Every finding on record at Mustang Park Therapy and Living Center

Based on interviews, observations, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Residents #1 and #2) reviewed for quality of life. The facility failed to ensure Residents #1 and #2 received their scheduled showers for May, June and July 2026. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings included: Record review of Resident #1's Face Sheet, dated 07/08/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had a diagnosis of multiple sclerosis (disease that affects the brain, spinal cord, and nerves). Record review of Resident #1's Quarterly MDS Assessment, dated 04/02/26, reflected the resident had a BIMS score of 15 (intact cognitive response). The MDS Assessment reflected the resident had active diagnosis of multiple sclerosis. The resident required setup and supervision for ADL care. Record review of Resident #1's Quarterly Comprehensive Care Plan, dated 11/20/25, reflected the resident had an ADL self-care deficit and the resident required supervision assistance by one staff with personal hygiene. There was no mention of the resident refusing showers.Record review of Resident #1's Progress notes for the months of May, June, and July 2026, reflected no documentation of the resident refusing showers.During an observation and interview on 07/08/26 at 12:30 p.m., Resident #1 was lying in bed. There was a bad odor coming from his area. He stated he had not had a shower in probably one to two months. He stated he refused some showers in the past because he was too tired, but the nursing staff never asked him if he wanted one every time he was scheduled, which was Monday, Wednesday, and Friday. He stated he wanted a shower. Record review of Resident #1's shower sheet on 07/08/26 for the months of May, June, and July 2026 reflected the following: 05/25/26 (self-shower/refused assistance); 05/27/26 (Resident does own shower); 06/01/26 (self-shower); 06/03/26 (self-shower); 06/05/26 (self-shower); 06/08/26 (self); 06/10/26 (self); 06/17/26 (refused); 06/24/26 (refused); 06/26/26 (refused); 06/29/26 (self-shower).Record review of Resident #2's Face Sheet, dated 07/08/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses of reduced mobility and repeated falls. Record review of Resident #2's Quarterly MDS Assessment, dated 05/07/26, reflected the resident had a BIMS score of 3 (severe cognitive impairment). The MDS Assessment reflected the resident had active diagnoses of reduced mobility and repeated falls. The resident was totally dependent on staff providing showers and baths. Record review of Resident #2's Quarterly Comprehensive Care Plan, dated 05/19/26, reflected no plan of care regarding ADL care.Record review of Resident #2's Progress notes for the month of May, June, and July 2026, reflected no documentation of resident refusing showers.During an anonymous interview on 07/08/26 at 10:00 a.m., they stated Resident #2 was not receiving showers. During an observation on 07/08/26 at 12:20 p.m., Resident was in the dining room eating lunch. Her hair appeared unkempt and her clothing appeared dingy.Record review of Resident #2's shower sheet on 07/08/26 for the months of May, June, and July 2026 reflected the following: 05/5/26 (shower); 05/25/26 (shower); 06/01/26 (shower); 06/03/26 (shower); 06/22/26 (shower); 06/26/26 (shower); 07/01/26 (shower).During an interview on 07/08/26 at 2:30 p.m., CNA B and CNA M stated they often provided care to Resident #1, which included providing his showers. They stated the resident often refused showers. CNA B stated they were required to complete shower sheets for all residents when they were scheduled for their showers, whether they received their shower or refused. CNA B stated they were to advise the charge nurse if the resident had refused showers, and she had informed the charge nurse every time the resident refused a shower. They stated they did not know why the resident did not have all his shower sheets on file. They stated if the resident did not receive his scheduled showers he could have skin breakdown. They stated Resident #1 was required to receive supervised showers. They stated he required assistance to the shower room and setup. During an interview on 07/08/26 at 2:40 p.m., the DON was informed of Resident #1 and Resident #2 reflecting they had not had their scheduled showers based on the shower sheets reviewed. The DON stated all CNAs were required to complete shower sheets each time the resident was scheduled for their showers, whether they were provided or refused. He stated the CNA was required to inform the charge nurse if the resident refused a shower so the charge nurse could attempt to persuade the resident to take a shower, and if the resident still refused, the nurse was required to contact a family member to attempt to persuade the resident to take a shower and document the refusal in the resident's progress notes. He stated leadership should be frequently auditing shower sheets to ensure residents were receiving their scheduled showers. He stated if residents did not receive their scheduled showers, they could have skin problems. He was informed Resident #1's shower sheets reflected self-shower and he stated the resident could not physically go into the shower room on his own and complete his own shower. During an interview on 07/08/26 at 2:49 p.m., CNA L stated she provided Resident #2 her showers but often got busy and had not completed the shower sheets for the resident. She stated it was required for staff to complete shower sheets for the residents, which showed proof the residents were provided with showers, or they attempted to provide the residents with showers. She stated they also had to chart it in the facility's system of records if a shower was provided or not. She stated if the residents did not receive their scheduled showers, they could get sores. She stated the residents did not refuse showers. During an interview on 07/08/26 at 2:52 p.m., CNA W stated she provided showers to Resident #2. She stated she completed shower sheets for the resident, and the shower sheets the resident had completed were from her. She stated staff were required to complete shower sheets for all residents scheduled. She stated if they refused the showers, she would get the charge nurse on duty. She stated if the resident did not receive showers, it could impact the integrity of their skin.During an interview on 07/08/26 at 3:11 p.m., the ADON stated staff should shower the resident when scheduled, and if the resident refused, the CNA should step away for a few minutes and then comeback to attempt to try again. The ADON stated if the resident still refused, the CNA should notify the charge nurse and the nurse should attempt to persuade the resident to take a shower. She stated if the resident refused, they should step away for a few minutes and then make another attempt to persuade the resident to take a shower. She stated if the resident still refused, the nurse must contact a family member and document the refusal. She stated the CNA must complete a shower sheet and the charged nurse must sign it. She stated if the residents did not receive their scheduled showers, they could have skin breakdown. She stated all residents required supervised showers and none of them were independent. During an interview on 07/08/26 at 4:00 p.m., Clinical Resource Nurse J stated he was informed by the DON of Resident #1 not having shower sheets indicating an attempt was made to shower him and some of his shower sheets indicating self-shower. He stated he was also informed of Resident #2 not having any shower sheets indicating she received her scheduled showers. He stated none of the residents in the facility could independently shower themselves, and they require at least supervision. He stated staff were to complete a shower sheet for all residents when they are scheduled for a shower; whether they were showered or refused a shower. He stated he in-serviced the nursing staff on 07/08/26 on the protocol when showering residents and the protocol when a resident refused showers. Record review of the facility's policy, Bath/Shower, dated 05/2020, reflected It is the policy of the facility to promote cleanliness, stimulate circulation and assist in relaxation. Assist resident to shower room. Orient residents to water controls and emergency call bell. Provide necessary assistance or privacy. Document all appropriate information in medical records. Note: Never leave resident unattended in the shower room.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services.The facility failed to discard expired milk stored in the refrigerator. This failure placed residents at risk of exposure to food contamination and illness. Findings included:During an interview on 07/08/26 at 1:00 p.m., Resident #3 stated she was drinking milk during breakfast on 07/07/26, and the milk tasted spoiled. She stated she did not drink that milk and did not drink it today because it smelled spoiled. During an interview and observation on 07/08/26 at 1:10 p.m., in the kitchen area, a gallon of white milk, stored in the refrigerator, had an expiration date of 07/08/26. However, the milk smelled spoiled. Dietary Manager B was informed of a resident's complaint about drinking milk, on 07/07/26, and that it tasted spoiled. Dietary Manager B also smelled the milk and stated it was spoiled. She stated the kitchen staff informed her the refrigerator had malfunctioned over the weekend for 1 to 2 hours, and she had instructed her kitchen staff to discard all items in the refrigerator. She stated she was unsure if the milk was one of the items in the refrigerator at the time the equipment malfunctioned. She stated the kitchen staff was responsible for checking the milk prior to serving it to residents. She stated if the resident consumed spoiled milk, they could get sick. During an interview on 07/08/26 at 3:39 p.m., the Administrator stated he was informed by the dietary manager of the spoiled milk being served to residents. He stated the dietary manager did a pretty good job of ensuring residents were not served expired foods. He stated the kitchen staff should have followed the dietary manager's instruction to discard all the food in the refrigerator. He stated if residents consumed spoiled food they could get ill. Record Review of the Facility's policy titled Food Receiving and Storage, dated 2001, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Residents #31, #23, and #6) of seven residents, reviewed for infection control. The facility failed to ensure CNA/MA D performed hand hygiene between Residents #31 and #23 during medication administration.The facility failed to ensure CNA E performed hand hygiene during incontinence care for Resident #6. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Review of Resident# 31's Quarterly MDS Assessment, dated 01/01/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 15. Her cognitive skills were intact. Her diagnoses included end-stage renal disease and schizophrenia. Review of Resident 23's Quarterly MDS Assessment, dated 01/02/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 10. Her cognitive skills were moderately impaired. Her diagnoses included stroke, diabetes, and non-Alzheimer's dementia. An observation on 03/31/26 at 9:05 AM of medication administration with CNA/MA D revealed she administered medications to Resident #31. CNA/MA D returned to the medication cart and did not perform hand hygiene. CNA/MA D prepared medication for Resident #23, administered them, returned to the medication cart, and CNA/MA D did not perform hand hygiene. An interview on 03/31/26 at 9:25 AM with CNA/MA D revealed she did not know she was supposed to perform hand hygiene between residents. She said she had never been trained to. CNA/MA D did say it was important to perform hand hygiene between residents because of spread of infection. Review of Resident 6's Annual MDS Assessment, dated 02/19/26, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 11. His cognitive skills were moderately impaired. His diagnoses included end-stage renal disease, diabetes, and schizophrenia. An observation on 04/01/26 at 1:22 PM of incontinence care for Resident #6 revealed CNA E prepared supplies. CNA E put on gloves, removed the resident's brief and changed gloves. CNA E cleaned the resident's penis and scrotum and changed gloves and did not perform hand hygiene. CNA E cleaned the resident's buttocks, changed gloves, and did not perform hand hygiene. CNA E laid down a clean brief, changed gloves, and did not perform hand hygiene. CNA E applied barrier cream to the resident's buttocks, changed gloves, and did not perform hand hygiene. CNA E fastened the resident's brief. An interview on 04/01/26 at 1:30 PM, CNA E revealed she was supposed to perform hand hygiene when she changed gloves. CNA E said she had been trained to perform hand hygiene but did not do it this time because of nerves. CNA E said it was important to perform hand hygiene for infection control. An interview on 04/01/26 at 1:20 PM, DON revealed staff were supposed to perform hand hygiene between residents and staff were trained to do so. The DON said she monitored hand hygiene 1-2 times per week. The DON said hand hygiene was important to prevent the spread of infection. Record review of the facility in-service, Proper Hand-washing Technique, dated 03/24/26, reflected: All nurses and CNAs are to wash hands using either hand sanitizer or soap and water before and after every encounter with residents. This will prevent the spread of infection and bacteria.The in-service was not signed by CNA/MA D or CNA E. Record review of the facility policy, Hand Washing/Hand Hygiene, revised October 2023, reflected: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety The facility failed to ensure food items in the dry storage room were properly stored, sealed, and protected from exposure to air.The facility failed to ensure food items in the walk-in refrigerator were properly stored, sealed, and protected from exposure to air.The facility failed to ensure that only disposable paper towels were disposed of in the garbage receptacle at handwashing sink #1.The facility failed to ensure the presence of a garbage receptacle at handwashing sink #2.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation on 03/30/2026 at 9:22 a.m., the following was revealed: Handwashing sink #1 had garbage receptacles that contained items other than disposable paper towels, including food and plastic wrap.Handwashing sink #2 did not have a garbage receptacle.During an interview on 03/30/2026 at 9:25 a.m., the Dietary Manager stated that staff using handwashing sink #2 disposed of used paper towels by walking them to the garbage receptacle located at handwashing sink #1. She did not identify any concerns with staff walking wet paper towels to the nearby garbage receptacle.During an observation of the dry storage room on 03/30/2026 at 9:31 a.m., the following was revealed:1 can Butterscotch pudding 112 oz, (7 lbs.), dent on top of can on seal. The written/delivery date was 02/24/2026, no expiration or best by date.1 can Black eyed peas 104 oz, (6 lb. 8 oz), dent on top of the can on seal. The written/delivery date was 03/17/2026. Best by date 12/18/2026.1 can Mild cheddar cheese sauce 106 oz (6 lbs. 10 oz), dent on the side of the can. The written/delivery date was 03/16/2026. No best by date or use by date.1 can Marinara sauce 105 oz, (6 lbs. 9 oz), dent on the side of the can. The written/delivery date was 03.05.2026. No best by date or use by date.2 cans of diced tomatoes and green chilies, 1 lb. 12 oz, dent on the top seal. The written/delivery date was 03/19/2026, best by date 09/12/2027.2 cans of diced tomatoes and green chilies, 1 lb. 12 oz, dent on the side of the can. The written/delivery date was 03/19/2026, best by date 09/12/2027.2 cans of Beef raviolo in tomato and meat sauce, 108 oz (6 lbs. 12 oz), dent on the side of both cans. The written/delivery date was 01/29/2026, best by 09/07/2027.1 large white bin containing sugar was noted with an open date of 01/06/2026 and a use by date of 04/06/2026. The plastic lid was cracked from one end to the other, allowing exposure to air. The cracked lid had been taped; however, the tape was observed to be peeling off, leaving the bin not fully sealed.During an interview on 03/30/2026 at 10:10 a.m., the DM stated that delivery trucks arrived on Tuesdays and Fridays and that dietary aides and herself were responsible for stocking deliveries. She stated that the staff member stocking food items was responsible for checking cans for dents and that dented cans were removed from use and placed in her office. She further stated that, per the facility's dated can policy, any can with a dent would not be used, regardless of the size of the dent. She further stated that staff were responsible for dating cans upon receipt and that, if no best by date was present, the product was typically considered usable for one year from the delivery date. She said when products are opened, they should be sealed and closed with the open date and the use by date written on the product.She stated that she notified the Maintenance Director regarding the broken bin and informed the Administrator in December; however, the bin had not been replaced. She stated she had not yet notified the new Administrator. The DM stated that serving food exposed to air or food from dented cans could result in resident illness. She added that the factors that led to these failures is she's short staffed, she has 1 cook and 1 dietary aide for breakfast and lunch, with a cook and another dietary aide that comes in and overlaps for a couple hours before the first 2 employees go home.During an observation of the walk-in refrigerator on 03/30/2026 at 10:29 a.m., the following was revealed:1 Kosher dill spears 128 fl. oz. (1 gallon) opened, no receive, open or best by date.1 Deluxe Mayonnaise 128 fl. oz. (1 gallon) opened, no receive, open or best by date.1 sweet and sour sauce 1 gallon, opened, no receive or open date, best by date 10/07/2027.1 gallon zipper bag with sliced cheese, receive date 03/24/2026, best by date 04/24/2026, exposed to air.During an interview conducted on 03/30/2026 at 10:54 a.m., the [NAME] stated that all kitchen staff were responsible for stocking deliveries. She stated that dented cans were placed in the DM's office and that the size or location of the dent did not matter. She further stated that, if she was unsure whether a can was dented, she would ask the DM, who made the final decision. The [NAME] stated that the dates written on the cans reflected the date the items were received. She stated that, if residents were served food that was left open or food from dented cans, residents could become sick.In a record review of the facility's Food Receiving and Storage, dated November 2022, revealed: Dry Food Storage.3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated using a first in - first out system.Refrigerated/Frozen Storage1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.Review of the U.S. FDA Food Code 2022, Chapter 3, 3-202.15 Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants.may find their way into the food.Review of the U.S. FDA Food Code 2022 reflected: . Section 6-301.20 Disposable Towels, Waste Receptacle. Waste Receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.

Based on interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 10 confidential residents and one (Resident #40) of seven residents reviewed for frequency of snacks. The facility failed to ensure residents were offered snacks at bedtimes within a window of 14 hours and 45 minutes between the evening meal and breakfast the following day. This failure could affect all residents who received snacks by placing residents at risk for, unplanned weight loss, and side effects from low blood sugar without snack, and diminished quality of life.Findings included: Record review of Resident #40's face sheet, dated 01/01/2026, revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and was her own responsible party. Her diagnoses included Metabolic encephalopathy (a broad term for brain dysfunction resulting from chemical imbalances, systemic disease, or organ failure rather than structural damage), Chronic Obstructive Pulmonary Disease (acute flare-up, worsening of symptoms, increased breathlessness, cough, or sputum production beyond normal daily variations), Type 2 Diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), Severe protein-calorie malnutrition (a life-threatening condition caused by extreme, prolonged dietary deficiency of calories and protein, characterized by >20% body weight loss, significant muscle wasting, and edema), Spinal stenosis (the narrowing of spaces in the spine, compressing nerves and the spinal cord), and Spinal stenosis (the narrowing of spaces in the spine, compressing nerves and the spinal cord). Record review of Resident #40's MDS, dated [DATE], reflected a BIMS score of 10, indicating moderate impairment in cognitive function. Resident #40 required substantial to maximal assistance with care, meaning staff provided more than half of the effort, and active diagnoses of Diabetes During an interview with Resident #40 on 03/31/26 at 2:10 PM stated that she would like to get snacks at bedtime because she was diabetic and needed them but had never been offered any snacks. Resident stated that she had not asked for a snack. During confidential interviews 10 residents said they have not been provided snacks on a consistent basis. Residents stated that snacks are kept at the nurse's station and are not passed out, but if they are able to ambulate themselves they are able to get snacks from the nurses station. During interview on 03/31/2026 at 2:34 PM, LVN B stated that the snacks were placed at the nurses station and the aides took snacks to the bed bound residents and if residents asked for snacks they would be provided with a snack. LVN B stated the risk to residents who did not receive a snack might cause them to be hungry or unfulfilled. During interview on 04/01/2026 at 3:00 PM, the DON stated that dietary department delivered snacks daily to the nurses station and the CNAs passed them out. The DON stated the risk to the resident if they did not receive snacks would be mainly for diabetic residents if their blood sugar dropped. During interview on 04/01/2024 at 3:15 PM, the DM stated they place resident snacks at the nursing station daily before they leave for the day. During interview on 04/01/2026 at 3:32 PM, the ADM stated snacks were offered at bedtime to residents, nursing department and anytime a resident request a snack. The ADM stated the clinical staff were to offer bedtime snacks after dinner. The ADM stated if resident were not offered snacks, residents would be hungry and diabetic residents could have an effect on their blood sugars. The ADM stated residents can ask for snacks and nursing department can provide snacks. Record review of Snacks/Supplement in-service dated 03/24/2026 signed by 12 employees stated: All CNAs and nursing staff are responsible for ensuring that ordered snacks and nutritional supplements were delivered to resident accurately. I understand that this is for multiple reasons: weight management, wound healing or chronic conditions. Record review of the resident roster dated 3/30/2026 reflected a census of 55 residents. Record review of the posted Meal Service Times in the dining room revealed the following:Breakfast - 7:45 AMLunch - 12:00 PMEvening meal - 5:00 PMThere is no posting to advise any residents about a snack or availability of type of snack after specified times. Record review of the Facility Policy Offering/Serving Snacks undated revealed It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preference and requested on a daily basis. Policy Explanation and Compliance Guidelines: 1.The nursing staff offers snacks to all residents in accordance with the residents' needs, preference and request on a daily basis. 2.All diabetic residents are provided with a bedtime snack.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for nutritive value, flavor, and appearance for 10 confidential residents and 2 (Residents #31 and #23) of 7residents reviewed for cold food. The facility failed to provide palatable food served at an appetizing temperature to10 confidential residents and Residents #31 and #23. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction with the meals served and weight loss.The findings included: Record review of Resident #31's Quarterly MDS Assessment, dated 01/01/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 15. Her cognitive skills were intact. Her diagnoses included end-stage renal disease and schizophrenia. Record review of Resident #23's Quarterly MDS Assessment, dated 01/02/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 10. Her cognitive skills were moderately impaired. Her diagnoses included stroke, diabetes, and non-Alzheimer's dementia. During an interview on 3/30/2026 at 1:14 PM, Resident #23 stated that the food is not good, it was always cold, on a rare occasion it was lukewarm. Resident #23 stated she did not feel if she told anyone that it would get fixed. Stated she did not ask staff reheat her food. During an interview on 3/30/2026 at 1:33 PM, Resident #31 stated that the food was always cold never hot, she stated that she told residents council. Observation of food cart on 03/31/2026 at 12:25 PM, revealed a non-insulated food cart on hall 500 with 10 food trays. Two staff members observed passing trays. During a confidential interview on 03/31/2026 at 10:34 AM, 10 residents stated that they received cold food if they ate in their room. Residents stated that it was not dietary fault as the dietary staff gets the food out, but the carts have sat on the hall for five to ten minutes before staff would pass the trays. During an interview on 03/31/2026 at 2:07 PM, CNA F stated that she had received one or two cold food complaints. CNA F stated that when she received a cold food complaint that she would take the tray and rewarm the tray in the microwave. During interview on 03/31/2026 at 2:34 PM, LVN B stated that she had received cold food complaints. She stated that she reported it to the previous DON and put in grievances five months ago. LVN B stated that since then she had not received any complaints. Record review of resident council meeting minutes dated 02/26/2026 revealed new meal cart is not insulated, which caused food to cool faster. Record review of January, February and March 2026 grievance log and no complaints of cold food. Record review of seven residents weights and no significant weight loss noted. During interview on 04/01/2026 at 3:00 PM, the DON stated that he was not aware of any cold food complaints. The DON stated that his expectation of his staff were that they needed to pass the food trays as soon as dietary department delivered them to the halls. During interview on 04/01/2026 at 3:32 PM, the ADM stated that his expectation of his staff was that food be served to residents at a safe and appetizing temperature. The ADM stated that the nursing staff was responsible for ensuring food trays were delivered as soon as the dietary staff brought the trays to the hall so that the residents who ate in their rooms received meals at appetizing temperatures. The ADM stated if food was not served at an appetizing temperature, it could have caused residents to not want to eat their food which could have led to weight loss. Record review of meal trays in-service dated 3/24/2026, revealed staff are to ensure that all residents have meal trays offered, regardless of whether residents eat or not. Unless resident is nothing by mouth. Staff are to feed residents as needed and ensure food order matches what's on the tray and trays are passed in a timely manner. Record review of facility policy Nutritional Management undated revealed, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Requested meal service policy via email on 04/01/2026 at 1:25 PM. Did not receive it prior to exit.

Based on interviews, and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 5 of 5 confidential residents reviewed for call lights. The facility failed to ensure call lights were answered in a timely manner. This failure could place residents at risk for decreased quality of life, self-worth and dignity.Findings included: During confidential interviews with 5 residents, reported call light response time was greater than 30 minutes. Record review of Resident Council Meeting Minutes indicated the following: - 12/30/25 complaints were made regarding call light response times,- 1/30/26 complaints were made regarding call light response from nursing staff, and that staff would come into the room to turn the call light off and not assist with their needs,- 2/26/2026 call light response was poor at times, and- 03/27/2026 call light response was poor at times. During confidential interview resident stated that it takes up to an hour to respond to her call bell. During confidential interview resident stated that the staff are slow at responding to call lights. Resident stated that she had waited up to an hour before someone had come on but could not state a date. Resident stated that she had not reported this to anyone, just figured they would get to me when they could. During an interview on 03/31/2026 at 2:34 PM, LVN B stated that she had not received any call light response time complaints. LVN B stated that all staff were able to answer call lights. She stated that the facility expectation of call light response time was to answer immediately. LVN B stated they had in-service in March on call light response time. During an interview on 04/01/2026 at 3:00 PM, the DON stated he expected his staff to answer call lights timely. The DON said that all his staff were to answer call lights and if they could not take care of the problem, they needed to get someone who could. The DON said the call light should never stay on longer than five minutes and anything over that time was too long. The DON said there was no reason that the staff should not answer the call lights or go in and turn the light off without fulfilling the residents request. The DON stated that if a facility staff member could not fulfill resident request the resident light should remain on and that staff member was to go get someone who could assist. During interview on 04/01/2026 at 3:32 PM, the ADM stated that his expectation of his staff was that they answered residents call lights as soon as possible. The ADM stated that the risk to the resident if staff did not answer call light would be dependent on the need of the residents, but safety concerns for falls and injuries to residents. Record review of facility in-service on Rounding and Answering call lights 03/24/2026 revealed the importance of responding promptly to call lights to ensure resident safety, satisfaction and quality of care. Record review of facility policy titled Answering the Call Light undated revealed the following:The purpose of this procedure is to ensure timely responses to the residents' requests and needs.

Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment that described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #37) of three residents reviewed for care plans. 1. The facility failed to ensure Resident #37 was positioned correctly to provide care and services that promote the highest practical well-being while being fed. This failure could place residents at risk for choking and aspiration.Findings included: Record Review of Resident #37's annual MDS assessment, dated 02/06/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The BIMs score was blank, but cognitive skills for daily decision-making were severely impaired. The resident was dependent on staff for eating and was on a mechanically altered diet. His diagnoses included heart failure, end-stage renal disease, Alzheimer's disease, seizure disorder, malnutrition, respiratory failure, and dysphagia (difficulty swallowing). Record review of Resident #37's Order Summary report, dated 08/20/25, reflected:Pureed texture, nectar consistency liquids. Record review of Resident #37's Care Plans, revised 03/06/26, reflected the risk for nutritional complications related to dysphagia. Diet: pureed texture, nectar consistency.Facility interventions reflected: Resident in chair at 90 degrees for all food and fluid intake. Record review of an in-service for Resident #37, dated 03/24/26, reflected:Proper Positioning when Feeding Resident #37.Resident needed to be positioned upright at a 90-degree angle. Pillows could be used to support positioning.Signed by LVN C and CNA/MA D. An observation and interview on 03/30/26 at 1:05 PM, revealed Resident #37 was being fed by LVN C. The resident was being fed a puree diet. He was seated in a geri-chair that was leaning back, he was not at a 90-degree angle. He was not coughing or choking. LVN C said the resident was supposed to sit upright to eat, but it required two staff to sit him up. LVN C stood up and adjusted the geri-chair and the resident was able to sit upright. LVN C said the resident was at risk for choking due to being laid back to eat. LVN C said the resident was supposed to be at a 90-degree angle to eat. An observation and interview on 03/31/26 at 12:42 PM revealed CNA/MA D fed Resident #37 a bite of pureed food while he was leaning back in his geri-chair. CNA/MA D said she could not sit him up because he would slide out of the chair. The DON walked over to the table and sat up the resident's geri-chair. CNA/MA D said the resident was not supposed to be lying down to eat. An interview on 03/31/26 at 12:50 PM revealed the DON said the staff received an in-service on how to feed Resident #37. The DON said the resident was at risk for choking if he was left lying down in his geri-chair to eat. In an interview on 03/31/26 at 12:55 PM, CNA/MA D revealed the resident was supposed to be at a 90-degree angle to eat. CNA/MA D said she did not sit up the resident's geri-chair because she did not know the geri-chair could be positioned to an upright position. CNA/MA D said Resident #37 was at risk for choking if he was fed while laying down. An interview on 04/01/26 at 12:10 PM with the DON revealed Resident #37 had not suffered from aspiration. The DON also said the facility was ordering the resident a new wheelchair to sit in to eat upright. A follow-up interview on 04/01/26 at 12:15 PM with LVN C revealed she received an in-service regarding Resident #37. LVN C said she did not sit up the geri-chair because she was afraid the resident would slide out of the geri-chair. LVN C said the resident had never slid out of the geri-chair. Review of the facility policy, Positioning the Resident, not dated, reflected: .Positioning the Residentd. Maintain natural spinal curves: Stabilize pelvis. Chest up and forward. Head erect.

Based on interviews and record reviews, the facility failed to notify the resident and/or resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 (Resident #5, Resident #40, and Resident #45) of 6 residents reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #5, #40, and #45.The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #5, #40, and #45.These failures could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. A record review of Resident #5's face sheet, dated 03/31/2026, revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and was her own responsible party. Her diagnoses included Osteomyelitis of the lower leg (a serious bacterial or fungal bone infection), Type 2 Diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), Atherosclerosis of native arteries of extremities with gangrene (a severe, chronic condition where plaque buildup causes extreme arterial narrowing, restricting blood flow to limbs), Type 2 Diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), Severe protein-calorie malnutrition (a life-threatening condition caused by extreme, prolonged dietary deficiency of calories and protein, characterized by >20% body weight loss, significant muscle wasting, and edema), and Hallux rigidus (a common form of degenerative arthritis causing pain, swelling, and stiffness in the big toe joint, often leading to an immovable joint).A record review of Resident #5's MDS, dated [DATE], reflected a BIMS score of 12/15, indicating moderate cognitive impairment or some memory problems. Resident #5 required maximum to dependent assistance with care, meaning staff provided more than half, to all the effort.A record review of Resident #5's progress note dated 03/16/2026, indicated Resident #5 was sent to the ER, due to Avascular necrosis (the death of bone tissue due to interrupted blood supply). There was no evidence that a transfer or discharge notice had been provided to Resident #5 in writing or to the LTC Ombudsman. In an interview on 03/31/2026 at 12:05 p.m., Resident #5 revealed she had never received a written letter when she was sent to the emergency room. She also stated she would have liked to receive a letter from the facility for her records.2. A record review of Resident #40's face sheet, dated 01/01/2026, revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and was her own responsible party. Her diagnoses included Metabolic encephalopathy (a broad term for brain dysfunction resulting from chemical imbalances, systemic disease, or organ failure rather than structural damage), Chronic Obstructive Pulmonary Disease (acute flare-up, worsening of symptoms, increased breathlessness, cough, or sputum production beyond normal daily variations), Type 2 Diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), Severe protein-calorie malnutrition (a life-threatening condition caused by extreme, prolonged dietary deficiency of calories and protein, characterized by >20% body weight loss, significant muscle wasting, and edema), Spinal stenosis (the narrowing of spaces in the spine, compressing nerves and the spinal cord), and Spinal stenosis (the narrowing of spaces in the spine, compressing nerves and the spinal cord).A record review of Resident #40's MDS, dated [DATE], reflected a BIMS score of 10/15, indicating moderate impairment in cognitive function. Resident #40 required substantial to maximal assistance with care, meaning staff provided more than half of the effort.A record review of Resident #40's progress note dated 12/23/2025, indicated Resident #40 was sent to the ER, due to their oxygen being at 85%, she was lethargic, could not keep her eyes open, and had a temperature of 104.5. There was no evidence that a transfer or discharge notice had been provided to Resident #40 in writing or to the LTC Ombudsman. In an interview on 03/31/2026 at 12:45 p.m., Resident #40 revealed she had never received a written letter when she was sent to the emergency room. She also stated it did not bother her that she did not receive one.3. A record review of Resident #45's face sheet, dated 03/31/2026, revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and was her own responsible party. Her diagnoses included Systolic Congestive Heart Failure (the heart's left ventricle becomes too weak or enlarged to contract properly), Type 2 Diabetes mellitus without complications (indicates the presence of high blood sugar but without established damage to nerves, eyes, kidneys, or the cardiovascular system), Obstructive and Reflux Uropathy (a urinary tract disorders where urine flow is blocked or flows backward into the kidneys), Chronic Kidney Disease (the long-term, irreversible loss of kidney function, causing waste buildup, fluid retention, and blood pressure issues), and Presence of urogenital implants (refers to the existence of artificial materials or devices in the urinary or reproductive tracts, typically used to treat incontinence, or structural issues).A record review of Resident #45's MDS, dated [DATE], reflected a BIMS score of 15/15, indicating the resident was cognitively intact. Resident #45 was mostly independent and completed activities without staff assistance; however, she required staff set-up or clean-up assistance for tub/shower transfers.A record review of Resident #45's progress note, dated 11/16/2025, reflected that Resident #45 was sent to the emergency room due to shaking, only able to verbalize her name, reported having pain, was disoriented to other questions asked, and was unable to recognize staff or her roommate. There was no evidence that a transfer or discharge notice had been provided to Resident #45 in writing or to the LTC Ombudsman.In an interview on 03/31/2026 at 1:33 p.m., Resident #45 revealed she had never received a written letter when she was sent to the emergency room. She also stated she would have liked to receive a letter from the facility so she could have more details about why she was sent to the ER.During an interview on 03/31/2026 at 2:05 p.m., LVN A revealed that she did not provide a written notice to the resident or the resident's responsible party when a resident was transferred to the emergency room. She explained that she notified the responsible party by telephone at the time of the transfer.During an interview on 03/31/2026 at 2:18 p.m., the ADON revealed that she did not provide written notices or letters to residents or their responsible parties when residents were transferred to the emergency room. She explained that she and the nursing staff notified the responsible party by telephone at the time of the transfer. The ADON further stated that no written information, including resident names, was provided or sent to the LTC Ombudsman.During an interview on 03/31/2026 at 2:47 p.m., the DON revealed that written transfer or discharge notices were not issued to residents or their responsible parties when residents were sent to the emergency room. He stated that notification was provided by a telephone call made by nursing staff to the responsible party at the time of the transfer. The DON further indicated that he believed information regarding discharged residents was forwarded to the LTC Ombudsman by the Social Worker.An attempt was made to contact the facility's LTC Ombudsman; no response was received, and the voicemail was not returned.During an interview on 04/01/2026 at 10:08 a.m., the SW revealed that she was not aware of any written letters or notices being provided to residents or their responsible parties when residents were transferred to the emergency room. She further indicated that she had not been aware that a list of discharged residents was required to be sent to the LTC Ombudsman. During an interview on 04/01/2026 at 10:32 a.m., the Administrator stated that the facility did not provide written transfer or discharge notices to residents or their responsible parties when residents were sent to the emergency room. He explained that residents were verbally informed of the transfer, and the responsible party was notified by telephone at the time of the transfer. The Administrator further stated that, if a written notice were provided, it would clearly communicate the reason for the resident's discharge; however, he acknowledged that this practice was not occurring at the facility.In a record review of the facility's Discharge Summary and Plan, dated December 2006, revealed that the facility's policy addressed only residents who discharged to a private residence or another nursing care facility.Regulation S483.15(c)(3) states Notice before transfer. Before a facility transfers or discharges a resident, the facility must-(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and(iii) Include in the notice the items described in paragraph (c)(5) of this section.S483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge;(ii) The effective date of transfer or discharge;(iii) The location to which the resident is transferred or discharged ;(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of one resident observed during a transfer. RN A and CNA B failed to transfer Resident #1 safely when they failed to use a gait belt and independently lifted Resident #1 under her armpits when transferring Resident #1 from the floor to her wheelchair on 10/12/25. This failure could affect the residents by placing the residents at risk for discomfort, pain, and/or injury. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: coronary artery disease (the coronary arteries, which supply blood to the heart muscle, become narrowed or blocked), hypertension (a condition where the force of blood against the artery walls in consistently too high), renal insufficiency (where the kidneys are not working as well as they should to filter waste, regulate blood pressure, and manage body fluids), hyperlipidemia (a condition characterized by high levels of lipids), and non-Alzheimer's disease (memory impairment). Resident #1 required partial/moderate assistance (helper does less than half the effort.) for sit to stand and chair/bed-to-chair transfer. Resident #1's BIMS score of four indicated she was severely cognitively impaired. Review of Resident #1's Care Plan dated 10/07/25, reflected, Resident #1's ADL Self Care Performance deficit related to dementia: transfers: I can bear weight, pivot, use arms to support, ambulates using walker Record review and interview on 10/14/25 at 7:36 AM, revealed the ADM, the DON and the Surveyor reviewed the video provided by Family Member C regarding the transfer incident of Resident #1 on 10/12/25. The video was recorded on 10/12/25 with an unknown time and revealed RN A and CNA B and Resident #1 were standing next to Resident #1's bed in Resident #1's room. RN A and CNA B transferred Resident #1 from the floor to her wheelchair. RN A and CNA B both placed their arms under the resident's arm pits and had Resident #1 place her arms to her side and lifted the resident from the floor without a gait belt. The ADM and the DON both stated that the video showed an inappropriate transfer of Resident #1 when RN A and CNA B both placed their arms under the resident's arm pits and did not use a gait belt. The DON identified RN A and CNA B as the staff members in the video. The ADM and the DON both said there had been no reports or concerns regarding RN A or CNA B's care and treatment of the residents. The ADM said the employees had received training with a competency checkoff on appropriate transfer and gait belt usage. The DON and the ADM both stated the expectation was for staff to use gait belts rather than to place their arms under a resident's arm pit to transfer a resident. The ADM and the DON both stated the risk of an inappropriate transfer could result in injury to the residents. The DON stated they teach staff to use a gait belt for all transfers for safety and to prevent injury to themselves and the residents. Interview on 10/15/25 at 10:07 AM with Family Member C revealed she had not provided the video on 10/12/25 of Resident #1 being transferred by two staff members inappropriately by her armpits to the facility yet. Observation and attempted interview on 10/14/15 at 11:29 AM, revealed Resident #1 was up in her wheelchair in her room. Resident #1 was smiling and appeared to be in a good mood. Resident #1 could not answer questions appropriately. Interview on 10/14/25 via the telephone at 7:52 AM with CNA B regarding the observation of the video of Resident #1's transfer on 10/12/25 revealed CNA B acknowledged she was the staff member in the video. CNA B acknowledged she did not use a gait belt for the transfer and had been trained on safe transfers. CNA B knew Resident #1 was a one-person assist with transfers and to always use a gait belt. CNA B was asked about the placement of her arms in the pictures from the video and CNA B stated she had her arms under Resident #1's armpits which was incorrect. CNA B stated she would use a gait belt for transfers and not place his arms under the Resident's armpits during transfers moving forward. CNA B stated that the risk of transferring a resident inappropriately could result in fracture of resident's arm. Interview on 10/14/25 via telephone at 8:00 AM with RN A regarding the observation of the video of Resident #1's transfer on 10/14/25 revealed RN A acknowledged he was the staff member in the pictures from the video. RN A acknowledged he did not use a gait belt for the transfer and had been trained on safe transfers. RN A knew Resident #1 was a one-person assist with transfers and to always use a gait belt. RN A was asked about the placement of his arms in the pictures from the video and RN A stated he had his arms under Resident #1's armpits which was incorrect. RN A stated he would use a gait belt for transfers and not place his arms under the Resident's armpits during transfers moving forward. RN A stated that the risk of transferring a resident inappropriately could result in a fracture. Interview on 10/14/15 at 6:56 AM with CNA E revealed Resident #1 was a one-person transfer with a gait belt for all transfers. CNA E was asked about the hand placement for a one-person transfer, CNA E stated they were to hold onto the gait belt during the transfer. CNA E was asked if transferring a resident by grabbing under a resident's armpit was appropriate and CNA E stated no armpit transfers were allowed because they risked causing injury to a resident. Interview on 10/14/15 at 7:01 AM with the DON revealed Resident #1 was a one-person transfer with a gait belt for transfers since that is standard practice. The DON stated the staff were not to use a resident's armpits during a transfer because that could result in fracture or bruising to the resident. Interview on 10/14/25 at 8:06 AM with LVN D revealed Resident #1 was a one-person transfer with a gait belt for all transfers. LVN D was asked about the hand placement for a one-person transfer, LVN D stated they were to hold onto the gait belt during the transfer. LVN D was asked if transferring a resident by grabbing under a resident's armpit was appropriate and LVN D stated no armpit transfers were allowed because they risked causing a shoulder injury to a resident. Interview on 10/14/15 at 8:16 AM with PT F revealed Resident #1 was a one-person transfer with a gait belt for all transfers. PT F stated that they did not use a resident's armpit during a transfer that was not safe for the resident and could cause an arm dislocation. Review of the facility's In-Service Training Report dated 10/05/25-10/09/25, Inservice Topic: Falls. Objective/Key Points: .using gait belt with proper assistance. Review of [NAME] and [NAME] Clinical Nursing Skills and Techniques 9th edition, dated February 2016, page 276 reflected: . Patients should never be lifted by or under their arms. Review of the facility's policy, Safe Lifting and Movement of Residents, dated July 2017, reflected, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

Based on observation, interviews and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside for one of five residents (Resident #1) reviewed for call lights. The facility failed to answer Resident #1's call for assistance in a timely manner due to a malfunction with her call light. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.Findings include: Record review of Resident #1's facility face sheet, dated 11/10/25, revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included cervical disc disorder (affecting the neck's spinal discs, causing pain and discomfort), fusion of spine (surgery to connect two or more bones in any part of the spine), osteoporosis (bones become weak and are likely to break) and anxiety (feeling of fear, dread, and uneasiness). Record review of Resident #1's quarterly MDS assessment, dated 10/23/25, indicated she had a BIMS score of 13, which indicated she was cognitively intact. She was substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toileting transfers. Record review of Resident #1's comprehensive care plan, dated 08/01/25, indicated she was a moderate risk for falls and had an intervention to include 1/4 side rails to aid in mobility and positioning, resident must be able to use rails independently with only prompting and cueing. During an interview on 11/10/25 at 2:45 PM with Resident #1, she revealed she never requested the police to come, she asked them to call the facility for her. She stated after waiting for what she believed was two hours, she called 911 to have them call the facility for her. Resident #1 stated the new company took over on 9/1/25 and she spoke to the DON, the ADON, Nurses and CNAs, but not the ADM. Resident #1 stated the call light turned on in her room, at its will, and sometimes it did not work in the hall. Resident #1 said it took about 2 hours for someone to come on 11/8. Resident #1 stated the ADM gave her a bell on Monday (11/10/25) and staff now came when she rang her bell. In an interview on 11/12/25 at 11:40 AM with CNA A, she stated Resident #1 was having issues with her call light before she started working at the facility. CNA A said there was a shortage with the wire because it happened several times since she started. CNA A said they offered to move Resident #1, but she did not want to move to a new room. CNA A said Resident #1 complained about the light not working on Monday (11/10/25) and they gave her a call bell. CNA A said they could hear the bell at the front desk. CNA A stated Resident #1 never complained about staff taking too long. CNA A stated she was unsure if Resident #1 ever requested a call bell prior to this incident. CNA A said she was not sure if Resident #1 had ever called 911, but she knew for certain she had never called while she was working. CNA A said the MTD did some work on the call light weeks ago, but it kept happening. CNA A stated that was why they offered her to move rooms, but she declined. In an interview on 11/12/25 at 2:25 PM with RN F, she stated Resident #1 said her call light was not working and they would fix it and then it would stop working again. RN F stated they provided her with a call bell on Monday (11/10/25). RN F said the call light was having issues for about two weeks. RN F stated staff completed regular checks on her. RN F said she was unsure if Resident #1 was offered the chance to move to another room. RN F said the DON went to her room daily to address her needs and ensured they were being met. RN F stated Resident #1 had not complained during her shift and she never called 911 due to staff not answering her call light. In an interview on 11/12/25 at 3:55 PM with the DON, she stated Resident #1 stated her call light worked off and on. The DON stated whenever Resident #1 would report her call light was not working, the MTD checked it and reported back that it worked. The DON stated she confirmed Monday (11/10/25), one time when she checked the call light, it did not work for her. The DON stated Resident #1 told her she called 911 on Saturday (11/8/25) because no one was answering her call light. The DON stated she told Resident #1 evidently it may be a shortage with her call light because the resident had been reporting it was not working and when we checked it, sometimes it worked and sometimes it did not, so it was something wrong with the call light. The DON stated she texted the ADM on Monday (11/10) and asked him if he could get Resident #1 a call bell and the ADM went to the store and purchased her a call bell. The DON stated the call light had a shortage and the MTD had to call a technician to come out. In an interview on 11/13/25 at 9:50 AM, the MTD stated he checked Resident #1's call light 1-2 times a week. The MTD said the first time was 2 months ago. The MTD stated maybe once or twice there was a delay when he checked it. The MTD stated a technician should be called to come out to inspect the call light because they had the tools to do so. The MTD stated it had not completely failed, it was just a delay. The MTD stated the priority was to get a technician out. The MTD stated Resident #1 could have fallen and needed urgent medical attention. The MTD stated he did not have anything documented. The MTD stated Resident #1 repeatedly reported her call light did not work, but it was just a delay. In an interview on 11/13/25 at 2:55 PM, LVN G stated she went into Resident #1's room on Saturday (11/8) at 6:10 AM and Resident #1 stated her call light had been on the entire night. LVN G stated she had Resident #1 push the call light and the light turned on and it was beeping. LVN G stated she asked Resident #1 what she needed and Resident #1 said she forgot. LVN G stated she turned the call light off and told Resident #1 to let her know what she needed. LVN G stated throughout the shift Resident #1 would turn her call light on and it worked. LVN G stated Resident #1 had never mentioned a call bell to her. LVN G stated on Sunday (11/9/25), towards the end of her shift, Resident #1 said her call light was not working again. LVN G stated she told Resident #1 to press the call light and the light came on and it beeped again. LVN G stated Resident #1 told her she called 911 because her call light was not working. LVN G stated 911 personnel never came to the facility, but they called the facility. In an interview on 11/13/25 at 4:55 PM, the ADM stated Resident #1 complained of her call light not working, but he could not recall the exact dates. The ADM stated he was unaware of Resident #1's call light being tested and not working. The ADM stated they discussed getting her a call bell during one of their meetings, but he could not recall the date. The ADM stated his expectation was for all call lights to be answered in a reasonable time with urgency. Record review of the facility's policy, Call System, Resident dated September 2022, revealed, .3. The resident call system remains functional at all times. 6. Calls for assistance are answered as soon as possible, but no later than 5 minutes. Record review of the facility's, undated, policy Resident Call System revealed, Ensure that residents have a means of direct communication between the resident and his/her caregivers when in their rooms.

Based on interviews and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for one of five residents (Resident #4) reviewed for resident rights. The facility failed to ensure Residents #4's call light was answered in a timely manner. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings include: Record review of Resident #4's facility face sheet, dated 11/10/25, revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #4 had diagnoses which included cerebral edema (swelling in the brain), chronic respiratory failure with hypoxia (improper gas exchange), diabetes (blood sugar, is too high) and acute kidney failure (reduction in kidney function). Record review of Resident #4's quarterly MDS assessment, dated 08/26/25, indicated she had a BIMS score of 15, which indicated she was cognitively intact. She was partial/moderate assistance with toileting hygiene and dependent with toilet transfers. Record review of Resident #4's comprehensive care plan, dated 08/28/25, indicated: I am resistant to care r/t Anxiety with interventions: If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. I have the potential to demonstrate verbally abusive behaviors r/t Ineffective coping skills, Mental / Emotional illness, Poor impulse control. [Resident #4] has a behavior problem r/t Delusions (Thinking her gown is wet when it is not, thinking she is hearing staff members engaging in sexual activity outside of her room), Resident [#4] has a history of making false allegations against staff. During an interview on 11/12/25 at 10:10 AM with Resident #4, she stated on 11/09/25 she pushed the call light quite a few times. Resident #4 stated she waited about 15 minutes and then called 911. Resident #4 stated the police came to her room and then they went to the front desk and spoke with someone. Resident #4 stated the police returned to her room and staff had told the police they sent someone in her room to change her, but they had not. Resident #4 stated the staff lied to the police because it would be crazy for her to refuse for someone to change her. Resident #4 stated the police did not seem to care and acted as though it was another day. During an interview on 11/12/25 at 11:40 AM with CNA A, she stated Resident #4 only came out of her room for showers and therapy. CNA A said Resident #4 never complained to her about anything. CNA A said she was not aware of Resident #4 requesting help and having to call 911. CNA A stated it was expected for Resident # 4's call light to be answered promptly. During an interview on 11/12/25 at 2:25 PM with RN F, she stated Resident #4 kept her call light on due to being needy. RN F said right after you finished doing something for Resident #4 and left her room, the call light would be on within 5 minutes . RN F said they would ask Resident #4 if she needed anything before they left her room and she would say no but then turn the call light back on. RN F stated Resident #4 would say she did not want something, then staff left her room and she turned on her light and wanted the exact same thing staff just did for her. RN F said one day she was going to check her blood sugar, and she said no because she did not understand why the doctor wanted them to check it. RN F stated Resident #4 would then call the staff back and ask if they still had the equipment to do it. RN F stated Resident #4 changed her mind a lot and she appeared as though she was a very angry person. RN F stated once staff had just left Resident #4's room and Resident #4 called 911 to tell them she needed something. RN F said it was more of a behavior. RN F said they constantly went in and out of her room. RN F said Resident #4 never complained to her about staff refusing to assist her or taking too long to respond to her call light. RN F said Resident #4 was care-planned for these behaviors, and they charted on her behaviors. RN F stated the DON constantly checked in with Resident #4. RN F stated when the DON was not in the facility, staff checked in with Resident #4. During an interview on 11/13/25 at 2:55 PM, LVN G stated Resident #4 refused to allow CNA B to enter her room on 11/9/25. LVN G stated she went to Resident #4's room and asked her why she did not want CNA B to change her. LVN G stated Resident #4 said CNA B took her brief off and did not give her a blanket. LVN G stated she asked Resident #4 if she put CNA B out of the room and Resident #4 said, Yes, I put her out of the room, I just do not like her. LVN G stated she told Resident #4 that CNA B provided care for you yesterday and you liked her and Resident #4 responded, Well, today I do not like her. LVN G stated she sent a different CNA to Resident #4's room and Resident #4 put that CNA out too. LVN G stated then Resident #4 stated CNA B could come finish what she started. LVN G stated when she exited Resident #4's room, the CNAs were picking up trays and the police arrived and she escorted them to Resident #4's room. LVN G stated the police came to the nursing station and was asking a ton of questions, and Resident #4 pressed her call light again. LVN G stated the police informed her that they were going to go back to Resident #4's room and let her know that a different CNA would be in to provide care and the police left the facility. LVN G stated she had only worked at the facility for three weeks and was unaware if Resident #4 had ever complained that staff refused to assist her or took too long to answer her call light. LVN G stated Resident #4 was care-planned for these types of behaviors prior to this incident. Interview was attempted on 11/13/25 at 3:36 PM with CNA B prior to exit but was unsuccessful. During an interview on 11/13/25 at 4:15 PM, the DON stated she wrote a grievance yesterday after speaking with Resident #4. The DON stated the investigation was ongoing. The DON stated Resident #4's Care Plan captured her behaviors for accusing staff of things that were untrue. The DON stated her behaviors were initially reported to her when they purchased the facility on 9/1/25. The DON stated after that, they started seeing her report things like the call light not being answered for 4 hours. The DON stated now she was able to confirm these false allegations . The DON stated this was Resident #4's second time calling 911. During an interview on 11/13/25 at 4:55 PM, the ADM stated Resident #4 was care-planned for making false accusations and inaccurate timeframes. The ADM stated Resident #4 wanted staff at her bedside continuously. The ADM stated every incident Resident #4 alleged was always elaborated and elongated. The ADM stated staff should have good customer service. The ADM stated staff should be the Residents friend, family and help them with what they needed. The ADM stated he spoke with Resident #4 and it was more of a customer service issue. The ADM stated his expectation was for call lights to be answered as quickly as possible. Record review of the facility's policy, Call System, Resident dated September 2022, revealed, .6. Calls for assistance are answered as soon as possible, but no later than 5 minutes.

Based on interview and record review the facility failed to ensure the resident had the right and the facility made prompt efforts to resolve grievances the resident may have for one of three residents (Resident #2) reviewed for grievances. The facility failed to respond to two of Resident #2's grievances with an appropriate resolution to his concerns. This deficient practice could place facility residents at risk for a decreased sense of self-worth, a decline in quality of life, and loss of dignity.Findings include: A record review of Resident #2's, undated, face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included anxiety (feeling of worry, dread, or fear), diabetes, major depressive disorder (persistent sadness, hopelessness, and loss of interest in activities), morbid obesity, multiple sclerosis (autoimmune disease that affects the central nervous system). A record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS of 15, which indicated the resident was cognitively intact. Resident #2 experienced feeling down, depressed, or hopeless 12-14 days (nearly every day). A record review of Resident #2's care plan, with a target date of 12/9/25, revealed Problem: I use antidepressant medications, and benzodiazepines, interventions: Monitor/document/report to MD PRN ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. A record review of Resident #2's grievance form, dated 11/5/25, revealed Tonight dinner served consisted of vegetable soup and baked potato, the baked potato was very under cooked and hard essentially making it inedible. Vegetable soup was the only side.[DM] interviewed Resident [#2] and discussed Resident #2's preferences. Interview on 11/10/25 at 3:30 PM with Resident #2 revealed he had spoken with the ADM and gave him a grievance form. Resident #2 stated 10 minutes later the DM approached him in therapy and informed him he would like to meet with him when he was finished. He stated the DM should have apologized to him first for the undercooked baked potato. He stated instead, the DM asked him if he asked the dietary staff to reheat the baked potato. He stated the DM should have discussed the grievance with the kitchen staff about why it happened and then addressed it with him. He stated the DM did not take any responsibility. He stated this was last Wednesday (11/5/25). Resident #1 stated the DM nor the ADM had not followed up with him directly regarding the status of the grievance. Resident #2 stated this situation made him feel targeted and discouraged from reporting issues in the future. Interview on 11/12/25 at 12:50 PM with the DM revealed on his first day at the facility (11/5/25), the ADM asked him to address a grievance with Resident #2 regarding an undercooked baked potato. The DM stated he went to meet with Resident #2 and informed him it was unfortunate that it happened and if it ever happened again, to let someone in the kitchen know at that time, opposed to two days later so they could give him a different one or prepare something different. Interview on 11/13/25 at 4:55 PM with the ADM revealed Resident #2 brought him a 3-day old baked potato and grievance form on 11/5/25. The ADM stated he gave the grievance form to the new DM on his first day (11/5/25) and asked him to follow up with Resident #2. The ADM stated Resident #2 concluded due to him giving his grievance form to the DM it was a breach of confidentiality. The ADM stated normally the Department Head would meet with the resident and discuss the grievance in a timely manner within 24 hours unless it was over the weekend. The ADM stated since 11/5/25, he had not received the resolution. Record review of the facility's, undated, policy Grievance Resolution revealed The resident's grievance will be resolved promptly and the decision conveyed to the resident in writing. 6. The Grievance Officer will complete the review of the grievance and provide a written response to the resident or resident representative which includes: i. Date the grievance/concern was received.ii. Summary of grievance presented.iii. Investigation steps involved.iv. Findings of the investigation.v. Resolution outcome and actions taken andvi. Date the decision was issued.

Based on observation, interview and record review the facility failed to ensure residents received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of five residents (Resident #2) reviewed for dietary services. The facility failed to provide food served that was palatable and thoroughly cooked to Resident #2. This failure could place residents at risk of weight loss, altered nutritional, status, and diminished quality of life. Findings include: A record review of Resident #2's, undated, face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included anxiety (feeling of worry, dread, or fear), diabetes, major depressive disorder (persistent sadness, hopelessness, and loss of interest in activities), morbid obesity, multiple sclerosis (autoimmune disease that affects the central nervous system). A record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS of 15, which indicated the resident was cognitively intact. Resident #2 experienced feeling down, depressed, or hopeless 12-14 days (nearly every day). A record review of Resident #2's care plan, with a target date of 12/9/25, revealed Problem: I am at risk for nutritional problem R/T Morbid Obesity (BMI over 40). I have unexpected weight gain r/t Overeating, I request double portions on all meals and I have a lot of snacks in my room which I eat as needed, interventions: If weight is not within range, contact a physician. [Doctor's name], the registered dietitian is aware of the resident weight gain. Educated the resident about the importance of cutting down on snacks and not eating double portions on all meals, he verbalized understanding. He got Boast [sic] stuck in his refrigerator in his room and drink as needed. During an observation on 11/11/25 revealed the following:12:18 PM - 500 - 800 Halls meal trays delivered on tray cart12:23PM - 100 - 400 Halls meal trays delivered on tray cart During an observation on 11/11/25 at 12:29 PM in the facility's only dining room revealed residents assembled at multiple tables eating lunch. Interview on 11/10/25 at 3:30 PM with Resident #2, he stated one day the food may be good, then the next day it was not. Resident #2 stated it was hard to tell at this time if the food was going to get better. Resident #2 stated on 11/5/25, he was served an undercooked baked potato and the vegetable soup was lukewarm. Resident #2 stated the quality of the food being served was hit or miss. He stated he had not discussed the food with the DM. Interview on 11/12/25 at 11:40 AM with CNA A, she stated he had not received a lot of complaints about food. CNA A stated one day last week, Resident #2 received a half baked potato that was not fully cooked. CNA A stated Resident #2 saved the potato from the day before. CNA A stated she remembered the day because he showed it to her last Thursday (11/6/25) on his shower day. CNA A stated Resident #2 was served the baked potato the day before on Wednesday (11/5/25). CNA A stated Resident #2 saved the baked potato to show the ADM the next day, so she placed it in a bag for him because he had it laying out next to his sink. CNA A stated Resident #2 never complained to her about the food except for the undercooked baked potato. CNA A stated in the dining room they were not allowed to pass the trays until a nurse was present. CNA A stated they passed out the drinks first and then the meal trays. CNA A stated they only had 2 residents who required assistance with eating. CNA A stated once the trays were delivered to the halls, the nurse checked off on the trays, and then the CNAs delivered the trays to the rooms. During an interview on 11/12/2025 at 12:30 PM, the State Surveyors requested the DM provide a sample tray with regular texture meal items, same portions and resident set up. The sample tray will be the last tray served. Test Tray - Lunch at 12:45 PMBaked Chicken = 178.2 Pasta with Pesto Sauce = 170.3 Mixed Veggies = 164.5 Dinner Roll = Room temperature and softButterscotch Pudding with [NAME] Cracker Crumbles = 41.2 Fruit Punch = 40.0 During an interview on 11/12/2025 at 12:50 PM with the DM, he stated on his first day (11/5/25), the ADM had him address a grievance regarding an undercooked baked potato from over the weekend. The DM stated he went to meet with Resident #2 and informed him it was unfortunate that it happened and if it ever happened again, to let someone in the kitchen know at that time, opposed to two days later so they could give him a different one or fix him something different. The DM stated he had a meeting with all the residents yesterday (11/11/25) to introduce himself and to let them know changes were coming. The DM stated he informed the residents that he could not change anything that may have happened prior to him starting at the facility. In an interview on 11/13/25 at 4:55 PM with the ADM, he stated Resident #2 brought him the baked potato 3 days after it was served. The ADM stated they switched food vendors on 9/1/25 when they purchased the facility and he received compliments saying the food was better. The ADM stated residents were allowed to request alternate meals. The ADM stated his expectation was for the residents to enjoy their meals at the appropriate temperature hot or cold. The ADM stated not adhering to standards, the risk was dissatisfaction where residents may eat less which resulted in malnutrition and weight loss. Record review of the facility's, undated, policy, Food and Drink, revealed, Procedure: Each resident receives and the facility provides- Food prepared by methods that conserve nutritive value, flavor, and appearance.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (Resident #1) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 10/28/2025.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #1's Face Sheet, dated 10/28/2025, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (progressive cognitive decline, memory loss, and behavioral changes) and muscle wasting and atrophy. Record review of Resident #1's Quarterly MDS Assessment, dated 08/14/2025, reflected moderate cognitive impairment with a BIMS score of 08. Resident #1 required assistance for self-care and mobility needs. Record review of Resident #1's Comprehensive Care Plan, dated 08/01/2025, reflected the resident was at risk for falls related to unsteady gait/balance. One intervention was to keep call light within reach and encourage to ask for assistance. During an observation and interview on 10/28/2025 at 9:27 AM, Resident #1 was lying in bed. The call light was lying on the floor next to her bed. When asked about her call light, Resident #1 replied she could not reach it and asked the surveyor to get it. The DON was in the hall in the time. She came into Resident #1's room and observed the call light on the floor. The DON clipped Resident #1's call light to her blanket within the resident's reach. Upon exiting the room, the DON stated she was in Resident #1's room before the surveyor entered and Resident #1 was holding the call light in her hand. The DON stated the resident's call light should always be available to the resident to notify staff of any needs. During an interview on 10/28/2025 at 10:20 AM, CNA B stated at the beginning of her shift and during rounds, she checked to ensure residents had their call lights within reach. She stated it was important for Resident #1 to have her call light in reach to be able to call for help. She stated if something happened, no one would know. During an interview on 10/28/2025 at 10:26 AM, LVN A stated it was important for Resident #1 to have her call light in reach. He stated it was important for Resident #1 and all residents to be able to communicate with staff when they needed something. During an interview on 10/28/2025 at 2:11 PM, the Administrator stated every resident should have their call light placed where they could reach it. He stated it was important to ensure call lights were always within reach so residents could get help when they needed it. Record review of the facility's policy, Answering the Call Light, revised September 2022, reflected The purpose of this procedure is to ensure timely responses to the resident's requests and needs.Ensure that the call light is accessible to the resident when in bed.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 (Resident #2) residents reviewed for infection control.The facility failed to ensure CNA C performed hand hygiene between touching Resident #2's curtain with her bare hand and putting on gloves to apply a clean brief 10/28/2025.This failure could place residents at risk of cross-contamination and development of infections.The findings included:Record review of Resident #2's Face Sheet, dated 10/28/2025, reflected the resident was an [AGE] year-old female who admitted on [DATE]. Resident #2 had diagnoses which included hypertension (high blood pressure), hyperlipidemia (blood has too many lipids, or fats), and vascular dementia (decline in mental ability caused by reduced blood flow to the brain). Record review of Resident #2's Quarterly MDS Assessment, dated 10/23/2025, reflected intact cognition with a BIMS score of 13. Section H (bladder and bowel) indicated Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's Comprehensive Care Plan, dated 10/02/2025, reflected Resident #2 was incontinent. Interventions included to check the resident every two hours and assist with toileting as needed, and provide care after each incontinent episode.During an observation and interview on 10/28/2025 at 10:48 AM, CNA C provided incontinence care for Resident #2. Resident #2 was lying in bed and gave consent for the surveyor to observe care. CNA C pulled the curtain around the bed to provide privacy. CNA C used hand sanitizer and put on gloves. CNA C pulled down the front of Resident #2's brief and cleaned her, using a single wipe for each pass. CNA C used hand sanitizer when she changed gloves. Resident #2 rolled to her left side. CNA C removed the soiled brief from under Resident #2 and dropped it in the wastebasket. CNA C removed her gloves and used hand sanitizer. CNA C moved the curtain to get gloves from a box on the wall in the resident's room. She pulled the curtain to the side when she returned to the resident's bed. CNA C did not use hand sanitizer before she put on clean gloves. CNA C cleaned the resident's bottom and placed a clean brief under her. Resident #2 rolled to her back and CNA C secured the brief in front. CNA C removed her gloves and used hand sanitizer. After exiting the room, CNA C stated the curtain was probably dirty and she should have used hand sanitizer before putting on gloves to care for Resident #2. She stated it was important to use appropriate hand hygiene for infection control. In an interview on 10/28/2025 at 11:01 AM, the DON stated CNA C should have washed her hands or used hand sanitizer before and after each glove change. The DON stated there can be bacteria on curtains and it was important to decrease the risk of infection. During an interview on 10/28/2025 at 11:06 AM, LVN A stated CNA C should have sanitized her hands before putting on gloves and after removing the gloves. He stated that was universal precautions and proper hand hygiene was the most effective way to prevent the spread of bacteria. He stated the facility recently had an in-service on hand hygiene. Review of the facility's policy Handwashing/Hand Hygiene, revised October 2023, reflected This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Perform hand hygiene before applying non-sterile gloves.when removing gloves. perform hand hygiene.The use of gloves does not replace hand washing/hand hygiene.

Based on observation, interview and record review the facility failed to ensure the nurse call system was assessable for six of ten residents (Resident #1, #2, #3, #4, #5 and #6) reviewed for call systems access. The facility failed to ensure the call light system in Resident #1, #2, #3, #4, #5 and #6's rooms was in a position that was accessible to the residents on 10/08/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #1's Face Sheet, dated 10/08/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and muscle weakness. Record review of Resident #1's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance and had an active diagnosis of muscle weakness. Record review of Resident #1's Comprehensive Care Plan, dated 8/28/25, reflected the resident's need for ADL care and included an intervention of encouraging the resident to use the call light. In an observation on 10/08/25 at 8:34 AM Resident #1 was observed lying in bed. Her call light was hanging from the bed, near the floor, and out of reach. 2. Record review of Resident #2's Face Sheet, dated 10/08/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included repeated falls and lack of coordination. Record review of Resident #2's Quarterly MDS assessment, dated 8/05/25, reflected a BIMS score of 14 (intact cognitive response). For ADL care, it reflected the resident required total assistance. Active diagnoses included repeated falls and lack of coordination. Record review of Resident #2's Comprehensive Care Plan, dated 8/29/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/08/25 at 8:44 AM, Resident# 2 was observed lying in bed and her call light was on the floor and under her bed. 3. Record review of Resident #3's Face Sheet, dated 10/08/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included difficulty walking and unsteadiness on feet. Record review of Resident #3's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 13 (intact cognitive response). For ADL care, it reflected the resident required moderate assistance. Active diagnoses included difficulty walking and lack of coordination.Record review of Resident #3's Comprehensive Care Plan, dated 10/01/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach. In an observation on 10/08/25 at 8:49 AM, Resident #3 was observed lying in bed and her call light was observed hanging on another bed in the room, out of reach of the resident. 4. Record review of Resident #4's Face Sheet, dated 10/08/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and repeated falls. Record review of Resident #4's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required moderate assistance. Active diagnosis included history falls. Record review of Resident #4's Comprehensive Care Plan, dated 6/20/25, reflected the resident was a fall risk and an intervention included ensuring call light was within reach of the resident and encouraging the resident to use it. In an observation on 10/08/25 at 8:49 AM, Resident #4 was observed lying in bed and his call light was observed on the floor under the head of the bed, out of reach of the resident. 5. Record review of Resident #5's Face Sheet, dated 10/08/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included muscle weakness. Record review of Resident #5's Quarterly MDS assessment, dated 7/18/25, reflected a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required full assistance. Active diagnosis included muscle weakness. Record review of Resident #5's Comprehensive Care Plan, dated 8/01/25, reflected the resident was a fall risk and an intervention included ensuring call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/08/25 at 8:50 AM, Resident #5 was observed lying in bed and his call light was observed on the floor behind the head of the bed, out of reach of the resident. 6. Record review of Resident #6's Face Sheet, dated 10/08/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and a history of falls. Record review of Resident #6's Quarterly MDS assessment, dated 8/02/25, reflected a BIMS score of 15 (intact cognitive response). For ADL care, it reflected the resident required some assistance. Active diagnosis included muscle weakness. Record review of Resident #6's Comprehensive Care Plan, dated 10/02/25, reflected the resident had muscle weakness and an intervention included ensuring call light was within reach of the resident and to encourage the resident to use it. In an observation and interview on 10/08/25 at 8:43 AM, Resident #6 was lying in bed, and her call light was observed on the floor. She was asked if she knew where her call light was located and she stated she did and reached down from the bed, nearly falling over to grab the call light. In an interview and observation on 10/08/25 at 8:43 AM, LVN R was shown by the Surveyor of Resident #1, #2, #3, #4, #5 and #6 call light being out of reach of the residents. He stated the call lights should be in reach of the resident so they could contact staff. He stated staff should be checking to ensure call lights were in reach of the residents when they made their rounds. In an interview and observation on 10/08/25 at 8:50 AM, CNA O was shown by the Surveyor Resident #1, #2, #3, #4, #5 and #6 call light not being in their reach. She stated the call lights needed to be within reach of the resident so they could contact staff if they needed help. She stated it was just her second day at the facility and was learning the process of what to look for when checking on residents. In an interview and observation on 10/08/25 at 8:50 AM, CNA C was shown by the Surveyor Resident #1, #2, #3, #4, #5 and #6 call light not being in their reach. She stated the call lights needed to be within reach of the resident so they could contact staff if they needed help. In an interview on 10/08/25 at 2:40 PM, ADON J was told by the Surveyor of Resident #1, #2, #3, #4, #5 and #6 call light not within their reach. He stated call lights needed to be within reach of the residents so they could be able to contact staff if they needed assistance or had an emergency. He stated staff should be checking and ensuring call lights were within reach of the residents every time they entered the residents' room. In an interview on 10/08/25 at 2:44 PM, the DON stated when she started on September 1, 2025. She was shown pictures by the Surveyor of Resident #1, #2, #3, #4, #5 and #6 call light not within their reach. She stated she was in the process of training staff to ensure call lights were within the residents' reach whenever they did their rounds and to also clip them to the bed to ensure they did not fall off. She stated the residents needed their call light within their reach to contact staff for assistance. Record review of the facility's policy on Call System, Resident, undated, revealed Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of seven residents (Resident #1, #6, #7, and #8) reviewed for respiratory care. The facility failed to ensure Resident #1, #7, and #8's nasal cannulas were properly stored in a bag when not in use on 10/08/25. The facility failed to ensure Resident #6's tracheostomy hose was not on the floor but properly stored when not in use on 10/08/25. These failures could place the resident at risk for respiratory infection and not having his respiratory needs met.Findings include: 1. Record review of Resident #1's Face Sheet, dated 10/08/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included heart disease. Record review of Resident #1's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance and had an active diagnosis of history of COVID-19. Record review of Resident #1's Comprehensive Care Plan, dated 8/28/25, reflected the resident's need for oxygen therapy and the use of a nasal canula. Record review of Resident #1's physician orders, dated 10/08/25, reflected Mat Titrate O2 to maintain saturation greater than 90% every shift for shortness of breath. In an observation on 10/08/25 at 8:34 AM, Resident #1's nasal canula was observed on the floor near an oxygen tank, unbagged. 2. Record review of Resident #6's Face Sheet, dated 10/08/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included tracheostomy (opening in the neck). Record review of Resident #6's Quarterly MDS assessment, dated 8/02/25, reflected a BIMS score of 15 (intact cognitive response). For ADL care, it reflected the resident required some assistance. Active diagnosis included tracheostomy care. Record review of Resident #6's Comprehensive Care Plan, dated 10/02/25, reflected the resident had a tracheostomy and an intervention included ensuring trach ties are secured and provide oxygen care. Record review of Resident #6's physician orders, dated 10/08/25, reflected Tube size 18 FR/10 cc may replace if dislodged and Albuterol Sulfate Inhalation Nebulization Solution 0.63 NG/3ML I inhalation via Trach In an observation on 10/08/25 at 8:43 AM, Resident #6's Trach hose (the opening) was observed on the floor. 3. Record review of Resident #7's Face Sheet, dated 10/08/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included heart failure. Record review of Resident #7's Quarterly MDS assessment, dated 9/01/25, reflected her BIMS score of 14 (intact cognitive response). The resident had an active diagnosis of heart failure. Record review of Resident #7's Comprehensive Care Plan, dated 6/26/25, reflected a plan of care for oxygen therapy by way of nasal canula. Record Review of Resident #7's physician orders, dated 10/08/25, reflected Oxygen at 2 Liters per nasal canula as needed for Oxygen saturation below 90. In an observation on 10/08/25 at 8:42 AM, Resident #7's nasal canula was observed on the floor near a chair, unbagged. 4. Record review of Resident #8's Face Sheet, dated 10/08/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included heart failure. Record review of Resident #8's Quarterly MDS assessment, dated 8/25/25, reflected his BIMS score of 12 (moderate cognitive impairment). The resident had an active diagnosis of heart failure. Record review of Resident #8's Comprehensive Care Plan, dated 8/29/25, did not reflect a plan of care for oxygen therapy. Record Review of Resident #8's physician orders, dated 10/08/25, reflected Oxygen at 2 Liters per nasal canula as needed for Oxygen saturation below 90. In an interview and observation on 10/08/25 at 8:43 AM, LVN R was shown a Resident #1, #7, and #8 not having their nasal canula bagged and Resident #6's Trach hose on the floor. He stated the hose and nasal cannulas should not be on the floor to avoid the residents from getting an infection. In an interview on 10/08/25 at 10:00 AM, the DON was told and shown pictures of Resident #1, #7, and #8 not having their nasal canula bagged and Resident #6's Trach hose on the floor. She stated the expectation was for the nursing staff to ensure all mask and nasal cannulas are bagged when not in use to avoid the resident getting an infection. She stated Resident #6's Trach hose should not have been on the floor and should be replaced to avoid contamination. In an interview on 10/08/25 at 2:40 PM, ADON J was shown pictures by the Surveyor of Resident #1, #7, and #8 not having their nasal canula bagged and Resident #6's Trach hose on the floor. He stated the hose and nasal cannulas should not be on the floor to avoid the residents from getting an infection. He stated it was the nurses' responsibility to ensure nasal cannulas were bagged and the trach hose not on the floor when they make their rounds, which occurred at least every two hours. Review of the facility's policy Respiratory Care Policy, undated, reflected Purpose - To ensure that all residents requiring respiratory care in the long-term care facility receive safe, evidence-based, and individualized respiratory services that optimize respiratory function, prevent complications, and improve quality of life.

Based on interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 4 residents (Resident #9, #10, #11, and #12) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #9, #10, #11, and #12 received their scheduled showers based on records reviewed for September 2025. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings Included: 1. Record review of Resident #9's face sheet, dated 10/08/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis of muscle weakness. Record review of Resident #9's Comprehensive MDS Assessment, dated 07/29/25, reflected her BIMS score of 15 (intact cognitive response). The Comprehensive MDS Assessment reflected the resident required limited assistance with bathing. Record review of Resident #9's Comprehensive Care Plan, dated 9/16/25, reflected the resident required a one person assist when bathing. An attempted record review of Resident #9's Bath/Shower Sheets for the month of September 2025, was not made because the DON and ADON J could not provide any documents or records of when the resident received showers. 2. Record review of Resident #10's face sheet, dated 10/08/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis of Cerebral Palsy (neurological damage). Record review of Resident #10's Comprehensive MDS Assessment, dated 9/01/25, reflected her BIMS score of 15 (intact cognitive response). The Comprehensive MDS Assessment reflected the resident required one person assistance with bathing. Record review of Resident #10's Comprehensive Care Plan, dated 8/21/25, reflected the resident was required a one person assist when bathing. An attempted record review of Resident #10's Bath/Shower Sheets for the month of September 2025, was not made because the DON and ADON J could not provide any documents or records of when the resident received showers. In an interview on 10/08/25 at 9:00 AM, Resident #9 and Resident #10 stated they were not pleased with the care being provided since the new leadership took over. They stated they only received about one shower a week because the facility had lost a lot of CNAs and were short staffed. They stated they did not like feeling dirty. They stated it took a while for staff to answer their call lights. They stated they had to complain to the DON to get a shower. 3. Record review of Resident #11's face sheet, dated 10/08/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident had a diagnosis of morbid obesity and muscle weakness. Record review of Resident #11's Comprehensive MDS Assessment, dated 10/02/25, reflected her BIMS score of 15 (intact cognitive response). The Comprehensive MDS Assessment reflected the resident required total assistance with bathing. Record review of Resident #11's Comprehensive Care Plan, dated 10/02/25, reflected the resident was required total assistance when bathing. An attempted record review of Resident #11's Bath/Shower Sheets for the month of September 2025, was not made because the DON and ADON J could not provide any documents or records of when the resident received showers. In an interview on 10/08/25 at 9:00 AM, Resident #11 stated he had not been getting his scheduled showers on a consistent basis. He stated he only received them when he complained about it and he needed his showers. He stated there were other residents not getting their showers, and this was not right. He stated the facility had been short staffed until recently when they started hiring staff. He stated he only received one shower in the past two weeks. He stated he was scheduled for showers on Tuesday, Thursday, and Saturdays. 4. Record review of Resident #12's face sheet, dated 10/08/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnoses of muscle weakness and unsteadiness on feet. Record review of Resident #12's Comprehensive MDS Assessment, dated 10/07/25, reflected her BIMS score of 15 (intact cognitive response). The Comprehensive MDS Assessment reflected the resident required total assistance with bathing. Record review of Resident #12's Comprehensive Care Plan, dated 10/07/25, reflected the resident was required total assistance for showers and required three showers a week. An attempted record review of Resident #12's Bath/Shower Sheets for the month of September 2025, was not made because the DON and ADON J could not provide any documents or records of the resident receiving showers. In an interview on 10/08/25 at 2:00 PM, the DON was told by the surveyor of Resident #10, #11, and #12 complaint of not receiving their scheduled showers. She stated that when she first started with the facility on 9/01/25, she received complaints from residents of not receiving their showers and she confirmed residents were either not receiving their showers or the CNAs were not updating the system of records of the shower occurring. She stated the CNAs work on an honor system, and they should document when showers had been given, and she spot checked with residents to confirm they were given. She stated she placed many CNAs on a performance improvement plan and many of them had resigned because of it. She stated she completed an in-service on showers with the Nursing staff recently. She stated if the residents did not receive their showers, they could have skin breakdown. She stated since the new company took over, they did not have a consistent way of tracking when residents received their showers. She stated they currently had no proof the residents were receiving their scheduled showers. She was asked for shower records for Resident #12, and she stated she did not have any records for this resident either. In an interview on 10/08/25 at 2:40 PM, ADON J was told by the Surveyor of Resident #10, #11, and #12 complaint of not receiving their scheduled showers. He stated they had a lot of CNA turnover and a change in the system of records because of the change in ownership. He stated he had mentioned to leadership the concern of recording resident showers. He stated he thought residents were receiving their scheduled showers but could not confirm it. He stated if residents were not receiving their scheduled showers, it could impact their skin integrity. Record review of the facility's policy on Activities of Daily Living (ADL), Supporting, dated 2001, (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. b. Unavoidable decline may occur if he or she: (1) has a debilitating disease with known functional decline; (2) has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; and/or (3) refuses care and treatment to restore or maintain functional abilities and: a) the resident and or representative has been informed of the risk and benefits of the proposed care or treatment; and b) he or she has been offered alternative interventions to minimize further decline; and c) the refusal and information are documented in the resident's clinical record. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care)

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one of six residents (Resident #5) reviewed for dignity. The facility failed to conceal Resident #5's catheter bag lying in public view. This failure placed residents at risk of not having their right to a dignified existence and self-determination maintained.Findings included: Record review of Resident #5's Face Sheet, dated 10/08/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included urinary tract infection. Record review of Resident #5's Quarterly MDS assessment, dated 7/18/25, reflected a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required full assistance. Active diagnosis included renal failure (kidney failure). Record review of Resident #5's Comprehensive Care Plan, dated 8/01/25, reflected the resident was care planned for bladder incontinence, but the intervention did not include an intervention for the use of a catheter bag. Record Review of Resident #5's physician orders, dated 10/08/25, reflected Catheter Suprapubic catheter (16)fr 10 (cc) to close drainage system. In an observation on 10/08/25 at 8:40 AM, Resident #5 was observed with a catheter bag hanging from his bed. The catheter bag was visible from the door entrance, and it did not have a privacy bag. In an interview and observation on 10/08/25 at 8:43 AM, LVN R was shown a picture by the Surveyor of Resident #5 not having his catheter bag covered with a privacy bag. He stated the resident should have a privacy bag covering the catheter bag to protect the resident's dignity. In an interview on 10/08/25 at 10:00 AM, the DON was told and shown a picture of Resident #5 with a catheter bag and no privacy bag over it. She stated a CNA had brought this to her attention this morning and she had given him a privacy bag to cover it. She stated it was a dignity concern for the resident and the catheter bag should always have privacy bag. Record review of the facility's policy on Dignity, dated February 2021, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #6) reviewed for accidents and hazards. The facility failed to ensure Resident #6 did not exit the facility through an unknown door and walk 2.7 miles to a free-standing emergency department where he was found outside. The noncompliance was identified as PNC. The noncompliance began on 03/13/2025 and ended 03/14/2025. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of harm and serious injuries. The findings include: Record review of Resident #6's wandering risk assessment, dated 01/31/2025, reflected a score of 4, which indicated a low risk for elopement. Record review of Resident #6's Quarterly MDS (tool used to assess health status) Assessment, dated 02/13/2025, reflected a BIMS (screening tool to assess cognitive status) was not completed because the resident was rarely/never understood. The staff assessment indicated the resident had moderately impaired cognition for daily decision making. Record review of Resident #6's Comprehensive Care Plan, dated 03/09/2025, reflected Resident #6 had impaired cognitive function/dementia or impaired thought processes related to neurological symptoms: Aphasia. Interventions included Administer meds as ordered. Date Initiated: 02/21/2025. I need supervision/assistance with all decision making. Date initiated 02/21/2025. Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date initiated 02/21/2025. Record review of Resident #6's Comprehensive Care Plan, dated 03/09/2025 and updated 03/14/2025, reflected Resident #6 was an elopement risk as evidenced by 03/13/2025 2200 (10 PM) last seen in facility - 3/14/25 2:00 (2 AM) Return to facility. Elopement with Hospital Visit, returned to facility. One intervention was 3/13/2025 ELOPEMENT . 1:1 (one on one staff-resident) care for continuous monitoring due to elopement incident to begin on resident return to facility and end on transfer to secure unit/facility. Date Initiated: 03/14/2025. Record review of Resident #6's Face Sheet, dated 04/15/2025, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (blood flow to a part of the brain is blocked, dementia (decline in mental ability that interferes with daily life), aphasia (disorder that affects communication), anxiety disorder with behaviors (persistent worry and fear about everyday situations) and major depressive disorder (persistent feelings of sadness and loss of interest in activities once enjoyed). Observation of all exit doors on 04/15/2025 at 1:20 PM revealed the doors closed and locked properly and alarms could be heard at the nurses' stations. During a telephone interview on 03/25/2025 at 9:45 AM (before midday), a nurse at the hospital ER (department equipped to provide emergency care) stated she was told a bystander saw Resident #6 at a free-standing (not attached to a hospital) ER and called EMS (responds to medical emergencies and transports to appropriate hospital).The ER nurse stated she did not know what time the resident was picked up. She stated when Resident #6 arrived at the hospital ER, he did not have any complaints and could not tell them what he was doing or why he went to the free-standing emergency room . She stated Resident #6 was given medication for anxiety and blood pressure. She stated Resident #6 said he was hungry and thirsty, so they fed him and let him hang out. The ER Nurse stated during her break a co-worker was talking to Resident #6 when he received a call from nursing facility staff. The ER Nurse stated her co-worker talked to the facility staff and was told Resident #6 somehow got out of the facility. She stated her co-worker told the facility staff where Resident #6 was. The ER Nurse stated the ADON came to the hospital to pick up Resident #6. The ER Nurse stated they were concerned because the nursing facility did not know the resident was out of the building for that long. During an interview on 03/25/2025 at 2:30 PM (after midday), the ADON stated LVN E called him on 03/14/2025 about 1:30 AM to notify him Resident #6 was missing. The ADON stated LVN E told him he had not seen Resident #6 during his shift, which began on 03/13/2025 at 10:00 PM. The ADON stated LVN E told him CNA C did not see Resident #6 when he made rounds at 11:00 PM. The ADON stated he told LVN E he should have been notified at 11:00 PM when they could not find the resident. The ADON stated he called LVN A, who was Resident #6's nurse the previous shift on 03/13/2025 from 2:00 PM to 10:00 PM. The ADON stated LVN A said just before 10:00 PM Resident #6 told him he was going to his room to lay down and LVN A saw the resident before he left the facility. The ADON stated LVN A called him on 03/14/2025 at 2:12 AM and told him Resident #6 was at the hospital emergency room . The ADON stated he understood Resident #6 called LVN A who spoke with a nurse in the emergency room . The ADON stated he drove to the hospital to pick up Resident #6 and hospital staff told him there was no need to admit Resident #6. The ADON stated hospital staff told him EMS brought the resident to the hospital ER after he was seen outside a free-standing ER and said he needed help. The ADON stated he returned Resident #6 to the facility where he was placed on one-on-one monitoring until he discharged later that day to another facility. The ADON stated upon his return from the hospital, he immediately did a head count to ensure all residents were accounted for. He stated he contacted the administrator, the director of nurses, the residents family, and the resident's doctor. He stated a wander assessment was completed for all residents, door lock codes were changed, and staff members received in-service training on resident elopement. He stated LVN E was no longer employed at the facility. The ADON stated he believed the resident left the faciity on [DATE] during shift change between 10:30 PM- 11:00 PM. The ADON stated Resident #6 may have exited during shift change, while staff members were entering and leaving the facility, since the door did not alarm. During an interview on 03/25/2025 at 2:55 PM, LVN A stated he was Resident #6's nurse from 2:00 PM-10:00 PM on 03/13/2025. He stated Resident #6 went to his room about 10:00 PM and he was in his room when LVN A left about 10:15 PM. LVN A stated it was after 1:00 AM on 03/14/2025 when Resident #6 called from his cell phone. LVN A stated Resident #6 was aphasic and when trying to communicate his words would get jumbled. He stated if you catch the first couple of words, you can usually figure out what the resident was trying to say. LVN A stated the resident gave the phone to a nurse who said the resident was in the hospital ER. LVN A stated he contacted the ADON and told him where the resident was. An interview was attempted with CNA C on 03/25/2025 at 3:10 PM and was unsuccessful. During an interview on 03/25/2025 at 3:54 PM, the Administrator stated on 03/14/2025 at 11:00 PM staff noticed Resident #6 was not in his room. She stated the resident was rarely in his room. She stated he was usually in the court-yard or the day room. She stated staff did not think much about it, because Resident #6 was only in his room to sleep. She stated she was not sure what time facility staff notified the ADON Resident #6 was not at the facility. She stated facility staff searched all the rooms, closets, offices, common areas, storage areas, and outside the building. She stated a facility nurse spoke with Resident #6 on his cell phone and he gave his phone to a nurse who reported the resident was at the hospital emergency room . She stated the ADON was called, and he went to the hospital and brought Resident #6 back to the facility. The Administrator stated a full skin assessment was completed when the resident returned to the facility, and he had no pain or injury. The Administrator stated the resident was placed on one-on-one monitoring until he was discharged to a facility with a locked unit on 03/14/2025. An interview was attempted with LVN E on 03/25/2025 at 4:23 PM and was unsuccessful. During an interview on 03/25/2025 at 4:35 PM, the DON stated a wandering assessment was completed for all residents on admission and then quarterly. She stated Resident #6 had not displayed exit seeking behavior prior to the elopement. The DON stated after Resident #6 eloped, his care plan was updated and an elopement risk was completed for all residents. She stated no other resident triggered for elopement risk. The DON stated if a resident were exit seeking, the social worker would be notified to look for a secure unit. During an interview on 03/26/2025 at 1:35 PM, the Social Worker stated she was responsible for sending out referrals to find placement. She stated after Resident #6 was able to get out of the building, he could no longer stay at the facility. She stated Resident #6 was placed on one-on-one monitoring until he was transferred to another facility on 03/14/2025. She stated the facility provided in-service training and went over elopement protocols. During an interview on 03/26/2025 at 2:20 PM, CNA B stated she worked 2:00 PM-10:00 PM on 03/13/2025. CNA B stated during her shift Resident #6 kept asking for the time. She stated Resident #6 came out of his room with his coat when he saw she was getting ready to leave and LVN A distracted him. CNA B stated she later realized Resident #6 had asked for the time so he would know when to be at the door. She stated he was not around the door when she left the facility after her shift. CNA B stated LVN A called her on 03/14/2025 at about 1:30 AM and said the ADON texted him that Resident #6 had left the facility. She stated a few minutes later, Resident #6 called her from the hospital ER and she called LVN A on her tablet so the three could communicate. She stated Resident #6 was aphasic and difficult to understand. She stated other people were heard in the background and it took about 10 minutes of them asking Resident #6 to give the phone to someone before he did. CNA B stated the person who took the phone could not provide information about Resident #6 but told them where he was. She stated LVN A notified the ADON. During an interview on 04/15/2025 at 1:15 PM, the Administrator stated Resident #6 was not a known elopement risk. She stated criteria which indicated a resident was high risk for elopement included going to a door, pushing on a door, not re-directable, or exiting the facility. She stated prior to accepting a resident, they always asked the family if there were attempts to leave the home. She stated if they had left home or attempted to but were unsuccessful, they were not accepted. She stated they did not accept a resident from another facility who had this concern. The Administrator stated staff attended elopement in-service training and participated in elopement drills after Resident #6 left the building. She stated training included what to do if staff noticed someone was missing or trying to leave. She stated if a resident was not seen, staff should check to see if they signed out. She stated if not, staff should check every room in the facility and around the outside of the building. She stated if the resident was not found, the police were to be notified. She stated some residents were more independent and if a resident was not seen when staff was rounding, they must look until they lay eyes on the resident. The Administrator stated some resident rooms had a camera but the facility had not placed any cameras inside or outside of the building. An interview attempt with Resident #6's family member on 04/15/2025 at 1:53 PM was unsuccessful. Interviews on 03/25/2025-03/26/2025 and 04/15/2025-04/16/2025 were conducted with multiple staff members which included the Administrator, DON, ADON, LVN A, CMA F, CNA G, Receptionist, Social Worker, CNA B, CNA H, CNA I, LVN J, Maintenance Supervisor, Environmental Services, RN K, Speech Therapist, Physical Therapist, and CNA L. Interviews across multiple shifts revealed staff members received elopement in-service training and participated in elopement drills. The elopement in-service training/drills reflected each staff member was designated an assigned search area and provided a census to cross reference and ensure each resident was present. Staff was educated that when rounding they must lay eyes on each resident. If a resident was not in their room when rounding, staff must search every room in the facility to ensure they were in the building and safe. If a resident was not located, staff must initiate the elopement procedure. If a resident was not located inside or outside the building, police, family, and the physician must be notified. No lack of knowledge or procedure was identified. The facility initiated the following interventions prior to the state surveyor entry on 03/25/2025: Record review of Resident #6's clinical file on 03/25/2025 at 11:15 AM reflected the following: -A full skin assessment of Resident #6, dated 03/14/2025, was completed with no injuries or pain. -Resident #6's Comprehensive Care Plan was updated on 03/14/2025 after the resident exited the building. - Record review of Resident #6's risk assessment, dated 03/14/2025, reflected a score of 11, which indicated a high risk for wandering. -The facility provided a log, dated 03/14/2025, of 1:1 (constant observation) staff monitoring from 2:45 AM until Resident #6 discharged on [DATE] at 4:30 PM. -The medical doctor, psychiatrist, director of nurse, administrator, and Resident #6's family member were notified of the elopement on 03/14/2025. -Documentation of elopement drills and education with all employees beginning with 1st shift staff on 03/14/2025. The elopement drills and education included all residents must be visualized upon making rounds, and if they were not seen initially, the staff must conduct a search of the immediate area. If the resident is not located, they initiate the elopement procedures and notify all relevant parties. No lack of knowledge or procedure was identified. -Elopement drills and in-service training , signed by staff members on 03/14/2025, were cross referenced with the facility staff list to ensure all staff were educated. Record review of the facility's policy Elopements, dated 3/15/2022, reflected .4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate and extensive search of the surrounding area. Record review of the facility's policy Wandering, Unsafe Resident, revised 3/01/2022, reflected 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . 7. Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility.

Based on interviews, observations, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote the prevention of pressure ulcer/injury development, the healing of existing pressure ulcers/injuries, and prevent development of additional pressure ulcer/injury for 1 (Resident #1) of 5 residents reviewed for quality of care, in that: 1. The facility failed to consistently perform weekly skin assessments for Resident #1. 2. On 01/11/24, LVN C notified the primary physician of a dime-sized open area to Resident #1's sacrum. The facility implemented the interventions/treatment to the open area but failed to consult the WMD (for 12 days, 01/11/24 - 01/23/24) as ordered. 3. The facility failed to monitor and reassess the wound to Resident #1's sacrum for evidence of progress toward healing. The wound developed into an unstageable pressure ulcer (PU) (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present). 4. The WMD assessed and evaluated the sacrum wound on 01/23/24. The WMD categorized the wound as Unstageable (due to necrosis [death of body tissue]) and surgical excisional debridement was performed on the sacrum wound. The WMD categorized the sacrum wound as a Stage 4 pressure wound after the second surgical excisional debridement (cutting away of devitalized [injured, damaged] wound tissue, necrosis, or slough [yellow/white material in the wound bed] down to viable [healthy] tissue, and outside or beyond wound margin using a blade/scalpel) on 01/30/2024. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: A record review of Resident #1's Annual MDS Assessment, dated 01/02/24, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #1 had diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss); Encounter for palliative care; Muscle wasting and atrophy; and Muscle weakness (generalized). Resident #1's BIMS Summary Score was 06, which suggested severe impaired cognition. Resident #1's functional abilities required one-person physical assist with ADLs and transfers. Resident #1 was frequently incontinent of bowel and bladder. Section M - Skin conditions of the Annual MDS Assessment revealed Resident #1 had one or more unhealed pressure ulcers/injuries. Resident #1 had a Stage 4 pressure ulcer and an unstageable pressure injury presented as a deep tissue injury over bony prominences; and was at risk for developing pressure ulcers/injuries based on clinical assessment. Pressure reducing devices for chair and bed, pressure ulcer/injury care, a turning/repositioning program, and applications of ointments/medication other than to feet were active skin and ulcer/injury treatments in place. Resident #1 was admitted to hospice services on 07/14/23. Record review of Resident #1's comprehensive care plan [Date initiated: 04/16/2016; Next Review Date: 12/04/23] Focus problem(s) reflected impaired cognitive function; bladder/bowel incontinence; potential for pressure ulcer development; communication problem; unstageable (DTI) pressure injury to right heel; receiving hospice services; Stage 4 pressure injury to left heel; and ADL self-care performance deficit. Resident #1's care plan goals indicated maintain current level of cognitive function; remain free from skin breakdown r/t incontinence; have intact skin, free of redness, blisters, or discoloration; and will be free from infection or complications r/t unstageable DTI pressure injury to right heel and Stage 4 pressure injury to left heel through review date (Target Date: 03/04/24). Resident #1's care plan interventions/tasks revealed bedside care and assistance, medication administration, pain control, fall prevention, position changes, teaching moments, monitoring, and reporting to doctor as needed, to improve the resident's comfort and health. A record review of Resident #1's current Physician's orders reflected: - Start Date 07/14/23: Complete Weekly Skin Assessment. Every evening shift, every Saturday. - Start Date 11/10/23: No shoe on the left foot in pressure boot. Every shift for wound left heel to decrease pressure to foot. - Start Date 01/11/24 [Discontinued 01/24/24]: Treatment: Clean sacrum with wound cleanser, pat dry, apply xeroform and cover with border gauze. Every evening shift for Wound Healing. - Start Date 01/24/24: [Discontinued 01/30/24] Treatment: Clean sacrum with wound cleanser, pat dry, apply Santyl, xeroform and cover with border gauze. May use Wound Gel if Santyl is unavailable. Every evening shift for wound healing. - Start Date 01/24/24: Clean DTI to the right heel, pat dry and apply skin prep to area. Every evening shift for wound healing. - Start Date 01/24/24 [Discontinued: 01/29/24]: Clean wound to left heel with NS, pat dry, apply Antimicrobial wound gel and xeroform, and secure with border dressing daily. Every evening shift for wound healing. - Start Date 01/29/24: Clean wound to the left heel with NS, pat dry, apply Santyl, xeroform and secure with border dressing daily. Every evening shift for wound healing. - Start Date 01/31/24: Treatment: Clean sacrum with wound cleanser, pat dry, apply Alginate Calcium with Silver. Apply Metronidazole sprinkles and cover with border gauze. Cleanse peri wound with Dakin's [solution]. Every evening shift for wound healing. A record review of Resident #1's TAR for January 2024 and February 2024 revealed wound care orders were completed as ordered. Record review of Resident #1's Wound Evaluation and Management Summary's, dated 01/09/24 and 01/16/24, reflected the WMD evaluated and treated wounds on Resident #1's left and right heels. The left heel was a Stage 4 pressure wound greater than 119 days and the right heel was an unstageable DTI with intact skin greater than 71 days. The WMD did not evaluate or provide further intervention for other wounds in these or previous visits. Record review of Resident #1's Wound Evaluation and Management Summary, dated 01/23/24, revealed the WMD performed an initial evaluation of an unstageable (due to necrosis) wound to the sacrum. The WMD documented the etiology (quality) of the wound was Pressure, was Unstageable, a duration of greater than 5 days, measured (LxWxD) 5 cm x 6 cm x Not Measurable [depth is unmeasurable due to presence of nonviable tissue and necrosis (The skin is severely damaged, and the surrounding tissue begins to die)], and light serous exudate. A surgical excisional debridement procedure was performed to the sacrum and a dressing treatment plan was ordered to perform wound care daily with Santyl, Xeroform gauze, and cover with bordered gauze dressing for 30 days. As a result of the procedure, 20 percent of nonviable tissue was removed. Record review of Resident #1's Wound Evaluation and Management Summary, dated 01/30/24, revealed the WMD performed a surgical excisional debridement procedure of the sacrum wound. As a result of the procedure, the nonviable tissue decreased to 40 percent. A dressing treatment plan reflected: . discontinue Santyl and Xeroform Gauze. Add Alginate Calcium with Silver and Metronidazole Sprinkled, continue secondary bordered gauze dressing. Cleanse peri wound with Dakin's [solution] once daily for 30 days. The WMD indicated Resident #1's wound exacerbated due to generalized decline (increased weakness, fatigue, and drowsiness. Changes in cognitive and functional abilities), bacterial skin infection (inflammation of the skin and subcutaneous tissues), and compromised nutritional status. A record review of Resident #1's clinical assessments revealed Skin Assessments: Type: Weekly Date and time: 01/02/24 at midnight Signed and locked: 01/04/24 at 11:05 PM by LVN E Skin Condition: Intact. Site(s): BLANK Comments: LVN E entered, healing pressure wound on the left heel, boots on the left leg without shoes per order, continue to monitor. Type: Weekly Date and time: 01/11/24 at midnight Signed and locked: 01/21/24 at 10:02 PM by ADON A Skin Condition: Intact. Site(s): BLANK Comments: ADON A entered, healing pressure wound on the left heel, boots on the left leg without shoes per order, continue to monitor. Type: Admission Date and time: 01/28/24 at 8:00 AM Signed and locked: 01/28/24 at 8:44 AM by LVN F Skin Condition: Bruises . Redness . New Area. Site(s): Right lateral heel - Stage 1 quarter size no drainage, purple discoloration. Left heel - Stage 3, measured (L x W x D) 4.0 cm x 4.5 cm x 0.2 cm, 25% yellow slough, redness to peri wound, moderate amount of serous sanguineous drainage. Left lateral foot - Stage 1, measured 1.5 cm x 1.5 cm x 0 cm. Sacrum - Stage 3, measured 8.0 cm x 7.5 cm x 2.0 cm, eschar, large amount of purulent drainage. Comments: LVN F entered, Need turning Q2H and PRN, will continue to monitor. Neighbor [Resident #1] has poor appetite. Type: Wound Nurse Weekly Skin Assessment Date and time: BLANK Signed and locked: 01/29/24 at 1:16 PM by LVN C Skin Condition: Bruises . Redness . New Area. Site(s): Left heel: Type - Pressure, Stage - IV, measured (L x W x D) 2.0 cm x 2.0 cm x 0.4 cm. Sacrum: Type - Necrosis, Stage - II, measured 5.0 cm x 6.0 cm x N/A. Right heel: Type - Pressure, Stage - Suspected Deep Tissue Injury, measured 3 cm x 2.5 cm x N/. Description of wounds: Stage 4 Pressure Wound of the Left heel full thickness. Exudate light serous drainage. Has no odor. Thick adherent devitalized necrotic tissue, granulation tissue at 40%, other viable tissue at 40%. Unstageable Sacrum Full thickness has some odor, Exudate light serous drainage, and thick adherent devitalized necrotic tissue at 100%. Unstageable DTI Right Heel undermined thickness has no odor or drainage. Skin is intact with purple/ maroon discoloration. Comments: LVN C entered, Recommendation for neighbor are off load wound, Low air loss Mattress, reposition per facility protocol, Float Heels in bed, and wear pressure off loading boats. A record review of the Weekly Skin Log for January 2024 [01/02/24, 01/09/24, 01/16/24, and 01/23/24] reflected Resident #1 had a wound to the left heel and right foot. The Weekly Skin Logs did not reflect a wound to the sacrum on Resident #1. Record review of Resident #1's progress notes reflected: On 01/04/24 at 10:56 PM, LVN E wrote that a Weekly Skin Assessment was completed. On 01/16/24 at 12:47 PM, a Plan of Care Note entered by Social Services, indicated a Quarterly care conference was held (01/16/24) with the RP and other family members in attendance via telephone. ADON discussed wound care; wounds on heels are improving . Next care conference 04/10/24. On 01/17/24 at 9:41 AM, LVN G wrote, Sacral wound dressing removed and redressed. Redness is minimal with no drainage noted. Monitoring is ongoing. On 01/21/24 at 10:01 PM, ADON A wrote that a Weekly Skin Assessment was completed. Healing pressure wound on the left heel . On 01/24/24 at 12:00 PM, LVN G wrote, [Resident #1] has a new order for treatment. Clean sacrum wound with wound cleanser, pat dry, apply Santyl, xeroform and cover with border gauze. On 01/28/24 at 8:32 AM, LVN C wrote that a Weekly Skin Assessment was completed. Need turning Q2H and PRN, will continue to monitor, [Resident #1] has poor appetite. Observation on 01/29/24 at 10:45 AM, revealed Resident #1 on a low air loss mattress lying on her back with head of bed raised approximately 45 degrees and heel boots applied to both feet. Resident #1 was non-interviewable. Resident #1 did not present with visible injuries or behavior suggestive of abuse, neglect, or SQC. During observation of wound care on 01/29/24 at 10:47 AM, LVN C perform wound care to Resident #1. ADON A assisted LVN C with positioning of Resident #1 during wound care. LVN C observed and assessed wounds to left heel, right heel, and sacrum prior to performing treatment. The old dressings that were removed were dated 01/28/2024. During treatment to the sacrum wound, the old dressing presented a brown discoloration and there was a slight odor to the wound. The wound bed to the left lateral border appeared pink in color. The remaining area of the wound bed was covered with dry, black tissue. LVN C performed wound care in accordance with accepted standards of treatment and per physician's orders. During an interview on 01/29/24 at 11:02 AM, LVN C indicated she was the 6A - 2P nurse Monday through Friday. LVN C indicated the 2P - 10P shift was responsible for providing wound care. LVN C said that skin assessments were completed weekly by the 2P - 10P shift and as needed. LVN C said that although wound care was not scheduled on her shift, she was still responsible for implementing care to prevent skin breakdown and assessing a resident if it was reported to her about a concern about a resident skin noted during a shower or incontinent care. LVN C said that the WMD followed Resident #1 for other wounds and thought ADON A informed the WMD about the open area to Resident #1's sacrum. LVN C indicated that the old dressing removed from Resident #1's sacrum had a brown discoloration, the wound bed presented a partial light red wound bed on the left side, and there was necrotic tissue over the other areas of the wound. LVN C said that she would document her findings on the 24-hour report sheet to communicate with other team members. An outbound call to the WMD on 01/29/24 at 11:09 AM indicated the WMD rounded at the facility every Tuesday. The WMD followed Resident #1 for wounds to the left and right heels. During the wound care visit on 01/23/24, facility nursing staff informed [the WMD] of a wound consultation for Resident #1. The WMD conducted an initial evaluation of Resident #1's sacrum wound. The WMD indicated the wound was unstageable due to necrosis. The WMD spoke to the RP and explained treatment options, risks, benefits, and the need for a surgical excisional debridement procedure to remove necrotic tissue from the sacral wound. The WMD explained to the RP that the necrotic tissue interfered with healing. The RP agreed to the procedure. The WMD performed debridement of the sacrum area and removed over a 5.0 square cm area and 0.3 cm depth of necrotic tissue until healthy tissue (bleeding tissue) was observed. The WMD categorized the wound a Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or able to directly feel fascia [thin casing of connective tissue] or muscle) to the sacrum after debridement. The WMD ordered Santyl and Xeroform Gauze as a primary dressing and a bordered gauze as a secondary dressing. The WMD recommended to off-load the wound, reposition per facility policy, and low air loss mattress. The WMD anticipated wound healing over two months and would see Resident #1 at the next visit (01/30/24). During an interview on 01/29/24 at 12:38 PM, ADON A said that he was responsible for overseeing that skin assessments and wound care was completed as ordered. ADON A said that the nurses were responsible for completing the skin assessments and wound care. ADON A said that he was familiar with Resident #1. ADON A said that he recalled a CNA [later identified as CNA D] telling him about a wound to Resident #1's sacrum. ADON A said he couldn't remember when the incident occurred, but he remembered telling the CNA to apply barrier cream to the buttocks when incontinent care was performed. ADON A said that Resident #1 was already getting wound care to the area that CNA reported. Record review of Resident #1 orders and TAR with ADON A revealed an order to clean, apply xeroform (occlusive dressing for use on low exudating wounds), and apply a dressing to the sacrum 01/11/24 - 01/24/24. ADON A said that the WMD was not following the wound to the sacrum and the order was obtained from the primary physician. ADON A said that the order was temporary treatment until seen by the WMD for an appropriate treatment plan and to reduce the amount of pressure on the site. ADON A agreed that he completed the weekly skin assessment on 01/21/24 and documented Resident #1's skin was intact because the sacral area was not open. ADON A could not explain why the skin assessment date and time reflected 01/11/24 if he performed, signed, and locked the skin assessment on 01/21/24 at 10:02 PM. During an interview on 01/29/24 at 12:51 PM, CNA J said that she worked at the SNF for less than 3 months. CNA J said that she provided care to Resident #1 whenever assigned to the LTC unit. CNA J said that Resident #1 required total assistance by one person with ADLs. CNA J said that Resident #1 had a wound on her bottom and on her heels. CNA J said that she tried to check on residents every two hours or more frequently if a high fall risk or require incontinent care often. CNA J said that she would report to the nurse immediately after provided care to the resident and ensured was safe if discovered a skin tear, redness, a rash, or if a dressing was soiled or came off. CNA J said that she applied barrier cream to Resident #1's buttocks after changing the brief to protect skin when soiled and prevent breakdown of skin. During a phone interview on 01/29/24 at 2:09 PM, CNA D stated she worked at the facility for six months. CNA D indicated on Sunday, 01/21/24, while she provided incontinent care to Resident #1, she saw a green-black discoloration on the tailbone area. CNA D stated she notified ADON A about the findings. CNA D said that ADON A told her to put barrier cream on it. CNA D said she applied barrier cream to Resident #1's buttocks as instructed but not directly on the green-black discolored area. During a follow-up interview on 02/23/24 at 12:40 PM, ADON A indicated that there were wound and skin management standing delegation orders in place to treat minor skin tears, abrasions, intact and shallow skin impairment with no or minimal drainage. Treatments included cleaning, topical barrier ointments and creams, dressing change frequency, and protecting the site. ADON A said wounds that were open to the level of fatty tissue (or deeper), mostly red, had more than minimal drainage, or non-healing wounds required a consultation with the WMD. ADON A said that he rounded with the WMD during weekly visits to provide support, and complete wound documentation. ADON A said that the WMD needed to assess a wound to determine the appropriate treatment. ADON A said that a nurse would notify him of a change in wound condition or if a wound consult was needed and he would send the face sheet to the WMD as notification. ADON A said that Resident #1 was already followed by the WMD and thought he notified the WMD about the open area discovered to the sacral area. During a follow-up interview on 02/23/2024 at 1:30 PM, LVN C indicated that she vaguely recalled [on 01/11/24] that a CNA (could not recall who it was) called her into Resident #1's room to look at Resident #1's buttocks for possible skin breakdown. LVN C said that she saw a dime-sized open area to the upper midline groove that separates the buttocks. LVN C said that she notified Resident #1's primary physician and received a telephone order to provide treatment [Clean sacrum with wound cleanser, pat dry, apply xeroform and cover with border gauze every evening (2P - 10P) shift] and to consult the WMD. LVN C said that she notified ADON A that Resident #1 needed a wound consult. LVN C said that was the facility protocol to notify the ADON/DON when a resident required a Specialist/Wound Doctor Consultation. The ADON/DON would request the consultation and rounded with the WMD during weekly visits. LVN C said that she did not document the communication with the primary physician or ADON and did not follow-up if the WMD was consulted. LVN C said that documentation was important to ensure continuity of care and consistency. Review of the Wound Care policy and procedure provided by the facility, revised September 2016 indicated: - Verify that there is a physician's order. - Review the resident's care plan to assess for any special needs of the resident. - Documentation should include the type of wound care given, date and time, all assessment data, how the resident tolerated the procedure and any problems or complaints made by the resident related to the procedure. If a resident refused and why. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy and procedure, revised December 2010 indicated: Assessment and Recognition - The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores . - The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage 1 pressure area that has not yet ulcerated at the surface. - The physician will help the staff define the type and characteristics of an ulceration. Cause Identification - The physician will help identify factors contributing or predisposing residents to skin breakdown . Treatment/Management - The physician will authorize pertinent orders related to wound treatments . - The physician will help identify medical interventions related to wound management. - The physician will help staff characterize the likelihood of wound healing . Monitoring - During resident visits, the physician will evaluate and document the progress of wound healing . - The physician will help the staff review and modify the care plan as appropriate .

Based on interviews and record review, the facility failed to notify and consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status for 1 (Resident #1) of 5 residents reviewed for Notification of Changes. 1. The facility failed to notify the wound physician on 01/11/24 about an open area discovered on Resident #1's sacrum. The area developed into an unstageable pressure ulcer (PU) (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) to the sacrum. The WMD assessed and evaluated the sacrum wound on 01/23/24. The WMD categorized the wound as Unstageable (due to necrosis [death of body tissue]) and surgical excisional debridement was performed on the sacrum wound. The WMD categorized the sacrum wound as a Stage 4 pressure wound after the second surgical excisional debridement (cutting away of devitalized [injured, damaged] wound tissue, necrosis, or slough [yellow/white material in the wound bed] down to viable [healthy] tissue, and outside or beyond wound margin using a blade/scalpel) on 01/30/2024. This failure could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: A record review of Resident #1's Annual MDS Assessment, dated 01/02/24, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #1 had diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss); Encounter for palliative care; Muscle wasting and atrophy; and Muscle weakness (generalized). Resident #1's BIMS Summary Score was 06, which suggested severe impaired cognition. Resident #1's functional abilities required one-person physical assist with ADLs and transfers. Resident #1 was frequently incontinent of bowel and bladder. Section M - Skin conditions of the Annual MDS Assessment revealed Resident #1 had one or more unhealed pressure ulcers/injuries. Resident #1 had a Stage 4 pressure ulcer and an unstageable pressure injury presented as a deep tissue injury over bony prominences; and was at risk for developing pressure ulcers/injuries based on clinical assessment. Pressure reducing devices for chair and bed, pressure ulcer/injury care, a turning/repositioning program, and applications of ointments/medication other than to feet were active skin and ulcer/injury treatments in place. Resident #1 was under hospice services. Record review of Resident #1's comprehensive care plan [Date initiated: 04/16/2016; Next Review Date: 12/04/23] Focus problem(s) reflected impaired cognitive function; bladder/bowel incontinence; potential for pressure ulcer development; communication problem; unstageable (DTI) pressure injury to right heel; receiving hospice services; Stage 4 pressure injury to left heel; and ADL self-care performance deficit. Resident #1's care plan goals indicated maintain current level of cognitive function; remain free from skin breakdown r/t incontinence; have intact skin, free of redness, blisters, or discoloration; and will be free from infection or complications r/t unstageable DTI pressure injury to right heel and Stage 4 pressure injury to left heel through review date (Target Date: 03/04/24). Resident #1's care plan interventions/tasks revealed bedside care and assistance, medication administration, pain control, fall prevention, position changes, teaching moments, monitoring, and reporting to doctor as needed, to improve the resident's comfort and health. Record review of Resident #1's Wound Evaluation and Management Summary, dated 01/23/24, revealed the WMD performed an initial evaluation of an unstageable (due to necrosis) wound to the sacrum. The WMD documented the etiology (quality) of the wound was Pressure, was Unstageable, a duration of greater than 5 days, measured (LxWxD) 5 cm x 6 cm x Not Measurable [depth is unmeasurable due to presence of nonviable tissue and necrosis (The skin is severely damaged, and the surrounding tissue begins to die)], and light serous exudate. A surgical excisional debridement procedure was performed to the sacrum and a dressing treatment plan was ordered to perform wound care daily for 30 days. Record review of Resident #1's progress notes did not reflected documentation that the WMD was notified of a wound consultation to assess and evaluate the open area to the sacrum. During an interview on 01/29/24 at 11:02 AM, LVN C indicated she was the 6A - 2P nurse Monday through Friday. LVN C indicated the 2P - 10P shift was responsible for providing wound care. LVN C said that skin assessments were completed weekly by the 2P - 10P shift and as needed. LVN C said that although wound care was not scheduled on her shift, she was still responsible for implementing care to prevent skin breakdown and assessing a resident if it was reported to her about a concern about a resident skin noted during a shower or incontinent care. LVN C said that the WMD followed Resident #1 for other wounds and thought ADON A informed the WMD [on 01/11/24] about the open area to Resident #1's sacrum. An outbound call to the WMD on 01/29/24 at 11:09 AM indicated the WMD rounded at the facility every Tuesday. The WMD followed Resident #1 for wounds to the left and right heels. During the wound care visit on 01/23/24, facility nursing staff informed [the WMD] of a wound consultation for Resident #1. The WMD conducted an initial evaluation of Resident #1's sacrum wound on 01/23/24. The WMD indicated the wound exacerbated due to generalized decline of Resident #1, infection, and compromised nutritional status. The WMD ordered Santyl and Xeroform Gauze as a primary dressing and a bordered gauze as a secondary dressing. The WMD recommended to off-load the wound, reposition per facility policy, and low air loss mattress. The WMD anticipated wound healing over two months and would see Resident #1 at the next visit (01/30/24). During a follow-up interview on 02/23/24 at 12:40 PM, ADON A indicated that there were wound and skin management standing delegation orders in place to treat minor skin tears, abrasions, intact and shallow skin impairment with no or minimal drainage. Treatments included cleaning, topical barrier ointments and creams, dressing change frequency, and protecting the site. ADON A said wounds that were open to the level of fatty tissue (or deeper), mostly red, had more than minimal drainage, or non-healing wounds required a consultation with the WMD. ADON A said that he rounded with the WMD during weekly visits to provide support, and complete wound documentation. ADON A said that the WMD needed to assess a wound to determine the appropriate treatment. ADON A said that a nurse would notify him of a change in wound condition or if a wound consult was needed and he would send the face sheet to the WMD as notification. ADON A said that Resident #1 was already followed by the WMD and thought he notified the WMD about the open area discovered to the sacral area. During a follow-up interview on 02/23/2024 at 1:30 PM, LVN C indicated that she vaguely recalled [on 01/11/24] that a CNA (could not recall who it was) called her into Resident #1's room to look at Resident #1's buttocks for possible skin breakdown. LVN C said that she saw a dime-sized open area to the upper midline groove that separates the buttocks. LVN C said that she notified Resident #1's primary physician and received a telephone order to provide treatment [Clean sacrum with wound cleanser, pat dry, apply xeroform and cover with border gauze every evening (2P - 10P) shift] and to consult the WMD. LVN C said that she notified ADON A that Resident #1 needed a wound consult. LVN C said that was the facility protocol to notify the ADON/DON when a resident required a Specialist/Wound Doctor Consultation. The ADON/DON would request the consultation and rounded with the WMD during weekly visits. LVN C said that she did not document the communication with the primary physician or ADON and did not follow-up if the WMD was consulted. LVN C said that documentation was important to ensure continuity of care and consistency. Record review of the facility's Change of Condition and Physician/Family Notification policy, revised 03/25/21, reflected the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #58) of four residents reviewed for elopements. 1. The facility failed to ensure Resident #58 was adequately supervised to prevent the resident from leaving the facility unsupervised. Resident #58 had severe cognitive impairment, wandering behavior, was a high fall risk and lacked safety awareness. Resident #58 eloped from the facility on 08/03/21 and was found by facility staff in the grass 12 feet from the facility in the back-parking lot area. 2. The facility failed to ensure staff were trained and able to demonstrate competency on elopement and supervision. An Immediate Jeopardy was identified on 08/06/21 at 2:00 p.m. While the Immediate Jeopardy was removed on 08/09/21, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme weather exposure. Findings included: 1. Review of Resident #58's face sheet 08/05/2021 revealed he was a [AGE] year old male admitted to the facility on [DATE] and discharged on [DATE]. His diagnoses included metabolic [CONDITION(S)], [CONDITION(S)] with delusions, Dementia with Lewy bodies, and unspecified Mood (affective) disorder . The care plan did not reflect high risk for wandering and elopement nor did it include interventions. Review of Resident #58's Wandering Risk Assessment , dated 07/11/21, reflected Resident #58 was disoriented X3 {person, place and time}, did not understand his surroundings, and did speak clearly. The assessment reflected a diagnosis of dementia with [CONDITION(S)] and known wanderer/hx of wandering. The assessment score was 12 meaning at high risk. Review of Resident #58's Fall Risk Assessment, dated 07/08/2021, reflected Resident #58 history of falls within the last six months was multiple falls. The assessment reflected agitated behavior in the last seven days as behavior occurred daily or more. Resident #58's gait analysis reflected exhibits loss of balance when standing, requires hands on assistance to move from place to place, and uses short discontinuous steps and/or shuffling steps. The fall assessment reflected the resident was High Risk. Review of Resident #58's Resident Progress notes, dated 07/10/21 reflected, . confused, walking without using wheelchair, refused to use wheelchair most of the time. Will be monitoring. On 7/11/21, patient continues to be exit seeking at times and wanders and intrudes to other patients' rooms. He is extremely confused. On 07/14/21, Resident #58 wanders about all night, refuses to stay in bed. Intruding into other neighbors' rooms and waking them up. On 7/14/21, attempts to wander in the hallway and into other rooms. Re-direction provided. On 07/15/21, Resident #58 is uncooperative with care, keeps wandering in the hallway and into other neighbors' rooms, re-direction is provided without effect as he refuses to settle down, is combative with re-direction. At 0445 [4:45 AM] he attempted to elope, was in the hallway on 200 hall by the exit, CNA saw him pushing the door and it did open, the door did not alarm, and she managed to stop him before he got out. Frequent monitoring in place. Needs someone with him at all times. Another note on 07/15/21 reflected, Resident continues to wander around and intrudes into other residents' rooms. He gets re-directed frequently. On 07/16/21, during the morning meeting that staff was requesting that neighbor [Resident #58] needed to be discharged due to behaviors such elopement, appearing disrobed in other neighbors' room, and getting physical with staff. On 07/18/21, Resident #58 awake all through the night, kept pacing around with very unsteady gait on the hallway and into other neighbors' rooms. Tried to encourage him to use wheelchair but kept getting up and walking. On 07/27/21, social worker called [Resident #58's] wife and told her that she was told by the administrator to tell [Resident #58's] wife that a sitter was needed. The wife stated she could not afford a sitter and she still is still working so she could not personally come sit with him at night. The request was made due to the facility felt that Resident #58 needed constant supervision due to fall risk and wandering risk. Further review reflected, 08/03/21 4:01 p.m., Resident was found outside walking by himself. Nurse informed DON. Per RN D. Interview with LVN E 08/05/21 10:38 AM revealed she did not feel this facility was appropriate placement. LVN E stated Resident #58 had been exit seeking and she felt he needed a secured unit. She stated she had seen him get close to the door but never push on the door. She stated she was unaware Resident #58 had eloped because she was not there, but has worked with Resident #58 before. The resident has been exit seeking since arrival at the facility. LVN E confirmed the facility is not a secured facility. Resident #58 can be redirected at times, but other times has become combative. Observation of Resident #58 on 08/05/21 at 10:42 AM revealed he was in the TV room sitting in a chair with another resident in the room. There were no staff in the TV room. Surveyor was unable to see Resident #58 from where LVN E was being interviewed. The CNA for this hallway was nowhere in sight. Interview with CNA A on 08/05/21 at 10:43 AM revealed she was concerned with Resident #58's safety. She stated she had observed Resident #58 push on the exit door. She stated Resident #58 had not opened an exit door during her shift. CNA A was unaware the resident had eloped. Resident #58 can redirected. CNA has been the aide for Resident #58. It is well known that the resident is a wandering risk as well as a fall risk. There were not interventions in place. CNA A did what she thought would help the resident. Interview with CNA B on 08/05/21 at 11:35 AM revealed Resident #58 had tried to get out of the facility. CNA B stated Resident #58 would walk over and push the door, but it had never fully opened. She stated she felt Resident #58 should have one on one care due to him being a fall and wandering risk. Observation on 08/05/21 at 11:45 AM revealed Resident #58 was walking around nurse's station and trying to open locked doors to rooms. No one tried to redirect Resident #58 but there was staff near the exit door and nurses station. Interview with RN D on 08/05/21 at 12:34 PM revealed, [Resident #58] was outside, yes. He went out through the back. I came out. I am in the position where I am always looking for him so if I don't see him the next thing I do is rush outside. I rushed outside to the parking lot in the back area. He did not get far. No one saw him go towards the door or exit the door. I already knew he was exit seeking. I documented I believe he exited twice (in progress notes). Not sure of the other day, but I was here on the 3rd [August 2021]. I try to do 1 on 1 and put him in nurses' station and sit with him. On recovery (specific area in facility), most of the time only one other CNA and me. We always communicate with each other to try our best to leave someone with him because just two of us. We have been doing it every day but unfortunately there are times that we can't have one person sitting there . Resident is not cognitively aware to answer questions accurately. RN D did visual assessment and reported what happened to the DON immediately. RN D is the main 2pm to 10pm nurse for Resident #58. RN D is able to redirect resident successfully and has to redirect the resident often. Resident has been displaying wandering and exit seeking behavior since admittance to facility. The resident wanders down 200 hall, nursing station area, 400 hall, and TV area. Observation on 08/05/21 at 2:24PM revealed Resident #58 walking around nurses' station and TV room by himself. Interview with RN D on 08/05/21 at 2:24 PM revealed the door across from 100 hall was not armed. RN D stated Resident #58 knew to push and exit. RN D stated when he eloped on 08/03/21, RN D was in a room in the 400 hall and CNA C's location was unknown. RN D stated Resident #58 was outside four to five minutes at most. She stated Resident #58 was approximately 12 feet from the door in the grass to the left. When questioned about the previous elopement RN D was unsure exactly when. RN D stated it was two to three weeks ago. RN D stated that time the resident was at the door and opened it but was not found outside. Interview with CNA C on 08/05/21 at 2:54 PM stated, He wanders a lot. He will go to the door and push it, but he did not open it. The nurse caught it. CNA C did not know that Resident #58 eloped . CNA C works 2pm to 10 pm and is the residents CNA. The resident requires redirection often. Stated the resident listens to RN D. CNA did not have training from the facility, but knows to redirect and try to keep the resident busy if possible. Interview with LVN I on 08/05/21 at 3:24 PM revealed the week of July 15th (2021) Resident #58 got close to the door on the 200 hall. LVN I stated a CNA saw him and grabbed him before he could open the door. LVN I stated Resident #58 opened it but didn't get out. LVN I stated on Tuesday (08/03/21), he was found outside. She stated she was told in report since it happened before she came in that night. LVN I works the overnight shift and is his nurse. She stated she does not know of any other elopements. Resident is a fall and wandering risk and requires frequent redirection. There were no specific interventions in place. Interview with Administrator on 08/06/21 at 11:58 AM revealed, four wanderers. (This includes Resident #58) The Administrator stated a resident had eloped , but the she was unable to state when it happened or how many times. Administrator did not know that Resident #58 eloped on 08/03/21 . The Administrator stated that getting outside of the building did not put the resident at risk. She stated only to report if he was off the Remarkable of Prestonwood property. The Administrator was aware the resident was at high risk for wandering since admittance and acknowledged the facility has been trying to find a new placement. Interview with Administrator on 08/08/21 at 11:21 AM revealed she followed facility guidelines as far as when to report elopement. Administrator stated the criteria to report to the state agency were if the resident left the property or was in an unsafe circumstance. She stated she did not feel the back-parking lot area was unsafe. Administrator stated the incident involving Resident #58 was not reported the state agency, and no investigation was done. Administrator stated she was required to report abuse and neglect incidents within two hours. Administrator stated the reason for reporting was so that the stated agency could look at the facility's policies and make sure things were put in place for the safety and health of the resident . Interview with DON on 08/06/21 at 12:17 PM revealed Resident #58 eloped this week and he was the only one she knew of. DON stated there was one other elopement risk resident. DON stated training on elopement had not been done before or after this incident . DON stated, there is nothing on [Resident #58's] care plan about elopement or exit seeking behaviors. DON stated they reviewed the care plan only mentioned dementia the first day the team arrived. The resident has been wandering since admittance to facility. She was not able to say why the care plan did not reflect the wandering and fall risk. The DON was told 08/03/21 about the elopement by RN D. The resident did not have any injuries. No interventions were put into place except trying to find a new facility to place the resident at. DON stated she did tell the Administrator about the elopement by Resident #58. Interview with DON on 08/09/21 at 9:45 AM revealed the elopement involving Resident #58 was not investigated or reported to the state agency that she knew of. The DON stated the criteria to report was only if the resident left the property. DON stated to report to the state agency so the state could make sure the resident was safe, interventions were put in place, and protocol was being followed so it wouldn't happen again . Review of the facility's Wandering, Unsafe Resident policy, dated December 2008, reflected, The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator or Director of Nursing immediately and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility. An Immediate Jeopardy was identified on 08/06/21 at 2:00 PM and the Administrator was informed of IJ in the area of accidents/supervision and the IJ template was provided to her via email. The plan of removal was accepted on 08/09/21 at 12:09 PM and included: 1. Two facility residents had the potential to be affected by this alleged deficient practice. [Resident #58] and [Resident #1]. 2. DON completed head counts to ensure all residents were present in facility. Resident census and head count at 2:30 pm on 8.6.21 were: 48. Completed another head count after [Resident #58] was discharged and at 5pm on 8.6.21, facility head count was 47. 3. On 8.5.21, at the time mag locks on exit doors were disarmed, facility engaged in intervention that all managers were assigned to supervise and monitor an exit door to ensure exit-seeking residents don't elope, until 6:45pm 8.5.21 at which time facility found a one: one sitter to supervise resident [Resident #58] at that time. The one: one sitter [CNA H[ was trained by facility DON on sitter guidelines and duties. 4. All residents assessed beginning at 3:30pm on 8.6.21 for elopement risk. The tool used for this assessment is the Wandering Risk Assessment Tool in the EMR, Point Click Care [electronic charting system]. No residents were found to be high risk for elopement at time of assessment other than [Resident #58]. 5. Training and in-service specific to current [Resident #1] was initiated by [HR Director G] and Administrator on wandering and elopement risks and door lock procedures related to [Resident #58] immediately on 8.6.21 at 3pm, continued through the evening and CCO and DON continued training with night shift and into Saturday morning, 8.7.21. Training will be ongoing. Training specific to all current wandering risk residents will be included in orientation of new employees moving forward to ensure all current staff always know what residents residing in-facility are at risk for elopement. Current elopement risk patients will be tracked via daily clinical meeting that occurs at 0830 am each day and via Kardex/POC EMR portal communication to ensure all nursing staff have access 24/7 to current elopement risk residents. Charge nurses completing Wandering Risk assessments will complete the update/change to Kardex/POC EMR portal. All nursing staff at every level have access to edit the Kardex and make amendments at any time to ensure 24/7 compliance and accuracy should a change in status with a resident occur at any time.' 6. All on-coming staff moving forward will be in-serviced at the beginning of their shift by [HR Director F] and DON related to: [Resident #58], elopement policy and process, wandering policy and process, reporting processes for wandering, and staff proficiency and understanding of wandering behaviors and elopements. The delivery method of training will be via: BEHAVIORAL AND ELOPEMENT POWERPOINT PRESENTATION, POST TEST COMPLETION, and ACKNOWLEDGEMENT ATTESTATION FORM confirming that the training has been completed. Inservice will be continued by [HR Director F], [HR Director G], DON, Administrator, and CCO until all facility staff trained. [HR Director F] will audit and ensure that all training is completed and at 100 percent compliance. This audit will be completed no less than monthly and will be reviewed at QA Committee meeting by Facility Administrator. All staff on PTO or off currently will be required to receive training prior to coming to work for their first shift. Training began on 8.6.21 and will continue through 8.7.21 to get all immediate staff working, then will be ongoing to capture all staff employed at [facility name]. Elopement training will also be provided to all new hires during orientation, via Behavior/Elopement PPT presentation and staff members will acknowledge their understanding of the policy and process at time of hire. Each new hire will complete a training post-test and each current staff member will complete the test annually with Behavior/Elopement training. 7. A QA Conference Call was held with the Medical Director at 8.6.21 at 6:00pm via phone to verbally inform him of the IJ status. 8. Placement into a locked unit was confirmed and [Resident#58] was discharged safely via RH contractor transport company at 5pm on 8.6.21. 9. Facility will continue to monitor and ensure that all elopement risk residents residing in facility will have immediate interventions and actions to ensure there are no delays in care or safety by: A. Immediate trainings happening currently in facility B. Training during New Hire Orientation of all new employees C. Post Training test for all employees to ensure understanding of process. D. Annual training and post- test on elopements and behaviors E. Facility will monitor by reviewing compliance of training during monthly QA meetings and address any issues of non- compliance at that time. 10. Specific Nursing Protocol for Elopement Risk: A. Admission assessment and wandering risk assessment to identify Elopement Risk score and risk. B. If Moderate risk score AND has documented exit seeking behaviors in the last 30 days, resident will be assigned 1:1. DON will assign sitter, who will have received [facility name] elopement training, and return demonstrated (via verbalization) and written acknowledgement that they have received the training. C. If moderated risk score WITHOUT documented exit seeking behavior, resident will be placed on regular oversight and safety precautions, which are: safety checks every two hours and PRN, to include re-direction of wandering residents if needed. D. If high risk is noted, resident will be assigned a 1:1 sitter while facility seeks alternate placement in a locked unit and will remain with sitter until placement is found. At any point during Wandering Risk assessment is completed and identified to move forward with 1:1 sitter, the charge nurse is to notify facility DON immediately to ensure swift action is taken. In the interim, the charge nurse will complete oversight management and assign another nursing team member to 1:1 with resident during the interim. E. At any point during Wandering Risk assessment is completed and identified to move forward with 1:1 sitter, the charge nurse is to notify facility DON immediately to ensure swift action is taken. In the interim, the charge nurse will complete oversight management and assign another nursing team member to 1:1 with resident during the interim. Monitoring of this system will be monitored in Daily Clinical meeting, held by DON, via observation or written documentation in the EMR, through weekly SOC meetings, and reviewed at Monthly QA Committee meeting. DON will be the nursing administrator monitoring the system. Weekend monitoring will be maintained via the Nurse on call system and an immediate phone call would be made to inform DON of the need for a 1:1 sitter. F. Wandering Risk assessments are to be completed: 1. At admission 2. Weekly x 2 weeks after admission 3. Quarterly 4. When any symptoms change, or resident has change in condition G. Charge Nurses of each resident are the assigned and designated personnel who will identify and assess the risk level via the Wandering Risk assessments listed above. These assessments and any other documentation related to the resident's safety status will be documented in the EMR. Monitoring of this system will be monitored in Daily Clinical meeting, held by DON, via observation or written documentation in the EMR, through weekly SOC meetings, and reviewed at Monthly QA Committee meeting. DON will be the nursing administrator monitoring the system. DON will be the nursing administrator monitoring the system. Weekend monitoring will be maintained via the Nurse on call system and an immediate phone call would be made to inform DON of the need for a 1:1 sitter. H. Actual Elopement Process: A. Any staff member observing a confused or previously identified wandering resident attempting to leave the premises shall attempt to prevent such departure. Should the attempt fail, the staff member shall obtain the assistance of other staff in the immediate vicinity. If none are available, the staff member shall immediately notify Facility DON and Facility Administrator that the resident has left the premises, and then return quickly to the resident, continuing an attempt to redirect the resident safely back into the building. Staff members are not to leave the resident for any reason if the resident's safety is in immediate jeopardy. 2 Upon notification that a resident is missing, the charge nurse supervisor shall be responsible for initiating a thorough search of the facility and the premises. o Call all staff to a central location. o Give specific instructions for the search: - Two staff per hall, one on each side. - Check all rooms, bathroom, closets, etc. - Check the activity room, dining room, etc. - Two staff members will go outside around the building, each going in the opposite direction. After meeting behind the building, if resident is not found, the individuals should return to the central location to report results to the DON, and Facility Administrator. B. Should the search prove unsuccessful, the DON shall carry out the following steps: 1. Notify the Police Department, i.e., 911; 2. Notify the resident's responsible party; 3. Notify the resident's physician; and 4. Notify any other regulatory agencies required by law. 5. Facility Administrator or DON will self-report incident to HHSC per guidelines. C. If resident is found and brought back into the facility, facility will implement all elopement policies and processes above. A Wandering Risk Assessment and complete physical assessment will be completed by charge nurse and resident will be assigned a 1:1 sitter at that time and will remain with sitter while facility looks for memory care facility placement for resident. D. Reporting Elopements: The facility will report any missing residents per the HHSC reporting guidelines for missing residents. Facility Administrator will document on the Remarkable Healthcare Investigative Reportable Tool and complete the full investigation on that document. [Facility name] COO and [facility name] CCO will approve all reportable incidents. [Facility name] Investigative tool will be sent to COO and CCO for final review and approval. {Facility name] will follow the entire reportable process, including full investigation in writing and completing the 5-day notification report to HHSC. [Facility name] will also communicate the incident to appropriate resident responsible parties and physicians as required. E. Any missing resident will have documentation and assessment completed in the EMR upon return into the facility. This documentation will be completed by the charge nurse on duty and by the facility DON and Administrator. F. All action items above in this plan of removal will be monitored via appropriate documentation. Monitoring interviews for the Immediate Jeopardy were started on 08/07/21 at 3:45 PM and continued through 08/09/21 1:22 PM with 13 staff across all three shifts, including weekdays and weekends, and all departments. The staff were interviewed about the elopement policy and procedure, elopement and wandering interventions, behaviors monitor documentation, how to recognize residents with elopement seeking behaviors, and training. Observations were made of the nursing staff using one on one staffing. (08/07/21 thru 08/09/2921 on many occasions). The following staff's in-service logs and competency tests were reviewed and staff were interviewed during the monitoring time frame and were able to articulate what they had been taught, new protocols and procedures related to elopements and the facility policy for one on one sitter, functionality and elopement seeking behaviors: CNA A, CNA B, CNA C, RN D, LVN E, CNA H, LVN I, HR Director F, LVN J, CNA K, LVN L, Dietary Manager, LVN M, CNA N, and RN O. An Immediate Jeopardy was identified on 08/06/21 at 2:00 PM While the Immediate Jeopardy was removed on 08/09/21, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure one (Resident #1) of four residents received adequate supervision and assistance devices to prevent accidents. The Physical Therapist failed to provide adequate supervision to Resident #1, who had limited sensation, while she received heat pack therapy to her left arm. As a result, Resident #1 suffered a second degree burn on her left, lateral breast area from prolonged contact with the heat pack. This failure had the potential to affect the four residents who were receiving hot pack therapy and placed them at risk for possible injury. Findings included: Resident #1's MDS assessment, dated 08/30/16, reflected she was a [AGE] year-old female, who was admitted to facility on 08/23/16. The assessment reflected the Resident #1 had [DIAGNOSES REDACTED]. The assessment further reflected Resident #1 was cognitively intact and required total assistance of two to three staff with activities of daily living. Review of an incident report dated 1/26/17 documented by LVN revealed an incident involving resident #1. The report reflected: .observed that neighbor (Resident #1) had a blister to her left lateral breast; area has some inflammation to the edges of the blister, blister measures 14cm x 3.0cm x unknown; blister has clear fluid noted to area. Neighbor (Resident #1) stated that she did not know how she got the blister .upon investigation heat pad slipped out of protective cover and remained on the skin causing blister. Therapist with neighbor (Resident #1) throughout treatment and did not leave side. Document further revealed on 1/27/17 IDT met regarding previous day incident which occurred in therapy. Wound care specialist evaluated area, antibiotics initiated as prophylactic. Review of Resident #1's progress notes revealed the injury was noted on 01/26/17 by CNA and reported to the charge nurse -LVN. Further revealed the charge nurse reported the incident, provided first aid and notified Resident #1 primary Doctor. Also revealed upon investigation it was determined the hot pack caused Resident #1 injury. Review of Resident #1's Physician orders [REDACTED]. Change daily and PRN. Review of Resident #1's wound care consultation notes dated 02/08/17 revealed burn wound to the left breast due to heat pad that displaces on patients elbow and with misplacement of left arm patient did not realize heat pad was in contact with her left breast. Also revealed Resident #1 was a paraplegic and denied sensation to breast area. Further revealed burnt site examined and without signs of obvious infection, and with minor blister. Interview with Resident #1 on 02/22/16 at 12:17 P.M, revealed hot pack was bent in half and put in sleeve with no towel and applied to the left arm with Velcro wrap. Resident #1 revealed hot pack was applied for 15 minutes with Physical Therapist present in the therapy room. She revealed supervision was not provided because therapist was busy doing other things in the office behind glassed window. She revealed while she was receiving hot pack therapy she did not feel being burned due to decreased sensation to burnt area. She said she went to bed with the same top on upon her request, and the following morning the CNA discovered burn on left breast. Interview with the Director of Therapy on 02/22/17 at 9:53 A.M revealed he interviewed the Physical Therapist after Resident #1 allegedly burned with a heat pack. Further raveled Resident #1 did not know she had been burned until the next day when the CNA discovered the burn. Also revealed Physical Therapist was checking Resident #1 per protocol, and in-service was completed on heat pack treatments following the incident. Interview with the Director of Therapy on 03/09/17 at 10:40 A.M, revealed the Physical therapist applied a hot pack to Resident #1's left elbow. Resident #1's left arm was contracted and Resident #1 would pull her left arm closer to her body. Also revealed Resident #1 could not feel the burn during therapy due to having no sensation to the area. The Director of Therapy stated there was a possibility Resident #1 got her hand closer to her left breast causing the burn. Interview with the ADON on 02/22/17 at 1:35 P.M, revealed resident #1 received a burn to her left lateral breast. She said she interviewed Resident #1 who stated she did not know how the burn happened, or that it was there until the CNA notified her. Also revealed Physician was notified and treatment orders obtained. She said other possible causes of burn was investigated including over-heating of head control or hot fluid spills. Interview with the ADON on 03/09/17 at 11:00 A.M, revealed Resident #1 did not have sensation to the breast area where the burn occurred due to Resident #1 being Quadriplegia. The ADON completed the investigation of the incident and her conclusion was second degree burn by hot pack, because she was unable to determine what else could have caused the burn. She said Resident #1 should have supervision during therapy due to her diagnosis. She said if the therapist was close to resident he could have seen the hot pack misplaced. Interview with Administrator the on 02/22/17 at 8:37 A.M, revealed completed the investigation of the incident. She said on 1/27/17 she went on DAD's site to self-report of the incident and category was not found that fitted the incident. Also said she reviewed the findings of not being able to file incident on DADs page with Facility Owner and he approved the decision. Further revealed Therapy follows policy and procedures and guidelines with hot packs applied under supervision in the Therapy gym to prevent burns. Interview with Administrator the 03/09/17 at 2:00 P.M regarding Resident #1 revealed the resident was a larger lady and did not have a brassiere and the position of the breast was lower, so that made it high risk for the hot pack to touch the left breast. She also stated the Physical Therapists maybe was not present throughout therapy because the policy did not require one-on-one with the resident during therapy, and Resident #1 might have moved her arm causing herself injury. She stated per investigation the causative agent of the burn was hot pack, and she did not report the incident because when she went through the reasons to report an incident, she did not note the one with burns. Interview with the Physical Therapist on 02/22/17 at 10:12 A.M, revealed having given hot packs treatment to Resident #1 before on the left shoulder without any incident. Also revealed hot pack therapy was given to help Resident #1's spasms and contractures. He said he applied the hot pack to Resident #1 left elbow and the hot pack was approximately two inches from the resident body at all times. He also said Resident #1 did not experience spasm during therapy. Revealed Physical Therapist was a Doctor of Physical Therapy and had been trained in using/applying heat packs. Also revealed in-service received in proper application, precautions, monitoring skin and signs and symptoms of pain during hot pack therapy. Interview with the Physical Therapist on 03/09/17 at 1:20 P.M, revealed he applied the hot pack on Resident #1's left elbow and rested Resident #1's left arm on the power chair. The hot pack was one to one - half inches from Resident #1's body. The hot pack was padded with six layers of towel. The hot pack was on the resident #1's elbow for about five minutes, and then he took the hot pack off Resident #1 and inspected the areas with no burns noted. The Physical Therapist stated he was in the Therapy room during Resident #1's treatment but not next to Resident #1. He checked Resident #1's sensation on the arm before application of the hot pack, and did not check sensation on the left breast. He said they were not supposed to apply a hot pack to any part of the body where sensation was not felt. He said he assessed the area where he had applied the hot pack and did not notice any changes. Interview with the Regional Director on 03/09/17 at 3:30 P.M stated she knew about the incident and she was involved on the investigation. Also stated there was no clinical indication for the Physical Therapist to sit with Resident #1 during hot pack treatment. Also stated per conclusion of investigation the burns were caused by the hot pack and Resident #1 moved her arm resulting in self-injury. The Regional Director stated the facility policy does not require staff providing therapy to sit with the Resident during therapy. Review of facility Policy and Procedures Moist Heat packs on 3/9/17 reflected hot packs were contraindicated for residents with impaired circulation. Further reflected cover the hot pack with a terry cloth covering, and place a towel between the terry cloth and patient creating six to eight layers. Also reflected to Recheck the patient regularly and adjust toweling, if needed. On 03/09/17, the Director of Therapy provided a list of residents who were treated with hot pack therapy. The list reflected four residents who were treated with hot packs.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit abuse, neglect, and exploitation of residents and misappropriation of resident property for one (Resident #1) of four residents reviewed for neglect. 1. The Physical Therapist failed to provide adequate supervision to Resident #1, who had limited sensation, while she received heat pack therapy to her left arm. As a result, Resident #1 suffered a second degree burn on her left, lateral breast area from prolonged contact with the heat pack. 2. The Administrator failed to report Resident #1's burn to the State Survey and Certification Agency within 24-hours of becoming aware. Findings included: Record review of facility policy on Abuse and Neglect undated reflected Neglect . failure to provide goods and services as necessary to avoid physical harm, .Further reflected signs of/actual physical Neglect: leaving someone unattended who needs supervision. the staff, with the physician input ( as needed) will investigate. 1 substaniated incident of mistreatment, neglcect, injuries of unknown source . be reported, the facility Administrator, or his/her designee will promptly notify the following persons or agencies of such incident. a. The state licensing/certification agency responsible for survey/licensing the facility .2. tnotices to agencies wil be made within timely after the allegatio of an occurance of such incident . Review of facility Policy and Procedures Moist Heat packs on 3/9/17 reflected hot packs were contraindicated for residents with impaired circulation. Further reflected cover the hot pack with a terry cloth covering, and place a towel between the terry cloth and patient creating six to eight layers. Also reflected to Recheck the patient regularly and adjust toweling, if needed. Resident #1's MDS assessment, dated 08/30/16, reflected she was a [AGE] year-old female, who was admitted to facility on 08/23/16. The assessment reflected the Resident #1 had [DIAGNOSES REDACTED]. The assessment further reflected Resident #1 was cognitively intact and required total assistance of two to three staff with activities of daily living. Review of an incident report dated 1/26/17 documented by LVN revealed an incident involving resident #1. The report reflected: .observed that neighbor (Resident #1) had a blister to her left lateral breast; area has some inflammation to the edges of the blister, blister measures 14cm x 3.0cm x unknown; blister has clear fluid noted to area. Neighbor (Resident #1) stated that she did not know how she got the blister .upon investigation heat pad slipped out of protective cover and remained on the skin causing blister. Therapist with neighbor (Resident #1) throughout treatment and did not leave side. Document further revealed on 1/27/17 IDT met regarding previous day incident which occurred in therapy. Wound care specialist evaluated area, antibiotics initiated as [MEDICATION NAME]. Review of Resident #1's progress notes revealed the injury was noted on 01/26/17 by CNA and reported to the charge nurse -LVN. Further revealed the charge nurse reported the incident, provided first aid and notified Resident #1 primary Doctor. Also revealed upon investigation it was determined the hot pack caused Resident #1 injury. Review of Resident #1's Physician orders [REDACTED]. Change daily and PRN. Review of Resident #1's wound care consultation notes dated 02/08/17 revealed burn wound to the left breast due to heat pad that displaces on patients elbow and with misplacement of left arm patient did not realize heat pad was in contact with her left breast. Also revealed Resident #1 was a paraplegic and denied sensation to breast area. Further revealed burnt site examined and without signs of obvious infection, and with minor blister. Interview with Resident #1 on 02/22/16 at 12:17 P.M, revealed hot pack was bent in half and put in sleeve with no towel and applied to the left arm with Velcro wrap. Resident #1 revealed hot pack was applied for 15 minutes with Physical Therapist present in the therapy room. She revealed supervision was not provided because therapist was busy doing other things in the office behind glassed window. She revealed while she was receiving hot pack therapy she did not feel being burned due to decreased sensation to burnt area. She said she went to bed with the same top on upon her request, and the following morning the CNA discovered burn on left breast. Interview with the Director of Therapy on 02/22/17 at 9:53 A.M revealed he interviewed the Physical Therapist after Resident #1 allegedly burned with a heat pack. Further raveled Resident #1 did not know she had been burned until the next day when the CNA discovered the burn. Also revealed Physical Therapist was checking Resident #1 per protocol, and in-service was completed on heat pack treatments following the incident. Interview with the Director of Therapy on 03/09/17 at 10:40 A.M, revealed the Physical therapist applied a hot pack to Resident #1's left elbow. Resident #1's left arm was contracted and Resident #1 would pull her left arm closer to her body. Also revealed Resident #1 could not feel the burn during therapy due to having no sensation to the area. The Director of Therapy stated there was a possibility Resident #1 got her hand closer to her left breast causing the burn. Interview with the ADON on 02/22/17 at 1:35 P.M, revealed resident #1 received a burn to her left lateral breast. She said she interviewed Resident #1 who stated she did not know how the burn happened, or that it was there until the CNA notified her. Also revealed Physician was notified and treatment orders obtained. She said other possible causes of burn was investigated including over-heating of head control or hot fluid spills. Interview with the ADON on 03/09/17 at 11:00 A.M, revealed Resident #1 did not have sensation to the breast area where the burn occurred due to Resident #1 being [MEDICAL CONDITION]. The ADON completed the investigation of the incident and her conclusion was second degree burn by hot pack, because she was unable to determine what else could have caused the burn. She said Resident #1 should have supervision during therapy due to her diagnosis. She said if the therapist was close to resident he could have seen the hot pack misplaced. Interview with Administrator the on 02/22/17 at 8:37 A.M, revealed completed the investigation of the incident. She said on 1/27/17 she went on DAD's site to self-report of the incident and category was not found that fitted the incident. Also said she reviewed the findings of not being able to file incident on DADs page with Facility Owner and he approved the decision. Further revealed Therapy follows policy and procedures and guidelines with hot packs applied under supervision in the Therapy gym to prevent burns. Interview with Administrator the 03/09/17 at 2:00 P.M regarding Resident #1 revealed the resident was a larger lady and did not have a brassiere and the position of the breast was lower, so that made it high risk for the hot pack to touch the left breast. She also stated the Physical Therapists maybe was not present throughout therapy because the policy did not require one-on-one with the resident during therapy, and Resident #1 might have moved her arm causing herself injury. She stated per investigation the causative agent of the burn was hot pack, and she did not report the incident because when she went through the reasons to report an incident, she did not note the one with burns. Interview with the Physical Therapist on 02/22/17 at 10:12 A.M, revealed having given hot packs treatment to Resident #1 before on the left shoulder without any incident. Also revealed hot pack therapy was given to help Resident #1's spasms and contractures. He said he applied the hot pack to Resident #1 left elbow and the hot pack was approximately two inches from the resident body at all times. He also said Resident #1 did not experience spasm during therapy. Revealed Physical Therapist was a Doctor of Physical Therapy and had been trained in using/applying heat packs. Also revealed in-service received in proper application, precautions, monitoring skin and signs and symptoms of pain during hot pack therapy. Interview with the Physical Therapist on 03/09/17 at 1:20 P.M, revealed he applied the hot pack on Resident #1's left elbow and rested Resident #1's left arm on the power chair. The hot pack was one to one - half inches from Resident #1's body. The hot pack was padded with six layers of towel. The hot pack was on the resident #1's elbow for about five minutes, and then he took the hot pack off Resident #1 and inspected the areas with [MEDICAL CONDITION]. The Physical Therapist stated he was in the Therapy room during Resident #1's treatment but not next to Resident #1. He checked Resident #1's sensation on the arm before application of the hot pack, and did not check sensation on the left breast. He said they were not supposed to apply a hot pack to any part of the body where sensation was not felt. He said he assessed the area where he had applied the hot pack and did not notice any changes. Interview with the Regional Director on 03/09/17 at 3:30 P.M stated she knew about the incident and she was involved on the investigation. Also stated there was no clinical indication for the Physical Therapist to sit with Resident #1 during hot pack treatment. Also stated per conclusion of investigation [MEDICAL CONDITION] caused by the hot pack and Resident #1 moved her arm resulting in self-injury. The Regional Director stated the facility policy does not require staff providing therapy to sit with the Resident during therapy. On 03/09/17, the Director of Therapy provided a list of residents who were treated with hot pack therapy. The list reflected four residents who were treated with hot packs.

Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of four residents reviewed for neglect. The Physical Therapist failed to prevent neglect of Resident #1, who had limited sensation, while she received heat pack therapy to her left arm. As a result, Resident #1 suffered a second degree burn on her left, lateral breast area from prolonged contact with the heat pack. This failure had the potential to affect the four residents including resident #1, who were receiving hot pack therapy and placed them at risk for possible injury. Findings included: Resident #1's MDS assessment, dated 08/30/16, reflected she was a [AGE] year-old female, who was admitted to facility on 08/23/16. The assessment reflected the Resident #1 had [DIAGNOSES REDACTED]. The assessment further reflected Resident #1 was cognitively intact and required total assistance of two to three staff with activities of daily living. Review of an incident report dated 1/26/17 documented by LVN revealed an incident involving resident #1. The report reflected: .observed that neighbor (Resident #1) had a blister to her left lateral breast; area has some inflammation to the edges of the blister, blister measures 14cm x 3.0cm x unknown; blister has clear fluid noted to area. Neighbor (Resident #1) stated that she did not know how she got the blister .upon investigation heat pad slipped out of protective cover and remained on the skin causing blister. Therapist with neighbor (Resident #1) throughout treatment and did not leave side. Document further revealed on 1/27/17 IDT met regarding previous day incident which occurred in therapy. Wound care specialist evaluated area, antibiotics initiated as [MEDICATION NAME]. Review of Resident #1's progress notes revealed the injury was noted on 01/26/17 by CNA and reported to the charge nurse -LVN. Further revealed the charge nurse reported the incident, provided first aid and notified Resident #1 primary Doctor. Also revealed upon investigation it was determined the hot pack caused Resident #1 injury. Review of Resident #1's Physician orders [REDACTED]. Change daily and PRN. Review of Resident #1's wound care consultation notes dated 02/08/17 revealed burn wound to the left breast due to heat pad that displaces on patients elbow and with misplacement of left arm patient did not realize heat pad was in contact with her left breast. Also revealed Resident #1 was a paraplegic and denied sensation to breast area. Further revealed burnt site examined and without signs of obvious infection, and with minor blister. Interview with Resident #1 on 02/22/16 at 12:17 P.M, revealed hot pack was bent in half and put in sleeve with no towel and applied to the left arm with Velcro wrap. Resident #1 revealed hot pack was applied for 15 minutes with Physical Therapist present in the therapy room. She revealed supervision was not provided because therapist was busy doing other things in the office behind glassed window. She revealed while she was receiving hot pack therapy she did not feel being burned due to decreased sensation to burnt area. She said she went to bed with the same top on upon her request, and the following morning the CNA discovered burn on left breast. Interview with the Director of Therapy on 02/22/17 at 9:53 A.M revealed he interviewed the Physical Therapist after Resident #1 allegedly burned with a heat pack. Further raveled Resident #1 did not know she had been burned until the next day when the CNA discovered the burn. Also revealed Physical Therapist was checking Resident #1 per protocol, and in-service was completed on heat pack treatments following the incident. Interview with the Director of Therapy on 03/09/17 at 10:40 A.M, revealed the Physical therapist applied a hot pack to Resident #1's left elbow. Resident #1's left arm was contracted and Resident #1 would pull her left arm closer to her body. Also revealed Resident #1 could not feel the burn during therapy due to having no sensation to the area. The Director of Therapy stated there was a possibility Resident #1 got her hand closer to her left breast causing the burn. Interview with the ADON on 02/22/17 at 1:35 P.M, revealed resident #1 received a burn to her left lateral breast. She said she interviewed Resident #1 who stated she did not know how the burn happened, or that it was there until the CNA notified her. Also revealed Physician was notified and treatment orders obtained. She said other possible causes of burn was investigated including over-heating of head control or hot fluid spills. Interview with the ADON on 03/09/17 at 11:00 A.M, revealed Resident #1 did not have sensation to the breast area where the burn occurred due to Resident #1 being [MEDICAL CONDITION]. The ADON completed the investigation of the incident and her conclusion was second degree burn by hot pack, because she was unable to determine what else could have caused the burn. She said Resident #1 should have supervision during therapy due to her diagnosis. She said if the therapist was close to resident he could have seen the hot pack misplaced. Interview with Administrator the on 02/22/17 at 8:37 A.M, revealed completed the investigation of the incident. She said on 1/27/17 she went on DAD's site to self-report of the incident and category was not found that fitted the incident. Also said she reviewed the findings of not being able to file incident on DADs page with Facility Owner and he approved the decision. Further revealed Therapy follows policy and procedures and guidelines with hot packs applied under supervision in the Therapy gym to prevent burns. Interview with Administrator the 03/09/17 at 2:00 P.M regarding Resident #1 revealed the resident was a larger lady and did not have a brassiere and the position of the breast was lower, so that made it high risk for the hot pack to touch the left breast. She also stated the Physical Therapists maybe was not present throughout therapy because the policy did not require one-on-one with the resident during therapy, and Resident #1 might have moved her arm causing herself injury. She stated per investigation the causative agent of the burn was hot pack, and she did not report the incident because when she went through the reasons to report an incident, she did not note the one with burns. Interview with the Physical Therapist on 02/22/17 at 10:12 A.M, revealed having given hot packs treatment to Resident #1 before on the left shoulder without any incident. Also revealed hot pack therapy was given to help Resident #1's spasms and contractures. He said he applied the hot pack to Resident #1 left elbow and the hot pack was approximately two inches from the resident body at all times. He also said Resident #1 did not experience spasm during therapy. Revealed Physical Therapist was a Doctor of Physical Therapy and had been trained in using/applying heat packs. Also revealed in-service received in proper application, precautions, monitoring skin and signs and symptoms of pain during hot pack therapy. Interview with the Physical Therapist on 03/09/17 at 1:20 P.M, revealed he applied the hot pack on Resident #1's left elbow and rested Resident #1's left arm on the power chair. The hot pack was one to one - half inches from Resident #1's body. The hot pack was padded with six layers of towel. The hot pack was on the resident #1's elbow for about five minutes, and then he took the hot pack off Resident #1 and inspected the areas with [MEDICAL CONDITION]. The Physical Therapist stated he was in the Therapy room during Resident #1's treatment but not next to Resident #1. He checked Resident #1's sensation on the arm before application of the hot pack, and did not check sensation on the left breast. He said they were not supposed to apply a hot pack to any part of the body where sensation was not felt. He said he assessed the area where he had applied the hot pack and did not notice any changes. Interview with the Regional Director on 03/09/17 at 3:30 P.M stated she knew about the incident and she was involved on the investigation. Also stated there was no clinical indication for the Physical Therapist to sit with Resident #1 during hot pack treatment. Also stated per conclusion of investigation [MEDICAL CONDITION] caused by the hot pack and Resident #1 moved her arm resulting in self-injury. The Regional Director stated the facility policy does not require staff providing therapy to sit with the Resident during therapy. Record review of facility Moist Heat Packs Policy and Procedures reflected hot packs were contraindicated for residents with impaired circulation. Further reflected cover the hot pack with a terry cloth covering and place a towel between the terry cloth and patient creating six to eight layers. Recheck the patient regularly and adjust toweling, if needed. Record review of facility policy on Abuse and Neglect not dated reflected Neglect . failure to provide goods and services as necessary to avoid physical harm, .Further reflected signs of/actual physical Neglect: leaving someone unattended who needs supervision. On 03/09/17, the Director of Therapy provided a list of residents who were treated with hot pack therapy. The list reflected four residents who were treated with hot packs.