Every finding on record at South Dallas Nursing & Rehabilitation

Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State in which practicing to provide activities for 1 of 1 facility reviewed for qualifications of activity professionals. The facility failed to ensure they had a qualified Activities Professional to direct their activities program. This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident.Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State in which practicing to provide activities for 1 of 1 facility reviewed for qualifications of activity professionals. The facility failed to ensure they had a qualified Activities Professional to direct their activities program. This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Interview on 07/13/26 at 02:35 PM with the BOM, she stated that due to the facility not having an AD, she kept the residents busy and did activities with them. The BOM stated if it was something the residents did not want to do listed on the activity calendar; she would switch out the activity. The BOM stated the DOR assisted her with physical exercises. The BOM stated because residents could become restless, she volunteered to do activities. The BOM stated she asked residents during the Resident Council Meeting what they preferred to do. The BOM stated that without having an AD to oversee activities, there was a potential for residents to become bored from not having any activities to do. Interview on 07/13/26 at 03:00 PM with the DOR, she stated the facility did not have a qualified AD. The DOR stated she oversaw and worked with the BOM to ensure there was engagement despite the residents' ability. The DOR stated she ensured the facility had appropriate items to ensure the safety of the residents. The DOR stated she participated two to three times a week and on other days they did one-on-one activities. The DOR stated during the resident council meetings, they collected input from the residents and based the activities off what the residents wanted to do. The DOR stated once the prior AD left, the facility had someone from another department step in to get licensed, but that person decided to leave. The DOR stated as a result of not having a licensed AD, the residents' might not receive activities centered to meet their individual needs. In an interview on 07/13/26 at 3:25 PM with the ADM, a policy reflecting the requirements of an AD was requested, buy not provided prior to exit. Interview on 07/13/26 at 03:50 PM with the ADM, he stated they had not had an AD for 2 months. The ADM stated when the AD quit, he replaced her with a dietary aide, and had the dietary aide sign up to become certified, but it did not work out. The ADM stated the BOM and the HRD did activities with the residents. The ADM stated he met with the residents to see what they wanted to do. The ADM stated as of today the DOR would officially start covering activities. The ADM stated the BOM would manage the activities under the DOR. The ADM stated the DOR would create a check-off list for the BOM until they could secure an appropriate AD. The ADM stated today (07/13/26), he listed another advertisement for an AD on an employment site. The ADM stated he understood the activities program required a qualified AD to direct the program so the residents could receive specialized activities to meet their needs. The ADM stated the worse that could happen would be a potential for boredom. Record review of the facility's policy, Activity Programs, revised August 2006, reflected: Policy Statement: Activity programs designed to meet the needs of each resident are available on a daily basis. Policy Interpretation and Implementation1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident.9. Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. Record review of the facility's policy, Activities and Social Services, revised December 2006, reflected: .5. Should a resident be considered to lack sufficient decision making capacity, mental incompetence, or physical capacity to participate in Activity and Social Service Programs, the Activities or Social Services Staff will document the reasons for any limitations in the resident's medical record (chart).

Based on interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (Resident #1) reviewed for supervision. Resident #1 walked out of the facility unattended and was missing from the building for approximately 24 hours on 05/16/26 at 7:00 PM to 05/17/26 at 6:50 PM. This failure could place residents at risk for Elopement. Findings included: Record Review of a Resident #1's face sheet, dated 05/18/26, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included dementia (a loss of thinking, remembering, and reasoning skills), cerebral infarction (disrupted blood flow to the brain), hemiplegia and hemiparesis (physical impairments following cerebral infarction), hyperlipidemia (high level of lipids (fats) in the blood), and hypertension (high blood pressure).Record Review of Resident #1's initial admission Elopement assessment dated [DATE] reflected her Elopement Risk rating was a 7 which indicated Resident #1 was at low risk to wander. Record Review of Resident #1's annual MDS assessment, dated 01/29/26, reflected she had a BIMS score of 8, which indicated she was moderately cognitively impaired. Record Review of Resident #1's Elopement assessment dated [DATE] reflected her Elopement Risk rating was a 7 which indicated Resident #1 was at low risk to wander. Record review of Resident #1's Quarterly MDS assessment reflected the MDS assessment was in progress. The resident's electronic record reflected the Quarterly MDS assessment needed to be completed by 05/15/26. Record Review of Resident #1's care plan did not indicate Resident #1 could go out on pass without supervision. Record Review of Resident #1's care plan did not indicate Resident #1 needed special supervision. Record Review of Resident #1's care plan, revised 05/17/26 reflected Resident #1 had impaired cognitive function related to diagnosis of dementia and cognitive function and social well-being related to CVA, BIMS 13 (indicated Resident #1 was cognitively intact) and varies. Interventions included ask yes/no questions in order to determine the resident's needs, cue, reorient and supervise as needed, keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion, monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record Review of Resident #1's Progress Notes written by LVN B and dated 05/17/26 at 2:32 PM reflected This morning while doing rounds [Resident #1] was not in her room. Night nurse asked where the resident is, she stated that she might be outside smoking. During breakfast, the resident was not back yet. This writer went the back of the smoking patio but Resident #1 was missing there. Search initiated in the building from room to room but resident still missing. We went round the building and outside the building but resident still missing. Administrator and Family notified. Record Review of Resident #1's Progress Notes written by LVN B and dated 05/17/26 at 3:21 PM, reflected Resident missed her morning medication and Medical Director was notified. Record Review of Resident #1's Progress Notes written by LVN B, dated 05/17/26 at 8:15 PM, reflected Resident came back in the building at 6:50 PM. The police requested to see if [Resident #1] was ready to go to the hospital for checkup and [Resident #1] denied. [Resident #1] stated that she is an adult and she does not need lecturing. Record Review of the sign out sheet dated 05/16/26 and 05/17/26, indicated Resident #1 did not sign out. Record review on 05/18/26 of a list of resident's names who could sign out reflected the following, Only residents on this list are able to sign themselves out of this building. If their name is not on this list, they are not allowed to go out of the building on their own. The list did not indicate Resident #1 could sign out. Record Review of the Police Report, dated 05/17/26, reflected the resident went missing on 05/16/26 at 7:00 PM. The report reflected, Officers responded to the incident on 05/17/26 at 12:33 PM and received a call regarding a missing person. Upon arrival, responding officers made contact with the administrator who explained that an elderly resident who was identified as [Resident #1], had been missing since approximately 7:00 PM on 05/16/2026. The Administrator reported [Resident #1]was last seen wearing a multi-shade/dark blue top and yellow slippers. The Administrator also informed responding officers that [Resident #1]1 was diagnosed with dementia. The Administrator provided responding officers with the medical documentation that showed [Resident #1's]diagnosis. The Administrator stated that [Resident #1] had been staying at the [facility] for approximately one year and that she had not gone missing before. While on scene, responding officers also spoke with [Family Member] who also stated [Resident #1]was diagnosed with dementia. [Family member] on scene provided responding officers with a photo of [Resident #1]. Responding officers canvassed the surrounding areas and did not locate [Resident #1]. While searching responding officers spoke with multiple individuals who stated that they knew [Resident #1]but could not provide accurate location for whereabouts. Responding officers notified youth operations who dispatched a detective to the scene. Record Review of Resident #1's Elopement assessment dated [DATE], reflected her Elopement Risk Rating was a 9, indicating she was at risk to wander. In an interview on 05/18/26 at 9:55 AM, the Administrator stated Resident #1 left the building on 05/16/26 and returned around 7:53 PM, on 05/17/26. The Administrator stated Resident #1 said that she wanted to have a relationship with a guy in the community, and she did not want anyone to know she left the building. The Administrator stated he was notified by LVN B on 05/17/26 at 9:00 AM that Resident #1 was not in the building, and she had not touched her breakfast tray. The Administrator stated he needed to verify if Resident #1 signed out, but he did not think she did. The Administrator stated when Resident #1 returned, she was educated on leaving the facility without informing staff first. In an interview on 05/18/26 at 11:06 AM, Resident #1 stated she did not remember the day she left the facility. She stated she did not sign out. Resident #1 stated she did not tell anyone she was leaving because she did not want anyone to know she had left. Resident #1 stated it was the first time she left the building. She stated if she wanted to sign out staff did not let her sign out to leave the building. Resident #1 stated she went to a nearby city. Resident #1 would not specify where she went or how she got out of the building. In an interview on 05/18/2026 at 11:09 AM, Resident #2 stated she was outside in the front of the building smoking a cigarette when Resident #1 asked her to use her lighter for a cigarette. Resident #2 stated Resident #1 was dressed so pretty in a pink spaghetti strap dress with yellow shoes. She stated she turned around and next thing she knew Resident #1 was gone, and she did not see where she went. She stated she thought Resident #1 left on Friday 05/15/26. Resident #2 stated while she was outside on Sunday 05/17/26 smoking a cigarette in the front she saw a red van pull up and Resident #1 got out of the van and returned to the facility. Resident #2 stated she had been in the facility 3 months now, and she had never seen Resident #1 leave the building like she did. In an interview on 05/18/26 at 11:27 AM, the Family Member of Resident #1 stated they were notified on 05/17/26 around 10:30 AM that Resident #1 was missing from the building. The Family Member stated they received a call from one of the staff members on Sunday morning 05/17/26, and they asked was Resident #1 with Family member. The Family Member stated she told the staff Resident #1 was supposed to be there in the building. The Family Member stated that they told the staff they were on the way to the facility. The Family Member stated when they arrived at the facility and Resident #1 still had not come back yet. The Family Member stated once they had arrived at the facility no one called the police yet, and once the police finally were called, officers took about two hours to arrive at the building. Family member stated that it was not safe for her mother to be outside of the facility due to Resident #1 having dementia, her pass of having strokes as well as her pass drug history. Family Member stated Resident #1 had not been able to sign out on her own before the incident. Family member stated Resident #1 had signed out a month ago with her uncle but that was the only time. Family member stated all Resident #1 knew is she is at a nursing home and that's where she should be and she is not aware of any type of safety concerns. Family member stated when Resident #1 had her last stroke it took her cognitive status back to as if she was almost [AGE] years old again and her cognitive abilities are not well and it goes in and out too much for her to be out on her own. Family member stated Resident #1 has had ministrokes and they never know when they are going to happen. Family member stated when Resident #1 calls her over the phone she will refer to her as her sister and sometimes refer to her as her mother. Family member stated when Resident #1 eventually will call her by her name after a while. In an interview on 05/18/26 at 11:40 AM, LVN A stated Resident #1 lived on the 500 hall, and she was pretty much alert and high functioning. LVN A stated she worked a double on 05/16/26 Saturday and Resident #1 was still in the building during her 2 PM-10 PM shift. LVN A stated the last time she physically saw Resident #1 was around 4:30 AM early Sunday morning on 05/17/2026, when she went into Resident #1's room to give her roommate some medication and she saw Resident #1 lying in her bed. LVN A stated she did not have any medication for Resident #1, but she had medication for her roommate. LVN A stated when she entered Resident #1's room around 4:30 AM, she noticed Resident #1 looked up at her when she walked in the room. LVN A stated that Resident #1 was really skeptical when staff went into the room because she liked her door open and Resident #1 was always making sure staff left the door open when they left the room. LVN A stated that they realized Resident #1 went missing because LVN B went into work around 5:45 AM and started doing his rounds. LVN A stated that LVN B caught her attention because he stopped her and caught her attention and asked her if she had seen Resident #1. LVN A stated she was not sure of the specific time it was when LVN B asked her where Resident #1 was, she stated that she just remembered it was around 5:45 AM when LVN B went in to work and started doing his rounds that morning. LVN A stated that she told LVN B she had just saw Resident # 1, she was fine and she was lying down. LVN A told LVN B to check her restroom and to also check out by the back doors in the smoking area. LVN A stated they went outside and looked all over the building and noticed that she was not outside of the building. LVN A stated she then helped LVN B immediately and started to assist LVN B in finding Resident #1 when they realized Resident #1 was nowhere in the building. LVN A stated that Resident #1 had unspecified dementia and she should not be allowed to go outside unsupervised, but she stated she was unsure if she was on the list to not be able to sign out due to her BIMS always changing. LVN A then stated they did have a list for certain residents who could sign themselves out and leave the building, but Resident #1 was not on that list. LVN A stated that when she came back to work the next day she attempted to go and question Resident #1 to ask her where she went, but she stated Resident #1 told her she was grown and she could do what she wants. LVN A stated that Resident #1 also told her if she wanted to sign out, they would not have let her sign out. LVN A stated the risk of Resident #1 leaving from the building unsupervised is that the neighborhood was not safe and she could have had an accident, she could had become dehydrated, or anything else could have happened to her and no one would had known about it. LVN A stated she could have even been robbed by homeless people. LVN A stated that LVN B notified the ADON, DON, and the Administrator. LVN A stated that she was not sure who else was notified since LVN B was the one who notified everyone, but she stated that in instances such as that one the physician, the state, the police, and family members also need to be notified immediately. In an interview on 05/18/26 at 2:27 PM, LVN B stated he came into work at 5:50 AM on 05/17/26 and he usually started to do his rounds on hallways 700, 500, and 400. LVN B stated around 6:00 AM he went to Resident #1's room and noticed she was not in her bed. LVN B stated he asked LVN A where Resident #1 was and LVN A told him to go and check at the back door to see if she was in the smoking area. LVN B stated usually when breakfast was served at 7:00 AM, she as usually eating breakfast in her room, but she still had not shown up for her breakfast. LVN B stated that he notified the Administrator and the family. LVN B stated that when he notified the resident's family member she then went to the facility and called the police. LVN B stated that he was asking himself why the family called the police and not staff. He stated the risk of Resident #1 leaving the building unsupervised was that some people were sick and they had confusion. LVN B stated that he was not sure if Resident # 1 was one of the residents who could sign out because the sign out sheet of which resident who can sign out changed frequently. LVN B stated that he felt that they needed another receptionists at the door. In an interview on 05/18/26 at 2:31 PM, CNA C stated that she saw Resident #1 right before she left on 05/16/26, she said she had a family emergency, and she had to leave a little early that night. CNA C stated that the last time she saw Resident #1 was when she was walking back from the smoking area around 9:10ish to 9:15ish PM on 05/16/26. CNA C stated the next time she recalled seeing Resident #1 was when she went to a resident's room across the hallway from Resident #1's room to pick up some trash and when she turned around she saw Resident#1 in her bed lying down around 9:50ish to 10 o'clock PM. She stated the risk of Resident #1 leaving the building unsupervised was that she could get hurt or injured and they would never know. CNA C stated that when situations such as this happen the administrator, nurses, family members, and police would need to be notified. In an interview on 05/18/26 at 2:58 AM, the ADON stated that she was not working at the facility when the incident happened with Resident #1, but the Administrator, Medical Director, police, and the family were notified when they realized they couldn't find Resident #1 anywhere. The ADON stated they tried to call the hospital to see if she was there, but she was not. The ADON stated she was not sure how the resident could have gotten out of the building. The ADON stated that there as not a receptionist at the front door overnight. The ADON stated the Medical Director was notified around 6:00 PM, that the resident had gone back to the building. The ADON stated she attempted to ask the resident where she had gone, but Resident #1 stated she as grown and she shouldn't be asking her where she went. The ADON stated the resident had not left the building before and this was the first time. When asked where the BIMS of 13 was documented due to the annual MDS being in progress, the ADON stated she had thought the Social Worker did the BIMS assessment and put it into the Resident #1's EHR. The ADON stated the recent elopement risk assessment that was completed on the resident did not indicate the resident was at high risk for elopement. The ADON stated she was not sure what interventions were going to be put into place moving forward to make sure this did not happen again. The ADON stated the only intervention she could think of was to put a receptionist at the front door to see if that could help. The ADON stated the risk of Resident #1's leaving the building unsupervised was injury, she could get hurt outside, and she could be kidnapped. In an interview on 05/18/26 at 3:16 PM, the DON stated she received a call on 05/17/26 from LVN B stating Resident #1 missed her aspiration medication and that she missed breakfast. The DON stated that she was unaware of what other medications Resident #1 missed. She stated that she couldn't remember off the top of her head. The DON stated Resident #1 only took about 4 to 5 medications. The DON stated that she received another call at 10:58 AM from LVN B notifying her that the resident was nowhere in the building. The DON stated this was the first time the resident had left the building. The DON stated that she attempted to have the resident placed in another facility, but she was denied due to not being eligible to reside in a secure unit. The DON stated any other intervention after that she believed a receptionist should be placed at the front door other than nursing staff. The DON stated that the Administrator told the nurses it was their job to watch the front door. The DON stated there waw a receptionist at the front in the morning, but there was not a receptionist at the door after 5:00 PM nor overnight. The DON stated there was a receptionist at the front desk on 05/16/26 and 05/17/26 from 8:00 AM- 5:00 PM only. The DON stated that she was unsure how the resident got out of the building and the cameras did not work so they were unable to see what door she went out of. The DON stated that there were no orders in place stating Resident #1 could not sign out. The DON stated Resident #1 could sign out. The DON stated that Resident #1 was on the list to be able to sign out and she would bring it. The DON stated that residents were determined if they could sign out by their BIMS scores and elopement assessments. The DON stated Resident #1's BIMS score was 13. The Surveyor informed the DON that the last BIMS score that was in PCC was the annual MDS that reflected the resident had a BIMS of 8, due to the Quarterly MDS showing as in progress and showing overdue. The DON stated that the last BIMS score of 8 was from when the resident was sick, but she was better now. The DON stated the Administrator, DON, and the ADON were notified when the resident was unable to be found in the building. The DON stated Resident #1 returned on her own on 05/17/26 around 6:50 PM and she was witnessed getting out of a van by one of the residents. The DON stated the expectations of staff when a resident could not be located in the building were to search the whole building, check all door entry ways, search outside the building, behind the building, call all managers, notify the medical director, and notify the appropriate family members. The DON stated the risks of the resident leaving the building unsupervised could cause death and dehydration. The DON stated The facility is a locked unit and does require a keycode at all times. The DON stated they have the sign out sheets to know which residents can sign out and which residents can't sign out. When asked why was the resident's name on one of the sign out sheets but not the other her response was that the residents who sign out heavily names are put on the sign out sheet. The DON said the residents that don't sign out as much or don't sign out at all, the receptionists or whoever is at the front at that time are supposed to go and ask the nurse if the resident is able to sign out and their names are not on the sign out sheet. She said that she couldn't find the original sign out sheet, so she went to the binder and grabbed a copy that they keep. The DON was unsure when the sign out sheets for residents were created and she had only been the DON for two months. When asked how would they know it would not be okay for the resident to sign out The DON stated knowing if a resident is allowed to leave unattended is the same as any other basic nursing assessment by noting a change of condition or lack of change of condition. The DON stated Resident #1 had no change of condition and was acting according to her current baseline except for one thing different she was purposely being sneaky so she could go with someone she had a relationship with. The DON stated nursing facilities do not routinely give BIMS scales every time someone wants to sign out and go with friends or family. Record Review of the Resident #1's Quarterly MDS on 05/18/26 at 3:45 PM, reflected it was now in the system and indicated Resident #1 had a BIMS score of 13. Record review of the sign out sheet titled, Only residents on this list are able to sign themselves out of this building. If their name is not on this they are not allowed to go out of the building on their own, undated, reflected Resident #1's name was on the list. In an interview on 05/18/26 at 3:52 PM, The Medical Director stated she was informed that the resident was missing on 05/17/26 at 11:45 AM. The Medical Director stated that Resident #1 did not have any orders regarding not being able to sign out due to Resident #1 being cognitive. The Medical Director stated that Resident #1 did not sign herself out on pass. The Medical Director stated that Resident #1 would not have missed any medications overnight, just medication in the morning. The Medical Director stated she could not recall the last time she saw the resident due to not having that information in front of her at the time of the interview. In an interview on 05/18/26 at 4:24 PM, the Administrator stated all they could do as educate the resident on not leaving the building, but they could not stop the residents from leaving the building if they wanted to leave AMA. The Administrator stated Resident #1 left the building at 8:00 PM on 05/16/26. When the administrator was asked was he sure the resident left the building on 05/16/2026 around 8:00 PM, The Administrator stated that he had multiple sources that stated they saw Resident #1 leave on Saturday. When the Administrator was asked how did the resident get out of the building, he stated the residents were cognitive enough to find out what the door code was and even if he were to change the door code the residents would still figure out what the new door code was too. The administrator stated that any cognitive resident could figure out what the door code was. The Administrator was unsure of how the residents were getting the door code and stated that there was a possibility that the residents watched staff put the code in. The Administrator stated all staff have the door code and residents are not supposed to have the door code. The Administrator stated whenever a resident as found not to be in the building the Administrator and the medical director would need to be notified. The Administrator stated staff were then expected to follow his directions and whatever he told them to do, which was start sweeps of the building, contact the police, contact HHS, and as well as anyone else that needs to be involved. The Administrator stated the risk of a resident leaving the building unsupervised is not getting their medication, or inclement weather. The Administrator stated that if he needed to have an immediate intervention to prevent this type of situation from happening, again he could work on getting a receptionist hired at the front desk to be sure residents that were leaving were signing themselves out. Interview on 05/21/26 at 1:17 PM, the SW stated when she spoke with Resident #1, she told her that she just wanted to go and meet up with her friends and that she had stuff to go and do. The SW stated that she then asked Resident #1 to sign herself in and out and let the nurses know that she was going to leave just in case she needed to get any medication next time. The SW stated that she didn't know how Resident #1 had gotten out of the facility because she didn't tell her how she had gotten out of the building. The SW stated she was unsure how some of the residents get the door code but some of them did get it. The SW also said that the handle on the front door could be held down for 30 seconds and the door would open also. The SW stated that she could sign herself out. The SW stated the risk of a resident leaving the building unsupervised was getting in a car and not being able to get back to the building. Interview on 05/21/26 at 1:36 PM, the MDS Coordinator stated that when Resident #1 was admitted she had a BIMS score of 3 then it went to 7 (indicates severe cognitive impairment), 11 (indicates moderate cognitive impairment), and then 13 (indicating cognition is in tact) recently. The MDS Coordinator stated Resident #1's BIMS score did vary and she had dementia. The MDS Coordinator stated Resident #1 shouldn't be able to sign out. The MDS Coordinator stated Resident #1 had not tried to leave the facility before and this had been the first time. The MDS Coordinator stated because her BIMS was recently a score of 13 then Resident #1 was okay to leave this time. The MDS Coordinator stated that the risk of a resident leaving the building unsupervised is unsafe. Record review of the facility's policy titled Elopements, not dated, reflected in part Policy statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation- 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or DON. 3. When a departing individual returns to the facility, the DON or charge nurse shall: a. examine the resident for injuries b. notify the attending physician c. Notify the resident's legal representative of the incident, d. complete and file report of incident/accident; and document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building and premises; c. If a resident is not located, notify the administrator and the DON, the resident's legal representative, attending physician, law enforcement official, and volunteer agencies. D. provide search teams with resident identification information; and e. initiate an extensive search of the surrounding area.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for two rooms (Halls 100 and 600), exit glass doors on 3 of (100, 200, and 300) 6 facility resident halls and area between the kitchen and dining room reviewed for environment.The facility failed to ensure:- that there was not an accumulation of dust, debris, stains, and bacteria, creating an unsanitary, unkempt, exit room [ROOM NUMBER], 200, and 300 door plates; - that there were not torn vinyl with ripped edges exposing the black protective padding on the flooring near kitchen and dining area on 04/08/2026;- the air conditioning unit in Resident #3's room did not gapping away from the wall with gunk (sticky substance) with dirt, soft fluffy black substance on the top, right, and left of the air conditioning unit and the right side of the unit did not have a small tear in the wall structure; and- that there was not a missing toilet tank cover Resident #3's room on 04/08/2026.The failures could result in residents having diminished quality of life due to the lack of a well-kept environment and equipment and affect the staff and visitors.Findings included: During an observation on 04/08/2026 at 1:20 PM, of the 100, 200, and 300 halls revealed the exit glass doors at the end of each hallway had an accumulation of dark black dirt and leaves. During an observation on 04/08/2026 at 1:20 PM, the flooring in the dining room next to the kitchen entrance and ice machine was damaged, with torn vinyl.The following was observed in Resident #3's room on 04/08/2026 at 1:20 PM:The A/C unit was loose and separated from the wall creating gaps. The unit was observed with gunk (sticky substance) and matted dirt (black sticky, greasy) around the unit, and a hole in the wall structure to the right side of the A/C unit next to the resident closet. The toilet was missing the tank cover. During an interview on 04/08/2026 at 1:35 PM, the ADON said it was all of the staffs responsibility to report environment and maintenance needs immediately to prevent staff and resident from accidents, injuries and exposure, to bacteria, insects, bugys, and rodents that may result in changes of health. During an interview on 04/08/2026 at 2:00 PM, CNA-A stated that housekeeping was cleaning the residents' rooms. CNA-A had not observed the housekeepers cleaning the door and floors at the end of every hall. CNA-A stated staff were responsible for reporting environmental and housekeeping issues to the Administrator. CNA-A stated failing to report could result in residents living in unsanitary conditions.During an interview on 04/08/2026 at 3:10 PM, the MHS revealed if the bathrooms needed repair, it was his responsibility. The MHS stated if there were any structure issues with gaps and holes in the wall, he contracted out when notified. He stated that they just hired housekeeping staff and he was monitoring. He stated he had not observed the condition of the doors on the 100, 200, and 300 halls to be soiled. He said the facility had problems maintaining housekeepers. He stated that some residents removed the toilet tank cover, however once the room number for Resident #3 was provided, it was determined that the resident was unable to remove the tank cover. He said unsanitary conditions failing to repair environment could result in resident accidents, unsanitary conditions, and rodent entry.During an interview on 04/08/2026 at 3:00 PM, the SW stated the residents report all environment concerns to the ADM and MHS. She said there have not been any observations of insects or rodents, nor reports by residents. During an interview on 04/08/2026 at 3:30 PM, ADM stated that all facility staff were trained on reporting maintenance and environment repairs immediately to prevent residents, visitors, and staff from injuries. The ADM was not aware of the A/C unit in Resident #3's room, nor the debris and dirt that had accumulated on residents halls (100, 200, and 300.). ADM stated it was the MHK responsible to monitor and ensure facility maintenance and repairs were completed timely. said he will continue to repair and address the concerns in the building. ADM said the conditions place residents at risk for diminished quality of life and accidents. The environment policy was requested on 04/08/2026 at 3:30 PM from the ADM and was not received.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen reviewed in that:1.The facility failed to ensure the floor drain was covered in the kitchen on 04/08/2026. 2. Gnats were observed in the kitchen on 04/08/2026.3. A rodent was observed coming out of the kitchen sink on 04/08/2026. The failures could place residents at risk for food born illnesses, infections, and possible hospitalization. Findings included: During an observation on 04/08/2026 at 1:23 PM the kitchen revealed the following:An infestation of about 30 gnats swarming all over the plates and old food on the tray rack in the dishwashing room. A rodent exited the plastic bag covering a non-operational sink in the kitchen near prep area.The drain in the floor near the dishwashing area was not covered.A large rat trap with a small food scooper was observed on the bottom rack of the food preparation table in the kitchen. The dining room staff were not preparing food at the time of the observation. During an attempted interview on 04/08/2026 at 1:40 PM with the dietary staff (DA-B, DA-C, and DW-A who were present during the observations of the rodent exiting the sink) resulted in them all declining to be interviewed on kitchen insect and rodent concerns. During an interview on 04/08/2026 at 1:35 PM, with the ADON stated that there had not been any resident reports of insects in food. ADON reported that there had not been any resident illnesses related to food or kitchen related issues. During an interview on 04/08/2026 at 2:50 PM, the DM stated he transitioned from housekeeping to DM 2 weeks ago. He said the plumbing repairs were conducted as needed. The DM stated the sink stopped up at times causing standing water. He said that he had just vacuumed up the standing water. The DM stated that a plastic trash bag was used to cover the sink to prevent bugs, insects, and rodents from entering the kitchen. He said the sink did not work and he would request that the sink be removed to prevent further concerns with pest and rodents. He stated the facility has a history of pest and rodents observations; however they are back. He stated the floor drain next to the dishwashing room had a cover, but he removed it during the vacuuming. He stated the Housekeeping/Maintenance Supervisor was notified of kitchen repair and plumbing issues on 04/08/2026 at 12:00 PM. The DM stated they could notify PCC anytime they needed assistance or have observed rodents and gnats. The DM said the last visit was today 04/08/2026 at 10:00 AM. PCC removed rodents, treated them for rodents and pest. He stated when the sink gets stopped up, the water overflows and gnats tend to multiply. He did not have an answer for the treatment of the gnats. He stated that the insects, rodents, and rat traps created an unsanitary environment that could make residents sick. The DM denied reported incidents of resident illness related to the pest and insect issues. During an interview on 04/08/2026 at 3:10 PM, The MHS stated the Administrator and MHS had increased the pest control contract according to the recommendation of the PCT dated 02/25/2026. The MHS stated the PCC was visiting daily and he had observed improvement in the facility. He stated that PCT and maintenance checked the glue traps daily and removed rodents. He stated that all rat traps should be on the floor in areas away from others and not on a food prep table. He stated he would contact the plumber about the sink and dishwasher overflowing drain. He said unsanitary conditions and failing to repair the environment could result in resident accidents, unsanitary conditions, and rodent entry. During an interview on 04/08/2026 at 3:15 PM, the DON stated that she had not observed rodents and insects in the building nor have residents reported observations. She said rodents and an infestation could potentially lead to resident illnesses due to unsanitary conditions. The DON said it was her responsibility as well as all staff to ensure unsanitary conditions, rodent and insect activities were reported immediately by staff. During an interview on 04/08/2026 at 3:30 PM, the ADM said residents had not complained about rodent and pest issues regarding dietary services. He stated that he had signed a new pest agreement, on 03/31/2026 (the contract reviewed was dated 02/24/2025.) with the PCT, and the PCT addressed the additional treatments and services needed to remedy the rodent and insect problems. He expected the DM to report all kitchen concerns immediately to him and the MHS, and he could contact the PCC himself to request onsite treatment. He would report the gnats to the PCC. He also stated that HHSC RRT were visiting and working with him weekly to address facility sanitation, repairs maintenance, and environmental concerns. He declined to answer questions about observations and reports of rodents and insects. He provided the new PCT, and statement for review, as well as the RRT treatment plan for the building. He further stated that all facility staff were trained on reporting maintenance needs and resident safety precautions to prevent unsanitary conditions, resident and staff accidents, resident and staff illnesses, and decline in facility structures. The ADM denied reports and incidents of resident illnesses related to food. Record review of the facility's PCC visit titled Customer Detail dated 03/24/2026 reflected Checked in with MHS inspected the kitchen .Captured 3 rats (large type of rodent) in the kitchen .set glue traps(adhesive boards that catch insects and rodents and reset traps, treated to prevent ants, roaches crawling insects applied treatment to repel American and German cockroaches, ants, ground beetles, pill bugs, and spiders, crawling insects and mice. captured a total of 3 rats and 8 mice (small type of rodent) during visit. Treated 50 fruit flies (small insect that feeds off decaying fruit)Record review of the Facility's policy titled Sanitation dated 10/2008 reflected in part Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. I. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair.All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.Dishwashing machines must be operated using the manufacture specifications.Sanitizing of environmental surfaces must be performed with one of the following solutions: The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests.1.An anonymous resident reported observing a rodent in his room on 02/11/20262.Gnats and one rodent were observed in the during the kitchen inspection on 04/08/2026.3.Resident #3 reported observing rodents in his room on 04/07/2026.4.Kitchen observation on 04/08/2026 of a small mice/rodent exiting the kitchen sink that was covered with a clear plastic trash bag. The failures could result in residents having infections, exposure and inhalation of environmental substance, and diminished quality of life. Findings included:Record review of grievance log from 02/01/2026 to 04/07/2026 revealed no reports of rodent, pest, and insect issues. Record review of the facility's maintenance log dated 04/06/2026 from the BOM revealed an observation of a rodent in the front office. Record review of the pest sighting log from 01/30/2026 to 04/06/2026 reflected on 04/06/2026 a rat observed in the front office. During an interview on 04/08/2026 at 1:20 PM, Resident #1 stated that he observed a rodent coming out of his closet 04/07/2026 at night. During an interview on 04/08/2026 at 1:35 PM, with ADON she stated that she denied observing rodents and insects in the building. She have not received resident reports of insects and rodents in the building. She said rodents and infestation could potentially lead to resident illnesses due to unsanitary conditions. ADON said all staff were responsibility for reporting concerns with environment changes, rodents, and insects to protect resident from unsanitary living conditions related to bugs and rats.During an interview on 04/08/2026 at 2:00 PM, CNA-A stated a rodent was observed on 04/07/2026 in the hallway. The CNA-A stated the residents did not observe the rodent, nor reported pest and rodent concerns on her unit. CNA-A stated that the PCC left glue traps to be put down on the floor in areas where rodents were observed. CNA-A stated that PCC came and removed a rodent off a glue trap this morning (specific time unknown). CNA-A stated that housekeeping were cleaning the residents rooms. CNA-A had not observed the housekeepers cleaning the door and floors at the end of every hall. During an interview and review on 04/08/2026 at 2:20 PM with an anonymous resident revealed he wanted the surveyor to see a video on his phone that was stamped 02/11/2026. The Surveyor reviewed a video that revealed on the resident's side of the room (matched furnishing, and personal items) a rodent on the floor, near his bed. Resident stated that he did not report the observations of the rodent to anyone, and he has observed rodents in his area 2 other times. During an interview on 04/08/2026 at 2:45 PM, the BOM stated she observed a rodent come in the front reception office, then headed down the hallway. The BOM stated she reported it immediately to the Administrator and MHS. The BOM stated that this had been an on and off issue and the facility had an active contract for pest control and treatment as ongoing. The BOM stated the rodents in the building could cause the residents to develop infections and get sick. During an interview on 04/08/2026 at 2:50 PM, the DM stated a plastic trash bag was used to cover the sink in the kitchen that did not work to prevent bugs, insects, and rodents from entering the kitchen. The DM stated the Housekeeping/Maintenance Supervisor, and he could notify the PCC anytime they needed assistance or observed rodents and gnats. He did not have an answer for the treatment of the gnats. He stated that the gnats and observation of the rat in the kitchen created an unsanitary environment. The DM stated he reported rodent and insect observations immediately to the MHS, ADM, and PCC for an onsite visit to prevent residents from being exposed to uncomfortable and unsanitary conditions. During an interview on 04/08/2026 at 3:00 PM, the SW stated in her role, she was responsible for regular contact and visits to resident rooms, as well as reporting grievance and complaints to the ADM. SW said she had not personally observed rodents and insects, and the resident's had not reported any observations or concerns. She said all staff were responsible for reporting complaints, observations, and reports of rodents and insects immediately to ADM and MHS. The SW said the MHS and ADM were doing their best to make sure the facility was clean and in good repair. During an interview on 04/08/2026 at 3:15 PM with the DON, she stated that she had not observed rodents and insects in the building nor had residents reported observations. She said rodents and infestation could potentially lead to resident illnesses due to unsanitary conditions. The DON said it was her responsibility as well as all staff to ensure unsanitary conditions, rodent and insect activities were reported immediately. During an interview on 04/08/2026 at 3:10 PM, the ADM stated that the MHS was responsible for pest control, and he had recently signed another contract increasing pest treatment on the property. The ADM stated that the PCC was visiting daily, and he has observed improvement in the facility. He stated that PCT and maintenance checked the glue traps daily and removed rodents. Record review of the Grievance log from 2/01/2026 to 04/07/26 revealed no reports of rodent, pest, and insect issues. Record review of the facility's PCC visits titled Customer Detail dated 03/02/2026 reflected exterior inspection The inspection revealed observations and details of moisture damage soft back door, hole in exterior wall, cracks in mortar, bricks, gaps and rotten structure from water damage on the exterior. Kitchen inspection conducted on 03/02/2026 reflected poor sanitation, accumulated debris around the pipes, food residue under appliances/machinery/equipment severity medium. The PCC recommended an advance plan to address the insects, bugs, rodents, and pest. Record review of the facility's PCC visits titled Customer Detail dated 02/23/2026, reflected [PCC] checked in with MHS inspected treated the interior kitchen .common areas of the facility and resident rooms to prevent roaches, ants, and crawling insects. Treated fruit flies in the kitchen dishwashing room. Captured mice (small size rodent) and 2 rodents (large size rodent) in the kitchen .set glue traps (adhesive boards that catch insects and rodents and reset traps, treated to prevent ants, roaches crawling insects applied treatment to repel American and German cockroaches, ants, ground beetles, pill bugs, and spiders, crawling insects and mice. captured a total of 3 rats and 8 mice (small type of rodent) during visit. Treated 50 fruit flies (small insect that feeds off decaying fruit). Recommended mass trapping to reduce rodent population. PCC captured 2 mice and 6 rodents during this visit. There were no PCC recommendation documented for this visit. Record review of the facility's PCC visits titled Customer Detail dated 03/09/2026 reflected [PCC] checked in with MHS inspected treated the interior kitchen .common areas of the facility and resident rooms to prevent roaches, ants, and crawling insects. completed property inspection treated the interior kitchen and other interior areas to prevent ants, roaches, and insects. Treated fruit flies. Captured 3 mice in the kitchen. Treated exterior perimeter (area), service rodent bait stations. PCC captured 3 mice, 3 rats, 1 ant, and 30 fruit and vinegar flies tiny (3-4 mm), yellowish-brown to dark brown insects with red or dark eyes. They are highly attracted to rotting fruit, fermenting liquids (vinegar, beer, soda), and decaying organic matter, where they lay eggs, causing infestations in homes and agricultural settings.). There were no PCC recommendation documented for this visit. Record review of the facility's PCC visits titled Customer Detail dated 03/24/2026 reflected [PCC] checked in with MHS inspected treated the interior kitchen .common areas of the facility and resident rooms to prevent roaches, ants, and crawling insects. Captured 3 rats (large type of rodent) in the kitchen .set glue traps (adhesive boards that catch insects and rodents and reset traps, treated to prevent ants, roaches crawling insects applied treatment to repel American and German cockroaches, ants, ground beetles, pill bugs, and spiders, crawling insects and mice. captured a total of 3 rats and 8 mice (small type of rodent) during visit. Treated 50 fruit flies (small insect that feeds off decaying fruit). There were no PCC recommendation documented for this visit.Record review of the facility PCT titled Commercial Service Purchase order.date of services 02/25/2025.C-Rodent - Commercial Rodent Premium Coverage: Involves sealing all potential rodent entry points throughout the building to prevent rodents access. Includes an initial mass trapping using a variety of traps and rodent insecticides to effectively reduce the rodent population.This replaces current rodent services. Includes 9 additional rodent bait stations to be strategically placed around the exterior.Following the exclusion process, 6 visits will be conducted for trapping and removal of any existing rodents within the facility.Includes ongoing maintenance of rodent bait stations and other rodent control devices to prevent future infestations. Regular inspections of the building are performed to identify, prevent, and repair any new potential entry points, ensuring long-term protection against rodents.Wildlife live trapping inside facility is included.No extra for rodent call backs.General Terms and Conditions Materials: The materials used in pest control work shall conform to federal, state, and local ordinances and laws. All pest control work shall be performed in a safe manner and in accordance with the most modern and effective procedures. Record review of the pest control policy dated May 2008 reflected in part Policy Statement our facility shall maintain an effective pest control program.Policy Interpretation and Implementation: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.Pest control services are provided by [contractor name]. Windows arc screened at all times. (window screens secured at all times). Only approved FDA (ensures food safety) and EPA (ensures environment safety) insecticides (substance formulated to kill, repel, and control insects.) and rodenticides (a chemical substance designed to kill, repel, and control rodents) are permitted in the facility and all such supplies are stored in areas away from food storage areas.Garbage and trash are not permitted to accumulate and are removed from the facility daily.Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview and record review, the facility failed to provide a safe environment for residents, staff, and the public for one of two oxygen tanks observed for oxygen storage safety.The facility failed to securely store oxygen cylinders in the facility's one of two nurse's stations.This failures could affect the residents by placing them at risk of injury due to oxygen cylinders becoming unsecured and becoming a hazard.Findings included: Observation on 03/16/2026 at 10:57 a.m. revealed two oxygen cylinders next to the crash cart behind the nurse's station. One cylinder was secured in a rack, and one was not. Observation and interview on 03/16/2026 at 2:45 p.m. with LVN A revealed the oxygen tank was not secured. She stated she had just started her shift and did not notice it was unsecured. LVN A stated it should always be secured in a rack, and the risk was it was a hazard and could cause a fire. An interview on 03/16/2026 at 2:54 p.m. with the DON revealed she was not aware the tank was unsecured. She stated the night shift has been tasked with checking the crash carts and probably had changed it out and forgot to take it back to the storage room. She stated her expectation was that the tank should be secured at all times and the risk was it could get knocked over. She stated they did not have a policy on oxygen storage. Review of National Fire Protective Association, (NFPA) 99, 2012 Edition, Section 11.6.2.3, reflected: .(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart .

Based on interviews the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 6 of 6 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. During a confidential resident group meeting 6 of 6 members in the group stated they never received mail on Saturdays because the Business Office didn't work on Saturdays but they did have a receptionist. During an interview on 12/15/2025 at 3:20 p.m., with the Administrator, he stated that he was acting as the Business office staff person for now. He stated that for both he and the receptionist were passing the mail. During an interview on 12/16/25 at 9:22 a.m., the Receptionist stated the mail is dropped off with her at the front desk. She stated that both she and the Administrator passed out the mail. She stated there is someone at the front desk on the weekends, but when she comes in on Monday the mail had not been passed out. She stated that she has not opened any mail she just passed it out. During an interview on 12/16/25 at 02:15 p.m., the Administrator stated that mail should be passed out on the weekends by the weekend receptionist on Saturday.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for 10/19/24; 10/20/2411/16/24; 11/17/2412/07/24; 12/08/24; 12/14/24; 12/15/24; 12/21/24; 12/22/24; 12/28/24; 12/29/2401/04/25; 01/05/25; 01/11/25; 01/12/25; 01/18/25; 01/19/25; 01/25/25; 01/26/2502/22/25; 02/23/2504/19/25; 04/20/25; 04/26/25; 04/27/2505/03/25; 05/04/25; 05/10/25; 05/11/25; 05/17/25; 05/18/25; 05/24/25; 05/25/25; 05/31/2506/01/25; 06/07/25; 06/08/25; 06/14/25; 06/15/25; 06/21/25; 06/22/25; 06/23/2508/10/25; 08/16/25; 08/17/25; 08/23/25; 08/24/25; 08/30/25 08/3/2509/06/25; 09/07/25; 09/13/25; 09/14/25; 09/20/25; 09/21/25; 09/27/25; 09/28/25 This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities.During an interview on 12/16/25 at 12:35 p.m., with the DON revealed she was hired on 08/11/2025 and was the only RN to provide RN coverage. The DON stated that they had held interviews for RNs, but the requested pay was too high. She stated the importance of RN coverage was to ensure oversight of nursing including cardiac life support. She stated since she started, the facility had no RN weekend coverage. She stated she was not able to provide RN coverage 7 days a week for 8 hours, but least four hours each day on weekends. She stated the facility does not use agency staffing to provide RN coverage. During an interview on 12/16/25 at 3:31 p.m. with the Administrator revealed the hours that were submitted on the PBJ were correct. He stated the only RN the facility had was the DON. He stated the DON provided RN coverage during the week and she worked four hours on Saturdays and Sundays, but she was unable to provide 8-hour daily coverage. He stated the facility did not use agency staff to provide RN coverage. He stated the facility nurses on the weekends were LVNs not RNs. The Administrator stated the importance of having RN coverage was for oversight. He stated he was aware of the regulations requiring 8 hour in-facility RN coverage in the facility daily. He stated RN's scope of practice covered areas the LVN's scope of practice did not cover. He stated the facility had RN weekend coverage job posting up and had not been able to fill the job posting to date. Review of facility's employee list reflected there were no other RN nurses on the facility's employee list. Record Review of facility's PBJ Staffing Data Report for Quarter 2 (January 1-March 31), Quarter 3(April 1-June 30), and Quarter 4 (July 1-September 30) 2024 reflected the facility triggered for no RN hours. Review of facility's policy Staffing revised October 2017 reflected the facility provides sufficient nursing staff with the skills and competencies necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.2. Staffing numbers and the skill requirements of the direct care staff are determined by the needs of the residents based on each resident's care plan.

Based on interviews the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety,The facility failed to correctly label and date items in the dry storage and refrigerated areas. The facility failed to correctly label and date 4 bulk containers. These containers held flour, rice, breadcrumbs, and potatoes. There were no corresponding labels to indicate what the items were and when they were placed there and when they should be used by. The pantry had open packages of dry oats, breadcrumbs, and tortillas without the corresponding labels without the use by dates on the packages. There was no indication of when these items were opened and when the items should be discarded. These failures could place residents at risk for food-borne illness and cross contamination. Observation of the kitchen on 12/14/2025 at 9:25 a.m., revealed in the kitchen storage area, 5 bins of dry goods, rice, flour, breadcrumbs, potatoes and beans with only 1 date marked on a label. The labels on these bins did not list the exact item inside, when it was placed and when it should be discarded. Observation of the dry storage area, a room outside of the kitchen in a service corridor on 12/14/2025 at 9:37 a.m., revealed previously opened packages with no dates on them. There was a package of tortillas with no label on it to indicate what it was, when it was opened and when it should be discarded. There was a package of puree rice with a date of 09/18 and nothing else on the label. In an interview with the weekend cook on 12/14/2024 at 9:26 a.m., she stated that she had only worked at the facility a few weeks. She stated that she worked double shifts Saturday and Sunday. She stated the food had already put up when she arrived to work. She stated she was still getting a feel for the facility but had worked as a cook before coming here. She stated there were only 2 people working on the weekend. In an Interview with the Dietary Manager on 12/15/2025 at 10:15 a.m., she stated she had worked at the facility a few months. She stated that she was trying to work with what she has. She stated that she was trying to get the kitchen in order. She stated the packages are supposed to be labeled after they are taken from the box and opened. She stated the staff were labeling the items like they should. She believed it may be the weekend staff who are not labeling the packages after they open them. She stated she will get with all staff and retrain them. Interview with the Administrator on 12/16/2025 at 2:15 p.m., he stated the Dietary Manager was new and is doing a good job so far. He did not know the packages were not meeting the labeling requirement for dates and identification.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for two (Resident #5 and Resident #10) of five residents reviewed for PASRR Level 1 screenings. The facility failed to submit a new PASRR Level 1 screening when Resident #5 received a bipolar diagnosis.The facility failed to provide resident assessments to the habilitation coordinator within 20 days for Resident # 10. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Review of Resident #5's Face Sheet, dated 12/16/25, reflected a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, psychotic disorder with delusions, post-traumatic stress disorder, and bipolar disorder. Review of Resident #5's MDS Assessment, dated 10/30/25, reflected he had documented diagnoses of Bipolar Disorder, Psychotic Disorder and Post-Traumatic Stress Disorder. Review of Resident #5's PASRR Level I Screening, dated 10/31/23, reflected he did not qualify for a PASRR Level II Evaluation at that time. There was no evidence that Resident #5 had a mental illness, intellectual disability, or developmental disability. Review of Resident #5's electronic medical record reflected no evidence that any additional PASRR Screenings/Evaluations had been completed since the initial PASRR Level I Screening was conducted on 10/31/2023. Review of Resident #10's Face Sheet, dated 12/16/25, reflected a [AGE] year-old male, who was admitted to the facility on [DATE], with diagnoses including Duchenne or [NAME] muscular dystrophy (genetic disorder characterized by the progressive loss of muscle. It is a multi-systemic condition, affecting many parts of the body, which results in deterioration of the skeletal, cardiac, and pulmonary muscles), chronic pain syndrome, unspecified dementia without behavioral disturbance, major depressive disorder. Review of Resident #10's MDS Assessment, dated 09/04/25, reflected he had a diagnosis of Duchenne or [NAME] Muscular Dystrophy. Review of Resident #10's Preadmission Screening and Resident Review Report of Specialized Services Non-Compliance to Consumer Rights and Services, dated 08/31/2025, reflected that the facility failed to submit assessments for all three therapy disciplines within 20 day deadline to the PASRR staff. During an interview on 12/15/25 at 11:00 a.m., the PASRR Habilitation Coordinator (HC) revealed that 3/10/25 Resident #10 selected his PASRR specialty mattress. The PASRR HC stated she contacted the facility MDS Coordinator on 04/29/2025 to find out what the status of Resident #10 physical, occupational and speech assessments were as they had not been received. The PASRR HC stated that the facility had 20 days to send in the three therapy assessments to have PASRR services approved. The PASRR HC stated since Resident #10 missed the 20-day deadline, that meant that the resident missed out on services and would have to wait for another quarterly meeting to start the process again. During an interview on 12/15/25 at 11:25 a.m., the MDS Coordinator said she had been the MDS Coordinator for the facility for 5 years and worked remotely. The MDS Coordinator stated she was responsible for all PASRR forms in the facility. MDS Coordinator stated that a mental illness, intellectual disability and developmental disability would result in a positive Level 1 PASRR screening. The MDS Coordinator stated that she was not apart of the PASRR meetings until August. She only submitted documents the social worker sent her. The MDS Coordinator stated Resident #5's initial PASRR Level I Screening was completed on 10/31/2023. Resident #5 did not qualify for services at that time, as there was no indication that Resident #5 had a mental illness, intellectual disability, and/or developmental disability. The MDS Coordinator said she was not aware Resident #5 was later diagnosed with bipolar disorder. The MDS Coordinator stated that when two items caused a change to the resident's MDS, that would trigger her to look for a new diagnosis. The MDS Coordinator stated that with new diagnoses Resident #5 should have had a PASRR Level II Evaluation completed to determine if he qualified for services. She stated she planned on conducting a facility-wide audit to ensure no other residents had missed receiving a required PASRR Screening/Evaluation. The MDS Coordinator stated she did not believe there was a risk in Resident #5 not receiving a new PASRR Screening/Evaluation upon his new diagnosis of bipolar disorder, as Resident #5 also had a diagnosis of Dementia, which would prevent resident from receiving services. The MDS coordinator stated that Resident #10 had a PASRR meeting in March, but she was not involved. The MDS Coordinator stated that it was not until the PASRR habilitation coordinator contacted her in April asking for Resident #10's assessment was when she found out Resident #10 needed the assessments uploaded. The MDS Coordinator stated that when she was contacted the facility had missed the 20-day deadline. The MDS Coordinator stated that the facility has 20 days after a resident selects their services to have assessments uploaded to be approved. Failure to have the assessment uploaded would cause the residents to miss out of specialized services.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #58) of ten residents reviewed for pharmaceutical services. 1. The facility failed to ensure that there was no expired insulin inside the medication room on 12/15/2025. 2. The facility failed to ensure LVN B did not put her personal beverage on the medication cart while passing medications on 12/15/2025. 3. The facility failed to ensure MA G did not put her personal beverage on the medication cart while passing medications on 12/15/2025. These failures could place the residents at risk of not receiving medications as ordered by the physician and potential interference with medication preparation.Findings included: Record review of Resident #58's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old male resident admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #58's Comprehensive MDS Assessment, dated 10/15/2025, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus. Record review of Resident #58's Comprehensive Care Plan, dated 10/17/2025, reflected the resident had diabetes mellitus and one of the interventions was to administer diabetes medications as ordered. Record review of Resident #58's Physician's Order, dated 10/26/2025, reflected Humalog (man-made insulin) Injection Solution 100 UNIT/ML (Insulin Lispro) Inject subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA ((high blood sugar in the blood stream). An observation on 12/15/2025 at 10:09 AM revealed that during inspection of the medication room, a vial of Humalog, with opening date of 09/24/2025, was inside the medication room's refrigerator. During an observation and interview on 12/15/2025 at 10:11 AM, LVN A stated she was not sure when the expiration date of the Humalog was. She said she would ask the ADON. She took the insulin and went out of the medication room. In an interview on 12/15/2025 at 10:22 AM, the ADON stated they already disposed of the Humalog because it was already expired. She said, for Humalog, the shelf life is 28 days after opening, meaning it would be expired after 28 days. She said the risk would be either the resident could have adverse reactions, or the insulin would be less effective because it was already expired. She said the nurses, as well as herself, were responsible in auditing the refrigerator in the medication room for expired medications. She said there was a list of insulins posted in the nurse's station with the number of days they could be stored after opening. She said this was an oversight on her part. She said she would audit the refrigerator inside the medication room to check the dates the insulins were opened. In an interview on 12/15/2025 at 10:26 AM, LVN B stated she was Resident #58's nurse and she was the one administering his insulin. She said she did not use the Humalog vial because the facility was using the Humalog KwikPen. She said the Humalog vial was from the resident's former facility and came with him when he was admitted to the facility. She said, still, even though she was not using the insulin, it should not be inside the fridge because it could be accidentally used and might cause side effects to the resident. She said she was also responsible in auditing the items inside the fridge of the medication room. Observation on 12/15/2025 at 7:06 AM revealed LVN B's personal tumbler was on top of the nurse's cart that she was using to pass medications. During an observation and interview on 12/15/2025 at 7:22 AM, LVN B stated she could not have her personal tumbler on the cart when passing medications or doing treatments because it could cause cross contamination. She said it could be an infection control issue or could create clutter on the medication cart. She said the only required supplies and medications should be on top of the medication cart. She took her personal tumbler and put it inside the nurse's station. Observation on 12/15/2025 at 8:15 AM revealed MA G's water bottle was on top of the medication cart that he was using to pass medications. An interview and observation on 12/15/2025 at 10:34 AM revealed the water bottle was still on top of MA G's medication cart. MA G stated he should not have the water bottle on top of his cart because of cross contamination, and he might accidentally use it for the residents or might accidentally be mixed with the medications he was preparing. In an interview on 12/16/2025 at 8:26 AM, the ADON stated no personal beverages should be on the medication carts because aside from being clutter that might contribute to medication error, staff might bring some microorganism from their home to the medication cart. She said she would coordinate with the DON to do an in-service about not placing any personal beverages on top of the cart and to check the expiration dates of the medications. In an interview on 12/16/2025 at 9:04 AM, the Administrator stated that the DON or the designee should frequently check the medication room and medication carts for expired medications to prevent any adverse effects. He said personal beverages should not be on the cart to prevent any potential medication error. He said the expectation was for the staff to frequently check for expired medications and for the staff not to put any of their personal beverages on top of the cart or even inside the cart. He said he would coordinate with the DON and the ADON about the issue. In an interview on 12/16/2025 at 9:36 AM, the DON stated the nurses were responsible for checking the expiration dates of the medications every time they administer them. She said even though the nurse was not using it, the insulin should not be inside the fridge because it was beyond 28 days. She said Humalog should only be used for 28 days after it was opened. She said expired medications could either cause adverse reactions or could be less effective. She said there was a breakroom near the nurse's station where the staff could put their personal belongings as well as their drinks. She said aside from the risk of cross contamination, some residents might take it and drink the content. She said the expectations were for the medication room to be audited thoroughly for expired medications and no personal beverages were in any cart. The DON said she would do an in-service pertaining to all the issues mentioned and would monitor the staffs' compliance. She said their policy might not include putting personal beverages on the carts, but it was the best practice. Record review of the facility's policy, Administering Medications Operational Policy and Procedure Manual for Long-Term Care revised December 2021 reflected Policy Statement: Medications shall be administered in a safe and timely manner . Policy Interpretation and Implementation . 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of fifteen residents (Resident #34 and Resident #42) reviewed for infection control. 1. The facility failed to ensure CNA E performed hand hygiene during Resident #34's incontinent care on 12/15/2025. 2. The facility failed to ensure CNA D performed hand hygiene and changed her gloves during Resident #42's incontinent care on 12/15/2025. 3. The facility failed to ensure CNA F did not walk down the hallway wearing a gown and gloves on 12/15/2025. These failures could place residents at risk of cross-contamination and development of infections.Findings included: Record review of Resident #34's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #34's Comprehensive MDS Assessment, dated 12/10/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident was incontinent for blader and bowel. Record review of Resident #34's Comprehensive Care Plan, dated 12/14/2025, reflected that the resident was frequently incontinent and one of the interventions was to assist during toilet use. An observation on 12/15/2025 at 11:32 AM revealed CNA E was about to do Resident #34's incontinent care. She washed her hands and put on a pair of gloves. She wet a small towel and put some soap in it and started to clean the perineal area using the front to back technique. She took off her gloves and put on a new pair of gloves. She did not sanitize her hands before putting on the pair of gloves. She cleaned the perineal area again. She then rolled the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief, threw it in the trash can, and changed her gloves. She did not sanitize her hands before putting on the new pair of gloves. She took the new brief from the resident's overbed table and fixed it under the resident. In an interview on 12/15/2025 at 11:54 AM, CNA E stated hands should be sanitized before putting on a pair of new gloves because her hands might be dirty from cleaning Resident #34's bottom and touching the new gloves with dirty hands rendered the new gloves dirty. She said she would be mindful the next time she would do incontinent care to prevent any infection such as urinary tract infections. Record review of Resident #42's Face Sheet, dated 12/16/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with benign prostatic hyperplasia. Record review of Resident #42's Comprehensive MDS Assessment, dated 10/06/2025, reflected that the resident had severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated that the resident was incontinent (unable to control) for bladder and bowel. Record review of Resident #42's Comprehensive Care Plan, dated 10/13/2025, reflected that the resident had an ADL self-care performance deficit and needed supervision for toileting. Observation on 12/15/2025 at 8:08 AM revealed CNA D was about to do Resident #42's incontinent care. She washed her hands and put on a pair of gloves. She took a brief from the resident's overbed table, opened it, and put it at the resident's side. She pulled some wipes and put them on top of the overbed table. She did not sanitize the overbed table before placing the wipes on it. She unfastened the brief and pushed it between the resident's legs. She then cleaned the resident's perineal area using the wipes she put on the overbed table. She then changed her gloves but did not sanitize her hands before putting on the pair of gloves. She turned the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she took the brief from the resident's side and placed it under the resident. She rolled back the resident and fixed the brief. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. In an interview on 12/15/2025 at 8:19 AM, CNA D stated she did not clean Resident #42's overbed table before putting the wipes on it. She said she should have cleaned the table first or just pulled the wipes from its container. She said she was not sure if the table was clean or not. She said the right thing to do was to change her gloves after cleaning the resident's bottom because she touched something soiled. She said using soiled gloves could cause transfer of germs to the new brief. She said the hands should also be sanitized if she changed her gloves. She said she would be mindful the next time she did incontinent care because her actions could cause infection. An observation and interview on 12/14/2025 at 12:59 PM revealed CNA F was walking in the hallway with gowns and gloves on. She said she should have discarded the gown and the gloves before going out of the resident's room to prevent cross contamination. She said she just came out of the room of the resident that had a catheter, that was why she was wearing a gown and gloves. In an interview on 12/16/2025 at 8:26 AM, the ADON stated the staff should be mindful that they were not causing any spread of infection in the facility and one way to do that was to do hand hygiene before, after, and during any care. She said the staff should change their gloves after touching soiled items like a soiled brief, soiled linens and even after cleaning the residents' bottom. She said the hands should be sanitized before putting on new gloves to make sure that the gloves that they were to use were clean. She said gowns and gloves were not worn in the hallway especially if the staff already went inside a resident's room that required PPE. She said the staff might already had contact with the resident that was on EBP and could spread to others any potential microorganisms. She said she would coordinate with the DON to do an in-service about infection control. In an interview on 12/16/2025 at 9:04 AM, the Administrator stated that staff should sanitize their hands to decrease potential infections and must not wear gowns and gloves in the hallway to prevent potential spread of infections. He said he would coordinate with the DON and the ADON about the issue and to monitor closely the staff's compliance to the policy. In an interview on 12/16/2025 at 9:36 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene when changing their gloves and change their gloves after touching something soiled. She said hand hygiene and changing the gloves should be done to prevent using soiled items. She said the staff should discard the gown and the gloves before going out of the room because there was no way of knowing what the staff touched inside the resident's room. She said the expectation was for the staff to practice hand hygiene when required and to practice proper handling of gowns and gloves. She said she would re-educate the staff with regards to infection and control and disposing of the gowns and gloves before going out of the room. Record review of the facility's policy Personal Protective Equipment - Using Gloves Nursing Services Policy and Procedure Manual for Long-Term Care September 2010 reflected Purpose: To guide the use of gloves . Objectives . 1. To prevent the spread of infection . Removing Gloves . 5. Discard the glove into the designated waste receptacle inside the room. Record review of the facility's policy Personal Protective Equipment - Using Gowns Nursing Services Policy and Procedure Manual for Long-Term Care September 2010 reflected Purpose: To guide the use of gowns . Objectives . 1. To prevent the spread of infection . Removing the gown . 6. If the gown is disposable, discard it into the waste receptacle inside the room. Record review of the facility's policy Handwashing/Hand Hygiene Operational Policy and Procedure Manual for Long-Term Care revised August 2015 reflected Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . m. After removing gloves . 9. The use of gloves does not replace hand washing/hand hygiene . Applying and Removing Gloves . 1. Perform hand hygiene before applying non-sterile gloves.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Halls 100 and 600) of 4 halls reviewed for environmental concerns. 1.The facility failed to ensure rooms' electrical outlets were covered in room [ROOM NUMBER] on hall 600. 2. The facility failed to ensure rooms were free from holes in the walls in room [ROOM NUMBER] on hall 600. 3. The facility failed to ensure windows were in a good state of repair in room [ROOM NUMBER] on hall 100. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant and unsafe.During an observation on 12/14/25 at 9:15 a.m., room [ROOM NUMBER] on hall 600 had an outlet that did not have a cover, no wires exposed . During an observation on 12/14/25 at 9:22 a.m., in room [ROOM NUMBER] on hall 600, there were two holes found in the walls. One hole was located at the bottom right of the clothes storage area and the second hole was in the corner of the room near the window. During an observation on 12/14/25 at 10:45 a.m., room [ROOM NUMBER] on the 100 hall had a broken window with glass on the windowsill. During an interview on 12/16/25 at 3:02 p.m., the Maintenance Director revealed he was responsible for the repair of the rooms. The Maintenance Director stated that the clinical staff had access to the rooms and would let him know if something was broken or needed to be fixed/replaced. He stated he also did rounds of the rooms. The Maintenance Director stated that he was not aware there were holes in the walls in room [ROOM NUMBER] and was not aware of room [ROOM NUMBER]'s uncovered outlet. He stated that he was only aware of the broken window in room [ROOM NUMBER]. He stated that he was notified on 12/16/25 that a resident threw their tray and it broke the window. The window was double-lined so only the inside panel of the glass broke, he tried to remove the broken glass but was unsuccessful. The Maintenance Director stated they removed the residents from the room until the window could be repaired. During an interview on 12/16/25 at 3:31 p.m., the Administrator stated it was the requirement of the maintenance department staff to ensure rooms are functioning properly. The Administrator stated he was not aware of holes in walls, or any outlet covers that were missing, but was aware of the broken window and stated that the resident was moved to another room until the cosmetic damage is repaired. The Administrator stated that all residents should have rooms that function properly. Requested facility policy for safe environment policy on 12/14/25 at 1:16 p.m. but did not receive it prior to exit.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (Resident #23) of eight resident reviewed for quality of care. The facility failed to ensure that LVN A used the proper procedures when providing wound care to Resident #23's diabetic ulcer on his right heel on 12/15/2025. This failure could place the residents with wounds at risk for infection or worsening of existing wounds.Findings included: Record review of Resident #23's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with non-pressure chronic ulcer (skin injuries that occur without the influence of pressure) of right posterior (back) heel. Record review of Resident #23's Quarterly MDS Assessment, dated 11/27/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needed little support) with a BIMS score of 14. The Quarterly MDS Assessment indicated that the resident had a non-pressure chronic ulcer of right posterior heel. Record review of Resident #23's Comprehensive Care Plan, dated 12/01/2025, reflected the resident had a diabetic (high blood sugar) ulcer (slow-healing wound due to diabetes) on his posterior heel and one of the interventions was to administer treatment as ordered. Record review of Resident #23's Physician Order, dated 12/09/2025, reflected Clean wound to the right posterior lower heel, with N/s or wound cleanser, pat dry and apply Anasept (antibiotic ointment), collagen (protein-based dressing to promote wound healing) and a dry dressing three times a week. in the morning every Mon, Wed, Fri for wound care. [sic] An observation on 12/15/2025 at 11:09 AM revealed LVN A was about to provide wound care to Resident #23's right heel. She prepared the normal saline, gauzes, Anasept, and collagen. She put the gauzes in two separate plastic cups. She sanitized the resident's overbed table and waited for it to dry. She then placed a wax paper on top of the overbed table and put the items needed for wound care. She poured normal saline in one of the plastic cups to wet the gauzes. She started cleaning the wound by getting a wet gauze and cleaned the wound from inside to outside. She took another wet gauze, cleaned the wound again, and discarded the gauze. With the second gauze, she cleaned the inside of the wound, then the surrounding skin of the wound, and then tapped again the inside of the wound before discarding the gauze. She took some gauze to pat dry the wound. She dried the wound, the surrounding skin of the wound, and used the same gauze to pat dry the wound again. In an interview on 12/15/2025 at 11:38 AM, LVN A stated the right procedure in cleaning the wound was to clean the wound from inside to outside. She said when she cleaned the wound again, she should have thrown the gauze away after she used it to clean the surrounding skin to avoid touching the inside of the wound with the gauze that she used to clean the outside of the wound. She said she needed to be careful not to introduce the germs from the surrounding skin of the wound into the wound that could cause infection. She said the same principle applied when drying the wound. In an interview on 12/16/2025 at 8:26 AM, the ADON stated the best practice was to clean the wound from the cleanest to the dirtiest and then discard the gauze after one stroke. She said the gauze used to clean the skin around the wound should not be used to clean the inside of the wound again because it would only introduce additional bacteria to the wound. She said the expectation was to keep the bacteria out and not introduce them to the wound that could result in infection. She said she would coordinate with the DON to do an in-service for all the staff doing wound care about the proper procedures in doing wound care. In an interview on 12/16/2025 at 9:04 AM, the Administrator stated that the expectation was for the staff to practice the right procedure of wound care to avert any harm to the residents. He said the objective of wound care was to clean the wound and not introduce microorganisms that could eventually cause infection. In an interview on 12/16/2025 at 9:36 AM, the DON stated the wound should be cleaned from the least contaminated area and the gauze should be discarded after every stroke. She said using the same gauze used to clean around the wound, could only introduce the bacteria, if there were any, into the wound. She said using the same gauze that cleaned the skin around the wound would only re-introduce germs into the wound. She said the order did say to pat dry, but it did not say to pat dry with the gauze that already was inside of the wound that was soiled. She said the expectation was for the staff doing wound care would do the right procedure. She said she would do an in-service about wound care. Record review of the facility's policy Wound Care Nursing Services Policy and Procedure Manual for Long-[NAME] Care revised October 2010 reflected Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for one (Resident #43) of sixteen residents reviewed for medication storage. The facility failed to ensure Resident #43 did not have a bottle of nasal spray on his side table on 12/14/2025. This failure could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible side effects.Findings included: Record review of Resident #43's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with asthma (lung disorder caused by narrowing of the airways). Record review of Resident #43's Comprehensive MDS Assessment, dated 10/03/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had asthma. Record review of Resident #43's Comprehensive Care Plan, dated 10/10/2025, reflected the resident had asthma and one of the interventions was to give medications as ordered. Record review of Resident #43' Physician Order on 12/14/2025, reflected no order for nasal spray. Record review of Resident #43's Assessment Notes on 12/14/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. During an observation and interview on 12/14/2025 at 9:26 AM revealed Resident #43 was in his bed, awake. It was observed that there was a nasal spray on the resident's side table, in plain view. The resident said it was his nasal spray, and it had always been on his side table. He said he was not sure if the staff knew he had a nasal spray inside the room. During an observation and interview on 12/14/2025 at 10:46 AM, LVN H stated that the nasal spray should not be inside Resident #43's room unless he had an assessment that he could administer it himself. He said if the resident needed a nasal spray, the staff should be the one administering it and it should be stored inside the cart. He went inside Resident 43's room and talked to the resident. LVN H said he would also call the doctor to get an order for the nasal spray. He said he did not see the nasal spray when he made his morning round. In an interview on 12/16/2025 at 8:26 AM, the ADON stated no medications should be stored inside the residents' rooms because the residents might administer them incorrectly and there should be physician orders for such medications as well. She said the nasal spray should be stored in the cart and not inside the resident's room and the staff should be the one administering it. She said the expectation was for the staff to scan the residents' rooms for any medications. She said confused residents might go inside the room and use the nasal spray and might have an allergic reaction. She said she would coordinate with the DON to do an in-service about medication storage. In an interview on 12/16/2025 at 9:04 AM, the Administrator stated that he was made aware of the issues about the medication inside the residents' rooms. He said the Resident #43 would go out to the community and would buy the nasal spray. But still the staff should have seen it, especially if it was in plain view. He said the expectation was for the staff to be mindful in scanning the residents' rooms for any medication to ensure resident safety. He said he would coordinate with the DON and the ADON on what to do so the issue discussed would be addressed. In an interview on 12/16/2025 at 9:36 AM, the DON stated no medications should be stored inside the residents' rooms. She said if Resident #43 needed a nasal spray, the staff should be the one administering it to ensure proper use of the medication and there should be an order for. She said the nasal spray should be stored inside the cart. She said the resident, other confused residents, or a visitor might accidentally use it and could be allergic to it. She said the expectations were for the staff to always scan the residents' rooms to make sure the residents were not storing any medications. She said she would do an in-service about medication storage. Record review of the facility policy, Storage of Medications Operational Policy and Procedure Manual for Long-Term Care revised April 2007 reflected Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . Policy Interpretation and Implementation . 2. The nursing staff shall be responsible for maintaining the medication storage . 10. Only persons authorized to prepare and administer medications.

Based on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for four of five dietary staff members reviewed for qualified dietary staff.The facility failed to ensure four (Cook A, [NAME] B, [NAME] C and Dietary Aide G) dietary staff members had their Texas Food Handler's License.This failure could place residents at risk of not having met their nutritional needs and place them at risk of foodborne illnesses.Findings included: A request for food handlers' licenses was made for all kitchen staff via email to the Administrator on 10/14/2025 at 3:10 p.m. and they were not provided. Record reviews of the four dietary staff members (Cook A, [NAME] B, [NAME] C and Dietary Aide G) personnel files on 10/15/2025 at 11:30 a.m. revealed all four dietary staff did not have a Food Handler's Certificate. All four dietary staff had been employed longer than 30 days.A request for job description was made for job description for kitchen staff members sent via email to the Administrator on 10/15/2025 at 2:15 p.m.During an interview with [NAME] A on 10/14/2025 at 9:33 a.m., he stated that he had been at the facility for 1.5 months and he did not have his food handlers license, was not aware he had to have one. During an interview with [NAME] B on 10/14/2025 at 10:17 a.m., she stated she had been at the facility since June 2025 and did not have her food handlers license and was not aware of how long she had to obtain it. She stated that without proper knowledge of how to prepare food properly would lead to residents getting sick. During an interview with [NAME] C on 10/14/2025 at 2:06 p.m., she stated she had been at the facility since April 2025 and did not have her food handlers license, but the new dietary manager spoke to her about completing it today. During an interview on 10/15/25 at 4:17 p.m., the DM revealed she was hired nine days ago and assumed that the dietary staff had their food handlers license , but on 10/14/2025 that she could not locate any current food handler certificates for the four staff (Cook A, [NAME] B, [NAME] C and Dietary Aide G) who worked in the kitchen. The DM manager stated that she is responsible for ensuring kitchen staff maintain current training on their responsibilities in the kitchen. To ensure the dietary staff were trained would be noted by license posted on the wall and in a book that the DM maintained with everything that the state required. She said not having a current certification places the residents at risk of not having food prepared correctly. During an interview on 10/16/25 at 1:20 p.m., the Administrator said it was important for anyone who prepared or cooked in the kitchen to have their food handler's license to ensure everyone knew the best practices across the board. He said they needed to know how to follow the rules and regulations, ensure proper sanitation, and how to not cross-contaminate. He said he would have to refer to the policy when asked how long after hire should the certification be completed. He stated that it is the DM responsibility to ensure kitchen staff was trained under the instruction of the Administrator. A request for food handlers licenses was made for all kitchen staff during the interview with the Administrator who did not provide them prior to exit.Record review of the Texas Department of State Health Services accessed on 10/16/2025 at 1:10 p.m.atcms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes (Statues and Laws - Retail Food Establishments | Texas Laws indicated:Rules & Regulations - Chapter 228 - Texas Food Establishments Rules (TFER) dated 11/07/2024Subchapter B - Management and Personnel (d) All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment.(e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee.

Based on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety.1. The facility failed to ensure both handwashing sinks were in proper working order.2.The facility failed to ensure drainage in the dishwashing room was in working order.3. The facility failed to ensure the kitchen remained free of bugs and insects (pests).These failures could place residents at risk for food-borne illness and cross contamination.Findings included:Observations of the Kitchen on 10/14/2025 at 09:30 a.m., with [NAME] A revealed the following: -Handwashing sink #1 /eyewash station leaked from a pipe beneath the sink. There was a large black rectangular basin there beneath the sink to catch the water.-Handwashing sink #2 was non-functioning. There was no running water that came from the faucet when the handle was turned on the hot or cold side.-Dishwasher - water would not drain. In the center of the dishwasher room, there was a wet vacuum (designed for wet debris pickup), which had a long (an inch or two longer than a 12-inch ruler) black slender cylindrical tube (vacuum attachment); it extended up beyond the drain opening approximately 5 inches to soak up/suction water when it backed up. Once the wet vacuum was full staff would pour the water into a drain nearby.-Pest droppings (small black pellets) in all three sections of a nonfunctioning dishwashing sink on the back wall near the fridge, and on the floor beneath another nonfunctioning sink in the back of the kitchen. Additionally, there were five gnats in the nonfunctioning handwashing sink #2.In an Interview with [NAME] A on 10/14/2025 at 9:33 a.m., he stated the black tube protruding out of the kitchen floor (drain in the center of the floor) was a wet vacuum attachment. It was there to allow the staff to use a wet vacuum to suction up the water to prevent overflowing onto the floor when the drain beneath the dishwasher machine or the dishwasher sink started to fill up. He stated the drain under the dishwashing sink and dishwasher did not drain well due to a drainage problem. [NAME] A stated that the sink and plumbing issues have been like this for the month and half he had been there. During an interview on 10/15/25 at 4:17 p.m., the DM stated that the plumbing issues were her top priority with the handwashing sink and dishwasher. She said that she was told that a plumber was supposed to come out to assess the damage but could not provide a date. The DM stated that her expectation of the kitchen was for it to always be clean to prevent any possible food borne illness. In an Interview with the Administrator on 10/16/2025 at 1:20 p.m., he stated that he learned about the broken sink and drainage problem in the kitchen prior to 10/13/2025 but was not sure of the exact date. The Administrator stated that the facility hired a plumber on 10/14/2025 and he was going to assess the concern in the kitchen as the previous plumbing company had not done a sufficient job. He stated his expectation was for the drainage issues to be fixed in the kitchen. Additionally, he was made aware of the pest issues on 10/14/2025 and his expectation was to shut down the kitchen for a day to allot time for the kitchen to be deep cleaned to help rid of pests as having pests could lead to illness.Review of the facility's Nutrition Services Policy & Procedures: Food Receiving and Storage, Version 1.3, Effective Date: 2001, Revised October 2017, reflected: Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times.

Based on observation, interview, and record review, the facility failed to maintain the kitchen equipment in good repair for 1 of 1 range hood reviewed for safe operating equipment.The facility did not ensure the range hood in the kitchen was in good repair.This failure could place the staff and residents at risk of a fire and not having safe operating equipment.Findings included:During an observation and interview on 10/14/18 at 9:30 a.m., [NAME] A tried to turn on the range hood and the range hood did not come on. He stated the range hood had not worked since he had been working there for a month and half. [NAME] A did state that the kitchen there had been times when the kitchen was smokey if someone cooked on high. During an interview on 10/14/2025 at 9:45 a.m., the DM stated she had been at the facility for nine days and there was a quote for the range hood to be replaced. The DM stated that to her knowledge a company had come out and stated that the motors had gone out on the range hood and needed to be replaced and the facility was quoted roughly $4,000 so they needed another quote. The DM stated when she arrived at the facility she called in someone she knew and that person stated all that needed to be done was the belts replaced, and the range hood serviced. Request for quote of the range hood was requested verbally to the DM on 10/14/2025 during our 9:45 a.m. interview. During an interview on 10/14/2025 at 10:17 a.m., [NAME] B revealed that the range hood inside the kitchen had not worked for at least four months she had worked there and that there was occasions that the kitchen was full of smoke, because they were unable to use the range hood. [NAME] B revealed all residents in the facility eat from the kitchen. Request for a quote of the range hood was requested via email to the Administrator on 10/15/2025 at 2:15 p.m.An interview with the DM on 10/16/2025 at 11:03 a.m., indicated all residents received food from the kitchen. The facility census on 10/14/2025 was 68. In an Interview with the Administrator on 10/16/2025 at 1:20 p.m., he stated that he learned about the nonfunctional rangehood problem in the kitchen prior to 10/13/2025 but was not sure of the exact date. The Administrator stated that there had been a work order and quote for the range hood to be fixed but was told that the motors were gone out and needed to be replaced and it would be $4,000 so the facility got a second quote which was for the belts to be replaced and serviced. The Administrator stated that the person fixed the range hood on 10/16/2025.Observation of the kitchen on 10/16/2025 at 3:05 p.m., the range hood in the kitchen had been repaired and in working order. Review of Maintenance Service policy dated 2001, revised December 2009 revealed the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all time.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pest.The facility failed to ensure the kitchen was free of gnats and rodent droppings on 10/14/2025, 10/15/2025 and 10/16/2025.These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. Findings include:In an interview on 10/14/2025 at 9:30 a.m., [NAME] A revealed he saw rats and/or mice in the kitchen of the facility many times. [NAME] A stated he had seen pest droppings in the kitchen. [NAME] A stated that there are gnats in and near the hand washing sink. Observation on 10/14/2025 at 10:00 a.m. there was pest droppings (small black pellets) in all three sections of a nonfunctioning dish washing sink on back wall near the fridge, another nonfunctioning sink in the back of the kitchen and on the floor beneath that sink. Additionally, there was five gnats in the nonfunctioning hand washing sink near the dishwasher. In an interview on 10/14/2025 at 10:17 a.m., [NAME] B revealed the kitchen was full of mice and/or rats in the pantry, five was just caught in the trap, but there was droppings on sinks (they don't use), there was gnats that flew around the kitchen all day. In an interview on 10/14/2025 at 2:06 p.m., [NAME] C revealed that she had to place the bread in the freezer due to rat and/or mice eating through the packaging and eating the bread. [NAME] C also observed rat/mice in the pantry once when she went and got an item one jumped out and hit her arm. [NAME] C stated that pest control came twice per month they spray. In an interview on 10/15/2025 at 10:37 a.m., the Maintenance Director stated the facility did not have a rodent problem until the facility broke up the concrete on the back patio but from June to current there was rodents. The Maintenance Director stated he had been treating the issue with sticky bait; the rodents will get on there and die. The Maintenance Director stated he had not seen any rodents in a while and that no one from the kitchen staff had reported to him that there was rodents in the kitchen. The Maintenance Director was shown the pest droppings and seemed surprised. The maintenance director informed the state surveyor that pest control comes to the facility twice per month and as needed and that residents and staff can verbally communicate with him their pest control concerns as well as all staff was able to write in the pest control book that he checked daily. Record review of the Pest Management Binder found: Last sighting log on 10/06/25 reflected 10 mice captured and 15 fruit flies. It was noted by the pest control technician that they inspected the kitchen common areas found some fruit flies by dishwasher, storage room and treated fruit flies and to prevent ants, roaches, and crawling insects. It is noted that pest control came to the facility twice per month from June to current.In an Interview with the Administrator on 10/16/2025 at 1:20 p.m., he stated that pest control is at the facility twice per month and as needed. He was made aware of the pest droppings in the kitchen during this investigation. He stated the harm oof pest droppings to the staff and residents is the potential for infection. His expectation is that the kitchen should be cleaned daily and free of pest droppings. The Administrator was not sure when the last time the pest droppings had been cleaned up. He stated the responsibility of the cleaning falls on the dietary manager under the instruction of the Administrator. Record review of the facility's undated policy and procedure titled Pest Control reflected Purpose: to provide an environment free of pests. Policy: 1. The facility will have pest control that provides frequent treatment of the environment for pests. It will allow for periodic treatment when a problem is detected. There will be emphasis on pest control in the kitchens, cafeterias, laundries, loading docks, construction activities and other areas prone to infestation. Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly. Screens will be maintained in all windows that open to the outside.

Based on interviews, and record reviews, the facility failed to ensure care plans were developed in consultation with the resident's representative for 1 of 4 residents (Resident #1) reviewed for Comprehensive Care Plan in that:The facility failed to ensure Resident #1, or the resident's representative were invited to participate in the resident's care plan meeting.This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their care.Findings included: Record review of Resident #1's face sheet dated 10/15/2025, revealed a [AGE] year-old male admitted to the facility 09/11/2017. His diagnoses included Alzheimer's disease with late on set (memory and cognition issues, impaired judgment), heart failure unspecified (a condition where the heart is unable to pump enough blood to meet the body's needs, but the specific cause or type of heart failure is unknown), hypertension(condition where the blood pressure in the arteries is consistently elevated above normal levels), and psychotic disorder with delusions due to known physiological condition (psychiatric diagnosis characterized by the presence of delusions (false beliefs) that are directly caused by an underlying medical condition). Record review of Resident #1's MDS dated [DATE], reflected Resident #1's BIMS score of 3, which indicated severe impairment.In an interview on 10/14/2025 at 10:50 a.m., Resident #1 did not respond to any questions. Resident #1 smiled when asked questions. Resident #1 was observed sitting in the day room at a table alone. Resident #1 appeared clean and appropriately dressed. In an interview on 10/14/2025 at 3:16 p.m., the SW stated she had been employed at the facility for about three months. She stated it was her responsibility to work with the MDS coordinator to coordinate and schedule care plan meetings. She stated the facility's IDT and the resident; the resident's RP was included in care plan meetings. She stated she sent out invitations by contacting the RP via phone so the RP could be included. She stated the RPs had the option to attend care plan meetings via phone. She stated since she's been in her position, she had not coordinated a care plan meeting for Resident #1. She stated that the RP's or family not being included in care plan meetings could become a problem in the future. In an interview on 10/15/2025 at 9:32 a.m., Resident #1's responsible party revealed Resident #1 was admitted to the facility 8 years ago and she's never been invited or included in a care plan meeting. She stated when she voiced her concerns about being included in care plan meetings, the facility stated they would include her, but he never received an invite from the facility. She stated the facility had contacted her for consent of medical decisions for Resident #1 but no communication about care plan meetings. She stated she knew she was supposed to be included in Resident #1's care plan meetings. In an interview on 10/15/2025 at 2:25 p.m., the MDS Coordinator stated she's been employed at the facility for 4 years. She stated it was the SW responsibility to coordinate care plan meetings. She stated it was the SW responsibility to reach out to RP and/or family members to be included in care plan meetings. She stated Resident #1's last care plan meeting was 8/20/2025. She stated she could not recall if Resident #1's RP was invited or attended the care plan meeting. She stated she could not provide a sign-in sheet for the care plan meeting dated 8/21/2025. She stated RP's or family members not included in care plan meetings could lack advice or recommendations to address behaviors and concerns. In an interview on 10/16/2025 at 1:20 p.m. ADM stated was employed at the facility since July 2025. He stated the SW was responsible for coordinating care plan meetings under the direction of the MDS Coordinator. He stated the IDT, the residents, RPs, and family members should be included in care plan meetings. He stated care plan meetings should be documented and the SW maintained a file for sign in sheets. He stated he had not attended a care plan meeting for Resident #1 since he's been employed at the facility. He stated the importance of including RPs or family members could benefit residents that are cognitively impaired. He also stated any concerns RPs or family members had could not be addressed. Record review of Resident #1's Multidisciplinary Care Conference assessment dated [DATE] revealed the registered nurse, dietary, social worker, activities, therapy, and nursing administration attended the meeting. No indication of the RP or family attended the meeting. Record review of Resident #1's Multidisciplinary Care Conference assessment dated [DATE] revealed therapy, MDS nurse, and licensed nurse attended the meeting. No indication of the RP or family attended the meeting. Record review of Resident #1's Multidisciplinary Care Conference assessments for 5/22/2025 and 08/21/2025 were requested but the facility could not provide the assessments. Record review of Resident #1's medical chart revealed documentation of completed MDS assessments dated 02/27/2025, 05/22/2025, and 08/21/2025. Record review of the facility's policy Resident Rights Guidelines dated revised October 2010. Purpose: to provide general guidelines for resident rights while caring for the resident. I. resident/family participation in care planning. Record review of the facility's policy Resident Assessment Instrument dated revise September 2010. Policy statement A comprehensive assessment of a resident's needs shall be made within fourteen days of the resident's admission. 5. Residents and/or their representatives(sponsors) will be encouraged to participate in the initial, quarterly, and annual assessments. The Assessment Coordinator or designee will notify the residents and/or sponsor in advance of the scheduled assessment or review.Record review of the facility's Social Services policy dated revised October 2010. Policy Statement Our facility provides medically-related social services that each resident can attain or maintain his/her highest practicable physical, mental, psychosocial well-being. H. Maintaining contact with the resident's family members, involving them in the resident's total plan of care.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, and deprivation of goods and services for 1 of 3 residents (Resident #1) reviewed for neglect. 1. The facility failed to provide Resident #1 with services for pain assessments from 02/10/25 to 02/21/25 which resulted in Resident #1 not being diagnosed with a fracture to his left humeral bone for 11 days. 2. The facility staff failed to report a fall to the administrative staff which resulted in Resident #1 not receiving an x-ray from 02/10/25 to 02/21/25. 3. The facility failed to make an appointment for Resident #1 as ordered by a hospital physician to be seen by an orthopedic surgeon from 02/22/25 to 06/07/25. An Immediate Jeopardy (IJ) situation was identified on 06/02/25. While the IJ was removed on 06/09/25, the facility remained out of compliance at a scope of pattern with the 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 of deprivation of goods and services. Findings include: Record review of Resident#1's face sheet, dated 05/28/25, reflected a [AGE] year-old male with an initial admission date of 11/27/24. Resident #1 had diagnoses which included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes) and Aphasia (Language disorder caused by brain damage). Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS of 12, which indicated mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. Record review of Resident #1's Significant Change MDS, dated [DATE], reflected Resident #1 had a BIMS of 12 which indicated Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step. Record review of Resident #1's Care Plan, dated 03/06/25, reflected a Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy(damage to nerves), dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are mad to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery. Record review of Resident #1's Active Orders, as of 06/08/25, reflected Resident #1 had 2 active orders for pain medications prior to the left humerus comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. Record review of Resident #1's Active orders, as of 06/08/25, reflected Resident #1 had 4 active orders for pain after the right humorous comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by mouth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. 3. Tramadol HCL Oral Tablet 50 mg, Give 50 mg by mouth three times a day for pain. Start Date: 02/10/25, Revision Date: 03/10/25, New orders, give 50 mg by mouth every 8 hours as needed for pain. End Date: Indefinite 4. Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet by mouth three times a day for pain. Start Date: 03/06/2025. End Date: Indefinite. Record review of Resident #1's weights taken at the facility found reflected Resident #1 weighed 154.4 LBS on 02/07/25. Record review of the facility's PIR, dated 02/25/25, reflected on 02/10/25 CNA A and CNA B stated Resident #1 had a slip in the shower chair while transferring from a shower chair to a wheelchair. Resident #1 stated to the facility that Resident #1 had slipped and hit his shoulder while he was in the shower. Resident #1 did not report the incident to the facility until 02/21/25. The PIR Investigation Summary reflected on 02/10/25 CNA A had taken Resident #1 to the shower room and Resident #1 started to slip out of the shower chair. CNA A then called for LVN B who helped assist the resident immediately by placing their arms (CNA A and LVN B) under Resident #1's arms (while resident was still wet) and pulled Resident #1 back up into the shower chair. LVN B reported Resident #1 did not report any injuries and subsequent skin assessments found no injuries, bruises, or skin integrity issues. Both CNA A and LVN B stated there was no fall or change of plan as they prevented Resident #1 from having a fall. Record review of CNA A's witness statement, included in the PIR, dated 02/24/25, and signed by CNA A, reflected CNA A had assisted the nurse with a transfer in the shower room, shower was given to Resident #1. The nurse assisted with transferring Resident #1 back to the wheelchair from the shower chair. Record review of LVN B's witness statement, included in the PIR, dated 02/24/25, and signed by LVN B, reflected LVN B had assisted CNA A with a transfer of Resident #1 from a wheelchair to a shower chair and then from a shower chair to wheelchair on 02/10/25. She stated Resident #1 had no complaint of pain upon transferring to the wheelchair. Record review of Resident #1's EHR for Resident #1 from 02/04/25 to 2/11/25 found no evidence of a fall being reported, no documentation of skin or pain assessments. No documentation of Resident #1 slipping from a shower chair. Two progress notes related to the incident of 02/10/25 were found (1) denoting a pain medication ordered after LVN E had been informed by Hospice RN D about a fall and need for pain medications, and (2) When the facility first found out about the incident: 1. A Progress Note was found, dated 02/10/25 at 9:17 PM written by LVN E, ordering tramadol HCL Oral tablet 50 mg, give 50 mg by mouth three times a day for pain. 2. A Progress Note, dated 02/21/25 at 9:36 AM by the DON, reflected Resident (#1's) family reported to this nurse, he (Resident #1) still had pain from the fall that happened Monday before last. Skin assessment pain assessment and stat left shoulder x-ray. Notified hospice, family present, notified MD and administrator. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of a document entitled Radiology Report for Resident #1, dated 02/21/25, reflected Left Shoulder X-ray Complete 2 or more views .Significant Findings .Multiple views of the left shoulder show a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral head/neck (top part of the arm bone). Fracture of the glenoid (where the head of the arm bone connects to the shoulder) is also noted .No soft tissue swelling is seen. Record review of a document titled After Visit Summary, dated 02/22/25, found an order for an appointment to a named Orthopedic Surgeon was to be made as soon as possible. This order was put into place to address the right humorous comminuted fracture after the resident had been admitted to the hospital on [DATE], and discharged from the hospital on [DATE]. Interview on 05/28/25 at 9:45 AM with Resident #1 revealed Resident #1 was able to speak with some difficulty but was able to make his needs known. Resident #1 stated his arm was broken several months ago. He identified the CNA as the facility CNA not his hospice CNA, and he stated it was just CNA A in the shower room with him when the fall occurred. He stated he hit his shoulder when the fall occurred. He stated he went to the hospital but had not been out for any follow-up appointments. Interview on 05/28/25 at 9:58 AM with the Hospice SW C revealed she had been in the building that morning to visit with Resident #1 to discuss care plan options with the resident since he had come under her hospice agency care on 02/04/25. She stated Resident #1 told her he was in pain and he had a fall in the shower room earlier that morning and he indicated his left shoulder where the pain was the worst. Hospice SW C stated she contacted Hospice RN D and reported to her Resident #1 was complaining of 5/10 pain in his left shoulder and Resident #1 told her he had a fall earlier that morning in the shower. Interview on 05/28/25 at 9:58 AM with Hospice RN D revealed Resident #1 reported to her he had a fall in the shower room earlier that day (02/10/25). Hospice RN D stated she did an assessment on Resident #1, and Resident #1 complained of pain in his left shoulder at 5/10 on a pain scale and Resident #1 had no swelling and no redness no bruising. Hospice RN D stated she notified the hospice physician and ordered 50 mg Tramadol three times a day. Hospice RN D stated she informed the facility nurse, LVN E about the new order, fall and pain and another Hospice RN had assessed Resident #1 on 02/13/25 and Resident #1 did not complain of pain that day. Interview on 05/29/25 at 10:58 AM with LVN E revealed she worked on Resident #1's hall on 02/10/25. She stated she remembered speaking with Hospice RN D that day and Hospice RN D told her Resident #1 had complained of 5/10 pain in his left shoulder, he reported to her that he had a fall earlier that day in the shower and she ordered Tramadol 50 mg three times a day for Resident #1. LVN E stated she was a brand-new nurse at the time and assumed LVN B, who had been at the facility much longer, told the DON about the fall in the shower room. LVN E stated she first learned of Resident #1's fracture on 02/23/25 when the DON asked if she knew anything about Resident #1's fracture. Interview on 05/28/25 at 1:58 PM with CNA A, CNA A reported CNA A and LVN B were transferring Resident #1 from a shower chair to a wheelchair in the shower room on 02/10/25. CNA A stated she and LVN B had Resident #1 up from the shower chair and were pivoting him around to sit in the wheelchair and Resident #1 was yelling that he was slipping. CNA A stated Resident #1 did not have a fall. CNA A stated he had started to slip a little out of the shower chair but she and LVN B caught him. She stated he did not complain of pain at any time even after she placed him back into bed. She stated she had not used a gait belt and she was unaware if there was a gait belt in the shower room at the time. CNA A stated that Resident #1 was still wet at the time of the transfer. Interview on 05/29/25 at 2:56 PM with LVN B revealed CNA A called her into the shower room to assist with transferring Resident #1 from a shower chair to a wheelchair. She stated Resident #1 was already unclothed and she and CNA A had their arms around Resident #1 to transfer him. She stated the resident was still a little wet and he had a towel around his private area. She stated Resident #1 did not say anything or indicate he was slipping. She stated she did not report anything because there was never any fall. She stated it was possible they could have broken his arm during the transfer but there had been no indication of it, she stated that because nothing happened and there was no indication of pain or discomfort, she did not assess Resident #1. Interview on 05/30/25 at 9:45 AM with the DON revealed she was aware of the need to make an Orthopedic appointment for Resident #1 after he returned from the hospital on [DATE]. She stated the hospice agency was contacted about the need for an appointment at that time but had not addressed the Orthopedic appointment again after that. The DON was unable to explain why the appointment for Resident #1 had never been arranged. The DON was unable to provide any documentation that the hospice agency had been contacted, who was spoken to at the hospice agency or when the conversation may have taken place. Interview on 05/30/25 at 11:09 AM with LVN Q revealed she understood follow-up appointments for residents returning from the hospital were to be handled through the Social Worker or the ADON but because the Social Worker had quit a few weeks ago it was mainly through the ADON. Interview on 05/30/25 at 11:11 AM with the ADON revealed for residents who were on hospice care and returned from the hospital to the facility with orders to have an appointment made the facility should have contacted the hospice agency about the appointment. She stated in the case of Resident #1 she did not see any in any progress notes that the hospice agency for Resident #1 had been contacted about the follow-up order for Resident #1, she stated that in the absence of the SW the ADON or the DON would be responsible for the follow up appointment and notifying the hospice agency. Interview on 05/30/25 at 11:30 AM with the ADM revealed he was not at the facility when this incident occurred. He stated his expectations were that a physical communication sheet should have been filled out showing when, who, what had been communicated to any outside agency. He stated he was not aware of any documentation that showed if Resident #1's orthopedic appointment had been made or if anyone was contacted about the appointment having to be made. Interview on 05/30/25 at 11:48 AM with facility MD, MD stated that it was acute fx, meaning the fracture was recent, around 1-2 weeks, no soft tissue swelling could indicate that there had been enough time for the swelling to have been resolved. Resident #1 might not have been as uncomfortable as someone who did not have paralysis in the affedted arm. Looking back it looks like I was informed about Resident #1 having pain in that arm on the 21st, but I had been informed that the family may have had some idea of a mechanism of injury previous to the 21st of February. I would not expect Resident #1 to have a spontaneous fracture, he did not have diagnosis that would be indicative of that. The two bones could have articulated during a lift. I would say that injury could happen in both a lift or fall scenario. She stated usually the facility will make appointments for residents. Interview on 06/02/25 at 10:26 PM with Hospice SW C revealed her hospice agency had no record of ever being contacted about a referral appointment for Resident #1. She stated she would have been the person who would have been contacted about making an appointment. She stated she had no idea Resident #1 had come back from the hospital with orders to make an appointment to an Orthopedic surgeon. Interview on 06/02/25 at 2:24 PM with the ADM revealed it was ultimately his facility nurses responsibility to make sure all orders from physicians were followed and that his nurses made sure the appointment was made and kept. He stated it was a major concern that a resident returned from the hospital on [DATE] and still had not gone to the appointment that had been ordered. Interview on 06/02/25 at 2:49 PM with the MD revealed she was aware of the referral to Orthopedics for Resident #1, but the hospice agency should have been responsible for making the appointment since they were the ones who had to pay for it. Interview on 06/06/25 at 12:00 PM with the ADON revealed she received and gave training on the new Admissions/Re-admissions binder. She stated the binder was to always be located at the main nursing station next to the permanent computer at the nursing station. She stated if she were to receive re-admission orders on a Sunday, she would have to document the information in the progress note. She stated the new binder was where staff put appointments, informed all parties, family included. Then staff would make the appointment during business hours. After the appointment was made staff would arrange for transportation and then staff would log all of the appointment information in the communication log in the Electronic Health Record to make sure all parties knew the information. She stated all nurses and CNA's had access to the Electronic Health Record communication tab/board. She stated the new binder ensured the resident was receiving all of the services available to them. She stated there had been updates to the Ambassador rounds, staff were more in-depth question on a new form that staff asked the residents assigned to them, she stated an email with all of the new questions was sent to all staff, identified as Ambassadors, and a paper copy was also presented at the morning meeting. Interview on 6/2/25 at 5:59 PM with the DON revealed she defined a fall as anytime a resident stumbled, lost balance or their knees touched the floor. She stated all falls, witnessed or unwitnessed should be reported to the ADON, DON, and the ADM. She stated all orders from a physician, referrals, and appointments should be scheduled, and transportation arranged to get residents to appointments, she stated all appointment/referrals should be documented in the Admission/re-admission binder and in the Electronic Health Record. She stated the family went to her on 02/21/25 because they wanted Resident #1 repositioned, and they told her he had a fall a couple of Mondays ago and he complained his left shoulder hurt. She stated Resident #1 described he had a fall in the shower and his arm hurt. The DON stated that was when she did pain/skin assessments, informed the Administrator and ordered x-rays. Interview on 6/2/25 at 6:08 PM, the ADM stated a fall was defined as anyone who lost balance or for example knees gave out and had to be lowered to the floor, would be a fall. Also, even if they lost balance of gave got and caught themselves and the staff had to assist them in any manner was considered a fall according to the policy/procedure. He stated all physician orders should be carried out by the nursing staff and all appointments made in accordance with those orders, he stated he would monitor the new Admission/re-admission binder to monitor all orders/appointments were followed/made and all corresponding documentation was present. Record review of the facility's policy titled Abuse Investigation and Reporting, dated 2001 and revised July 2017, reflected: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Policy Explanation and Compliance guidelines: The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. Established policies and procedures to investigate any such allegations; and Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention. Provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Existing staff will receive annual education through planned and services and as needed. Training topics will include prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators. Reporting process for abuse, neglect exploitation and misappropriation of resident property comma including injuries of unknown sources. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: wandering Preventative abuse, neglect and exploitation the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, license, and certified staff on each shift the sufficient numbers to meet the needs of the residents, and ensure that the staff assigned have knowledge of the individual residence care needs and behavioral symptoms; The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with need and behaviors which might lead to conflict or neglect. Addressing features of physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. Record review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, dated 2001 and revised July 2017, reflected: Policy Statement. All accidents or incidents involving residents, employees, visitors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Guidelines. 1. The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Record review on 06/07/25 of the Admission/re-admission Binder documented Resident #11 had been entered into the binder as a new admission. All relevant paperwork for Resident #11 was found in the Admission/re-admission Binder. Subsequent review of the Electronic Health Record documented progress notes with orders for Resident #11. This was determined to be an Immediate Jeopardy (IJ) on 06/02/25 at 8:00 PM. The ADM and the DON were notified. The ADM was provided with the IJ template on 06/02/25 at 8:00 PM. The following Plan of Removal submitted by the facility was accepted on 06/05/25 at 3:00 PM: [The Facility] [address and phone number] FTAG 600- The facility failed to protect Resident # 1 and neglected Resident #1 because CNA A and LVN B failed to report a Slip/Fall on 2/10/2025 during Residents #1 shower which resulting in delay of care and X-rays for Resident #1. Facility will focus on reporting, education on safe transfers, freedom form neglect. 1. DON and ADON will in-service nursing staff on Safe Transfer. Nursing staff will be able to voice concepts of safe transfer to include residents limitations taken into account to determines how many people are required for transfer, where is the transfer taking place, is the resident dried off from a shower, are clothes donned before applying gait belt. Nursing will turn in a written test of knowledge over Safe Transfer and complete a return demonstration for DOR. Weekend staff and PRN will be provided training by DON and ADON and DOR. DON, will visually monitor each member of the nursing staff safely transfer a residents, every shift, starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into every day. After meeting with the survey team, additional education provided on 6/4/2025. To include place of transfer, resident ability, number of staff required, resident clothed, resident dry. Date completed: 6/9/2025 2. DON and ADON will in-service ALL staff on the definition of a FALL, AWARENESS, REPORTING, INTERVENTION AND PREVENTION. All staff will complete a written test of knowledge to be placed on file immediately. Weekend staff and PRN will be provided training by DON and ADON and DOR. This training must be completed before returning to the floor. ADON, will visually monitor each charge nurse report a fall, every shift, starting on 6/5/2025, until 100% of staff have been monitored. DON will maintain competency audit and update it daily and give to Administrator daily. Date initiated: 6/2/2025 Date completed: 6/5/2025 Upon hire, and quarterly thereafter 3. DON has reviewed all of May admissions and readmissions up to current date to verify there weren't any appointments or referrals needed. No issues identified. An admission/readmission report has been ran, printed and marked with a check mark for reviewed and no issues or a question mark requiring a hospital request for additional records. Date initiated: 6/2/2025 Date completed: ongoing, daily Upon hire, and quarterly thereafter 4 Skills check off will be completed for Nursing staff, in relation to their roles required for a fall, by DON/ADON. Now, Upon hire, and quarterly. Training must be completed before returning to the floor. DON and Administrator will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Individual interviews will be conducted for all nursing staff by ADON. During the interview the staff member will recite respective response to a fall, according to their position. These interviews will start on 6/5/2025, every shift until 100% of nursing staff have been interviewed. A spread sheet will indicate all staff have been interviewed and will be updated and provided to the Administrator for review daily. Nurse roles in a fall Completing and documenting fall risk assessments to identify residents at risk of falling. Monitoring the resident's medical condition for any changes that could affect the resident's fall risk status. Reporting falls to the physician, DON/ADON and Administrator, and obtaining medical orders as needed. Supervising nursing aides and educating patients and their families on fall prevention measures CNA role for a fall: Report to Charge nurse immediately and do not move the resident. Date initiated: 6/5/2026 Date complete:6/9/2025 5. Starting on 6/4/2025, DON will ensure that 1st and 2nd shift CNA's have a gait belt readily available. ADON will be assigned to monitor for 3rd shift on 6/4-5/2025 Will have gait belts readily available for use. This ensures proper preparedness for safe transfer immediately. Administrator will verify gait belts were provided on 6/4/2025 and 6/5/2025 by reviewing the gait belt audit log, daily. Date initiated:6/4/2025 Completed by: 6/5/2025 6. DON and ADON will in-service charge nurses about Admission/ readmission Binder. It will be kept at the nurses' station. DON/ADON, will review this Binder daily, during their assigned shift, to ensure any appointments/ referrals are made according to admission paperwork. All admission paperwork will be uploaded by admitting nurse to Medical Records via front office scanner and logged into the binder log in sheet located in the front of the binder. Weekend staff and PRN will be provided training by DON. This training must be completed before returning to the floor DON and ADON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Date initiated 6/3/2025 Date completed: ongoing Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders. She uploaded the paperwork to medical records and placed in in the communication binder, at the nurses station. She also logged the information onto the login sheet in the front of said binder. Information included: resident name, date/time, reason for ER/visit or discharge, charge nurse initials, and yes or no boxes for needing appointments or new orders. See exhibit- A readmission paperwork login form. 7. Charge nurses will be in-serviced on reporting incidents such as falls, made by third party vendors, such as Hospice. When report of a fall is received by a third party or family, it is to be reported immediately to the DON/ADON. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep audit of competencies/training completed/required. Administrator will confirm education provided by interviewing staff on 6/4/2025. Inservice to begin 6/4/2023. Completed by 6/5/2025 Third party vendors will be notified via telephone, by DON/ADON, of referrals recommended, or appointments made. A progress note will be entered into PCC, by the charge nurse, naming who they spoke with, date and time and short description on the nature of the information relayed. 8. Charge nurses will be in-serviced on the Appointments/ Referral Protocol immediately, intermittently, upon hire. Any appointment obtained by a charge nurse, will be reported to DON/ADON as soon as possible, but no later than the end of their shift. DON/ADON will update information pertaining to the resident's appointment in PCC on community board. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON maintain competency audit and ensure compliance. This training must be completed before returning to the floor. DON/ADON, will visually monitor each member of the nursing staff recite or perform the Appointments/ Referral Protocol starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into Administrator for review every day. Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders and a referral appointment. Initiated 6/4/2025 Completion: ongoing daily 9.Starting today, 6/4/2025, all department heads will conduct Ambassador rounds. The revised form has been provided to all department heads by email. This will identify any incidents or accidents that may have happened and weren't properly reported, documented or identified. These rounds consist of room conditions, meal satisfaction, needs and will address falls, abuse, neglect and feelings of safety. These will be provided to Administrator daily. A

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of 3 residents (Resident #1) reviewed for transfers. The facility failed to ensure that CNA A and LVN B transferred Resident #1 using a gait belt as per facility protocol, and dried the resident off before transfer, which resulted in a fall and a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral neck (top part of the arm bone) and fractures to the glenoid bone (where the head of the arm bone connects to the shoulder), which were discovered from X-Ray results on 02/21/25. An Immediate Jeopardy (IJ) situation was identified on 06/02/25. While the IJ was removed on 06/09/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risks of accidents, and could result in serious harm, injury, impairment, and death. The findings include: Record review of Resident#1's face sheet dated 05/28/25 revealed he was a [AGE] year-old male resident with an initial admission date of 11/27/24 with diagnosis that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes), and Aphasia (Language disorder caused by brain damage). Record review of Resident #1's quarterly MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12, meaning mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required Substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. Record review of Resident #1's Significant Change MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step. Record Review of Resident #1's Care Plan dated 03/06/25 reflected that Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy, dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are mad to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery. Record review of the Facility PIR (Provider Investigation Report) dated 02/25/25 reflected that on 02/10/25 CNA A and CNA B stated that Resident #1 had a slip in the shower chair while transferring from a shower chair to a wheelchair. Resident #1 stated to the facility that Resident #1 had slipped and hit his shoulder while he was in the shower. Resident #1 did not report the incident to the facility until 02/21/25. The PIR Investigation Summary reflected that on 02/10/25 CNA A had taken Resident #1 to the shower room and that Resident #1 had started to slip out of the shower chair. CNA A then called for LVN B who helped to assist the resident immediately by placing their arms (CNA A and LVN B) under Resident #1's arms and pulled Resident #1 back up into the shower chair. LVN B reported that Resident #1 did not report any injuries and subsequent skin assessments found no injuries, bruises, or skin integrity issues. Both CNA A and LVN B had stated that here had been no fall or change of plan as they had prevented Resident #1 from having a fall. Record review of CNA A's witness statement included in the PIR dated 02/24/25 and signed by CNA A, reflected that CNA A had assisted nurse with transfer in the shower room, shower was given to Resident #1, nurse assisted with transferring Resident #1 back to the wheelchair from the shower chair. Record review of LVN B's witness statement included in the PIR and dated 02/24/25 and signed by LVN B, reflected that LVN B had assisted CNA A with a transfer of Resident #1 from a wheelchair to a shower chair and then from a shower chair to wheelchair on 02/10/25. She stated Resident #1 had no complaint of pain upon transferring of Resident #1 to a wheelchair. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of a document entitled Radiology Report for Resident #1, dated 02/21/25, reflected Left Shoulder X-ray Complete 2 or more views .Significant Findings .Multiple views of the left shoulder show a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral head/neck (top part of the arm bone). Fracture of the glenoid (where the head of the arm bone connects to the shoulder) is also noted .No soft tissue swelling is seen. Record review of a document titled After Visit Summary, dated 02/22/25, found an order for an appointment to a named Orthopedic Surgeon was to be made as soon as possible. This order was put into place to address the right humorous comminuted fracture after the resident had been admitted to the hospital on [DATE]. Record review of Resident #1 EHR (Electronic Health Record) for Resident #1 from 02/04/25 to 2/11/25 found no evidence of a fall being reported, no documentation of skin or pain assessments. No documentation of Resident #1 slipping from a shower chair. Two progress notes related to the incident of 02/10/25 were found (1) denoting a pain medication ordered and (2) When the facility first found out about the incident: 1. A Progress Note was found on 02/10/25 at 9:17 PM written by LVN E ordering [after being told by Hospice RN D of the fall and need for pain medications] tramadol HCL Oral tablet 50 mg, give 50 mg by mouth three times a day for pain. 2. A Progress Note on 02/21/25 at 9:36 AM by the DON reflected that Resident (#1's) family reported to this nurse, he (Resident #1) still had pain from the fall that happened Monday before last. Skin assessment pain assessment and stat left shoulder x-ray. Notified hospice, family present, notified MD and administrator. Record review of the facility Incident Accident Log found no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25. Record review of Resident #1's Active Orders as of 06/08/25 revealed that Resident #1 had 2 active orders for pain medications prior to the left humerus comminuted fracture of 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. Record review of Resident #1's Active orders as of 06/08/25 revealed that Resident #1 had 4 active orders for pain after to the right humorous comminuted fracture after 02/10/25 listed as the following: 1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite. 2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite. 3. Tramadol HCL Oral Tablet 50 mg, Give 50 mg by mouth three times a day for pain. Start Date: 02/10/25, Revision Date: 03/10/25, New orders, give 50 mg by mouth every 8 hours as needed for pain. End Date: Indefinite 4. Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet by mouth three times a day for pain. Start Date: 03/06/2025. End Date: Indefinite. Record review of Resident #1's weights taken at the facility found that Resident #1 weighed 154.4 LBS on 02/07/25. Interview on 05/28/25 at 9:45 AM with Resident #1 revealed Resident #1 was able to speak with some difficulty but was able to make his needs known. Resident #1 stated arm was broken several months ago. He identified the CNA as the facility CNA not his hospice CNA, and he stated it was just CNA A in the shower room with him when the fall occurred. He stated he hit his shoulder when the fall happened and he had less movement in his left arm and hand than he did before. He indicated with his right arm and hand to his left shoulder and indicated his left hand where it was observed he could still move his pinky and ring finger. Interview on 05/28/25 at 9:58 AM with the Hospice SW C revealed that she had been in the building that morning to visit with Resident #1 to discuss care plan options with Resident #1 since had had come under her hospice agency care on 02/04/25. She stated that Resident #1 told her that he was in pain and that he had a fall in the shower room earlier that morning and that he indicated his left shoulder where the pain was the worst. Hospice SW C stated that she contacted Hospice RN D and reported to her that Resident #1 was complaining of 5/10 pain in his left shoulder and that Resident #1 had told her he had a fall earlier that morning in the shower. Interview on 05/28/25 at 9:58 AM with Hospice RN D revealed that Resident #1 reported to her that he had a fall in the shower room earlier that day (02/10/25). Hospice RN D stated that she did an assessment on Resident #1, she stated that Resident #1 complained of pain in his left shoulder at 5/10 on a pain scale and that Resident #1 had no swelling, no redness no bruising. Hospice RN D stated that she notified the hospice physician and ordered 50 mg Tramadol three times a day. Hospice RN D stated that she had informed facility nurse LVN E about the new order, fall and pain and that another Hospice RN had assessed Resident #1 on 02/13/25 and that Resident #1 did not complain of pain that day. Interview on 05/28/25 at 1:58 PM with CNA A, CNA A reported that CNA A and LVN B were transferring Resident #1 from a shower chair to a wheelchair in the shower room on 02/10/25. CNA A stated that she and LVN B had Resident #1 up from the shower chair and were pivoting him around to sit in the wheelchair and Resident #1 was yelling that he was slipping. CNA A stated that Resident #1 did not have a fall. CNA A stated that he had started to slip a little out of the shower chair but that she and LVN B had caught him. She stated that he did not complain of pain at any time even after she had placed him back into bed. She stated that she had not used a gait belt and she was unaware if there had been a gait belt in the shower room at the time. CNA A stated that resident #1 was still wet at the time of the transfer. Interview on 5/30/25 at 11:48 AM with the Facility Physician revealed the fracture to Resident #1's arm was acute and if the fracture occurred on 02/10/25 then by the time the x-ray was taken on 02/21/25 soft tissue swelling could have been absent. She stated looking at Resident #1's diagnosis, she would not expect Resident #1 had a spontaneous fracture, and Resident #1 might not be as uncomfortable as someone who did not have paralysis in the affected arm. Interview on 6/2/25 at 5:59 PM with the DON revealed she defined a fall as anytime a resident stumbled, loses balance or their knees touched the floor. She stated staff were always expected to use a gait belt for transfers she stated she had not been aware all CNA's did not have a gait belt and there seemed to be only a few gait belts in the facility at that time. She stated any resident being transferred from a wheelchair to a shower chair, the staff must use a gait belt, the resident should have a shirt on or a gown and once the resident was safely transferred to a shower chair the gait belt and then the shirt/gown should come off. She stated the resident should be completely dried and a gown or a shirt should be placed back on the resident and a gait belt applied to transfer the resident back to a wheelchair. Interview on 6/2/25 at 6:08 PM, the ADM stated a fall was defined as anyone who had lost balance or for example knees gave out and had to be lowered to the floor would be a fall. Also, even if they lost balance of gave out and caught themselves and the staff had to assist them in any manner was considered a fall according to the policy/procedure. Record review of the facility's policy titled Safe Lifting and Movement of Residents, dated 2001 and revised July 2017, reflected: Policy Statement: In order to protect the safety and well being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on and ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; b. Addresses workplace injuries; c. Provides training on safety, ergonomics and proper use of equipment; and d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. This was determined to be an Immediate Jeopardy (IJ) on 06/02/25 at 8:00 PM. The ADM and the DON were notified. The ADM was provided with the IJ template on 06/02/25 at 8:00 PM. The following Plan of Removal submitted by the facility was accepted on 06/05/25 at 3:00 PM: [The facility][address and phone number] FTAG 689- The facility failed to protect Resident #1 because CNA A and LVN B did not use proper assistive device and proper procedure drying resident/using gait belt when assisting Residents #1 during shower. Adequate supervision and assisted devices are required to prevent accidents. Focus will be safe transfers and proper supervision. 4. DON and ADON will in-service nursing staff on Safe Transfer. Nursing staff will be able to voice concepts of safe transfer to include residents limitations taken into account to determines how many people are required for transfer, where is the transfer taking place, is the resident dried off from a shower, are clothes donned before applying gait belt. Nursing will turn in a written test of knowledge over Safe Transfer and complete a return demonstration for DOR. Weekend staff and PRN will be provided training by DON and ADON and DOR. DON, will visually monitor each member of the nursing staff safely transfer a residents, every shift, starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into every day. After meeting with the survey team, additional education provided on 6/4/2025. To include place of transfer, resident ability, number of staff required, resident clothed, resident dry. Date completed: 6/9/2025 5. DON and ADON will in-service ALL staff on the definition of a FALL, AWARENESS, REPORTING, INTERVENTION AND PREVENTION. All staff will complete a written test of knowledge to be placed on file immediately. Weekend staff and PRN will be provided training by DON and ADON and DOR. This training must be completed before returning to the floor. ADON, will visually monitor each charge nurse report a fall, every shift, starting on 6/5/2025, until 100% of staff have been monitored. DON will maintain competency audit and update it daily and give to Administrator daily. Date initiated: 6/2/2025 Date completed: 6/5/2025 Upon hire, and quarterly thereafter 6. DON has reviewed all of May admissions and readmissions up to current date to verify there weren't any appointments or referrals needed. No issues identified. An admission/readmission report has been ran, printed and marked with a check mark for reviewed and no issues or a question mark requiring a hospital request for additional records. Date initiated: 6/2/2025 Date completed: ongoing, daily Upon hire, and quarterly thereafter 4 Skills check off will be completed for Nursing staff, in relation to their roles required for a fall, by DON/ADON. Now, Upon hire, and quarterly. Training must be completed before returning to the floor. DON and Administrator will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Individual interviews will be conducted for all nursing staff by ADON. During the interview the staff member will recite respective response to a fall, according to their position. These interviews will start on 6/5/2025, every shift until 100% of nursing staff have been interviewed. A spread sheet will indicate all staff have been interviewed and will be updated and provided to the Administrator for review daily. Nurse roles in a fall Completing and documenting fall risk assessments to identify residents at risk of falling. Monitoring the resident's medical condition for any changes that could affect the resident's fall risk status. Reporting falls to the physician, DON/ADON and Administrator, and obtaining medical orders as needed. Supervising nursing aides and educating patients and their families on fall prevention measures CNA role for a fall: Report to Charge nurse immediately and do not move the resident. Date initiated: 6/5/2026 Date complete:6/9/2025 5 Starting on 6/4/2025, DON will ensure that 1st and 2nd shift CNA's have a gait belt readily available. ADON will be assigned to monitor for 3rd shift on 6/4-5/2025 Will have gait belts readily available for use. This ensures proper preparedness for safe transfer immediately. Administrator will verify gait belts were provided on 6/4/2025 and 6/5/2025 by reviewing the gait belt audit log, daily. Date initiated:6/4/2025 Completed by: 6/5/2025 6. DON and ADON will in-service charge nurses about Admission/ readmission Binder. It will be kept at the nurses' station. DON/ADON, will review this Binder daily, during their assigned shift, to ensure any appointments/ referrals are made according to admission paperwork. All admission paperwork will be uploaded by admitting nurse to Medical Records via front office scanner and logged into the binder log in sheet located in the front of the binder. Weekend staff and PRN will be provided training by DON. This training must be completed before returning to the floor DON and ADON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep track of competencies/training completed/required. Date initiated 6/3/2025 Date completed: ongoing Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders. She uploaded the paperwork to medical records and placed in in the communication binder, at the nurses station. She also logged the information onto the login sheet in the front of said binder. Information included: resident name, date/time, reason for ER/visit or discharge, charge nurse initials, and yes or no boxes for needing appointments or new orders. See exhibit- A readmission paperwork login form. 7. Charge nurses will be in-serviced on reporting incidents such as falls, made by third party vendors, such as Hospice. When report of a fall is received by a third party or family, it is to be reported immediately to the DON/ADON. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON will maintain competency audit and ensure compliance. This training must be completed before returning to the floor. A staff roster containing staff member name, department and status of employment, will be utilized to keep audit of competencies/training completed/required. Administrator will confirm education provided by interviewing staff on 6/4/2025. Inservice to begin 6/4/2023. Completed by 6/5/2025 Third party vendors will be notified via telephone, by DON/ADON, of referrals recommended, or appointments made. A progress note will be entered into PCC, by the charge nurse, naming who they spoke with, date and time and short description on the nature of the information relayed. 8. Charge nurses will be in-serviced on the Appointments/ Referral Protocol immediately, intermittently, upon hire. Any appointment obtained by a charge nurse, will be reported to DON/ADON as soon as possible, but no later than the end of their shift. DON/ADON will update information pertaining to the resident's appointment in PCC on community board. Weekend staff and PRN will be provided training by DON and ADON. This training must be completed before returning to the floor. DON maintain competency audit and ensure compliance. This training must be completed before returning to the floor. DON/ADON, will visually monitor each member of the nursing staff recite or perform the Appointments/ Referral Protocol starting on 6/4/2025, until 100% of staff have been monitored. Date initiated: 6/2/2025. A master copy of in-services/training/tests table with employee names is being used to audit. This form will be updated and turned into Administrator for review every day. Monitored in real time on 6/4/2025, LVN B, notified DON, a resident had returned from the hospital with new orders and a referral appointment. Initiated 6/4/2025 Completion: ongoing daily 9.Starting today, 6/4/2025, all department heads will conduct Ambassador rounds. The revised form has been provided to all department heads by email. This will identify any incidents or accidents that may have happened and weren't properly reported, documented or identified. These rounds consist of room conditions, meal satisfaction, needs and will address falls, abuse, neglect and feelings of safety. These will be provided to Administrator daily. A manager on duty will be assigned to work 4 hours on Saturday and Sunday, four hours each day. Manager on Duty will be responsible for completing room rounds on all residents, turning form into administrator's mailbox and reporting incidents, accidents, fall or alleged abuse to Administrator immediately via phone. Exhibit E. Administrator will be responsible for monitoring the plan of removal. If it is found the plan is not working or an issue is identified, a meeting amongst department heads will convene immediately to discuss and determine revisions necessary for the safety of the residents and positive outcomes. Monitoring of the POR included the following: Observation on 5/28/25 at 1:23 PM revealed CNA A transferred Resident #2 from a wheelchair to the residents bed. CNA A explained to Resident #2 they were about to perform a transfer. CNA A placed Resident #2's wheelchair next to the bed that was on a level equal to the height of the wheelchair. Wheelchair was observed to be locked. CNA A then placed a gait belt on Resident #2 and counted down with the resident to stand up, Resident #2 was successfully transferred to the bed with no issues. In an interview on 06/07/25 at 3:00 PM the DON stated that in-services had been completed on all nursing staff. Record review of all in-service rosters and written competencies revealed that all nursing staff had received all in-services and written competency tests had been conducted and completed by all nursing staff. Between the dates of 06/05/25 and 06/07/25 6 gait-belt and 2 mechanical lift transfer trainings were observed to be conducted by the DOR and re-demonstrations in front of the DOR by the following staff members: CNA A, LVN B, CNA F, CNA H, CNA M, ADON, LVN Q, LVN R, CNA T, CNA X and LVN Y. Between the dates of 06/05/25 and 06/09/25, during all shifts, twenty-seven nursing staff members out of 39 nursing staff members were asked the following questions: All: -Title/Name/Length of time at the facility? -Did you receive training on transfers? /Did you demonstrate a safe transfer? To whom? -Describe a safe transfer related to showers. -Why are safe transfers important? When would you need a nurse to assess a resident? -Did you take a test for transfers/falls after training? -What is a fall? -Did you learn anything new from your latest in-services/demonstrations? CNA's: -If you see a fall, who do you report it too/What is your role? -When do you use a gait belt? RN's: -What is your role in falls? -Where exactly is the admission/re-admission folder located? What is its purpose? -What methods can you use to report incidents to the ADON/DON? -Why is it important to make sure hospital/specialist/orders are followed/appointments made? -Admissions/re-admissions/falls this shift? ADON, DON, DOR, CNA A, LVN B, LVN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, LVN P, LVN Q, LVN R, LVN S, CNA T, LVN U, LVN V, CNA W, CNA X, LVN Y and CNA Z representing and interviewed during the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and the 10:00 PM to 6:00 AM shifts, were able to answer all questions in a satisfactory manner that suggested training had been conducted and understood, written competencies had been conducted and completed, and nursing staff performed transfers in front of the DOR, DON or the ADON. Between the dates of 06/05/25 and 06/09/25 during all shifts, 8 gait-belt transfers and 3 mechanical lifts were observed to be conducted in a safe and competent manner by the following nursing staff CNA A, LVN B, CNA F, CNA K, CNA M, LVN Q, LVN U, CNA W, CNA X, and CNA Z, with Residents #1, #2, #3, #4, #5, #6, #7, and #8. The ADM and the DON were informed the Immediate Jeopardy was removed on 06/09/25 at 4:00 PM. 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 and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for two of nine residents (Residents #1 and #2) reviewed for elopement. 1. The facility failed to ensure Resident #1 did not elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized . An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on [DATE] 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in one arrest due to obstructing traffic and one hospitalization due to being found lying on the ground and had suffered a stroke. Findings included: 1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of [DATE]. Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care. Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM, written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back. Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM, written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him. Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM, written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property. Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker. Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested /checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train. Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM, she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they have not found Resident #1, and the SW stopped communicating with her. Interview with the ADM on 05/23/24 at 10:30 AM, she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested. Interview with the DON on 05/23/24 at 10:40 AM, she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him. Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he woke up around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoke and visit other residents. Resident #3 stated Resident #1 never showed any signs that he was leaving or that he did not like it here. Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 would follow him outside and he may have seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1. Interview with DET A on 5/23/24 at 01:35 PM, he stated it was believed Resident #1 was arrested in [City] , but then it was determined he had been arrested by the DTP. DET A stated when he was assigned to locate Resident #1, he was not missing as he had already been arrested. DET A stated when he located Resident #1 in jail, his case was closed as Resident #1 was no longer considered a missing person. Interview with the MD on 5/23/24 at 01:50 PM, he stated he was made aware that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated he had not been made aware that there were any concerns for Resident #1 smoking on his own. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently. Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated they are not supposed to give the door code to any residents. LVN H stated the door codes are now changed once a month. LVN H stated you must make sure the door was fully closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you must notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, they would notify the police. LVN H stated if the resident was found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer. Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he did not see Resident #1 up and walking around prior to taking his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room around 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 was probably outside smoking. CNA K stated he told LVN J that Resident #1 was not in his room, and LVN J said he may be smoking. CNA K stated around 9:00 AM, it was discovered Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours but now it was every 1 hour. CNA K stated when you complete the checks, you must chart in PCC any care provided. CNA K stated if you are just laying eyes on a Resident, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List only after physically laying eyes on them. CNA K stated he has never known for a resident to go missing. CNA K stated previously residents that were authorized to enter and exit with the door code, had the freedom to go as they please if they signed in and out. CNA K stated the door code was now changed once a month and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed and locked so no resident follows them out. Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on Monday (5/13), Resident #1 tried to go out front to smoke by himself when the ADM was entering the building and she explained to Resident #1 that he must sign out first. The ADON stated Resident #1 complied and then went out and returned, and everything was fine. The ADON stated the next morning on 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the ADM had Management driving throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she does not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated they are making sure any resident that leaves the facility signs out and informs the nurse. The ADON stated the aides and nurses now completes rounds every hour. The ADON stated Resident #1 could have been hit by a vehicle, ended up in the hospital, or even killed. Interview with the ADM on 05/23/24 at 03:25 PM, she stated they have completed re-assessments on all residents to make sure the assessments were accurate. The ADM stated all residents that were already exit-seeking had a doctor's order to wear a wander guard. The ADM stated the SW had recently reassessed the residents that are allowed to sign themselves out. The ADM stated they completed in-services on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses must print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all the residents that are allowed to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they are having another in-service tomorrow on 05/24/24 on the same items. During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility. Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she looked Resident #1 up on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #1's friend, Resident #4 most likely gave Resident #1 the door code. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 could not be found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process has changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would tell you if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if it was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, and CNA K took Resident #1 his breakfast tray, he was still not in his room. CNA L stated LVN J asked her if Resident #1 was in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and did not see Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must make sure the wander guard was working by observing the light taking the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must walk the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope. Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM, Surveyor left a voicemail and sent a text requesting a callback. Record review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked his halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During his last round at 4:00 AM, he assumed Resident #1 was asleep and did not disturb him nor his roommate. Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback. Record review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications. 2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. Review of Resident #2's Order Summary Report for May 2024 reflected: -04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. -04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. Review of Resident #2's Care Plans reflected: -05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. Facility interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering. Provide structured activities. Wander alert on left ankle. Monitor function and skin integrity every shift. Review of Resident #2's Progress Notes reflected: -05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A -05/22/24 2:30 PM Type: Behavior Note Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON -05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW -05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A -05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON -05/23/24 11:09 AM Late Entry Resident being sent to hospital for evaluation. Arranging transportation. - DON -05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON -05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A -05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A -05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B -05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B -05/26/24 5:20 PM, Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside in the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B Review of Resident #2's Ambulance Record, dated 05/26/24, reflected: Dispatch notified: 7:31 PM On scene: 7:36 PM Resident transferred: 8:10 PM Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected: Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. Final Diagnosis: Stroke Review of website: timeanddate.com on 05/29/24 reflected the following temperatures: [NAME] TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 97 degrees Dallas TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 98 degrees Observation of Resident #2 on 05/25/25 at 1:20 PM, revealed the resident was wearing a wander-guard transmitter on the left lower extremity and the presence of the LED light indicated it was functional. Observation of Resident #2 on 05/25/24 at 03:15 PM, revealed the DM sitting one-on-one with Resident #2 in the facility's lobby with his wander-guard transmitter still visible on the left lower extremity and the presence of the LED light indicated it was functional. An interview on 05/25/24 at 01:00 PM, with the MTD he stated he adjusted the front door to make the door close faster and changed the door code. The MTD stated the front door was monitored by the wander-guard system. The MTD stated normally, [Company] instructed him over the phone how to change the door code, but this time, he had [Company] come to the facility and [Company] installed a button under the receptionist's desk in order to open the door remotely and provided him a manual on how to change the door code himself. The MTD stated there had not been any concerns and everything was working properly. The MTD stated he monitored the doors as needed to ensure they are closing properly. The MTD stated he completed door checks three times a day and completed Tail Logs for documentation purposes. The MTD stated he had never been aware of any residents being in possession of the door code. On 05/25/24 at 01:20 PM, Surveyor observed the five residents identified for placement of a Wander Guard. Surveyor observed the five residents in their rooms with their Wander Guard placed according to their individual Care Plans and Orders. Surveyor also conducted testing with the ADON at the front door to ensure the Wander Guards were functioning properly. An interview on 05/25/24 at 02:15 PM, with the DM, he stated he drove around looking for Resident #1 when he was reported missing. The DM stated he was in-serviced on not giving the door code out or allowing residents to follow anyone outside. The DM stated the door codes were changed and a remote access button was installed under the receptionist's desk. An interview on 05/25/24 at 02:30 PM, with HR, she stated she was in-serviced on making sure all residents know they must be buzzed in and out. HR stated no residents nor visitors should have access to the door code. HR stated the approved residents must sign in and out of the facility and let staff know they are leaving. HR stated the MTD changed the door codes last on Thursday, 05/23/24. HR stated when she ends her shift at 5:00 PM and over the weekend, various staff members would cover the front door. An interview on 05/25/24 at 02:45 PM, HK O stated she was in-serviced on being more concerned when entering and exiting the front door. HK O stated she was informed the door code would be changed once a month. HK O stated she was informed to keep an eye on the residents that wear a Wander Guard. Interviews were conducted with facility staff across multiple shifts on 05/23/24, 05/24/24, and 05/25/24. Staff interviewed were LVN H, LVN J, CNA L, CNA K, CNA F, CNA G, CNA C, HK O, LVN B, LVN J and MA A. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on obtaining orders when a resident was assessed and determined to require a wander guard to ensure the wander guard monitoring populated into the TARS. They stated they had been in-serviced on checking to ensure the wander guard was functional every shift by observing that the light was visible and taking residents to the front door to ensure the alarm sounded. Staff verbalized the wander guard could[TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibited and prevented abuse and neglect for two of nine residents (Resident #1 and Resident#2) reviewed for elopement. 1. The facility failed to follow the policy and procedure for neglect which allowed Resident #1 to elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. The facility failed to follow the policy and procedure for neglect which allowed Resident #2 to elope from the facility. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized . An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on [DATE] 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in the failure to follow the policy for neglect as well as hospitalization with stroke. Findings included: Review of facility's policy Abuse and Neglect Clinical Protocol, revised March 2018, reflected: Neglect .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. 1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of [DATE]. Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care. Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM, written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back. Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM, written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him. Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM, written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property. Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker. Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested /checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train. Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM, she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they have not found Resident #1, and the SW stopped communicating with her. Interview with the ADM on 05/23/24 at 10:30 AM, she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested. Interview with the DON on 05/23/24 at 10:40 AM, she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him. Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he woke up around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoke and visit other residents. Resident #3 stated Resident #1 never showed any signs that he was leaving or that he did not like it here. Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 would follow him outside and he may have seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1. Interview with DET A on 5/23/24 at 01:35 PM, he stated it was believed Resident #1 was arrested in [City] , but then it was determined he had been arrested by the DTP. DET A stated when he was assigned to locate Resident #1, he was not missing as he had already been arrested. DET A stated when he located Resident #1 in jail, his case was closed as Resident #1 was no longer considered a missing person. Interview with the MD on 5/23/24 at 01:50 PM, he stated he was made aware that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated he had not been made aware that there were any concerns for Resident #1 smoking on his own. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently. Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated they are not supposed to give the door code to any residents. LVN H stated the door codes are now changed once a month. LVN H stated you must make sure the door was fully closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you must notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, they would notify the police. LVN H stated if the resident was found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer. Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he did not see Resident #1 up and walking around prior to taking his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room around 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 was probably outside smoking. CNA K stated he told LVN J that Resident #1 was not in his room, and LVN J said he may be smoking. CNA K stated around 9:00 AM, it was discovered Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours but now it was every 1 hour. CNA K stated when you complete the checks, you must chart in PCC any care provided. CNA K stated if you are just laying eyes on a Resident, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List only after physically laying eyes on them. CNA K stated he has never known for a resident to go missing. CNA K stated previously residents that were authorized to enter and exit with the door code, had the freedom to go as they please if they signed in and out. CNA K stated the door code was now changed once a month and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed and locked so no resident follows them out. Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on Monday (5/13), Resident #1 tried to go out front to smoke by himself when the ADM was entering the building and she explained to Resident #1 that he must sign out first. The ADON stated Resident #1 complied and then went out and returned, and everything was fine. The ADON stated the next morning on 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the ADM had Management driving throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she does not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated they are making sure any resident that leaves the facility signs out and informs the nurse. The ADON stated the aides and nurses now completes rounds every hour. The ADON stated Resident #1 could have been hit by a vehicle, ended up in the hospital, or even killed. Interview with the ADM on 05/23/24 at 03:25 PM, she stated they have completed re-assessments on all residents to make sure the assessments were accurate. The ADM stated all residents that were already exit-seeking had a doctor's order to wear a wander guard. The ADM stated the SW had recently reassessed the residents that are allowed to sign themselves out. The ADM stated they completed in-services on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses must print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all the residents that are allowed to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they are having another in-service tomorrow on 05/24/24 on the same items. During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility. Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she looked Resident #1 up on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #1's friend, Resident #4 most likely gave Resident #1 the door code. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 could not be found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process has changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would tell you if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if it was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, and CNA K took Resident #1 his breakfast tray, he was still not in his room. CNA L stated LVN J asked her if Resident #1 was in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and did not see Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must make sure the wander guard was working by observing the light taking the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must walk the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope. Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM, Surveyor left a voicemail and sent a text requesting a callback. Record review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked his halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During his last round at 4:00 AM, he assumed Resident #1 was asleep and did not disturb him nor his roommate. Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback. Record review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications. 2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. Review of Resident #2's Order Summary Report for May 2024 reflected: 04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. 04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. Review of Resident #2's Care Plans reflected: 05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. Facility interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering. Provide structured activities. Wander alert on left ankle. Monitor function and skin integrity every shift. Review of Resident #2's Progress Notes reflected: 05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A 05/22/24 2:30 PM Type: Behavior Note Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON 05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW 05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A 05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON 05/23/24 11:09 AM Late Entry Resident being sent to hospital for evaluation. Arranging transportation. - DON 05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON 05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A 05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A 05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B 05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B 05/26/24 5:20 PM Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B Review of Resident #2's Ambulance Record, dated 05/26/24, reflected: Dispatch notified: 7:31 PM On scene: 7:36 PM Resident transferred: 8:10 PM Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected: Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. Final Diagnosis: Stroke Review of website: timeanddate.com on 05/29/24 reflected the following temperatures: [NAME] TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 97 degrees Dallas TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 98 degrees An interview on 05/28/24 at 2:00 PM with a family member of Resident #2 revealed facility staff told her the resident was trying to leave the facility prior to his elopement. She said facility staff did not say he was on any enhanced monitoring. The family member said Resident #2 had tried to leave the previous facility he was in also. She said Resident #2 moved to the current facility because the facility had the wander guard system. The facility called her on 05/26/24 between 5:30 PM and 6:00 PM to tell her the resident had eloped. On 05/27/24 a person from the hospital called her and said the resident had been found and was in the hospital. An interview on 05/28/24 at 12:15 PM with the DON revealed she did not know how Resident #2 had eloped from the facility on 05/26/24. She said the resident was on 15-minute checks and provided a document showing 15-minute checks were completed and signed by staff. The DON said the resident kept attempting to get out of the facility and he was placed on a wander guard. She said the way the door worked was that if it was pressed on it would beep with the wander guard and then open. She said the resident was admitted on [DATE]. She said the facility staff noticed he was missing and began searching for the resident on 05/26/24. The DON said the resident was found in a gas station restroom and was taken to the hospital. The DON said the resident would not be returning to the facility. The DON said she had been working at the facility since 02/26/24. An interview on 05/28/24 at 12:40 PM with the Administrator revealed she said Resident #2 kept trying to get out and the staff were keeping him in sight. The Administrator said the resident forced himself out earlier when visitors were coming in and he was holding the door even though the alarm sounded, and staff had to tell him in to coming back again. The Administrator said Resident #2 was on 15-minute checks. Record review of the Resident Behavior Monitoring Log for Resident #2, dated 05-22-24 to 5-26-24 and provided by the DON, reflected 15-minute checks were documented and each entry was signed. The form showed LVN B's initials were signed for each entry on 05/26/24 from 6:00 AM to 5:45 PM. An interview on 05/29/24 at 9:45 AM with LVN B revealed he last saw Resident #2 on 04/26/24 at 4:00 PM when he went out to smoke. His initials were on the 15-minute checks provided by the DON. He said he went back to passing medications and noticed the resident's walker was in the front area next to the kitchen. LVN B said he did not perform 15-minute monitoring checks and also did not sign a form saying that he did. He said the resident was on hourly checks. He said he was the charge nurse, and the other staff were also not performing 15-minute checks on the resident. An interview on 05/29/24 at 11:06 AM with CNA C revealed she worked on 05/26/24 and last saw Resident #2 after smoke break between 4:00 PM and 4:30 PM. She said she was not checking on the resident every 15 minutes. She said she checked on the resident every hour. An interview on 05/29/24 at 11:55 AM with CNA D revealed she last saw Resident #2 on 05/26/24 after [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to ensure residents receives adequate supervision and assistance devices to prevent accidents for two of nine residents (Resident #1 and Resident #2) reviewed for elopement. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized . An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on [DATE] 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in one arrest due to obstructing traffic and one hospitalization due to being found lying on the ground and had suffered a stroke. Findings included: 1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of [DATE]. Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL (activities of daily living) self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care. Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back. Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him. Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property. Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker. Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested /checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train. Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they had not found Resident #1, and the SW stopped communicating with her. Interview with the ADM on 05/23/24 at 10:30 AM she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested. Interview with the DON on 05/23/24 at 10:40 AM she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him. Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he awakened around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoked and visited other residents. Resident #3 stated Resident #1 never showed any signs that he wanted to leave or that he did not like it here. Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 followed him outside and on occasion might had seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1. Interview with DET A on 5/23/24 at 01:35 PM, he stated it appeared Resident #1 had been arrested in Waxahachie, but later confirmed he had been arrested by the [Agency] Police. DET A stated when he started his search for Resident #1, he was not deemed missing as he had already been arrested. DET A stated his case was closed as Resident #1 was no longer considered a missing person. Interview with the MD on 5/23/24 at 01:50 PM, he stated he was notified by the facility on 05/14/24 that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently. Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8:00 PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated staff was not supposed to give the door code to any residents. LVN H stated now the door codes would be changed monthly by the MTD. LVN H stated you had to make sure the door closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a Resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you would notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, the police would be notified. LVN H stated if the resident were found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer. Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns. CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he had not seen Resident #1 up and walking around when he delivered his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room approximately 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 had probably gone outside to smoke. CNA K stated he then told LVN J that Resident #1 was not in his room, and LVN J said he probably had gone outside to smoke too. CNA K stated approximately 9:00 AM, Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours, but it had now been changed to every one hour. CNA K stated when you completed the checks, you had to chart in PCC any care provided. CNA K stated if you just laid eyes on a Resident only, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List, but only after physically laying eyes on them. CNA K stated he had never known for a resident to go missing. CNA K stated previously residents authorized to enter and exit with the door code, had the freedom to go as they pleased if they signed in and out. CNA K stated the MTD changed the door code, and it would now be changed monthly and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed to prevent any resident from following them out. Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on the morning of 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the Management drove throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she did not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated any resident that leaves the facility must sign out and inform the nurse. The ADON stated aides and nurses completes rounds every hour. The ADON stated Resident #1 could had been hit by a vehicle, ended up in the hospital, or even killed. Interview with the ADM on 05/23/24 at 03:25 PM, she stated they had completed re-assessments on all residents to ensure the assessments were accurate. The ADM stated all exit-seeking residents had a doctor's order to wear a wander guard. The ADM stated the SW reassessed the residents that are allowed to sign themselves out. The ADM stated the DON completed in-services with staff on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses had to print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all residents approved to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they would have another in-service tomorrow on 05/24/24 to discuss the same items. During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility. Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she searched for Resident #1 on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 was not found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process had changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would confirm if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if the wander guard was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, CNA K took Resident #1 his breakfast tray, and he was still not in his room. CNA L stated LVN J asked her if Resident #1 were in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and could not located Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must check the wander guard by observing the light taking and take the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must escort the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope. Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM. Surveyor left a voicemail and sent a text requesting a callback. Record Review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked my halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During my last round at 4:00 AM, I assumed Resident #1 was asleep and did not disturb him nor his roommate. Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback. Record Review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications. 2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. Review of Resident #2's Order Summary Report for May 2024 reflected: 04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. 04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. Review of Resident #2's Care Plans reflected: 05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. Facility interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering. Provide structured activities. Wander alert on left ankle. Monitor function and skin integrity every shift. Review of Resident #2's Elopement Assessment, dated 05/22/24 revealed the resident was ambulatory, had a history of wandering, and diagnosis of dementia/cognitive impairment. The assessment reflected the resident was at a high risk for wandering with a score of 13.0. Review of Resident #2's Progress Notes reflected: 05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A 05/22/24 2:30 PM Type: Behavior Note Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON 05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW 05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A 05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON 05/23/24 11:09 AM Late Entry Resident being sent to hospital for evaluation. Arranging transportation. - DON 05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON 05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A 05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A 05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B 05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B 05/26/24 5:20 PM Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B Review of Resident #2's Ambulance Record, dated 05/26/24, reflected: Dispatch notified: 7:31 PM On scene: 7:36 PM Resident transferred: 8:10 PM Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected: Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. Final Diagnosis: Stroke Review of website: timeanddate.com on 05/29/24 reflected the following temperatures: [NAME] TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 97 degrees Dallas TX temperature: 5/26/24 4:53 PM 97 degrees 5/26/24 6:53 PM 98 degrees Observation of Resident #2 on 05/25/25 at 1:20 PM revealed the resident was wearing a wander-guard transmitter on the left lower extremity and the presence of the LED light indicated it was functional. Observation of Resident #2 on 05/25/24 at 03:15 pm revealed the DM sitting one-on-one with Resident #2 in the facility's lobby with his wander-guard transmitter still visible on the left lower extremity and the presence of the LED light indicated it was functional. An interview on 05/25/24 at 01:00 PM with the MTD he stated he adjusted the front door to make the door close faster and changed the door code. The MTD stated the front door was monitored by the wander-guard system. The MTD stated normally, [Company] instructed him over the phone how to change the door code, but this time, he had [Company] come to the facility and [Company] installed a button under the receptionist's desk in order to open the door remotely and provided him a manual on how to change the door code himself. The MTD stated there had not been any concerns and everything was working properly. The MTD stated he monitored the doors as needed to ensure they are closing properly. The MTD stated he completed door checks three times a day and completed Tail Logs for documentation purposes. The MTD stated he had never been aware of any residents being in possession of the door code. On 05/25/24 at 01:20 PM, Surveyor observed the five residents identified for placement of a Wander Guard. Surveyor observed the five residents in their rooms with their Wander Guard placed according to their individual Care Plans and Orders. Surveyor also conducted testing with the ADON at the front door to ensure the Wander Guards were functioning properly. An interview on 05/25/24 at 02:15 PM, with the DM, he stated he drove around looking for Resident #1 when he was reported missing. The DM stated he was in-serviced on not giving the door code out or allowing residents to follow anyone outside. The DM stated the door codes were changed and a remote access button was installed under the receptionist's desk. An interview on 05/25/24 at 02:30 PM, with HR, she stated she was in-serviced on making sure all residents know they must be buzzed in and out. HR stated no residents nor visitors should have access to the door code. HR stated the approved residents must sign in and out of the facility and let staff know they are leaving. HR stated the MTD changed the door codes last on Thursday, 05/23/24. HR stated when she ends her shift at 5:00 PM and over the weekend, various staff members would cover the front door. An interview on 05/25/24 at 02:45 PM, HK O stated she was in-serviced on being more concerned when entering and exiting the front door. HK O stated she was informed the door code would be changed once a month. HK O stated she was informed to keep an eye on the residents that wear a Wander Guard. Interviews were conducted with facility staff across multiple shifts on 05/23/24, 05/24/24, and 05/25/24. Staff interviewed were LVN H, LVN J, CNA L, CNA K, CNA F, CNA G, CNA C, HK O, LVN B, LVN J and MA A. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on obtaining orders when a resident was assessed and determined to require a wander guard to ensure the wander guard monitoring populated into the TARS. They stated they had been in-serviced on checking to ensure the wander guard was functional every shift by observing that the light was visible and taking residents to the front door to ensure the alarm sounded. Staff verbalized the wander guard could only be monitored and checked at the front door and they stated if they saw a resident with a wander guard, they would ensure there were orders and monitoring in the clinical record. All were aware to notify the ADON, DON, or ADM for any [TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent elopements for three (Residents #1 #2 and #3) of six residents reviewed for elopements. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility unsupervised. Resident #1 had severe cognitive impairment, wandering behavior, and lacked safety awareness. Resident #1 eloped from the facility on 04/03/23 and was found by facility staff two blocks away. 2. The facility failed to routinely monitor wander-guard transmitters to ensure they were functional for Residents #1, #2 and #3. 3. The facility failed to ensure staff were trained and able to demonstrate competency in monitoring and checking wander-guard transmitters. An Immediate Jeopardy was identified on 04/19/23 at 3:50 p.m. While the Immediate Jeopardy was removed on 04/20/23, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme weather exposure. Findings included: 1. Review of Resident #1's admission MDS assessment, dated 03/21/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included dementia, muscle weakness, lack of coordination and cardiac pacemaker. The MDS reflected he had a BIMS (Brief Interview for Mental Status- is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 5 indicating severe cognitive impairment, symptoms of delirium to include continuous inattention that did not fluctuate and disorganized thinking. He had an unsteady gait, and impaired vision. Resident #1's undated Admission Record reflected a discharge date of [DATE]. Review of Resident #1's care plan revised on 03/15/23 revealed the resident's risk for elopement, wandering and impaired safety awareness was addressed. Interventions included an alert that the resident had a wander-guard to the right ankle, offering pleasant diversions, structured activities, and food. The care plan did not address testing, checking, or monitoring the wander-guard transmitter to ensure it was functional. Review of Resident #1's Elopement Risk Assessment, dated 03/14/23, revealed the resident was ambulatory, had a history of wandering, and diagnosis of dementia/cognitive impairment. The assessment reflected the resident was at a high risk for wandering. Review of Resident #1's progress notes dated 03/31/23 revealed the resident was alert and confused. The notes reflected Continued exit seeking noted wandering, easily redirected to join in on activities and other things. Review of Resident #1's MARS/TARS (Medication Administration Records/Treatment Administration Records) dated 03/2023 revealed no evidence of wander-guard monitoring/checks since his admission 03/14/23 and his elopement on 04/03/23. Review of Resident #1's physician orders dated from 03/2023 to 04/2023 revealed no orders related to the wander guard to include monitoring the wander guard to ensure it was functional. Review of the Provider Investigation Report dated 04/05/23 revealed Resident #1 was observed at a service station two blocks from the facility by CNA C who recognized the resident by his gait. CNA C took the resident back to the facility at approximately midnight where he was assessed by LVN B without injuries and placed on every 15-minute checks. The investigation report reflected Resident #1 was last seen by the evening nurse, LVN D at 11:21 p.m. sitting in the dining room. The investigation report further reflected the resident's wander-guard was in place and working properly. Review of in-service training dated 04/04/23, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested /checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. Interview with the Administrator on 04/18/23 at 9:53 a.m. she stated Resident #1 wore a wander-guard transmitter but when the resident eloped from the facility on 04/03/23 no staff reported hearing the alarm. The Administrator stated the wander-guard system that monitored the front door of the facility was tested weekly to ensure it was functional and individual wander-guard transmitters worn by residents were routinely tested , but she was not sure how often or where the testing was documented. Interview with maintenance on 04/18/23 at 10:25 a.m. he stated there were magnetic (Mag) locks on all exit doors to include the front door that was also monitored by a wander-guard system. He stated all exit doors except the front door could be opened after pushing on the door bar for 15 seconds causing an alarm to sound that had to be silenced by staff. The front door required a code to enter and exit and the wander-guard system would cause an alarm to sound when a resident wearing a transmitter was close to the door and staff would have to silence the alarm. He stated he checked all exit door alarms weekly to include the wander-guard system on the front door and there had been no problems with the alarms functioning. He further stated he was not aware of Resident #1's elopement. Interview with ADON on 04/18/23 at 2:05 p.m. she stated she checked the function of Resident #1's wander-guard transmitter on 04/04/23 the day after the resident eloped. She stated it was the same transmitter he had always worn, and when she took the resident to the front door, the alarm sounded, and the red indicator light was blinking on the transmitter indicating it was functional. Interview with LVN A on 04/18/23 at 3:59 p.m. she stated she worked on an as needed basis and she checked resident's wander-guard transmitters every shift by taking them to either the front door or the exit door at the end of Hall 100. She stated she did not recall receiving any training or instruction on the wander-guard system and did not know all of the residents who wore a wander-guard to include the residents she was assigned to. She stated she would have to check the TARS to determine who the residents were that had physician orders in reference to checking the wander-guard transmitter. Interview with the ADON on 04/18/23 at 4:20 p.m. she stated an order for wander-guard checks had to be put into the resident's EHR (Electronic Health Record) for the checks to populate onto the TAR so that nursing staff would be aware to perform and document the checks. She stated putting the order in must have been missed for Resident #1. The ADON confirmed the wander-guard system could only be monitored and/or checked at the front door of the facility. Interview with LVN B on 04/18/23 at 4:32 p.m. she stated she was the night nurse on duty on 04/03/23 when she saw CNA C bring Resident #1 back into the facility. LVN B stated she had been making rounds and was not aware Resident #1 was out of the facility. LVN B stated Resident #1 was wearing a wander-guard transmitter when he returned, but she did not know if it was working because she did not check it but placed the resident on every 15-minute checks. LVN B stated she was aware Resident #1 wore a wander-guard transmitter but had never checked it at the front door as residents were usually in bed during her shift. She usually checked the light on the resident's transmitters to ensure they were functioning. Resident #1's transmitter appeared dead when she checked it on the night he eloped as there was no visible light. LVN B further stated she notified the Administrator that there was no light on the resident's transmitter and was told arrangements would be made to get the resident another one. LVN B was unable to recall if she had received training on the wander-guard system and stated she might not have fully understood during orientation. She stated she never documented any checks of Resident #1's wander-guard transmitter and never noticed there were no orders on the TAR to check the transmitter. She stated, We just missed that part. Interview on 04/18/23 at 4:46 p.m. with LVN D he stated he was the evening nurse on 04/03/23 the day Resident #1 eloped. He stated when he clocked out sometime after 11:00 p.m. he saw Resident #1 ambulating in the hallway. He stated Resident #1 did not use a wander-guard and therefore he had performed no wander-guard checks for the resident. LVN D stated he checked residents with wander-guard transmitters by pressing the button on the transmitter to ensure the light flashed green to ensure it was functioning. Interview on 04/18/23at 6:19 p.m. CNA C stated on the morning of 04/04/23 at approximately 12:00 midnight or 12:30 a.m. she just happened to be at a service station located two blocks from the facility when she recognized Resident #1 walking by. She stated she asked the resident where he was going, and he told her he didn't know. CNA C stated she recalled the resident was wearing a wander-guard transmitter on his ankle and when she put the code in the front door of the facility and entered with the resident the alarm sounded. She further stated she did not check for or recall seeing a light on the wander-guard transmitter. Interview with the Administrator on 04/19/23 at 9:41 a.m. she stated she was not aware Resident #1's wander-guard was not being monitored/checked to ensure it was functional. She stated the ADON was responsible for monitoring physician orders, MARS, and TARS to ensure nothing was missed and there was no missing documentation. She confirmed the wander-guard system monitored the front door only. Interview with Staff E on 04/19/23 at 10:15 a.m. she stated she was the central supply staff and was responsible for activating the Accutech wander-guard Tags/transmitters before they were placed on residents. She stated after activated the transmitter had a constant red light indicating it was functional. Prior to 04/18/23 she had not been provided any training or instruction related to checking or testing the transmitter after it was placed on a resident. Staff E stated she would provide the user manual for the Accutech Tag/transmitter. Review of the undated user manual for the Accutech Tag/transmitter section 1-1 revealed the function of the system was to alert facility staff of the possible egress of a monitored resident. The system could be utilized for special care residents suffering from wandering with tendencies of leaving the facility. Section 2-4 of the manual reflected the Tag/transmitter operated by an internal battery and over the course of normal operation would lose battery power and would need to be replaced as the battery was not replaceable. Recommendations were that the Tag/transmitter be tested on a weekly basis. Interview with ADON on 04/19/23 at 1:44 p.m. she stated when there was no DON, she was responsible for checking MARS/TARS and physician orders. She stated, I can only do what I can being one person, sometimes things get missed. She stated the best practice was for nurses to make rounds to ensure all residents were accounted for. Observation on 04/19/23 at 2:00 p.m. with the Administrator to test the sound level of the wander-guard system on the front door. The alarm sounded loudly near the front door but further away from the front door the sound of the alarm decreased and was barely audible at the nurse's station. Interviews on 04/19/23 at 2:12 p.m. with three nursing staff (CNA C, LVN F and LVN G) who were sitting at the nurse's station when the alarm was tested on [DATE] at 2:00 p.m. They all stated they were able to hear the alarm if they listened intently and it would be helpful if the alarm was louder. Interview on 04/20/23 at 11:10 a.m. LVN F stated she was aware Resident #1 wore a wander-guard transmitter, but she had never checked it to ensure it was functioning. She stated there were no orders for checking the wander-guard on the resident's TAR. She stated she was not aware that all residents who wore a wander-guard had to be checked at the front door or that they needed an order. She further states she had received no training prior to training received on 04/18/23. 2. Review of Resident #2's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease. The MDS assessment reflected she had a BIMS of 4 indicating severe cognitive impairment, an unsteady gait, and symptoms of delirium, to include continuous inattention that did not fluctuate. Review of Resident #2's care plan revised on 02/20/23 revealed the resident's risk for elopement, wandering behavior and that the resident wore a wander-guard was addressed. Interventions included offering pleasant diversions, structured activities, and food. The care plan did not address testing, checking, or monitoring the wander-guard transmitter to ensure it was functional until the revision dated 04/19/23 which reflected, Nurse will monitor wander guard to make sure its functioning properly every shift. Review of Resident #2's Elopement Assessment, dated 02/15/23 revealed the resident was ambulatory, had a history of wandering, and diagnosis of dementia/cognitive impairment. The assessment reflected the resident was at a high risk for wandering. Observation of Resident #2 on 04/18/23 at 4:15 p.m. revealed the resident was wearing a wander-guard transmitter on the left lower extremity and the presence of the LED light indicated it was functional. Review of a list provided by the Administrator on 04/20/23 revealed Resident #2's wander-guard transmitter was placed on 01/17/23. Review of MARS/TARS dated from 01/2023 to 04/2023 reflected there was no evidence of monitoring or checking the wander-guard transmitter to ensure it was functional prior to 04/18/23. Review of Resident #2's physician order dated 04/18/23 revealed, Monitor wander-guard to left lower extremity. Review of the resident's clinical records revealed no orders or monitoring the function of the wander-guard prior to 04/18/23. 3. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included vascular dementia. The MDS assessment reflected he had a BIMS of 6 indicating severe cognitive impairment, he used a wheelchair for mobility and required extensive assistance of one person for dressing and personal hygiene. Review of Resident #3's care plan revised on 04/19/23 revealed Check wander guard on leg. Check for any pressure problems and assure he has it on lower leg/ankle. Review of Resident #3's Elopement Assessment, dated 03/30/23 revealed the resident was ambulatory, had no history of wandering, and diagnosis of dementia/cognitive impairment. The assessment reflected the resident was at risk for wandering. Observation on 04/18/23 at 4:18 p.m. revealed Resident #3 was wearing a wander-guard transmitter on the right lower extremity and the presence of the LED light indicated it was functional. Review of a list provided by the Administrator on 04/20/23 revealed Resident #3's wander-guard transmitter was placed on 12/28/22. Review of MARS/TARS dated from 12/2022 to 04/2023 revealed there was no evidence of any monitoring or checking of the wander-guard transmitter to ensure it was functional prior to 04/18/23. Review of Resident #3's physician order dated 04/18/23 revealed Monitor wander-guard to the right lower leg for functioning. Review of the resident's clinical records revealed no orders or monitoring the function of the wander-guard prior to 04/18/23. Observations on 04/18/23 from 4:03 p.m. to 4:18 p.m. with the ADON and LVN A revealed five residents were wearing wander-guard transmitters and the presence of LED lights for four of the residents indicated they were functional. One resident became aggressive and declined to allow a full observation or test of his wander guard transmitter. Review of a list of residents with wander-guard transmitters provided by the Administrator on 04/18/23 revealed Resident #2 and Resident #3 were not listed as having wander-guard transmitters. Interview with Administrator on 04/20/23 at 9:56 a.m. she confirmed there were no orders to monitor Resident #2's and Resident #3's wander-guard transmitters prior to 04/18/23. She stated she was not sure if the monitoring was listed on the TARS or if staff had been monitoring the transmitters to ensure they were functional. Interview on 04/20/23 at 11:55 a.m. the Administrator stated when nurses placed wander-guard transmitters on residents they should have an order in the EHR so that the monitoring would populate on the TAR. She stated she did not know the wander-guards for Residents #2 and #3 were not being monitored to ensure they were functional. Interview on 04/20/23 at 11:10 a.m. LVN F stated she was aware of Residents #2 and #3 having wander-guard transmitters, but she had never checked them to ensure they were functioning. She stated there were no orders and checking them was not listed on the TARS. She stated she was not aware that all residents who wore a wander-guard had to be checked at the front door or that they needed an order. She further stated she had received no training prior to the training received on 04/18/23. Interview on 04/22/23 at 1:15 p.m. the Administrator stated her expectations were for nursing staff caring for residents with wander guards to ensure the wander guard was checked every shift to ensure it was operational and the resident was safe. She stated if wander guards were not checked to ensure they were functional a resident could get out of the facility and be harmed while outside. She stated it was important for staff to be trained on the wander guard system and know what residents used a wander guard so they could watch out for residents who could elope. Review of the facility's P/P entitled Wandering, Unsafe Resident revised August 2014 revealed in part: 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Review of the facility's P/P entitled Elopements revised December 2007 revealed the procedure for searching for and reporting a missing resident was included. Page three of the P/P addressed staff training for residents exhibiting wandering behavior to include education on the various alarm systems utilized for wandering residents. The P/P reflected Our facility uses the Accutech Alarm Tags which are activated by our Nursing Department. The flashing led red light shows the wandering tag is active. Confirmation of the active unit can be determined by presenting the tag within a few feet of the installed Mag Lock system which is located at the front door (only) as well as mini security alarms that will sound upon opening. They can only be de-activated by entering the proper code in the keypad 11* and resetting the mini security alarm. An Immediate Jeopardy was identified on 04/19/23 at 3:50 p.m. and the Administrator was informed of IJ in the area of accidents/supervision and the IJ template was provided via email at 3:59 p.m. The Plan of Removal was accepted on 04/20/23 at 1:26 p.m. and reflected: Plan of Removal [Facility Name] 04- 19-2023 The Facility failed to provide evidence of any wander-guard checks to ensure the wander guard bracelet or system was functional and in good working order for the Identified Resident #l 's admitted (3/14/2023), which resulted in an elopement. Identified Resident #2 and Resident #3 did not elope but were wearing wander-guards and were not included on the Facility wander guard. Removal Plan: l) Identified resident no longer resides in the facility. 2) Residents listed (see attached) are at risk for elopement and have the potential to be effected (sic) by the alleged deficient practice. On 04/19/2023 none of the 5 residents are currently exit seeking. The ADON verified wander guard orders to include: placement and functionality 04-19-2023 on the TAR. Care Plans have been completed on residents being at risk for elopement by 04-19-2023. 3) Administrator will re-educated facility staff starting 04-18-2023 and completing by 04-19-2023: Licensed nurses will verify and document that wander guards are properly placed on resident's arms or legs and properly functioning, each shift by taking the resident, who is wearing the wander guard unit, to the front door to hear the alarm sound. Licensed nurses will be re-educated on if a resident develops new onset of exit seeking behaviors, an elopement assessment will be initiated and Care Plans will be updated to reflect the new behavior. If a resident is deemed appropriate for wander guard but refuses to wear the wander guard, DON will be notified, and this resident will be placed on one-to-one monitoring pending possible discharge. Facility Staff will complete a post test on the above education to validate the understanding of the facility procedure. The employee roster will be used to validate compliance for every staff member trained. The Maintenance Director will check every door in the facility and make sure they are operational and alarms are sounding appropriately by 04/19/23. Total Fire and Safety will be on site 04/20/23 to ensure speaker volume of the alarm that sounds when the wander guard system is amplified. Prior to the Administrator training the ADON, the VP (Vice President) of Operations will conduct a train the trainer education with the Administrator and she will then, in turn, conduct a train the trainer in-service with the ADON on how to accurately use the Accutech wander guard device to ensure the wander guards are working properly by 04/19/23. Once the ADON performs a correct return demonstration, she will train all licensed nurses on the proper procedure for Accutech to ensure the doors and alarms are operational. This training will begin on 04/19/23 and will continue with each nurse prior to their next scheduled shift. 4) The Administrator and ADON will observe a minimum of 3 nurses each week for 1 month to conduct return demonstration to validate the understanding and proper checking of placement and functionality of the wander guard. The Medical Director was notified on 04/19/23 of the Immediate Jeopardy. The VP of Operations will monitor the tasks of the Administrator and ADON, once weekly, for a minimum of 1 month. Plan of removal monitorng: Review of in-service training logs and competency tests dated 04/18/23 and 04/19/23 revealed education included checking wander guards, completing assessments to determine the resident's risk for wandering and determining if a wander guard unit was needed. Obtaining and placing an order into the EHR for the use and monitoring of the wander guard unit. Documenting in the MAR/TAR to confirm the wander guard unit was being checked every shift. Ensuring the red light was flashing on the wander guard unit and performing a double check to confirm the wander guard unit was active by taking the resident to the front door. Observing residents on the wander guard list and responding immediately to any alarms. Interviews were conducted with facility staff across multiple shifts on 04/20/23 from 2:48 p.m. to 4:10 p.m. and on 04/22/23 from 11:40 a.m. to 12:06 p.m. Staff interviewed were LVN D, LVN F, LVN G, LVN H, LVN I, CNA J, CNA K, CNA L, CNA M, Housekeepers N, Housekeeper O, Dietary Aide P and Cook Q. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on obtaining orders when a resident was assessed and determined to require a wander guard to ensure the wander guard monitoring populated to the TARS. Checking to ensure the wander guard was functional every shift buy observing that the light was visible and taking residents to the front door to ensure the alarm sounded. Staff verbalized the wander guard could only be monitored/checked at the front door and they stated if they saw a resident with a wander guard, they would ensure there were orders and monitoring in the clinical record. All were aware to notify the ADON or Administrator for any concerns with the wander guard system. The Administrator was notified on 02/17/22 at 4:15 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate supervision and assistance devices to prevent accidents for one (Resident #1) of 72 residents reviewed for incidents and accidents. The facility failed to ensure Resident #1 received adequate supervision during smoking to ensure he was free from injury. Resident #1 [MEDICAL CONDITION] three fingers with necrotic tissue and pain to his third finger. This failure placed residents at risk for serious harm or bodily injury. Findings included: Review of Resident #1's MDS assessment dated , 01/26/20, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. He had moderate cognition. Review of Resident #1's care plan dated 11/19/19 revealed he was a smoker. The long-term goal for Resident #1 was that the resident would not suffer injury from unsafe smoking practices. The interventions for the resident were to instruct resident about smoking risks and hazards and about smoking cessation aids that were available, instruct resident about the facility policy on smoking: locations, times, safety concerns, monitor oral hygiene, notify charge nurse immediately if it was suspected resident had violated facility smoking policy, and observe clothing and skin for signs of [MEDICAL CONDITION]. There was no evidence of intervention regarding smoking or clothing protection. Observation of the smoking patio area on 03/05/20 at 4:34 PM revealed Resident #1 was being supervised while smoking and had visible black marks on his thumb and index finger. The ash on Resident #1's cigarette was long and CNA A had to inform the Resident to ash his cigarette at least twice. Resident #1 was not wearing an apron during the smoke break. Review of Resident #1's smoking safety screen dated August 2019 and November 2019 revealed he was a modified independent smoker due to burning fingers while smoking, sneaking cigarettes when he feels others are not watching, and keeps a lighter in his possession. Review of Resident #1's skin assessment completed by LVN A dated 01/04/20 revealed he [MEDICAL CONDITION] both thumbs and right index finger due to cigarette smoking. Review of Resident #1's physician orders, MAR, and TAR dated 1/1/20 to 3/31/20 revealed no documentation of Resident #1'[MEDICAL CONDITION] his fingers being monitored or treated. Review of Resident #1's nurse's note dated 01/06/20 revealed both thumbs and right index finger were burnt from cigarette smoking. The notes indicated Resident #1 smoked cigarette butts and he was educated by nursing staff not to smoke the butts of cigarettes. According to the note written by LVN A , the ADON and SW were notified . Observation and Interview on 03/05/20 at 5:44 PM with Resident #1 revealed he had dark black marks on both of his thumbs and left index finger. Resident #1 stated he burned his hand badly two days ago while smoking his cigarette to the butt. He stated he informed staff, the nurse evaluated his hand, and told him he should not have burned himself. Resident #1 pulled a cigarette and lighter out of his pocket at that time and burn holes were noted to his sleeves and the front of his jacket. Interview on 03/06/20 at 5:57 PM with Resident #1 revealed his fingers were numb and he could not feel his fingers due to the burns. Resident #1 stated he knew his fingers would get burnt from smoking cigarette butts. He stated [MEDICAL CONDITION] ever been treated. He stated he had [MEDICAL CONDITION] months and continued to burn himself every time he smoked. He stated staff knew about [MEDICAL CONDITION] never intervened when he smoked cigarettes to the butt. Resident #1 stated staff did not always supervise him while smoking. Resident #1 stated staff walked away when they saw him smoking by himself. Resident #1 stated he currently had a cigarette and lighter on his person. Resident #1 stated he received a cigarette from his roommate. He stated staff knew he had a cigarette and a lighter. Resident #1 stated the holes in his jacket were [MEDICAL CONDITION] staff had never assessed his clothes [MEDICAL CONDITION] smoking. Resident #1 stated the facility has not provided treatment. Observation and Interview on 3/07/20 at 4:14PM revealed Resident #1 had [MEDICAL CONDITION] his shirt. He stated he does not wear an apron during smoking break. Resident stated he does not have any new burns. Observation and Interview on 3/06/20 6:55PM with DON revealed she did not know if Resident #1 smoked unsupervised. She stated Resident #1 should not have cigarettes or lighters in his room. She stated, I cannot tell you if he has cigarettes or lighters in his room. She stated Resident #1 did not have any skin issues. She stated he likes to pick in the ash tray with his thumb and index finger. The DON assessed Resident #1's hands. She squeezed on the resident's index finger and he said it hurt. The DON grabbed a wipe and cleaned residents fingers and stated he [MEDICAL CONDITION] his fingers. She stated this is the first time she has seen them and told resident wound care will l see him. She informed Resident #1 there were calluses under his burn and he will get medication to treat burns. The DON stated she will put in orders for wound care and pain medication for Resident #1. She stated skin assessments were completed weekly and is completing a skin assessment for Resident #1 now. She stated residents were not checked [MEDICAL CONDITION] they smoke. Interview on 3/05/20 at 7:57 PM with LVN A revealed residents need to be supervised during smoking and wear an apron so they do not burn themselves. She stated Resident #1 was non-complaint. She stated Resident #1 had not burned his fingers since 2019 and a skin assessment was completed for the burns. She stated the resident did not have any recent burns. Interview on 3/05/20 at 8:15PM with LVN B revealed independent and supervised smokers were not allowed to keep cigarettes and lighters in their room. LVN B stated Resident #1 burned his fingers months ago. She stated skin assessments are completed daily during the 6:00AM to 2:00PM shift. She stated she had never completed a skin assessment for Resident #1 because she works 2:00PM to 10:00PM. She stated supervised residents need to be monitored to prevent injury, fire, and some residents have dementia. She stated when a resident burned themselves the physician, ADM, ADON, DON were notified and a skin assessment was completed. She stated skin assessments were completed weekly . Interview on 3/05/20 at 8:46PM with the ADON revealed independent and dependent smokers were not allowed to keep their cigarettes or lighters in their possession. She stated supervised smokers were monitored and wore aprons for safety because residents could get burns. The ADON stated there had not been any residents including Resident #1 who had recently burned themselves while smoking. She stated skin assessments were completed any time there was a skin issue. Interview on 03/06/20 at 9:33 AM with the SW revealed she completed residents' smoking assessments with assistance of the nurses. She stated the smoking assessments were completed quarterly and determined the resident's safety during smoking. She stated there were three types of smokers: independent, modified independent, and supervised. She stated independent smokers were not allowed to keep their cigarettes or lighters in their possession unless the resident signed out of the facility on pass. She stated modified independent smokers were residents that the IDT team thought might be unsafe smoking alone due to level of orientation, mental health, and psych meds. She stated only supervised residents were required to wear an apron. The SW stated Resident #1 was supervised while smoking and [MEDICAL CONDITION] his hands prior to being admitted to the facility. There was no evidence suggesting Resident #1 arrived at facility [MEDICAL CONDITION] his fingers. She stated Resident #1 does not need to wear an apron while smoking. She stated there had been no residents recently who had burn due to cigarettes. She stated residents to not have any cigarettes or lighters. She stated she confiscates cigarettes and lighters from residents. Interview on 3/06/20 at 10:30AM with the DON revealed there were independent, modified independent, and supervised smokers. She stated no residents were allowed to keep their cigarettes or lighters. She stated there is a resident smoking list located in the smoke box kept at the nurse's station and reception area. She stated the SW completed and nursing assisted with the smoking assessments. She stated the smoking assessments were completed quarterly or when there were changes with the residents; the IDT team would discuss. She stated modified independent smokers were to be supervised and do not have to wear aprons. She stated supervised smokers have to be monitored and sometimes have to wear an apron based on disability and mental health. She stated if a modified [MEDICAL CONDITION] then there has to be re-evaluated by a smoking assessment, a skin assessment is completed, and physician is notified. She stated the smoking assessment would be updated and the resident would be recommended to wear an apron. She stated if a [MEDICAL CONDITION] hands all you can do is educate them and consult the wound doctor. The DON stated there has not been any resident with burns. She stated an in-service was completed and staff was informed to supervise residents while smoking. She stated residents were aware of the smoking policy because it is signed at admission . The DON stated she was not aware of Resident #1 burning himself in January 2020. Observation and Interview on 3/08/20 at 1:22PM Resident #1 was observed during a supervised smoke break using a cigarette holder. He was not wearing an apron and there was ash on his pants. Resident #1 stated he was not provided an apron to wear while smoking. Interview on 03/06/20 at 11:07AM with ADM revealed there were independent, modified independent, and supervised smokers at the facility. She stated residents were not allowed to have cigarettes or lighters and are kept in the smoke box at the nurse's station. She stated CNAs are informed of the different types of smokers by referring to the smoking list and asking department heads. She stated independent smokers can sign out to smoke outside of the facility but have to turn in their cigarettes and lighters when they return. She stated modified independent smokers can only smoke in the patio area, do not have to wear aprons, and have to be supervised. She stated supervised smokers have to wear aprons and were supervised. The ADM stated she had not been made aware of any recent incidents of residents burning themselves while smoking. She stated if a resident who was a modified independent smoker burned themselves then they were changed to supervised smoking. She stated I have tried to put aprons on residents but they cuss and say no . She stated Resident #1 was not offered an apron. She stated smoking assessments were completed quarterly. She stated the importance of a smoking assessment was to make sure residents were safe smoking, could complete all the task associated with smoking, and aprons were worn to keep residents from burning themselves. She stated residents were supervised while smoking and monitored after to see if anything else was going on. She stated residents signed the smoking policy when completing the admission paperwork. She stated the DON completed a smoking in-service with staff. She stated staff were informed to be more aware of residents on the patio smoking. She stated she did not know residents had cigarettes and lighters in their possession. She stated Over half the census are smokers, residents are informed of smoking rules, and I don't have time to search everyone's room for cigarettes or lighters. Interview on 3/9/20 at 6:43PM with LVN A revealed she wrote a note on 1/04/20 and completed a skin assessment on 1/4/20 regarding [MEDICAL CONDITION] Resident #1's fingers. She stated [MEDICAL CONDITION] his fingers were scabbed over and light brown. She stated the resident informed her [MEDICAL CONDITION] from smoking. She informed Resident #1 not to burn himself again. LVN A stated she informed the SW and ADON about [MEDICAL CONDITION] fingers. She stated she told the SW because she completed the smoking assessments. LVN A stated she did not order wound care because there was nothing to treat. Record review of Resident #1's smoking safety assessment dated [DATE] revealed he has to be supervised during smoke breaks and wear smoking gloves or use a cigarette holder to prevent further injury. Record review of Resident #1's skin assessment dated [DATE] revealed he has dark callus to right first finger, right second finger, and left first finger. He has discomfort to right second finger with pain 3/10. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's wound care evaluation dated 3/09/20 revealed he has wounds on right first finger, right second finger, and left first finger. There is thick black necrotic tissue on all wounds and Resident #1 refused debridement. The wounds dressing treatment plan is skin prep applied once daily for 30 days. Observation and Interview on 3/09/20 at 7:52PM revealed Resident #1 had [MEDICAL CONDITION] pants. He stated he did not wear an apron today during the smoke breaks. He stated he has no new burns. Review of the facility's Smoking Policy dated 7/01/18 revealed the nursing staff will evaluate residents to determine their individual ability to smoke safely. The facility has designated smoking times and staff will be available to distribute smoking materials and supervise the residents if indicated by their smoking assessment. Residents are prohibited from keeping smoking paraphernalia in their possession. The residents are to keep cigarettes and lighters in smoke box kept at the nurse's station. There is a list of smokers that have been evaluated in the smoke box. Assist all residents to the designated smoking area. Smoking material will not be distributed to the resident until they are in the designated smoking area. Smoking aprons and other assistant devices used for safety are to be placed in the designated smoking boxes.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate supervision and assistance devices to prevent accidents for one (Resident #1) of 72 residents reviewed for incidents and accidents. The facility failed to ensure Resident #1 received adequate supervision during smoking to ensure he was free from injury. Resident #1 [MEDICAL CONDITION] three fingers with necrotic tissue and pain to his third finger. This failure placed residents at risk for serious harm or bodily injury. Findings included: Review of Resident #1's MDS assessment dated , 01/26/20, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. He had moderate cognition. Review of Resident #1's care plan dated 11/19/19 revealed he was a smoker. The long-term goal for Resident #1 was that the resident would not suffer injury from unsafe smoking practices. The interventions for the resident were to instruct resident about smoking risks and hazards and about smoking cessation aids that were available, instruct resident about the facility policy on smoking: locations, times, safety concerns, monitor oral hygiene, notify charge nurse immediately if it was suspected resident had violated facility smoking policy, and observe clothing and skin for signs of [MEDICAL CONDITION]. There was no evidence of intervention regarding smoking or clothing protection. Observation of the smoking patio area on 03/05/20 at 4:34 PM revealed Resident #1 was being supervised while smoking and had visible black marks on his thumb and index finger. The ash on Resident #1's cigarette was long and CNA A had to inform the Resident to ash his cigarette at least twice. Resident #1 was not wearing an apron during the smoke break. Review of Resident #1's smoking safety screen dated August 2019 and November 2019 revealed he was a modified independent smoker due to burning fingers while smoking, sneaking cigarettes when he feels others are not watching, and keeps a lighter in his possession. Review of Resident #1's skin assessment completed by LVN A dated 01/04/20 revealed he [MEDICAL CONDITION] both thumbs and right index finger due to cigarette smoking. Review of Resident #1's physician orders, MAR, and TAR dated 1/1/20 to 3/31/20 revealed no documentation of Resident #1'[MEDICAL CONDITION] his fingers being monitored or treated. Review of Resident #1's nurse's note dated 01/06/20 revealed both thumbs and right index finger were burnt from cigarette smoking. The notes indicated Resident #1 smoked cigarette butts and he was educated by nursing staff not to smoke the butts of cigarettes. According to the note written by LVN A , the ADON and SW were notified . Observation and Interview on 03/05/20 at 5:44 PM with Resident #1 revealed he had dark black marks on both of his thumbs and left index finger. Resident #1 stated he burned his hand badly two days ago while smoking his cigarette to the butt. He stated he informed staff, the nurse evaluated his hand, and told him he should not have burned himself. Resident #1 pulled a cigarette and lighter out of his pocket at that time and burn holes were noted to his sleeves and the front of his jacket. Interview on 03/06/20 at 5:57 PM with Resident #1 revealed his fingers were numb and he could not feel his fingers due to the burns. Resident #1 stated he knew his fingers would get burnt from smoking cigarette butts. He stated [MEDICAL CONDITION] ever been treated. He stated he had [MEDICAL CONDITION] months and continued to burn himself every time he smoked. He stated staff knew about [MEDICAL CONDITION] never intervened when he smoked cigarettes to the butt. Resident #1 stated staff did not always supervise him while smoking. Resident #1 stated staff walked away when they saw him smoking by himself. Resident #1 stated he currently had a cigarette and lighter on his person. Resident #1 stated he received a cigarette from his roommate. He stated staff knew he had a cigarette and a lighter. Resident #1 stated the holes in his jacket were [MEDICAL CONDITION] staff had never assessed his clothes [MEDICAL CONDITION] smoking. Resident #1 stated the facility has not provided treatment. Observation and Interview on 3/07/20 at 4:14PM revealed Resident #1 had [MEDICAL CONDITION] his shirt. He stated he does not wear an apron during smoking break. Resident stated he does not have any new burns. Observation and Interview on 3/06/20 6:55PM with DON revealed she did not know if Resident #1 smoked unsupervised. She stated Resident #1 should not have cigarettes or lighters in his room. She stated, I cannot tell you if he has cigarettes or lighters in his room. She stated Resident #1 did not have any skin issues. She stated he likes to pick in the ash tray with his thumb and index finger. The DON assessed Resident #1's hands. She squeezed on the resident's index finger and he said it hurt. The DON grabbed a wipe and cleaned residents fingers and stated he [MEDICAL CONDITION] his fingers. She stated this is the first time she has seen them and told resident wound care will l see him. She informed Resident #1 there were calluses under his burn and he will get medication to treat burns. The DON stated she will put in orders for wound care and pain medication for Resident #1. She stated skin assessments were completed weekly and is completing a skin assessment for Resident #1 now. She stated residents were not checked [MEDICAL CONDITION] they smoke. Interview on 3/05/20 at 7:57 PM with LVN A revealed residents need to be supervised during smoking and wear an apron so they do not burn themselves. She stated Resident #1 was non-complaint. She stated Resident #1 had not burned his fingers since 2019 and a skin assessment was completed for the burns. She stated the resident did not have any recent burns. Interview on 3/05/20 at 8:15PM with LVN B revealed independent and supervised smokers were not allowed to keep cigarettes and lighters in their room. LVN B stated Resident #1 burned his fingers months ago. She stated skin assessments are completed daily during the 6:00AM to 2:00PM shift. She stated she had never completed a skin assessment for Resident #1 because she works 2:00PM to 10:00PM. She stated supervised residents need to be monitored to prevent injury, fire, and some residents have dementia. She stated when a resident burned themselves the physician, ADM, ADON, DON were notified and a skin assessment was completed. She stated skin assessments were completed weekly . Interview on 3/05/20 at 8:46PM with the ADON revealed independent and dependent smokers were not allowed to keep their cigarettes or lighters in their possession. She stated supervised smokers were monitored and wore aprons for safety because residents could get burns. The ADON stated there had not been any residents including Resident #1 who had recently burned themselves while smoking. She stated skin assessments were completed any time there was a skin issue. Interview on 03/06/20 at 9:33 AM with the SW revealed she completed residents' smoking assessments with assistance of the nurses. She stated the smoking assessments were completed quarterly and determined the resident's safety during smoking. She stated there were three types of smokers: independent, modified independent, and supervised. She stated independent smokers were not allowed to keep their cigarettes or lighters in their possession unless the resident signed out of the facility on pass. She stated modified independent smokers were residents that the IDT team thought might be unsafe smoking alone due to level of orientation, mental health, and psych meds. She stated only supervised residents were required to wear an apron. The SW stated Resident #1 was supervised while smoking and [MEDICAL CONDITION] his hands prior to being admitted to the facility. There was no evidence suggesting Resident #1 arrived at facility [MEDICAL CONDITION] his fingers. She stated Resident #1 does not need to wear an apron while smoking. She stated there had been no residents recently who had burn due to cigarettes. She stated residents to not have any cigarettes or lighters. She stated she confiscates cigarettes and lighters from residents. Interview on 3/06/20 at 10:30AM with the DON revealed there were independent, modified independent, and supervised smokers. She stated no residents were allowed to keep their cigarettes or lighters. She stated there is a resident smoking list located in the smoke box kept at the nurse's station and reception area. She stated the SW completed and nursing assisted with the smoking assessments. She stated the smoking assessments were completed quarterly or when there were changes with the residents; the IDT team would discuss. She stated modified independent smokers were to be supervised and do not have to wear aprons. She stated supervised smokers have to be monitored and sometimes have to wear an apron based on disability and mental health. She stated if a modified [MEDICAL CONDITION] then there has to be re-evaluated by a smoking assessment, a skin assessment is completed, and physician is notified. She stated the smoking assessment would be updated and the resident would be recommended to wear an apron. She stated if a [MEDICAL CONDITION] hands all you can do is educate them and consult the wound doctor. The DON stated there has not been any resident with burns. She stated an in-service was completed and staff was informed to supervise residents while smoking. She stated residents were aware of the smoking policy because it is signed at admission . The DON stated she was not aware of Resident #1 burning himself in January 2020. Observation and Interview on 3/08/20 at 1:22PM Resident #1 was observed during a supervised smoke break using a cigarette holder. He was not wearing an apron and there was ash on his pants. Resident #1 stated he was not provided an apron to wear while smoking. Interview on 03/06/20 at 11:07AM with ADM revealed there were independent, modified independent, and supervised smokers at the facility. She stated residents were not allowed to have cigarettes or lighters and are kept in the smoke box at the nurse's station. She stated CNAs are informed of the different types of smokers by referring to the smoking list and asking department heads. She stated independent smokers can sign out to smoke outside of the facility but have to turn in their cigarettes and lighters when they return. She stated modified independent smokers can only smoke in the patio area, do not have to wear aprons, and have to be supervised. She stated supervised smokers have to wear aprons and were supervised. The ADM stated she had not been made aware of any recent incidents of residents burning themselves while smoking. She stated if a resident who was a modified independent smoker burned themselves then they were changed to supervised smoking. She stated I have tried to put aprons on residents but they cuss and say no . She stated Resident #1 was not offered an apron. She stated smoking assessments were completed quarterly. She stated the importance of a smoking assessment was to make sure residents were safe smoking, could complete all the task associated with smoking, and aprons were worn to keep residents from burning themselves. She stated residents were supervised while smoking and monitored after to see if anything else was going on. She stated residents signed the smoking policy when completing the admission paperwork. She stated the DON completed a smoking in-service with staff. She stated staff were informed to be more aware of residents on the patio smoking. She stated she did not know residents had cigarettes and lighters in their possession. She stated Over half the census are smokers, residents are informed of smoking rules, and I don't have time to search everyone's room for cigarettes or lighters. Interview on 3/9/20 at 6:43PM with LVN A revealed she wrote a note on 1/04/20 and completed a skin assessment on 1/4/20 regarding [MEDICAL CONDITION] Resident #1's fingers. She stated [MEDICAL CONDITION] his fingers were scabbed over and light brown. She stated the resident informed her [MEDICAL CONDITION] from smoking. She informed Resident #1 not to burn himself again. LVN A stated she informed the SW and ADON about [MEDICAL CONDITION] fingers. She stated she told the SW because she completed the smoking assessments. LVN A stated she did not order wound care because there was nothing to treat. Record review of Resident #1's smoking safety assessment dated [DATE] revealed he has to be supervised during smoke breaks and wear smoking gloves or use a cigarette holder to prevent further injury. Record review of Resident #1's skin assessment dated [DATE] revealed he has dark callus to right first finger, right second finger, and left first finger. He has discomfort to right second finger with pain 3/10. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's wound care evaluation dated 3/09/20 revealed he has wounds on right first finger, right second finger, and left first finger. There is thick black necrotic tissue on all wounds and Resident #1 refused debridement. The wounds dressing treatment plan is skin prep applied once daily for 30 days. Observation and Interview on 3/09/20 at 7:52PM revealed Resident #1 had [MEDICAL CONDITION] pants. He stated he did not wear an apron today during the smoke breaks. He stated he has no new burns. Review of the facility's Smoking Policy dated 7/01/18 revealed the nursing staff will evaluate residents to determine their individual ability to smoke safely. The facility has designated smoking times and staff will be available to distribute smoking materials and supervise the residents if indicated by their smoking assessment. Residents are prohibited from keeping smoking paraphernalia in their possession. The residents are to keep cigarettes and lighters in smoke box kept at the nurse's station. There is a list of smokers that have been evaluated in the smoke box. Assist all residents to the designated smoking area. Smoking material will not be distributed to the resident until they are in the designated smoking area. Smoking aprons and other assistant devices used for safety are to be placed in the designated smoking boxes.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for two residents (Resident #1 and Resident #2) of 10 residents reviewed for elopements. 1. The facility failed to ensure the maglocks (electromagnetic locks) on the exterior doors located on Halls 100, 200, 300, and 400 where secured, locked, and functioning properly. 2. The facility failed to adequately supervise residents while the maglocks on their doors were not functioning properly. Resident #1 eloped from the exterior door located on Hall 200 on 11/21/18 at 5:15 a.m. (while 15-minute check monitoring was in progress) and was found in the parking lot on the ground. Resident #2 eloped from the exterior door located on Hall 100 on 11/21/18 at approximately 10:45 a.m. (while 15-minute check monitoring was in progress) and was also found in the parking lot lying on the ground. An Immediate Jeopardy (IJ) was identified to have occurred on 11/20/18 to 11/21/18. This was determined to be a Past Immediate Jeopardy due to the facility having implemented action that lowered the immediacy to potential for harm at a pattern of isolated prior to the investigation. These failures could affect residents by having the potential to result in serious bodily harm, [MEDICATION NAME] physical impairment, or death. Findings included: Resident #1's MDS assessment, dated 10/02/18, revealed the resident was a [AGE] year-old male re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He had moderate cognitive impairment and wandering behaviors. Resident #1's Care Plan revealed he was at risk for elopement, wandering, and had a history of [REDACTED]. Facility interventions included: determine patterns of wandering, ensure doors were secured, and the resident's name would be included in the elopement book located at the nursing station. Resident #1's Wandering Risk Assessment, dated 03/20/18, revealed the resident was at risk for elopement. Resident #1's Incident Report dated 11/21/18 revealed the following information: 5:15 AM - The nurse was informed that a resident was on the ground outside the building. Resident #1 was found lying on his left side on the ground in the parking lot. The resident was assessed and had pain in his left hip and leg. The resident said he was going to his mom/sister's house in (local city) when he fell . The resident was placed on 15-minute checks and the physician ordered a stat urine analysis, stat X-ray, PRN Tylenol, and neurological checks. Resident #1's X-ray of left hip and leg showed no acute abnormalities. Resident #1's Behavior Observation Log, dated 11/21/18, revealed 15-minute checks were documented for the resident starting at 6:00 AM and ending on 11/22/18 at 5:45 AM. Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. An interview with Resident #1 on 11/30/18 at 9:09 AM revealed he was confused. He thought he had been staying at the facility since 1951, and he did not recall leaving the facility without telling staff. He stated if he wanted to leave the facility, he talked to the receptionist at the front desk. 2. Resident #2's MDS assessment, dated 09/14/18, revealed the resident was a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. The resident had a memory problem with severely impaired daily decision making. Wandering behaviors were noted. Resident #2's Care Plan, dated 08/09/17, and revised on 12/04/18 revealed the resident was at risk for elopement and wandering. The resident had a history of [REDACTED]. Facility interventions included: Wanderguard bracelet, disguise exits, cover door knobs, and distract resident from wandering. Resident #2's incident report dated 11/21/18 reflected: Resident #2 was found on the ground, outside of the facility, lying on his left side. Resident #2 said, I was walking, and my leg gave up. It could not carry me. No injuries were noted, and an x-ray of the hip was ordered. Resident #2's (MONTH) (YEAR) physician's orders [REDACTED]. Resident #2 X-ray of the left hip, dated 11/21/18, revealed no acute abnormalities. An interview with Resident #2 on 11/30/18 at 9:19 AM revealed he had lived at the facility for about 3 years. He stated he had never left the facility and did not have to sign out whenever he wanted to leave the facility. An observation on 11/30/18 at 5:09 p.m. of Resident #2 revealed he was wearing a Wanderguard bracelet on his left ankle. Observation on 12/04/18 at approximately 8:50 a.m. of the facility parking lot revealed it spanned the front of the building and down one side. There was one exit that was alarmed by the wanderguard system and four exit doors that had a maglock system. Depending upon the route of exit, egress from the facility could lead an individual to the service road of a major highway. Observations on 11/30/18 at 10:09 AM, 10:13 AM, 10:15 AM, and 10:18 AM with the Maintenance Director revealed the exterior door on hallway 200 would not lock after he entered the door code. He stated the door was supposed to lock after entering the code into the keypad. He stated that the door had not been working properly for about two weeks. The exterior door on Hallway 100 would not allow him to enter the code to lock the door. He pushed on the door, it unlocked but the alarm did not sound. He stated when he entered the code into the keypad it was supposed to lock the door. The exterior door located on Hallway 300 would not unlock and the alarm would not sound when he pushed on the door for 15 seconds. He entered the code into the keypad and the door unlocked but did not sound. The exterior door located on Hallway 400 would not unlock after pushing on the door for 15 seconds. He placed the code into the keypad, the door opened, and the alarm sounded. Interviews with the DON on 11/30/18 at 12:02 PM and 12/05/18 at 1:17 p.m. revealed that she heard an explosion, the lights went out at the facility, and she believed lighting struck the building on 11/20/18 at 2:20 p.m. She called the Maintenance Director at 2:22 p.m. on 11/20/18 to inform him the facility lost power, and the power came back on. Resident #1 and Resident #2 eloped from the facility on 11/21/18. Resident #1's elopement occurred on the night shift on 11/21/18 and she was notified by LVN A. LVN A informed her that Resident #1 had eloped through an exterior door and the DON called the Maintenance Director at approximately 5:42 a.m. to inform him the doors were not locking. The DON said she also notified the Administrator. Resident #1 was out the facility for about 15 minutes and was found on the ground outside. The DON stated it was the first time Resident #1 had tried to leave the facility and the resident was placed on 15-minute checks immediately after the incident. The DON stated Resident #2 eloped from the facility on 11/21/18 through an exterior door also but could not remember which hallway. The DON was informed by one of the staff members that Resident #2 was outside and staff brought the resident back inside the facility. The DON stated that Resident #2 did not have any injuries from the fall. Resident #2 used a Wanderguard due to elopement risk. The DON stated after 11/21/18, Resident #2 had no further elopements. The DON stated that Resident #2's family, the Administrator, and physicians were notified of the incident and the facility was using a monitoring system of 15-minute checks. Staff were supposed to make sure that every resident was accounted for and watch to ensure no residents tried to walk out the door. She stated that the staff, including LVNs and CNAs, were supposed to sign the monitoring book. The DON stated that the facility was aware the maglocks were not working prior to Resident #2's elopement incident on 11/21/18 and the 15 minutes checks were already in place. The DON stated that the facility did not have any additional elopements after 11/21/18. Interviews with the Maintenance Director on 11/30/18 at 10:00 AM, 11/30/18 at 4:12 p.m., and 12/05/18 at 12:54 p.m. revealed that on 11/20/18, the DON called him and told him the facility was struck by lightning. He stated that he was off that day and was sick. He stated the next morning on 11/21/18, he arrived at the facility at 7:30 a.m. to check and see what damages the storm caused. He stated the storm had fried everything. The fire panel was not working, and the exterior doors were not locking. Exterior doors located on hallways 100, 200, 300, 400 were supposed to open after 15 seconds, and an alarm should sound. The exterior door on hallway 200 was malfunctioning. He informed the administrator on 11/21/18 around 9:00 a.m. about the issues. The contractor repaired the fire panel and maglocks and he completed a check of all the systems. The fire panel and doors were locking/working properly on 11/21/18 at 3:00 p.m. On 11/22/18 during the morning checks of the facility doors and fire panel, he observed the maglocks were not working at 8:30 a.m. He immediately contacted the contractor to come out to the facility to fix the maglocks again. He stated that the facility staff were instructed by the Administrator to complete 15-minute checks to make sure the residents were accounted for at that time. Review of a Facility In-service dated 11/21/18 to 11/23/18 regarding elopement revealed that staff were supposed to promptly report any residents who tried to leave the facility without staff or family. Staff were supposed to insist the resident return to the facility and notify the nurse, DON, and Administrator. The resident would be assessed, and the family, responsible party, and the physician would be notified. Facility staff had to closely monitor residents for risk of elopement. A red elopement book was located at the front desk or nurse's station. The in-service did not contain information regarding 15-minute checks. Interview with LVN D on 11/30/18 at 2:10 p.m. revealed on 11/21/18 Resident #2 exited out of an exterior door located on hallway 100 during the time when the doors were not locking. LVN D stated Resident #2's elopement occurred around 10:45 a.m. and she was informed by CNA B that the resident was found outside on the ground in the facility parking lot. LVN D stated when she went outside to assess Resident #2, he stated to her that he wanted to go to work downtown. LVN D stated that Resident #2 did not sustain any injuries and was assisted back inside the facility. LVN D notified the DON, Resident #2's family member, and physician of the elopement. LVN D stated that Resident #2's physicians ordered an x-ray of the left hip and there were no fractures or broken bones noted. LVN D stated that Resident #2 had a Wanderguard bracelet. LVN D stated that she was not working during the time that Resident #1 eloped from the facility, but at that time the alarm and computer system were down and the doors were not locking due to a recent storm. During the time the system was down, staff were informed to monitor the exteriors doors located on Halls 100, 200, 300, 400 every 15 minutes, and to complete a head count of the residents. LVD D stated the facility was already monitoring the exteriors doors every 15 minutes prior to Resident #1's elopement. Interview with the Social Worker on 11/30/18 at 11:07 AM revealed Resident #1 and Resident #2 eloped from the facility on 11/21/18. The facility was informed of Resident #2's elopement by another resident that lived in the facility. Resident #2's elopement occurred around 10:45 AM and the resident was out the facility for about five minutes. The Social Worker said Resident #2 eloped out of an exterior door located on hallway 300. Interview with CNA B on 11/30/18 at 1:24 PM revealed Resident #2 exited the facility through the exterior door located on 100 hallway. She stated that Resident #3 alerted the staff that Resident #2 was on the ground outside the facility. CNA B stated Resident #2 was assisted back into his wheelchair and brought back into the facility. Resident #2 informed staff that he was going to work. CNA B stated that this was the first time Resident #2 had eloped from the facility. CNA B stated she had been instructed to check the exterior doors every 15 minutes, and to document the 15-minute checks in a red book located at the nurse's station. Interview with CNA C on 11/30/18 at 1:50 p.m. revealed Resident #2 eloped from the facility and staff were informed by Resident #3 that Resident #2 was outside. CNA C stated that Resident #2 informed the staff while they were assisting him back into the facility that he had to go to work. CNA C stated that LVN D came outside to assess Resident #2 for injuries. CNA C said the facility had issues with the exterior doors not working properly for almost two weeks. CNA C stated that she had been informed to check the exterior doors every 15 minutes and document the information inside the red book located at the nurse's station. CNA C stated she also performed a head count of all the residents that she was assigned to work with that day. Interview with the Administrator on 12/04/18 at 1:00 p.m. revealed that the facility had a power outage around Thanksgiving and the exterior doors were still not working properly. She had instructed the ADON to initiate 15-minute monitoring checks of the doors and residents after the power outage and the Maintenance Director had been in contact with the contractor to get the doors fixed multiple times. The Administrator stated she was told that Resident #2 did not leave the facility. Interview with CNA B on 12/05/18 at 8:41 a.m. revealed staff were supposed to complete 15-minute checks by going down each hallway, completing a head count, and checking the doors located on the hallway. On the day of the elopement, Resident #2 eloped from the facility through an exterior door located on 100 hallway. CNA B stated the facility provided the staff with an in-service regarding missing residents after the elopement. Interview with Medication Aide on 12/05/18 at 9:06 a.m. revealed on 11/21/18 Resident #2 eloped from the facility. She heard Resident #3 yelling and pointing that Resident #2 was outside the building. She stated that she, CNA B, and CNA C rushed outside to assess the resident. She stated Resident #2's elopement occurred after the facility had a storm on Saturday that caused the exits doors to malfunction. She stated that she had been provided in-service training regarding elopement. Interview with LVN D on 12/05/18 at 9:26 a.m. revealed she was working the day Resident #2 eloped. LVN D stated that she had received in-service training regarding policy and procedures for missing residents after the incident. LVN D stated if there was a missing resident, staff were informed to alert everybody in the building, check each resident room, conduct a head count, and check all the doors, and surrounding areas of the building to search for the resident. Interview with LVN G on 12/05/18 at 10:58 a.m. revealed that Resident #1 was found in the facility parking lot on 11/21/18, and he informed her that he was going to the city to work. LVN G did not know what intervention were in place to prevent elopement prior to Resident #1's elopement. Interview with CNA E on 11/30/18 at 4:40 p.m., revealed that CNAs and nurses were responsible for completing the documentation for 15-minute checks by initialing in the 15-minute fire watch book located at the nursing station. CNA E stated that staff were supposed to check the doors to make sure none of the residents had has exited out of the door. Interview with the Corporate Nurse on 11/30/18 at 5:01 p.m. revealed that she had spoken to the contractor regarding coming out to the facility to fix the exteriors doors and was informed by the contactor the company was currently going through audit with the Fire Marshall and the technician could not leave to come fix the doors. She was informed as soon as the audit was completed with the Fire Marshall, the contractor would send a technician out to fix the doors. Review of the undated Maintenance Service policy revealed, The maintenance department is responsible for maintaining the building, grounds and equipment in a safe and operable manner at all times. Maintaining the building in good repair and free from hazards. Establishing priorities in providing repair service. Review of the undated Maintenance schedule policy revealed, The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. It was determined that the above failures put Resident #1 and Resident #2 in an IJ from 11/20/18 to 11/21/18. An IJ was identified at past non-compliance and the Vice President was notified of this on 12/05/18 at 2:58 p.m. The facility took the following actions to correct the deficient practice prior to the investigation: 4. Review of invoice dated 12/04/18, revealed on 11/21/18 the fire alarm control panel was installed. Review of invoice dated 11/29/18 revealed on 11/19/18, keypads in the 100, 200, and 300 halls needed to be replaced. Technicians picked 3 keypads up from supplier and arrived on-site to remove old keypads, installed new keypads and programmed them. Review of Timeline for getting doors repaired provided by Maintenance Director revealed the following: 11/20/18 at 10:28 a.m. Maintenance Director contacted contractor to check on the status of replacement of the fire panel. 11/23/18 at 9:58 a.m. Maintenance Director contacted contractor to check on the status of door locks five times and was informed they were only two techs, would get someone scheduled when they could. 11/28/18 at 10:06 a.m. Maintenance Director contacted another contractor and inquired on whether or not they could send a tech to troubleshoot doors; was told they could schedule someone but would be a few days. 11/30/18 at 8:52 a.m. Maintenance Director contacted another contractor trying to get a tech to come out and attempted another six times to get a technician out but was told there were only two available and scheduling would be done when they were able. 11/30/18 at 4:34 p.m., facility Vice President contacted the contractor and was informed that the contactor would be replacing the maglock system on Wednesday, 12/05/18. Review of elopement risk assessment dated [DATE], revealed Resident #1 was assessed for elopement, indicated he was moderate risk for wandering with wandering score of 6. Review of elopement risk assessment dated [DATE], revealed Resident #2 was assessed for elopement, and indicated he was moderate risk for wandering with score of 6.