Every finding on record at Paradigm at Stevens

Based on observation, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #43) of 2 residents observed for incontinent and catheter care.LVN A failed to change Resident #1's soiled incontinent brief after she completed catheter care.This deficient practice could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #43's electronic face sheet dated 05/13/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: nontraumatic subacute subdural hemorrhage (bleeding in the space between the brain and tissues that cover the brain), respiratory failure (condition in which blood does not have enough oxygen or has too much carbon dioxide) and persistent vegetative state (condition resulting from severe brain damage, patients exhibit no cerebral cortical function and remain unconscious) Record review of Resident #43's clinical record reflected he was not at the facility long enough for an MDS assessment. Record review of Resident #43's comprehensive care plan dated 05/09/2026 reflected Focus, catheter, has an indwelling urinary catheter and is at risk for urinary tract infections, Interventions/tasks, provide catheter care and perineal hygiene as indicated. Observation on 05/14/2026 at 2:37 pm revealed LVN A perform catheter care for Resident #43, she opened the incontinent brief on the resident and folded the top down onto the bed linens. LVN A cleaned the front of the perineal area and wiped front to back and cleaned the tubing from the tip of the penis and urethral opening to the tubing junction. She then closed the brief. Resident #43 appeared unconscious and was not interviewable. During an interview on 05/14/2026 at 2:40 pm, LVN A stated she was not aware that after she performed catheter care she needed to change Resident #43's brief. She stated she was not aware she needed to complete catheter care as if it was incontinent care. During an interview on 05/14/2026 at 3:00 pm, the RNC stated LVN A needed to change the brief for Resident #43 when she performed catheter care because it was treated the same as incontinent care. She stated the brief was not a clean one, and after the resident was cleaned, a clean brief needed to be applied. She stated cross contamination or a urinary tract infection could occur. Record review of LVN A's Competencies dated 12/30/2026 reflected she had successfully completed catheter care. Record review of the facility competency checklist Peri Care (undated) reflected apply clean undergarment/brief as necessary. Record review of the facility's policy and procedure titled Catheter Care dated 02/2024 reflected Provide routine perineal care using pre-moistened wipes.Record review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated 2025, reflected, This facility has established and maintained an infection control prevention and control program designed to provide a sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 3 residents (Resident # 1) reviewed for oxygen therapy. The facility failed to replace or clean dirty and dusty oxygen filters in Resident #1's oxygen concentrator. These deficient practices could place residents at risk of respiratory infection and difficulty breathing.The findings included: Record review of Resident #1's electronic face sheet dated 05/13/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: chronic obstructive pulmonary disease (progressive group of lung diseases, primarily consisting of emphysema), emphysema (irreversible lung disease where the tiny air sacs in the lungs are damaged), and dependence on supplemental oxygen (a medical state where the body requires a breathing device to maintain safe blood oxygen levels). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he scored a 9 of 15 on his BIMS which signified his cognitive status was moderately impaired. He could usually understand and usually be understood by others. He required extensive assistance with his care. He received oxygen therapy while he was a resident. Record review of Resident #1's comprehensive care plan dated 03/28/2024 reflected Focus, Shortness of Breath, at risk for respiratory distress, continuous oxygen, Interventions/Tasks, Apply O2 as ordered. Record review of Resident #1's Active Orders as of 05/15/2026 reflected Oxygen at 2.5L/min per nasal cannula continuously with a start date of 02/10/2026. Further review reflected Check and clean concentrator filter every month and as needed, with a start date of 03/01/2026. Record review of Resident #1's MAR dated 05/01/2026-05/31/2026 reflected the oxygen concentrator filter check and clean was initialed on 05/01/2026 with a number 8 which indicated other. Observation on 05/12/2026 at 10:40 am of Resident #1's oxygen concentrator in his room revealed the black filter appeared gray, covered with dust and dirt particles. Observation on 05/14/2026 at 10:00 am revealed Resident #1, lying in bed in his room. His oxygen concentrator was infusing oxygen via nasal cannula at 2.5 L/min. The oxygen concentrator filter was gray with dust and dirt particles. Interview on 05/14/2026 at 10:05 am, Resident #1 stated he hated his oxygen and stated he would take the nasal cannula off. He stated the nurses checked his oxygen during each shift. Observation on 05/15/2026 at 11:00 am with the RNC revealed Resident #1's oxygen filter was gray with dust and dirt particles. Interview on 05/15/2026 at 11:05 am, the RNC stated the oxygen concentrator filters needed to be cleaned or changed as needed and she said the nurses were responsible. She stated a dirty concentrator filter could result in dirt particles blocking the flow of oxygen and could result in respiratory distress. Interview on 05/15/2026 at 11:30 am, LVN A stated she did not check the oxygen filter on this day, but she usually did. She did not know why she had not checked it. She stated a dirty oxygen filter could block the oxygen flow and result in respiratory distress or infection. Record review of the facility's policy and procedure titled Infection Control: Cleaning and Disinfecting Resident Care Equipment dated 06/2024 reflected Oxygen Concentrators-external filters: Clean when visibly soiled and in between resident usage.

Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (resident #11) of 8 residents reviewed for accurate assessments. The facility failed to reflect Resident #11 was administered opioid medication on her quarterly MDS assessment dated [DATE]/2026. This deficient practice could place residents at risk of missed or inaccurate care.The findings included: Record review of Resident #11's electronic face sheet dated 05/13/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: type 2 diabetes mellitus with diabetic neuropathy (chronically high blood sugar causes nerve damage that can lead to pain, numbness and functional impairments), fibromyalgia (chronic disorder that causes widespread pain throughout the body) and joint pain (discomfort, soreness, or aching in one or more joints of the body). Record review of Resident #11's Active Orders as of: 04/13/2026 reflected she was ordered Hydrocodone-Acetaminophen (opioid pain medication) Oral Tablet 5-325 mg, give one tablet by mouth as needed for pain every 4-6 hours. Record review of Resident #11's MAR dated 04/1/2026-04/30/2026 reflected Hydrocodone-Acetaminophen oral tablet 5-325 mg was administered on April 14th, 16th three times, 17th three times, 18th three times, 19th and on the 20th two times. Record review of Resident #11's quarterly MDS dated [DATE] assessment reflected she scored a 15 of 15 on her BIMS which signified her cognitive status was intact. Review of section J0300 Pain Presence reflected she had occasional pain. Review of section N0415 High-Risk Drug Classes: Use and Indication revealed that Opioid was not checked off for the residents use during the last 7 days. Record review of Resident #11's comprehensive care plan dated 06/27/2025 reflected Focus, pain (Norco), resident complains of increased pain, Interventions/Tasks, monitor for effectiveness of pain medications. Observation on 05/12/2026 at 10:30 am of Resident #11, revealed she was sitting in a recliner and stated her side hurt pointing to her right side. Interview on 05/12/2026 at 10:35 am, Resident #11 stated she had pain frequently and received hydrocodone medication. She stated she was taking pain medication since she was admitted . She stated the pain medication was effective and the nurse knew about her present pain and would bring her medication. Interview on 05/14/2026 at 09:28 am, LVN A stated she cared for Resident #11 frequently and she would ask for her hydrocodone every 4 hours as needed. Interview on 05/15/2026 at 11:54 am, the MDS nurse stated she missed Resident #11's opioid medication because it was as needed. She stated the system she used did not focus on the as needed medications only the scheduled. She stated the importance of an accurate MDS assessment related to the type of care residents needed, and care could be missed. She stated the MDS provided an accurate picture of the resident and the care required. Interview on 05/15/2026 at 12:00 pm, the RNC stated the facility just hired a DON and the previous DON left right before the survey. She stated the new DON would not start work until the following week. She stated the ADON was new also and was not at the facility long. She stated she was not aware Resident #11's quarterly MDS assessment dated [DATE] was inaccurate. She stated the importance was the MDS reflected care needed and provided and an inaccurate assessment could lead to inaccurate information about the resident and result in missed care. Interview on 05/15/2026 at 12:15 pm, the ADM stated he was not informed of an inaccurate MDS. He stated it was important for MDS assessments to be accurate to reflect resident care and requirements. Record review of the facility policy and procedure titled Minimum Data Set dated 06/2019 reflected Each assessment must represent an accurate picture of the resident's status during the observation period of the MDS. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on interview and record review, the facility failed to maintain complete medical records for 1 of 5 residents (Resident #33) reviewed for accurate records.1.The facility failed to obtain signed consents for Valproic Acid (anti-seizure medication) to be used as an antipsychotic for Resident #33.This failure could place residents at risk for inaccurate documentation of clinical records and misuse of medication used as an antipsychotic that could result in diminished quality of care.The findings included:Record review of Resident #33's face sheet dated 5/14/2026 revealed an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses including; delusional disorders (a serious mental illness characterized by the presence of one or more fixed, false beliefs), dementia ( a decline in mental ability, including memory, language, reasoning, and problem solving, severe enough to interfere with daily life), and depressive disorders (a persistent feeling of sadness, emptiness, or a loss of interest in activities).Record review of Resident #33's Care Plan dated 3/22/2026 revealed the resident was care planned for dementia, depression, psychotropic medications (Valproic Acid) related to behavior, risk for falls, physical aggression towards staff, and delirium (severe state of mental confusion and fluctuating awareness). Record review of Resident #33's quarterly MDS dated [DATE] revealed the resident was unable to obtain a BIMS score due to severe cognitive deficits. Further review revealed the resident was maximal assistance for ADLs and transfers.Record review of Resident #33's physician orders dated 1/26/2026 revealed Valproic Acid 250mg/5ml- 10ml (500mg) by mouth twice daily for delusional disorders.Record review of Resident #33's electronic medication administration record dated 1/26/2026 (start date of medication) through May 15/2026, revealed the resident received the medication as ordered.During an interview on 5/14/2026 at 11:15AM, the RP for Resident #33 said she was aware of the medication for Resident #33 was given, but she did not sign anything for it to be given to Resident #33. She said she had not seen her drowsy from taking the medication.During an observation on 5/14/2026 at 11:35AM, Resident #33 was sitting in the dining room on the secured unit, waiting for lunch to be served. She was alert, clean and groomed, looking at the television and looking around the room.During an interview on 5/14/2026 at 2:49PM, the RNC (Regional Nurse Consultant) reviewed Resident #33's physician orders and stated there was no consent for the Valproic Acid used for delusional disorders. The RNC said a consent was necessary for the medication because it was being used for a psychotic disorder. The RNC said it was important to have a signed consent for Valproic Acid before it was to be administered to the resident because the resident and/or the RP needed to be educated on the side effects and the expected result with the use of the medication. Record review of the facility's policy titled, Psychotropic Drug Usage dated 1/2026 stated, Psychotropic medication cannot be administered without the consent of the resident or their responsible party, except in an emergency.

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse, neglect and exploitation.The facility administrator failed to report to a law enforcement entity or the State Agency of an allegation of misappropriation when a former employee used the [store] account containing Resident #1's debit card information for personal use. This failure had the potential to affect the residents in the facility by placing them at further risk of exploitation and/or misappropriation of resident funds.Record review of Resident #1's admission Record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis of the abdominal wall (a bacterial infection destroying skin, fat, and fascia, often from issues like perforated organs or gastrostomy sites), Type 2 diabetes mellitus with diabetic neuropathy (high blood sugar has damaged peripheral nerves, commonly starting in feet/hands with numbness, tingling, burning or pain), major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and impacts feelings) and fibromyalgia (a chronic disorder causing widespread musculoskeletal pain, fatigue, sleep problems, and cognitive difficulties). Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating resident was cognitively intact. Record review of Facility Grievance Log on 12/30/25 revealed a concern brought to the charge nurse by Resident #1 about her bank account missing over $300. Resident #1 was directed by the charge nurse to consult the Business Office Manager and Administrator who then conducted an investigation. Record review on 12/30/2025 of document authored by the BOM stated she was contacted by the local bank regarding disputed charges on Resident #1's debit card. It stated, The bank gave me, with Resident #1's permission, the attached documents showing that the disputed items were purchased by A, an ex-employee at [this facility.] The items were then shipped to A's home address. Record review on 12/30/2025 of grievance log showed a list of the disputed items was attached to the Grievance Report and revealed over $312.94 worth of items purchased through the [store] app with the shipping address of ex-employee, A. An interview was conducted with the DON on 12/30/25 at 3:30 pm since the Administrator who conducted the investigation was no longer employed. The DON stated that the Administrator had told her that since the amount was only around $300 and the bank had replaced the money and canceled her debit card, they did not have to report the incident to State and did not call the police. During an interview with the current Administrator on 12/30/25 at 3:50 pm, who had only been in the facility for a week, the Administrator agreed the incident should have been reported since there was no regulation about the amount of money taken or whether the bank refunded the money. During an interview with Resident #1 on 12/31/25 at 10:30 am, resident stated she felt the previous employee had made an honest mistake and accidentally used the card. Resident #1 stated that when she first arrived at the facility, she did not have any clothes and only had the facility hospital gowns to wear. Resident #1 gave her debit card to the employee and asked her to order some clothes for her which was done. Employee A left employment on 08/05/25 and the disputed charges were made in October and November of this year. During a phone interview on 12/31/25 at 11:17 am with ex-employee, A, she stated she was not aware that Resident #1's card was still being used. Ex-employee, A, acknowledged Resident #1 had given her a debit card to purchase clothes when Resident #1 first arrived and due to Resident #1's size it was difficult to find the correct sized clothes locally. Ex-employee, A, stated that she used her family card for herself and the last 4 numbers are similar to Resident #1's card. She stated this was a total accident and said she would call the BOM to see what she needed to do. Record review of Tulip reporting system on 12/30/2025 revealed no self reported incidents related to Resident # 1's misappropriated money was called in. Record review on 12/31/2025 of the facility policy and procedures titled Abuse, Neglect, and Exploitation (ANE) Prohibition dated 10/24 stated:The Nursing Facility strictly prohibits abuse, neglect, exploitation, or any mistreatment or residents by anyone at the Facility, including: staff, residents, volunteers, visitors, and others. Reporting and Response:Do Report: an incident that does not result in serious bodily injury but that involves any of the following:-exploitation-misappropriation of resident property-Immediately, but not later than 24 hours after the incident occurs or is suspected. The Facility will submit a summary of its investigation as required by applicable state and federal regulations. Definitions, reporting guidelines, and responses are governed by applicable state and federal regulations, including HHSC PL 2024-14 or as amended by subsequent Provider Letter.

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional food standards for food service safety for 1 of 2 residents (Resident #1) reviewed for food storage. The facility failed to ensure Resident #1's personal refrigerator was maintained at proper temperature and the food was dated and labeled appropriately for September 2025. This failure could lead to food-borne illness and decreased quality life of residents. Findings included:Record review of Resident #1's face sheet dated 9/6/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included schizophrenia (a mental health disorder in which a person has difficulty distinguishing their own thoughts/delusions from reality), depression, and generalized anxiety disorder. Record review of Resident #1's admission MDS, submitted 8/14/2025, reflected a BIMS score of 15, indicating intact cognition. In an observation and interview on 9/6/2025 at 9:55 AM, Resident #1 was observed to have a small, personal refrigerator in her room containing several items of fruit, open containers of ketchup and mayonnaise, and a partially empty container of lunch meat. All items felt warm to the touch. The temperature of the refrigerator was recorded as 75.3 degrees F. Resident #1 stated someone used to check the temperature of the refrigerator, but it had not been checked lately and did not contain a thermometer. She stated her family had visited recently and provided groceries. She denied any gastro-intestinal illness related to food intake. In an observation and interview on 9/6/2025 at 1:17 PM, the ADON stated the night nursing staff was responsible for monitoring the temperature logs of residents' personal refrigerators. A binder containing the temperature logs was observed, but it did not contain a temperature log of Resident #1's refrigerator for September 2025. She was unsure of the facility's policy regarding labeling and dating the food contained in residents' personal fridges. She said the staff will clean the personal refrigerators approximately once a week to ensure there is no expired food inside. In an interview with the Admin on 9/6/2025 at 3:25 PM, she stated she was the person responsible for the temperature log of Resident #1's personal refrigerator as she was the Resident Ambassador for the room. She stated she had not performed a check of Resident #1's refrigerator temperature in September. She was unsure what the proper range was for food storage. She was unsure of the facility policy regarding food labeling/dating for personal food. She reported the potential harm to residents of having improperly stored food was sickness. Record review of the facility policy titled Resident Refrigerators revised 9/2024, reflected the following: All food items must be labeled with the resident's name and date of placement.Perishable items must be discarded after 3 days unless otherwise directed by dietary services.Temperature must be maintained at or below 41 degrees F.

Based on observation, interview, and record review, the facility failed to maintain comfortable temperature levels for 2 of 5 residents (Residents #1 and #2) reviewed for environment. The facility failed to ensure the temperature in the room shared by Residents #1 and #2 was cooled to a comfortable level in September 2025. This failure could lead to decreased quality of life for residents. Findings included:Record review of Resident #1's face sheet dated 9/6/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included schizophrenia (a mental health disorder in which a person has difficulty distinguishing their own thoughts/delusions from reality), depression, and generalized anxiety disorder. Record review of Resident #1's admission MDS, submitted 8/14/2025, reflected a BIMS score of 15, indicating intact cognition. Record review of Resident #2's face sheet dated 9/6/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included hypertensive (elevated blood pressure) and schizoaffective disorder (a mental health disorder with similar presentations as schizophrenia). Record review of Resident #2's admission MDS, submitted 8/14/2025, reflected a BIMS score of 13, indicating intact cognition. In an observation and interview on 9/6/2025 at 10:55 AM, the room shared by Residents #1 and #2 had a recorded temperature of 75.5 degrees F. Three fans were observed to be circulating air in the room. Resident #1 stated the room frequently becomes so hot that she sweats profusely in spite of the fans. She said the room had been intermittently hot since she admitted to the facility. She had reported the temperature to the nursing staff, and they provided the additional fans for cooling. She stated that the temperature of the room at the time was warm and slightly uncomfortable. Resident #2 stated the room felt warm and that she wished it was cooler. In an observation and interview on 9/6/2025 at 1:17 PM, the same room had a recorded temperature of 80.2 degrees F. The temperature recorded next to the air conditioning vent above the door measured 80.1 degrees F. Resident #1 stated she felt hot and was uncomfortable. In an observation on 9/6/2025 at 1:18 PM, the temperature at the nurse's station in the hallway of Residents' #1 and #2 room was recorded at 79.4 degrees F. The air conditioning control panel next to the nurse's station was observed to be set at 72 degrees F. In an interview with the ADON on 9/6/2025 at 1:17 PM, she stated she was unaware that Residents #1 and #2 had ongoing discomfort related to the temperature of their room. She was aware of ongoing issues with the air conditioning in that area of the building and stated the air conditioning had been worked on recently. She stated the air conditioning was set to cool at 72 degrees F and maintained by the Maint. Dir., but she would relocate both residents to a cooler area of the facility. In an interview on 9/6/2025 at 1:53 PM, LVN A stated the hallway in front of Resident #1 and #2's room frequently became very hot as well as their room. She had reported the issue to the ADON in August, when both residents admitted to the facility, but stated nothing had been done to correct the temperature. She reported no adverse effects of the warm temperature to either resident other than discomfort. In an observation and interview on 9/6/2025 at 2:52 PM, the Maint. Dir. was observed on a ladder working in the ceiling in the hallway in front of the room shared by Residents #1 and #2. He stated he was not aware of any issues with the air conditioning in that hallway, and the air conditioning unit had been replaced earlier in the year. He then said the staff had notified him previously that some of the rooms in the same hallway were hot, but he found no issues when he checked the temperatures of the rooms. He stated he came to the facility that day after being notified by the ADON that the room was hot, and he found that an area of the air conditioning duct was dislodged, but he had been able to repair it. In an observation and interview on 9/6/2025 at 2:59 PM, Residents #1 and #2 were observed to have been relocated to a room across the hall from their original, shared room. The temperature in the room was measured at 72.9 degrees F near Resident #2's bed and 64.5 degrees F next to the air conditioning vent above the doorway. Residents #1 and #2 both stated they felt better and more comfortable, and they were satisfied with the temperature of the room. In an interview with the Admin. on 9/6/2025 at 3:25 PM, she stated she was unaware of the ongoing discomfort of Residents #1 and #2 with the temperature in the room. She was not sure how the residents obtained the fans in their room. She stated the potential harm to residents who had an uncomfortable temperature in their rooms was discomfort. Record review of the facility policy titled Dignity: Residents' Right for revised 6/2019, reflected the following: 7) Create a home-like environment for the resident that includes .e. proper temperature and ventilation.

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 from 1 of 1 kitchen and 1 of 1 Resident (Resident #2) reviewed for food sanitation and preparation. 1. [NAME] H failed to remove her gloves, wash her hands and put on clean gloves, after opening a drawer of utensils (dirty surface) and continuing with preparing beef tacos with the same gloved hands (she went from dirty to clean). 2. DA I left 2 pans of cake on the prep table to cool off. She did not cover them. 3. CNA used her bare right hand to give Resident #2 two slices of bread during a lunch meal. These deficient practices could affect any resident and could contribute to the spread of food-borne illnesses. The findings were: 1. Observation on 03/06/25 at 4:59 PM revealed [NAME] H plating flour beef tacos, rice and refried beans for the dinner meal. She plated about 18 meals. [NAME] H would take a flour tortilla with her hands, put a scoop of beef on it, put a scoop of lettuce/tomatoes mix and then a scoop of cheese. Further observation revealed [NAME] H walked over from the steam table to a prep table. She opened the drawer of utensils (dirty surface) and then closed it. [NAME] H asked DA I to wash a scoop with a lever to continue meal preparation. [NAME] H commented the refried beans were sticking to the scoop she was using. Observation on 03/06/25 at 5:12 PM revealed DA I handing [NAME] H a scoop with a lever. [NAME] H proceeded with plating the resident meals. [NAME] H did not remove her gloves and did not wash her hands before continuing with meal service. She plated the remaining resident meals using the same procedure: she would take a flour tortilla with her hands, put a scoop of beef on it, put a scoop of lettuce/tomatoes mix and then a scoop of cheese. Further observation revealed [NAME] H placing the scoop she used for the lettuce/tomatoes mix and the scoop she used for the cheese falling onto the food after she put it back in the bowl. [NAME] H continued with this same procedure until she plated all meals for the residents. Interview on 03/07/25 at 12:45 PM with [NAME] H revealed she had already analyzed her meal prep and service completed on 03/06/25. She stated she realized she contaminated her gloves at the point she opened the drawer to look for a different scoop. She stated she should have removed her gloves, washed her hand and put on clean gloves. [NAME] H stated everything she touched afterwards she contaminated including the tortillas, the scoop handles which landed on top of the cheese and on top of the salad mix. [NAME] H stated contaminating the food could result in transmission of food-borne illnesses like salmonella causing the residents to get sick with stomach viruses which could result in nausea and diarrhea. Interview on 03/07/25 at 2:45 PM with the DM revealed on 03/06/25, during meal prep, she saw [NAME] H walk over to the prep table and open the drawer looking for a scoop. She stated [NAME] H went from clean to dirty and should have removed her gloves, washed her hands and put on clean gloves before proceeding with meal prep. The DM stated [NAME] H contaminated the tortillas. She stated she did not realize the scoops were landing on top of the lettuce/tomatoes mix and the cheese. She stated if that was the case the salad mix and the cheese were also contaminated. The DM stated any contaminated food could cause the residents to get sick. 2. Observation on 03/06/25 at 3:34 PM revealed two large baking pans with cooked cake mix on top of a prep table. Interview 03/06/25 at 3:40 PM with DA I revealed she had placed the pans on top of the prep table for cooling about 10 to 15 minutes ago. Interview on 03/06/25 at 3:43 PM with the DM revealed the cake pans should be covered with foil during the cooling period to avoid being contaminated. The DM stated if contaminated it could get the residents sick. 3. Observation on 03/05/25 at 12:09 PM revealed the meal trays arrived on hallway 300 A. Further observation revealed CNA E passing out meal trays. Observation on 03/05/25 at 12:18 PM revealed Resident #2 sitting on the side of her bed eating her lunch meal. Further observation revealed CNA E delivered two slices of bread in a sandwich bag to Resident #2. She removed the bread out of the sandwich bag with her right hand. CNA E did not put on a glove before removing the bread from the sandwich bag. Interview with on 03/05/25 at 12:20 PM with CNA E revealed she removed the two slices of bread with her right hand; she did not wash or put on gloves prior to removing the bread. She stated she should have either sanitized or washed her hands and put on a glove before removing the two slices of bread to prevent cross contamination. CNA E stated contaminated food could cause the resident to get sick. Review of facility policy, Nutrition Services Policies and Procedures, undated, read in relevant part: SUBJECT: SAFE FOOD HANDLING Goals: Food acquisition, storage, and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing food-borne illness. Unsafe food handling practices can increase the risk of pathogen exposure to residents. Sanitary conditions must be present to promote safe food handling. 6. Follow all local, State, and Federal Regulations when handling food. Food/Beverages Prepared and Served by Facility Staff for Patients/Residents: 6. Food is served with clean, sanitized utensils. There is no bare hand contact.

Based on observation, interview and record review the facility failed to ensure resident's care plans were revised by the interdisciplinary team after each assessment for 3 of 7 Residents (Resident #16, Resident #35 and Resident #19 ) whose records were reviewed. 1. Resident #16's Care Plan did not reflect he used one 1/4 bed rail for mobility and transfers. 2. Resident #35's Care Plan did not reflect she had impaired vision and needed optometry care. 3. Resident #19's Care Plan did not reflect she was receiving Depakote Sprinkles Delayed Release as a mood stabilizer. These deficient practices could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs. The findings were: 1. Review of Resident #16's face sheet, dated 3/4/25, revealed he was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting non-dominant side and Dementia in other Diseases classified elsewhere, severe, with psychotic disturbance. Review of Resident #16's quarterly MDS assessment, dated 1/22/25, revealed his BIMS score was 14 of 15 reflective of minimal cognitive impairment and he did not use a BR while in bed. Review of Resident #16's Care Plan last updated on 3/2/25 revealed there was no indication he used a BR while in bed. Review of Resident #16's physician orders for March 2025 revealed an order L side rail to assist with bed mobility and transfers. No directions specified for order. Active: 1/22/2025. Observation and interview on 03/04/25 at 11:27 AM revealed Resident #16 lying in bed holding on to left side 1/4 BR. Interview with Resident #16 revealed he used the BR to help him sit up in bed and for transfers out of bed. Interview on 03/06/25 at 02:58 PM with the MDS Coordinator revealed Resident #16's Care Plan, revised 3/2/25, did not reflect he used a bed rail for mobility and transfers. The MDS Coordinator stated failure to revise Resident #16's Care Plan could result in the Resident not being provided with assistive devices which could contribute to a decline in physical mobility or inability to assist with mobility to order to maintain independence as much as possible. 2. Review of Resident #35's face sheet, dated 3/5/25, revealed she was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus without complications and Anxiety Disorder. Review of Resident #35's quarterly MDS assessment, dated 12/24/24, revealed her BIMS score was 15 of 15 which was reflective of no cognitive impairment; she had adequate vision; and was not receiving rehabilitation services. Review of Resident #35's Care Plan, revised on 2/10/25, revealed there was no indication she had impaired vision or that she was in need of optometry care. Interview on 03/05/25 at 01:49 PM with the facility Ombudsman revealed Resident #35 had complained about her vision; not being able to see like she used to and she had been waiting to see an optometrist since the latter part of 2024. Interview on 03/05/25 at 04:13 PM with Resident #35 revealed she had blurred vision since before Thanksgiving 2024. She stated the staff told her they were trying to get an optometrist to come to the facility and provide care in-house but expressed concern about the length of time she had waited. Interview on 03/05/25 at 5: 00 PM with the MDS Coordinator revealed Resident #35 had been waiting to see an optometrist for at least a couple of months. She stated Resident #35 had complained about blurred vision. Further interview revealed the MDS Coordinator stated Resident #35's Care Plan did not identify she had blurred vision and was in need of optometry services. The MDS Coordinator stated it could result in Resident #35 not receiving care and services as needed. 3. Review of Resident #19's face sheet, dated 3/6/25, revealed she was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, current episode depressed, severe with psychotic features, psychotic disorder with delusions due to known physiological condition, Anxiety Disorder, and Major Depressive Disorder, recurrent, severe with psychotic symptoms. Review of Resident #19's quarterly MDS assessment, dated 12/24/25 revealed her BIMS score was 14 of 15 reflective of minimal cognitive impairment and she received antidepressant, antianxiety and antipsychotic medications. Review of Resident #19's physician orders for March 2025 revealed an order for Depakote Sprinkles Oral Capsule Delayed Release Sprinkle (according to drugs.com it is used to treat manic episodes related to bipolar disorder). Review of Resident #19's Care Plan revised on 3/7/25 revealed it did not reflect she received Depakote Sprinkles Delayed Release (mood stabilizer). Interview on 03/07/25 at 2:43 PM with the MDS Coordinator revealed Resident #19 was receiving Depakote Sprinkles Oral Capsule Delayed Release Sprinkle as a mood stabilizer and stated the list of medications were not updated on Resident #19's Care Plan to reflect this medication. The MDS Coordinator stated it was important to revise the Care Plan to ensure Resident #19 received the care and services she needed. Review of the facility policy, CARE PLANNING, revised 6/2019, read in relevant part: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident.

Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional to provide activities for 42 of 42 residents. The facility did not have a qualified Activities Professional to direct their activities program. This deficient practice could affect any resident and could result in residents not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Review of the facility contract binder revealed they did not have a qualified Activity Director. Interview on 03/05/25 at 02:20 PM with the MDS Coordinator revealed the facility did not have a qualified Activity Director since she started working during April 2024. She stated the facility had an activities assistant but was not qualified to lead specialized activities. As a result, the resident's might not receive activities centered to meet their individual needs. Interview on 03/05/25 at 02:50 PM with the ADM revealed the facility did not have a certified Activity Director since she started working during December 2024. She stated they had an Activity Assistant but understood the activities program required a qualified Activity Director to direct the program so the resident's could receive specialized activities to meet their needs. Review of the facility policy, Activities, revised 6/2019, read in relevant part: The Facility's activity program shall provide meaningful, person-centered activities to meet each resident's physical, mental, and psychosocial well-being, per their comprehensive care plan. Offer a variety of activities that promote engagement and meet the diverse needs of the resident population. Schedule activities at various times of the day, including weekends and evenings, to accommodate different preferences. Ensure activities are adaptable for residents with physical or cognitive limitations. Assign a qualified Activity Director to oversee the program. This individual must meet CMS and HHSC qualifications (e.g., completion of a state-approved activity training course or related certification).

Based on observation, interview and record review the facility failed to ensure residents received proper treatment to maintain vision; the facility must, if necessary, assist the resident in making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision for 1 of 1 Resident (Resident #35) whose records were reviewed for optometry care. Nursing staff failed to ensure Resident #35 received transportation in order to obtain optometry care as needed for more than 2 months. This deficient practice could affect any resident and contribute to the decline of the resident's vision. The findings were: Review of Resident #35's face sheet, dated 3/5/25, revealed she was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus without complications and Anxiety Disorder. Review of Resident #35's quarterly MDS assessment, dated 12/24/24, revealed her BIMS score was 15 of 15 which was reflective of no cognitive impairment and that she had adequate vision. Review of Resident #35's Care Plan, revised on 2/10/25, revealed there was no indication she had impaired vision or that she was in need of optometry care. Interview on 03/05/25 at 01:49 PM with the facility Ombudsman revealed Resident #35 had complained about her vision; not being able to see like she used to; and she had been waiting to see an optometrist since the latter part of 2024. Interview on 03/05/25 at 04:13 PM with Resident #35 revealed she had blurred vision since before Thanksgiving 2024. She stated the staff told her they were trying to get an optometrist to come to the facility and provide care in-house, but expressed concern about the length of time she had waited. Interview on 03/05/25 at 5: 00 PM with the MDS Coordinator revealed she had been assisting with securing ancillary services for the residents. She stated Resident #35 had been waiting to see an optometrist for at least a couple of months. She stated Resident #35 had complained about blurred vision. The MDS Coordinator stated the facility had been sending residents out for services in the community until they secured a contract to have an optometrist provide in-house services. Further interview revealed the MDS Coordinator stated one of the wheel's on the wheelchair Resident #35 was using for transportation broke. The plastic came off of the wheel. She stated the facility did not have another wheelchair that was suitable for Resident #35's weight and she had not been able to schedule an optometry appointment. The MDS Coordinator stated they had a sister facility within close proximity but did not think about calling to ask if they had a suitable wheelchair for Resident #35. Interview on 03/06/25 at 10:30 AM with the DON and the ADM revealed the facility did not have an optometrist providing in-house care since they both started working at the facility. The ADM stated they had been sending residents out for optometry care. The DON stated it had been a collaborative effort made by all administrative staff to refer residents for ancillary services. She stated she was aware Resident #35 had been waiting since about December 2024 for optometry care. She stated Resident #35 reported she had blurred vision. The DON reiterated what the MDS Coordinator stated about the situation. She stated the wheelchair Resident #35 used for transport was broken and the facility did not have another wheelchair for Resident #35 to use. The DON stated she talked with the Rehabilitation Director who reported she had ordered a replacement wheel for the broken wheelchair. The ADM stated she had also secured a contract this week for an optometrist to provide in-house care and services.

39049 Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 of 6 nursing staff(CNA C, CNA-E and CNA K) reviewed for competencies. 1. a. CNA C and CNA K failed to use safe technique when transferring Resident #19 from the bed to the wheelchair using a mechanical lift. 2. When CNA D and E mechanically transferred Resident #28 from the bed to the wheelchair on 03/05/2025, CNA E did not hold the spreader bar to prevent the spread bar from hitting the resident's head that was swinging while CNA D was lowering the spread bar to connect it to the sling. These failures could place the residents at risk for avoidable falls and injuries as a result of a fall. The findings included: 1. Review of Resident #19's face sheet, dated 3/6/25, revealed she was admitted to the facility on [DATE] with diagnosis including Hemiplegia, unspecified affecting left non-dominant side. Review of Resident #19's quarterly MDS assessment, dated 12/24/25 revealed her BIMS score was 14 of 15 reflective of minimal cognitive impairment and she required substantial to maximal assistance with transfers from chair/bed -to-chair transfer. Review of Resident #19's Care Plan revised on 1/7/25 revealed Resident #19 was at risk for falling related to history of CVA (stroke). One of the interventions included Fall mat on floor next to bed. Review of Resident #19's physician orders for March 2025 revealed an order: Fall Mat: Place fall mat on the floor, beside the bed, while in bed. Bed to be in the lowest and safest position possible for frequent falls Active 9/23/24. Observation and interview on 03/04/25 at 11:11 AM revealed CNA C and CNA K transferring Resident #19 from the bed to a wheelchair using a mechanical lift. CNA K operated the lift on her own. She positioned the base of the lift under the bed; she did not widen the base or lock the lift when she parked it. CNA K and CNA C attached the sling to the spreader. CNA K pulled the lift backwards and away from the bed with Resident #19 in mid-air. She attempted to turn the lift in the direction of the wheelchair positioned at the foot of the bed. Resident #19 rocked from side to side. CNA K was struggling to get the lift to turn. CNA C walked over and helped to turn the lift by pulling on the sling with Resident #19. CNA K did not widen the base of the lift while turning the lift and did not lock the lift when she stopped in front of the wheelchair. CNA K then widened the base of the lift and positioned the legs of the lift around the wheelchair while CNA C held the wheelchair. CNA K lowered Resident #19 and her feet got stuck under the actuator of the lift. CNA K pulled on Resident #19's feet away from the actuator. Interview with CNA K and CNA C revealed the lift had been getting stuck during transfers but stated they had not said anything to the MS. CNA K stated she did not widen the base which stated would provide stability. She stated she did not lock the lift when she came to a stop but should have to keep the lift from moving. CNA K further stated she tugged on Resident #19's feet because they were stuck and did not know how else to get her feet loose. CNA C stated she did not assist CNA K until CNA K was unable to turn the lift. She helped to turn the lift and then walked back over behind the wheelchair. She stated she was supposed to guide Resident #19 to the wheelchair to help keep the resident steady on the lift so the lift did not tip over and the Resident did not fall. CNA K and CNA C stated they received training on operating a mechanical lift during February 2025, but both stated they did not follow the steps provided in training to safely transfer Resident #19. CNA K and CNA C stated she could have fallen and been injured. Interview on 03/06/25 at 10:30 AM with the DON revealed a mechanical lift required two staff; one staff operated the lift while the second staff guided the resident during the transfer. The DON stated the base should be widened when positioning it under the bed to provide stability when lifting the resident. The legs of the base should be put back to the original position when moving the resident back and away from the bed. Once the base was completely out then the base should be widened again making it easier to maneuver the lift. The staff guiding the resident should never leave the resident's side and continue to guide ensuring the resident did not hit any part of the lift. The DON stated the base of the lift should be locked anytime it came to a stop or was parked. The DON stated the rehabilitation department provided training on all transfers. Interview on 03/06/25 at 01:49 PM with the DOR revealed the rehabilitation department provided all training on all resident transfers including using a mechanical lift. She stated the base of the lift should be widened under the bed as much as the bed would allow when preparing for transfer from the bed to the wheelchair. She stated widening the base of the lift provided support/stability to keep a resident from tipping over. The DOR stated the lift should also be locked anytime it came to a stop. The DOR stated the second staff assisting should guide and keep her hands on the resident during the transfer for additional support. The second staff should also ensure the resident did not bump any part of their body on the lift. 2. Record review of Resident #28's face sheet, dated 03/07/2025, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnosis of poly-osteoarthritis (degenerative multiple joint disease), cerebral palsy (congenital disorder of movement, muscle tone, or posture), spastic quadriplegia (muscle stiffness and weakness in the arms and legs), muscle weakness, severe intellectual disability (motor impairment, severe damage to or abnormal development), and other reduced mobility. Record review of Resident #28's annual MDS, dated [DATE], revealed the resident's BIMS was 0 indicated the resident had severe cognitive impairment and was dependent to all activities of daily living such as bed mobility, char-to-bed transfer, and toilet transfer. Record review of Resident #28's comprehensive care plan, dated 08/04/2023, revealed [Resident #28] has activities of daily living self-care deficits and is at risk for further decline in the functions and injury as evidence by cerebral palsy. For intervention - total assistance of 2 support persons for transfers - hoyer lift (mechanical lift) for transfers. Observation on 03/05/2025 at 4:13 p.m. revealed CNA-D was driving a mechanical lift toward Resident #28 laying down on her bed to transfer the resident to a wheelchair. CNA-D was lowering a spread bar of the mechanical lift to connect it to the sling below Resident #28, and CNA-E was standing apposite side of CNA-D. When CNA-D was lowering a spread bar toward Resident #28's head, the spread bar was swing, but CNA-E did not hold the spread bar that was swing. CNA-E was just waiting for connecting the spread bar to the sling. CNA-D and E transferred Resident #28 to the wheelchair with a mechanical lift, then disconnected the sling to the spread bar. Interview on 03/05/2025 at 4:28 p.m. with CNA-E stated when CNA-D was lowering the spread bar, it was swing over Resident #28's head, but CNA-E did not hold it to prevent hitting the resident's head. Further interview with CNA-E stated she should have held the spread bar swing to prevent it from hitting Resident #28's head while CNA-D was lowering it. CNA-E stated she took training regarding how to transfer residents with mechanical lift and passed on skill check-off evaluation in 2024. However, CNA-E was nervous so forgot holding it. Resident #28 might have injury if the spread bar hits the resident's head. Interview on 03/06/2025 at 5:45 p.m. with DON stated CNA-E should have held the spread bar swing to prevent it from hitting Resident #28's head while CNA-D was lowering it because Resident #28 might have injury if the spread bar hits the resident's head. The previous DON conducted CNA-E's skill check-off on 10/30/2024, and the CNA passed the check-off. Record review of CNA-E's Resident Care Specialist Competency for Annual, dated 10/30/2024, revealed CNA-E received training and passed the skill check-off regarding mechanical lift on 10/30/2024. Record review of the facility policy, titled Transfer/Lifts, revised 01/2024, revealed The purpose of this policy is to ensure the safety, dignity, and well-being of residents during transfers and lifts within the nursing home facility. This policy aims to minimize the risk of injury to both residents and staff while promoting efficient and respectful care practice. Review of OWNER'S MANUAL for the mechanical lift, undated, read in relevant part: SAFETY INSTRUCTIONS: During lifting or lowering, whenever possible, always keep the base of the lift in the widest position. The base of the lift should be closed before moving the lift. Do not roll casters over any object while the user/patient is in the sling. While being lifted in a sling, always keep the user/patient centered over the base.

Based on observations, interviews, 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 for 1 of 2 medication rooms (3-side medication room) reviewed for pharmacy services. There were total eighteen (18) syringes of 0.9 % sodium chloride injection for flush 10 milliliters expired on 02/28/2025 found inside 3-side medication room on 03/05/2025. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Observation on 03/05/2025 at 11:28 a.m. revealed a total of eighteen (18) syringes of 0.9 % sodium chloride injection for flush 10 milliliters expired on 02/28/2025 found inside the 3-side medication room. Interview on 03/05/2025 at 11:46 a.m. with DON acknowledged there were total of eighteen (18) syringes of 0.9 % sodium chloride injection for flush 10 milliliters expired on 02/28/2025 found inside the 3-side medication room. The DON said she did not know what the reason the expired syringes for flush were inside the 3-side medication room, and nurses should discard all expired medications and syringes for flush from the medication rooms as per the facility policy. The facility did not have any resident with intravenous therapy for using normal saline syringes for flush. Potential harm was nurses might use the expired normal saline syringes for flush, and the expired normal saline syringes for flush might not have therapeutic effects. Record review of the facility policy, titled Consultant Pharmacist Services Provider Requirements, revised 08/2020, revealed 6 d. checking the medication storage areas and the medication carts for proper storage and labeling of medications, cleaning, and removal of expired mediations.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Resident #143) reviewed for care plans. The facility failed to ensure Resident #143's care plan reflected her bowel incontinence and included a care plan regarding how to take care of the resident's bowel incontinence. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #143's face sheet, dated 03/07/2025, revealed Resident #143 was [AGE] years old, female, and originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included: encounter for other orthopedic aftercare (caring after muscle or bone surgery), hyperlipidemia (high level of fat), muscle wasting and atrophy (wasting or thinning of muscle mass), dementia (group of thinking and social symptoms that interfere with daily functioning), and muscle weakness. Record review of Resident #143's quarterly MDS assessment, dated 12/23/2024, revealed Resident #143's BIMS score was 0 which indicated she had severe cognitive impairment, and she had frequent bladder incontinence, but always had bowel incontinence. Record review of Resident #143's comprehensive care plan, dated 10/07/2024, revealed [Resident #143] has bladder incontinence. For interventions - Monitor for incontinent episodes and provide peri care as indicated. Further record review of the resident's comprehensive care plan revealed there was no care plan regarding bowel incontinent care. Observation on 03/06/2025 at 9:24 a.m. revealed CNA-B and CNA-C were providing bowel and bladder incontinent care to Resident #143. Interview on 03/06/2025 at 9:32 a.m. with CNA-B and C stated Resident #143 was bowel and bladder incontinent, and the CNAs provided perineal care to the resident whenever the resident had incontinent episode. Interview on 03/07/2025 at 9:31 a.m. with the MDS nurse stated Resident #143 was incontinent of bowel and bladder and needed to have bowel and bladder incontinent care whenever she had an episode. She stated there were care plans regarding only bladder incontinent care, and the MDS nurse removed the resident's care plans regarding the resident's bowel incontinence because it was resolved. However, Resident #143's bowel incontinence was not resolved. She stated the resident still needed to have bowel incontinent care. It was the MDS nurse's mistake to remove the care plans related to Resident #142's bowel incontinence, and not developing and updating the care plan might cause lack of care to the resident. Record review of the facility policy, titled Minimum Data Set, revised 06/2019, revealed . 13. The quarterly MDS does not require the completion of care area assessment, however, the resident's care plan must be reviewed and revised by the interdisciplinary team after each assessment.

Based on observation, interview and record review the facility failed to provide a clean, comfortable, and homelike environment including a clean bed in good condition for 1 of 1 Resident (Resident #14) whose bed was observed for sanitation. The facility failed to replace Resident #14's mattress which was heavily soiled with urine and the urine stains covered at least 50% of the mattress. This deficient practice could affect any resident and result in dissatisfaction and poor self-esteem. The findings were: Review of Resident #14's face sheet, dated 3/7/25, revealed she was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Schizoaffective Disorder (according to Mayo clinic: mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), Major Depressive Disorder, recurrent severe without psychotic, Anxiety Disorder, unspecified Dementia, and bed confinement status. Review of Resident #14's quarterly MDS assessment, dated 12/20/24, revealed her BIMS score was 4 of 15 reflective of severe cognitive impairment; she had impaired vision; and required substantial to maximal assistance with toileting. Review of Resident #14's Care Plan, revised 1/7/25, read: ADL SELF CARE DEFICITS: Resident #14 [name]has ADL self-care deficits and is at risk for further decline in ADL functioning and injury AEB (as evidenced by) bilateral leg amputations. One of the interventions read: Provide Total assistance of 1 support person for toileting/incontinent care. Observation and interview on 03/05/25 at 10:15 AM revealed Resident #14's mattress had been stripped of its linens. The mattress was heavily soiled with urine and there was a large stain on the middle of the mattress that covered at least half of the mattress. The stain was brown/red in color and the room smelled heavily of urine. Interview with the ADON revealed she commented, oh that's got to get thrown out. She stated it was severely stained and it smelled like urine. The ADON stated the CNA's should be cleaning and disinfecting the mattress when soiled after providing pericare. She stated usually a mattress was replaced when ripped, but in this case, it was so heavily soiled she did not believe it could be adequately cleaned for continued use. The ADON stated nursing staff should report when there was a problem, but stated no one had said anything to her. She stated she also made rounds but had not seen the condition of the mattress because it had always been covered. The ADON stated Resident #14 had not said anything to her either but couldn't imagine being ok with the condition of the mattress. Interview on 03/05/25 at 10:57 AM with Resident #14 revealed she was sitting in a wheelchair by the nurse's station. Resident #14 stated usually she did not spend much time in her room once staff helped her to get out of bed. She stated she was not aware of the condition of her mattress. She stated she had not paid attention. Resident #14 reviewed the picture taken of the mattress she was using and immediately commented, Oh my God that doesn't look good. I would not want to lay on that. Interview on 03/05/25 at 11:15 AM with CNA D revealed she often worked with Resident #14 and stated today was her shower day. CNA D stated they would strip the resident's bed during shower days. CNA D stated she had not really paid attention to the condition of Resident #14's bed but stated she would wipe it down with disinfectant if soiled. CNA D looked at Resident #14's mattress and commented, I don't remember it looking that way. She stated it was really soiled and it smelled like urine. She further stated she was not sure if the mattress would come clean. CNA D stated any resident would probably not be happy sleeping on a mattress that was that dirty. Review of the facility policy, Dignity: Resident's Right for, revised 6/2019, read in relevant part: It is the policy of this facility that the Facility staff will provide the resident with the right to an environment that preserves dignity and contributes to a positive self-image. 7) Create a home-like environment for the resident that includes: c. Clean, orderly, comfortable, safe environment with clean bed and bath linen in good condition, and personal closet. Review of the facility policy, General Environment Cleaning Techniques, revised 2/2022 read in relevant part: The primary objective of this policy is to establish and maintain a standardized approach to environmental cleaning, minimizing the risk of infections and promoting clean and sanitary living and working environment. General Surface Cleaning Process. Thoroughly wet (soak) a fresh cleaning cloth in the environmental cleaning solution. Fold the cleaning cloth in half until it is about the size of your hand. This will ensure that you can use all surface area efficiently. Wipe surfaces using the general strategies as above (clean to dirty, high to low), making sure to use mechanical action and making sure the surface is thoroughly wetted to allow required contact time.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and misappropriation for 1 of 5 staff (housekeeper-F) reviewed for criminal backround checks. The facility administrator and human resources completed checking housekeeper-F's criminal background on 03/06/2025, but the housekeeper was hired to the facility on [DATE]. This failure could place all residents at risk of abuse from facility staff. Findings included: Record review of housekeeper-F's employee's profile revealed the housekeeper was hired and started working to the facility on [DATE], but the housekeeper's criminal background was checked on 03/06/2025. Interview on 03/07/2025 at 3:12 p.m. with the administrator stated housekeeper-F was hired and started working at the facility on 02/05/2025, but the housekeeper's criminal background was checked on 03/06/2025. The facility did not have staff for human resources, so the staff from the ssociated facility came to the facility sometimes and checked the criminal backgrounds of newly hired employees. Along the way, the staff might have miss checking the housekeeper-F's background before the housekeeper was hired. The facility should have checked the housekeeper-F's criminal background before the housekeeper was hired. Housekeeper-F had clear criminal background when it was checked on 03/06/2025. However, not checking criminal backgrounds before hiring dates might cause resident's abuse due to inappropriate staff. Record review of the facility policy, titled Authorization and release form to obtain an investigative and/or consumer report used for pre- and post-employment evaluation for employee, undated, revealed prospective employees authorize the facility to obtain an investigative and/or consumer report. These reports may include but are not limited to personal credit history and criminal history.

Based on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 7 Residents (Resident #16 and Resident #35) whose records were reviewed. 1. Resident #16's quarterly MDS did not reflect he used one 1/4 bed rail for mobility and transfers. 2. Resident #35's quarterly MDS did not reflect she had impaired vision. This deficient practice could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs. The findings were: 1. Review of Resident #16's face sheet, dated 3/4/25, revealed he was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting non-dominant side and Dementia in other Diseases classified elsewhere, severe, with psychotic disturbance. Review of Resident #16's quarterly MDS assessment, dated 1/22/25, revealed his BIMS score was 14 of 15 reflective of minimal cognitive impairment and he did not use a bed rail while in bed. Review of Resident #16's Care Plan last updated on 6/25/24 revealed there was no indication he used a bed rail while in bed. Review of Resident #16's physician orders for March 2025 revealed an order L side rail to assist with bed mobility and transfers. No directions specified for order. Active: 1/22/2025. Observation and interview on 03/04/25 at 11:27 AM revealed Resident #16 lying in bed holding on to 1/4 bed rail x1; on his left side. Interview with Resident #16 revealed he used the bed rail to help him sit up in bed and for transfers out of bed. Interview on 03/06/25 at 02:58 PM with the MDS Coordinator revealed Resident #16's quarterly MDS assessment, dated 1/22/25, did not reflect he used a bed rail for mobility and transfers. The MDS Coordinator revealed clinical assessments were used to update the Care Plan. The accuracy of assessments were important to ensure staff captured all assistive devices provided to help Resident #16 become as independent as possible. The MDS Coordinator stated the inaccuracy of the MDS assessment could contribute to the Care Plan not reflecting assistive devices that should be provided and could result in a decline in physical mobility or inability to assist with mobility to maintain independence as much as possible. 2. Review of Resident #35's face sheet, dated 3/5/25, revealed she was admitted to the facility on [DATE] with diagnoses included Type 2 Diabetes Mellitus without complications and Anxiety Disorder. Review of Resident #35's quarterly MDS assessment, dated 12/24/24, revealed her BIMS score was 15 of 15 which was reflective of no cognitive impairment and that she had adequate vision. Review of Resident #35's Care Plan, revised on 2/10/25, revealed there was no indication she had visual impairment. Interview on 03/05/25 at 01:49 PM with the facility Ombudsman revealed Resident #35 had complained about her vision; not being able to see like she used to and had been waiting to see an optometrist since the latter part of 2024. Interview on 03/05/25 at 04:13 PM with Resident #35 revealed her vision was blurry since before Thanksgiving 2024. She stated the staff told her they were trying to get an optometrist to come to the facility and provide care in-house. Interview on 03/05/25 at 5: 00 PM with the MDS Coordinator revealed Resident #35 had been waiting to see an optometrist for at least a couple of months. She stated Resident #35 had complained about blurry vision. Further interview revealed Resident #35's quarterly MDS assessment, dated 12/24/24 did not reflect that she had blurred vision. She stated furthermore, the Care Plan, would not include it as a care need because the quarterly MDS did not accurately reflect Resident #35's status. She stated it could result in Resident #35 not receiving vision services as needed. Review of a facility policy, Minimum Data Set revised 6/2019, read in relevant part: Policy: It is the policy of this facility that a registered nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #11 and #143) reviewed for incontinence care. 1. When CNA-C was providing incontinent care to Resident #11 on 03/05/2025, CNA-F did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). 2. When CNA-B was providing incontinent care to Resident #143 on 03/06/2025, CNA-G did not separate and clean the resident's labia area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #11's face sheet, dated 03/07/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus ( uncontrolled blood sugars), cerebral infarction (lack of blood flow to an area of the brain), chronic obstructive pulmonary disease (restricted airflow and breathing problem), muscle wasting and atrophy (wasting or thinning of muscle mass), reduced mobility, and benign prostatic hyperplasia (prostate gland enlargement). Record review of Resident #11's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 3 which indicated the resident had severe cognitive impairment and always incontinent of bowel and bladder. Resident #11 required substantial/maximal assistance (helper does more than half the effort) to chair-to bed transfer and was dependent (helper does all of the effort) to toilet transfer. Record review of Resident #11's comprehensive care plan, dated 08/01/2023, revealed [Resident #11] has bowel and bladder incontinence related to resident does not voice need to toilet. For intervention - Clean perineal area with each incontinence episode and monitor for signs and symptoms of urinary tract infection such as pain, burning, blood-tinged urine and cloudiness. Observation on 03/05/2025 at 4:32 p.m. revealed CNA-C opened Resident #11's old and dirty brief and cleaned the resident's penis, and then cleaned the left and right groin area. CNA-C turned the resident to his left side without cleaning the suprapubic area, which was the area of the abdomen located below the umbilical region, and CNA-C cleaned the resident's buttock area, then put a new and clean brief on the resident. In an interview on 03/05/2025 at 4:46 p.m. CNA-C stated she did not clean Resident #11's suprapubic area, which was the area of the abdomen located below the umbilical region because she was nervous and forgot to clean the area. CNA-C said she should have cleaned the area when providing peri-care to Resident #11 and had peri-care training last year. 2. Record review of Resident #143's face sheet, dated 03/07/2025, revealed Resident #143 was [AGE] years old, female, and originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included: encounter for other orthopedic aftercare (caring after muscle or bone surgery), hyperlipidemia (high level of fat), muscle wasting and atrophy (wasting or thinning of muscle mass), dementia (group of thinking and social symptoms that interfere with daily functioning), and muscle weakness. Record review of Resident #143's quarterly MDS assessment, dated 12/23/2024, revealed Resident #143's BIMS score was 0 indicated she had severe cognitive impairment, and she frequently had bladder incontinence, but always had bowel incontinence. Record review of Resident #143's comprehensive care plan, dated 10/07/2024, revealed [Resident #143] has bladder incontinence. For interventions - Monitor for incontinent episodes and provide peri care as indicated. Observation on 03/06/2025 at 9:24 a.m. revealed CNA-B opened Resident #143's old and dirty brief and cleaned her suprapubic area, left and right groin area, then turned the resident to left side without separating and cleaning Resident #143's labia area. The CNA-B cleaned her buttock area and put a new and clean brief on Resident #143. In an interview on 03/06/2025 at 9:32 a.m. CNA-B stated she did not separate and clean Resident #143's labia area because she was nervous and forgot to separate and clean the area. CNA-B said she should have separated and cleaned Resident #143's labia area and she had peri-care training last year. In an interview on 03/06/2025 at 5:45 p.m. the DON stated CNA-C should have cleaned Resident #11's suprapubic area when providing peri-care to Resident #11, and CNA-B should have separated and cleaned Resident #143's labia area to prevent possible infection. The DON and the ADON were responsible for providing training related to peri-care and monitoring skill check-offs and conducting skill check-offs on 10/2024. Record review of the facility policy, titled Perineal care, revised 12/2023, revealed The facility will provide perineal care in a manner that maintain privacy, reduced the risk of infection, and promote skin integrity. Cleaning - for female residents, separate the labia and clean from front to back using a clean wipe for each stroke. For male residents, retract the foreskin (if applicable) and clean the penis from the tip down to the base, then the scrotum.

39049 Based on the observations, interviews, and record review, the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 2 of 2 (Resident #19 and Resident #28) reviewed for mechanical transfers. 1. a. CNA K and CNA C failed to use safe technique when transferring Resident #19 from the bed to the wheelchair using a mechanical lift. b. Nursing staff failed to ensure a floor mat was at Resident #19's bedside while she was in bed. 2. When CNA-D and CNA E mechanically transferred Resident #28 from the bed to the wheelchair on 03/05/2025, CNA-E did not hold the spreader bar to prevent the spread bar from hitting the resident's head that was swinging while CNA-D was lowering the spread bar to connect it to the sling. These failures could place the residents at risk for avoidable falls and injuries as a result of a fall. The findings included: 1. a. Review of Resident #19's face sheet, dated 3/6/25, revealed she was admitted to the facility on [DATE] with diagnosis including Hemiplegia, unspecified affecting left non-dominant side. Review of Resident #19's quarterly MDS assessment, dated 12/24/25 revealed her BIMS score was 14 of 15 reflective of minimal cognitive impairment and she required substantial to maximal assistance with transfers from chair/bed -to-chair transfer. Review of Resident #19's Care Plan revised on 1/7/25 revealed Resident #19 was at risk for falling related to history of CVA (stroke). One of the interventions included Fall mat on floor next to bed. Review of Resident #19's physician orders for March 2025 revealed an order: Fall Mat: Place fall mat on the floor, beside the bed, while in bed. Bed to be in the lowest and safest position possible for frequent falls Active 9/23/24. Observation and interview on 03/04/25 at 11:11 AM revealed CNA C and CNA K transferring Resident #19 from the bed to a wheelchair using a mechanical lift. CNA K operated the lift on her own. She positioned the base of the lift under the bed; she did not widen the base or lock the lift when she parked it. CNA K and CNA C attached the sling to the spreader. CNA K pulled the lift backwards and away from the bed with Resident #19 in mid-air. She attempted to turn the lift in the direction of the wheelchair positioned at the foot of the bed. Resident #19 rocked from side to side. CNA K was struggling to get the lift to turn. CNA C walked over and helped to turn the lift by pulling on the sling with Resident #19. CNA K did not widen the base of the lift while turning the lift and did not lock the lift when she stopped in front of the wheelchair. CNA K then widened the base of the lift and positioned the legs of the lift around the wheelchair while CNA C held the wheelchair. CNA K lowered Resident #19 and her feet got stuck under the actuator of the lift. CNA K pulled on Resident #19's feet away from the actuator. Interview with CNA K and CNA C revealed the lift had been getting stuck during transfers but stated they had not said anything to the MS. CNA K stated she did not widen the base which stated would provide stability. She stated she did not lock the lift when she came to a stop but should have to keep the lift from moving. CNA K further stated she tugged on Resident #19's feet because they were stuck and did not know how else to get her feet loose. CNA C stated she did not assist CNA K until CNA K was unable to turn the lift. She helped to turn the lift and then walked back over behind the wheelchair. She stated she was supposed to guide Resident #19 to the wheelchair to help keep the resident steady on the lift so the lift did not tip over and the Resident did not fall. CNA K and CNA C stated they received training on operating a mechanical lift during February 2025, but both stated they did not follow the steps provided in training to safely transfer Resident #19. CNA K and CNA C stated she could have fallen and been injured. Interview on 03/06/25 at 10:30 AM with the DON revealed a mechanical lift required two staff; one staff operated the lift while the second staff guided the resident during the transfer. The DON stated the base should be widened when positioning it under the bed to provide stability when lifting the resident. The legs of the base should be put back to the original position when moving the resident back and away from the bed. Once the base was completely out then the base should be widened again making it easier to maneuver the lift. The staff guiding the resident should never leave the resident's side and continue to guide ensuring the resident did not hit any part of the lift. The DON stated the base of the lift should be locked anytime it came to a stop or was parked. The DON stated the rehabilitation department provided training on all transfers. Interview on 03/06/25 at 01:49 PM with the DOR revealed the rehabilitation department provided all training on all resident transfers including using a mechanical lift. She stated the base of the lift should be widened under the bed as much as the bed would allow when preparing for transfer from the bed to the wheelchair. She stated widening the base of the lift provided support/stability to keep a resident from tipping over. The DOR stated the lift should also be locked anytime it came to a stop. The DOR stated the second staff assisting should guide and keep her hands on the resident during the transfer for additional support. The second staff should also ensure the resident did not bump any part of their body on the lift. b. Observation on 03/05/25 at 09:30 AM revealed Resident #19 lying in bed. Interview with Resident #19 revealed the last time she fell she broke her hip and had not been able to walk since. Further observation revealed a mat propped up on the chest of drawers across the room from Resident #19. Observation on 03/05/25 at 09:35 AM revealed MA J walking into Resident 19's room. MA J commented to Resident #19 I'm going to put the mat back down. Interview with MA J revealed whoever removed Resident #19's meal tray probably forgot to put it down. She stated the mat was used to prevent Resident #19 from being injured in case she fell out of bed and should be by her bedside whenever Resident #19 was in bed. Interview on 03/06/25 at 10:30 AM with the DON revealed Resident #19 was a fall risk related to confusion and debility. She stated a mat was used and placed beside the bed at all times when in bed. She stated the staff should ensure they put the mat back in place when removing for meals and or care to prevent injuries in case Resident #19 fell out of bed. The DON stated Resident #19 had not had any recent falls this year. 2. Record review of Resident #28's face sheet, dated 03/07/2025, revealed the resident was a [AGE] year old female and admitted to the facility on [DATE] with diagnoses of poly-osteoarthritis (degenerative multiple joint disease), cerebral palsy (congenital disorder of movement, muscle tone, or posture), spastic quadriplegia (muscle stiffness and weakness in the arms and legs), muscle weakness, severe intellectual disability (motor impairment, severe damage to or abnormal development), and other reduced mobility. Record review of Resident #28's annual MDS, dated [DATE], revealed the resident's BIMS score was 0 which indicated the resident had severe cognitive impairment and was dependent on all activities of daily living such as bed mobility, char-to-bed transfer, and toilet transfer. Record review of Resident #28's comprehensive care plan, dated 08/04/2023, revealed [Resident #28] has activities of daily living self-care deficits and is at risk for further decline in the functions and injury as evidence by cerebral palsy. For intervention - total assistance of 2 support persons for transfers - hoyer lift (mechanical lift) for transfers. Observation on 03/05/2025 at 4:13 p.m. revealed CNA-D was driving a mechanical lift toward Resident #28, who was laying down on her bed, to transfer the resident to a wheelchair. CNA-D was lowering a spread bar of the mechanical lift to connect it to the sling below Resident #28, and CNA-E was standing on the opposite side of CNA-D. When CNA-D was lowering a spread bar toward Resident #28's head, the spread bar was swinging, but CNA-E did not hold the spread bar that was swinging. CNA-E was waiting for connecting the spread bar to the sling. CNA-D and E transferred Resident #28 to the wheelchair with a mechanical lift, then disconnected the sling to the spread bar. In an interview on 03/05/2025 at 4:28 p.m. CNA-E stated when CNA-D was lowering the spread bar, it was swinging over Resident #28's head, but CNA-E did not hold it to prevent it from hitting the resident's head. Further interview with CNA-E stated she should have held the spread bar swing to prevent it from hitting Resident #28's head while CNA-D was lowering it. CNA-E stated she took training regarding how to transfer residents with the mechanical lift and passed it on a skill check-off evaluation in 2024. However, CNA-E was nervous and forgot to it. Resident #28 might receive an injury if the spread bar hit the resident's head. In an interview on 03/06/2025 at 5:45 p.m. the DON stated CNA-E should have held the spread bar swing to prevent it from hitting Resident #28's head while CNA-D was lowering it. Resident #28 might have had an injury if the spread bar hit the resident's head. The previous DON conducted CNA-E's skill check-off on 10/30/2024, and the CNA passed the check-off. Record review of CNA-E's Resident Care Specialist Competency for Annual, dated 10/30/2024, revealed CNA-E received training and passed the skill check-off regarding mechanical lift on 10/30/2024. Record review of the facility policy, titled Transfer/Lifts, revised 01/2024, revealed The purpose of this policy is to ensure the safety, dignity, and well-being of residents during transfers and lifts within the nursing home facility. This policy aims to minimize the risk of injury to both residents and staff while promoting efficient and respectful care practice. Review of OWNER'S MANUAL for the mechanical lift, undated, read in relevant part: SAFETY INSTRUCTIONS: During lifting or lowering, whenever possible, always keep the base of the lift in the widest position. The base of the lift should be closed before moving the lift. Do not roll casters over any object while the user/patient is in the sling. While being lifted in a sling, always keep the user/patient centered over the base.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 14 residents (Residents #6) reviewed for accommodation of needs. The facility failed to ensure Resident #6's call light was within reach while she was positioned on her bed in her room. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: Record review of Resident #6's face sheet, dated 03/07/2025, revealed the resident was a [AGE] year old female and an original admitted [DATE] with diagnoses that included: traumatic subdural hemorrhage with loss of consciousness of unspecified duration (a pool of blood between the brain and it outermost covering), dysphagia (difficulty swallowing), hypertension (high blood pressure), extrapyramidal and movement disorder (increase motor tone and changes in the amount and velocity of movement), difficulty in walking, and muscle wasting and atrophy (wasting or thinning of muscle mass). Record review of Resident #6's quarterly MDS assessment, dated 01/21/2025, indicated her BIMS score was 15 reflecting her cognition was intact. Further record review indicated the resident was independent to all daily activities such as toilet hygiene, dressing, personal hygiene, and chair-to-bed transfer. Record review of Resident #6's comprehensive care plan, dated 10/17/2023, reflected [Resident #6] has activities of daily living self-care deficits and is at risk of further decline in activities of daily living functioning and injury. For intervention - call light is within reach and answer in a timely manner. Observation on 03/04/2025 at 9:34 a.m. revealed Resident #6 was laying down on her bed in her room, and the call light was on the floor, which was beside her roommate's bed, and it was not within reach. Interview on 03/04/2025 at 10:40 a.m. with Resident #6 stated she could use the call light when she needed to have help, but she did not know where the call light was. The resident said to the state surveyor, Please give to me the call light because I could not reach it now. Further interview with Resident #6 stated she did not know why the call light was located on the floor bedside her roommate's bed where she could not reach it. Interview on 03/04/2025 at 10:43 a.m. LVN-A stated Resident #6 was on her bed in her room, and the call light was on the floor beside the resident's roommate's bed. She stated Resident #6 could not reach her call light. The call light should have been within reach all the time. She stated Resident #6 could use the call light to get help. LVN-A did not know what reason the call light was on the floor beside the resident's roommate's bed. The resident might not have proper care. Interview on 03/06/2025 at 5:45 p.m. the DON stated Resident #6 could use the call light to get help. The call light should have been within reach at all times per the facility policy. If Resident #6 could not use the call light because it was not within reach, the resident's care might be delayed. Record review of the facility policy, titled Call Lights, revised 12/2023, revealed Accessibility - Call lights will be placed within reached of the resident's bed or sitting area in the resident's room.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed (Resident #1) accidents in that: CNA A attempted to complete peri-care for Resident #1 alone when the resident's MDS called for two-person assist, resulting in the resident falling from the bed and sustaining a neck fracture. This failure could place residents who require two-person assistance for transferring, peri-care, and repositioning at risk of injury. The findings included: Record review of Resident #1's face sheet, dated 05/31/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: bed confinement status, right and left shoulder contractures, joint pain, Dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and [CONDITION(S)] (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment. Further review revealed Resident #1 was Two+ persons physical assist for bed mobility, transfer, dressing, toilet use, (and) personal hygiene. Record review of Resident #1's care plan, dated 06/29/2022 revealed ADL SELF CARE DEFCITS: [Resident Name] has ADL self-care deficits and is at risk for further decline in ADL functioning and injury. Date Initiated: 02/06/2022. Revision on: 02/06/2022. [Resident Name] will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury over the next 90 days. Date Initiated: 02/06/2022. Revision on: 02/06/2022. Target Date: 06/28/2022 2/23/22. OT recertification. 5xweek x 4 weeks. 3/23/22 OT recertification 5xweek x 4 weeks. 4/20/22. OT recertification. 5xweek x 4 weeks. Date Initiated: 03/01/2022 Revision on: 04/22/2022. OT 4/14/22 PT clarification. 3xweek x 12 weeks. Date Initiated: 04/15/2022 PT. Anticipate needs - provide prompt assistance. Date Initiated: 02/06/2022. Ensure call light is within reach and answer in a timely manner Date Initiated: 02/06/2022. Hoyer lift for transfers. Date Initiated: 02/10/2022. Pericare - 2 staff members. Date Initiated: 3/11/2022 Provide privacy and maintain dignity Date Initiated: 02/06/2022. Record review of the facility incident, dated 06/29/2022 at 10:49 p.m., completed by LVN C revealed 8:15 am CNA (unknown) asked nurse to come into the room to look at resident's (#1) face. Noted 7cm x 2.5cm bruise to left lower jaw neuros begun. Neuro's WNL. [ .] Resident unable to give Description. Record review of grievances revealed a grievance/complaint, dated 06/29/2022, completed by the Administrator, pertaining to Resident #1, revealed Family member came up to facility to see what was going on with Resident#1 - Family member was notified by about (Resident #1) having a fall and being sent to the ER for evaluations. [ .] The family member came up to facility wanting to know more information about the fall that occurred last night with (Resident #1). He was informed that after finding a bruise this am. I reached out to to help identify where the origin of bruise came from. She informed me after reviewing the camera in Resident #1's room that she fell out of bed during peri-care with agency night CNA (A). family member said, that [OBSCENITY] better not be coming in tonight or both he (agency CNA A) and myself are going to have some serious [OBSCENITY] ing issues. Informed him that agency CNA (A) will not be coming in tonight and investigation is ongoing at this time. Record review of grievances revealed a grievance/complaint, dated 06/29/2022, completed by the Administrator, pertaining to Resident #1, revealed @ 8:48 am - Family member notified by Admin, (Name of family member), of bruise to left jaw - Since family has a camera in room, requested they (facility staff) review camera to help us (facility staff) identify source. Family called back stating Resident #1 fell out of bed last night, agency CNA was providing peri-care. [ .] at approximately 9:16 am. (Resident #1's) came up to facility. They showed Administrator video footage from last night where night CNA (A) was providing pre-care behind closed curtain. Able to see in video where (Resident #1) hits floor but unable to tell how high the bed was at that time. Reached out to both CNA (A) and night nurse (LVN B) - who says she was not aware of the situation. Resident sent to ER for an evaluation. Investigation ongoing at this time. Record review of LVN B's statement, provided by the facility, undated, revealed I (LVN B) received a phone call this am concerning (Resident #1), a resident at my (LVN B) place of employment (Name of Facility). I (LVN B) was asked if resident (#1) had a fall last night and I (LVN B) said no. Resident (#1) was given Tylenol last night for c/o pain at family request. I (LVN B) had also performed nail care on resident and was in room later than normal because of this. Which I (LVN B) went back in room this am to administer morning meds around 5:15 - 5:30 am res was resting in bed. Resident (#1) did not mention a fall, but resident (#1) normal LOC is confused and a/ox1 (person) I (LVN B) was also not informed by the CNA (A) I was working with that the resident had fallen. I (LVN B) would have taken the proper steps of my job duties if I had been told such as the correct documentation and assessment of resident and notification of family employer and md. Record review of CNA A's written statement, dated 06/29/2022, revealed I (CNA A) went into patient (Resident #1's) room around 10:00 pm on 06/28/22. Resident's had just left but before leaving he told me that he thought Resident #1 might have soiled her brief, and she had a very large diarrhea accident. I (CNA A) let him know that I (CNA A) would check. I (CNA A) entered the resident's (#1) room and closed the door. I (CNA A) proceeded to pull the curtains closed. I (CNA A) undid the residents (#1) brief and she had a very large diarrhea accident. I (CNA A) stepped out of the resident (#1) room to go and grab new bed linens. The resident (#1) was on her back lying flat in bed. I (CNA A) returned to the room with the new linens and placed them behind me on resident's nightstand. I (CNA A) proceeded to wipe the residents (#1) frontal area. I (CNA A) turned behind me to grab the new linens and brief and I (CNA A) read the resident (#1) yelling for help. I (CNA A) turned around and the resident's (#1) upper body was on the ground. I (CNA A) ran to the other side of the bed and she (Resident #1) had landed on pillows. I (CNA A) proceeded to lower the bed. I (CNA A) first check the residents (#1) head and seen no blood or bruises then I (CNA A) checked her (Resident #1) back and seen no blood or redness. I (CNA A) picked the patient back up and placed her (Resident #1) back in bed. I (CNA A) then checked her (Resident #1) right arm and legs and seen no redness or bruising. I (CNA A) finished changing the resident (#1) and placed her (Resident #1) wedge and a pillow underneath her (Resident #1) back and underneath her legs. I (CNA A) repositioned her (Resident #1) bed and turned the lights out. Record review of LVN C's written statement, dated 06/29/22 at 11:00 a.m., revealed 8:15 am CNA (unknown) called nurse to room to report bruising to left of jaw. Area measured 7cm x 2.5cm. Resident (#1) unable to say what happened. Resident (#1) able to move jaw with no discomfort. 8:30 am Administrator notified. notified. 9:15 am MD notified of change in condition. Orders given to sent to (name of hospital) for evaluation & treatment. 9:45 am EMS notified of transfer. 9:50 am Report given to ER. 9:55 EMS here to transfer to ER to evaluate and treat. Record review of hospital paperwork, dated 06/29/2022, read FINDING: T-SPINE: [ .] Acute oblique fracture of the T1 vertebral body without significant displacement or retropulsion. During an interview on 06/30/2022 at 4:47 p.m., the Administrator stated this incident was not reported to HHSC. The Administrator stated, because she was not officially aware of the broken neck until she received the paperwork from the hospital this morning. The Administrator stated she preferred for the break to be confirmed through official hospital paperwork. However, the Administrator stated she was verbally told about the broken neck yesterday by the family. The Administrator stated she was the abuse coordinator. The Administrator stated the potential harm, by not reporting to HHSC in a timely manner, was a resident being abused. During an interview on 06/30/2022 at 5:10 p.m., the DON stated she was aware of the break in Resident #1's neck right after the Administrator was told yesterday. The DON continued that it was the family who told them Resident #1 had a broken neck. The DON stated the potential harm, by not reporting to HHSC in a timely manner, was a resident being abused. During an interview on 06/30/2022 at 5:59 p.m., the RP stated she was contacted by the facility about a bruise on Resident #1's jaw and was asked to look at the video to determine how the bruise occurred. She further stated in the video, Resident #1 fell off the bed and onto the floor while CNA A provided care but it was difficult to see exactly what happened because the curtain was pulled around the bed and all that can be seen was below the curtain. Record review of video, given by RP, dated 06/28/2022 at 10:24 p.m., revealed and observed Resident #1 fell from her bed onto the opposite side of where CNA A was standing. CNA A was standing on Resident #1's left side of the bed, and she fell on to the right side of her bed. There was a pillow on the floor, that fell off the bed prior to Resident #1 falling, however, she barely missed landing on the pillow. The resident landed on her left side. There was about a foot below the curtain that can be observed from the angle of the camera in Resident #1's bedroom. CNA A walked to the side where she fell and rolled her over a bit, and he appeared to look over the resident. Resident #1 was not observed to be yelling or crying during and around the time of her fall. The sound quality of the video was difficult to understand because Resident #1's television was on during the recording. During an interview and observation on 06/30/2022 at 6:30 p.m., Resident #1 was observed in her room and laying more on her right side with a pillow propped behind her back for support. Resident #1 stated she hurt all over, however, she also repeated the same statement over and over after her need was addressed. Further observation revealed bruising on left side of resident's jaw and jaw line closer to the mouth. When resident was asked if her jaw hurt, resident stated she hurt all over. During an interview on 07/19/2022 at 1:15 p.m., Administrator stated CNA A was an agency employee and his trainings and background checks were completed prior to the incident. Administrator stated CNA A knew where to look to get information on if a resident requires a two person assist or not. Administrator said the requirements for staff assistance can be found in the resident's electronic record that all nursing staff have access to. Administrator stated the facility completed their investigation and their findings were confirmed that CNA A did not follow Resident #1's MDS requiring two person assist and because of this the resident was injured. Administrator said CNA A has not been allowed to return to the facility after the incident was discovered. Administrator stated all staff were immediately in-serviced on falls, nursing policies and procedures, A/N/E, Resident Rights, where to look to find special instructions i.e., for a certain resident was completed on 06/29/2022 for all nursing staff. Observation on 07/19/2022 at 1:30 p.m. revealed DON and ADON providing two person assisted incontinent care for Resident #1. During an interview on 07/19/2022 at 1:45 p.m., LVN C stated she entered Resident #1's room with CNA D to get her ready for lunch which includes changing her, peri-care, and repositioning. LVN C said when her and CNA D rolled Resident #1 onto her side and discovered a bruise on the resident's face near her jawline. LVN C stated she called LVN B to ask if she knew where the bruise came from and LVN B said she did not know. LVN C said she asked LVN B if Resident #1 had fallen and LVN B told her no. LVN C stated she informed the Administrator who also said she is not aware of any accidents for Resident #1 that would have caused the bruise and Administrator told her she would look into it. Attempted telephone interview on 07/19/2022 at 2:10 p.m. with CNA D was unsuccessful. A voicemail request to return the call was left, no call back was received before exit. Attempted telephone interview on 07/19/2022 at 2:15 p.m. with LVN B was unsuccessful. Attempt to leave a message but was not possible due to voicemail being full. No call back was received before exit. Attempted telephone interview on 07/19/2022 at 2:20 p.m. with CNA A was unsuccessful. Initial call was answered by a male and when asked to speak with CNA A by name, the call disconnected. Attempted telephone interview on 07/19/2022 at 2:21 p.m. with CNA A was unsuccessful. A voicemail was left detailing the reason for the call and identification of the caller. A call was not returned prior to exit. During an interview on 07/19/2022 at 2:30 p.m., RP E stated she had reviewed Resident #1's video clips and had noticed CNA A regularly performing care for Resident #1 alone and not following the orders for a two person assist. RP E stated this was the first time that Resident #1 had fallen because he did not have another staff member to assist him. RP E stated after Resident #1 was on the floor, CNA A walked over, picked her up, and placed her back in bed. RP E said, again he was transferring her alone and did not request assistance from another staff member. During an interview on 07/19/2022 at 2:40 p.m., RP F stated he had seen the video clips from Resident #1's room camera and noted on several occasions CNA A providing peri-care, transfers, and/or repositioning alone and against orders for two person assists. RP F stated this incident was the first time an injury to Resident #1 was inflicted during CNA A's care. RP F said CNA A would follow two-person assist orders when he was there, but the videos show he would not request help when they were not there. During an interview on 07/19/2022 at 2:50 p.m., CNA G stated she was in-serviced on where to look to find if a resident is a two person assist or not and said the training was held around the begining of the month. CNA G stated if she found a resident that needed changing and they were a two person assist she would ask for help or wait to complete care until someone was available. During an interview on 07/19/2022 at 3:00 p.m., LVN C stated she was in-serviced on where to look for a resident's reguirements for staff assistance as well as abuse/neglect, falls, and resident rights. LVN C stated the in-serivce occurred after the incident occured and was on or about 6/29/2022. During and interview on 07/19/2022 at 3:15 p.m., Administrator stated the facility will in-service all new/agency staff on where to look for requirements on staff assistance for residents before they are allowed to start working. Administrator stated management has required all nursing staff to review the resident's record to find any special instructions for that resident prior to working with them or providing care to them to include peri-care. Administrator stated charge nurses and/or managment will be responsible for ensuring staff are checking prior to care. Record review of facility in-service attendance record dated 06/29/2022 revealed falls, nursing policies and procedures, A/N/E, Resident Rights, where to look to find special instructions to include staff assistance for peri-care for a certain resident was completed on 06/29/2022 for all nursing staff. Record review of facility policy Where to Look for Special Intructions dated 06/29/2022 revealed; Topic POL: When providing care to residents, you can look up specific instructions for resident care by selecting a resident, click menu @ top right of screen, choose Kardex. Information can be found on resident care, daily routine, transferring, toileting, eating nutrition, skin integrity, and several other categories. Please review prior to working with residents.

Based on observation, interview, and record review revealed the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Residents #1 and #4) reviewed for supervision for elopement, in that: There was not adequate supervision for Residents #1 and #4 who had histories of elopement and were at risk for elopement and inadequate interventions were put in place after the Residents' first elopements while the facility's wander guard alarm system was not operational and the two dining room doors were not equipped with an alarm system that would alert staff if a resident exited either door. An Immediate Jeopardy (IJ) was identified on 1/22/21. While the IJ was removed on 1/24/21, the facility remained out of compliance at no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope was a pattern while they continued to monitor their Plan of Removal. These deficient practices could place residents at risk for elopement, at risk for further avoidable incidents of elopement, injury or death. The findings were: Observation on 1/22/21 at 5:40 PM, while testing the wander guard alarm system by the front door with the ED and the DON present, revealed Resident #5's wander guard did not trigger the alarm when walking passed the wander guard system. Further observation revealed Resident #5's device had a flashing red light, which indicated the Resident's wander guard bracelet was operational. Observation on 1/22/21 at 5:42 PM, while testing the wander guard alarm system by the front door with the ED and the DON present, revealed Resident #6's wander guard did not trigger the alarm when walking passed the wander guard alarm system by the front door. Further observation revealed Resident #6's device had a flashing red light, which indicated the resident's wander guard bracelet was operational. Interview on 1/22/21 at 6:05 PM with the ED and DON stated they did not know the wander guard system by the front door was not working properly. The ED and DON confirmed that any resident who should be wearing a wander guard bracelet and took it off would be able to exit through the front door. The ED and DON further stated there were two other doors equipped with a wander guard alarm system; at the end of the front hall and the end of the east hall. The ED stated she did not know if the Maintenance Supervisor had tested the wander guard alarms on any of the doors for functionality. Interview on 1/22/21 at 6:54 PM with the Maintenance Supervisor stated that about two months ago the wander guard alarm system by the front door was triggered very easily and was constantly sounding. The Maintenance Supervisor stated he was not familiar with the alarm system, so he called the manufacturer who provided him with instructions on how to adjust the sensitivity device on the alarm. The Maintenance Supervisor stated he had adjusted the wander guard alarm system and it quit sounding all the time, but stated he did not know for sure if it had fixed the problem or if there were any other mechanical issues. The Maintenance Supervisor stated he let the ED know what was going on with the wander guard alarm system, but they did not talk about calling a technician to check that the system was working properly. The Maintenance Supervisor further stated the back door at the end of the front hall and the back door at the end of the east hall were also equipped with a wander guard alarm system and he had not checked them for functionality since his employment. The Maintenance Supervisor confirmed that if a resident removed their wander guard bracelet then they could potentially exit from the front door and the back door at the end of the east hall because the doors were only equipped with a wander guard alarm. The Maintenance Supervisor stated the ED was his immediate supervisor. Observation on 1/22/21 at 7:15 PM, while touring the facility with the Maintenance Supervisor, revealed the front door was not equipped with an exit alarm. During interview at this same time with the Maintenance Supervisor stated the front door would remain unlocked until all administrative staff left for the day. Further observation revealed the back door at the end of the front hall had a wander guard alarm and an exit alarm that sounded every time the door was opened. The back door at the end of the east hall only had the wander guard alarm and did not have an exit alarm that sounded every time the door was opened. The two doors in the dining room only had a chime on them that would sound for a few seconds when the doors were opened. Further interview with the Maintenance Supervisor confirmed any resident without a wander guard bracelet could exit the dining room doors or the back door at the end of the east hall. In addition, if the wander guard system near the front door did not work properly then any resident with or without a wander guard bracelet could exit the facility through the front door. Interview on 1/22/21 at 7:45 PM with the ED confirmed she knew the Maintenance Supervisor had worked on the wander guard alarm system near the front door because it was sounding all the time. The ED stated she did not call and did not instruct the Maintenance Supervisor to call a technician to service the wander guard system to ensure it was working properly. The ED confirmed it would be the Maintenance Supervisor's responsibility to check the doors' wander guard system for functionality, and further confirmed she was the Maintenance Supervisor's immediate supervisor. Review of Resident #1's face sheet, undated, revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 1, which indicated the Resident was severely cognitively impaired, and usually understood and was usually understood. Further review revealed the Resident wandered which placed the Resident at significant risk of getting to a potentially dangerous place, required supervision and set up by staff while walking in the corridor, on and off unit, had [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, last revised on 1/5/21, revealed Resident #1 was a potential high risk for injury related to identified elopement risk factors and or exit seeking behavior. Further review revealed some of the approaches included apply alarm system, wander guard to reduce risk of elopement, check device for proper functioning and placement per facility protocol (every shift), consider placement into secure unit if wandering, elopement attempts continue, supervise closely and make regular compliance rounds whenever resident is in room. Review of a nurses note, dated 12/13/20, written by ADON E at 5:30 AM, revealed Resident #1 was not in her room, and, Staff started looking through the facility and determined Resident #1 was not in the facility nor was she in surrounding property. Difficulty looking for Resident due to darkness and misting outside. Last seen in bed by staff after dinner time. Further review revealed, 07:24 AM noted Resident walking in park to sit down on concrete bench. Assisted Resident to bench and noted she is bare foot, in cotton pants and t shirt with ball cap on. She was shivering and pale. Noted dark purple bruise to right temple area about a half an inch long and 1/4 inch wide she also has a scabbed abrasion to her right chin that is less than 1/2 inch of thin straight abrasion. Note: According to Google maps the facility is located .01 miles from TX Highway 111 E. a major highway used highway in the area. Review of Provider Investigation Report, dated 12/24/20, revealed Resident #1 had eloped from the facility on 12/13/20 and was noted missing from her room during medication pass at 6:00 AM. Resident #1 was located across the street in a community park at approximately 7:25 AM. Resident #1 had removed her wander guard bracelet and was found in her biohazard bag on 12/14/20 and placed on left ankle. MD was notified and assessed Resident #1 in the facility on 12/13/20. Further review revealed Resident #1 was placed on 1-to-1 supervision for 24 hours and then on 15 minute checks until she transitioned into the locked memory care unit on 12/16/20. Review of an incident report, dated 1/1/21 written by LVN C, revealed LVN C noted Resident #1 was seen in doorway of her room at 10:35 AM. Nurse stepped into another resident's room, came out at 10:36 AM and noted Resident #1 was not in her room. LVN C alerted other staff. Further review revealed Resident #1 was spotted walking one block from elementary school at 10:37 AM. Noted Resident #1 fell over stump and got back up. Staff escorted Resident #1 back to the facility. Resident #1 had a wander guard bracelet on. Review of incident report, dated 1/3/21 written by ADON E, revealed that at 6:00 AM Resident #1 was not in the room. Staff searched the premises and was patrolling neighborhood. Resident #1 was located at the elementary school playground area one block away from the facility. Police drove Resident #1 back to the facility. Review of Provider Investigation Report, dated 1/11/21, revealed Resident #1 was moved to the COVID-19 isolation hall on 12/31/20 due to positive [MEDICATION NAME] test. Wander guard placed on right ankle. Resident #1 removed her bracelet and left it on top of a table in the hall way . Further review revealed staff noted she was missing at 6:00 AM and later located at a local elementary school playground. A police officer drove Resident #1 back to the facility where she was placed back into the COVID-19 isolation unit. Further review revealed Resident #1, was remained on 1:1 supervision for duration of COVID isolation period. Resident #1 was moved back to the locked memory care unit on 1/10/21. Interview on 1/20/21 at 3:04 PM with CNA J confirmed she knew Resident #1 had eloped from the facility more than once. CNA J stated staff called police when unable to locate her and the police brought her back. CNA J stated she was coming on shift one morning and Resident #1 was gone from the facility a few hours. CNA J stated Resident #1 was determined to leave the facility. Interview on 1/21/21 at 10:26 AM with the ED, DON, and Corporate Nurse present confirmed Resident #1 had eloped from the COVID unit three times, and further confirmed Resident #1 was admitted with a history of elopement but until her first elopement on 12/13/20 Resident #1 had stayed in her room the entire time. The ED, DON, and Corporate Nurse confirmed Resident #1 eloped from the COVID-19 isolation unit on 12/13/20. The ED stated Resident #1 was on quarantine as a new admission and staff noted Resident #1 was gone during shift change at 6:00 AM. The ED stated Resident #1 was last accounted for at 4:00 AM per ADON E. The ED stated Resident #1 was located about 7:25 AM at the elementary school down the street. The ED and DON stated Resident #1 was moved to the locked memory care unit on 12/16/20, but then on 12/31/20 Resident #1 was moved back to the COVID-19 isolation unit after testing positive for COVID-19. The ED, DON, and Corporate Nurse stated on 1/1/21 LVN C noted Resident #1 was gone mid-morning. LVN C had seen Resident #1 in her room; LVN C went into another resident room returned to Resident #1's room and noted Resident #1 was gone. The ED and DON stated staff swept the facility and grounds and noted Resident #1 had stepped off the facility grounds and was walking toward the elementary school. The ED stated LVN C was the only dedicated staff on the COVID-19 unit at the time who was caring for the four residents in the unit. The ED stated she emailed the self-report to HHSC and did not check for a read or delivery receipt and was not aware the report was not received. The ED and DON stated on 1/3/21 staff noted Resident #1 was gone during shift change at 6:00 AM. The DON stated ADON E was coming off the night shift and LVN C was reporting for the morning shift. The ED stated that per ADON E, LVN C told her, she had seen Resident #1 shortly before staff realized Resident #1 was gone. The ED stated staff found Resident #1 at 8:00 AM at the elementary school playground and the police officer that was also out looking for the Resident transported the Resident back to the facility. The ED and DON stated there were no witnesses to the elopement on the east hall and they suspected Resident #1 probably eloped from one of the doors in the dining room. Although, they stated Resident #1 took her wander guard bracelet off so the doors with the wander guard alarm system would not have sounded. The ED stated the front door, the back door at the end of the front hall and the back door at the end of the east hall were equipped with the wander guard alarm system, but they did not have another alarm on them. The ED stated the dining room exit doors had like a chime on them that sounded when the door was opened but it did not sound off continuously. Interview on 1/21/21 at 11:35 AM with Resident #1 confirmed she had eloped three times and exited through one of the doors in the dining room. Resident #1 stated the front door did not have an alarm either. Interview at 1/21/21 at 1:56 PM with LVN C confirmed she was the dedicated staff working the COVID-19 unit when Resident #1 eloped on 1/1/21. LVN C stated she saw Resident #1 outside her room, and then she went to help another resident, and when she returned to Resident #1's room the Resident was gone. LVN C stated she immediately alerted other staff including the ED and staff began a search of the facility and surrounding premises. LVN C stated staff found Resident #1 one block away from the facility and understood Resident #1 had a wander guard bracelet on. LVN C stated staff talked about that Resident #1 might have exited the facility from the exit door in the activity room. LVN C stated she was not sure if the door had an alarm. LVN C stated the two doors in the dining room had always chimed when the doors were opened but did not have an alarm. LVN C stated staff was supposed to lock the doors at night. Interview on 1/22/21 at 10:00 AM with the ED and DON revealed interventions in place for Resident #1 after she eloped on 1/1/21 included changing the location of the wander guard bracelet, and night staff was to check in on the Resident every 15 minutes. The ED stated on 1/3/21 the night staff included ADON E and CNA F and the morning nurse coming on was LVN C. The ED stated they planned to assign 1-to-1 supervision for Resident #1 beginning at 6:00 AM on 1/3/21. The ED stated on the morning of 1/3/21 CNA F left before her replacement relieved her. The ED and DON stated they suspected Resident #1 had eloped during this time; during shift change. The ED further stated staff had been in-serviced and advised they were not to leave at the end of their shift until their replacement relieved them. The ED and DON stated 1-to-1 supervision was started for Resident #1 when she returned to the facility on [DATE] until the resident was moved back to the locked memory care unit on 1/10/21 upon completing her isolation period. The DON stated staff sat right outside Resident #1's door and staff was not given any other duties. The ED stated they provided staff training and maintained a log to ensure staff was completing the 15 minute checks. However, stated she had misplaced all of the documentation. Interview on 1/22/21 at 1:44 PM with LVN C confirmed that on 1/3/21 she reported to work at 6:00 AM. LVN C stated she was rounding with ADON E during shift change when they noted Resident #1 was not in her room. Interview on 1/22/21 at 2:05 PM with ADON E confirmed she worked the night shift on 1/3/21, and stated she and CNA F were assigned to work the COVID-19 unit which was where Resident #1 resided. ADON E stated it was usually manageable because the residents slept through the night, and they were supposed to round on residents every two hours at a minimum. ADON E stated she and CNA F alternated making rounds on Resident #1 on 1/3/21, and further stated she rounded on Resident #1 at midnight and then at 2:00 AM. ADON E stated CNA F told her she checked in on Resident #1 about 4:30 AM. ADON E stated she then went to Resident #1's room to give her a scheduled medication at 5:00 AM, and noted Resident #1 was not in the room. ADON E stated she started looking for Resident #1 in the facility and called the nurse assigned to the memory care unit. ADON E stated that nurse started, running around the park, across the street looking for Resident #1. ADON E stated when the relief staff came in at 6:00 AM they continued to look for Resident #1 and then she and other staff searched the surrounding premises outside. ADON E stated she called the ED when they were unable to locate Resident #1. ADON E stated the interventions in place for Resident #1 included the wander guard bracelet and staff monitoring. ADON E stated she found Resident #1's wander guard bracelet on the night stand. Review of Resident #4's face sheet, undated, revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Annual MDS, dated [DATE], revealed the Resident had a BIMS score of 4, which indicated the Resident was severely cognitively impaired, usually understood and was usually understood, and had impaired vision. Further review revealed Resident #4 required supervision and set up by staff while walking in the corridor, on and off unit, and had [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan, revised on 1/12/21, revealed the Resident had a behavior problem related to exit seeking and going in and out of other resident rooms. Some of the approaches included, explain all procedures before starting to help Resident adjust to changes, intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. Further review revealed Resident #4's care plan did not identify the Resident had eloped from the facility twice. Review of elopement risk assessment, dated 1/20/21, revealed Resident #4 was an elopement risk and Care Plan interventions included routine monitoring, redirect resident and apply elopement security bracelet. Review of an incident report, dated 11/20/20, revealed Resident #4 was observed outside walking on the road between the facility and the gazebo in the mini park. Further review revealed the delivery person from pharmacy made facility staff aware Resident #4 was walking down the street. Staff discovered Resident #4 had slipped the wander guard off her right wrist. Review of an incident report, dated 1/1/21, revealed Resident #4 was walking outside on the walkway by the dining room. Interview on 1/22/21 at 6:05 PM with the ED and the DON confirmed Resident #4 eloped from the facility and the pharmacy delivery person notified staff that Resident #4 was outside. The ED stated she understood Resident #4 was still on facility grounds, however upon reviewing the incident report, dated 11/20/20, confirmed Resident #4 was walking on the street in front of the facility in front of the park across the street. The ED and the DON confirmed Resident #4 had removed the wander guard bracelet on 11/20/20. The ED and the DON stated on 1/1/21 a Resident Aide in the memory care unit told the nurse he saw Resident #4 outside walking on the walkway outside the dining room. The ED and the DON stated they were not sure if Resident #4 had a wander guard bracelet on. The ED and the DON stated they did not consider there was a potential trend after Residents #1 and #4 eloped from the facility and that they might be exiting from the dining room doors. Although, they previously stated they suspected Resident #1 had exited from one of the dining room doors. The ED and the DON stated they were focused on the fact the Residents were removing the wander guard bracelets. The ED stated she just did not think about it when asked how she believed the dining room doors did not pose a risk for Resident #1 and Resident #4 from eloping from the facility or that the front door and the door at the end of the east hall were also potential risks for the Resident's to exit and elope from the facility. On 1/25/21 at 3:24 PM an attempted call was made to CNA F and then a text was sent to the number provided by the ED. CNA F did not return call per Surveyor's request. Interview on 1/25/21 at 4:26 PM with RA B confirmed he noted Resident #4 walking on the walkway outside of the dining room. RA B stated he reported it to the nurse and the nurse escorted Resident #4 back into the facility. Interview on 1/25/21 at 4:45 PM with LVN K stated she worked nights and there were typically two nurses and two CNAs working the facility. LVN K stated one morning she heard Resident #1 had eloped from the facility during shift change while in the COVID-19 unit. LVN K stated she also heard Resident #1 had taken the wander guard bracelet off. LVN K stated there were times the facility could use more staff but usually the assigned staff managed the care of the residents. Interview on 1/25/21 at 4:59 PM with CNA T stated she had worked the night shift for two years and stated there were usually two nurses and two CNAs assigned to work the facility. CNA T stated once in a while she was the only CNA working the entire facility and further stated the last time she worked alone was during December 2020. CNA T stated it was extremely difficult and stated the nurses assisted when they could. CNA T confirmed she was on shift when Resident #1 eloped from the facility and staff thought she exited through the exit door in the activity room. CNA T stated she understood that night staff assigned to work the memory care unit was supposed to check that all doors including the double doors leading into the activity room were locked. An IJ was identified on 1/22/21 at 8:37 PM per the above findings. The ED, the DON, and the Corporate Nurse were provided with a copy of the IJ Template and a Plan of Removal was requested. Review of the Plan of Removal, dated 1/24/21, revealed: Immediate Action Residents #1 and #4 are safely residing on the facility locked and secured unit exclusively. On 1/22/21, the Director of Nursing immediately checked the wander guard bracelets of the eight (8) residents residing on the outside of the secured unit to validate that their devices were in place and functioning properly by identifying the red flashing light on the bracelet which indicates that the battery is working. On 1/22/21, the treatment administration records (TARs) were reviewed for these eights (8) residents by the Regional Nurse Consultant for every shift checks on the wander guard bracelets for placement and functioning; to be completed by staff nurses. No concerns were identified. On 1/22/21, the facility purchased loud sounding alarms that do not cease sounding until turned off for the four (4) identified doors that did not have a wander guard alarm system. On 1/22/21, the Maintenance Director installed the alarms and validated that they were functioning properly under the state surveyor's surveillance and approval. An alarm was also installed on the front entrance door until the wander guard alarm system on that door is repaired. On 1/22/21, the Regional Director of Operations educated the Maintenance Director and the Executive Director on the company approved wander guard monitoring log (see compliance below). On 1/22/21, the Regional Nurse Consultant began education with the facility staff on Accidents and Supervision including the monitoring of residents deemed as being at risk from elopement, the alarms on the doors and responding immediately to the sounding of the alarm, monitoring residents wearing a wander guard bracelet, every shift at minimum for placement and function and the importance of immediately notifying the Executive Director of any concerns with the system. Education included immediately notifying the administrator or director of nursing with any problems or concerns with the alarm system. Staff have been directed to not leave the alarmed door or wander guard door unmanned until the problem is corrected. So, a 1:1 will need to sit by the door until the concern is corrected. Staff not attending the initial education will be required to receive it before starting their next assigned shift. Continued Compliance and Monitoring Initially, the Executive Director, Maintenance Director (Maintenance Supervisor), Director of Nursing, and select members of the Corporate Regional Team will monitor that all of the door alarms and the wander guard alarmed doors are functioning properly utilizing a monitoring log for documentation, four times a day for seven (7) days. Afterwards, the Maintenance Director/Designee will be responsible for completing weekly checks on the proper functioning of all the door alarms and the wander guard alarmed doors. The Executive Director will be responsible for validating these checks are completed by reviewing the monitoring log, daily for seven (7) days and weekly thereafter and additionally make random checks of the door alarms and the functioning of the system. New staff will receive education on this system during new hire orientation. Any concerns will be corrected immediately, and trends brought to the monthly Quality Assurance Performance Improvement (QAPI) meeting for tracking, trending, and further Interdisciplinary Team (IDT) review and recommendations. The verification of the facility's Plan of Removal revealed: Review of an in-service training, Safety and Alarmed doors-Elopement, initiated and dated 1/22/21 provided by the ED, revealed 22 staff had signed the in-service. Review of an in-service training, New Alarms installed at front door, both dining room doors and at 3-side nurses station to ensure the safety of residents, initiated and dated 1/22/21 provided by the ED, revealed 31 staff signed the in-service and 13 staff received training via phone. Review of the TARs for all eight residents identified as being an elopement risk were reviewed to ensure staff was checking placement every shift and that placement of the wander guard bracelet was identified. Furthermore, review of the log of these same residents revealed staff had checked that the wander guard device had a flashing light indicating the device was working. Review of work invoice, dated 1/24/21, revealed that a service technician, made some adjustments to the wandering patient alarm at front door area. Also tested the other two doors with the alarms and all are working properly. Interviews on 1/24/21 at 10:38 AM with CNA D, at 3:24 PM with DA L and Cook M, at 3:28 PM with CNA G, at 3:32 PM with Housekeeper N, at 3:41 PM with CNA O, at 3:49 PM with DA P, at 4:00 PM with MA Q, at 4:06 PM with LVN C, at 4:11 PM with RN R and at 4:26 PM with LVN S revealed they all verbalized the understanding disarming and resetting the alarm at the front door. All staff reported that the alarm at the front door was to remain on at all times; therefore, another staff would have to follow them out, so the alarm was reset. All staff identified all doors equipped with a wander guard system and stated that if a resident's wander guard bracelet did not trigger the alarm they would tell their charge nurse and the ED. All staff understood the wander guard device had a flashing red light indicating that the device was working. All staff also stated they would re-direct and escort a resident back to the facility if they noted the resident had eloped and then would notify their charge nurse, DON and the ED. Interview on 1/24/21 at 3:36 PM with the Maintenance Supervisor revealed he and other selected staff would monitor that all doors with an alarm were working properly every four hours for seven days. The Maintenance Supervisor stated he would check all doors with an alarm and all doors with a wander guard system for functionality weekly, and staff would document findings on a log. Interview on 1/24/21 at 4:49 PM with the ED confirmed the monitoring system in place as explained by the Maintenance Supervisor. The ED stated she would review the log for seven days and then weekly to ensure staff was completing monitoring. The ED stated new staff would receive education on this system during orientation. The ED provided a copy of the monitoring log. The facility Plan of Removal provided by the ED was accepted on 1/24/21 at 10:38 AM and the IJ was removed. While the IJ was removed the facility remained out of compliance at no actual harm with potential for more than minimal harm that was not immediate jeopardy and the scope was pattern. Interview on 1/25/21 at 1:46 PM with ADON E confirmed she and other staff assigned to work with Resident #1 from 1/1/21 and 1/3/21 was supposed to do 15 minute checks on Resident #1. ADON E was asked if she and the CNAs completed the 15 minute checks on Resident #1 and if not asked whether staffing was an issue. ADON E stated, they kept a good eye on her. ADON E stated staffing or the fact there were only two night staff assigned was not an issue. ADON E further stated it was usually not that busy because the residents were sleeping. ADON E stated she, just didn't make it a point to conduct the 15 minute checks and she didn't want to be shining the light on Resident #1's face and risk waking her up. ADON E stated she could not change what happened. Review of facility policy, Elopements, revised February 2014, revealed: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 4. If an employee discovers that a resident is missing from the facility, he/she shall: b. If the resident was not authorized to leave, initiate a search of the building (s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary volunteer agencies (i.e. Emergency Management, Rescue Squad). The Maintenance Supervisor was asked for a policy on maintaining essential equipment in proper working order but he did not provide a policy.