Every finding on record at The Laurenwood Nursing and Rehabilitation

Based on observation, interview, and record review, the facility to ensure the residents had a right to secure and confidential personal and medical records for one (Residents #1) of 6 residents reviewed for resident rights. The facility failed to ensure MA A did not leave the computer tablet unlocked on top of a medication cart which disclosed Residents #1's EMAR on 06/22/26 from 10:05 am to 10:06 am. This failure could place residents at risk of embarrassment, feelings of vulnerability, and a decline in health and psycho-social well-being. The findings included: An observation on 06/24/26 at 10:05 am, on the 500 hall, revealed an unattended medication cart with Resident #1's EMAR showing her medication profile. No one was around the medication cart or had walked by it during this time. An observation on 06/24/26 at 10:06 am, revealed MA A walking towards the 500 hall to the medication cart. He stated he had to get something and then said he went to the bathroom, He stated he was gone for one to two minutes and was sorry he made the mistake leaving the tablet open and walking away from it. He stated it was not a good idea to leave the computer tablet unlocked and showing Resident #1's information. He stated the computer tablet detailed Resident #1's private medical information and someone unauthorized could have walked by and viewed her documentation. He stated people such as visitors and residents could have viewed Resident #1's information. He stated he normally did not leave the computer tablets unlocked. He stated this was the one time he did, and would not do again. Record review of Resident #1's June [DATE] on 06/24/26 morning medications revealed, MA A administered: 300 mg Allopurinol 1 tablet 1 x D for gout, 2.5 mg Amlodipine 1 tablet 1 x D for HTN, 81 mg Aspirin 1 tablet 1 x D for prophylactic, 25 mcg 2 tablets 1 x D, 25 mcg Cholecalciferol 2 tablets 1x D for supplements, 15 mg Buspirone 1 tab every morning, 30 mg Duloxetine 1 capsule 2 x D, 300 mg Gabapentin 1 capsule 2 x D for nerve pain, 25 mg and Hydroxyzine pamoate 1 capsule 2 x D. During an interview on 06/24/26 at 2:14 pm, MA A stated he worked there for almost a year, and stated his last HIPAA compliance training was last month. He stated he had not spoken to management about leaving the computer tablet open with resident information. During an interview on 06/24/26 at 2:52, Medical Records B stated she believed the Administrator was responsible for HIPPA compliance at the facility, but was not sure. She stated the last HIPAA training was two weeks ago. During an interview on 06/24/26 at 3:43 pm, the DON stated they did a good job with HIPAA compliance. She stated she was aware of MA A leaving his computer screen up with resident information disclosed. She stated MA A was human and was not sure what called his attention away. She stated he had never done that before, and she would give him grace, because if the Lord gave her grace she was going to give it to him too. She stated MA A was very conscientious, but MA A said someone called him away from the medication cart. She stated that MA A apologized and she told him people made mistakes and she was not going to fire him. She stated she did HIPAA re-education for him to remember to turn off his tablet or take it with him. She stated leaving Resident #1's personal information out for anyone to see could have caused somebody else to get her medical information. She stated anyone walking by could do whatever they wanted with Resident #1's information. She stated she knew it was very important to comply with their HIPAA policy and said MA A was a good MA and she was not going to keep punishing him over it. She stated MA A had the knowledge and understanding for his job.During an interview on 06/24/26 at 3:57 pm, the Administrator stated the facility was good with HIPAA compliance. She stated if they had any HIPAA issues, they would address them right then and there. She stated she was ultimately responsible for HIPAA compliance, and the DON and each staff member were also responsible. She stated any staff that dealt with the resident's health information was responsible for HIPAA compliance. She stated she was not aware of there being a HIPAA issue today (06/24/26) involving MA A leaving his computer tablet open with resident information disclosed. She stated she would make sure she addressed this issue right away. She said typically they did not have any HIPAA concerns. She stated her expectation was to make sure everybody was HIPAA complaint. Record review of MA A's Inservice Training Report dated 06/24/26 conducted by the DON revealed MA A signed this form acknowledging being educated on: HIPAA - Safeguarding resident information - Contents/Summary of Training session: Safeguarding resident information Policy and procedures. Record review of the facility's Guidelines for all nursing procedures dated December 2024 revealed, Purpose: To provide general guidelines for resident rights while caring for the resident. Preparation: Prior to having direct care responsibilities for residents, staff must have appropriate in-service training on resident rights, including:. e. Confidentiality of protected health information. General guidelines: f. Close the room entrance door and provide for the residents privacy. Record review of the facility's HIPAA Security Measures policy revised 09/19/26 revealed, Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and /or records that are in electronic format. Policy Explanation and Compliance Guidelines: 1.Facility leadership will ensure the implementation of policies and procedures to prevent, detect, contain, and correct any security violations. 4.The facility will implement policies and procedures to address security incidents, including identification and response to suspected or known incidents; mitigation, to the extent practicable, harmful effects of any security incidents; and documentation of security incidents and their outcomes.

Based on interview and record review, the facility failed to notify the resident and/or resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 of 6 residents (Resident #7, Resident #8, and Resident #77) reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #7, Resident #8, and Resident #77.The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #7, Resident #8, and Resident #77. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. A record review of Resident #7's face sheet, dated 06/03/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] and was her own responsible party. Her diagnoses included Non-St Elevation Myocardial Infarction (type of heart attack caused by a partial or temporary blockage in a coronary artery), Cognitive Communication deficit (often caused by brain injury or neurological disease), Chronic Obstructive Pulmonary Disease (acute flare-up, worsening of symptoms, increased breathlessness, cough, or sputum production beyond normal daily variations), Acute Respiratory Failure with Hypoxia (when the respiratory system cannot adequately transfer oxygen into the bloodstream), and Paranoid Personality Disorder (a mental health condition of unwarranted distrust and suspicion of others).A record review of Resident #7's quarterly MDS assessment, dated 04/06/2026, reflected that Resident #7's BIMS score was 03/15, indicated severe cognitive impairment. Resident #7 required set-up or clean-up assistance (which meant staff set up or cleaned up) and she completed the activity.A record review of Resident #7's progress note, dated 12/09/2025, revealed that Resident #7 complained of chest pain and shortness of breath, an ambulance was called and Resident #7 was transferred to the hospital. There was no evidence that a transfer or discharge notice was provided to Resident #7 in writing or to the State LTC Ombudsman.A record review of Resident #7's progress note, dated 12/28/2025, revealed that Resident #7 had abnormal vital signs, altered mental status, and increased confusion. Resident #7 was transferred to the hospital for further evaluation and treatment. There was no evidence that a transfer or discharge notice was provided to Resident #7 in writing or to the State LTC Ombudsman.During an interview on 06/03/2026 at 11:28 a.m., Resident #7 stated she did not remember if she received a written letter when she was sent to the emergency room. She also stated she would have liked to receive a letter from the facility so she could give it to her family member.A record review of Resident #8's face sheet, dated 06/04/2026, revealed a [AGE] year-old female admitted to the facility on [DATE], she was her own responsible party. Her diagnoses included Chronic Obstructive Pulmonary Disease (acute flare-up, worsening of symptoms, increased breathlessness, cough, or sputum production beyond normal daily variations), Type 2 Diabetes Mellitus without complications (indicates the presence of high blood sugar but without established damage to nerves, eyes, kidneys, or the cardiovascular system), Morbid (severe) obesity due to excess calories (excessive fat accumulation), and Chronic Hypoxic Respiratory Failure (an ongoing condition where your lungs cannot transfer enough oxygen into the bloodstream).A record review of Resident #8's MDS assessment, dated 12/16/2025, reflected that Resident #8's BIMS score was 12/15, indicated moderate impairment in cognitive function. Resident #8 required mostly substantial to maximal assistance (which meant staff did more than half the effort) with care. A record review of Resident #8's progress notes, dated 12/16/2025, revealed that she had fallen earlier and complained of leg pain, was not willing to wait for the facility mobile x-ray, called 911, and was taken to the hospital. There was no evidence that a transfer or discharge notice was provided to Resident #8 in writing or to the State LTC Ombudsman. During an interview on 06/04/2026 at 1:13 p.m., Resident #8, stated she had never received a written letter when she was sent to the hospital. She explained that having the information provided in writing would have allowed her to review the details more carefully later.A record review of Resident #77's face sheet, dated 06/04/2026, revealed a [AGE] year-old female admitted to the facility on [DATE], she was her own responsible party. Her diagnoses included Cognitive Communication Deficit (often caused by brain injury or neurological disease), Muscle Wasting (the shrinking of muscle tissue caused by disuse), Hypokalemia (lower-than-normal potassium levels in the blood), and Diaphragmatic Hernia (a hole or weakness in your diaphragm).A record review of Resident #77's admission MDS assessment, dated 03/28/2026, reflected that Resident #77's BIMS score was 11/15, indicated moderate impairment in cognitive function. Resident #77 required mostly setup or clean-up assistance (which meant staff set up or cleaned up) and she completed the activity.A record review of Resident #77's progress notes, dated 04/02/2026, revealed she had a planned discharge home. There was no evidence that a transfer or discharge notice was provided to the State LTC Ombudsman.During an interview on 06/04/2026 at 10:28 a.m., the Social Worker revealed that she had not provided written notification to the residents or their representatives regarding the transfer or discharge, including the reason for the transfer or discharge. She also stated that the only list she sent to the State LTC Ombudsman was 30-day notices. The Social Worker said if residents or their representatives received a transfer or discharge letter it would help them understand what happened or they could give it to their doctor for better understanding of why they were sent to the hospital.During an interview on 06/04/2026 at 11:25 a.m., the DON revealed that the nursing staff only provided a transfer form to the hospital, not a written transfer or discharge letter, she also added she did not send a list of discharged residents to the State LTC Ombudsman. She was asked to explain the potential impact on residents if they did not receive a discharge letter; she did not provide a response. During an interview on 06/04/2026 at 2:43 p.m., the Facility LTC Ombudsman revealed she was not provided with the facility's monthly list of discharged residents. She reported that throughout the year, she had received the names of only two discharged residents.A record review of the facility's discharge policy Discharging the Resident, dated 12/2025, revealed it did not contain any requirements requiring written notification to be provided to the resident or the resident's representative regarding discharge.According to eCFR S483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must-(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and(iii) Include in the notice the items described in paragraph (c)(5) of this section.S483.15(c)(4) Timing of the notice.(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged .(ii) Notice must be made as soon as practicable before transfer or discharge when-(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or(E) A resident has not resided in the facility for 30 days.S483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:(i) The reason for transfer or discharge;(ii) The effective date of transfer or discharge;(iii) The location to which the resident is transferred or discharged ;(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety reviewed for food safety. The facility failed to ensure that only disposable paper towels were disposed of in the garbage receptacle at handwashing sink #1.The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation on 06/03/2026 at 11:22 a.m., of the #1 handwashing sink's garbage receptacle the following was revealed: #1 handwashing sinks garbage receptacles contained items other than disposable paper towels, including used gloves, and plastic wrapping.During an observation on 06/03/2026 at 11:43 a.m., of the dry storage room the following was revealed:1 can of fruit cocktail 6 lbs. 5 oz., written received date 04/16/2026, no best by date, with a dent on the top seal and bottom seal.1 can of fruit cocktail 6 lbs. 5 oz., written received date 05/12/2026, no best by date, with a dent on the top seal and bottom seal.1 can of fruit cocktail 6 lbs. 5 oz., no written received date, no best by date, with a dent on the side of the can. 1 can of fruit cocktail 6 lbs. 5 oz., written received date 05/27/2026, no best by date, with a dent on the bottom seal.1 can of crushed pineapple 6 lbs. 7 oz., written received date 05/26/2026, with a dent on the bottom seal.1 can of vegetarian beans 7 lbs. 5 oz., written received date 06/02/2026, with a dent on the side of the can.During an interview on 06/03/2026 at 11:59 a.m., the DM stated that the date written on all canned goods was the date the facility received the item. She stated the Dietary Aides were responsible for stocking the shelves in the dry storage area and ensuring products were properly labeled. She stated a dent was considered any noticeable damage or puncture that could be easily seen during a visual inspection. During an interview on 06/03/2026 at 12:08 p.m., the DA said she was responsible for writing the date on all canned goods and the date was when the facility received the items. She explained that when stocking the canned goods, if she noticed a dent she would remove the can from the storage area and place it in the DM's office. In a record review of the facility's Food Safety and Sanitation policy, dated 2023, revealed: .3. Food Purchasing. e. Bulging or leaking cans, cans with severe dents on the seam or broken containers of food will not be used.4. Food Storage.Canned and dry foods without expiration dates should be used within six months of delivery or according to the manufacturer's guidelines.In a record review of the U.S. FDA Food Code 2022 reflected: Section 6-301.20 Disposable Towels, Waste Receptacle. Waste Receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.In a record review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Residents #4, #19, and #42) of 5 residents reviewed for infection control. The facility failed to ensure Resident #4 was not exposed to Resident #19 (roommate) who was treated for MRSA infection. The facility failed to ensure CNA A changed gloves and performed hand hygiene during incontinence care for Resident #42. This failure could place residents at risk of infection. Findings included: 1. Record review of Resident #4's Quarterly MDS Assessment, dated 03/11/26, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her cognitive skills for daily decision making were severely impaired. Her diagnoses included stroke and respiratory failure. The resident had an indwelling catheter, feeding tube, and a tracheostomy. Record review of Resident #4's Comprehensive Care Plans, dated 02/02/26, reflected:Resident had a terminal prognosis related to chronic respiratory failure.Facility interventions included:Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. 2. Record review of Resident #19's Annual MDS Assessment, dated 03/02/26, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 8, which indicated her cognitive skills were moderately impaired. Her diagnoses included heart failure and non-Alzheimer's disease. The resident required supervision for toileting hygiene. Record review of Resident #19's Comprehensive Care Plans, dated May 2026, reflected there was not a care plan for isolation or MRSA. Record review of Resident #19's Lab Summary, collected 05/18/26, reflected:Urine Culture: greater than 75,000 CFU/ML of MRSA (type of bacteria that many antibiotics cannot treat) isolated. Record review of Resident #19's Order Summary Report, dated 05/23/26, reflected:Strict isolation related to MRSA. Contact isolation. Resident would receive all services including but not limited to meals, activities, therapy, treatments and nursing services in their room. Record review of Resident #19's Progress Notes reflected:06/04/26 10:43 AMError in documentation. (reference date/time: 05/23/26 1:06 PM) Note states ESBL (enzymes from bacteria that are difficult to treat) and should state MRSA.Author: RN B 05/23/26 1:06 PMResident has a new order for Vancomycin 1 gram IV daily for 10 days due to ESBL infection. Resident placed on contact isolation precautions.Author: RN B Record review of Resident #19's Comprehensive Care Plans, dated 06/03/26, reflected:ADL self-care performance deficit related to weakness.Facility interventions included:Encourage resident to participate to the fullest extent possible with each interaction. There was not a care plan for MRSA in the urine. In an observation on 6/02/26 at 11:05 AM, Residents #19 and #4 were observed in their room together. There was a contact isolation sign posted on the door. PPE was present. Resident #19 was in bed. Resident #4 was in her bed and was non-verbal. Resident #4 had a tracheostomy, feeding tube, and a catheter. In an interview on 06/03/26 at 2:07 PM, LVN C and LVN D revealed they were infection control nurses. They said Resident #19 was in contact isolation for MRSA in the urine. They said Resident #4 did not have an infection. They said it was safe for the residents to be in the same room together because Resident #19 used the toilet and Resident #4 had a catheter. They said they did not know what the facility policy said about cohorting residents in the same room when one resident had MRSA. In an interview on 06/03/26 at 2:46 PM, the DON said Resident #19 did not have an active urinary tract infection of MRSA, but the facility did place a PICC line in Resident #19 to administer vancomycin to treat it. The DON said Resident #19 did not need to be in strict isolation. The DON said for Resident #19 to have an active infection, the MRSA level in her urine culture would have to be <100,000 CFU/ML. In an interview on 06/03/26 at 3:40 PM, FNP revealed Resident #19 was tested for a urinary infection because she was not feeling well and had nausea. She was treated for MRSA in the urine, but she did not meet the definition of having an active infection because her MRSA level was only <75,000 CFU/ML. The FNP said staff should wash their hands and wear gloves when caring for Resident #19. In a follow-up interview on 06/04/26 at 10:29 AM, the DON said Resident #4 was on enhanced barrier precautions because she had in-dwelling devices and a tracheostomy. The DON said Resident #4 was not immunocompromised (impaired immune system) and was not at risk for developing a MRSA infection from Resident #19. The DON said Resident #19 and Resident #4 could be co-horted together in the same room because Resident #4 had a catheter and was cared for by nurses, not CNAs. The DON said the nurses changed the resident briefs, not the CNAs. In an interview on 06/04/26 12:42 PM, LVN D said the CNAs were responsible for providing brief changes for Resident #4. In an interview on 06/04/26 at 1:19 PM, Hospice RN said Resident #4 was on Hospice and was immunocompromised. She said Hospice was not made aware that Resident #19 was being treated for MRSA and should not have been in a room with Resident #4. In an interview on 06/04/26 at 3:05 PM, Physician revealed Resident #4 was at risk for developing infections because she had indwelling devices. He said Resident #19 was colonized (the bacteria is carried in the blood but is not causing an active infection) with MRSA and did not have an active MRSA infection in the urine. He said he did not know why Resident #4 was kept in the room with Resident #19 and he was going to go and assess each resident and draw more labs on Resident #19. He said the decision to keep them in a room together needed to be done in accordance with policy and procedure. Record review of the facility's policy and procedure, Multidrug-Resistant Organisms, dated December 2025, reflected: .Room Placement .4. A resident with a multidrug-resistant organism may need to be separated from a roommate who has any of the following: a device such as an indwelling urinary catheter, gastrostomy feeding tube, or intravenous access line; a pressure ulcer or other open skin wound including a postoperative wound; or significant immunosuppression (due to malignancy, chemotherapy, etc.).5. The resident need not be moved from his/her room until after screening is done and the need for Contact Precautions is determined.6. Depending on the situation, placement may include the following:a. Placement in a room with someone else who is colonized or infected with the same organism, but does not have any other infection (cohorting);b. Placement with someone who does not have invasive devices or wounds;c. Placement in a private room, if possible.7. A resident who is infected or colonized with a multidrug-resistant organism will be permitted to participate in group meals and activities if draining wounds are covered, bodily fluids are contained, and he/she observes good hygiene practices. 3. Record review of Resident #42's Quarterly MDS Assessment, dated 03/22/26, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. His BIMS score was 13, which indicated his cognitive skills were intact. The resident had an in-dwelling catheter and was always incontinent of bowel movement. His diagnoses included stroke and respiratory failure. The resident was dependent on staff for toileting hygiene. Record review of Resident #42's Comprehensive Care Plan, dated 09/11/23, reflected:ADL self-care performance deficit related to decreased mobility.Facility interventions included: Dependent on staff for toilet use In an observation on 06/03/26 at 11:35 AM of incontinence care for Resident #42, CNA A folded down the resident's brief, cleaned the penis and scrotum, cleaned the buttocks, and did not change gloves or perform hand hygiene. CNA A applied barrier cream, placed a clean brief, and straightened the sheets with her soiled gloves. In an interview on 06/03/26 at 12:05 PM, CNA A said she was trained months ago to perform hand hygiene after changing gloves. CNA said she messed up this time and failure to perform hand hygiene could lead to contamination, germs, and infection. In an interview on 06/04/2026 at 10:29 AM, the DON said hand hygiene was supposed to be performed after glove changes and training was completed with staff. The DON said monitoring was in place and management observed staff for hand hygiene. The DON said residents were at risk for the spread of infection if hand hygiene was not performed. Record review of the facility's policy, Hand-Washing/Hand Hygiene, revised December 2025, reflected: This facility considers hand hygiene the primary means to prevent the spread of infections.7. Use an alcohol-based hand rub; or, alternatively, soap (antimicrobial or non-antimicrobial) and water forthe following situations.:m. After removing gloves.

Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for one (Residents #12) of 8 residents reviewed for PASSR. The facility failed to refer Resident #12, who had mental illness, to the state designated service for review. This failure could place residents at risk of missed PASSR services.Findings included: Record review of Resident #12's Quarterly MDS Assessment, dated 05/08/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 8, which reflected her cognitive skills for daily decision making were moderately impaired. Her diagnoses included bipolar disorder and schizophrenia. She did not have dementia. The MDS did not include PASSR status. Record review of Resident #12's Comprehensive Care Plans, dated 05/05/26, reflected:Resident had unspecified psychosis, schizoaffective disorder, and bipolar disorder. The resident could see and hear people in her room trying to rape her. Facility interventions included:Give medications as ordered and evaluate with psychological care. Record review of Resident #12's PASSR Level-I screening, dated 12/08/25, reflected the resident did not have mental illness and did not have dementia. In an observation on 06/02/26 at 11:25 AM, Resident #12 was sleeping and not available for interview. In an interview on 06/04/26 at 2:45 PM, the MDS Coordinator said she received Resident #12's PASSR Level-I screening and did not submit a new one. She said she was not supposed to correct the PASSR Level-I screening and did not know the effect it could have on the resident if it was incorrect. She said she did not know who was responsible for overseeing her work. In an interview on 06/04/26 at 3:40 PM, the DON revealed PASSR was data entry and she would look at the PASSR Level-1 screenings that were received by the facility to ensure they were put in SIMPLE correctly. The DON said she did not know the process to follow if the PASSR Level-I screening received was inaccurate. The DON said the resident could be at risk for missed services if the PASSR Level-I screening was incorrect. Review of the facility's policy and procedure, PASSR Requirements and Level I and Level II, dated December 2025, reflected: .2. Review the Level 1 screen, at least quarterly, and assure it is filed in the medical record and accurately reflects the patient's/resident's current status.3. Ensure that the appropriate state designated agency is contacted for any resident/patient requiring a Level II screen either on preadmission, annually, or upon learning of an SMI/ID diagnosis that was previously unknown or undetermined.

Based on record reviews and interviews, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 4 (Residents #1, #2, #3, and #4) of 10 residents reviewed for personal privacy.The facility failed to protect the personal information of Residents #1, # 2, #3, and #4, by placing their personal information such as their name, date of birth , social security number, Medicare number, Medicaid number, address, and phone numbers for contacts in the Elopement Binder by the facility's front door. This failure could place residents at risk of identity theft and loss of private information. Findings included:Observation on 03/16/26 at 8:35 AM revealed a yellow notebook on a table located by the front door of the facility labeled Elopement Binder. Included in the notebook were the policy and procedures for elopement management. The notebook also included four admission Records for residents of the facility that had been deemed as having elopement potential. Review of the admission Record for each resident included their name, date of birth , social security number, Medicare number, Medicaid number, address, and phone numbers for contacts. In an interview on 03/16/26 at 3:57 PM the DON stated residents in the Elopement Binder had been determined to have the potential to leave the facility without notice. The binder was located at each nurse's station as well as the front door so it could be easily located in the event of an elopement. The DON stated resident personal information was protected information with restricted access as prescribed by HIPAA regulations. She stated personal information should not be left lying around where anyone could access it. The DON stated the ADON was responsible for maintaining the binder, and she was unaware that each resident's admission Record was included in the binder. The DON stated the risk of personal information being exposed to someone without authorization could be identity theft of the resident. She did not recall the last time staff were in-serviced on HIPAA regulations. In an interview and observation on 03/06/26 at 4:00 PM the ADON stated she had not initiated the Elopement Binder; it was in place when she assumed the role and she simply maintained what had been established in the past. She stated the binder located by the front door should not have had the residents' personal information included, only the binders located at the nurses' station. She stated the risk of a resident's personal information being taken by an unauthorized person could be identity theft committed to the resident. She removed the information from the binder immediately. In an interview on 03/16/26 at 4:10 PM the Administrator stated resident personal information was restricted to a limited number of people in the facility. The business office, the social worker, and other members of the Interdisciplinary Team would be the only staff who would need access to that information. She stated resident information should not be left lying around so that anyone could access it. The Administrator stated she was unaware the binder by the front door contained resident identifying information. She stated the risk of that information being exposed to unauthorized people could be identity theft. Record review of the facility's policy Safeguarding and Storing of Protecting Health Information, revised December 2025, revealed in part: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 6 residents (Residents #1) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1's care plan included a diagnosis of Pneumonia. This failure could place residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's face sheet dated 03/27/25, reflected an [AGE] year-old female, with an initial admission date of 08/05/22, and a readmission date of 03/12/25. Resident #1 had a diagnosis of Dementia (loss of memory and other thinking abilities) and Secondary Hypertension (high blood pressure). Record review of Resident #1's care plan, dated 03/27/25, did not address her diagnosis of Pneumonia. Record review of the facility's Infection Surveillance Monthly Report, dated 03/27/25, reflected Resident #1 had an infection: Infection onsite date (identification date): 02/24/25 admit date : [DATE] Infection: Pneumonia Status: Open, Confirmed Order: Levaquin Tablet 250 MG (an antibiotic medication) In an interview on 03/27/25 at 3:22 PM, the DON stated she was not sure why Resident #1's care plan did not address pneumonia. She stated Resident #1 started taking the Levaquin on 02/25/25. The DON she would be notified by central intake if a resident went to the hospital and returned with a change or new medication. She stated nurses on the floor or audits that she completed would alert her to changes that occurred in the facility. She stated she would then know the care plan needed to be updated. The DON stated the risk of pneumonia not addressed on the care plan was missed needs of Resident #1 and potential issues for the resident. In an interview on 03/27/25 at 3:51 PM, the Administrator stated she was not sure why the pneumonia was not listed on Resident #1's Care Plan. She stated she would have to refer to her DON regarding the care plans and the risk of pneumonia not addressed, because that was not her lane. Record review of the facility's policy titled, Care Plans, Comprehensive, dated [DATE], reflected the following: Policy Statement A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. incorporate identified problem areas h. incorporate risk factors associated with the identified problems m. Aid in preventing or reducing decline in the resident's functional status and/or element of care 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #2) reviewed for infection control. The facility failed to add Resident #2 to the infection control log when he was diagnosed with Pneumonia on 03/15/25. This deficient practice could place residents at-risk for infections. Findings included: Record review of Resident #2's face sheet, dated 03/27/25, reflected a [AGE] year-old male, with an initial admission date of 09/04/24, and a re-admission date of 03/21/25. Resident #1 had a diagnosis of Pneumonia (lung infection causing inflammation and fluid buildup), Acute Respiratory Failure (lungs cannot adequately supply oxygen to the blood), Alzheimer's Disease (progressive memory loss and cognitive decline), and Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it hard to breathe). Record review of the progress notes on Resident #2's electronic record dated 03/15/25 reflected Resident #2's doctor ordered the resident to be sent to the hospital after the facility received results of his chest x-ray, which noted the resident had possible pneumonia. The progress notes noted Resident #2 was discharged from the hospital back to the facility on [DATE]. Record review of Resident #2's hospital record dated, 03/15/25, reflected Resident #2 had an encounter diagnosis of Pneumonia and Sepsis (life-threatening medical emergency caused by the body's overwhelming response to infection). The hospital record reflected the encounter diagnosis was, Pneumonia of the right lung due to infectious organism, unspecified part of the lung. Record review of the facility's Infection Surveillance Monthly Report did not reflect that Resident #2 had an infection. Resident #2 was not on the report. In an interview on 03/27/25 at 3:22 PM, the DON stated she was aware Resident #2 went to the hospital and was diagnosed with pneumonia. She stated Resident #2 was treated for pneumonia while at the hospital. The DON stated he returned to the facility around 03/21/25. She stated she was the infection control preventionist, and she was the one responsible for updates on the infection control log. The DON stated any infection that was identified at the facility, would be added to the infection control log. The DON stated she did not add Resident #2 to the infection control log, because he was treated for pneumonia at the hospital. The DON stated she felt there was no risk of Resident #2 not listed on the infection control log, because he was not diagnosed with pneumonia at the facility. The DON stated the facility did not have a policy on infection control logs. In an interview on 03/27/25 at 3:51 PM, the Administrator stated she would have to refer to the DON for information regarding the infection control log. She stated the DON was also the facility's infection preventionist. The Administrator stated she was not sure what needed to be on the infection control log. The Administrator stated she would also have to refer to the DON regarding the risk of a resident not listed on the infection control log when the resident was diagnosed upon admission to the hospital. A general infection control policy was requested on 03/27/25 at 3:30 PM but not provided. Record review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, dated December 2024, reflected the following: Purpose To provide guidelines for general infection control while caring for residents.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure dented cans were placed in a separate storage area. 2. The facility failed to ensure food items were labeled and dated with the preparation date or discard by date. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the dry storage on [DATE] at 7:50am revealed the following: -1 4lbs can of tuna received date [DATE] was dented on top right. -1 4lbs can of tuna received date [DATE] was dented on front. -1 3lbs 2 oz can of cream of mushroom received date [DATE] was dented on front and bottom right, -1 3lbs 2oz can of cream of mushroom received date [DATE] was dented on back. -1 6.27 lbs can of zucchini tomato juices received date [DATE] was dented on bottom left. Observation of the dining room on [DATE] at 8:09am revealed the following: -4 large pitchers of unidentified liquid drinks. There was no label description or preparation dates. In an interview with the DM on [DATE] at 11:18 am she stated her, or the kitchen aides were responsible for putting away canned goods once the canned goods were delivered. She stated dented cans were kept in her office and then returned to vendor. She stated all kitchen staff were responsible for ensuring food and drinks were labeled and dated. She stated the risks of dented cans not stored in a separate area and food and drinks could cause residents to become sick. Interview with [NAME] E on [DATE] at 11:30am she stated dented cans were stored in the DM's office. She stated all kitchen staff were responsible for checking canned goods for dents. She stated all kitchen staff were responsible for correctly labeling and dated all food items. She stated the risks of not separating dented cans could cause residents to be sick. She stated not labeling and dating food or drinks could cause staff to serve expired or spoiled food that could cause residents to become sick. Record review of the facility's Food Receiving and Storage Policy, revised 2017 reflected, Policy Statement: Food and supplies will be received according to facility approved standards and practices to ensure quality of products received. Procedure: Unacceptable products (dented cans) will be rejected, and a notation made on both the delivery receipt and the order form. Cool per regulations, label, and date all food. Record review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. Section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section ,d+[DATE].17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - Section ,d+[DATE].11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation Food shall be protected from cross contamination by: when combined as ingredients, separating raw animals' foods during storage, preparation, holding, and display.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (MA A and CNA B) staff members and 4 of 4 residents (Residents #4, #30, #54, and #31) reviewed for infection control procedures. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #4 and #30. CNA B failed to change their soiled gloves and perform hand hygiene during incontinent care on Residents #54 and #31. These failures could place residents at risk for cross contamination and infections. Findings included: Record review of Resident #4's quarterly MDS assessment, dated 02/24/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included: Schizophrenia (mental illness), and hypertension (high blood pressure). Resident #4 was not cognitive and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #4's physician orders dated 03/14/25 reflected, amlodipine Besylate (high blood pressure) 5mg give one tab by mouth two times a day and to obtain blood pressure one time a day on each shift. Record review of Resident #30's quarterly MDS Assessment, dated 03/26/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included: cerebrovascular accident (stroke), hypertension (increased blood pressure), and cerebrovascular disease (clogged up vessels in heart). Resident #30 was moderately cognitively impaired and unable make all decisions for herself and required one staff for assistance with activities of daily living. Record review of Resident #30's physician orders dated 03/21/25 (open ended) reflected, Coreq (high blood pressure) 3.125 mg give one tab by mouth two times a day. Obtain blood pressure one time a day on each shift. Record review of Resident #54's quarterly MDS Assessment, dated 01/15/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included: peripheral vascular disease (clogged arteries), hypertension (increased blood pressure), and diabetes (high blood sugar). Resident #53 was moderately cognitively impaired and able make all decisions for herself and required one staff for assistance with activities of daily living. She was incontinent of bowel and bladder. Record review of Resident #31's quarterly MDS Assessment, dated 03/18/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included: end stage renal disease (kidneys do not work correctly), cerebrovascular accident (stroke), and diabetes (high blood sugar). Resident #31 was moderately cognitively impaired and able make all decisions for himself and required one staff for assistance with activities of daily living. He was incontinent of bowel and bladder. Observation on 03/31/25 at 8:29 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #4. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #4. Observation on 03/31/25 at 8:44 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure, on Resident #30, used the same blood pressure cuff used on Resident #4. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #30. An interview on 03/31/25 at 9:00 a.m., MA A stated she did not think about cleaning the blood pressure cuff between usage, she did not know she needed to. MA A stated she had washed her hands between each usage when she took the blood pressure. MA A stated if the cuff was on the residents and then not cleaned it could spread germs to others. Observation on 03/31/2025 at 9:30 a.m. CNA B entered the room to perform incontinent care and activities of daily living with Resident #54. CNA B did not use hand gel in the hallway or wash his hands and donned clean gloves. Resident #54 was lying on her back in the bed. CNA B explained to the resident what he was going to do, the resident agreed. CNA B picked out the clothing that Resident #54 requested. CNA B unfastened the brief tabs and wiped the pubic area with a disposable wipe, discarded the wipe. CNA B used another wipe on the peri area and discarded. CNA B repositioned Resident #54 to her right side while pulling the clean brief under the resident, He then used another wipe on the left buttocks, pulling the urine soiled brief off and placing in the trashcan. CNA B repositioned Resident #54 to her left side while pulling the clean brief under the resident. CNA B without changing his soiled gloves or washing his hands fastened the tabs of the clean brief, placed on the resident's pants and shirt, repositioning her on the bedside. CNA B picked up a clean pillowcase placed on a pillow and placed the pillow in the wheelchair, transferred the resident into her wheelchair. CNA B while still wearing his soiled gloves and not washing his hands, combed the resident's hair, placed on her glasses, moved her around in the wheelchair, and placed her bedside table in front of the resident, turned on the TV using the remote. CNA B placed his gloves in the trashcan and left the room, without washing his hands or using hand sanitizer. Observation on 04/01/2025 at 10:00 am with CNA B entered the room to perform incontinent care on Resident #31. CNA B did not use hand gel in the hallway or wash his hands and donned clean gloves. Resident #31 was lying on his back in the bed. CNA B explained to the resident what he was going to do, the resident agreed. CNA B unfastened the brief tabs and wiped the pubic area with a disposable wipe discarded wipe, and used another disposable wipe cleaned the penal shaft and head of penis discarded the wipe. CNA B assisted Resident #31 to reposition to his left side, used a disposable wipe and cleaned the left buttocks and anal area of urine and small soft bowel movement. CNA B placed the clean brief under Resident #31, assisted in repositioning Resident #31 to his right side, pulling the urine and bowel movement soiled brief from under resident. CNA B placed the brief in the trashcan. CNA B used additional disposable wipes to clean the right buttocks and anal area, discarding the wipes. CNA B wearing the same soiled gloves applied barrier cream to Resident #31's buttocks, then assisted the resident to reposition himself to his back. CNA B still wearing the soiled gloves and not washing his hands pulled the clean gown down for the resident and pulled the clean linens up over the resident. The CNA moved the bedside table back into place and offered the resident the television remote. CNA B removed the soiled gloves, placed them in the trashcan and left the room with the surveyor, without washing his hands or using hand sanitizer. An interview on 04/01/2025 at 10:00 a.m. with CNA B revealed the CNA stated, he did not bring his [A game] yesterday, but today he was going to show the surveyor how good he was and how he was supposed to do incontinent care. CNA B stated he knew he did not change his gloves. CNA A did not appear to understand that by not removing his gloves what could happen. An interview with the DON, who was the infection control preventionist on 04/01/25 at 2:39 p.m., revealed the DON stated that all direct care staff must clean equipment, including blood pressure cuffs after having contact with each resident. The DON stated, the staff has available the disinfectant wipes that will kill all germs. The DON stated the staff when performing incontinent care should be changing gloves from dirty to clean and washing their hands or using the available hand sanitizer. The DON stated she had just had an in-service on 03/25/25 concerning all of this, presenting step by step the cleaning of equipment and incontinent care. The DON stated that some of the CNAs she had spent extra time with, to make sure they understood. The DON stated during the in-service the staff did not ask any questions and appeared to understand and indicated they knew everything. The DON stated if they do not clean the blood pressure cuffs appropriately and change glovers and clean their hands when they should, they could spread germs to themselves and the residents. Record review of an in-service log dated 03/25/25 revealed MA A and CNA B, had received cleaning and properly storing equipment after each use and how to perform correct incontinent care. Record review of the Facility's Policy titled Infection Control Guidelines for All Nursing Procedures dated December 2024, reflected: Purpose: to provide guidelines for general infection control while caring for residents . for residents when performing high-contact resident care activities: dressing, grooming, transferring, providing hygiene, changing linens, changing briefs ., 4. Employees must wash hands for twenty (20) seconds or longer using antimicrobial or non-antimicrobial soap and water under the following conditions: .a. after direct contact with resident, d. after removing gloves, after handling items potentially contaminated with blood, body fluids, or secretions, Record review of the Facility's Policy titled Cleaning and Disinfecting Resident Care items and Equipment dated December 2024 reflected: Resident care equipment, including reusable items Will be cleaned an disinfected . 4. Reusable resident care equipment with be decontaminated and/or sterilized between residents Record review of the Facility's Policy titled Perineal/Incontinent Care dated December 2024 reflected: Purpose: The purposes of this procedure are to provide cleanliness an discomfort to the resident t, to prevent infections and skin irritations, and to observe the resident's skin condition . Steps to procedure 1. Place equipment on bedside . 2. Wash and dry your hands thoroughly . 7. Put on gloves . [steps to perform incontinent care for male/female] . 12. Remove gloves and discard into designated container. Wash and dry hands thoroughly. 13. Replace the bed covers. Make the resident comfortable . 17. Wash and dry hands thoroughly

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #179) of five residents reviewed for injury of unknown origin reporting. The facility failed to ensure on 03/12/25 Resident #179's injury of unknown origin was reported to HHSC when the staff did not know why she had an unwitnessed fall (03/10/25) that was later diagnosed (03/12/25) as periprosthetic fracture (broken) in the region of the greater trochanter (hip). This failure could place fall risk residents of getting more injuries, bruises, and pain which could result in emotional turmoil and cause decreased health and psycho-social well-being. Findings included: Record review or Resident #179's Admission MDS assessment dated [DATE] revealed, an [AGE] year-old female who admitted on [DATE], and did not return after hospitalization . Resident #179 had diagnoses which included: hypertension (high blood pressure), anemia, (low red blood cells), dementia (confusion), and malnutrition (skinny). Resident #179 was severely cognitively impaired and unable to make all decisions for herself and required one staff for total care for all activities of daily living. Resident #179 had not been coded for falls, as she had no actual falls. Record review of Resident #179's Care Plan dated 12/10/24 revealed, Impaired cognitive function/dementia or impaired thought processes related to dementia. On 12/10/24 At risk for at risk for falls related to decreased safety awareness, impaired cognition, and gait and balance problems. On 03/11/25 was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. On 03/10/25 had an actual fall. On 03/12/25 was diagnosed with periprosthetic fracture (broken) in the region of the greater trochanter (hip). Record review of Resident #179's Incident Report by LVN C dated 03/10/25 at 9:38 a.m. revealed, Incident Description Nursing Description: Resident was observed on the floor leaning on left side with left elbow holding her head up. Incident was unwitnessed. Resident Description: Resident was unable to specify. Was this incident witnessed: No. Immediate Action Taken: Description: ROM exercises and Neuro checks within normal limits. No injuries noted, continue to monitor. Resident Taken to Hospital? No. Mental status: oriented to person, lack of safety awareness, forgetful. Predisposing physiological factors: confused, gait imbalanced, DON, ADON, doctor, and family member notified. Record review of the nursing progress notes dated 03/12/25 at 5:21 p.m. by LVN G reflected, Upon last completion of rounds. [Patient] Resident #179 in bed resting with eyes closed during assessment and repositioned Patient showed objective signs of pain as evidence by yelling out and guarding left thigh.The nurse immediately notified doctor with orders for x-ray of entire left leg STAT (right away). Pain medication ordered and given. Family notified and DON notified. Record review of Resident #179's Left Hip X ray dated 03/12/25 reflected, S/p total hip arthroplasty. There is periprosthetic fracture in the region of the greater trochanter, this appears new. Record review on Resident #179's Nurses note dated 03/12/25 by LVN F revealed, [physician] new order to send resident to ER for evaluation. Record review of Resident #179's Medication Administration Record dated March 2025 reflected no pain medications administered after 03/10/2025 until 03/12/2025, when Resident #179 was assessed by LVN G and Resident #179 was transferred to the emergency room following the positive x-ray results. Interview on 04/02/25 at 10:39 am, LVN C stated she worked 6:00 a.m. through 2:00 p.m. She stated Resident #179 admitted several years ago and she was very familiar with Resident #179. Resident #179 normally wheeled about in her wheelchair and was always leaning over trying to pick up something or touch someone and they always made sure her bed was in the lowest position. She stated they also increased monitoring of Resident #179 and anticipated her needs and that she was alert and oriented to herself. She stated Resident #179 was doing well wheeling without assist. She stated she worked on the day shift the day she was found on the floor in the television room. LVN C stated she had seen Resident #179 earlier sitting in her wheelchair in the television room. She stated she did not remember Resident #179 having any other falls for over three months. She stated when she assessed Resident #179, she found no injuries. She stated she began neurological checks and continued to monitor for pain, as was the policy to monitor for 72 hours after any fall in case there were latent injuries. LVN C stated Resident #179 had no pain for the remaining of her shift and had no pain assessed the next day during her shift of 6:00 a.m. to 2:00 p.m. LVN C stated she reported the fall to the DON, ADON, and the family. LVN C stated through the monitoring another nurse assessed Resident #179, the resident exhibited pain and guarding with the left leg, the nurse notified physician and gotten x-rays ordered, that later indicated a left hip fracture. Resident #179 was sent to the hospital. Interview on 04/02/2025 at 1:15 p.m. with CNA F revealed CNA F worked 6:00 a.m. to 2:00 p.m. shift and was working the day that Resident #179 fell . CNA F stated she had seen Resident #179 in the television room approximately 20 minuets earlier and she was sitting in her wheelchair. CNA F sated she came back around by the television room and Resident#179 was on the floor. CNA F stated she went and got the nurse in charge LVN C, who assessed her and Resident #179 did not complain of any pain. CNA F stated she and LVN C got Resident #179 up an into her wheelchair, she did not want to go back to bed, and she started wheeling around, she ate a very good lunch and then I placed her back in bed and completed incontinent care. CNA F stated she did not complain of any pain during care. CNA F stated that Resident #179 had no current falls and she had a low bed in place, with a stability mat. Resident #179 had been in therapy and anti-tip bars had been added to the wheelchair and the seat had been lowered on the wheelchair. CNA F stated Resident #179 was a busy lady she liked to pick up items on the floor and pat other resident's on their back, she also likes to rearrange and arrangements that are available to her. CNA F stated she had taken care of Resident #179 the next day after the fall and she complained of no pain that day, The CNA performed transfer, incontinent and got her dressed. Interview on 04/02/2205 at 2:00 p.m. with CNA I revealed she worked 10:00 p.m. through 6:00 a.m. shift. CNA I stated she did care for Resident #179 and she complained of no pain, when she performed incontinent care. CNA I stated she would have told the charge nurse. Interview on 04/02/2025 at 2:15 p.m. with LVN G revealed she was working on the 2:00 p.m. through 10:00 p.m. shift. LVN G stated she was aware that Resident #179 had fallen out of her wheelchair in the television room, and there was no witness to the fall. LVN G stated she was making her rounds and completing the assessment her assessment of Resident #179, when she exhibited pain and guarding. LVN G stated she contacted the physician, followed orders for the x-ray and later the resident was transported to the hospital for further evaluation of her left hip. LVN G stated Resident #179 had exhibited no pain prior to this assessment. Interview on 04/02/25 at 2:02 p.m., the Administrator stated she was on maternity leave at the time and had no idea Resident #179 had fallen and had an injury of unknown origin. The Administrator said if she had been working at the time, she would have investigated the incident and reported it to HHSC. The Administrator knew that it was supposed to be reported should have been reported timely, but she was not there at the time. The Administrator the facility had various interims that were sitting in her place, as she was out on maternity leave, but was not aware of who the individuals were. Interview on 04/02/2025 at 2:45 p.m. with CNA H revealed that he works the 2:00 p.m. through 10:00 p. m. and had taken care of Resident #179. CNA H stated was working when she complained of pain with her leg during the LVN G's nursing assessment, she did not complain of any pain when I had gone in to check on her earlier. CNA H stated he had taken care of her on the day that she had fallen. Resident #179 complained of no pain, the CNA stated he performed incontinent care, changed her clothing, had gotten her up for dinner and placed her back in bed, she did not complain of any pain. Interview on 04/02/25 at 3:30 p.m. the DON stated there was different people covering for the Administrator while she was out on maternity leave. The DON could not recall who was there on the day that Resident #179 fell . The DON was aware that the resident had fallen and later had a diagnosis of a hip fracture but was unaware that the incident had not been reported and investigated as an unwitnessed fall. The DON stated she had never been trained how to report incidents and would have reported and investigated if she had of known how. The DON stated that different individuals were sitting in during the Administrator's maternity leave, but she had no idea who they were or who was there when this occurred. Review of the neurological assessments dated 03/10/2025 through 03/12/2025 reflected that each nursing shift was following the neurological assessments for each shifts with no omissions noted, or complaints of pain or related changes in conditions, until the assessment reflected a change of condition completed by LVN G. Record review of the facility's policy Abuse, Neglect, and exploitation dated January 2012 and revised December 2024 revealed, Purpose: It is the policy of this facility to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .IV Identification of Abuse, Neglect, and Exploitation: B. Possible indicator of abuse include, but not limited to: 3. Physical injury of a resident, of unknown source . V. Investigation of Alleged Abuse, Neglect and Exploitation A. and immediate investigation is warranted .B. 1. Identify staff responsible for investigation; . 3. Investigation of different types of alleged violations; 4. Identify and interview all involved person . and other who might have knowledge .5. Focusing the investigation on determine if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; 6. Proving complete and through documentation of the investigations.VII Reporting/Response . 1. Reporting of alleged violations to the Administrator, state agency A. immediately, but not later than 2 hours after . if the event . result in bodily injury 13. The Administrator should/will follow-up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies .

Based on interviews and record review, the facility failed, in response to allegations of neglect, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator and to other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident for 1 of 5 (Resident #179) residents reviewed for abuse, neglect, and exploitation investigations. The facility failed to investigate an injury of unknown origin sustained by Resident #179 that was suspicious of abuse or neglect. This failure could cause diminished quality of life and place residents at risk for mistreatment. Findings included: Record review or Resident #179's Admission MDS assessment dated [DATE] revealed, an [AGE] year-old female who admitted on [DATE], and did not return after hospitalization . Resident #179 had diagnoses which included: hypertension (high blood pressure), anemia, (low red blood cells), dementia (confusion), and malnutrition (skinny). Resident #179 was severely cognitively impaired and unable to make all decisions for herself and required one staff for total care for all activities of daily living. Resident #179 had not been coded for falls, as she had no actual falls. Record review of Resident #179's Care Plan dated 12/10/24 revealed, Impaired cognitive function/dementia or impaired thought processes related to dementia. On 12/10/24 At risk for at risk for falls related to decreased safety awareness, impaired cognition, and gait and balance problems. On 03/11/25 was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. On 03/10/25 had an actual fall. On 03/12/25 was diagnosed with periprosthetic fracture (broken) in the region of the greater trochanter (hip). Record review of Resident #179's Incident Report by LVN C dated 03/10/25 at 9:38 a.m. revealed, Incident Description Nursing Description: Resident was observed on the floor leaning on left side with left elbow holding her head up. Incident was unwitnessed. Resident Description: Resident was unable to specify. Was this incident witnessed: No. Immediate Action Taken: Description: ROM exercises and Neuro checks within normal limits. No injuries noted, continue to monitor. Resident Taken to Hospital? No. Mental status: oriented to person, lack of safety awareness, forgetful. Predisposing physiological factors: confused, gait imbalanced, DON, ADON, doctor, and family member notified. Record review of the nursing progress notes dated 03/12/25 at 5:21 p.m. by LVN G reflected, Upon last completion of rounds. [Patient] Resident #179 in bed resting with eyes closed during assessment and repositioned Patient showed objective signs of pain as evidence by yelling out and guarding left thigh.The nurse immediately notified doctor with orders for x-ray of entire left leg STAT (right away). Pain medication ordered and given. Family notified and DON notified. Record review of Resident #179's Left Hip X ray dated 03/12/25 reflected, S/p total hip arthroplasty. There is periprosthetic fracture in the region of the greater trochanter, this appears new. Record review on Resident #179's Nurses note dated 03/12/25 by LVN F revealed, [physician] new order to send resident to ER for evaluation. Record review of Resident #179's Medication Administration Record dated March 2025 reflected no pain medications administered after 03/10/2025 until 03/12/2025, when Resident #179 was assessed by LVN G and Resident #179 was transferred to the emergency room following the positive x-ray results. Interview on 04/02/25 at 10:39 am, LVN C stated she worked 6:00 a.m. through 2:00 p.m. She stated Resident #179 admitted several years ago and she was very familiar with Resident #179. Resident #179 normally wheeled about in her wheelchair and was always leaning over trying to pick up something or touch someone and they always made sure her bed was in the lowest position. She stated they also increased monitoring of Resident #179 and anticipated her needs and that she was alert and oriented to herself. She stated Resident #179 was doing well wheeling without assist. She stated she worked on the day shift the day she was found on the floor in the television room. LVN C stated she had seen Resident #179 earlier sitting in her wheelchair in the television room. She stated she did not remember Resident #179 having any other falls for over three months. She stated when she assessed Resident #179, she found no injuries. She stated she began neurological checks and continued to monitor for pain, as was the policy to monitor for 72 hours after any fall in case there were latent injuries. LVN C stated Resident #179 had no pain for the remaining of her shift and had no pain assessed the next day during her shift of 6:00 a.m. to 2:00 p.m. LVN C stated she reported the fall to the DON, ADON, and the family. LVN C stated through the monitoring another nurse assessed Resident #179, the resident exhibited pain and guarding with the left leg, the nurse notified physician and gotten x-rays ordered, that later indicated a left hip fracture. Resident #179 was sent to the hospital. Interview on 04/02/2025 at 1:15 p.m. with CNA F revealed CNA F worked 6:00 a.m. to 2:00 p.m. shift and was working the day that Resident #179 fell . CNA F stated she had seen Resident #179 in the television room approximately 20 minuets earlier and she was sitting in her wheelchair. CNA F stated she came back around by the television room and Resident#179 was on the floor. CNA F stated she went and got the nurse in charge LVN C, who assessed her and Resident #179 did not complain of any pain. CNA F stated she and LVN C got Resident #179 up an into her wheelchair, she did not want to go back to bed, and she started wheeling around, she ate a very good lunch and then I placed her back in bed and completed incontinent care. CNA F stated she did not complain of any pain during care. CNA F stated that Resident #179 had no current falls and she had a low bed in place, with a stability mat. Resident #179 had been in therapy and anti-tip bars had been added to the wheelchair and the seat had been lowered on the wheelchair. CNA F stated Resident #179 was a busy lady she liked to pick up items on the floor and pat other resident's on their back, she also likes to rearrange and arrangements that are available to her. CNA F stated she had taken care of Resident #179 the next day after the fall and she complained of no pain that day, The CNA performed transfer, incontinent and got her dressed. Interview on 04/02/2205 at 2:00 p.m. with CNA I revealed she worked 10:00 p.m. through 6:00 a.m. shift. CNA I stated she did care for Resident #179 and she complained of no pain, when she performed incontinent care. CNA I stated she would have told the charge nurse. Interview on 04/02/2025 at 2:15 p.m. with LVN G revealed she was working on the 2:00 p.m. through 10:00 p.m. shift. LVN G stated she was aware that Resident #179 had fallen out of her wheelchair in the television room, and there was no witness to the fall. LVN G stated she was making her rounds and completing the assessment her assessment of Resident #179, when she exhibited pain and guarding. LVN G stated she contacted the physician, followed orders for the x-ray and later the resident was transported to the hospital for further evaluation of her left hip. LVN G stated Resident #179 had exhibited no pain prior to this assessment. Interview on 04/02/25 at 2:02 p.m., the Administrator stated she was on maternity leave at the time and had no idea Resident #179 had fallen and had an injury of unknown origin. The Administrator said if she had been working at the time, she would have investigated the incident and reported it to HHSC. The Administrator knew that it was supposed to be reported should have been reported timely, but she was not there at the time. The Administrator the facility had various interims that were sitting in her place, as she was out on maternity leave, but was not aware of who the individuals were. Interview on 04/02/2025 at 2:45 p.m. with CNA H revealed that he works the 2:00 p.m. through 10:00 p m. and had taken care of Resident #179. CNA H stated was working when she complained of pain with her leg during the LVN G's nursing assessment, she did not complain of any pain when I had gone in to check on her earlier. CNA H stated he had taken care of her on the day that she had fallen. Resident #179 complained of no pain, the CNA stated he performed incontinent care, changed her clothing, had gotten her up for dinner and placed her back in bed, she did not complain of any pain. Interview on 04/02/25 at 3:30 p.m. the DON stated there was different people covering for the Administrator while she was out on maternity leave. The DON could not recall who was there on the day that Resident #179 fell . The DON was aware that the resident had fallen and later had a diagnosis of a hip fracture but was unaware that the incident had not been reported and investigated as an unwitnessed fall. The DON stated she had never been trained how to report incidents and would have reported and investigated if she had of known how. The DON stated that different individuals were sitting in during the Administrator's maternity leave, but she had no idea who they were or who was there when this occurred. Review of the neurological assessments dated 03/10/2025 through 03/12/2025 reflected that each nursing shift was following the neurological assessments for each shifts with no omissions noted, or complaints of pain or related changes in conditions, until the assessment reflected a change of condition completed by LVN G. Record review of the facility's policy Abuse, Neglect, and exploitation dated January 2012 and revised December 2024 revealed, Purpose: It is the policy of this facility to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .IV . Identification of Abuse, Neglect, and Exploitation: B. Possible indicator of abuse include, but not limited to: 3. Physical injury of a resident, of unknown source . V. Investigation of Alleged Abuse, Neglect and Exploitation A. and immediate investigation is warranted .B. 1. Identify staff responsible for investigation; . 3. Investigation of different types of alleged violations; 4. Identify and interview all involved person . and other who might have knowledge .5. Focusing the investigation on determine if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; 6. Proving complete and through documentation of the investigations.VII Reporting/Response . 1. Reporting of alleged violations to the Administrator, state agency A. immediately, but not later than 2 hours after . if the event . result in bodily injury 13. The Administrator should/will follow-up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies .

Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 2 of 4 residents (Residents #44 and #30) reviewed for nutritional status. MA A administered nutritional supplement to Resident #44, who was interviewable but moderately confused and unable to make decision for herself, without a physician's order. MA administered nutritional supplement to Resident # 30, who was interviewable moderately confused and unable to make decisions for herself, without a physician's order. This failure could result in residents not having an accurate overall view of their care and services. The findings included: Record review of Resident #44's admission MDS assessment dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #44 had diagnoses which included: hypertension (high blood pressure), Peripheral vascular disease (inadequate blood circulation), and diabetes (high blood sugar). Resident #44 was moderately cognitively impaired, and unable to make all decisions for herself and required one staff for assistance with activities of daily living. Record review of Resident #44's Physician Order Summary report dated 03/10/2025 revealed there was no written order for a nutritional supplement. Record review of Resident #44's Medication Administration Record dated 03/20205 revealed there was no area to document the nutritional supplement. Record review of Resident #30's quarterly MDS Assessment, dated 03/26/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included: cerebrovascular accident (stroke), hypertension (increased blood pressure), and cerebrovascular disease (clogged up vessels in heart). Resident #30 was moderately cognitively impaired and unable make all decisions for herself and required one staff for assistance with activities of daily living. Record review of Resident #30's Physician Order Summary Report dated 03/21/25 revealed there was no written order for a nutritional supplement. Record review of Resident #30's Medication Administration Record dated 03/2025 revealed there was no area to document the nutritional supplement. Observation on 03/31/2025 at 8:26 a.m. with MA A during the morning medication pass revealed she administered 4 ounces of nutritional supplement to Resident #44. Observation on 03/31/15 at 8:44 a.m. with MA A during the morning medications pass revealed she administered 4 ounces of nutritional supplement to Resident #30. An interview on 04/02/2025 at 10:47 a.m. with MA A revealed if she gave the nutritional supplement to residents, she would have physician orders to do so. The MA stated if she gave the nutritional supplement to resident's #44 and #30 and did not have a physician order, she would be wrong. The MA said if a resident asked for the nutritional supplement she would have to tell the charge nurse, to get a doctor's order, before it could be given. An interview on 04/02/2025 at 10:58 a.m. with LVN D revealed all the nutritional supplements given to the residents must have a physician order before anyone can give. An interview on 04/02/2025 at 11:00 a.m. with LVN C revealed the nurse or the medication Aide must have a physician order to give nutritional supplements to any resident, unless they eat less than 50% of their meal, then the staff can give them a health shake, but that was not the same as nutritional supplement. An interview on 04/02/2025 at 11:52 a.m. with the DON revealed that any resident receiving nutritional supplements, including Resident #44 and #30, had a nutritional reason to need them and they must have physician orders to receive them. If the nutritional supplements were given without a physician order, that could possibly cause harm to the resident. The physician orders are followed-up monthly by nursing administration. Record review of the facility policy and procedure titled Medications Orders, dated December 2024 revealed in part, .Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders . Recording Orders: . 7. Commercial Dietary Supplements-When recording orders for commercial dietary supplements, specify the type, amount, and frequency. Resident mush gave physician's order to receive nutritional supplements

Based on observations, record reviews and interviews, the facility failed to ensure the resident received adequate supervision to prevent accidents for one (Resident #1) resident of three residents reviewed for elopement. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility unsupervised on 01/13/2025. Resident #1 had unspecified dementia, other lack of coordination and wore a wander guard. Resident #1 eloped from the facility without anyone noticing him or hearing the wander guard alarm system go off. Resident #1 was located between the facility's white fence and the home next door approximately 10-15 feet from the facility's nearest exit door. The noncompliance was identified as PNC. The IJ began on 01/13/2025 and ended on 01/13/2025. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for harm and/or serious injury. Findings included: Record review of Resident #1's undated Facesheet reflected Resident #1 was a [AGE] year-old-male who admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 had diagnoses which included: dementia (confusion and forgetfulness), other lack of coordination (problem with balance), unspecified cataracts (clouding of the lens in your eye) and viral hepatitis (infection that causes liver inflammation and damage). Record review of Resident #1's Quarterly MDS assessment, dated 12/05/2024 reflected Resident #1 had a BIMs score of 3, which indicated severe cognitive impairment. Under Section E (Behavior) did not reflect any wandering behavior for Resident #1. Under Section GG (Functional Abilities) reflected Resident #1 ambulated independently. Record review of Resident #1's undated care plan, reflected Resident #1 was an elopement risk/wanderer with interventions/tasks that included, staff to monitor wander guard. Record review of Resident #1's clinical record reflected an Elopement Risk Assessment completed on 01/13/2025, indicating a high risk for elopement. Record review of the Provider Investigation Report dated 01/13/2025 revealed on 01/13/2025 [Resident #1] was observed sitting in the dining room eating breakfast at 8:00 am. At 08:15 am, staff were alerted that the resident was outside. [Resident #1] was noted to be found by staff on the facilities sidewalk between the facility and the adjacent home, approximately 15-20 feet from the facility's exterior door. [Resident #1] was promptly and easily re-directed back into the facility and a head-to-toe assessment followed immediately, with no injuries noted. When asked about his intentions, [Resident #1] stated, I was going to pick up some money [Resident #1] was placed on one-on-one supervision, and an elopement assessment was competed. [Resident #1] reported no pain or discomfort. The MD and Family was promptly notified. An Order was received for transfer to a male secure unit at another SNF facility. [Resident #1] remained on one-on-one supervision until time of transfer the same day at 04:00 pm. The facility investigation findings were inconclusive. Record review of Resident #1's Physician Orders reflected Check wander guard every shift effective 11/1/2023. Record review of Resident #1's order summary dated 12/01/2024 to 01/13/2025 revealed a new order starting on 01/13/2025 for 1:1 Monitoring x 24 hours every shift for 2 days. Review of website: timeanddate.com on 01/30/2025 reflected the following temperatures for the area the facility was located: 1/13/24 7:53 AM 31 F 1/13/24 8:53 AM 34 F Record review of Resident #1's progress notes dated 01/13/2025 at 09:33 AM written by the SW revealed, [Resident #1] recently moved to another room due to [Resident #1] and roommate not being compatible. [Resident #1's] prior roommate stated that [Resident #1] was packing up his belongings and putting them on the roommate's bed while he was in the bed. [Resident #1] had confusion and wandered about the facility and appeared to be more lost since the room move. [Resident #1] was pleasantly confused. The nurse reported that [Resident #1] exited the facility this morning. [Resident #1] will need alternate placement in a secured memory care unit. [Resident #1] was currently on one-to-one supervision at this time. Record review of Resident #1's progress notes dated 01/13/2025 at 11:59 AM written by the SW revealed, I called other facilities with secured areas ([Name of other Facilities]) to see if they have any openings in their secured areas. [Name of Facilities] have openings. I have sent [Resident #1] referral paperwork to [Name of Facilities] (marked urgent) and will follow up shortly. I spoke with [Resident #1] [family member]/RP. He understood and is fine with [Resident #1] moving to either of the above facilities. I will notify him once I know which facility [Resident #1] will be going to and what time. [Resident #1] remains on one-to-one supervision at this time. Record review of Resident #1's progress notes dated 01/13/2025 at 01:25 PM written by [LVN] revealed, the resident was found walking outside of facility by another employee. [Resident #1] went out the side door of the facility after he finished breakfast. [Resident #1] stated he was trying to get his money. [Resident #1] was brought back into the facility by staff, he was redirected, and educated on the importance/safety of not exit seeking from the building. [Resident #1] was also placed on 15-minute observation, and an aide was with him at all times. [Family member] was notified of situation and understood that [Resident #1] did leave facility, and the actions the facility has taken to ensure his safety. Record review of Resident #1's progress notes dated 01/13/2025 at 03:54 PM written by LVN C revealed, the representative from [Facility] was at the facility to pick up the resident for admission to facility. All meds, med list with face sheet were provided and the resident was transported. The MD was notified. During an observation and interview on 01/24/2025 at 12:05 pm with the DON, the outside of the facility, the parking lot, both sides of the facility, the house next door, the four-lane street and surrounding area were observed by Surveyor. The facility was located in a business and residential area and was adjacent to a multi-purpose gas station on one side and a private residence on the other side. The DON reported Resident #1 was located standing in the grass area adjacent to the house next door approximately 10-15 feet from the facility's nearest exit door. In an interview on 01/24/2025 at 02:15 pm with the HRM, she stated when she returned to the facility on [DATE] around 08:15 am, as she walked towards the door, something caught her eye and she saw Resident #1 walking outside of the facility. The HRM stated CNA E had already ran outside and yelled that was Resident #1. The HRM stated Resident #1 stopped by the white fence that separated the facility from the home next door. The HRM stated they spoke with Resident #1 and redirected him back into the building. The HRM stated Resident #1 kept saying let me go. The HRM stated nothing they said worked. The HRM stated they eventually got Resident #1 to return to the facility as they convinced him he needed to put on a jacket. The HRM stated she was in-serviced by the DON and the MTD on elopements, wander guard and door alarms and they completed elopement drills on several days. In an interview on 01/24/2025 at 02:40 pm with LVN A, she stated they believed Resident #1 exited the front door when someone left out because it took 15 seconds for the alarm to re-activate. LVN A said the HRM saw Resident #1 outside and CNA E ran outside after him. LVN A stated they brought Resident #1 back inside, assessed him, and placed him on 1:1 monitoring until he transferred to a secure unit. LVN A said Resident #1 wore a wander guard and he had never eloped prior to the incident. LVN A said she took the two residents that wore a wander guard to the front door and ensured the wander guards worked properly. LVN A said she was in-serviced on abuse and neglect, elopements, wander guards, door alarms and they completed elopement drills. LVN A stated the wander guard alarm sound was now different and louder throughout the facility. LVN A said she was in-serviced by the DON and the MTD. LVN A stated she did not learn anything new, and the only thing that was different was the sound of the alarm and its increased volume. In an observation and interview on 01/24/2025 at 03:50 pm with the MTD, revealed the wander guard system had been checked weekly. The MTD provided a copy of the Doors, Locks, & Alarms logbook and it revealed it was updated. The MTD stated they had a wander guard alarm on the 100 and 200 hall exit doors by the nurse's station. The MTD stated the main entrance, the 400 hall and the backdoor all have an alarm that released in 15 seconds. The MTD stated management requested he check the alarms weekly, but he checked the alarms three times a day. The MTD stated they had not had any issues with the alarms. The MTD stated if they had any issues, they called [Service Company]. The MTD stated no resident knew the door code. The MTD stated he checked all the exit doors and they were all operating properly. The MTD stated he still called [Service Company] to come out. The MTD stated the DON and he conducted in-services on door alarms, elopements, fire drills, abuse and neglect and they also conducted elopement drills on 01/14/2025, 01/15/2025, and 01/16/2025. The MTD demonstrated for the Surveyor at each door and both nursing stations that the alarm system worked properly. In an interview on 01/24/2025 at 04:20 pm with the DON, she stated only two residents remained with wander guards. The DON stated they had three nurses on duty and now utilized four nurses. The DON stated at the time of the elopement, the nurses were away from the nurse's station on dining duty and did not hear the alarm. The DON stated [Service Company] came out and adjusted the alarm volume on all doors and ensured everything worked properly. The DON stated [Service Company] increased the volume of the alarm system at the nurse's station and it was now heard throughout the facility. The DON stated they completed elopement drills and in-serviced on abuse and neglect, elopements and missing residents, and fire drills. The DON stated she was in-serviced by the DOR on the Elopement Process on Missing Residents and they toured the building and checked all doors. The DON stated the biggest thing for her was the alarm system and how crucial and important it was it worked properly. The DON stated it exposed her to what she needed to improve on and ensured staff did not become complacent. The DON stated it was bad it happened, but good due to being retrained and refreshed on the emergency codes. In an interview on 01/27/2025 at 10:00 am with LVN B, she stated she was told the HRM saw Resident #1 outside. LVN B stated Resident #1 wore a wander guard. LVN B stated Resident #1 was high functioning. LVN B stated Resident #1 liked to walk up to the doors but had never eloped. LVN B stated she was in-serviced on the alarm systems, how to recognize the sounds, and the protocols if a resident was missing. LVN B stated they completed an in-service on elopements and completed an elopement drill. LVN B stated she was in-serviced by the ADON, DON and the MTD. LVN B stated she learned the new sound system. LVN B stated the wander guard system had a different tone now and the volume was much louder. In an interview on 01/27/2025 at 10:25 am with CNA A, he stated he was informed when he exited a door to make sure the door closed properly. CNA A stated if someone eloped, he searched the inside and outside of the building and if needed, he expanded the search. CNA A stated he was in-serviced on abuse and neglect, doors and door codes, elopements, fire drills and they signed the paperwork. CNA A stated he was in-serviced by the MTD and the DON. CNA A stated the in-services were more of a re-education as he already knew the information. In an interview on 01/27/2025 at 10:50 am with CNA B, she stated she was at work when Resident #1 eloped. CNA B stated Resident #1 had recently moved to another hall. CNA B stated after Resident #1 finished breakfast, he walked back towards his room. CNA B stated she returned to the dining room and assisted with breakfast. CNA B stated she observed Resident #1 re-enter the facility with the HRM and CNA E. CNA B stated the ADON assigned her to 1:1 supervision and she completed a 15-minute checklist. CNA B stated she was in-serviced on abuse and neglect, elopement policy, wander guard system, 15-Miniute elopement checklist, and the different emergency color codes. CNA B stated she was in-serviced by the ADON, the DON, and the MTD. CNA B stated she did not learn anything new. CNA B stated she continued to monitor all residents more closely. In an interview on 01/27/2025 at 01:25 pm with CNA C, she stated she was not at work when the incident occurred. CNA C stated she was in-serviced by the DON and the MTD on abuse and neglect, the different alarm systems, door codes, elopement, and what to do and how to react if one of these situations occurred. CNA C stated they completed an elopement drill and had unscheduled fire drills without warning. CNA C stated whenever she saw Resident #1 approach the door, she immediately redirected him. CNA C stated even if Resident #1 stared at the door, she redirected him. CNA C stated the in-services were more of a refresher. CNA C stated she would not do anything different, just remain aware and vigilant. In an interview on 01/27/2025 at 01:50 pm with CNA D, she stated Resident #1 eloped prior to her shift. CNA D stated Resident #1 stayed in his room mostly and did things for himself. CNA D stated she did not know what made Resident #1 leave. CNA D said she was in-serviced by the DON and the MTD on door alarms and if the fire alarm sounded, they called 911. CNA D said they had alarms on the doors in case a resident attempted to leave unsupervised. CNA D stated the alarms were now louder and she noticed the difference. CNA D said they were in-serviced on elopements and they completed an elopement drill. CNA D stated the MTD conducted the drills. CNA D said the DON conducted the training on abuse and neglect. CNA D stated she did not know what could had been done different. CNA D stated based on what she learned, it was a refresher and she would not be doing anything different. In an interview on 01/27/2025 at 02:15 pm with LVN C, he stated this incident occurred prior to his shift, but Resident #1 was transferred out during his shift. LVN C stated he was told Resident #1 exited the building and had to be redirected inside. LVN C said Resident #1 was new to his hall as he had transferred to a new room. LVN C stated he was unaware if Resident #1 ever attempted to leave the facility. LVN C stated he believed everything was handled accordingly. LVN C stated all doors had been tested . LVN C stated Resident #1 would ask him where his room was located. LVN C stated Resident #1 never came across as an exit-seeker. LVN C stated he was in-serviced on elopements, abuse and neglect, and they conducted an elopement drill. LVN C stated he was in-serviced by the ADON and the DON. LVN C stated the MTD was present and he led the actual elopement drill. LVN C stated the wander guard system is now much louder. LVN C stated he did not learn anything new and it was more of a refresher. LVN C stated moving forward, he would be more vigilant and mindful of the residents that like to wander. In an interview on 01/27/2025 at 02:30 pm with the MR/ADC, she stated she was at work but did not see what happened. The MR/ADC stated she sat at the main entrance and Resident #1 had not exited from her area. The MR/ADC stated she did not see Resident #1 walk past her office window. The MR/ADC stated when she heard Resident #1 got out, she searched inside and outside. The MR/ADC stated she completed a fire and elopement drill and was in-serviced on abuse and neglect, door codes, and elopement. The MR/ADC stated Resident #1 was quiet and had never eloped. The MR/ADC stated she learned to pay attention even when she was already paying attention. The MR/ADC stated moving forward, she would go outside and look to make sure no resident was out front. The MR/ADC stated the alarm system was much louder now. In an interview on 01/27/2025 at 02:45 pm with LVN D, she stated she was not working when Resident #1 eloped. LVN D stated Resident #1 recently transferred from her hall. LVN D stated she was in-serviced on abuse and neglect, the elopement policy, monitoring the residents, door safety, and the alarm systems. LVN D said they also conducted an all-staff elopement drill. LVN D stated if they saw a resident leaving, they were supposed to make sure the wander guard is on and working properly. On 01/27/2025, multiple attempts were made to contact the MD. A returned phone call was not received prior to exiting. On 01/27/2025, multiple attempts were made to contact the ADON. A returned phone call was not received prior to exiting. On 01/27/2025, multiple attempts were made to contact CNA E. A returned phone call was not received prior to exiting. In an interview on 01/27/2025 at 04:15 pm with the DON, she stated Resident #1 recently moved to a new room. The DON stated the room change made Resident #1 confused and disoriented due to his new surroundings. The DON stated Resident #1 wore a wander guard due to aimlessly wandering throughout the facility. The DON stated Resident #1 had been in the dining room eating breakfast as usual. The DON stated once Resident #1 finished eating, he normally went back to his room. The DON stated Resident #1 was stopped between the facility and the house next door. The DON stated there had been maybe a 15-minute gap from the time Resident #1 finished breakfast. The DON stated Resident #1 had never tried to elope. The DON stated Resident #1 watched tv, slept, and minded his business. The DON stated Resident #1 was not an exit-seeking resident. The DON stated Resident #1 started wearing a wander guard in July 2023 due to wanting to return home and pushing on the door. The DON stated they kept eyes on Resident #1 and he had done good. The DON stated they explained to the family back then if Resident #1 tried to elope he would be transferred out. The DON stated Resident #1 never tried to leave until the recent incident on 01/13/2025. The DON stated Resident #1 was assessed with no injuries, placed on 1:1 and transferred out the same day. The DON stated the MTD checked the alarms every morning and at the end of the day. The DON stated on 01/13/2025 the MTD said he checked the doors and alarms at 08:00 am and they worked properly. The DON stated she could not say for sure, which door Resident #1 exited from because they found him on the side of the building. The DON stated if Resident #1 had exited the front door, the alarm was loud and the wander guard would had triggered it. The DON stated the side doors had alarms and wander guard systems were at both nursing stations. The DON stated they did not have video cameras. The DON stated staff observed Resident #1 at 08:00 am in the dining room, and they observed him again outside at approximately 8:15 am. The DON stated the alarms were checked at 08:00 am and worked properly. The DON stated the HRM saw Resident #1 outside when she returned from the store. The DON stated either Resident #1 pushed the door, or he followed someone out. The DON stated due to it being breakfast time, no one was at either nurse's station. The DON stated the nurses went to the dining room to assist. The DON stated the CNAs assisted in the dining room after passing trays on the halls. Record review of the Quality Assurance Performance Improvement Meeting revealed it was held on 01/20/2025 with the Medical Director in attendance. Under Nursing Concerns, QM Action Plan or PIP reflected, Elopement Incident regarding Resident #1 with interventions put in place. Elopement - Dated 01/13/2025 A new elopement assessment was conducted on 01/13/2025 to identify any residents who may be at imminent risk of elopement. No residents were found to be at immediate risk. Responsibility: Nurse Management Monitoring: Regional Director of Clinical Services / Director of Nursing Elopement assessments will be completed upon admission, on a quarterly basis, and whenever a resident triggers a potential imminent risk for elopement. In such cases, the elopement response protocol will be activated. Any resident identified as having an elopement risk will be placed under 1:1 monitoring until it is no longer deemed necessary. Monitoring: Regional Director of Clinical Services - Residents at risk of elopement will remain on 1:1 supervision until alternative or safe living arrangements are found. They will be supervised by facility staff. The resident's photo and face sheet will be included in an elopement binder, and care plans will be updated accordingly. The Director of Nursing and/or Nurse Manager will conduct weekly audits to ensure compliance by reviewing elopement assessments and the elopement binders. These audits will be performed weekly for a duration of four weeks, ending on 02/06/2024, and will then be conducted monthly on an ongoing basis. The Regional Director of Clinical Services will also review the documentation weekly for compliance. The Executive Director will monitor daily compliance for the first four weeks, then conduct a review. Record review of an in-service dated 01/13/2025 reflected all staff attended and the subject matter was regarding the facility policy on Missing Resident Drill: Create an incident response protocol that staff can easily activate when a patient is missing. The protocol should specify the sequence of events (e.g., the action plan) that should take place when staff are notified that a patient is missing. The protocol should include the communication plan (e.g., notification of unit supervisor, security, patient's physician, patient's family, administration) and must include up-to-date contact information for all parties who need to be notified. Ensure that all staff are educated about preventing and responding to elopement events e.g., risk factors, communication protocols, action plans). Evaluate elopement events and attempted elopement events to identify gaps in the protocol or in staff education or response. Modify the protocol as needed. Record review of the Elopement Drill Checklists for an all-staff elopement drill revealed drills were conducted on 01/14/2025 at 10:00 am, 01/15/2025 at 10:00 pm, and 01/16/2025 at 01:30 pm. Record review of an in-service dated 01/14/2025 reflected all staff attended and the subject matter was regarding the facility policy on abuse and neglect. Record review of an invoice from [Company] dated 01/13/2025 revealed under notes, Checked all doors and all mag locks are locked and alarming and egressing as they should. Interviews were conducted with facility staff from various shifts on 01/27/2025 from 3:00 pm to 4:00 pm. Staff interviewed were ADON, HRM, CNA A, CNA B, CNA C, CNA D, LVN A, LVN B, LVN C, LVN D. Interviews with staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on responding to all alarms to ensure resident safety, how to check the panel on the halls to determine what door alarm was sounding, conducting a resident head count, full searches inside/outside the facility, and ensuring they searched all sides of the building outside. Record review of the Facility's Policy titled Elopements revised December 2024 reflected: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the departure in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the Charge Nurse or the Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall; a. examine the resident; b. Notify the attending physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record.

Based on interviews, and record review, the facility failed to immediately notify the resident's responsible party consistent with his or her authority, when there was an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 4 residents (Resident #2) reviewed for notification of changes. LVN D failed to promptly notify Resident #2's responsible party when an injury of unknown origin was discovered on Resident #2's face during the evening on 01/18/2025. Resident #2's responsible party was not made aware of the injury of unknown origin until she arrived at the facility to visit the next day on 01/19/2025. Resident #2 was transferred back to the Hospice In-House Unit where she was diagnosed with a hematoma (collection of blood that has accumulated outside of blood vessels in a localized area). This deficient practice could place residents at risk of not having their responsible party informed when there was a change in condition resulting in a delay in medical intervention and decline in health. Findings included: Record review of Resident #2's undated Face Sheet revealed that the resident was an [AGE] year-old female that admitted to the facility on [DATE]. Resident #2 admitted under hospice with diagnoses including cirrhosis of the liver (scar tissue), chronic obstructive pulmonary disease (inflammation and narrowing of the airways), coronary artery disease (narrowing of the arteries), heart failure, restlessness and agitation, and personal history of other diseases of the circulatory system. Record review of Resident #2's Admission MDS Assessment, dated 01/11/2025, reflected Resident #2 did not meet the criteria for a Brief Interview for Mental Status (assess a person's cognitive function). Resident #2 was assessed to require assistance with ADLs including the following: eating, dressing, personal hygiene, showers, and transfers. Record review of Resident #2's undated Care Plan revealed she was a DNR with interventions including keep my family and MD updated on my condition. Record review of Resident #2's electronic medical records reflected Resident #2 had a progress note on 01/18/2025 at 2:24 pm that was entered by LVN D. The progress note revealed [LVN D] was called by the CNA to [Resident #2's] room regarding she had a small scratch on her right forehead. Upon entering the room [Resident #2] was in the bed, awake, alert, confused and disoriented, respirations even and unlabored, and there was no bleeding from the small area on the right forehead. The MD [Name] was notified and gave an order to monitor [Resident #2]. The family was called, left no answer. [Resident #2] was monitored, and the call light was within reach. Record review of Resident #2's electronic medical records reflected Resident #2 had a progress note on 01/18/2025 at 2:33 pm that was entered by LVN D. The progress note revealed. Vitals: Temperature 97.4 degrees F - 1/19/2025 02:37 pm Route: Forehead (non-contact); Blood Pressure 126/52 - 1/19/2025 02:37 pm Position: Lying left/arm; Pulse 70 - 1/19/2025 02:37 pm Pulse Type: Regular; Respiratory 18 - 1/19/2025 02:37 pm; O2 93 % - 1/19/2025 02:37 pm Method: Oxygen via Nasal Cannula. Record review of Resident #2's electronic medical records reflected Resident #2 had a progress note on 01/19/2025 at 2:47 pm that was entered by LVN D. The progress note revealed follow-up area on the forehead, [Resident #2's] face looked bruised and area on the forehead remained. The right side of the face was bruised with some bruises; pain medication was given this morning and lorazepam for anxiety. [Resident #2] was monitored. Interview on 01/24/2025 at 11:15 am with the RP, she stated Resident #2 entered hospice in July 2024 for COPD, cirrhosis of the liver and heart failure. The RP stated she was not notified on Saturday evening (01/18/2025) by LVN D when Resident #2 was observed with bruising to her face. The RP stated she noticed the bruising when she arrived to visit Resident #2 the next morning on Sunday (01/19/2025). The RP stated hospice then went to assess Resident #2 and transferred her back to the Hospice In-House Unit. The RP confirmed the DON followed up with her the next day and informed her that she believed the bruising was delayed from her fall on 01/15/2025. Interview on 01/27/2025 at 02:45 pm with LVN D, she stated on 01/18/2025, CNA B told her that Resident #2 had a small bruise on her forehead. LVN D stated she went to look at it, and Resident #2 was sitting up on the bed. LVN D stated there was no blood, so she completed a Skin Incident Report for Resident #2's forehead and called hospice. LVN D stated she did not notice any pronounced bruising on Resident #2's face until the next morning. LVN D stated she did not see Resident #2 fall nor observe her on the floor, she was still sitting up on the side of the bed. LVN D stated Resident #2's bruising must had set in overnight and she saw it the next morning. LVN D stated she called hospice on 01/18/2025 about Resident #2's forehead and called them that morning on 01/19/2025 about the bruising. LVN D stated she did not call the family. LVN D stated she thought hospice may relay the message to the family. LVN D stated they normally called the family. LVN D stated there was no reason she did not call the RP. LVN D stated per policy, she should had called the RP. Interview on 01/27/2025 at 03:20 pm with Hospice RN A, she stated she was Resident #2's assigned hospice nurse. Hospice RN A stated she had no concerns for the care provided at the facility. Hospice RN A stated Resident #2 had a rapid decline and she believed she would have passed within 7 days. Hospice RN A stated when she saw Resident #2 on 01/15/2025, she was going to mark her status as being, eminent. She stated Resident #2 was always in pain and she was thinking was it restlessness from pain or more terminal restlessness, but she just was not ready to make that call that day. She stated she was going to update Resident #2's status the following week, but Resident #2 was readmitted back to their Hospice In-House Unit on 01/19/2025. Hospice RN A confirmed that hospice provided Resident #2 with a bedside table. Interview on 01/27/2025 at 03:40 pm with Hospice RN B, she stated she sent Resident #2 back to the Hospice In-House Unit on 01/19/2025. Hospice RN B stated Resident #2 was evaluated by the doctor and noted with a hematoma to the left side of the forehead. Hospice RN B stated there was nothing suspicious and she did not suspect foul play. Hospice RN B stated the bruising was blackish blue and could had been from the night before. Hospice RN B stated she notified the family that Resident #2 would be transferred back to Hospice In-house Unit and they agreed. Hospice RN B stated it looked as though Resident #2 may had bumped something hard. Hospice RN B stated with Resident #2's condition, she sustained injuries easily. Hospice RN B stated when she assessed Resident #2 she was resting in bed. Hospice RN B stated staff reported Resident #2 was found yesterday, 02/28/2025 sitting on the side of the bed with a small bruise to the face. Hospice RN B stated staff reported they believed Resident #2 hit her face on the overbed table while sitting up. Hospice RN B stated LVN D reported she did not believe it was from a fall and that was why she did not report a fall. Hospice RN B stated the bruising probably developed through the night. Hospice RN B stated Resident #2 had poor skin turgor and only weighed 85 lbs. Hospice RN B stated she believed Resident #2 was getting close to the end. Interview on 01/27/2025 at 04:15 pm with the DON, she stated Resident #2 admitted to the facility on [DATE] already on hospice and she was impulsive and very confused. The DON stated she assessed Resident #2 and you could not keep her in the bed. The DON stated they would reposition her, and she continued to move. The DON stated even Lorazepam could not control Resident #2. The DON stated the bed was kept in the lowest position and Resident #2 would crawl all over the place. The DON stated she was informed Resident #2 sustained a fall on 01/15/2025 and landed on her right side. Resident #2 said she was sorry and did not know how she fell . The DON stated they assessed her, completed neuro checks around the clock and reported it to hospice. The DON stated Resident #2 had slight bruising on the right side of her forehead, but there was no bleeding or broken skin. The DON stated hospice brought in a thick bedside table and kept it by the bed. The DON stated they would sometimes find Resident #2 lying under the table. The DON stated when Resident #2 raised up, her head would sometimes be under the table. The DON stated she believed the bruising on 01/19/2025 was delayed from Resident #2's fall on 01/15/2025. The DON stated there was even a scab on it and if it had been bruising from 01/18/2025, it would have been fresh bruising. The DON stated they were able to determine that the bruising was delayed. The DON stated they could tell that the bruising was yellow and the purple was coming in. The DON stated she, the ADON and the IDT discussed it during their morning meeting. The DON stated per policy, LVN D should had called the RP in addition to hospice. On 01/27/2025, multiple attempts were made to contact the MD. A returned phone call was not received prior to exiting. Record Review of the Change in a Resident's Condition or Status Policy dated December 2024 reflected that: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status;.

Based on observations, interviews, and record reviews, the facility failed to ensure resident was free from abuse and neglect for 1(Resident # 2) of 10 residents reviewed for abuse and neglect. 1. The facility failed to protect Resident # 2 from physical abuse by CNA F. Resident #2 was aggressively respositioned and hit twice in the face with an opened hand and closed fist by CNA F. Resident #2 grimaced after being hit twice in the face by CNA F. This failure could place residents at risk of abuse, injury, and emotional distress. The noncompliance was identified at PNC. The noncompliance began on 5/15/2024 and ended on 5/15/2024. CNA F was arrested by law enforcement and terminated immediately. The facility had corrected the non-compliance by conducting skin assessments on all nonverbal residents, conducted safe surveys for every verbal resident, educated staff on abuse and neglect and customer service, and the facility implemented monitoring by all departments completing guardian angel daily rounds daily for six weeks. Findings include: Record review of Resident #2 face sheet dated 12/19/2024 reflected an [AGE] year-old female who was admitted to the facility 6/24/2021 with diagnoses which included: combined systolic and diastolic heart failure, dysphasia following other cerebrovascular disease, hyperlipidemia, and Alzheimer's disease. Record review of Resident #2 quarterly MDS assessment dated [DATE] reflected a BIMS score of 99 which indicated the interview was unable to be completed. Record review of Resident #2 care plan dated 10/4/2024 reflected Resident #2 had impaired cognitive function and impaired thoughts and communication problem related to Alzheimer's, ADL self-care performance deficit related to Alzheimer's, confusion, and limited mobility, and swallowing problem related to dysphasia. (Requires total assistance with eating, bed mobility, transfers, dressing, toilet use and personal hygiene) Record review of provider investigation report dated 5/22/2024 reflected video footage of CNA F slapping and hitting Resident #2 and rearranging Resident #2 forcefully. Skin assessments and x-rays were conducted and showed no results of bodily harm or bruising. CNA F was removed by law enforcement and was terminated immediately. Further investigation, documentation, and evidence confirmed the allegation. In an interview on 12/17/2024 at 4:37pm, Resident #2's representative stated Resident #2 room had video surveillance camera installed 5/14/2024. The representative stated on 5/15/24 at approximately 5:00am, she reviewed the video footage and observed a staff member hitting resident twice in the face with an open hand, and aggressively pulling Resident #2 from the top of the head to the other side of the bed. Resident #2's representative stated after viewing the video footage she notified law enforcement. She stated law enforcement visited the facility and arrested CNA F. Observation and interview on 12/18/2024 at 12:28pm. Resident #2 were observed sitting up staring at the ceiling. The state surveyor attempted to interview Resident #2 but Resident #2 could not verbally communicate. In an interview on 12/18/2024 at 1:00pm, the DON stated Resident #2 is nonverbal and require total care and is dependent on staff for ADL's. She stated on 5/14/2024 at approximately 5:00pm or 6:00pm, resident # 2 had video surveillance camera installed in her with approval from the facility. She stated on 5/15/2024 at approximately 6:00am, she was contacted by staff and informed law enforcement showed up to the facility with video footage of CNA F hitting Resident #2 twice in the face. She stated staff told her law enforcement addressed the incident with CNA F and then arrested CNA F. She stated immediately following the arrest, CNA F was terminated. She stated there were no witnesses present during the incident. She stated following the incident, the resident was treated off site, and a skin assessment and X-rays were conducted. She stated no injuries were founded. She stated on 5/15/2024, the facility started their investigation and initiated skin assessments on all non-verbal residents, safe surveys on all verbal residents, in services on abuse and neglect and customer service, and Angel rounds were conducted and completed by all department heads daily for six weeks. Attempted interview on 12/19/2024 at 12:55pm, the state surveyor attempted to contact CNA F via phone. The attempt was unsuccessful, the state surveyor left a message requesting a call back. In an interview on 12/20/2024 at 4:37am, RN D stated on 5/15/2024, she was the nurse on duty during the 10pm-6am shift. She stated at approximately 5:00am, law enforcement showed up to the facility and approached the nurse's station. She stated the officer asked who provided care to Resident # 2. She stated CNA F was standing at the nurse's station and responding to the officer stating she provided care to Resident # 2. She stated the officer asked CNA F if she physically assaulted Resident #2 and CNA F denied physically assaulting Resident # 2. She stated the officer showed CNA F video footage of CNA F physically assaulting Resident # 2. She stated after the officer showed CNA F the video footage, she still denied physically assaulting Resident # 2. She stated the officer handcuffed CNA F and escorted CNA F out of the facility. She stated the officer showed her the video footage. She stated in the video footage she identified CNA F and observed CNA F pulling Resident # 2 roughly and slapping Resident #2 on her forehead. She stated she notified the ADM and the DON immediately. She stated she was in serviced on abuse and neglect. She stated the risks of staff not reporting abuse or neglect to the abuse coordinator could allow the abuse to continue. In an interview on 12/20/2024 at 5:17am, CNA G stated she worked full time during the 10pm-6am at the facility. She stated the night the incident between CNA F and Resident # 2 took place, she was off. She stated she was in serviced on abuse and neglect. She stated the risks of staff failing to report abuse or neglect could put the residents a harm for continued abuse. In an interview on 12/20/2024 at 8:07am, the ADM stated she was not employed at the facility when the incident between CNA F and Resident # 2 occurred. She stated she was hired in September 2024. She stated after reviewing the PIR, she was informed there was video footage of CNA F physically hitting Resident # 2 twice to the face. She stated the PIR indicated law enforcement arrested CNA F at the facility. She stated the PIR revealed CNA F was terminated immediately and the facility-initiated safety and prevention measures. She stated the facility initiated in services on abuse and neglect and customer service. She stated skin assessments were conducted on all non-verbal residents, and safe surveys conducted on all verbal residents. She stated the facility's monitoring plan included angel rounds conducted daily for 6 weeks by all department heads. She stated the risks of staff failing to report abuse or neglect could put the residents at risks of getting hurt and having adverse effects. Observation and interview on 12/20/2024 at 9:00am with the ADM and the DON, the state surveyor revealed she received the video footage of the incident between CNA F and Resident # 2 on 12/20/2024. Surveyors reviewed the video with the ADM and the DON. The video revealed at 5/15/24 at 2:26am, CNA F was observed in Resident #2 room whipping Resident #2 chin with a towel. CNA F was observed slapping Resident # 2 on her forehead with a right open hand causing loud noise. CNA F was then observed aggressively grabbing Resident #2 by the head and pulling Resident #2 to the other side of the bed as she positioned Resident #2. CNA was then observed hitting Resident #2 on the forehead with a right closed fist. Resident #2 was observed with a grimacing face after being hit in the face. After watching the video, the DON was able to identify the CNA as CNA F. The DON stated after she was informed about the incident, the facility terminated the CNA F immediately. She stated she tried to contact CNA F, but the attempt was unsuccessful. Record review revealed a skin assessment performed on 5/15/2024 on Resident # 2 with no adverse physical findings. Record review revealed skin assessments performed on 5/15/2024 on all non-verbal residents. Record review of in-service training record dated 5/15/2024 revealed nurses, CNAs, and CMAs were in serviced by nursing management on abuse and neglect and customer service. Dietary staff was in serviced on customer service. Record review of safe surveys dated 5/15/2024 revealed departments heads conducted safe surveys on verbal residents. Record review of Guardian Angel Daily Rounds revealed department heads conducted angel rounds. The angel rounds were initiated on 5/15/2024 and completed on 7/16/2024. Record review of Police Report dated 5/15/2024, reflected law enforcement dispatched to the facility. The video footage was provided to the responding officer. Due to the video evidence CNA F was taken into custody for the offense of injury to elderly. The disposition of the police report was cleared by arrest. Record review of the facility's policy titled Risk Management: Abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property dated December 2023, Policy statement: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement/involuntary seclusion, or separation of a resident from other residents or from their room or other area against the resident's will or the will of the resident's legal representative. Intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, or pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. 1. Residents must bit be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, or other individuals.

Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) resident of three residents reviewed for elopement. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent her from leaving the facility unsupervised. Resident #1 had severely cognitive impairment and lacked safety awareness. Resident #1 eloped from the facility rolling in her wheelchair across a four-lane busy residential street arriving at the fire station across the street 50 yards away. It was determined these failures placed Resident #1 in a non-compliance Immediate Jeopardy (IJ) situation from 07/01/24-07/02/24. The facility corrected the noncompliance before the survey began. This failure placed residents at risk for harm and /or serious injury. Findings included: Record review of Resident #1's other MDS assessment, dated 07/11/2024 reflected the Resident was an [AGE] year-old-female who admitted to the facility on [DATE] and readmission on 05/31/2023 and discharged on [DATE]. The resident had diagnosis which included: Malignant Neoplasm of colon (cancer of the colon), intestinal obstruction (mass in the intestine), dementia (confusion and forgetfulness), functional decline, generalized weakness, anxiety (restlessness) and lack of coordination (unable to walk). The MDS reflected he had a BIMs score of 4, which indicated severe cognitive impairment and the resident was ambulatory with a wheelchair and required assist of one staff for activities of daily living. The MDS did not reflect any wandering behavior. Record review of Resident #1's care plan, dated with an review date of 07/01/2024, addressed the resident's impaired cognition due to short term memory loss (unable to remember after 5 minutes), and assistance required for activities of daily living. Further review of the clinical record reflected, the resident's moderate risk for elopement was not addressed, until 07/01/2024. Record review of Resident #1's Elopement [NAME] Assessment completed 06/05/2023 scored Resident #1 as no risk for elopement. Further review of Resident #1's elopement risk dated 06/04/2024 reflected Resident #1 as no risk for elopement. Record review of the clinical record reflected an Elopement Risk Assessment completed on 07/01/2024, indicating a high risk for elopement. Record review of Provider Investigation Report dated 07/01/2024 reflected a finding of Unfounded for Neglect. Review of the External/Internal/Systemic Approach Investigation Summary dated 07/01/2024 completed on 07/05/2024 reflected: . An emergency QAPI meeting was held on 07/02/2024 with Medical Director in attendance . all residents had a new elopement assessment to identify any current patients that are imminent risk for elopement (no other residents were found to be at imminent risk of elopement) . (who was responsible: Nurse Management . who will monitor: Regional Director of Clinical Services/Director of Nursing.elopement assessment will be completed upon admission and quarterly by the charge nurse and/or nurse managers and for any resident that triggers an imminent risk for elopement, the elopement response protocol will be initiated Any patient that triggers elopement risk will be placed on 1:1 monitoring until no longer deemed necessary. DON will monitor for compliance for 4 weeks until 08/08/2024 and then monthly on an ongoing basis .Who will monitor: Regional Nurse of Clinical Services Until alternative and or safe living arrangements are made, they will be placed on one-one-supervision with facility staff. The resident's picture and face sheet will be placed in an elopement binder. Resident care plans will also be updated. The Director of Nursing and/or Nurse Manager will monitor weekly for compliance by completing an audit of the elopement assessments and the elopement binders. Audits will be completed weekly for 4 weeks until 08/08/2024 and monthly on an ongoing basis The Regional Director of Clinical Services will review the documentation each week for compliance The Executive Director will monitor daily to ensure compliance for four weeks and will review . Further review of the Providers Investigation Report reflected monitoring and audits by the designated staff (DON Nurse Managers and Regional Nurse consultant) had occurred. Record review of progress notes reflected Resident #1 on 06/01/2024 through 07/01/2024 had previously indicated she had no behaviors of wandering or attempting to exit the facility. Further review of the progress note reflected Resident #1 had a diagnosis of anxiety, that had increased on 06/17/2024, The nursing staff contacted the physician, who came and visited the resident who as not sleeping well at night and stating she did not know what to do with herself anymore. The physician medications changes increased the anxiety medication. Record review of the Medication Administration Records for Resident #1 reflected the Lorazepam 05mg two time a day had been increased to three times a day on 06/17/2024. Record review of progress notes reflected Resident #1 on 07/01/2024 she was observed by LVN A, who was the MDS coordinator at the time, in her wheelchair mobilizing across a busy four lane residential road. Record review of In-service dated 07/01/2024 reflected all staff attended and the subject matter was regarding Facility policy on elopement and reducing the risk for elopement: initiating a frequent monitoring form, communicating any related changes in any resident immediately to the charge nurse, if you notice a residents exhibiting exit seeking behavior to notify the charge nurse immediately and do not leave the resident alone, and to be aware where the elopement binders are located at each nurses station. and updating the care plan. Record review of the In-serviced dated 07/02/2024 reflected an all-staff elopement drill. In an interview on 12/18/2024 at 10:00 am with the ADON revealed she was working on the day that Resident #1 left the facility, she did not know which door she went out of. ADON stated, A code was called and everyone went running, I stayed inside to assist the other nurse to make sure all the other residents were accounted for and were safe. The ADON said she did not know the resident that well, she had not worked here long. Resident #1 was pleasant and she had never been told by staff that she would elope, she did not wear a wander guard. The ADON stated at times the resident was anxious, but not exit seeking. In an interview on 12/18/2024 with LVN A at 10:53 a.m. revealed he was looking at the window and he thought he saw the resident crossing the street in her wheelchair, going towards the old fire station. LVN A said, I could not believe my eyes; I called a code pink and ran out telling he receptionist to tell everyone. By the time I got to her she was already across the street and in the parking lot of the fire station. LVN A stated the traffic had stopped on both sides of the street as she crossed. Resident #1 told me she was coming to see about the fireman, the DON was right behind me and a whole lot of staff. She was brought back to the facility and the DON assessed her; she was not injured. Resident #1 never mentioned about leaving, the LVN stated he saw her every day and she was always out of her room and she was wheeling around in her wheelchair, but not trying to leave. The LVN stated Resident #1 goes to all activities and she will sit at the nurse's station and talk to other residents. An observation on 12/18/2024 at 4:00 p.m. revealed the surrounding outside area, parking lot, and streets adjacent to the facility. The facility was in a residential/business area with multiple car lots, multiple restaurants, a large shopping center, and multiple businesses. The street in front of the facility was very busy with cars. There was a popular highway less than a quarter of a mile away, as well as a very busy main four lane street that leads to residential areas, and large shopping centers, that has heavy traffic on the road all times of the day and night. Where the resident was found (in the parking lot of the old fire station) is approximately 150-200 feet away across busy streets. In an interview on 12/18/2024 with Social Worker at 11:10 a.m. revealed she had worked here since December 2017 there had not been any elopements. The Social Worker stated she had been in-served by the new Administrator. The staff is supposed to report any exit seeking behaviors, that would include a resident talking about leaving. The resident is immediately replaced on 1:1 until they can locate a safe place for them to reside. The Social Worker stated she assisted in locating several secured units for the family to tour and pick from. The Social Worker stated Resident #1 had never had any exit seeking behaviors. The Social Worker stated the facility had an in-service about elopement and conducted an elopement drill. In an interview on 12/18/2024 at 11:15 a.m. with CNA B revealed she was working the day that Resident #1 left the facility. CNA B stated she had been in the dining area around 12:30 p.m. and Resident #1 had been in the dining room, ate her lunch and left the dining area. The CNA stated she did not say anything about leaving and she did not notice any unusual behavior related to Resident #1. The CNA stated the resident came into the dining area ate her lunch and left, came as she has always done. CNA B stated when she came back inside, I got the feeling she was not eloping, she was just going to introduce herself to the fireman, like she was their neighbor. The CNA stated the facility had in-service on elopement and we had an elopement drill also. CNA B stated Resident #1 had a wander guard placed on her and staff was asked to do 1:1 monitoring her 24 hours a day until she left the facility. In an interview on 12/18/2024 with CNA E at 12:00 p.m. revealed she knew where the wander guard binders were at the nurse's station. CNA E stated she had taken care of Resident #1; she was very busy resident and would sit for awhile if you gave her an activity book. CNA E stated Resident #1 attended all the activities. The resident never said anything about leaving the facility. The CNA stated she had been in-serviced on elopement and had attended a drill for elopement and knew what to do. In an interview/observation on 12/18/2024 with the Maintenance Director at 12:10 p.m. revealed the wander guard system was checked once a week. The Maintenance Director and the Surveyor revealed the maintenance logs together the last check had been on 12/16/2024. Further view revealed the wander guard system had been checked the morning of 07/01/2024. The Maintenance Director stated the doors were easy release doors that if you hold them, they will release in 15 seconds and if you wear a wander guard the doors will alarm. The maintenance demonstrated that the wander guard worked with a loose wander guard that had been engaged. The maintenance Director explained if the wander guard bracelet was engaged it was blinking. In an interview on 12/18/2024 with LVN C at 12:45 p.m. revealed LVN C had seen Resident #1 on 07/01/2024 coming out of the dining room. LVN C stated it was after she had eaten lunch. Resident #1 was not her resident, but she knew her because she mobilized all around in her wheelchair. LVN C stated that Resident #1 had never said anything about wanting to leave that day or any other day. LVN C stated she was working that day. She stayed inside and made sure all the other residents were accounted for. The LVN stated the facility had an in-service on elopement and had an elopement drill. In an interview on 12/18/2024 at 3:45 p.m. with primary care physician revealed Resident #1 was his resident. The physician stated the resident could be confused at times due to the cancer that had spread to her brain. He stated Resident #1 did not have history of wandering. Resident #1 anxiety medications had been changed prior to her leaving the facility, when the nurses had called me informing me that her anxiety had increased. I came to see her around June the 17th 2024 and she was more anxious, but she never mentioned to me about leaving or wanting to go home. I was concerned about her pain making her more anxious, but she said she did not hurt, so I made sure her pain medication was scheduled since she did not have to ask for it. The facility informed me when she left the building and then when she was back inside. I told them she needed to be moved to a secured unit, since she was so mobile still in her wheelchair. I spoke to the family about her moving, they did not want her to, since she had lived there for so long, but I assured them this was the right thing to do for her safety, The facility was offered several options, and moved her. The physician stated that Resident #1 had never tried to leave the facility before and he had not had other occurrences of elopement. In an interview on 12/20/204 at 4:45 a.m. with RN D revealed she was surprised when she heard about Resident #1 leaving the facility. RN D stated she would get up at night and roll around the facility, but never tried to leave. She did not sleep that much at nighttime, but she was not disruptive. RN D stated Resident #1 was more restless at times than others and would ask what she should do, but she was easily redirected and she would go back to bed most of the time. The physician had changed the anxiety medicine sometime in June I cannot recall, the increase settled her down some. Resident #1 never went into other resident's rooms and she always recalled where her room was. The RN stated she had an in-serviced on elopement a drill and on abuse/neglect after this happened. Resident #1 had a 1:1 staff member on the night shift until she transferred to another facility with a secured unit. In an interview on 12/20/2024 at 8:45 a.m. with DON revealed Resident #1 did leave the facility on 07/01/2024. The DON stated she was in the medication room when the code was called and went out the side door and ran out to the street. The MDS nurse was already there with Resident #1 in the old fire station parking lot. The DON stated that it really scared me, Resident #1 had no history of exit seeking behavior, and never tried to leave before, we immediately placed a wander guard on here and I called the family and told them she needed to be relocated to a secured unit for her safety. The family did not want her to move, but only agreed that it was best for her. The DON stated Resident #1 was placed on 1:1 monitoring until she transferred. The DON stated Resident #1 tried one time when she was on 1:1 to leave again, that was when I told the Social Worker the family had to decide right away. The Social Worked called the family again and she left the next day. The DON stated that she had an all-staff elopement drill on 07/02/2024 and had an in-service on 07/01/2024. In an interview on 12/20/2024 at 10:15 a.m. with the Administrator revealed she was not the administrator at that time and there had been no elopements since she had been at the facility. The Administrator stated she had been informed of the elopement when she first came to work at the facility. The DON had informed me that in-services had been conducted as well as an elopement drill. There is a wander guard system on the doors and the maintenance director checks it once a week and the nurses are required to check the wander guards each shift to make sure they are working correctly. Attempts were made to contact the previous administrator on 12/18/2024, 12/19/2024 and 12/20/2024 with no return calls. Record review of the Facility's Policy titled Elopements revised December 2023 reflected: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .2. I an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the departure in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the Charge Nurse or the Director of Nursing Services that a resident has left the premissies.3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall; a. examine, the resident; b. Notify the attending physician; c. Notify the resident's legal representative (sponsor) of the incident; Record review of the facility's policy titled Risk Management: Abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property dated December 2023, Policy statement: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property Definitions: Abuse means the willful infliction of injury, unreasonable confinement/involuntary seclusion, or separation of a resident from other residents or from their room or other area against the resident's will or the will of the resident's legal representative. Intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, or pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. 1. Residents must be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, or other individuals

Based on interviews and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services for 1 (CNA F) of 11 employees reviewed for staff qualifications. 1. The facility failed to ensure CNA F had a current nurse aide certification while employed at the facility while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. Findings include: Record review of CNA F's personnel file revealed her date of hire was [DATE]. Record review of CNA F's NAR, Certificate registry date [DATE], revealed CNA F's certification expired on [DATE]. Record review of CNA F's Timecard Report for [DATE]-[DATE], revealed CNA F worked a total of 9 shifts scheduled 10:00pm-6:00am. Record review of CNA F's Timecard Report for [DATE]-[DATE], revealed CNA F worked a total of 21 shifts scheduled 10:00pm-6:00am. Record review of CNA F's Timecard Report for [DATE]-[DATE] , revealed CNA F worked a total of 9 shifts scheduled 10:00pm-6:00am. The record review revealed CNA F last day worked was [DATE]. Record review of CNA F's New Hire/Termination Form revealed CNA F was terminated [DATE]. Record review of Tulip Credentialing Transition Grace Period dated [DATE], revealed HHS extended the grace period to [DATE]st for aides to allow users additional time to learn and understand the new credentialing system. Attempted interview on [DATE] at 12:55pm, the state surveyor attempted to contact CNA F via phone. The attempt was unsuccessful, the state surveyor left a message requesting a call back. In an interview on [DATE] at 10:26am, HR stated she has worked for the facility since 2014. She stated she transitioned into the HR role in [DATE]. She stated HR is responsible for completing background checks and registry checks prior to hire and annually once hired. She stated when she transitioned into her role, she was trained on how to complete background and registry checks. She stated she completed background checks once a year and registry checks ,d+[DATE] times a year. She stated completing checks annually is how she monitors criminal history and expired licenses and certifications. She stated if an aide's certification was close to expiring, it is her responsibility to remind the aide to renew their certification. She stated she would inform the aide as soon as possible. She stated if an aide's certification is expired, an aide cannot perform duties until their certification is renewed. She stated CNA F's certification expiration date was [DATE]. She stated she informed CNA F, her certification was expiring however, HR did not follow up with CNA F regarding the status of the certification renewal. She stated the risks of staff working with an expired license or certification while working with residents can cause a lack of skills and affect the quality of care the resident will receive. In an interview on [DATE] at 1:02pm, the Regional Nurse Consultant stated HR is expected to complete background and registry checks routinely. She stated background checks and registry checks should be completed prior to hire and annually once hired. She stated HR is responsible to have communication when notifying staff about certification expiration. She stated HHS sent out a memo regarding a waiver. The wavier extended the grace period for certification renewal twice. She stated the first grace period was extended to [DATE]st then extended to [DATE]th. However, a copy of the waiver application was not provided. She stated the risks of staff working with an expired license of certification can result in incompetent staff and put residents at risk for abuse and neglect and a lack of quality of care. The state surveyor requested a policy for nurse aide registry verification and was informed the facility did not have a policy for nurse aide registry verification .

Based on observation, interview and record review the facility failed to ensure each resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's bed was in the lowest position possible while the resident was lying in bed. Resident #1 was noted to be at risk for falls. This deficient practice could place residents at risk for falls and could contribute to avoidable falls, resulting in injury. Findings include: Record review of Resident #1's face sheet, accessed on 4/02/24, reflected an [AGE] year-old female who was readmitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's Disease, unspecified (a progressive brain disorder, leads to changes in memory, thinking, and behavior), Acquired absence of Left leg above the knee (above the knee amputation), Muscle Wasting and Atrophy, not elsewhere classified (loss or thinning of muscle tissue), and Other, Lack of Coordination. Record review of Resident #1's quarterly MDS assessment, dated 3/28/24, reflected she was severely cognitively impaired with a BIMS score of 03. She was fully dependent on two staff for bed mobility, repositioning, and transfers. Record review of Resident #1's Comprehensive Care Plan, accessed on 4/02/24, reflected she was at risk for falls related to Alzheimer's Disease. Related goals, initiated on 1/24/24 with a target goal date of 4/23/24, reflected the following: I will not sustain serious injury through the review date . I will be free of minor injury through the review date . I will be free of falls through the review date Related interventions included, bed in the lowest position possible. The Care Plan further reflected Resident #1 sustained a fall on 3/26/24. Record review of Resident #1's Nurse's Notes reflected the resident sustained a fall on 3/29/24: 3/29/24 at 9:10 PM authored by the Wound Nurse revealed, Writer notified of resident laying on floor. Upon entering room, resident awake, alert as per resident normal, laying towards left side on floor next to bed, head resting hands on base of bedside table. No immediate signs of pain or distress. Denies pain when asked. Able to move all extremities as per normal. Redness noted to left side of face and shoulder. Assisted onto bed X 4 staff staff .Spoke to [Name], NP and received orders for Neuro checks, hold anticoagulants x 3 days, X-ray; skull series, left arm and left shoulder, and give Norco as prescribed and PRN . Record review of Resident #1's nurse's note, dated 03/30/2024 at 12:30 AM, written by RN C revealed no delayed injuries noted from fall, x-ray skull series, left shoulder and left arm done, awaiting results. Record review of Resident #1's Radiologic Report, dated 3/30/24 at 5:04 AM by the Radiologist, included the following: Left shoulder x-ray complete, two or more views. Impression reflected: Inferior and medial dislocation in relation to the glenoid (the socket of the ball-and-socket shoulder joint). Left Humerus x-ray, two views. Impression reflected: Inferior and medial dislocation in relation to the glenoid. Record review of Resident #1's nurse's note, dated 03/30/2024 at 11:10 PM, written by LVN D revealed Remains on fall follow up with neuro check, no delayed injury noted. Record review of Resident #1's progress note, dated 03/31/2024 revealed Patient seen via telemedicine with nurse - [Name] .transfer to ED for management of left shoulder dislocation. Record review of Resident #1's nurse's note, dated 03/31/2024 at 9:00 PM, written by Wound Nurse revealed X-rays sent to [Provider Name], NP. New order to send to nearest ER for further evaluation. Charge nurse notified. DON notified. Record review of Resident #1's nurse's note, dated 03/31/2024 at 9:22 PM, written by LVN E revealed Nurse informed by Treatment nurse [Name] patient needed to be transferred to [Hospital Name] for possible shoulder dislocation. Nurse was unable to secure non-emergency transport. Nurse called for 911 assistance EMS arrived stating they could not assist with transport d/t situation being non-emergent at this time. Pt x-ray results received on 3/30/24. Nurse informed on call nurse to contact Administrator or DON to escalate the situation d/t all resorts have been done by nurse. Nurse notified family by text and call without a response. Record review of Resident #1's nurse's note, dated 03/31/2024 at 9:24 PM, written by Wound Nurse revealed Received call from charge nurse with 911 paramedics that verbalizing this is a non-emergency and they will not take the resident. Call placed to [Transport Name] in attempt to set up ER transport. Spoke to [Name]. Pick up scheduled for 04/01/2024 at 08:00am. Record review of Resident #1's nurse's note, dated 04/01/2024 at 8:10 AM, written by LVN F revealed Called [Name] transport to see when resident is supposed to be picked up and if stretcher or W/C. Was informed that they were going to pick her up at 0930 AM and by stretch. Stated Ok and thank you. Will continue to monitor. Record review of Resident #1's nurse's note, dated 04/01/2024 at 9:45 AM, written by LVN F revealed [Name] transportation here to take resident to [Hospital Name] ER D/T X-Ray showed a dislocated collarbone/shoulder for further eval. Resident was assisted to stretcher times 3 people 2 EMTS and this nurse. PRN pain med given at this time. Resident left facility via stretcher in stable condition accompanied by 2 EMTS. Record review of Resident #1's hospital After Visit Summary, dated 4/01/24 at 5:41 PM, reflected the resident was admitted to the emergency department on 4/01/24 with a complaint of shoulder pain. Imaging was conducted of Resident #1's Right foot and Left shoulder. Review of hospital records dated 04/01/2024 revealed Resident #1 is a 81 y.o. female with Alzheimer, hyperlipidemia and hypertension presents with left shoulder pain and possible dislocation. Per transfer facility they stated they got films that revealed that patient had a shoulder dislocation brought her into the ER evaluation . Further review revealed X-ray shoulder 2+ view left .Findings: No fracture or dislocation of the left shoulder is seen. Alignment and joint spaces are preserved. Mild glenohumeral and acromioclavicular joint degenerative changes with marginal osteophyte formation. Bones appear demineralized. No erosions or bone destruction. Surrounding soft tissues are unremarkable. Observation on 4/02/24 at 9:52 AM revealed Resident #1 was resting in bed. The bed was in a high position (at waist level), no fall mats were present, and a wedge pillow was sitting on the resident's night stand next to the resident's bed. Observation on 4/02/24 at 11:29 AM revealed Resident #1's resting in bed with bed in a high position (at waist level). Interview on 4/02/24 at 9:51 AM with Resident #1 was unsuccessful due to the resident's communication and cognitive limitations. In an interview on 4/02/24 at 12:44 PM with Nurse Aide A, she stated Resident #1's bed was not in the lowest position. She stated the resident was not a fall risk. In an interview on 4/02/24 at 12:50 PM with the ADON, she stated the bed was not in the lowest position possible. She stated the resident was a fall risk, and the bed should be in a low position. She stated injury was a possibility if the bed was in a high position. Interview with Resident #1's physician on 4/02/24 at 1:10 PM and on 4/04/24 at 12:02 PM were unsuccessful. In an interview on 4/02/24 at 1:50 PM with LVN B, he stated Resident #1 had never fallen before except in the last week . He stated he was not working when the resident fell . LVN B stated Resident #1 was a fall risk, and her bed should be in the lowest possible position. He stated if it was not in the lowest position, the resident could fall out of bed. He stated he checked bed heights during his rounds when he went to work. In an interview on 4/02/24 at 2:02 PM with the Physical Therapy Director, she stated Resident #1 was not receiving physical or occupational therapy. She stated the resident was discharged because she had plateaued. She stated Resident #1's last PT treatment was on 2/23/24 and her last OT treatment was on 3/01/24. She stated Resident #1 was a fall risk. She stated the resident could not transfer or reposition herself in bed; she needed complete assistance. She stated the aides must reposition her in bed and in her wheelchair. The PT Director stated she thought the aides used wedges to address the resident's fall status. She stated side bed rails were ruled out because Resident #1 did not have the ability to reposition herself. In an interview on 4/02/24 at 2:26 PM with the Social Worker, she stated Resident #1 had recently become a fall risk. She stated as a team, they tried to find interventions to address falls. She stated that primarily, nursing and therapy worked on interventions for resident falls and was not aware of the interventions for Resident #1. Interview with Resident #1's representative on 4/02/24 at 2:42 PM was unsuccessful. Voicemail was left with a call back number. In an interview on 4/02/24 at 4:34 PM with the DON, she stated Resident #1 had an unwitnessed fall on 3/29/24, had x-rays on her Left shoulder on 3/20/24, and was sent to the emergency roiagnom on [DATE] for a possible dislocation of Resident #1's Left shoulder. She stated the hospital did not verify a dislocation to the resident's shoulder. The DON stated Resident #1 had fallen maybe twice in the past 30 days. She stated that on 3/26/24, the resident fell out of her wheelchair and on 3/29/24, the resident fell from her bed. She stated the resident was completely dependent for transfers and could not independently reposition herself in bed. The DON stated Resident #1 was not a fall risk so bed height was not something that would need to be addressed. She stated for residents who were fall risks, ensuring their beds were in a low position would be the responsibility of nurses, aides, or anyone who saw the bed in a high position. She stated the risks of a high positioned bed for fall risk residents depended on the resident and what their needs were. In an interview on 4/02/24 at 4:50 PM with the Administrator, he stated he was aware of the happenings with the residents but was not really involved in the clinical part. He stated he left that to the DON and ADON and expected them to follow policy and procedures. In an interview on 4/02/24 at 5:17 PM with Resident #1's representative, he stated he received a call from the facility on Sunday night, 3/31/24 to inform him the resident had an unwitnessed fall from her bed. He stated he found it hard to believe she would fall because she could not move by herself. The resident's representative stated he was aware of her emergency room visit but had not heard back from the facility regarding the resident's current condition. The interview was cut short due to his time constraints. Interview on 4/04/24 at 1:35 PM with Resident #1's representative was reattempted but was unsuccessful. Record review of the facility's Fall In-Service Training Record, dated 3/25/24, administered by Nursing Leadership which consisted of the DON, ADON, and the Wound Nurse to all staff reflected the topic of the training was Fall Prevention Awareness and included the following: Keep bed at lowest position Keep floor clutter free Keep call light and familiar items within reach Ensure residents are positioned in bed properly Record review of the facility's Fall - Clinical Protocol, dated December 2023, included the following protocols: As part of the initial assessment, the physician will help identify individuals with a history of fall and risk factors for subsequent falling . In addition, the nurse shall assess and document/report the following: .precipitating factors, details on how fall occurred . The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk . For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall . Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent fall and to address risks of serious consequences of falling . If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one of 5 residents (Resident #1) reviewed for care plans. 1. The facility failed to ensure the comprehensive care plan for Resident #1 was developed to accurately address the resident's need for dining assistance. 2. The facility failed to ensure Resident #1's bed was in the lowest position possible as noted in the care plan while the resident was lying in bed. Resident #1, noted to be at risk for falls, fell out of bed and sustained a left shoulder injury. This failure could place residents at risk for not receiving care and services to meet their needs. Findings include: 1. Record review of Resident #1's face sheet, dated 4/02/24, reflected an [AGE] year-old female who was readmitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's Disease unspecified (a progressive brain disorder, leads to changes in memory, thinking, and behavior), Major Depressive Disorder, recurrent, unspecified (mood disorder characterized by persistent feelings of sadness and hopelessness, often accompanied by a loss of interest in activities they once enjoyed), Dysphagia, oropharyngeal phase (disorder or impairment in the ability to swallow), Muscle Wasting and Atrophy, not elsewhere classified (loss or thinning of muscle tissue), and Other, Lack of Coordination. Record review of Resident #1's quarterly MDS assessment, dated 3/28/24, reflected she was severely cognitively impaired with a BIMS score of 03. She required Substantial/Maximal assistance with eating. She was fully dependent with toileting/hygiene, shower/bathing self, upper body dressing, and lower body dressing. Record review of Resident #1's Comprehensive Care Plan reflected she had an ADL Self Care Performance Deficit related to Alzheimer's Disease. Her goals included she would maintain current level of function through the review date and she would improve current level of function through the review date. Related intervention reflected Resident #1 was independent with eating with setup assistance and monitoring . Resident #1's care plan did not address the resident's need for dining assistance. Record review of Resident #1's Intake records, accessed on 4/04/24, reflected from 3/22/24 to 4/04/24, Resident #1 consumed 41 meals as follows: 22 meals at 51-75% 9 meals at 26-50% 6 meals at 76-100% 4 meals at 0-25% Interview on 4/02/24 at 9:51 AM with Resident #1 was unsuccessful due to the resident's communication and cognitive limitations. Observation on 4/02/24 at 12:33 PM revealed lunch was delivered to Resident #1. Nurse Aide A was observed assisting the resident with eating. In an interview on 4/02/24 at 12:34 PM with Nurse Aide A, she stated Resident #1 did not need assistance with eating. She stated the resident only required encouragement and supervision. She stated the resident's food intake was recorded in her chart. In an interview on 4/02/24 at 12:50 PM with the ADON, she stated Resident #1 could not eat independently. She stated care plans were updated quarterly and with any change in the residents' condition. She stated the DON updated the care plans. Interview with Resident #1's physician on 4/02/24 at 1:10 PM and on 4/04/24 at 12:02 PM were unsuccessful. In an interview on 4/02/24 at 1:45 PM with the Dietary manager, she stated the leadership staff had care plan meetings once a week. She stated Resident #1 was on a low sodium diet. The Dietary manager stated Resident #1 did not feed herself independently. She stated the resident ate in the assisted dining room. The Dietary manager stated nurse leadership was responsible for updating the residents' care plans. In an interview on 4/02/24 at 2:26 PM with the Social Worker, she stated she was responsible for organizing weekly SOC and Care Plan meetings. She stated the facility leaders attended the meetings to discuss resident concerns and the DON updated the residents' care plans accordingly. Interview with Resident #1's representative on 4/02/24 at 2:42 PM was unsuccessful. Voicemail was left with a call back number. In an interview on 4/02/24 at 4:34 PM with the DON, she stated care plans were updated quarterly and as needed based on the residents' needs and the SOC meetings. She stated SOC meetings addressed interventions with nursing, the NP, therapy, the social worker, ADON, treatment nurse and the dietician. She stated the resident recently had a decline in her disease process. She stated Resident #1 could not eat independently and the aides were aware they needed to assist the resident with her meals. The DON stated the interdisciplinary team, which included nurse leadership, was responsible for updating resident care plans . In an interview on 4/02/24 at 5:17 PM with Resident #1's representative, he stated the resident needed assistance with feeding but did not know if the aides were helping her eat. The interview was cut short due to his time constraints. Interview on 4/04/24 at 1:35 PM with Resident #1's representative was reattempted but was unsuccessful. In an interview on 4/04/24 at 10:21 AM with the Dietician, he stated Resident #1 could not eat independently. He stated she needed assistance due to her cognitive and physical limitations. He stated he could just look at Resident #1 and determine she could not feed herself. He stated he believed it was the DON and ADON's responsibility to update care plans. 2. Record review of Resident #1's face sheet, accessed on 4/02/24, reflected an [AGE] year-old female who was readmitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's Disease, unspecified (a progressive brain disorder, leads to changes in memory, thinking, and behavior), Acquired absence of Left leg above the knee (above the knee amputation), Muscle Wasting and Atrophy, not elsewhere classified (loss or thinning of muscle tissue), and Other, Lack of Coordination. Record review of Resident #1's quarterly MDS assessment, dated 3/28/24, reflected she was severely cognitively impaired with a BIMS score of 03. She was fully dependent on two staff for bed mobility, repositioning, and transfers. Record review of Resident #1's Comprehensive Care Plan, accessed on 4/02/24, reflected she was at risk for falls related to Alzheimer's Disease. Related goals, initiated on 1/24/24 with a target goal date of 4/23/24, reflected the following: I will not sustain serious injury through the review date . I will be free of minor injury through the review date . I will be free of falls through the review date Related interventions included, bed in the lowest position possible. The Care Plan further reflected Resident #1 sustained a fall on 3/26/24. Record review of Resident #1's Nurse's Notes reflected the resident sustained a fall on 3/29/24: 3/29/24 at 9:10 PM authored by the Wound Nurse revealed, Writer notified of resident laying on floor. Upon entering room, resident awake, alert as per resident normal, laying towards left side on floor next to bed, head resting hands on base of bedside table. No immediate signs of pain or distress. Denies pain when asked. Able to move all extremities as per normal. Redness noted to left side of face and shoulder. Assisted onto bed X 4 staff. Record review of Resident #1's Radiologic Report, dated 3/30/24 at 5:04 AM by the Radiologist, included the following: Left shoulder x-ray complete, two or more views. Impression reflected: Inferior and medial dislocation in relation to the glenoid (the socket of the ball-and-socket shoulder joint). Left Humerus x-ray, two views. Impression reflected: Inferior and medial dislocation in relation to the glenoid. Record review of Resident #1's hospital After Visit Summary, dated 4/01/24 at 5:41 PM, reflected the resident was admitted to the emergency department on 4/01/24 with a complaint of shoulder pain. Imaging was conducted of Resident #1's Right foot and Left shoulder . Observation on 4/02/24 at 9:52 AM revealed Resident #1 was resting in bed. The bed was in a high position, no fall mats were present, and a wedge pillow was sitting on the resident's night stand next to the resident's bed. Observation on 4/02/24 at 11:29 AM revealed Resident #1's resting in bed with bed in a high position. Interview on 4/02/24 at 9:51 AM with Resident #1 was unsuccessful due to the resident's communication and cognitive limitations. In an interview on 4/02/24 at 12:44 PM with Nurse Aide A, she stated Resident #1's bed was not in the lowest position. She stated the resident was not a fall risk. In an interview on 4/02/24 at 12:50 PM with the ADON, she stated the bed was not in the lowest position possible. She stated the resident was a fall risk, and the bed should be in a low position. She stated injury was a possibility if the bed was in a high position. Interview with Resident #1's physician on 4/02/24 at 1:10 PM and on 4/04/24 at 12:02 PM were unsuccessful. In an interview on 4/02/24 at 1:50 PM with LVN B, he stated Resident #1 had never fallen before except in the last week. He stated he was not working when the resident fell . LVN B stated Resident #1 was a fall risk, and her bed should be in the lowest possible position. He stated if it was not in the lowest position, the resident could fall out of bed. He stated he checked bed heights during his rounds when he went to work. In an interview on 4/02/24 at 2:02 PM with the Physical Therapy Director, she stated Resident #1 was not receiving physical or occupational therapy. She stated the resident was discharged because she had plateaued. She stated Resident #1's last PT treatment was on 2/23/24 and her last OT treatment was on 3/01/24. She stated Resident #1 was a fall risk. She stated the resident could not transfer or reposition herself in bed; she needed complete assistance. She stated the aides must reposition her in bed and in her wheelchair. The PT Director stated she thought the aides used wedges to address the resident's fall status. She stated side bed rails were ruled out because Resident #1 did not have the ability to reposition herself. In an interview on 4/02/24 at 2:26 PM with the Social Worker, she stated Resident #1 had recently become a fall risk. She stated as a team, they tried to find interventions to address falls. She stated that primarily, nursing and therapy worked on interventions for resident falls and she was not aware of the interventions for Resident #1. Interview with Resident #1's representative on 4/02/24 at 2:42 PM was unsuccessful. Voicemail was left with a call back number. In an interview on 4/02/24 at 4:34 PM with the DON, she stated Resident #1 had an unwitnessed fall on 3/29/24, had x-rays on her Left shoulder on 3/20/24, and was sent to the emergency roiagnom on [DATE] for a possible dislocation of Resident #1's Left shoulder. She stated the hospital did not verify a dislocation to the resident's shoulder. The DON stated Resident #1 had fallen maybe twice in the past 30 days. She stated that on 3/26/24, the resident fell out of her wheelchair and on 3/29/24, the resident fell from her bed. She stated the resident was completely dependent for transfers and could not independently reposition herself in bed. The DON stated Resident #1 was not a fall risk so bed height was not something that would need to be addressed. She stated for residents who were fall risks, ensuring their beds were in a low position would be the responsibility of nurses, aides, or anyone who saw the bed in a high position. She stated the risks of a high positioned bed for fall risk residents depended on the resident and what their needs were. In an interview on 4/02/24 at 4:50 PM with the Administrator, he stated he was aware of the happenings with the residents but was not really involved in the clinical part. He stated he left that to the DON and ADON and expected them to follow policy and procedures. In an interview on 4/02/24 at 5:17 PM with Resident #1's representative, he stated he received a call from the facility on Sunday night, 3/31/24 to inform him the resident had an unwitnessed fall from her bed. He stated he found it hard to believe she would fall because she could not move by herself. The resident's representative stated he was aware of her emergency room visit but had not heard back from the facility regarding the resident's current condition. The interview was cut short due to his time constraints. Interview on 4/04/24 at 1:35 PM with Resident #1's representative was reattempted but was unsuccessful. Record review of the facility's Comprehensive Care Plans policy, dated December 2023, reflected the following policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan will: Include measurable objectives and timeframes. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Incorporate identified problem areas. Reflect treatment goals, timetables, and objectives in measurable outcomes. Aid in preventing or reducing decline in the resident's functional status and/or functional levels. Enhance the optimal functioning of the resident by focusing on a rehabilitative program. Reflect currently recognized standards of practice for problem areas and conditions

Based on observations, interviews and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment for one of one facility reviewed for infection control. The facility failed to identify the source and implement measures timely to respond to Legionella after a resident (Resident #1) was diagnosed on [DATE] with the disease while at the hospital. The facility completed testing of the water on [DATE] and received information on [DATE] that the facility had three areas positive for legionella. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:35 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy a scope of isolated, due to the facility's need to monitor effectiveness of their corrective systems. The failure increased the risk of the residents being infected with Legionnaires' disease, which could result in the residents becoming ill or dying. Findings include: Record Review of Resident's #1 face sheet dated [DATE] revealed she was an [AGE] year-old female that was originally admitted to the facility [DATE]. She was readmitted to the facility on [DATE] after returning from the hospital. The resident discharged from the the facility on [DATE]. Resident #1 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged home from the facility on hospice. She was placed on hospice related to COVID-19 and expired on [DATE] while discharged from the facility. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan dated [DATE] revealed she had previous respiratory infections. The facility would give the resident oxygen therapy as order by the physician. The facility would monitor for difficulty breathing, the facility would monitor for signs and symptoms of acute respiratory insufficiency. Review of Resident #1's hospital physician notes dated [DATE] reflect Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . People can get sick when they breathe in small droplets of water or accidentally swallow water containing Legionella into the lungs.). An interview with the Health Department staff on [DATE] at 10:07 am revealed she was contacted by the hospital on [DATE] after Resident #1 was diagnosed with legionella. She began an investigation of the nursing facility Resident #1 had resided. On [DATE] she informed the nursing facility Administrator an investigation was started to determine the source of legionella. On [DATE] , the Health Department staff had a meeting with the facility requesting information to be provided and rule out the spread of the infection. She informed the facility to complete environment sampling, to include testing Resident #1's room water sources for legionella. She requested weekly updates, a Center for Disease Control and Prevention Legionella Environmental Assessment form completed and installing point of use filters on sinks and showers to ensure the water was safe for use. Health Department staff requested a copy of the water management plan for the facility. The Health Department staff stated as of [DATE], she had not received any of the things she requested. She had contacted the facility management staff and did not get cooperation starting on [DATE]. Review of the emails provided by the DON, addressed to the DON and ADM on [DATE], an email dated [DATE] revealed a request for the facility to complete environment sampling, to include testing Resident #1's room water sources for legionella. The Health Department Staff requested weekly updates, a Center for Disease Control and Prevention Legionella Environmental Assessment form completed and installing point of use filters on sinks and showers to ensure the water was safe for use. There were also subsequent emails dated [DATE] and [DATE] from the health department asking for updates. An interview with the ADM on [DATE] at 10:17 am revealed she had been contacted by the Health department after Resident #1 had tested positive for legionella while at the hospital. She was informed by the health department staff an investigation was starting to determine the source on [DATE]. The Health Department Staff had informed the facility it needed to complete the following: -complete environment sampling, to include testing Resident #1's room water sources for legionella. -weekly updates regarding the progress. - a Center for Disease Control and Prevention Legionella Environmental Assessment form. - installing point of use filters on sinks and showers to ensure the water is safe for use. - Water management plan. The ADM stated she did not immediately complete the requested information for the health department because she believed Legionella likely was at the hospital that Resident #1 had been admitted to and did not think legionella was at the facility. She did not complete the CDC assessment, she did not install the point of use filters as requested. She did not have a water management plan and had been working to complete the plan. She completed 6 environmental samplings on [DATE], that resulted in 3 areas (500 hallway shower area, room [ROOM NUMBER] shower head and 100 hallway shower area) testing positive for legionella. She received the results on [DATE]. She informed the health department on [DATE] of the positive legionella test results. She said there was currently no plan to treat legionella. The residents were instructed to eat from paper plates on [DATE], following the positive test results. Review of the Legionella summary Sheet on [DATE] provided by a laboratory revealed the following area tested positive for legionella: 500 hallway shower area (9 residents assigned to the hallway), room [ROOM NUMBER] shower head(non occupied single room) and 100 hallway shower area (13 residents assigned to the hallway). All the showers had not been tested on ly 2 showers. On [DATE] the residents were prohibited from showering in the area that tested positive. The two additional showers had not been tested and were being used daily. The other areas that were tested were the kitchen sink, sink in room [ROOM NUMBER] and 200 hallway shower room, these areas were negative. Observation on [DATE] at 11:19 am of the facility revealed the staff were providing the residents with papers products and bottled water. However, the kitchen are reflected the staff using the water in the kitchen area (not tested for legionella) for cooking. The showers that had not been tested were being used by the residents. An interview with the DON on [DATE] at 11:24 am revealed the residents of the facility were not being actively monitored for signs and symptoms of legionella. An interview with the Medical Director on [DATE] at 4:15 pm revealed he became the director on [DATE]. He was not aware of Resident #1's testing positive for legionella. He was not aware of the list of items requested to be done and had not been completed. Record review of the Legionella Surveillance and Detection policy dated ,d+[DATE] revealed As part of the infection Prevention and Control Program, all cases of pneumonia that are diagnosed in resident under 48 hours will be investigated for possible Legionnaires Disease. Review of the Legionella Water Management program policy dated ,d+[DATE] revealed the control limits or parameters that are acceptable and that are monitored, a plan for when control limits are not met and or control measures are not effective and documenting of the program. The ADM and DON was notified on [DATE] at 4:35 p.m. an Immediate Jeopardy (IJ) was identified due to the above failures The ADM was provided with the IJ Template on [DATE] at 4:37 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:42 pm: The facility failed to identify the source and implement measures timely to respond to Legionella after a resident was diagnosed with the disease while at the hospital. The facility completed testing of the water on ,d+[DATE] and received information on [DATE] that identified three sources of legionella. o The facility's plan is to no longer use the water sources in the building that has been deemed contaminated and unknown. But will continue to use the source deemed clear of the bacteria: shower room [ROOM NUMBER] o All residents are to receive only purified water to take care of their ADL needs. The administrator has taken action on to ensure all processes are in place and will continue to monitor the plan. Action put in place on [DATE] Staff have been educated on the precautions put in place. o All facility staff have been educated on the precaution put in place [DATE] o Facility will provide a mandated facility wide in -service to in-service all staff on Legionella disease and the measures that are in place. This training will take place on [DATE] @ 2 p.m. o Ongoing training to all staff: there will be a training pamphlet in all new hire packets prior to working The DON will be responsible for this action To be completed [DATE] Facility will not use any kitchen equipment that requires water use for cleaning such as pots, pans, and utensils used to eat and drink. o Styrofoam utensils have been put in place for the residents use effective [DATE] o All meals have been modified to accommodate no water use approved by the dietitian o Ready to eat meals o Cold sandwich o All water sources have been labeled do not use in the kitchen are until completed treatment o We are not using any kitchen equipment that produces a mist in the air until water treatment is completed. Equipment identified: o Steam table o Stove top o Dishwasher o Water faucets o Dishwasher sprayer Competed by [DATE] Continued monitoring system in place by the dietary manager and administrator Medical Director notified for further evaluation and only recommended Continued routine care as needed. The medical Director and the Nursing Department will track acquired pneumonia as part of the quality monitoring system for legionnaires disease. o There are no orders from the medical director, however residents were informed about the signs and symptoms of legionnaires. They are to immediately notify their nurse of any sign. o The Administrator and/or designee will conduct QA review Biweekly to verify that DON and ADON are reviewing daily. o When any signs or symptoms are present the attending physician shall be informed. o If a positive chest X ray is determined abnormal, an antigen urine test will be completed as stated by the Health Department. o Will be reviewed by the Director if Nursing, Assistant Director of Nursing and/or Wound care Nurse by auditing daily for completion. o Continue routine care as needed Monitoring of the POR included: Observation on [DATE] at 2:24 pm revealed education of all facility staff regarding legionella. Observation of the facility kitchen on [DATE] at 2:39 pm revealed no use of the water in the facility kitchen. Staff brought in bottled water from outside sources. Observation on [DATE] at 2:44pm revealed staff handing out legionella information and providing education to residents of the facility of the signs and symptoms. Record review Inservice training regarding signs and symptoms of legionella and the common sources of infection. Interview with CNA B(10pm -6am shift), CNA C (6am-2pm), CNA D (2pm-10pm), LVN E(2pm-10pm), MA F(2pm-10pm) , Dietary Aide G, Cook, RN H (10pm -6am shift), on [DATE] from 3:50 pm to 4:30 pm revealed they had been informed regarding legionella. The staff members were educated on the signs and symptoms of legionella, the response if residents were showing signs and symptoms, not using the water source until testing was completed. An interview with the DON on [DATE] at 4:45 pm revealed she had educated the residents on signs and symptoms of legionnaire on [DATE] and [DATE]. The staff members were informed if residents have symptoms the aides are required to report to the charge nurse. The charge nurse must notify the physician and respond the accordingly, additional test would likely be required to determine the diagnosis. An interview with the ADM on [DATE] at 4:52 pm revealed she had completed the CDC assessment form, scheduled and hired a water treatment company for [DATE] to complete additional testing. Provided the health department with updates. The staff were informed to use only purchased water in the facility. The ADM was informed the Immediate Jeopardy was removed on [DATE] at 3:42 p.m. However, the facility remained out of compliance at a severity level of actual harm that is not immediate a scope of isolated, , due to the facility's need to monitor effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents, for one (Resident #1) of five residents reviewed for accidents. CNA A and CNA B failed to transfer Resident #1 appropriately, with the assistance of a Hoyer lift. As a result, she sustained a transverse supracondylar/distal diaphyseal right femoral fracture with impaction and 30 degrees of volar angulation. This failure could affect the 16 residents who required the assistance of two staff members and a Hoyer lift for transfers by placing them at risk for injury. Findings included: Review of Resident #1's Face Sheet, dated 05/16/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 04/20/17, reflected Resident #1 had moderately impaired cognition. She was identified as being totally dependent and requiring the assistance of at least two staff members for transfers. Review of Resident #1's Comprehensive Plan of Care, dated 05/16/17, reflected she required two staff members and a mechanical lift to assist with transfers. This portion of the Comprehensive Plan of Care was initiated on 07/25/14. Review of Resident #1's Documentation Survey Reports (identified by the ADON as the form direct care staff utilized to determine the required type of transfer for each resident), dated April 2017 and May 2017, reflected she required two staff members and a mechanical lift to assist with transfers. Review of the facility's Provider Investigation Report, dated 05/05/17, revealed on 05/04/17, CNA A and CNA B transferred Resident #1 from a shower chair to the bed without the assistance of a Hoyer lift, which was the type of transfer Resident #1 required. Resident #1 slipped during the transfer, which caused her knee to buckle under her. Neither CNA A nor CNA B reported the inappropriate transfer or the incident to LVN C, who was Resident #1's nurse at the time of the incident. Instead, CNA A only reported that Resident #1 sustained a skin tear during the transfer. During the skin tear treatment, Resident #1 complained of pain. Her legs were assessed with [REDACTED]. LVN C asked CNA A if any incident occurred that would cause Resident #1 to be in pain, and CNA A denied that any incident occurred. A few hours later on the same shift, Resident #1 again complained of pain to her right knee. LVN C reassessed the area and noted swelling. Resident #1's Nurse Practitioner was notified and an order for [REDACTED]. Prior to the mobile x-ray company arriving at the facility, Resident #1 was sent to the hospital via ambulance due to continued complaints of pain. Resident #1's POA and physician were notified of the incident. CNA A and CNA B were suspended pending the outcome of the investigation. CNA A admitted to the inappropriate transfer and the incident which resulted in Resident #1's injury. Safe surveys were completed with interviewable residents on how they were transferred by staff members. Staff members were in-serviced on following care plan guidelines, reporting of all incidents, the facility's policy regarding abuse/neglect, and the facility's policy regarding transfers. CNA A and CNA B's employment was ultimately terminated. Observation of Resident #1 on 05/16/17 at 2:45 p.m. revealed she was lying in bed at the hospital. She was in-and-out of sleep during the visit and was unable to participate in an interview due to cognitive impairment. Review of x-ray results completed on Resident #1, dated 05/04/17, reflected she sustained a transverse supracondylar/distal diaphyseal right femoral fracture with impaction and 30 degrees of volar angulation (a traumatic fracture to the right upper leg). Interview with CNA A on 05/16/17 at 11:44 a.m. revealed on 05/04/17, she and CNA B transferred Resident #1 from a shower chair into the bed without a Hoyer lift. During the transfer, Resident #1 stopped bearing weight and slid, which resulted in her knee hitting the floor. CNA A stated she did not know Resident #1 required the assistance of a Hoyer lift for transfers, as she had never previously transferred Resident #1. She stated she knew she could have found this information in Resident #1's Plan of Care, but she did not think to look up this information. She stated the facility had previously trained her on the imperativeness of looking in residents' Plans of Care and knowing what type of transfer each resident required prior to transferring the resident. CNA A stated at the time of the incident, Resident #1 did not complain of pain. When LVN C asked if any incident occurred that would cause Resident #1 to be in pain, CNA A stated she denied the occurrence of any incident because she did not believe Resident #1 had been injured. Once Resident #1 was found to have been injured and the facility found out about the incident, CNA A stated she was suspended pending the outcome of the investigation. Her employment was ultimately terminated. Attempted telephone interview with CNA B on 05/16/17 at 11:52 a.m. was unanswered. CNA B did not return the telephone call. Interview with LVN C on 05/16/17 at 10:36 a.m. revealed on 05/04/17 at approximately 7:50 a.m. revealed she was in the dining room when CNA A notified her that Resident #1 sustained a skin tear during a transfer that was completed by CNA A and CNA B. LVN C stated she was providing treatment to the skin tear when Resident #1 complained of pain to her legs. LVN C reported she assessed Resident #1's legs and did not note any swelling or injuries. She was administered medication for pain, as ordered by the physician. Approximately one hour later, LVN C checked on Resident #1, who reported no complaints of pain at that time but stated it was actually her knee that was previously hurting. LVN C reassessed the area and did not note any swelling or injuries. She asked CNA A if anything occurred during the transfer that could have caused Resident #1 to be in pain, and CNA A denied any incidents other than the skin tear to Resident #1's arm. Resident #1 again complained of pain at approximately 1:00 p.m., and an assessment of Resident #1's right knee revealed mild swelling. Resident #1's POA and physician were notified, and an order for [REDACTED]. LVN C stated she called the mobile x-ray company to notify them of the need for a stat x-ray and notified the oncoming shift. Interview with the ADON on 05/16/17 at 4:30 p.m. revealed on 05/04/17 at approximately 1:00 p.m., Resident #1 complained of pain to her right knee. An assessment of the knee revealed mild swelling. Resident #1's physician was contacted and an order was received for an x-ray. Prior to the mobile x-ray company arriving to the facility, Resident #1 was sent to the hospital via ambulance due to continued complaints of pain. The ADON stated she contacted CNA A and CNA B regarding Resident #1's complaints of pain, and they admitted to transferring Resident #1 without a Hoyer lift. It was reported that Resident #1 began to slip during the transfer, so CNA A and CNA B grabbed her by the arms and legs and put her in bed. CNA A wrote a statement and was suspended pending the outcome of the investigation. CNA B did not present herself at the facility to write a statement. CNA A and CNA B's employment was ultimately terminated. The ADON stated CNA A and CNA B had access to Resident #1's Plan of Care, which outlined the need for Resident #1 to be transferred with a Hoyer lift. She stated they had been previously trained and were aware of the need to determine the type of transfer a resident required prior to transferring that resident. She further stated both CNA A and CNA B had previously participated in competency checks for transfers, although she was unable to locate documentation for verification. She said Resident #1 sustained a fracture due to CNA A and CNA B's failure to ensure she was appropriately transferred. The ADON stated following the incident, staff members were in-serviced on following care plan guidelines, reporting of all incidents, the facility's policy regarding abuse/neglect, and the facility's policy regarding transfers. When asked how the facility is monitoring to ensure this type of incident does not occur again, the ADON stated the facility is training new hires on the need to look in Plans of Care for transferring requirements. She further said she is verbally quizzing staff members on the types of transfers various residents require, as well as observing staff members as they complete transfers for residents. The ADON stated the facility's monitoring techniques were not documented. Interviews with 10 direct care staff members across the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift revealed they had been in-serviced regarding abuse, neglect, and exploitation as well as residents transfers. Observations of four resident transfers (two two-person transfers and two Hoyer lift transfers) across the 6:00 a.m. to 2:00 p.m. shift and the 2:00 p.m. to 10:00 p.m. shift revealed the transfers were completed appropriately. Review of the facility's Time Card Report, dated 05/04/17, reflected both CNA A and CNA B worked on the day of the incident. Review of the facility's Employee Termination Notification for CNA A, dated 05/08/17, reflected CNA A failed to follow the facility's policy and procedure regarding transferring of residents, which resulted in Resident #1 sustaining a significant injury. Review of the facility's Employee Termination Notification for CNA B, dated 05/05/17, reflected CNA B was terminated on 05/05/17. Review of the facility's Safe Lifting and Movement of Residents Policy and Procedure, dated December 2013, reflected, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . Review of the facility's Resident Census, provided by the ADON on 05/16/17, indicated 16 residents required the assistance of two staff members and a Hoyer lift for transfers.

Based on observation, interview, and record review the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers and ensure residents having pressure ulcers received the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing for one of six residents (Resident # 2,) reviewed for pressure ulcers. The facility failed to follow their own recommendations for the prevention of pressure ulcers. 1) The facility failed to identify, assess and and provide appropriate treatment for [REDACTED]. Resident #2 had a history of [REDACTED]. 2)The facility also did not follow the care plan for Resident #2. The facility had not implemented the a low air loss mattress at all times, and to elevate the residents legs when up in the chair or in bed. The resident has a history of [MEDICAL CONDITION] of lower extremities, and the facility failed to provide timely incontinent care to the resident. These failures had the potential to affect the six resident with pressure ulcers and the other 79 residents of the facility. An Immediate Jeporady (IJ) was identified on 09/04/15. While the IJ was removed on 09/05/15, the facility remained out of compliance at a severity level of Actual Harm that is not Immediate Jeopardy and a scope of Pattern because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. Findings included: The MDS completed on 06/04/15 reflected Resident #2 was admitted on [DATE] and was a [AGE] year old female with the following Diagnoses: [REDACTED]. Resident #2 was cognitively impaired with long and short term memory loss. She was non- ambulatory required 2 person total assistance for transferring. Resident # 2 also was dependent the staff for dressing, grooming, feeding, toileting, and bed mobility. Resident #2 had a history of [REDACTED].#2 did not have any pressure ulcers at the time the MDS was completed. As for the preventative skin and ulcer care the MDS did not reflect the facility was providing any care. The Minimum Data Set (MDS) assessment dated [DATE] (marked as a change in condition) reflected Resident #2 had an unhealed Stage 3 pressure ulcer and a Stage four pressure ulcer and an unstageable pressure ulcer. The MDS further reflected the measurements for the worse ulcer was 6.5cm x 6.0 cm x 0.3 cm eschar. The preventative measures marked were a pressure relieving mattress for the bed, nutrition or hydration, pressure ulcer treatment, application of non surgical dressings and application of ointment or medication for the treatment of [REDACTED]. On 09/03/15 the DON signed Resident #2's MDS. Review of Resident #2's (Physician) Order Summary Report dated 04/10/14 reflected Resident #2 was to have a Low Air loss Mattress at all times. Review or the current orders this order had been dropped. DON was asked to provide documentation that the order had been discontinued. The DON revealed the order had not been discontinued and it was current and she would update the physician orders. (Physician) Summary Order Report run 09/04/15 at 3:33 PM reflected the following wound care treatments for Resident #2 : a. Clean Stage 4 left heel with normal saline, pat dry, apply santyl/calcium alginate, and cover with a dry dressing. b. Clean un-stageable DTI of right heel with normal saline, pat dry, apply santyl/calcium alginate, and cover with a dry dressing. Ordered 09/03/15. c. Clean Stage 2 Sacrum with normal saline, pat dry, and apply [MEDICATION NAME] every 3 days and as needed. Ordered 09/03/15. d. Clean Stage 3 coccyx with normal saline, pat dry, and apply [MEDICATION NAME] every 3 days and as needed. Ordered 09/01/15. e. Heel boots at all times every shift. Ordered 09/03/15 and start 09/04/15 f. Low air loss mattress at all times. Re-Ordered 09/03/15. Care Plan dated 02/18/13 Revised Care plan dated 04/23/13 for [MEDICAL CONDITION] revealed the resident legs were to be elevated when sitting or sleeping. Care Plan dated 12/04/13 Revised 05/14/14 revealed the resident was at risk for pressure ulcer on coccyx due to history of pressure ulcers/ immobility. The Goal was resident would have intact skin, free of redness, blisters or discoloration by/through next review date of 10/7/15. The interventions included: Administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention /treatment of [REDACTED]. To ensure resident's comfort. Resident #2 had [MEDICATION NAME] HCL 50 mg 1 tablet by mouth every 8 hours as needed for pain. Care Plan dated 09/01/15 and revised on 09/01/15 Stage 4 Pressure ulcer on right heel (actually left) and stage III on coccyx and an un-stageable DTI on Left (actually right) heel development r/t (related to) Hx (history of) ulcers /immobility. The Goal were the following: 1. The resident would have intact skin, free of redness, blisters or discoloration by next review date of 10/7/15. 2. Residents pressure ulcer would show signs of healing and remain free from infection through 10/7/15. Interventions included: Administer treatments as ordered.(Date initiated 08/11/15) Monitor/document for side effects and effectiveness . (select) Require pressure relieving device on (bed and chair). (Neither bed nor chair was selected.),Treat pain as per orders prior to treatment/turning etc. to ensure my comfort. Observation on 09/02/15 at 9:45 AM during initial tour revealed Resident #2 was up sitting in the wheel-chair at the nurse's station. Her feet were hanging down and she had bilateral padded heel protectors on each foot. Observation on 09/02/15 at 3:15 PM revealed Resident #2's sacral coccyxageal area had a [MEDICATION NAME] dressing which was rolled up on the edges. CNA G lifted the dressing and the surveyor observed a Stage II pressure ulcer. The CNA did not see the wound. It was noted the brief CNA G removed from Resident #2 was saturated with urine and this could contribute to the breakdown of Resident #2's skin. Observation on 09/03/15 at 9:35 AM revealed Resident #2 lying in bed on her back. The mattress the resident was lying on was not an low air loss mattress. The resident had on heel protectors which were flat on the bed causing pressure to the pressure ulcers on the heels. It was noted Resident #2 crossed her legs and there was not a positioning devise between her legs to alleviate further pressure, consequently there was an additional red area noted on the residents right leg. The pressure ulcers were as follows: The surveyor observation of left heel determined the measurements of the heel were approximately 6.5 cm(centimeter)Length x 6 cm width x 0.2 cm depth Stage IV with yellow and black eschar (dead tissue) throughout the wound and spots of red granulation tissue seen in the wound bed. There was a strong foul odor. The treatment performed by LVN E including cleansing with normal saline, patting the wound dry, applying Santyl Ointment ([MEDICATION NAME] agent), Calcium alginate, and applying a dry dressing. Resident grimaced when legs were lifted in the air. The legs were lifted in the air to view the pressure ulcer, drip the saline over the wound and apply the dressings. Resident #2's right lateral heel had an un-stageable pressure ulcer which the surveyor determined measured approximately 2cm x 1 cm x 0.1 cm. LVN E wiped the skin with a gauze pad wet with normal saline but did not look at the area on the heel.The surveyor informed LVN E the black eschar area appeared concave (hollowed) with ragged edges. According to LVN E she was unaware the wound on the right heel was no longer intact. (flush with the skin.) LVN E withheld treatment of [REDACTED]. LVN revealed she normally treated the wound with skin prep. LVN E revealed she treats the wounds on day shift. Observation of Resident #2's the left side of the coccyx was the surveyor noted a pressure ulcer approximately 2cm x 1.5 cm Stage 3 with black eschar covering the pressure ulcer. In the center of the coccyx there was a pressure ulcer approximately 1.5cm x1.5cm Stage II area. LVN E revealed she had not seen this stage II area before. LVN E treated the area with a [MEDICATION NAME] dressing (a thick rubber type dressing used for padding and to prevent moisture.) This dressing covered both areas on the coccyx. Resident grimaced when the dressing was removed and she was positioned on her right side. Observation on 09/03/15 at 11:00 AM revealed Resident #2 was asleep in the hallway by the nurses' station sitting in her geriatric-chair. Her lower legs were crossed and not elevated. Her feet were in heel protector boots that were directly touching the floor. LVN C pushed Resident # 14 in the geriatric chair to her room and her feet were dragged on the floor all the way to her room (approximately 50 feet)The resident chair did not have foot pedals. Review of Wound Care Specialist Evaluation for Resident #2 dated 08/31/15 revealed the following: Right Heel (actually left) Stage IV, 6.5x6x0.3 cm, Thick Adherent necrotic tissue providing 100% coverage of the wound. The physician did a surgical debridement (removal) of the necrotic tissue, and muscle. The physician documented he recieved permission to debride the wound from the healthcare surrogate on 08/17/15. Developed on 08/10/15 Coccyx Stage 3, Wound size: 1x2x0.1 cm, Granulation tissue of the wound 100%. Developed 08/18/15. Left Heel(actually right) Unstageable DTI (Deep Tissue Injury) wound size: 1x2x not measurable cm. Developed 08/10/15. The Stage II area near the coccyx evidentily had not developed when the wound care specialist visited on 08/31/15 . Surveyor identified this area on 09/02/15 during incontinent care. Facility had not identified this area. The residents wounds on the heels were documented incorrectly, and the unstageble pressure ulcer was on the right heel, and the stage four wound was on the left heel. A Progress note dated 09/03/15 revealed: NOTE: right and left transposed left change to cacium(calcium) alginate and santyl During wound care treatment on 09/03/15 at 9:42 AM during the wound care treatment ADON B (Assistant Director of Nurses) revealed the pressure ulcers developed while the resident was in the facility. She did not elaborate how they developed. She further revealed she had spoken to Resident #2's family member about hospice care but he had not made a decision. According to ADON B the resident was dependent on the staff for care, and the staff had to feed her, and she had declined some. Interview on 09/03/15 at 9:55AM with ADON B revealed the facility had to get a new treatment for [REDACTED]. LVN E told her there had been a change in the right heel and it was no longer intact. ADON B further revealed she did not know how long the resident had been without the low air loss mattress. She remembered ordering one, but thought it may have been put on the wrong patient. I know she had one last year, but I do not know how long she had been without the mattress. ADON B revealed she would get the resident an low air loss mattress today. Interview on 09/03/15 at 11:10 AM - 11:15 AM the surveyor inteviewed four staff members (CNA BB, LVN C, LVN E, and ADON F) who stated they were unaware of how long Resident #2 had been without a low air loss mattress. CNA BB revealed she had worked with Resident #2 for the last two years but did not know when the resident last had an low air loss mattress. LVN E revealed, at this time Resident #2 did not have foot pedals or leg rest on her wheelchair to enable the residents feet to be elevated. Observation on 09/03/15 at 4:00 PM revealed Resident # 2 had received a Low Air Loss Mattress on her bed. Policy & Procedure Skin Assessments Policy: It is the policy of this facility that all residents will be assessed according to their needs and risk factors to prevent adverse skin conditions. Procedure: 1. Braden Scale assessment will be completed upon admission, quarterly and with significant change in condition. 2. Follow up skin assessments will be performed as follows according to the score of the Braden scale: · High Risk (12 or below) -weekly · Moderate Risk (13-14)- every other week · Low Risk (15-16 if under age 75 OR 15-23 if over age 75)-monthly 3. Any resident with an existing skin condition (decubitus ulcer, stasis ulcer rash etc.) will receive weekly skin assessments regardless of their Braden score. 4. Skin assessment will be completed by day shift licensed nursing staff according to the schedule by the Director of Nursing or their designee. On 09/04/15 at 12:41 PM an Immediate Jeopardy was identified and the Administrator and Director of Nursing were informed. The Plan of Removal was accepted on 09/04/15 at 7:07 pm. Plan of Removal Residents Involved: Resident #2 admitted [DATE] Age: 95 Diagnosis: [REDACTED]. Total Care with ADLs and Transfers; Uses hoyer lift; Alert and Oriented to Self Pressure Sores: Stage III to Coccyx (1cmx0.5cmx0.1); Stage IV to Left Heel (6.5cmx6cmx0.3cm); Unstageable to Right Heel (2cmx1.5cm) Failure to follow Attending Physician order [REDACTED]. The facility ' s Skin Assessment Policy and Procedure objectives were not followed through by Licensed Nursing Staff and Certified Nursing Assistants, in the area of head-to-assessments, resulting in a system wide failure of Pressure Sores. Failure of ADON B to monitor and ensure that the Wound Assessments were completed accurately, and in a timely manner resulted in a system wide failure. Employees involved in this failure include, ADON B; LVN E (6-2); LVN AA (2-10); RN Z(10-6); , LVN Y (10-6); LVN J (6-10 WE); LVN C (6-2); LVN X (10-6); LVN A (6-10WE). Disciplinary action includes termination of ADON B due to employee being in charge of the Pressure Ulcer system, and all other employees will receive a Written Reprimand regarding Not Following Facility Protocol Regarding Wound Treatment before the start of their next assigned shift. Starting at 4:00PM on Friday, September 4, 2015, the facility will be in-serving all Licensed Nursing Staff on all shifts regarding appropriate head-to-toe assessments on all residents. The in-service will be conducted by RN W for Dr. V. During this in-service, Licensed Nursing Staff will be retrained on proper head-to-toe assessments, and visual competency checks will be done per the Assessment Schedule. This in-service will be completed by Saturday, September 5, 2015 at 3:00PM. The attached Policy and Procedures will be taught during the in-services. Licensed Nursing Staff will not be allowed to return to work until this mandatory in-service has been completed. DON will monitor all individuals who did not attend the in-service by 3:00PM on Saturday, September 5, 2015, that these individuals will be trained/in-serviced before returning to work. As an addition, all facility Certified Nursing Assistants will be retrained on proper Turning and Repositioning techniques. This in-service will be conducted in conjunction with the Licensed Nursing Staff in-service. Also, an in-service will be conducted for the Certified Nursing Assistants on how to complete the CNA Communication Form ensuring that Licensed Nursing Staff will be notified of any change in skin condition(s). A CNA Communication Form competency test will be developed by Administrator, to ensure proficiency on communication of skin conditions. DON, ADON D, and ADON F, will train Certified Nursing Assistants now, quarterly, and upon hire on the correct use of the Communication Form. This training will start on Friday, September 4, 2015 and will be ongoing. Should a skin issue be identified, the resident ' s Attending Physician will be notified, and orders will be carried out according to his/her orders. In addition to the Attending Physician notification, additional notification will be made to resident ' s responsible party. In addition to the above, additional training will be conducted by DON, with all Licensed Nursing Staff regarding the importance of medicating residents prior to receiving wound treatments. This training will be conducted now, quarterly, and upon hire. The facility ' s Medical Director, Dr. V was contacted at 1:30PM on Friday, September 4, 2015 regarding the Immediate Jeopardy situation. At this time, the Medical Director suggests the facility contact the wound care physician, Dr. U of VOHRA Wound Physicians for ongoing training. The facility recognizes the failure to medicate the residents (#2 and 14) prior to wound care, and as a result, has initiated standing orders for all residents to be medicated 30-minutes prior to wound care. The facility ' s Pain Assessment or the Pain Assessment with Advanced Dementia will be used to assess the resident ' s level of pain. The proper use of the facility ' s Pain Assessment tool will also be included in the in-service, performed by RN W, now, quarterly, and upon hire. The new standing-order for pain medication prior to wound treatment will be initiated upon the next wound treatment. DON, ADON D, and ADON F, will monitor pain Medication Administration Record [REDACTED]. Currently, Assistant Directors of Nurses, ADON F, ADON D, and LVN T, along with the DON, and also Nurses, and LVN Khave been performing head-to-toe assessments on all residents to ensure that currently Weekly Skin Assessment are accurate. At this time, 46 out of 85 residents have been assessment, with no new areas being identified. Director of Nurses, and the Assistant Directors of Nurses, ADON F and ADON D will perform random checks daily on skin assessments that were completed by the Licensed Nursing Staff on the previous day to ensure that proper skin assessments were accurate, and if warranted, proper physician orders [REDACTED]. These random checks will start on Saturday, September 5, 2015 and will be ongoing. In addition to the random skin assessment checks, the above mentioned inservice will take place with all Licensed Nursing Staff on a quarterly basis, and upon new hire. The Administrator, will monitor this Plan of Removal for completeness and accuracy. The system aforementioned will be monitored at a minimum of quarterly during the facility ' s Quality Assurance and Assessment meeting. The next scheduled Quality Assurance and Assessment meeting is October 2015. Interviews were conducted on 09/05/15 between 10:45 AM and 2:45 PM with the following staff representing all shifts: LVN A, LVN I, LVN J, LVN K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, and CNA S. All nurses interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do in regards to preventing, identifying and reporting pressure ulcers and addressing pain prior to wound treatment. All nurse aides who were interviewed stated they had received the in-service training and post-tests. They were knowledgeable in regards to turning and repositioning residents and communicating to nurses any old and new skin changes on residents. On 09/05/15 at 2:40 PM, The Administrator was notified the IJ was removed. While the IJ was removed on 09/05/15, the facility remained out of compliance at a severity level of Actual harm that is not an Immediate Jeopardy and a scope of pattern, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal.

Based on observation, interview, and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident for one (Residents #2 and) of six residents reviewed for pressure ulcers. 1. The Administrator failed to develop an effective policy for preventing the development and or worsening of pressure ulcers, and the treatment of [REDACTED]. 2. The Administrator failed to supervise the DON to ensure she was monitoring the staff to ensure they were fully knowledgeable and proficient in managing the treatment of [REDACTED]. 3. DON, LVN E, and ADON B failed to identify new pressure ulcers or existing change, and accurately describe and identify pressure ulcers on Resident #2. Resident #2 had existing pressure ulcers on the left side of the sacral coccyxagreal area, right heel unstageable and left heel a stage four area. They failed to identify a new stage two area on the sacralcoccyxageal area which was next to the stage 3 area. 4. The DON, ADON B, and LVN E failed to ensure residents with pressure ulcers (#2 and #14) were assessed for pain prior to treatment. An Immediate Jeporady (IJ) was identified on 09/04/15. While the IJ was removed on 09/05/15, the facility remained out of compliance at a severity level of Actual Harm that is not Immediate Jeopardy and a scope of Pattern because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures to ensure that Resident #2 and #14 received appropriate treatment and medication for pain prior to the treatment of [REDACTED]. These failures had the potential to affect not only Resident #2 and #14 but also the other three residents who had pressure ulcers. These failures had the potential to result in serious injuries and trauma and to result in the development of unnecessary pain and potential for infection which could lead to avoidable injury and death. These failures could affect all 85 residents by placing them at risk for the development or worsening of pressure ulcers by not being adequately assessed, and treated appropriately, also the failure to assess the residents for pain prior to treatment of [REDACTED]. Findings included: 1) The Minimum Data Set (MDS) assessment dated [DATE] (marked as a change in condition) reflected Resident #2 was a [AGE] year old female with the following Diagnoses: [REDACTED]. Resident #2 was cognitively impaired with long and short term memory loss. She was non- ambulatory required 2 person total assistance for transferring. Resident # 2 also was dependent on the staff for dressing, grooming, feeding, toileting, and bed mobility. The MDS further reflected the resident had an unhealed Stage 3 pressure ulcer and a Stage four pressure ulcer and an unstageable pressure ulcer. the MDS further reflected the measurements for the worse ulcer was 6.5cm x 6.0 cm x 0.3 cm eschar. The preventative measures marked were a pressure relieving mattress for the bed, nutrition or hydration, pressure ulcer treatment, application of non surgical dressings and application of ointment or medication for the treatment of [REDACTED]. The MDS done on 06/04/15 reflected Resident #2 had a history of [REDACTED].#2 did not have any pressure ulcers at the time the MDS was completed. As for the preventative skin and ulcer care the MDS dated [DATE] did not reflect the facility was providing any care. Observed Resident #2 on 09/02/15 at 9:45 AM during the initial tour, she was up sitting in the wheel-chair at the nurse's station. Her feet were hanging down and she had bilateral padded heel protectors on each foot. An observation 09/02/15 at 3:15 PM revealed Resident #2's sacral coccyxageal area had a [MEDICATION NAME] dressing which was rolled up on the edges. CNA G lifted the dressing and the surveyor saw a Stage II pressure ulcer. The CNA did not see the wound. It was noted the brief he removed from Resident #2 was saturated with urine and had brown rings on the brief. On 09/03/15 at 4:00 PM during an interview with CNA G he revealed he only has seen the one pressure ulcer and did not know there was a second area under the dressing. I'm not in trouble am I? An observation on 09/03/15 at 9:35 AM revealed Resident #2 lying in bed on her back. The mattress the resident was lying on was not an low air loss mattress.esident was not on an anti-pressure mattress. The resident had on heel protectors which were flat on the bed causing pressure to the pressure ulcers on the heels. It was noted Resident #2 crossed her legs and there was not a positioning devise between her legs to alleviate further pressure. The pressure ulcers were as follows: The surveyor observation of left heel determined the measurements of the heel were approximately 6.5 cm(centimeter)Length x 6 cm width x 0.2 cm depth Stage IV with yellow and black eschar (dead tissue) throughout the wound and spots of red granulation tissue seen in the wound bed. There was a strong foul odor. The treatment performed by LVN E including cleansing with normal saline, patting the wound dry, applying Santyl Ointment ([MEDICATION NAME] agent), Calcium alginate, and applying a dry dressing. Resident grimaced when legs were lifted in the air. The legs were lifted in the air to view the pressure ulcer, drip the saline over the wound and apply the dressings. The resident could have been turned on her side and the wound treated. Resident #2's right lateral heel had an un-stageable pressure ulcer which the surveyor determined measured approximately 2cm x 1 cm x 0.1 cm. The surveyor informed LVN E the black eschar area appeared concave (hollowed) with ragged edges. According to LVN E she was unaware the wound on the right heel was no longer intact and appeared concave. LVN E withheld treatment of [REDACTED]. LVN revealed she normally treated the wound with skin prep. LVN E revealed she treats the wounds on day shift. Observation of Resident #2's the left side of the coccyx was the surveyor noted a pressure ulcer approximately 2cm x 1.5 cm Stage 3 with black eschar covering the pressure ulcer. In the center of the coccyx there was a pressure ulcer approximately 1.5cm x1.5cm Stage II area. LVN E revealed she had not seen this stage II area before. LVN E treated the area with a [MEDICATION NAME] dressing. This dressing covered both areas on the coccyx. Resident grimaced when the dressing was removed and she was positioned on her right side. 09/03/15 at 9:42 AM during the wound care treatment ADON (Assistant Director of Nurses)B revealed the pressure ulcers developed while the resident was in the facility. She did not elaborate how they developed. She further revealed she had spoken to Resident #2's family member about hospice care but he had not made a decision. According to ADON B the resident was dependent on the staff for care, and the staff had to feed her, and she had declined some. On 09/03/15 at 9:55AM, ADON B revealed they had to get a new treatment for [REDACTED]. LVN E told her there had been a change in the right heel and it was no longer intact. ADON B further revealed she did not know how long the resident had been without the low air loss mattress. She remembered ordering one but thought it had been put on the wrong patient. I know she had one last year, but do not know how long she had been without the mattress. ADON B revealed she would get the resident an low air loss mattress today. On 09/04/15 between 11:10 AM and 11:15 AM the surveyor inteviewed four staff members CNA BB, LVN C, LVN E, and ADON F were unaware of how long Resident #2 had been without a low air loss mattress. CNA BB revealed she had worked with Resident #2 for the last two years but did not know when the resident last had an low air loss mattress. LVN E revealed, at this time Resident #2 did not have foot pedals or leg rest on her wheelchair to enable the residents feet to be elevated. On 09/03/15 at 11:00 AM Resident #2 was observed asleep in the hallway by the nurses' station sitting in her geriatric-chair. Her lower legs were crossed and not elevated. Her feet were in heel protector boots that were directly touching the floor. LVN C pushed Resident # 14 in the geriatric chair to her room and her feet were dragged on the floor all the way to her room (approximately 50 feet)The resident chair did not have foot pedals. Resident #2's (Physician) Order Summary Report dated 04/10/14 reflected Resident #2 was to have a Low Air loss Mattress at all times. Review or the current orders this order had been dropped. DON was asked to provide documentation that the order had been discontinued. The DON revealed the order had not been discontinued and it was current and she would update the physician orders. On 09/03/15 at 9:55AM, ADON B revealed they had to get a new treatment for [REDACTED]. ADON B further revealed she did not know how long the resident had been without the low air loss mattress. She remembered ordering one but thought it had been put on the wrong patient. I know she had one last year, but do not know how long she had been without the mattress. ADON B revealed she would get the resident an low air loss mattress on this day. On 09/03/15 at 4:00 PM the surveyor observe Resident # 2 had received a Low Air Loss Mattress on her bed. Review of Wound Care Specialist Evaluation for Resident #2 dated 08/31/15 revealed the following: Right Heel (actually left) Stage IV, 6.5x6x0.3 cm, Thick Adherent necrotic tissue providing 100% coverage of the wound. The physician did a surgical debridement (removal) of the necrotic tissue, and muscle. The physician documented he recieved permission to debride the wound from the healthcare surrogate on 08/17/15. Coccyx Stage 3, Wound size: 1x2x0.1 cm, Granulation tissue of the wound 100%. Left Heel(actually right) Unstageable DTI (Deep Tissue Injury) wound size: 1x2x not measurable cm. The Stage II area near the coccyx evudentily had not developed when the wound care specialist visited on 08/31/15 The residents wounds on the heels were documented incorrectly, and the unstageble pressure ulcer was on the right heel, and the stage four wound was on the left heel. A Progress note dated 09/03/15 revealed: NOTE: right and left transposed left change to cacium(calcium) alginate and santyl Care Plan dated 02/18/13 Revised Care plan dated 04/23/13 for [MEDICAL CONDITION] revealed the resident legs were to be elevated when sitting or sleeping. Care Plan dated 12/04/13 Revised 05/14/14 revealed the resident was at risk for pressure ulcer on coccyx due to history of pressure ulcers/ immobility. The Goal was resident would have intact skin, free of redness, blisters or discoloration by/through next review date of 10/7/15. The interventions included: Administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention /treatment of [REDACTED]. To ensure resident's comfort Resident #2 had [MEDICATION NAME] HCL 50 mg 1 tablet by mouth every 8 hours as needed for pain. Care Plan dated 09/01/15 and revised on 09/01/15 Stage 4 Pressure ulcer on right heel (actually left) and stage III on coccyx and an un-stageable DTI on Left (actually right) heel development r/t (related to) Hx (history of) ulcers /immobility. The Goal were the following: 1. The resident would have intact skin, free of redness, blisters or discoloration by next review date of 10/7/15. 2. Residents pressure ulcer would show signs of healing and remain free from infection through 10/7/15. Interventions included: Administer treatments as ordered.(Date initiated 08/11/15) Monitor/document for side effects and effectiveness . (select) Require pressure relieving device on (bed and chair). (Neither bed nor chair was selected.),Treat pain as per orders prior to treatment/turning etc. to ensure my comfort. (Physician) Summary Order Report run 09/04/15 at 3:33 PM reflected the following wound care treatments for Resident #2 a. Clean Stage 4 left heel with normal saline, pat dry, apply santyl/calcium alginate, and cover with a dry dressing. b. Clean un-stageable DTI of right heel with normal saline, pat dry, apply santyl/calcium alginate, and cover with a dry dressing. Ordered 09/03/15. c. Clean Stage 2 Sacrum with normal saline, pat dry, and apply [MEDICATION NAME] every 3 days and as needed. Ordered 09/03/15. d. Clean Stage 3 coccyx with normal saline, pat dry, and apply [MEDICATION NAME] every 3 days and as needed. Ordered 09/01/15. e. Heel boots at all times every shift. Ordered 09/03/15 and start 09/04/15 f. Low air loss mattress at all times. Ordered 09/03/15. On 09/03/15 at 12:25 PM Administrator and the Director of Nursing were notified of substandard quality of care was called in quality of care. The DON stated there was a total of six residents with identified pressure ulcers. She stated she had not seen any of the pressure ulcers that Resident #2 had and was not aware of the stage two pressure ulcers on her coccyx identified on 09/02/15. The Administrator stated he asked ADON B why Resident #2 was not on a low air loss mattress and she was surprised and said she ordered one but was not sure when. She stated she thought the low air loss mattress went to another resident and was not sure how long Resident #2 had been on a regular mattress. On 09/04/15 at 8:40 AM The DON was queried as to what systems she had put in place and she revealed the wound care physician would no longer be at the facility. She further stated the Admission Coordinator was going to try and get one of the wound doctors from the hospital to come to the facility. The DON also stated she wrote a ton of orders on 09/03/15. The orders included, proper treatments, ensuring pressure relieving devices were in place, pain management for every resident who had a wound and they were to be medicated before treatment. The DON further revealed there was going to be more staff education, monitoring the staff closely, get another wound doctor, pain management of the residents with wounds, and after the survey do a complete skin sweep. The MDS dated [DATE] reflected Resident #14 is a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #14 had a pressure ulcer Stage II, and required the following assistance with Activity of Daily Living: The resident required extensive assistance of one person in bed mobility, dressing, and personal hygiene. Resident # 14 required extensive assistance with transferring and was dependent on the staff for mobility and bathing. On 09/04/15 at 8:52 AM observed ADON F and the DON turned Resident #14 to her right side. During the positioning the resident moaned and complained of pain with movement. The DON removed the [MEDICATION NAME] dressing on left buttocks area. Resident #14 stated Oh when the dressing was removed. Under the dressing it was noted there was a Stage 3 pressure ulcer measuring approximately 1x1x0.2 cm. Resident #14 had an order for [REDACTED].>On 09/04/15 at 9:20 AM LVN E was asked if she had given Resident #14 any pain medication prior to the removal of the dressing or during the treatment of [REDACTED]. At this time the DON stated all residents are supposed to get medicated for pain thirty minutes before the treatment. I went over this with all the nurses this morning. The DON queried why LVN E had not medicated the resident? LVN E revealed there was not an order to medicate the resident. The DON revealed she had put orders in on all residents with pressure ulcers. The DON looked in the computer and noted she had entered the wrong day for the pain medication prior to treatment to begin, noting it should start on 09/05/15. At this time LVN E revealed she had not given the resident anything for pain. On 09/04/15 at 9:25 AM Resident # 14 revealed her pain was not too bad at this time. the residents treatment to the pressure ulcer on the sacral coccyxageal area was to apply a [MEDICATION NAME] dressing to the wound and change every three days or as needed. (Physician) Order Summary Report dated 09/04/15 reflected Resident #14 could receive [MEDICATION NAME] HCL 50mg tablet one tablet every six hours for pain. The Care Plan Revised on 09/01/15 reflected the resident was to be treated for [REDACTED]. To ensure Resident #14 ' s comfort. Reference to Perry and Potter Clinical Nursing Skills and Treatment Techniques 7th Edition page 983. Procedure guidelines 38-1 Preforming Wound Assessment revealed . Procedural steps: . 2. Assess comfort level or pain on scale 0-10 and identify symptoms of anxiety. . 10. Reassess patient ' s pain and comfort level . Policy & Procedure Skin Assessments Policy: It is the policy of this facility that all residents will be assessed according to their needs and risk factors to prevent adverse skin conditions. Procedure: 1. Braden Scale assessment will be completed upon admission, quarterly and with significant change in condition. 2. Follow up skin assessments will be performed as follows according to the score of the Braden scale: · High Risk (12 or below) -weekly · Moderate Risk (13-14)- every other week · Low Risk (15-16 if under age 75 OR 15-23 if over age 75)-monthly 3. Any resident with an existing skin condition (decubitus ulcer, stasis ulcer rash etc.) will receive weekly skin assessments regardless of their Braden score. 4. Skin assessment will be completed by day shift licensed nursing staff according to the schedule by the Director of Nursing or their designee. On 09/04/15 at 12:41 PM an Immediate Jeopardy was identified and the Administrator and Director of Nursing were informed. The Plan of Removal was accepted on 09/04/15 at 7:07 pm. Plan of Removal Residents Involved: Resident #11, admitted [DATE] Age: 76 Diagnosis: [REDACTED]. Total Care with ADLs and Transfers; Alert and Oriented to Self Pressure Sores: Stage II to Sacrum (3.5cmx2cm); Stage II to Coccyx (5cmx1.5cm); Stage II to Coccyx (1cmx1.2cm); Stage II to Coccyx (1.5cmx2cm); Stage II to Coccyx (2cmx1.5cm); Stage I to Left Heel (1cmx1.5cm) Failure to identify and treat one pressure area on left heel, and failure to identify and treat one additional pressure area on sacrum which contained eschar. Resident #2 admitted [DATE] Age: 95 Diagnosis: [REDACTED]. Total Care with ADLs and Transfers; Uses hoyer lift; Alert and Oriented to Self Pressure Sores: Stage III to Coccyx (1cmx0.5cmx0.1); Stage IV to Left Heel (6.5cmx6cmx0.3cm); Unstageable to Right Heel (2cmx1.5cm) Failure to follow Attending Physician order [REDACTED]. Resident #14 admitted [DATE] Age: 75 Diagnosis: [REDACTED]. Total Care with ADLs and Transfers; Uses hoyer lift; Alert and Oriented x3 Pressure Sores: Stage III to Left Buttock (1.5cmx1cmx0.1cm) Failure to medicate resident prior to wound treatment. The facility ' s Skin Assessment Policy and Procedure objectives were not followed through by Licensed Nursing Staff and Certified Nursing Assistants, in the area of head-to-assessments, resulting in a system wide failure of Pressure Sores. Failure of ADON B to monitor and ensure that the Wound Assessments were completed accurately, and in a timely manner resulted in a system wide failure. Employees involved in this failure include, ADON B; LVN E (6-2); LVN AA (2-10); RN Z(10-6); , LVN Y (10-6); LVN J (6-10 WE); LVN C (6-2); LVN X (10-6); LVN A (6-10WE). Disciplinary action includes termination of ADON B due to employee being in charge of the Pressure Ulcer system, and all other employees will receive a Written Reprimand regarding Not Following Facility Protocol Regarding Wound Treatment before the start of their next assigned shift. Starting at 4:00PM on Friday, September 4, 2015, the facility will be in-serving all Licensed Nursing Staff on all shifts regarding appropriate head-to-toe assessments on all residents. The in-service will be conducted by RN W for Dr. V. During this in-service, Licensed Nursing Staff will be retrained on proper head-to-toe assessments, and visual competency checks will be done per the Assessment Schedule. This in-service will be completed by Saturday, September 5, 2015 at 3:00PM. The attached Policy and Procedures will be taught during the in-services. Licensed Nursing Staff will not be allowed to return to work until this mandatory in-service has been completed. DON will monitor all individuals who did not attend the in-service by 3:00PM on Saturday, September 5, 2015, that these individuals will be trained/in-serviced before returning to work. As an addition, all facility Certified Nursing Assistants will be retrained on proper Turning and Repositioning techniques. This in-service will be conducted in conjunction with the Licensed Nursing Staff in-service. Also, an in-service will be conducted for the Certified Nursing Assistants on how to complete the CNA Communication Form ensuring that Licensed Nursing Staff will be notified of any change in skin condition(s). A CNA Communication Form competency test will be developed by Administrator, to ensure proficiency on communication of skin conditions. DON, ADON D, and ADON F, will train Certified Nursing Assistants now, quarterly, and upon hire on the correct use of the Communication Form. This training will start on Friday, September 4, 2015 and will be ongoing. Should a skin issue be identified, the resident ' s Attending Physician will be notified, and orders will be carried out according to his/her orders. In addition to the Attending Physician notification, additional notification will be made to resident ' s responsible party. In addition to the above, additional training will be conducted by DON, with all Licensed Nursing Staff regarding the importance of medicating residents prior to receiving wound treatments. This training will be conducted now, quarterly, and upon hire. The facility ' s Medical Director, was contacted at 1:30PM on Friday, September 4, 2015 regarding the Immediate Jeopardy situation. At this time, the Medical Director suggests the facility contact the wound care physician, of VOHRA Wound Physicians for ongoing training. The facility recognizes the failure to medicate the residents (#2 and 14) prior to wound care, and as a result, has initiated standing orders for all residents to be medicated 30-minutes prior to wound care. The facility ' s Pain Assessment or the Pain Assessment with Advanced Dementia will be used to assess the resident ' s level of pain. The proper use of the facility ' s Pain Assessment tool will also be included in the in-service, performed by RN W, now, quarterly, and upon hire. The new standing-order for pain medication prior to wound treatment will be initiated upon the next wound treatment. DON, ADON D, and ADON F, will monitor pain Medication Administration Record [REDACTED]. Currently, Assistant Directors of Nurses, LVN's along with Director of Nurses, RN's have been performing head-to-toe assessments on all residents to ensure that currently Weekly Skin Assessment are accurate. At this time, 46 out of 85 residents have been assessment, with no new areas being identified. Director of Nurses, and the Assistant Directors of Nurses, ADON F and ADON D will perform random checks daily on skin assessments that were completed by the Licensed Nursing Staff on the previous day to ensure that proper skin assessments were accurate, and if warranted, proper physician orders [REDACTED]. These random checks will start on Saturday, September 5, 2015 and will be ongoing. In addition to the random skin assessment checks, the above mentioned inservice will take place with all Licensed Nursing Staff on a quarterly basis, and upon new hire. The Administrator, will monitor this Plan of Removal for completeness and accuracy. The system aforementioned will be monitored at a minimum of quarterly during the facility ' s Quality Assurance and Assessment meeting. The next scheduled Quality Assurance and Assessment meeting is October 2015. Interviews were conducted on 09/05/15 between 10:45 AM and 2:45 PM with the following staff representing all shifts: LVN A, LVN I, LVN J, LVN K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, and CNA S. All nurses interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do in regards to preventing, identifying and reporting pressure ulcers and addressing pain prior to wound treatment. All nurse aides who were interviewed stated they had received the in-service training and post-tests. They were knowledgeable in regards to turning and repositioning residents and communicating to nurses any old and new skin changes on residents. On 09/05/15 at 2:40 PM, The Administrator was notified the IT was removed. While the IJ was removed on 09/05/15, the facility remained out of compliance at a severity level of Actual harm that is not an Immediate Jeopardy and a scope of pattern, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. The CMS-672, Resident Census and Conditions of Residents, dated as completed on 09/02/15 by the Administrator reflected there were 85 residents