Every finding on record at The Heights at Medical Center

Based on observation and interview, the facility failed to provide a comfortable, and homelike environment including a window that would open to allow fresh air in for 1 (Resident #54) of 1 observed for comfortable and homelike environment. The facility failed to ensure Resident #54's room window was not screwed shut and would be able to open when resident desired fresh air. This failure could place the residents at risk of feeling uncomfortable and could diminish quality of life. The findings were: Record review of Resident #54's face sheet, dated 08/15/2025, revealed he was admitted to the facility on [DATE] with diagnoses which included: acute respiratory failure, unspecified whether hypoxia or hypercapnia (a condition where the lungs are unable to adequately oxygenate the blood or remove carbon dioxide, and the specific cause (either low oxygen or high carbon dioxide) is not identified), sleep apnea (a common disorder where breathing repeatedly stops and starts during sleep), and chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe). Record review of Resident #54's Optional State MDS assessment, dated 07/22/2025, revealed the resident's BIMS score was 15, which indicated resident's cognition to be intact. Record review of the last 6 months grievances and resident council minutes revealed no concerns noted regarding windows or windows being screwed shut. During resident group interview on 08/14/2025 at 11:00 a.m. Resident #54 stated his room window was screwed shut and wondered if he could have it opened so he could open it when he wanted fresh air. Resident #54 further stated he did sign out every day usually due to his being a photographer but would like to be able to open his window sometimes. Observation on 08/14/2025 at 11:21 a.m. LSC observed a screw to Resident #54's window while rounding after being informed of what Resident #54 had said during resident group. During an interview on 08/14/2025 at 12:33 p.m. the Maintenance Supervisor stated the facility at one time had a couple residents who were trying to go out the windows and screws were put in the windows. The Maintenance Supervisor further stated he now had the locks to be able to minimize how much the windows would be able to be opened if needed. During an observation and interview on 08/15/2025 at 11:23 a.m. Resident #54's room window revealed a hole and metal shavings in the area where a screw had been. Resident #54 stated he had not asked anyone about the screws in the window nor to have them removed from the window so he could open it. Resident #54 further stated he really did not give it much thought because he was near and emergency exit. Resident #54 stated even though he did not ask about why the window had been screwed shut, it did bother him that he was not able to open the window. During an interview on 08/15/2025 at 11:53 a.m. LVN A stated Resident #54 would communicate with staff anytime he had a concern however, Resident #54 had never mentioned his window was screwed shut. LVN A further stated he was not aware there had been a screw in Resident #54's room window. LVN A stated if Resident #54 had voiced a concern regarding the window he would have put information regarding the concern in the portal for maintenance to address. LVN A stated he was not aware of anyone with screws in windows and had not had anyone complain about windows being screwed shut. During an interview on 08/15/2025 at 1:18 p.m. the DNS stated Resident #54 had never voiced to her a concern regarding his window being screwed closed. The DNS stated she was aware the windows had been screwed closed for patient safety, but they were supposed to be able to open a small amount. The DNS stated the windows should not have been screwed totally shut. The DNS stated she did not feel it would affect Resident #54 in the event of an emergency as he would be dependent on staff to assist him out due to his being a Hoyer transfer and reliant on staff for transfers. The DNS further stated it would only affect his ability to open the window if he wanted fresh air. During an interview on 08/15/2025 at 1:57 p.m. the Administrator stated he was aware that windows were prevented from opening fully but not that some could not open at all. The Administrator further stated the company policy was that the windows were to only be able to open partially for the safety of the resident to keep people from being able to get in through the windows. The Administrator stated Resident #54 never came to him to tell him the window would not open. The Administrator stated Resident #54 should have been able to open his window to get fresh air. During an interview at 08/15/2025 at 3:07 PM Administrator stated the facility did not have a written policy regarding windows. Record review of facility's resident rights Statement of Resident Rights (26 Tex. Admin. Code 554.401), no date, read You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Record review of facility's rights of the elderly Rights of the Elderly, no date, read An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.

Based on observation, interviews, and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for two residents (Resident #2 and Resident #76) of twenty-one residents reviewed for MDS assessments. 1.The facility failed to ensure Resident #2's annual MDS, dated [DATE], indicated the resident was receiving the services of the state level II PASRR due to his intellectual disability. 2. The facility failed to ensure Resident #76's quarterly MDS, dated [DATE], indicted the resident used a CPAP (Continuous Positive Airway Pressure) at hours of sleep due to his sleep apnea. These deficient practice could affect residents who receive care and could result in missed or inappropriate care.The findings included: 1. Record review of Resident #2's face sheet, dated 08/15/2025, revealed the resident was [AGE] years old male, originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnosis of intellectual disability (disability that affects the acquisition of knowledge and skills), and seizures (sudden burst of electrical activity in the brain). Record review of Resident #2's annual MDS assessment, dated 01/07/2025, revealed the resident's BIMS was 8 out of 15, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Record review of Resident #2's comprehensive care plan, dated 09/26/2024, revealed [Resident #2] is considered PASRR positive due to intellectual disability. For intervention, coordinate services and plan of care with the local mental health authority and provide PASRR services. Record review of Resident #2's Local Intellectual and Developmental Disabilities Authorities' Habilitation Service Plan, dated 12/01/2024, revealed Resident #2 was receiving PASRR level II services per the plan because the resident was PASRR level II positive due to his intellectual disability. During an interview on 08/15/2025 at 10:45 a.m. with the Director of Clinical Reimbursement stated she had a responsibility to oversee the facility's MDS assessments, and Resident #2's annual MDS assessment dated 01/07/ was inaccurate, and it should have been coded Yes because Resident #2 was PASRR II positive resident due to his intellectual disability. The Director of Clinical Reimbursement said it was a mistake and did not affect Resident #2 because the resident was anyway receiving PASRR services, but MDS assessment should be accurate. 2. Record review of Resident #76's face sheet, dated 08/15/2025, revealed the resident was [AGE] years old male, originally admitted on [DATE], and re-admitted on [DATE] to the facility with diagnosis of sleep apnea (breathing stops and restarts many times while sleeping). Record review of Resident #76's quarterly MDS assessment, dated 05/22/2025, revealed the resident's BIMS was 10 out of 15 indicated the resident had moderate cognitive impairment. Further record review of the MDS assessment revealed the resident did not have Non-invasive Mechanical Ventilator use. Record review of Resident #76's comprehensive care plan, dated 06/10/2025, revealed the resident had the care plan of [Resident #76] am at risk for experience shortness of breath related to sleep apnea. For intervention - Administer CPAP (Continuous Positive Airway Pressure) for sleep apnea as ordered. Record review of Resident #76's physician order, dated 06/27/2025, revealed the resident had the order of Apply CPAP (Continuous Positive Airway Pressure) at bedtime at 10:00 p.m. and remove at 6:00 a.m. for Sleep Apnea. Observation and interview on 08/12/2025 at 10:44 am revealed there was Resident #76's CPAP (Continuous Positive Airway Pressure) on the nightstand covered with a plastic bag, and the resident said he put on his CPAP every 10:00 p.m. During an interview on 08/15/2025 at 12:48 p.m. with the Director of Clinical Reimbursement stated she had a responsibility to oversee the facility's MDS assessments, and Resident #76's quarterly MDS assessment dated [DATE]'s coding regarding CPAP (Continuous Positive Airway Pressure) was inaccurate, and it should have been coded Yes because Resident #76 was wearing CPAP (Continuous Positive Airway Pressure) every night due to his sleep apnea. The Director of Clinical Reimbursement said it was a mistake and did not affect Resident #76 because the resident was anyway receiving care, but MDS assessment should be accurate. Further interview with the Director of Clinical Reimbursement said they did not have specific policy regarding MDS accurate, and they followed CMS's RAI Manual. Record review of CMS's RAI version 3.0 Manual, dated 10/2024, revealed Code - yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or intellectual disability or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions and For Non-invasive Mechanical Ventilator, code any type of CPAP (Continuous Positive Airway Pressure) and BiPAP (bi-level positive airway pressure) respiratory support devices that prevent airway from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #51 and #60) of 4 residents reviewed for incontinence care. 1. When CNA-B was providing peri care to Resident #51, CNA-B cleaned the resident's genital area without separating the labia. 2. When CNA-C was providing peri care with urinary indwelling catheter to Resident #60, CNA-C did not clean entire scrotum. These failures could place residents who required incontinence care at risk for cross contamination and the development of urinary tract infections. The findings included: 1. Record review of Resident #51's face sheet, dated 08/15/2025, revealed the resident was [AGE] years old female, originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnosis of overactive bladder. Record review of Resident #51's quarterly MDS assessment, dated 05/13/2025, revealed the resident's BIMS score was 5 out of 15 indicating the resident had severe cognitive impairment and was always incontinent of bladder and bowel. Record review of Resident #51's comprehensive care plan, dated 09/18/2024, revealed the resident has incontinence related to overactive bladder. For intervention - incontinent care assistance every shift and as needed and check and change on rounds and as needed. Observation on 08/14/2025 at 2:38 p.m. revealed CNA-B removed Resident #51's dirty brief, and CNA-B started cleaning the resident's suprapubic area, left groin, and right groin. When CNA-B cleaned the middle area of Resident #51's genitals, CNA-B did not separate the resident's labia. CNA-B cleaned the middle area of the resident's genitals without separating the labia, then rolled the resident to her left side and cleaned the resident's buttock area. During an interview on 08/14/2025 at 2:56 p.m. CNA-B stated when she cleaned the middle area of Resident #51's genitals, she did not separate the resident's labia, and she said she should have separated the resident's labia area when cleaning to prevent infection. CNA-B said she got checked-off regarding female peri care every year. During an interview on 08/14/2025 at 4:16 p.m. DNS stated the facility did not have a specific policy regarding peri care. The DNS said they used a skill check-off sheet for female peri care without catheter, and the sheet did not indicate separating female labia area when providing peri care, but the facility was following general professional guidelines. DNS said improper incontinence care might cause infection. Record review of professional guidelines (National Library of Medicine - Chapter 5: Provide for Personal Care Needs of Clients - Nursing Assistant - NCBI Bookshelf), titled Provide for Personal Care Needs of Client - perineal care for female, undated, revealed Expose their perineum only, Separate the labia, Use water and a soapy washcloth, Clean one side of the labia from top to bottom, and Using a clean portion of the first washcloth, clean the other side of the labia from top to bottom. 2. Record review of Resident #60's face sheet, dated 08/15/2025, revealed the resident was [AGE] years old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnosis of dementia (loss of memory and thinking ability). Record review of Resident #60's Medicare five days MDS assessment, dated 07/28/2025, revealed the resident's BIMS was 0 out of 15 which indicated the resident had severe cognitive impairment, had urinary indwelling catheter, and was always incontinence to bowel. Record review of Resident #60's comprehensive care plan, dated 04/03/2025, revealed the care plan had the care of the resident has urinary indwelling catheter and incontinence of bowel. For intervention - incontinent and urinary indwelling catheter care assistance every shift and as needed and check and change on rounds and as needed. Observation on 08/14/2025 at 2:04 p.m. revealed CNA-C removed dirty brief from Resident #60, cleaned the urinary indwelling catheter and only penis with circular motions, cleaned right and left groin areas, and turned the resident to right side without cleaning Resident #60's scrotum, especially middle of scrotum. CNA-C cleaned Resident #60's buttock areas and put new and clean brief under the resident after sanitizing his hands. During an interview on 08/14/2025 at 2:29 p.m. with CNA-C stated when he cleaned Resident #60's left and right groin area, he cleaned left and right side of Resident #60's scrotum. However, he said he did not clean middle area of Resident #60's scrotum. CNA-C said he should have cleaned Resident #60's entire scrotum area to prevent possible infection. Further interview with CNA-C said he received skill check for peri care of male resident on 08/2025. During an interview on 08/14/2025 at 4:16 p.m. DNS stated the facility did not have a specific policy regarding peri care. The DNS said they used a skill check-off sheet for male peri care with catheter, and the sheet did not indicate cleaning male scrotum area when providing peri care, but the facility was following general professional guidelines. DNS said improper incontinence care might cause infection. Record review of professional guidelines (National Library of Medicine - Chapter 5: Provide for Personal Care Needs of Clients - Nursing Assistant - NCBI Bookshelf), titled Provide for Personal Care Needs of Client - perineal care for male, undated, revealed Using a clean portion of the first washcloth, start from the urethra and clean in a circular motion toward their scrotum. Using a clean portion of the first washcloth, clean one groin fold and the scrotum. Using a clean portion of the first washcloth, clean the other groin fold and the other side of scrotum. Put the first washcloth in a linen bag. Using the second clean washcloth, rinse from the urethra in a circular motion toward the scrotum. Using a clean portion of the second washcloth, rinse one groin fold and the scrotum. Using a clean portion of the second washcloth, rinse the other groin fold and the other side of the scrotum.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Residents #36) of 1 Resident whose records were reviewed for oxygen use. The facility failed to ensure Resident #36's oxygen tubing was changed every week, and oxygen filter was checked and cleaned every week per the physician order. This deficient practice could affect any respiratory on oxygen therapy and could contribute to respiratory distress, infections, pneumonia and an overall decline in their physical condition.The findings included: Record review of Resident #36's face sheet, dated 08/15/2025, revealed the resident was [AGE] years old female, originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses of shortness of breath, and hypertension (high blood pressure). Record review of Resident #36's quarterly MDS assessment, dated 08/06/2025, revealed the resident's BIMS was 9 out of 15, which indicated the resident had moderate cognitive impairment, the resident was dependent (Helper does ALL of the effort) to activities of daily living, such as sit to stand and chair to bed transfer, and was receiving oxygen therapy. Record review of Resident #36's comprehensive care plan, dated 12/10/2024, revealed the resident had the care of oxygen therapy related to chronic lung disease. For intervention - provide oxygen as ordered and monitor for signs and symptoms of respiratory distress and report to medical doctor as needed. Record review of Resident #36's physician orders, dated 04/17/2025, revealed Change nasal cannula/mask and oxygen tubing every Sunday and as needed and Oxygen Filter; Check, Clean and/or replace filter every Week every night shift every Sunday - started 07/30/2025. Observation on 08/12/2025 at 10:38 a.m. revealed Resident #36 was on the bed in her room with oxygen via nasal cannular. The oxygen tubing was dated on 08/03/2025. Further observation revealed the oxygen concentrator had oxygen filter, and the oxygen filter was dirty with gray colored dust. During an interview on 08/12/2025 at 11:27 a.m. with LVN-A stated Resident #36 had oxygen via nasal cannular. She stated Resident #36's oxygen tubing was dated 08/03/2025, and oxygen filter was dirty with gray colored dust. Further interview with LVN-A said night nurse should have been changed Resident #36's oxygen tubing on 08/10/2025 (Sunday) and cleaned or replaced the oxygen filter on 08/10/2025 (Sunday) as ordered. It might cause possible respiratory infection. During an interview on 08/15/2025 at 1:18 p.m. with DNS stated Resident #36 had oxygen via nasal cannular and night nurse should have been changed Resident #36's oxygen tubing on 08/10/2025 (Sunday) and cleaned or replaced the oxygen filter on 08/10/2025 (Sunday) as ordered. It might cause possible respiratory infection. Record review of the facility policy, titled Oxygen - Respiratory Tubing/Equipment Management, dated 03/12/2018, revealed 1. Change tubing weekly . 6. Air filter should be changed and/or cleaned at least monthly and as needed.

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 observed for food service.Cook failed to wear beard restraints while working in the kitchen.Dietary Aide did not properly wear hair restraints in a way that covered all their hair. This failure could place residents who receive food prepared in the facility's only kitchen by placing them at risk for food-borne illness and food contamination. The findings were: Observation of the facility kitchen on 08/13/2025 at 03:48 PM revealed Cook's beard restraint not covering his facial hair while in the kitchen's food prep area. Observation of the facility's kitchen on 08/14/2025 at 10:40 AM revealed Dietary Aide not wearing hair restraint that covered all his hair while in the kitchen's food prep area.Interview with Dietary Aide on 08/14/2025 at 3:10 PM revealed he had received training from the dietary manager on appropriate hygiene when he started. The Dietary Aide stated hair restraints should cover all hair on top the head. Dietary Aide stated any hair not in the hair restraint could fall into the food and cause foodborne illness in those who ate food from the kitchen. Dietary Aide stated it was his responsibility to ensure his hair was fully in the hair restraint. Interview with [NAME] on 08/14/2025 at 3:12 PM revealed the [NAME] received training from the dietary manager on appropriate hygiene when first hired. The [NAME] stated hair restraints are to cover all hair to prevent hair from falling into food. The [NAME] stated that hair falling into food could cause foodborne illness in the residents. [NAME] stated it was his responsibility to ensure his hair was fully in the hair restraint. Interview with Dietary Manager on 08/14/2025 at 3:15 PM AM revealed staff are trained on appropriate hygiene when they start and all hair, including facial hair, was to be in a hair restraint when in the kitchen. Dietary manager stated hair that was not in a hair restraint could fall into food being prepared causing it to be contaminated. Dietary Manager stated contaminated food could cause foodborne illness in the residents. Dietary manager stated it was her responsibility to ensure staff wore their hair restraints properly. Record review of the facility policy named Employee Sanitation, dated October 1, 2018, revealed 3. Employee Cleanliness Requirements b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 states Except as provided in, (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #60) of 21 residents reviewed for infection control practices. LVN-A was administering medications via Resident #60's gastrostomy tube, LVN-A did not wear a gown while . Resident #60 had EBP (Enhanced Barrier Precautions) status. This deficient practice could place residents at risk for cross contamination and infections.The findings included: Record review of Resident #60's face sheet, dated 08/15/2025, revealed the resident was [AGE] years old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnosis of dementia (loss of memory and thinking ability), acute respiratory failure (usual exchange between oxygen and carbon dioxide in the lungs does not occur), heart failure (the heart cannot pump enough oxygen-rich blood to meet the body's needs), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #60's Medicare five days MDS assessment, dated 07/28/2025, revealed the resident's BIMS was 0 out of 15 which indicated the resident had severe cognitive impairment and had eternal feeding tube. Record review of Resident #60's comprehensive care plan, dated 07/08/2025, revealed the care plan had the care of [Resident #60] require a feeding tube related to dysphagia (difficulty of swallowing) - for intervention, maintain NPO (nothing by mouth) status and provide feeding tube care as ordered and monitor any infection and At risk for infection or recurrent/chronic infection r/t compromised medical condition - for intervention, Enhanced Barrier Precaution practices as clinically indicated. Observation on 08/14/2025 at 8:44 a.m. revealed LVN-A entered to Resident #60's room, sanitized his hands, put on only gloves, and started administering morning medications via Resident #60's gastrostomy feeding tube, and LVN-A completed administering all medications then came out from the resident's room and washed his hands. At 9:00 a.m. further observation revealed there was a big signage posting on the resident's door indicated Wear gown and gloves during high-contact resident care, such as device care or use - central line, urinary catheter, and feeding tube. During an interview on 08/14/2025 at 9:05 a.m. with LVN-A stated he did not wear a gown when administering medications via Resident #60's gastrostomy tube. LVN-A said he forgot wearing a gown and he should have put on a gown because Resident #60 had EBP (Enhanced Barrier Precautions) to prevent possible infection. He stated the signage posting on the resident's door indicated Wear gown and gloves during high-contact resident care, such as device care or use - central line, urinary catheter, and feeding tube. Not wearing a gown might cause possible infection to the resident. During an interview on 08/14/2025 at 4:16 p.m. with DNS stated LVN-A should have put on a gown when he administered medications via feeding tube because Resident #60 had EBP (Enhanced Barrier Precautions) to prevent possible infection Not wearing a gown might cause possible infection to the resident. Record review of the facility policy, titled Infection Prevention and Control, dated 03/13/2019, revealed EBP (Enhanced Barrier Precautions) required the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer pf MDRO (Multidrug-resistant Organism) to staff hands and clothing. High-contact resident acre activities are device care or use: Central line, urinary catheter, feeding tube, and tracheostomy/ventilator.

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 8 residents (Resident #26) reviewed for MDS transmission.The facility failed to transmit a discharge MDS assessment to the CMS system for Resident 26 who discharged on 04/29/2025 within 14 days of the discharge date .This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.Findings were: Record review of Resident #26's face sheet, dated 08/15/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 04/29/2025 to an assisted living facility. Resident #26's face sheet indicated resident had diagnosis of encounter for orthopedic aftercare following surgical amputation, acute hematogenous osteomyelitis, left ankle and foot, and type 2 diabetes mellitus with unspecified complications. Record review of Resident #26's Medicare-5 day MDS revealed it was completed on 04/01/2025. Record review of Resident #26's medical record, progress note, dated 04/29/2026, revealed Resident 26 was discharged home with home health care. Interview with MDS Coordinator on 08/15/2025 at 1:35 PM revealed Resident #26 was discharged on 04/29/2025 and a discharge MDS was not completed. MDS Coordinator stated it was her responsibility to complete discharge MDS when a resident was discharged . MDS Coordinator stated the discharge MDS should be submitted to CMS within 14 days of a resident's discharge. MDS Coordinator stated the facility followed the RAI (Resident Assessment Instrument) to complete resident MDS.Interview with DNS on 08/15/2025 at 1:48 PM revealed MDS Coordinator was responsible for completing a discharge MDS when a resident was discharged . DNS stated the discharge MDS was to be submitted to CMS within 14 days of a resident's discharge. DNS stated there was no impact on a resident if a discharge MDS was not completed. Interview with Administrator 08/15/2025 at 2:01 PM revealed a discharge MDS should have been completed for all discharged residents. Administrator stated he was unsure of the exact timeframe the discharge MDS should have been submitted to CMS for Resident 26. Administrator stated it was the responsibility of the MDS Coordinator to complete the discharge MDS when a resident was discharged . Policy on MDS completion and transmission was requested on 08/15/2025 at 1:35 PM. MDS coordinator said she followed the RAI manual.

Based on interview and record review, the facility failed to develop a discharge summary that included a post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, and the resident representative that included where the individual planned to reside, any arrangements that have been made for the resident's follow up care and any post discharge medical and non-medical services for 1 of 1 resident (Resident #1) reviewed for inappropriate discharge.The facility failed to ensure Resident #1 was given a proper discharge when the resident checked out on pass on 7/11/25 and did not return to the facility. This deficient practice could place residents at risk of being discharged and causing a disruption in their care and services and potential decline in health. The findings included:Record review of Resident #1's face sheet dated 7/30/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] and 4/16/25 with diagnoses that included heart failure, seizures (sudden, uncontrolled electrical disturbance in the brain that may cause changes in behavior, movements, feelings, or levels of consciousness), diabetes (chronic medical condition in which the body either doesn't produce enough insulin or doesn't use insulin effectively which helps regulate blood sugar levels), chronic kidney disease stage 3 (moderate stage of kidney damage where the kidneys aren't functioning as well as they should to filter waste and fluids from the blood), atrial fibrillation (irregular heartbeat rhythm where the heart beats rapidly and irregularly), hypertension (elevated blood pressure), and pain.Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, utilized a wheelchair for mobility, was dependent on staff with transfers, and was always incontinent of bowel and bladder.Record review of Resident #1's comprehensive care plan with revision date 1/28/25 revealed the resident had a self-care deficit related to poor mobility, debility, weakness, and seizures with interventions that included to assist the resident with bed mobility, required the use of a wheelchair, and required assistance with transfers with use of a mechanical lift. The comprehensive care plan revealed Resident #1 was at risk for falls related to debility, weakness, amputation, and seizures. The comprehensive care plan revealed Resident #1 wished to return to his home with supportive care and services group home with home health and the resident wished to leave community AMA several times despite education, with interventions that included to discuss discharge goals with the resident/family/representative; establish plan, set tentative discharge date as indicated, evaluate the resident's progress and revise the plan as indicated.Record review of Resident #1's Exit Seeking Risk Tool dated 5/15/25 revealed the resident was not at risk for exit seeking.Record review of Resident #1's IDT Discharge Planning/Instructions/Recapitulation document dated 7/11/25 revealed the resident discharged AMA, the anticipated discharge date was 7/11/25, the resident/representative declined post discharge care elections, and orders were reviewed and confirmed with the medical provider.Record review of the facility document titled, Release of Responsibility for Leave of Absence revealed Resident #1 signed out to go on pass on Friday, 7/11/25 at 12:09 p.m. The document had Resident #1's signature under the section which read, Signature of Person Accepting Responsibility.Record review of Resident #1's electronic record revealed a progress note dated 7/10/25 with time stamp 5:08 p.m. and authored by LVN B revealed, Resident #1 wanted to go AMA. LVN B's progress note indicated she provided the resident with an AMA form, provided patient teaching, and referred the resident to the Social Worker. LVN B's progress note indicated Resident #1's friend called and would be picking him up the following day, 7/11/25, to take the resident out on pass to lunch and shopping. LVN B's progress note revealed Resident #1 stated he would wait until the following day when his friend, who used to be his former home health aide, to decide about going AMA. Record review of Resident #1's electronic record revealed a progress note dated 7/11/25, with time stamp 12:15 p.m. and authored by the Administrator revealed, Resident #1 stated that he was going out on pass with friend. He [Resident #1] said he was planning on leaving and staying at her house overnight to attend church tomorrow for services. Patient signed himself out in the sign out book.Record review of Resident #1's electronic record revealed a progress note dated 7/11/25, with time stamp 1:55 p.m. and authored by the SW revealed, Patient [Resident #1] stated he was going out on pass with his friend. He stated that he would be leaving today and staying overnight at her house and would be going out to eat, shop, and attend church services tomorrow. Patient signed himself out in the sign out book.Record review of Resident #1's electronic record revealed a progress note dated 7/12/25 (Saturday), with time stamp 3:35 p.m. and authored by LVN A revealed Resident #1 was OOP (out on pass).Record review of Resident #1's electronic record revealed a progress note dated 7/14/25 (Monday), with time stamp 7:48 a.m., and authored by LVN A revealed Resident #1 was Out on pass.Record review of Resident #1's electronic record revealed a progress note dated 7/14/25, with time stamp 11:00 a.m. and authored by the Administrator revealed, spoke with [family member], of Resident #1, to inform her that ex-caregiver [friend] took [Resident #1] out on pass on Friday stating that they would return Saturday after church. Explained that [Resident #1's friend] didn't return with him and he was now considered discharging AMA. [Family member] understood and appreciated the call. During an interview on 7/30/25 at 2:43 p.m., LVN A stated Resident #1 was a double amputee and had vision problems that were being addressed by the facility. LVN A stated Resident #1 signed out on pass (Friday, 7/11/25) and never came back. LVN A stated, Resident #1 was picked up by the resident's friend who used to be his former caretaker. LVN A stated it was the first time that happened (the resident not coming back) and was not sure what our administrators did about it. During a telephone interview on 7/31/25 at 9:34 a.m., Resident #1's family member stated she was contacted by the Administrator and was told Resident #1 was missing in action after three days and never returned. The family member stated she was told by the Administrator the facility policy was if Resident #1 was gone from the facility for more than 3 days they had to start the re-admission process before allowing Resident #1 to return to the facility. Resident #1's family member stated she recalled the day the Administrator called her, Monday 7/14/25, because she had just got back home after being out of town. Resident #1's family member stated, the facility knew me well, and they should have called me. Resident #1's family member stated she was familiar with Resident #1's friend, who was his former caretaker from the group home, but only talked to her on the phone and never met her personally. Resident #1's family member stated Resident #1 was responsible for himself and she was not his POA. Resident #1's family member stated the resident was currently at another nursing facility receiving therapy related to care for kidney stone surgery.During an interview on 7/31/25 at 10:20 a.m., at the Administrator's request, he stated Resident #1 leaving the facility was not considered an elopement but was considered leaving AMA because the resident was able to make his own decisions and was his own RP. The Administrator stated Resident #1 signed himself out to leave the facility, and did not answer his phone when the Administrator tried to call him the following day, Saturday 7/12/25, when he did not return. The Administrator stated Resident #1 did not sign any AMA paperwork. The Administrator stated, per Medicaid guidelines, if the resident did not return for three consecutive midnights, the resident was considered discharged . The Administrator was unable to provide telephone logs of the attempt at a telephone call to Resident #1 for Saturday, 7/12/25. During an interview on 7/31/25 at 11:23 a.m., the SW stated LVN B reported to her on 7/10/25 Resident #1 wanted to go AMA. The SW stated she spoke briefly to Resident #1, and he retracted his statement about wanting to leave AMA the same day because she informed him his friend was coming to pick him up to go out on pass the following day. The SW stated Resident #1's friend was picking him up and taking him overnight and then bringing him back to the facility the next day. The SW stated, when Resident #1 did not return the following day, she believed the Administrator reached out to the resident, but he did not answer and believed the Administrator then reached out to the resident's family member. The SW stated, I don't think the (family member) had anything to say, because he [Resident #1] was the RP. The SW stated Resident #1 was never an elopement risk and never known to exit seek and he was cognitively intact. The SW stated, the facility would have reached out to Resident #1 before the end of the third midnight, to explain that if he did not come back, he would have been discharged per the Medicaid guidelines. The SW stated, we were not concerned for his safety. The SW stated she assumed Resident #1 was with the person he left with, his friend.During a follow up interview on 7/31/25 at 11:33 a.m., LVN A stated, Resident #1 told him he was only going out on pass for a couple of hours and was coming back the same day (7/11/25), which was why he did not give the resident medications to take with him on pass. LVN A stated, if a resident was out of the facility for more than 72 hours, it was considered AMA. LVN A stated he reported to the Administrator on Monday 7/14/25 that Resident #1 had gone out on pass on Friday 7/11/25 and it was now Monday (7/14/25), and the resident was not back. LVN A stated he reported that information to the Administrator because it was more than three days. LVN A stated the Administrator took the information from him but did not say anything to him. During an interview on 7/31/25 at 12:35 p.m., the DON stated Resident #1 was leaving out on pass with a friend but was not aware the resident was going to leave overnight until she saw the SW's progress note the following working day, Monday 7/14/25. During an interview on 7/31/25 at 1:32 p.m., the RN Regional Support Nurse stated, Resident #1 had his rights and if he wanted to leave, we would have talked to the physician. The RN Regional Support Nurse stated she was aware Resident #1 made comments about leaving AMA, but the resident changed his mind. The RN Regional Support Nurse stated, Resident #1 told LVN A he was only going out for an hour, and he told the SW and the Administrator he was going out overnight. The RN Regional Support Nurse stated there was a miscommunication. During an interview on 7/31/25 at 4:55 p.m., Resident #1 stated he told the Administrator he was going out on pass on 7/11/25 and would return on Monday 7/14/25. Resident #1 stated he communicated with the DON about leaving out on pass and was referred to the nurse to sign out. Resident #1 stated he did not recall who the nurse was but stated he told the nurse he would be back on Monday 7/14/25. Resident #1 stated the facility tried to get me to sign an AMA before I left, but I wouldn't. Resident #1 stated the facility never called him or his friend about his whereabouts. Resident #1 stated, I was coming back in three days, not overnight. Resident #1 stated he did not return to the facility because he had a fall while at his friend's house and went to the hospital on 7/20/25. Resident #1 stated the hospital found a kidney stone and he required a laparoscopy (surgical procedure used to examine and operate on the organs inside the abdomen or pelvis) and was now receiving physical therapy at another nursing facility. An attempted interview on 8/1/25 at 8:28 a.m. with the MD was unsuccessful. A telephone message was left requesting an interview with the MD. During a telephone interview on 8/1/25 at 10:00 a.m., Resident #1's friend stated she contacted the facility to tell them she was picking up Resident #1 to take him to lunch on Friday 7/11/25. Resident #1's friend stated the Administrator followed them out to her vehicle and she overheard Resident #1 say under his breath, I don't think I'm coming back. Resident #1's friend stated she planned to take the resident out on pass for lunch and had no intention of keeping him overnight. Resident #1's friend stated the facility did not reach out to her while Resident #1 was with her about trying to get him back. Resident #1's friend stated she did not try to reach out to the facility to let them know the resident was with her because she knew Resident #1 did not want to go back to the facility. During a follow up interview on 8/1/25 at 10:21 a.m., LVN B stated she reported to the DON and the SW about Resident #1 requesting to leave AMA on 7/10/25. LVN B stated she, the DON and SW discussed the AMA document and what it meant to leave AMA with Resident #1, and the resident's only response was that he understood. LVN B stated after that conversation, the SW told her the resident's friend was coming to take him out on pass the following day, 7/11/25 and Resident #1 changed his mind about leaving AMA. LVN B stated Resident #1 did not sign the AMA document.During a follow up interview on 8/1/25 at 10:31 a.m., the DON stated she recalled the conversation held with Resident #1 about his request to leave AMA. The DON stated Resident #1 was provided with education and offered the AMA paperwork. The DON stated Resident #1 would let whoever was picking him up to go out on pass know about the AMA paperwork and that was the end of the conversation. The DON stated Resident #1's friend picked him up the following day, Friday 7/11/25, to go out on pass, and not that he was leaving AMA. The DON stated she did not know how long Resident #1 was going to be gone.During a follow up interview on 8/1/25 at 11:36 a.m., the SW stated she recalled LVN B reporting to her and the DON about Resident #1 wanting to leave AMA. The SW stated the resident was provided education, acknowledged he understood and then Resident #1 stated he was not leaving AMA. The SW stated, after Resident #1 did not return to the facility at the designated time, she believed the Administrator tried to contact the resident and the resident's friend but was not successful. The SW stated, because Resident #1 was alert and oriented, and able to sign himself out, it was not considered an elopement but was considered leaving AMA. During a follow up interview requested by the Administrator on 8/1/25 at 11:44 a.m., he stated he wanted to be clear Resident #1 leaving the facility on pass and not returning was considered a discharge and not AMA. The Administrator stated, Resident #1 went out on pass and chose not to return and as per Medicaid guidelines after being out 3 consecutive nights without returning to the facility meant he was discharged . The Administrator stated, Resident #1 made that choice as his own RP and tried to reach out to the resident on Saturday, 7/12/25 but was unable to provide the telephone logs to prove he had attempted to call the resident. A request made to the DON for a facility policy on residents going out on pass was requested on 8/4/25 at 10:43 a.m. but was not provided.Record review of the facility document titled, Statement of Resident Rights with revision date January 2023 revealed in part, .The community should educate, encourage, and honor the rights of those we serve.Further, the community should assist a resident/patient fully to exercise their rights as applicable.Resident/Patient Rights include.To go out on pass by means of self-coordinated outings, with family, representative and to attend structured outings.To not be discharged from the community, except as provided in the nursing community regulations.Residents will have the right to exercise their rights as residents of the community and as citizens.The community will provide autonomy and choice to all residents, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the communities' rules, as long as those rules do not violate regulatory requirement.Record review of the facility document titled, Activities Program with revision date January 2025 revealed in part, .Self-determination and participation.The resident has the right to interact with members of the community, both inside and outside the community, and to make choices about aspects of his or her life.In order to ensure the resident's continuity of care, the resident and/or their representative or family should collaborate with the nursing team to coordinate medical care, support needs, and services accordingly.

Based on interview and record review the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plan of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 3 nursing staff (LVN A) reviewed for nursing services. LVN A did not notify the DON or the Administrator until Monday 7/14/25 when Resident #1 went out on pass on Friday 7/11/25, and the resident did not return. Resident #1 was scheduled to return to the facility on Saturday 7/12/25.This failure could place residents at risk of staff not providing nursing or related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being.The findings included:Record review of Resident #1's face sheet dated 7/30/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] and 4/16/25 with diagnoses that included heart failure, seizures (sudden, uncontrolled electrical disturbance in the brain that may cause changes in behavior, movements, feelings, or levels of consciousness), diabetes (chronic medical condition in which the body either doesn't produce enough insulin or doesn't use insulin effectively which helps regulate blood sugar levels), chronic kidney disease stage 3 (moderate stage of kidney damage where the kidneys aren't functioning as well as they should to filter waste and fluids from the blood), atrial fibrillation (irregular heartbeat rhythm where the heart beats rapidly and irregularly), hypertension (elevated blood pressure), and pain.Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, utilized a wheelchair for mobility, was dependent on staff with transfers, and was always incontinent of bowel and bladder.Record review of Resident #1's comprehensive care plan with revision date 1/28/25 revealed the resident had a self-care deficit related to poor mobility, debility, weakness, and seizures with interventions that included to assist the resident with bed mobility, required the use of a wheelchair, and required assistance with transfers with use of a mechanical lift. The comprehensive care plan revealed Resident #1 was at risk for falls related to debility, weakness, amputation, and seizures. Record review of the facility document titled, Release of Responsibility for Leave of Absence revealed Resident #1 signed out to go on pass on Friday, 7/11/25 at 12:09 p.m. The document had Resident #1's signature under the section that read, Signature of Person Accepting Responsibility.Record review of Resident #1's electronic record revealed a progress note dated 7/11/25, with time stamp 12:15 p.m. and authored by the Administrator revealed, Resident #1 stated that he was going out on pass with friend. He (Resident #1) said he was planning on leaving and staying at her house overnight to attend church tomorrow for services. Patient signed himself out in the sign out book.Record review of Resident #1's electronic record revealed a progress note dated 7/11/25, with time stamp 1:55 p.m. and authored by the SW revealed, Patient (Resident #1) stated he was going out on pass with his friend. He stated that he would be leaving today and staying overnight at her house and would be going out to eat, shop, and attend church services tomorrow. Patient signed himself out in the sign out book.Record review of Resident #1's electronic record revealed a progress note dated 7/12/25 (Saturday), with time stamp 3:35 p.m., and authored by LVN A revealed Resident #1 was OOP (out on pass).Record review of Resident #1's electronic record revealed a progress note dated 7/14/25 (Monday), with time stamp 7:48 a.m., and authored by LVN A revealed Resident #1 was Out on pass.During an interview on 7/31/25 at 11:33 a.m., LVN A stated, Resident #1 told him he was only going out on pass for a couple of hours and was coming back the same day (7/11/25), which was why he did not give the resident medications to take with him on pass. LVN A stated he reported to the Administrator on Monday 7/14/25 that Resident #1 had gone out on pass on Friday 7/11/25 and it was now Monday (7/14/25), and the resident was not back. LVN A stated he reported that information to the Administrator because it was more than three days. LVN A stated the Administrator took the information from him but did not say anything to him. During an interview on 7/31/25 at 12:35 p.m., the DON stated Resident #1 was leaving out on pass with a friend but was not aware the resident was going to leave overnight until she saw the SW's progress note the following working day, Monday 7/14/25. During an interview on 7/31/25 at 4:55 p.m., Resident #1 stated he told the Administrator he was going out on pass on Friday 7/11/25 and would return on Monday 7/14/25. Resident #1 stated he communicated with the DON about leaving out on pass and was referred to the nurse to sign out. Resident #1 stated he did not recall who the nurse was but stated he told the nurse he would be back on Monday 7/14/25. Resident #1 stated he did not leave with any medications.During a follow up interview on 8/1/25 at 9:49 a.m., LVN A stated, when Resident #1 did not return on Saturday, 7/12/25, I don't remember telling administration, I only passed on that information at report with the nursing staff. LVN A stated, I was like he (Resident #1) didn't come back and he's not getting his medications and insulin, and he was still out on pass, what could I do about it. He's out on pass, so. LVN A stated he could not recall talking to the DON or ADON about it and was off on Sunday, 7/13/25, and when he returned on Monday 7/14/25 he informed the Administrator about it and probably mentioned it to the ADON or DON, because at that point I was like is he coming back? During a follow up interview on 8/4/25 at 12:45 p.m., the DON stated it was her expectation, when a resident went out on pass and did not return at the designated time, the nursing staff were supposed to have some sort of follow up, notify the representative, and the resident themselves. The DON stated nursing staff were supposed to notify her and the Administrator when the resident did not return at the designated time. The DON stated, if they (nursing staff) didn't report to us, we would not know the resident didn't return.

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, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for since April 2024. The facility failed to have either a full-time dietitian or certified dietary manager on staff since April 2024. This failure could place the residents at risk of not receiving sufficient food and nutritional services, which could negative impact overall resident nutrition. Findings included: Record review of the facility's key staff report reflected no dietary manager or dietitian listed. In an interview on 07/18/24 at 10:21 AM with the Head Cook/Supervisor in Training, he stated he had been at the facility for three years. He stated the Dietary Manager had left the facility about four months ago. He stated the Dietitian visits the facility at least three or four times a month to ensure concerns she had previously observed was corrected. He stated the previous dietary manager had trained him on maintaining the kitchen and he had been a cook for over [AGE] years. In an interview on 07/18/24 and 12:07 PM Administrator stated they had been without a Dietary Manager for couple of months now, but the acting supervisor was now taking all the required courses to get certified. She stated that she works closely with him to ensure that he was keeping the kitchen within guideline. She stated they did have a dietitian, but she was contracted and not a permanent member. She stated the risk of not having a full-time dietitian or certified dietary manager at the facility could impact the resident's ability to have nutritional meals.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure food in the facility's refrigerator was labeled and dated according to guidelines. 2. The facility failed to ensure the ice machine in the kitchen area was thoroughly cleaned. 3. The facility failed to ensure food in the facility's freezer was labeled and dated according to guidelines. 4. The facility filed to ensure kitchen equipment in the kitchen area, was thoroughly cleaned. 5. The facility failed to ensure food in the facility's dry food area was labeled and dated according to guidelines. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 07/16/24 from 08:35 AM to 08:50 AM in the facility's only kitchen reflected: One large container of diced pineapples in the refrigerator was not labeled with item name and did not have the date stored. One small cup of pudding was unlabeled with item name and undated with the date stored. A tray of beverages containing cups of apple juice and milk was unlabeled with item name and undated with the date stored. Three 5-pound bags of salad were undated with date stored. Three loaves of wheat bread were undated with the date stored. Three bags of hamburger buns were undated with the date stored. The ice machine had dust and dirt particles along the outside of the unit. The inside of the unit had light dirt stains along the inside panel of the unit, which touched the ice. The upper inside of the door had a black substance on a metal bar that stretched horizontally along the inside door. Two zip locked bags of frozen meat were unlabeled with item name and undated with the date stored. One large frozen turkey was undated with dated stored. In an interview on 07/18/24 at 10:21 AM with the Head Cook/Supervisor in Training, stated he had been at the facility for three years. He stated the Dietary Manager had left the facility about four months ago. He stated the Dietitian visits the facility at least three or four times a month to ensure concerns she had previously observed was corrected. He stated the previous dietary manager had trained him on maintaining the kitchen and he had been a cook for over [AGE] years. He was shown pictures of the concerns that were observed in the kitchen. He stated he had corrected some of the concerns. He stated he was the one in charge of ensuring inventory were labeled and dated when stored and he ensures that kitchen staff are wiping down the kitchen equipment and cleaning the ice machine. He stated he cleans the ice machine every two weeks but will start monitoring it more frequently. He stated the risk of not addressing the areas mentioned could in result in cross contamination and food contamination. In an interview on 07/18/24 and 12:07 PM with the Administrator, she stated they had been without a Dietary Manager for couple of months now, but the acting supervisor was now taking all the required courses to get certified. She stated he did tell her about the findings in the kitchen but not sure if he advised her of everything. She was advised of the concerns observed in the kitchen and she stated she expected all items to be labeled and dated and the kitchen cleaned. She stated the risk to the resident was the potential for contamination. Record Review of the Facility's policy on Food Storage dated 06/01/2019, revealed To ensure all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and U.S Food Codes and HACCP guidelines. The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards. Refrigerators, coolers and freezers will be kept clean on a daily basis and will be thoroughly cleaned every month or more often as needed . Procedure: 1 .d .all containers must be labeled and dated .2. Refrigerators .d. Date, label and tightly seal all refrigerated foods . Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 8 (room [ROOM NUMBER], #103, #104, #106, #110, #113, #116, and facility shower room) of 12 rooms observed for environment. The facility failed to ensure Resident rooms #102, #103, #104, #106, #110, #113, #116, and facility shower room were clean and sanitized. The facility failed to ensure Resident room [ROOM NUMBER]'s floor was repaired of cracks to prevent accidents. These deficient practices could place residents at risk of living in an unclean, unsafe and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 07/16/24 at 10:06 AM of Resident room [ROOM NUMBER] reflected the entry way into the resident's bathroom had a large crack in the floor and a piece of tile was broken off. On the floor, behind the toilet was a large brown stain. The floor along the resident room wall, had a long crack going down the length of the room. The air conditioning in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. An observation on 07/16/24 at 10:20 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. An observation on 07/16/24 at 10:23 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. The floor along the wall had built up black stains. An observation on 07/16/24 at 10:27 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. The middle of the floor had brownish stains. An observation on 07/16/24 at 10:32 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filter had a thick layer of dust on it. The floor along the walls had built-up black stains. There was a broken tile located near a bedside table. There was a long crack in the floor near the middle of the room. The bathroom sink was scraped and damaged near the drain. An observation on 07/16/24 at 10:36 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. A white air vent along the wall was stained and dirty. An observation on 07/16/24 at 10:47 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. The floor along the front of the toilet had a black stain. The handrails in the bathroom had dark and reddish stains. An observation on 07/16/24 at 10:57 AM of the Residents' only shared shower room, reflected the shower room floor had blackish and reddish stains along the floor and shower walls. The handrails and shower heads had built-up soap scum on them. One of the shower stalls had a dead cockroach dead in the corner of the stall. In an interview on 07/18/24 at 10:45 AM Housekeeping G, stated she had been at the facility a month. She stated she was given a cleaning cart and was shown by a housekeeper who was at the facility longer on what to clean. She stated they had to clean restrooms, dressers, windows, air condition units, and dust. She stated she worked the 300- hall. She was shown pictures of the concerns observed in the resident rooms. She stated that they were supposed to clean the air conditioning units in the resident rooms and also clean the air filters. She stated they are supposed to wipe down the handrails in the rooms, bathrooms, and hallways. She stated she and another co-worker are responsible for cleaning the showers, which are supposed to be cleaned daily. She stated the risk of not ensuring the resident rooms are not thoroughly the residents could get sick, bacteria could spread, and the residents would not want to take a shower in a dirty shower. In an interview on 07/18/24 at 11:00 AM with Housekeeping M, she stated she had been at the facility for a year. She stated she had been doing this [housekeeping] for [AGE] years. She stated she was supposed to clean the 100 Hall rooms, wipe down the handrails daily, but she did not clean the shower room. She stated she had helped them when they are short staffed. She stated they [housekeeping] was supposed to empty the trash, dust, clean the air conditioning unit, including cleaning the air conditioning filter, clean the restrooms, and sweep and mop. She was shown pictures of the findings in the facility, and she stated she cleans everything. She stated the risk of not cleaning the resident room thoroughly is was not right and it should be clean. In an interview on 07/18/24 at 11:18 AM Maintenance/Housekeeping Director stated he had been at the facility for over 3 years. He stated staff was supposed to clean the entire rooms, including the bathrooms, sweep and mop floor, clean the air conditioning units, and wipe the furniture down. He was shown pictures of the damages to the floor, and he stated that there were foundational problems on the 100 Hall. He stated the resident rooms, handrails, and showers were to be cleaned daily. He stated there was no excuse why those areas were not clean. He stated he tried to inspect the rooms and other areas daily but sometimes he just checks with the housekeeping team to ensure that it was done. He stated he would get right on resolving the issues observed. He stated the risk of the issues not being resolved could result in residents getting sick. In an interview on 07/18/24 at 12:07 PM the Administrator stated the facility had foundation concerns and they are getting bids for redoing the foundation. She was shown pictures of the findings for housekeeping and maintenance, and she stated that she expected housekeeping to clean all areas of the building not being thoroughly cleaned could result in contamination. Review of the facility's policy on Safe/Comfortable/Homelike Environment (Revised 2022) reflected Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #9, Resident #40,and Resident #43) of nineteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #9, Resident #40, and Resident #43's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #9 Review of Resident #9's Face Sheet, dated 07/16/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Resident #9 was diagnosed with Parkinson's disease (a chronic and progressive movement disorder) without dyskinesia (uncontrolled, involuntary movements of the face, arms, or legs). Review of Resident #9's Quarterly MDS Assessment, dated 05/01/2024, reflected that Resident #9 was cognitively intact with a BIMS score of 15. Resident #9 required supervision for eating, oral hygiene, toileting, and dressing. Review of Resident #9's Comprehensive Care Plan, dated 06/15/2024, reflected that Resident #9 was at risk for falls and one of the interventions was to keep the call light in reach. Observation and interview with Resident #9 on 07/16/2024 at 10:34 AM revealed Resident was on her bed, awake. Resident #9's call light was on the floor behind her side table. Resident #9 stated she did not usually use the call light because she could do everything by herself. She said but to be sure, she wanted her call light near her especially at night in case she cannot stand up or move around. Resident #9 checked the side of her bed and said the call light was not clipped on her pillow. Resident #9 did not notice her call light was behind her side table. Resident #40 Review of Resident #40's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included cerebral infarction (blockage in the blood vessels of the brain), epilepsy (a brain condition that causes recurrent seizures), and age related debility (a state of general weakness). Review of Resident #40's Quarterly MDS Assessment, dated 04/13/2024, reflected Resident #40 had a severe cognitive impairment with a BIMS score of 04. Resident #40 needed supervision when ambulating 10 feet or more. Review of Resident #40's Comprehensive Care Plan, dated 06/18/2024, reflected Resident #40 was at risk for falls and one of the interventions was to keep call light in reach. Observation and interview with Resident #40 on 07/16/2024 at 8:46 AM revealed resident #40 was sitting on his bed eating breakfast. It was observed that his call light was on the floor at the back of his bed's headboard. The resident stated he was just finishing his breakfast. When he was done with his breakfast, Resident #40 looked for his call light and said he wanted to call somebody to take his tray. Resident #40 found the cord of his call light and tried to pull it. Resident #40 said the call light was stuck. He said the staff who made his bed did not notice his call light was not clipped on the bed. Resident #40 stood up, put his tray on his walker, started to push his walker outside his room, and said he would just take his tray to the dining area. Resident #40 started walking towards the dining area. Resident # 43 Review of Resident #43's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included muscle weakness and epilepsy. Review of Resident #43's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #43 had a severe cognitive impairment with a BIMS score of 03. Resident #43 was dependent on staff for oral hygiene, shower, dressing, and bed mobility. Review of Resident #43's Comprehensive Care Plan, dated 06/18/2024, reflected Resident #43 was at risk for falls and one of the interventions was to keep call light in reach. Observation on 07/16/2024 at 8:51 AM revealed that Resident #43 was on his bed, awake. It was observed that his call light was on the floor, under his roommate's bed. Resident #43 did not reply when asked about his call light. Observation and interview with CNA E on 07/16/2024 at 10:56 AM, CNA E stated it was important that the call lights were placed near the residents. CNA E said the call lights should always be with the residents because the residents used them to call the staff if they needed something. CNA E said if the call lights were not with the residents, the residents would not be able to communicate their needs and wants. CNA E said the residents might be frustrated, mad, or might fall if the call light was far from them. CNA E went to Resident #40 and Resident #43's room. She confirmed that the call lights were on the floor. CNA E picked up Resident #43's call light from beneath his roommate's bed and placed it near the resident. CNA E then proceeded to pull Resident #40's call light from behind the headboard and said it was stuck on something. CNA E pushed Resident #40's bed, pulled the call light, and placed it near Resident #40. She said she was assigned to Resident #9. She said she did not notice the call light was on the floor when she did her initial round because she was in a hurry. In an interview with CNA D on 07/16/2024 at 11:04 AM, CNA D stated he was assigned to Residents #40 and #43. CNA D said he did not notice the call lights were not with the residents. He said it was important for the call light to be within reach, so the residents could be helped when they needed assistance or help. CNA D said if the call lights were not with the residents, the residents might fall or the staff would not know the residents were having an emergency. He said he was responsible in ensuring the call lights were within reach for his assigned residents. In an interview with LVN A on 07/17/2024 at 9:21 AM, LVN A stated the call lights should always be with the residents because the call lights were their form of communication. For some residents, the call lights were their sense of security that if they needed help, they could call the staff to help them. If the call lights were not with the residents, the residents might fall while trying to do things by themselves. Some of the residents would be mad and frustrated because they could not call the staff. She said all the staff were responsible in making sure the call lights were within reach of the residents. In an interview with the DON on 07/18/2024 at 8:24 AM, the DON stated call lights were very essential for the residents. The DON said, for some residents, the call lights were the only way of communication between the residents and the staff. The DON said the call lights were used by the resident if they needed something, like pain medication, refill of water, or to turn the lights off. The DON said without the call lights, the needs of the residents would not be known and would not be met. He added, without the call lights the needed care would not be provided. The DON said the expectation was for the staff would be mindful that every time they leave the resident's room, the call lights were with the residents. The DON said he would conduct an in-service about the call lights because the call lights were everybody's responsibility. He said the in-service would be for the nurses, CNAs, housekeeping, therapists, and management. He said he would personally monitor that all the residents' call lights were within reach. In an interview with the ADON on 07/18/2024 at 8:51 AM, the ADON stated the call lights should not be on the floor or in a place where the residents could not reach them. The ADON said the call light must be within reach of the residents at all times because they use the call light to let the staff know they needed something. The ADON said if the call lights were far from the residents, the residents would not be able to call the staff and their needs would not be addressed. The ADON said the resident might even have a fall if they try to go to the bathroom by themselves because they could not call the staff. The ADON said the expectation was for all the staff to make sure the call lights were within the reach of all the residents. The ADON said they would do an in-service about call lights being accessible to the residents. In an interview with the Administrator on 07/18/2024 at 9:21 AM, the Administrator stated the call lights should not be far from the residents. The Administrator said the call lights were used by the residents to call the attention of the staff if they needed something. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should be sensible about call light placement. The Administrator said they would re-educate the staff regarding call lights and would constantly remind them that before leaving the room, make sure the call lights were with the resident. Record review of facility's policy Answering The Call Light revealed Purpose: The purpose of this procedure is to respond to the resident's request and needs . general Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Residents #26 and #63) of 2 residents reviewed for (ADLs) care provided to dependent residents. 1.The facility failed to ensure Resident #26 received scheduled showers reviewed for the past 30 days (06/16/24 - 07/16/24). 2. The facility failed to ensure Resident and #63 received scheduled showers reviewed for the past 30 days (06/16/24 - 07/16/24). These failures placed residents at risk of not receiving necessary services to maintain good personal hygiene and decreased self- esteem. Findings included: 1. Record review of Resident #26's Face Sheet, dated 07/17/2024, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Kidney Failure and required ADL assistance. Record review of Resident #26's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, he had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and for ADL care it stated, for transfers, toileting, and bathing, the resident required moderate assistance. In an interview on 07/16/24 at 11:38 AM with Resident #26, he stated he had not been getting his showers at the facility. He stated he had never refused any showers and he was scheduled to receive three showers a week. He stated he wanted his showers. 2. Record review of Resident #63's Face Sheet, dated 07/17/2024, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Kidney Failure and required ADL assistance. Record review of Resident #63's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, he had a Brief Interview for Mental Status (BIMS) score of 09 (moderate cognitive impairment) and for ADL care it reflected, for transfers, toileting, and bathing, the resident required moderate assistance. In an interview on 07/16/24 at 10:46 AM with Resident #63, he stated he had not been getting his showers at the facility. He stated he had never refused any showers and he was scheduled to receive three showers a week. He stated he wanted his showers. Record review of the facility's shower sheet binder for the past 30 days (06/16/24 - 07/16/24) reflected no shower sheets on file for Resident # 26 and #63. In an interview on 07/17/24 at 10:15 AM CNA S stated she had been at the facility for [AGE] years, she stated she works the 100 hall and she cares for Resident #26 and #63. She stated they were required to complete the shower sheets for all residents, whether a shower was provided or refused. She was advised that neither resident had shower sheets in the shower sheet binder provided by the facility for the past 30 days reviewed. She stated that she did provide the residents their showers, but she just forgot to complete the shower sheet. She stated the risk of the resident not receiving their scheduled showers and she stated that they could get sores and redness. An interview on 07/17/24 at 10:15 AM LVN A stated she had been at the facility since December (2023). She stated she monitored the 100 hall and Resident #26. She advised that all CNAs were required to complete shower sheets for all residents. She stated she usually monitored the showers and ensured that the shower sheets were completed correctly and completely. She stated that she did not do a great job monitoring Resident#26 showers. She stated CNA S covered both the 100 and 300 halls and sometimes got overwhelmed. LVN A stated Resident #26 was receiving showers, but it was not being recorded. She was asked why the resident stated they were not receiving showers and she could not explain why the resident stated he was not receiving his showers. She stated the risk of the resident not receiving showers could result in skin breakdown and skin irritation. In an interview on 01/17/24 at 01:57 PM with LVN R, she stated she had been there four weeks. She stated resident are required to complete shower sheet for residents on their scheduled days whether they received or refused one. She was advised that the shower sheet book was reviewed, and no shower sheet was observed. She stated Resident #63 was scheduled to receive his showers in the evening and it was the evening nurse responsibility to ensure that the resident received his showers. She stated they do communicate during shift change but not about Resident #63's showers. She stated she really did not know if the resident ever refused shower or was given a shower. She stated the risk of the resident not receiving their shower could result in dirty skin, breakdown, and infection. In an interview on 07/17/24 at 02:15 PM ADON stated she had been at the facility 18 months. She stated she was familiar with Residents #26 and #63. She stated her nursing staff had made her aware that there were no shower sheets for either resident. She stated she was sure the residents were receiving their showers and she thought that they may have refused a few of them. She was advised that the two residents had stated they were not receiving their showers. She stated she was not sure why they would have made those comments, but she was sure that they received them when scheduled. Record review of facility policy on Bath, Bed, Tub, Shower, dated 05/25/2017 reflected, Purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: The following information should be recorded on the resident's ADL record and or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual who assisted the resident with the shower/tub bath. 3. All assessments data obtained during the shower/bath. 4. If the resident refused the shower/bat, the reason why and the intervention taken.

Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for one (Resident #43) of four residents reviewed for gastrostomy tube management. The facility failed to ensure that Resident #43 had orders to observe the g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) even though it was not used by the resident. The facility failed to ensure that Resident #43 had order to flush and check the placement of the g-tube every shift. These failures could place residents who had g-tube at risk for having a clogged g-tube. Findings include: Review of Resident #43's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #43 was diagnosed with dysphagia (difficulty in swallowing). Review of Resident #43's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #43 had a severe cognitive impairment with a BIMS score of 03. Resident #43's Quarterly MDS Assessment did not indicate that the resident still had a feeding tube. Review of Resident #43's Comprehensive Care Plan, dated 06/01/2024, reflected Resident #43 required enhanced barrier precautions due to having an enteral feeding tube. Review of Resident #43's Physician Orders on 07/16/2024 reflected no orders to check for placement of the g-tube. Review of Resident #43's Physician Orders on 07/16/2024 reflected no orders to flush the g-tube. Review of Resident #43's Physician Orders on 07/16/2024 reflected no orders to observe the g-tube insertion site. Observation and interview on 07/16/2024 at 8:52 AM revealed Resident #43 had a g-tube to the right lower quadrant of his abdomen. Resident #43 did not reply when asked how long he had not been using the g-tube. In an interview with the DON on 07/18/2024 at 8:24 AM, the DON stated a resident with g-tube should be flushed to maintain patency (keeping it from becoming blocked or clogged). He said the g-tube was still with the resident when the resident was being weaned off from formula. He said there should still be an order for the resident with g-tube even if the resident was not using it to prevent clogging and complications. He said the expectation was that there were orders to monitor, flush, and check the placement of the g-tube even though the resident was not using it. He said he would do an in-service about g-tube care and making sure there was an order for monitoring, flushing, and checking for placement. Record review of facility's policy Maintaining Patency of a Feeding Tube revealed Purpose: The purpose of this procedure is to maintain patency of a feeding tube . General Guidelines . 1. Flush enteral feeding tubes every four (4) to six (6) hours. Record review of facility's policy Medication Orders revealed Purpose: the purpose of this procedure is to establish uniform guidelines . recording of medications orders . 2. A current list of orders must be maintained . 3. Orders must be written.

Based on observation, interview and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #51) of 5 residents reviewed for dignity. The facility failed to ensure LVN A closed the door and provided privacy obtaining Resident #51's blood sugar. This failure could place the residents at risk of not having their right to a dignified existence maintained. Findings included: Review of Resident #51's Face Sheet, dated 07/17/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Resident #51 was diagnosed with Type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar) without complication. Review of Resident #51's Quarterly MDS Assessment, dated 07/05/2024, reflected resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated diabetes mellitus as one of resident #51's active diagnosis. Review of resident #51's Care Plan, dated 07/05/2024, reflected resident had potential for hyperglycemia (high blood sugar)/hypoglycemia (low blood sugar) secondary to diabetes mellitus and one of the interventions was obtain blood sugar as ordered. Review of Resident #51's Physician Order, dated 07/01/2024, reflected Humalog Kwik Pen (U-100) insulin 100 unit/ml subcutaneous. Inject 7 unit(s) subcutaneously 6:30 A, 11:30 A, 4:30 P every day. Document blood sugar. Document how many units administered . inject 7 units subcutaneously before meals if glucose is greater than 200. Observation and interview with LVN A on 07/16/2024 at 11:29 AM revealed Resident #51 was sitting in the dining area waiting for lunch. LVN A stated she needed to get Resident #51's blood sugar before lunch. LVN A said she would go to the dining area because the resident was already in the dining area. LVN A then pushed her nurse's cart towards the dining area. Observation on 07/16/2024 at 11:33 revealed LVN C approached LVN A and said she should not get the blood sugar at the dining area. LVN C told LVN A that she should move the resident from the dining area to get her blood sugar. Observation on 07/16/2024 at 11:37, LVN C approached LVN A again and said she needed to get Resident #51's blood sugar inside the resident's room. LVN A pushed Resident #51 to her room and then pushed her cart in front of the resident's room. LVN A prepared the things needed to obtain the blood sugar. LVN A then went inside the resident's room and proceeded to check the Resident #51's blood sugar. LVN A did not close the door when she was checking Resident #51's blood sugar. In an interview with LVN A on 07/16/2024 at 12:16 PM, LVN A stated she would sometimes get the blood sugar in the dining area if the resident was already in the dining area. She said, next time, she would get the resident from the dining area if the resident was already in the dining area. She said she would also instruct the CNAs next time that she would get the blood sugar and administer insulin before they take the residents to the dining room before meals. She said getting the blood sugar in the dining area would be a dignity issue. She said the resident could be embarrassed or their self-esteem could be affected. She also said that the resident's door should be closed eveytime she was checking the blood sugar or administering insulin. In an interview with LVN C on 07/16/2024 at 12:37 PM, LVN C stated he did approach LVN A when he saw she was about to go to the dining area with her cart. He said the blood sugar, or the insulin administration should be done inside the resident's room with the door closed to provide privacy to the resident. The door should be closed every time a staff was providing care to the residents. He said some resident could not communicate and even though they were feeling embarrassed, they could not verbalize it. In an interview with the DON on 07/18/2024 at 8:24 AM, the DON stated a nurse could not get the blood sugar of a resident in the dining area. The DON said the staff should get it from the resident's room. The DON said the door should also be closed when the insulin was being administered to provide privacy to the resident and to avoid embarrassment. The DON said all the staff, including him, were responsible in providing dignity to the residents. The DON said the expectation was for the staff to make sure all care provided would be in the resident's room with the door closed. He concluded that he would continually remind the staff the importance of providing dignity and privacy through an in-service. In an interview with the ADON on 07/18/2024 at 8:51 AM, the ADON stated what she learned from school was to provide care in the privacy of the residents' room. She said the blood sugar should never be taken from the dining area. She said the blood sugar should be taken before the resident was taken to the dining area or get the resident from the dining area and take her to her room and get the blood sugar. Getting the blood sugar in-front of other residents, staff, and visitors might cause embarrassment to the resident. She said it was important that the residents will be safe and would not be embarrassed. She said she would coordinate with the DON to do an in-service about dignity. In an interview with the Administrator on 07/18/2024 at 9:21 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent embarrassment. She said the expectation was for the staff to get the blood sugar inside the room and give the insulin with the door closed. Said she would do an in-service about privacy and dignity. Facility's policy for Dignity requested on 07/18/2024 at 8:04 AM but was not provided prior to exit.

Based on observation, interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for two (Resident #40 and Resident #43) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #40's Quarterly MDS Assessment accurately reflected that Resident #40 still had his g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach). The facility failed to ensure Resident #43's Quarterly MDS Assessment accurately reflected that Resident #43 still had his g-tube. The facility failed to ensure Resident #'s 43's Quarterly MDS Assessment accurately reflected that Resident #43 had impairment to his right hand. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #40 Review of Resident #40's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #40 was diagnosed with dysphagia (difficulty in swallowing). Review of Resident #40's Quarterly MDS Assessment, dated 04/13/2024, reflected Resident #40 had a severe cognitive impairment with a BIMS score of 04. Resident #40's Quarterly MDS Assessment did not indicate that the resident still had a feeding tube. Review of Resident #40's Comprehensive Care Plan, dated 06/18/2024, reflected Resident #40 required feeding tube for nutrition and interventions were check for placement of tube, check for residual (food from previous feeding left in the stomach), and flush feeding tube with water as ordered. Resident #40's Comprehensive Care Plan did not reflect that the resident's g-tube was not in use. Review of Resident #40's Physician Order, dated 07/13/2024, reflected G-tube Flush: 60 cc H2o Q shift. Review of Resident #40's Physician Order, dated 07/13/2024, reflected G-tube observation: site/drsg, assess for leakage or skin irritation at tube insertion site Q shift - Cleanse with normal saline q shift. Review of Resident #40's Physician Order, dated 07/13/2024, reflected G-tube placement check: via auscultation (listening to the sounds inside the body through the use of a stethoscope) AC H2O medications and formula Q shift. Observation and interview with Resident #40 on 07/16/2024 at 8:46 AM revealed Resident #40 was sitting on his bed eating breakfast. After eating breakfast, Resident #40 stood up to fix his tray. It was observed that Resident #40 had a g-tube. Resident #40 stated he had a g-tube but he was not using it anymore. He said he was already eating through his mouth. Resident # 43 Review of Resident #43's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #43 was diagnosed with dysphagia. Review of Resident #43's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #43 had a severe cognitive impairment with a BIMS score of 03. Resident #43's Quarterly MDS Assessment did not indicate that the resident still had a feeding tube and had an impairment on his right hand. Review of Resident #43's Comprehensive Care Plan, dated 06/01/2024, reflected Resident #43 required enhanced barrier precautions due to having an enteral feeding tube. Resident #43's Comprehensive Care Plan indicated that the resident was receiving restorative therapy PROM, splint to right hand. Review of Resident #43's Physician Order, dated 06/12/2024, reflected Restorative to provide: AROM and right hand splint. Observation on 07/16/2024 at 8:51 AM revealed that Resident #43 was on his bed, awake. It was observed that he was wearing a splint to his right hand. Resident did not reply when asked how long he had the splint. It was also observed that he had a g-tube to the right lower quadrant of his abdomen. In an interview with CNA D on 07/16/2024 at 10:46 AM, CNA D stated Resident #43 was dependent on staff for most of the ADLs. He said Resident #43's right hand was contracted and that was why he was wearing a splint. CNA D also said Resident #43 had a feeding tube but he was not aware if the resident was still using it. In an interview with the DON on 07/18/2024 at 8:24 AM, the DON stated if a resident still had his g-tube but was not using it, it should still be reflected in the MDS because it still needed to be care planned. There should still be an order on how to take of Resident #43's g-tube because the g-tube was still there for a reason. He said it should still be reflected on the medical diagnosis, physician orders, MDS, and care plan. He also said that if a resident had an impairment to the upper extremity, it should also be reflected in the MDS. He said the resident should be accurately assessed to provide the needed interventions. If the residents were not properly assessed, the proper care and needs would not be met. The DON said the expectation was the residents were properly assessed not only during admission but every day to see if there was a change in condition, any refusal of care, or resident acting different than usual. He said he would collaborate with the MDS Nurse and the ADON to audit MDS assessments and make appropriate changes. In an interview with the MDS Nurse on 07/18/2024 at 8:38 AM, the MDS Nurse stated if a resident had an impairment, it should be reflected on the MDS assessment or on the resident's profile. She said the medical diagnosis, physician order, MDS, and the care plan should be all in-line and should match to provide a clear overview of the resident's current condition. She said, by doing so, accurate goals and interventions would be provided. The MDS Nurse said she would check Resident #40 and Resident #43's profile and make the needed modifications. She said she was the one doing the assessment and must had overlooked it. She said if the resident had impairments, it should be reflected in the MDS. She added if the resident still had a g-tube, it should also be reflected in the MDS. She said an accurate MDS assessment was important because it would be the basis of the care needed by the resident. If the assessment was not accurate, the current status of the resident would not be correct resulting in a possible confusion on the residents' care. She said inaccurate assessment could also result in the resident not getting the appropriate care needed. She said she would make an audit to make sure the MDS would reflect the current condition of the residents. In an interview with the ADON on 07/18/2024 at 8:51 AM, the ADON stated if a resident had an impairment, it should be reflected on the system to make sure all the needed care was given to the residents. She added if a resident still had his g-tube, it should be reflected on the resident's profile because even though the resident was not using it, the g-tube site should still be observed. She added if the resident had an impairment, it should be reflected on the MDS. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. She said she would coordinate with the DON and MDS Nurse to address the issues. In an interview with the Administrator on 07/18/2024 at 9:21 AM, the Administrator stated that if a resident had an impairment or a g-tube, it should be on the MDS to reflect the current condition of the resident. She said, by doing so, the needs of the residents would be addressed. She said she would coordinate with the clinical managers to evaluate the situation, discuss it during quality assurance and do in-services. Record review of facility policy, Resident assessment Instrument 2001 MED-PASS 2001, Inc. Rev. December 2006 revealed Policy Interpretation . 3. The Purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity .

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two (Resident #40 and Resident #43) of eight residents reviewed for Care Plans. The facility failed to ensure Resident #40 and Resident #43 were care planned for their g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) not being used for nutrition but was still connected to the residents. This failure could place the residents at risk of not receiving necessary care and services. Findings included: Resident #40 Review of Resident #40's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #40 was diagnosed with dysphagia (difficulty in swallowing). Review of Resident #40's Quarterly MDS Assessment, dated 04/13/2024, reflected Resident #40 had a severe cognitive impairment with a BIMS score of 04. Resident #40's Quarterly MDS Assessment did not indicate that the resident still had a g-tube. Review of Resident #40's Comprehensive Care Plan on 07/16/2024 reflected no care plan for a feeding tube not being in use. Observation and interview with Resident #40 on 07/16/2024 at 8:46 AM revealed Resident #40 was sitting on his bed eating breakfast. After eating breakfast, Resident #40 stood up to fix his tray. It was observed that Resident #40 had a g-tube. Resident #40 stated he had a g-tube but he was not using it anymore. He said he was already eating through his mouth. Resident # 43 Review of Resident #43's Face Sheet, dated 07/16/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #43 was diagnosed with dysphagia. Review of Resident #43's Quarterly MDS Assessment, dated 04/30/2024, reflected Resident #43 had a severe cognitive impairment with a BIMS score of 03. Resident #43's Quarterly MDS Assessment did not indicate that the resident still had a feeding tube. Review of Resident #43's Comprehensive Care Plan on 07/16/2024 reflected no care plan for a feeding tube not being in use. Observation on 07/16/2024 at 8:51 AM revealed that Resident #43 was on his bed, awake. It was observed that he had a g-tube to the right lower quadrant of his abdomen. Resident did not reply when asked how long he had his g-tube. In an interview with the DON on 07/18/2024 at 8:24 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents receive the appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON said the care plan served as a tool for all individuals caring for the residents. He said the care plan should be comprehensive and should show what specific care the resident needed. He said the expectation was for all residents to have a complete and detailed care plan. He said he was responsible in checking if the care plans of the residents were comprehensive and in accordance with the current condition of the residents. He said he would audit the care plans of the residents and then make an in-service about care plans. In an interview with the MDS Nurse on 07/18/2024 at 8:38 AM, the MDS Nurse stated care plans were important to ensure the residents were getting the care needed. The MDS Nurse said care plans served as guides on how the staff will take care of the residents. The MDS Nurse said care plans were comprised of the problem lists, the goals, and the interventions appropriate to the needs of the residents. The MDS Nurse added that without the care plans, the staff could miss out significant interventions needed by the residents. She added if a resident still had his g-tube, there should be a care plan on how to take care of the g-tube while waiting to discontinue it. The MDS Nurse said she would go ahead and add the care plan for both residents. In an interview with the ADON on 07/18/2024 at 8:51 AM, the ADON stated it was important that residents have a care plan to fully provide the care and services the residents needed. The ADON said that for this case, there should be a care plan for g-tube like flushing it every shift so it will not be clogged up. She added if the g-tubes were not taken care for, there could be complications like infection to the g-tube site. She said the expectation was all the issue of the residents were care planned. In an interview with the Administrator on 07/18/2024 at 9:21 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff will ensure that every issue of the residents was care planned. She said she would coordinate with the DON and MDS Nurse to make sure all the residents were care planned accordingly. Record review of facility's policy, Care Planning - Interdisciplinary Team 2001 MED - PASS, Inc. rev. September 2013 revealed Policy Statement: Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident . 7. Care plans are updated to reflect items that are specific to the resident's care.

Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #1) of four residents reviewed for respiratory care. The facility failed to ensure that Resident #1's mask for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was properly stored. The facility failed to ensure that Resident #1's humidifier had water in it. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #1's Face Sheet, dated 07/16/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included pneumonia (inflammation of the lungs) and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body). Review of Resident #1's Comprehensive MDS Assessment, dated 04/03/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #1as on oxygen therapy and on non-invasive mechanical ventilator while a resident of the facility. Review of Resident #1's Comprehensive Care Plan, dated 07/05/2024, reflected that the resident was experiencing sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep) and required BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs)/CPAP. Review of Resident #1's Comprehensive Care Plan, dated 07/05/2024, reflected that the resident was receiving oxygen therapy continuously and one of the interventions was provide with humidification. Review of Resident #1's Physician's Order, dated 02/21/2023, reflected, BiPAP OFF @ 6 AM. Review of Resident #1's Physician's Order, dated 02/21/2023, reflected, BiPAP ON @ 11 PM. Review of Resident #1's Physician's Order, dated 08/14/2023, reflected Oxygen: Administer Oxygen @ 2-4 L/minute via nasal cannula or mask PRN for SOB/Cyanosis (bluish skin color due to decreased amounts of oxygen) if O2 < 93%. Observation and interview with Resident #1 on 07/16/2024 at 10:04 AM revealed resident was on her bed, awake. Resident #1 had a CPAP machine on top of her bed side table and a CPAP mask was connected to the machine. The CPAP mask was noted on top of the CPAP machine. The CPAP mask was not bagged. Resident #1 stated she used the CPAP machine at night. The resident said the staff would put the CPAP on her at night and a staff would take it off in the morning. She said she never saw a plastic bag for the CPAP mask and nobody told her to put the mask on it on a bag if ever she would take it off. It was also observed that Resident #1 was on oxygen therapy at 3 liters per minute via nasal cannula. The nasal cannula was connected to an oxygen concentrator. The oxygen concentrator had no water in it. Resident #1 said she did not notice there was no water on her humidifier. In an interview with LVN A on 07/16/2024 at 10:07 AM, LVN A stated she did not notice that Resident #1's mask for CPAP was not bagged when she did her morning round. She also said she did not notice the water in the humidifier was running low. She said the mask should be bagged to prevent cross contamination. She said there should be water in the humidifier to prevent irritation in the nasal passage. She said she would get a plastic bag for the CPAP mask and a new pre-filled humidifier for the resident. In an interview with the DON on 07/18/2024 at 8:24 AM, the DON stated the CPAP mask should be bagged when not in use. He said if the CPAP mask was not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said it could also result in cross contamination and respiratory infections. He said the humidifier should have water in it to prevent irritation of the nose and throat. He said the expectation was for the CPAP mask to be stored properly and the humidifier to have water in it always. The DON concluded that moving forward, he would do an in-service about bagging the CPAP mask and monitoring if the humidifier had water in it. He said he would continually remind them to be diligent in making sure the procedures for respiratory care were followed. In an interview with the ADON on 07/18/2024 at 8:51 AM ,the ADON stated the CPAP mask should be bagged when the resident was not using it to prevent cross contamination and infection. She said the staff who take off the mask should put it in a bag. She said if the resident was the one taking it off, there should be a bag ready for them to put the mask in. She also said that the resident should be educated why the mask should be bagged. The ADON said there should be water in the humidifier to prevent irritation of the nasal passage. She said the expectation was for the staff to bag the CPAP mask. She said she would coordinate with the DON to do an in-service pertaining to bagging the CPAP mask and making sure there was water in the humidifier. In an interview with the Administrator on 07/18/2024 at 9:21 AM, the Administrator stated that in general, the CPAP masks should be stored properly to prevent respiratory issues or exacerbation of whatever respiratory issues the residents already had. The Administrator said there was water in the humidifier for a reason. The Administrator said the expectation was for the staff to be mindful during their rounds and make sure the CPAP masks were bagged and there was water in the humidifier. The Administrator said she would check if the clinicians already did correct the issue. Record review of facility policy, Oxygen Administration 2001 MED - PASS, Inc. revised March 2004 revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administrator . Steps in the Procedure . 12 . be sure there is water in the humidifying.

Based observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one (Resident #44) of twelve residents observed for incontinent care . The facility failed to ensure that CNA D did not wipe from front to back while providing incontinent care to Resident 44 on 07/16/24. These failures could place the residents at risk of cross-contamination and development of urinary tract infections. Findings included: 1.Review of Resident #44's Face Sheet, dated 07/16/2024, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included post COVID-19 condition and pneumonia. Review of Resident #44's Comprehensive MDS Assessment, dated 06/01/2024, reflected Resident #44 was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #44 was always incontinent for bowel and bladder. Review of Resident #44's Comprehensive Care Plan, dated 06/15/2024, reflected resident was incontinent for bowel and bladder: wears incontinent briefs and requires staff assistance for incontinent care and one of the interventions was incontinent care by staff every two hours and prn. Observation on 07/16/2024 at 11:59 AM revealed Resident #44 was on her bed, awake. CNA D told the resident that he was going to clean her up. CNA D washed his hands and put on a pair of gloves. CNA D then lowered the head of the bed, unfastened the brief on both sides, and tucked the front part of the brief between the legs of the resident. CNA D cleaned the front part of the resident using the front to back technique. After cleaning the front part, CNA D told the resident to roll to one side. Resident #44 had a small bowel movement. CNA D then started to clean the bottom. CNA D wiped the resident from back to front. The wipes had feces on them. He wiped the resident's bottom towards the front resident's front part five times. CNA D took off his gloves, sanitized his hands, and put on a new pair of gloves. CNA D then took the new brief, placed it on the resident's bottom, and fixed it. He then told the resident to roll back. The resident rolled back and CNA D fastened the brief. CNA D fixed the blanket and gave the resident her call light. In an interview with CNA D on 07/16/2024 at 12:19 PM, CNA D stated he used the front to back technique when he cleaned Resident #44's front part. CNA D said for the bottom, the wiping should not be towards the front to prevent the microorganisms from the anal area going to the front part of the resident. He said this could cause a urinary tract infection. He said he was unaware he did the wrong wiping. He said he should be mindful of how he does incontinent care because the resident would be at risk for infection. In an interview with the DON on 07/18/2024 at 8:24 AM, the DON stated he would do an in-service about infection control for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control. In an interview with the Administrator on 07/18/2024 at 9:21 AM, the Administrator She said she would collaborate with the clinicians to in-service the staff about infection control. Review of facility policy, Perineal Care revealed Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections . Steps in the Procedure . 11. For a female resident . d. Cleanse the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 11 resident (Resident #1) reviewed for accidents and hazards supervision. The facility failed to provide adequate supervision to prevent the elopement of Resident #1 between 01/28/2024 at 10:30 PM and in Resident #1 being found outside of the facility on 01/29/2024 at 3:06 AM. An IJ was identified on 05/26/2024 at 12:52 PM. The IJ template was provided to the facility on [DATE] at 2:00 PM. While the IJ was removed on 05/28/2024 at 2:05 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on supervision and elopement. This deficient practice could result in a risk to the residents' health and safety and placed the resident at risk of heat or cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. The findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old male admitted initially on 10/23/2023 and readmitted on [DATE] with a discharge date on 02/05/2024. Diagnoses included: PTSD (A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), MDD (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), mood disorder (a disorder in which you experience long periods of extreme happiness, extreme sadness or both), and other stimulant abuse (Excessive use of psychoactive drugs, such as alcohol, pain medications, or illegal drugs.) Record review of Resident #1's EHR and physician orders reflected five related orders for a wandeguard all dated on 01/30/2024. Further review of the EHR reflected no consents obtained from the RP. Record review of Resident #1's progress notes, dated 01/29/2024 at 12:32 AM, authored by LVN E, reflected a late entry from 01/27/2024 that Resident #1 was trying to elope when a late arrival of a CNA resulted in him being revealed to be outside of the facility on the corner of the street and coaxed back into the facility. The notes reflected Resident #1 was being supervised and observed while he was outside of the facility by staff, including but not limited to LVN E. Record review of Resident #1's progress notes, dated 01/29/2024 12:40 AM, authored by LVN E, reflected Late entry for 1/28/24 . resident continued to elope and exit seek all day, wanderguard placed to R wrist, resident set off alarm to front entrance . ammonia last checked 12/21/23, also received order for prn lorazepam 0.5 mg q 6 hrs, nurse called [in order] and went through process of requesting first dose through [emergency med kit], medication was effective, resident also ripped off wandergaurd, it was found on his room floor by his bed . Record review of Resident #1's progress notes, dated 01/29/2024 4:51 AM, authored by LVN A, reflected at 10:30 PM Resident #1 was observed to be wandering around the nurse's station going toward the snack machines with walker and without his wanderguard. The note continues that at 1:40 AM the following morning on 01/29/2024 Resident #1 was unable to be located after searching his room and bathroom. The note continues that at 2:05 AM, the DON, ADON, and ADM were notified of the elopement. The note continues that at 3:06 AM, the DON located Resident #1 2.5 blocks away at a local fast food restaurant location with Resident #1 stating he was hungry and felt pain in his bilateral lower extremities. The note continues at 3:16 AM, LVN A assessed Resident #1 and Resident #1 stated he is always hurting and denied medication for pain and answered why he left the facility with Resident #1 responding that he was hungry and wanted to get something to eat. Record review of google maps reflected distance from [Resident #1's destination] to facility is 0.9 miles away, winding road, typically high traffic area. Record review of historic temperature records reflected on 01/29/2024 at 1:51 AM, the temperature was 44 degrees Fahrenheit. Record review of SBAR, dated 01/29/2024, authored by LVN A, reflected Resident #1 returned cooperatively, was provided PRN Ativan for agitation, and the incident was reported to the RN case manager, and RP. Record review of wanderguard placement Q 30 minute monitoring, dated 02/05/2024, reflected monitoring took place from 10:30 PM to 7:30 AM the following morning. Phone interview on 05/22/2024 at 1:53 PM, Resident #1's Family Member B stated Resident #1 was only recently revealed to be an elopement risk after a change in condition. Resident #1's Family Member B stated the staff discussed with him about having a wanderguard and being exit-seeking. Resident #1's Family Member Bstated he felt concerned with the number of staff at the facility in the evening and overnight. Resident #1's Family Member B stated he was notified about the elopement on 01/29/2024 and that after, the facility stated they were going to look into accepting facilities for a transfer. Interview on 05/22/2024 at 3:11p.m., LVN R stated Resident #1 experienced a sudden change in condition, and that the elopement was very unexpected. LVN R stated Resident #1 would verbalize wanting to go home frequently since before the elopement. LVN R stated Resident #1 has attempted to elope from the facility since the successful elopement on 01/29/2024. LVN R stated after the elopement, Resident #1 was discharged from the facility within a couple days but before he was discharged , he was placed on a perpetual 1:1 supervision. Phone interview on 05/23/2024 at 9:57 AM, LVN A stated she did more frequent rounding as she knew Resident #1 was an elopement risk due to being confused, having liver disease, and being on hospice. LVN A stated constant watch was needed for Resident #1. LVN A stated each nurse had two halls to cover during the 10 PM to 6 AM shift, and on 01/29/2024, after midnight during rounds, she noticed Resident #1 was not in bed while assisting with another resident concern across the hall. She returned to search his bathroom to no avail, followed by telling the remaining staff to help in the search. LVN A stated after they swept the building, she contacted the ADM, DON, and ADON. LVN A stated the front door had an alarm, and that the alarm did not go off. LVN A stated CNA D was working that night. LVN A stated the staff might have turned off the front door alarm off as they went outside to smoke, get food, or get fresh air. LVN A stated there were normally three aides in the night, but sometimes four. LVN A stated any of the staff can turn on the front door alarm, but she will check the door herself. LVN A stated Resident #1 was aware of potential danger with leaving the facility, and when Resident #1 returned she asked him how he got out and stayed safe to which he replied he walked out the front door and was staying on the sidewalk. LVN A stated the primary danger with Resident #1 potentially eloping was Resident #1 would have moments of confusion and not know where he was and be in danger. LVN A stated Resident #1 would refuse medications frequently thus causing his ammonia levels to be toxic which would result in confusion. LVN A stated staff were doing the rounds and felt the primary reason she was not aware of Resident #1 being gone was because there were too many residents to staff. LVN A stated she had expressed concern with her administration to explain the need for more staff but stated she felt the facility was actually higher staffed than most other buildings she had worked at previously. LVN A stated CNA B was the last one to see him at midnight and noted his brief was dirty. Phone interview on 05/23/2024 at 10:16 AM, CNA B stated she was present for when Resident #1 was found and missing. CNA B stated she was not sure what time he was missing or when he returned. CNA B stated the facility front door was supposed to be kept locked after hours, but it isn't always locked due to pharmacy, family, or a food delivery service. CNA B stated the staff must lock the door manually by the keypad, and the door stays unlocked until it is locked back again manually. CNA B stated she does not remember if the front door was locked during the night of 01/28/2024. Interview on 05/23/2024 at 12:27 PM, the ADM stated the front door had a code and that the staff are required to lock the door. The ADM stated she interviewed the nursing staff regarding Resident #1's elopement but did not discover why the front door alarm did not go off. She stated the risk was that Resident #1 or someone else could be stuck by a motor vehicle. Interview on 05/24/2024 at 3:42 PM, the DON stated Resident #1 was assessed on 01/28/2024 to require a wanderguard, initially place on resident on 1/28/24, due to repeated attempts to elope, was placed on 1:1 but resumed to a regular state. The DON confirmed all staff had been trained on elopement prevention prior during regular in-services and annual training but could not identify the last date of a training that all staff took part in. Record review of the facility Provider's Investigation Report, dated 02/05/2024, reflected the incident occurred on 01/29/2024 at 3:06 AM when victim was found at a local restaurant, Resident #1 was noted by charge nurse in bed at 1:40 AM, Resident #1 had removed wanderguard and it was observed next to bed, after incident, in-service completed on elopement, routine checks, resident ID system, and ANE. Also completed referrals for d/c but were denied initially and was eventually sent out to VA per his request. Record review of the facility's policy, titled Protocol for WanderGuard Placement, undated, reflected WanderGuards were to ordered by the physician. Record review of policy for securing exits/entrances, grounds security, titled Exits or Means of Egress, dated revised June 2005, reflected did not provide any relevant information related to securing the facility's doors. Record review of schedule for 01/28/2024 reflected on the 10PM - 6AM shift had 2 nurses and 4 CNA's: CNA D, CNA D, CNA B, and Staff W. Record review of in-service, titled Communication between nurses and CNA's, nurses completing 24hr report, CNA's notifying of changes, dated 01/29/2024, intended for All nursing staff reflected 42 staff in-serviced. Record review of in-service, subjected Elopement, dated 01/29/2024, intended for All staff, reflected 42 staff in-serviced. Record review of in-service, subjected ANE, dated 01/29/2024, intended for All staff, reflected 56 staff in-serviced Record review of elopement prevention policy, titled Elopements, dated revised August 2006, reflected staff were to complete routine rounding, to immediately have begun a search if suspected missing resident with have notified other staff to assist in search, and one they were believed to have left the premises they were to notify ADM, DON, and MD/NP to continue/assist search off premises, followed by doing a full report and full assessment to confirm of injury, along with incident report. An Immediate Jeopardy (IJ) was identified on 05/26/2024 at 12:52 PM and presented to the Administrator at 2:00 PM. A Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/27/2024 at 02:11 PM. Date:_05/26/2024 Immediate action: Facilities Plan to ensure compliance quickly Resident #1 was discharged from the facility on 02/05/2024. This resident had no injuries related to the elopement. Elopement occurred on 01/29/2024. See nurses note for resident assessment: 01/29/2024 0316 Resident assisted to bed. Assessed head to toe. No obvious injuries noted. Denies falling. Verbalizes pain/discomfort to bilateral lower extremities. Noted with edema to bilateral feet/ankles. Resident again denies fall or hurting himself. Stated that he is always hurting. Able to move both feet and ankles with no issues. Full range of motion to all extremities without any complaints of acute pain. Denies wanting anything for pain. Asked resident why he left the building. Resident stated he was hungry and wanted something to eat. Reminded resident needed to call for assist and that it is not safe to be outside by himself. Resident then stated he was tired and wanted to go to sleep. No signs of acute distress. Will continue to monitor. Role: N, Category: Nurses Note, Significance: High Signed by: [LVN A] 05/26/2027 The facility will perform an elopement risk assessment for all residents to ensure no current residents are at risk for elopement. As of 05/26/2027[sic 2024] - 0 residents triggered for elopement risk after 100% elopement risk assessment completed. 05/26/2027 [sic 2024]No residents currently with a wander guard in the building at this time. If a resident removes a wander guard they will be placed on a 1:1 until wander guard can be replaced or resident is discharged . 05/26/2027 [sic 2024]All nursing staff to be in-serviced on facility Elopement Policy. 05/27/2024 Elopement policy to be part of all new hire orientation and orientation to agency staff. Per preliminary findings noted see below: Phone interview on 05/23/2024 at 10:16 AM, CNA B stated she was present for when Resident #1 was found and missing. She stated she was not sure what time he was missing or when he returned. She stated the facility front door is supposed to be kept locked after hours, but it isn't always locked due to pharmacy, family, or a food delivery service. She stated the staff must lock the door manually by the keypad, that the door stays unlocked until it is locked back again manually. She stated she does not remember if it was locked during the night of 01/18/2024. Incorrect date of elopement was not 01/18/2024 but 01/29/2024. 05/27/2024 Door lock check to be completed and logged by 2-10 shift and 10-6 shift. 05/27/2024 DON/Designee to monitor by spot checking each shift by contacting nurses. Monitoring of the POR was as follows: Interview on 05/27/2024 at 3:19 PM, LVN G stated she works the 2-10 shift and confirmed she received an in-service on elopement. She stated the appropriate protocol is to check on every resident every two hours. She stated the facility uses wanderguards and if the resident takes it off, to consider changing the position. She stated protocol when a resident is attempting to elope and removes the wanderguard, and can utilize 1:1. She confirmed front door locking is to take place once the receptionist leaves, even if there are visitors in the facility. Interview on 05/27/2024 at 3:25 PM, CNA H stated she normally works the 6-2 shift and confirmed she received an in-service on 05/26/2024 regarding elopement. CNA H confirmed she understood the policy as it was described and affirmed confidence on the protocol. CNA H stated she understood the expected protocol related to elopement prevention and the in-service affirmed her understanding of the policy. Interview on 05/27/2024 3:39 PM, CNA I, stated she works the 2-10 shift and confirmed she received an in-service on elopements. CNA I confirmed she understood the policy as it was described and affirmed confidence on the protocol. CNA I stated she understood the expected protocol related to elopement prevention and the in-service affirmed her understanding of the policy. Phone interview on 05/27/2024 at 4:08 PM, LVN K, stated he works generally the 10-6 shift and confirmed he received an elopements in-service that included reviewing the residents during the shift. LVN K confirmed the in-service included front door locking and monitoring, ensuring it was locked. LVN K stated he understood the expected protocol related to elopement prevention and the in-service affirmed her understanding of the policy. Phone interview on 05/27/2024 at 4:12 PM, RN L stated she works the 2-10 and 6-2 shift and confirmed she received the in-service regarding elopement, and what to do when a resident attempts to elope. RN L stated she understood the expected protocol related to elopement prevention and the in-service affirmed her understanding of the policy. Phone interview on 05/27/2024 at 4:19 PM, LVN A stated she works the 6-2 shift and confirmed she received the in-service on elopement, and confirmed she understood the policy to a high degree and described the elopement protocol was to attempt wanderguards but even to attempt 1:1 supervision if the wanderguard is ineffective. LVN A stated she understood the expected protocol related to elopement prevention and the in-service affirmed her understanding of the policy. Interview on 05/28/2024 at 9:24 AM, CMA O stated she normally worked the 6-2 shift and confirmed she was in-serviced on elopement before the start of her shift. CMA O stated she in-service was conducted by the ADON and discussed elopement prevention measures including wanderguards, frequent monitoring, and observing the front door. CMA O stated she understood the expected protocol related to elopement prevention and the in-service affirmed her understanding of the policy. Interview on 05/28/2024 at 9:31 AM, LVN F stated he normally works the 6-2 shift but will also work the 2-10 shift and on weekends. LVN F stated he received an in-service on elopement and confirmed he felt confident on the content of the in-service. LVN F stated the in-service discussed prevention measures in elopement and denied any current residents being an elopement risk. Interview on 05/28/2024 at 9:42 AM, CNA P stated he was the staffing coordinator for the facility but will frequently work the floor as an aide during the 6-2, 2-10, and will often fill in shifts on the 10-6 shift. CNA P he confirmed he received an in-service on elopement and felt confident on the content. CNA P stated he was also in-serviced on the front door locking as to ensue the front door was locked during the evening times after the receptionist leaves. Interview on 05/28/2024 at 9:49 AM, RA Q stated she generally worked the 6-2 and 2-10 but will also sometimes work the 10-6 shift including weekends. RA Q stated the received an in-service on elopement and denied any current residents who were exit-seeking and elopement risks. RA Q stated she was in-serviced on the protocol regarding the front door locking and felt confident on the course content. Interview on 05/28/2024 at 9:55 AM, CMA R stated she normally works the 6-2 and 2-10 shift in doubles, and confirmed she received an in-service before she started her shift yesterday. CMA R confirmed the ADON provided the in-service to her and felt confident on the in-service content. CMA R confirmed the elopement in-service included elopement prevention measures and protocol when residents might remove the wanderguard equipped. Interview on 05/28/2024 at 10:18 AM, LVN S stated she was the case manager for the special-contracted residents and confirmed she did receive the in-service regarding elopements and the front door locking. LVN S stated she normally only works from 8-5 M-F but stated she will assist on the floor and will conduct trainings herself. LVN S stated she received the in-service along with other staff and that it was delivered by the ADON. LVN S stated she felt confident on the course content and felt comfortable with how the in-service was conducted. Interview on 05/28/2024 at 10:21 AM, LVN T stated she normally worked the 6-2 and 2-10 every weekend but has recently started working the 6-2 shift on the weekdays as well. LVN T stated she received the training on elopement and felt confident on the content of the in-service. LVN T stated the ADON provided the in-service and denied any current residents were an elopement risk and stated she was also in-serviced on the front door locking protocol to ensure the front door remained locked after the receptionist left at 7 each day. Interview on 05/28/2024 at 10:36 AM, CNA U stated she normally worked the 6-2 shift exclusively and stated she received the in-service on elopement. CNA U stated the in-service described when an elopement resident is admitted or when someone has a change in condition that they would receive more frequent supervision and to communicate with the charge nurse if the resident is exit-seeking or if they remove their wanderguard. Interview on 05/28/2024 at 10:41 AM, RN V stated he was primarily the weekend RN supervisor and stated he will also work the 6-2 on occasion as he was today. RN V stated he received the in-service on elopement that discussed the front door remaining locked after hours. RN V stated he was also in-serviced on elopement prevention measures to take such as increased monitoring and supervision, in addition to having wanderguards to alert staff. Record review of Elopement Risk Tool assessments completed, dated assessments all on 05/26/2024 from 3:37 PM through 7:13 PM reflected a total of 76 total residents reviewed for elopement risk. Record review of Resident #3's Elopement Risk Tool Assessment, dated 05/26/2024, reflected Resident #3 was determined to not be an elopement risk. Record review of Resident #4's Elopement Risk Tool Assessment, dated 05/26/2024, reflected Resident #3 was determined to not be an elopement risk. Record review of Resident #5's Elopement Risk Tool Assessment, dated 05/26/2024, reflected Resident #3 was determined to not be an elopement risk. Record review of Resident #6's Elopement Risk Tool Assessment, dated 05/26/2024, reflected Resident #3 was determined to not be an elopement risk. Record review of Resident #7's Elopement Risk Tool Assessment, dated 05/26/2024, reflected Resident #3 was determined to not be an elopement risk. Record review of Resident #8's Elopement Risk Tool Assessment, dated 05/26/2024, reflected Resident #3 was determined to not be an elopement risk. Record review of Resident #9's Elopement Risk Tool Assessment, dated 05/26/2024, reflected Resident #3 was determined to not be an elopement risk. Record review of Resident #10's Elopement Risk Tool Assessment, dated 05/26/2024, reflected Resident #3 was determined to not be an elopement risk. Record review of in-service, dated 05/26/2024, titled Policy and procedures; Risk of elopement - routine resident checks to help maintain resident safety and well-being, address to [Facility] Nursing Staff, reflected 56 of 63 total signatures. Record review of the DON's spot check list for nurses, titled Monitoring: DON/ Designee will spot check each shift by contacting nurses and verify if there is no incidents or accidents with in the current shift. It reflected a layout of five instances asking Any incident or accident during the shift? If YES, is complete incident and accident protocol completed by nurse. With date, details box, and whether the care plan was initiated. Further reflected were indications of spot checks completed on 05/27/2024 on the 2-10 shift with a single unwitnessed fall, to add note and initiate protocol. An additional indication was reflected on 05/27/2024 - 05/28/2024 on the 10-6 shift with a reported resident expiration taken place. Record review of an email, dated 05/27/2024 at 12:03 PM, reflected the ADM enacted a new policy to the Human Resources Director to amend the new hire orientation for all staff and agency to also review and sign the policies: Elopements, Falls - Clinical Protocol, and Falls P&P Assessing Falls and Their Cause. The Administrator was informed on 05/28/2024 at 2:05 PM that the IJ was removed, however the facility remained out of compliance at a scope of Isolated and a severity level of No Actual Harm with Potential for More Than Minimal Harm that is Not Immediate Jeopardy because all staff had not been trained on supervision and elopement.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 11 resident (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2 was not left without care after her initial fall on 03/08/24 at 1:30 AM until after a second fall on 03/08/24 at 6:30 AM which resulted in a left hip and left distal radius fracture. An IJ was identified on 05/26/2024 at 12:52 PM. The IJ template was provided to the facility on [DATE] at 2:00 PM. While the IJ was removed on 05/28/2024 at 2:05 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on fall prevention. This deficient practice placed residents at risk of experiencing a delay in treatment that could resulted in harm or potentially death. The findings included: Record review of Resident #2's Comprehensive MDS assessment, dated 03/18/2024, reflected an [AGE] year-old female with an admitted [DATE], was assessed to have moderate cognitive impairment, with a primary diagnosis of Encounter for other orthopedic aftercare (receiving orthopedic services after a treatment). Additionally it reflected Resident #2 was assessed to be dependent on staff of both toilet transfers and toilet hygiene. Record review of Resident #2's Comprehensive MDS, dated [DATE], reflected Resident #2 was assessed to be independent for toilet transfers and toilet hygiene. Record review of Resident #2's Comprehensive Person-Centered Care Plan on fall prevention, reflected an intervention dated 03/11/2024 that upon return from acute care to enact fall prevention policy minimize risk. Record review of Resident #2's face sheet, dated 03/25/2024, reflected Family Member A was Resident #2's RP. Additionally reflected was Resident #2 was diagnoses with but not limited to: Dementia, unspecified lack of coordination, other specified disorders of muscle, muscle weakness, adult failure to thrive, and displaced intertrochanteric fracture of left femur. Record review of the EMS run report, dated 03/08/2024, reflected EMS was contacted at 7:00 AM, Resident #2 was picked up by EMS at 7:44 AM, and arrived at the ER at 7:56 AM. Record review of Resident #2's progress notes, dated 03/08/2024 at 11:36 PM as a late entry for 1:30 AM, by LVN C, reflected: Called to resident's room by CNA. Found resident sitting on floor with her back against the closet. Crying, anxious calling for help. Assessed for injury. With assist of CNA resident lifted off floor to a standing position. Gait unsteady but did walk to bed. Placed in Bed . Record review of Pain Evaluation, dated 03/08/2024 at 11:55 PM as a late entry for 1:30 AM, by LVN C, and revealed to be the first assessment completed for Resident #2, in reference to the fall on 03/08/2024 at 1:30 AM, reflected Resident #2 denied pain and did not receive pain medication, and that Resident #2 had discoloration on left thumb with good dexterity. Record review of Skin/Wound Observation, dated 03/08/2024 at 11:59 PM as a late entry for 1:30 AM, authored by LVN C, in reference to fall on 03/08/2024 at 1:30 AM, reflected Resident #2 had bruising on her left hand and that there was a change in skin condition, and there was a slight discoloration forming on left thumb. Record review of SBAR, dated 03/09/2024 at 12:12 AM as a late entry for 1:30 AM, authored by LVN C, reflected [Resident #2] found on floor sitting in room sitting up with back against the wall next to closet and feet stretched out toward bed. Crying and calling for help. And further reflected under Provider Notification Comments At 0635 [AM] [Resident #2] fell again while attempting to ambulate to bathroom without assistance, when lifted off floor and assisted back to bed, noted dislocation of left hip. Nurse notified physician and MD okayed transfer to [ER] to eval and treat. Record review of Resident #2's progress notes, dated 03/09/2024 at 2:56 AM as a late entry for 03/08/2024 at 6:30 AM, authored by LVN F, reflected .nurse note bruising to the left hand, c/o pain to left leg after getting in bed the resident could no longer move her leg out of pain, [notified] md who gave order to send to [local] hospital to eval and treat, notified rp and management assist x2 (two person assistance) to Transferring Record review of Resident #2's hospital records, dated 03/11/2024 from 3:19 PM, reflected the following related to a CT scan of Resident #2's left hip: 1. Com minuted, displaced and angulated fracture of the left proximal femur. This involves the basicervical portion of the femoral neck, and intertrochanteric regions with displaced fractures of the greater and lesser trochanters. 2. Osteopenia. No discrete underlying bone lesion is identified. 3. Posttraumatic soft tissue edema about the lateral aspect of the left proximal thigh and the hip. Referring to a CT scan of both hips reflected: Comminuted, laterally angulated subtrochanteric/intertrochanteric left femoral fracture. 2. Osteopenia and degenerative bony changes. I, [NAME] F [NAME], have personally interpreted the image(s) and dictated this examination or I have reviewed the image(s) as well as the residents interpretation and agree with the interpretation. Referring to an x-ray of the left hand, left wrist, left forearm, and left elbow: Left distal radius intra-articular impaction fracture with mild articular diastases. 2. Age-indeterminate scapholunate diastases. 3. Chronic ulnar styloid ossified body. 4. No acute fracture or dislocation of the left elbow or hand. 5. Osteopenia and osteoarthrosis. Record review of Provider's Investigation Report, dated 03/25/2024, reflected the incident involving Resident #2 occurred on 03/08/2024 at 1:30 AM, and reported to the state on 03/18/2024 based on Resident #2's family member expressing concerns and allegations of neglect, that LVN C failed to notify MD and RP of fall. Additionally reflected, after the fall occurred at 6:35 AM an assessment of Resident #2 was completed and transferred to the ER at 7:00 AM, followed by completing an in-service on fall prevention, ANE, charting and documentation and terminating LVN C. Observation on 05/22/2024 at 3:32 PM, Resident #2 was revealed to be sitting in a wheelchair in her room with a bandage on her right arm. Resident #2 stated she has had the bandage for an unknown time and stated she showers herself on her own and fell recently which caused her arm injury needing the bandage. Resident #2 stated she did not remember her fall from 03/08/2024 and denied memory of anything related. Phone interview on 05/23/2024 at 11:10 AM, Resident #2's Family Member A stated the morning of the incident, at about 6:50 AM someone called her to tell her that Resident #2 was sent to the ER, to which the caller denied it being about seizures and specified it being about a fall that morning. Resident #2's family member stated the staff found her on the floor before she was sent to the ER. Resident #2's family member stated the caller notified her Resident #2 possibly broke her leg or her hip, and it was later discovered she did break her left hip and left wrist. Resident #2's Family Member A stated Resident #2 had surgery the following day and received a rod in her femur. Resident #2's Family Member A stated the following morning (03/09/2024) she called the ADM and was informed that Resident #2 had experienced two falls and not one, to which Resident #2's family member was confused about the occurrence of a second fall. Resident #2's family member stated Resident #2 mobilized with a walker. Resident #2's family member stated the ADM told her the bed was soiled, Resident #2 was placed back in the bed and was later found on the floor by LVN F and was sent to the ER. Resident #2's family member stated Resident #2 asked for assistance from the staff but the staff will not always come promptly. Resident #2's family member stated the conversation with both the ADM and DON regarding whether the incident appeared to be neglectful was on the following Monday (03/18/2024). Phone interview on 05/23/2024 at 11:58 AM, CNA D stated she remembered the first fall on 03/08/2024 at 1:30 AM involving Resident #2 yelling for help very faintly against the wall when CNA D told LVN C to which they both laid Resident #2 in the bed. CNA D stated Resident #2 expressed a lot of pain, but Resident #2 kept asking for a restroom break repeatedly, but CNA D declined so as to not cause more pain. CNA D stated she felt uncomfortable with how LVN C declined to take action on the fall at 1:30 AM but did not express this as she felt it was out of her scope of practice. Interview on 05/26/2024 at 11:50 AM, LVN F stated during shift change on 03/08/2024 he and LVN C heard Resident #2 yelling, observed Resident #2 to be wrapped up in the sheets, without a brief or any clothing whatsoever and observed a wet substance on the floor, unsure if it was urine. LVN F stated after he assisted Resident #2 back into the bed, he observed one leg to be shorter than the other and believed it to be consistent with a potential fracture. LVN F stated Resident #2 expressed pain, and she described her pain expression to be on her leg. LVN F stated Resident #2 stated she fell in the shower room, but due to the Resident #2 being a 2PM to 10PM shower he concluded Resident #2 was confused. Interview on 05/23/2024 at 11:55 AM, the DON stated he was contacted on 03/08/2024 regarding Resident #2's 2nd fall and discussed with LVN F whether the MD was contacted. The DON stated LVN F confirmed the MD was contacted after the 2nd fall but was uncertain on the first fall earlier that morning. Interview on 05/23/2024 at 12:10 PM, the ADM confirmed she was the ANE coordinator. The ADM stated she had the responsibility of reporting and investigating abuse and neglect. The ADM stated she was first informed on 03/08/2024 of Resident #2's fall by the family and not by any staff member. The ADM stated all major injuries were to be reported to her. The ADM stated during the termination conference LVN C was apathetic and did not seem to care about her termination. The ADM stated the expectation was for LVN C to report the fall to the MD and to the DON or ADM. The ADM stated Resident #2 was independent at the time and would not ask for help, during which she felt Resident #2 slipped on her way to the restroom and was assessed to go out. The ADM stated during the in-person meeting with Resident #2's family member, the determination of neglect was made. Interview on 05/23/2024 at 1:33 PM, the MD confirmed he was informed of this incident afterwards with no known particular time, but confirmed he was never informed by the charge nurse during the first fall regarding the details of the fall and that if he had been contacted, an assessment and review could have taken place but he was never given the opportunity. The MD stated he was uncertain of what action he would have taken at that time as he would have questioned LVN C of what observations and assessments she made of Resident #2 to determine if discharge to the ER was necessary. Attempted a phone interview with LVN C on 05/23/2024 at 11:09 AM and 2:51 PM, and on 05/24/2024 at 12:27 PM, there was no answer, left voicemail. Record review of LVN C's skills checkoff, dated 12/21/2023, titled LVN/LPN --- Job Functions, reflected a hire date of 11/21/2023, and further reflected the LVN C was determined to Performs Function Satisfactorily in the areas of Notify the resident's attending physician when the resident is involved in an accident or incident but no evaluation of notifying family of incidents. Record review of LVN C's termination notice, dated 03/11/2024, reflected LVN C signed confirming their termination and understanding for the incident. Record review of in-service, dated 03/19/2024, subjected documentation of incidents, notification to RP's and MD's, completing assessments, intended for Nursing reflected 17 nurses in-serviced. Record review of in-service, dated 03/19/2024, subjected ANE intended for All Staff, reflected 33 total staff in attendance. Record review of in-service, dated 03/22/2024, subjected ANE intended for All Staff, reflected 17 total staff in attendance. Record review of facility fall prevention policy, titled Falls, undated, reflected The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications associated with increased falling risk) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant). a. Falls often have medical causes; they are not just a nursing issue. And The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. And Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. And The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. And The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. An Immediate Jeopardy (IJ) was identified on 05/26/2024 at 12:52 PM. The IJ template was presented to the Administrator at 2:00 PM. A Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/27/2024 at 02:11 PM. Immediate action: Facilities Plan to ensure compliance quickly Resident #2 head to toe assessment completed and resident with no injuries at this time, no complaints of pain. 05/26/2024 04:44 PM Head to toe: scab to back of head from previous fall area is flat no swelling scab is intact. No drainage signs of infection. No other areas of concern to head. Right people is around, even and brisk with light stimulation at 33MM, left eye with blindness, presents with corneal opacity, orbital mucosal membranes are pale and color, no conjunctivitis, or drainage. Nasal and oral membranes are appropriate and color, no aeration or areas of concern. Upper range of motion assessed move appropriately. Hand grasps And even. Multiple areas are see now per are seen to bilateral upper extremities. Chest, abdomen and back are intact with no areas of concern. Left lower presents with 0.5 inch skin tear. No signs of infection. Skin is presented with no skin loss. [NAME] skin was retracted and is healing well. Range of motion, assess and move appropriately. Abdomen, genital, and [NAME] crest are all intact with no skin concerns. Left upper leg presents with surgical incision scar, which is flushed to skin no redness or irritation, signs or symptoms of infection and intact. Areas of concern to lower leg heels, feet or toes, Resident denies any pain discomfort, or any other concerns at this time. Role: N, Category: Nurses Note Signed by: [Staff] Nurse, LVN C failed to notify MD and RP was immediately suspended and terminated on 03/11/2024. Termination is part of the self-report submitted. Second fall noted at 0635 hrs. LVN F notified MD and RP of fall and MD ordered resident sent to the hospital. Per preliminary findings indicating LVC C instead of LVN F. At 0635 [Resident #2] fell again while attempting to ambulate to bathroom without assistance, when lifted off floor and assisted back to bed, [LVN C] noted dislocation of left hip. [LVN C] notified [MD] and [MD] okayed transfer to [ER] to eval and treat. 05/26/2024 All nursing licensed staff immediately in-serviced on facility policy Fall - Clinical Protocol and facility policy Assessing Falls and Their causes. 05/27/2024 Fall - Clinical Protocol policy and Assessing Falls and Their causes will be part of orientation packet to be reviewed with new hires and part of orientation for agency staff. 05/26/2024 Fall Risk Assessment to be completed on all residents to ensure fall risk are up to date. 05/27/2024 DON/Designee to spot check each shift by contacting nurses. Monitoring of the POR was as follows: Interview on 05/27/2024 at 3:01 PM, RN J stated she worked the 2-10 shift and confirmed she received an in-service on falls and felt confident on the content. RN J stated the in-service was completed by LVN F and felt affirmed on the appropriate protocol. Interview on 05/27/2024 at 3:19 PM, LVN G stated she works the 2-10 shift and confirmed she received an in-service on falls. She confirmed the falls training included protocol during and after a fall, to assess the resident, and to report to the physician. She stated when residents will be on the floor and even if they can explain it, those are falls. Phone interview on 05/27/2024 at 4:12 PM, RN I stated she works the 2-10 and 6-2 shift confirmed she received an in-service related to falls, when she had a phone in-service, what to do when there was a fall and how to identify when there is a fall. RN I stated if the resident was on the floor to presume there was a fall. She stated she understood the content perfectly well and had even conducted the in-services herself. Phone interview on 05/27/2024 at 4:19 PM, LVN M stated she worked the 10-6 shift and confirmed she received the in-service on falls, such as doing paperwork and assessments, notifying the MD after an incident. She stated she understood the content, and affirmed confidence in the protocol. Interview on 05/28/2024 at 9:31 AM, LVN F stated he normally worked the 6-2 shift but would also work the 2-10 shift and on the weekends. LVN F stated he received an in-service on falls and confirmed he felt confident on the content of the in-service. LVN F stated the in-service discussed prevention measures in falls. Interview on 05/28/2024 at 10:18 AM, LVN S stated she was the case manager for the special-contracted residents and confirmed she did receive the in-service regarding falls. LVN S stated she normally only works from 8-5 M-F but stated she will assist on the floor and will conduct trainings herself. LVN F stated she received the in-service along with other staff and that it was delivered by the ADON. LVN S stated she felt confident on the course content and felt comfortable with how the in-service was conducted. Interview on 05/28/2024 at 10:21 AM, LVN T stated she normally worked the 6-2 and 2-10 every weekend but has recently started working the 6-2 shift on the weekdays as well. LVN T stated she received the training on falls and felt confident on the content of the in-service. LVN T stated the ADON provided the in-service. Interview on 05/28/2024 at 10:41 AM, RN V stated he was primarily the weekend RN supervisor and stated he will also work the 6-2 on occasion as he was there day. RN V stated he received the in-service on falls. RN V stated he was also in-serviced on fall prevention measures to take such as increased monitoring and supervision. Record review of in-service, dated 05/26/2024, titled Falls - Clinical Protocol Policy, addressed to [Facility] Nursing Staff, reflected a total of 25 signatures of licensed nursing staff. Record review of [NAME] Fall Risk Assessments completed, dated assessments all on 05/26/2024 from 4:56 PM through 7:14 PM reflected a total of 76 residents reviewed for fall risk. Record review of Resident #3's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #3 was determined to be a high fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #4's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #4 was determined to be low a fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #5's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #5 was determined to be low a fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #6's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #6 was determined to be a high fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #7's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #7 was determined to be a high fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #8's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #8 was determined to be a high fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #9's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #9 was determined to not be a fall risk. Record review of Resident #10's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #10 was determined to be low a fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of DON's spot check list for nurses document, titled Monitoring: DON/ Designee will spot check each shift by contacting nurses and verify if there is no incidents or accidents with in the current shift. Reflected a layout of five instances asking Any incident or accident during the shift? If YES, is complete incident and accident protocol completed by nurse. With date, details box, and whether the care plan was initiated. Further reflected were indications of spot checks completed on 05/27/2024 on the 2-10 shift with a single unwitnessed fall, to add note and initiate protocol. An additional indication was reflected on 05/27/2024 - 05/28/2024 on the 10-6 shift with a reported resident expiration taken place. Record review of an email, dated 05/27/2024 at 12:03 PM, reflected the ADM enacted a new policy to the Human Resources Director to amend the new hire orientation for all staff and agency to also review and sign the policies: Elopements, Falls - Clinical Protocol, and Falls P&P Assessing Falls and Their Cause. The Administrator was informed on 05/28/2024 at 2:05 PM that the IJ was removed, however the facility remained out of compliance at a scope of Isolated and a severity level of No Actual Harm with Potential for More Than Minimal Harm that is Not Immediate Jeopardy because all staff had not been trained on fall prevention.

Based on interview and record review the facility failed to immediately consult with Resident #2's primary care physician when an incident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 11 residents (Resident #2) reviewed for resident rights. The facility failed to notify Resident #2's responsible party and ensure the MD was notified of an incident when Resident #2 fell on [DATE] at 1:30 AM which resulted in bruising to the left hand, slight discoloration began to form on the left thumb and a change in skin condition. An IJ was identified on 05/26/2024 at 12:52 PM. The IJ template was provided to the facility on [DATE] at 2:00 PM. While the IJ was removed on 05/28/2024 at 2:05 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on fall prevention. This deficient practice could place residents at risk for not having their change of condition addressed appropriately by their attending physician which could cause serious harm. The findings included: Record review of Resident #2's Comprehensive MDS assessment, dated 03/18/2024, reflected an [AGE] year-old female with an admitted [DATE], was assessed to have moderate cognitive impairment, with a primary diagnosis of Encounter for other orthopedic aftercare (receiving orthopedic services after a treatment). Additionally it reflected Resident #2 was assessed to be dependent on staff for both toilet transfers and toilet hygiene. Record review of Resident #2's Comprehensive MDS, dated [DATE], reflected Resident #2 was assessed to be independent for toilet transfers and toilet hygiene. Record review of Resident #2's face sheet, dated 03/25/2024 reflected Family Member A was Resident #2's RP. Record review of Resident #2's Comprehensive Person-Centered Care Plan on fall prevention, reflected an intervention dated 03/11/2024 that upon return from acute care to enact fall prevention policy minimize risk. Record review of the EMS run report, dated 03/08/2024, reflected EMS was contacted at 7:00 AM, Resident #2 was picked up by EMS at 7:44 AM, and arrived at the ER at 7:56 AM. Record review of Resident #2's progress notes, dated 03/08/2024 at 11:36 PM as a late entry for 1:30 AM, by LVN C, reflected: Called to resident's room by CNA. Found resident sitting on floor with her back against the closet. Crying, anxious calling for help. Assessed for injury. With assist of CNA resident lifted off floor to a standing position. Gait unsteady but did walk to bed. Placed in Bed . Record review of Pain Evaluation, dated 03/08/2024 at 11:55 PM as a late entry for 1:30 AM, by LVN C, and revealed to be the first assessment completed for Resident #2, in reference to the fall on 03/08/2024 at 1:30 AM, reflected Resident #2 denied pain and did not receive pain medication, and that Resident #2 had discoloration on left thumb with good dexterity. Record review of Skin/Wound Observation, dated 03/08/2024 at 11:59 PM as a late entry for 1:30 AM, authored by LVN C, in reference to fall on 03/08/2024 at 1:30 AM, reflected Resident #2 had bruising on her left hand and that there was a change in skin condition, and there was a slight discoloration forming on left thumb. Record review of SBAR, dated 03/09/2024 at 12:12 AM as a late entry for 1:30 AM, authored by LVN C, reflected [Resident #2] found on floor sitting in room sitting up with back against the wall next to closet and feet stretched out toward bed. Crying and calling for help. And further reflected under Provider Notification Comments At 0635 [AM] [Resident #2] fell again while attempting to ambulate to bathroom without assistance, when lifted off floor and assisted back to bed, noted dislocation of left hip. Nurse notified physician and MD okayed transfer to [ER] to eval and treat. Record review of Resident #2's progress notes, dated 03/09/2024 at 2:56 AM as a late entry for 03/08/2024 at 6:30 AM, authored by LVN F, reflected .nurse note bruising to the left hand, c/o pain to left leg after getting in bed the resident could no longer move her leg out of pain, [notified] md who gave order to send to [local] hospital to eval and treat, notified rp and management assist x2 (two person assistance) to Transferring Record review of Resident #2's hospital records, dated 03/11/2024 from 3:19 PM, reflected Resident #2 sustained a left femoral fracture and intra-articular impaction fracture with mild articular diastases. Record review of Provider's Investigation Report, dated 03/25/2024, reflected the incident involving Resident #2 occurred on 03/08/2024 at 1:30 AM, and reported to the state on 03/18/2024 based on Resident #2's family member expressing concerns and allegations of neglect, that LVN C failed to notify MD and RP of fall. Additionally reflected, after the fall occurred at 6:35 AM an assessment of Resident #2 was completed and transferred to the ER at 7:00 AM, followed by completing an in-service on fall prevention, ANE, charting and documentation and terminating LVN C. Phone interview on 05/23/2024 at 11:10 AM, Resident #2's family member A stated the morning of the incident, at about 6:50 AM someone called her to tell her that her Resident #2 was sent to the ER, to which the caller denied it being about seizures and specified it being about a fall that morning. Resident #2's family member A stated the staff found her on the floor before she was sent to the ER. Resident #2's family member A stated the caller notified her Resident #2 possibly broke her leg or her hip, and it was later discovered she did break her left hip and left wrist. Resident #2's family member A stated Resident #2 had surgery the following day and received a rod in her femur. Resident #2's family member A stated the following morning (03/09/2024) she called the ADM and was informed that Resident #2 had experienced two falls and not one, to which Resident #2's family member A was confused about the occurrence of a second fall. Resident #2's family member A stated Resident #2 mobilized with a walker. Resident #2's family member A stated the ADM told her the bed was soiled, Resident #2 was placed back in the bed and was later found on the floor by LVN F and was sent to the ER. Resident #2's family member A stated Resident #2 asked for assistance from the staff but the staff will not always come promptly. Resident #2's family member A stated the conversation with both the ADM and DON regarding whether the incident appeared to be neglectful was on the following Monday (03/18/2024). Phone interview on 05/23/2024 at 11:58 AM, CNA D stated she remembered the first fall on 03/08/2024 at 1:30 AM involving Resident #2 yelling for help very faintly against the wall when CNA D told LVN C to which they both laid Resident #2 in the bed. CNA D stated Resident #2 expressed a lot of pain, but Resident #2 kept asking for a restroom break repeatedly, but CNA D declined so as to not cause more pain. CNA D stated she felt uncomfortable with how LVN C declined to take action on the fall at 1:30 AM but did not express this as she felt it was out of her scope of practice. Interview on 05/26/2024 at 11:50 AM, LVN F stated during shift change on 03/08/2024 he and LVN C heard Resident #2 yelling, observed Resident #2 to be wrapped up in the sheets, without a brief or any clothing whatsoever and observed a wet substance on the floor, unsure if it was urine. LVN F stated after he assisted Resident #2 back into the bed, he observed one leg to be shorter than the other and believed it to be consistent with a potential fracture. LVN F stated Resident #2 expressed pain, and she described her pain expression to be on her leg. LVN F stated Resident #2 stated she fell in the shower room, but due to the Resident #2 being a 2PM to 10PM shower he concluded Resident #2 was confused. Interview on 05/23/2024 at 11:55 AM, the DON stated he was contacted on 03/08/2024 regarding Resident #2's 2nd fall and discussed with LVN F whether the MD was contacted. The DON stated LVN F confirmed the MD was contacted after the 2nd fall but was uncertain on the first fall earlier that morning. Interview on 05/23/2024 at 12:10 PM, the ADM confirmed she was the ANE coordinator. The ADM stated she had the responsibility of reporting and investigating abuse and neglect. The ADM stated she was first informed on 03/08/2024 of Resident #2's fall by the family and not by any staff member. The ADM stated all major injuries were to be reported to her. The ADM stated during the termination conference LVN C was apathetic and did not seem to care about her termination. The ADM stated the expectation was for LVN C to report the fall to the MD and to the DON or ADM. The ADM stated Resident #2 was independent at the time and would not ask for help, during which she felt Resident #2 slipped on her way to the restroom and was assessed to go out. The ADM stated during the in-person meeting with Resident #2's family member, the determination of neglect was made. Interview on 05/23/2024 at 1:33 PM, the MD confirmed he was informed of this incident afterwards with no known particular time, but confirmed he was never informed by the charge nurse during the first fall regarding the details of the fall and that if he had been contacted, an assessment and review could have taken place but he was never given the opportunity. The MD stated he was uncertain of what action he would have taken at that time as he would have questioned LVN C of what observations and assessments she made of Resident #2 to determine if discharge to the ER was necessary. Attempted a phone interview with LVN C on 05/23/2024 at 11:09 AM and 2:51 PM, and on 05/24/2024 at 12:27 PM, there was no answer, left voicemail. Record review of LVN C's skills checkoff, dated 12/21/2023, titled LVN/LPN --- Job Functions, reflected a hire date of 11/21/2023, and further reflected the LVN C was determined to Performs Function Satisfactorily in the areas of Notify the resident's attending physician when the resident is involved in an accident or incident but no evaluation of notifying family of incidents. Record review of LVN C's termination notice, dated 03/11/2024, reflected LVN C signed confirming their termination and understanding for the incident. Record review of in-service, dated 03/19/2024, subjected documentation of incidents, notification to RP's and MD's, completing assessments, intended for Nursing reflected 17 nurses in-serviced. Record review of in-service, dated 03/19/2024, subjected ANE intended for All Staff, reflected 33 total staff in attendance. Record review of in-service, dated 03/22/2024, subjected ANE intended for All Staff, reflected 17 total staff in attendance. An Immediate Jeopardy (IJ) was identified on 05/26/2024 at 12:52 PM and presented to the Administrator at 2:00 PM. A Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/27/2024 at 02:11 PM. Immediate action: Facilities Plan to ensure compliance quickly Resident #2 head to toe assessment completed and resident with no injuries at this time, no complaints of pain. 05/26/2024 04:44 PM Head to toe: scab to back of head from previous fall area is flat no swelling scab is intact. No drainage signs of infection. No other areas of concern to head. Right people is around, even and brisk with light stimulation at 33MM, left eye with blindness, presents with corneal opacity, orbital mucosal membranes are pale and color, no conjunctivitis, or drainage. Nasal and oral membranes are appropriate and color, no aeration or areas of concern. Upper range of motion assessed move appropriately. Hand grasps And even. Multiple areas are see now per are seen to bilateral upper extremities. Chest, abdomen and back are intact with no areas of concern. Left lower presents with 0.5 inch skin tear. No signs of infection. Skin is presented with no skin loss. [NAME] skin was retracted and is healing well. Range of motion, assess and move appropriately. Abdomen, genital, and [NAME] crest are all intact with no skin concerns. Left upper leg presents with surgical incision scar, which is flushed to skin no redness or irritation, signs or symptoms of infection and intact. Areas of concern to lower leg heels, feet or toes, Resident denies any pain discomfort, or any other concerns at this time. Role: N, Category: Nurses Note Signed by: [Staff] Nurse, LVN C failed to notify MD and RP was immediately suspended and terminated on 03/11/2024. Termination is part of the self-report submitted. Second fall noted at 0635 hrs. LVN F notified MD and RP of fall and MD ordered resident sent to the hospital. Per preliminary findings indicating LVC C instead of LVN F. At 0635 [Resident #2] fell again while attempting to ambulate to bathroom without assistance, when lifted off floor and assisted back to bed, [LVN C] noted dislocation of left hip. [LVN C] notified [MD] and [MD] okayed transfer to [ER] to eval and treat. 05/26/2024 All nursing licensed staff immediately in-serviced on facility policy Fall - Clinical Protocol and facility policy Assessing Falls and Their causes. 05/27/2024 Fall - Clinical Protocol policy and Assessing Falls and Their causes will be part of orientation packet to be reviewed with new hires and part of orientation for agency staff. 05/26/2024 Fall Risk Assessment to be completed on all residents to ensure fall risk are up to date. 05/27/2024 DON/Designee to spot check each shift by contacting nurses. Monitoring of the POR was as follows: Interview on 05/27/2024 at 3:01 PM, RN J stated she worked the 2-10 shift and confirmed she received an in-service on falls and felt confident on the content. RN J stated the in-service was completed by LVN F and felt affirmed on the appropriate protocol. Interview on 05/27/2024 at 3:19 PM, LVN G stated she works the 2-10 shift and confirmed she received an in-service on falls. She confirmed the falls training included protocol during and after a fall, to assess the resident, and to report to the physician. She stated when residents will be on the floor and even if they can explain it, those are falls. Phone interview on 05/27/2024 at 4:12 PM, RN I stated she works the 2-10 and 6-2 shift confirmed she received an in-service related to falls, when she had a phone in-service, what to do when there was a fall and how to identify when there is a fall. RN I stated if the resident was on the floor to presume there was a fall. She stated she understood the content perfectly well and had even conducted the in-services herself. Phone interview on 05/27/2024 at 4:19 PM, LVN M stated she worked the 10-6 shift and confirmed she received the in-service on falls, such as doing paperwork and assessments, notifying the MD after an incident. She stated she understood the content, and affirmed confidence in the protocol. Interview on 05/28/2024 at 9:31 AM, LVN F stated he normally worked the 6-2 shift but would also work the 2-10 shift and on the weekends. LVN F stated he received an in-service on falls and confirmed he felt confident on the content of the in-service. LVN F stated the in-service discussed prevention measures in falls as well as discussing Interview on 05/28/2024 at 10:18 AM, LVN S stated she was the case manager for the special-contracted residents and confirmed she did receive the in-service regarding falls. LVN S stated she normally only works from 8-5 M-F but stated she will assist on the floor and will conduct trainings herself. LVN F stated she received the in-service along with other staff and that it was delivered by the ADON. LVN S stated she felt confident on the course content and felt comfortable with how the in-service was conducted. Interview on 05/28/2024 at 10:21 AM, LVN T stated she normally worked the 6-2 and 2-10 every weekend but has recently started working the 6-2 shift on the weekdays as well. LVN T stated she received the training on falls and felt confident on the content of the in-service. LVN T stated the ADON provided the in-service. Interview on 05/28/2024 at 10:41 AM, RN V stated he was primarily the weekend RN supervisor and stated he will also work the 6-2 on occasion as he was there day. RN V stated he received the in-service on falls. RN V stated he was also in-serviced on fall prevention measures to take such as increased monitoring and supervision. Record review of in-service, dated 05/26/2024, titled Falls - Clinical Protocol Policy, addressed to [Facility] Nursing Staff, reflected a total of 25 signatures of licensed nursing staff. Record review of [NAME] Fall Risk Assessments completed, dated assessments all on 05/26/2024 from 4:56 PM through 7:14 PM reflected a total of 76 residents reviewed for fall risk. Record review of Resident #3's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #3 was determined to be a high fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #4's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #4 was determined to be low a fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #5's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #5 was determined to be low a fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #6's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #6 was determined to be a high fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #7's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #7 was determined to be a high fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #8's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #8 was determined to be a high fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of Resident #9's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #9 was determined to not be a fall risk. Record review of Resident #10's Morse Fall Risk Assessment, dated 05/26/2024, reflected Resident #10 was determined to be low a fall risk. Further review of the comprehensive person-centered care plan reflected interventions in place to prevent and respond to falls. Record review of DON's spot check list for nurses document, titled Monitoring: DON/ Designee will spot check each shift by contacting nurses and verify if there is no incidents or accidents with in the current shift. Reflected a layout of five instances asking Any incident or accident during the shift? If YES, is complete incident and accident protocol completed by nurse. With date, details box, and whether the care plan was initiated. Further reflected were indications of spot checks completed on 05/27/2024 on the 2-10 shift with a single unwitnessed fall, to add note and initiate protocol. An additional indication was reflected on 05/27/2024 - 05/28/2024 on the 10-6 shift with a reported resident expiration taken place. Record review of an email, dated 05/27/2024 at 12:03 PM, reflected the ADM enacted a new policy to the Human Resources Director to amend the new hire orientation for all staff and agency to also review and sign the policies: Elopements, Falls - Clinical Protocol, and Falls P&P Assessing Falls and Their Cause. The Administrator was informed on 05/28/2024 at 2:00 PM that the IJ was removed, however the facility remained out of compliance at a scope of Isolated and a severity level of No Actual Harm with Potential for More Than Minimal Harm that is Not Immediate Jeopardy because all staff had not been trained on fall prevention.