at 10:03 a.m. Resident #76 I observed lying in bed and the hair to the left side of head is matted into a ball. An observation on 12/02/2025 at 8:44 a.m. Resident observed lying in bed with hair pulled up on top of hair with a hair tie. Unable to see if hair is matted at this time. An observation on 12/02/2025 at 9:40 a.m. Observation of Resident #76's hair with S16 LPN revealed the left side of resident's hair is matted. S16 LPN confirmed Resident #76's matted hair and stated that she would not be able to comb through matted hair. An interview on 12/03/2025 at 12:05 p.m., S17CNA stated that she baths Resident #76 often and has noticed her hair matted like it currently is since 10/2025. S17CNA stated she notified S16LPN on 10/2025 and asked her to call the family to see if it could be cut out but she had not heard back. S17CNA stated she typically washes her hair weekly and will put in conditioner and try to work out the matt. S17CNA stated she stops after a while because she does not want to hurt her. An interview on 12/03/2025 at 10:13 a.m. with S16LPN states that she was not aware that her hair was that matted. S16 LPN stated she did know around not long ago that her hair was matted but was told that they worked it out. S16LPN stated the plan to try to work it out and if it cannot they will speak to family and see if they would be ok with a haircut.

Based on observation, record review and interview, the facility failed to ensure 1 (Resident #10) of 3 ( Resident #10, Resident #57, and Resident #86) sampled residents received the necessary treatment and services to prevent and promote the healing of pressure ulcers by failing to perform hand hygiene during treatment of a pressure ulcer. Findings:Review of Resident #10's medical records revealed an admit date of 11/9/2023 with diagnoses that included: Pressure Ulcer of Sacral Region, Stage 3, and Vascular Dementia. Review of Resident #10's 12/2025 Physician Orders read in part.Cleanse Stage 4 to sacrum with wound cleanser, pat dry, skin prep periwound, calcium alginate and cover with a dry dressing daily until resolved. Observation of Resident #10's wound care on 12/03/2025 at 2:25 p.m., S18TXNurse nurse cleaned the sacrum wound with wet gauze, discarded gauze, reached over onto clean field with soiled gloves, removed gauze from cup and cleansed would. S18TXNurse nurse completed this action 4 more times without removing gloves or sanitizing hands. Interview on 12/03/2025 at 2:30 p.m., S18TXNurse confirmed she did not remove gloves and sanitize hands after cleaning the wound and reaching over into clean field to get new gauze.

Based on interview and record review, the facility failed to implement, monitor, and modify interventions, consistent with the resident's assessed needs and current professional standards of practice, to maintain acceptable parameters of nutritional status for 1 (Resident #86) of 1 resident sampled for nutrition. Findings: Review of the facility's policy titled Management of Residents with Nutrition Problems revised 05/2018 revealed residents with unintended significant weight loss are referred to the RD for evaluation. A Weight Evaluation Form is completed for residents who have a significant weight change. Review of Resident #86's EMR revealed an admission date of 03/07/2024 with diagnoses including Seizures, DM II, and Benign Neoplasm of Brain. Review of Resident #86's Quarterly MDS with ARD of 10/07/2025 revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #86 required substantial/maximal assistance with eating. Review of Resident #86's orders revealed the following, dated 08/07/2025: House Supplement 4 oz. with med pass four times a day for Weight Gain, Document intake: 0=None, 1=25%, 2=50%, 3=75%, 4=100%, 5=Refused. Review of Resident #86's weight record revealed the following, in part: Weight of 157.5 pounds on 11/26/2025; Weight of 167.4 pounds on 10/29/2025; Weight of 169.2 pounds on 08/27/2025; and Weight of 186.6 pounds on 05/13/2025. Review of Resident #86's RD Nutrition assessment dated [DATE] revealed the following, in part.Significant weight loss of -8.1% x 1 month and -11.6% x 3 months. Monitor weights and po intake. Refer to RD prn. Review of Resident #86's RD Nutrition assessment dated [DATE] revealed the following, in part. Significant Weight Loss: -10.7% x 6 months. Monitor weights and po intake. Refer to RD prn. Review of Resident #86's Weight Evaluation Form dated 11/19/2025 revealed the following, in part.Significant and unintentional weight loss of -5.9% x 30 days, and -14.4% x 180 days. Review of Resident #86's care plan revealed the resident had unplanned/unexpected weight loss related to poor food intake. Goal was for resident to consume 75% of two of three meals per day. Interventions included, in part.observe food intake, give the resident supplements as ordered, and alert nurse/dietician if not consuming on a routine basis. Review of Resident #86's Task - Nutrition dated 11/05/2025 through 12/04/2025 revealed meal intake was not documented for: 11/06/2025: 2 meals; 11/10/2025: 3 meals; 11/11/2025: 2 meals; 11/13/2025: 2 meals; 11/14/2025: 2 meals; 11/15/2025: 3 meals; 11/16/2025: 1 meal; 11/17/2025: 1 meal; 11/18/2025: 2 meals; 11/20/2025: 2 meals; 11/22/2025: 2 meals; 11/23/2025: 3 meals; 11/24/2025: 1 meal; 11/25/2025: 3 meals; 11/26/2025: 3 meals; 11/27/2025: 2 meals; 11/30/2025: 3 meals; 12/02/2025: 1 meal; and 12/03/2025: 2 meals. Review of Resident #86's 11/2025 and 12/2025 MARs revealed the percentage consumed was not documented for the House Supplement, as ordered. Interview with S19CNA on 12/04/2025 at 11:38 a.m. revealed CNAs were to document the percentage of every meal consumed and nurses were to document the percentage of house supplement consumed. Interview with S6ADON/IP on 12/04/2025 at 11:50 a.m. revealed CNAs were to document the percentage of every meal consumed and nurses were to document the percentage of house supplement consumed. Interview with S20RD on 12/04/2025 at 11:55 a.m. confirmed the percentage of meal and house supplement intake was not consistently documented for Resident #86, but should have been.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure:1. EBP were utilized for 1 (Resident #57) of 3 residents reviewed for pressure ulcers;2. Staff performed proper hand hygiene while feeding residents; 3. Staff followed proper infection prevention and control practices during transport of soiled linens; and4. Staff followed proper infection prevention and control practices while laundering resident clothing.Findings: 1. Review of a facility policy on 12/02/2025 at 2:26 p.m. titled Enhanced Barrier Precautions, with a revision date of 03/2024 revealed in part.Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing home. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Review of Resident #57's medical record revealed and admission date of 10/02/2024, with diagnoses that included in part .Pressure Ulcer of Right Heel, Un-stageable; Pressure-Induced Deep Tissue Damage of Left Heel; and Pressure Ulcer of Sacral Region, Un-stageable. Review of Resident #57's MDS revealed Resident #57 had a BIMS summary score of 8, which indicated moderate cognitive impairment. Resident #57 required substantial/maximal assistance with toileting hygiene and had unhealed/un-stageable pressure ulcers. Review of Resident #57's care plan revealed in part . At risk for complication related to Right Heel Deep Tissue: At risk for complication related to Left Medial Heel Deep Tissue Injury. Intervention: Enhanced Barrier Precautions in place (initiated: 11/18/2025). At risk for complications related to Un-stageable to Sacrum, 11/26/2025 Right Ischium Pinrose Drain Surgical Site. Interventions: Apply Wound-vac; Enhanced Barrier Precautions in place (initiated: 11/18/2025). In an interview on 12/03/2025 at 10:27 a.m., S15 CNA stated she was familiar with Resident #57. S15 CNA revealed Resident #57 was incontinent of bowel and bladder and had a bed sore which required a wound vac. S15 CNA stated she's unsure on how to know if a resident is on EBP. S15 CNA stated the only precautions Resident #57 was on is fall precautions. Observation on 12/03/2025 at 10:33 a.m., revealed S15 CNA entered Resident #57's bedroom to provide incontinent care and to turn Resident #57. S15 was observed putting on gloves and not a disposable gown. S15 CNA performed incontinent care to Resident #57 without placing on disposable gown. In an interview on 12/03/2025 at 10:42 a.m., S14 LPN revealed Resident #57 had a wound on her back and a midline IV (intravenous) to her right upper arm for antibiotic treatment. S14 LPN confirmed Resident #57 was on EBP. In an interview on 12/03/2025 at 10:52 a.m., S13 CNA Supervisor confirmed Resident #57 was on EBP and that S15 CNA should have worn a disposable gown along with gloves when she provided incontinent care to Resident #57 and did not. #2 Observation of room [ROOM NUMBER] on 12/03/2025 at 8:53 a.m. revealed S10CNA feeding two residents without applying hand sanitizer or performing hand hygiene between direct contacts with residents. Interview with S13CNASupervisor on 12/03/2025 at 11:31 a.m. confirmed staff did not use hand sanitizer or perform hand hygiene between direct contacts with residents, but should have. #3 Observation of Hall A on 12/01/2025 at 11:35 a.m. revealed S7CNA carrying soiled bedding in her hands. S7CNA opened a door and placed the soiled bedding into a yellow barrel inside the room. Interview with S7CNA on 12/01/2025 at 11:36 a.m. confirmed she had been carrying soiled linens in her hands, but should not have been. Interview with S19CNA on 12/01/2025 at 11:36 a.m. revealed soiled linens should have been transported in a yellow barrel. Interview with S13CNASupervisor on 12/03/2025 at 11:31 a.m. confirmed staff had not followed proper infection prevention and control practices during transport of soiled linens, but should have. #4 Observation of Laundry with oversight from S9Laundry on 12/03/2025 at 9:20 a.m. revealed Cart 1 was used to obtain and transport soiled personal clothing of residents from the rooms. Cart 1 was then taken into the laundry room and the clothing was placed into a washing machine and laundered. Upon completion of the wash cycle, the resident clothing was placed into Cart 1, transported to the dryer area, and placed inside a dryer. Upon completion of drying, resident clothing was removed from the dryer and placed into Cart 2. Interview with S9Laundry confirmed Cart 1 was used to transport both soiled and washed resident clothing, but should not have been. Interview with S8Corporate on 12/03/2025 at 3:35 p.m. confirmed soiled clothing and clean clothing should not be transported in the same cart.

Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#3 of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and 1 (Resident #R1) of 1 random resident. The facility failed to:1. Ensure Resident #3's physician was notified of and immediately responded to the request of an antibiotic for a tooth abscess; and 2. Ensure Resident #R1's received wound care as ordered by the physician. Findings:Resident #3Review of the facility policy with a review/revision date of for Physician Orders read as. It is the policy of this community that all physician orders shall be implemented timely and carried out in a professional manner. When new or revised orders are requested due to consultant recommendations, the attending physician or nurse practitioner, clinical nurse specialist, or physician assistant shall be documented in the resident clinic record. Additional follow-up may be needed until a response was received. Review of the medical record for Resident #3 revealed an admit date of 11/30/2023, with diagnoses that included in part.Gastro-Esophageal Reflux Disease, Hypertension, Delusional Disorder, and Cellulitis of Back. Review of Resident #3's Quarterly MDS with an ARD of 09/02/2025, revealed a BIMS score of 15, which indicated intact cognition. Review of a nurse's progress note dated 08/18/2025 at 9:00 p.m. read as. Resident returned from a local eye and laser appointment with a progress note stating the resident needed an antibiotic for a tooth abscess. Resident #3's physician was contacted at this time and a message was left. Review of a Nursing Communication Book dated 08/18/2025 revealed Resident #3's physician was contacted to request an antibiotic for a tooth abscess, left message. Follow up in the morning. Review of a nurse's progress note dated 08/22/2025 at 3:38 p.m. read in part. Resident #2 complained of an abscess to the right side of her jaw. Noted some swelling to area. Resident was afebrile at this time. Call placed to MD with order given for Amoxil 250 mg po TID for 7 days. Review of a verbal phone order dated 08/22/2025 at 3:51 p.m. read in part. Amoxcillin Capsule 250 mg (an antibiotic) give 1 capsule by mouth every 8 hours for bacterial infection related to Cellulitis and Abscess of mouth for 7 days. Interview on 09/24/25 at 3:25 p.m. with S3 LPN revealed on 08/18/2025 Resident #3 returned from her eye appointment with a new Progress Note to contact a physician to request an antibiotic for an abscess. S3 LPN confirmed she should have followed up with Resident #'s physician the next day and she did not. Interview on 09/24/2025 at 3:33 p.m. S4 LPN revealed she was Resident #3's nurse on 08/19/2025, 08/20/2025, or 08/21/2025. S4 LPN revealed she was not aware of Resident #3's mouth pain until 08/22/2025 when Resident #3 had pain and swelling to her jaw area. S4 LPN revealed she contacted Resident #3's physician. S4 LPN revealed a verbal order was given to administrator Amoxicillin 250 mg every 8 hours for 7 days. Interview on 09/24/2025 at 4:03 p.m. S1 DON revealed it was good nursing judgement for the nurse to follow up with the physician when they do not get an answer. S1 DON stated the nurse should have given report to the oncoming nurse and documented in the 24 hour report. S1 DON revealed the 24 report book should have been read at the standup meeting the next morning. Telephone interview 09/25/2025 at 10:58 a.m. with Resident #3's Physician revealed if he had been notified of Resident #3 needing an antibiotic for an abscess, he would have called back. He stated the nurse should have called back or tried to contact the other facility Medical Director concerning Resident #3's mouth pain. Resident #R1 Review of the medical record for Resident #R1 revealed an admit date of 11/03/2021, with diagnoses that included in part. Quadriplegia, Pain, Hypertension, Urinary Tract Infection, Pressure Ulcer to Right and Left Buttock Stage 4, Pressure Ulcer of Sacral Region, and Pressure-Induced Deep Tissue Damage of Right Buttock. Review of Resident #R1's Quarterly MDS with an ARD of 09/02/2025, revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed Resident #R1 was dependent on staff for all ADLs. Review of Resident #R1's Care Plan read as. Limited mobility related to diagnosis of Quadriplegia. Resident #R1 was Dependent on staff for bed mobility, transfer, and toileting. The MDS revealed Resident #R1 had a Stage 4 Pressure Ulcer to Left Buttocks. Review of Resident #R1's TAR dated 09/01/2025 to 09/302/205 read in part. Stage 4 Pressure Ulcer to Left and Right Buttock: Clean with wound cleanser pat dry apply Lidocaine Ointment Betadine packed gauze, wet to dry and secure with ABD pad and secure with tape daily, until resolved every day shift for Wound healing. Review of Resident #R1's TAR dated 09/01/2025 to 09/30/2025 revealed there was no documentation of the following dates: 09/06/025, 09/07/2025, 0920/2025, and 09/21/2025. Interview on 09/23/2025 at 9:52 a.m. with S5 Treatment Nurse revealed she worked from 8:00 a.m. to 4:30 p.m. Monday through Friday. S5 Treatment Nurse stated when she was off the floor nurse was responsible for treatments on their residents. S5 Treatment Nurse revealed the RN Supervisor was responsible for treatments on the weekends. Interview on 09/25/2025 at 11:15 a.m. with S5 DON stated the Weekend Supervisor was responsible for doing wound treatments on the weekends. S5 DON confirmed that #R1 did not receive wound care on 09/06/2025, 09/07/2025, 09/20/2025, and 09/21/2025.

Based on record review and interview the facility failed to immediately inform the resident, consult the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) resident records reviewed for falls. Findings: Review of a facility policy with a revision date of 09/2017 and titled Change in Resident Medical Status revealed the following in part . A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment. These changes may include: a fall and/or injury . A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is - 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention. Review of Resident #2's Electronic Health Record revealed an admitted [DATE]. Resident #2 had the following diagnoses including: Unspecified Severe Protein-Calorie Malnutrition, Functional Quadriplegia; and Pain, Unspecified. Review of Resident #2's 11/2024 Physician Orders revealed the following including: 11/08/2024 - DNR 11/08/2024 - Admit to [NAME] Memorial for long term care 11/15/2024 - Lorazepam 2 mg/ml give 0.25 ml SL q 4 hours prn agitation r/t pain 11/15/2024 - MS 20 mg/ml give 0.25 ml po q 4 hours prn pain or SOB 11/15/2024 - Admit to Guardian Hospice with terminal diagnosis Severe Protein Caloric Malnutrition. Review of Resident #2's 11/2024 Nurse Notes revealed the following including: 11/10/2024 at 2:15 a.m. - Upon making rounds, noticed resident not in his bed, found on floor lying on his back on left side of bed. Resident reported he wanted to try to get up, and stated, I didn't realize how weak I am. Denied hitting his head and denies any pain at this time. Performed full ROM, moving all extremities x 4 without any difficulties or complaints of pain. Obtained VS - BP-147/82, P-77, R-20, T-97.4, SaO2-97% on room air. Initiated neuro checks and all WNL, bilateral weakness to extremities noted. Resident had a BM noted, and staff cleaned and changed resident prior to assisting him back to bed. Notified MD via fax at this time. Side rails up x 2, bed in lowest position, and call light within reach. Implemented resident safety education on importance of using call light for assistance before attempting to get out of bed/transfer, resident verbalized understanding at this time. Will continue to monitor. 11/10/2024 at 10:55 a.m. - 97.2 temporal,67-22-112/72-O2 sat 98% room air - Resident's family member to nurse's station - states resident said he fell in the middle of the night-requesting x-ray to be done due to Left and Right pelvis fractures prior to admit- resident denies pain or discomfort at this time- Physician notified with new order for stat x-ray of pelvic area; imaging company informed of x-ray order -family members in room-informed of new order. 11/10/2024 at 12:15 p.m. - stat x-ray of pelvic done at this time per imaging company 11/10/2024 at 1:10 p.m. - received stat x-ray result: acute right pubic fractures - On call Physician notified - states ok-inform Primary Physician on Monday-results faxed to Primary Physician office at this time-RP informed of results and md notification - states ok- I'm glad he's okay. Telephone interview was conducted on 11/19/2024 at 8:58 a.m. with Resident #2's RP who reported the facility did not notify her of the resident's fall on 11/10/2024. Resident #2's RP stated during a visit to Resident #2 on 11/10/2024, he told her he fell . She stated she asked the nurse and was told he did have a fall. Resident #2's RP stated that an x-ray was not done after the fall and she ask for one to be done. Resident #2's RP stated she was unsure of the x-ray results, but stated that he received the hip fractures he was admitted with about 3 weeks ago from a fall at his apartment in Texas. Interview on 11/19/2024 at 10:30 a.m. with S1 DON and S2 Corporate Nurse revealed that Resident #2's family/RP should have been notified of the fall at the time of the incident and should not have been told by the resident during a visit later that day. Interview on 11/19/2024 at 12:05 p.m. with S1 DON revealed S3 LPN had been suspended following the event. Review of S3 LPN's Employee Warning Report dated 11/12/2024 revealed the type of violation as failure to notify RP of fall with an action of immediate suspension noted.

38894 Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #27 and Resident #64) of 29 sampled residents reviewed for quality of care. Findings: Patient #27 Review of Resident #27's Electronic Health Record revealed an admitted [DATE] with the following diagnoses including Type 2 DM with Neuropathy and long term use of Insulin. Review of Resident #27's 09/2024 Physician Orders revealed the following including: 07/03/2024 - Insulin Glargine Soln Pen-Injector 100U/ml inject 15U q HS 07/03/2024 - HGBA1C q 3 months (Sept, Dec, Mar, June) 07/18/2024 - Accuchecks BID notify MD if CBG <60 or >300 Review of Resident #27's 09/2024 Electronic Medication Administration Record revealed Capillary Blood Sugars above 300 on the following dates and times: 09/05/2024 at 6:00 a.m. - 301 09/06/2024 at 6:00 a.m. - 330 09/08/2024 at 6:00 a.m. - 324 Review of Resident #27's 09/2024 Nurse Notes revealed no documentation that the Physician was notified concerning capillary blood sugar results greater than 300. Interview on 09/10/2024 at 10:10 a.m. with S3 Corporate RN confirmed there was no documentation that Resident #27's physician was notified concerning capillary blood sugar results over 300 and there should be. Resident #64 Review of Resident #64's medical record revealed an admitted [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety, Muscle Weakness, and Moderate Protein-Calorie Malnutrition. Review of Resident #64's Significant Change MDS with an ARD of 06/12/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #64 required supervision with eating, substantial/maximal assistance with toilet hygiene and chair/bed to chair transferring, and partial/moderate assistance with rolling left and right, sitting to lying, lying to sitting, and sitting to standing. Review of Resident #64's current physician's orders revealed the following orders: 09/06/2024: Tresiba FlexTouch Subcutaneous solution pen injector 100 units/ml-inject 15 units subcutaneously at HS. 07/29/2024: Humalog Kwikpen subcutaneous Solution Pen-injector 100 unit/ml-inject subcutaneously before meals and at bedtime related to type 2 meals. Inject as per SS: If 60-180=0 notify MD if less than 60. 181-250=3 251-300=6 301-350=9 351-400=12 401-9999=15; Administer 15 units and notify MD if greater than 400, subcutaneously before meals and at bedtime r/t Type 2 DM w/ hyperglycemia; Review of Resident #64's medical record revealed the following capillary blood sugars: 08/01/2024 at 10:44 p.m.: 539 08/01/2024 at 10:45 p.m.: 499 08/08/2024 at 5:18 p.m.: 497 08/09/2024 at 5:21 p.m.: 570 09/04/2024 at 5:50 p.m.: 450 Review of the nurses' notes revealed no documentation of reporting these capillary blood sugars greater than 400 to the physician, as ordered. In an interview at 10:16 a.m. on 09/10/2024, S3 Corporate RN confirmed there was no documentation the nurse reported Resident #64's capillary blood sugars greater than 400 to the physician and acknowledged it should have been reported.

Based on record review and interview, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (#4, #64) of 2 residents reviewed for pain. The facility failed to ensure Resident #4 and #64, who reported pain, received medication or interventions to alleviate pain. Findings: Review of the facility's policy titled Pain Screen and Management with a revision date of 12/2023 revealed in part . 1. All residents have the right to treatment for pain. 2. The resident's statements are the most valid measurement of pain. 3. A pain scale is used whereby the resident describes his/her pain and amount of pain relief. Chronic Pain Management: Documentation requirements for Chronic Pain Management focus on the following: E-MAR documentation Use of as needed (PRN) medication Review and revision of care plan as appropriate Resident #4 Resident #4's medical record revealed an admitted [DATE] with diagnoses that included .Chronic Pain Syndrome, Chronic Kidney Disease, Multiple Sclerosis, Localized Edema, and Unspecified Convulsions. Review of Resident #4's Quarterly MDS with an ARD of 06/01/2024 revealed Resident #4 had a BIMS score of 15 indicating intact cognition. Review of the MDS revealed Resident #4 required supervision with eating, dependent with toilet hygiene and bathing, and transfers. Review of the MDS revealed Resident #4 had a pain assessment interview and received PRN pain medication. Review of Resident #4's Care Plan with a review date of 07/16/2024 revealed in part .Resident has pain related to Multiple Sclerosis and Chronic Pain Syndrome with interventions that included: Administer medications as ordered, Observe onset, location, severity and duration of pain. Observation and interview on 09/08/2024 at 10:05 a.m. revealed Resident #4 in bed. Resident #4 revealed she had not received her pain medication as requested and she was hurting. Resident #4 stated she had Multiple Sclerosis and her legs were hurting (10/10 on a pain scale). Resident #4 revealed she received oxycodone every 4 hours as needed for pain. Resident #4 revealed on 09/07/2024 she had called for the nurse twice between 1:00 a.m. and 5:00 a.m. Resident #4 revealed the nurse never came to her room all night and she never received any pain medication. Review of Resident #4's Physician's orders for September 2024 revealed an order for Oxycodone 10 MG by mouth every 4 hours as needed for pain related to Chronic Pain Syndrome. Interview on 09/09/2024 at 9:00 a.m. with Resident #4 revealed she received pain medication on 09/08/2024 at approximately 10:30 a.m. Resident stated she was not able to attend the Resident Council Meeting held on 09/08/2024 due to pain. Telephone Interview with S8 CNA revealed on 09/07/2024 Resident #4 had called for the nurse twice for pain medication between 1:00 a.m. and 5:00 a.m. S8 CNA stated she had looked for Resident #4's nurse and had paged her, but she never came. Interview on 09/09/2024 at 1:15 p.m. with S9 Agency LPN revealed she was the nurse for Resident #4 on 09/07/2024 from 11:00 p.m. to 7:00 a.m. S9 Agency LPN revealed she did not provide any care for Resident #4 on 09/07/2024 from 11:00 p.m. to 7:00 a.m. S9 Agency LPN stated I never laid eyes on Resident #4, my whole shift. S9 Agency LPN confirmed she did not administer any pain medication to Resident #4 on 09/07/2024 from 11:00 p.m. to 7:00 a.m. Resident #64 Resident #64's medical record revealed an admitted [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety, Muscle Weakness, and Moderate Protein-Calorie Malnutrition. Review of Resident #64's Significant Change MDS with an ARD of 06/12/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #64 required supervision with eating, substantial/maximal assistance with toilet hygiene and chair/bed to chair transferring, and partial/moderate assistance with rolling left and right, sitting to lying, lying to sitting, and sitting to standing. In an interview on 09/08/2024 at 12:57 p.m., Resident #64 stated he hurts all the time because he has problems with his back. He stated the facility doesn't give him anything for pain, not even Tylenol or Ibuprofen. Review of Resident #64's September 2024 MAR revealed the following pain levels entered by S5 LPN: 09/09/2024-6 at 10:02 a.m. 09/06/2024-7 at 9:55 a.m. 09/05/2024-7 at 9:09 a.m. 09/04/2024-6 at 11:04 a.m. 09/03/2024-6 at 9:54 a.m. Review of the September 2024 MAR revealed no pain medication had been given to Resident #64. Review of Resident #64's medical record revealed he was currently care planned for being at risk for pain. Interventions included Administer medications as ordered, Notify MD of any unrelieved pain, Reposition for comfort as needed, Observe onset, location, severity and duration of pain, and Observe effectiveness of medication. In an interview on 09/09/2024 at 10:41 a.m., S5 LPN stated Resident #64 hadn't complained of pain to her today but may have complained of pain to her last week. S5 LPN stated Resident #64 doesn't have anything ordered for pain and the ASA 81 mg he received was ordered related to hemiplegia. S5 LPN stated she could have contacted his doctor last week to report his pain but did not. In an interview on 09/10/2024 at 10:16 a.m., S3 Corporate RN reviewed Resident #64's MAR and the documentation by nursing staff of the resident's pain levels of 6 and 7 this month. S3 Corporate RN acknowledged the nurse should have called the doctor to report the resident's pain. S3 Corporate RN stated if she was the nurse she would have called the doctor to report the pain since he didn't have anything ordered for pain. 44844

Based on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 Resident (#3) of 3 sampled Residents (#1, #2, and #3). The facility failed to ensure that Resident #3 was safely secured in a shower chair prior to showering. This deficient practice resulted in an actual harm for Resident #3 on 04/19/2024 at approximately 7:30 p.m., when Resident #3 was placed in a shower chair that was not equipped with a safety belt. Resident #3 fell from the shower chair to the floor, after being showered by S5 CNA. Resident #3 was transferred to the emergency room and diagnosed with a Displaced Left Intertrochanteric Femur Fracture. Resident #3 required surgical intervention of an Intramedullary Nail placement, Left Intertrochanteric Femur Fracture, on 04/21/2024. Findings: Review of the facility's policy and procedure titled Bathing, with a revision date of 01/2024, read in part . Shower - Dependent Resident 2. When using the shower chair, always apply the safety belt. Review of Resident #3's EHR revealed an admitted [DATE], with admitting diagnoses that included: Endocarditis, End Stage Renal Disease, Acute Kidney Failure with Tubular Necrosis, Benign Prostatic Hyperplasia, and Thoracic Aortic Aneurysm. Review of Resident #3's Annual MDS with an ARD of 02/29/2024, revealed a BIMS score of 15 (intact cognition). The MDS revealed Resident #3 required substantial/maximal assistance x1 with shower/bathe, and partial/moderate assistance x1 with sit to standing, transfer from chair/bed-to-chair, toilet transfer, and tub/shower transfer. Resident #3 had impairment on one side to the upper/lower extremities, and used a motorized wheelchair for mobility. Review of Resident #3's Comprehensive Care Plan with a target date of 06/04/2024, revealed in part . 1. Resident required Restorative Nursing Program for transfers, with a problem onset of 10/04/2022. Resident needs staff assistance with ADLs and transfers. Approaches included in part .Assist with transfers 2. Resident has Hx. of falls with potential for fall impaired mobility, has unstable balance, has motorized wheelchair, and 04/19/2024 fall with injury. Approaches included in part .assist with ADLs. Review of the Post-Incident Actions notes dated 04/19/2024 at 7:30 p.m., read as follows in part . S6 CNA called S4 LPN to the shower room. Resident #3 was sitting on the wet floor on his buttocks - slid from the shower chair. Resident c/o severe pain to left leg and hip. Assisted Resident to wheelchair with lift, and placed in bed. Resident's pain = 10. Resident #3's physician was notified with orders given to transfer to ER for evaluation and treatment. Review of the Radiology Interpretation dated 04/19/2024 revealed in part . There is a Basicervical Left Proximal Femoral Fracture. Review of the hospital Discharge Summary read in part .Resident #3 was admitted to the hospital on 04/19/2024, with a diagnosis of Status Post Fall with Left-Sided Hip Fracture. The course of hospital treatment included: Surgical repair of the left hip with preoperative diagnosis of Displaced Left Intertrochanteric Femur Fracture, with PT and OT. Resident #3 was discharged back to the facility on [DATE]. Discharge instructions included: Continue PT and OT at the facility, and recommend to follow-up with primary care provider within 7 days. Interview on 04/30/2024 at 2:00 p.m. with S1 Administrator, revealed Resident #3 was transferred and admitted the hospital with a fractured left femoral, after sliding from the shower chair while in the shower on 04/19/2024. S1 Administrator stated Resident #3 required surgery in order to repair the left femoral fracture, and was scheduled to be discharged back to the facility this evening. Telephone interview on 05/01/2024 at 4:23 p.m. with S5 CNA, revealed she worked on 04/19/2024 from 3:00 p.m. - 11:00 p.m., and was assigned to Resident #3. S5 CNA stated on 04/19/2024, Resident #3 went into the shower room and transferred from the motorized wheelchair to the shower chair using his walker. S5 CNA stated there is a floor threshold before entering the shower stall, and while standing in front of Resident#3, she tried to pull the shower chair over the threshold, and Resident #3 fell forward. S5 CNA stated she tried to push the resident back onto the chair, but because he was heavier than her, the resident went down to the floor. S5 CNA stated on the day that Resident #3 fell out of the shower chair, there was no safety belt attached to the chair. S5 CNA stated the shower chair had been without a safety belt for a while (unable to recall how long). S5 CNA stated that she never reported the shower chair being without a safety belt, because she thought that the issue had already been reported by the day shift. S5 CNA stated this was not the first time she had used the shower chair without a safety belt, and never had any problems. Telephone interview on 05/02/2024 at 8:50 a.m. with S6 CNA, revealed S5 CNA called her cellphone, and asked that she come to the shower room, and get the nurse because Resident #3 had fallen. S6 CNA stated she went to get S4 LPN and reported to her that Resident #3 had fallen in the shower. S6 CNA stated when she entered the shower room, Resident #3 was sitting straight up on his buttocks, and S5 CNA was standing up holding the resident's back. S6 CNA stated she assisted with transferring Resident #3 from the shower floor into his motorized wheelchair using the lift, along with assistance from S4 LPN, S5 CNA, and S7 CNA. S6 CNA stated she didn't see a safety belt on the shower chair on the day that Resident #3 fell (04/19/2024), and she was aware that the shower chair should have had a safety belt attached to it. Interview on 05/02/2024 at 9:40 a.m. with S8 CNA, revealed she was aware that the shower chairs were supposed to have safety belts, but they didn't always because the belts would break, and/or wouldn't snap close, and they would not be replaced. S8 CNA stated it was not usual for the shower chairs to be without safety belts. S8 CNA stated she was unable to recall the exact length of time that the shower chairs had been without safety belts, or if she had ever logged in the maintenance log book that the shower chairs needed safety belts. S8 CNA stated safety belts were attached to all shower chairs after Resident #3 fell on [DATE]. Interview on 05/02/2024 at 9:42 a.m. with S9 CNA, revealed she last used the shower chair in Shower Room B about 1 week before Resident #3 fell , and there was no safety belt on it at that time. S9 CNA stated she was aware at the time that she last used the shower chair, that it was supposed to have a safety belt on it. S9 CNA stated there were 2 shower chairs in Shower Room B, neither one had a safety belt on it, and that she used one of the shower chairs anyway. S9 CNA stated it was not until after Resident #3 fell last month that safety belts were attached to the shower chairs. Interview on 05/02/2024 at 10:00 a.m. with Resident #3, revealed he fell from the shower chair on 04/19/2024, as S5 CNA was trying to get him out of the shower stall. Resident #3 stated S5 CNA pulled him forward after she showered him, and while trying to get him out of the shower stall, he fell out of the shower chair. Resident #3 stated he was not strapped in the shower chair, and was not able to recall if the shower chair had a strap or not. Resident #3 stated his legs felt as if they had buckled underneath him and the chair came from under him as S5 CNA was pulling the shower chair forward. Resident #3 stated S4 LPN examined him, and his pain level at that time was a 10. Resident #3 stated he was transferred to the hospital, admitted on [DATE] with a fractured left hip, and had surgery on 04/21/2024. Telephone interview on 05/02/2024 at 11:30 a.m. with S4 LPN, revealed on 04/19/2024 Resident #3 fell out of a shower chair in the shower, and sustained a fractured left hip. S4 LPN stated when she arrived in shower room B, Resident #3 was seated on the shower floor in front of the threshold, and S5 CNA was bent over holding the resident up. S4 LPN stated S5 CNA told her that Resident #3 slipped out of the shower chair while she was trying to pull him over the threshold, and she was not able to stop his fall. S4 LPN stated she asked S5 CNA if she had used the safety belt to strap Resident #3 in, and S5 CNA answered, No ma'am, the shower chair had no safety belt on it. S4 LPN stated she checked the shower chair at that time, and there was no safety belt attached. Telephone interview on 05/02/2024 at 1:00 p.m. with S7 CNA revealed she assisted with transferring Resident #3 from off floor in the shower room using the lift, to his motorized wheelchair. S7 CNA stated when she entered the shower room, Resident #3 was sitting on the floor on his buttocks. S7 CNA stated there was no safety belt on the shower chair, and there should have been. Interview on 05/02/2024 at 2:10 p.m. with S11 Maintenance Supervisor revealed if there were problems with any of the shower chairs, whether it be a missing safety belt, brakes or anything, the staff would personally tell him, and/or write it in the maintenance log, at which time he would address it. S11 Maintenance Supervisor stated the logs are kept at each nurse's station, and he checked them daily. After checking each maintenance log with surveyor present, S11 Maintenance Supervisor confirmed there was nothing in the logs in regards to shower chairs. Interview on 05/02/2024 at 2:35 p.m. with S1 Administrator confirmed that the shower chair in use for Resident #3 when he fell on [DATE], did not have a safety belt, and stated that all shower chairs should have safety belts attached for residents' safety.

Based on observation, record review and interview the facility failed to ensure that each resident receives adequate supervision and monitoring to prevent accidents for 2 (#1 and 2) of 10 sampled residents (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) that wandered and were at high risk for elopement, and who wore secure care bracelets, in a total sample of 11 (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11). The facility failed to: 1. provide adequate supervision and protect resident #1 who was mobile by wheelchair, and who wore a secure care bracelet from exiting the front entrance of the facility and propelling her wheelchair onto a busy 2-way 4 lane street; and 2. increase supervision of resident #1 after she eloped from the facility and propelled herself in her wheelchair onto a busy 2-way 4 lane street. This failed practice resulted in an Immediate Jeopardy situation for resident #1 when on 12/24/16 at 7:50 a.m., the wheelchair bound resident (#1) identified at high risk for elopement and who wore a secure care bracelet, opened the facility's front door and propelled her wheelchair onto a busy 2-way 4 lane street unnoticed by staff. At 8:11 a.m., the facility staff was alerted by S9 CNA who was looking out onto the street through the facility's glass windows, and saw the resident in the street in her wheelchair, and cars stopping for the resident. A passing driver on the street, who stopped her car for the resident, pushed the resident in her wheelchair into the facility's parking lot. 2 LPNS went out and met the passing driver to get the resident, and brought the resident back into the facility at 8:13 a.m. S1 Administrator and S2 DON were informed of the Immediate Jeopardy situation on 12/29/16 at 5:50 p.m. The Immediate Jeopardy for resident #1 ended when she was taken to theER on [DATE] at 9:00 p.m. after the resident barricaded herself in her room with furniture, screaming and cursing and combative when staff entered the room. The physician was notified and gave orders to send the resident to the ER by ambulance for psych evaluation and was then admitted to a psych hospital. An acceptable plan of removal was received from the administrator on 01/03/17 with evidence that the plan was implemented on 12/29/16 at 10:00 p.m., and the immediacy had been removed. The plan of removal included the following: 1. Ensure the safety of all residents who are at risk for elopement: Resident #1 eloped from the facility and was returned to the facility. A head to toe assessment was done with no injuries noted. A new wander guard (secure care bracelet) was replaced on the resident and was tested to function properly. An OTIS report was filed on this date, 12/29/16. Video camera footage was reviewed to determine how the resident eloped. The resident was found to have no negative outcome. Actions put in place to prevent residents at risk for elopement from exiting the facility unsupervised: a. The Administrator designee increased monitoring of exit doors from 6:00 p.m. to 9:00 p.m. on 12/29/16 by having a staff member posted at exit doors for visual observation until a service representative from the company ensured the secure care system was functioning properly. b. The DON or designee developed a schedule of staff to assist in the increased monitoring of residents at risk for elopement to q 1 hour visual checks indefinitely until the new system the facility had ordered would be in place (approximate completion date 2/5/17) to replace the current system. Documentation of monitoring of visual checks log was provided to evidence the monitoring was implemented since 12/29/16. 2. Ensure that Wander guards (Secure Care bracelets) were working properly. Audit of Facility Entrances and transmitters: All Wander guard (same as secure care bracelet) safety devices have been increased to daily checks to assure proper functioning (previously done weekly) and exit doors monitored daily. Resident #2 ' s wander guard that had malfunctioned was immediately replaced on 12/29/16. The 2 wander guards were returned to the service Company for testing. A letter was provided from the Medical Equipment Service Company attesting that on 12/29/16, the technician tested all transmitters on residents, checked all aspects of doors and alarm to ensure the doors were locking and unlocking properly. The two functioning wandering doors were found to be working properly and picked up transmitters at a good distance from the door. Surveyor interview with the Service Technician who checked out the facility ' s secure care system attested that all alarms, doors, resident secure care devices were thoroughly tested and were all operational by 10:00 p.m. on 12/29/16. 3. In-services were conducted with facility staff on topics of Following up on Actual Elopement, Reporting, and Use of Transmitters. In-services began on 12/29/16 at 6:00 pm and documentation of staff sign-in logs were provided. 4. Established and implemented policy/procedures on ensuring functionality of the Secure Care System. Policy titled Elopement/Wandering- Security System outlined the step by step procedures for proper application of secure care bracelets, ensure proper operation to include proper placement, positioning, cleaning and handling do ' s and don ' ts; checking each door equipped with security system for proper operation at least daily along with each individual resident ' s security bracelet also checked daily, follow manufacturer ' s recommendations for any other type transmitter used. Daily log will be used to record results. The policy read that during testing of the bracelets if the transmitter fails the test, then proceed to the main exit door to test the transmitter using the secure care lock system. If the transmitter fails this test, the resident is to be put on 1:1 supervision immediately until a new transmitter is in place on the resident and assured to be working properly. At this time, the DON and Administrator would be notified of the transmitter failure and the Medical Equipment Company would be notified so further testing can be done. The policy further read that a visual check of resident's with security bracelets presence in the facility will be done q 1 hour indefinitely until a new security system is in place and functioning properly and daily thereafter. 5. QAPI - Quality Assurance Performance Improvement Plan dated 12/29/16 addressed that a resident with wander guard eloped and the concern of potential harm of residents at risk for eloping. The root care analysis read that the facility failed to investigate the malfunction of a secure bracelet after a resident eloped and failed to ensure a resident at risk for elopement did not leave the facility unsupervised. The goal was to supervise, monitor, and protect residents who wore secure care bracelets and are at risk for elopement. The action items were assigned to team members with the start date of 12/29/16 and goal completion dates, the items addressed read: increased supervision of all residents at risk for elopement, increased monitoring of exit doors, Medical Service Equipment Company to come to the facility to check all exit doors, Wander guards testing , continuing staff education, increase Wander Drill to weekly, signage at all exit doors for visitors not to allow residents out the door, daily checks of all transmitters per manufacturer ' s recommendations. This deficient practice continued at a potential for more than minimal harm for the facility ' s remaining 9 residents (#2, 3, 4, 5, 6, 7, 8, 9, 10) identified at risk for elopement. Findings: Review of the Secure Care Transmitter User Guide by the Manufacturer revealed the following: Page 5 under the caption Immediately have replacements or repairs checked on-site by a Qualified Service Technician . the only way to assure that software, parts, or products are installed, set-up, tested , supported, maintained or repaired correctly or that a Secure Care system is functioning properly is to have it examined on site by a Qualified Service Technician. Page 7 under the caption Daily Transmitter Testing: Each transmitter should be tested daily, to ensure it is working properly, a Tester is available for fast easy testing of all transmitters. A documented test of each transmitter at the facility must be made each day. This testing should also include those transmitters not currently in use. Observation and interview of resident #1 on 12/29/16 at 11:45 a.m. revealed the resident was in her room, was getting up from her wheelchair and was unsteady. The resident was observed to hold onto her locked wheelchair to steady herself and was able to pivot and propel herself to bed. The resident was observed to be able to bear some weight while holding on to her wheelchair. The resident was observed to wear a secure care bracelet to her right ankle. Interview with the resident revealed she spoke in a garbled manner, but was understandable at times with repeated clarification. The resident held a baby doll wrapped in a blanket close to her while in bed. The resident was confused to place, person and situation and was easily distractible. When asked how she had gotten out of the facility in her wheelchair, she responded in a shouting manner, I just pushed the door! Review of resident #1's face sheet revealed the resident was [AGE] years old with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS records with the ARD of 10/18/16 revealed the resident had a BIMS score of 5, was mobile by wheelchair, and moved around the facility with supervision. Review of the resident's elopement risk assessment record dated 12/9/16 revealed the resident was cognitively impaired with poor decision making skills, diagnosed with [REDACTED]. The assessment revealed a wander guard was in place to the resident's ankle. Review of the resident's care plan with onset date of 4/26/16 and a target date of 1/25/17 read that the resident could not leave the facility without staff or family. The goal read: At risk for elopement, goes to facility entrance/exit doors and will kick doors saying she wants to go home, or that her sister is right out there and tries to get the doors to open; will say that her sister lives right next door - poorly redirected; able to propel self in wheelchair; dx of Alzheimer's, Dementia and Schizophrenia. The approaches included: wander guard to ankle at all times, activities staff to visit with resident and provide diversional activities, alert staff to resident's wandering behavior, monitor and document resident behavior and report increase in negative findings to the physician. Further review of resident #1's care plan with a target date of 3/24/17 revealed the resident was identified with actual elopement on 12/24/16. The approach included to observe the function of the wander guard at least weekly and as needed. There was no documentation to increase supervision of the resident after the elopement incident. Interview with S7 CNA on 12/29/16 at 11:50 a.m. revealed she usually worked the resident's hall during the day shift. She revealed she was on day shift duty on 12/24/16 and was the hall monitor for the resident's hall at breakfast time. She stated S8 CNA was the resident's CNA on 12/24/16, but was assisting in the dining room for breakfast. She stated she last saw the resident at 7:30 a.m. on the morning of 12/24/16 when the resident refused to go to the dining room for breakfast. She stated the hall cart was delivered around 8:00 a.m. and that's how she remembered hearing S9 CNA hollering that the resident was outside the facility. She stated staff rushed outside and 2 LPNs were the ones who brought the resident back from the outside. She stated she did not see the resident's ankle, but stated that she heard the nurse on duty with the resident (S5 LPN) say that the wander guard was under the resident's socks and it did not work. She stated the resident was already being pushed in her wheelchair back inside the facility when she saw her, and she was not hurt. She stated that S9 CNA was the first one to observe the resident outside the facility. Interview with S9 CNA on 12/29/16 at 12:05 p.m. revealed she was the hall monitor on the other side of the building and was walking towards a resident's room to answer a resident's call light around 8:00 a.m. on 12/24/16 when she saw through the glass windows that cars had stopped on the street, and saw that resident #1 was in her wheelchair out in the street. She stated she ran down towards the front of the facility and hollered at the other staff to let them know the resident was out in the street. She stated she saw that a lady (passing driver) started to push the resident from the street telling them the resident was in the street, and by that time, the nurses met the passing driver and pushed the resident back in the facility. Further interview and observation with S9 CNA at 12:45 p.m. revealed she showed the surveyor where her location was at the time she first saw the resident in the street. Observation of the CNA's location revealed a clear view of the street from the large glass windows on the Versailles side of the facility (the name of the wing attached to Matthews HCC). The street was a high traffic 2-way street with 4 lanes and had no pedestrian walk area. The paved drive right in front of the facility's front door led directly into the street. Testing with the 2 facility RNs (S3 RN and S13 RN) of the other 9 (#2, 3, 4, 5, 6, 7, 8, 9 and 10) residents identified at risk for elopement revealed on 12/29/16 at 12:35 p.m., 1 (#2) of the 9 other residents with secure care bracelets did not trigger the alarm and the door did not lock. Resident #2 was able to open the door and walk out. The resident was escorted back in the building and down the hall to have her ankle wander guard bracelet replaced. Review of resident #2's risk assessment record dated 11/7/16 revealed the resident had: cognitive impairment, [DIAGNOSES REDACTED]. The resident was identified at risk for elopement and the resident had a wander guard placed to her ankle. Review of resident #2's care plan revealed a problem onset on 11/8/16 that the resident was at risk for elopement: Resident has Dementia, goes to doors in the evening looking for a way out to go home, especially restless after daughter leaves. The approaches included to have wander guard in place to the resident's ankle, alert staff to resident's wandering behavior, monitor and document resident behavior, report increase in negative findings to the physician, activities staff to visit with the resident and provide diversional activities. Interview with S4 SSD on 12/29/16 at 1:25 p.m. revealed he was the one who tested the Secure Care System bracelets with the product tester every Friday (weekly). He stated only 2 doors of the facility remain open (equipped with the secure care alarm locking mechanism: the front entrance door and the Versailles door by the Therapy room). He stated all the other doors to the facility were continuously locked and required a code to open. Review of the Wander Guard Resident Checks log maintained by S4 SSD for each resident revealed from August 2016 to December 23, 2016, resident #1's wander guard/security care bracelet was being tested weekly and it tested okay. Further review of the 9 other residents who wore security care bracelets revealed they were also checked weekly. Interview with S10 LPN on 12/29/16 at 1:30 p.m. revealed she was not on duty on 12/24/16 when the resident eloped. She revealed the facility routinely checked the residents at risk for elopement with secure care bracelets weekly, and the nurses checked the placement of the secure care bracelet on the resident each shift and recorded this on their EMAR. Interview with S4 SSD on 12/29/16 at 1:45 p.m. revealed he was the staff who usually replaced the secure care bracelets. He stated that on 12/24/16, he was not on duty and that resident #1's secure care bracelet was replaced by S5 LPN. He revealed the secure care bracelets had expiration dates imprinted on it and was good for a year. He revealed the last one put on the resident prior to 12/24/16, was on 4/2016. He confirmed their process was to test the bracelets weekly and revealed he was not aware of the Manufacturer's specification to test the bracelets daily and to call a qualified service technician for malfunction and that this was the first time he became aware of the manufacturer's guidelines. Interview with S2 DON along with S6 Assistant Administrator on 12/29/16 at 2:15 p.m. revealed the incident happened on Saturday morning (12/24/16) and the DON was called by S5 LPN to report the resident went out of the facility, had no injuries, and she was fine. She stated she then instructed S5 LPN to change the secure care bracelet with a new one. Review of the incident report dated 12/24/16 provided by S2 DON revealed the resident had eloped from the building, was assessed and was fine, and her bracelet replaced. S2 DON further provided an SBAR (Situation Background Assessment Request) form that was completed by S5 LPN regarding the incident. The SBAR record dated 12/24/16 under the caption Assessment, revealed S5 LPN documented Resident eloped from building. The incident report and the SBAR did not reveal an intervention to increase supervision of resident #1 after her elopement. There was no indication a qualified service technician was called on site to check the bracelet malfunction. Interview with S3 MDS Nurse on 12/29/16 at 2:30 p.m. revealed when she became aware of the resident's elopement, she noted the actual elopement on the care plan and they were to monitor q shift for the proper placement of the secure care bracelets which they had been doing routinely before the elopement incident, and confirmed increase in supervision of the resident was not addressed in the care plan. Interview with S2 DON on 12/29/16 at 2:45 p.m. revealed they were not aware of the manufacturer's guidelines on trouble shooting using the flow chart in the guide and the requirement to do daily testing of the functionality of the bracelets. She revealed the only time she called the manufacturer was when she ordered the bracelets, and confirmed she had not called the Secure Care service company technician to check the system functionality after the incident. When asked if they had reviewed the video camera footage of the incident since the date of the incident (12/24/16), she stated they just started to view the footage today, 12/29/16. Interview with S6 Assistant Administrator/AIT on 12/29/16 at 2:00 p.m. that she had used the tester to check the other 9 residents on 12/24/16, but confirmed she did not have it documented, and stated that she would write it. Observation on 12/29/16 at 3:00 p.m. of the facility's video camera footage of resident #1's elopement incident on 12/24/16 with the DON and the Corporate Nurse revealed the resident was observed opening the front door of the facility by herself at 7:50 a.m. on 12/24/16. The resident was observed to stand up in front of the door with her wheelchair behind her to steady herself while she pushed the door open. The resident exited the building, and was able to pull her wheelchair through the door. Continued observation revealed at 8:11 a.m., staff were seen rushing to the door. The resident was pushed in her wheelchair back into the facility by staff at 8:13 a.m. A telephone interview with S12 LPN on 12/29/16 at 4:25 p.m. revealed she worked a double shift on weekends from 7:00 a.m. to 11:00 p.m. She revealed on Saturday, 12/24/16 at approximately 8:00 a.m., she was passing medications towards the back of her hall when S9 CNA reported resident #1 was outside in the street. S12 LPN revealed she ran out the front door and S5 LPN (resident #1's nurse) was right behind her. S12 LPN revealed as she exited the front door she saw the resident in the street, and a passing driver had stopped her car and was pushing the resident back to the facility. She stated S5 LPN and herself retrieved the resident at the parking lot from the passing driver. She stated she felt the resident's legs/ankles but did not feel or see the wander guard bracelet on the resident. S12 LPN stated later on, S5 LPN informed her the resident had her wander guard bracelet on and it was under the resident's sock. S12 LPN stated the resident would usually go to the front entrance door and try to get out; however, the door would lock and she could not open the door. S12 LPN stated the resident wanted to leave and was cussing them out when they pushed her back inside the facility. A telephone interview with S5 LPN on 12/29/16 at 4:34 p.m. revealed that he was resident #1's nurse on 12/24/16 on the dayshift, and saw the resident last when he made rounds around 7:00 a.m. He revealed he saw the resident's secure care bracelet was underneath her socks, and stated it did not work, because the resident got through the facility's front doors. He stated he was alerted that the resident was in the street and saw a lady (passing driver) pushing the resident in her wheelchair back towards the facility. He stated they took over from her and pushed the resident back into the facility. He stated the resident was fine and he then reported to his DON by phone, and the DON instructed him to put a new secure care bracelet on the resident. He stated he did, and checked to make sure it worked. He revealed they did not test functionality of the other resident's bracelets and that they checked them weekly. He further revealed they continued to do their routine q 2 hr. checks of the resident. Interview with S1 Administrator on 1/3/16 at 10:45 a.m. revealed he was not notified of the incident on the date of the occurrence. He stated he was available by phone, was on vacation leave out of state, and found out about the issue on 12/29/16. He stated a preliminary OTIS report was submitted on 12/29/16. He revealed that he is the Interim Administrator of the facility and that the Corporate Regional Administrator was also not notified until 12/29/16 and he came to the facility. He confirmed resident #1's elopement incident should have been investigated thoroughly, reported immediately, and immediate actions taken to increase supervision of the residents at risk, have the secure care technician thoroughly check the system, develop and implement step by step procedures for dealing with device malfunction and procedures based on manufacturers guidelines to do daily testing of the secure care bracelets and doors, and closely monitor and protect the residents at risk for elopement. Interview with S6 Assistant Administrator/AIT on 1/3/16 at 11:30 a.m. revealed that she was the one who brought the new secure care bracelet to replace resident #1's bracelet that had malfunctioned on the morning of 12/24/16. She revealed she was not acting in place of the Administrator because she had not completed her training and had not been licensed yet. A facility policy titled Elopement/Wandering-Security System was later discovered and was provided on 1/3/16 at 4:00 p.m. by S1 Administrator, S2 DON and S6 Assistant Administrator/AIT. However, the policy/procedure was not adequate and consistent with the manufacturer's specifications to test secure care bracelets daily and there was no provision to call a Qualified Service Technician on site. There was no process addressing resident's need for increased supervision when there was a malfunction, until the functionality of the system was checked by a service technician.

Based on record review and interview the Administrator failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (#1 and 2) of 10 residents at risk for elopement. The facility failed to: 1. Ensure staff monitor residents assessed as high risk for elopement from exiting the facility through unlocked exit doors (resident #1); 2. Ensure interventions were implemented to increase monitoring and supervision for a resident that had a history of [REDACTED].#1); 3. Investigate to discover reasons staff were not alert to when an incognitive resident with a risk for elopement, and who frequently voiced a desire to go home left out of the front door of the facility without being noticed (resident #1); and 4. Establish policy and procedures to ensure testing and monitoring of the residents with secure care bracelets device used as an intervention to prevent elopement was functioning properly (resident #1 and resident #2). This failed practice resulted in an Immediate Jeopardy situation for resident #1 when on 12/24/16 at 7:50 a.m., the wheelchair bound resident (#1) identified at high risk for elopement, and wore a secure care bracelet, opened the facility's front door and propelled her wheelchair onto a busy 2-way, 4 lane street unnoticed by staff. At 8:11 a.m., the facility staff was alerted by S9 CNA who was looking out onto the street through the facility's glass windows, and saw the resident in the street in her wheelchair, and cars stopping resident. A passing driver on the street, who stopped her car for the resident, pushed the resident in her wheelchair into the facility's parking lot. 2 LPNS went out and met the passing driver to get the resident, and brought the resident back into the facility at 8:13 a.m. S1 Administrator and S2 DON were informed of the Immediate Jeopardy situation on 12/29/16 at 5:50 p.m. The Immediate Jeopardy for resident #1 ended when she was taken to theER on [DATE] at 9:00 p.m. after the resident barricaded herself in her room with furniture, screaming and cursing and combative when staff entered the room. The physician was notified and gave orders to send the resident to the ER by ambulance for psych evaluation and was then admitted to a psych hospital. An acceptable plan of removal was received from the administrator on 01/03/17 with evidence that the plan was implemented on 12/29/16 at 10:00 p.m., and the immediacy had been removed. The plan of removal included the following: 1. Ensure the safety of all residents who are at risk for elopement: Resident #1 eloped from the facility and was returned to the facility. A head to toe assessment was done with no injuries noted. A new wander guard (secure care bracelet) was replaced on the resident and was tested to function properly. An OTIS report was filed on this date, 12/29/16. Video camera footage was reviewed to determine how the resident eloped. The resident was found to have no negative outcome. Actions put in place to prevent residents at risk for elopement from exiting the facility unsupervised: a. The Administrator designee increased monitoring of exit doors from 6:00 p.m. to 9:00 p.m. on 12/29/16 by having a staff member posted at exit doors for visual observation until a service representative from the company ensured the secure care system was functioning properly. b. The DON or designee developed a schedule of staff to assist in the increased monitoring of residents at risk for elopement to q 1 hour visual checks indefinitely until the new system the facility had ordered would be in place (approximate completion date 2/5/17) to replace the current system. Documentation of monitoring of visual checks log was provided to evidence the monitoring was implemented since 12/29/16. 2. Ensure that Wander guards (Secure Care bracelets) were working properly. Audit of Facility Entrances and transmitters: All Wander guard (same as secure care bracelet) safety devices have been increased to daily checks to assure proper functioning (previously done weekly) and exit doors monitored daily. Resident #2's wander guard that had malfunctioned was immediately replaced on 12/29/16. The 2 wander guards were returned to the service Company for testing. A letter was provided from the Medical Equipment Service Company attesting that on 12/29/16, the technician tested all transmitters on residents, checked all aspects of doors and alarm to ensure the doors were locking and unlocking properly. The two functioning wandering doors were found to be working properly and picked up transmitters at a good distance from the door. Surveyor interview with the Service Technician who checked out the facility's secure care system attested that all alarms, doors, resident secure care devices were thoroughly tested and were all operational by 10:00 p.m. on 12/29/16. 3. In-services were conducted with facility staff on topics of Following up on Actual Elopement, Reporting, and Use of Transmitters. In-services began on 12/29/16 at 6:00 p.m. and documentation of staff sign-in logs was provided. 4. Established and implemented policy/procedures on ensuring functionality of the Secure Care System. Policy titled Elopement/Wandering- Security System outlined the step by step procedures for proper application of secure care bracelets, ensure proper operation to include proper placement, positioning, cleaning and handling do's and don'ts; checking each door equipped with security system for proper operation at least daily along with each individual resident's security bracelet also checked daily, follow manufacturer's recommendations for any other type transmitter used. Daily log will be used to record results. The policy read that: during testing of the bracelets if the transmitter fails the test, then proceed to the main exit door to test the transmitter using the secure care lock system. If the transmitter fails this test, the resident is to be put on 1:1 supervision immediately, until a new transmitter is in place on the resident and assured to be working properly. At this time, the DON and Administrator would be notified of the transmitter failure and the Medical Equipment Company would be notified so further testing can be done. The policy further read that a visual check of resident's with security bracelets presence in the facility will be done q 1 hour indefinitely until a new security system is in place and functioning properly and daily thereafter. 5. QAPI - Quality Assurance Performance Improvement Plan dated 12/29/16 addressed that a resident with wander guard eloped and the concern of potential harm of residents at risk for eloping. The root care analysis read that the facility failed to investigate the malfunction of a secure bracelet after a resident eloped and failed to ensure a resident at risk for elopement did not leave the facility unsupervised. The goal was to supervise, monitor, and protect residents who wore secure care bracelets and are at risk for elopement. The action items were assigned to team members with the start date of 12/29/16 and goal completion dates, the items addressed read: increased supervision of all residents at risk for elopement, increased monitoring of exit doors, Medical Service Equipment Company to come to the facility to check all exit doors, Wander guards testing , continuing staff education, increase Wander Drill to weekly, signage at all exit doors for visitors not to allow residents out the door, daily checks of all transmitters per manufacturer's recommendations. This deficient practice continued at a potential for more than minimal harm for the facility's remaining 9 residents (#2, 3, 4, 5, 6, 7, 8, 9, 10) identified at risk for elopement and who wore the secure care/wander guard bracelets. Findings: Cross refer to findings at Tag F-323. Review of the policy provided by S2 DON titled Elopement/Wandering - General Policy revealed the following: In the event that a resident attempts to leave the facility unescorted or is found to be missing, they will be considered high risk An employee observing a resident leaving the premises should: a. attempt to redirect the resident to prevent departure b. should an attempt fail, obtain assistance from other staff members in the immediate vicinity c. instruct another staff member to inform the Charge nurse or DON and Administrator that the resident has left the premises. d. Be courteous in preventing the departure and in returning the resident to the facility --4. Upon return of the resident to the facility: a. Examine for injuries b. Contact the attending MD, report findings and condition of resident, follow orders c. Contact the resident's RP and inform them of the incident d. Notify search teams that the resident has been located e. Complete and file Accident/Incident Report f. Make appropriate entries into the resident's medical record g. NOTIFY REGULATORY AGENCIES per state guidelines. Continued review of the policy revealed there was no documentation in the procedures to increase supervision once the resident returned to the facility. Interview with S2 DON on 12/29/16 at 2:45 p.m. revealed they were not aware of the manufacturer's guidelines on trouble shooting using the flow chart in the guide and the requirement to do daily testing of the functionality of the bracelets. She revealed the only time she called the manufacturer was when she ordered the bracelets, and confirmed she had not called the Secure Care service company technician to check the system functionality after the incident. She further revealed she did not think the resident was considered missing according to their Elopement policy and confirmed they did not file a report to OTIS. Interview with S1 Administrator on 1/3/16 at 10:45 a.m. revealed he was not notified of the incident on the date of the occurrence. He stated he was available by phone and was on vacation leave out of state and found out about the issue on 12/29/16. He stated a preliminary OTIS report was submitted on 12/29/16. He revealed that he is the Interim Administrator of the facility and that the Corporate Regional Administrator was also not notified until 12/29/16 and he came to the facility. He confirmed resident #1's elopement incident should have been investigated thoroughly, reported immediately, and immediate actions taken to increase supervision of the residents at risk, have the secure care technician thoroughly check the system, develop and implement step by step procedures for dealing with device malfunction and procedures based on manufacturers guidelines to do daily testing of the secure care bracelets and doors, and closely monitor and protect the residents at risk for elopement. Interview with the Assistant Administrator/AIT on 1/3/16 at 11:30 a.m. revealed that she was the one who brought the new secure care bracelet to replace resident #1's bracelet that had malfunctioned on the morning of 12/24/16. She revealed she was not acting in place of the Administrator because she had not completed her training and had not been licensed yet.