Every finding on record at Oakmont Guest Care Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure:- food appliances, including the microwave, toaster, and steamer were clean and sanitized; - the kitchen floors were clean and free of dust and debris;- 3 large dry ingredient food containers were clean;- food preparation tables were clean and free of old food residue; - the dishwasher's wash cycle reached 120 degrees Fahrenheit to properly clean and sanitize dishware and utensils; and - all kitchen staff were educated on 03/18/26 regarding the facility's expectations for the kitchen. These failures could place residents at risk for cross-contamination and foodborne illness.Findings included: Observation on 06/08/26 from 9:15 AM to 9:55 AM in the facility's kitchen revealed: -The inside of the microwave had food stains and residue -The inside of the toaster had food residue, and the outside had food stains and rust. -The food steamer had a metal pan underneath with stagnant water that had buildup and white floating substances. -The floors had excessive dust and debris. -3 large containers that were filled with dry food ingredients had stains and old, sticky food residue.-The food preparation table had food stains and debris. -The dishwasher's wash cycle only reached a temperature of about 97 degrees Fahrenheit per digital stick thermometer and the thermometer on the machine; however, the chemical sanitizing solution concentration level was between 50-100 ppm. Record review of an in-service, dated 03/18/26, reflected that all kitchen staff were educated on completing temperature logs for the freezer, refrigerator, dishwasher, food temperatures, and department cleanliness. During an interview on 06/08/26 at 10:20 AM, the Dietary Manager revealed he worked at the facility since November 2024. He stated it was the responsibility of all kitchen staff to keep the kitchen clean and sanitized daily. The Dietary Manager stated he was responsible for ensuring that all cleaning tasks were completed, and he would do pop-ups during the weekend to ensure that the cleaning remained consistent. The Dietary Manager stated he was not at the facility this past weekend and did not have time to inspect the kitchen for cleanliness prior to surveyor entering. He acknowledged the surveyor's observations and stated it was unacceptable and did not meet his expectations regarding how the kitchen was supposed to be cleaned. The Dietary Manager stated he assigned tasks for each kitchen staff, and the last in-service on cleaning was a few months ago. He stated all food appliances and preparation tables should be cleaned after each use, and floors should be cleaned after each meal service. The Dietary manager stated deep cleaning was completed by the night staff at the end of each day. He stated the large containers that stored dry food ingredients should be cleaned once emptied and before being refilled. He stated that the pan underneath the food steamer collected water and should be emptied and cleaned daily and as needed to prevent bacteria from growing. The Dietary Manager stated the dishwashing staff were expected to test and accurately log the water temperature and chemical concentration for the mechanical dishwasher daily to ensure that it was in working order and the dishes were properly cleaned and sanitized. He stated he was unaware that the temperature was not reaching above 97 degrees Fahrenheit, and that they would immediately switch to manual dishwashing in a 3-compatrment sink where all dishes could be rinsed, washed, and sanitized. The Dietary Manager stated not maintaining a clean and sanitized kitchen could place the residents at risk of food-borne illnesses, especially those with weakened immune systems due to age or conditions. Observation on 06/08/26 at 1:45 PM in the facility's kitchen revealed the kitchen staff were using the 3-compartment sinks to clean and sanitize the dishes. The water was maintained above 110 degrees Fahrenheit for washing and rinsing, and the sanitizing compartment had an appropriate chemical concentration level. Observation on 06/09/26 at 8:45 AM in the facility's kitchen revealed the mechanical dishwasher was fixed and the water temperature reached 120 degrees Fahrenheit. During an interview on 06/09/26 at 10:11 AM, Dietary Aide D revealed she worked at the facility since 10/2025. She stated all kitchen staff shared the responsibility of keeping the kitchen clean and sanitary, and they followed a schedule to ensure that all tasks were completed. Dietary Aide D stated general cleaning for the aides consisted of wiping down all counters and preparation tables after each meal service, cleaning all appliances after each use, cleaning and refilling containers as needed, sweeping the entire kitchen area after each meal service, and mopping at the end of the day. She stated she was trained upon hire regarding the expectations for cleanliness of the kitchen and in-serviced as needed. She could not recall when she last received an in-service. During an interview on 06/09/26 at 10:23 AM, Dishwasher E revealed it was his responsibility to keep the washroom area clean, test the water temperature and chemical levels for the dishwasher, and log it daily. Dishwasher E stated the mechanical dishwasher was working to his knowledge. He stated they used a digital thermometer to test the temperature and it reached 120 degrees Fahrenheit when he tested it. Dishwasher E stated any issues with the kitchen equipment had to be reported to the Dietary Manager. During an interview on 06/10/26 at 3:30 PM, the Administrator revealed the expectation was for the kitchen staff to follow policy and procedures to keep the kitchen clean and sanitized, and for the Dietary Manager to ensure that it was being done. The Administrator stated the kitchen would be inspected by management for cleanliness before kitchen staff left for the day. Record review of the facility's current General Kitchen Sanitation policy, dated 10/01/18, reflected in part the following: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness.Procedure:Clean and sanitize all food preparation areas, food-contact surface, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes.Clean food-contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens at least once a day; except for hot oil cooking equipment and hot oil filtering systems.6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them freeof dust, dirt, and food particles and otherwise in a clean and sanitary condition.Further review of this policy reflected that it did not address the use of mechanical dishwashers. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) reflected in part the following: 4-501.110 Mechanical Ware-washing Equipment, Wash Solution Temperature.(B) The temperature of the wash solution in spray-type ware-washers that use chemicals to SANITIZE may not be less than 49oC (120oF).4-602.12 Cooking and Baking Equipment. Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. Because of the nature of the equipment, it may not be necessary to clean cooking equipment as frequently as the equipment specified in S 4-602.11. 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not.6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. 6-501.13 Cleaning Floors, Dustless Methods. (A) Except as specified in (B) of this section, only dustless methods of cleaning shall be used, such as wet cleaning, vacuum cleaning, mopping with treated dust mops, or sweeping using a broom and dust-arresting compounds. (B) Spills or drippage on floors that occur between normal floor cleaning times may be cleaned: (1) Without the use of dust-arresting compounds; and (2) In the case of liquid spills or drippage, with the use of a small amount of absorbent compound such as sawdust or diatomaceous earth applied immediately before spot cleaning.

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 one of two residents (Resident #4) reviewed for infection control, in that: The facility failed to ensure after Resident #4 readmitted to the facility with rhinovirus (a type of virus that is one of the most common causes of the common cold) that physician orders were obtained for the resident to be placed on droplet precautions, which are infection control measures to prevent the spread of infection through respiratory droplets. This failure could place residents at risk for exposure to a contagious disease, infection, and possible hospitalization.Findings included:Record review of Resident #4's admission MDS Assessment, dated 05/28/26, which revealed he was a [AGE] year-old male who originally admitted to the facility on [DATE]. He had a BIMS score of 11 which indicated mild cognitive impairment. His active diagnoses included hypertension (high blood pressure), malnutrition (lack of proper nutrition), and diabetes mellitus (a condition that occurs when the body cannot properly use blood sugar). Record review of Resident #4's Order Summary Report, dated 06/08/26, did not reflect an order for droplet isolation precautions. Record review of Resident #4's care plan, initiated 06/04/26, reflected the following: Focus: [Resident #4] admitted with Respiratory Infection (rhinovirus) & Sepsis r/t recent hospitalization; he remains on droplet precautions.Interventions/Tasks: Continue droplet isolation precautions as indicated. Record review of Resident #4's Progress Notes reflected RN A wrote on 06/05/26 at 1:43 PM the following: Patient remain on isolation for Rhino virus [sic]. Observation and interview on 06/09/26 at 11:45 AM, revealed Resident #4 was in his room resting in his bed with his eyes closed. Resident #4 did not open his eyes while the surveyor was talking to him. Outside of Resident #4's room, there was a sign posted, which reflected: Contact & Droplet Precautions. During an interview on 06/09/26 at 2:40 PM, RN B said he was caring for Resident #4 who had been on droplet isolation precautions since the resident returned from the hospital last week. RN D said he was not sure how long Resident #4 should be on droplet isolation precautions because the doctor decided that. RN D said there should be an order in Resident #4's chart that he was on droplet isolation precautions for the condition that he had. RN D said he was not sure what his condition was that caused him to be on droplet isolation precautions. RN D said he was not sure who was supposed to contact the doctor for the order for a resident to be on droplet isolation precautions. During an interview on 06/09/26 at 2:45 PM, CNA C said this was his first time caring for Resident #4. CNA C said he was only told Resident #4 was on droplet isolation precautions but was not aware of why. CNA C said he was also not sure how long Resident #4 was supposed to be on droplet isolation precautions or how long he had been on droplet isolation precautions. During an interview on 06/09/26 at 3:18 PM, the IP said she had been in the role since November 2025. The IP said Resident #4 was on droplet isolation precautions because he came back from the hospital with rhinovirus. The IP said all orders came from the doctor and would also include the timeframe for when the resident would be on droplet isolation precautions and the reason why. The IP said she was not sure when Resident #4 was supposed to come off droplet isolation precautions. The IP said after a resident admitted to the facility she usually went through their orders to make sure all the necessary orders were in the chart but she did not do that for Resident #4. The IP said if she had caught the missing order she would have called the doctor for the order. The IP said the purpose of Resident #4 having an order to be on droplet isolation precautions was to ensure the prevention of the condition to be spread through the facility. The IP said if there was not an order for droplet isolation precautions, the staff caring for that resident may not know why they were on precautions or what their condition was. During an interview on 06/10/26 at 2:08 PM, the DON said Resident #4 was on droplet isolation precautions for rhinovirus. The DON said Resident #4 came back from the hospital on Thursday of last week (06/04/26) and he had rhinovirus from the hospital. The DON said that was when his isolation started and the doctor would decide when he would come off isolation precautions after that. The DON said there should have been an order in Resident #4's chart for him being on droplet isolation precautions. The DON said the purpose of that was for informational purposes so that staff were aware of why the resident was on droplet isolation precautions and for how long he was to be on those isolation precautions. The DON said the IP was responsible for ensuring the order was in the chart after the resident was admitted . Record review of the facility's current Isolation- Categories of Transmission-Based Precautions policy, revised September 2022, reflected: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection, and is at risk of transmitting the infection to other residents.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of four medication carts (Hall 700/Hall 800 nurses' medication cart) and 2 of 2 Residents (Residents#10 and #24) reviewed for pharmacy services. 1. The facility failed to ensure the Narcotic Log on the Hall 700/Hall 800 nurses' medication cart were accurate for administration of the narcotic pain medication hydrocodone/acetaminophen for Resident #24 and the narcotic pain medication oxycodone for Resident #10.2. LVN F failed to document the administration of narcotic medications in a correct and timely manner on the MAR and NAR for Residents #10 and #24. These failures could place residents at risk for drug diversion and not receiving the therapeutic dose of medication. Findings included:Record review of Resident #24's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fibromyalgia (a chronic disorder causing widespread musculoskeletal pain, fatigue, sleep problems, and cognitive difficulties), and she was on a scheduled pain management regimen. Resident #24's cognition was intact with a BIMS score of 14. Record review of Resident #24's care plan dated 04/01/26 reflected the resident has chronic pain rule out primary osteoarthritis (the most common form of arthritis. It occurs when the protective cartilage that cushions the ends of your bones gradually wears down, causing bones to rub against one another) and fibromyalgia. The plan reflected: Goal - Resident will not have an interruption in normal activities due to pain through the review date Interventions- Administer pain medications per order if non-medication interventions are ineffective. Administer analgesia Norco as per orders. Give 1/2 hour before treatments or care.Record review of Resident #24's order dated 02/15/26 reflected the following:Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth four times a day for pain .Record review of Resident #10's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus (a chronic metabolic condition characterized by high blood sugar levels). The MDS reflected the resident received as needed pain medication. Resident #10's cognition was moderately impaired with a BIMS score of 12. Record review of Resident #10's care plan dated 06/08/26 reflected the resident was at risk for acute pain/chronic pain related to diagnoses of chronic pain and polyneuropathy. The care plan reflected: Goal - Resident will report satisfactory pain control through review date. Interventions- Administer prescribed medication before activity and therapy.Record review of Resident #10's order dated 05/04/26 reflected the following:Oxycodone HCl Oral Tablet 5 MG (Oxycodone [narcotic pain medication]). Give 2 tablet by mouth every 6 hours as needed for pain severe pain more than 7 on scale of 0-10 .Observation and record review on 06/09/26 at 10:58 AM of the Hall 700/Hall 800 nurses' medication cart, with LVN F revealed the following information:Resident #24's NAR log sheet for hydrocodone-acetaminophen 5/325 mg four times a day (narcotic pain medication) was last signed off on 06/08/26 for a one-tablet dose given at 9:00 PM, for a total of 57 pills. The blister pack had 56 pills remaining. The MAR reflected LVN F documented administering the hydrocodone-acetaminophen 5/325 to Resident #24 at 9:00 AM. Resident #10's NAR log sheet for oxycodone 5 mg 2 tablets every six hours as needed (narcotic pain medication) reflected it was last signed off on 06/08/26 for a two-tablet dose given at 9:00PM with a total of 94 pills remaining. The blister pack had 92 remaining. There was no documentation on the MAR reflecting the oxycodone had been administered. During an interview on 06/09/26 at 12:16 PM, LVN F revealed she gave Resident #24 and Resident #10 the medication. She said she was expected to administer, document on the MAR, and sign out on the NAR. She said she forgot to document on the MAR and sign it out on the NAR. She could not tell when she administered the medication. She said she knew she was supposed to sign-out on the narcotic count sheet after she administered narcotic medication and on the MAR, but she did not. She stated failure to document would cause the narcotic count sheet to show more of the medication on the next count, which could lead to a narcotics diversion. She said she had not done training since she was newly hired.During an interview on 06/10/26 at 2:39 PM, the DON revealed his expectation was for staff administering narcotic medications to follow the facility's medication administration policy. He stated he expected the nurses to document the medications when they were given to the resident on the MAR and to sign on the narcotic log. He stated management did spot checks during the day and reported the findings during the daily stand-up meeting every day at 4:00 PM. He stated failure to document medication administration on the MAR and sign-off on the NAR could lead to drug diversion . She had not done training she was newly hired. Facility started training.Record review of facility's current Medication Administration Controlled Substances policy, dated 2007, reflected the following: . 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: (Note: Refer to state regulations forparticulars regarding Scheduled Classes and proper storage.)a.Date and time of administrationb.Amount administeredc.Signature of the nurse administering the dose.

Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #1) of 4 residents reviewed for nutrition. -On 01/07/26 the facility failed to ensure Resident #1 received appropriate treatment to prevent complications of enteral feeding when LVN A did not connect the resident's g-tube to the feeding pump, causing the formula to waste onto the floor for approximately 1.5 hours. This failure could place residents who receive enteral feeding at risk for inadequate nutrition and hydration, which could cause a decline in health.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: type II diabetes (body's inability to control blood sugar levels), gastrostomy status (g-tube placement), dysphagia, pharyngeal phase (difficulty moving food from the throat to the esophagus), muscle wasting atrophy (loss of muscle tissue and mass), and malignant neoplasm of endometrium (cancer of the uterus). Record review of Resident 1's Nursing Home Comprehensive MDS assessment, dated 12/22/25, reflected her BIMS score was 00, which indicated it could not be determined either due to refusal or inability to participate. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 was dependent on staff for most ADLs. The MDS Assessment under Section K-Swallowing/Nutritional Status reflected Resident #1 required a feeding tube for nutrition. Record review of Resident 1's care plan, revised on 01/07/26, reflected the resident required tube feeding and would remain free of side effects or complications with interventions that included: obtaining and monitoring diagnostic work as ordered and reporting results to MD, receiving a speech therapy evaluation and treatment as ordered, and following current feeding orders. Record review of Resident #1's consolidated physician orders, dated 01/07/26, reflected in part the following:-NPO (nothing by mouth) diet related to dysphasia, pharyngeal phase. Starte date: 12/19/25-G-Tube: every shift Diabetic Source 1.5 at 55ml/hr. x 22 hr./day with 175 ml water q 4 hr. flush. Start date: 12/19/25-G-Tube: downtime 8:00 AM-10:00 AM one time a day. Start date: 01/07/26. Discontinue date: 01/07/26-G-Tube: downtime 8:30 AM-10:00 AM one time a day. Start date: 01/08/26 Record review of a video provided by Resident #1's RP, dated 01/07/26 at 12:16 PM, revealed the resident's G-tube was disconnected from the pump and closed off. The video also revealed a puddle of formula on the floor from when the pump was running without being connected to Resident #1's G-tube. Record review of Resident #1's progress notes, dated 01/07/26 at 1:13 PM written by the DON, reflected the following: [MD] notified that [Resident #1's] G-tube feeding was noted disconnected, resulting in approximately 30 minutes of feeding wastage. [Resident #1] assessed; no acute distress noted. [MD] provided new order to extend tube feeding by an additional 30 minutes to compensate for missed volume. RP made aware. Will continue to monitor. In an observation and interview on 01/07/26 at 10:45 AM, Resident #1 was observed to be lying awake in bed under the covers and dressed in a gown, with only her chest up visible to the surveyor. Resident #1 had an enteral feeding pump that was in a corner on the opposite side from where the surveyor was standing to speak with the resident. The surveyor was able to see from the opposite side that the pump was running at a rate of 55 ml/hr. and there were no visible concerns from that position. Resident #1's thoughts were scattered but she was able to state that she was okay. Resident #1 also stated that she had not been at the facility long and she was a little nervous in her new environment. In an interview via phone on 01/07/26 at 12:25 PM, Resident #1's RP returned a missed call from the surveyor and stated that she was currently at the facility visiting. The RP stated she found that Resident #1 had not been fed for at least the past hour due to her G-tube not being connected to the feeding pump. The RP stated there was formula running on the floor from where LVN A turned on the pump and never connected Resident #1's G-tube. The RP stated she had a video recording that she was going to provide for the surveyor. Resident #1's RP stated she had a major concern about the resident not receiving her feeding as ordered and that she was unable to visit daily to ensure that it was being done. In an observation on 01/07/26 at 12:30 PM, the surveyor returned to Resident #1's room and found that Resident #1's G-tube had been re-connected to the feeding pump and running at 55 ml/hr. The surveyor observed that there was formula still on the floor from the previous spill. In an interview on 01/07/26 at 1:28 PM, LVN A stated she worked at the facility for 1.5 years. She stated she worked with Resident #1 today and was responsible for the resident's enteral feeding. LVN A stated she went in Resident #1's room between 9:00 AM and 9:30 AM to turn the enteral feeding pump off for two hours and administered medication. LVN A stated she returned to Resident #1's room after 2 hours, at approximately 11:30 AM, to turn the enteral feeding pump back on. LVN A stated when she turned the pump back on, she forgot to reconnect Resident #1's G-tube. LVN A stated it was busy during that time, and she was being called to assist another resident, so she made a mistake. LVN A stated there were enough staff working on the hall; however, as the nurse she had multiple residents to care for. LVN A stated she worked with residents on enteral feedings often and that was the first time she had forgotten to reconnect a G-tube. LVN A stated it was important to follow protocol and ensure that the G-tube was connected to the enteral feeding pump so that the resident received proper nutrition. In an interview on 01/07/26 at 1:40 PM, CNA B stated she worked at the facility since 11/2025. She stated she worked with Resident #1 today and at approximately 12:20 PM she went in the resident's room to clean her up and found that her family was visiting. CNA B stated as she was removing Resident #1' gown, she noticed that the resident's G-tube was still clamped off, and at the same time the family walked to the side of the bed and noticed that the formula was running from the enteral feeding pump onto the floor. CNA B stated she immediately called LVN A in the room and the nurse was shocked to see that Resident #1's G-tube was not connected to the pump, and she reconnected it. In an interview on 01/07/26 at 2:34 PM, the DON stated LVN A immediately reported to him that she forgot to reconnect Resident #1's G-tube when she restarted the resident's enteral feeding after the downtime. The DON stated LVN A reported that she turned the enteral feeding pump on at approximately 11:30 AM, so there was only about 30 minutes of formula wasted before the error was found. The DON stated he notified the MD and received a new order to decrease the next downtime by 30 minutes to make up for the missed formula, and the order would be ongoing until the MD made additional changes. The DON stated the MD informed him that a 30 min waste of formula would not harm Resident #1. The DON stated during enteral feeding downtime, the nurses were expected to disconnect and flush the G-tube to allow the residents the ability to move around as needed, then reconnected the G-tube when it was time to restart the feeding. The DON stated the aides and nurses were in the same clinical meetings, and they were all aware of the protocol for enteral feedings and the aides knew to immediately report any issues to the nurses. The DON stated an in-service to address the issue had already been started. The DON stated the aides and nurses alternated on doing rounds and would catch any issues with the enteral feeding during that time. The DON stated that forgetting to reconnect the G-tube would not place the residents at risk of harm because they could get an order from the MD to make up for any lost time. In an interview on 01/07/26 at 3:05 PM, the MD stated that he was notified that Resident #1's G-tube was not reconnected to the enteral feeding pump, and she lost approximately 30 mins of feeding time. The MD stated if the report was correct, Resident #1 would have lost about 1 oz of formula at 55 ml/hr., and that was not clinically significant enough to cause the resident any harm. The MD stated Resident #1 was overweight and her feeding downtime could actually be increased more; however, to satisfy the family he gave the facility an order to make up for the lost 30 mins. The surveyor asked the MD if Resident #1 would be at risk of harm if she missed over an hour of feeding and the MD stated he had never heard of anything like that happening due to how frequently the residents were checked; however, he would expect the facility to notify him if it did happen so that he could adjust the order based on the report. In an interview on 01/07/26 at 4:11 PM, LVN C stated she worked at the facility since 7/2025. She stated she worked with residents who received enteral feedings, and they followed the MD orders to provide the appropriate formula, rates, runtimes, and downtimes for the feedings. LVN C stated the feedings provided the residents with caloric and fluid intake for nutrition and hydration. LVN C stated during the enteral feeding downtime, the nurses would have to turn the pump off, flush the tube with water, clamp it off and completely disconnect the G-tube. LVN C stated when it was time to restart the enteral feeding, the nurses would have to check the G-tube for any residual before reconnecting it to the pump, turn the on the pump and ensure it was set to the correct rate, flush the tube and reconnect it to the pump. LVN C stated she always double checked the pump and G-tube to endure that everything was connected and running correctly before leaving the resident. She stated not reconnecting the G-tube to the enteral feeding pump could place the resident at risk for nutrition and hydration issues. She stated if this happened, the nurse would have to immediately report it to the MD, DON, and family. Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, undated, revealed in part the following:PurposeThe purpose of this procedure is to provide guidelines for the use of a pump for enteral feedings.Preparation1. Verify that there is a physician's order for this procedure.2. Review the resident's care plan and provide for any special needs of the resident.3. Assemble equipment and supplies needed.4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 resident (Residents #1) of 7 residents reviewed for respiratory care. -The facility failed to ensure that Residents #1, who required continuous oxygen therapy, received adequate oxygen when his portable oxygen tank ran out of oxygen while the resident was in the community at an appointment on 10/29/2025. Resident #1 was transported to the local hospital and diagnosed with acute hypoxia (low levels of oxygen) The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 10/29/25 and ended on 10/30/25. The facility had corrected the non-compliance before the state's investigation began. This failure could place residents who receive oxygen therapy at risk of receiving inadequate oxygen support, which could result in serious harm or death.Findings included:Record review of Resident #1's face sheet, dated 10/31/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (lung disease) and acute and chronic respiratory failure. Record review of Resident 1's Nursing Home PPS MDS assessment, dated 09/12/25, reflected his BIMS score was 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required supervision to moderate assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1 had a primary medical condition of cardiorespiratory with other comorbidities that included chronic lung disease, asthma, and respiratory failure. Further review of this document, under Section O-Special Treatments, Procedures, and Programs, reflected Resident #1 received continuous oxygen therapy. Record review of Resident 1's care plan, revised 09/08/25, reflected the resident had altered respiratory status/difficulty and was on continuous oxygen therapy r/t acute and chronic respiratory failure with hypoxia. Interventions included: administering medication as orders, monitoring for effectiveness and s/sx of respiratory distress and reporting to the MD. Record review of Resident #1's consolidated physician orders, dated 10/31/25, reflected in part the following: -Oxygen at 2-4 lpm via nasal cannula continuous for COPD -start date: 10/31/25-Continuous BIPAP at night at bedtime-start date: 09/09/25 Record review of Resident #1's progress notes, dated 10/29/25 at 1:45 PM by ADON A, reflected the following: [Resident #1] on the way from dental appointment. [CNA D] report [Resident #1] is having SOB in transport although resident is on oxygen tank via nasal canula. [MD] informed HGB was 6.4 and [Resident #1] is now having SOB. Order given to send to [local hospital]. Transport pulled over van and 911 called. Record review of Resident #1's hospital records, dated 10/29/25, reflected in part the following: Chief Complaint: hypoxic- pt on 02 at baseline, was being transported to doctor's appointment by [transportation service] and ran out of 02, leading to hypoxia w/ Spo2 50% on EMS arrival. EMS implemented CPAP PTA and sats came up 100%. History of present illness:[Resident #1] is a 74 y.o. male with past medical history of chronic respiratory failure secondary to COPD and chronic diastolic CHF was transported from his long-term facility to a dental appointment where apparently he had longer than usual stay and his tank ran out of oxygen. EMS called and patient was noted to be hypoxic. The patient was then brought to the hospital for further evaluation. Upon arrival, the patient noted to be in acute on chronic respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide). In the ED, chest x-ray showed peripheral infiltrate (fluid/substance in lungs) over the right lower lobe. The patient was having difficulty breathing but was on BiPAP when interviewed. The patient denied any chest pain. Does complain of some shortness of breath. Denies any nausea vomiting or abdominal pain. No headache or blurry vision. In an interview on 10/31/25 at 10:43 AM, ADON A stated she worked at the facility for about 1 and 1/2 years. She stated Resident #1 had a dental appointment at the VA and he left the facility around 8:00 AM with a full portable oxygen tank. ADON A stated Resident #1 was escorted to his appointment by CNA D, and the appointment was expected to last about 30 mins because Resident #1 was only picking up new dentures. However, ADON A stated the appointment lasted longer than expected. She stated a full portable oxygen tank could last 3-4 hours, but Resident #1 was away from the facility for approximately 5 hours. ADON A stated around 1:00 AM, CNA D notified her that Resident #1 was complaining of shortness of breath. ADON A stated she advised them to pull the van over and call 911, and Resident #1 was transported to the local hospital. ADON A stated she had never experienced a resident running out of oxygen while away from the facility because the nurses always ensured they had full portable oxygen tanks before leaving, and the residents returned when expected. She stated the facility immediately held an IDT meeting and implemented interventions to prevent this from happening again. ADON A stated they updated the procedures for oxygen care to include sending an extra portable oxygen tank to appointments with residents who were on continuous oxygen therapy and training all staff on oxygen care. ADON A stated she had designated aides who escorted residents to all appointments with other aides who could assist if needed, and she ensured those staff were trained on how to check the oxygen tanks for oxygen levels and settings. She also stated that nurses were responsible for ensuring that the oxygen tanks were full and functioning while preparing the residents for their appointments, and aides were expected to assist with checking the oxygen tanks and reporting any issues to the nurses. In an interview on 10/31/25 at 12:35 PM, with the Assistant Administrator and DON, the DON stated the expectation was for the nurses to check all oxygen tanks before a resident left the facility to ensure the portable oxygen tanks were full and working properly. The DON stated the incident of Resident #1 running out of oxygen at his appointment was a huge learning lesson for the facility because it had never happened. The DON stated they updated the procedures to ensure that it did not happen again. The Assistant Administrator stated they prioritized in-servicing all dayshift staff since that was when resident appointments took place; however, the training was ongoing to include all staff before the start of their shifts. The DON stated not ensuring residents received adequate oxygen at all times could place them at risk of inadequate oxygen and death. In an interview on 10/31/25 at 12:51 PM, CNA D stated she worked at the facility since August 2025. She stated she escorted Resident #1 to his dental appointment on 10/29/25. CNA D stated she and the nurse checked Resident #1's portable oxygen tank before leaving the facility and it was full. She stated they left the facility at about 8:00 AM, and Resident #1 was fine during the ride to his appointment. She stated his appointment time was 9:00 AM; however, they waited a long time for the resident to be called back. CNA D stated after waiting at the clinic and waiting for transportation to pick them back up, it was 1:00 PM. CNA D stated they were on the van returning to the nursing facility when Resident #1 stated he could not feel any oxygen coming out of his cannula. CNA D stated she checked, and the oxygen was very low, so she called ADON A, and they were told to pull over and call 911. She stated Resident #1 was still able to talk but she could tell that he was having a hard time breathing. CNA D stated Resident #1 remained conscious until the EMTs arrived and transported him to the local hospital. She stated she escorted a lot of residents on appointments and that was the first time a resident ran out of oxygen. CNA D stated the following day she was in-serviced on oxygen care, which included a new procedure to take an extra portable oxygen tank on appointments with residents who were on continuous oxygen. CNA D stated the aides knew to check oxygen tanks to make sure they were full and to report any issues to the nurse. She stated the aides were not allowed to change or adjust the oxygen equipment. In an observation and interview on 10/31/25 at 3:08 PM, Resident #1 stated he had just returned to the facility from the hospital and felt better. Resident #1 stated he was admitted to the hospital for 2 days because they found that he also had pneumonia. Resident #1 stated he did not feel any symptoms of pneumonia while at the facility. He stated he resided at the facility for about 5 months and had never run out of oxygen at any time. Resident #1 stated he was at his dental appointment for a long time because the VA was slow. He stated he was fine while waiting at the appointment; however, on the way back to the facility, he remembered feeling like he could not breathe, and he let the aide know. Resident #1 stated he tried to remain calm, but it was scary not being able to breathe. He stated he felt himself blacking out before hearing 911 arrive, and that was all he could recall. Observation of Resident #1 revealed he was wearing a nasal cannula that was connected to an oxygen concentrator set on 3 lpm, and the resident showed no signs of respiratory distress. Review of the facility's policy titled Oxygen Administration, undated, revealed in part the following: PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify that there is a physician's order for this procedure2. Assemble the equipment and supplies as needed.Further review of this document reflected it did not address transporting residents on continuous oxygen therapy. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 10/29/25 and ended on 10/30/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of a document provided by the Assistant Administrator titled AD HOC QA, dated 10/30/25, reflected an IDT meeting was held to discuss the failure and implement interventions. Record review of an in-service titled Transporting Residents on Oxygen, dated 10/30/25, reflected all staff, who were responsible for preparing residents and escorting them on appointments/outings, had been educated by ADON A on ensuring that residents receiving continuous oxygen therapy were transported with an extra portable oxygen tank. The education was ongoing to include all staff. Record review of an in-service titled Oxygen Tanks, dated 10/30/25, reflected all staff, who were responsible for preparing residents and escorting them on appointments/outings, had been educated by ADON A on ensuring that residents receiving oxygen therapy had oxygen tanks that were full and working properly. The education was ongoing to include all staff. Record review of an in-service titled Appointment Scheduling and Dashboard, dated 10/30/25, reflected central supply staff, ADON A, ADON B, and ADON C were all educated on monitoring appointments to ensure that residents who were on continuous oxygen therapy left the facility with a second regulator. In an interview on 10/31/25 at 10:43 AM, ADON A stated a chart audit was completed on all residents receiving oxygen therapy to ensure they had orders and care plans with appropriate intervention in place. Record review of a document provided by the Assistant Administrator titled Order Listing Report (O2), dated 10/30/25, reflected the facility had 20 residents receiving oxygen therapy, with 3 being on continuous oxygen therapy. Observation on 10/31/25 at 3:00 PM of the facility's oxygen closet revealed there were 36 extra portable oxygen tanks available and functioning. Interviews on 10/31/25 at various times from 9:30 AM-3:00 PM, conducted with the Assistant Administrator, DON, ADON A, ADON B, ADON C, nurses, MAs, and CNAs: CNA D (1st shift), LVN E (1st shift), CNA F (1st shift), CNA G (1st shift), MA H (1st shift), CNA I (1st/2nd double weekends), LVN J (2nd shift), CNA K (1st shift), LVN L (1st shift), CNA M (1st shift), CNA N (1st/2nd double weekends), LVN O (1st/2nd double weekends), CNA P (3rd shift), CNA Q (3rd shift), CNA R (2nd shift), LVN S (2nd shift), and CNA T (3rd shift) indicated they all participated in in-service trainings on 10/30/25. The nurses were able to state they were responsible for ensuring that residents who required oxygen therapy received treatment according to orders, always had adequate oxygen available, and residents who required continuous oxygen therapy had 2 full portable tanks when leaving the facility. The CNAs were able to state that while providing care to residents with portable oxygen tanks, they were responsible for checking the tanks to ensure there was adequate oxygen and to immediately notify the nurse of any issues. The Assistant Administrator, DON, and ADONs stated it was their responsibility to ensure the effectiveness of interventions. Interviews on 10/31/25 at various times from 10:00 AM-3:00 PM with Residents #1, #2, #3, #4, #5, #6, and #7, who all received oxygen therapy, revealed no concerns for respiratory care. All sampled residents denied ever running out of oxygen at the facility or while out in the community. Resident #1 stated the incident on 10/29/25 was the first time he had ever run out of oxygen since being admitted to the facility. Observations on 10/31/25 at various times from 10:00 AM-3:00 PM of Residents #1, #2, #3, #4, #5, #6, and #7, who all received oxygen therapy, revealed no s/sx of respiratory distress and they all had clean and working oxygen concentrators and portable oxygen tanks available Record reviews of EHRs for Residents #1, #2, #3, #4, #5, #6, and #7 revealed they all had orders and care plans that included appropriate interventions to address respiratory needs.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 of 5 residents (Residents #1, #2, #3, and #4) reviewed for infection control. 1. MA A, CNA B, and CNA C failed to perform hand hygiene before entering and exiting Resident #1's room on 08/01/25. 2. MA A, CNA B, and CNA C failed to put on PPE recommended for residents on contact precautions on 08/01/25. 3. MA A failed to sanitize the blood pressure cuff (reusable medical devices) between residents on 08/01/25.This failure could place residents at risk of cross contamination. Findings included:1. Record review of Resident #1's face sheet reflected, the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was diagnosed with and not limited to sepsis, unspecified organism (condition in which the body responds improperly to an infection. The infection-fighting processes turn on the body, causing the organs to work poorly), enterocolitis (inflammation that occurs throughout intestines) due to Clostridium (Clostridioides) Difficile (infection from a bacterium that causes colitis, an inflammation of the colon, causing diarrhea.), not specified as recurrent, and Type 2 Diabetes Mellitus (This condition happens due to the body not responding well to the hormone insulin, which causes high blood sugar levels), Chronic Kidney Disease (involves a gradual loss of kidney function). Record review of Resident #1's medication orders dated 07/22/25 reflected, Vancomycin HCl Oral Suspension 50 MG/ML (Vancomycin HCl) Give 2.5 ml by mouth every 6 hours for C-diff for 30 Days for 30 days. Record review of Resident #1s hospital records dated 07/31/25 reflected, Resident#1 was admitted to the hospital on [DATE] from the dialysis center for severe abdominal pain. Resident #1 was diagnosed with C. Diff on 07/11/25. Resident #1 was discharged from the hospital on [DATE] and returned to the facility. Observation on 07/31/25 at 5:30 PM of Resident#1 revealed signage outside of the door which reflected, STOP.CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before exit. DO not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reuseable equipment before use on another person. Observation on 08/01/25 at 6:25 AM revealed CNA B and CNA C walked into Resident #1's room without PPE which included: gown and gloves. Observed CNA B leave Resident#1's room to go to laundry to find Resident #1's pants and she did not perform hand hygiene when she exited. The surveyor knocked on door and observed CNA B and CNA C providing patient care to Resident #1 with no gloves and gown on. 2. Observation and interview on 08/01/25 at 6:15 AM revealed MA A walked into room [ROOM NUMBER] to take Resident#2's BP and passed medications. MA A did not sanitize the blood pressure cuff. MA A went into Resident #1's room (#508) to take his BP and passed medication. MA A did not put on PPE which included gown and gloves, and did not perform hand hygiene before she entered and exited Resident #1's room. MA A did not sanitize the blood pressure cuff. Observed MA A go into Room# 509 and passed medication to Resident #3. MA A went into Room# 510 and took Resident #4's BP and did not sanitize the blood pressure cuff. Observation and interview on 08/01/25 at 6:38 AM, MA A stated staff did not have to wear PPE to go into Resident #1's room because staff only had to wear PPE when they provided direct care to the resident#1. MA A continued to the other side of building to pass medication. MA A stated she thought she had wiped down the blood pressure cuff. Observation of the medication cart revealed no sanitation wipes on the medication cart. Interview and observation on 08/01/25 at 6:45 AM revealed CNA B put on full PPE before she entered Resident #1's room. CNA B stated she had to put on PPE to prevent the spread of infection to other residents. Interview on 08/01/25 at 8:10 AM, the IP stated Resident #1 was on isolation contact precautions which meant staff, visitors and providers must put on gloves and a gown before entering and remove when exiting. The IP stated staff should wash their hands before entering and exiting Resident#1's room. The IP stated these precautions prevented other residents and staff from being exposed to the infection. Interviews on 08/01/25 at 9:15 AM to 9:50 AM with CNA B, CNA D, CNA E, LVN G, and LVN F, they stated when a resident was on EBP, PPE was worn when care was being provided to the resident such as during incontinent care, wound care and catheter care. LVN F stated when a resident was on contact precautions staff were supposed to wear a gown, gloves and could wear a face mask, shield and shoe covers if necessary. CNA B stated Resident #1 had a little loose stool this morning and it looked like diarrhea. The staff stated putting on PPE prevented the spread of infection to staff, visitors and other residents. Interview on 08/01/25 at 8:26 AM over the phone with the PCP revealed Resident #1 was on isolation because he was diagnosed with C. Diff. The PCP stated Resident #1 should stay on contact precautions until he had formed stools. The PCP stated staff should wear secretion general precautions (refer to the measures taken to prevent the transmission of microorganisms from both recognized and unrecognized sources. These precautions are essential for protecting both healthcare workers and patients by reducing the risk of infection) such as a mask, gloves and gown to prevent the spread of the infection. Interview on 08/01/25 at 10:30 AM revealed the ADON and Administrator stated they completed an in-service with staff about the TBP. The ADON stated staff were nervous because the surveyor did observation with them. The ADON stated the facility would work on the infection control concerns. Record review of facility policy titled Isolation-Categories of Transmission-Based Precautions, dated 2021 reflected : Policy statement- Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other resident.2.) Transmission based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person.5.) When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door. a.) The signage informs the staff of that type of CDC precautions(s), instructions for use of PPE.6.) When transmission -based precautions are in effect, non-critical resident - care equipment items. a) If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident.Contact precautions: 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the residents' environment. Record review of website at http://www.cdc.gov/handhygiene/providers/index.html; titled: Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24, reflected: .according to the Centers for Disease Control and Prevention (CDC), strict adherence to glove use is the most effective means of preventing hand contamination with C. difficile spores as these spores are not killed by ABHR and may be difficult to remove even with thorough hand washing. Additional information on appropriate hand hygiene practices may be found in CDC's Hand Hygiene in Healthcare Settings. Record review of website https://www.cdc.gov/infectioncontrol/guidelines/mdro/index.html,; titled: Guidelines and Guidance library dated 04/25/25, and Transmission based precautions, dated 04/03/24 reflected: .Contact Precautions Contact precautions are intended to prevent transmission of pathogens that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment (e.g., C. difficile, norovirus, scabies), and requires the use of appropriate PPE, including a gown and gloves before or upon entering (i.e., before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed, and hand hygiene is performed.

Based on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for four (Resident #1, #2, #3 and #4) of seven residents reviewed for pressure ulcers and non-pressure wounds. 1. The facility failed to document skin care was provided for Resident #1 on 05/01/25 and 05/06/25. 2. The facility failed to document wound care was provided for Resident #2 on 05/02/25. 3. The facility failed to document wound care was provided for Resident #3 on 04/24/25 and 05/02/25. 4. The facility failed to document wound care was provided for Resident #4 on 04/27/25, 04/28/25 and 04/29/25. The facility failure could place residents at risk of not receiving wound care, wounds worsening and a lack of oversight of their clinical records by the nursing staff and nursing management. Findings included: 1. Record review of Resident #1's quarterly MDS dated [DATE] reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included in part, dementia and seborrheic dermatitis (a common inflammatory skin condition that causes scaly, red patches, and sometimes crusting, particularly on oily areas like the scalp, face, and chest). Resident #1's BIMS score was 04 which indicated severe cognitive impairment. Resident #1 had no rejection of care issues and used a wheelchair for mobility. She was physically dependent on staff for all ADLs and was always incontinent of bowel and bladder. Resident #1 was at risk of developing pressure ulcers/injuries but did not have any identified during the assessment period. For skin treatment, Resident #1 required applications of ointments/medications. Record review of Resident #1's care plan last revised on 12/06/24 reflected, Focus: [Resident #1] has potential for impairment to skin integrity r/t fragile skin, incontinence, impaired mobility and scratching. [Resident #1] has a history and current behavior of scratching at skin, sometimes till area opens up and is bleeding. Will pull off dressings, scabs, scratch at face. Actual skin tear: 10/20/23- Arm L forearm, 7/15/24 Red raised scabbed area to Left lower jaw, 9/30/24-red area on face from rubbing, 10/7/24-Skin tear to R hand, 11/21/24-bruise left hand, 11/25/24-bruise right 3rd finger on right hand; Interventions .Follow facility protocols for treatment of injury, Keep skin clean and dry. Use lotion on dry skin. Record review of Resident #1's current May 2025 physician's orders reflected, Mupirocin External Ointment 2 % Apply to left chin/face wound topically two times a day for skin wound on face for 10 Days (start date 05/01/25). Record review of Resident #1's May 2025 MAR reflected the treatment of Mupirocin to her face wound was blank and not documented as completed on 05/01/25 at bedtime and on 05/06/25 in the morning. Record review of Resident #1's clinical chart, to include nursing progress notes, did not document or indicate why the skin care was not performed on 05/01/25 and 05/06/25 . 2. Record review of Resident #2's Face Sheet dated 05/08/25 reflected he was a [AGE] year-old male who was a newer admission to the facility on [DATE] with active diagnoses that included osteomyelitis (a serious infection of the bone, most often caused by bacteria, that can lead to inflammation and damage) of the lower leg. Record review of Resident #2's admission physician orders dated 05/02/25 reflected, Clean wound every other day with wound cleanser and pack with moistened damp gauze (4x4s or rolled gauze with saline), apply sacrum (bone in the lower back) foam dressing with silicone border and change every other day, see wound specialists next visit for further eval-may need a wound vac (a medical device that uses negative pressure to help wounds heal) for stage 4 pressure wound sacrum. Record review of Resident #2's May 2025 TAR reflected the treatment to his stage 4 pressure wound on the sacrum was blank and not documented as completed on 05/02/25. Record review of Resident #2's clinical chart, to include nursing progress notes, did not document or indicate why the wound care was not performed on 05/02/25 . 3. Record review of Resident #3's admission assessment dated 0416/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included dementia, cancer and dysphagia (difficulty swallowing). Resident #3's BIMS score was a 03 which indicated severe cognitive impairment and she had no rejection of care issues. Resident #3 used a wheelchair for mobility and required physical assistance of staff for ADLs. Resident #3 weighed 101 pounds and had three wounds- one Stage 2, one Stage 3 and one Stage 4 and two deep tissue injuries, all present at the time of admission. Resident #3 required pressure ulcer/injury care, application of nonsurgical dressings, applications of ointments/medications, application of dressings to feet and a pressure reducing device for the bed. Record review of Resident #3's care plan dated 05/07/25 reflected, The resident has stage 2 pressure ulcer left lateral ankle or potential for pressure ulcer development r/t immobility; [Resident #3] has stage 4 pressure ulcer sacrum r/t immobility, [Resident #3] has unstageable dti pressure ulcer to the right hip r/t immobility; Interventions: Assess/record/monitor wound healing as directed, Measure length, width and depth where possible, Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD, monitor dressing as directed to ensure it is intact and adhering. Report loose dressing to Treatment nurse, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaks from blood vessels into surrounding tissues, often in response to inflammation or infection). Record review of Resident #3's treatment order summary for April and May 2025 included: -Stage 2 Pressure to left lateral ankle: skin prep daily everyday shift (start date 05/02/25) - Stage 4 Pressure wound to sacrum: Cleanse with normal saline/wound cleanser pat dry, apply calcium alginate with silver and collagen sheet cover with Superabsorbent gelling fiber with silicone border and changed daily and prn as needed (start date 04/22/25) - Stage 3 wound to left hip: Cleanse with normal saline/wound cleanser pat dry apply hydrogel with silver and cover with superabsorbent gelling fiber with silicone border and faced daily and prn everyday shift (start 04/23/25, discontinued 05/01/25) Record review of Resident #3's April 2025 and May 2025 TAR reflected the treatment for her Stage 3 to 4 wound was not documented as completed on 04/24/25 and on 05/02/25. The treatment for her Stage 2 pressure wound to her left lateral ankle was not documented as completed on 04/24/25 and 05/02/25. Record review of Resident #3's clinical chart, to include nursing progress notes, did not document or indicate why the wound care was not performed on 04/24/25 and 05/02/25 . 4. Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included multiple sclerosis (a chronic, unpredictable disease of the central nervous system), dysphagia (difficulty swallowing) and anorexia (An eating disorder causing people to obsess about weight and what they eat). Resident #4's BIMS score was 12 which indicated moderate cognitive impairment. Resident #4 had no rejection of care issues and used a wheelchair for mobility. She was physically dependent on staff for ADLs, was always incontinent of bowel and bladder and weighed 116 pounds. Resident #4 had one stage 4 pressure ulcer she admitted with and she required pressure ulcer care, applications of ointments/medications, turning/repositioning program and a pressure reducing device for bed. Record review of Resident #4's care plan last revised on 02/24/25 did not address her pressure ulcer care or treatment. Record review of Resident #4's April 2025 physicians' orders reflected, Stage 4 pressure wound of the sacrum-Cleanse with [wound cleanser] 1/4 strength, pat dry, apply skin prep and triad and miconazole 2% powder to peri wound, apply collagen powder to wound bed cover with silicone border dressing daily and PRN every day shift for wound care (start 04/25/25, discontinue date 05/07/25). Record review of Resident #4's April 2025 TAR reflected the treatment for her Stage 4 pressure wound was blank and not documented as completed on 04/27/25, 04/28/25 and 04/29/25. Record review of Resident #4's clinical chart, to include nursing progress notes, did not document or indicate why the wound care was not performed on 04/27/25, 04/28/25 and 04/29/25. 5. An interview with the ADM on 05/07/25 at 2:43 PM revealed he did see some gaps in wound care documentation for Residents #1, #2, #3 and #4. An interview with RN A on 05/08/25 at 11: 14 AM revealed if wound care was not documented on the TAR or in the clinical records, then one could not be able to tell if the wound care was done. RN A stated he was the charge nurse in the mornings for Resident #4 and he would know if her dressing had not been changed because the date would not be current on the dressing. He denied seeing any issues with her wound care dressings being changed per orders. An interview with LVN B on 05/08/25 at 11:38 AM revealed the problem with not documenting wound care completed on the TAR could result in ordered wound care being overlooked. He stated a resident could have a new infection or an infection that was getting worse or a bandage could have come off. He stated he would know if a wound dressing had not been changed because the date written on the dressing would be the same, That shows evidence of it not being changed. An interview with LVN C on 05/08/25 at 12:02 PM revealed if a TAR was not initialed, then it indicated the treatment was not done, or sometimes could mean people did the treatment but forgot to sign it. She stated if wound care was not completed on the e-chart it would pop up as red. After that, she would check the resident's wound to see if it was dated current or not, then she would know if the wound care was done. An interview with ADON D on 05/08/25 on 12:42 PM revealed the rule of nursing was, If it was not documented, it wasn't done. She stated the documentation supported that wound care was completed as ordered. ADON D stated in her position, she would run a missed medication report through the online e-charting system. However, if an order had been changed that day for wound care or a wound had resolved and the discontinue order was not received yet, it could flag as missed treatment in the system. ADONLVN D stated with current resident with missing treatments documented, such as Resident #2, there was a lot of stuff going on that day of his admission. She said management would normally do an audit of the new admission's chart the next day but there was a training and she did not do it. ADON D stated she was the one who did his wound care on the date it was showing as not done. She said she did it before she left the building on 05/02/05 and said she documented it on a progress note. An interview with the wound care nurse, LVN E on 05/08/25 at 1:17 PM revealed wound dressings needed the date to be current and there needed to be a signature or initial. LVN E stated, The biggest thing is not doing the care, it is not documenting. I don't see undated dressings. LVN E then stated, It is important to document wound care to let us know if it was done because we have to follow the order. 6. Review of the facility's policy titled, Wound Care dated 2001 reflected, Documentation-The following information should be recorded in the resident's medical record: 1. The type of wound care given; 2. The date and time the wound care was given; 3. The position in which the resident was placed; 4. The name and the title of the individual performing the wound care; 5. Any change in the resident's condition; 6. All assessment data obtained when inspecting the wound; 7. How the resident tolerated the procedure; 8. Any problems or complaints made by the resident related to the procedure; 9. If the resident refused the treatment and the reason why; and 10. The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 2 meals (lunch) reviewed for food meeting residents' needs. The facility failed to prepare and serve pureed turkey tetrazzini as a pudding consistency for residents who required pureed diets during the lunch meal on 04/09/25. This deficient practice could place residents at risk of not receiving meals that meet their needs. Findings included: Record review of the lunch menu ticket for 04/09/2025 revealed the menu for the lunch service was Turkey Tetrazzini, Vegetable Medley, Breadstick, Fruit Cup. Observation on 04/09/25 at 11:02 AM revealed the [NAME] prepared turkey tetrazzini with a food processor and then placed it on the steam table. The Dietary Manager did not check the consistency or ensure it was all blended to a pudding smooth consistency. Observation and interview with the Dietary Manager on 04/09/25 beginning at 1:05 PM revealed the test tray included the regular textured menu items and the pureed menu items. The Dietary Manager stated the pureed turkey tetrazzini did not have a smooth, pudding consistency. He also said the turkey tetrazzini had chunks of turkey and noodles throughout the entree. Interview on 04/09/25 at 1:07 PM with the Dietary Manager revealed his expectation was for pureed food to have a smooth, pudding consistency. The Dietary Manager stated the turkey tetrazzini was not the correct consistency. The Dietary Manager stated residents could choke if dietary items were not blended to a smooth pudding texture. Interview on 04/10/25 at 1:44 PM with the Administrator revealed the facility did not have a policy for pureed foods. The Administrator stated the Dietary Manager had completed an in-service with the dietary staff on 04/09/25. The Administrator provided the in-service that included directions on preparing purees. Record review of the Facility In-Service dated 04/09/25 reflected: 1. The desired thickness should be smooth mashed potato or pudding. There should be no large lumps or particles. 2. Do not add water to pureed food. 3. Add liquid, if needed (ex. reserved liquid, broth, sauces, gravy, milk or juice 4. If needed, gradually add thickener. Ex mashed potato flakes, cream of rice, or commercial thickener)

Based on interview and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 5 residents (Resident #13) reviewed for PASRR assessments. The facility did not refer Resident #13 to the appropriate state-designated mental health authority for review when he received a new diagnosis of major depressive disorder. This failure could place residents at risk of not being evaluated and receive needed PASRR services. Findings included: Record review of Resident #13's face sheet dated 04/10/25 reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #13 was diagnosed with major depressive disorder on 03/14/25. Record review of Resident #13's MDS Assessment, dated 04/03/25, reflected the resident had an active diagnosis of depressive disorder, and the resident had severe cognitive impairment with a BIMS score of 07. Record review of Resident #13's undated Care Plan reflected [Resident #13] uses psychotropic medications (Seroquel) r/t Behavior management. Record review of Resident #13's PASRR Level 1 Screening, dated 05/15/24, reflected he did not have a mental illness. PASARR Level 1 screening did not indicate Resident #13 had primary diagnosis of dementia. Interview on 04/10/25 at 9:47 AM, the MDS Coordinator revealed she was aware Resident #13 was given a diagnosis of major depressive disorder on 03/14/25. The MDS Coordinator stated Resident #13 had a primary diagnosis of dementia and did not require another PASRR Level 1. The MDS Coordinator stated a 1012 Form (Mental Illness/Dementia Resident Review) should had been completed but needed time to locate it. Follow up interview on 04/10/25 at 10:42 AM, the MDS Coordinator revealed a Form 1012 was not completed until today (04/10/25). The MDS Coordinator reviewed Resident #13 PASRR Level 1 and stated she was not aware Resident #13 primary diagnosis was not Dementia. She stated a PASRR Level 1 should have been completed when the new diagnosis of major depressive disorder was given. She stated it was the responsibility of the MDS Coordinators to review PASRRs. She stated she had been employed for 8 years, she stated Resident #13's PASRR was missed. She stated there was no harm to the resident. The MDS Coordinator stated they did not have a PASRR policy, they followed state regulation. Interview on 04/10/25 at 1:50 PM with the Interim DON revealed the MDS Coordinators were responsible for updating the PASRR assessments and submitting them timely and complete new ones when a new diagnosis was given. The Interim DON stated by not reviewing resident PASRR.

Based on observation, interviews, and record reviews, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #40) reviewed for unnecessary medications. The facility failed to ensure Resident #40 had an appropriate diagnosis for her prescribed Seroquel (used to treat depression). This failure could place residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of Resident #40's admission Record, dated 04/10/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #40's Quarterly MDS Assessment, dated 03/24/25, reflected she had a BIMS score of 12 indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident/transient ischemic attack/stroke, non-alzheimer's dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), anxiety disorder (refers to a group of specific psychiatric disorders characterized by extreme fear or worry), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). For the medication review, it was noted Resident #40 received antipsychotics on a routine basis. Record review of Resident #40's care plan, revised 01/24/25, reflected the following: Focus: [Resident #40] uses psychotropic medications -Resident takes Seroquel .Goal: [Resident #40] will reduce the use of psychotropic medication through the review date .Interventions: Administer PSYCHOTROPIC [sic] medications as ordered by physician. Record review of Resident #40's Order Summary Report, dated 04/10/25, reflected the following : - Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for ANTIPSYCHOTICS/ANTIMANIC AGENTS [sic], Take one tablet by mouth in the morning Record review of Resident #40's April 2025 MAR reflected she received Seroquel every day as ordered. Record review of Resident #40's Consultant Pharmacist/Physician Communication Report, dated 10/13/24, reflected: Dear [Physician A], This resident was admitted on an antipsychotic, Quetiapine. Please ensure approved psych diagnosis has been documented to support continued use .Physician/Prescriber Response 'acute on [illegible] psychosis'. The report was signed by Physician A on 10/17/24. Record review of Resident #40's Medication Regimen Record review Report, dated 11/13/24, reflected: Resident has an order for the following medication. I recommend including a diagnosis to the medication order to support therapy. Quetipaine. Observation and interview on 04/08/25 at 12:00 PM with Resident #40 revealed she was in her room with a family member. Resident #40 said she was doing okay today. Interview on 04/10/25 at 3:27 PM with LVN B revealed she was caring for Resident #40. LVN B said she reviewed Resident #40's Seroquel order and saw that a diagnosis was missing. LVN B said there should be a diagnosis listed with the medication which would come from the doctor. Interview on 04/10/25 at 3:50 PM with the Interim DON revealed normally the Charge Nurse would put an order for an antipsychotic medication into a resident's chart with the indications for use and a nurse manager, such as herself, would add the diagnosis. The Interim DON said Resident #40 should have had a diagnosis associated with her antipsychotic medication and staff should have caught that. The Interim DON said she just stepped into her role last week and the previous DON would have been responsible for ensuring the Pharmacist's recommendations were followed up on. The Interim DON said she was now responsible for them going forward, however. The Interim DON said the purpose was to complete or respond to the recommendations based on the regulations and to allow for communication between the pharmacist and the doctor to occur. The Interim DON said the previous DON was the only one following up on the recommendations and there was not anyone going behind her to ensure they were completed. The Interim DON said the previous DON was expected to complete the recommendations herself. Interview on 04/10/25 at 4:15 PM with the Interim DON revealed the facility did not have a policy regarding pharmacy recommendations.

Based on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #40) whose drug regimens were reviewed. The facility's Pharmacy Consultant recommended the facility include a diagnosis to the medication order to support therapy for Quetiapine on 10/13/24 and 11/13/24 for Resident #40. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Record review of Resident #40's Admission Record, dated 04/10/25, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #40's Quarterly MDS Assessment, dated 03/24/25, reflected she had a BIMS score of 12 indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident/transient ischemic attack/stroke, non-alzheimer's dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), anxiety disorder (refers to a group of specific psychiatric disorders characterized by extreme fear or worry), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). For the medication review, it was noted Resident #40 received antipsychotics on a routine basis. Record review of Resident #40's care plan, revised 01/24/25, reflected the following: Focus: [Resident #40] uses psychotropic medications -Resident takes Seroquel .Goal: [Resident #40] will reduce the use of psychotropic medication through the review date .Interventions: Administer PSYCHOTROPIC [sic] medications as ordered by physician. Record review of Resident #40's Order Summary Report, dated 04/10/25, reflected the following: - Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for ANTIPSYCHOTICS/ANTIMANIC AGENTS, Take one tablet by mouth in the morning. Record review of Resident #40's April 2025 MAR reflected she received Seroquel every day as ordered. Record review of Resident #40's Consultant Pharmacist/Physician Communication Report, dated 10/13/24, reflected: Dear [Physician A], This resident was admitted on an antipsychotic, Quetiapine. Please ensure approved psych diagnosis has been documented to support continued use .Physician/Prescriber Response 'acute on [illegible] psychosis'. The report was signed by Physician A on 10/17/24. Record review of Resident #40's Medication Regimen Record review Report, dated 11/13/24, reflected: Resident has an order for the following medication. I recommend including a diagnosis to the medication order to support therapy. Quetiapine. Observation and interview on 04/08/25 at 12:00 PM revealed Resident #40 was in her room with a family member. Resident #40 said she was doing okay today. Interview on 04/10/25 at 3:27 PM with LVN B revealed she was caring for Resident #40. LVN B said she reviewed Resident #40's Seroquel order and saw a diagnosis was missing. LVN B said there should be a diagnosis listed with the medication which would come from the doctor. Interview on 04/10/25 at 3:50 PM with the Interim DON revealed normally the Charge Nurse would put an order for an antipsychotic medication into a resident's chart with the indications for use and a nurse manager, such as herself, would add the diagnosis. The Interim DON said Resident #40 should have a diagnosis associated with her antipsychotic medication and staff should have caught that. The Interim DON said the nurse managers would have been responsible for ensuring the diagnosis was included with the order. The Interim DON said the purpose of this was to ensure the resident was not receiving unnecessary medications. The Interim DON said the nurse managers should have been monitoring residents' medication orders. The Interim DON said the nurse managers should have identified the issue and were trained to look for those things and correct them. The Interim DON said the concern with the missing diagnosis was that it was not right and needed to be fixed. Record review of the facility's Medication Utilization and Prescribing- Clinical Protocol policy, dated 2001, reflected the following: 1. When a medication is prescribed in response to an identified problem, condition, or risk, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, condition, risks, health status, and existing medication regimen.

Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good grooming, and personal hygiene for 1 of 25 residents (Resident #1) reviewed for ADL care. The facility failed to ensure Resident #1's fingernails was clean and cut. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: Record review of Resident #1's Optional State MDS Assessment, dated 03/20/25, reflected the resident was a an [AGE] year-old female admitted on [DATE]. The MDS also reflected the resident had a BIMS score of 11 indicating moderate cognitive impairment. The MDS also reflected diagnoses of Asthma, COPD (chronic obstructive pulmonary disease), or chronic lung disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #1's Care Plan, undated, reflected: Focus: Resident exhibits ADL Self Care Performance Deficit, r/t decrease in mobility. Goal: Resident will maintain current level of function through the review date. Interventions: Bathing/Showering: The resident limited assistance from staff for bathing. Bed Mobility: The resident is able to reposition self in bed with limited assist from CNA staff. Dressing: The resident requires extensive assistance by (1) staff to dress. Eating: The resident is able to feed self meals; tray set up required from staff. Personal hygiene: The resident requires limited assistance with personal hygiene. Toilet use: The resident requires extensive assistance by (1) staff for toileting. Transfer: The resident uses limited assistance with transfers. Observation and interview on 04/08/25 at 1:44 PM revealed Resident #1 sitting in her wheelchair in her room's doorway observing staff and residents passing in the hallway. Resident #1's fingernails were unclean and needed to be trimmed. Resident #1 stated that staff had not offered to trim her nails when she was showered nor at any other time that she could recall. Resident #1 said she would like them trimmed. Observation and interview on 04/10/25 at 9:02 AM revealed Resident #1 sitting in her wheelchair in her room. Resident's nails were unclean and needed to be trimmed. Resident #1 stated she had been showered, but staff did not offer to trim her nails. Resident #1 said she would like her nails trimmed. Interview on 04/10/25 at 9:52 AM with CNA C revealed she was Resident #1's aide for the day shift. CNA C stated she had not offered to trim Resident #1's nails. CNA C said the aides did not trim residents' fingernails in case residents were diabetic. CNA C revealed aides should alert their nurse if a resident's nails needed to be trimmed. CNA C stated if a resident's were too long, they could cut themselves or scratch another resident. CNA C said she would report it to the ADON if a nurse failed to speak with the resident about the importance of nail care and notify the correct individuals. Interview on 04/10/25 at 9:59 AM with RN D revealed CNAs should trim residents' nails unless the resident was a diabetic. RN D stated the aides should notify the nurse if the resident refused nail care so the nurse could educate the resident on the importance of their nails being trimmed. RN D revealed the nurse should offer to trim the resident's nails up to three times on their shift. RN D stated if the resident refused for an entire day, the nurse should contact the family for assistance. RN D revealed untrimmed nails could lead to infection and spreading of an infection. RN D said the nurse should report the resident's nail care refusal to the ADON and DON. Interview on 04/10/25 at 11:19 AM with ADON E revealed nail care should be offered during showers by CNAs or as soon as they saw a resident's nails were too long. ADON E also said nurses should trim diabetic residents' nails. ADON E revealed if residents refused nail care, the CNAs should notify their nurse. ADON E then stated the nurse should educate the residents who refused nail care on the importance of nail care. ADON E said the nurse should contact the resident's family if the resident continued to refuse nail care. ADON E then stated the nurse should notify the DON if the resident continued to refuse nail care, so the DON could contact the physician to determine if interventions such as medication changes were necessary. ADON E revealed residents with untrimmed nails were at risk for infection and harm to other residents and staff as well as themselves. Interview on 04/10/25 at 1:48 PM with the Interim DON revealed she expected the CNAs to offer nail care during showers. The Interim DON stated if the resident refused nail care by the CNA during an entire shift, she expected the CNA from the next shift to attempt nail care. If the resident still refused nail care, the Interim DON stated the nurse should educate the resident on the importance of nail care as a part of hygiene. The Interim DON said if a resident's nails were untrimmed, it could lead to injury and infection. Record review of the facility's current Care of Fingernails/Toenails policy, dated February 2018, reflected the following: Policy Statement: The nursing services department shall be responsible for identifying and performing nail care as needed and unless otherwise permitted. General Guidelines: 1. Nail care includes cleaning and trimming as tolerated by the resident. 2. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. 3. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. Reporting 1. Notify the supervisor if the resident refuses the care. 2. Report other information in accordance with facility policy and professional standards of practice

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 5 residents (Resident #1) reviewed for foot care. The facility failed ensure foot care, specifically trimming of toenails, was provided for Residents #1. This failure could result in residents developing fungal infections or other podiatric problems. Findings included: Record review of Resident #1's Face Sheet, dated 11/21/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's quarterly MDS assessment, dated 10/30/24, reflected her diagnoses included cirrhosis (severe scarring) of liver, hypertension, pain, muscle weakness, and need for assistance with personal care. Resident #1 had a BIMS score of 07, which indicated severe cognitive impairment. The MDS further revealed Section GG - Functional Abilities indicated resident was totally dependent on staff to assist with getting personal hygiene and getting dressed. Record review of Resident #1's care plan, revised 11/18/24, reflected: Focus: [Resident #1] has a terminal prognosis r/t alcoholic cirrhosis of the liver. She has chosen [Hospice Name] hospice for her end-of-life care provider. Goal: [Resident #1] comfort will be maintained through the review date. Interventions/Tasks: Adjust provision of ADLs to compensate for resident's changing abilities. The care plan did not address Resident #1's ADL care or nail care. Record review of the facility's podiatry visits for 10/09/24 and 11/05/24 reflected Resident #1 had not been seen by the Podiatrist. Resident #1 was also not scheduled to see the Podiatrist on 12/09/24. Interview on 11/21/24 at 9:39 AM with Resident #1 revealed she had some concerns regarding her toenails. Resident #1 stated her toenails were long and they were bothering her. She stated the second and third toe from her right foot bother her the most. She stated since being admitted she had never seen a Podiatrist, and her toenails had not been cut but staff. She stated she had attempted to cut her own toenails a few weeks ago, but she was not able to cut them. She stated she had asked several staff to cut her toenails, but staff would not do it. She stated she was told by staff the Podiatrist would need to cut her toenails. She stated the Social Worker informed her the Podiatrist would see her on 10/09/24, but she was never seen by the Podiatrist. Observation and interview on 11/21/24 at 11:34 AM with RN A revealed the second and third toenails on Resident #1's right foot were long and curving in. RN A stated Resident #1's toenails were overgrown and needed to be cut. Resident #1 stated her toenails bothered her. RN A stated he would notify the Social Worker and request that she put in a Podiatry referral for Resident #1. RN A stated he was able to cut Resident #1 toenails, but the second toenail might need to be cut by the Podiatrist. RN A stated if residents were not diabetic, the nurses or CNAs would be able to cut them; otherwise, the Podiatrist would have to cut their toenails. RN A stated he could not recall if the resident had been seen by the Podiatrist or when her toenails were last cut. He stated he was not aware Resident #1 toenails needed to be cut. He stated the resident was able to make her needs known, and she never mentioned it to him. RN A stated neither facility staff nor the hospice aide had mentioned anything about cutting Resident #1's toenails. He stated the potential risk of not cutting the resident's toenails was that it could lead to ingrown toenail or the toenail cutting into the skin. Interview on 11/21/24 at 11:43 AM with CNA B revealed she was the CNA assigned to Resident #1. She stated Resident #1 was a hospice patient, and the hospice aide would come daily to give the resident a shower and get the resident ready for the day. She stated at times she would assist the resident with putting her socks on. She stated she had seen Resident #1's toenails and they were long; however, Resident #1 had not mentioned anything to her about wanting them cut. She stated she had not asked if she wanted her toenails cut. CNA B stated the nurses or the Podiatrist were responsible for cutting residents' toenails. She stated the risk of not trimming residents' toenails was that it could lead to discomfort or the toenails cutting into the skin. Interview on 11/21/24 at 12:16 PM with the Social Worker revealed she was responsible for completing referrals, and today (11/21/24) she sent a referral for podiatry for Resident #1. She stated prior to today Resident #1 had not been referred to the Podiatrist nor had she been seen by Podiatrist. She stated no one had mentioned to her that Resident #1 needed to be seen by the Podiatrist. She stated Resident #1 had not mentioned anything to her about wanting to see a Podiatrist. She stated the Podiatrist last visited the facility on 10/09/24 and 11/05/24, and the next visit would be 12/09/24. Interview on 11/21/24 at 1:20 PM with the ADON revealed podiatry was responsible for cutting residents' toenails. She stated if a resident needs a podiatry referral, the staff would notify the Social Worker, who would then send a referral. She stated she was unsure if Resident #1 had ever been seen by the Podiatrist. She stated Resident #1 had not mentioned anything regarding her toenails and had not asked to be seen by the Podiatrist. Interview on 11/21/24 at 2:19 PM with the DON revealed all the residents' toenails were cut by the Podiatrist. She stated during morning meetings they verbally talked about referrals that were needed. She stated no one had mentioned to her that Resident #1 needed to be seen by the Podiatrist. She stated Resident #1 was able to make needs known, and she had not mentioned anything regarding her toenails. She stated the potential risk of not keeping toenails trimmed was that it could lead to pain or skin issues. Interview on 11/21/24 at 2:33 PM with the Administrator revealed not all residents were seen by the Podiatrist. He stated if podiatry was needed, the Social Worker would send a referral. He stated residents' needs were communicated during clinical meetings and by report. He stated Resident #1 had not mentioned her toenails to anyone nor had she requested needing podiatry. He stated Resident #1 was capable of making her needs known and had a daily opportunity to report to staff that she needed podiatry care. Record review of the facility's Foot Care policy, revised October 2022, reflected the following: Residents receive appropriate care and treatment in order to maintain mobility and foot health. -Residents are provided with foot care and treatment in accordance with professional standards of practice. -Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for resident without complicating disease processes.

Based on interview and record review, the facility failed to develop and 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, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan addressed activities of daily living. This failure could place residents at risk of not receiving the care required to meet their individual needs. Findings included: Record review of Resident #1's Face Sheet, dated 11/21/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's quarterly MDS assessment, dated 10/30/24, reflected her diagnoses included cirrhosis (severe scarring) of liver, hypertension, pain, muscle weakness, and need for assistance with personal care. Resident #1 had a BIMS score of 07, which indicated severe cognitive impairment. The MDS further revealed Section GG - Functional Abilities indicated resident was totally dependent on staff to assist with getting personal hygiene and getting dressed. Record review of Resident #1's care plan, revised 11/18/24, reflected: Focus: [Resident #1] has a terminal prognosis r/t alcoholic cirrhosis of the liver. She has chosen [Hospice Name] hospice for her end-of-life care provider. Goal: [Resident #1] comfort will be maintained through the review date. Interventions/Tasks: Adjust provision of ADLs to compensate for resident's changing abilities. The care plan did not address Resident #1's ADL care. Interview on 11/21/24 at 9:39 AM with Resident #1 revealed she had some concerns regarding her toenails. Resident #1 stated her toenails were long, and they were bothering her. She stated she was on hospice but was discharged about two days ago. She stated hospice would assist with showers and getting her ready, but now that she was no longer on hospice the facility staff would assist. She stated she had asked several staff to cut her toenails, but staff would not do it. She stated she was told by staff the the Podiatrist would need to cut her toenails. She stated she the Social Worker informed her the Podiatrist would see her on 10/09/24, but she was never seen by the Podiatrist. Interview on 11/21/24 at 11:49 AM with RN A revealed the MDS Coordinators and DON were responsible for updating care plans. He stated ADLs should be care planned because it was part of a resident's daily care. RN A stated he was unable to see the residents' care plans. Interview on 11/21/24 at 11:51 AM with the MDS Coordinator revealed the MDS Coordinators were responsible for creating and updating care plans. She stated ADLs should be care planned for residents. The MDS Coordinator stated Resident #1's care plan was on her to-do list to be revised. The MDS Coordinator reviewed Resident #1's care plan and stated ADLs were not care planned, but they should be. She stated it was missed. She stated there was no potential risk to Resident #1 for the lack of ADL care planning since the resident was now more independent in performing her ADLs. Interview on 11/21/24 at 2:19 PM with the DON revealed the MDS Coordinators were responsible for creating care plans, and nursing staff could update care plans. She stated ADLs should be part of the comprehensive care plan. The DON reviewed Resident #1's care plan and stated ADLs were not care planned for the resident. Record review of the facility Care Plans - Baseline policy, revised March 2022, reflected the following: .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident .C. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility

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 1 of 1 kitchen, in that: 1. The facility failed to ensure DCH A wore a hair restraint while in the kitchen. 2. The facility failed to ensure foods stored in the walk-in cooler, walk-in freezer and dry storage area were properly sealed, labeled and dated. 3. The facility failed to ensure the walk-in cooler maintained an internal temperature below 41 Fahrenheit. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observations of the facility's kitchen on 10/30/24 from 11:19 AM and 11:58 AM revealed the following: - upon entrance, DCH A was observed rolling silverware, near prepared food. DCH A was observed with a hair net on the top half of his hair, the bottom of his hair was not restrained. - an open bag of spaghetti noodles was loosely wrapped in saran wrap in the kitchen's dry storage area. - three half empty bags of pasta were observed to be loosely twisted closed in the kitchen's dry storage area. The bags of pasta were not secured, labeled or dated for date of opening or date of discard. - one small, opened box of beans was observed in the kitchen's dry storage area. The box of beans was unsecured and were not labeled or dated. - an opened bag of cubed meat was observed in the kitchens walk-in cooler. The bag of meat was opened, undated and was not labeled. - a container of hardboiled eggs covered in saran wrap was undated and not labeled in the walk-in cooler. - an opened can of applesauce was covered with saran wrap and was not dated in the walk-in cooler. - a container of a white liquid substance was covered with saran wrap and was not dated or labeled in the walk-in cooler. - a large tray of a green gelatinous substance was covered with saran wrap and was not labeled or dated in the walk-in cooler. - a large tray of partially served brownies was covered with saran wrap and was not labeled or dated in the walk-in cooler. - a opened bag of crinkle cut French fries was unsecured, not labeled or dated in the walk-in freezer - an opened bag of a tan food item was unsecured, not labeled or dated in the walk-in freezer. - the walk-in coolers temperature gauge read 48 degrees Fahrenheit at the time of investigation; an internal temperature gauge was not observed in the walk-in cooler. In an observation and interview on 10/30/24 at 12:06 PM, [NAME] B stated she was the assistant to the Dietary Supervisor and was in charge in the supervisor's absence. [NAME] B stated all foods, prepared or out of their original packaging, stored in the dry storage area, walk-in cooler or freezer should be sealed, dated, and labeled. [NAME] B stated they always use saran wrap to cover or re-wrap foods to be stored. [NAME] B stated she was uncertain of who placed the opened, unlabeled, and undated food items in the food storage areas, but she would discard the items before the end of her shift. [NAME] B stated the dietary supervisor had taken the internal thermometer out of the walk-in cooler to replace it, but she guessed he had not. [NAME] B looked in the walk-in cooler for an internal thermometer, which she could not locate, and directed the surveyor to the thermometer next to the cooler door which read 48 degrees Fahrenheit. [NAME] B stated the temperature of the walk-in cooler was off because the latch at the top of the door would sometimes prevent the door from closing correctly. [NAME] B stated they would check the door to ensure it was closed. [NAME] B stated they were trained to ensure their hair was properly restrained while in the kitchen. [NAME] B stated improper food storage and improper hair restraint practices could lead to food illness. [NAME] B stated she would ensure all dietary staff properly restrained their hair and report all findings to her supervisor. In an observation and interview on 10/30/24 at 12:25 PM, DCH A stated he was trained to ensure his hair was fully restrained when he was in the kitchen. DCH A stated he was primarily washed dishes, did not prepare foods but he would prepare silverware when needed. DCH A stated he tried to restrain his hair, but it would often fall out of the hair net. DCH A stated if his hair was not properly restrained hair could get in food or in the silverware. Following the interview, DCH A placed a second hair restraint over his hair and returned to the kitchen. In a telephone interview on 10/30/24 at 4:14 PM, the Dietary Supervisor stated [NAME] B made him aware of the issues observed in the kitchen prior to his interview with the surveyor. The Dietary Supervisor stated all opened foods should be sealed, labeled and dated with a discard date when stored. The Dietary Supervisor stated food not in their original packaging should be placed in a storage container or a Ziploc bag and saran or cling wrap should not be utilized to seal foods for storage. He stated it was expected for all individuals who entered the facility's kitchen to ensure their hair was fully restrained, as not doing so could lead to contaminated food which would make residents sick. The Dietary Supervisor stated he was not aware of the missing thermometer in the walk-in cooler or that the cooler was observed with a temperature outside of range. The Dietary Supervisor stated the walk-in coolers door did not close all the way because of a latch at the top and he guessed the staff did not ensure the door was closed properly. The Dietary Supervisor stated not storing food at the proper temperature could cause foodborne illness. The Dietary Supervisor stated he would Inservice staff on food storage, preparation and hair restraints to ensure all policies and regulations were followed in the future. In an interview on 10/30/24 at 4:52 PM, the Administrator stated he was aware of the issues observed in the kitchen prior to his interview with the surveyor. He stated it was expected for all foods stored in the facility's kitchen to be properly packaged, sealed, labeled, dated, and stored at the proper temperature. He stated it was expected for all dietary staff and any persons who entered the kitchen to fully restrain their hair prior to entrance. He stated improper food storage and failing to properly restrain hair could lead to food contamination and bad food would be served to residents. He stated he had maintenance look at the walk-in cooler door, the top latch was adjusted and oiled and the door properly closed. He stated he would in-service all dietary staff on food storage, preparation and hair restrains. He stated he planned to conduct random kitchen checks to ensure the kitchen was in compliance at all times in the future. Record review of the facility's policy entitled Preventing Foodborne Illness- Food Handling, revised October 2017, read in part: POLICY STATEMENT: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. POLICY INTERPREPTATION AND IMPLEMENTATION: 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. poor personal hygiene of food service employees; b. inadequate cooking and improper holding temperatures . 5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state specific requirements. Federal standards require that refrigerated food be stored below 41 [degrees Fahrenheit] . 12. Hair nets or caps and/ or beard restraints must be worn to keep hair from contacting exposed, clean equipment, utensils and linens. Record review of the e Food and Drug Administration Food Code, accessed on 10/31/24 at https://www.fda.gov/media/164194/download, read in part: .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLE .3-501 Temperature and Time Control 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen. 3-501.12 Time/Temperature Control for Safety Food, Slacking. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is slacked to moderate the temperature shall be held: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less; or .3-202.11 Temperature. (A) Except as specified in (B) of this section, refrigerated, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be at a temperature of 5oC (41oF) or below when received. P (B) If a temperature other than 5 C (41 F) for a TIME/TEMPERATURE CONTROL FOR SAFETY FOOD is specified in LAW governing its distribution, such as LAWS governing milk and MOLLUSCAN SHELLFISH, the FOOD may be received at the specified temperature. (C) Raw EGGS shall be received in refrigerated equipment that maintains an ambient air temperature of 7oC (45oF) or less. 5 (D) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked to a temperature and for a time specified under SS 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57oC (135oF) or above .

Based on interview and record review, the facility failed to notify the resident or the resident's representative of the transfer or discharge and the reasons for the move 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 one (Resident #1) of three residents reviewed for discharge notices. The facility failed to notify Resident #1 or her representative in writing of her transfer/discharge to the hospital for behavioral reasons, the reason for the transfer, and the right to appeal and they failed to send a copy of the notice to the ombudsman as soon as practicable of the transfer/discharge. This failure could place residents at risk of being transferred or discharged , and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #1's face sheet, dated 09/04/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged [DATE] to an acute care hospital. Record review of Resident #1's 5-day scheduled MDS assessment, dated 03/26/24, reflected a BIMS score of 12, which indicated moderate cognition impairment. Her diagnosis included encephalopathy (brain dysfunction), legal blindness, acute respiratory failure, and schizophrenia. Record review of Resident #1's Nurses Notes, dated 03/28/24, reflected the following: [Resident #1] was discharged today to the VA Hospital due to her increasing and escalating mental health concerns that were preventing her from fully participating in her rehab here at this facility. VA LCSW confirmed she spoke with the VA physician as well as the VA ER LSW and sent notes stating [Resident #1] had been discharged from the VA CCN Contract program effective today due to her needs not being able to be safely met at this facility. Facility Administrator phoned and notified [Resident #1] guardian, [Guardian Name]. [Guardian Name] stated she and the family would be at this facility at some point this weekend to pick up [Resident #1] personal belongings. Review of Resident #1's clinical record reflected there was no documentation of the resident, the resident's responsible party, or the Ombudsman being notified in writing of the resident's discharge or the reason for the resident's discharge. Interview on 09/04/24 at 10:01 AM with Resident #1's POA revealed she had received a phone call on 03/28/24 at around 11 AM stating Resident #1 was going to be transferred to the VA ER to get a mental health evaluation and medication adjustment. Resident #1's POA stated the same day 03/28/24 at around 3 PM she received a call from the Administrator, and he stated the resident was going to be discharged from the facility. Resident #1's POA stated she did not receive any paperwork or discharge information. Interview on 09/04/24 at 4:11 PM with the Ombudsman revealed she was not notified of Resident #1's discharge. Interview on 09/04/24 at 4:32 PM with the Administrator revealed Resident #1 was transferred to the hospital for a mental health assessment and stabilization. He stated Resident #1 was being combative, verbally aggressive, and refusing care. He stated by Resident #1 agreeing to go to the hospital Resident #1 initiated the transfer. The Administrator stated the VA ended Resident #1's contract on 03/28/24 and the resident was discharged . He stated the family was made aware verbally. He stated nothing in writing had been sent with the resident or family explaining the reason for her discharge. The Administrator stated he was not aware the Ombudsman had to be contacted for any discharges other when a resident was issued a 30-day discharge notice. Review of the facility's current Transfer and Discharge, facility - Initiated policy, revised October 2022, reflected the following: Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Notice of Transfer or Discharge (Emergent or Therapeutic Leave) 1. When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfer, NOT discharges, because the resident's return is generally expected. 2. Residents who are sent emergently to an acute care setting, such as hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility . 3. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable. 4. Notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer. 5. Notices are provided in a form and manner that the resident can understand, taking into account the resident educational level, language, communication barriers, and physical or mental impairments.

Based on observation, interview and record review, the facility failed to ensure resident rooms were equipped with privacy curtains the assured full visual privacy for 11 of 53 rooms (Rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409) reviewed for visual privacy. 1. LVN C and CNA D failed to ensure Resident #2 had full visual privacy while providing care. 2. The facility failed to ensure the residents in the A beds in Rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409 had privacy curtains to assure full visual privacy. This failure could place residents at risk of being exposed to the hallway during cares. Findings included: Review of Resident #2's undated Admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain chemical imbalance), muscle weakness, and reduced mobility. Review of Resident #2's quarterly MDS, dated [DATE]. revealed a BIMS score of 3 indicating severe cognitive impairment. Her Functional Status indicated she required total assistance with all of her ADLs. Review of Resident #2's care plan, dated 02/20/24, revealed she had a self-care deficit requiring assistance with her ADLs, impaired cognitive function and impaired thought processes, and was a high fall risk. Observation on 06/06/24 at 1:40 PM revealed LVN C and CNA D were assisting Resident #2 back to bed from her wheelchair, using the lift device. LVN C closed the resident's door, blocking the view from the hallway. After the resident was in bed, during her skin assessment, the door to the hallway popped open slightly. There was not a privacy curtain around Resident #2's bed. Interview on 06/06/24 at 1:50 PM LVN C stated privacy for residents in A bed was created by closing the door and pulling the curtain between the beds. LVN C agreed the door was not secured to prevent someone from walking in during care when the resident was exposed. LVN C stated they yelled Cares! when someone knocked on the door or walked in, but that would not stop another resident from coming in. LVN C stated being exposed during care could lead to decreased feelings of self-worth by the resident. Observation on 06/06/24 from 1:55 PM-2:20 PM of Halls 100, 200, 300, and 400 revealed 11 (Rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409) of 53 rooms had no privacy curtain for residents of the A bed. Residents of the B bed only had a curtain between the beds, no curtain across the end of the bed. Interview on 06/06/24 at 3:15 PM with the DON revealed residents needed privacy when they were receiving care. She was not aware the rooms did not have the appropriate privacy curtains installed. She stated it was a dignity issue for the residents. Interview on 06/06/24 at 3:30 PM with the Administrator revealed he was not aware there were not appropriate curtains for the resident's privacy. He stated it was a dignity issue of someone walked in on a resident receiving care. Interview on 06/06/24 at 4:00 PM with the Administrator revealed the facility did not have a policy addressing privacy curtains specifically.

Based on observation, interview and record review, the facility failed to maintain an infection control program for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for 1 of 5 residents (Resident #1) reviewed for infection control. Housekeeper A picked popcorn off the floor and placed it back into Resident #1's bag and was subsequently eaten by Resident #1. This failure could place residents at risk of exposure to pathogens from the floor. The noncompliance was identified as PNC. The noncompliance began on 03/20/24 and ended on 03/21/24. The facility corrected the noncompliance before the survey began. Findings included: Review of Resident #1's undated Admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included pelvic fracture, history of falls, and dementia. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 10 indicating mild cognitive impairment. Review of Resident #1's care plan, dated 05/13/24, revealed he had impaired cognitive function related to dementia, he suffered from depression related to being in the nursing home, and he is on anti-anxiety medications. Interview on 06/06/24 at 9:10 AM with Resident #1 revealed he had no recall of the event. Resident #1 stated he liked popcorn, and his family brought him popcorn as a snack. Interview on 06/06/24 at 11:00 AM with Resident #1's family member revealed the family reviewed video footage of Resident #1's room from 03/20/24. The video footage showed a female staff member, they assumed a housekeeper, cleaning the resident's room. The video also showed this staff member [Housekeeper A] picked some popcorn off the floor and placed it in the resident's bag of popcorn sitting at his bedside. The family member stated Resident #1 returned to his room later and continued to eat his popcorn, consuming the entire bag. The family notified the Administrator on 03/21/24 and supplied the video footage. Interview on 06/06/24 at 12:00 PM with Housekeeper B revealed she had been helping Housekeeper A with Resident #1s room. She stated she had seen Housekeeper A pick popcorn off the floor and place it in a bag of popcorn on the resident's bedside table. Housekeeper B stated she thought Housekeeper A was going to throw the whole bag away, and she did not know she had not until she spoke with the Administrator the next day. Interview was attempted on 06/06/24 at 12:45 PM with Housekeeper A via telephone; however, the attempt was not successful and Housekeeper A did not return the call. Interview on 06/06/24 at 3:30 PM with the Administrator revealed the family of Resident #1 contacted him via telephone about the incident. When he reviewed the video footage, he stated it was very clear what Housekeeper A had done. He stated Housekeeper A was called to his office to discuss the incident and was then terminated. Review of the facility's policy Resident Rights, dated February 2021, revealed: Employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 12 of 12 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview on 03/19/24 at 10:00 AM during a confidential resident group meeting with 12 residents, revealed the resident council meeting were held once a month in the dining room. The meeting was held in a TV room that was closed off to the staff and private. The residents stated normally the resident council meetings were being held in the dining room, which was an open space and no way to keep staff from walking by or overhearing. The resident further stated they really liked the privacy of the current meeting because they felt like they could speak freely without feeling like they were being overheard by staff. Interview on 03/21/24 at 2:47 PM with the Activity Director revealed they had been having the resident council meetings in the dining room for the past two years. She stated they were having the meetings in a private room but they moved to the dining room because that private room did not fit all the residents that wanted to attend. The residents were asked if they had any problems having the resident council meetings in the dining room and she said they all said no. The Activity Director further stated they had a bigger room and she had no problem moving the council meetings there. She also stated by having meetings out in the open, staff could potentially listen in and residents would be more hesitant to complain about certain staff members. Interview on 03/21/24 at 3:06 PM with the Administrator revealed resident council meetings were being held in the dining room and per the Activity Director, she had asked the residents if the location was ok and they had all said yes. The Administrator was asked if there were any risks of having the resident council meetings in the dining area he stated it was the resident's rights to have it where they wanted. Review of the facility's undated policy titled Resident Council reflected the following: .3. The resident council group is provided with space, privacy, and support to conduct meetings

Based on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for 1 (Resident #45) of 16 residents reviewed for quality of care. The facility failed to obtain follow-up orders when Resident #45 returned to the facility from the hospital with a splint after she was diagnosed with an elbow fracture. The failure placed residents at risk of not receiving needed treatments to prevent conditions from worsening. Findings included: Review of Resident #45's MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, hemiplegia (paralysis of one side of the body), respiratory failure, fracture of lower end of humerus, and acute cholecystitis (inflammation of the gallbladder). Resident #45 had a BIMS of 9, cognition moderately impaired, and was able to be understood and she understood others. Observation and interview on 03/18/24 at 12:40 PM with Resident #45 revealed she was in her wheelchair sitting across from the nurse's station. Her left arm was covered with an ace bandage and Resident #45 said she had fallen in the bathroom over a week ago and broke her arm. The resident said she had been sent to the hospital with other issues other than her broken arm and she also said she was not in any pain at the time. The Resident said no one had taken her splint off since she readmitted from the hospital (02/29/24) nor had she been assessed by any doctors. Review of Resident #45 hospital records dated 02/28/24 reflected the resident had a left elbow fracture, ortho was consulted and there was a sling in place. The hospital records did not have any discharge instructions/ orders or follow-ups for her arm. Review of Resident #45's hospital records dated 03/09/24 reflected the resident had been transferred for reasons unrelated to her arm. Further review of the records revealed Resident #45 had a left radial head fracture, a splint was in place and Resident #45 had an out patient follow-up with an ortho but there was no date added. Interview on 03/20/24 at 4:33 PM with LVN A revealed she had readmitted Resident #45 from the hospital on 02/29/24 and she did not recall seeing any orders regarding the resident's arm. The LVN said she called Resident #45's physician but did not recall if she heard back from him or if she followed up. LVN A said she did not know if Resident #45 had a cast or a splint and she have never taken the wrap off to see what was underneath. She said she would check the skin around the ace wrap and look at the resident's fingernails for any discoloration. LVN A further stated the ADON and DON knew the resident had returned with a wrapped arm and LVN let them, ADON and DON, take over . The LVN stated she should have continued to follow-up with the physician to get orders. Interview on 03/21/24 at 10:42 AM with LVN B revealed he never looked underneath Resident #45's wrap because he believed it was a cast and he only checked her fingers for circulation. LVN B further stated if residents did not have a cast, they were expected to look under any device to check their skin integrity and make sure there was no breakdown. Interview on 03/20/24 at 3:09 PM with the ADON revealed there should have been some type of orders to care for Resident #45's arm to check the skin integrity under the ace bandage but did not know why there was not. The ADON said the Physician was contacted (03/20/24) and ordered an xrays for the following day (03/21/24). Observation and interview on 03/21/24 at 8:40 AM revealed the xray company had just left the facility after Resident #45's arm xray. The ADON stated the Physician had given them an order to take resident's splint off and apply a soft wrap around the resident's arm. Observation of Resident #45's skin on her fractured arm was intact and there were no skin breakdown and the resident denied having any pain. The ADON said they would send the xray results to the Physician as soon as they arrived. Interview on 03/21/24 at 12:34 PM with the DON revealed when Resident #45 was readmitted from the hospital it was discussed with IDT and she did notice the resident did not have any orders for her arm so they contacted the resident's Physician and he took over the care, but was not able to say what the Physician had put in place. The DON said staff were checking capillary refills on the resident's hand. The DON further stated when Resident #45 readmitted (02/29/24), she personally would have called the hospital to get clarification or further instructions. The DON said she would have expected the admitting nurse to continue to try and reach the doctor for orders when Resident #45 returned from the hospital to get clarification and follow-up orders for her arm or they should have called the hospital to get clarification on the ortho appointments mentioned in the discharge paperwork. They interpreted the ortho appointments as mentioned that the resident had seen an ortho doctor at the hospital. Interview on 03/21/24 at 2:23 PM with the Wound Care Nurse revealed she was making a wound care appointment for Resident #45, 03/21/24, and she went ahead and made an ortho appointment because she had not seen what was under the resident's bandage on her arm. The Wound Care Nurse looked through Resident #45's discharge paperwork from the hospital and she did not see any follow-ups related to her fractured arm. She said normally if there were no follow-ups nursing should call the surgeon for care instructions. Attempts to contact the hospital on 03/21/24 for clarifications orders for Resident #45's arm were unsuccessful. Interview on 03/21/24 at 3:34 PM with the Physician revealed he did not recall if he was ever contacted about Resident #45's arm when she was readmitted from the hospital (02/29/24). He stated if the resident did not come back with orders for her arm, the facility should have followed up with the surgeon or provider that cared for the resident at the hospital for clarification. The Physician further stated if the facility was not able to get in touch with the hospital staff, then he would have to take over the care and gave the nurses care orders. The Physician said he did see Resident #45 the day prior, 03/20/24, but did not unwrap her arm but he had ordered some xrays to be completed. He also said he looked at the xray results and saw some osteoporosis but he would have the facility follow-up with the ortho doctor. He stated risk of not getting follow-up orders could worsen a resident's condition or health. At the time of exit, the facility did not have a policy related to resident admission or re-admission to the facility.

Based on observation, interview, and record review, the facility failed to ensure that the residents are free from accidents and hazards for one (Resident #1) of two residents reviewed for mechanical lift transfers. The facility failed to safely transfer Resident #1 and prevent injury during the use of the mechanical Hoyer lift, resulting in a laceration on the forehead on 12/16/23 and back pain on 11/20/23. This failure could place residents at risk for accidents that could lead to injuries such as bruising, skin tears and fractures. Findings included: Record review of Resident #1's MDS assessment dated , 10/11/223, revealed the resident was a [AGE] year-old male, who was initially admitted to the facility on [DATE] and readmitted on [DATE]. The resident was cognitively intact with a BIMS score of 15, and his diagnoses included displaced tri malleolar fracture of right lower leg (fracture of the lower leg sections that form ankle joint and help move foot and ankle) and morbid severe obesity (weights are more than 80 to 100 pounds above ideal body weight). Record review of Resident #1's undated care plan, reflected, Focus: Impaired physical mobility. Goal: Will be free of complications of immobility. Interventions: Educate resident, representatives on exercise and safe transfer techniques. Educate resident/representatives on safety precautions. Evaluate skin for areas of blanching or redness. Resident requires a Hoyer lift with transfer. Record review of Resident #1's hospital record, dated 11/20/23, revealed Resident #1 was referred to the hospital emergency roiagnom on [DATE], with the reason for referral identified as severe back pain. The hospital radiology record reflected Resident #1 had no acute fracture of the lumbar spine, mild irregularity of the right aspect of the cecum(abnormal wear on the cartilage and bones of the neck), sacral insufficiency fracture not excluded, and severe lumbar spondylosis (abnormal wear on the cartilage and bones of the neck). Resident #1 was discharged on [DATE]. Record review of Resident #1's hospital record, dated 12/16/23, revealed Resident #1 was referred to the hospital emergency roiagnom on [DATE], with the reason for referral identified head injury. The hospital radiology record reflected Resident #1 had: 1. Age-indeterminate tiny left occipital condyle avulsion. 2. Otherwise, no acute osseous abnormalities of the cervical spine. Resident #1 was discharged on [DATE] with no new orders. Observation and interview on 12/18/23 at 9:53 AM with Resident #1 revealed he was in his wheelchair ready for therapy. He was observed to have a steri-strip (a thin adhesive bandage) on the forehead, no bruise or swelling observed. Resident #1 stated he had been sent to the emergency room twice after having been injured during transfers with the Hoyer lift (a mechanical patient lift or portable total body lift). Resident #1 stated during both transfers he had two staff at all times. Resident #1 stated four days prior to 11/20/23, CNA A and LVN B were transferring him from the chair to the bed, and the Hoyer lift jerked and hurt his back after the battery went off. Resident #1 stated the day he was taken to the hospital emergency room was not the day the Hoyer lift jerked. He stated from the day of incident he was being transferred daily with the Hoyer lift and was not in pain until four days later. Resident #1 stated when he started having pain he did not report it to the facility, but he reported to his VA Case Manager. He stated he thought the VA Case Manager later notified the facility Administrator, who came and checked on him. He stated they concluded he needed to be taken to the emergency room where x-rays were taken and later that evening he was sent back to the facility with no spine injury. Resident #1 stated the second incident happened when two CNAs were transferring him, and the Hoyer lift tripped and hurt him on the forehead, which caused a laceration and bleeding. Resident #1 stated he was taken to the hospital and was sent back with no new orders. Review of Resident #1's progress notes, dated 11/20/23, revealed the following: Resident care of severe lower back pain rating 9/10. Resident has been on pian management with Tylenol #3 but at this moment he stated that the pain had increased severely. He cited the pain from few days ago while transferred to bed using Hoyer lift. MD notified new order received to send him to ER for eval and treatment. Review of Resident #1's progress notes, dated 12/16/23, written by the Charge Nurse reflected the following: This morning at about 9:45am, while this charge nurse was attending to other functions, notified by aide that resident had sustained head injury while being transferred to his wheelchair via Hoyer lift. Two aides present at time of transfer. Other charge nurses who were present in the immediate area were also notified and responded immediately and took care of resident. This charge nurse then went to resident's room to assess and was notified by aide that while resident was being transferred to his wheelchair with the Hoyer lift, as resident was being lowered into the wheelchair, the Hoyer lift tilted forward towards the resident and hit him in the forehead which led to resident sustaining a small laceration measuring 0.1 cm x 1 cm x 0.1 cm. head was wrapped with dry dressing to control bleeding. This charge nurse took dressing off to assess area. Mid forehead slightly swollen and scant bleeding noted to dressing. no active bleeding noted from site. resident reported pain to wound site and tenderness to touch. When asked what happened, resident stated, 'I don't know. It just hurts especially when you touch it.' Resident was medicated with prn Tylenol #3 for pain management at his request. Resident also reported difficulty staying awake while seated in wheelchair. vitals - 146/82; [heart rate] 79; [respirations] 16; [temperature] 97.6; [oxygen saturation level] 97% on room air; pain level 9/10. Charge nurse asked resident at least 3 times if he wanted to go to the hospital and resident refused. On the 5th try, resident stated, 'I am waiting for my son to get here and then we will go from there.' Manager on duty spoke with resident and he eventually agreed to go to hospital. Interview on 12/18/23 at 12:56 PM with the Administrator revealed he had visited with Resident #1 on Monday 11/20/23 in the morning during his normal rounds before the morning meetings. He did not mention pain, or any complaints until later in the day when the Administrator received a call from the VA Case Manager that Resident #1 had made complaints. He stated he reported the incident to the State agency (HHSC) because the resident claimed the CNAs did not know what they were doing. He stated he started and investigation and found the Hoyer lift battery went off. He stated Resident #1 did not fall. Interview on 12/18/2023 at 2:25 PM with CNA A revealed he was working on 11/16/23 when the incident occurred with Resident #1. He stated he was being assisted by LVN B who was the charge nurse to transfer Resident #1 back to bed. CNA A stated when Resident #1 was being lowered back to bed, LVN B was the one controlling the Hoyer lift when the battery went off making the Hoyer lift jerk. CNA A stated he went for another battery, and they lowered Resident #1 back to bed. He stated the resident did not complain of pain until 11/20/23, when he was notified that Resident #1 was referred to the hospital due to back pain, and he was told it was due to the jerking of the Hoyer lift that had happened days before. CNA A stated the Hoyer lift batteries were charged overnight and at the end of the shifts. CNA A stated he did not know the battery would go off, but he was supposed to have changed the battery before the transfer because he did not know how long that battery was on the Hoyer lift. He stated it was hard to tell the battery was out of power unless when it was connected to the machine, and it failed to operate. A telephone interview was attempted on 12/18/23 at 2:56 PM with LVN B, but the attempt was not successful. A voicemail message was left, but LVN B was out of the country as confirmed by management. Interview on 12/18/23 at 3:00 PM with LVN F revealed she was on duty on 12/16/23 and assigned to Resident #1. LVN F stated when the incident happened, she was not in the facility because she had gone to buy coffee. She stated CNA D called her back to the facility. She stated she asked the CNAs what happened, and they told her that as they were lowering Resident #1 from the bed to the chair, the Hoyer lift tipped over and the hooks that held the sling hit Resident #1 on the face causing a laceration and bleeding. LVN F stated by the time she got to the room LVN G had already arrested the bleeding and had put a bandage on the area. LVN F stated she ensured Resident #1 was safe and then she called 911 for transfer to the ER because it was hard to keep the resident awake. LVN F stated she asked CNA D and CNA E to take her through the procedure of transferring the resident with the Hoyer lift because by the time she got to the room the Hoyer lift was already disconnected from the resident, who was seated on the chair. She stated the Hoyer lift was in good condition and could lift a maximum of 450 pounds. She stated she could not tell what the CNAs did wrong. She stated she had done training on Hoyer lift transfers, checking of the maximum weight, and every transfer there should be two staff. Interview on 12/18/23 at 3:20 PM with CNA D revealed she and CNA E were transferring Resident #1 from the bed to the chair when the Hoyer lift tilted toward Resident #1 and the hooks that held the sling banged Resident #1's forehead causing a laceration and bleeding. CNA D stated they used the correct Hoyer lift, but she suspected the Hoyer lift legs tilted causing the accident. CNA D stated she did not identify the problem. She stated two nurses came and helped with repositioning of the Hoyer lift and the resident assessment. She stated she stayed with Resident #1 while CNA E went to call the nurse. She stated she had done training on Hoyer lift transfers prior to the incident, and they also received Hoyer lift transfer training after the incident. A telephone interview was attempted on 12/18/23 at 3:25 PM with CNA E; however, the CNA's telephone number was not in service. Telephone interview on 12/18/23 at 3:41 PM with LVN G revealed she was on duty on 12/16/23 but was not assigned to Resident #1. LVN G stated CNA D came and notified her that during a transfer Resident #1 sustained laceration on his forehead. She stated she asked the CNAs what happened, and they told her the Hoyer lift hit him after it tipped as they were transferring Resident #1. LVN G stated it had stopped bleeding and as she was conducting the assessment the assigned nurse came and took over. LVN G stated by the time she got to the room the Hoyer lift was already disconnected from the resident, and it looked normal with nothing was broken. She stated she had done training on Hoyer lift transfers and there should be two staff for every Hoyer lift transfer. Interview on 12/18/23 at 4:14 PM with the DON revealed she was made aware of Resident #1's accident with the Hoyer lift the morning of 12/16/23 when she came to the facility after learning of the incident. The DON stated her staff used a Hoyer lift that lift 450 pounds, and the resident weighed 380 pounds. She stated the staff told her when they were transferring Resident #1 from the bed to the chair with a Hoyer lift, the Hoyer came down and the bars that hold the sling hit Resident #1's head causing a laceration on his forehead. The DON stated the incident that happened on 11/16/23, LVN B and CNA A stated they were transferring Resident #1 from the chair to bed when the battery went off and to her understanding the staff did a quick manual release of the Hoyer lift. The DON stated it is the responsibility of her staff to ensure the batteries were charged before they used them on Hoyer lifts. She stated during her investigation she noted one charging port was not charging the batteries, and it was replaced. She stated it was her responsibility and her ADONs to ensure the staff were charging the batteries. She stated staff should swap batteries every shift and as needed. She stated the Hoyer lifts were maintained every time they suspected there was a problem. She stated the maintenance personnel checked on them every month. She had done in-services on Hoyer lift transfers on 12/16/23 and 11/21/23 with all her staff and also one-on-one with CNA A and LVN B. Interview on 12/19/23 at 12:17 PM with the Physiotherapist revealed she knew Resident #1 was a two-person Hoyer lift transfer. She stated the Hoyer lift could have tripped if the weight shifted, positioning of the Hoyer lift, and opening of the Hoyer lift legs. Record review on 12/19/23 of the maintenance list of lifts and scales revealed the lifts were last inspected on 11/30/23. Record review of the facility's current Safe Lifting and Movement of Resident policy, dated 2017, reflected the following: .In order to protect the safety and wellbeing of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents

Based on observations, interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #2) of ten residents reviewed for neglect. The facility failed to ensure Resident #2 did not elope from the facility. The facility staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. The resident was located around 6:00 pm 12 miles away from the facility after police became involved and a Silver Alert had been issued. An Immediate Jeopardy was identified on 08/22/23. The IJ Template was provided to the facility on [DATE] at 5:03 PM. While the Immediate Jeopardy was removed on 08/24/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could affect residents and place them at risk of further abuse/neglect with exit-seeking behaviors by placing them at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme heat exposure. Findings included: Review of Resident #2's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain. Vascular dementia can develop after a stroke blocks an artery in your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one- person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one-person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2 did not have an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard. Review of Resident #2's care plan dated 03/17/23 and last revised 08/21/23 reflected the following: - Date initiated 03/17/23: The resident has Dx of Vascular Dementia unspecified severity without behavioral disturbance. Resident is taking Aricept; Interventions: Cue, orient and supervise as needed. - Date Initiated: 06/11/2023- Resident removed wander guard (not found in room); Interventions: Encourage resident to participate in activities of choice, Notify MD of increase wandering behavior if needed. - Date initiated: 07/20/23- Wander guard removed related to no exit seeking; Interventions: Educate Resident / Representative on the necessity of care attempted to provide, Ensure the safety of Resident and others. -Date initiated: 08/21/23- Resident elopement from facility 8/19/23; returned 8/20/23. Resident will remain 1:1 until alternate placement is found; Interventions: Assess resident's coping skills and support system, Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Review of Resident #2's Elopement Evaluation at his time of admitted d 03/17/23 reflected he had no prior history of elopement at home no wandering behavior that was a pattern or goal-directed, no wandering that was likely to affect the safety or well-being of self/others and his elopement score was a 0 (zero). As a result, no interventions were checked on the assessment as being needed to prevent elopement. No other elopement evaluations were completed until after Resident #2's elopement incident on 08/19/23. Review of Resident #2's nursing progress notes for 08/19/23 and 08/20/23 did not reflect he was missing or eloped from the facility. The only nursing notes for those dates reflected, 08/20/2023-Nursing: MD notified that resident was found [signed by ADON I]; 08/20/2023-Nursing: Called MD and notified him that family, responsible party was in facility with resident at this time and requests that he has his night medications at this time. MD gave N/O to give meds now. [signed by ADON I]; 08/20/2023-Nursing: [hospital] notified that resident was found [Signed by ADON I]; 08/20/2023-Nursing: Resident returns to the building with family at bedside. Head to toe assessment and VS done. VS: BP 130/92, 02 96% RA, HR 96, RR 17, and no c/o pain. No injuries or tears noted to skin. Dry scaly heels bilaterally. Resident is calm, friendly and engaging in conversation; 08/20/2023-Nursing: Resident currently resting in bed. He is on 1 to 1 observation; 08/21/2023 Nursing: MD notified of the resident increased confusion and gave order to increase Donepezil HCl Oral Tablet to 10 MG at bedtime. MD also gave dx of Psychosis with Dementia for Seroquel. [RP] notified via VM. Record review of the facility's incident report for Resident #2 dated 08/20/23 at 12:10 PM and completed by ADON I reflected, Incident description: Resident noted to be missing from room at approximately 12pm. Search conducted at facility. Admin notified ASAP. Approximately 6pm police notified facility that resident was found. Immediate Action Taken: Facility was searched and administration, responsible party, physician, DON, and [hospital] notified. Police department notified. MD notified of missed medications, no new orders given. Upon return to facility, head to toe assessment and pain assessment done. Resident placed on one on one care, sitter at bedside. Review of Resident #2's August 2023 physician orders reflected they were ordered by MD D. Resident #2 had two discontinued orders that reflected, Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift [Verbal Discontinued 03/17/2023], and Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift [Verbal Discontinued 07/14/2023]. Review of Resident #2's August 2023 MAR reflected he missed the following prescribed medications during the time he was missing from the facility on 08/20/23 were Aspirin Oral Capsule 81 MG (blood thinner), Calcium-Vitamin D Oral Tablet 500 MG Protein Oral Liquid 30 ml (supplement). An interview with MD D on 08/23/23 at 1:00 PM revealed he did not know Resident #2 was on his caseload until the incident with the elopement. He stated he did not know he was missing for over 18 hours and only got notified when he was located . Review of website: https://www.accuweather.com (retrieved 08/22/23) revealed the temperature high for the location Resident #2 was found on 08/20/23 was 109 degrees fahrenheit. An interview with Resident #2's RP on 08/22/23 at 6:30 AM revealed when Resident #1 was located by the Police, she went to see him and transport him back to the facility. The RP stated she observed Resident #1 to be extremely confused and scared. He was covered from head to toe in dirt and had a trash bag full of garbage one would find in a dumpster. The RP stated she was a RN and was able to assess her father and noted that he had 4+pitting edema. An interview with the ADM on 08/22/23 at 9:40 AM revealed he was notified on 08/20/23 at approximately 1:00 PM that Resident #2 was missing by ADON I. He asked her what happened and she said staff had just searched the entire facility to verify Resident #2 was not there, so the ADM drove to the facility and on his way called the local police department and filed a report. The police arrived at the same time he arrived at the facility. Then the ADM started going through surveillance footage in the facility with police and while he was doing that, DA M came to his office and said she thought she may have known what happened. DA M told him on her way out the door the evening before on Saturday, 08/19/23, at approximately 7:38 PM, someone had slipped out the front door behind her and she thought it was a family member of a resident; she didn't recognize the person. The ADM said he went to that part of the surveillance footage and sure enough, it was [Resident #2] that went outside, walked out. In her defense, it was very smooth, he has dementia but you wouldn't know that, you would have to have a conversation to determine that. The ADM stated there would not have been a front desk staff at 7:40 PM the evening of the incident. The ADM stated he then checked the outside surveillance footage and was able to see Resident #2 coming around the side of the building walking down the sidewalk to the left of the facility. He stated, At that point, by the time I found that footage, the police had already started the process for a silver alert and approx. 30 minutes later, I got a call from a sergeant saying he had been found in a hotel lobby in [city name]. The ADM stated the police notified the family who were on their way to pick Resident #2 up. He stated the family had been notified around 1:00 PM that afternoon that Resident #2 was missing and he was found around 6:00 PM. The ADM stated he was told Resident #2 was found with a trash bag and a water bottle, a banana and a couple rachet straps and surmised the resident may have gotten a ride due to the distance. He was brought back to the facility, placed on 1:1 supervision and had been on 1:1 since then. The ADM stated, So this was the confusion, I had a couple of statements from staff saying he was identified later that night of when he eloped around 11:00 PM asking for snacks at the nurses station. Number one, it is very common for him to not be in his room, he has no history of exit seeking, just walking around the facility. The ADM stated Resident #2 would not have known how to get back into the facility if he was locked outside and confirmed the front exit door locked after the door closed. The ADM further stated Resident #2 was not wearing a wander guard anymore because he was a low-elopement risk and just walked around the facility and had dementia. The ADM stated he ordered a tamper-resistant wander guard bracelet, but did not have any evidence of it, and he stated Resident #2 kept removing it. The ADM stated Resident #2 had cut through four to five wander guards off his wrists, even though he had no evidence of it, did not know when the wander guards were attempted to be placed, was not present for the placement and no one ever saw the resident remove them. He stated he met with Resident #2's family in July 2023 and told them Resident #2 was not exit-seeking and was cutting the wander guard off, so we need it removed or if they want him to keep it on, he needed to move. He stated the resolution was to take it off his ankle and move it to his wrist by family request because the family told him Resident #2 had a criminal history with ankle monitors and having one on his leg may have triggered him. The ADM stated, We agreed to have it discontinued because he has never tried to elope before. The [family member] was okay with that and we were all on the same page. It was in a way a perfect storm for this to happen. We had the wander guard removed because of no exit seeking and he doesn't come across as having dementia and looks like a family member. The ADM stated once Resident #2 was located post-elopement and brought back to the facility, he did not interview him. He stated, I want to say someone from our nursing staff talked to him. The ADM admitted the overnight staff working 08/19/23 into 08/20/23 did not round on Resident #1. He said he was still conducting his facility investigation, but from what he could tell thus far, he had been told CNA X rounded on Resident #2 at midnight but then later said maybe she got the resident rooms mixed up. The ADM stated, He does not like to be bothered at night and gets agitated, so that was why he had less rounds. If he doesn't require incontinent care, then it would be opening his door to make sure he was there as rounding. He does not have a roommate. It could be done quietly and that was my conversation with them yesterday when we started the in-service. The ADM stated the elopement incident could have been prevented by staff ensuring when they left the facility exits, to make sure there were no residents trying to leave and if they were unsure who a resident was, to stop and ask them. The ADM stated, This goes back to us not being equipped to care for his needs. He is not the type of resident appropriate for this care, but we would not have known that. A wander guard would have solved this problem. He removed four or five wander guards. An observation of the facility video footage dated 08/19/23 at approximately 7:38 PM showed Resident #2 walking down the hallway casually towards the front lobby. DA M was also observed coming down a different hallway to the front entrance. No other staff, family members or residents were observed. DA M went to the keyed alarm panel to the left side of the front door and while she was putting in the code, Resident #2 walked towards her and was standing behind her. When she opened the door, she held it open for him and he walked out through the door after her. Then there was a second sliding door that automatically opened without a code and they both proceeded out of that door together out into the parking lot. An interview with DA M on 08/22/23 at 10:12 AM revealed she did not interact much with residents and 95% of the time she was in the kitchen and at other times, she was delivering meal carts to CNAs or nurses. She said she did not know who Resident #2 was and could not recall seeing him before. DA M stated, When I let him out, I saw him standing the door, I had my head down and was ready to head out, I typed in the code and he followed right behind me, he said thank you so much, clear as day, and I thought he was family member. I didn't think much of it. DA M stated she had not been informed by the facility who were potential exit-seekers or what to do if she saw one of those residents attempting to elope. She stated, 'I didn't think I would be in a situation where I would be dealing one-on-one with a resident. I had not been informed on what to do if one wanted to leave. If I had seen him around and knew him, I would have grabbed a CNA or nurse and told them he was trying to leave, but it was the end of my shift, I clocked out and wasn't thinking much of it, I thought he was a visitor of a resident here. I walked out and my mom who was in a car picking me up, said she had seen a man walk out behind me but didn't think much of it. He spoke clear as day and said thank you very much, he was dressed in casual clothing, I glimpsed at him. DA M stated when she came to work Sunday 08/20/23, the kitchen staff were telling her about a resident who had eloped the day before and it was then she realized through their description of him, that it might be the man she let out the day before. DA M said she ran to the ADM's office and police were there and she told them what had happened the night before and they were able to then pull it up on surveillance camera and verify Resident #2 went out the door behind her around 7:38 PM. An interview with ADON I on 08/22/23 at 10:41AM revealed she was at the facility on 08/19/23 until 5:00 PM and was at the facility on 08/20/23 from 6:00 AM until 11:00PM. ADON I stated when she came into work on 08/20/23, no one mentioned Resident #2 was missing. She said the CNA that worked with him [CNA B], went to pick up is breakfast tray around 12:10 PM and it had not been eaten and she then asked ADON I if she had seen him around. ADON I said the CNA B would have delivered the breakfast tray around 7:45AM-8:30AM. ADON I stated they immediately checked all the resident rooms and bathroom, his friends' rooms and he was not present. Then someone drove the perimeter outside, down to the nearby shopping strip and did not see him. Then ADON I called the family and asked them if Resident #2 was with them and they said no. At that point ADON I stated she called the DON, called ADM and called the staff who worked the night shift before. She said there was an agency nurse [LVN P] who said she remembered checking on Resident #2 during her overnight shift. ADON I also stated she called the overnight CNA, who also remembered checking on Resident #2 during the overnight shift. Once ADON I was informed by the ADM that Resident #2 was seen through video surveillance leaving the facility on 08/19/23 at approximately 7:40 PM, she stated, That made me question staff that told me they had seen him that night. ADON I said by the time Resident #2 was found and returned to the facility, he had missed three shifts of medications over two days. ADON I stated Resident #2 did not have a wander guard on because he kept cutting them off and the facility had been through about 10 or 12 of them. She said Resident #2 had never tried to exit-seek before, I have never even heard him ask, he is usually very pleasant and interactive. She stated, When we have done a wander guard in past, it was on his ankle. We have never tried one on his wrist that I can remember, don't know if it was tried. ADON I stated, Plan now for him is he has been so far one on one and I think they are going to place him in a more secured facility. That I can't say for sure. ADON I stated there were photos in a binder of the residents who exit-seeked and that binder was at each nurses station and the front desk. She said Resident #2 was not in the binder. ADON I stated most of the staff understand that during the day, the front desk receptionist let people out through the front door with a code, but staff would also let them in and out too but most of them knew who the residents were and who was not supposed to leave. She said if a staff member was not sure if a person was a resident, they should not let them out and check with the charge nurses or other direct care staff. ADON I stated LVN N was the weekend supervisor who worked until 10:00 PM on 08/19/23. An interview with LVN N on 08/22/23 at 11:09 AM revealed he was the weekend supervisor on 08/19/23 and he left the facility around 11:00 PM and was off work on 08/20/23. He said he got a call from one of the ADONs on 08/20/23 and she told him Resident #2 was missing and they were in the process of looking for him. He remembered seeing Resident #2 on 08/19/23 around 3:45 PM in the hallway, He normally comes out and stands in the hallway then comes back to his room. As far as I know, he hasn't tried to get out of the door before. A follow up interview with the ADM on 08/22/23 at 12:16 PM revealed he did not have a policy for wander guards. The ADM stated, I do want to touch on and I am not saying everything was handled perfectly . As soon as we noticed he [Resident #1] was not here, all were parties notified. We had police at the facility in and out about 30 minutes, camera reviewed, silver alert approved and issued by the state within 2 1/2 hours and he was found unharmed about 30 minutes after that was issued. At the end of the day, when it comes to our elopement procedure, we followed all the necessary steps and we found him. The ADM said he QAPI'ed the incident and also terminated the DON on 08/21/23 for a number of reasons. An interview with MA O on 08/22/23 at 12:52 PM revealed he was working a double shift on 08/19/23 from 6:00AM to 10:00 PM, but not on Resident #2's hall. He stated the nurse for Resident #2 on the 2-10PM shift was LVN Q. MA O stated he knew who Resident #2 was and that he had eloped from the facility and he usually had a wander guard on him. He remembered seeing Resident #2 on his 08/19/23 shift because he normally came to the nurses' station for snacks and MA O remembered him coming to get one after dinner on 08/19/23, but there were no snacks left because they had all been passed out already. He stated Resident #2 was okay with it and not upset. MA O stated Resident #2 usually went to bed and would come out during the evening around 8-9PM most nights. The next morning, 08/20/23, MA O stated he worked Resident #2's hall from 6AM-2PM and was told by CNA B around lunch time that she had not seen him and could not find him. They began looking in each residents' room and around the hall, and then some staff went outside to look for him and that was when everyone realized he was missing and the police and family were notified. An interview with LVN P on 08/22/23 at 1:06 PM revealed she was the agency nurse who worked the overnight shift on Resident #2's hall on 08/19/23 into 08/20/23 and it was her first time working at the facility. She stated that night she was the charge nurse for four halls. She stated she came into the facility to work around 10:00 PM and left around 6:45 AM the next morning. When she arrived at her shift that night, LVN P stated, When I got there, I can't really say I was oriented, but I did make rounds while the 2-10 nurse was finishing up stuff. LVN P stated no one told her who was exit-seeking on her halls or who wore a wander guard. She stated she rounded on her own with no one else. LVN P stated she had rooms 507-510 (where Resident #2 resided) and she opened up each door when she started her shift to make sure there was a body in each bed. LVN P stated she remembered seeing a body in each bed; she did not go into the rooms and touch the residents but when she opened each door, she saw a body and assumed each resident was asleep . She stated she did not turn the lights on. Around 11:30 PM, the off-going nurse came back around and gave LVN P a report and then LVN P took over from there. LVN P stated she did not know who the residents were and a nurse named [LVN N] gave her a login to chart in the residents' e-chart. LVN P could not remember if she gave Resident #2 any medications or treatments during that overnight shift because there were two residents in the facility with the same last name, Resident #2 and Resident #7. She stated, So I don't remember which one I saw. I think one was on 500 and one on 700, I could be mistaken. After she left the next morning, she got a call from the facility around 12:30 PM on 08/20/23, asking questions about Resident #2. Review of Resident #2's clinical chart revealed no documentation in his care plan or progress notes that he did not want to be disturbed at night. An interview with CNA B on 08/22/23 at 1:20 PM revealed she was Resident #2's CNA on the 6AM-2PM shift 08/20/23 and got to the facility around 6:15 AM. She said she clocked in, looked at the assignment sheet, made sure her linens were stocked and all the CNAs were present and started to get the heavy-care residents up, which was not Resident #2. CNA B did not remember who the nurse was on her hall that shift. She said Resident #2 liked to walk around, so when she did not see him in his room that morning, she initially did not think anything of it. She put his breakfast tray in his room because she thought he was visiting with another resident at that time. CNA B then proceeded to get some more residents up for the day and fed a resident, then at some point went to pick up Resident #2's breakfast tray and he still was not in his room and his food had not been eaten. She said she did not panic but tried to look for him and around 9:45 AM and checked one of his friend's rooms but he was not there. CNA B stated, I figured he would pop back up. I went to dress another resident. He wasn't in his doorway asking me for a penny like he normally does and I am thinking that is not like him. I thought maybe he went out with the [family member]. At that time, CNA B said she looked at the piano in the dining room because he played sometimes, but nothing, I am thinking he will pop back up. I got up another resident then went back, not there. CNA B said she asked ADON I if she had seen him and they checked the sign out sheet. CNA B stated there was sign out for Resident #7, but not Resident #2, they both had the same last name. She asked the front desk receptionist what time Resident #7 left and she had it mixed up with Resident #2, so she asked another staff member when did Resident #2 leave, to which she was told he did not leave, he was in his room. CNA B stated, I started to panic and told [ADON I] and she and I started looking for him, did a wide search everywhere in the facility, looked outside, drove around McDonalds, grocery store, the neighborhood. Everyone in all departments looking for him. He was nowhere to be found. We just kept looking and then [ADON I] made calls. CNA B stated she was present when Resident #2 was found and brought back to the facility, it was after dinner on 08/20/23. She said she gave him his dinner tray and he looked normal but a little upset because there was a staff doing 1:1 with him and he was asking why they were in his room. CNA B stated Resident #2 did not have any recollection of what happened. CNA B stated she had never seen Resident #2 wear a wander guard when she worked with him prior to the elopement incident and he was not someone who she ever witnessed wanting to leave the facility. CNA B stated since he had been placed on 1:1, he was kind of quiet and reserved, like in a shell. He just keeps saying he doesn't want to leave this place. An interview with LVN Q on 08/22/23 at 1:41 PM revealed she worked a double shift 08/19/23 from 6AM-10PM and was the charge nurse for 500, 600, and 700 halls and was relieved by the agency nurse [LVN P]. LVN Q stated she saw Resident #2 on her shifts and the last time she saw him was around 6-7 PM when she was at the nurses station and he was walking from one nurses' station to the other one. She stated she did not pass medications for him on her shift, MA R did, but MA R never came and told her that she could not locate Resident #2 for 9PM med pass. LVN Q was not aware MA R was giving Resident #2 his medications early by MA R. LVN Q stated she did not round with the oncoming nurse for the overnight shift [LVN P] and most times, when she rounded with a nurse, it would be to give report at the nurses' station, not go room to room. LVN Q stated Resident #2 wore a wander guard but he kept cutting it off. She said Resident #2 wore one because he wandered around the building but he had never tried to leave and she had never seen him take a wander guard off or found a wander guard in his room, it was just what she had heard. She did not know if the facility ever tried to place one on his wrist. An interview and observation of Resident #2 on 08/23/23 at 10:50 AM revealed he was in his room with a staff member sitting on a chair in the corner of his room. Resident #2 was interviewed privately and he stated he did not like the staff member being in his room all the time and did not know why she was there and liked his privacy. Resident #2 was able to talk, but when asked about the elopement incident when he left the facility, he was surprised and said he did not leave. He could not recall being found by the police and being gone all night and day. Resident #2 said he liked living at the facility and they understood his kind of person. He said he liked to watch television and denied that he wanted to leave. He talked about loving God and being right with him. Resident #2's cognition did not remember the incident and had trouble with recall/memory . An interview with MA R on 08/23/23 at 12:27 PM revealed she worked a double shift on 08/19/23 from 6AM-10PM and was in charge of passing medications for about 50 residents on four different halls. She said there was one other medication aide for the other halls in the building. MA R stated no one notified her that Resident #2 was missing and she remembered last seeing him around 4:00 PM between smoke break and dinner time because she saw him when dinner trays were coming out and a resident had made a comment about his cowboy that he was wearing. MA R stated she told Resident #2 hello as she was wheeling another resident down the hall, and she had just administered Resident #2 his medications a few minutes earlier. MA R said the way she was trained was to give Resident #2 his medications when he was in a good mood, even if it was outside of his medication pass time and order time frame, because he tended to attack people and she was told he had balled up his first once to a staff in the past. MA R stated Resident #2 was usually in a good mood right after he ate dinner, so that was when she gave him his medications on 08/19/23, which was around 4-5PM, not at 9:00 PM as she had documented on his MAR/TAR. She stated the next morning she was working (08/20/23), she had asked other staff where he was because she went to pass his morning medication and he was not in the room, which was not unusual because he walked around a lot. Someone told her that he was out on pass with his a family member, and I was like cool, I'll catch him when he gets back. Around noon, MA R stated she walked past one of the aides who asked her where he was and MA R told her he had gone out on pass. They both looked in the sign out book and realized it was the other resident with the same last name who left [Resident #7], not Resident #2. MA R stated, I guess that was the confusion on where he was. She said once staff realized that it was a mistake, they started looking around, informed the nurses and then that was when phone calls started to be made and the police got involved. MA R stated in hindsight, knowing there were two residents with the same last name, she thought the facility should have made sure it was the correct person who signed out on pass. MA R stated, I feel like someone had to have gone in the room and noticed he was missing because two shifts went by. They say he left at 7:30 Saturday night, so the nurse rounding should have noticed, any of us should have noticed that he was gone but then again, it was not unlike him to not be in his room, but no one could pinpoint when they last saw him. I do think that if people had been rounding and laying eyes on him, we probably would have caught on to it earlier. MA R stated she made a comment to a police officer that even if Resident #2 had the code to get out of the facility, he would not know how to come back in because it the entry code to come in was different. MA R stated the shift on 08/20/23 she worked was crazy, no one initially knew what to do once they realized Resident #2 was missing, and it was frightening, like where did he go? MA R stated there were residents who looked completely normal, like they did not belong in the nursing home and god forbid, something could have happened and this could have gone a lot worse. Interviews with nursing staff and medication aides from 08/22/23 through 08/24/23 that worked with Resident #2 did not indicate they had any issues with administering his medications to him at the times prescribed, except for MA R. An interview with CNA X on 08/23/23 at 3:24 PM revealed she was the CNA assigned to Resident #2's hall on the overnight shift on 08/19/20 into 08/20/23 but was working a double shift that day. CNA X stated the facility was short-staffed that night and that was why she was assigned Resident #2's hall as well as all of 500 and 600 halls and one on 400 hall and some on 500 hall. She stated in total it was about 26 residents. CNA X stated she was newer to the facility about three months and was not used to faces and names yet. What she did know of Resident #2 was that he liked to be independent and did most of his ADLs by h [TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #2) of ten residents reviewed for neglect policies. The facility failed to ensure their abuse and neglect policy was implemented for Resident #1 when he eloped from the facility. The facility staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. The resident was located around 6:00 pm 12 miles away from the facility after police became involved and a Silver Alert had been issued. An Immediate Jeopardy was identified on 08/22/23. The IJ Template was provided to the facility on [DATE] at 5:03 PM. While the Immediate Jeopardy was removed on 08/24/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems. This failure could affect residents and place them at risk of further abuse/neglect due to policy not being developed/implemented. Findings included: Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised March 2018, reflected, .2. 'Neglect', as defined at 483.5, means 'the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress'; .Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Review of Resident #2's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain. Vascular dementia can develop after a stroke blocks an artery in your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one-person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one-person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2 did not have an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard. Resident #2's care plan dated 03/17/23 and last revised 08/21/23 reflected the following: - Date initiated 03/17/23: The resident has Dx of Vascular Dementia unspecified severity without behavioral disturbance. Resident is taking Aricept; Interventions: Cue, orient and supervise as needed. - Date Initiated: 06/11/2023- Resident removed wander guard (not found in room); Interventions: Encourage resident to participate in activities of choice, Notify MD of increase wandering behavior if needed. - Date initiated: 07/20/23- Wander guard removed related to no exit seeking; Interventions: Educate Resident / Representative on the necessity of care attempted to provide, Ensure the safety of Resident and others. -Date initiated: 08/21/23- Resident elopement from facility 8/19/23; returned 8/20/23. Resident will remain 1:1 until alternate placement is found; Interventions: Assess resident's coping skills and support system, Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Review of Resident #2's Elopement Evaluation at his time of admitted d 03/17/23 reflected he had no prior history of elopement at home no wandering behavior that was a pattern or goal-directed, no wandering that was likely to affect the safety or well-being of self/others and his elopement score was a 0 (zero). As a result, no interventions were checked on the assessment as being needed to prevent elopement. No other elopement evaluations were completed until after Resident #2's elopement incident on 08/19/23. Review of Resident #2's nursing progress notes for 08/19/23 and 08/20/23 did not reflect he was missing or eloped from the facility. The only nursing notes for those dates reflected, 08/20/2023-Nursing: MD notified that resident was found [signed by ADON I]; 08/20/2023-Nursing: Called MD and notified him that family, responsible party was in facility with resident at this time and requests that he has his night medications at this time. MD gave N/O to give meds now. [signed by ADON I]; 08/20/2023-Nursing: VA notified that resident was found [Signed by ADON I]; 08/20/2023-Nursing: Resident returns to the building with family at bedside. Head to toe assessment and VS done. VS: BP 130/92, 02 96% RA, HR 96, RR 17, and no c/o pain. No injuries or tears noted to skin. Dry scaly heels bilaterally. Resident is calm, friendly and engaging in conversation; 08/20/2023-Nursing: Resident currently resting in bed. He is on 1 to 1 observation; 08/21/2023 Nursing: MD notified of the resident increased confusion and gave order to increase Donepezil HCl Oral Tablet to 10 MG at bedtime. MD also gave dx of Psychosis with Dementia for Seroquel. [RP] notified via VM. Review of the facility's incident for Resident #2 dated 08/20/23 at 12:10 PM completed by ADON I reflected Incident description: Resident noted to be missing from room at approximately 12pm. Search conducted at facility. Admin notified ASAP. Approximately 6pm police notified facility that resident was found. Immediate Action Taken: Facility was searched and administration, responsible party, physician, DON, and VA notified. Police department notified. MD notified of missed medications, no new orders given. Upon return to facility, head to toe assessment and pain assessment done. Resident placed on one on one care, sitter at bedside. Review of website: https://www.accuweather.com (retrieved 08/22/23) revealed the temperature high for the location Resident #2 was found on 08/20/23 was 109 degrees fahrenheit. Review of Resident #2's August 2023 physician orders reflected they were ordered by MD D. Resident #2 had two discontinued orders that reflected, Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift [Verbal Discontinued 03/17/2023], and Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift [Verbal Discontinued 07/14/2023]. Review of Resident #2's August 2023 MAR reflected he missed the following prescribed medications during the time he was missing from the facility on 08/20/23 were Aspirin Oral Capsule 81 MG (blood thinner), Calcium-Vitamin D Oral Tablet 500 MG Protein Oral Liquid 30 ml (supplement). An interview with Resident #2's RP on 08/22/23 at 6:30 AM revealed when Resident #1 was located by the Police, she went to see him and transport him back to the facility. The RP stated she observed Resident #1 to be extremely confused and scared. He was covered from head to toe in dirt and had a trash bag full of garbage one would find in a dumpster. The RP stated she was a RN and was able to assess her father and noted that he had 4+pitting edema. An interview with the ADM on 08/22/23 at 9:40 AM revealed he was notified on 08/20/23 at approximately 1:00 PM that Resident #2 was missing by ADON I. He asked her what happened and she said staff had just searched the entire facility to verify Resident #2 was not there, so the ADM drove to the facility and on his way called the local police department and filed a report. The police arrived at the same time he arrived at the facility. Then the ADM started going through surveillance footage in the facility with police and while he was doing that, DA M came to his office and said she thought she may have known what happened. DA M told him on her way out the door the evening before on Saturday 08/19/23, at approximately 7:38 PM, someone had slipped out the front door behind her and she thought it was a family member of a resident; she didn't recognize the person. The ADM said he went to that part of the surveillance footage and sure enough, it was [Resident #2] that went outside, walked out. In her defense, it was very smooth, he has dementia but you wouldn't know that, you would have to have a conversation to determine that. The ADM stated there would not have been a front desk staff at 7:40 PM the evening of the incident. The ADM stated he then checked the outside surveillance footage and was able to see Resident #2 coming around the side of the building walking down the sidewalk to the left of the facility. He stated, At that point, by the time I found that footage, police had already started process for silver alert and approx. 30 minutes later, I got a call from sergeant saying he had been found in a hotel lobby in Grapevine. The ADM stated the police notified the family who were on their way to pick Resident #2 up. He stated the family had been notified around 1:00 PM that afternoon that Resident #2 was missing and he was found around 6:00 PM. The ADM stated he was told Resident #2 was found with a trash bag and a water bottle, a banana and a couple rachet straps and surmised the resident may have gotten a ride due to the distance. He was brought back to the facility, placed on 1:1 supervision and had been on 1:1 since then. The ADM stated, So this was the confusion, I had a couple of statements from staff saying he was identified later that night of when he eloped around 11:00 PM asking for snacks at the nurses station. Number one, it is very common for him to not be in his room, he has no history of exit seeking, just walking around the facility. The ADM stated Resident #2 would not have known how to get back into the facility if he was locked outside and confirmed the front exit door locked after the door closed. The ADM further stated Resident #2 was not wearing a wander guard anymore because he was a low-elopement risk and just walked around the facility and had dementia. The ADM stated he ordered a tamper-resistant wander guard bracelet, but did not have any evidence of it, and he stated Resident #2 kept removing it. The ADM stated Resident #2 had cut through four to five wander guards off his wrists, even though he had no evidence of it, did not know when the wander guards were attempted to be placed, was not present for the placement and no one ever saw the resident remove them. He stated he met with Resident #2's family in July 2023 and told them Resident #2 was not exit-seeking and was cutting the wander guard off, so we need it removed or if they want him to keep it on, he needed to move. He stated the resolution was to take it off his ankle and move it to his wrist by family request because the family told him Resident #2 had a criminal history with ankle monitors and having one on his leg may have triggered him. The ADM stated, We agreed to have it discontinued because he has never tried to elope before. The [family member] was okay with that and we were all on the same page. It was in a way a perfect storm for this to happen. We had the wander guard removed because of no exit seeking and he doesn't come across as having dementia and looks like a family member. The ADM stated once Resident #2 was located post-elopement and brought back to the facility, he did not interview him. He stated, I want to say someone from our nursing staff talked to him. The ADM admitted the overnight staff working 06/19/23 into 06/20/23 did not round on Resident #1. He said he was still conducting his facility investigation, but from what he could tell thus far, he had been told CNA X rounded on Resident #2 at midnight but then later said maybe she got the resident rooms mixed up. The ADM stated, He does not like to be bothered at night and gets agitated, so that was why he had less rounds. If he doesn't require incontinent care, then it would be opening his door to make sure he was there as rounding. He does not have a roommate. It could be done quietly and that was my conversation with them yesterday when we started the in-service. The ADM stated the elopement incident could have been prevented by staff ensuring when they left the facility exits, to make sure there were no residents trying to leave and if they were unsure who a resident was, to stop and ask them. The ADM stated, This goes back to us not being equipped to care for his needs. He is not the type of resident appropriate for this care, but we would not have known that. A wander guard would have solved this problem. He removed four or five wander guards. An observation of the facility video footage dated 08/19/23 at approximately 7:38 PM showed Resident #2 walking down the hallway casually towards the front lobby. DA M was also observed coming down a different hallway to the front entrance. No other staff, family members or residents were observed. DA M went to the keyed alarm panel to the left side of the front door and while she was putting in the code, Resident #2 walked towards her and was standing behind her. When she opened the door, she held it open for him and he walked out through the door after her. Then there was a second sliding door that automatically opened without a code and they both proceeded out of that door together out into the parking lot. An interview with DA M on 08/22/23 at 10:12 AM revealed she did not interact much with residents and 95% of the time she was in the kitchen and at other times, she was delivering meal carts to CNAs or nurses. She said she did not know who Resident #2 was and could not recall seeing him before. DA M stated, When I let him out, I saw him standing the door, I had my head down and ready to head out, I typed in code and he followed right behind me, he said thank you so much, clear as day, and I thought he was family member. I didn't think much of it. DA M stated she had not been informed by the facility who were potential exit-seekers or what to do if she saw one of those residents attempting to elope. She stated, 'I didn't think I would be in a situation where I would be dealing one-on-one with a resident. I had not been informed on what to do if one wanted to leave. If I had seen him around and knew him, I would have grabbed a CNA or nurse and told them he was trying to leave, but it was the end of my shift, I clocked out and wasn't thinking much of it, I thought he was a visitor of a resident here. I walked out and my mom who was in a car picking me up, said she had seen a man walk out behind me but didn't think much of it. He spoke clear as day and said thank you very much, he was dressed in casual clothing, I glimpsed at him. DA M stated when she came to work Sunday 08/20/23, the kitchen staff were telling her about a resident who had eloped the day before and it was then she realized through their description of him, that it might be the man she let out the day before. DA M said she ran to the ADM's office and police were there and she told them what had happened the night before and they were able to then pull it up on surveillance camera and verify Resident #2 went out the door behind her around 7:38 PM . An interview with ADON I on 08/22/23 at 10:41AM revealed she was at the facility on 08/19/23 until 5:00 PM and was at the facility on 08/20/23 from 6:00 AM until 11:00PM. ADON I stated when she came into work on 08/20/23, no one mentioned Resident #2 was missing. She said the CNA that worked with him [CNA B], went to pick up is breakfast tray around 12:10 PM and it had not been eaten and she then asked ADON I if she had seen him around. ADON I said the CNA B would have delivered the breakfast tray around 7:45AM-8:30AM. ADON I stated they immediately checked all the resident rooms and bathroom, his friends' rooms and he was not present. Then someone drove the perimeter outside, down to the nearby shopping strip and did not see him. Then ADON I called the family and asked them if Resident #2 was with them and they said no. At that point ADON I stated she called the DON, called ADM and called the staff who worked the night shift before. She said there was an agency nurse [LVN P] who said she remembered checking on Resident #2 during her overnight shift. ADON I also stated she called the overnight CNA, who also remembered checking on Resident #2 during the overnight shift. Once ADON I was informed by the ADM that Resident #2 was seen through video surveillance leaving the facility on 08/19/23 at approximately 7:40 PM, she stated, That made me question staff that told me they had seen him that night. ADON I said by the time Resident #2 was found and returned to the facility, he had missed three shifts of medications over two days. ADON I stated Resident #2 did not have a wander guard on because he kept cutting them off and the facility had been through about 10 or 12 of them. She said Resident #2 had never tried to exit-seek before, I have never even heard him ask, he is usually very pleasant and interactive. She stated, When we have done a wander guard in past, it was on his ankle. We have never tried one on his wrist that I can remember, don't know if it was tried. ADON I stated, Plan now for him is he has been so far one on one and I think they are going to place him in a more secured facility. That I can't say for sure. ADON I stated there were photos in a binder of the residents who exit-seeked and that binder was at each nurses station and the front desk. She said Resident #2 was not in the binder. ADON I stated most of the staff understand that during the day, the front desk receptionist let people out through the front door with a code, but staff would also let them in and out too but most of them knew who the residents were and who was not supposed to leave. She said if a staff member was not sure if a person was a resident, they should not let them out and check with the charge nurses or other direct care staff. ADON I stated LVN N was the weekend supervisor who worked until 10:00 PM on 08/19/23. A follow up interview with the ADM on 08/22/23 at 12:16 PM revealed he did not have a policy for wander guards. ADM stated, I do want to touch on and I am not saying everything was handled perfectly. As soon as we noticed he [Resident #1] was not here, all parties notified. We had police at facility in and out 30 minutes, camera reviewed, silver alert approved and issued by the state within 2 1/2 hours and he was found unharmed about 30 minutes after that was issued. At the end of the day, when it comes to our elopement procedure, we followed all the necessary steps and we found him. The ADM said he QAPI'ed the incident and also terminated the DON on 08/21/23 for a number of reasons. An interview with MA O on 08/22/23 at 12:52 PM revealed he was working a double shift on 08/19/23 from 6:00AM to 10:00 PM, but not on Resident #2's hall. He stated the nurse for Resident #2 on the 2-10PM shift was LVN Q. MA O stated he knew who Resident #2 was and that he had eloped from the facility and he usually had a wander guard on him. He remembered seeing Resident #2 on his 08/19/23 shift because he normally came to the nurses' station for snacks and MA O remembered him coming to get one after dinner on 08/19/23, but there were no snacks left because they had all been passed out already. He stated Resident #2 was okay with it and not upset. MA O stated Resident #2 usually went to bed and would come out during the evening around 8-9PM most nights. The next morning, 08/20/23, MA O stated he worked Resident #2's hall from 6AM-2PM and was told by CNA B around lunch time that she had not seen him and could not find him. They began looking in each residents' room and around the hall, and then some staff went outside to look for him and that was when everyone realized he was missing and the police and family were notified. An interview with LVN P on 08/22/23 at 1:06 PM revealed she was the agency nurse who worked the overnight shift on Resident #2's hall on 08/19/23 into 08/20/23 and it was her first time working at the facility. She stated that night she was the charge nurse for four halls. She stated she came into the facility to work around 10:00 PM and left around 6:45 AM the next morning. When she arrived at her shift that night, LVN P stated, When I got there, I can't really say I was oriented, but I did make rounds while the 2-10 nurse was finishing up stuff. LVN P stated no one told her who was exit-seeking on her halls or who wore a wander guard. She stated she rounded on her own with no one else. LVN P stated she had rooms 507-510 (where Resident #2 resided) and she opened up each door when she started her shift to make sure there was a body in each bed. LVN P stated she remembered seeing a body in each bed; she did not go into the rooms and touch the residents but when she opened each door, she saw a body and assumed each resident was asleep . She stated she did not turn the lights on. Around 11:30 PM, the off-going nurse came back around and gave LVN P a report and then LVN P took over from there. LVN P stated she did not know who the residents were and a nurse named [LVN N] gave her a login to chart in the residents' e-chart. LVN P could not remember if she gave Resident #2 any medications or treatments during that overnight shift because there were two residents in the facility with the same last name, Resident #2 and Resident #7. She stated, So I don't remember which one I saw. I think one was on 500 and one on 700, I could be mistaken. After she left the next morning, she got a call from the facility around 12:30 PM on 08/20/23, asking questions about Resident #2. An interview with CNA B on 08/22/23 at 1:20 PM revealed she was Resident #2's CNA on the 6AM-2PM shift 08/20/23 and got to the facility around 6:15 AM. She said she clocked in, looked at the assignment sheet, made sure her linens were stocked and all the CNAs were present and started to get the heavy-care residents up, which was not Resident #2. CNA B did not remember who the nurse was on her hall that shift. She said Resident #2 liked to walk around, so when she did not see him in his room that morning, she initially did not think anything of it. She put his breakfast tray in his room because she thought he was visiting with another resident at that time. CNA B then proceeded to get some more residents up for the day and fed a resident, then at some point went to pick up Resident #2's breakfast tray and he still was not in his room and his food had not been eaten. She said she did not panic but tried to look for him and around 9:45 AM and checked one of his friend's rooms but he was not there. CNA B stated, I figured he would pop back up. I went to dress another resident. He wasn't in his doorway asking me for a penny like he normally does and I am thinking that is not like him. I thought maybe he went out with the [family member]. At that time, CNA B said she looked at the piano in the dining room because he played sometimes, but nothing, I am thinking he will pop back up. I got up another resident then went back, not there. CNA B said she asked ADON I if she had seen him and they checked the sign out sheet. CNA B stated there was sign out for Resident #7, but not Resident #2, they both had the same last name. She asked the front desk receptionist what time Resident #7 left and she had it mixed up with Resident #2, so she asked another staff member when did Resident #2 leave, to which she was told he did not leave, he was in his room. CNA B stated, I started to panic and told [ADON I] and she and I started looking for him, did a wide search everywhere in the facility, looked outside, drove around McDonalds, grocery store, the neighborhood. Everyone in all departments looking for him. He was nowhere to be found. We just kept looking and then [ADON I] made calls. CNA B stated she was present when Resident #2 was found and brought back to the facility, it was after dinner on 08/20/23. She said she gave him his dinner tray and he looked normal but a little upset because there was a staff doing 1:1 with him and he was asking why they were in his room. CNA B stated Resident #2 did not have any recollection of what happened. CNA B stated she had never seen Resident #2 wear a wander guard when she worked with him prior to the elopement incident and he was not someone who she ever witnessed wanting to leave the facility. CNA B stated since he had been placed on 1:1, he was kind of quiet and reserved, like in a shell. He just keeps saying he doesn't want to leave this place. An interview and observation of Resident #2 on 08/23/23 at 10:50 AM revealed he was in his room with a staff member sitting on a chair in the corner of his room. Resident #2 was interviewed privately and he stated he did not like the staff member being in his room all the time and did not know why she was there and liked his privacy. Resident #2 was able to talk, but when asked about the elopement incident when he left the facility, he was surprised and said he did not leave. He could not recall being found by the police and being gone all night and day. Resident #2 said he liked living at the facility and they understood his kind of person. He said he liked to watch television and denied that he wanted to leave. He talked about loving God and being right with him. Resident #2's could not remember the incident and had trouble with recall/memory. An interview with MA R on 08/23/23 at 12:27 PM revealed she worked a double shift on 08/19/23 from 6AM-10PM and was in charge of passing medications for about 50 residents on four different halls. She said there was one other medication aide for the other halls in the building. MA R stated no one notified Resident #2 was missing and she remembered last seeing him around 4:00 PM between smoke break and dinner time because she saw him when dinner trays were coming out and a resident had made a comment about his cowboy that he was wearing. MA R stated she told Resident #2 hello as she was wheeling another resident down the hall, and she had just administered Resident #2 his medications a few minutes earlier. She stated the next morning she was working (08/20/23), she had asked other staff where he was because she went to pass his morning medication and he was not in the room, which was not unusual because he walked around a lot. Someone told her that he was out on pass with his [family member] and I was like cool, I'll catch him when he gets back. Around noon, MA R stated she walked past one of the aides who asked her where he was and MA R told her he had gone out on pass. They both looked in the sign out book and realized it was the other resident with the same last name who left [Resident #7], not Resident #2. MA R stated, I guess that was the confusion on where he was. She said once staff realized that it was a mistake, they started looking around, informed the nurses and then that was when phone calls started to be made and the police got involved. MA R stated in hindsight, knowing there were two residents with the same last name, she thought the facility should have made sure it was the correct person who signed out on pass. MA R stated, I feel like someone had to have gone in the room and noticed he was missing because two shifts went by. They say he left at 7:30 Saturday night, so the nurse rounding should have noticed, any of us should have noticed that he was gone but then again, it was not unlike him to not be in his room, but no one could pinpoint when they last saw him. I do think that if people had been rounding and laying eyes on him, we probably would have caught on to it earlier. MA R stated she made a comment to a police officer that even if Resident #2 had the code to get out of the facility, he would know how to come back in because it the entry code to come in was different. MA R stated the shift on 08/20/23 she worked was crazy, no one initially knew what to do once they realized Resident #2 was missing, and it was frightening, like where did he go? MA R stated there were residents who looked completely normal, like they did not belong in the nursing home and god forbid, something could have happened and this could have gone a lot worse. Interviews with nursing staff and medication aides from 08/22/23 through 08/24/23 that worked with Resident #2 did not indicate they had any issues with administering his medications to him at the times prescribed, except for MA R. An interview with CNA X on 08/23/23 at 3:24 PM revealed she was the CNA assigned to Resident #2's hall on the overnight shift on 08/19/20 into 08/20/23 but was working a double shift that day. CNA X stated the facility was short-staffed that night and that was why she was assigned Resident #2's hall as well as all of 500 and 600 halls and one on 400 hall and some on 500 hall. She stated in total it was about 26 residents. CNA X stated she was newer to the facility about three months and was not used to faces and names yet. What she did know of Resident #2 was that he liked to be independent and did most of his ADLs by himself. CNA X remembered seeing Resident #2 eat dinner on 08/19/23 and she picked up his room tray from him around 6:30 PM. Then around 7:00 PM, CNA X remembered seeing him pushing a resident in a wheelchair to the nurses' station and then she did not see him again. On the overnight shift, CNA X stated she went to open his bedroom at 5:00 AM in the morning, but she remembered he was independent and did not want his room opened when he was sleeping. CNA X stated, I knew he didn't want us to opening the door because in the past he will tell me not to open it at night when he is sleeping. CNA X stated rounding was supposed to occur every two hours but she did not go into his room to check on him on the overnight shift because of the aforementioned reason. CNA X stated she left the next morning 08/20/23 around 6:00 AM and did not complete a final round on Resident #2. CNA X stated, I didn't try to check on him at all, not even quietly. I never knew he left until someone told me around noon the next day, I was at home. I talked to [ADON I] who asked when I last saw him and I told her I removed his tray at dinner time. CNA X confirmed again that she did not round on Resident #1 at the change of shift 08/20/23 when the 6:00 AM CNA and nurse came to work. CNA X stated now she felt like she should have done things differently, like even though Resident #2 was independent, she still should have opened his room to see if he was okay or needed anything, not just assume he was fine. She realized a resident could have fallen or have a serious injury and not be able to use the call light or call out for help, so rounding was crucial to check on the residents. An interview with Resident #2's family member on 08/24/23 at 10:20 AM revealed she was the RP/MPOA and was very upset over the lack of supervision and response by the facility, which allowed Resident #2 to be let out of the building by a staff member without anyone knowing until the next day. The RP was also upset because she had just met with the ADM who stated Resident #2 was going to be discharged because he kept cutting off his wander guard. The RP was incredulous that Resident #2 had cut a wander guard off because the staff had told her there were never any scissors or knives located in his room, and s [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two (Resident #2 and #4) of four residents reviewed for accidents and supervision. 1. The facility staff DA M allowed Resident #2 to leave behind her without ensuring he was not a resident. 2. The facility failed to ensure Resident #2 did not elope from the facility and staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. 3. The facility staff including MA R, LVN P, LVN Q and CNA B and CNA X failed to check on Resident #2 on the 2-10PM, 10PM-6AM, AND 6AM-2PM shifts from 08/19/23 through 08/20/23 to ensure he was present in the facility. 4. The facility nurses failed to check on Resident #2 every shift per the physician's order to monitor for increased signs and symptoms of exit-seeking and/or wandering on the 10pm-6am shift from 08/19/23 through 08/20/23. 5. The facility failed to ensure the wander guard system was effective as Resident #4's wander guard did not alarm on 08/22/23 when she approached the front exit door and the side emergency exit door on Hall 700. An Immediate Jeopardy (IJ) situation was identified on 08/22/23 at 4:50 PM. While the Immediate Jeopardy was removed on 08/24/23, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of their plan of corrective systems . These failures could place residents at risk for injury and/or death from elopement related harm, including vehicular accidents, falls, missing medications, and extreme heat exposure. Findings include: 1. Record review of Resident #2's quarterly MDS assessment, dated 06/22/23, reflected a [AGE] year old male who was admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain. Vascular dementia can develop after a stroke blocks an artery in your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2 did not have an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard. Record review of Resident #2's care plan, dated 03/17/23 and last revised 08/21/23, reflected the following: - Date initiated 03/17/23: The resident has Dx of Vascular Dementia unspecified severity without behavioral disturbance. Resident is taking Aricept; Interventions: Cue, orient and supervise as needed. - Date Initiated: 06/11/2023- Resident removed wander guard (not found in room); Interventions: Encourage resident to participate in activities of choice, Notify MD of increase wandering behavior if needed. - Date initiated: 07/20/23- Wander guard removed related to no exit seeking; Interventions: Educate Resident / Representative on the necessity of care attempted to provide, Ensure the safety of Resident and others. Record review of Resident #2's Elopement Evaluation at his time of admission, dated 03/17/23, reflected he had no prior history of elopement at home no wandering behavior that was a pattern or goal-directed, no wandering that was likely to affect the safety or well-being of self/others and his elopement score was a 0 (zero). As a result, no interventions were checked on the assessment as being needed to prevent elopement. No other elopement evaluations were completed until after Resident #2's elopement incident on 08/19/23. Record review of Resident #2's facility progress notes, pertinent to his use of a wander guard and elopement, incident included: -03/17/2023- Behavior: Resident noted wandering on the hallways, other resident rooms and exit doors. Resident easily redirected back into his room and comes out of the room immediately. MD was notified and gave order to monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. RP present at the facility, notified and agreed with order. Family Member confirmed resident behavior. -06/09/2023-Nursing: This nurse notified the MD that the resident has pitting edema +3. MD has a new order of reduce salt intake, no excessive liquids and elevate legs for one hour three times a day. MD will re-evaluate resident. -06/11/2023-Nursing: Resident #2's family member asked nurse to encourage resident to have a shower. This nurse went to try and assist resident with shower, resident refused. Family notified. Nurse attempted multiple ways to encourage resident to shower, resident keeps telling nurse that you don't know what you're talking about. Also, nurse noticed that resident removed wander guard, family notified, admin notified. Resident keeps stating that the wander guard fell off in the shower. Unable to locate in resident's room, admin notified. -06/28/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place. (signed by ADON I) -06/29/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. On order (signed by LVN A) -06/29/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place. -07/07/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. On order (signed by LVN A) -07/10/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. The resident does not have a wander guard in place. -07/11/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. Wander guard is not in place of the resident. -07/12/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. Wander guard not in place. -07/13/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place. -07/18/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident has removed wander guard (signed by LVN A) -07/19/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident Removed (signed by LVN A) - 07/20/2023- Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A) -07/21/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A) -07/21/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. No wander guard in place. (signed by ADON I) -07/24/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed, DON aware (signed by LVN A) -07/25/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A) -07/26/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A) -07/20/23-Review of a Multidisciplinary Care Conference: (ADM and RP checked as only participants) reflected, Problems/needs-CP meeting held with Administrator and RP to discuss behaviors of resident cutting wander guard off. Discussed recent elopement assessment reflecting resident is not at risk for elopement. Based off initial elopement assessment resident has not shown exit seeking behavior and therefore not considered elopement risk. Family, Nursing administration, and Administrator that wander guard is not necessary. However, if exit seeking behavior begins, alternate placement will be discussed. -Note: Review of a Resident #2's physician order dated 07/27/23 reflected, Monitor for increased S/S of exit seeking and/or wandering every shift (Active 07/27/2023). -07/28/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (Signed by LVN A) -07/31/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (signed by LVN A) -08/02/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (signed by LVN A) -08/03/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed. (Signed by LVN A) -08/07/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed. (Signed by LVN A) -08/08/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (Signed by LVN A) An interview with LVN A on 08/24/23 at 12:05 PM revealed she was no longer employed at the facility. LVN A stated she was one of the charge nurses for Resident #2 and she had not been working very long at the facility when she was told Resident #2 had a wander guard in the past but he had cut it off or pulled it off. LVN A stated Resident #2 did not display exit-seeking behavior and at point, she tried to put a wander guard on his wrist one time only, but he removed it on the same shift. She said she did not see him remove it and after that, someone tried his ankle, and he took it off unwitnessed. She said it was in the 24-hour report that he removed it and no staff had seen it happen. LVN A stated the wander guard was not located and she did not know if it was ever found. Aside from placing a wander guard on his wrist that one time, LVN A stated she did not try to place another one on him after that. LVN A stated, I kept saying resident removed in my notes and asked the DON if she wanted me to get the order discontinued and she said let me see if I can have it replaced with metal band or get with family to figure it out. Record review of Resident #2's nursing progress notes, for 08/19/23 and 08/20/23, did not reflect he was missing or eloped from the facility. The only nursing notes for those dates reflected, 08/20/2023-Nursing: MD notified that resident was found [signed by ADON I]; 08/20/2023-Nursing: Called MD and notified him that family, responsible party was in facility with resident at this time and requests that he has his night medications at this time. MD gave N/O to give meds now. [signed by ADON I]; 08/20/2023-Nursing: [hospital] notified that resident was found [Signed by ADON I]; 08/20/2023-Nursing: Resident returns to the building with family at bedside. Head to toe assessment and VS done. VS: BP 130/92, 02 96% RA, HR 96, RR 17, and no c/o pain. No injuries or tears noted to skin. Dry scaly heels bilaterally. Resident is calm, friendly and engaging in conversation; 08/20/2023-Nursing: Resident currently resting in bed. He is on 1 to 1 observation; 08/21/2023 Nursing: MD notified of the resident increased confusion and gave order to increase Donepezil HCl Oral Tablet to 10 MG at bedtime. MD also gave dx of Psychosis with Dementia for Seroquel. [family member] notified via VM. Record review of the facility's incident for Resident #2, dated 08/20/23 at 12:10 PM, reflected Incident description: Resident noted to be missing from room at approximately 12 PM. Search conducted at facility. Admin notified ASAP. Approximately 6 PM police notified facility that resident was found. Immediate Action Taken: Facility was searched and administration, responsible party, physician, DON, and [hospital] notified. Police department notified. MD notified of missed medications, no new orders given. Upon return to facility, head to toe assessment and pain assessment done. Resident placed on one on one care, sitter at bedside. Review of website: https://www.accuweather.com (retrieved 08/22/23) revealed the temperature high for the location Resident #2 was found on 08/20/23 was 109 degrees Fahrenheit. Review of Resident #2's August 2023 MAR reflected he missed the following prescribed medications during the time he was missing from the facility on 08/20/23 were Aspirin Oral Capsule 81 MG (blood thinner), Calcium-Vitamin D Oral Tablet 500 MG Protein Oral Liquid 30 ml (supplement). An observation of the facility video footage, dated 08/19/23 at approximately 7:38 PM, showed Resident #2 walking down the hallway casually towards the front lobby. DA M was also observed coming down a different hallway to the front entrance. No other staff, family members or residents were observed. DA M went to the keyed alarm panel to the left side of the front door and while she was putting in the code, Resident #2 walked towards her and was standing behind her. When she opened the door, she held it open for him and he walked out through the door after her. Then there was a second sliding door that automatically opened without a code and they both proceeded out of that door together out into the parking lot. An interview with Resident #2's RP on 08/22/23 at 6:30 AM revealed when Resident #1 was located by the Police, she went to see him and transport him back to the facility. The RP stated she observed Resident #1 to be extremely confused and scared. He was covered from head to toe in dirt and had a trash bag full of garbage one would find in a dumpster. The RP stated she was a RN and was able to assess her father and noted that he had 4+pitting edema. An interview with the ADM on 08/22/23 at 9:40 AM revealed he was notified on 08/20/23 at approximately 1:00 PM that Resident #2 was missing by ADON I. He asked her what happened and she said staff had searched the entire facility to verify Resident #2 was not there, so the ADM drove to the facility and on his way called the local police department and filed a report. The police arrived at the same time he arrived at the facility. Then the ADM started going through surveillance footage in the facility with police and while he was doing that, DA M came to his office and said she thought she may have known what happened. DA M told him on her way out the door the evening before on Saturday 08/19/23, at approximately 7:38 PM, someone had slipped out the front door behind her and she thought it was a family member of a resident; she didn't recognize the person. The ADM said he went to that part of the surveillance footage and sure enough, it was [Resident #2] that went outside, walked out. In her defense, it was very smooth , he has dementia but you wouldn't know that, you would have to have a conversation to determine that. The ADM stated there would not have been a front desk staff at 7:40 PM the evening of the incident. The ADM stated he then checked the outside surveillance footage and was able to see Resident #2 coming around the side of the building walking down the sidewalk to the left of the facility. He stated, At that point, by the time I found that footage, police had already started process for silver alert and approximately. 30 minutes later, I got a call from sergeant saying he had been found in a hotel lobby in Grapevine. The ADM stated the police notified the family who were on their way to pick Resident #1 up. He stated the family had been notified around 1:00 PM that afternoon that Resident #2 was missing and he was found around 6:00 PM. The ADM stated he was told Resident #2 was found with a trash bag and a water bottle, a banana and a couple rachet straps and surmised the resident may have gotten a ride due to the distance. He was brought back to the facility, placed on 1:1 supervision and had been on 1:1 since then. The ADM stated, So this was the confusion, I had a couple of statements from staff saying he was identified later that night of when he eloped around 11:00 PM asking for snacks at the nurses station. Number one, it is very common for him to not be in his room, he has no history of exit seeking, just walking around the facility. The ADM stated Resident #2 would not have known how to get back into the facility if he was locked outside and stated the front exit door locked after the door closed. The ADM further stated Resident #2 was not wearing a wander guard anymore because he was a low-elopement risk and just walked around the facility and had dementia. The ADM stated he ordered a tamper-resistant wander guard bracelet, but did not have any evidence of it, and Resident #2 kept removing it. The ADM stated Resident #2 had cut through four to five wander guards off his wrists, even though he had no evidence of it, did not know when the wander guards were attempted to be placed, was not present for the placement and no one ever saw the resident remove them. He stated he met with Resident #2's family in July 2023 and told them Resident #2 was not exit-seeking and was cutting the wander guard off, so we need it removed or if they want him to keep it on, he needed to move. He stated the resolution was to take it off his ankle and move it to his wrist by the family request because the family told him Resident #2 had a criminal history in the past where he had to wear and ankle monitor and having one on his leg in the nursing home may have triggered him. The ADM stated, We agreed to have it discontinued because he has never tried to elope before. The [family member] was okay with that and we were all on the same page. It was in a way a perfect storm for this to happen. We had the wander guard removed because of no exit seeking and he doesn't come across as having dementia and looks like a family member. The ADM stated once Resident #2 was located post-elopement and brought back to the facility, he did not interview him. He stated, I want to say someone [name unknown] from our nursing staff talked to him [name unknown] . The ADM admitted the overnight staff working 08/19/23 into 08/20/23 did not round on Resident #1. He said he was still conducting his facility investigation, but from what he could tell thus far, he was told CNA X rounded on Resident #2 at midnight but then later said maybe she got the resident rooms mixed up. The ADM stated, [Resident #2] does not like to be bothered at night and gets agitated, so that was why he had less rounds. If he doesn't require incontinent care, then it would be opening his door to make sure he was there as rounding. He does not have a roommate. It could be done quietly and that was my conversation with them yesterday when we started the in-service. The ADM stated the elopement incident could have been prevented by staff ensuring when they left the facility exits, to make sure there were no residents trying to leave and if they were unsure who a resident was, to stop and ask them. The ADM stated, This goes back to us not being equipped to care for his needs. He is not the type of resident appropriate for this care, but we would not have known that. A wander guard would have solved this problem. He removed four or five wander guards . An interview with MD D on 08/23/23 at 1:00 PM revealed he did not know Resident #1 was on his caseload until the incident with the elopement. He stated he did not know he was missing for over 18 hours and only got notified when he was located. An interview with DA M on 08/22/23 at 10:12 AM revealed she did not interact much with residents and 95% of the time she was in the kitchen and at other times, she was delivering meal carts to CNAs or nurses. She said she did not know who Resident #2 was and could not recall seeing him before. DA M stated, When I let him out, I saw him standing the door, I had my head down and ready to head out, I typed in code and he followed right behind me, he said thank you so much, clear as day, and I thought he was family member. I didn't think much of it. DA M stated she had not been informed by the facility who were potential exit-seekers or what to do if she saw one of those residents attempting to elope. She stated, 'I didn't think I would be in a situation where I would be dealing one-on-one with a resident. I had not been informed on what to do if one wanted to leave. If I had seen him around and knew him, I would have grabbed a CNA or nurse and told them he was trying to leave, but it was the end of my shift, I clocked out and wasn't thinking much of it, I thought he was a visitor of a resident here. I walked out and my mom who was in a car picking me up, said she had seen a man walk out behind me but didn't think much of it . He was dressed in casual clothing, I glimpsed at him. DA M stated when she came to work Sunday 08/20/23, the kitchen staff were telling her about a resident who had eloped the day before and it was then she realized through their description of him, that it might be the man she let out the day before. DA M said she ran to the ADM's office and the police were there and she told them what happened the night before and they were able to then pull it up on surveillance camera and verify Resident #2 went out the door behind her around 7:38 PM. An interview with ADON I on 08/22/23 at 10:41AM revealed she was at the facility on 08/19/23 until 5:00 PM and was at the facility on 08/20/23 from 6:00 AM until 11:00PM. ADON I stated when she came into work on 08/20/23, no one mentioned Resident #2 was missing. She said the CNA that worked with him (CNA B), went to pick up his breakfast tray around 12:10 PM and it had not been eaten and she then asked ADON I if she had seen him around. ADON I said the CNA B would have delivered the breakfast tray around 7:45AM-8:30AM. ADON I stated they immediately checked all the resident rooms and bathroom, his friends' rooms and he was not present. Then someone drove the perimeter outside, down to the nearby shopping strip and did not see him. Then ADON I called the family and asked them if Resident #2 was with them and they said no. At that point ADON I stated she called the DON, called ADM and called the staff who worked the night shift before. She said there was an agency nurse (LVN P) who said she remembered checking on Resident #2 during her overnight shift. ADON I also stated she called the overnight CNA, who also remembered checking on Resident #2 during the overnight shift. Once ADON I was informed by the ADM Resident #2 was seen through video surveillance leaving the facility on 08/19/23 at approximately 7:40 PM, she stated, That made me question staff that told me they had seen him that night. ADON I said by the time Resident #2 was found and returned to the facility, he had missed three shifts of medications over two days. ADON I stated Resident #2 did not have a wander guard on because he kept cutting them off and the facility had been through about 10 or 12 of them. She said Resident #2 had never tried to exit-seek before, I have never even heard him ask, he is usually very pleasant and interactive. She stated, When we have done a wander guard in past, it was on his ankle. We have never tried one on his wrist that I can remember, don't know if it was tried. ADON I stated, Plan now for him is he has been so far one on one and I think they are going to place him in a more secured facility. That I can't say for sure. ADON I stated there were photos in a binder of the residents who exit-seeked and that binder was at each nurses station and the front desk. She said Resident #2 was not in the binder. ADON I stated most of the staff understand that during the day, the front desk receptionist let people out through the front door with a code, but staff would also let them in and out too but most of them knew who the residents were and who was not supposed to leave. She said if a staff member was not sure if a person was a resident, they should not let them out and check with the charge nurses or other direct care staff. ADON I stated LVN N was the weekend supervisor who worked until 10:00 PM on 08/19/23. An interview with LVN N on 08/22/23 at 11:09 AM revealed he was the weekend supervisor on 08/19/23 and he left the facility around 11:00 PM and was off work on 08/20/23. He said he got a call from one of the ADONs on 08/20/23 and she told him Resident #2 was missing and they were in the process of looking for him. He remembered seeing Resident #2 on 08/19/23 around 3:45 PM in the hallway, He normally comes out and stands in the hallway then comes back to his room. As far as I know, he hasn't tried to get out of the door before. A follow up interview with the ADM on 08/22/23 at 12:16 PM revealed he did not have a policy for wander guards. The ADM stated, I do want to touch on and I am not saying everything was handled perfectly. As soon as we noticed he [Resident #1] was not here, all parties notified. We had police at facility in and out 30 minutes, camera reviewed, silver alert approved and issued by the state within 2 1/2 hours and he was found unharmed about 30 minutes after that was issued. At the end of the day, when it comes to our elopement procedure , we followed all the necessary steps and we found him . The ADM said he QAPI'ed the incident and also terminated the DON on 08/21/23 for a number of reasons . An interview with MA O on 08/22/23 at 12:52 PM revealed he was working a double shift on 08/19/23 from 6:00AM to 10:00 PM, but not on Resident #2's hall. He stated the nurse for Resident #2 on the 2-10PM shift was LVN Q. MA O stated he knew who Resident #2 was and he had eloped from the facility. The resident usually had a wander guard on him. He remembered seeing Resident #2 on his 08/19/23 shift because he normally came to the nurses' station for snacks and MA O remembered him coming to get one after dinner on 08/19/23, but there were no snacks left because they had all been passed out already. He stated Resident #2 was okay with it and not upset. MA O stated Resident #2 usually went to bed and would come out during the evening around 8-9PM most nights. The next morning, 08/20/23, MA O stated he worked Resident #2's hall from 6AM-2PM and was told by CNA B around lunch time that she had not seen him and could not find him. They began looking in each residents' room and around the hall, and then some staff went outside to look for him and that was when everyone realized he was missing and the police and family were notified. An interview with LVN P on 08/22/23 at 1:06 PM revealed she was the agency nurse who worked the overnight shift on Resident #2's hall on 08/19/23 into 08/20/23 and it was her first time working at the facility. She stated that night she was the charge nurse for four halls. She stated she came into the facility to work around 10:00 PM and left around 6:45 AM the next morning. When she arrived at her shift that night, LVN P stated, When I got there, I can't really say I was oriented, but I did make rounds while the 2-10PM nurse was finishing up stuff. LVN P stated no one told her who was exit-seeking on her halls or who wore a wander guard. She stated she rounded on her own with no one else. LVN P stated she had rooms 507-510 (where Resident #2 resided) and she opened up each door when she started her shift to make sure there was a body in each bed. LVN P stated she remembered seeing a body in each bed; she did not go into the rooms and touch the residents but when she opened each door, she saw a body and assumed each resident was asleep. She stated she did not turn the lights on. Around 11:30 PM, the off-going nurse came back around and gave LVN P a report and then LVN P took over from there. LVN P stated she did not know who the residents were and a nurse named (LVN N) gave her a login to chart in the residents' e-chart. LVN P could not remember if she gave Resident #2 any medications or treatments during the overnight shift because there were two residents in the facility with the same last name, Resident #2 and Resident #7. She stated, So I don't remember which one I saw. I think one was on 500 and one on 700, I could be mistaken. After she left the next morning, she got a call from the facility around 12:30 PM on 08/20/23, asking questions about Resident #2. Review of Resident #2's clinical chart revealed no documentation in his care plan or progress notes that he did not want to be disturbed at night. An interview with CNA B on 08/22/23 at 1:20 PM revealed she was Resident #2's CNA on the 6AM-2PM shift 08/20/23 and got to the facility around 6:15 AM. CNA B did not remember who the nurse was on her hall that shift. She said Resident #2 liked to walk around, so when she did not see him in his room that morning, she initially did not think anything of it. She put his breakfast tray in his room because she thought he was visiting with another resident at that time. CNA B then proceeded to get some more residents up for the day and fed a resident, then at some point went to pick up Resident #2's breakfast tray and he still was not in his room and his food had not been eaten. She said she did not panic but tried to look for him and around 9:45 AM and checked one of his friend's rooms but he was not there. CNA B stated, I figured he would pop back up. I went to dress another resident. He wasn't in his doorway asking me for a penny like he normally does and I am thinking that is not like him. I thought maybe he went out with the [family member]. At that time, CNA B said she looked at the piano in the dining room because he played sometimes, but nothing, I am thinking he will pop back up. I got up another resident then went back, not there. CNA B said she asked ADON I if she had seen him and they checked the sign out sheet. CNA B stated there was sign out for Resident #7, but not Resident #2, they both had the same last name. She asked the front desk receptionist what time Resident #7 left and she had it mixed up with Resident #2, so she asked another staff member when did Resident #2 leave, to which she was told he did not leave, he was in his room. CNA B stated, I started to panic and told [ADON I] and she and I started looking for him, did a wide search everywhere in the facility, looked outside, drove around McDonalds, grocery store, the neighborhood. Everyone in all departments looking for him. He was nowhere to be found. We just kept looking and then [ADON I] made calls. CNA B stated she was present when Resident #2 was found and brought back to the facility, it was after dinner on 08/20/23. She said she gave him his dinner tray and he looked normal but a little upset because there was a staff doing 1:1 with him and he was asking why they were in his room. CNA B stated Resident #2 did not have any recol [TRUNCATED]

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for four (Residents #1, #10, #14 and #21) of 21 residents reviewed. 1) Resident #14's post-[MEDICAL TREATMENT] assessments were incomplete; her shunt for [MEDICAL TREATMENT] was not assessed and the resident's care plan addressed peritoneal [MEDICAL TREATMENT] instead of hemo-[MEDICAL TREATMENT]. These failures could affect Resident #14, placing the resident at risk for hemorrhage, infection, shunt failure, [MEDICAL CONDITION], uncontrolled hypertension, unnecessary pain and emotional distress. 2) On 10/18/11, Resident #1 had three open areas on her buttocks. On 10/19/11 the resident had four open areas on her buttocks. CNA E did not remember when she first noted the resident's open areas and had not reported them to the charge nurse. RN A was unaware of the resident's open areas. The physician assessed Resident #1 on 10/20/11 and a treatment was ordered. These failures resulted in Resident #1 developing a fourth open area and all four areas required treatment and placed the resident at risk for pain, infection and the potential for deterioration of existing wounds. These failures could affect the 79 residents receiving preventive skin care and placed them at risk for the potential of developing open wounds, pain, infection, decreased mobility and decreased quality of life. 3) Resident #10 had impaired skin integrity on the palm of her left hand, which had not been identified or treated by the facility until surveyor inquiry. This failure affected the resident causing the possibility of pain, infection and further deterioration of the resident's contraction. This failure could affect the facility's 32 residents, who had contractures placing them at risk for impaired skin integrity, pain, infection and decreased mobility. 4) Resident #21's UA dated 09/27/11 was not followed up on or treated for [REDACTED].#21 presented with: absence of BMs; nausea; coffee ground emesis; absence of bowel sounds; distended abdomen; use of laxative without results; expelling of hard-formed stool; no evidence of assessments for 17 - 18 hours at a time and not notifying the physician until 10/15/11 when the resident was sent to the ER and diagnosed with [REDACTED]. These failures could affect two residents identified as not having had a BM and placed them at risk for the potential of unrelieved constipation, impaction, and hospitalization for dis-impaction. Findings included: 1) Resident #14 was a [AGE] year-old resident admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 10/20/11 at 12:15 p.m. revealed Resident #14 was awake, alert and oriented, eating lunch. In an interview with Resident #14 on 10/20/11 at 12:15 p.m., when the surveyor asked her to see her peritoneal [MEDICAL TREATMENT] site, she responded, "I have a port on my left arm." When asked how long she had been receiving hemo-[MEDICAL TREATMENT], Resident #14 responded, "Well over a year." When asked if the nurses checked her [MEDICAL TREATMENT] site each shift, she responded, "No." When asked if the nurses checked her vital signs when she returned from [MEDICAL TREATMENT], she responded, "No." Review of Resident #14's Nurses Notes in the resident's entire clinical record revealed there was no documentation regarding the status of the resident's hemo-[MEDICAL TREATMENT] shunt. Review of Resident #14's Post [MEDICAL TREATMENT] Assessments dated 10/14/11, 10/17/11 and 10/19/11 revealed the assessments of the resident had not been completed. Review of a Care Plan for Resident #14 dated 06/03/11 and signed by LVN CC revealed: "Peritoneal (sic) [MEDICAL TREATMENT] - monitor shunt for patency issues every shift and notify Medical Doctor of redness, irritation, drainage, etc.; monitor vital signs every shift, measure accurate intake and output every shift." ADON B was interviewed on 10/20/11 at 2:00 p.m. When asked if he was aware Resident #14's clinical record reflected she received peritoneal [MEDICAL TREATMENT] instead of [MEDICAL TREATMENT], he answered, "No." When asked if he was aware there was no documentation Resident #14's [MEDICAL TREATMENT] shunt was being checked/assessed and post [MEDICAL TREATMENT] assessments were not being completed, he then asked, "There isn't?" When the surveyor informed ADON B Resident #14 had told the surveyor none of the nurses in the facility had ever checked her shunt within the last year, he responded, "Really?" Review of a Physician's Telephone Order dated 10/20/11 for Resident #14 and signed by the DON revealed an order to "Check shunt Left arm every shift for bruit and thrill." 2) Review of the MDS assessment dated [DATE] revealed Resident #1 was [AGE] year-old female and admitted on [DATE] with the [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 was cognitively impaired, incontinent of bladder and bowel and dependent on staff for ADLs. Observation on 10/18/11 at 10:00 a.m. revealed Resident #1 was supine in bed. An unidentified CNA was providing incontinent care. The surveyor observed two opened areas on her left buttock and one open area on her right buttock. Resident #1 stated the sores hurt, and the nurses often forgot to apply the physician-ordered cream until she reminded them to do so. Resident #1 also stated the night shift (10:00 p.m. to 6:00 a.m.) would not change her incontinent brief at night. She stated, "I have to wait for the day shift to clean me up." Observation on 10/19/11 at 9:10 a.m. revealed Resident #1 was in bed. CNA E entered the room and the resident told her she was wet and needed to be changed. CNA E responded she would be back later to give her a shower. On 10/19/11 at 9:45 a.m. (35 minutes later), CNA E returned to Resident #1's room. While CNA E was removing the resident's urine-soaked brief, the surveyor observed the same open areas seen on 10/18/11 at 10:00 a.m. and a new open area on her right buttock. Interview on 10/19/11 at 10:25 a.m. with the DON revealed the only treatment order on Resident #1's treatment sheets for her skin was for an allergic rash on her arms and legs. Interview on 10/19/11 at 10:35 a.m. with CNA E revealed she had not reported Resident #1's open areas to the charge nurse, and could not remember when she first noticed Resident #3's open areas on her buttocks. Interview on 10/19/11 at 11:08 a.m. with RN A revealed Resident #1 had an order for [REDACTED].#1's open areas and said the CNAs had not reported any open areas to her. The surveyor asked RN A if she had applied the [MEDICATION NAME] to Resident #1 on 10/18/11, and RN A responded she did not because the CNAs had already applied A&D ointment and the [MEDICATION NAME] would not have stayed in place. RN A stated she would notify the physician of the new open areas. Review of Resident #1's October 2011 treatment sheet revealed nurses had documented [MEDICATION NAME] had been applied on day and evening shifts from 10/01/11 through 10/18/11. Review of Resident #1's October 2011 Skin Evaluation Flow Sheets revealed there were no open areas/pressure ulcers documented on 10/14/11. Review of Resident #1's consolidated physician's orders for October 2011 revealed there was an order to cleanse the right and left inner buttocks with water and to apply [MEDICATION NAME] twice a day until healed, then as needed. Review of a Change of Condition note dated 10/19/11 revealed the physician was notified of Resident #1's new open areas, and there were no new orders until 10/20/11, at which time Physician FF assessed Resident #1. A Physician's Telephone Order dated 10/20/11 for Resident #1 reflected an order to "Cleanse with normal saline, pat dry, apply collagen and cover with [MEDICATION NAME] three times a week on Monday, Wednesday and Friday." 3) Resident #10, a [AGE] year-old female, was readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment further reflected the resident depended on staff for total assistance with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. An observation and interview during initial tour on 10/18/11 at 9:42 a.m. with LVN L revealed Resident #10 was alert and oriented and on psychoactive medications. The resident had contractures to both of her hands, which were held like fists. There were no hand splints or hand rolls observed in use with either hand. The resident was incontinent of bowel and bladder and had no pressure ulcers or skin problems per LVN L. An observation on 10/18/11 at 11:44 a.m. revealed Resident #10 was asleep, positioned on her back with the both side rails in the upright position. Neither hand was observed with hand splints or hand rolls. No odors were noted. An observation on 10/18/11 at 1:20 p.m. revealed Resident #10 was eating with assistance. She still did not have any hand splints in either hand. An observation on 10/18/11 at 3:25 p.m. revealed CNA T had repositioned Resident #10 on her back. Resident #10 did not have any hand splints or hand rolls in either hand. An observation on 10/19/11 at 8:30 a.m. revealed Resident #10 was asleep and positioned on her back. The resident did not have any hand splints or hand rolls in either hand. An observation on 10/19/11 at 11:10 a.m. revealed Resident #10 was positioned on her back watching television. The resident did not have any type of hand splint or hand roll in her hands. The resident allowed the surveyor to inspect the inside of her clenched, contracted hands. The surveyor noted a yellowish-white substance in the palm of her left hand, which had an unpleasant odor. Observation on 10/19/11 at 2:30 p.m. revealed Resident #10 was awake watching television. She did not have any hand splints or hand rolls in either hand. On 10/19/11 at 2:45 p.m. the DON and the surveyor inspected Resident #10's hands together. The right hand was clear of any breakdown. The palm of the left hand still had a yellowish-white substance with an odor but due to the amount of the substance in the left hand, the surveyor and the DON could not tell if there was skin breakdown in the left hand. The DON and the surveyor went to the nursing station, and the DON notified LVN L she needed to call the doctor for a treatment for [REDACTED]. The surveyor asked LVN L if there was already a treatment order for Resident #10's left hand, and LVN L said,"No." LVN L was also asked if the area on the left hand had already been assessed and was documented on the skin sheets. LVN L responded, "No." Resident #10's entire clinical record chart reflected no physician order for [REDACTED]. Review of the weekly skin sheets revealed no documentation about Resident #10's left hand. The October 2011 treatment book reflected no treatment for [REDACTED]. 4) ) Resident #21 was admitted to the facility on [DATE] according to the admission sheet dated 08/20/11. According to a telephone order dated 10/15/11, Resident #21 was transferred to the ER. Resident #21's October 2011 physician's orders reflected the following Diagnoses: [REDACTED]. Review of Resident #21's nurse's notes dated 09/25/11 at 7:30 p.m. revealed the resident complained of stomach pain. An assessment later that night at 11:40 p.m., revealed bowel sounds were absent on the upper and lower right quadrants. The nurse checked the resident for an impaction. The nurse's note reflected, "Rectal vault full of soft stool." A [MEDICATION NAME] suppository was inserted rectally into the resident. On 09/26/11 at 2:00 a.m. the nurse's note reflected: "Expelled lg (large) amt (amount) soft stool." There was no further documentation about Resident #21's bowels on 09/26/11. Nurse's Notes dated 09/27/11 at 4:30 a.m. for Resident #21 reflected she had a "small amt thick dark yellow cloudy urine (with) foul odor." A urine specimen was labeled and placed in the refrigerator for pick-up by the lab. There were no further nurse's notes until 10/09/11 (12 days later) at 3:00 p.m. The note reflected Resident #21's family was upset a urine specimen had been collected on 09/27/11 but "apparently was not picked up by lab" according to the note. The physician was also with Resident #21 and the resident's family at that time and issued a new order for a urinalysis. Review of Resident #21's nurse's notes revealed no evidence to reflect a urine specimen was obtained on 10/09/11. Another entry on 10/10/11 at 6:40 p.m. reflected a new order from the physician to collect a urine specimen for a urinalysis, which was to be picked up in the morning. Resident #21's nurse's notes reflected two "late entry" notes: one on 10/10/11 at 10:00 p.m. documenting a failed attempt to get a urine specimen and one on 10/11/11 for 4:30 a.m. when two LVNs attempted, but failed to get a urine specimen. Resident #21's nurse's notes reflected the nurse on the 10:00 p.m. to 6:00 a.m. shift on 10/10/11 at 2:45 a.m. called the lab to obtain the results from the urine specimen taken on 09/27/11. That nurse called the lab two more times (at 3:20 a.m. and 4:00 a.m.) and did receive the urinalysis and culture. On 10/13/11 at 2:30 a.m., Resident #21's nurse's notes reflected the resident vomited a small amount of "coffee gind (ground) emesis. Abd (abdomen) distended. BS (bowel sounds) absent. (check mark) for imp (impaction). Formed stool filling rectal vault." [MEDICATION NAME] suppository was given to the resident. Notes for 4:00 a.m. and 5:00 a.m. reflected there were no results from the laxative. At 6:00 a.m., the nurse's notes reflected, "Expelled only brown water. Will pass on to 6-2 nurse." Continued review of Resident #21's nurse's notes revealed there was no evidence of assessment/treatment until 11:00 p.m. on 10/13/11. Documentation reflected, "Awake, c/o nausea but had not vomited... (check mark) for impaction sm (small) amt hard formed stool removed. Enema given." At midnight a note reflected resident was "expelling mod (moderate) amts thick liquid stool along (with) formed stool." A note at 5:30 a.m. reflected the resident expelled a moderate amount of soft brown stool. No evidence of assessment/treatment/follow-up was found until 11:00 p.m. on 10/14/11. "Face flushed. Abd remains very distended & tender to touch. BS absent on (right) vey(very) sluggish on (left)... When questioned resident denied having BM (bowel movement) today." A Change of Condition form dated 10/14/11 at 11:30 p.m. reflected Resident #21's urinalysis results reflected "Gram Negative Lactose Fermenting isolated." The sensitivity report was to follow. A lab report dated 10/14/11 reflected the bacteria was E. coli. Review of Resident #21's lab report from the 09/27/11 urinalysis also revealed "Gram Negative Lactose Fermenting isolated" and "E. coli." Resident #21's Change of Condition form at midnight (on 10/15/11) reflected the nurse called the physician. He stated, "Do you know what time it is? This better be important." Resident #21's condition was given, and the physician ordered she be sent to the ER. Resident #21's vital signs were: BP 140/60, pulse 128, and respirations 20. Review of the Bowel and Bladder Chart Detail Report from 10/07/11 to 10/14/11 revealed: a) on 10/07/11 the resident did not have a BM, b) on 10/08/11 the resident did not have a BM, c) on 10/09/11 at 5:10 p.m. the resident had a medium BM, d) on 10/10/11 at 2:44 a.m. the resident had a medium BM, e) on 10/11/11 at 2:12 a.m. the resident had a medium BM, f) on 10/12/11 the resident did not have a BM, g) on 10/13/11 the resident did not have a BM, h) on 10/14/11 at 2:22 a.m. the resident had an extra large BM, and at 1:08 p.m. the resident had an extra large BM. Review of Resident #21's October 2011 MAR indicated [REDACTED].m shift on 10/10/11 and 10/14/11. Resident #21's telephone order dated 10/10/11 (no time) reflected, "May give enema prn (as needed) Dx (diagnosis) Constipation." Resident #21's health care plan (HCP) dated 02/14/11 reflected: a) "History of chronic constipation." Goals included: "Established bowel evacuation routine at least q 3 days. No fecal impactions reported." b) "Diuretic therapy/potential fluid status alteration, Resident Receives Lasic (sic) daily." A Goal reflected "No clinical signs of hydration problems through 05/14/11." Handwritten dates of 08/15/11 and 11/08/11 were also on the HCP. One approach included "Encourage PO intake of fluids to include several glasses of H2O daily." c) "Difficulty in making decisions related to cognitive deficits (dated 02/21/11)." Approaches included: "Observe for changes in cognitive status." Review of the facility's current Constipation Assessment/Documentation and Protocol dated 01/02/08 revealed, "It is the policy of this facility that residents will be monitored for constipation and when identified treated accordingly." The Procedure reflected, "Residents will be monitored for signs and symptoms of constipation using the following assessment procedures: Does the resident complain of any? 1. Abdominal discomfort, loss of appetite, constipation, loose stools, watery stools 2. Are there any contributing factors? 3. Medications: fiber supplements, narcotic [MEDICATION NAME], etc. 4. Decreased fluid intake from usual pattern Inspect: ...2. Abdomen: distention, vomiting, small loose or liquid stools, fecal smearing 3. Bowel movement record for most recent bowel movement and usual frequency of bowel movements Auscultate: 1. Bowel sounds: present, absent, hyperactive, hypoactive (if fecal impaction will have absent at site of impaction, and hyperactive above the impaction, usually) Palpate: 1. Abdomen: soft, tender, guarding, rigidity... 2. Rectum: hard stool, large amount of soft stool Document: 1. Any of the above changes to the resident ...3. Response to laxative/enema therapy NOTE: It is imperative that resident bowel habits be monitored on a daily basis to prevent constipation." The surveyor interviewed ADON B about constipation on 10/21/11 at 10:15 a.m. ADON B said he would know a resident was constipated when "the aides put it into caretracker." He said he would use medication after two to three days with no BM. The surveyor asked when he would "check for impaction" after the resident had received medication. ADON B said, "Two days. I would call the Doctor for orders to see if I can do that (check for impaction); if it's in my scope (of practice as an LVN)." The surveyor interviewed RN A about constipation on 10/21/11 at 10:20 a.m. RN A said she would know a resident was constipated when there was a report of no BM. She said she would do an assessment, auscultaTe (listen to bowel sounds with a stethoscope), palpate (use hands to determine if stomach was abnormal in size, shape, or firmness), and to check for impaction. The surveyor asked when the RN would "check for impaction" after the resident had received medication. RN A said she would check for impaction one shift after medicating. RN A reported Dr. GG had standing orders an LVN could check for impaction and disimpact (remove BM with a finger) the resident. Review of Resident #21's hospital records revealed the resident arrived at the ER at 1:36 a.m. on 10/15/11. The resident vomited a large amount of dark brown chunks when a naso-[MEDICAL CONDITION] tube was inserted. Resident #21's hospital history reflected the resident had "severe aching generalized Abdominal Pain without [MEDICAL CONDITION]. The pain was of gradual onset [MEDICATION NAME] for 2 days. Symptoms are worsening. Pain is worse with movement. It is relieved with nothing. Also complains of confusion, nausea, vomiting and constipation...." The hospital's physical exam reflected Resident #21's vital signs were: BP 147/92, pulse 122, respirations 24. General appearance - "ill appearing" Abdomen - "tenderness noted diffuse, no rebound tenderness noted, severe distension noted, No bowel sounds, no pulsatile masses." A CT (Computed Tomography - combines a series of X-ray views taken from many different angles to produce cross-sectional images of the bones and soft tissues inside your body. (<http://www.bing.com/health/article/mayo-MAMY /CT-scan?q=ct+scan)> retrieved on 10/27/11) of Resident #21's Abdomen and Pelvis dated 10/15/11 reflected the following Impression: "1. There is marked [MEDICATION NAME] distention of the colon, diffusely. There is severe stool seen in the distal colon and rectum. The distal sigmoid colon measures up to 15 cm in diameter. Mildly dilated small bowel loops are noted in the upper abdomen, measuring up to 3.7 cm in diameter. Findings are compatible with severe obstipation (Intestinal obstruction; severe constipation) / constipation. Findings may be secondary to underlying stercorat [MEDICAL CONDITION] or intestinal pseudobstruction. No free air is seen." The Internal Medicine Discharge Summary dated 10/19/11 reflected: "Patient was admitted with Abdominal distension due to constipation and fecal impaction. Patient was initially tried on tested medical regimen to relieve constipation [MEDICATION NAME], Mineral Oil, Fleet enema and manual disimpaction. There was not enough response to it initially. Given her continuous constipation and possibilities of upper GI bleed she was seen by GI and taken for Upper [MEDICAL CONDITION] endoscopy. After the upper GI, the patient passed out a "bed full of stool." She had Grade D esophagitis with contact bleeding with large clean base [MEDICAL CONDITION] ulcer... During the attempt to perform a sigmoidoscopy (Sigmoidoscopy is an examination of the bottom one-third of the large intestine, including the rectum and bottom part of the colon. A sigmoidoscope-a flexible viewing tube with a light and a lens or video camera on one end, and an eyepiece or video monitor on the other is used to see the inside of your bowel through fiber optic technology. http://www.bing.com/health/article/harvard- /Sigmoidoscopy?q=sigmoidoscopy Retrieved 10/28/11), the physician was not able to pass the scope because there was still too much hard stool in the rectum. The physician determined there was severe obstruction and [MEDICAL CONDITION] of the colon. After that event she (Resident #21) had continuous liquid stool for one to two days and her abdominal distention was relieved... Patient also had dark brown [MEDICAL CONDITION] aspirate and she was also evaluated for source of bleeding. She was found to have esophagitis and [MEDICAL CONDITION] ulcer as mentioned above... Patient is not able to eat without vomiting. She will require life long PPI (Proton-pump inhibitors) and [MEDICATION NAME] to prevent future similar episodes...." Resident #21's hospital Admission History and Physical dated 10/15/11 "Assessment & Plan" reflected: "1. Abdominal Pain and Distention likely from worsened chronic constipation with overflow incontinence. CT abdomen consistent with large colonic distention with large amount of stool in distal colon segments. NG tube placed for decompression of bowel and will continue with rectal suppositories and manual disimpaction for relief of constipation. General surgery consult requested for large distention of abdomen. Continue IV fluid and IV antibiotics for now. NG tube draining dark brown fluid likely from gastritis or from upper GI bleed. There is no overt bleeding noted...." 5) The facility's 24-Hour Reports were reviewed for the 20-day period between 09/25/11 and 11/14/11. Documentation reflected two residents did not have bowel movements. 6) The Form CMS-672, Resident Census and Conditions of Residents, dated 10/18/11 and signed by the DON reflected 32 residents had contractures, 79 resident received preventive skin care, five residents had pressure ulcers, and one resident received [MEDICAL TREATMENT].

Based on observation, interview and record review, it was determined the facility failed to ensure eight (Residents #5, #10, #19, #28, # 31, #32, #33, and #35) of 31 residents reviewed for pharmacy, were free of significant medication errors. 1. Resident #10 did not receive approximately 99 doses (one tablet three times a day for 33 days) of her [MEDICATION NAME], a medication used for her Ulcerative [MEDICAL CONDITION], which caused the resident to experience an exacerbation with five episodes of bloody diarrhea. The facility was unaware Resident #10 was not receiving her [MEDICATION NAME] until 11/03/10 following surveyor intervention. 2. MA K administered and initialed the November 2010 MARs before 2:10 p.m. for twelve medications ordered at 4:00 p.m. and 5:00 p.m. for seven residents (Residents #5, #19, #28, #31, #32, #35, and #33). Seven residents received their medications two to three hours earlier than scheduled for administration. The medications included: 1) [MEDICATION NAME] XL (Blood Pressure), 2) [MEDICATION NAME] ([MEDICATION NAME]) (Pain), 3) [MEDICATION NAME] 5/500 (Pain), 4) [MEDICATION NAME] Gel (Anxiety), 5) Levetiracetam ([MEDICATION NAME]) ([MEDICAL CONDITION]), 6) [MEDICATION NAME] ([MEDICATION NAME]) (Pain), 7) [MEDICATION NAME] ([MEDICATION NAME]) (Blood Pressure), 8) [MEDICATION NAME] (Quetiapine) (Antipsychotic), 9) [MEDICATION NAME] (Antipsychotic) and 10) [MEDICATION NAME] (Phosphorus control in [MEDICAL TREATMENT] patients). All the medications listed were ordered to be administered twice a day, three times a day or four times a day. These failures could affect the facility's 119 residents, including Residents #5, #10, #19, #28, # 31, #32, #33, and #35, and placed them at risk for: 1) ineffective therapeutic levels of [MEDICAL CONDITION] medications, causing uncontrolled [MEDICAL CONDITION]; 2) unstable blood pressures and/or heart rates, causing stroke and/or [MEDICAL CONDITION] emboli; 3) anxiety, or become overmedicated if doses were administered too close together; 4) behaviors from doses of antipsychotic medications being too far apart, and overmedicated from doses being given too close together; and 5) increased phosphorus levels in [MEDICAL TREATMENT] residents. Findings included: (1) Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's clinical record revealed a physician's telephone order dated 07/28/10. The order reflected, "Computer update: Mesamine ([MEDICATION NAME]) 250 mg CR 2 caps po TID...." Review of the Lippincott Nursing 2011 Drug Handbook (31st Edition, page 946) revealed, "[MEDICATION NAME] ([MEDICATION NAME]) ...Indications & Dosages...Active mild to moderate distal ulcerative [MEDICAL CONDITION], proctitis or proctosigmoiditis...." Review of the August 2010 consolidated physician's orders [REDACTED]. On the second page of the August 2010 consolidated physician's orders [REDACTED]. Review of the August 2010 MAR for Resident #10 revealed she received the medication as ordered. Review of the September 2010 consolidated physician's orders [REDACTED]. There was a handwritten notation to the right of the entry, which reflected, "07/28/10 error." The "07/28/10" was scribbled through. There were no additional handwritten notations regarding the [MEDICATION NAME]. Review of the September 2010 MAR for Resident #10 revealed she received the medication as ordered. Review of the October 2010 and November 2010 consolidated physician's orders [REDACTED]. There were not any handwritten notations regarding the [MEDICATION NAME]. Review of the October 2010 and November 2010 MARs for Resident #10 revealed she did not receive the [MEDICATION NAME] as ordered. Review of nurse's notes for Resident #10 revealed, "10/30 (10/30/10) 1 pm Resident have 2 LBM (large bowel movement) episodes. Stool sample collection ordered for [MEDICAL CONDITION]...7:15 p.m. Resident have 3 episodes of LBM (with) blood....Stool sample for [MEDICAL CONDITION] taken...1920 (7.20 p.m.) (Medical Director) returned call; monitor stool for (increased) blood; CBC on Monday...11/03/10 12:10 p.m. Spoke to (Medical Director) regarding the [MEDICATION NAME] that was not administered in Oct...(Medical Director) gave orders to restart [MEDICATION NAME]." A physician's telephone order dated 10/30/10 for Resident #10 reflected, "Collect stool sample for [MEDICAL CONDITION]." A physician's telephone order dated 11/03/10 for Resident #10 reflected, "Restart [MEDICATION NAME] CR 2 caps po TID." Review of the Pharmacy requisition for Resident #10 revealed [MEDICATION NAME] 250 mg CR 180 tablets were ordered and received on 08/09/10, 09/20/10 and 10/26/10. Interview on 11/03/10 at 11:10 a.m. with ADON P revealed over the weekend (10/30/10-10/31/10) Resident #10 had dark, loose stools containing blood. ADON P was informed of the [MEDICATION NAME] not being on the November 2010 MAR. Review of Resident #10's clinical record with ADON P revealed she was not able to locate an order to discontinue the [MEDICATION NAME]. Telephone interview on 11/03/10 at 1:37 p.m. with the Medical Director (also Resident #10's attending physician) revealed he was notified of the medication error. When asked what could happen when the [MEDICATION NAME] was not administered, the Medical Director stated, "Like she has now with blood in the stool. It confirms her [DIAGNOSES REDACTED]. Interview on 11/04/10 at 9:55 a.m. with the Pharmacy Consultant revealed on 11/03/10 his staff had begun conducting a 100% medication audit. When asked what the monthly review consisted of, the Pharmacy Consultant stated they reviewed the clinical record with the current MAR. When asked how far back they audited, the Pharmacy Consultant stated he went back to July 2010 but was not aware of how far back the facility staff went. When asked why the pharmacy staff did not catch the medication error during the pharmacy review in October 2010, the Pharmacy Consultant stated it should have been caught. He added at times, it was hard for the consultant to get the clinical record and the MAR indicated [REDACTED]. Review of a [MEDICAL CONDITION] test collected on 11/01/10 for Resident #10 revealed the result was negative. (2) MA K was observed administering medications to residents on the 500 hall at 1:50 p.m. on 11/04/10. The surveyor asked to review the MAR book when MA K was finished. MA K gave the surveyor the MARs at 2:10 p.m. Review of the 500 Hall MARs revealed 12 medications for the following seven residents scheduled to be administered at 4:00 p.m. and 5:00 p.m. were administered before 2:10 p.m.: A) Resident #32's 4:00 p.m. [MEDICATION NAME] had been initialed as given and the time was 2:15 p.m. In addition, Resident #32 had orders for: (1) [MEDICATION NAME] XL ([MEDICATION NAME]) 25 mg 1 tab PO BID (8:00 a.m. and 4:00 p.m.); and (2) [MEDICATION NAME] ([MEDICATION NAME]) 5/325 mg 1 tab PO BID (8:00 a.m. and 4:00 p.m.). MA K administered and initialed the MAR before 2:10 p.m., approximately two hours early, for two of Resident #32's medications ordered at 4:00 p.m. B) Resident #31 had orders for: (1) [MEDICATION NAME] 5/500 1 tab BID (9:00 a.m. and 5:00 p.m.); and (2) [MEDICATION NAME] Gel 0.5 mg Topically apply to inner wrist with gloved hands BID (9:00 a.m. and 5:00 p.m.). MA K administered and initialed the MAR before 2:10 p.m., three hours early, for two of Resident #31's medications ordered at 5:00 p.m. C) Resident #19 had orders for: (1) [MEDICATION NAME] ([MEDICATION NAME]) 5/325 mg 1 tab PO QID (6:30 a.m., 12 noon, 5:00 p.m., and 9:00 p.m.); and (2) Levetiracetam ([MEDICATION NAME]) 1000 mg 1 tab PO BID (9:00 a.m. and 5:00 p.m.). MA K administered and initialed the MAR before 2:10 p.m., three hours early, for two of Resident #19's medications ordered at 5:00 p.m. D) Resident #35 had orders for: (1) [MEDICATION NAME] ([MEDICATION NAME]) 50 mg 1 tab PO TID routinely (9:00 a.m., 1:00 p.m., and 5:00 p.m.). MA K administered and initialed the MAR before 2:10 p.m., three hours early, for one of Resident #35's medications ordered at 5:00 p.m. E) Resident #33 had orders for: (1) [MEDICATION NAME] ([MEDICATION NAME]) 30 mg 1 cap PO BID (9:00 a.m. and 5:00 p.m.). MA K administered and initialed the MAR before 2:10 p.m., three hours early, for one of Resident #33's medications ordered at 5:00 p.m. F) Resident #5 had orders for: (1) [MEDICATION NAME] (Levetiracetam) 1000 mg tab 1 PO BID (9:00 a.m. and 5:00 p.m.); (2) [MEDICATION NAME] (Quetiapine) 50 mg tab 1 PO BID (9:00 a.m. and 5:00 p.m.); and (3) [MEDICATION NAME] 20 mg tab 1 PO BID (9:00 a.m. and 5:00 p.m.). MA K administered and initialed the MAR before 2:10 p.m., three hours early, for three of Resident #9's medications ordered at 5:00 p.m. G) Resident #28 had orders for: (1) [MEDICATION NAME] 800 mg 1 tab PO TID give with meals (7:00 a.m., 12 noon, and 5:00 p.m.). MA K administered and initialed the MAR before 2:10 p.m., three hours early, for one of Resident #28's medications ordered at 5:00 p.m. 6. Review of facility General Medication Administration Procedure (no date) revealed, "...2. Read label three times, comparing with MAR (Medication Administration Record) ...6. Make sure you are giving the correct medication...at the correct time...in the right dosage form...Compare the medications with the MAR indicated [REDACTED]." 7. The resident census was 119 according to the Form CMS 672 dated 11/03/10.