Every finding on record at Pebble Creek Nursing Center

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 24 residents (Resident #59, #67 and #90 ) reviewed for medication storage.-RN P failed to take Resident #59's two liquid medications with him when he left the resident's room on 07/13/26.-The facility failed to ensure on 07/13/2026 at 10:26 a.m. to ensure Resident #90 did not have his prescription prednisone and unprescribed Aleve in a medication cup.-The facility failed on 07/14/2026 at 9:02 a.m. to ensure Resident #67 did not have unprescribed Vitamin b12 bottle with capsules in her nightstand.-The facility failed on 07/14/2026 at 1:46 p.m. to ensure Resident #90 did not have unprescribed Aleve bottle with capsules in his dresser. This failure could place residents at risk of access to medications not approved for administration by their physician.Findings included: 1. Record review of Resident #59's face-sheet, dated 07/15/26, revealed a [AGE] year-old female with an admission date of 06/23/23 and re-admission date 04/16/26. Record review of Resident #59's history and physical, dated 01/09/26, revealed the following medical history: GERD (Gastro-esophageal reflux or known as heartburn). Record review of Resident #59's Quarterly MDS, dated [DATE], revealed a BIMS score of 5, which indicated severe cognitive impairment. During an observation on 07/13/26 at 2:47 PM, RN P was observed to bring 2 cups of liquid medication, 1 red and 1 clear, and left them at Resident #59's tray table and was heard stating he would be right back. RN P was heard stating medications were Resident #59's Acetaminophen and Mylanta before leaving the room. On 07/13/2026 at 2:50 PM, RN P returned and assisted administering Resident #59's medications by placing the medication cups in her mouth for her to drink, one by one. In an interview on 07/13/26 at 3:00 PM with RN P, he stated he left the Acetaminophen and Mylanta medications at Resident #59's bedside because he was concerned about infection control issues. RN P stated the medications were exposed to other factors when he walked down the hall. RN P stated the nurses who administered the medications were responsible for not leaving medications unattended. RN P stated the potential risks of leaving medications unattended included other residents going into the room and taking the medication, which could cause an unknown reaction. In an interview on 07/15/2026 at 4:22 p.m., the DON stated residents could not have their own OTC medications and vitamins in their room. He stated the champion rounds were completed in the morning to see if residents had medication in their room and completed visual checks for any environment concerns. The DON stated it was the nurse's responsibility for the medication administration. She she could not recall the last in service for medication storage. Record review of the Nursing Facility's Medication Administration and General Guidelines policy, dated 2005, read in part: Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Findings include: 2. Record review of Resident #67's admission sheet, dated 07/15/2026, revealed a [AGE] year-old female with an admission date of 04/09/2026. Record review of Resident #67 quarterly MDS, dated [DATE], revealed under section C- cognitive patterns the resident had a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #67's care plan, dated 05/11/2026, did not reveal the resident had a behavior for bringing in unauthorized medications. Record review of Resident #67 history and physical, dated 04/09/2026, revealed the resident was diagnosed with cognitive communication deficit (affects your ability to communicate effectively due to underlying problems with thinking and memory, rather than the physical mechanics of speech), constipation (occurs when bowel movements become infrequent), and edema (swelling caused by excess fluid trapped in the body's tissues). Record review of Resident #67 orders, dated 07/15/2026, revealed the resident was not prescribed Vitamin B12. In an interview, observation and record review on 07/14/2026 at 9:02 a.m., Resident #67 stated vitamin B12 capsules were hers. It was noted to be in her nightstand drawer that was left open for anyone near to see. Record review of the resident's orders and medication administration revealed the resident was not prescribed Vitamin B12. 3. Record review of Resident #90's admission, dated 07/15/2026, revealed a [AGE] year-old male with an admission date of 06/23/2026. Record review of Resident #90's admission MDS, dated [DATE], revealed under section C – cognitive patterns revealed the resident had a BIMs of 12, which indicated moderate cognitive impairment. Record review of Resident #90's care plan, dated 07/03/2025, did not reveal the resident had difficulty swallowing medication or had a behavior for bringing in unauthorized medications. Record review of Resident #90's history and physical, dated 06/23/2026, revealed the resident was diagnosed with chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes restricted airflow and severe breathing difficulties) and pulmonary fibrosis (a progressive disease causing irreversible scarring in the lungs, making breathing difficult and lowering blood oxygen levels). Record review of Resident #90's medication administration record, dated 07/14/2026, revealed the resident did not have an order or medication administration for Aleve. In an interview, observation, record review on 07/13/2026 at 10:26 a.m., Resident #90 stated the medication was his prednisone (20 milligrams, suppresses the immune system and reduces inflammation) that he had coughed up earlier. It was observed e was a blue pill that read Aleve (over the counter anti-inflammatory) in the medicine cup with the prednisone on top of his dresser. Record review of the resident's orders and medication administration revealed the resident was not prescribed nor administered Aleve. In a Follow-up interview on 07/14/2026 at 1:16 p.m. the resident stated he got the Aleve from a pill bottle he brought into the facility himself. He stated it was in his top drawer and proceeded to open it and show the Aleve bottle. In an interview on 7/13/2026 at 3:38 p.m., CMA M stated she took Resident #90's blood pressure and did not dispense any medication. She stated CNA K found prednisone in Resident #90's room and reported it to RN D. She stated she left the room after she dispensed medication and the resident had taken the medication. She stated she had to verify medication was taken in front of her and reviewed mouths as needed. She stated if the resident declined the medication, she needed to notify the nurse. She stated she did not leave the medication with the resident. She stated it could affect a resident because they could forget to take it, staff could take it, or someone could access it. She stated she was instructed never to leave medication in residents room. She stated the last in service for medication administration was this afternoon and last month. She stated medication left at the bed side, if it was located it was reported to the ADON and physician. She stated the ADONs oversaw medication administration and ensured medication was dispensed and administered properly. In an interview on 7/14/2026 at 1:21 p.m., CNA K stated she found medication inside Resident #90's room. She stated there were 2 pills in a cup (blue and white). She stated she notified the nurse on the 400 hall and did not leave the resident alone with the medication. She stated residents could not have medication in their room and she did not know the reason for this rule. She stated if she found medication she would report it to the nurse immediately. She stated the nurse was in charge for making sure residents were not left with medication or holding medication bottles in their room. She stated the last in service for medication was a week ago. In an interview on 7/14/2026 at 1:30 p.m., CMA N stated she ensured medication was not left in the room because she was familiar with residents who would pocket or guard medication. She stated she would report medication found right away to the charge nurse. She stated she received an in service for medication storage yesterday and prior to that 2-3 months ago. She stated she reviewed the residents to ensure they took their medication by reviewing their mouth, checking for coughing, and offering liquids. She stated she tried to give residents more water to ensure they could swallow it. She stated if medication was difficult for them she would check to see if it could be crushed or cut in half. She stated she came back to check if they appeared they were having difficulty swallowing the medication. She stated Resident #90 did not exhibit difficulty swallowing medication. She stated she did not have Aleve in her cart. She stated if she found medication she was unfamiliar with in a residents room she would report it to the nurse right away. She stated she did not ask residents often if they had medication in their room. She stated the nurse was in charge of over seeing medication administration and leadership oversaw the staff were being observant of the medication policy adherence. In an interview on 07/14/2026 at 2:45 p.m., RN D stated CNA K notified her about Resident #90's medication at the bedside. She stated a white and blue pill was left at the bedside. She stated Resident #90 reported the prescription was from a day prior that he could not swallow (prednisone). She stated she did not conduct a medication audit for the blue pill. She stated residents could not have medications at the bedside because they would not be able to monitor if they were taking them and other wandering residents could ingest them. She stated everyone was responsible for ensuring medication was not left at the bedside especially the staff administering the medication. She stated she stayed with the resident until the medication was administered. She stated she monitored for residents who were resistant to medication. She stated Resident #90 was compliant with medication and no difficulty swallowing. She stated she did not usually see residents in their room with vitamins and over the counter medication. She stated she was not aware of the resident's preference for over the counter medications. She stated it would need to be care planned for residents to have medication in their room. She stated the facility tried to be observant on medications the resident was requesting or bringing in and asked if they had any medication on their person. Ointments could not be left at the bedside. RN D stated she reported the medication to the ADONs. Record review of the Nursing Facility's Medication Administration and General Guidelines policy, dated 2005, read in part: Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Record review of the facility's policy titled medication storage in the facility undated read in part: Medications and biologicals are stored safely, secured, and properly following manufactures recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications

Based on interview and record review the facility failed to provide sufficient personnel to safely and effectively carry out the functions of the food and nutrition service for 1 of 8 dietary staff (Dietary Supervisor M) reviewed for dietary services.The facility failed to ensure Dietary Supervisor M possessed the appropriate certification, training, and qualifications to direct the food and nutrition services department.These failures could place residents at risk of foodborne illness.Findings included:In an interview on 07/13/2026 at 09:05 AM, Dietary Manager M stated she had been employed by the facility for only two weeks. Dietary Manager M stated she had not received any training from the facility herself, and is unaware of who should be during the training since there is no CDM. The Dietary Manager stated the risk of improper use of the three-compartment sink could be infection control.In an interview on 07/14/2026 at 2:29 PM, CDM from a different facility that was filling in until the current facility hired a Certified Dietary Manager, stated the facility did not provide formal in-service training for newly hired dietary staff which included Dietary Manager M. The CDM was only able to provide a Food Handlers certifications for Dietary Manager M, and stated there was nothing more to provide for their requirements or any in-services.Record review of job discerption dietary Service Manager signed and dated, on 06/11/2026, by Dietary Manager M revealed, The following is a non-exhaustive criteria that relates to the job of a Dietary Service Manager, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Dietary service Manager and are related to the functions that are essential to the job of a Dietary Service Manager. Base knowledge: Current certification by state as required. Ability to supervise the operation of the dietary service department staff on a daily basis. Ability to comply with company and departmental safety policies and procedures. Accountable for dietary compliance and excellence. Ability to ensure the proper handling and utilization of all foods and equipment to prevent contamination and unsafe acts, improve quality, and to minimize costs. Ability to develop and conduct in-service and orientation programs for dietary services employees on a monthly basis.In an interview on 07/15/2026 at 05:30pm with HR Manager, reviewed Dietary Managers M filed and stated The Dietary Manager does not need any certifications but the food handlers from his knowledge. He is unaware of what current certification by stated is required and only assumed it was the food handlers certification.

Based on observation, interview and record review the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 2 of 8 dietary staff (Dietary Cooks I, Dishwasher) reviewed for dietary services.1. The facility failed to ensure the Dishwasher possessed the appropriate training on three-compartment sink usage, to direct the food and nutrition services department.2. The facility failed to ensure Dietary [NAME] I possessed the appropriate training in preparing puree foods, to direct the food and nutrition services department.These failures could place residents at risk of foodborne illness.During an observation on 07/13/2026 at 08:56 AM, during the initial kitchen tour, the Dishwasher was asked to demonstrate the sanitizer testing procedures using Hydrion paper strips for the three-compartment sinks and to obtain water temperature readings for each compartment. The Dishwasher stated she was unfamiliar with the proper use of the Hydrion paper strips and requested assistance from the Dietary Manager M. After receiving brief instruction, the Dishwasher demonstrated the sanitizer testing procedure. The dishwasher then obtained water temperature readings, which revealed the first compartment sink was not filled to the appropriate water level and had a water temperature of 101.8 F. The second compartment sink, designated for rinsing, contained no water at the time of observation.In an interview on 07/13/2026 at 09:00 AM, the Dishwasher stated she had been employed at the facility for a couple of months. She stated the facility had not had a Dietary Supervisor since February 2026 and reported she had not received training on the proper use of the three-compartment sink. The Dishwasher stated she was unaware of the potential risks associated and their potential impact on residents. The Dishwasher stated she believed the temperature should be above 100 degrees Fahrenheit had not reported any improper temperature to management and stated Dietary Manager M had just started 2 weeks ago. During an observation on 07/13/2026 at 09:02 AM, instructional materials for the proper use of the three-compartment sink were reviewed. The instructional posters, which were available in both English and Spanish, were located above the three-compartment sink. It revealed the wash compartment was required to maintain a minimum water temperature of 110 F (43 C), Rinse compartment required at a minimum of 120 F, and sanitize compartment with a minimum of 75 F, and provided step by step instructions regarding proper water levels and sink utilization for washing, rinsing, and sanitizing. In an interview on 07/13/2026 at 09:05 AM, Dietary Manager M stated she had been employed by the facility for only two weeks. Dietary Manager M stated she was unsure whether the Dishwasher had received training and stated she did not believe she had been properly trained based on her inability to perform the sanitizer testing procedure independently. Dietary Manager M stated that she had just started a week ago and assumed everyone working was trained. Dietary Manager M asked Dishwasher if she had been trained, and dishwasher answered no. Dietary Manager M stated she had not received any training from the facility herself, and is unaware of who should be during the training since there is no CDM. The Dietary Manager stated the risk of improper use of the three-compartment sink could be infection control.In an interview on 07/14/2026 at 2:29 PM, CDM from a different facility that was filling in until the current facility hired a Certified Dietary Manager, stated the facility did not provide formal in-service training for newly hired dietary staff which included Dietary [NAME] I, Dishwasher, Dietary Manager M. The CDM was only able to provide a Food Handlers certifications for Dietary Manager M, dishwasher, [NAME] I and stated there was nothing more to provide for their requirements or any in-services.In an interview on 07/14/2026 at 02:50 PM, the DON stated dietary staff, including dishwashers, were expected to receive training and demonstrate competency in proper sanitation procedures. The DON stated the potential risks associated with improper sanitization practices included cross-contamination and the transmission of infectious organisms.Record review on 07/15/2026 of facility's Temperature/Chemical Log (Dish machine or Pot/Pan sink) July 2026, revealed Dishwasher had been inputting temperatures and signing off with initials on the days dishwasher was working. 15 out of 129 temperatures were out of range from July 1st thru July 15h. (July 7th (lunch)- Wash sink 104F, Rinse sink-105F. Dinner; was sink-103F, rinse sink 102F. July 8th (breakfast) wash sink-104F, Rinse sink 102F, July 8th (lunch)- wash sink 105F, Dinner; was sink- 104F, rinse sink 102F. July 9th dinner; wash sink-103F. July 10th dinner; was sink-104F, Rinse sink 114F. July 11th- wash sink 107F, Rinse sink 115F. Dinner; wash sink 106F, Rinse sink-117F. July 13th- wash sink 51F, rinse sink 39F, July 14th (lunch)-wash sink 60F, rinse sink-63FRecord review of job discerption dietary Service Manager signed and dated, on 06/11/2026, by Dietary Manager M revealed, The following is a non-exhaustive criteria that relates to the job of a Dietary Service Manager, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Dietary service Manager and are related to the functions that are essential to the job of a Dietary Service Manager. Base knowledge: Current certification by state as required. Ability to supervise the operation of the dietary service department staff on a daily basis. Ability to comply with company and departmental safety policies and procedures. Accountable for dietary compliance and excellence. Ability to ensure the proper handling and utilization of all foods and equipment to prevent contamination and unsafe acts, improve quality, and to minimize costs. Ability to develop and conduct in-service and orientation programs for dietary services employees on a monthly basis.In an interview on 07/15/2026 at 05:30pm with HR Manager, reviewed Dietary Managers M filed and stated The Dietary Manager does not need any certifications but the food handlers from his knowledge. He is unaware of what current certification by stated is required and only assumed it was the food handlers certification. Record review of the facility's, undated, policy titled Equipment Sanitation revealed, 6.) Pots and pans: a.) Manual dishwashing of pots, pans and equipment: Three compartment sinks should be used. 7.) Facilities shall use an approved test kit to measure the PPM of the chemical solutions in pots sinks on a daily basis. Records of test results should be kept on the temperature/chemical log. Any abnormal test results shall be reported to the Dietary Service Manager, and the solution shall not be used until at the correct PPM.

Based on observation, interviews, and record review, the facility failed to ensure the menus were followed for 1 of 1 facility for food and nutrition services. The facility failed to ensure Dietary [NAME] I followed the proper recipe menu for Pureed Honey Kissed Rolls.This failure could place residents at-risk of inadequate nutrition and weight loss, decreased appetite, and overall meal dissatisfaction.In an observation and interview conducted on 07/13/2026 at 11:00 a.m., Dietary [NAME] I was observed preparing a pureed Honey Kissed Roll. Dietary [NAME] I placed regular loaf bread into the blender and assessed the consistency by shaking the blender container. She then added an unmeasured amount of chicken base and continued adding additional pieces of loaf bread, for a total of approximately 70 slices (11/2 bags). Dietary [NAME] I stated she used regular loaf bread because the Honey Kissed Rolls were placed in the oven late and were not ready when she began preparing the pureed food items. Dietary cook stated, she always gradually adds thickener, until it's the right consistency to her seeing. She did not know any risk of not measuring the thickener to residents. In an interview conducted on 07/13/2026 at 11:10 a.m., Dietary Supervisor M stated she was present while Dietary [NAME] I prepared the pureed food items. Dietary Supervisor M stated she had not approved substituting regular loaf bread for the Honey Kissed Rolls identified in the recipe. She further stated it was her responsibility to ensure staff followed standardized recipes and did not make unauthorized substitutions or improperly utilize food products. Dietary Supervisor M stated Dietary [NAME] I informed her the Honey Kissed Rolls were not ready at the time the pureed foods were being prepared but were ready shortly thereafter, which was the reason provided for using regular loaf bread.Record review of the facility's recipe titled Recipes to Scale P.[NAME]. Honey Kissed Roll, dated 07/13/2026 for lunch service, revealed the recipe required Honey Kissed Rolls as the ingredient, with reconstituted chicken base in the amount specified. The recipe further directed staff to measure the appropriate number of servings using the regular prepared recipe portion, place the product in a blender or food processor, add liquid if needed, and, if necessary, gradually add thickener according to manufacturer instructions.Record review of manufacture commercial thickener instructions revealed preparation instructions add the desired amount of ReadyCare instant food thickener to beverages or pureed foods. Process for several seconds or until the thickener is thoroughly mixed. 1.) to thicken liquid by the glass, add level measured amount of thickener to the liquid and stir for 10-20 seconds. 2.) allow 4 minutes to reach desired thickness. Recommended usage for 4fl oz serving; water, spoon thick 1 Tbsp + 2 Tsp. Record review of the Dietary [NAME] I job description revealed Ability to ensure quality food products are prepared according to the menu and standardized recipes. Ability to prepare all foods according to the menu and the standardized recipes in a safe, efficient, and sanitary manner. Ability to ensure the proper preparation, portioning and serving of foods as indicated on the spreadsheets and the recipes.

Based on the observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to keep clean dishes away from damaged drywall from an active water leak.This failure could place residents at risk of foodborne illness.In an observation and interview conducted on 07/13/2026 at 8:37 AM, revealed water leaking from a roof vent in the kitchen. The leak had caused drywall damage, with pieces of deteriorated drywall falling onto a freezer below. Water was observed on the floor, and droplets from the leak were splashing onto clean cups stored nearby. Dietary Manager M stated she had not reported the leak to maintenance and intended to notify maintenance staff once they arrived in the kitchen. She stated she was unaware of when the leak had started and had not reported the issue to anyone. Dietary Manager M further stated she was unaware of the potential risks associated with water leaking onto clean cups and dishware intended for resident use.In an interview on 07/13/2026 at 9:17 AM, the Maintenance Supervisor stated he had not been notified of the water leak until he entered the kitchen that morning. He stated he believed the leak had likely occurred that morning; however, he could not confirm whether the condition had existed over the weekend. The Maintenance Supervisor stated he inspected the roof and determined the leak was caused by a clogged air-conditioning condensate drain line that had overflowed into the ductwork. He stated the active leak stopped and the remaining moisture would be allowed to dry. He further stated repairs would be made to the damaged drywall in the kitchen.In an interview on 07/15/2026 at 5:50 PM, the Administrator stated he had been employed at the facility for approximately two weeks and expected all dietary staff to be appropriately trained and in-serviced regarding kitchen operations and food safety practices. He stated the Dietary Supervisor was responsible for overseeing daily kitchen operations and ensuring compliance with dietary procedures. The Administrator stated failure to properly clean and relocate clean drinking cups could result in resident harm, which included illness due to contamination.Record review of the facility's policy titled infection control, dietary service policy and procedure Manual revised 04/09/2025, revealed We will ensure that all employees practice infection control in the Food and Nutrition Services department and maintain sanitary food preparation.4.) The facility will follow all state and local regulations concerning initial hire and annual health examinations of dietary associates. all kitchenware and food contact used in the preparation and or serving of food as clean and sanitized before use and clean after each meal preparation sanitizing agents are used for cleaning on surfaces after cleaning equipment and utensils are stored so as to prevent contaminationRecord review of the Federal Food Code section 6-101.11 wall surface characteristics and Section 6-501.11 for maintaining physical facilities in good repair. These rules prevent dust, pests, and mold from contaminating clean dishes stored or used nearby.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 10 residents (Resident #88) reviewed for privacy.The facility failed to ensure Student Nurse Aide provided Resident #88 with privacy when she failed to knock on the door before entering the room.This failure violates privacy and dignity rights, potentially leading to loss of trust.Findings included:Record review of Resident #88's admission sheet dated 07/30/2024 revealed a [AGE] year-old female with an initial admission date of 07/30/2024.Record review of Resident #88's quarterly MDS dated [DATE] revealed under section C - cognitive patterns the resident had a BIMS score of 7 indicating the resident was severely cognitively impaired.Record review of Resident #88's care plan dated 06/26/2026 identified cognitive impairment and included individualized interventions to support dignity, communication, and participation in care. Interventions directed staff to use the resident's preferred name, identify themselves during each interaction, communicate using simple and respectful language, maintain eye contact, reduce distractions, provide cues and adequate response time, involve the resident and family in care discussions, maintain a consistent routine, engage the resident in activities consistent with her abilities, and provide a homelike environment that honored the resident's preference.Record review of Resident #88's history and physical dated 08/15/2025 revealed resident had a serious mental illness (schizophrenia), had difficulty thinking, learning, or understanding (cognitive delay), and had several long-term health problems. Because of these conditions, the resident needed help with everyday tasks such as bathing, dressing, eating, taking medications correctly, and being reminded or guided to stay focused and safe. In an observation on 07/13/2026 around 3:30pm Student Nurse Aide went inside Resident #88's room without knocking or introducing herself.In an interview with Student Nurse Aide on 07/13/2026 at 3:33 PM, she stated she forgot to knock before entering a resident's room, but she got nervous. She stated she was here and she was concerned about the resident potentially falling so she just went straight to the room. She stated she had been here for 3 months and stated she would not like anyone going into her room if staff would just march in her room and she would be naked. She stated the charge nurse over sees her. In an interview with NP on 07/14/2026 at 10:03AM, NP said staff should be knocking and introducing themselves before entering residents' room, and it was something they all were taught to do in school. Not knocking violates residents' rights. All staff should be knocking before entering rooms. Potential harm could happen as residents could be startled and react differently depending on residents' medical diagnosis. In an interview with LVN H on 07/14/2026 at 10:07am LVN H stated staff should be knocking before entering residents' rooms and it was something Student Nurse Aide should have done prior to entering the room. In an interview with CNA G on 07/15/2026 at 10:13am, CNA G stated the first thing that they do when they enter a resident room is knock and state their name. CNA G stated they need to do that because that was the resident's room and they have the right to know who was trying to enter their room and so the residents can know who the staff are. CNA G said if they do not knock the resident will ask why they were in their room and what they were doing and they might get anxiety. CNA G stated they report to RNs and LVNs. The student nurses also report to LVNs and RNs. In an interview with LVN I on 07/15/2026 at 10:27am, LVN I said staff were supposed to knock on the door to announce themselves and alert residents they were about to enter the room., LVN I said they need to knock because some residents have different diagnosis and they might scare them and they will not like that so they always have to verify who they were to them. Some residents may become aggressive, and some may refuse the attention that they need.In an interview with the DON on 07/15/2026 at 10:37am, the DON stated the first thing that she would do was knock and let the resident know she was entering the room and introduce herself. The DON said they do that because the residents need to know who they were. The DON stated it was a privacy issue, and common courtesy to let the residents know who they were and why they were entering their room, as this was their home. The DON said they should respect their privacy. As an example, if they enter their room without knocking, the residents could get upset and get frustrated as they do not know why they were in their room. In an interview with RN J on 07/15/2026 at 11:25am, she stated they were trained to knock, introduce themselves, and explain to the resident what they were there to do. RN J stated it was not ok to go into a resident's room without knocking or introducing themselves because the residents can get combative and they will not know who they were or what they were there to do, and it was their privacy.In an interview with ADON B on 07/15/2026 at 5:16pm, stated the first thing they do before entering a resident's room was knock and introduce who they were to let the resident know who they were and let them know they were about to enter. ADON B residents should be treated with dignity, respect, and professionalism. ADON B said they could anger the resident, they could feel not respected, and the resident might not be ready to see them in the room.In an interview with Administrator on 07/15/2026 at 5:28pm, the Administrator stated he had been here about 2 weeks. He said they should always knock and introduce themselves so the residents know who was coming in and what they might be doing., The Administrator stated some residents were hard of hearing and it was the resident's home so they need to be respectful of their room. They can startle the residents, scare the residents, or it could make the resident startle or jump or hurt someone.Review of the facility's Residents Rights policy dated 11/28/2016 revealed the facility was responsible for protecting residents' privacy and dignity by respecting their personal space and ensuring privacy during care and interactions.

Based on observation, interview and record review, the facility failed to ensure that residents had the right to a safe, clean, comfortable and homelike environment, for 1 of 21 residents' bedrooms (Resident #20) observed for environment.The facility failed to ensure Resident #20's room had a functioning TV remote and window blinds on 07/13/2026.The facility failed to ensure Resident #20's footboard was secured on 07/13/2026.This failure could place the resident at risk for injury due to the loose footboard and decreased quality of life.Findings include:Record review of Resident #20's face-sheet revealed an [AGE] year-old female with admission date 07/03/26.Record review of Resident #20's Nursing Home and Swing Bed Tracking Item set dated 07/03/26 revealed there was no BIMS noted.Record review of Resident #20's history and physical dated 07/13/26 revealed the following medical history: Schizoaffective Disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression);, and Diabetes Mellitus type 2 (a chronic condition characterized by insulin resistance and high blood sugar levels). Record review of Resident #20's care plan dated 07/03/26 revealed resident had impaired cognitive function/dementia or impaired thought processes and interventions included for staff to provide a homelike environment.In an observation and interview on 07/13/2026 at 11:13 AM with Resident #20, she stated she did not have a functioning TV remote or window blinds. Resident #20 stated her bed had a loose footboard. Resident #20 stated she had notified staff and they were aware of these concerns and had advised her they would get to it, but have not since her admission. Resident #20 stated she felt bad because she preferred sunlight during the day and wanted to watch TV but was unable to. Resident #20's footboard was observed to be loose and was able to be swung up and down on the bed's left side. Resident #20's blinds were observed closed, this State Surveyor was unable to open blinds, it was missing the wand to rotate the blinds from close to open. This State Surveyor attempted to use the TV remote and was able to turn on the TV in Resident #20's room. The TV remote was pressed to go up and down, to pick a Streaming Application observed on the TV screen, but it did not work. The TV remote only worked when turning it on or off.In an interview on 07/15/2026 at 12:42 PM with CNA O, she stated she was not aware of Resident #20's loose footboard, non-functioning TV remote, and window blinds. CNA O stated any staff that observed or was notified of residents having non-functioning equipment; they were to notify the nurse or Maintenance. CNA O stated the potential risk for residents not having functioning equipment included affecting their mood. CNA O stated Resident #20 having non-functioning blinds could cause a risk of lack of sunlight which could potentially affect her mood. CNA O also stated Resident #20 not being able to watch TV could affect her mood or feel depressed.In an interview on 07/15/2026 at 2:22 PM with LVN H, she stated she was the nurse for Resident #20, and she was not aware her blinds and TV remote were not functioning. She stated Maintenance was responsible and if any staff were aware of these concerns, they were to report it to Maintenance. LVN H stated she was aware Resident #20 did not like sunlight and preferred her blinds closed, but if the blinds were not functioning, it placed Resident #20 at risk for her mood to be negatively affected. LVN H stated the loose footboard was a potential risk for injury as it was not secured. LVN H stated residents could feel as if they were not important or be in a low mood if their equipment did not work properly.In an interview on 07/15/2026 at 4:16 PM with the DON, she stated staff were responsible for reporting any non-functioning equipment or equipment needing repair, to maintenance which could be done with the QR code posted throughout the facility. The DON stated staff were able to scan the QR code and immediately log their concerns to Maintenance. The DON stated she was not aware of Resident #20's concerns, and that every resident had the right to functioning equipment. The DON stated the possible risks for the TV remote and window blinds not working could affect the resident's mood, and possibly injury if the footboard was not secured as it could fall off.Record review of the Nursing Facility's Resident Rights policy, with revision date 11/28/2016, read in part: The resident has a right to a dignified existense, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Recognizing each resident's individuality. The facility must protect and promote the rights of the residents.

Based on observation, interview and record review, the facility failed to make a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 days after the facility determines, or should have determined, that there had been a significant change in the resident's physical or mental condition for 2 out of 3 residents (Resident #97, Resident #87) reviewed for comprehensive assessments. -The facility failed to complete a Comprehensive assessment after significant change for Resident #97 after multiple falls. The failure could place residents at risk of not having their needs met. Record review of Resident #97's face sheet dated 07/15/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #97's diagnoses included Dementia, communication deficit (brain's changing health makes it harder for a person to speak, understand others, find the right words, or organize their thought), Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), Muscle wasting (gradual shrinking and weakening of your muscles), unsteadiness on feet (having trouble maintaining balance or walking in a smooth, coordinated way), Lack of coordination (brain and body aren't communicating smoothly), difficulty in walking, Multiple Fractures of Ribs (Broken or cracked ribs), Fracture of unspecified part of neck of left femur (Broken left hip), Left artificial hip joint (thigh bone part of a prosthetic left hip). Record review of Resident #97's Nursing Home Comprehensive item set dated 03/07/2026, reflected a BIMS score of 03, which indicated severe cognitive impairment. Resident #97 had no impairment to upper extremity (shoulder, elbow, wrist, hand), and impairment on one side to lower extremities (hip, knee, ankle, foot). Resident #97 had an active diagnosis of Repeated falls. Resident #97 had no documentation filled out for falls Record review of Resident #97's Quarterly MDS dated [DATE], reflected a BIMS score of 03, which indicated severe cognitive impairment. Resident #97 had no impairment to upper extremity (shoulder, elbow, wrist, hand), and impairment on one side to lower extremities (hip, knee, ankle, foot). Resident #97 had no active diagnosis of Repeated falls. Resident #97 had no documentation filled out for falls. Record review of Resident #97's Order Summary Report dated 07/08/2026, revealed Fall mats while in bed every shift. Record review of Resident #97's Care plans dated 07/15/2026, revealed a focus; [Resident #97] is risk for falls related to self-transferring and walking without asking for assistance. [Resident #97] had an actual fall. Goal for focus; The resident will be free of falls through the review date. The resident will not sustain a serious injury through the review date (target date 04/21/2026). Interventions for focus; Call, don't fall sign, anticipate and meet the residents needs, be sure the residents call light is within reach and encourage to use it, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Fall mats while in bed, keep bed in low position. Review information on past falls and attempt to determine the cause of falls. Record possible root causes. After remove any potential causes if possible. Record review of Resident #97's History and Physical dated 06/17/2026, revealed history of present Illness/Summary of hospitalization, a [AGE] year-old male. Staff reports that he had an ER visit on 06/13 after he had a fall, and family insisted on sending him due to pain. It was confirmed that he did have a left clavicle fracture (broken left collarbone). He was sent back to facility with orthopedic consultation and pain management by hospice services. Staff reports that he has not ambulated since fall. In an observation and interview on 07/13/2026 at 10:13 AM, Resident #97 was lying in bed, bed at lowest position and floor mat in place. Resident was unable to voice any concerns when asked. Resident did not respond to any verbal communication. Call light was within reach and call, don't fall sign was located in resident's room. In an interview on 07/15/2026 at 11:29 AM, CNA M stated she had been employed with the facility since August 2025. She stated Resident #97 does ambulate alone and they have to be constantly watching him as he does attempt to get up alone and has had several falls that she is aware of. CNA M was unable to provide a specific number of falls but stated she is aware of multiple falls within the past couple of months, which is why staff have to ensure the floor mats are always in place as well as the bed in the lowest position. In an interview on 07/15/2026 at 02:38 PM, Regional MDS Coordinator stated MDS assessments followed the Resident Assessment Instrument (RAI) schedule, including quarterly and annual assessments or a change in condition warranted an additional assessment. Regional MDS Coordinator stated nursing staff were responsible for reporting changes in a resident's condition to the MDS department. She stated falls could constitute a significant change depending on the circumstances and severity of the resident's condition. Regional MDS Coordinator stated that if a resident sustained a fall resulting in a significant injury, a Significant Change in Status Assessment would be completed. Upon review of the resident's fall assessments, Regional MDS Coordinator stated Resident #97 had experienced a total of five falls within the previous 90-day look-back period, which should have been coded on the MDS. She stated the resident sustained a major injury related to one of the falls and stated the facility did not have a full-time MDS nurse at the time of the incident and utilized a PRN MDS nurse, who provided services at multiple facilities. She stated she was unaware of whether the incident had been reported to the MDS department at that time but would assume residents MDS should have been updated. Regional MDS Coordinator stated that when MDS assessments were not completed timely or accurately, associated assessments and care plans could also be incomplete or inaccurate. She stated care plan revision dates must be updated appropriately to ensure nursing staff and CNAs had accurate information to provide resident care. In an interview on 07/15/2026 at 04:50 PM, DON stated she had been employed at the facility for 2 months. DON stated Resident #97 had been identified as a frequent fall risk and had been discussed during the morning clinical meeting. The DON stated the MDS team typically reviewed residents during morning meetings and attendees always communicated concerns to MDS staff and on Mondays following weekends. The DON stated she did not routinely oversee the MDS process and assumed the Administrator and corporate staff were responsible for those duties. The DON stated the risk of an MDS not being updated could lead to improper care. In an interview on 07/15/2026 at 05:50 PM, Administrator stated he just started at the facility 2 weeks ago and was not aware of the MDS not being complete for Resident #97. Administrator stated the risk for an MDS not being completed would be inadequate care. He stated that the responsibility falls on the Regional Coordinator and DON because she had to sign off on all MDSs. Record review of facility policy titled Notifying the Physician of Change in Status revision March 11, 2013, stated 8.) If the resident remains in the facility and significant change has occurred, update the care plan accordingly. Record review of facility policy titled Resident Assessment no date revealed, 3.) RAI assessment must be conducted withing 14 days after the date of admission; promptly after a significant change in the resident's physical or mental condition (as soon as the resident stabilizes at a new functional or cognitive level, or withing whichever is earlier), 8.) Each assessment must be conducted or coordinated by a registered nurse who signs and certifies the completion of the assessment. 10.) Reassessment will occur quarterly thereafter or in response to a change in the resident's condition. Documentation reflecting assessment and changes in the plan of care will be reflected in the resident's medical record and/or plan of care. Resident #87 Record review of Resident #87s admission sheet dated 07/11/2026 revealed a [AGE] year-old female with an initial admission date of 12/12/2022 with a medical diagnosis of acute respiratory failure with hypoxia, requiring monitoring and treatment of decreased oxygen levels. Significant secondary diagnoses included neuromuscular bladder dysfunction requiring urinary management, combined systolic and diastolic congestive heart failure, acute kidney failure, history of cerebrovascular accident (stroke) with dysphagia (difficulty swallowing), transient ischemic attack, dementia, protein calorie malnutrition, anemia, hypertension, hyperlipidemia, obstructive. Reflux uropathy, gastroesophageal reflux disease, atrophic skin disorder, increasing risk for skin breakdown, and allergic rhinitis. Record review of Resident #87s quarterly MDS dated [DATE] revealed under section C – BIMS score was noted but was marked as severely impaired under the cognitive skills for daily decision making. Record review of Resident #87's care plan dated 03/18/2026 revealed care plan didn't capture G-Tube placement. Record review of Resident #87's annual history and physical dated 05/27/2026 revealed the resident was bedbound, nonverbal, and dependent on G-tube feedings due to dysphagia following a prior stroke. The resident had multiple chronic medical conditions, including heart failure, protein-calorie malnutrition, metabolic encephalopathy, pressure injuries, muscle contractures, and muscle wasting. The treatment plan included continuation of current medications, G-tube feedings, wound care, nutritional support, monitoring of chronic conditions, and interdisciplinary skilled nursing care. In an interview with Regional MDS Coordinator on 07/15/2026 at 2:28 PM she stated she had been here 2 years The Regional MDS Coordinator stated there was nothing stating where Resident #87 had the G-Tube. She stated that since it was a change in condition, they should have noticed that the G-Tube was in place. Regional MDS Coordinator stated well that the interventions were there for the G-Tube. Regional MDS Coordinator stated that the documentation on care plan was not up to date. In an interview with DON on 07/15/2026 at 5:04 PM she stated, yes MDS should have been updated because they could have given the resident not enough formula or the right nutrition, the residua the placement, the assessment when the resident had a G-Tube, MDS should have been updated because that was something we inform each other about, I think administration over sees MDS, and corporate, I do sign the MDs that were given to them since I've been here but I didn't sign off resident #88s MDS. Record review of facility policy titled Notifying the Physician of Change in Status revision March 11, 2013, stated 8.) If the resident remains in the facility and significant change has occurred, update the care plan accordingly. Record review of facility policy titled Resident Assessment no date revealed, 3.) RAI assessment must be conducted withing 14 days after the date of admission; promptly after a significant change in the resident's physical or mental condition (as soon as the resident stabilizes at a new functional or cognitive level, or withing whichever is earlier), 8.) Each assessment must be conducted or coordinated by a registered nurse who signs and certifies the completion of the assessment. 10.) Reassessment will occur quarterly thereafter or in response to a change in the resident's condition. Documentation reflecting assessment and changes in the plan of care will be reflected in the resident's medical record and/or plan of care.

Based on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out ADLs to maintain good grooming and personal hygiene for 1 of 7 residents (Resident #45) reviewed for ADL care.-The facility failed to ensure Resident #45's nail were cleaned on 07/13/2026 and 07/14/2026.This failure could place residents at risk of loss of dignity, risk for infections, and a decreased quality of life.Findings included:Record review of Resident #45's admission sheet dated 07/15/2026 revealed the resident was a [AGE] year-old male with an initial admission date on 11/17/2025 with a readmission date on 12/09/2025.Record review of Resident #45's quarterly MDS under section C - cognitive patterns revealed the resident had a BIMS of 12 indicating the resident had moderate cognitive impairment. Under section GG - functional abilities, the resident was coded as unable to carry out activities for personal hygiene due to medical or safety concerns.Record review of Resident #45's care plan dated 04/21/2026 revealed the resident had a focus area of impaired visual function with interventions of monitor/document/report signs and symptoms of acute eye problems: change in ability to perform ADLs.Record review of Resident #45's history and physical dated 11/17/2025 revealed the resident was diagnosed with primary generalized osteoarthritis (widespread form of arthritis affecting three or more distinct joint groups), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures, which are sudden bursts of abnormal electrical activity in the brain), malnutrition (a condition that occurs when a person's diet does not provide the right amount of nutrients, leading to health problems), muscle weakness ( perceived or actual lack of physical strength), and congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should).In an interview and observation on 07/13/2026 at 10:30 a.m., Resident #45 was observed with black debris underneath the nails edge from side to side on both hands. He stated he had not received a shower yet but usually received nail cleaning during his showers. He stated he could not recall the last time he had received nail cleaning and stated they were currently dirty. He stated he needed assistance with nail cleaning since he could not get underneath his nail. The resident proceeded to put his fingers in his mouth. In a follow-up observation completed on 07/14/2026 at 8:56 a.m., Resident #45 was observed with dirty nails still.In an interview on 07/15/2026 at 3:13 p.m., RN D stated that CNAs and nurses could provide fingernail cleaning. She stated that she did not know what the schedule was for nail care since she was PRN. She stated she monitored residents' nails while responding to call lights, administering medication, and as reported by CNAs. She stated that residents' nails needed to be cleaned because of safe hygiene practices and provided since some residents had visual and dexterity limitations. She stated that a resident could potentially scratch themselves resulting in injuries and infections if their nails were dirty. She stated dirty fingernails affected their dignity, self-esteem, or could result in infections. She stated that nurses oversee ADLs and needed to ensure nail care was being adhered to. She stated the wound care nurse could share nail findings during skin assessments, CNAs during showers, and activity staff.In an interview on 07/15/2026 at 3:43 p.m., CNA E stated his responsibilities included providing showers and completing finger nail cleaning. He stated he utilized a washcloth or a loofa during showers. He stated nailcare services were offered every shower. He stated if he came across a resident with dirty nails he would offer the services and begin by soaking the residents' fingers to clean underneath them. He stated dirty fingernails affected residents because it could lead to the spread of germs. He stated that residents could have weaker immune systems, and the germs could infect a potential wound. He stated that CNAs were responsible for ensuring fingernails were cleaned on a regular basis. He stated the last in service for ADLs was in March 2026.In an interview on 07/15/2026 at 4:30 p.m., DON stated that the facility utilized grooming audits. She stated nail care was completed weekly. She stated that staff should be checking residents' nails on a regular basis. She stated that resident's nails needed to be cleansed to prevent bacterial infections to open wounds or for residents who placed their fingers in their mouth. She stated the facility utilized nail picking tools, washcloths, basins and nailfiles located in central supply. She stated that the champion rounds and direct care staff were responsible for offering and monitoring the residents' nail conditions throughout the day.Record review of the facility's policy titled Nail Care undated read in part, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity issues, to prevent infection, and injury from scratching by fingernails It includes cleansing, trimming, smoothing, and cuticle area and is usually done during the bath (Goals) nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions (Procedure) Should be performed according to the resident centered plan of care. (4) remove debris from under the nail with an orange stick while soaking. (14) When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident.

Based on observation, interview, and record review the facility failed to ensure that residents receive care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers for 1 of 4 residents (Resident #75) reviewed for skin integrity.-The facility failed on 07/14/2026 at 9:46 a.m. to report Resident #75's gluteal skin opening along with irritation, grimacing, and excoriation to bilateral buttocks noted during incontinent care.This failure could lead to residents developing preventable ulcers and skin breakdowns.Findings included:Record review of Resident #75's admission sheet dated 07/15/2026 revealed the resident was a [AGE] year-old female with an original admission date of 01/09/2019.Record review of Resident #75's quarterly MDS dated [DATE] under section C- cognitive patterns revealed the resident had a BIMS score of 11 indicating the resident had moderate cognitive impairment. Under section GG - functional abilities revealed the resident was coded for requiring substantial to maximal assistance (helper does more than half of the effort) for toileting hygiene. Under section H - bowel and bladder the resident was coded for being frequently incontinent for urinary and bowel incontinence. Under section M - skin conditions the resident was coded for being at risk for developing pressure ulcers and injuries.Record review of Resident #75's care plan dated 04/13/2026 revealed the resident had a focus area for potential for impairment to skin integrity related to incontinent of bowel and bladder with a goal of being free from skin injury. The facility developed interventions including: follow facility protocols for treatment of injury and identify/document potential causative factors and eliminate/resolve where possible. An additional focus area was to address the resident's potential for pressure ulcer development with a goal to have intact skin free of redness, blisters, or discoloration by/through review date. The facility developed interventions including: notify nurse immediately of any new areas of skin breakdown: open area, blisters, bruises, discoloration noted during bath or daily care.Record review of Resident #75's history and physical dated 10/27/2025 revealed the resident was diagnosed with moderate protein-calorie malnutrition (occurs when you consume less than 75% of your caloric needs for over a month and weight loss), dementia without behavioral disturbances (a cognitive decline such as memory loss and impaired problem-solving, occurring without psychiatric or physical symptoms like aggression, wandering, or anxiety), vascular parkinsonism (a condition causing movement issues, such as walking difficulty, stiffness, and slow movement, triggered by restricted blood flow or small, silent strokes in the brain's movement-control areas), and muscle weakness (a perceived lack of physical strength where extra effort is required to move).In an interview and observation on 07/14/2026 at 9:30 a.m., Resident #75 stated she utilized incontinent briefs and added it took a long time for staff to respond and approximated 15-30 minutes. She stated her buttocks area was red with irritation and had ulcers. She illuminated the call light and CNA K (student), and CNA L (preceptor) arrived at 9:40 a.m. to provide peri care. At 9:46 a.m. it was observed, Resident #75 grimaced while staff wiped the peri area and vocalized it burned and felt irritated. Resident # 75 was noted for some skin breakdown, redness, irritation, and excoriation (blemishes, lesions, scarring) noted to both buttocks. The midline in between gluteal area was noted to be open, with no drainage to irritated area. CNA K was present during gluteal midline opening observation while CNA L was away practicing hand hygiene and changing gloves.Record review of Resident #75's progress notes for 07/14/2026 at 2:00 p.m. revealed there had not been a nursing progress note completed on the resident's opening to the gluteal medial line.In an interview on 07/14/2026 at 2:25 p.m., CNA L stated she did not report to the nurse about Resident #75's skin. She stated Resident #75 was getting close to a rash and a little ointment would be fine. She stated Resident #75 did not flinch or complain of irritation when she received peri care and added there was no redness to the buttocks. She stated Resident #75 did not have a rash or redness but was requesting barrier cream to the vaginal area. She stated CNA K did not report to her that the resident had redness to the buttocks or a skin opening. She stated that she did not review the buttocks or gluteal midline because she had faith in her coworker to assess and report to her about any skin compromises. She stated as CNA K's preceptor she was responsible for reviewing the work completed by the student and needed to conduct her own assessment. She stated she would notify ADON A when residents had skin compromises but had not reported it about Resident #75. She stated that skin breakdown, irritation, openings, and redness needed to be reported immediately to the nurse. She stated Resident #75 had not asked for incontinent change prior to the call light being illuminated.Record review of Resident #75's progress notes on 07/14/2026 at 2:40 p.m. revealed ADON A had entered a note about resident's skin condition after being notified by CNA L, approximately 4-hours and 50 minutes after the discovery was made by CNA K .In an interview on 07/14/2026 at 3:00 p.m., RN D stated she was not made aware of any residents in her hall with new skin breakdown to include Resident #75. She stated no nurse or CNA during shift change had notified her about Resident #75's gluteal opening. She stated that CNAs needed to notify the nurse about any findings during peri care or when requesting ointments and patches. She stated the early signs of ulcer development were the surrounding skin would be red, there could be a skin opening, the resident would vocalize pain, exhibit grimacing, report burning sensation, or require frequent repositioning. She stated that she needed to be made aware immediately if a resident was exhibiting any of the signs and symptoms of skin breakdown so that she could complete an assessment and refer to wound care nurse. She stated that the sacral/coccyx (large triangular bone at the base of the spine) and perineal area (diamond shape region at the base od the pelvis located between the thighs) needed to be evaluated and checked for any openings between skin crevices. She stated that the CNA providing care should be looking at the skin and ensure the integrity and cleanliness of the area. She stated that the CNA preceptor should be conducting their own review of the residents instead of relying on the student CNA's assessment. She stated she could not recall the last peri care in service due to being PRN.In an interview on 07/15/2026 at 4:33 p.m., DON stated early signs of ulcer development would be skin redness, skin breakdown, and reports of irritation/burning. She stated that CNA should use barrier cream, approach it gently and report skin compromises to the nurse immediately after care. She stated that the gluteal opening is considered compromised skin integrity, and it needed to be reported. She stated that the CNA needed to complete their own observation of the peri area rather than rely on the student CNA's assessment of the area. She stated the 4-hour and 50 minute delay was not considered an immediate notification. She stated by not reporting this to the nurse the skin breakdown could get worse, the resident could be in pain, and the nurse would not be aware resulting in a delay of care. Record review of the facility's policy titled, Pressure Injury: Prevention Assessment and Treatment dated 05/05/2025, read in part: (Procedure) (1) Nursing personnel will continually aim to maintain the skin integrity, tone, turgor(the normal state of firmness and tension of living cells) and circulation to prevent breakdown, injury and infection. (3) Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. (4) Causes of pressure Injuries. (4.9) External Irritations (feces, urine, sweat, wrinkles in bedding, catheter tubing, etc.).

ased on interview, observation, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status such as usually body weight for 1 (Resident #72) of 6 residents reviewed for weight loss. -The facility failed to report Resident #72's severe weight loss of 9.09% (16.2 Lbs.) to the registered dietician as per facility policy. This deficient practice could place residents at risk to have further weight loss, decreased quality of life related to debility, weakness and malnutrition related complications.Findings:Record review of Resident #72's admission sheet dated 07/15/2026 revealed a [AGE] year-old male with an original admission date of 09/09/2019 and a readmission date of 06/27/2025.Record review of Resident #72's quarterly MDS dated [DATE] revealed under section B - hearing, speech, and vision the resident was coded for having severe impairment for hearing and vision. Under section C - cognitive patterns the resident had a BIMS score of 4 indicating the resident had severe cognitive impairment. Under section D - mood the resident responded to the PHQ-9 (a screening tool used to determine the severity of depression) that he experienced poor appetite with a severity of 7 to 11 days over the past 2 weeks and had a final score of 10 indicating the resident was experiencing moderate depression. Under section gg - functional abilities the resident was coded for needing set-up or clean up assistance for eating.Record review of Resident #72's significant change MDS dated [DATE] revealed the resident had no remarkable change to the previously mentioned sections. Under section I - active diagnoses revealed the resident was diagnosed with dysphagia (difficulty or discomfort swallowing). Under section O - special treatments revealed the resident had entered Hospice care.Record review of Resident #72's care plan dated 07/14/2026 revealed the resident had a focus area to address the risk for unplanned weight loss with interventions of encourage meal completion, monitor weight per facility protocol, registered dietician asses per facility protocol.Record review of Resident #72's Health and physical dated 07/02/2025 revealed the resident was diagnosed with Glaucoma (a group of eye diseases that damage the optic nerve) of both eyes, advanced dementia (final phase of the disease where individuals become entirely dependent on others due to cognition deficits in memory and thought process), and chronic major depressive disorder (a long-lasting form of clinical depression where major depressive episodes-characterized by profound sadness, loss of interest, and fatigue-persist continuously for two years or longer), malnutrition related to chronic disease (a nutritional imbalance driven by persistent illness and systemic inflammation), chronic kidney disease (the gradual loss of kidney function over time, which causes waste and fluid to build up in your blood), hypothyroidism (a common condition where your thyroid gland does not produce enough thyroid hormones to regulate your body's metabolism usually characterized by unexpected weight gain). Record review of Resident #72's Hospice binder revealed the resident entered Hospice care on 06/25/2026 due to protein calorie malnutrition with orders for mechanical soft food and thin fluids diet.Record review of the grievance binder revealed Resident #72 had submitted a grievance on 04/28/2026. The grievance read in part: Resident states some staff doesn't help uncover his food and he is mostly blind and has difficult time seeing. With the resolution documented as all staff assigned to or working with resident will need to make sure when his tray is brought out to assist him with removing covers including unwrapping silverware and guiding resident as to what is on his plate.Record review of Resident #72's weight log revealed on 06/03/2026 the resident weighed 176.6 lbs and on 07/05/2026 the resident weighed 160.4 lbs completed by ADON A. A progress note related to the resident's weight was entered to mark the initiation of the weight watchers program.In an over-the-phone interview on 07/15/2026 at 9:10 a.m., Resident #72's family member stated Resident #72 had entered hospice within the past two weeks. She stated there were complications with the facility about 2 months prior regarding the facility placing Resident #72's food out of reach, covered, or not assisting with feeding. She stated these concerns have been addressed and Resident #72 had not reported any ongoing difficulty regarding dining service. She stated the resident has had a drastic appearance change and looked weak.In an over-the-phone interview on 07/15/2026 at 5:16 p.m., the RD stated she visited the facility once a week typically on Tuesdays. She stated that she was not aware of Resident #72's weight loss from 07/05/2026. She stated she needed to be notified immediately if there was significant weight loss or on her next visit. She stated it did not make a difference if Resident #72 was on hospice, she still needed to be notified immediately for significant weight loss. She stated had she been aware of Resident #72's significant weight loss she would have suggested and evaluated interventions in place. She stated she was usually notified by email or in person by DON, ADONs, or nurses. She stated that it negatively affected a resident if there was an unexpected significant weight loss but was unable to elaborate further has to how. She stated that Resident #72's weight loss was a significant change if it was anything over 5% of weight loss. She stated prior to the interview she was not made aware via email and had verified in her emails. She stated weight watchers was a nursing program that the nursing department oversaw that she had no part in. She stated she would still need to be notified and conduct her own assessment even if the facility enacted weight watchers.In an interview on 07/15/2026 at 5:35 p.m., ADON A stated she did not do a reweigh on Resident #72 following this weight loss and had not reweighed him since 07/05/2026. She stated that she was supposed to reweigh him every week as per weight watchers program for 4 weeks straight. She stated she had notified the RD via email and her response was to encourage Resident #72 to eat more meals; documentation of this exchange was requested. She stated she reviewed her sent emails and could not find a notification to the RD or conversation with her regarding Resident #72's significant weight loss. She stated the RD needed to be made aware of this weight loss immediately. She stated that she did not know how it affected Resident #72 if the dietician was not made aware of his significant weight loss. She stated the interventions in placed for Resident #72 were to weigh him weekly, encourage him, offer substitutes and supplements, honor refusals and document refusals. She stated some influences that could affect Resident #72's appetite were his thyroid medication, his diagnosis of diabetes, Lexapro prescription, and glaucoma diagnosis. She stated Resident #72's intakes were 0-75% of his meal across 3 meals. She stated the physician only provided orders for cuing and monitoring Resident #72. She stated that there had not been any new orders following Resident #72's significant weight loss. She stated she had not been notified by staff about Resident #72 refusing meals as of recently.In an interview on 07/15/2026 at 6:05 p.m., DON stated that when residents are on hospice and experience significant weight loss they report it the hospice nurse, RD, and physician but they do not really do any kind of intervention. She stated that Resident #72 dropping 9% body mass within a month was not okay even if he was on hospice care. She stated she was responsible for ensuring the RD was notified about all significant weight losses amongst the facility's residents. She stated Resident #72's 9% reduction in weight was considered significant weight loss based on the facility policy. She stated not notifying the RD affected Resident #72 by potentially experiencing further decline in health related to not having nutritional needs met. She stated that Resident #72 could deteriorate more, influence his physical wellbeing, and be more prone to infections, injuries, or diseases. She stated Resident #72 did not have a diagnosis or prescription that would result in him losing 16lbs within a month. She stated Resident #72 was diagnosed with hypothyroidism, which meant he experienced slower metabolism. She stated that she has not been made aware of Resident #72 exhibiting poor eating habits or resistance to food. She stated that the facility did not adhere to their own policy on notifying the RD for significant weight loss. In an observation completed on 07/15/2026 at 6:23 p.m. ADON A provided a reweigh of Resident #72 utilizing the Hoyer lift. Resident #72 weighed in at 163 lbs, up 3 lbs from previous measuring on 07/05/2026.Record review of the facility's policy titled, Resident Weight undated, read in part: All resident will be weighed by the 10th day of the month and their weights documented correctly. The appropriate actions regarding significant changes will be carried out. (Procedure) (7) Significant weight loss, the facility review resident weights after monthly weights are obtained to determine residents with significant weight changes. A significant weight change will be defined as 5% greater in one month, 7.5% or greater in three months. (9) all significant weight changes will be referred to the Regional Dietician on the next visit. The Regional Dietician will complete an assessment on all significant weight losses. The Regional Dietician will review all facility interventions, and will make appropriate recommendations which will be approved by the physician, if necessary.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Residents #73 and #90) of 8 residents reviewed for oxygen management.The facility failed to ensure Resident #73's and Resident #90's oxygen concentrators were free of dust and had clean filtersThis failure could place residents at risk of receiving incorrect or inadequate oxygen support and a decline in health.Findings included:Resident #73:Record review of Resident #73's admission sheet dated 07/15/2026 revealed the resident was a [AGE] year-old male with an original admission date on 12/27/2022 and a readmission dated on 01/18/2025.Record review of Resident #73's quarterly MDS dated [DATE] revealed under section C - cognitive patterns revealed the resident had a BIMs of 02 indicating the resident had severe cognitive impairment. Under section I - active diagnoses revealed the resident was diagnosed with respiratory failure, unspecified hypoxia (the lungs are not properly transferring oxygen into the red blood cells). Under section O - special treatments, procedures, and programs the resident was coded for receiving oxygen therapy while a resident.Record review of Resident #73's care plan dated 04/14/2026 revealed the resident had a focus to have continuous oxygen therapy related to respiratory failure with an intervention to administer continuous oxygen at 2 liters per minute and give medication as ordered by physician while monitoring for side effects and effectiveness.Record review of Resident #73's history and physical dated 10/27/2025 revealed the resident was diagnosed with hypertensive heart disease without heart failure (occurs when long-term high blood pressure damages the heart.) and abnormality of lung on chest x-ray (indicates that a shadow, opacity, or unusual pattern was detected).Record review of Resident #73's order summary dated 07/15/2026 revealed the resident had an order to clean oxygen concentrator filter weekly; active since 01/21/2025. Further review revealed the resident was ordered to receive 2 liters of oxygen per minute continuous via nasal cannula; active since 09/01/2025.In an observation on 07/13/2026 at 9:35 a.m. Resident #73's oxygen concentrator had dust on the back portion and a dirty filter. Resident #90Record review of Resident #90's admission sheet dated 07/15/2026 revealed the resident was a [AGE] year-old male with an admission date on 06/23/2026.Record review of Resident #90's admission MDS dated [DATE] revealed under section C - cognitive patterns revealed the resident had a BIMS of 12 indicating the resident had moderate cognitive impairment. Under section I - active diagnoses revealed the resident was diagnosed with chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes restricted airflow and severe breathing difficulties). Under section O - special treatments, procedures, and programs the resident was coded for receiving oxygen therapy while a resident. Record review of Resident #90's care plan dated 07/03/2026 revealed the resident had a focus to have continuous oxygen therapy related to respiratory failure with an intervention to administer continuous oxygen at 3-4 liters per minute and give medication as ordered by physician while monitoring for side effects and effectiveness.Record review of Resident #90's history and physical dated 06/23/2026 revealed the resident was diagnosed with chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes restricted airflow and severe breathing difficulties) and pulmonary fibrosis (a progressive disease causing irreversible scarring in the lungs, making breathing difficult and lowering blood oxygen levels).Record review of Resident #90's medication administration record dated 07/14/2026 revealed the resident had an order to receive 3-4 liters of continuous oxygen via nasal cannula and ensure the canister was changed weekly.In an observation on 07/13/2026 at 10:05 a.m. Resident #90's oxygen concentrator had dust on the back portion along with notable dust near the air intake slit.In an interview on 07/15/2026 at 2:47 p.m., CNA C stated she reviews oxygen concentrators to ensure there is no dust present. CNA C stated that dust developed on the concentrator probably took a month to develop. CNA C stated that there was no routine for checking equipment weekly, and it was only situational. CNA C stated she suspected that central supply or ADON oversaw reviewing the oxygen concentrators. CNA C stated that dust could affect the oxygen concentrator and could create allergens to the resident. CNA C stated that the equipment could potentially fail and leave the resident in a life threatening position. CNA C stated that she did not recall the last in service for oxygen.In an interview on 07/15/2026 at 3:17 p.m., RN D stated that the oxygen concentrator was checked and changed the tubing once a week by nurses on Sunday nights. She stated that there should not be dust build up on the oxygen concentrator and could cause a hygiene issue. She stated that if the oxygen concentrator malfunctions then the resident could not be receiving the correct amount of oxygen. RN D stated that a resident could enter hypoxia (reduced oxygen in the blood), altered mental status and death if they are not on their continuous oxygen. She stated ADONs were responsible for ensuring the oxygen concentrators are being monitored and serviced as needed. She denied any concentrator malfunctions. She stated the last in service for oxygen concentrators was within the past 3 weeks.In an interview on 07/15/2026 at 4:39 p.m., DON stated that the central supply was responsible for ensuring the oxygen concentrators were clean and had a filter. She stated that if there was dust on the oxygen concentrator it was more than likely not cleaned within the past week. She stated nurses were responsible for ensuring it was working and the humidifier and tubing changed weekly. She stated that nurses would report the oxygen concentrator issues or dirtiness to central supply. She stated she believed there was a log but does not know where it is or who has it. The oxygen concentrator maintenance log was requested from the DON but not provided prior to exit on 07/15/2026 at 6:30 p.m.Record review of the facility's policy titled Oxygen Administration undated read in part, Oxygen therapy is also prescribed to ensure oxygenation of all body organs and systems (Goals) The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. The resident will maintain an effective breathing pattern with administration of oxygen (Procedures) Become familiar with the type of oxygen administration, medical diagnosis, and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered Turn on oxygen after properly setting for volume and place device in position oxygen concentrators should be cleaned according to manufacturer recommendations. Change or clean oxygen concentrators filters according to manufacturer recommendations.

Based on observation, interview and record review, the facility failed to ensure a student nurse aide had the specific competencies and skill sets necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for 1 out of 10 staff reviewed for competent nursing staff. The facility failed to ensure the Student Nurse Aide did not provide independent resident care to residents. These deficient practices could place residents at risk for receiving care from personnel who were not authorized or competent to provide care independently.Findings include:Record review of Resident #88's admission sheet, dated 07/30/2024, revealed a [AGE] year-old female with an initial admission date of 07/30/2024.Record review of Resident #88's quarterly MDS, dated [DATE], revealed under section C - cognitive patterns the resident had a BIMS score of 7, with the significance being the resident was severely impaired cognition.Record review of Resident #88's care plan, dated 06/26/2026, revealed an ADL self-care deficit requiring one-person assistance with bathing, transfers, walking, toileting, dressing, and bed mobility. The care plan directed staff to encourage resident participation, monitor changes in function, provide therapy services, and maintain skin integrity during ADL assistance. Record review of Resident #88's history and physical, dated 08/15/2025, revealed resident had diagnoses which included schizophrenia, cognitive delay, multiple chronic medical conditions, and required assistance with activities of daily living, medication management, and redirection, and ongoing nursing care. The provider ordered continued interdisciplinary services, which included physical, occupational, and speech therapy, to support the residents' functional abilities and maintain independence with ADLs.In an interview with student nurse aid on 07/13/2026 at 3:33 PM Student nurse aid stated she took resident to shower and did not have a nurse supervise her. The Student Nurse Aid stated she should be over shadowing certified staff when providing care for residents as there was potential harm to residents and her if left unattended because she is not license and has not finished her training and would not know the proper ways to handle certain situations if not supervised. In an interview with the NP on 07/14/2026 at 10:03 AM, the NP stated no student nurse should be left alone doing any kind of care if they were not licensed or uncertified. The NP stated the student nurse aids, if left alone, they could make a mistake and put the patient at risk without proper guidance of anyone overseeing their work. The NP expectations of the charge nurse were to follow standard care of practice at all times. In an interview with LVN H on 07/14/2026 at 10:07 AM LVN H (Charge Nurse), stated the difference between a student nurse aid was they had not taken their test and they were not a CNA yet as they were not certified or trained to be left alone on the floor proving care. LVN H charge nurse stated student nurse aids were not certified and should not be left unattended. LVN H charge nurse stated if the student nurse aid was left alone, residents could fall or could choke if the student nurse aids didn't know their meals. LVN H charge nurse stated student nurse aids were supposed to shadow CNAs. LVN H charge nurse stated charge nurses oversaw the nurses. LVN H charge nurse stated she's also responsible as a charge nurse to oversee the CNAs. LVN H charge nurse stated since it was shift change she was no longer responsible for the 2-10PM shift and it's no longer her responsibility to oversee them as she's a 6AM to 2PM shift. LVN H charge nurse stated by the time she was approached LVN H charge nurse was done with her responsibility as a charge nurse, but since she was still physically still on floor finishing up, it was still the LVN H charge nurse responsibility to oversee staff in the designated hall. LVN H charge nurse stated nobody told her there was student nurse aid on the floor. In an interview with the DON on 07/15/2026 at 10:37 AM, revealed the student nurse aids were always supposed to shadow someone, they shadowed the CNAs, the nurses should know be aware when student nurse aids were working on floor because we made the schedule and everyone was able to see who would be on the floor that day. The CNAs reported to the ADONs, the charge nurse would be the one responsible for whoever was in that section, it was important for the nurses to know the difference between a student nurse aid and a CNA because they did not have the qualifications to identify the difference between a student nurse aid and a CNAs, the staff should know the difference between the 2, one was qualified to do certain tasks and the other was not, it's not okay for any staff to see a student nurse aid doing any task alone like showering a resident with no proper supervision or over shadowing someone, it would be a safety issue to the resident because they were not fully aware of what task was what to that specific resident.In an interview with RN J on 07/15/2026 at 11:25 AM, revealed the nurses were responsible for the CNAs and the CNAs were responsible to oversee the student nurse aids, if the student nurse aid was left alone the patient could fall, worst case scenario the patient could be dead, staff should be aware of where the student nurse aid was at all times for patients' safety. If the student was alone, RN J stated she would not leave the student nurse aid alone because it's patient safety, which could result in an injury. RN J stated she would go get the CNA and make sure she stayed with the CNA. The CNAs were certified, the student was not certified. Which was not the same; they had not taken the certification to practice alone, as a CNA.In an interview with ADON B on 07/15/2026 at 5:16 PM, ADON B stated the facility had student nurse aids training with other CNAs. The student nurse aids were not supposed to be left alone because they had not completed their training. Student nurse aids were not supposed to left alone doing patient tasks alone because they did not have the certifications or the training to be practicing by themselves safely, Unsafe transfer, falls, depending's who they were putting at risk, also aspirations could occur. ADON B stated, if she saw a student nurse aid she would redirect them to another staff who was trained to oversee them. The difference between a CNA was one had completed the training, and the other one had not completed the training; they would be a liability if left alone. The facility had a schedule so they should know who student nurse aids were assigned to when arriving at the facility. Student nurse aids were not supposed to shower residents alone without supervision. In an interview with the Administrator on 07/15/2026 at 5:28 PM, revealed the student nurse aids needed to be supervised and not left alone. Nursing student aids should not doing any kind of direct patient care by themselves, because if they were showering a resident by themselves that's a potential risk. Student nurse aids were assigned to CNAs, but nurses were also responsible for student nurse aids on floor. Student nurse aids were not the same as a CNA because they were not certified, the Administrator stated they would hope the staff would know the difference between a student nurse aid and a CNA, even if the nurse saw the student nurse aid alone, it was also their responsibility to oversee them.Record review of the facility's Charge Nurse Job Description revealed the charge nurse was responsible for directing and supervising nurse aids, implementing nursing policies and procedures, educating support staff, and ensuring resident care was provided safely and in accordance with facility's policies and federal requirements.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #92) reviewed for accommodation of needs.-The facility failed on 07/13/2026 to cut Resident #92's meal into edible pieces during lunch service.This failure could place residents at risk of poor meal service and long waits before beginning their meal.Record review of Resident #92's admission sheet dated 07/15/2026 revealed a [AGE] year-old female with an initial admission date of 08/14/2025.Record review of Resident #92's quarterly MDS dated [DATE] revealed under section C - cognitive patterns the resident had a BIMS score of 14 indicating the resident was cognitively intact. Under section GG - Functional Abilities the resident required set-up assistance for eating. Under section K - swallowing/nutritional status the resident did not require a mechanically altered diet.Record review of Resident #92's care plan dated 06/24/2026 revealed the resident had a focus to address the resident's ADL self-care performance deficit related to hemiplegia (severe or complete loss of motor function on one vertical half of the body) and impaired balance. The interventions to address this focus included encourage resident to participate to the fullest extent possible with each interaction and required 1 staff participation to eat.Record review of Resident #92's history and physical dated 08/14/2025 revealed the resident was diagnosed with cerebral infarction (blocked blood vessel interrupts blood flow to the brain damaging tissue) with hemiplegia (complete paralysis) and hemiparesis (weakness), Lupus (chronic autoimmune disease where the immune system attacks healthy tissues and organs), and was scheduled to receive ADL assistance as indicated.Record review of Resident #92's physician orders dated 08/15/2025 revealed the resident was prescribed a regular diet with regular texture and consistency.In an observation on 07/13/2026 at approximately 12:30 p.m., Resident #92 was served regular diet plate as per orders but displayed an inability to cut her main course of chicken into smaller edible portions due to left sided paralysis. Resident #92 waited approximately 10 minutes until a family member of another resident began assisting by cutting the chicken for Resident #92. Staff intervened and proceeded to cut Resident #92's chicken despite most of it being cut by the family member. Resident #92's meal ticket did not have specific instructions under special notes on the tab. Resident #92 ate 100% of meal after receiving proper assistance.In an interview on 07/14/2026 at 8:58 a.m., Resident #92 stated that she was 100% dependent on staff due to left side paralysis. She stated that she required assistance with unpacking and cutting her meal. She stated that she was capable of scooping and poking her food and bringing utensils to her mouth but could not cut her food with a knife if needed. She stated that usually staff cuts her meal upon delivery of her plate, but it depended on which staff member was bringing it and if they were aware of her condition. She stated she sometimes waited for them to cut her food after delivering but could not specify the amount of time she waited. She stated if they had not returned, she would approach a staff member or call for them to come to her table.In an interview on 07/15/2026 at 2:39 p.m., CNA C stated they would assist a resident with cutting their food if they displayed difficulty with handling utensils, were paralyzed, or if their diet calls for assistance. She stated that they would cut the food as soon as they serve the tray. She stated it was expected for the staff to cut the residents' food upon delivery. She stated that if staff did not cut the residents' food it could affect them in the form of difficulty eating, they could miss their meal entirely, they could feel sadness and confusion, and that the food would eventually become cold and undesirable. She stated the last in service for feeding and dining service was in June 2026. She stated the charge nurse was responsible for ensuring the CNAs were preparing residents and unpacking meal trays for residents upon delivery. She stated she had not seen meal tickets with special notes to cut the residents' food and added she would like this instruction on the meal ticket. In an interview on 07/15/2026 at 3:26 p.m., RN D stated that her responsibilities during dining were ensuring that the residents' meal tickets and diet matched, reviewing consistency, screening for allergic reactions, ensuring that residents at a table get served at the same time, overseeing the feeding assistance and monitoring for residents in distress. She stated that her expectation for CNAs was to uncover the residents' plate, unpack all the utensils and remove lids, and cut the residents' food when required. She stated that if a resident needed their food cut for them it should be on special notes on their meal ticket. She stated a resident with paralysis to one side might be able to feed themselves but not be able to cut their food. She stated it affected the residents because they could be left without eating, feel embarrassed, and lead to poor intake. She stated it was expected for staff to cut the meal into smaller portions for the resident upon delivery when requested or required.In an interview on 07/15/2026 at 4:26 p.m., DON stated if a resident required assistance for feeding or preparing then it was expected for the staff to assist upon delivery of the meal tray. She stated that staff should be observant of residents and assist when it appeared if they were struggling. She stated staff needed to set up the residents' meal and provide assistance it affected the residents by creating a dignity issue if they could not cut their own food. She added that not providing this service upon arrival, the resident's food would get cold and the resident would experience meal dissatisfaction. She stated that the staff members in dining were responsible for offering meal assistance services. Record review of the facility's policy titled, Eating, Assistive/Complete undated, read in part: (Procedure)(1) Become familiar with the resident's diet and any special modifications, amount of assistance needed, interests in self-feeding, nutritional assessment for history, pattern and other characteristics of food and fluid intake. (9) remove the covers on the hot food and allow the resident to view the food. (10) Assist with eating as needed. (10-d) Cut meat, place straw in glass (unless contraindicated), open and pour fluids from container into a glass cup. Open salt, sugar, pepper, and margarine and use on food or in fluids as desired or requested by the resident.

Based on observation, interview and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption 2 of 10 residents (Resident #35 and Resident# 81) reviewed for personal fridges. The facility failed to ensure Resident #35 and Resident #81's personal fridges were kept at appropriate temperatures. This defiant practice could place residents at risk for foodborne illness due to proper storage and monitoring of personal food items and increasing the risk of foodborne illness.Findings include:1. Record review of Resident #35's admission sheet, dated 03/18/2025, revealed an [AGE] year-old female with an initial admission date of 03/18/2025. Diagnosis includes dementia, insomnia, essential tremor, osteoarthritis of both knees, rheumatoid arthritis, generalized muscle weakness, impaired coordination, left toe amputation, gastroesophageal reflux disease, depression, hypertension, generalized anxiety disorder, vitamin D deficiency, and thickened toenails, contributing to cognitive impairment, decreased mobility, and increased risk for falls and functional decline.Record review of Resident #35's quarterly MDS, dated [DATE], revealed under section C - cognitive patterns the resident had a BIMS score of 09, which indicated the resident was cognitively intact.Record review of Resident #35's care plan, dated 04/01/2026, included interventions to maintain adequate nutrition and hydration. Staff were directed to encourage fluid intake, monitor food and fluid consumption, provide the prescribed diet, monitor intake and weight, report significant change to the physician, and obtain laboratory studies as ordered. Record review of Resident #35's annual history and physical, dated 10/27/2025, revealed resident had dementia, generalized weakness, wheelchair dependence, urinary incontinence, anxiety, osteoarthritis, and multiple chronic medical conditions requiring ongoing nursing care. The provider ordered continuation of medications, fall precautions, supportive care, therapy interventions, and assistance with activities of daily living.Observation on 07/13/2026 at 09:23 AM revealed Resident #35 had a personal fridge in room, a thermometer was inside the fridge, the temperature inside the fridge read 52F. Resident#35 had Jello inside which was opened; the Jello had a use by date. Observation on 07/15/2026 at 2:39 observed same Jello still inside the fridge and thermometer still read 52F.2. Record review of Resident #81s admission sheet, dated 04/07/2021, revealed an [AGE] year-old male with initial admission date of 04/07/2021.Record review of Resident #81's quarterly MDS, dated [DATE], revealed under section C - cognitive patterns the resident had a BIMS score of 15, which indicated the resident was cognitively intact.Record review of Resident #81's care plan, dated 05/05/2026, included the resident's physical, cognitive, psychosocial, and medical needs and included interventions to address safety, fall prevention, nutrition and hydration, pain management, ADL assistance, medication management to maintain the resident's highest practicable level of functioning and well-being. Record review of Residents #81's annual history and physical, dated 10/29/2025, revealed the resident had multiple chronic medical and psychiatric diagnoses, including dementia, paranoid schizophrenia, depression, anxiety, hyperlipidemia, gastroesophageal reflux disease, osteoarthritis, chronic constipation, muscle weakness, impaired mobility, cognitive deficits, malnutrition, and fall risk. The examination noted the residents were well nourished, alert, with intermittent confusion, impaired memory and judgment, generalized weakness, and required an assistive device for mobility. The treatment plan included continued skilled nursing care, medication management, nutritional support, fall and aspiration precautions, hydration monitoring, pain management, behavioral health follow-up and ongoing monitoring of chronic medical conditions.Observation on 07/13/2026 at 10:18 AM revealed Resident #81 had a personal fridge in his room, a thermometer was inside in the fridge and the temperature inside the fridge read 49F. Resident #81 had beverages at this time, no open food or drinks. In an interview with CNA G on 07/15/2026 at 10:13 AM, revealed CNA G had been working at the facility for a year, housekeeping was the one in charge of monitoring the fridge and also the nurses. CNA G stated they didn't know who kept a log of the fridges, but did know that it was required to have a date on the food when it was brought. If the facility didn't monitor the food temperature, the food could spoil and the residents would get sick.In an interview with LVN I on 07/15/2026 at 10:27 AM, revealed LVN I had been working at the facility for 27 years. LVN I stated the, personal fridge was the family's responsibility, but the facility was also responsible for overseeing the fridge to see if it's working properly or if the food was good. If the temperature was not the correct temperature, food could spoil and make the residents sick if spoiled food was consumed.In an interview with the DON on 07/15/2026 at 10:37 AM, revealed the night nurses had a temperature log, and they kept track of it. The night shift and morning shift should keep a log of the fridge temperature. The food could go bad; it could spoil. The residents may become sick, and it would affect them greatly. All nurses should be responsible. The facility had service training for food temperatures.In an interview with RN J on 07/15/2026 at 11:25 AM, RN J stated they had no idea who was responsible for the personal fridge temperature log, the staff didn't have a personal fridge temperature log, housekeeping cleaned the fridge and was responsible RN J said she assumed. If the fridge was not set to a specific temperature and the residents ate the food, the residents could get sick. In an interview with housekeeping on 07/15/2026 at 11:37 AM, housekeeping stated they had been at the facility for 2 1/2 years. The resident was responsible for keeping the fridge clean and housekeeping didn't know who was responsible for monitoring the temperature inside the personal fridge, and stated they assumed their supervisor, but housekeeping didn't keep track of the temperature log.In an interview with the housekeeping supervisor on 07/15/2026 at 11:42 AM, revealed the housekeeping supervisor had been working at the facility for about 5 years. The family was responsible to keep the fridge clean and throw away the food that was no longer good, the temperature log the housekeeping supervisor did not know but there was a thermometer inside the fridge, we did clean the fridge when it's necessary like when they didn't have family. An example was if the milk had expired and the temperature was not correct, the resident could get sick if the resident drank the milk. The housekeeping supervisor stated their staff did not keep a log of the personal fridge.In an interview with ADON B on 07/15/2026 at 5:16 PM, revealed ADON B worked at the facility for about 2 months, and was not sure who kept track of the temperature logs for the resident's personal fridge. ADON B stated if residents took the food that's expired or not the right temperature, they could get sick like vomiting if consumed.In an interview with the Administrator on 07/15/2026 at 5:28 PM, he stated the family was responsible for the personal fridge and any staff were responsible for making sure the temperature was correct or the food was not spoiled. The facility didn't have to check the personal fridge temperature, the facility wouldn't know if the food in their fridge was spoiled because they didn't keep track of that, if the residents drank the milk, it could make the resident sick if fridge was not set to the correct temperature it was supposed to be. Record review of the facility's Personal Refrigerators Policy required residents' personal refrigerators to be maintained between 35F and 41F. The policy also stated that housekeeping may inspect resident refrigerators at least weekly and assist with the removal of expired or spoiled food items.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 2 residents (Resident #5, Resident #57) reviewed for infection control.The facility failed to ensure the urinary catheter bag for Resident #57 was anchored to the bed rail and secured to prevent infection.CNA O failed to practice hand hygiene after disposing the dirty wipes and brief, and before putting on a new disposable brief, when providing perineal care to Resident #5 on 07/13/2026.This failure could place residents at risk of infection due to improper care practices. Record review of Resident #57's face sheet dated 07/15/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #57's diagnoses included disorder of Neuromuscular Dysfunction of bladder (a miscommunication between the brain and the bladder), Spondylosis (arthritis of the spine), Cervical Region (arthritis of the neck), Hypertension (high blood pressure), Altered Mental status (suddenly confused, disoriented, or not acting like their normal self), Alzheimer's Disease (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to perform simple tasks), Major Depressive Disorder (serious mood disorder), Anxiety Disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry.), Polyneuropathy(Many nerves outside your brain and spinal cord are damaged). Record review of Resident #57's MDS dated [DATE], reflected a BIMS score of 00, which indicated severe cognitive impairment. Resident #57 had an indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of Resident #57's Order Summary Report dated 07/15/2026, stated Ensure catheter strap is in place and holding, every shift change as needed, ensure every foley bag is in privacy bag while in bed or wheelchair every shift, provide catheter care every shift. Record review of Resident #57's Care Plan dated 07/15/2026, stated focus [Resident #57] has (indwelling Suprapubic Catheter: neurogenic bladder). The goal stated, The resident will be/remain free from catheter related trauma through review date, Interventions stated Catheter: Check tubing for kinks and maintain the drainage bag off the floor. In an interview attempt and observation on 07/13/2026 at 2:57 PM, Resident #57 was lying in bed. Resident #57 was nonverbal. Resident's bed was at its lowest position. The catheter bag was lying on the floor, inside the privacy bag. Catheter tubing was lying directly on the floor. In an observation on 07/14/2026 at 02:40 PM, Resident #57 was in bed asleep, bed at lowest position, and catheter bag and tubing were observed lying directly on the floor. In an interview conducted on 07/14/2026 at 02:42 PM, CNA Q stated she had been employed at the facility since June 2026. CNA Q observed Resident #57's catheter bag and tubing lying on the floor and stated the catheter bag should not have been on the floor. She stated that, although the resident was a fall risk and the bed was maintained in a low position, the catheter bag and tubing should not have been in contact with the floor. CNA Q reported that allowing the bag or tubing to touch the floor increased the risk of contamination and could result in backflow into the resident. She further stated the potential risks to the resident included infection, UTI, and sanitation concerns. CNA Q reported she had received infection control training upon hire and had also attended in-service education related to infection prevention and control. In an interview on 07/15/2026 at 04:50 PM, DON stated she had been employed at the facility for 2 months. DON stated it is the responsibility of all staff to ensure catheter bags, privacy bags, and tubing are not touching the floor. She stated there are protocols in place for catheter care starting with competencies, and QAPI to determine if certain hallways have had a spike in UTIs, then in-services and trainings are conducted. Staff are also checked off yearly on peri-care. DON stated staff are to ensure the tubing and bags are not touching the floor even with a low positioned bed. The DON said they could just adjust the strap or reposition the bed a specific way in order for the catheter bag and tubing to not touch the floor. DON stated the risk to the resident with her catheter bag and tubing located on the floor is bacteria and infection. In an interview on 07/15/2026 at 05:50 PM, The Administrator stated that all staff are responsible for ensuring that resident's catheters are not located on the floor as the risk could be infection. Record review of facility policy titled Catheter Care no date provided revealed Be sure the catheter tubing and drainage bags are kept off the floor. Findings included: Resident #5 Record review of Resident #5's face-sheet dated 07/15/26 revealed a [AGE] year-old female with initial admission date 09/18/23, and re-admission date 05/07/26. Record review of Resident #5's history and physical dated 10/09/25 revealed the following past medical history: Dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, and behavior); Urinary Tract Infection history; and Muscle weakness. Record review Resident #5's Discharge MDS dated [DATE] revealed a BIMS score of 0, indicating severe cognitive impairment. The Discharge MDS noted Resident #5 was completely dependent for toileting hygiene, meaning the Helper does all the effort to complete the task. Record review of Resident #5's care plan revised on 02/04/26 revealed the resident had bladder incontinence and staff interventions included for staff to provide incontinent care as needed and apply moisture barrier after each episode. In an observation on 07/13/26 at 9:51 AM of CNA O providing perineal care to Resident #5. CNA O was observed putting on 3 pairs of gloves before performing perineal care. CNA O adjusted the bed height to her waist level and uncovered Resident #5. CNA O was observed wiping resident's perineal area, with a clean wipe each time. CNA O was observed to have disposed of the dirty wipes into the trash that was located next to her and the resident's bed. CNA O was observed to instruct Resident #5 to turn to her right side, and wiped Resident #5's buttocks, disposing dirty wipes into the trash. CNA O was observed to dispose of the dirty brief into the trashcan and then disposed of her 1st pair of gloves on. CNA O was observed with 2 pairs of gloves still on, one clear pair of gloves and black gloves. CNA O was observed to apply a new brief. CNA O disposed her 2 pairs of gloves into the trash and then performed hand hygiene. In an interview on 07/15/26 at 12:40 PM with CNA O, she stated she used multiple gloves because she was allergic to the latex gloves in the resident's room. CNA O stated she also did not want to leave Resident #5 laying in a high level bed and feared she would fall. CNA O stated the potential risks to residents having perineal care with no hand hygiene between disposing the dirty supplies, and before putting on a new brief, was a cross-contamination issue that could affect their health. In an interview on 07/15/2026 at 4:19 PM with the DON, she stated it was not acceptable for her nursing staff to put on multiple sets of gloves, when providing residents with perineal care. The DON stated staff were expected to dispose of gloves after disposing the dirty brief and wipes, and before providing the resident with a new brief. The DON stated staff donning multiple sets of gloves and not performing hand hygiene in between dirty and clean was an infection control issue. The DON stated annual competencies were completed for nursing staff. She stated that if the staff had allergic reactions to the gloves in resident rooms, there were other available gloves for those staff members. Record review of Nursing Facility's Perineal Care, dated 04/25/22, read in part under Back, 21. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area. It continued, 24. Doff [take off] gloves and PPE. 25. Perform hand hygiene. Under Conclusion, it read, 26. Provide resident comfort and safety by re-clothing.

Based on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services, in that: The facility, which was licensed for 120 beds, failed to employ a qualified social worker on a full-time basis since 05/20/2026.This failure put facility residents at risk of not having their psychosocial or discharge planning needs met. Findings included:Review of the Facility's Summary Report revealed the facility was licensed for 120 beds.Record review of the facility's Census Report dated 05/20/2026 revealed that the facility had a capacity of 120 beds and had a census of ninety-five.During a telephone interview on 05/22/26 at 2:08 p.m. with the current Social Worker J it was revealed he was hired on 05/19/26. He said, I have a master's degree in social services, and yes I am the social worker at the facility. He said he had finished school on 05/15/26 and was scheduled to take his licensing exam on 06/06/26 for Licensed Master Social Worker. He said he was responsible for completing Discharge Planning, Social Services assessments, Care Plans, and addressing Grievances/Concerns at the facility. He said he was not familiar with Resident #1.Duringn interview on 05/22/26 at 3:05 p.m. with the Administrator, it was revealed that the facility was licensed for 120 beds and had to have licensed Social Worker full time at the facility. She said she was not aware that Social Worker J could not work as the Social Worker prior to taking the licensing exam. She said they had a difficult time hiring a social worker because they had very few applicants apply for the position. She said the previous Social Worker was licensed and her last day was 05/20/26. She said, I just moved to Texas and was under the impression that Social Worker were allowed to work pending to take their licensing exam like in Florida. The state surveyor requested a copy of the Social Worker Job Description. The Administrator did not provide a copy of the Social Worker Job description prior to exit.

Based on interview and record review, the facility failed to have a designated Infection Preventionist who had completed specialized training in infection prevention and control for 2 of 2 nurses reviewed as designated Infection Preventionists.The facility failed to ensure DON and ADON LVN K, designated Infection Preventionists, completed the required specialized training in infection prevention and control.This failure could affect the facility's ability to appropriately recognize and respond to communicable diseases and infections including COVID-19.Findings include:During an interview on 05/22/26 at 10:37 a.m. with Regional Compliance Nurse M and DON revealed that the DON and ADONs implemented and monitored infection control protocols and surveillance activities for infection control. The state surveyor was provided with a copy of the training certificate for completion for Nursing Home Infection Preventionist Training Course - WB4973 dated 03/20/26 for ADON RN L.During an interview on 05/22/26 at 2:48 p.m. with ADON RN L she said, I am not the Infection Control Preventionist. I do not assist at all with the Infection Control Program and do not track infections.During an interview on 05/22/26 at 2:54 p.m. with HR Coordinator N said the previous DON's last day of work was on 12/09/25.During an interview 05/22/26 at 2:55 p.m. with Regional Compliance Nurse M and DON revealed the previous DON was designated as the Infection Control Preventionist. The Regional Compliance Nurse said that the DON, ADON LVN K and the Administrator were in the process of completing the required Infection Control Preventionist. The DON said that she and ADON LVN K had started the Infection Control Preventionist training and it had not been completed as of 05/22/26.Record review of facility's Infection Control Plan: Overview updated 3/2025 provided by Regional Compliance Nurse M revealed: Infection Control: The facility will establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Infection Control Program: The facility will establish an infection control program which it - Investigates, controls and prevents infection in the facility. Decides what procedures, such as isolation should be applied to an individual resident; and maintains records of incidents and corrective actions related to infections. Intent: The intent of this policy is to assure that the facility develops, implements, and maintains an infection prevention and control program in order to prevent, recognize and control to the extent possible, the onset and spread of infection within the facility. Infection Preventionist (IP) The IP will ensure education and training coordinate the specific activities necessary. For the implementation of the infection control program at the facility. The IP function includes evaluation and appropriate performance improvement activities designed to improve the quality of care rendered by the providers of healthcare services within the facility. Facility IP, DON and Administrator will complete the CDC training course to provide initial and ongoing education of all health care workers and the theory and practice of infection control prevention. The IP will monitor the infection control program and will recommend corrective actions as needed. Responsibilities include: reviewing and assisting with the development of specific infection control policies and procedures, ensuring the development and implementation of facility policy and procedures as they relate to the prevention and control of infections and communicable disease, provide initial and ongoing education to ALL healthcare workers in the theory and practice of infection control and prevention, recommend prudent infection control measures, techniques, and practices based on the analysis of monitoring and surveillance activities for infection control, provide input into the purchase of equipment and supplies used for sterilization, decontamination, disinfection and cleaning within the home in compliance with the regulating and licensing agents.

Based on observation, interview and record review the facility failed to ensure the resident had a right to be treated with respect and dignity including the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 5 residents (Resident #3) reviewed for restraints. The facility failed to ensure Resident #3 was free from any physical restraint when a pillow was observed tucked under the bedsheet in a manner that restricted movement to Resident #3. This failure could place residents at risk for restricted movement, feeling of entrapment, decreased mobility, and possible injury.Record review of Resident #3's face sheet, dated 04/22/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and then readmitted on [DATE]. Resident #13 had diagnoses which included Unspecified Dementia (decline in mental abilities), Amnesia (total loss of memory), Ataxia (lack of muscle control or coordination), communication deficit (difficulty understanding of using spoken/written language), pain in joints (discomfort, stiffness, or soreness in the bones), displaced fracture of base of third metacarpal bone (long bone in your palm connecting your right middle finger to your wrist is broken near the wrist, and the pieces have moved out of their normal alignment, right hand (long bone in your palm connecting your right middle finger to your wrist is broken near the wrist, and the pieces have moved out of their normal alignment), rectal prolapse (last part of the intestines (rectum) loses its support, slides out of place, and protrudes through the anus), dysphagia (difficulty swallowing), depressive disorder (intense feeling of sadness, emptiness, or loss of interest in activities), gait and mobility (breakdown of gait and mobility), osteoarthritis (arthritis in the bones), muscle wasting and weakness (muscles shrink and lose power making daily tasks difficult), Hypothyroidism (thyroid gland in the neck does not produce enough thyroid hormones, causing the body's metabolism to slow down), type 2 diabetes (he body cannot properly use or make enough insulin to manage blood sugar), hyperglyceridemia (too much of a specific type of fat triglycerides circulating in your blood), polyneuropathy (multiple peripheral nerves throughout the body are damaged). Record review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 01, which indicated the resident had severe cognitive impairment. The resident had impairment on one side in upper extremity (shoulder, elbow, wrist, hand) and had impairment on both sides of lower extremities (hip, knee, ankle, foot). Record review of Resident #3's Care Plan, dated 04/22/2026, reflected no focus, goal or interventions that would indicate a medical use of a pillow tucked under the bed sheet. Record Review of Resident #3's Orders dated, 04/22/2026, did not reveal any physical orders that would indicate a medical use of a pillow tucked under the bed sheet. In an interview and observation on 04/22/2026 at 11:43 AM, revealed Resident #3 was lying in bed asleep tilted on her left side. The Hospice nurse was sitting on a chair and stated she had just completed her nursing assessment on the resident. During observation, the hospice nurse removed the blanket that was covering the resident to show the resident had no bruising or swelling on any part of her body and a pillow was tucked under the resident's bed sheet. The Hospice nurse stated the pillow placement was already there when she arrived and did not see who had placed it. Hospice nurse stated she had no idea why the pillow was placed there or what the use for it was. In an observation and interview on 04/22/2026 at 11:59 AM, revealed the resident was awake and sitting at a 90 degree angle and food tray front of her. Upon observation of resident's room, and the pillow placement under the bedsheets were no longer there. LVN S was shown a picture of the pillow under the bed sheet and was asked what the risks were of having a pillow under the bedsheet. LVN S stated it was not appropriate and it should not have been there. It causes a restraint to the resident. In an interview on 04/22/2026 at 03:38 PM, with Resident #3 responsible party (RP) stated that be believed the pillow had been placed to keep Resident #3 positioned on her side to prevent wounds. The RP stated that Resident #3 was unable to move independently, very fragile, and was bedbound. In in interview on 04/23/2026 at 05:13 PM, with DON was shown a photograph of a pillow tucked under the bedsheet of Resident #3. DON stated that the use of the pillow in this matter was considered a restraint and that staff were not trained to perform this practice. The DON explained that the risk to the resident included the possibility of feeling trapped and being unable to move, especially since the resident did not ambulate. DON stated that the responsibility for monitoring this practice fell on the charge nurses. The DON stated reported that residents were expected to be responded at least every two hours. In an interview on 04/23/26 at 06:06 PM, with the Administrator, the Administrator was also shown the photograph of the pillow tucked into the sheet. Administrator stated that the pillow had been keeping the resident in bed and confirmed that this would be considered a restraint. Administrator stated that staff were not trained to use pillows in this way and stated she had not previously observed or instructed staff to do so. She stated that only approved devices, such as U-bars, were permitted. Administrator stated that staff received training on restraints during orientation upon hire and that nursing staff were responsible for ensuring residents were not improperly restrained. The administrator stated that residents had the right to move freely in and out of bed. Record review of the facilities policy named Restraints reflected It is the policy of this facility to maintain an environment that prohibits the use of restraints or discipline or convenience restraint usage shall be limited to circumstances in which the resident has medical symptoms that warrant the use of restraint A restraint assessment committee will evaluate and establish the need for restraint youth or restraint reduction for residents in our facility the facility is committed to nurturing the autonomy and independence of our residents by attempting to provide a restraint free environment. Physical restraint Any manual method or physical mechanical device material or equipment attached or adjacent to the residence body that the resident cannot remove easily which restricts freedom or movement or normal access to 1 body physical restraints include but are not limited to leg restraints arm restraints handmaidens soft tie or vest weird true safety bars [NAME] chairs lap cushions and trades that the resident cannot remove. 5.) Those three staff will develop a care plan for the alternative method identified and or the restraint usage. 18) Practices that are not to be used: using bedrooms to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed sucking sheets so tightly that a bed bound resident cannot move using wheelchair safety bar to prevent a resident from rising out of the chair placing a resident in a chair that prevents the resident from rising and placing a resident who uses a wheelchair so close to the wall that the law prevents the resident from rising.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. - The facility's kitchen staff failed to ensure a zip top bag that contained meat slices was sealed in the walk-in refrigerator on 03/28/2026.- The facility's kitchen staff failed to maintain safe consumable produce as evidence by overripened whole bananas with black peels in a container in the walk-in refrigerator. On 03/28/2026.-The facility's kitchen staff failed to ensure the rims of 2 containers in the walk-in refrigerator were free from dried drippings on 03/28/2026-The facility's kitchen staff failed to ensure whole eggs were sealed in a labeled and dated container in the walk-in refrigerator on 03/28/2026.-The facility's kitchen staff failed to ensure that two refrigerator temperature logs and one freezer temperature logs were filled out for the date of 03/27/2026 on 03/28/2026. These failures could place all residents who received meals from the kitchen at risk of food-borne illnesses from cross-contaminated food and beverages. Findings included:Observation on 03/28/2026 at 3:55 p.m., of walk-in refrigerator revealed:-One zip top bag containing meat slices, was not fully sealed. Exposed to air.-One gallon of sauce had black drippings on the handle-One jar of sauce had yellow, dried drippings around the rim.-One container with approximately 10 over ripened whole bananas with black peels.- 3 whole eggs uncovered, exposed to air in a container bowl that was not dated or labeled.-Two temperature logs for the reach in refrigerators missing a temperature check and signature for the PM shift for date 03/27/2026.-One temperature log for the reach in freezer was missing a temperature check and signature for the PM shift for date 03/27/2026.In an interview on 03/31/2026 at 12:57 p.m., with Dietary [NAME] C revealed that the temperature logs were to be completed at the start of their shift and at the end of the shift. She stated that the cook and dietary aides were responsible for filling out the temperature logs and the Dietary Manger would be responsible for ensuring that they were being completed as well. She stated that it was pertinent for staff to fill the logs out to ensure the refrigerator and freezer were at adequate temperatures to avoid food spoilage that could potentially affect the resident. She stated that eggs needed to be returned to the original container not left out due to sanitation reasons. She stated that when bananas were observed to be overripe, they were to be thrown out. She stated that all zip top bags were to be sealed properly to prevent any cross contamination. She stated that jars and gallon containers were to be wiped down after every use. She stated that all kitchen staff were responsible to ensure everything was stored properly, sealed and labeled and cleaned. She stated that this could potentially cause harm to residents by making them sick.In an interview on 03/31/2026 at 1:32 p.m., with the Dietary Manager revealed the temperature logs were filled out at the start of every shift both in the morning and in the evening by the dietary aids and the cooks. He stated that it was important for the staff to fill the logs out to ensure proper temperature and report any discrepancy in a timely manner. He stated that all containers to include zip top bags were to be closed properly to avoid cross contamination. He stated that the veggies and fruits were to be discarded as soon as they were visibly damaged or rotting. He stated that was done to prevent residents from being served food that could possibly make them sick. He stated that all jars and gallon containers were to be cleaned after each use to prevent cross contamination. He stated that whole eggs were to be stored in a container, sealed, labeled with what the food was and dated with the open date He stated that all kitchen staff were responsible for ensuring all containers were clean, labeled with what the food was and dated with the open date and closed properly.In an interview on 03/31/2026 at 3:55 p.m., with the Administrator revealed, temperature logs were to be filled out daily, the kitchen staff were responsible for filling them out and the Dietary Manager was responsible for oversight. She stated that eggs were to be covered, labeled and dated. She stated that ripened bananas could be placed in the refrigerator and used to make banana bread. She stated that jars and gallon containers were to be cleaned after use. She stated that zip top bags were to be completely sealed to prevent cross contamination. She stated that depending on how the food was handled there was no risk of harm to the residents.Review of facility policy titled Food Storage and Supplies dated 2012 revealed in part 4. open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.Review of facility policy titled Dietary Food Service Personnel Policy and Procedure dated 2012 revealed in part .11. All unused food must be securely covered. All items are to be dated and labeled as to their content. Store items in their original container unless instructed otherwise.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 11 residents (Residents #16) reviewed for Neglect. The facility failed to immediately implement protective measures on 03/03/25 when the charge nurse reported to the DON concerns related to Resident #6 not receiving anticonvulsant medication according to the physician's order. The facility proceeded to allow the doses to be missed during the weekend of 3/08/25-03/09/25 without interventions/protections during that time. An Immediate Jeopardy (IJ) situation was identified on 05/18/25. While the IJ was removed on 05/20/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm , due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for further abuse and neglect. Findings include: Record Review of Resident #16's face sheet dated 05/15/25 revealed resident was a [AGE] year-old female with admission date 05/14/2024. Record Review of Resident #16's annual history and physical dated 05/16/25 revealed Resident #16 was non-verbal and was prescribed Levetiracetam 100mg/ml solution 7.5ml by mouth twice a day for seizures. Record Review of Resident #16's annual MDS dated [DATE] revealed there was no BIMS score due to resident's inability to answer questions. Resident #16 had the following diagnoses noted: Unspecified Dementia (A group of symptoms affecting memory, thinking, and social abilities), Dysphagia (difficulty swallowing), seizure disorder (abnormal electrical activity in your brain which causes changes in awareness and muscle control), Unspecified intellectual disabilities, Down Syndrome, and anxiety disorder. Record Review of Resident #16's care plan with initiation date 05/15/25 revealed the resident had a Seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Review of Physician's Telephone Order dated 01/30/25 revealed: Levetiracetam (Keppra) 500 mg tablet give 1 tablet by mouth two times a day for Seizure Disorder. Discontinued Date: 01/30/25. Reason for Discontinue: Changed to liquid format due to medication instructions not to crush. Keppra Oral Solution 100 mg/ml give 5 ml by mouth two times for seizures. Review of Physician's Telephone Order dated 03/03/25 revealed Order Summary: Keppra Oral Solution 100 mg/ml give 7.5 ml by mouth two times for seizures. Review of Lab report dated 02/24/25 revealed Levetiracetam (Keppra) level was Low 2.50 (Reference Range 6.00 - 46.00 ug/ml) Review of Resident #16's electronic medication administration record revealed Levetiracetam oral solution 100mg/ml, 7.5ml by mouth two times a day related to seizures was marked as administered by Medication Aide A on Saturday 03/08/25 at 08:00AM and 08:00 PM, and Sunday 03/09/25 at 08:00 AM. Review of electronic medication administration records revealed Medication Aide B marked Levetiracetam (oral solution 100mg/ml, 7.5ml by mouth two times a day related to seizures) as administered on Sunday 03/09/25 at 08:00 PM. Review of Event Nurses Note dated 05/15/25 written by the DON revealed Resident #16 medication was not administered as prescribed resulting in a seizure, no injuries. Event Nurses Note revealed physician was notified 03/10/25 at 08:41 AM. Review of the undated Employee Time Entry Report with no date revealed Medication Aide A worked Saturday 03/08/2025 from 6:38 AM to 10:06 PM, and Sunday 03/08/25 from 6:42 AM to 2:34 PM. Review of Employee Time Entry Report dated 05/20/25 revealed Medication Aide B worked Sunday 03/09/25 from 2:08 PM to 10:04 PM. Review of facility Progress Notes dated 05/19/25 revealed Nurse Practitioner reviewed Levetiracetam labs on 03/03/25 and results were low at 2.50, new orders added to increase Levetiracetam to 7.5ml twice a day. Review of nursing progress notes dated 03/10/25 at 09:00 AM revealed LVN C documented a CNA notified him of Resident #16 having spasms while eating breakfast. LVN C documented he monitored Resident #16 and she started having seizure like movements. LVN C documented Resident #16 had abnormal breathing, oxygen decreased, placed on supplemental oxygen 2 L (liters) NC (Nasal Cannula, a medical device used to deliver supplemental oxygen directly into the nostrils, helping individuals with respiratory issues breathe more easily) . Seizure lasted 1 minute 38 seconds. Review of Medication Error Form dated 03/10/25 completed by the DON revealed, Date of Occurrence: 03/10/25 at 8:00 AM, Type of Incident: Medication not administered as ordered. Description of Incident: Medication not given over the weekend. Physician Order: Keppra level. No medication changes. Interview on 05/15/25 at 03:20 PM with LVN C revealed that he had notified the physician on Monday 03/10/25 to report that Resident #16 had not been administered 4 doses of the Keppra, and the physician had come to assess the resident on that day at 9:20 a.m. Interview on 05/15/25 at 04:04 PM with the DON revealed LVN C had reported to her on 03/03/25 that he suspected the weekend Medication Aide A was not administering the Keppra to Resident #16 as ordered because the Keppra level was low. The DON stated that she told LVN C on that day that she needed to have concrete evidence to show that the resident was not getting Keppra as ordered. So, she instructed LVN C on 03/07/25 to take a picture of the Keppra's liquid medication bottle after the night dose was administered, and that they would check the level of medication in the on Monday morning 03/10/25, to determine if the Keppra had been administered on the weekend by Medication Aide A according to physician's orders. The DON stated that she had not reported this allegation to the Administrator and had not immediately initiated an investigation to determine if the Resident #16 was being administered the Keppra as ordered and had not initiated any interventions until 03/12/25 when she initiated the anticonvulsive medication audits to determine if medications were being administered according to physician's orders. In a telephone interview on 05/15/25 at 5:23 PM with the Nurse Practitioner, she stated the facility investigated and confirmed Resident #16's seizure medication was not administered over the weekend of 03/08/25-03/09/25, as ordered. She stated Keppra labs were completed 03/11/25, the day after the resident's seizure, and the result values were within normal limits. She stated Resident #16 missing the 4 doses could be a possible reason the resident had a seizure. The Nurse Practitioner stated the Keppra Medication was not to be stopped abruptly and would need to be tapered off to prevent adverse reactions such as seizures. In a telephone interview on 05/15/25 at 05:48 PM with the Primary Physician, she stated Resident #16 was at increased risk for seizures from missing 4 Levetiracetam medication doses. She stated she was unable to call post Keppra lab values, but a patient could still experience seizures even with normal Keppra lab values. Interview on 05/16/25 at 03:52PM with the Administrator revealed he was the Abuse Coordinator. He stated he was notified by the DON reported the allegation of medication not being administered as ordered and it was an allegation of neglect. He stated he did not report it to HHSC, and he was not able to provide a reason why he did not call. Second interview on 05/18/25 with LVN C assigned to Resident #16 reported that on 03/10/25, Resident #16 was having shaking of her extremities, became unresponsive for a few seconds, eyes rolled back, muscle jerking, and oxygen dropped to 87%. She stated this last for 1 min and 38 seconds. In a telephone interview on 05/18/25 at 1:45 PM with Medication Aide B, he stated he recalled working Sunday afternoon shift on 03/09/25. He stated he did not administer Levetiracetam since it was liquid form which was kept in a different drawer of the medication cart. He stated he did not pull the bottle out of the drawer. He stated he recalled signing the MAR Levetiracetam as administered though he did not. He stated he was trained to pull out medications, compare labels to MAR, including name of resident, name of medication, dosage and frequency. He stated he did not pull-out medication of the drawer and did not administer it that day. He stated he forgot to administer it since it was in a different drawer. In a telephone interview on 05/18/25 at 02:30 PM with Medication Aide A, she stated she recalled not administering the Keppra medication the weekend of 03/08/25 for the 08:00 AM and 08:00 PM doses, and 03/09/25 for the 08:00 AM because she was helping answer a call light. She stated she intended to go back to administer the Keppra medication, but she forgot after helping answer the call light. She stated it was an honest mistake. She stated she had been previously counseled for not administering saline eye drops in 11/2024 though she documented she had on the electronic medication administration record. She stated she was trained to administer medications as ordered. Review of the facility's policy titled Abuse/Neglect revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse and situations that may constitute abuse or neglect to any facility. Definitions: Neglect: Is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention.: The facility will provide the residents, families, and staff an environment free from abuse and neglect. All reports of abuse or suspicion of abuse/neglect will be investigated as per facility protocol. The facility will be responsible to identify, correct and intervene in situations of possible abuse/neglect. Protection.: The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents, or misappropriation of a resident's property. This was determined to be an Immediate Jeopardy (IJ) on 05/18/2025 at 5:11 p.m. The Administrator was notified and requested a POR within one hour. The Administrator was provided with the IJ template on 05/18/2025 at 5:24 p.m. The following Plan of Removal submitted by the facility was accepted on 5/19/2025 at 5:00 p.m.: Interventions: -The alleged perpetrator Medication Aide A was terminated on 03/12/2025 . -Medication Aide B was counselled on 03/10/25 for not administering Keppra as ordered 03/09/25 at 8:00 PM. -On 3/24/25, 03/12/25, 03/17/25, 03/24/25 medication pass observation/evaluation was completed with Medication Aide B by the DON to verify that he was administering medications according to doctors' orders and no concerns were identified during the med pass observation . -The administrator reported on 05/15/25 to HHS an allegation of neglect related to failure to administer anticonvulsant medications as ordered. -Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan. Completed 5/16/2025 -On 05/16/25, the ADONS conducted a random count of all anticonvulsant medications to ensure that medications were being administered according to doctors' orders. The ADONS continue to conduct random checks of the anticonvulsant medications to ensure that medications are administered according to doctor's orders. The Administrator and Regional Compliance Nurse will randomly check that the ADONS are completing the random checks to ensure that medications are administered according to doctors' orders. -The DON completed a medication error report on 03/10/25 for the 4 Keppra Doses that were not administered on 03/08/25 and 03/09/25 by the medication aids. The medication error report was reviewed and signed by the attending physician on 03/12/25. -Audit of Anticonvulsant therapeutic labs conducted between 04/17/25 and 04/21/25 by ADON. No concerns were identified. The ADONs will continue to conduct random anticonvulsant therapeutic audits to ensure that labs have been completed according to doctors' orders and any abnormal levels are immediately reported to the physician. -Random medication pass observations were completed on 05/02/25, 05/15/25 and 05/17/25 by ADONs . No concerns were identified. -Regional compliance nurse will randomly check on a weekly basis that the ADONs/DON are conducting random medication pass observations to ensure that medications are administered according to doctors order. In-services: -All Licensed Nurses and Medication Aides by the DON, ADON and Regional Compliance Nurse. o Medication administration Policy. Completed on 3/12/2025 and 5/16/2025 o Following Physicians' orders. Completed on 5/16/2025 o Following the notification of physician when resident has a change in status: 5/16/2025 o Anticonvulsant medication count. Completed on 5/16/2025 o Ensure that therapeutic levels are drawn as ordered. Completed on 5/16/2025 -One to one in service for Administrator and DON on following policies and procedures to prevent abuse and neglect: Time frame of 2-24hrs: Completed by ADO on 5/16/2025 at 7:44pm -New Direct Care staff are to be in-serviced during the facility orientation. No staff will be allowed to take a shift until in-service education is completed. Monitoring of the facility's plan of removal included the following: Record review of Medication Aide A's discharge documentation for date of infractions noted 03/08/25-03/09/25, and Medication Aide A failed to administer Keppra to prevent seizures and falsely documented it on 03/08 and 03/09, 2nd offense termination requested. Document signed by the Administrator and the DON, dated 03/10/25. Record review of Medication Aide B's counseling document dated 03/10/25 for failed to adhere to corporate code of conduct and job duties. It noted Medication Aide B failed to administer to administer medication and falsified documentation stated that medication was given on days 03/08/25 and 03/09/25. Record review of medication pass observations completed by the DON while observing Medication Aide B 3/24/25, 03/12/25, 03/17/25, 03/24/25, to verify that he was administering medications according to doctors' orders and no concerns were identified during the med pass observation . Record review of anticonvulsant medication's were accounted of by ADONs dated 05/16/25. No issues noted. Record review of medication pass of various staff by the ADON's dated 05/02/25, 05/15/25, and 05/17/25. During an interview on 05/20/2025 at 9:57 am with LVN C revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation (ANE) immediately to facility administrator as he was Abuse Coordinator. He stated that the abuse coordinator contact information was posted outside of the human resourses office and at the front desk when entering the building. LVN C stated that if the Abuse Coordinator was not available, he would notify DON immediately. He stated that not administering medications to residents as per doctors' orders was considered neglect and would report it to the Abuse Coordinator and DON immediately. He stated that nurses could confirm if medications were being administered by med aides by looking at the count sheet and by reviewing the MAR. During an interview on 05/20/25 at 10:00 AM with Resident # 45, he stated he liked living at the facility and said staff treated him with respect and dignity. Resident # 45 said he always got his medications supervised every day and had not had issues with running out of medications. An interview on 05/20/25 at 10:00 AM with LVN AA revealed she was aware of the Abuse coordinator who was the Administrator. She stated she was trained to report allegations of ANE immediately to the Abuse Coordinator. She stated there was an orange sign with the Abuse Coordinator's contact information that was in the front office and in front of Human Resources. LVN AA stated if the Abuse Coordinator was not available, she would notify the DON of allegations immediately. She stated there was a new policy for only nurses to administer anticonvulsants as ordered. She stated not administering medications as ordered would be considered neglect and she would report that concern or allegation to the Abuse Coordinator immediately. An interview on 05/20/2025 at 10:06 AM with Med Aide R revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. She stated that his contact information was posted outside of the human resourses office and at the front desk when entering the building. Med Aide R stated that if the Abuse Coordinator was not available, she would notify DON immediately. She stated that not administering medications to residents as per doctors' orders was considered neglect and would report it to the Abuse Coordinator and DON. During an Interview on 05/20/2025 at 10:07 AM with CNA O revealed the facility provided training on 5/19/25 on how to report Abuse Neglect and Exploitation. She stated she would contact the abuse prohibition coordinator immediately if she suspected ANE and knew to find his phone number and contact information in the lobby. CNA O said in case that she was not able to contact the abuse prohibition coordinator, she would report it to the DON, ADON or call the state number and report it. She said the nurses were responsible for administering anticonvulsants. During an interview on 05/20/2025 at 10:11AM with RN S revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. He stated that the abuse coordinator contact information was posted outside of the human resourses office and at the front desk when entering the building. LVN S stated that if the Abuse Coordinator was not available, he would notify DON immediately. He stated that not administering medications to residents as per doctors' orders was considered neglect and he would report it to the Abuse Coordinator and DON. He stated that nurses could confirm if medications were being administered by med aides by looking at the count sheet and by reviewing the MAR. He stated that if medaids' have questions they knew to come to him and ask for clarification. During an Interview on 05/20/2025 at 10:16 AM with CNA J revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. She stated that his contact information was posted outside of the human resourses office and at the front desk when entering the building. CNA J stated that if the Abuse Coordinator was not available, she would notify DON immediately. During an interview on 05/20/25 at 10:24 AM with Med Aide G revealed she was trained on 5/19/25 on how to immediately report ANE to the abuse coordinator, DON, ADON or the state. She said the contact information was available for all staff and residents in the hallways of the facility as well as in the lobby. Med Aide G stated only nurses were able to supervise anticonvulsant medications. During an interview on 05/20/25 at 10:27 AM with ADON K revealed the facility provided training on reporting allegations of Abuse, Neglect, and Exploitation immediately to the Abuse Coordinator, who was the Administrator. She stated if the Abuse Coordinator was not at the facility, she would be able to obtain his phone number located outside the Human Resources office or by the front desk. She stated if he were not available, the next person to notify was the DON immediately. ADON K stated nurses were responsible for administering medications as ordered. She stated nurses could confirm medications were administered as ordered by confirming with the MAR and the count sheet. She stated medications that were not administered as ordered was neglect and it was to be reported to the physician, DON, and the Abuse Coordinator. During an interview on 05/20/25 at 10:28 AM with LVN N revealed she had been in-serviced on 5/19/25 about ANE and how to report it. She stated she had to immediately report it to the abuse coordinator and if he was not in the facility she had to immediately report to the DON, ADON or call the state. She said only nurses were able to supervise anticonvulsant medications. During an interview on 5/20/25 at 10:31 AM with Med Aide T revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. She stated that his contact information was posted outside of the human resourses office and at the front desk when entering the building. Med Aide T stated that if the Abuse Coordinator was not available, she would notify DON immediately. She stated that not administering medications to residents as per doctors' orders was considered neglect and would report it to the Abuse Coordinator and DON. During an interview on 05/20/2025 at 10:38 AM with CNA E revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. He stated that his contact information was posted outside of the human recourses office and at the front desk when entering the building. CNA E stated that if the Abuse Coordinator was not available, He would notify DON immediately. During an interview on 05/20/25 at 10:45 AM with the DON revealed the Regional Compliance Nurse and the ADON's would monitor medication administration weekly to ensure it was administered as ordered. She stated the ADON's would be doing random medication passes with Medication Aides. She stated she received in-service training in reporting Abuse, Neglect, and Exploitation within a 2-24-hour timeframe to the Abuse Coordinator. She stated she was aware that the Abuse Coordinator's contact information was located by the Human Resources office and the front desk. She stated if he was not available, she would be responsible for reporting it to HHSC and initiate an investigation. During an interview on 05/20/25 at 10:51 AM with LVN I revealed she had been trained on 05/19/25 and 05/20/25 on how to report ANE. She stated she had to report it immediately to the abuse prohibition coordinator and if he was not available, she would immediately report it to the DON and ADON. She said the contact information for reporting could be found in the hallways of the facility and in the lobby or front entrance. She stated only nurses were able to administer anticonvulsant medications. During an interview on 05/20/25 at 10:56 AM with Med Aide U revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. She stated that his contact information was posted outside of the human resourses office and at the front desk when entering the building. Med Aide T stated that if the Abuse Coordinator was not available, she would notify DON immediately. She stated that not administering medications to residents as per doctors' orders was considered neglect and would report it to the Abuse Coordinator and DON. During an interview on 05/20/25 at 10:58 AM with CNA Q revealed she had been in-serviced on how to immediately report ANE either to the state number or to the abuse prohibition coordinator and to the DON and ADON if she was not able to communicate with the administrator. CNA Q said she could find the contact information for the state and the abuse coordinator in the hallways from the facility and in the lobby at the front entrance. CNA Q said only nurses were able to supervise anticonvulsant medications and that she had been in-serviced on the administration of that medication in the last training provided on 5/19/25. During an interview on 05/20/25 at 11:04 AM with CNA V revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. She stated that his contact information was posted outside of the human resourses office and at the front desk when entering the building. CNA V stated that if the Abuse Coordinator was not available, she would notify DON immediately. During a telephone interview at 05/20/25 at 11:21 AM with LVN BB revealed he was trained for reporting allegations of Abuse, Neglect, and Exploitation immediately to the Abuse Coordinator. He stated the Abuse Coordinator was the Administrator and his contact information was located outside the Human Resources office and by the front desk. He stated that if the Abuse Coordinator was not available, he would report it to the DON immediately. He stated if staff were to intentionally not administer medication as ordered but documented on the electronic medication administration record as administered, that was Neglect and to be reported to the Abuse Coordinator immediately. Record review of the facility's document titled In-Service Training Attendance Roster, dated 05/16/25 In-Service Training Topic: Abuse, Neglect, and Exploitation. Record review of the facility's document titled In-Service Training Attendance Roster, dated 5/16/2025 In-Service Training Topic: Medication Administration Policy. Record review of facility's Nursing Policy and Procedure Manual, with no date, titled Abuse/Neglect, read in part: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions: Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The Administrator was informed that the IJ was removed on 05/20/2025 at 12:30 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident # 16) of 6 residents reviewed for pharmacy services. The facility failed to administer Resident #16's Levetiracetam 100 mg/ml 7.5 ml by mouth two times on 03/08/25 at 8:00 a.m. and 8:00 p.m. and two times on 03/09/25 at 8:00 a.m. and at 8:00 p.m. according to physician orders. An Immediate Jeopardy (IJ) was identified on 05/18/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a severity level of actual harm not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. This failure placed residents on anticonvulsant medications at risk for harm, or neglect. The findings included: Record Review of Resident #16's face sheet dated 05/15/25 revealed resident was a [AGE] year-old female with admission date 05/14/2024. Record Review of Resident #16's annual history and physical dated 05/16/25 revealed Resident #16 was non-verbal and was prescribed Levetiracetam 100mg/ml solution 7.5ml by mouth twice a day for seizures. Record Review of Resident #16's annual MDS dated [DATE] revealed there was no BIMS score due to resident's inability to answer questions. Resident #16 had the following diagnoses noted: Unspecified Dementia (A group of symptoms affecting memory, thinking, and social abilities), Dysphagia (difficulty swallowing), seizure disorder (abnormal electrical activity in your brain which causes changes in awareness and muscle control), Unspecified intellectual disabilities, Down Syndrome, and anxiety disorder. Record Review of Resident #16's care plan with initiation date 05/15/25 revealed the resident had a Seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Review of Physician's Telephone Order dated 01/30/25 revealed Order Summary: Levetiracetam (Keppra) 500 mg tablet give 1 tablet by mouth two times a day for Seizure Disorder. Discontinue Date: 01/30/25. Reason for Discontinue: Changed to liquid format due to medication instructions not to crush. Keppra Oral Solution 100 mg/ml give 5 ml by mouth two times for seizures. Review of Lab report dated 02/24/25 revealed Levetiracetam (Keppra) level was Low 2.50 (Reference Range 6.00 - 46.00 ug/ml) Review of Physician's Telephone Order dated 03/03/25 revealed Order Summary: Keppra Oral Solution 100 mg/ml give 7.5 ml by mouth two times for seizures. Review of Resident #16's electronic medication administration record revealed Levetiracetam oral solution 100mg/ml, 7.5ml by mouth two times a day related to seizures was marked as administered by Medication Aide A on Saturday 03/08/25 at 08:00AM and 08:00 PM, and Sunday 03/09/25 at 08:00 AM. Review of electronic medication administration records revealed Medication Aide B marked Levetiracetam oral solution 100mg/ml, 7.5ml by mouth two times a day related to seizures as administered on Sunday 03/09/25 at 08:00 PM. Review of Event Nurses Note dated 05/15/25 written by the DON revealed resident #16 medication was not administered as prescribed resulting in a seizure, no injuries. Event Nurses Note revealed physician was notified 03/10/25 at 08:41 AM. Review of Employee Time Entry Report with no date revealed Medication Aide A worked Saturday 03/08/2025 from 6:38 AM to 10:06 PM, and Sunday 03/08/25 from 6:42 AM to 2:34 PM. Review of Employee Time Entry Report dated 05/20/25 revealed Medication Aide B worked Sunday 03/09/25 from 2:08 PM to 10:04 PM. Record review of anticonvulsant monitoring forms dated 03/12/25, 03/14/25, 03/17/25, and 03/24/25 for 7 of 7 residents on anticonvulsants. Interview on 05/15/25 at 04:04PM with the DON revealed, on 03/03/25, LVN C reported he suspected Medication Aide A was not administering Levetiracetam, anticonvulsant medication that generally treats seizures, as ordered for Resident #16. She stated she reconciled medications that week of Monday 03/03/25 to Friday 03/07/25 and found no discrepancies. She stated she instructed LVN C to take a picture of Resident #16's levetiracetam medication bottle friday 03/07/25 to compare the amount on Monday 03/10/25. She stated the amount of the medication was unchanged from both days. She stated two medication aides, Medication Aide A and Medication Aide B, did not administer the medication as ordered. In an interview on 05/15/25 at 6:02 PM with LVN C, he stated he was instructed by the DON to take pictures of Resident #16's medication bottle Friday 03/07/25 and compare the amount on Monday 03/10/25. He stated there were no other instructions instructed by the DON at that time. Interview on 05/16/25 at 03:52PM with Administrator revealed he was the Abuse Coordinator, and he was to report and initiate an investigation into the allegation of neglect. He stated the DON informed him of the suspicion that the Medication Aide A was not administering Resident #16's medication as ordered before the weekend of Saturday 03/08/25 and Sunday 03/09/25 but could not recall the exact date he was informed by the DON. He said that he was aware that a picture was going to be taken, and the DON and Charge were going to check the level of medication on Monday 03/10/25. He stated that he did not recall if the DON had mentioned to him what action was going to protect the residents until they had evidence to prove that the medication was not being administered as ordered. In a telephone interview on 05/18/25 at 1:45 PM with Medication Aide B, he stated he recalled working Sunday afternoon shift on 03/09/25. He stated he did not administer Levetiracetam since it was liquid form which was kept in a different drawer of the medication cart. He stated he did not pull the bottle out of the drawer. He stated he recalled signing the MAR Levetiracetam as administered though he did not. He stated he was trained to pull out medications, compare labels to MAR, including name of resident, name of medication, dosage and frequency. He stated he did not pull-out medication of the drawer and did not administer it that day. In a telephone interview on 05/18/25 at 02:30 PM with Medication Aide A, she stated she recalled not administering the Keppra medication the weekend of 03/08/25 for the 08:00 AM and 08:00 PM doses, and 03/09/25 for the 08:00 AM because she was helping answer a call light. She stated she intended to go back to administer the Keppra medication, but she forgot after helping answer the call light. She stated it was an honest mistake. She stated she had been previously counseled for not administering saline eye drops in 11/2024 though she documented she had on the electronic medication administration record. She stated she was trained to administer medications as ordered. During a telephone interview on 05/18/25 at 4:44 PM with LVN C, it was revealed he observed Resident #16 during her seizure on 03/10/25. He stated he observed resident #16 shaking her extremities, resident #16 had her eyes rolled back, and that was observed for 1 minute and 38 seconds. LVN C stated Resident #16's arms were observed jerking but was not rigid. LVN C stated Resident #16's oxygen was monitored and dropped to a level 87% on room air until staff administered oxygen supplementation via nasal cannula. He stated he observed Resident #16 with a blank stare and observed unconsciousness. This was determined to be an Immediate Jeopardy (IJ) on 05/18/2025 at 5:11 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/18/2025 at 5:24 p.m. The following Plan of Removal submitted by the facility was accepted on 5/19/2025 at 5:00 p.m.: Interventions: The alleged perpetrator was terminated on. Completed on 5/12/2025. Self-report was completed to HHS by the administrator. Completed on 5/16/2025 Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan. Completed 5/16/2025 Implemented daily count of all anticonvulsant medications to ensure doses are not missed, completion date 05/16/25 Medication error completed for the missed doses on affected resident, completed 03/10/25. Pharmacy Consultant notified. [NAME] notified 05/16/25 by regional nurse. Clarification order obtained from the attending Physician on 05/16/25. Anticonvulsant monitoring from 03/12/25 to 03/24/25 was conducted by the DON, no medication errors identified during that time frame. Medication Pass Evaluation for Med Aid B by the DON and designee on 03/12/25, 03/17/25, 03/24/25. Audit of Anticonvulsant therapeutic labs conducted between 04/17/25 and 04/21/25 by ADON. Med Passes conducted with licensed staff on 05/02/25, 05/15/25 and 05/17/25 by ADON and RN. DON or designee began daily EMAR monitoring on 05/17/25. DON or designee began anticonvulsant In-services: All new staff will be in-serviced during the facility orientation. No staff will be allowed to take a shift until in-service education is completed. The following in-services were initiated by the DON, ADON and regional nurse Completed on 05/16/25 Licensed Nurses and Medication Aides Medication administration Following Physicians orders. Anticonvulsant medication count Ensure that therapeutic levels are drawn as ordered. One to one in service for Administrator and DON on following policies and procedures to prevent abuse and neglect. Completed by ADO on 5/16/2025 @ 7:44pm Monitoring of the facility's plan of removal included the following: During an interview on 05/20/2025 at 9:57 am with LVN C, he stated that not administering medications to residents as per doctors' orders was considered neglect and would report it to the Abuse Coordinator and DON immediately. He stated that nurses could confirm if medications were being administered by med aides by looking at the count sheet and by reviewing the MAR. During an interview on 05/20/25 at 10:00 AM with Resident # 45, he stated he liked living at the facility and said staff treated him with respect and dignity. Resident # 45 said he always got his medications supervised every day and had not had issues with running out of medications. During an interview on 05/20/25 at 10:00 AM with LVN AA revealed she was aware of the Abuse coordinator who was the Administrator. She stated there was a new policy for only nurses to administer anticonvulsants as ordered. She stated not administering medications as ordered would be considered neglect and she would report that concern or allegation to the Abuse Coordinator immediately. During an interview on 05/20/2025 at 10:11AM with RN S revealed that the facility provided training on not administering medications to residents as per doctors' orders was considered neglect and would report it to the Abuse Coordinator and DON. He stated that nurses could confirm if medications were being administered by med aides by looking at the count sheet and by reviewing the MAR. He stated that if medaids' have questions they knew to come to him and ask for clarification. During an interview on 05/20/25 at 10:27 AM with ADON K revealed the facility provided training on reporting allegations of Abuse, Neglect, and Exploitation immediately to the Abuse Coordinator, who was the Administrator. She stated if the Abuse Coordinator was not at the facility, she would be able to obtain his phone number located outside the Human Resources office or by the front desk. She stated if he were not available, the next person to notify was the DON immediately. ADON K stated nurses were responsible for administering medications as ordered. She stated nurses could confirm medications were administered as ordered by confirming with the MAR and the count sheet. She stated medications that were not administered as ordered was neglect and it was to be reported to the physician, DON, and the Abuse Coordinator. During an interview on 05/20/25 at 10:45 AM with the DON stated the Regional Compliance Nurse and the ADON's would monitor medication administration weekly to ensure it was administered as ordered. ADON's will be doing random medication passes with Medication Aides. She stated she received in-service training in reporting Abuse, Neglect, and Exploitation within a 2-24-hour timeframe to the Abuse Coordinator. She stated she was aware that the Abuse Coordinator's contact information was located by the Human Resources office and the front desk. She stated if he was not available, she would be responsible for reporting it to HHSC and initiate an investigation. During an interview on 05/20/25 at 10:47 AM with CNA P revealed she had been trained in how to report ANE on 5/19/25. She stated she would report it to the abuse prohibition coordinator or the administrator. CNA P said she could find his contact information in the lobby of the facility and in the room where the staff clocked in. She said if she was not able to communicate with the administrator, she would report to the DON or ADON and also call the state. CNA P said suspicions of ANE had to be reported immediately. She stated that regarding anticonvulsant medications, only the nurses were able to supervise them. During an interview on 05/20/25 at 10:51 AM with LVN I revealed she had been trained on 5/19/25 and in 5/20/25 on how to report ANE. She stated she had to report it immediately to the abuse prohibition coordinator and if he was not available, she would immediately report it to the DON and ADON. She said the contact information for reporting could be found in the hallways of the facility and in the lobby or front entrance. She stated only nurses were able to administer anticonvulsant medications. During an interview on 05/20/25 at 10:56 AM with med aid U revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. She stated that his contact information was posted outside of the human recourses office and at the front desk when entering the building. Med Aide T stated that if the Abuse Coordinator was not available, she would notify DON immediately. She stated that not administering medications to residents as per doctors' orders was considered neglect and would report it to the Abuse Coordinator and DON. During an interview on 05/20/25 at 10:58 AM with CNA Q revealed she had been in-serviced on how to immediately report ANE either to the state number or to the abuse prohibition coordinator and to the DON and ADON if she was not able to communicate with the administrator. CNA Q said she could find the contact information for the state and the abuse coordinator in the hallways from the facility and in the lobby at the front entrance. CNA Q said only nurses were able to supervise anticonvulsant medications and that she had been in-serviced on the administration of that medication in the last training provided on 5/19/25. During an interview on 05/20/25 at 11:04 AM with CNA V revealed that the facility provided training on reporting allegations of Abuse, Neglect and Exploitation immediately to facility administrator as he was Abuse Coordinator. She stated that his contact information was posted outside of the human recourses office and at the front desk when entering the building. CNA V stated that if the Abuse Coordinator was not available, She would notify DON immediately. During a telephone interview at 05/20/25 at 11:21 AM with LVN BB revealed he was trained to report allegations of Abuse, Neglect, and Exploitation immediately to the Abuse Coordinator. He stated the Abuse Coordinator was the Administrator and his contact information was located outside the Human Resources office and by the front desk. He stated that if the Abuse Coordinator was not available, he would report it to the DON immediately. He stated if staff were to intentionally not administer medication as ordered but documented on the electronic medication administration record as administered, that was Neglect and to be reported to the Abuse Coordinator immediately Record review of Medication Aide A's discharge documentation for date of infractions noted 03/08/25-03/09/25, and Medication Aide A failed to administer Keppra to prevent seizures and falsely documented it on 03/08 and 03/09, 2nd offense termination requested. Document signed by the Administrator and the DON, dated 03/10/25. Record review of Medication Aide B's counseling document dated 03/10/25 for failed to adhere to corporate code of conduct and job duties. It noted Medication Aide B failed to administer to administer medication and falsified documentation stated that medication was given on days 03/08/25 and 03/09/25. Record review of medication pass observations completed by the DON while observing Medication Aide B 3/24/25, 03/12/25, 03/17/25, 03/24/25, to verify that he was administering medications according to doctors' orders and no concerns were identified during the med pass observation . Record review of anticonvulsant medication's were accounted of by ADONs dated 05/16/25. No issues noted. Record review of medication pass of various staff by the ADON's dated 05/02/25, 05/15/25, and 05/17/25. Record review of facility policy Medication Administration and general Guidelines, with no date, read in part: Medications are administered as prescribed, in accordance with State regulations using good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician. The Administrator was informed that the IJ was removed on 05/20/2025 at 12:30 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 11 residents (Residents #16) reviewed for abuse/neglect. - The facility failed to investigate, prevent, correct, and report alleged violations of neglect for Resident #16 when reported by LVN C on 03/03/25. An Immediate Jeopardy (IJ) was identified on 05/18/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a severity level of actual harm not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. These failures could place residents at risk for further abuse, and neglect. Findings include: Record Review of Resident #16's face sheet dated 05/15/25 revealed resident was a [AGE] year-old female with admission date 05/14/2024. Record Review of Resident #16's annual history and physical dated 05/16/25 revealed Resident #16 was non-verbal and was prescribed Levetiracetam 100mg/ml solution 7.5ml by mouth twice a day for seizures. Record Review of Resident #16's annual MDS dated [DATE] revealed there was no BIMS score due to resident's inability to answer questions. Resident #16 had the following diagnoses noted: Unspecified Dementia (A group of symptoms affecting memory, thinking, and social abilities), Dysphagia (difficulty swallowing), seizure disorder (abnormal electrical activity in your brain which causes changes in awareness and muscle control), Unspecified intellectual disabilities, Down Syndrome, and anxiety disorder. Record Review of Resident #16's care plan with initiation date 05/15/25 revealed the resident had a Seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Review of Physician's Telephone Order dated 01/30/25 revealed Order Summary: Levetiracetam (Keppra) 500 mg tablet give 1 tablet by mouth two times a day for Seizure Disorder. Discontinued Date: 01/30/25. Reason for Discontinue: Changed to liquid format due to medication instructions not to crush. Keppra Oral Solution 100 mg/ml give 5 ml by mouth two times for seizures. Review of Lab report dated 02/24/25 revealed Levetiracetam (Keppra) level was Low 2.50 (Reference Range 6.00 - 46.00 ug/ml) Review of Physician's Telephone Order dated 03/03/25 revealed Order Summary: Keppra Oral Solution 100 mg/ml give 7.5 ml by mouth two times for seizures. Record review of anticonvulsant monitoring forms dated 03/12/25, 03/14/25, 03/17/25, and 03/24/25 for 7 of 7 residents on anticonvulsants. Interview on 05/15/25 at 04:04 PM with the DON revealed LVN C, assigned to Resident #16, had reported to her on 03/03/25 that he suspected the weekend Medication Aide A was not administering the Keppra to Resident #16 as ordered because the Keppra level was low. The DON stated that she told LVN C on that day that she needed to have concrete evidence to show that the resident was not getting Keppra as ordered. So, she instructed LVN C on 03/07/25 to take a picture of the Keppra's medication bottle after the night dose was administered, and that they would check the level of medication in the on Monday morning 03/10/25, to determine if the Keppra had been administered on the weekend by Medication Aide A according to physician's orders. The DON stated that she had not reported this allegation to the Administrator and had not immediately initiated an investigation to determine if the Resident #16 was being administered the Keppra as ordered and had initiated any interventions until 03/12/25 when she initiated the anticonvulsive medication audits to determine if medications where being administered according to physician's orders. In an interview on 05/16/25 at 11:32 AM with LVN C, he stated he suspected Medication Aide A was not administering Resident #16's Levetiracetam medication as ordered. He stated he notified the DON that day of his suspicion on Monday 03/03/25. Interview on 05/16/25 at 03:52PM with the Administrator revealed he was the Abuse Coordinator, and he was to report and initiate an investigation into the allegation of neglect. He stated the DON informed him of the suspicion that the Medication Aide A was not administering Resident #16's medication as ordered before the weekend of Saturday 03/08/25 and Sunday 03/09/25, but could not recall the exact date he was informed by the DON. He said that he was aware that a picture was going to be taken , and the DON and Charge were going to check the level of medication on Monday 03/10/25. He stated that he did not recall if the DON had mentioned to him what action was going to protect the residents until they had evidence to prove that the medication was not being administered as ordered. During a telephone interview on 05/18/25 at 4:44 PM with LVN C, it was revealed he observed Resident #16 during her seizure on 03/10/25. He stated he observed resident #16 shaking her extremities, resident #16 had her eyes rolled back, and that was observed for 1 minute and 38 seconds. LVN C stated Resident #16's arms were observed jerking but was not rigid. LVN C stated Resident #16's oxygen was monitored and dropped to a level 87% on room air until staff administered oxygen supplementation via nasal cannula. He stated he observed Resident #16 with a blank stare and observed unconsciousness . During an Interview on 05/20/2025 at 10:07 AM with CNA O revealed the facility provided training on 5/19/25 on how to report Abuse Neglect and Exploitation. She stated she would contact the abuse prohibition coordinator immediately if she suspected ANE and knew to find his phone number and contact information in the lobby. CNA O said in case that she was not able to contact the abuse prohibition coordinator, she would report it to the DON, ADON or call the state number and report. She said the nurses were responsible for administering anticonvulsants. This was determined to be an Immediate Jeopardy (IJ) on 05/18/2025 at 5:11 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/18/2025 at 5:24 p.m. The following Plan of Removal submitted by the facility was accepted on 5/19/2025 at 5:00 p.m.: Interventions: -The alleged perpetrator Medication Aide A was terminated on 5/12/2025. -Medication aide B was counseled on 03/10/25 for not administering Keppra as ordered 03/09/25 at 8:00 PM. -On 3/24/25, 03/12/25, 03/17/25, 03/24/25 medication pass observation/evaluation was completed with Med aide #2 by the DON to verify that he was administering medications according to doctors' orders and no concerns were identified during the med pass observation. -The administrator reported on 05/15/25 to HHS an allegation of neglect related to failure to administer anticonvulsant medications as ordered. -Out of cycle QAPI, this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan. Completed 5/16/2025 -On 05/16/25, the ADONS conducted a random count of all anticonvulsant medications to ensure that medications were being administered according to doctors' orders. The ADONS continue to conduct random checks of the anticonvulsant medications to ensure that medications are administered according to doctor's orders. The Administrator and Regional Compliance Nurse will randomly check that the ADONS are completing the random checks to ensure that medications are administered according to doctors' orders. -The DON completed a medication error report on 03/10/25 for the 4 Keppra Doses that were not administered on 03/08/25 and 03/09/25 by the medication aids. The medication error report was reviewed and signed by the attending physician on 03/12/25. -Random medication pass observations were completed on 05/02/25, 05/15/25 and 05/17/25 by ADONs. No concerns were identified. -The facility administrator and DON will immediately report all allegations of abuse and neglect to HHSC, Regional Compliance Nurse and Area Director of Operations to ensure that all abuse and neglect allegations are immediately investigated to prevent further abuse and neglect. -Regional Compliance Nurse and Area Director of Operations will randomly check during weekly visits that all abuse and neglect allegations are immediately reported to HHS and that an internal investigation was immediately initiated to prevent further abuse and neglect. In-services: 1. All Licensed Nurses and Medication Aides by the DON, ADON and Regional Compliance Nurse. o Medication administration Policy. Completed on 3/12/2025 &5/16/2025 o Following Physicians orders. Completed on 5/16/2025 o Following the notification of physician when resident has a change in status: 5/16/2025 o Anticonvulsant medication count. Completed on 5/16/2025 o Ensure that therapeutic levels are drawn as ordered. Completed on 5/16/2025 2. One to one in service for Administrator and DON on following policies and procedures to prevent abuse and neglect: Time frame of 2-24hrs: Completed by ADO on 5/16/2025 @ 7:44pm which included training on all allegations of abuse and neglect will be immediately reported to the administrator and will thoroughly investigate the allegations to prevent further abuse and neglect while the investigation is in progress and will take appropriate action as a result of the investigation findings. 3. New Direct Care staff are to be in-serviced during the facility orientation. No staff will be allowed to take a shift until in-service education is completed. Monitoring of the facility's plan of removal included the following: During an interview on 05/20/25 at 10:00 AM with LVN AA revealed she was aware of the Abuse coordinator who was the Administrator. She stated she was trained to report allegations of ANE immediately to the Abuse Coordinator. She stated there was an orange sign with the Abuse Coordinator's contact information that was in the front office and in front of Human Resources. LVN AA stated if the Abuse Coordinator was not available, she would notify the DON of allegations immediately. She stated there was a new policy for only nurses to administer anticonvulsants as ordered. She stated not administering medications as ordered would be considered neglect and she would report that concern or allegation to the Abuse Coordinator immediately. During an interview on 05/20/25 at 10:24 AM with Med Aide G revealed she was trained on 5/19/25 on how to immediately report ANE to the abuse coordinator, DON, ADON or the state. She said the contact information was available for all staff and residents in the hallways of the facility as well as in the lobby. Med Aide G stated only nurses were able to supervise anticonvulsant medications. During an interview on 05/20/25 at 10:27 AM with ADON K revealed the facility provided training on reporting allegations of Abuse, Neglect, and Exploitation immediately to the Abuse Coordinator, who was the Administrator. She stated if the Abuse Coordinator was not at the facility, she would be able to obtain his phone number located outside the Human Resources office or by the front desk. She stated if he were not available, the next person to notify was the DON immediately. ADON K stated nurses were responsible for administering medications as ordered. She stated nurses could confirm medications were administered as ordered by confirming with the MAR and the count sheet. She stated medications that were not administered as ordered was neglect and it was to be reported to the physician, DON, and the Abuse Coordinator. During an interview on 05/20/25 at 10:28 AM with LVN N revealed she had been in-serviced on 5/19/25 about ANE and how to report it. She stated she had to immediately report it to the abuse coordinator and if he was not in the facility she had to immediately report to the DON, ADON or call the state. She said only nurses were able to supervise anticonvulsant medications. During an interview on 05/20/25 at 10:45 AM with the DON stated the Regional Compliance Nurse and the ADON's would monitor medication administration weekly to ensure it was administered as ordered. ADON's will be doing random medication passes with Medication Aides. She stated she received in-service training in reporting Abuse, Neglect, and Exploitation within a 2-24-hour timeframe to the Abuse Coordinator. She stated she was aware that the Abuse Coordinator's contact information was located by the Human Resources office and the front desk. She stated if he was not available, she would be responsible for reporting it to HHSC and initiate an investigation. During an interview on 05/20/25 at 10:47 AM with CNA P revealed she had been trained in how to report ANE on 5/19/25. She stated she would report it to the abuse prohibition coordinator or the administrator. CNA P said she could find his contact information in the lobby of the facility and in the room where the staff clocked in. She said if she was not able to communicate with the administrator, she would report to the DON or ADON and also call the state. CNA P said suspicions of ANE had to be reported immediately. She stated that regarding anticonvulsant medications, only the nurses were able to supervise them. During an interview on 05/20/25 at 10:51 AM with LVN I revealed she had been trained on 5/19/25 and in 5/20/25 on how to report ANE. She stated she had to report it immediately to the abuse prohibition coordinator and if he was not available, she would immediately report it to the DON and ADON. She said the contact information for reporting could be found in the hallways of the facility and in the lobby or front entrance. She stated only nurses were able to administer anticonvulsant medications. During an interview on 05/20/25 at 10:58 AM with CNA Q revealed she had been in-serviced on how to immediately report ANE either to the state number or to the abuse prohibition coordinator and to the DON and ADON if she was not able to communicate with the administrator. CNA Q said she could find the contact information for the state and the abuse coordinator in the hallways from the facility and in the lobby at the front entrance. CNA Q said only nurses were able to supervise anticonvulsant medications and that she had been in-serviced on the administration of that medication in the last training provided on 5/19/25. During a telephone interview at 05/20/25 at 11:21 AM with LVN BB revealed he was trained for reporting allegations of Abuse, Neglect, and Exploitation immediately to the Abuse Coordinator. He stated the Abuse Coordinator was the Administrator and his contact information was located outside the Human Resources office and by the front desk. He stated that if the Abuse Coordinator was not available, he would report it to the DON immediately. He stated if staff were to intentionally not administer medication as ordered but documented on the electronic medication administration record as administered, that was Neglect and to be reported to the Abuse Coordinator immediately Record Review of Event Nurses' Notes dated 05/15/25, written by the DON noted Resident #16 was not administered medication as prescribed and had a seizure as a results with no injuries on 03/10/25. Record review of the facility's document titled In-Service Training Attendance Roster, dated 05/16/25 In-Service Training Topic: Abuse, Neglect, and Exploitation. Record review of the facility's document titled In-Service Training Attendance Roster, dated 5/16/2025 In-Service Training Topic: Medication Administration Policy. Record review of Nursing Policy and Procedure Manual, with no date, titled Abuse/Neglect, read in part: C. Prevention: All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The Administrator was informed that the IJ was removed on 05/20/2025 at 12:30 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews, and record reviews, the facility failed to ensure all residents were free from abuse for 1 (Resident #2) of 5 residents reviewed for abuse. On 08/01/24, CNA A was providing Perineal Care (cleaning the private areas of residents) to Resident #2. During the peri-care CNA A was observed being verbally and physically abusive, grunting, rough, and aggressive while turning Resident #2. CNA A was observed aggressively positioning Resident #2's legs and arms and aggressively putting on the brief, and Resident #2's bottoms. The following day 08/02/24 Resident #2 was assessed by the nursing staff revealing a 4 cm (a metric unit for the measurement of length of objects and small distances) by 3 cm left lower leg bruise, 7 cm by 4 cm left leg bruise, and 5 cm by 2 cm inguinal (relating to or situated in the region of the groin) area left side bruise. The noncompliance was identified as past non-compliance. The non-compliance began on 08/01/24 and ended 08/02/24 due to the facility having implemented action that corrected it before the investigation began. This failure could place residents at risk of physical harm and impact their psychosocial well-being in areas such as mental anguish, fear, dehumanization, and humiliation. Findings included: Record review of Resident #2's face sheet dated 09/17/24, revealed, admission on 05/14/24 to the facility. Record review of Resident #2's facility history and physical dated 05/15/24, revealed, a [AGE] year-old female diagnosed with Down Syndrome (a condition in which a person has an extra chromosome or an extra piece of a chromosome), 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 Seizures (a burst of uncontrolled electrical activity between brain cells). Record review of Resident #2's admission MDS dated [DATE], revealed, there was not BIMS score taken to identify Resident #2's cognition to be able to recall or make daily decisions. Resident #2 was dependent (nursing staff does all the work) for toileting and lower dressing. Resident #2 was substantial/maximal assistance (nursing staff does more then half the effort) for rolling to the left or right while being on the bed. Resident #2 was frequently incontinent. Record review of Resident #2's care plan dated 05/14/24, revealed the following care areas: *Bladder incontinence - monitor/document/report change in behavior. *Bowel incontinence - see care plans on mobility, ADLs, Cognitive Deficit, Communication. *Impaired Cognitive function/dementia - monitor/document/report changes in cognitive functions, decision making ability, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. *ADLs for bed mobility - one staff assistance, for toileting was one staff assistance, and dressing was one staff assistance. Record review of Resident #2's Care plan dated 06/11/24 revealed the resident had the potential to demonstrate physical behaviors and poor impulse control. Interventions were to notify the charge nurse of any physically abusive behavior, when agitated engage calmy in conversation, staff to walk calmy away and approach later. Record review of Resident #2's progress notes by LVN B dated 08/01/24, revealed, Full head to toe assessment done with assistance of CMA. Resident #2 cooperative with assessment. No injuries noted at time of assessment and no pain or discomfort. Resident #2 appears to be stable and in a calm affect. Record review of Resident #2's progress notes by LVN I dated 08/02/24, revealed, It was notified to DON that Resident #2 was found with some bruises. Checked on Resident #2 and found the following bruises: 4cm by 3cm left lower leg bruise, 7cm by 4cm left lower leg bruise, 5cm by 2cm inguinal area left side bruise. Resident #2 denied pain upon touching on the site. Color for all of them was purple. Record review of Resident #2's Progress note by SW dated 08/02/24, revealed, she checked on Resident #2 after the incident and was not in any emotional distress. Record review of Resident #2's Event Note by LVN B dated 08/02/24, revealed, Resident #2 had a cognitive impairment. The Family member reported to LVN B CNA A last night had been really rough with Resident #2. The Family member showed LVN B and then LVN B reported the situation to the DON. Assessed Resident #2 for injuries with CMA. No injuries noted at time of assessment. Record review of Resident #2's police report dated 08/02/24, revealed, Officer C and Officer D were dispatched to the facility in reference to an assault information call. Officers met with DON who advised that one of the nurses (CNA A) for the facility had been seen on video being Rough with one of the residents. DON advised she wanted the incident documented as they had to report it to the Health and Human Services Commission. Photograph were taken of Resident #2 and upload to the case. Record review of the EPPD Detective e-mail dated 09/23/24, revealed, The Officers asked how long CNA A had worked at the facility to which the DON stated for 6 years and there had been no other complaints. The officers asked the DON what happens in the event of a similar situation. The DON advised that the employee was placed on leave pending a further investigation, but due to the videos in this situation, they were able to immediately terminate CNA A. The Officers watched both surveillance videos and observed CNA A using force with Resident #2 in an attempt to change her diaper. In one of the videos CNA A was heard calling Resident #2 an Ingrata which translates to Ungrateful. Officers attempted to speak with Resident #2 but was non-verbal. Photos were taken and all three videos. Officer C observed that Resident #2 had two bruises to the left leg, which are also consistent with Resident #2 striking her leg with her right leg trying to cross her legs. Officer D spoke with family member who did not wish to prosecute. Family member did not wish for any relation to be taken against Resident #2 due to charges being pressed and was satisfied with the action the Administration had taken with CNA A. Record review of the Video Recordings 210139 dated 08/01/24 provided by the DON not time stamped revealed the following: CNA A was in Resident #2's room with the curtain closed. CNA A was trying to put on Resident #2's bottoms. Noises are heard as the CNA A turned Resident #2 towards her. CNA A aggressively pushed Resident #2s left leg down with her right hand and placed her right hand on Resident #2's left knee turning it towards her aggressively. CNA A used her left hand to aggressively grab Resident #2's left arm/elbow area to Resident #2 towards her. CNA A used her left hand to grab the top of the residents' brief and her right hand to grab the bottom of the brief and aggressively pulled upwards causing a wedgy like affect but in a vertical way. The brief was pulled so aggressively and high that Resident #2's private area could be seen. The brief was heard as it was stretching. CNA A used her right hand to move the liner in place and again pulled Resident #2's brief aggressively and Resident #2 made an noise. CNA A was trying to put on Resident #2's left leg in the pants as Resident #2 was still turned towards CNA A with her head facing upwards. Resident #2's private area could be seen and Resident #2 extended her left leg and CNA A forcefully pushed Resident #2's right leg down on the bed. CNA A stated (in Spanish) to wait as she puts her right hand on Resident #2's left side knee in an aggressive manner. Resident #2's left leg curved over her right leg as CNA A grabbed her left leg with her right hand to extend outwards. A thump could be heard as the left leg touches the bed. Resident #2's brief started coming off as the aide was trying to put Resident #2's left leg in her pants. The brief opened exposing the residents' private areas while the aide was trying to put Resident #2's right leg in her pants. As the aide tried to put the resident's leg in her pants, she in an aggressive manner tossed the residents left leg away onto the bed. CNA A used her left hand grabbed the residents brief and pulled it outwards in an aggressive manner, CNA A made a grunting noise. The brief tore due to the aggressive pull. CNA A pulled so hard that Resident #2's private area was exposed; she placed the brief over the private area while she went to grab something. CNA A tuned around and tossed part of the brief with her left-hand on the floor. CNA A grabbed a new brief from a drawer without changing her gloves and to open it. Resident #2 was laying with her gray pants up to her knee, having her left leg straight and her right leg curved over her left leg. CNA A went over to the resident with the new brief and forcefully extended the resident's right leg down into the bed making an aggressive noise. Resident #2 bent her right leg and the aide aggressively extended it outwards using both hands. CNA A grabbed Resident #2's left leg thigh with both hands to reposition Resident #2 aggressively and yelled hey at the resident as she forcefully turned Resident #2. CNA A with her right hand grabbed the white bedliner and with her left-hand grabbed Resident #2's shoulder to turn Resident #2 towards her. CNA A yanked Resident #2 two times and then placed her left hand behind the residents back. CNA A removed the old brief and tried to place the new brief by extending Resident #2's left leg out as Resident #2 remained positioned on her right-side. Resident #2's rear was exposed. CNA A used her left hand placing it on Resident #2's rear and with her right hand tried to place the white liner and the new brief. CNA A laid Resident #2 on her back and again extended Resident #2's left leg outwards in an aggressive manner opening Resident #2's legs exposing her private parts as she puts on the brief. The aide aggressively pulled out the old brief as the strings were heard snapping and dropped onto the fall mat. CNA A tried to turn Resident #2 away from her by leaning on the resident and placing her right forearm and elbow on Resident #2's hip/right thigh area to turn Resident #2. CNA A stopped leaning on the resident but to keep Resident #2 from repositioning herself CNA A took her right hand and hit Resident #2's right hip making a slapping sound. CNA A pulled on the brief and a tearing sound was heard. Resident #2 was seen curling her right leg as she tried to turn back over. The aide said, oh shit and turned Resident #2 on her back by pulling her right leg in an aggressive manner. Resident #2's private area was exposed again. CNA A aggressively pulled upwards on the brief and opening it in a fan to try to place it on Resident #2. CNA A grabbed Resident #2's right arm and tossed it upwards away from the brief. Resident #2 curled her legs inwards. The aide aggressively grabbed the resident's right leg and said in Spanish hold on. CNA A used her right forearm to move Resident #2's left leg outwards. The aide fastened both sides of the brief and placed her right hand on Resident #2's right thigh in an aggressive manner. At no time during the video did the CNA change gloves. Record review of the Video Recordings 210411 dated 08/01/24 provided by the DON not time stamped revealed the following: CNA A leaned over Resident #2 who was lying on her back in bed. Resident #2 crossed her right leg over her left leg/thigh area with the gray pant still on. CNA A forcibly grabbed Resident #2's right leg to extend it straight and grabbed Resident #2's left foot to put it in the gray pants. The aide pulled the pants over Resident #2's left knee and forcibly extended her left leg. CNA A pulled the pants up to Resident #2's waist and grabbed Resident #2's brief with her right hand and s Resident #2's left shoulder with her left hand to pull her towards her. CNA A moved the white draw sheet and began to pull up the gray pants with her right hand. The aide laid Resident #2 on her back. Resident #2 was turned on her left side and a sound was made once her knees touched the wall next to the bed. CNA A tossed Resident #2's right leg outward and pulled the pants to position them on the resident's waist . CNA A pulled down Resident #2's purple shirt and states in Spanish Ay Esta Ya. (English translation - there you go) Ah Si (English translation- Ah yes). Then says, Ay no. CNA A brings Resident #2 back onto her back and tosses her feet. Lowers the bed and cleans up. Record review of the Video Recordings 210835 dated 08/01/24 provided by the DON not time stamped revealed the following: CNA A threw a brief into the trash can with her right hand as she has Resident #2 on her left side away from her facing the wall. CNA A was holding onto Resident #2's right hip area with her left hand and grabbed for a brief that was open and position towards Resident #2 feet. CNA A told Resident #2 in an aggressive tone to hold on and turn around, like that in Spanish. While she pushed Resident #2 with both hands to stay on her side. CNA A was observed pushing Resident #2's right arm away in a forceful manner. CNA A tried to open the brief and place it on Resident #2. CNA A rolled Resident #2 on her back and put the brief into between the residents' legs. Resident #2's gray pants are placed between her left knee and her right ankle as her right ankle was bent inwards. CNA A then stated aver (English translation- lets see). Resident #2 was noted not to be combative and only had her right leg bent towards her left leg. CNA A pulled Resident #2's left wrist with her left hand. CNA A's right hand was seen grabbing the white draw sheet. CNA A stated in Spanish that Resident #2 does not help for anything. Then stated in Spanish to Resident #2 ingrata (Ungrateful). CNA A then says Hijole (geez). CNA A pulled on the brief upward in an aggressive manner The aide put her right arm underneath Resident #2's left leg/thigh area and picking her upwards and tossed her back to the middle of the bed and used her left hand to grab the brief to try to position it better. CNA A said Ah shit and some other word that was not able to make out. CNA A stated to Resident #2 in Spanish Very funny. Resident #2 was not seen laughing. - End of Video. During an observation on 09/17/24 at 11:03 am, Resident #2 was in the dining area and appeared to have no signs of distress. Staff was seen interacting with Resident #2 and again no distress was noted. During an interview on 09/17/24 at 3:17 PM, the DON stated she had received a call in the night on 08/01/24 from LVN A. The DON stated she spoke with the Family Member and was shown the videos. The DON stated it did not look nice. The DON stated the Family Member had told her she did not want CNA A to be taking care of Resident #2. The DON stated once viewing the video she called the Family Member back and told her she was sorry and there was no excuse for what had happened. The DON stated she had suspended CNA A and pushed for her termination. The DON stated a body assessment was conducted by LVN B which there were no injuries noted at that time. The DON stated she told the Family Member that the Administrator was going to report it to state and the Family Member was really thankful. The DON stated they did a skin assessment on all the residents cared for by CNA A. The DON stated no residents came forward stating that CNA A was mean or had done something to them. The DON stated the next day it was observed that Resident #2 had bruises and the local police was notified. The DON stated the local police showed up and took photos of the bruises and conducted some interviews. During an interview on 09/18/24 at 12:05 PM, LVN B stated the Family Member had something she wanted to talk to him about. LVN B stated the Family Member had told him CNA A had been rough with Resident #2, and it would be easier if she showed him. LVN B stated halfway through the video he told her he had seen enough. LVN B stated he reported it to the DON. LVN B stated he felt sad and upset after viewing the video and how Resident #2 was being treated. LVN B stated Resident #2 was being tossed around and pushed by CNA A. LVN B stated it was not appropriate for CNA A to be doing that. LVN B stated it was inappropriate because it was wrong, and it was abuse. LVN B stated CNA A was pushing and hitting Resident #2 during peri-care who had a serve impairment in cognition and was IDD. LVN B stated that sometimes Resident #2 was uncooperative and usually nursing staff would call for help with assistance. LVN B stated it would be expected for nursing staff to be calling for help if they needed the assistance. LVN B stated he assessed Resident #2, and she had no injuries. LVN B stated the facility staff are trained on Abuse, Neglect, and Exploitation as well as Perineal Care. During an interview on 09/18/24 at 11:22 AM, the SW stated she was made aware of CNA A mistreating and being verbally abusive to Resident #2. The SW stated the Family Member had a camera install in Resident #2's room and had bought the incident to the nursing staff's attention. The SW stated she did not watch the video as she could not bring herself to watch it. The SW stated she did not watch it because of her love for that population and would not want to see the elderly get mistreated. The SW stated Resident #2 was mistreated. The SW stated that CNA A called Resident a name and was being rather rough when changing her. The SW stated the facility spoke with CNA A to get her side of the story and then reported it to the local police. The SW stated the facility then proceed to terminate CNA A. During an interview on 09/19/24 at 1:39 PM, the Family Member stated she goes at night after work to review the camera and noticed CNA A being rough with Resident #2. The Family Member stated she did not want CNA A to be working with Resident #2 anymore. The Family Member stated Resident #2 needs help with ADLs and was not independent. The Family Member stated she sent the videos to the DON. The Family Member stated the DON had stated that CNA A was terminated, and it was going to be reported to the local police. The Family Member stated on the video it was observed that CNA A was pulling on Resident #2's legs and yelling at her. The Family Member stated CNA A was observed getting very upset with Resident #2. The Family Member stated on one of the videos the CNA A ripped off part of Resident #2's brief. The Family Member stated CNA A got mad that she was going to start over and try to put on another brief. The Family Member stated she had heard her calling Resident #2 Ingrate (English translation- Ungrateful). The Family Member stated it made her feel upset and did not want anybody mistreating Resident #2. During an interview on 09/20/24 at 8:18 AM, with LVN I. LVN I stated the facility was conducting a meeting about what had happened with CNA A, Resident #2, and the local police. LVN I stated the local police came and found bruising on Resident #2 on 08/02/24 on her legs. LVN I stated the DON immediately assessed Resident #2. LVN I stated Resident #2 was not on any Anti-Coagulant. LVN I stated she viewed the video. LVN I stated there were a lot of things that were wrong such as CNA A was talking very rude to Resident #2. LVN I stated also the way that CNA A was turning Resident #2 was also rude while she was providing peri-care. LVN I stated they would not want to turn Resident #2 rough because we have to treat the residents like they are humans and provide perineal care correctly. LVN I stated that they had to be gentle with the residents because there skins are delicate and with Resident #2 she was not able to voice that she was in pain. LVN I stated in the video Resident #2 was making moaning sounds and did not remember if Resident #2 was crying or just moaning. LVN I stated the risk could be bruising and open skin tears. LVN I stated it was abuse. On 09/202/4 at 8:22 AM, the Physician was called, and a call back message was left to call back state. Record review of CNA A's Witness Statement note dated, revealed, I'm very sorry what I did. I don't mean that to happen. I wasn't feeling to well to work. I'm very sorry. I don't know what else to say. I didn't mean to do that. I'm very very sorry. It had never happened before. I never done anything like this before. I didn't mean for this to happen. I am sorry. I been working for so many years I never done this before. During an interview on 09/20/24 at 11:10 AM, CNA A stated she was doing her job like always. CNA A stated she had not mistreated a resident in her life. CNA A stated she had told LVN B that she was not mistreating Resident #2. CNA A stated that day she had got a migraine out of nowhere and was in pain and nervous. CNA A stated sometimes that happens and she takes Tylenol or Ibuprofen. CNA A stated she took the Tylenol and went to attend to Resident #2. CNA A stated it did not take affect right away and did not tell the nurse that she needed some time before attending to the residents. CNA A stated Resident #2 had a bowel movement and was going to provide peri-care on her. CNA A stated Resident #2 was heavy and had her feet up and she was trying to put them down. CNA A stated she would put on leg down and then Resident #2 would lift the other leg up. CNA A stated the previous CNAs did not place a white draw sheet underneath Resident #2 and she was lifting her legs up. CNA A stated she was trained on perineal care. CNA A stated she had never mistreated a person. CNA A stated there were only three CNAs and the floor nurse was busy. CNA A stated she did not ask the floor nurses for help nor the CNAs. CNA A stated she felt she did good peri-care and did not mistreat Resident #2. CNA A stated she had changed her gloves three times that night. CNA A stated she was not trained on Abuse, Neglect, and Exploitation. During an interview on 09/20/24 at 1:09 PM, the DON stated the Family members are monitoring Resident #2 on there end and she does spot checks for perineal care 1-2 times a week on random shifts. The DON stated it was to ensure that peri-care was being provided correct and any incorrect perineal care would be corrected on the spot with staff being in-serviced. During an interview on 09/20/24 at 1:17 PM, the Administrator stated on 08/01/24 he was notified of the incident. The Administrator stated CNA A was suspended that day pending the outcome of the investigation. The Administrator stated Resident #2 was assessed by the nursing staff and there were no injuries noted on 08/01/24. The Administrator stated the SW conducted an emotional assessment and with no distress noted. The Administrator stated when the local police arrived and started investigating, they found bruises on Resident #2. The Administrator stated there was a lot of education that was given to the nursing staff such as Abuse and Neglect, Managing Frustration, two-person transferring in-services. The Administrator stated CNA A was terminated. The Administrator stated the Regional Nurse was conducting monitoring on the DON and ADONs who were monitoring the nursing staff with perineal care and on the lookout for burnt out staff to prevent another incident from happening again. The Administrator stated that they also follow their facility protocols with doing background checks, EMR checks, and conducting training. The Administrator stated the reason CNA A was terminated was for abuse of Resident #2. Record review of CNA A's Employee Disciplinary Report dated 08/02/24, revealed, coded Investigation Suspension. CNA A will be placed on investigatory suspension pending an investigation into allegations of abuse. Record review of CNA A's Employee Disciplinary Report (Termination Letter) dated 08/02/24, revealed, coded Discharge. CNA A failed to adhere to the corporate code of conduct. On 08/02/24, CNA A was placed on investigatory suspension pending an investigation into allegations of resident abuse. These allegations were substantiated. CNA A was aware of all polices and procedures via her signature on the employee handbook acknowledgement. CNA A meets criteria for immediate termination. Record review of CNA A's Official Transcript for training dated 06/07/24, revealed, she was trained on Abuse, Neglect, and Exploitation. Preventing, Recognizing, and Reporting Abuse on 05/24/24. Providing Customer Service on 11/14/23. Record review of CNA A's Proficiency Audit dated 06/11/24, revealed, she was trained with providing Perineal care: female, turns/repositions residents timely/correctly, and Infection Control awareness. Record review of the facility Abuse and Neglect policy 09/09/24, revealed, The resident had the rights to be free from abuse. Residents should not be subjected to abuse by anyone, including but not limited to facility staff and consultants or volunteers, staff of other agencies serving the resident, or other individuals. Abuse - Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse and physical abuse. Verbal Abuse - gestured language that willfully includes disparaging (to criticize someone or something in a way that shows you do not respect or value him, her, or it) and derogatory (expressing a negative or disrespectful connotation, a low opinion, or a lack of respect toward someone or something) terms to residents, or within hearing distance, regardless of their age, ability to comprehend, or disability. Physical Abuse - includes hitting, slapping, pinching, and kicking. Mistreatment - inappropriate treatment or exploitation of a resident. The Administrator was notified on 09/20/24 at 2:20 p.m., that a past non-compliance situation had been identified due to the above failures. The facility implemented the following interventions: Record review of 11 facility Resident Witness Statements dated 08/02/24, revealed, there were no issues with CNA A or negative comments about her. Record review of facility Resident who CNA A had were audited on 08/02/24, revealed, there was only 3 residents with injuries that was unrelated to CNA A. Record review of the facility Actual/Alleged Abuse Monitoring dated 08/02/24 was started on all three shifts. No negative outcomes were noted. Record review of the facility In-services for a 2-person assistance, Abuses & Neglect: Managing Frustration, and Abuse, Neglect, & Exploitation dated 08/02/24 were conducted. During an interview on 09/17/24 at 10:52 AM, with Resident #12, she stated she was treated well by the nursing staff and had no issues with anyone. During an interview on 09/18/24 at 9:31 AM, with Resident #13 stated facility staff have treated her well and had no issues with any of the staff. During an interview on09/19/24 at 3:09 PM, with Resident #6 revealed there were no issues with CNA A and deny any injuries During an interview on 09/19/24 at 3:16 PM, with Resident 9revealed there were no issues with CNA A of any kind. and deny any injuries. During an interview on 09/17/24 at 3:17 PM, with the DON, 09/18/24 at 12:05 PM, revealed she was gave and received training on Abuse and Neglect, 2-person transfers, Abuse and Neglect: Managing Frustration. During an interview on 9/19/24 from 12:05PM to 4:11PM with LVNB, LVN E, LVN F, and LVN G revealed they were given and had received training on Abuse and Neglect, 2-person transfers, Abuse and Neglect: Managing Frustration. They stated they stated if they suspected, see, or hear abuse happening they would report it to the Abuse Coordinator who was the Administrator. They stated they had received training on two-person transfers. They stated no resident may be transferred as a one-person transfer and had to be a two-person. They stated they received training on managing frustration and if they felt frustrated to go let management know and or take a break or a breather. During an interview on 09/20/24 from 8:18AM to 1:17PM with CNA H, LVN I, and the administrator revealed they were given and had received training on Abuse and Neglect, 2-person transfers, Abuse and Neglect: Managing Frustration. They stated they had received training on two-person transfers. They stated no resident may be transferred as a one-person transfer and had to be a two-person. They stated they received training on managing frustration and if they felt frustrated to go let management know and or take a break or a breather.

Based on interview and record review the facility failed to consult with and notify the resident's physician when an accident involving the resident which results in injury and change of condition and has the potential for requiring physician intervention for 1 (Resident #5) of 10 residents reviewed for changes in condition. Registered Nurse (RN) failed to consult with physician on 7/13/19 when Certified Nurse Aide (CNA) reported at 2:00 PM, resident #5 was complaining of pain to the right leg, was crying, yelling loudly and would not let them touch her to move her. Resident continued to complain of pain throughout the night and the pain was not relieved with prescribed pain medication. X-ray done on 7/14/19 at 1:30 PM, revealed a fracture to the right distal femur. This failure could affect residents by placing them at risk of potential medical complications [REDACTED]. The findings include: Review of the Admission Record dated 7/30/19 for resident #5 documented original admitted was 9/14/17 and was re-admitted on [DATE]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for resident #5 documented: minimal difficulty with hearing, clear speech, usually makes self understood, sometimes understands others, vision impaired, BIM (Brief Interview for Mental Status) score: 3 (severely impaired), ADLs (Activities of Daily Living) requires total assistance of one person with bed mobility, toilet use, personal hygiene, & bathing, total assistance of two persons with transfer, extensive assistance of one person with locomotion on/off the unit, & eating; balance during transition - not steady surface to surface transfer, wheelchair, incontinent of bowel & bladder, received scheduled pain medication regime, history of falls since admission with no injury, medications received antianxiety, antidepressant, opioid. Occupational therapy. Review of the Care Plan revised on 10/22/18 for resident #5 documented: Resident has limited physical mobility, Self Care deficit related to [MEDICAL CONDITION]-requires total assistance of two person with transfers, Resident is at risk for falls, Impaired thought process related to Dementia, Acute/Chronic pain related to fracture to right femur on 7/14/19; Resident is pain medication related to [MEDICAL CONDITION]. Review of History & Physical dated 7/22/19 documented resident #5 was [AGE] year old female readmitted to hospital from this facility. Patient admitted to hospital for the evaluation of right knee pain. Patient found to have a right femur fracture and underwent ORIF (open reduction internal fixation surgery) to the right knee. Medical History: Stress fracture of right femur, hypertensive [MEDICAL CONDITIONS], muscle wasting, [MEDICAL CONDITION] stage 3, acute [MEDICAL CONDITION] with [MEDICAL CONDITION], abnormal gait, lack of coordination, dysphagia, asthma, hypertension, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITIONS], vitamin D deficiency. Review of the Nurses's Progress Notes dated 7/14/19 at 5:04 AM, written by Registered Nurse (RN) A for resident #5 documented, resident had complained of pain on the right knee at about beginning of last shift. At about 1:00 AM, it was noticed that the knee was swollen. At about 5:40 AM, message was sent to physician. Pending reply. Review of Physician order [REDACTED].#5 documented, [MEDICATION NAME] Capsule give 25 mg by mouth three times a day for pain to right leg until 7/17/19. Event Nurses' Note dated 7/14/19 at 1:45 PM for resident #5 documented: Event-Patient complain of pain to right leg. Location Event Occurred: unknown. Fracture: Right Femur. Swelling to right leg, pain to thigh down to ankle. Pain Level: 10 (Pain Scale of 1-10, 10 being the worst pain). Physician notified 7/14/19 at 9:30 AM, ordered x-ray and [MEDICATION NAME] 25 mg by mouth three times a day x 3 days. Resident Statement: Resident denied fall, patient states pain is unbearable. Review of Hospital emergency room notes dated 7/14/19 at 3:56 PM, patient presents to ED (Emergency Department) with complaints of bilateral leg pain that occurred one day ago. Per EMS (emergency medical services), they were called to the nursing home after patient began complaining of pain to right knee. She had an x-ray done earlier today and it showed a distal femur fracture on the right. Resident was admitted on [DATE] at 6:36 PM. Review of Hospital x-ray dated 7/14/19 at 5:45 PM, documented Comminuted [MEDICAL CONDITION] right femur extending into the femoral component of the remotely placed right total knee arthroplasty. Review of Hospital Operative Report dated 7/15/19 at 1:57 PM, Distal femoral fracture, status [REDACTED]. Review of the Nurses's Progress Notes dated 7/14/19 at 10:54 AM, written by RN B for resident #5 documented, Patient complain of severe pain to right leg. RN A (evening/night) reported that patient had complained earlier of pain and issue was addressed by an ointment being applied to site and Tylenol was given early morning. Scribe went to assess patient and reported finding to MD (medical doctor) as a follow up. MD provided new orders. Will monitor. Review of the x-ray report dated 7/14/19 faxed to facility at 1:27 PM, for resident #5 documented: Reason-Swelling, pain, range of motion in excruciating pain. Impressions: Acute distal femur fracture. Review of the Provider Investigation Report dated 7/14/19 for resident #5 documented: Incident Category: Injury of unknown origin. Incident Date: 7/14/19. Who made allegation? x-ray results at 1:30 PM. Functional Ability: Extensive. Resident is not interviewable. Pertinent history: Arthroplasty on same leg. Description of allegation: X-ray obtained on 7/14/19 revealed the presence of a [MEDICAL CONDITION] femur. No reported falls or other incidents identified as the cause. Resident had persistent pain over 24 hours, except when she was asleep. Pain medication were administered shortly after pain was reported by Certified Nurse Aide (CNA) to nurse. The swelling worsened and x-ray were ordered on Sunday morning. X-ray revealed a fracture. Doctor was notified and ordered patient be sent to ER (emergency room ) immediately. Investigation Summary: Resident stated, It started hurting in the dining room yesterday 7/13/19. The onset of excruciating pain was not apparent until 7/14/19 and CNAs reported resident slept at night. Having voiced complaints of pain, resident was being monitored and administered pain medications regularly. Attending physician skeptical that this fracture could be sustained without excruciating pain. Written statement dated 7/14/19 at 2:40 PM written by RN A documented, When I was getting report yesterday at 2:00 PM, CNA C reported that resident #5 needed pain medication. She had a painful right knee, tender but was normal on appearance. I gave her Tylenol as ordered. At 9:00 PM, I also gave her [MEDICATION NAME]. At around 1:00 AM, it was noticed that the leg was swollen above the right knee and tends slightly warm. Tylenol was given and [MEDICATION NAME] cream applied. The resident mentioned that during the previous shift the CNA & daughter moved her in a manner that caused her knee pain. A text message was sent to physician for further order. Report was given to the on-coming shift. The reply from the MD was still pending. Written statement dated 7/14/19 written by CNA D documented, resident #5 was in pain yesterday. (MONTH) 13 at 2:00 PM, I went to check on resident #5 and she was crying in pain. Patient mentioned that the CNAs changed her and they moved her leg wrong, which caused pain. Written statement dated 7/14/19 written by CNA [NAME] documented, I transferred resident #5 yesterday at 7:15 AM, from the bed to the wheelchair because she was scheduled to be showered. Me and another CNA transferred the resident from the shower chair to the wheelchair at 8:15 AM. At 2:00 PM, CNA F and I transferred the resident from the wheelchair to the toilet. Resident was complaining of pain more than usual so I reported this to RN B. The resident was complaining more than usual when the knee was bent. Written statement attached to Provider Investigation Report dated 7/14/19 written by CNA C (6:00 AM-2:00 PM shift) documented, Yesterday while I was given report to RN A (2:00 PM-10:00 PM) nurse a CNA said, resident #5 needs pain medication, she is crying. Before we finished report RN A pulled medication and went to resident's room. Review of written Questionnaire attached to Provider Investigation Report dated 7/14/19 written by CNA F documented she had worked on 7/13/19 and had assisted CNA [NAME] transfer resident #5 from the wheelchair to the toilet at 2:00 PM. The resident cried and said she was having pain on her leg. This was reported to RN B. Review of written Questionnaire attached to Provider Investigation Report dated 7/15/19 written by CNA G documented on Sunday 7/14/19 the nurse told me not to get resident #5 up because her leg was swollen. Is resident #5 capable of expressing pain? How does she make it known? She will cry or yell. Describe her expression of pain Saturday to Sunday did it change? Did you report this to anyone? I assisted the x-ray tech when he came to do the x-ray. The resident was crying and yelling because she was in a lot of pain. She was telling us to stop because she couldn't stand the pain. Review of written Questionnaire attached to Provider Investigation Report dated 7/15/19 written by CNA H documented, When taking lunch bag to break room on 7/13/19, heard resident #5 crying. So I asked her what was wrong and she stated that her knee hurt. Went to Nurses's station and told RN A about her pain. CNA C stated that resident #5 had knee pain all day on Saturday. Review of undated written Questionnaire attached to Provider Investigation Report written by CNA D documented: Did you transfer her from the wheelchair to bed or bed to wheelchair this weekend? Anything irregular happened? Yes, she cried because of leg pain. I was careful with her that night because of pain. She would yell out and say that she was in pain. She had a lot of pain Saturday 7/13/19 in the afternoon. Reported to Nurse. Review of written Questionnaire attached to Provider Investigation Report dated 7/16/19 written by CNA I documented, worked with resident #5 on the night shift on Saturday. I tried to reposition, but she had a lot of pain. When I changed her at 11:00 PM, she complained of a lot of pain on her right leg. I reported to RN A. Review of undated written Questionnaire attached to Provider Investigation Report written by CNA J documented, Saturday 7/13/19 when I came in, resident #5 was crying, I fix her footrest, straightening of her leg in wheelchair at 2:00 PM, made her pain lessen. Reported to RN A Sunday just saw her in bed all day. Review of undated written Questionnaire attached to Provider Investigation Report written by CNA K documented, On Sunday 7/14/19 the nurse asked that we not move resident #5 for nothing. Review of written Questionnaire attached to Provider Investigation Report dated 7/15/19 written by CNA L documented, on Saturday 7/13/19 in the afternoon resident #5 complained of pain and I told the nurse & LVN (Licensed Vocational Nurse) ADON (assistant director of Nurses). Written statement attached to Provider Investigation Report dated 7/14/19 at 1:00 PM written by LVN, documented Resident stated her pain level was 10/10 when she moves her right leg. In an interview on 7/30/19 at 5:15 PM, with the Administrator & Director of Nurses (DON) reported that on 7/13/19 resident #5 complained of pain to the right knee. The knee had normal appearance, and the nurse medicated the resident with Tylenol & [MEDICATION NAME]. It was reported that the resident was sitting in her wheelchair most of the day on 7/13/19. CNA D is the one that reported to the nurse that resident #5 was having pain to the leg. Administrator reported that RN A works a double shift on the weekends from 2:00 PM - 6:00 AM. It was reported that on 7/13/19 at 2:15 PM, resident #5 started to complain of pain to right leg. CNA J reported that resident #5 was complaining of pain so he put her leg on the wheelchair's footrest and it was not hurting as much. He put the resident back to bed later on that day. X-ray results on 7/14/19 at 1:30 PM, revealed an acute [MEDICAL CONDITION] femur. Resident has a history of arthroplasty to the right knee. The resident had swelling to leg above the knee and complained of pain with movement. The nurse medicated the resident with Tylenol #3 and [MEDICATION NAME] and was effective enough for resident to sleep. At 9:11 PM, when resident was medicated with [MEDICATION NAME] the pain level was at 6 out of 10. On Sunday at 4:31 AM, the nurse medicated her with Tylenol and applied the [MEDICATION NAME] ointment to the right leg for pain. In an interview on 7/30/19 at 5:45 PM, CNA J reported that he had worked on the evening shift on 7/13/19. He said, At the start of the shift, I passed by resident #5's room and heard her moaning. I went to her room and asked her what was wrong. She complained of pain to the right leg, so I took her leg off the footrest and her leg slightly extended forward and she said it felt better and did not hurt anymore. I reported this to RN A right away. I don't know if he went to check the resident. Later that day, I helped CNA D transfer resident #5 from the wheelchair to the bed and she did not complain of pain. On Sunday when I came to work, I noted that resident #5 was in bed. She is usually sitting in her wheelchair. CNA J reported that resident #5 was confused, able to verbalize needs, required a two person transfer, could stand & bear weight and could take small steps. CNA J reported that resident #5 did not complain of pain with movement prior to the incident. CNA J stated that they had been trained to immediately report to the nurses any change in condition or complaints of pain. In an interview on 7/30/19 at 6:05 PM, CNA [NAME] reported that she had worked on the day shift on 7/14/19 and had been assigned to resident #5. It was reported that resident had been showered on that day and they did not notice anything unusual. CNA [NAME] stated that resident #5 always complained of pain to the right leg. CNA [NAME] said, At 2:00 PM, on that day the resident's call light was on, so I went to the room and the daughter was there. The resident asked to go to the bathroom, so I got CNA F, to help me transfer the resident from the wheelchair to the toilet and that is when I noted that she was having more pain than usual to the right leg. When we went to report this to the nurse, they were giving report, so we went to report this to RN B. I don't know what happened because my shift ended and I left. On Sunday when I came back to work LVN N asked me to write a report because resident #5 had a fracture to the right leg. Telephone interview on 7/30/19 at 6:18 PM, RN A confirmed that he had worked a double shift on 7/14/19 and had been assigned to resident #5. RN A reported that he was getting report at around 2:15 PM - 2:30 PM, when one of the CNAs came to report that resident was complaining of pain to the right leg. I assessed the resident, she had pain to touch and tenderness to the right leg directly above the knee. Later during the night, I went to check the resident and again she complained of pain, and noted swelling to the right knee. I sent a text message to the physician to get an order for [REDACTED].#5 had a fracture and the nurses were making arrangements to send the resident to the hospital. RN A reported that the CNAs have been trained to immediately report to the nurses changes in condition and complaints of pain. RN A stated resident #5 had Bi-polar disorder and had intermittent confusion and usually complained of pain to her legs and is medicated with Tylenol, [MEDICATION NAME], and [MEDICATION NAME] ointment. RN A reported that the resident's daughter & one of the CNAs had moved the resident on that day. I cannot give you details because that is all that I know. Telephone interview on 7/30/19 at 6:28 PM, RN B reported that she was the weekend supervisor. It was reported that RN A on the 2-10 shift had reported on 7/13/19 that resident #5 had started to complain of pain to the right leg in the evening. He reported that he had medicated the resident with Tylenol and the resident had continued to complain of pain during the night shift. On Sunday 7/14/19 LVN N and I went to assess the resident, she was in bed eating her breakfast and watching television, had no signs of pain. Later we went back to check her, and when we pulled the covers off, she complained of pain with movement. The resident had swelling on the right thigh and had sever pain with movement. She was yelling and moaning when she was moved. The pain radiated from the thigh to the toes. RN A reported that resident #5 had been in pain all night and he had tried to get a hold of the MD (medical doctor) and she had not returned his call or text message. He said that he had text the MD at approximately 5:30 AM - 5:40 PM and the MD had not replied back. RN A reported that he had administered pain medication throughout the night and had applied the pain cream to the resident's right leg. We called the physician and she gave orders for an x-ray and ordered a new medication which was not in the emergency kit, so it had to be ordered from the pharmacy. The x-ray was done and at 1:30 PM, we were stunned when we found she had a fracture to the right femur. The resident was sent out to the hospital ER for evaluation by ambulance. RN B reported that the nurses had been trained to immediately report changes of condition to the physician and to report to the ADON if unable to contact the attending physician. Telephone interview on 7/30/19 at 6:40 PM, with CNA D reported that she had worked on 7/13/19 on the evening shift and had been assigned to resident #5. I did not move the resident, because she was complaining of pain to the right leg. The resident was crying and yelling and did not want me to touch her. So, I went to report this to RN A right away. She was sitting in the wheelchair at the start of the shift, I tried to put her leg on the footrest but she would not let me touch her because she was having a lot of pain. I am not sure if RN A went to check the resident. Later on that day, I asked another CNA to help me put the resident in bed. I noted that her leg was very swollen above the knee, she was not able to stand and put weight on her legs, this was unusual for her, because she was in to much pain. We put her in bed and was not moved the rest of the shift. Resident was sent to the hospital on Sunday at the start of the evening shift on 7/14/19. CNA D reported that they had been trained to immediately report to the nurses any change in condition or resident complains of pain. Telephone interview on 7/30/19 at 6:50 PM, LVN N reported that she had been assigned to resident #5 on 7/14/19 on the day shift. LVN N reported that on 7/13/19 at 2:00 PM, they were getting report when one of the CNAs came to report to RN A that resident #5 was crying and yelling loudly and was complaining of pain to the right leg. RN A reported that he had medicated the resident with Tylenol and applied the pain cream for pain. LVN N said, The next day on Sunday during report RN A reported that he had been medicating the resident for pain and that the resident had complained of pain all night. We both went to assess the resident and noted that the right leg was swollen above the knee. RN A said he had notified MD and was still pending a return call/text from the physician. RN A reported resident's condition to RN B. RN B and I went to check the resident, we took a picture and she called the MD to get an order for [REDACTED].>Interview on 7/30/19 at 7:09 PM, Administrator in the presence of the DON reported the Physician had said, It did not make sense that resident's pain level was at a 6, since she had a fracture to a major bone. The physician said that with this type of fracture, resident would have excruciating pain. Telephone interview on 7/30/19 at 7:28 PM, attending physician for resident #5 confirmed that she had received a text message from RN A at 5:00 AM, reporting that resident's leg was swollen. She said, I had a late night, so I slept late on that day so I missed his text message. At 7:30 AM, RN A sent me another text to report that resident #5 had swelling and pain to the right leg. At approximately 8:30 AM, the morning nurse on 7/14/19 had already called me and I ordered a stat x-ray. When RN A sent me the text he made it seem like the resident only had inflammation to the right knee so I treated her with [MEDICATION NAME] 25 mg to be given by mouth three times a day. He did not report to me the gravity of her condition, that the resident was complaining of pain with movement was yelling out and crying. I would have given orders to send the resident to the hospital right away. This is the first time, that I hear the resident was yelling and crying with movement. This type of fracture to a large bone causes excruciating pain. If he had made an accurate report to me about the resident's condition, I would have given different orders to address the excruciating pain that she was having to the right leg right away. I would expect the nurses to call me right away and report that resident's pain was getting worse and was not relieved with pain medication. Interview on 7/30/19 at 7:04 PM, DON reported that nurses have been trained to call the physician if pain is not relieved with pain medication and the resident continues to complain of pain. DON said, RN A sent a text to MD. What made him call the MD, was because resident's pain was getting worse and interventions were not effective. I do not know, why it took so long to call the MD. The nurses have been trained to call me or whoever is on call if they cannot reach the MD to report changes in condition. RN A reported resident #5 did not have any visible signs of injury. He thought it was baseline pain, because she always complains of pain to the lower extremities. Observation and interview on 7/31/19 at 8:13 AM, resident #5 was sitting in a wheelchair in her room. Resident had a leg brace on right lower extremity. The right leg was elevated on footrest. Resident was awake, oriented to person, had a difficult time understanding simple questions. Resident denied having pain. Resident said, I fell down at home. Review of the Medication Administration Record [REDACTED]. Pain scale 1-10, 10 being the worst pain. Review of the Medication Administration Record [REDACTED]. Pain scale 1-10, 10 being the worst pain. Review of the Medication Administration Record [REDACTED]. Pain scale 1-10, 10 being the worst pain. Review of the Medication Administration Record [REDACTED]. Pain scale 1-10, 10 being the worst pain. Record review of the facility's policy and procedure on Notifying the Physician of Change in Status revised on (MONTH) 11, 2013 documented in part: The nurse should not hesitate to contact the physician at any time when as assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes an assessment tool, Change in Condition - When to Notify the MD/NP/PA (physician assistant) to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician immediately with significant change is status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The nurse is responsible for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. The resident's family member or legal guardian should be notified of significant change in resident's status. The nurse will monitor and assess the resident's status and response to interventions. Physician should develop a working [DIAGNOSES REDACTED]. If the resident remains in the facility and a significant change has occurred; update the care plan accordingly. Review of the facility's policy and procedure on Pain Management, Assessment Scale dated 5/25/16 documented: Pain is subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological. or psychological stimuli. Policy: Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals: Resident expresses a feeling of comfort and relief from pain. Cognitively impaired residents will demonstrate actions of pain relief. Procedure: Assess resident's physical symptoms of pain, physical complaints, and daily activities. Have the resident rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse must use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Monitor the effectiveness of pain interventions.

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person- centered care plan, and the resident's choices for 1 (Resident #5) of 10 residents reviewed for changes in condition. Registered Nurse (RN) failed to consult with physician on 7/13/19 when Certified Nurse Aide (CNA) reported at 2:00 PM, resident #5 was complaining of pain to the right leg, was crying, yelling loudly and would not let them touch her to move her. Resident continued to complain of pain throughout the night and the pain was not relieved with prescribed pain medication. X-ray done on 7/14/19 at 1:30 PM, revealed a fracture to the right distal femur. This failure could affect others by placing them at risk of potential medical complications [REDACTED]. The findings include: Review of the Admission Record dated 7/30/19 for resident #5 documented original admitted was 9/14/17 and was re-admitted on [DATE]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for resident #5 documented: minimal difficulty with hearing, clear speech, usually makes self understood, sometimes understands others, vision impaired, BIM (Brief Interview for Mental Status) score: 3 (severely impaired), ADLs (Activities of Daily Living) requires total assistance of one person with bed mobility, toilet use, personal hygiene, & bathing, total assistance of two persons with transfer, extensive assistance of one person with locomotion on/off the unit, & eating; balance during transition - not steady surface to surface transfer, wheelchair, incontinent of bowel & bladder, received scheduled pain medication regime, history of falls since admission with no injury, medications received antianxiety, antidepressant, opioid. Occupational therapy. Review of the Care Plan revised on 10/22/18 for resident #5 documented: Resident has limited physical mobility, Self Care deficit related to [MEDICAL CONDITION]-requires total assistance of two person with transfers, Resident is at risk for falls, Impaired thought process related to Dementia, Acute/Chronic pain related to fracture to right femur on 7/14/19; Resident is pain medication related to [MEDICAL CONDITION]. Review of History & Physical dated 7/22/19 documented resident #5 was [AGE] year old female readmitted to hospital from this facility. Patient admitted to hospital for the evaluation of right knee pain. Patient found to have a right femur fracture and underwent ORIF (open reduction internal fixation surgery) to the right knee. Medical History: Stress fracture of right femur, hypertensive [MEDICAL CONDITIONS], muscle wasting, [MEDICAL CONDITION] stage 3, acute [MEDICAL CONDITION] with [MEDICAL CONDITION], abnormal gait, lack of coordination, dysphagia, asthma, hypertension, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITIONS], vitamin D deficiency. Review of the Nurses's Progress Notes dated 7/14/19 at 5:04 AM, written by Registered Nurse (RN) A for resident #5 documented, resident had complained of pain on the right knee at about beginning of last shift. At about 1:00 AM, it was noticed that the knee was swollen. At about 5:40 AM, message was sent to physician. Pending reply. Review of Physician order [REDACTED].#5 documented, [MEDICATION NAME] Capsule give 25 mg by mouth three times a day for pain to right leg until 7/17/19. Event Nurses' Note dated 7/14/19 at 1:45 PM for resident #5 documented: Event-Patient complain of pain to right leg. Location Event Occurred: unknown. Fracture: Right Femur. Swelling to right leg, pain to thigh down to ankle. Pain Level: 10 (Pain Scale of 1-10, 10 being the worst pain). Physician notified 7/14/19 at 9:30 AM, ordered x-ray and [MEDICATION NAME] 25 mg by mouth three times a day x 3 days. Resident Statement: Resident denied fall, patient states pain is unbearable. Review of Hospital emergency room notes dated 7/14/19 at 3:56 PM, patient presents to ED (Emergency Department) with complaints of bilateral leg pain that occurred one day ago. Per EMS (emergency medical services), they were called to the nursing home after patient began complaining of pain to right knee. She had an x-ray done earlier today and it showed a distal femur fracture on the right. Resident was admitted on [DATE] at 6:36 PM. Review of Hospital x-ray dated 7/14/19 at 5:45 PM, documented Comminuted [MEDICAL CONDITION] right femur extending into the femoral component of the remotely placed right total knee arthroplasty. Review of Hospital Operative Report dated 7/15/19 at 1:57 PM, Distal femoral fracture, status [REDACTED]. Review of the Nurses's Progress Notes dated 7/14/19 at 10:54 AM, written by RN B for resident #5 documented, Patient complain of severe pain to right leg. RN A (evening/night) reported that patient had complained earlier of pain and issue was addressed by an ointment being applied to site and Tylenol was given early morning. Scribe went to assess patient and reported finding to MD (medical doctor) as a follow up. MD provided new orders. Will monitor. Review of the x-ray report dated 7/14/19 faxed to facility at 1:27 PM, for resident #5 documented: Reason-Swelling, pain, range of motion in excruciating pain. Impressions: Acute distal femur fracture. Review of the Provider Investigation Report dated 7/14/19 for resident #5 documented: Incident Category: Injury of unknown origin. Incident Date: 7/14/19. Who made allegation? x-ray results at 1:30 PM. Functional Ability: Extensive. Resident is not interviewable. Pertinent history: Arthroplasty on same leg. Description of allegation: X-ray obtained on 7/14/19 revealed the presence of a [MEDICAL CONDITION] femur. No reported falls or other incidents identified as the cause. Resident had persistent pain over 24 hours, except when she was asleep. Pain medication were administered shortly after pain was reported by Certified Nurse Aide (CNA) to nurse. The swelling worsened and x-ray were ordered on Sunday morning. X-ray revealed a fracture. Doctor was notified and ordered patient be sent to ER (emergency room ) immediately. Investigation Summary: Resident stated, It started hurting in the dining room yesterday 7/13/19. The onset of excruciating pain was not apparent until 7/14/19 and CNAs reported resident slept at night. Having voiced complaints of pain, resident was being monitored and administered pain medications regularly. Attending physician skeptical that this fracture could be sustained without excruciating pain. Written statement dated 7/14/19 at 2:40 PM written by RN A documented, When I was getting report yesterday at 2:00 PM, CNA C reported that resident #5 needed pain medication. She had a painful right knee, tender but was normal on appearance. I gave her Tylenol as ordered. At 9:00 PM, I also gave her [MEDICATION NAME]. At around 1:00 AM, it was noticed that the leg was swollen above the right knee and tends slightly warm. Tylenol was given and [MEDICATION NAME] cream applied. The resident mentioned that during the previous shift the CNA & daughter moved her in a manner that caused her knee pain. A text message was sent to physician for further order. Report was given to the on-coming shift. The reply from the MD was still pending. Written statement dated 7/14/19 written by CNA D documented, resident #5 was in pain yesterday. (MONTH) 13 at 2:00 PM, I went to check on resident #5 and she was crying in pain. Patient mentioned that the CNAs changed her and they moved her leg wrong, which caused pain. Written statement dated 7/14/19 written by CNA [NAME] documented, I transferred resident #5 yesterday at 7:15 AM, from the bed to the wheelchair because she was scheduled to be showered. Me and another CNA transferred the resident from the shower chair to the wheelchair at 8:15 AM. At 2:00 PM, CNA F and I transferred the resident from the wheelchair to the toilet. Resident was complaining of pain more than usual so I reported this to RN B. The resident was complaining more than usual when the knee was bent. Written statement attached to Provider Investigation Report dated 7/14/19 written by CNA C (6:00 AM-2:00 PM shift) documented, Yesterday while I was given report to RN A (2:00 PM-10:00 PM) nurse a CNA said, resident #5 needs pain medication, she is crying. Before we finished report RN A pulled medication and went to resident's room. Review of written Questionnaire attached to Provider Investigation Report dated 7/14/19 written by CNA F documented she had worked on 7/13/19 and had assisted CNA [NAME] transfer resident #5 from the wheelchair to the toilet at 2:00 PM. The resident cried and said she was having pain on her leg. This was reported to RN B. Review of written Questionnaire attached to Provider Investigation Report dated 7/15/19 written by CNA G documented on Sunday 7/14/19 the nurse told me not to get resident #5 up because her leg was swollen. Is resident #5 capable of expressing pain? How does she make it known? She will cry or yell. Describe her expression of pain Saturday to Sunday did it change? Did you report this to anyone? I assisted the x-ray tech when he came to do the x-ray. The resident was crying and yelling because she was in a lot of pain. She was telling us to stop because she couldn't stand the pain. Review of written Questionnaire attached to Provider Investigation Report dated 7/15/19 written by CNA H documented, When taking lunch bag to break room on 7/13/19, heard resident #5 crying. So I asked her what was wrong and she stated that her knee hurt. Went to Nurses's station and told RN A about her pain. CNA C stated that resident #5 had knee pain all day on Saturday. Review of undated written Questionnaire attached to Provider Investigation Report written by CNA D documented: Did you transfer her from the wheelchair to bed or bed to wheelchair this weekend? Anything irregular happened? Yes, she cried because of leg pain. I was careful with her that night because of pain. She would yell out and say that she was in pain. She had a lot of pain Saturday 7/13/19 in the afternoon. Reported to Nurse. Review of written Questionnaire attached to Provider Investigation Report dated 7/16/19 written by CNA I documented, worked with resident #5 on the night shift on Saturday. I tried to reposition, but she had a lot of pain. When I changed her at 11:00 PM, she complained of a lot of pain on her right leg. I reported to RN A. Review of undated written Questionnaire attached to Provider Investigation Report written by CNA J documented, Saturday 7/13/19 when I came in, resident #5 was crying, I fix her footrest, straightening of her leg in wheelchair at 2:00 PM, made her pain lessen. Reported to RN A Sunday just saw her in bed all day. Review of undated written Questionnaire attached to Provider Investigation Report written by CNA K documented, On Sunday 7/14/19 the nurse asked that we not move resident #5 for nothing. Review of written Questionnaire attached to Provider Investigation Report dated 7/15/19 written by CNA L documented, on Saturday 7/13/19 in the afternoon resident #5 complained of pain and I told the nurse & LVN (Licensed Vocational Nurse) ADON (assistant director of Nurses). Written statement attached to Provider Investigation Report dated 7/14/19 at 1:00 PM written by LVN, documented Resident stated her pain level was 10/10 when she moves her right leg. In an interview on 7/30/19 at 5:15 PM, with the Administrator & Director of Nurses (DON) reported that on 7/13/19 resident #5 complained of pain to the right knee. The knee had normal appearance, and the nurse medicated the resident with Tylenol & [MEDICATION NAME]. It was reported that the resident was sitting in her wheelchair most of the day on 7/13/19. CNA D is the one that reported to the nurse that resident #5 was having pain to the leg. Administrator reported that RN A works a double shift on the weekends from 2:00 PM - 6:00 AM. It was reported that on 7/13/19 at 2:15 PM, resident #5 started to complain of pain to right leg. CNA J reported that resident #5 was complaining of pain so he put her leg on the wheelchair's footrest and it was not hurting as much. He put the resident back to bed later on that day. X-ray results on 7/14/19 at 1:30 PM, revealed an acute [MEDICAL CONDITION] femur. Resident has a history of arthroplasty to the right knee. The resident had swelling to leg above the knee and complained of pain with movement. The nurse medicated the resident with Tylenol #3 and [MEDICATION NAME] and was effective enough for resident to sleep. At 9:11 PM, when resident was medicated with [MEDICATION NAME] the pain level was at 6 out of 10. On Sunday at 4:31 AM, the nurse medicated her with Tylenol and applied the [MEDICATION NAME] ointment to the right leg for pain. In an interview on 7/30/19 at 5:45 PM, CNA J reported that he had worked on the evening shift on 7/13/19. He said, At the start of the shift, I passed by resident #5's room and heard her moaning. I went to her room and asked her what was wrong. She complained of pain to the right leg, so I took her leg off the footrest and her leg slightly extended forward and she said it felt better and did not hurt anymore. I reported this to RN A right away. I don't know if he went to check the resident. Later that day, I helped CNA D transfer resident #5 from the wheelchair to the bed and she did not complain of pain. On Sunday when I came to work, I noted that resident #5 was in bed. She is usually sitting in her wheelchair. CNA J reported that resident #5 was confused, able to verbalize needs, required a two person transfer, could stand & bear weight and could take small steps. CNA J reported that resident #5 did not complain of pain with movement prior to the incident. CNA J stated that they had been trained to immediately report to the nurses any change in condition or complaints of pain. In an interview on 7/30/19 at 6:05 PM, CNA [NAME] reported that she had worked on the day shift on 7/14/19 and had been assigned to resident #5. It was reported that resident had been showered on that day and they did not notice anything unusual. CNA [NAME] stated that resident #5 always complained of pain to the right leg. CNA [NAME] said, At 2:00 PM, on that day the resident's call light was on, so I went to the room and the daughter was there. The resident asked to go to the bathroom, so I got CNA F, to help me transfer the resident from the wheelchair to the toilet and that is when I noted that she was having more pain than usual to the right leg. When we went to report this to the nurse, they were giving report, so we went to report this to RN B. I don't know what happened because my shift ended and I left. On Sunday when I came back to work LVN N asked me to write a report because resident #5 had a fracture to the right leg. Telephone interview on 7/30/19 at 6:18 PM, RN A confirmed that he had worked a double shift on 7/14/19 and had been assigned to resident #5. RN A reported that he was getting report at around 2:15 PM - 2:30 PM, when one of the CNAs came to report that resident was complaining of pain to the right leg. I assessed the resident, she had pain to touch and tenderness to the right leg directly above the knee. Later during the night, I went to check the resident and again she complained of pain, and noted swelling to the right knee. I sent a text message to the physician to get an order for [REDACTED].#5 had a fracture and the nurses were making arrangements to send the resident to the hospital. RN A reported that the CNAs have been trained to immediately report to the nurses changes in condition and complaints of pain. RN A stated resident #5 had Bi-polar disorder and had intermittent confusion and usually complained of pain to her legs and is medicated with Tylenol, [MEDICATION NAME], and [MEDICATION NAME] ointment. RN A reported that the resident's daughter & one of the CNAs had moved the resident on that day. I cannot give you details because that is all that I know. Telephone interview on 7/30/19 at 6:28 PM, RN B reported that she was the weekend supervisor. It was reported that RN A on the 2-10 shift had reported on 7/13/19 that resident #5 had started to complain of pain to the right leg in the evening. He reported that he had medicated the resident with Tylenol and the resident had continued to complain of pain during the night shift. On Sunday 7/14/19 LVN N and I went to assess the resident, she was in bed eating her breakfast and watching television, had no signs of pain. Later we went back to check her, and when we pulled the covers off, she complained of pain with movement. The resident had swelling on the right thigh and had sever pain with movement. She was yelling and moaning when she was moved. The pain radiated from the thigh to the toes. RN A reported that the resident #5 had been in pain all night and he had tried to get a hold of the MD (medical doctor) and she had not returned his call or text message. He said that he had text the MD at approximately 5:30 AM - 5:40 PM and the MD had not replied back. RN A reported that he had administered pain medication throughout the night and had applied the pain cream to the resident's right leg. We called the physician and she gave orders for an x-ray and ordered a new medication which was not in the emergency kit, so it had to be ordered from the pharmacy. The x-ray was done and at 1:30 PM, we were stunned when we found she had a fracture to the right femur. The resident was sent out to the hospital ER for evaluation by ambulance. RN B reported that the nurses had been trained to immediately report changes of condition to the physician and to report to the ADON if unable to contact the attending physician. Telephone interview on 7/30/19 at 6:40 PM with CNA D reported that she had worked on 7/13/19 on the evening shift and had been assigned to resident #5. I did not move the resident, because she was complaining of pain to the right leg. The resident was crying and yelling and did not want me to touch her. So, I went to report this to RN A right away. She was sitting in the wheelchair at the start of the shift, I tried to put her leg on the footrest but she would not let me touch her because she was having a lot of pain. I am not sure if RN A went to check the resident. Later on that day, I asked another CNA to help me put the resident in bed. I noted that her leg was very swollen above the knee, she was not able to stand and put weight on her legs, this was unusual for her, because she was in to much pain. We put her in bed and was not moved the rest of the shift. Resident was sent to the hospital on Sunday at the start of the evening shift on 7/14/19. CNA D reported that they had been trained to immediately report to the nurses any change in condition or resident complains of pain. Telephone interview on 7/30/19 at 6:50 PM, LVN N reported that she had been assigned to resident #5 on 7/14/19 on the day shift. LVN N reported that on 7/13/19 at 2:00 PM, they were getting report when one of the CNAs came to report to RN A that resident #5 was crying and yelling loudly and was complaining of pain to the right leg. RN A reported that he had medicated the resident with Tylenol and applied the pain cream for pain. LVN N said, The next day on Sunday during report RN A reported that he had been medicating the resident for pain and that the resident had complained of pain all night. We both went to assess the resident and noted that the right leg was swollen above the knee. RN A said he had notified MD and was still pending a return call/text from the physician. RN A reported resident's condition to RN B. RN B and I went to check the resident, we took a picture and she called the MD to get an order for [REDACTED].>Interview on 7/30/19 at 7:04 PM, DON reported that nurses have been trained to call the physician if pain is not relieved with pain medication and the resident continues to complain of pain. DON said, RN A sent a text to MD. What made him call the MD, was because resident's pain was getting worse and interventions were not effective. I do not know, why it took so long to call the MD. The nurses have been trained to call me or whoever is on call if they cannot reach the MD to report changes in condition. RN A reported resident #5 did not have any visible signs of injury. He thought it was baseline pain, because she always complains of pain to the lower extremities. Interview on 7/30/19 at 7:09 PM, Administrator in the presence of the DON reported the Physician had said, It did not make sense that resident's pain level was at a 6, since she had a fracture to a major bone. The physician said that with this type of fracture, resident would have excruciating pain. Telephone interview on 7/30/19 at 7:28 PM, attending physician for resident #5 confirmed that she had received a text message from RN A at 5:00 AM, reporting that resident's leg was swollen. She said, I had a late night, so I slept late on that day so I missed his text message. At 7:30 AM, RN A sent me another text to report that resident #5 had swelling and pain to the right leg. At approximately 8:30 AM, the morning nurse on 7/14/19 had already called me and I ordered a stat x-ray. When RN A sent me the text he made it seem like the resident only had inflammation to the right knee so I treated her with [MEDICATION NAME] 25 mg to be given by mouth three times a day. He did not report to me the gravity of her condition, that the resident was complaining of pain with movement was yelling out and crying. I would have given orders to send the resident to the hospital right away. This is the first time, that I hear the resident was yelling and crying with movement. This type of fracture to a large bone causes excruciating pain. If he had made an accurate report to me about the resident's condition, I would have given different orders to address the excruciating pain that she was having to the right leg right away. I would expect the nurses to call me right away and report that resident's pain was getting worse and was not relieved with pain medication. Observation and interview on 7/31/19 at 8:13 AM, resident #5 was sitting in a wheelchair in her room. Resident had a leg brace on right lower extremity. The right leg was elevated on footrest. Resident was awake, oriented to person, had a difficult time understanding simple questions. Resident denied having pain. Resident said, I fell down at home. Review of the Medication Administration Record [REDACTED]. Pain scale 1-10, 10 being the worst pain. Review of the Medication Administration Record [REDACTED]. Pain scale 1-10, 10 being the worst pain. Review of the Medication Administration Record [REDACTED]. Pain scale 1-10, 10 being the worst pain. Record review of the facility's policy and procedure on Notifying the Physician of Change in Status revised on (MONTH) 11, 2013 documented in part: The nurse should not hesitate to contact the physician at any time when as assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes an assessment tool, Change in Condition - When to Notify the MD/NP/PA (physician assistant) to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician immediately with significant change is status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The nurse is responsible for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. The resident's family member or legal guardian should be notified of significant change in resident's status. The nurse will monitor and assess the resident's status and response to interventions. Physician should develop a working [DIAGNOSES REDACTED]. If the resident remains in the facility and a significant change has occurred; update the care plan accordingly. Review of the facility's policy and procedure on Pain Management, Assessment Scale dated 5/25/16 documented: Pain is subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological. or psychological stimuli. Policy: Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals: Resident expresses a feeling of comfort and relief from pain. Cognitively impaired residents will demonstrate actions of pain relief. Procedure: Assess resident's physical symptoms of pain, physical complaints, and daily activities. Have the resident rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse must use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Monitor the effectiveness of pain interventions.

Based on observation, interview and record review the facility failed to prevent neglect which resulted in serious physical harm for 1 (Resident #5) of 21 residents reviewed for abuse and neglect. A. The facility failed to implement a system to ensure that the residents remain as free from neglect as possible and each resident receives adequate supervision to prevent accidents and to conduct a thorough investigation for one (Resident # 5) of six residents reviewed for accidents and supervision and to conduct a thorough investigation to prevent accidents. B. The facility failed to develop and implement a safe emergency evacuation route for 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway from the south side of the facility. On 4/27/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 5/05/17 the facility remained out of compliance at actual harm, isolated due to the facility's need to evaluate and monitor their corrective action system. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment, 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway at risk of serious injury or death. The findings included: A. Accident Hazards Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] 12:23 PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut. Assessment of Resident #5 was performed successfully, cervical spinal restriction of motion was performed, and reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (LOC). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of hospital trauma documentation recorded on 4/18/17 at 8:45 PM resident arrived at Level 2 Trauma. As per report patient left facility in wheelchair thru back door when she fell off 5 stairs striking head with unknown LOC, patient complains of pain to left arm, bruising and facial swelling to right side of face, laceration approximately 3 cm (centimeters) to right forehead, bleeding controlled, tenderness to right arm, abrasions to right knee. 10:48 PM patient confused and complaining of pain. 3:15 AM patient being admitted to critical care. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was LOC or not. Physical Exam, swelling to right side of face, 3 cm laceration above right eyebrow, bruising noted around right eye, right hip tenderness. Radiology report of right hip impression: no definite fracture or dislocation, possibility of nondisplaced fracture along the femoral neck. Radiology report of right shoulder impression: likely nondisplaced fracture involving the greater tuberosity. CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right [MEDICATION NAME] hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes. LVN D said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room [ROOM NUMBER] with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 3:10 PM CNA G said she put Resident #5 in her room on 4/18/17 after dinner so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:20 PM CNA Supervisor said she was in her office with LVN E and heard the alarm. She said she followed LVN E to the 400 hallway door, they went out and Resident #5 was on the ground at the bottom of the stairs. CNA Supervisor said she assisted in helping the LVN. In an interview on 4/21/17 at 2:25 PM LVN E said he was in the office with the CNA Supervisor when they heard the alarm they went to the 400 hallway door, went out and Resident #5 was face down at the bottom of the steps. LVN E said he put a towel on Resident #5's facial cut and asked her if she was in pain, she said yes. LVN E said the wheelchair was about 2-3 feet away from Resident #5, he did not remember the position of the wheelchair because his attention was on the injured resident. In an interview on 4/24/17 at 8:05 PM LVN E said when he arrived at the scene to assist with Resident #5 she was face down on the concrete at the bottom of the stairs. LVN E said Resident #5's head was away from the steps and her feet were toward the steps, the wheelchair was approximately 3 feet farther away for the steps. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said we know what happened Resident #5 went out the 400 hall fire door and fell down the stairs, she was not exit seeking so they had no way to know that might happen and no one else is exit seeking so it probably won't happen again. NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening, the painters were working in the facility the evening of 4/18/17, then the alarm was going off and going off for a long time, did not give a time estimate, but she was in a resident room and could not leave the resident. LVN I said the 400 hall door alarm sounded at both the East and West nursing stations. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on the 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the door alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29who resides on 400 hall, said it takes a long time for anyone to come. She said she did not remember the door alarm but her television was on. Review of Wandering, Unsafe Resident policy and procedure dated as revised December 2008 documented in part: The staff will identify residents who are at risk for harm because of unsafe wandering. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Observations on 4/24/17 at 12:20 PM revealed 7 doors in the facility as follows: 400 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter - 5 concrete stairs outside door 500 fire exit door - code key pad for exit and entrance - does not alarm- outside concrete sloped downward with a 7 inch drop at the end into the road. 100 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter 200 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter EAST side door code key pad for exit - push button for entry - does not alarm WEST side door code key pad for exit - push button for entry - does not alarm Front door - unlocked when the receptionist is at front desk - all other times entry and exit only with code key pad - does not alarm. Observation on 4/24/17 at 2:17 PM Resident # 3 goes to end of hallways, places hand on push bar, sits in front of the door and then turns around and goes to another door. Observation on 4/24/17 at 2:37 PM with Maintenance Director (Maint. Dir.) revealed the door alarm was not audible in a resident room with the door closed and the resident television on. In an interview on 4/24/17 at 2:50 PM the Maint. Dir. said he did not know if the alarm could be turned louder to be heard in resident rooms. Maint. Dir. said the alarm could not go over a certain decibel level but he did not know what that level was. He also said perhaps they could install alarms on the hallway as well as the nursing station so staff could hear the alarm when they were in a resident's room with the door closed. B. Emergency Evacuation Review of policy and procedure Emergency Response Fire/Explosion dated as revised October 2012 documented in part: Phase III: Evacuate all residents from the building by whatever means possible. Complete evacuation needs to be initiated by staff as quickly as possible and without hesitation. Review of policy and procedure Emergency Response Fire/Explosion dated as revised October 2012 revealed the plan did not include specific procedures and/or equipment to be implemented or utilized for evacuating residents who are not fully ambulatory through the 400 hall fire evacuation exit door and down 5 stairs or the 500 hall fire evacuation exit door and down a 7 inch curb. The plan did not include specific provision for evacuating all residents considering that there was no level standing area adjacent to the paving/fire land from 500 hall fire door. Observation on 5/4/17 at 2:20 PM revealed the posted emergency floor plans in the 400 and 500 hall both separately indicated that the 400 and 500 fire exits would be utilized for evacuation. Observation on 4/21/17 at 9:10 AM revealed the fire evacuation exit door at the end of hallway 400 opened freely from the inside by pushing on bar, alarm sounded at the nursing station not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. The door to the steps was 5 feet 10 inches, from the landing to the ground was 39 ¾ inches, each concrete was 7 inches high and at the bottom of the stairs was a 6 inch curb. There was a blood stain at the bottom of the stairs on the concrete. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 400 hallway 16 residents were in wheelchairs, 6 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. Observation on 4/21/17 at 9:30 AM revealed the fire evacuation exit door at the end of 500 could not open when pushed it required a code be used on a keypad on the wall to open the door. Outside the door was the laundry area which contained empty laundry barrels. The area outside the door was concrete with a steep decline leading down to a 7 inch curb dropping onto the driveway. Observation on 5/3/17 at 9:11 AM there were 10 wheeled linen barrels at the south east corner of the building by the facility 500 hall evacuation fire door. Only 31 inches were clear for passage. In an interview on 5/3/17 at 9:11AM the Maint. Dir said the wheeled linen barrels were usually kept there. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 500 hallway 20 residents were in wheelchairs, 5 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. In an interview on 4/24/17 at 6:30PM the Corporate Operations Officer (COO) said the fire exit door at the end of 400 hallway was an easy open door, it was not delayed release, Resident #5 went out and fell down the stairs but they had no problem with the door for [AGE] years. COO said if there was a fire and the 400 fire door had to be used they would take each resident down the 5 concrete stairs, you have to do what you have to do. If staff had to get residents down the 5 concrete stairs at 400 hall exit or the 7 inch curb at the 500 hall exit it wouldn't be easy but it would not be impossible. Observation on 4/24/17 at 8:00 PM 400 hallway no staff were visible in hallway or nursing station for 3 minutes. The glass on the 400 hallway door showed a reflection of inside, outside was not visible. In an interview on 4/28/17 at 3:10 PM LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall she does not know how they would get the non-ambulatory residents down the 7 inch curb. LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall she had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN I said it would have to be with the help of others. In an interview on 4/28/17 at 3:35 PM LVN F said in case of fire they rescue, alert, confine and extinguish. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall he had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall he does not know how they would get the non-ambulatory residents down the 7 inch curb but it would be easier than the 5 concrete stairs. LVN F said they would need a lot of staff and they would have to work as a team. In an interview on 5/2/17 at 2:50 PM the COO said if there was a fire they would take wheelchairs down the steps just like a baby stroller. He said just like a baby stroller, wheelchairs can go down stairs and curbs. In an interview on 4/26/17 at 1:35 PM, Maint. Dir. said he still did not know the acceptable decibel level for the door alarm and was still trying to find out. Nothing about exit changed since incident. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander. Review of census dated 4/26/17 documented 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway.

Based on observation, interview and record review the facility failed to prevent neglect which resulted in serious physical harm for 1 (Resident #5) of 21 residents reviewed for abuse and neglect. [NAME] The facility failed to implement a system to ensure that the residents remain as free from neglect as possible and each resident receives adequate supervision to prevent accidents and to conduct a thorough investigation for one (Resident # 5) of six residents reviewed for accidents and supervision and to conduct a thorough investigation to prevent accidents. B. The facility failed to develop and implement a safe emergency evacuation route for 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway from the south side of the facility. On 4/27/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 5/05/17 the facility remained out of compliance at actual harm, isolated due to the facility's need to evaluate and monitor their corrective action system. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment, 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway at risk of serious injury or death. The findings included: [NAME] Accident Hazards Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] 12:23 PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut. Assessment of Resident #5 was performed successfully, cervical spinal restriction of motion was performed, and reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (L[NAME]). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of hospital trauma documentation recorded on 4/18/17 at 8:45 PM resident arrived at Level 2 Trauma. As per report patient left facility in wheelchair thru back door when she fell off 5 stairs striking head with unknown L[NAME], patient complains of pain to left arm, bruising and facial swelling to right side of face, laceration approximately 3 cm (centimeters) to right forehead, bleeding controlled, tenderness to right arm, abrasions to right knee. 10:48 PM patient confused and complaining of pain. 3:15 AM patient being admitted to critical care. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was L[NAME] or not. Physical Exam, swelling to right side of face, 3 cm laceration above right eyebrow, bruising noted around right eye, right hip tenderness. Radiology report of right hip impression: no definite fracture or dislocation, possibility of nondisplaced fracture along the femoral neck. Radiology report of right shoulder impression: likely nondisplaced fracture involving the greater tuberosity. CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right [MEDICATION NAME] hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes. LVN D said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room [ROOM NUMBER] with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 3:10 PM CNA G said she put Resident #5 in her room on 4/18/17 after dinner so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:20 PM CNA Supervisor said she was in her office with LVN [NAME] and heard the alarm. She said she followed LVN [NAME] to the 400 hallway door, they went out and Resident #5 was on the ground at the bottom of the stairs. CNA Supervisor said she assisted in helping the LVN. In an interview on 4/21/17 at 2:25 PM LVN [NAME] said he was in the office with the CNA Supervisor when they heard the alarm they went to the 400 hallway door, went out and Resident #5 was face down at the bottom of the steps. LVN [NAME] said he put a towel on Resident #5's facial cut and asked her if she was in pain, she said yes. LVN [NAME] said the wheelchair was about 2-3 feet away from Resident #5, he did not remember the position of the wheelchair because his attention was on the injured resident. In an interview on 4/24/17 at 8:05 PM LVN [NAME] said when he arrived at the scene to assist with Resident #5 she was face down on the concrete at the bottom of the stairs. LVN [NAME] said Resident #5's head was away from the steps and her feet were toward the steps, the wheelchair was approximately 3 feet farther away for the steps. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said we know what happened Resident #5 went out the 400 hall fire door and fell down the stairs, she was not exit seeking so they had no way to know that might happen and no one else is exit seeking so it probably won't happen again. NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening, the painters were working in the facility the evening of 4/18/17, then the alarm was going off and going off for a long time, did not give a time estimate, but she was in a resident room and could not leave the resident. LVN I said the 400 hall door alarm sounded at both the East and West nursing stations. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on the 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the door alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29who resides on 400 hall, said it takes a long time for anyone to come. She said she did not remember the door alarm but her television was on. Review of Wandering, Unsafe Resident policy and procedure dated as revised (MONTH) 2008 documented in part: The staff will identify residents who are at risk for harm because of unsafe wandering. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Observations on 4/24/17 at 12:20 PM revealed 7 doors in the facility as follows: 400 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter - 5 concrete stairs outside door 500 fire exit door - code key pad for exit and entrance - does not alarm- outside concrete sloped downward with a 7 inch drop at the end into the road. 100 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter 200 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter EAST side door code key pad for exit - push button for entry - does not alarm WEST side door code key pad for exit - push button for entry - does not alarm Front door - unlocked when the receptionist is at front desk - all other times entry and exit only with code key pad - does not alarm. Observation on 4/24/17 at 2:17 PM Resident # 3 goes to end of hallways, places hand on push bar, sits in front of the door and then turns around and goes to another door. Observation on 4/24/17 at 2:37 PM with Maintenance Director (Maint. Dir.) revealed the door alarm was not audible in a resident room with the door closed and the resident television on. In an interview on 4/24/17 at 2:50 PM the Maint. Dir. said he did not know if the alarm could be turned louder to be heard in resident rooms. Maint. Dir. said the alarm could not go over a certain decibel level but he did not know what that level was. He also said perhaps they could install alarms on the hallway as well as the nursing station so staff could hear the alarm when they were in a resident's room with the door closed. B. Emergency Evacuation Review of policy and procedure Emergency Response Fire/Explosion dated as revised (MONTH) 2012 documented in part: Phase III: Evacuate all residents from the building by whatever means possible. Complete evacuation needs to be initiated by staff as quickly as possible and without hesitation. Review of policy and procedure Emergency Response Fire/Explosion dated as revised (MONTH) 2012 revealed the plan did not include specific procedures and/or equipment to be implemented or utilized for evacuating residents who are not fully ambulatory through the 400 hall fire evacuation exit door and down 5 stairs or the 500 hall fire evacuation exit door and down a 7 inch curb. The plan did not include specific provision for evacuating all residents considering that there was no level standing area adjacent to the paving/fire land from 500 hall fire door. Observation on 5/4/17 at 2:20 PM revealed the posted emergency floor plans in the 400 and 500 hall both separately indicated that the 400 and 500 fire exits would be utilized for evacuation. Observation on 4/21/17 at 9:10 AM revealed the fire evacuation exit door at the end of hallway 400 opened freely from the inside by pushing on bar, alarm sounded at the nursing station not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. The door to the steps was 5 feet 10 inches, from the landing to the ground was 39 ¾ inches, each concrete was 7 inches high and at the bottom of the stairs was a 6 inch curb. There was a blood stain at the bottom of the stairs on the concrete. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 400 hallway 16 residents were in wheelchairs, 6 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. Observation on 4/21/17 at 9:30 AM revealed the fire evacuation exit door at the end of 500 could not open when pushed it required a code be used on a keypad on the wall to open the door. Outside the door was the laundry area which contained empty laundry barrels. The area outside the door was concrete with a steep decline leading down to a 7 inch curb dropping onto the driveway. Observation on 5/3/17 at 9:11 AM there were 10 wheeled linen barrels at the south east corner of the building by the facility 500 hall evacuation fire door. Only 31 inches were clear for passage. In an interview on 5/3/17 at 9:11AM the Maint. Dir said the wheeled linen barrels were usually kept there. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 500 hallway 20 residents were in wheelchairs, 5 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. In an interview on 4/24/17 at 6:30PM the Corporate Operations Officer (COO) said the fire exit door at the end of 400 hallway was an easy open door, it was not delayed release, Resident #5 went out and fell down the stairs but they had no problem with the door for [AGE] years. COO said if there was a fire and the 400 fire door had to be used they would take each resident down the 5 concrete stairs, you have to do what you have to do. If staff had to get residents down the 5 concrete stairs at 400 hall exit or the 7 inch curb at the 500 hall exit it wouldn't be easy but it would not be impossible. Observation on 4/24/17 at 8:00 PM 400 hallway no staff were visible in hallway or nursing station for 3 minutes. The glass on the 400 hallway door showed a reflection of inside, outside was not visible. In an interview on 4/28/17 at 3:10 PM LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall she does not know how they would get the non-ambulatory residents down the 7 inch curb. LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall she had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN I said it would have to be with the help of others. In an interview on 4/28/17 at 3:35 PM LVN F said in case of fire they rescue, alert, confine and extinguish. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall he had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall he does not know how they would get the non-ambulatory residents down the 7 inch curb but it would be easier than the 5 concrete stairs. LVN F said they would need a lot of staff and they would have to work as a team. In an interview on 5/2/17 at 2:50 PM the COO said if there was a fire they would take wheelchairs down the steps just like a baby stroller. He said just like a baby stroller, wheelchairs can go down stairs and curbs. In an interview on 4/26/17 at 1:35 PM, Maint. Dir. said he still did not know the acceptable decibel level for the door alarm and was still trying to find out. Nothing about exit changed since incident. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander. Review of census dated 4/26/17 documented 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway.

Based on observation, interview and record review the facility failed to thoroughly investigate an unwitnessed incident resulting in serious physical harm for 1 (Resident #5) of 21 residents reviewed for abuse and neglect. Resident #5, who had a known history of wandering, exited the facility at 8:00 PM unnoticed through an unsecured fire exit at the end of her hallway. She fell down 5 concrete stairs in her wheelchair. She was hospitalized in the intensive care unit due to injuries sustained including a subarachnoid hemorrhage (bleeding in the brain), fractured humerus (long bone in the upper arm) and maxillary (jawbone) bones, and a facial laceration (cuts). The facility failed to investigate and to implement systems to prevent another occurrence. An immediate jeopardy was identified on 4/27/17. While the immediate jeopardy was removed on 5/5/17, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy, isolated as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment at risk of serious injury or death. The findings included: Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut. Assessment of Resident #5 was performed successfully, cervical spinal restriction of motion was performed, and reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (LOC). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of hospital trauma documentation recorded on 4/18/17 at 8:45 PM resident arrived at Level 2 Trauma. As per report patient left facility in wheelchair thru back door when she fell off 5 stairs striking head with unknown LOC, patient complains of pain to left arm, bruising and facial swelling to right side of face, laceration approximately 3 cm (centimeters) to right forehead, bleeding controlled, tenderness to right arm, abrasions to right knee. 10:48 PM patient confused and complaining of pain. 3:15 AM patient being admitted to critical care. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was LOC or not. Physical Exam, swelling to right side of face, 3 cm laceration above right eyebrow, bruising noted around right eye, right hip tenderness. Radiology report of right hip impression: no definite fracture or dislocation, possibility of nondisplaced fracture along the femoral neck. Radiology report of right shoulder impression: likely nondisplaced fracture involving the greater tuberosity. CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right [MEDICATION NAME] hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes. LVN D said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room [ROOM NUMBER] with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. LVN F said he has not been instructed to implement any changes. In an interview on 4/21/17 at 3:10 PM CNA G said on 4/18/17 she put Resident #5 in her room after dinner so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said it was obvious what happened, he didn't need to investigate NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening then the alarm was going off and going off for a long time but she was in a resident room and could not leave the resident. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29 said it takes a long time for anyone to come. She said she did not remember the alarm but her television was on. Review of undated policy and procedure Abuse Investigation provided by the NHA documented in part: Should an incident of resident abuse, neglect or injury of unknown origin be reported, the NHA and/or their designee will immediately investigate An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander.

Based on observation, interview and record review the facility failed to thoroughly investigate an unwitnessed incident resulting in serious physical harm for 1 (Resident #5) of 21 residents reviewed for abuse and neglect. Resident #5, who had a known history of wandering, exited the facility at 8:00 PM unnoticed through an unsecured fire exit at the end of her hallway. She fell down 5 concrete stairs in her wheelchair. She was hospitalized in the intensive care unit due to injuries sustained including a subarachnoid hemorrhage (bleeding in the brain), fractured humerus (long bone in the upper arm) and maxillary (jawbone) bones, and a facial laceration (cuts). The facility failed to investigate and to implement systems to prevent another occurrence. An immediate jeopardy was identified on 4/27/17. While the immediate jeopardy was removed on 5/5/17, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy, isolated as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment at risk of serious injury or death. The findings included: Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut. Assessment of Resident #5 was performed successfully, cervical spinal restriction of motion was performed, and reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (L[NAME]). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of hospital trauma documentation recorded on 4/18/17 at 8:45 PM resident arrived at Level 2 Trauma. As per report patient left facility in wheelchair thru back door when she fell off 5 stairs striking head with unknown L[NAME], patient complains of pain to left arm, bruising and facial swelling to right side of face, laceration approximately 3 cm (centimeters) to right forehead, bleeding controlled, tenderness to right arm, abrasions to right knee. 10:48 PM patient confused and complaining of pain. 3:15 AM patient being admitted to critical care. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was L[NAME] or not. Physical Exam, swelling to right side of face, 3 cm laceration above right eyebrow, bruising noted around right eye, right hip tenderness. Radiology report of right hip impression: no definite fracture or dislocation, possibility of nondisplaced fracture along the femoral neck. Radiology report of right shoulder impression: likely nondisplaced fracture involving the greater tuberosity. CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right [MEDICATION NAME] hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes. LVN D said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room [ROOM NUMBER] with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. LVN F said he has not been instructed to implement any changes. In an interview on 4/21/17 at 3:10 PM CNA G said on 4/18/17 she put Resident #5 in her room after dinner so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said it was obvious what happened, he didn't need to investigate NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening then the alarm was going off and going off for a long time but she was in a resident room and could not leave the resident. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29 said it takes a long time for anyone to come. She said she did not remember the alarm but her television was on. Review of undated policy and procedure Abuse Investigation provided by the NHA documented in part: Should an incident of resident abuse, neglect or injury of unknown origin be reported, the NHA and/or their designee will immediately investigate An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander.

Based on observation, interview and record review the facility failed to implement written policies and procedures to thoroughly investigate an unwitnessed incident resulting in serious physical harm for 1 (Resident #5) of 21 residents reviewed for abuse and neglect. Resident #5, who had a known history of wandering, exited the facility at 8:00 PM unnoticed through an unsecured fire exit at the end of her hallway. She fell down 5 concrete stairs in her wheelchair. She was hospitalized in the intensive care unit due to injuries sustained including a subarachnoid hemorrhage (bleeding in the brain), fractured humerus (long bone in the upper arm) and maxillary (jawbone) bones, and a facial laceration (cuts). The facility failed to implement systems to prevent another occurrence. An immediate jeopardy was identified on 4/27/17. While the immediate jeopardy was removed on 5/5/17, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy, isolated as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment at risk of serious injury or death. The findings included: Review of undated policy and procedure Abuse Investigation provided by the NHA documented in part: It is the policy of the facility that all reports of resident abuse, neglect or injury of unknown origin shall be promptly reported and thoroughly investigated by the facility management Should an incident of resident abuse, neglect or injury of unknown origin be reported, the NHA and/or their designee will immediately investigate Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] 12:23 PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut. Assessment of Resident #5 was performed successfully, cervical spinal restriction of motion was performed, and reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (LOC). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of hospital trauma documentation recorded on 4/18/17 at 8:45 PM resident arrived at Level 2 Trauma. As per report patient left facility in wheelchair thru back door when she fell off 5 stairs striking head with unknown LOC, patient complains of pain to left arm, bruising and facial swelling to right side of face, laceration approximately 3 cm (centimeters) to right forehead, bleeding controlled, tenderness to right arm, abrasions to right knee. 10:48 PM patient confused and complaining of pain. 3:15 AM patient being admitted to critical care. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was LOC or not. Physical Exam, swelling to right side of face, 3 cm laceration above right eyebrow, bruising noted around right eye, right hip tenderness. Radiology report of right hip impression: no definite fracture or dislocation, possibility of nondisplaced fracture along the femoral neck. Radiology report of right shoulder impression: likely nondisplaced fracture involving the greater tuberosity. CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right [MEDICATION NAME] hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift, documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Review of Wandering Risk Scale assessment dated [DATE] 12:23 PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes. LVN D said nothing had changed since the incident. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room [ROOM NUMBER] with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. In an interview on 4/21/17 at 3:10 PM CNA G said she put Resident #5 in her room after dinner on 4/18/17 so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said we know what happened Resident #5 went out the 400 hall fire door and fell down the stairs, she was not exit seeking so they had no way to know that might happen and no one else is exit seeking so it probably won't happen again. NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening, the painters were working in the facility the evening of 4/18/17, then the alarm was going off and going off for a long time, did not give a time estimate, but she was in a resident room and could not leave the resident. LVN I said the 400 hall door alarm sounded at both the East and West nursing stations. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on the 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the door alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29, who resides on the 400 hall, said it takes a long time for anyone to come. She said she did not remember the door alarm but her television was on. Review of Wandering, Unsafe Resident policy and procedure dated as revised December 2008 documented in part: The staff will identify residents who are at risk for harm because of unsafe wandering. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander.

Based on observation, interview and record review the facility failed to implement written policies and procedures to thoroughly investigate an unwitnessed incident resulting in serious physical harm for 1 (Resident #5) of 21 residents reviewed for abuse and neglect. Resident #5, who had a known history of wandering, exited the facility at 8:00 PM unnoticed through an unsecured fire exit at the end of her hallway. She fell down 5 concrete stairs in her wheelchair. She was hospitalized in the intensive care unit due to injuries sustained including a subarachnoid hemorrhage (bleeding in the brain), fractured humerus (long bone in the upper arm) and maxillary (jawbone) bones, and a facial laceration (cuts). The facility failed to implement systems to prevent another occurrence. An immediate jeopardy was identified on 4/27/17. While the immediate jeopardy was removed on 5/5/17, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy, isolated as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment at risk of serious injury or death. The findings included: Review of undated policy and procedure Abuse Investigation provided by the NHA documented in part: It is the policy of the facility that all reports of resident abuse, neglect or injury of unknown origin shall be promptly reported and thoroughly investigated by the facility management Should an incident of resident abuse, neglect or injury of unknown origin be reported, the NHA and/or their designee will immediately investigate Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] 12:23 PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut. Assessment of Resident #5 was performed successfully, cervical spinal restriction of motion was performed, and reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (L[NAME]). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of hospital trauma documentation recorded on 4/18/17 at 8:45 PM resident arrived at Level 2 Trauma. As per report patient left facility in wheelchair thru back door when she fell off 5 stairs striking head with unknown L[NAME], patient complains of pain to left arm, bruising and facial swelling to right side of face, laceration approximately 3 cm (centimeters) to right forehead, bleeding controlled, tenderness to right arm, abrasions to right knee. 10:48 PM patient confused and complaining of pain. 3:15 AM patient being admitted to critical care. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was L[NAME] or not. Physical Exam, swelling to right side of face, 3 cm laceration above right eyebrow, bruising noted around right eye, right hip tenderness. Radiology report of right hip impression: no definite fracture or dislocation, possibility of nondisplaced fracture along the femoral neck. Radiology report of right shoulder impression: likely nondisplaced fracture involving the greater tuberosity. CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right [MEDICATION NAME] hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift, documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Review of Wandering Risk Scale assessment dated [DATE] 12:23 PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes. LVN D said nothing had changed since the incident. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room [ROOM NUMBER] with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. In an interview on 4/21/17 at 3:10 PM CNA G said she put Resident #5 in her room after dinner on 4/18/17 so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said we know what happened Resident #5 went out the 400 hall fire door and fell down the stairs, she was not exit seeking so they had no way to know that might happen and no one else is exit seeking so it probably won't happen again. NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening, the painters were working in the facility the evening of 4/18/17, then the alarm was going off and going off for a long time, did not give a time estimate, but she was in a resident room and could not leave the resident. LVN I said the 400 hall door alarm sounded at both the East and West nursing stations. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on the 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the door alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29, who resides on the 400 hall, said it takes a long time for anyone to come. She said she did not remember the door alarm but her television was on. Review of Wandering, Unsafe Resident policy and procedure dated as revised (MONTH) 2008 documented in part: The staff will identify residents who are at risk for harm because of unsafe wandering. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free from accident hazards as possible and each resident received adequate supervision to prevent accidents for one (Resident # 5) of six residents reviewed for accidents and supervision. Resident #5, who had a known history of wandering, exited the facility at 8:00 PM unnoticed through an unsecured fire exit at the end of her hallway. She fell down 5 concrete stairs in her wheelchair.She was hospitalized in the intensive care unit due to injuries sustained including a subarachnoid hemorrhage (brain bleed), fractured humerus (long bone in the upper arm) and maxillary (jawbone) bones, and a facial laceration (cuts). The facility failed to implement systems to prevent another occurrence. An immediate jeopardy was identified on 4/27/17. While the immediate jeopardy was removed on 5/5/17, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy, isolated as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment at risk of serious injury or death. The findings included: Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut . reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (LOC). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was LOC or not .CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right buccal hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of hospital trauma documentation recorded on 4/19/17 at 3:15 AM patient being admitted to critical care. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes because they were in and out of the building. LVN D said nothing had changed since the incident. LVN D said he has not been instructed to implement and changes. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room 404 with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. In an interview on 4/21/17 at 3:10 PM CNA G said on 4/18/17 she put Resident #5 in her room after dinner so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:20 PM CNA Supervisor said she was in her office with LVN E and heard the alarm. She said she followed LVN E to the 400 hallway door, they went out and Resident #5 was on the ground at the bottom of the stairs. CNA Supervisor said she assisted in helping the LVN. In an interview on 4/21/17 at 2:25 PM LVN E said he was in the office with the CNA Supervisor when they heard the alarm they went to the 400 hallway door, went out and Resident #5 was face down at the bottom of the steps. LVN E said he put a towel on Resident #5's facial cut and asked her if she was in pain, she said yes. LVN E said the wheelchair was about 2-3 feet away from Resident #5, he did not remember the position of the wheelchair because his attention was on the injured resident. In an interview on 4/24/17 at 8:05 PM LVN E said when he arrived at the scene to assist with Resident #5 she was face down on the concrete at the bottom of the stairs. LVN E said Resident #5's head was away from the steps and her feet were toward the steps, the wheelchair was approximately 3 feet farther away from the steps. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said we know what happened Resident #5 went out the 400 hall fire door and fell down the stairs, she was not exit seeking so they had no way to know that might happen and no one else is exit seeking so it probably won't happen again. NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening, the painters were working in the facility the evening of 4/18/17, then the alarm was going off and going off for a long time, did not give a time estimate, but she was in a resident room and could not leave the resident. LVN I said the 400 hall door alarm sounded at both the East and West nursing stations. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on the 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the door alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29, who resides on 400 hall, said it takes a long time for anyone to come. She said she did not remember hearing the door alarm but her television was on. Review of Wandering, Unsafe Resident policy and procedure dated as revised December 2008 documented in part: The staff will identify residents who are at risk for harm because of unsafe wandering. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Observations on 4/24/17 at 12:20 PM revealed 7 doors in the facility as follows: 400 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter - 5 concrete stairs outside door 500 fire exit door - code key pad for exit and entrance - does not alarm- outside concrete sloped downward with a 7 inch drop at the end into the road. 100 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter 200 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter EAST side door code key pad for exit - push button for entry - does not alarm WEST side door code key pad for exit - push button for entry - does not alarm Front door - unlocked when the receptionist is at front desk - all other times entry and exit only with code key pad - does not alarm. Observation on 4/24/17 at 2:17 PM Resident # 3 goes to end of hallways, places hand on push bar, sits in front of the door and then turns around and goes to another door. Review of face sheet dated 4/25/17 documented Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Wandering Risk Scale Assessment Scoring Report provided by nursing on 4/24/17 documented Resident #3 was a High Risk to Wander score of 13.0 Observation on 4/24/17 at 2:37 PM with Maintenance Director (Maint. Dir.) revealed the 400 hall door alarm was not audible in a resident room with the door closed and the resident television on. In an interview on 4/24/17 at 2:50 PM the Maint. Dir. said he did not know if the alarm could be turned louder to be heard in resident rooms. Maint. Dir. said the alarm could not go over a certain decibel level but he did not know what that level was. He also said perhaps they could install alarms on the hallway as well as the nursing station so staff could hear the alarm when they were in a resident's room with the door closed. In an interview on 4/24/17 at 6:30 PM the Corporate Operations Officer (COO) said the fire exit door at the end of 400 hallway was an easy open door, it was not delayed release, Resident #5 went out and fell down the stairs but they had no problem with the door for [AGE] years. COO said if there was a fire and the 400 fire door had to be used they would take each resident down the 5 concrete stairs, you have to do what you have to do. If staff had to get residents down the 5 concrete stairs at 400 hall exit or the 7 inch curb at the 500 hall exit it wouldn't be easy but it would not be impossible. Observation on 4/24/17 at 8:00 PM 400 hallway no staff were visible in hallway or nursing station for 3 minutes. The glass on the 400 hallway door showed a reflection of inside, outside was not visible. In an interview on 4/25/17 at 10:45 AM LVN D said Resident #5 returned from the hospital the night of 4/24/17, was out of bed in a wheelchair in the morning but the staff put her back into bed because she was tired. Observation on 4/25/17 at 10:47 AM revealed Resident #5 in her bed with her eyes closed, her face was swollen and discolored from bruising. In an interview on 4/25/17 at 10:48 AM Resident #5's daughter said she was worried about her mother because she would not eat at the hospital. In an interview on 4/25/17 at 4:25 PM CNA H said on 4/18/17 she went out 500 hall door to take her dirty laundry then walked around the back of the building to the dumpster to take her trash. CNA H said when she got to the trash dumpster she saw Resident #5 on the concrete at the bottom of the stairs and LVN F and CNA G taking care of her. CNA H said nothing has changed, she didn't think, since the incident. Observation on 4/26/17 at 8:13 AM Resident #5 was sitting in the dining room at a horse-shoe table in a high-back wheelchair with a hoyer (a mechanical lift) sling under her. Resident #5's head was down on the table. In an interview on 4/26/17 at 8:15 AM LVN D said when Resident #5 returned from the hospital and was evaluated by therapy they ordered her to use a hoyer for transfer and a high-back wheelchair. Observation on 4/26/17 at 10:05 AM revealed Resident #5 in the therapy department with the Speech Language Pathologist (SLP) icing her face due to the swelling. In an interview on 4/26/17 at 10:10 AM the Physical Therapist (PT) said Resident #5 was evaluated on 4/25/17. PT said prior to the fall Resident #5 was standing and transferring herself and now after the incident she cannot stand. PT said because Resident #5 can no longer stand he ordered that she be transferred with a hoyer lift. PT also said now after the incident she no longer had trunk control and was leaning forward for that reason PT ordered a high-back wheelchair. In an interview on 4/26/17 at 1:35 PM, Maint. Dir. said he still did not know the acceptable decibel level for the door alarm and was still trying to find out. Nothing about exit changed since incident. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free from accident hazards as possible and each resident received adequate supervision to prevent accidents for one (Resident # 5) of six residents reviewed for accidents and supervision. Resident #5, who had a known history of wandering, exited the facility at 8:00 PM unnoticed through an unsecured fire exit at the end of her hallway. She fell down 5 concrete stairs in her wheelchair.She was hospitalized in the intensive care unit due to injuries sustained including a subarachnoid hemorrhage (brain bleed), fractured humerus (long bone in the upper arm) and maxillary (jawbone) bones, and a facial laceration (cuts). The facility failed to implement systems to prevent another occurrence. An immediate jeopardy was identified on 4/27/17. While the immediate jeopardy was removed on 5/5/17, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy, isolated as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment at risk of serious injury or death. The findings included: Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut . reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (L[NAME]). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was L[NAME] or not .CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right buccal hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of hospital trauma documentation recorded on 4/19/17 at 3:15 AM patient being admitted to critical care. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes because they were in and out of the building. LVN D said nothing had changed since the incident. LVN D said he has not been instructed to implement and changes. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room 404 with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. In an interview on 4/21/17 at 3:10 PM CNA G said on 4/18/17 she put Resident #5 in her room after dinner so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:20 PM CNA Supervisor said she was in her office with LVN [NAME] and heard the alarm. She said she followed LVN [NAME] to the 400 hallway door, they went out and Resident #5 was on the ground at the bottom of the stairs. CNA Supervisor said she assisted in helping the LVN. In an interview on 4/21/17 at 2:25 PM LVN [NAME] said he was in the office with the CNA Supervisor when they heard the alarm they went to the 400 hallway door, went out and Resident #5 was face down at the bottom of the steps. LVN [NAME] said he put a towel on Resident #5's facial cut and asked her if she was in pain, she said yes. LVN [NAME] said the wheelchair was about 2-3 feet away from Resident #5, he did not remember the position of the wheelchair because his attention was on the injured resident. In an interview on 4/24/17 at 8:05 PM LVN [NAME] said when he arrived at the scene to assist with Resident #5 she was face down on the concrete at the bottom of the stairs. LVN [NAME] said Resident #5's head was away from the steps and her feet were toward the steps, the wheelchair was approximately 3 feet farther away from the steps. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said we know what happened Resident #5 went out the 400 hall fire door and fell down the stairs, she was not exit seeking so they had no way to know that might happen and no one else is exit seeking so it probably won't happen again. NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening, the painters were working in the facility the evening of 4/18/17, then the alarm was going off and going off for a long time, did not give a time estimate, but she was in a resident room and could not leave the resident. LVN I said the 400 hall door alarm sounded at both the East and West nursing stations. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on the 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the door alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29, who resides on 400 hall, said it takes a long time for anyone to come. She said she did not remember hearing the door alarm but her television was on. Review of Wandering, Unsafe Resident policy and procedure dated as revised (MONTH) 2008 documented in part: The staff will identify residents who are at risk for harm because of unsafe wandering. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Observations on 4/24/17 at 12:20 PM revealed 7 doors in the facility as follows: 400 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter - 5 concrete stairs outside door 500 fire exit door - code key pad for exit and entrance - does not alarm- outside concrete sloped downward with a 7 inch drop at the end into the road. 100 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter 200 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter EAST side door code key pad for exit - push button for entry - does not alarm WEST side door code key pad for exit - push button for entry - does not alarm Front door - unlocked when the receptionist is at front desk - all other times entry and exit only with code key pad - does not alarm. Observation on 4/24/17 at 2:17 PM Resident # 3 goes to end of hallways, places hand on push bar, sits in front of the door and then turns around and goes to another door. Review of face sheet dated 4/25/17 documented Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Wandering Risk Scale Assessment Scoring Report provided by nursing on 4/24/17 documented Resident #3 was a High Risk to Wander score of 13.0 Observation on 4/24/17 at 2:37 PM with Maintenance Director (Maint. Dir.) revealed the 400 hall door alarm was not audible in a resident room with the door closed and the resident television on. In an interview on 4/24/17 at 2:50 PM the Maint. Dir. said he did not know if the alarm could be turned louder to be heard in resident rooms. Maint. Dir. said the alarm could not go over a certain decibel level but he did not know what that level was. He also said perhaps they could install alarms on the hallway as well as the nursing station so staff could hear the alarm when they were in a resident's room with the door closed. In an interview on 4/24/17 at 6:30 PM the Corporate Operations Officer (COO) said the fire exit door at the end of 400 hallway was an easy open door, it was not delayed release, Resident #5 went out and fell down the stairs but they had no problem with the door for [AGE] years. COO said if there was a fire and the 400 fire door had to be used they would take each resident down the 5 concrete stairs, you have to do what you have to do. If staff had to get residents down the 5 concrete stairs at 400 hall exit or the 7 inch curb at the 500 hall exit it wouldn't be easy but it would not be impossible. Observation on 4/24/17 at 8:00 PM 400 hallway no staff were visible in hallway or nursing station for 3 minutes. The glass on the 400 hallway door showed a reflection of inside, outside was not visible. In an interview on 4/25/17 at 10:45 AM LVN D said Resident #5 returned from the hospital the night of 4/24/17, was out of bed in a wheelchair in the morning but the staff put her back into bed because she was tired. Observation on 4/25/17 at 10:47 AM revealed Resident #5 in her bed with her eyes closed, her face was swollen and discolored from bruising. In an interview on 4/25/17 at 10:48 AM Resident #5's daughter said she was worried about her mother because she would not eat at the hospital. In an interview on 4/25/17 at 4:25 PM CNA H said on 4/18/17 she went out 500 hall door to take her dirty laundry then walked around the back of the building to the dumpster to take her trash. CNA H said when she got to the trash dumpster she saw Resident #5 on the concrete at the bottom of the stairs and LVN F and CNA G taking care of her. CNA H said nothing has changed, she didn't think, since the incident. Observation on 4/26/17 at 8:13 AM Resident #5 was sitting in the dining room at a horse-shoe table in a high-back wheelchair with a hoyer (a mechanical lift) sling under her. Resident #5's head was down on the table. In an interview on 4/26/17 at 8:15 AM LVN D said when Resident #5 returned from the hospital and was evaluated by therapy they ordered her to use a hoyer for transfer and a high-back wheelchair. Observation on 4/26/17 at 10:05 AM revealed Resident #5 in the therapy department with the Speech Language Pathologist (SLP) icing her face due to the swelling. In an interview on 4/26/17 at 10:10 AM the Physical Therapist (PT) said Resident #5 was evaluated on 4/25/17. PT said prior to the fall Resident #5 was standing and transferring herself and now after the incident she cannot stand. PT said because Resident #5 can no longer stand he ordered that she be transferred with a hoyer lift. PT also said now after the incident she no longer had trunk control and was leaning forward for that reason PT ordered a high-back wheelchair. In an interview on 4/26/17 at 1:35 PM, Maint. Dir. said he still did not know the acceptable decibel level for the door alarm and was still trying to find out. Nothing about exit changed since incident. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander.

Based on observation, interview and record review, the Nursing Facility Administrator (NFA) and Director of Nurses (DON) failed to ensure the facility was administered in a manner which enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. A. The NFA and the DON failed to implement a system to ensure that the resident environment remains as free from accident hazards as possible and each resident receives adequate supervision to prevent accidents and to conduct a thorough investigation for one (Resident # 5) of six residents reviewed for accidents and supervision and to conduct a thorough investigation to prevent accidents. B. The NFA and DON failed to develop and implement a safe emergency evacuation route for 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway from the south side of the facility. On 4/27/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 5/05/17 the facility remained out of compliance at actual harm, isolated due to the facility's need to evaluate and monitor their corrective action system. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment, 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway at risk of serious injury or death. The findings included: A. Accident Hazards Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] 12:23 PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (LOC). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was LOC or not. Physical Exam, swelling to right side of face, 3 cm laceration above right eyebrow, bruising noted around right eye, right hip tenderness CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right [MEDICATION NAME] hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of hospital trauma documentation recorded on 4/19/17 at 3:15 AM patient being admitted to critical care. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes. LVN D said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room [ROOM NUMBER] with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 3:10 PM CNA G said she put Resident #5 in her room on 4/18/17 after dinner so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:20 PM CNA Supervisor said she was in her office with LVN E and heard the alarm. She said she followed LVN E to the 400 hallway door, they went out and Resident #5 was on the ground at the bottom of the stairs. CNA Supervisor said she assisted in helping the LVN. In an interview on 4/21/17 at 2:25 PM LVN E said he was in the office with the CNA Supervisor when they heard the alarm they went to the 400 hallway door, went out and Resident #5 was face down at the bottom of the steps. LVN E said he put a towel on Resident #5's facial cut and asked her if she was in pain, she said yes. LVN E said the wheelchair was about 2-3 feet away from Resident #5, he did not remember the position of the wheelchair because his attention was on the injured resident. In an interview on 4/24/17 at 8:05 PM LVN E said when he arrived at the scene to assist with Resident #5 she was face down on the concrete at the bottom of the stairs. LVN E said Resident #5's head was away from the steps and her feet were toward the steps, the wheelchair was approximately 3 feet farther away for the steps. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said we know what happened Resident #5 went out the 400 hall fire door and fell down the stairs, she was not exit seeking so they had no way to know that might happen and no one else is exit seeking so it probably won't happen again. NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening, the painters were working in the facility the evening of 4/18/17, then the alarm was going off and going off for a long time, did not give a time estimate, but she was in a resident room and could not leave the resident. LVN I said the 400 hall door alarm sounded at both the East and West nursing stations. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on the 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the door alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29who resides on 400 hall, said it takes a long time for anyone to come. She said she did not remember the door alarm but her television was on. Review of Wandering, Unsafe Resident policy and procedure dated as revised December 2008 documented in part: The staff will identify residents who are at risk for harm because of unsafe wandering. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Observations on 4/24/17 at 12:20 PM revealed 7 doors in the facility as follows: 400 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter - 5 concrete stairs outside door 500 fire exit door - code key pad for exit and entrance - does not alarm- outside concrete sloped downward with a 7 inch drop at the end into the road. 100 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter 200 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter EAST side door code key pad for exit - push button for entry - does not alarm WEST side door code key pad for exit - push button for entry - does not alarm Front door - unlocked when the receptionist is at front desk - all other times entry and exit only with code key pad - does not alarm. Observation on 4/24/17 at 2:17 PM Resident # 3 goes to end of hallways, places hand on push bar, sits in front of the door and then turns around and goes to another door. Observation on 4/24/17 at 2:37 PM with Maintenance Director (Maint. Dir.) revealed the door alarm was not audible in a resident room with the door closed and the resident television on. In an interview on 4/24/17 at 2:50 PM the Maint. Dir. said he did not know if the alarm could be turned louder to be heard in resident rooms. Maint. Dir. said the alarm could not go over a certain decibel level but he did not know what that level was. He also said perhaps they could install alarms on the hallway as well as the nursing station so staff could hear the alarm when they were in a resident's room with the door closed. B. Emergency Evacuation Review of policy and procedure Emergency Response Fire/Explosion dated as revised October 2012 documented in part: Phase III: Evacuate all residents from the building by whatever means possible. Complete evacuation needs to be initiated by staff as quickly as possible and without hesitation. Review of policy and procedure Emergency Response Fire/Explosion dated as revised October 2012 revealed the plan did not include specific procedures and/or equipment to be implemented or utilized for evacuating residents who are not fully ambulatory through the 400 hall fire evacuation exit door and down 5 stairs or the 500 hall fire evacuation exit door and down a 7 inch curb. The plan did not include specific provision for evacuating all residents considering that there was no level standing area adjacent to the paving/fire land from 500 hall fire door. Observation on 5/4/17 at 2:20 PM revealed the posted emergency floor plans in the 400 and 500 hall both separately indicated that the 400 and 500 fire exits would be utilized for evacuation. Observation on 4/21/17 at 9:10 AM revealed the fire evacuation exit door at the end of hallway 400 opened freely from the inside by pushing on bar, alarm sounded at the nursing station not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. The door to the steps was 5 feet 10 inches, from the landing to the ground was 39 ¾ inches, each concrete was 7 inches high and at the bottom of the stairs was a 6 inch curb. There was a blood stain at the bottom of the stairs on the concrete. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 400 hallway 16 residents were in wheelchairs, 6 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. Observation on 4/21/17 at 9:30 AM revealed the fire evacuation exit door at the end of 500 could not open when pushed it required a code be used on a keypad on the wall to open the door. Outside the door was the laundry area which contained empty laundry barrels. The area outside the door was concrete with a steep decline leading down to a 7 inch curb dropping onto the driveway. Observation on 5/3/17 at 9:11 AM there were 10 wheeled linen barrels at the south east corner of the building by the facility 500 hall evacuation fire door. Only 31 inches were clear for passage. In an interview ON 5/3/17 at 9:11AM the Maint. Dir said the wheeled linen barrels were usually kept there. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 500 hallway 20 residents were in wheelchairs, 5 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. In an interview on 4/24/17 at 6:30PM the Corporate Operations Officer (COO) said the fire exit door at the end of 400 hallway was an easy open door, it was not delayed release, Resident #5 went out and fell down the stairs but they had no problem with the door for [AGE] years. COO said if there was a fire and the 400 fire door had to be used they would take each resident down the 5 concrete stairs, you have to do what you have to do. If staff had to get residents down the 5 concrete stairs at 400 hall exit or the 7 inch curb at the 500 hall exit it wouldn't be easy but it would not be impossible. Observation on 4/24/17 at 8:00 PM 400 hallway no staff were visible in hallway or nursing station for 3 minutes. The glass on the 400 hallway door showed a reflection of inside, outside was not visible. In an interview on 4/28/17 at 3:10 PM LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall she does not know how they would get the non-ambulatory residents down the 7 inch curb. LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall she had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN I said it would have to be with the help of others. In an interview on 4/28/17 at 3:35 PM LVN F said in case of fire they rescue, alert, confine and extinguish. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall he had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall he does not know how they would get the non-ambulatory residents down the 7 inch curb but it would be easier than the 5 concrete stairs. LVN F said they would need a lot of staff and they would have to work as a team. In an interview on 5/2/17 at 2:50 PM the COO said if there was a fire they would take wheelchairs down the steps just like a baby stroller. He said just like a baby stroller, wheelchairs can go down stairs and curbs. In an interview on 4/26/17 at 1:35 PM, Maint. Dir. said he still did not know the acceptable decibel level for the door alarm and was still trying to find out. Nothing about exit changed since incident. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander. Review of census dated 4/26/17 documented 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway.

Based on observation, interview and record review, the Nursing Facility Administrator (NFA) and Director of Nurses (DON) failed to ensure the facility was administered in a manner which enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. [NAME] The NFA and the DON failed to implement a system to ensure that the resident environment remains as free from accident hazards as possible and each resident receives adequate supervision to prevent accidents and to conduct a thorough investigation for one (Resident # 5) of six residents reviewed for accidents and supervision and to conduct a thorough investigation to prevent accidents. B. The NFA and DON failed to develop and implement a safe emergency evacuation route for 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway from the south side of the facility. On 4/27/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 5/05/17 the facility remained out of compliance at actual harm, isolated due to the facility's need to evaluate and monitor their corrective action system. This failure could place 21 residents who scored at risk to wander or high risk to wander on the Wandering Risk Scale Assessment, 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway at risk of serious injury or death. The findings included: [NAME] Accident Hazards Review of face sheet dated 4/25/17 documented Resident #5 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/17 the following [DIAGNOSES REDACTED]. Resident #5 lived on hallway 400. Review of annual Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated Resident #5 was severely impaired. Wandering - Presence and Frequency was coded 1 which indicated behavior of this type occurred 1 to 3 days during the last 7 days. MDS documented Resident #5 weighed 101 pounds, was 60 inches tall and used a wheelchair. Review of Care Plan dated as initiated on 1/21/16 documented Resident #5; Focus: elopement/wanderer risk related to exit seeking, resident wanders aimlessly. Impaired safety awareness. Goal: The resident will not leave facility unattended through the next review date. The resident's safety will be maintained through the review date. Interventions: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Monitor wandering. Review of Wandering Risk Scale assessment dated [DATE] 12:23 PM Quarterly Evaluation documented Resident #5 scored an 11 - high risk to wander. Review of Incident Report titled Un-witnessed, dated 4/18/17 8:00 PM and revision date 4/21/17 at 9:21 AM documented in part, Licensed Vocational Nurse (LVN) F and Certified Nursing Assistant (CNA) G heard door alarm, went running to the south door on west side, saw Resident #5 on the cement floor, down the stairs moaning and bleeding from the right side of her face. LVN E, CNA Supervisor and other staff came to help and assist. 911 was called they took her to the hospital. Review of El Paso Fire Department (EPFD) Prehospital Care Report dated 4/18/17 documented they arrived on scene at 8:04 PM. The report documented Resident #5 complained of shoulder or upper arm pain and her right eye was swollen shut reduction of dislocated joint was performed. The report documented female patient found on ground after rolling down flight of concrete stairs in her wheelchair. Patient was unsupervised when incident happened. Fall was not witnessed and unknown loss of consciousness (L[NAME]). Arrived on scene and found staff controlling bleeding from patient's right eye area. Review of Emergency Provider Report dated 4/18/17 documented Resident #5 was a [AGE] year old female who presented to the Emergency Department (ED) via EMS after a fall down 5 stairs at the nursing home, complained of right arm pain and head pain. Patient was in her wheelchair and was trying to escape when she rolled down the stairs. Nursing home reports it took them 15 minutes to find her and is unsure of downtime and if there was L[NAME] or not. Physical Exam, swelling to right side of face, 3 cm laceration above right eyebrow, bruising noted around right eye, right hip tenderness CT Scan of Brain without contrast impression: minimal linear subarachnoid hemorrhage within the right frontal region, 8 mm (millimeter) right frontal scalp hematoma, 1 cm periorbital hematoma, 2 cm right [MEDICATION NAME] hematoma, hemorrhage in the right maxillary sinus, right maxillary sinus anterior lateral wall fractures are identified. Clinical Impression: Subarachnoid hemorrhage, closed fracture of right proximal Humerus, facial laceration, fall, right maxillary fracture and urinary tract infection. Review of hospital trauma documentation recorded on 4/19/17 at 3:15 AM patient being admitted to critical care. Review of staffing schedule dated 4/18/17 2:00 PM - 10:00 PM shift documented LVN F and CNA G were assigned to care for residents on 400 hallway. CNA H was assigned as a split CNA, her assignment included residents on 200, 300 and 400 hallways. Review of electronic progress notes dated 4/18/17 at 10:46 PM documented Resident #5 had an unwitnessed fall. Resident #5 exited facility by west side south door (door at end of 400 hallway) and apparently had a fall from stairs, 911 called, MD notified and responsible party - left message. Observation on 4/21/17 at 9:10 AM revealed the fire exit door at the end of hallway 400 opened freely from the inside by pushing on bar, door alarm sounded at the nursing station, approximately 100 feet away, not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. There was a blood stain at the bottom of the stairs on the concrete. In an interview on 4/24/17 at 2:37 PM the Maintenance Director said the free swinging gate in the past had a lock on it but the fire department made them take it off a long time ago because the gate must be free to swing both directions because of its hinges. In an interview on 4/21/17 at 9:12 AM LVN D said Resident #5 was not an exit seeker but was constantly wandering. If any resident is an exit seeker the DON will not keep them. LVN D said construction people had been at the facility and worked very late and turned the door alarms off sometimes. LVN D said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 2:03 PM LVN F said he had worked at the facility for 7 years, he works 2p-10p on the 400 hallway. LVN F said on 4/18/17 he was passing his 8:00 PM medications when CNA G came and asked him had he seen Resident #5. LVN F said Resident #5 was a wanderer and went around the building, he told CNA G no, he had not seen Resident #5. LVN F said about 15 - 20 minutes later he was in room [ROOM NUMBER] with the door closed giving a resident medications. LVN F said he was in the room for about 10 minutes giving the medications and he thought he heard the alarm. LVN F said he heard the alarm as he was coming out and he ran to check the door. He said as he was running CNA G came out of another room and they ran together. They went out the door and looked down and saw Resident #5 at the bottom of the stairs bleeding. He said it was very upsetting to see Resident #5. LVN F said LVN E, the CNA supervisor and CNA H came so he ran to call 911. LVN F said nothing had changed since the incident. LVN D said he has not been instructed to implement any changes. In an interview on 4/21/17 at 3:10 PM CNA G said she put Resident #5 in her room on 4/18/17 after dinner so she could put her to bed. CNA G said she put the roommate in bed first and when she went to put Resident #5 in bed she wasn't there anymore. CNA G said she was looking for Resident #5, she asked LVN F if he had seen her and he told CNA G to put another resident in bed because Resident #5 was probably wandering around the facility. CNA G said she was in a room with the door closed putting a resident to bed when she heard the alarm. CNA G said as soon as she could safely leave the resident she went out of the room and saw LVN F running and ran with him to the door at the end of 400 hallway. CNA G said she did not remember if the door at the end of the hallway was open or closed. She said they got there and Resident #5 was at the bottom of the stairs. CNA G said nothing had changed, nothing new put into place since incident. In an interview on 4/21/17 at 2:20 PM CNA Supervisor said she was in her office with LVN [NAME] and heard the alarm. She said she followed LVN [NAME] to the 400 hallway door, they went out and Resident #5 was on the ground at the bottom of the stairs. CNA Supervisor said she assisted in helping the LVN. In an interview on 4/21/17 at 2:25 PM LVN [NAME] said he was in the office with the CNA Supervisor when they heard the alarm they went to the 400 hallway door, went out and Resident #5 was face down at the bottom of the steps. LVN [NAME] said he put a towel on Resident #5's facial cut and asked her if she was in pain, she said yes. LVN [NAME] said the wheelchair was about 2-3 feet away from Resident #5, he did not remember the position of the wheelchair because his attention was on the injured resident. In an interview on 4/24/17 at 8:05 PM LVN [NAME] said when he arrived at the scene to assist with Resident #5 she was face down on the concrete at the bottom of the stairs. LVN [NAME] said Resident #5's head was away from the steps and her feet were toward the steps, the wheelchair was approximately 3 feet farther away for the steps. In an interview on 4/21/17 at 2:45 PM the Director of Nursing (DON) said Resident #5 was a known wanderer but never tried to get out before she just goes around and around the facility. DON said it was not necessary to notify state office or to complete an investigation they knew what happened and it only took 1 minute, Resident #5 went out the door in her wheelchair and fell down the steps. In an interview on 4/21/17 at 2:52 PM the Nursing Home Administrator (NHA) said he was called on 4/19/17 in the morning and told Resident #5 went out the door and fell down 5 stairs. NHA said nothing had been done since the incident to address the resident going out the door, falling down the stairs and getting injured except he told the staff to watch closer. NHA said we know what happened Resident #5 went out the 400 hall fire door and fell down the stairs, she was not exit seeking so they had no way to know that might happen and no one else is exit seeking so it probably won't happen again. NHA said the door and stairs were good for the past [AGE] years with Life Safety so he didn't see where anything needed to change. In an interview on 4/21/17 at 3:47 PM LVN I said on the night of 4/18/17 the alarm was going off several times all evening, the painters were working in the facility the evening of 4/18/17, then the alarm was going off and going off for a long time, did not give a time estimate, but she was in a resident room and could not leave the resident. LVN I said the 400 hall door alarm sounded at both the East and West nursing stations. In an interview on 4/21/17 at 3:50 PM Resident #28, who resides on the 400 hall, and her daughter said there is very little staff and they are always in a hurry. They said they did not hear the door alarm but if the television is on they cannot hear the alarm. In an interview on 4/21/17 at 4:00 PM Resident #29who resides on 400 hall, said it takes a long time for anyone to come. She said she did not remember the door alarm but her television was on. Review of Wandering, Unsafe Resident policy and procedure dated as revised (MONTH) 2008 documented in part: The staff will identify residents who are at risk for harm because of unsafe wandering. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Observations on 4/24/17 at 12:20 PM revealed 7 doors in the facility as follows: 400 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter - 5 concrete stairs outside door 500 fire exit door - code key pad for exit and entrance - does not alarm- outside concrete sloped downward with a 7 inch drop at the end into the road. 100 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter 200 fire exit door - stop sign hung across the door with Velcro - opens freely - alarms at nursing station when opened - cannot reenter EAST side door code key pad for exit - push button for entry - does not alarm WEST side door code key pad for exit - push button for entry - does not alarm Front door - unlocked when the receptionist is at front desk - all other times entry and exit only with code key pad - does not alarm. Observation on 4/24/17 at 2:17 PM Resident # 3 goes to end of hallways, places hand on push bar, sits in front of the door and then turns around and goes to another door. Observation on 4/24/17 at 2:37 PM with Maintenance Director (Maint. Dir.) revealed the door alarm was not audible in a resident room with the door closed and the resident television on. In an interview on 4/24/17 at 2:50 PM the Maint. Dir. said he did not know if the alarm could be turned louder to be heard in resident rooms. Maint. Dir. said the alarm could not go over a certain decibel level but he did not know what that level was. He also said perhaps they could install alarms on the hallway as well as the nursing station so staff could hear the alarm when they were in a resident's room with the door closed. B. Emergency Evacuation Review of policy and procedure Emergency Response Fire/Explosion dated as revised (MONTH) 2012 documented in part: Phase III: Evacuate all residents from the building by whatever means possible. Complete evacuation needs to be initiated by staff as quickly as possible and without hesitation. Review of policy and procedure Emergency Response Fire/Explosion dated as revised (MONTH) 2012 revealed the plan did not include specific procedures and/or equipment to be implemented or utilized for evacuating residents who are not fully ambulatory through the 400 hall fire evacuation exit door and down 5 stairs or the 500 hall fire evacuation exit door and down a 7 inch curb. The plan did not include specific provision for evacuating all residents considering that there was no level standing area adjacent to the paving/fire land from 500 hall fire door. Observation on 5/4/17 at 2:20 PM revealed the posted emergency floor plans in the 400 and 500 hall both separately indicated that the 400 and 500 fire exits would be utilized for evacuation. Observation on 4/21/17 at 9:10 AM revealed the fire evacuation exit door at the end of hallway 400 opened freely from the inside by pushing on bar, alarm sounded at the nursing station not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. The door to the steps was 5 feet 10 inches, from the landing to the ground was 39 ¾ inches, each concrete was 7 inches high and at the bottom of the stairs was a 6 inch curb. There was a blood stain at the bottom of the stairs on the concrete. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 400 hallway 16 residents were in wheelchairs, 6 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. Observation on 4/21/17 at 9:30 AM revealed the fire evacuation exit door at the end of 500 could not open when pushed it required a code be used on a keypad on the wall to open the door. Outside the door was the laundry area which contained empty laundry barrels. The area outside the door was concrete with a steep decline leading down to a 7 inch curb dropping onto the driveway. Observation on 5/3/17 at 9:11 AM there were 10 wheeled linen barrels at the south east corner of the building by the facility 500 hall evacuation fire door. Only 31 inches were clear for passage. In an interview ON 5/3/17 at 9:11AM the Maint. Dir said the wheeled linen barrels were usually kept there. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 500 hallway 20 residents were in wheelchairs, 5 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. In an interview on 4/24/17 at 6:30PM the Corporate Operations Officer (COO) said the fire exit door at the end of 400 hallway was an easy open door, it was not delayed release, Resident #5 went out and fell down the stairs but they had no problem with the door for [AGE] years. COO said if there was a fire and the 400 fire door had to be used they would take each resident down the 5 concrete stairs, you have to do what you have to do. If staff had to get residents down the 5 concrete stairs at 400 hall exit or the 7 inch curb at the 500 hall exit it wouldn't be easy but it would not be impossible. Observation on 4/24/17 at 8:00 PM 400 hallway no staff were visible in hallway or nursing station for 3 minutes. The glass on the 400 hallway door showed a reflection of inside, outside was not visible. In an interview on 4/28/17 at 3:10 PM LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall she does not know how they would get the non-ambulatory residents down the 7 inch curb. LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall she had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN I said it would have to be with the help of others. In an interview on 4/28/17 at 3:35 PM LVN F said in case of fire they rescue, alert, confine and extinguish. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall he had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall he does not know how they would get the non-ambulatory residents down the 7 inch curb but it would be easier than the 5 concrete stairs. LVN F said they would need a lot of staff and they would have to work as a team. In an interview on 5/2/17 at 2:50 PM the COO said if there was a fire they would take wheelchairs down the steps just like a baby stroller. He said just like a baby stroller, wheelchairs can go down stairs and curbs. In an interview on 4/26/17 at 1:35 PM, Maint. Dir. said he still did not know the acceptable decibel level for the door alarm and was still trying to find out. Nothing about exit changed since incident. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of Wandering Risk Scale Assessment provided on 4/24/17 by MDS LVN documented 21 residents who scored at risk to wander or high risk to wander. Review of census dated 4/26/17 documented 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway.

Based on observation, interview and record review, the facility failed to ensure they had developed and implemented a safe emergency evacuation route for 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway from the south side of the facility. The facility did not address how they would evacuate residents who were dependent on wheelchairs or geri-chairs for mobility. The evacuation route required residents to go down 5 concrete stairs from the 400 hallway, or down a large curb from the 500 hallway. On 4/27/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 5/05/17 the facility remained out of compliance at actual harm, isolated due to the facility's need to evaluate and monitor their corrective action system. This failure could place 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway at risk of serious injury or death. The findings included: Emergency Evacuation Review of policy and procedure Emergency Response Fire/Explosion dated as revised October 2012 documented in part: Phase III: Evacuate all residents from the building by whatever means possible. Complete evacuation needs to be initiated by staff as quickly as possible and without hesitation. Review of policy and procedure Emergency Response Fire/Explosion dated as revised October 2012 revealed the plan did not include specific procedures and/or equipment to be implemented or utilized for evacuating residents who are not fully ambulatory through the 400 hall fire evacuation exit door and down 5 stairs or the 500 hall fire evacuation exit door and down a 7 inch curb. The plan did not include specific provision for evacuating all residents considering that there was no level standing area adjacent to the paving/fire land from 500 hall fire door. Observation on 5/4/17 at 2:20 PM revealed the posted emergency floor plans in the 400 and 500 hall both separately indicated that the 400 and 500 fire exits would be utilized for evacuation. Observation on 4/21/17 at 9:10 AM revealed the fire evacuation exit door at the end of hallway 400 opened freely from the inside by pushing on bar, alarm sounded at the nursing station not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. The door to the steps was 5 feet 10 inches, from the landing to the ground was 39 ¾ inches, each concrete was 7 inches high and at the bottom of the stairs was a 6 inch curb. There was a blood stain at the bottom of the stairs on the concrete. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 400 hallway 16 residents were in wheelchairs, 6 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. Observation on 4/21/17 at 9:30 AM revealed the fire evacuation exit door at the end of 500 could not open when pushed it required a code be used on a keypad on the wall to open the door. Outside the door was the laundry area which contained empty laundry barrels. The area outside the door was concrete with a steep decline leading down to a 7 inch curb dropping onto the driveway. Observation on 5/3/17 at 9:11 AM there were 10 wheeled linen barrels at the south east corner of the building by the facility 500 hall evacuation fire door. Only 31 inches were clear for passage. In an interview on 5/3/17 at 9:11 AM the Maint. Dir said the wheeled linen barrels were usually kept there. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 500 hallway 20 residents were in wheelchairs, 5 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. In an interview on 4/24/17 at 6:30PM the Corporate Operations Officer (COO) said the fire exit door at the end of 400 hallway was an easy open door, it was not delayed release, Resident #5 went out and fell down the stairs but they had no problem with the door for [AGE] years. COO said if there was a fire and the 400 fire door had to be used they would take each resident down the 5 concrete stairs, you have to do what you have to do. If staff had to get residents down the 5 concrete stairs at 400 hall exit or the 7 inch curb at the 500 hall exit it wouldn't be easy but it would not be impossible. Observation on 4/24/17 at 8:00 PM 400 hallway no staff were visible in hallway or nursing station for 3 minutes. The glass on the 400 hallway door showed a reflection of inside, outside was not visible. In an interview on 4/28/17 at 3:10 PM LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall she does not know how they would get the non-ambulatory residents down the 7 inch curb. LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall she had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN I said it would have to be with the help of others. In an interview on 4/28/17 at 3:35 PM LVN F said in case of fire they rescue, alert, confine and extinguish. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall he had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall he does not know how they would get the non-ambulatory residents down the 7 inch curb but it would be easier than the 5 concrete stairs. LVN F said they would need a lot of staff and they would have to work as a team. In an interview on 5/2/17 at 2:50 PM the COO said if there was a fire they would take wheelchairs down the steps just like a baby stroller. He said just like a baby stroller, wheelchairs can go down stairs and curbs. In an interview on 4/26/17 at 1:35 PM, Maint. Dir. said he still did not know the acceptable decibel level for the door alarm and was still trying to find out. Nothing about exit changed since incident. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of census dated 4/26/17 documented 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway.

Based on observation, interview and record review, the facility failed to ensure they had developed and implemented a safe emergency evacuation route for 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway from the south side of the facility. The facility did not address how they would evacuate residents who were dependent on wheelchairs or geri-chairs for mobility. The evacuation route required residents to go down 5 concrete stairs from the 400 hallway, or down a large curb from the 500 hallway. On 4/27/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 5/05/17 the facility remained out of compliance at actual harm, isolated due to the facility's need to evaluate and monitor their corrective action system. This failure could place 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway at risk of serious injury or death. The findings included: Emergency Evacuation Review of policy and procedure Emergency Response Fire/Explosion dated as revised (MONTH) 2012 documented in part: Phase III: Evacuate all residents from the building by whatever means possible. Complete evacuation needs to be initiated by staff as quickly as possible and without hesitation. Review of policy and procedure Emergency Response Fire/Explosion dated as revised (MONTH) 2012 revealed the plan did not include specific procedures and/or equipment to be implemented or utilized for evacuating residents who are not fully ambulatory through the 400 hall fire evacuation exit door and down 5 stairs or the 500 hall fire evacuation exit door and down a 7 inch curb. The plan did not include specific provision for evacuating all residents considering that there was no level standing area adjacent to the paving/fire land from 500 hall fire door. Observation on 5/4/17 at 2:20 PM revealed the posted emergency floor plans in the 400 and 500 hall both separately indicated that the 400 and 500 fire exits would be utilized for evacuation. Observation on 4/21/17 at 9:10 AM revealed the fire evacuation exit door at the end of hallway 400 opened freely from the inside by pushing on bar, alarm sounded at the nursing station not at the door, Outside the door on the right was an open free swinging gate, without a latching mechanism, which swings out over 5 concrete stairs going down to a concrete area. The door to the steps was 5 feet 10 inches, from the landing to the ground was 39 ¾ inches, each concrete was 7 inches high and at the bottom of the stairs was a 6 inch curb. There was a blood stain at the bottom of the stairs on the concrete. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 400 hallway 16 residents were in wheelchairs, 6 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. Observation on 4/21/17 at 9:30 AM revealed the fire evacuation exit door at the end of 500 could not open when pushed it required a code be used on a keypad on the wall to open the door. Outside the door was the laundry area which contained empty laundry barrels. The area outside the door was concrete with a steep decline leading down to a 7 inch curb dropping onto the driveway. Observation on 5/3/17 at 9:11 AM there were 10 wheeled linen barrels at the south east corner of the building by the facility 500 hall evacuation fire door. Only 31 inches were clear for passage. In an interview on 5/3/17 at 9:11 AM the Maint. Dir said the wheeled linen barrels were usually kept there. Review of Mode of Transport list provided by MDS on 4/25/17 at 9:06 AM documented on 500 hallway 20 residents were in wheelchairs, 5 residents were in large recliner geri-chairs, 1 resident used a wheelchair and ambulated and only 1 resident on all of 400 hallway could walk by their self. In an interview on 4/24/17 at 6:30PM the Corporate Operations Officer (COO) said the fire exit door at the end of 400 hallway was an easy open door, it was not delayed release, Resident #5 went out and fell down the stairs but they had no problem with the door for [AGE] years. COO said if there was a fire and the 400 fire door had to be used they would take each resident down the 5 concrete stairs, you have to do what you have to do. If staff had to get residents down the 5 concrete stairs at 400 hall exit or the 7 inch curb at the 500 hall exit it wouldn't be easy but it would not be impossible. Observation on 4/24/17 at 8:00 PM 400 hallway no staff were visible in hallway or nursing station for 3 minutes. The glass on the 400 hallway door showed a reflection of inside, outside was not visible. In an interview on 4/28/17 at 3:10 PM LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall she does not know how they would get the non-ambulatory residents down the 7 inch curb. LVN I said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall she had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN I said it would have to be with the help of others. In an interview on 4/28/17 at 3:35 PM LVN F said in case of fire they rescue, alert, confine and extinguish. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 400 hall he had no idea how they would get the non-ambulatory residents safely down 5 seven inch concrete steps and then down the 6 inch curb. LVN F said if there was a fire and residents had to be evacuated out of the evacuation door at the end of 500 hall he does not know how they would get the non-ambulatory residents down the 7 inch curb but it would be easier than the 5 concrete stairs. LVN F said they would need a lot of staff and they would have to work as a team. In an interview on 5/2/17 at 2:50 PM the COO said if there was a fire they would take wheelchairs down the steps just like a baby stroller. He said just like a baby stroller, wheelchairs can go down stairs and curbs. In an interview on 4/26/17 at 1:35 PM, Maint. Dir. said he still did not know the acceptable decibel level for the door alarm and was still trying to find out. Nothing about exit changed since incident. An immediate jeopardy was identified on 4/27/17 and the Nursing Facility Administrator (NFA) was informed at 2:26 PM. On 5/5/17 at 3:35 PM the 6th corrective action plan of removal was accepted, which included: With regards to the Immediate Jeopardy (IJ) being issued to the facility with regards to the incident with Resident #5 the facility has done the following: Facility Investigation: Immediately following the fall the DON conducted an investigation to identify the cause. It was determined via employee interviews, and physical evidence that Resident #5 fell down the stairs located in the rear of the facility after having exited the facility fire exit located on the 400 hallway, at approximately 8pm on 4/18/17 For the affected resident(s): Immediate response The facility will continue to monitor and assess Resident #5 to identify her ability to ambulate and identify any exit seeking behaviors. In addition: The following ambulatory residents have been identified as exhibiting, wandering behaviors: (resident room number/bed assignment) (listed 12 residents by room and bed number) The facility staff have been in-serviced on a systems approach to resident safety specifically dealing with wandering behaviors. This system includes procedures, activities and environmental factors such as: 1. Initial screening during admission - DON (in place prior to incident) 2. Ongoing routine observations and notes - Nursing staff, Social Worker (in place prior to incident) 3. Care Planning as to address specific wandering, interventions for each resident (in place prior to incident) 4. Increased level of observation of wanderers, i.e. care planned for 30 minute observation intervals by CNA or Nurse. Wandering residents to be prohibited with activities in common areas on both sides of facility near nurses' station for closer observation. (Noted to EMAR effective 4/27/17) if temporary 1:1 care is needed for the safety of a wandering resident, additional staff elements may be brought in at the charge nurse's discretion. 5. Fire exits will have Black Mats in place to deter wanderers and rooms/corridors free of clutter (4/27/17) These actions and procedures when combined provide a systematic approach to address concern for the safety of wandering residents. Please refer to In-Service Instructions dated 4/27/17 for additional detail. The facility has installed black mats in front of the hallway exits to deter exit seeking behavior. 4/27/17 A wandering specific Care Plan has been completed/updated for all identified residents on 4/27/17 An order was obtained from Medical Director for each resident of the listed residents that states: Charge nurse will monitor resident's whereabouts closely and observe for exit seeking behavior (visual check every 30 minutes that charge nurse will sign off on EMAR verifying being done) Instructions to update DON and MD if any active exit seeking occurs Charge nurse will communicate with the CNA who is providing care to a wanderer that every 30 minutes visual confirmation of the resident is needed for safety reasons. Facility corrective actions: The facility has disabled all Keypad magnetic locks on all the facility exits (5/3/17) Staff have been directed that with the magnetic locks removed all facility doors are now subject to the facility monitoring protocols (5/3/17) Access to the stairs at the South West - 400 Hall Fire Exit was removed by welding the gate shut. (5/3/17) The Facility has retained an engineering firm to assess the feasibility of an ADA/NFPA compliant ramp to replace the stairs (5/3/17) Staff have been directed on the correct SW fire door evacuation route, which runs SW to SE on the southern building perimeter The physical environment is being kept safe by maintaining clutter free rooms and corridors All staff have been educated as to which residents are likely to wander (Standard practice in place prior to incident) High risk residents identified to wander are kept busy with activities and exercise to deter wandering behavior. Activities Department is providing appropriate activities such as sorting boxes, coloring, TV/movies, exercises and instructions as required to CNA's for evening and night shift use. (4/27/17) The facility has an alarm panel at each nurses' station. All employees have been instructed that when an alarm goes off it requires immediate action, via in-service (4/27/17) Brief vendors such as painters, electricians etc, working temporarily working in the facility as to maintaining a secure physical environment (doors shut, clear floors, secure tools, etc.) and minimizing disruption of residents' routine, as well as respecting privacy. Localized alarms which must be shut off at the exit door, have been installed at each door Additional staff have been stationed at each Nurses station, East and West, during all shifts, charged with continually visually monitoring the residents, exit doors and alarms (5/5/17) Delayed egress door systems will be evaluated for instillation to all exits CCTV covering all doors, and monitored at both nurse's station, will be evaluated for installation (5/5/17) The plan of removal was verified as having been implemented as follows: Observation on 5/5/17 at 9:00 AM revealed magnetic locks were removed. Observation on 5/5/17 at 9:20 AM revealed Black Mats were placed at fire exit doors on hallways 100, 200 and 400. Observation on 5/5/17 at 2:40 PM revealed 1 staff person assigned to East Nursing Station and 1 to West Nursing Station. In an interview on 5/5/17 at 2:43 PM the additional staff for each nursing station said they were directed to stand at the nursing station and watch for residents to go toward the door. The said if a resident went to the doors they were instructed to remove them away from the door. Observation on 5/5/17 at 3:15 PM revealed the Localized alarms which must be shut off at the exit door, turned off when the door closed automatically and did not require staff to manually turn the alarm off at the door. In an interview on 5/5/17 at 3:25 PM the NHA said they were unable to find the alarms that required staff to manually turn off at the door. He said that type of lock would need to be ordered on-line. The NHA said the alarms could not arrive for 4 days but he would try to order overnight shipping. After the surveyors verified the plan of removal was implemented, the NHA was informed the immediate jeopardy was removed effective 5/5/17 at 4:15 PM. The facility remained out of compliance at a scope and severity at isolated, actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, to ensure all staff received all scheduled training and to ensure meetings for instillation evaluations will have occurred. Review of census dated 4/26/17 documented 28 residents residing on the south east (500) hallway and 24 residents residing on the south west (400) hallway.

Based on observation, record review and interview, it was determined that the facility failed to store and prepare food under sanitary conditions in 1 of 1 kitchens reviewed for sanitary conditions. The facility failed to ensure that A. Undercooked unpasteurized eggs were not served to 6 of 25 residents reviewed for meal service. Residents #3, 12, 21, 22, 23, and 24 were served over-easy unpasteurized eggs. B. Foods storage containers were clean and intact C. Freezer thermometer were functional D. Kitchen staff did not have thermometers to test food temperatures. The deficient practice of serving undercooked, unpasteurized eggs to residents resulted in an Immediate Jeopardy identified on 05/05/16. The Nursing Home Administrator was notified on 5/05/16 at 11:45 AM. While the immediate jeopardy was removed on 05/05/16 at 2:00 PM, the facility remained out of compliance at a scope and severity at a pattern level with no actual harm that is not immediate jeopardy as the implemented systems needed to be monitored and evaluated for effectiveness. These failures could affect 88 residents who were served meals from the kitchen. Residents could experience Salmonella food poisoning, severe gastrointestinal illness, fever, diarrhea, and even death. The findings include: A. Record review revealed the following: a) Review of face sheet on 5/2/16 documented Resident # 3 was an [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. b) The Admission Record dated 3/22/16 documented Resident #12 was an [AGE] year old man admitted on [DATE] with [DIAGNOSES REDACTED]. c) The Face Sheet dated 11/1/13 for Resident #21 indicated he was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. d) The Admission Record dated 9/24/15 for Resident #22 revealed she was a [AGE] year old woman admitted on [DATE]. The Personal history and physical examination [REDACTED]. e) The Face Sheet dated 8/25/14 for Resident #23 revealed he was a [AGE] year old male admitted to the facility on [DATE]. Review of the Personal history and physical examination [REDACTED]. f) Review of the Admission Record dated 11/6/15 revealed that Resident #24 was an [AGE] year old male admitted to the facility on [DATE]. Review of the Personal history and physical examination [REDACTED]. B. On 5/05/16 at 8:20 AM in an interview Cook B stated that there were no pasteurized eggs available that morning (5/5/16) because the shipment of pasteurized eggs that was to arrive the previous day (5/4/16) never arrived . She stated that she had cooked about 35 unpasteurized eggs over-easy that morning, and served them because residents requested them that way. C. Observation on 5/05/16 at 8:30 AM, Residents #21 and #22 were eating over-easy eggs with liquid yolks. D. On 5/05/16 at 9:40 AM in an interview with Cook B she provided the names of sixteen residents who were served over-easy unpasteurized eggs that morning including #3, #12, #21, 22, 23 and #24. E. On 5/05/16 at 9:45 AM in an interview the Dietary Manager stated that the facility usually does not serve unpasteurized eggs but that the usual shipment of pasteurized eggs had not been delivered Tuesday or Wednesday morning before breakfast was prepared. He stated it was an emergency situation and that as a result he had gone to the Shamrock Cash and Carry store and purchased unpasteurized eggs for that morning ' s breakfast. He stated that employees are trained to cook eggs until firm but that residents throw a fit if served hard eggs. He said he knew he was not to serve eggs that way (undercooked, unpasteurized) but that he tries to be accommodating. F. In an interview on 5/5/16 at 12:00 PM Licensed Vocational Nurse (LVN) I said contracting salmonella could be detrimental and even fatal to residents in the nursing facility. LVN I said Resident # 3 had diabetes which could make salmonella more dangerous G. Interview on 5/05/16 at 11:53 AM, LVN A said, because of his age, Resident #12 would be at risk if he were to get a Salmonella infection from eating undercooked eggs. Resident #12 had [MEDICAL CONDITION] which would be affected by an infection that caused dehydration. H. On 5/05/16 at 11:55 AM in an interview LVN B stated that although Resident #23 was strong, salmonella could lead to dehydration due to nausea and vomiting. I. On 5/5/16 at 12:00 PM the Nursing Home Administrator (NHA) stated that the facility did not have a policy regarding serving unpasteurized, undercooked eggs. K. According to CMS S&C letter 14-34 dated May 20, 2014 Skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritis (SE). In accordance with the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) standards, skilled nursing and nursing facilities should not prepare nor serve soft-cooked, undercooked or sunny-side up eggs from unpasteurized eggs. L. The elderly, infants, and those with impaired immune systems may have a more severe illness. In these patients, the infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics. <http://www.cdc.gov/Features/SalmonellaEggs/index.html> accessed 5/17/16 M. Per the Food and Drug Administration web site (www.fda.gov <http://www.fda.gov>) assessed 5/12/16: Egg Safety Final Rule Egg-associated illness caused by Salmonella is a serious public health problem. Infected individuals may suffer mild to severe gastrointestinal illness, short term or chronic arthritis, or even death. Implementing the preventive measures would reduce the number of Salmonella Enteritidis infections from eggs by nearly 60 percent. The Immediate Jeopardy was identified on 05/05/16, and the Nursing Home Administrator was notified at 11:45 AM. The Plan of Action dated 5/5/16 and accepted on 5/5/16 at 1:13 PM documented the following: A. The facility will monitor all residents with P.O. intake (by mouth) and identify those who consumed undercooked unpasteurized eggs the morning of 5/5/16 were identified and B. The facility identified sixteen residents who were served undercooked unpasteurized eggs the morning of 5/5/16. C. The facility notified identified residents' physicians, and received orders to monitor for side effects of having eaten undercooked unpasteurized eggs D. Facility Charge nurse will monitor for signs of Salmonella for 72 hours. E. Residents' physicians will be notified if symptoms occur F. Incident reports will be completed for each identified resident G. Facility had received pasteurized eggs to accommodate resident preferences H. Dietary Manager will ensure that an adequate supply of pasteurized eggs is available to accommodate resident requests I. Dietary staff received a training stating that unpasteurized undercooked eggs would not be served, including information about potential hazards of eating unpasteurized undercooked eggs. On 5/5/16 at 1:45 PM interview and observation with Cook B revealed that the facility had received a shipment of pasteurized eggs around mid-day and that no shell eggs remaining in the facility were unpasteurized. On 5/5/16 at 1:45 PM in interviews Cook B, Cook D, Cooks Helper E and Cooks Helper F stated they had received training that unpasteurized undercooked eggs would not be served, when unpasteurized eggs could be used, and information about potential hazards of eating unpasteurized undercooked eggs. After the surveyors verified the plan of removal was implemented, the NFA was informed the immediate jeopardy was removed effective on 05/05/16 at 2:00 PM. The facility remained out of compliance at a scope and severity at a pattern of no actual harm with potential for more than minimal harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. Observation on 5/2/16 at 8:00 AM revealed that the lid covering a bin of parboiled rice was observed to be broken, leaving a 6 inch by 2 inch opening in the bin lid. Pepper seeds were seen to be scattered across the plastic lid covering a bin of pasta. The lid covering both the pasta bin and the parboiled rice bin were observed to be coated with a film of accumulated dust and oil. On 5/2/16 at 8:00 AM in an interview Cook L stated that the bin lids were cleaned daily and could not explain the presence of the pepper seeds. He stated that the bin lid for the parboiled rice needed to be replaced. Observation on 5/2/16 at 8:00 AM revealed that the thermometer in the facility's walk-in freezer was broken, with the thermometer loose from the temperature gauge, so that the actual temperature of the freezer could not be determined. Observation revealed that the walk-in freezer did not have an external thermometer. On 5/3/16 at 8:25 AM in an interview the Dietary Manager stated that the thermometer in the facility's walk-in freezer was broken and needed to be replaced. On 5/2/16 at 4:45 PM in an interview Cook B stated that there was no thermometer available so she could not measure the temperatures of the food being held on the steam table for dinner. She stated that the thermometer that was used to test temperatures earlier in the day had broken, and that the rest of the thermometers were all locked in (the Dietary Manager's) office . She stated that the Dietary Manager was out of town and she did not have a key to his office. She stated that she did not know what to do in order to measure the temperatures of the evening meal. On 5/3/16 at 8:25 AM in an interview the Dietary Manager stated that there are usually several thermometers available in the kitchen area, and did not know why there was not one available on 5/2/16 in the afternoon. He stated that kitchen worker's did not know what to do because this had never happened before. The list of 16 residents who were served over-easy eggs on 5/5/16 was provided by Cook B on 5/05/16 at 9:40 AM. Review of the CMS-672 on 5/5/16 revealed that a total of 88 residents were served meals from the kitchen.