Every finding on record at The Villa at Mountain View

Based on observation, interview, and record review, the facility failed to ensure the services provided by the facility meet professional standards of quality for 1 of 6 residents (Resident # 1) reviewed for professional standards. The facility failed to ensure LVN A followed the physician's order to send Resident #1 out to the hospital by emergency transfer after a fall exposed residents' possible bloody stool on his bed on [DATE] at approximately 10:00 AM, which prevented Resident #1 from receiving preventative treatment subsequently leading to Resident #1's death six hours later in the facility. This failure could place the residents at the facility at risk for physical, verbal, and/or psychosocial harm. Findings included:Record review of Resident #1's resident assessment and care screening nursing home comprehensive item set MDS Assessment, dated [DATE], revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. The MDS also reflected active admitting diagnoses of unspecified intracapsular fracture of right femur subsequent for closed fracture with routine healing (right hip fracture) and pain in right knee on [DATE]. Resident #1 was admitted due to his history of falls and subsequent right femur fracture from the hospital after a fall at his home. The resident had been admitted four days, and further diagnoses had not yet been added to the resident's electronic health record. And, the resident was not on hospice care. Record review of Resident #1's BIMS Evaluation, dated [DATE], reflected that the resident had a score of 02 indicating severe cognitive impairment. Record review of Resident #1's progress notes reflected the following: On [DATE] at 9:46 PM RN B wrote: At 1430 (2:30 PM), this writer made a round on the patient with morning nurse and took report on patient, stating patient is a fall risk and need (sic) to be monitored for fall. Nurse introduced himself to the patient and patient (sic) looked up at the nurse and smile (sic), bed lowered and floor mat at bedside. Patient was checked upon periodically and @ 1725 (5:25 PM), while passing the evening meds that are due for some of the residents, patient observed laying down comfortably with eyes open and without distress, @ 1738 (5:38 PM), while getting meds from the medication room, staff notified me that there is a code blue (respiratory distress) in a room, this writer and three nurses and other staff immediately rush to the room and start CPR with the crash cart and AED pad in place (delivers a lifesaving shock) while the fourth nurse called EMS and get all (sic) paperwork ready. Between 5-10 minutes later, paramedics arrived at the facility and pronounce (sic) the patient deceased . Family Member YY (who was already at the facility) notified of the occurrence and at 2110 (9:10 PM), patient was pick (sic) up by Mortuary Services and left the facility without incident. Family Member notified that patient is picked up but to no avail and a voicemail was left. Record review of Change in Condition Assessment was marked as a status of Error by LVN A on [DATE]. Record review of Transfer to Hospital was marked as a status of Error by LVN A on [DATE]. Record review of Neurological Checks, dated [DATE] at 10:15 AM, reflected neurological checks started at 10:15 AM by LVN A and the last neurological check was at [DATE] 3:00 PM. There was no indication of which nurse completed the neurological checks on the resident on the assessment. Attempted telephone interviews on [DATE] at 10:43 AM, 12:32 PM, and 1:38 PM to LVN A were unsuccessful as there was no answer or call back. Interview on [DATE] at 9:54 AM with the RDRC revealed she was called to the building on the evening of [DATE] due to Resident #1's death in the facility and began conducting an investigation. The RDRC said they found that Resident #1 was admitted to the facility for four days. The RDRC said ADON D was notified by LVN A that Resident #1 fell that morning on [DATE] at approximately 10:00 AM and immediately notified ADON D during the morning meeting. The RDRC said that dark black stool was seen on Resident #1's bed sheets by ADON D when he fell onto the floor. The RDRC said LVN A contacted the NP after the fall and recommended to the NP to send the resident out through text, so the NP gave the order to send the resident out to the hospital. The RDRC said later that afternoon, LVN A reported the resident was doing better and that he did not need to go out to the hospital. LVN A said that he was more alert and participating so she changed her mind about wanting to send him out. LVN A did not consult anyone in her decision making. The RDRC said LVN A did not send him out to the hospital. The RDRC said LVN A said that she did not notify the NP of the change in condition. The RDRC said RN B arrived on his shift at 2:00 PM. The RDRC said LVN A reported to RN B Resident #1 fell and therefore was a fall risk. The RDRC said RN B did not know about possible blood in his stool or the order to send Resident #1 out to the hospital. The RDRC said RN B told the RDRC that he made his initial rounds between 2:30 PM and 3:00 PM and Resident #1 smiled at him. The RDRC said RN B told the RDRC that he saw Resident #1's eyes open at 5:25 PM when he was passing medications for other residents. The RDRC said that RN B went to the medication room around the same time the CNAs went to get the dinner trays to pass them on the halls. The RDRC stated that Resident #1's YY entered the facility at approximately 5:15 PM to visit Resident #1. The RDRC said when the RP entered the resident's room, he found Resident #1 unresponsive. The RDRC said the family member called out for assistance and CNA F responded and then called out for RN B. The RDRC said RN B brought the crash cart and other nurses arrived as well because a code blue (a life-threatening medical emergency like cardiac or respiratory arrest) was announced. The RDRC said RN B stated to the RDRC that Resident #1 was not breathing and had no pulse. The RDRC said at 5:38 PM code blue was announced and 5:39 PM per the telephone log, 911 was called. The RDRC said a nurse dialed 911 at 5:39 PM per RN B. The RDRC said EMS arrived approximately five minutes later and called the time of death for Resident #1 at 5:49 PM. The RDRC said RN B notified the medical examiner and the body was picked up at 8:10 PM by a mortuary service. The RDRC said the police were notified and a case number was pending. The RDRC stated that LVN A, ADON D, ADON E, RN B, and CNA F were all suspended until the investigation was completed. Interview on [DATE] at 10:49 AM with the Interim DON revealed that Resident #1's YY entered the facility about 5:15 PM and notified CNA F that Resident #1 was unresponsive. The Interim DON said CNA F then notified RN B and RN B went into the room, called a code blue, and grabbed the crash cart on the way to the resident's room. The Interim DON said chest compressions were initiated and 911 was called. The Interim DON said the paramedics called the time of death at 5:49 PM. The Interim DON said the regional staff arrived that evening ([DATE])and began their investigation of what occurred on the 2:00 PM - 10:00 PM shift and notified the medical director that Resident #1 passed away in the facility. The Interim DON said they learned through their investigation that evening that Resident #1 had a fall earlier that day. The Interim DON said the NP was notified by the Medical Director after 7:00 PM on [DATE], and she thought LVN A sent Resident #1 out to the hospital. The Interim DON said this did not occur. The Interim DON said LVN A said that she thought that ADON E was going to call 911 for her. The Interim DON stated that the NP also received a text from ADON D and she gave an order to get labs drawn and an x-ray of the right femur if there was pain prior to the text from LVN A requesting to send the resident out to the hospital prior to her order to LVN A to send Resident #1 out to the hospital. Telephone interview on [DATE] at 11:27 AM with ADON E revealed that she was new and still in training. ADON E stated that during morning meeting on [DATE], ADON D received a text that he was needed by LVN A because Resident #1 fell. ADON E stated that ADON D returned and stated that he believed that Resident #1 had bloody stool. ADON E said that someone texted the NP. ADON E then said that ADON D received an order to get labs and x-rays if the resident was in pain. She was instructed by ADON D to return to Resident #1's room to ask LVN A if x-rays were needed. ADON E said Resident #1 was moaning like he was in pain. LVN A said that she was going to send him out to the hospital because he had a prior fracture of his femur. ADON E then said that LVN A told her to print the documents needed for EMS and that she (LVN A) would call 911 because this was on her license. ADON E then went to the nurses' station, printed the medication sheet and face sheet, handed them to LVN A, and then left the facility to run an errand. ADON E said that at the point that she gave her the printed documents, she thought that 911 had already been called. ADON E then said that when she returned from her errand after time passed (she was unsure of the time) she saw Resident #1 in his room when she went down the hall to check on another resident. ADON E said that because she was new to the facility, she thought that perhaps LVN A and ADON D had decided to not send the resident out and there was a change in the orders. ADON E then went to ADON D at approximately 4:30 PM to ask him why Resident #1 was not sent out to the hospital. ADON E said that Resident #1 was alive at that point. ADON E said ADON D told ADON E that LVN A told him that Resident #1 had gotten better. ADON E said that it was not standard nursing practice to not send out a resident after not speaking with the doctor first. ADON E said that a nurse should not change a doctor's order to send a resident to the hospital (after receiving orders from the physician) without speaking with the physician and receiving physician's changed orders. Telephone interview on [DATE] at 11:44 AM, revealed that between 9:00 AM and 10:00 AM on [DATE], ADON D was on the hall when CNA C came to get him for an emergency as requested by LVN A. ADON D stated that he went to Resident #1's room immediately and observed large black stool in Resident #1's bed and Resident #1 on the floor from a fall. ADON D stated that he collected a specimen of the stool, bagged it, and labeled it because he suspected there was blood in the stool. ADON D stated he then sent a text to the NP of his observations. ADON D stated that LVN A continued to assess the resident as he exited the room and went to his office. ADON D stated the NP ordered a stool culture, CMP, CBC, and in addition, if the resident was having pain, also obtain x-rays. ADON D said that ADON E was in his office when he received the orders from the NP. ADON D stated that he asked ADON E to go to Resident #1's room and ask LVN A if x-rays were needed and where on the resident, they were needed. ADON D stated LVN A explained to ADON E that the resident did not need x-rays because she was going to be sending Resident #1 to the hospital due to his excessive pain from the fall. ADON D stated that he continued to put the orders in to be completed the following day in case the resident returned without the tests being completed. ADON D revealed that later in the day ([DATE]) something alerted him that Resident #1 was still in the building. ADON D stated he asked LVN A if ADON E assisted her with calling 911, and LVN A confirmed ADON E did assist her. ADON D stated LVN A stated to ADON D that ADON E called 911 for her. ADON D said that he assumed this had not been done because Resident #1 was still in the building. ADON D asked LVN A if she needed him to call 911. At that point, LVN A told ADON D that Resident #1 was better, so she was not sending him out. ADON D revealed that because Resident #1 was not on his hall, he assumed that ADON E and LVN A had spoken and explained to the NP what changed with the resident. He stated that he assumed the NP, ADON E, and LVN A discussed new orders for Resident #1 since Resident #1 was not sent out to the hospital. ADON D revealed that the nurse's responsibility was to follow the physician's orders to prevent negative outcomes for residents. Telephone interview on [DATE] at 12:09 PM with the NP revealed that she received a text message from ADON D at 10:19 AM on [DATE] that Resident #1 had a loose black bowel movement. The NP stated ADON D said in the text message that he collected a stool specimen in case the NP wanted to order tests. The NP also stated the text said that Resident #1 had a fall. The NP said that she replied in the text to order a stool culture, CBC, BMP, x-ray, and asked if the resident was on any protein pump inhibitors to help prevent bleeding. Then the NP received another text about the same fall from LVN A at 10:52 AM on [DATE] that Resident #1 fell out of bed and was admitted to the facility with a right femur fracture. LVN A told the NP that she wanted to send Resident #1 out for further treatment because he was moaning with pain. LVN A also explained that Resident #1 had dementia (per the BIMS evaluation of a 2) and got up out of bed because he did not remember he had a right femur fracture. The NP stated she asked LVN A if Resident #1 was in severe pain, which LVN A replied yes. The NP revealed that she thought the resident was sent out to the hospital after the text at 10:52 AM she received from LVN A. The NP said that she was on call until 5:00 PM daily as well as on [DATE], and the medical director took calls from 5:00 PM until 7:00 PM daily. The NP stated she received a text message from the medical director that Resident #1 passed away after 5:00 PM. The NP stated the medical director asked her if she saw the resident. The NP said yes (not in person but spoke with the nurse) and that she had sent him out to the hospital. The NP said she immediately called LVN A to ask what happened because she knew that she last discussed Resident #1 with LVN A and gave orders to send him out to the hospital. However, LVN A did not answer the NP's telephone call. The NP stated she then sent a text message to LVN A asking why Resident #1 was not sent out to the hospital and LVN A replied, via text message, she thought ADON E called 911, because she was busy obtaining neurological checks for Resident #1 and two other residents' neurological checks as well. LVN A said that she had an issue with another resident also. LVN A also texted the NP that Resident #1 was sitting up pressing his call light for water and his neurological checks were stable, so she thought he no longer needed to go out. The NP said that the text from LVN A also said that she told ADON D that Resident #1 was stable, so please obtain a stat x-ray on Resident #1's right femur. LVN A also through the text message said that Resident #1 was no longer in pain after she administered his pain medication. The NP said that LVN A also said that she passed on in report to the evening shift nurse to watch Resident #1 more frequently and Resident #1 was stable when she left the building around 4:30 PM. The NP then stated that a nurse cannot override the NP's order. The NP explained that if something changes with a resident, they should notify the NP and/or physician and then take the new order with new order changes. The NP stated that LVN A did not follow this protocol, and she therefore did not know that Resident #1 was not sent out to the hospital. The NP said that LVN A should have called 911 and sent Resident #1 out to the hospital per her orders. The NP said that it was possible that there was a communication issue with the timing between her, ADON D, and LVN A. The NP stated a nurse must follow the doctor's order. Telephone interview on [DATE] at 1:10 PM with RN B revealed that Resident #1 was stable when he made his initial rounds when he started his 2:00 PM shift. RN B said that he took report from LVN A who stated Resident #1 was a fall risk. RN B said that he made sure the resident's fall mat was at bedside and that his bed was on the lowest setting. RN B stated at 5:25 PM he saw Resident #1 with his eyes open and watching tv. RN B stated he then went to the medication room and, on the way back, was told there was a code blue and who it was. RN B stated he grabbed the crash cart and went to Resident #1's room where they put the resident on the floor and started compressions. The code was called at 5:38 PM. The paramedics arrived and pronounced the resident dead at 5:49 PM. RN B said that he knew nothing about Resident #1's order to be sent out to the hospital that morning ([DATE]). He stated he was only informed that the resident was a fall risk. He stated he was also unaware that labs were ordered for the following day. RN B stated that a nurse should never override a doctor or NP's order. He said that this was standard protocol. RN B said that you should text the doctor and NP when there was a change in the resident's condition such as an abnormal assessment. RN B said that a nurse could tell the physician or NP what they think should be done, and that the doctor or NP would agree or give another order based on vitals, what was observed, etc. RN B stated that a nurse should never change anything without notifying the doctor. Telephone interview on [DATE] at 1:25 PM with the Medical Director revealed that the NP was contacted about Resident #1's fall and possibly bloody stool. The Medical Director stated that the decision was made to send Resident #1 out to the hospital. The Medical Director said that something transpired at the facility with Resident #1, and the NP was not made aware. The Medical Director said NP thought that Resident #1 was sent out to the hospital, however he was not sent out. The Medical Director stated that he was communicated by leadership of the facility after Resident #1 passed away, significantly later, and that was his only notification about Resident #1. The Medical Director stated that the nurse should have notified the NP or him of the resident's changes so that the providers could make the decision to send the resident out, unless it was an emergency and 911 needs to be called. Attempted telephone interviews on [DATE] at 2:30 PM with Family Member YY were unsuccessful as there was no answer or call back. Interview on [DATE] at 3:07 PM with the Administrator revealed that he was not the Administrator at the time of this incident. He was brought in because the previous Administrator and previous Director of Nursing were suspended during an investigation of another incident. The Administrator stated that the previous Administrator and previous Director of Nursing had since been terminated at the conclusion of the investigation. The Administrator revealed that a nurse should follow the physician's order. The Administrator also said that in this case, if LVN A was too busy to dial 911, he would expect another nurse to call 911 or another clinical staff member to assist and dial 911. The Administrator explained that a resident's condition could decline if a physician's orders are not followed. Record review of the facility's policy, revised date, [DATE], and titled, Abuse, Neglect and Exploitation reflected: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Interviews with the following CNAs between [DATE] at 5:02 PM and [DATE] at 11:09 AM from all shifts revealed CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, and CNA Q were in-serviced on the following topics:They learned the facility's policy on abuse and neglect including when and to whom to report abuse and neglectThey learned to report any change in a resident's behavior, physical change, etc. to their nurse immediatelyThey learned should complete all their documentation before they leave for the day for each of their residentsThey learned if a resident fell, they should stay with the resident, should get the nurse immediately, and should not move the resident until after the nurse assessed the resident and asked for assistance. Interviews with the following LVNs between [DATE] at 5:02 PM and [DATE] at 11:10 AM from all shifts revealed LVN R, RN S, LVN T, LVN U, RN V, LVN W, LVN X, LVN Y, LVN Z, LVN AA, LVN BB:They learned the facility's policy on abuse and neglect including when and to whom to report abuse and neglectThey learned to report any change in a resident's behavior, physical change, etc. to the physician, family, and DONThey learned should complete all their documentation before they leave for the day for each of their residentsThey learned if a resident fell, the LVN should assess the resident, notify the DON, physician, family, begin neuros, complete an incident report, document in the progress notes, review the care plan, and follow any physician's orders receivedThey learned to document a change in condition and by completing an assessment on the resident's EMAR, obtaining the resident's vitals, notifying the physician, family, and the DON if a change in condition was identifiedThey learned that when dispensing pain medication, they should document on the narcotic count sheet and in the resident's EMAR and if the pain medication is a PRN, they should follow up with the resident with the effectiveness of the pain medication. Also, when signing out narcotics from the electronic medication dispensing system, two nurse signatures are requiredThey learned that nurses should review the residents' care plan to ensure that their interventions are followed. And if a new intervention was needed, they should notify their ADON.

Based on interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation or mistreatment have evidence that all alleged violations were thoroughly investigated for 1 of 5 residents (Resident #4) reviewed for abuse and neglect. The facility did not thoroughly investigate an incident in which Resident #4 made an allegation of alleged abuse. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.The findings include: Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had a diagnosis which included Cerebral Infraction (an ischemic stroke). Resident #4 had moderate cognitive impairment with a BIMS of 09. Record review of a progress note, on 08/02/2026 at 7:32 p.m., stated Resident #4's family member reported an allegation of verbal abuse to LVN B. LNV B went to knock on the Weekend Supervisor door to report the concern, but did not receive an answer at the office door. The Nurse attempted to contact the ED, and was able to report incident via text to the ED. The ED instructed LVN B to contact the DON, no answer from the DON and no return call noted. During an interview on 08/18/2026 at 11:49 a.m., LVN B stated Resident #4's family member reported to her that a staff member was verbally abusive towards Resident #4 by calling her out of her name on 08/02/2026. LVN B stated she went to inform the Weekend Supervisor, but they were no longer in the building. LVN B stated she then called the facility ED who did not answer the phone. LVN B stated she texted the facility ED and about 30 minutes later received a response back from the facility ED that instructed her to contact the DON and Weekend Supervisor. LVN B stated she called the DON twice with no answer. LVN B stated she did not contact the Weekend Supervisor as the DON was the next person in charge so that was who she tried to reach. LVN B stated to ensure Resident #4 was safe she assessed Resident #4, looked at the schedule to ensure the AP was not scheduled to work which they were not scheduled to work until 08/04/2026 and not on Resident #4 hall. LVN B stated that she placed a progress note in the system so everyone would be made aware after she left, and asked other residents did they feel safe. LVN B stated that due to unable to contact the DON she called in the alleged allegation of verbal abuse to the state agency herself. Durning an interview on 08/18/2026 at 12:20 p.m., the ED revealed she was notified on Sunday, 08/02/2026, of an allegation of alleged abuse by LVN B while she was out of the country. The ED stated there was no investigation of the alleged abuse due to LVN B not informing the DON while she was out of country. The ED stated while she was out the DON was able to conduct investigations. The ED stated she had not informed the DON about the allegations of alleged abuse. The ED stated she was on vacation out of the country and once she informed LVN B to contact the DON and Weekend Supervisor she thought it was taken care of as the DON was responsible for reporting to the state agency while she was on vacation. The ED stated she instructed LVN B to contact the DON and Weekend Supervisor and report the alleged abuse to them. The ED stated the alleged abuse was not reported and not investigated as the DON was never made aware of the allegations of alleged abuse. The ED could not provide response to why LVN B did not ensure the DON was made aware of the allegation of abuse. During interview on 08/18/2026 at 3:09 p.m., the DON stated when there was an allegation of abuse and neglect it would have to be investigated by the ED. The DON stated that if the ED was on vacation she would be responsible for starting the investigation. The DON stated that on Monday's she pulled the 72 hours report of progress notes and reviewed them. The DON stated she was not sure how she missed LVN B's progress note. The DON stated her role in an investigation was to ensure residents were safe, assessments were completed, in-services completed and review the incident report completed. The DON stated if an allegation of abuse was not investigated there would be risk of the residents to further abuse. During an interview on 08/18/2026 at 3:25 p.m., the ED stated it was her responsibility to ensure any allegation of abuse was thoroughly investigated. The ED stated a thorough investigation consisted of interviews with all parties involved, identify all involved parties, ensure residents were safe, suspension of the AP, notification to physician and family, safe surveys, if needed call the police, abuse and neglect in-service and report it to the state. The ED stated that a thorough investigation had not been completed, because LVN B never contacted the DON and she was on vacation and thought LVN B had contacted the DON as she requested. The ED stated if the allegation was not thoroughly investigated could place other residents at risk of further abuse and neglect. Record review of facility's policy titled, Abuse, Neglect and Exploitation, dated 10/01/2025 revised 12/01/2025, reflected V. Investigation of Alleged Abuse, Neglect and ExploitationAn immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.Written procedures for investigations include:Identifying staff responsible for the investigation;Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);Investigating different types of alleged violations;Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; andProviding complete and thorough documentation of the investigation.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, 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 and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Residents #4) reviewed for reporting allegations of abuse and neglect. The ED failed to report an allegation of abuse to State Survey Agency, on 08/02/2026. This failure could place residents at risk for continued abuse and neglect.The findings were: Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had a diagnosis which included Cerebral Infraction (an ischemic stroke). Resident #4 had moderate cognitive impairment with a BIMS of 09. Record review of a progress note, on 08/02/2026 at 7:32 p.m., stated Resident #4's family member reported an allegation of verbal abuse to LVN B. LNV B went to knock on the Weekend Supervisor door to report the concern, but did not receive an answer at the office door. The Nurse attempted to contact the ED, was able to report incident via text to the ED. The ED instructed LVN B to contact the DON, no answer from the DON and no return call noted. Record review of TULIP on 08/18/2026 revealed no facility investigation of the alleged incident. During an interview on 08/18/2026 at 10:48 a.m., Resident #4's family member stated she informed LVN B Resident #4 reported she had been verbally abused on 08/02/2026. During an interview on 08/18/2026 at 11:49 a.m., LVN B stated Resident #4's family member reported to her that a staff member was verbally abusive towards Resident #4 by calling her out of her name on 08/02/2026. LVN B stated she went to inform the Weekend Supervisor, but they were no longer in the building. LVN B stated she then called the facility ED who did not answer the phone. LVN B stated she texted the facility ED and about 30 minutes later received a response back from the facility ED that instructed her to contact the DON and Weekend Supervisor. LVN B stated she called the DON twice with no answer. LVN B stated she did not contact the Weekend Supervisor as the DON was the next person in charge so that was who she tried to reach. During an interview on 08/18/2026 at 12:32 p.m., the DON stated she had not been contacted by LVN B on 08/02/2026. The DON stated she had not received notification of an allegation of abuse on 08/02/2026. Attempted interview by phone on 08/18/2026 at 1:10 p.m. to the Weekend Supervisor, was unsuccessful. There was no return call prior to exit. During interview on 08/18/2026 at 3:09 p.m., the DON stated that she did not receive a call or text from LVN B reporting any allegation of abuse while the ED was on vacation. The DON stated staff were educated to report abuse and neglect to the ED immediately and if the ED was not available, they were to report abuse to DON and on weekends they shall report it to the Weekend Supervisor. The DON stated staff are educated to call or text until they receive a response acknowledging the allegation. The DON stated it was her expectation that it was the responsibility of the person who received the allegation to report it so the facility could report it to the state agency and start an investigation related to the alleged incident. The DON stated that if the ED was not present at the facility, she was able to submit the report to the state agency. During an interview on 08/18/2026 at 3:25 p.m., the ED revealed she was the facilities abuse coordinator and was notified on Sunday, 08/02/2026, of an allegation of alleged abuse by LVN B. The ED stated she informed LVN B to contact the DON and weekend Supervisor due to her being out of the country. The ED stated she did not inform the DON of the message she received. The ED stated she was on vacation out of the country and once she informed LVN B to contact the DON and Weekend Supervisor she thought it was taken care of as the DON was responsible for reporting to the state agency while she was on vacation. The ED stated when she returned on 08/06/2026 and inquired with the DON if she had received any allegations of abuse the DON told her she had not. The ED stated her expectation of her staff was to report all incidents and allegations of abuse to her immediately, if she was not available then report it to the DON and on weekends report to the Weekend Supervisor. The ED stated it was her responsibility to ensure any allegation of abuse was reported to the State Survey Agency within the allotted time frame. The ED stated if she was not in the facility and received an allegation of suspected abuse, the DON is able to report on her behalf, but she must verify the allegation was reported to the State Survey Agency. Record review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 10/01/2025, revised 12/01/2025 reflected, VII. Reporting/ResponseThe facility will have written procedures that include:Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orNot later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and failed to care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for dignity. The facility failed to ensure the door or curtain was closed for Resident #1 while she was asleep in Bed A in her underwear. These failures placed the resident at risk of not having her right to a dignified existence maintained.Findings included: Record review of Resident #1's Face Sheet, dated 04/14/26, reflected an [AGE] year-old female admitted on [DATE], with an initial admission date of 02/25/26. Resident #1 had diagnoses that included dementia (loss of memory, language, problem-solving, and thinking abilities), lack of coordination, muscle wasting and atrophy (loss of muscle mass), muscle weakness, and abnormalities of gait and mobility (limping, shuffling, or imbalance). Record review of Resident #1's Quarterly MDS Assessment, dated 03/02/26, reflected a BIMS score of 6, which indicated severe cognitive impairment. The Quarterly MDS Assessment indicated Resident #1 was dependent on staff for dressing. The Quarterly MDS Assessment indicated Resident #1 is dependent on staff for lower body dressing. The MDS Assessment also indicated Resident #1 was impaired on both sides of her lower extremity. Record review of Resident #1's Comprehensive Care Plan, undated, did not reflect the resident would undress. Observation on 04/14/26 at 10:46 AM reflected Resident #1 was asleep in Bed A in her underwear with the door open. In an interview on 04/14/26 at 1:37 PM, Resident #1 stated she did not remember that she did not have on pants earlier. In an interview on 04/14/26 at 1:39 PM, Resident #2 stated her roommate would get hot and take her pants off. Resident #2 stated Resident #1 had taken her pants off the night before and did not put them back on until the next morning. Resident #2 stated she told Resident #1 she needed to take off some of those clothes when she's hot. Resident #2 stated staff typically closed the curtain or closed the door when Resident #1 was in her underwear. In an interview on 04/14/26 at 1:44 PM, LVN A stated Resident #1 was confused and did not typically keep her pants on. LVN A stated staff typically closed the door after coming out of the room. LVN A stated staff had taken Resident #1's pants off for her when she needed to go to the restroom. LVN A stated it was not okay for the resident to lie in bed in her underwear with the door open. LVN A stated she had tried to keep the resident's door closed multiple times, but Resident #1 would get back up and open the door. LVN A stated she had tried closing the door, closing the curtain, and putting clothes on Resident #1. LVN A stated the risk of Resident #1 lying in bed in her underwear was that she did not have privacy. In an interview on 04/14/26 at 2:38 PM, CNA B stated it was not okay for Resident #1 to lie in bed in her underwear with the door open. CNA B stated the risk of Resident #1 being exposed in her underwear was that a male resident walking down the hallway could see her.In an interview on 04/14/26 at 3:08 PM, CNA C stated Resident #1 would get hot and take off her pants, leaving her in her underwear. CNA C stated Resident #1 would take off her clothes. CNA C stated Resident #1 would also be dressed in a gown and then take that off when she became hot. CNA C stated Resident #1's roommate controlled the air on her side of the room. CNA C stated she typically went into the room to ask Resident #2 to adjust the room temperature because Resident #1 was hot. CNA C stated Resident #2 would tell Resident #1 that she needed to take some of those clothes off when Resident #1 complained about being hot. CNA C stated the risk of Resident #1 lying in bed in her underwear and being exposed was that she lacked privacy. In an interview on 04/14/26 at 3:32 PM, the ADON stated today was his first time he had walked down the hallway at the wrong time and noticed Resident #1 putting a shirt on with the door open. The ADON stated he then asked a nurse whether that was something Resident #1 did on a regular basis. The ADON stated the facility would move forward by possibly putting Resident #1 in a B-bed or coming up with another solution to provide Resident #1 more privacy. When asked whether this behavior should have been in Resident #1's care plan, the ADON stated if that was Resident #1's behavior, it should have been included in the care plan. The ADON stated Resident #1 seemed as if she did not want the door closed. The ADON stated the risk of Resident #1 being in her underwear with the door open was exposure. In an interview on 04/14/26 at 4:22 PM, the Administrator stated staff were expected to protect residents and maintain their dignity. The Administrator stated Resident #1 had not been doing that before and believed it was a new behavior. The Administrator stated staff tried to give Resident #1 privacy as best they could. The Administrator stated that when Resident #1 was on the 400 hallway, she had never noticed the resident to be undressed with the door open. The Administrator stated staff were then updating the resident's care plan. The Administrator stated the risk of Resident #1 being in her underwear was a dignity issue and a resident rights concern. Record Review of the facility's policy titled Promoting/Maintaining Resident Dignity, dated 10/01/25, reflected in part: Policy- It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1.All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.2.During interactions with residents, staff must report, document and act upon information regarding resident preferences.

Based on interview, observation, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents on 5 (halls 100, 200, 400, 500 and 600) of 6 halls reviewed. The facility failed to provide a comfortable environment on 12/09/25 when the surveyor observed CNA C spraying a strong scented perfume down the 200 hall. The facility failed to provide a clean and comfortable environment on 12/09/25 when the surveyor observed 2 32-gallon trash bins on the 100, 200, 400, 500 and 600 hall. The facility failed to provide a safe environment on 12/09/25 when the surveyor observed unlocked mechanical lift were observed unlocked on halls 100 and 200. The facility failed to provide a safe environment on 12/10/25 when the surveyor observed an unlocked mechanical lift and shower bed on the 100 hall and an unlocked mechanical lift on the 200 hall. These failures could place residents at risk of an unsafe and diminished quality of life. Findings included:During an observation on 12/09/25 at 10:15 a.m., 32-gallon trash bins with an odor of urine and feces that could be smelled down hall 200,2 32 - gallon trash bins were observed on 100, 200, 400, 500 halls. mechanical lifts were observed unlocked on halls 100 and 200.During an observation on 12/09/25 at 10:50 a.m., CNA C was observed spraying a strong perfume down the hall 200 and no residents were observed in the hallway at that time.During an interview on 12/09/25 at 11:00 a.m., the Treatment Nurse stated the spray could affect residents with respiratory concern/issues and could cause an adverse reaction. The Treatment Nurse stated she would notify the DON so that staff could be in-serviced.During an interview on 12/09/25 at 11:30 a.m., LVN D stated sometimes the residents complained of the smell of urine and feces. LVN D stated CNA C sprayed the perfume close to the ground to prevent it from affecting residents with respiratory issues.During an interview on 12/09/25 at 1:19 p.m., CNA C stated she sprayed the perfume low to the ground because the hallway was smelly, and residents complained about the smell.During an interview on 12/09/25 at 2:10 pm, CNA F stated she brought Febreze to spray instead of perfume to help with the odor.During an interview on 12/09/25 at 2:40 p.m., the Admin stated the Hoyer lift could not be locked because life safety told her that the equipment had to be movable. The Admin stated the equipment on the Egress pathway could not be locked.During an observation on 12/10/25 at 5:15 a.m., the surveyor observed an unlocked mechanical lift and shower bed on the 100 hall and an unlocked mechanical lift on the 200 hall.During an observation and interview on 12/10/25 at 6:30 a.m., the ADON moved the mechanical lift and the shower bed out of the hallway. The ADON stated he moved the equipment to prevent residents from falling and removed the equipment from the floor.During an interview on 12/10/25 at 1:10 p.m., the Admin stated equipment in the hallway had to be left unlocked because of the egress pathway and she was going by what Life Safety told her.Record review of email to surveyor from Life Safety Director on 12/10/25 at 11:21 a.m. reflected, [LS] does not tell anyone not to lock Hoyer lifts [mechanical lift]. They cannot store Hoyer lifts [mechanical lift] in the corridors.Record review of email to LS from surveyor on 12/10/25 3:25 p.m. reflected if Hoyer lifts are on an egress pathway does that mean they can't be locked?Record review of LS email to surveyor reflected on 12/10/25 at 3:30 p.m. It has nothing to do with being locked or unlocked. They cannot store them in the path of egress.Record review of the facility policy Hazardous area, devices and Equipment, dated 07/2017 reflected, A hazard is defined as anything in the environment that has the potential to cause injuryor illness. Examples of environmental hazards include, but are not limited to the following: Openareas or items that should be locked when not in use;. Assessment and analysis of hazards. 2.Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous.

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 infection for 1 (Resident #1) of 5 residents reviewed for infection control. -The facility failed on 12/09/25 to ensure infection control procedures were followed when LVN F repositioned Resident #1, who was on enhanced barrier precautions, without donning appropriate PPE. -The facility failed on 12/10/25 to ensure infection control procedures were followed when CNA A and CNA B handled soiled linen and provided perineal care to Resident #1, who was on enhanced barrier precautions, without donning appropriate PPE. -The facility failed on 12/10/25 to ensure infection control procedures were followed when LVN B provided G-tube care to Resident #1, who was on enhanced barrier precautions, without donning appropriate PPE. This failure could place residents at risk of infection.Findings included:Record review of Resident #1's face sheet, dated 12/10/25 reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with cerebral infraction (type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue), hemiplegia following cerebral infraction right dominant side (Complete paralysis to one entire side of the body), Alzheimer's disease (the most common form of dementia, affecting memory, thinking, and behavior. It is characterized by the buildup of proteins in the brain, leading to the death of brain cells and gradual decline in cognitive function), and gastrotomy status (Refer to the condition of a patient who has undergone a gastrostomy procedure, which involves creating an opening into the stomach for feeding or drainage purposes).Record review of Resident #1's MDS, dated [DATE] reflected, his BIMS score was 03 which indicated severe cognitive impairment. Resident#1 always had urinary and bowel incontinent, Resident#1 was classified as dependent, which meant Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the residents to complete the activity for toileting hygiene, shower/bathe, lower body dressing, roll left and right, sit to lying, lying to sitting on side of bed.Record review of Resident #1's care plan, undated, reflected Resident#1 required tube feeding (PEG-TUBE) r/t GI complications. [Resident#1] goal reflected [Resident#1] will remain free of side effects or complications related to tube feeding through review date. Resident#1 Interventions did not include EBP.Record review of Resident #1's order, dated 10/15/25 reflected Enhanced Barrier Precautions r/t G-TUBE every shift Follow Facility Policy - **USE for patients with any of the following (when Contact Precautions do not otherwise apply): Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO**During an interview on 12/09/25 at 11:00 a.m., the wound care nurse stated residents who were on EBP precautions required staff to wear gown and gloves when high contact care was provided. The wound care nurse stated residents on EBP had a sign above each of their beds.During an interview and observation on 12/09/25 at 11:35 am, surveyor observed LVN F reposition Resident#1 in bed without putting on gown and gloves. Surveyor observed LVN F use hand sanitizer when she returned to the medication cart. LVN F stated a gown and gloves needed to be worn when peri care was provided to Resident#1. During an observation on 12/10/25 at 5:15 a.m., observed CNA A pick linens off the floor from Resident #1's side of the room with no gown on and carried the linens in her hand out of the room. Observed CNA A and CNA B provide peri care to Resident #1 (Surveyor stood out of view of Resident #1's private areas). Surveyor observed CNA A and CNA B not wearing PPE gown. LVN B entered the room and detached Resident #1's G-Tube from his port with no PPE gown on. LVN B walked out of the room with tubing and empty formula bottle. Observed CNA A walked out of the room with trash bags and gloves. Surveyor did not observe CNA A wash hands or use hand sanitizer after she disposed the trash. Observed CNA B, removed gloves and washed her hands before she exited the room. During an interview on 12/10/25 at 5:30 a.m., CNA A and CNA B stated residents with wounds, catheter and G-Tubes were supposed to wear gowns and gloves when direct care was provided. CNA A and CNA B stepped back in Resident #1's room and stated the enhanced barrier sign was posted above his bed. CNA A and CNA B both stated infections could be spread from resident to resident by not wearing the PPE. CNA A and CNA B stated hands should be washed before and after providing care to residents. Record review of matrix-802 and observations of resident's rooms with EBP signs above bed from 12/09/25 to 12/10/25 reflected 23 residents were on enhanced barrier precautions.During an over the phone interview at 1:20 pm, the Medical Director stated staff should wear gown and gloves when high contact care was provided to residents on EBP. The Medical Director stated staff should wash hands before and after care of residents. The Medical Director stated wearing the appropriate PPE helped to prevent the spread of MDRO's (multi-drug resistance organism) and fungal infections.During an interview on 12/10/25 at 1:00 p.m., the ADON stated he was the infection preventionist. The ADON stated residents on EBP had signs above their bed and staff put on gloves and gowns when they provided wound care, dressing, and peri care. The ADON stated the signs were posted above the bed to help identify the residents who needed EBP. The ADON stated residents on isolation precaution had signs outside the door and the facility currently does not have any residents on isolation. The ADON stated PPE bins were located inside the residents room and available.During an interview on 12/10/25 at 1:05 p.m., the DON stated when high contact care was provided gown and gloves should be worn by staff because wounds and open area could be contaminated.During an interview on 12/10/25 at 1:10 p.m., the Admin stated signs for EBP did not have to be posted outside of the door. The Admin stated staff should wear gloves and gowns when high contact was involved with those residents. Record review of Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH DATE: 03/20/24 TO: State Survey Agency Direct reflected Facilities have discretion on how to communicate to staff which residents require the use of EBP. CMS supports facilities in using creative (e.g., subtle) ways to alert staff when EBP use is necessary to help maintain a home-like environment, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities.Record review Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 06/28/24 reflected, .Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident.Record review of the facility policy, titled Enhanced barrier precautions, dated 08/22 reflected, .2. EBPs employ targeted gown and gloves use during high contact resident care activities when contract precautions do not otherwise apply.3. Examples of high contact resident care actvties requiring the use of gown and gloves for EBPs include: a)dressing .e) changing linens;.f) changing briefs or assisting toileting; g)device care or use (central line, uninary catheter, feeding tube,etc); h) wound care(any skin opening requiring a dressing).

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #1, #2, #3, #4, and #5) of fifteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2. #3, #4, and #5's rooms was in a position that was accessible to the residents on 08/12/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #1 Record review of Resident #1's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness, hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body). Record review of Resident #1's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 09/01/2025, reflected the resident had a severe impairment (the resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 05. The Quarterly MDS Assessment indicated that the resident required maximal assistance for dressing, bed mobility, and transfer. Record review of Resident #1's Comprehensive Care Plan, dated 09/23/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 10/09/2025 at 9:32 AM revealed Resident #1 was in her bed, awake. It was observed that the resident's call light was on the resident's side table and was not within reach. When asked where her call light was, the resident looked at her side and said she could not find her call light. Resident #2 Review of Resident #2's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #2's Quarterly MDS Assessment, dated 07/14/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident required moderate assistance for dressing, bed mobility, and transfer. Review of Resident #9's Comprehensive Care Plan, dated 09/10/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 10/09/2025 at 9:36 AM revealed Resident #2 was in his wheelchair, awake. It was observed that the resident's call light was on the floor behind his side table. He said the call light was behind his side table for some time. Resident #3 Review of Resident #3's Face Sheet, dated 10/09/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #3's Quarterly MDS Assessment, dated 08/14/2025, reflected the resident had severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident required moderate assistance for dressing, bed mobility, and transfer. Review of Resident #3's Comprehensive Care Plan, dated 09/30/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. An observation on 10/09/2025 at 9:39 AM revealed Resident #23 was in his bed with eyes closed. It was observed that the resident's call light was on the floor under his bed. Resident #4 Review of Resident #4's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #4's Quarterly MDS Assessment, dated 09/26/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident required maximal assistance for dressing, bed mobility, and transfer. Review of Resident #4's Comprehensive Care Plan, dated 09/23/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and an attempted interview on 10/09/2025 at 9:43 AM revealed Resident #4 was in her bed, awake. It was observed that the resident's call light was on the floor. When asked where her call light was, the resident did not answer. Resident #5 Review of Resident #5's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and abnormalities of gait. Review of Resident #5's Quarterly MDS Assessment, dated 09/01/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident required supervision for dressing, bed mobility, and transfer. Review of Resident #5's Comprehensive Care Plan, dated 09/24/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and an attempted interview on 10/09/2025 at 9:47 AM revealed Resident #5 was sitting at the side of her in her bed. It was observed that the resident's call light was on the floor under a walker. When asked where her call light was, the resident did not reply. During an observation and interview on 10/09/2025 at 9:57 AM, CNA C stated the call lights should be with the residents at all times because the call lights were used by the residents to call the staff if they needed something or if they needed help. She said without the call lights, the residents might fall if they tried to do things by themselves or might get mad because they cannot get hold of anybody. She said the call lights were for all the residents, whether independent or dependent residents. She went inside Resident's #1's room, took the call light from her side table, and placed it where Resident #1 could reach it. She then went to Resident #2's room and pulled his call light from behind the resident's side table and placed it where the resident could reach it. She then went to Resident #3's room and took the call light from the floor. She also did the same for Resident #4 and Resident #5. She said she went to the residents' rooms to change them but did not made sure that the call lights were with residents when she left their rooms. She said she would a round on her assigned hall to check the call lights. In an interview on 10/09/2025 at 10:31 AM, LVN B stated call lights should be with the residents in case they needed to call the staff because they needed to be changed, needed pain medications, or needed a refill of water. She said the CNAs and herself were responsible in making sure the call lights were with the residents. She said she did not notice the call lights were not with the residents when she checked on them. In an interview on 10/09/2025 at 11:19 AM, ADON A stated call lights should be with the residents at all times because the call lights were their lifeline. He said the residents used the call lights to call the staff if they were in distress or just needed a refill of water. He said the call lights were for independent or dependent residents. He said an independent resident might be having a heart attack and no one would know because the call light was not within reach. He said all the staff were responsible in checking if the call lights were with the residents and the expectation was for the staff to make sure the call lights were with the residents every time they left the rooms. He said an in-service had been going around and that he would coordinate with the DON to randomly check if the call lights were with the residents. In an interview on 10/09/2025 at 11:28 AM, the DON stated the expectation was for the staff to make sure the call lights were with the residents at all times. She said the call lights were used by the residents to call the staff if they needed something. She said residents might try to go to the bathroom by themselves because she had no way to call the staff that might result to a fall and injuries. She said all the staff were responsible for the call lights, including her. The DON said an in-service was already initiated and she would monitor the staffs' compliance about call lights. In an interview on 10/09/2025 at 11:48 AM, the Administrator stated the staff should make sure the call lights were with the residents before they leave the room. She said, for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said without the call light the residents might feel helpless. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said the DON already started an in-service about call lights. Record review of the facility's In-Service Training Report, dated 10/09/2025, reflected Call lights should be always be withing residents' reach/ability to push button/activate call light. Use clip for positioning. Everyone has the ability/responsibility to pick up call light and make sure it is in residents reach at all times. Record review of the facility's policy entitled Answering the Call Light 2001 MED-PASS, Inc. revised October 2010 reflected Purpose: The purpose of this procedure is to respond to the resident's requests and needs . General Guideline . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview and record review the facility failed to ensure the resident had the right to personal privacy and confidentiality of his or her personal and medical records for one of 8 residents (Residents #1) reviewed for confidentiality of records. The facility failed to ensure LVN A did not leave the computer tablet on top of a medication cart from disclosing Residents #1's EMAR's insulin administration on 09/05/25 from 11:10 AM to 11:13 AM; Subsequently there was not any staff around the medication cart for approximately three minutes. This failure could place residents at risk of having their medical information disclosed to residents and visitors which could cause embarrassment, frustration, and feelings of decreased privacy, which could result in a decline in health and psycho-social well-being. The findings include: Record review of Resident #1's admission MDS assessment, dated 06/26/25, revealed a [AGE] year-old who was admitted to the facility on [DATE]. Resident #1 had a BIMS score of 15, which indicated no cognitive impairment. He needed setup to partial/moderate assistance with his ADL and with rolling, sit to standing and transfers. Resident #1 had medically complex conditions with diagnoses which included cirrhosis (chronic liver damage), Renal insufficiency (non-functioning liver), viral hepatitis (liver inflammation), DM (diabetes mellitus), asthma (inflammation of airway), respiratory failure (abnormal lung function). For medications Resident #1 had six insulin injections in the past seven days. Record review of Resident #1's Care Plan, date initiated 06/20/25, revealed, Focus - The resident has diabetes mellitus and is currently receiving Insulin Regular Human injection Solution 100 unit/ml. Goal - the resident will have no complications related to diabetes through the review date. Interventions - Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #1's Order Summary Reported, printed 09/05/25, revealed, a start date of 07/28/25 for Humulin R 100 UNIT/ML Solution Inject as per sliding scale, subcutaneously before meals for diabetes. Record review of Resident #1's September [DATE] revealed On 09/05/25, the hour to administer the diabetic insulin was at 11:30 AM, Humulin R 100 Unit/ML solution, inject as per sliding scale 151-200 = 3 units. LVN A checked his BS (blood sugar) that was 200 and she gave [Resident #1] three (3) units, subcutaneously before meals for diabetes. Observation on 09/05/25 at 11:10 AM revealed an unattended medication cart which was in the doorway of room [ROOM NUMBER], the computer screen displayed a residents picture and administration of a Humulin injection on 09/05/25 at 11:04 AM. The medication cart was positioned in front of Resident #2 and Resident #3's opened room door, while they were lying in bed watching TV. (There was no one around the medication cart and at a distance, several of the staff was seen walking around the nurses station). Observation on 09/05/25 at 11:13 AM, LVN A walked up to the medication cart. Observation and interview on 09/05/25 at 11:14 AM, LVN A saw the HHSC investigator standing by the medication cart and moved the medication cart down the hall then she locked the computer screen. She stated she had just given Resident #1's his diabetic medication and left the medication cart because she was trying to catch the Doctor before he left. When queried about why the computer screen displayed resident information, she responded she had a key, and the computer only showed the resident's name. (After she reviewed a picture of Resident #1's EMAR on the computer screen) she stated nobody should have access to the computer and there were no issues with the residents' information being disclosed to others. She stated it was a HIPAA violation for the resident's information to be displayed on the computer. She stated the plan to prevent this from re-occurring was to ensure she locked the computer before she walked away from it. Interview on 09/05/25 at 4:55 PM, the Administrator (by phone) stated she was not aware of any of the nurses leaving the computer tablets unattended and unlocked today (09/05/25). She stated she could not say how it could affect the residents with unlocked computers displaying resident information. She stated it was against company policy to leave the computer tablets unlocked. She stated their plan to address this was for LVN A to be counseled and written up on HIPAA non- compliance. She stated the DON started the trainings this morning (09/05/25) with all the nurses . Interview on 09/05/25 at 5:24 PM, the DON stated she was aware of LVN A leaving the computer screen unlocked today (09/05/25). She stated LVN A was given a 1:1 training and was written up for leaving her screen unlocked and displaying resident information. She stated what LVN A did was a HIPAA violation and all of the resident's private information could have been disclosed for family or anybody to see. Record review of LVN A's Employee Coaching and Counseling Record, dated 09/05/25, revealed a written warning: time of violation 6 - 2, location 500 hall, type of violation: Major Infraction. Company/Supervisor remarks: It has come to the attention of management that the high standards that [This Company] espouses are not being met. Specifically 1. HIPPA compliance: b leaving resident information visible while unattended 2. Resident medication integrity/resident safety: Leaving medication cart unlocked care [sic]: our residents deserve great care. We want to give you an opportunity to correct this behavior, failure to do so can, and will lead to further disciplinary actions up to and including termination. Signed by LVN A, Supervisor ADON B and witness HR C with signature dated 09/05/25. Record review of the Facility's Resident Rights policy, revised date February 2021, revealed, Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation - 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to. t. privacy and confidentiality. Record review of the Facility's HIPAA Training program, revised dated April 2007, revealed, Policy Statement: All facility personnel, including business associates, are required to attend out facility's HIPAA compliance training program. Policy Interpretation and Implementation - 1. To ensure the confidentiality of our resident's protected health information (PHI) and facility information, a HIPAA and data security training program will be provided for all employees and business associates who have access to protected health and facility information. Record review of the Facility's HIPAA Compliance Policy, revise dated February 23, 2007, revealed HIPAA Compliance - The Health Insurance Portability and Accountability (HIPAA) is a government effort to help protect the privacy and security of resident's medical information. The requirements are intended to ensure strong privacy protections without interfering with access to quality of care.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 6 halls (Hall 500) reviewed for medication storage. The facility failed to ensure LVN A did not leave her medication cart, on the 500 hall, unattended and unlocked at the entrance of Resident #2 and #3's opened room door on 09/05/25 at 11:10 AM. This failure could place residents at risk of having their medications taken or consumed by other residents, which could cause a drug diversion, shortage of medications, change in condition which could result in a decline in health and psycho-social well-being.The findings include: Observation on 09/05/25 at 11:10 AM revealed an unattended medication cart that was in the doorway of room [ROOM NUMBER], and the medication cart's silver lock button was extended out and had a visibly seen red dot on the right side which revealed it was unlocked. The medication cart was positioned in front of Resident #2 and #3's opened room door, as they were lying in bed watching TV. (There was no one around the medication cart and at a distance, several of the staff was seen walking around the nurses station). Observation on 09/05/25 at 11:13 AM, LVN A walked up to the medication cart. Observation and interview on 09/05/25 at 11:14 AM, LVN A saw the HHSC investigator standing by the medication cart and moved the medication cart down the hall then she press in the lock to the medication cart. She stated she had just given Resident #1 his diabetic medication and had left the medication cart because she was trying to catch the Doctor before he left. When queried about why the medication cart was unlocked, she responded she had a key (and she lifted it into the air). She stated anybody could open the medication cart and could have taken the residents medications if the medication cart was unlocked. She stated the medication cart should have been locked. She stated she was not sure how it could affect the residents with having an unlocked medication cart. She stated the plan to prevent this from re-occurring was to lock the medication cart before she walked away from it. Interview on 09/05/25 at 4:55 PM, the Administrator (by phone) stated she was not aware of any of the nurses leaving the medication carts unattended and unlocked today (09/05/25). She stated she could not say how it could affect the residents with unlocked medication carts. She stated it was against company policy to leave the medication carts unlocked. She stated their plan to address the failure was for LVN A to be counseled and written up on making sure the medication carts were locked. She stated the DON started the trainings this morning (09/05/25) with all the nurses. Interview on 09/05/25 at 5:24 PM, the DON stated she was aware of LVN A leaving the medication cart unlocked today (09/05/25). She stated LVN A was given a 1:1 training and wrote her up for leaving her medication cart unlocked. She stated what LVN A did could have resulted in a drug diversion or other residents could have taken medications out of the medication cart. Record review of LVN A's Employee Coaching and Counseling Record, dated 09/05/25, revealed a written warning: time of violation 6 - 2, location 500 hall, type of violation: Major Infraction. Company/Supervisor remarks: It has come to the attention of management that the high standards that [This Company] espouses are not being met. Specifically 1. HIPPA compliance: b leaving resident information visible while unattended 2. Resident medication integrity/resident safety: Leaving medication cart unlocked care [sic]: our residents deserve great care. We want to give you an opportunity to correct this behavior, failure to do so can, and will lead to further disciplinary actions up to and including termination. Signed by LVN A, Supervisor ADON B and witness HR C with signatures dated 09/05/25. Record review of the Facility's Storage of Medications Policy, dated April 2007, revealed Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation - 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #154) reviewed for elopements. The facility failed to ensure Resident #154 did not elope from the facility's back door on 04/19/24. Resident #154 was found on the street attempting to go to the gas station across the street from the facility that was located directly off a busy highway. Resident #154 had suffered a skin tear to his arm . The noncompliance was identified as past noncompliance. The IJ began on 04/19/24 and ended on 11/01/24. The facility had corrected the noncompliance before the survey began. This failure could placed residents at risk of serious injury or death. Findings included: Review of Resident #154's Face Sheet, dated 05/13/25, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/20/24. Review of Resident #154's Quarterly MDS Assessment, dated 02/28/24, reflected he had a BIMS score of 04, indicating severe cognitive impairment. His MDS indicated he did not have any behaviors of wandering and that he utilized a wheelchair to ambulate. His active diagnoses included depression (feelings of severe despondency and dejection) and bipolar disorder (a mental health condition characterized by significant mood swings). Review of Resident #154's Care Plan, dated 05/14/25, reflected the following: Problems: [Resident #154] is at risk for wandering as evidenced by: Dementia/Alzheimer's .Interventions: Observe location each shift and prn .Report any attempts to exit the facility to IDT, family & MD as indicated and record in the clinical record .Place a wanderguard bracelet on [Resident #154] if attempt to leave out the facility [sic] .[Resident #154] requires a Wander Guard Bracelet [sic] and is at risk for injury from wandering in an un-safe enviornment [sic] .Interventions: Monitor for placement q shift, monitor for proper functioning q 24 hours . Review of Resident #154's Elopement Risk Assessment, dated 11/01/24, reflected the following : 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK, A) Patient is cognitively impaired AND .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .Comments: Shows no signs of elopement. Review of Resident #154's Elopement Risk Assessment, dated 06/27/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan . Review of Resident #154's electronic health chart revealed there were not any other elopement risk assessments completed. Review of Resident #154's Clinical Notes Report reflected the following: - pt left the facility and was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. She is getting me some coffee'. [sic] pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix written on 04/19/24 at 9:24 PM by RN G - At this time resident remains in bed, no s/s of pain and or discomfort noted. Resident noted to be resting on and off, but resident remains in bed and no attempts to get out of bed or facility noted at this time. All safety measures met. Written on 04/20/24 at 12:33 AM by LVN H - Resident was brought to nurses station by reception informed [sic] that resident pushed door open trying to go outside call [sic] placed to [the NP]. Notified of resident attempt to go out of front door [sic]. N/O may apply Wander guard for safety. Call to [Resident #154's Family Member] at [phone number] notified of attempt to go out of front door will be [sic] placing a wander guard to lower extremity. foe [sic] safety reason. stated'thank You' [sic] written by LVN I on 07/26/24 at 11:39 AM. Review of an Accident/Incident Report, dated 04/19/24, reflected the following: Person in charge- account of occurrence: pt left the facility was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. she is getting me some coffee'. pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix. Completed by RN G . Interview on the phone on 05/12/25 at 10:53 AM with Resident #154's Family Member revealed Resident #154 left the facility in November 2024. Resident #154's Family Member said Resident #154 used a wanderguard bracelet while at the facility which she said was not necessary because the resident as far as she knew he never tried leaving or left the facility. Interview on the phone on 05/13/25 at 2:06 PM with RN G revealed she no longer worked at the facility and could not remember the incident from April 2024. Interview on the phone on 05/13/25 at 2:24 PM with CNA J was unsuccessful as she did not answer. CNA J was working on 04/19/24 and was assigned to Resident #154. Interview on 05/13/25 at 2:30 PM with RA K revealed she was not here when Resident #154 eloped from the facility on 04/19/24 but she heard he had left through the back door of the facility near where the dumpsters were at. RA K said Resident #154 had a wander guard placed on his leg after this incident happened. RA K said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. RA K said she was in-serviced regarding elopements and wandering residents. RA K said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. RA K said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. Interview on 05/14/25 at 8:50 AM with LVN I revealed she cared for Resident #154 but had no idea about his elopement on 04/19/24. LVN I said she remembered Resident #154 had a wander guard bracelet because he had a tendency to wander around the facility. LVN I said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN I said she currently had residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN I said as the nurse she checks those identified resident's wander guard bracelets every shift for placement and functioning. LVN I said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN I said she was in-serviced regarding elopements and wandering residents. LVN I said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. Interview on 05/14/25 at 11:45 AM with LVN H revealed she could not recall anything about Resident #154's elopement on 04/19/24. LVN H said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN H said she did not currently have residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN H if she did care for a resident who used a wander guard bracelet, as the nurse she would check them every shift for placement and functioning. LVN H said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN H said she was in-serviced regarding elopements and wandering residents. LVN H said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. Interview on 05/14/25 at 1:07 PM with CNA L revealed he did not know about Resident #154 elopement from the facility on 04/19/24. CNA L said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA L said he was in-serviced regarding elopements and wandering residents. CNA L said he knew to immediately report to the nurse if he noticed a resident began to wander or make an attempt to elope from the facility. CNA L said he knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. Interview on 05/14/25 at 1:18 PM with CNA M revealed she had only been at the facility for four weeks. CNA M said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA M said she was in-serviced regarding elopements and wandering residents. CNA M said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. CNA M said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. Interview on 05/14/25 at 3:15 PM with the DON revealed she was in training in April 2024 when Resident #154 eloped from the facility so she did not have any details about it. The DON said she recalled when they had to put a wander guard bracelet on Resident #154 because he would stand up and try to walk towards the doors and set the alarms off to the doors. The DON said with the wander guard bracelet, if Resident #154 got too close to the door the door alarm and the wander guard alarm would both go off and scare Resident #154 so he would back away from it after that. The DON said Resident #154 was easily redirectable but was exit seeking while he tried to find his family. The DON said Resident #154's family was not happy with him having the wander guard bracelet and did not believe the resident required one. The DON said when a resident eloped from the facility she expected staff to get them back inside right away and report to the Administrator and her about what happened. The DON said when the elopement code was activated she also expected her staff to do a sweep of the facility to ensure all residents were in house and safe. The DON said after the resident was safe the facility would investigate to see how they eloped from the facility and that would be corrected. The DON said staff should know to be supervising residents and watching them to make sure they did not leave and if they heard an alarm going off they should make sure they are responding to them. The DON said a number of things could happen to a resident if they eloped from the facility, depending on the weather it could be too cold or hot so they could die, or be hit by a car since there's a busy street behind the facility. The DON said staff were trained and in-serviced regarding resident elopements recently. The DON said when a resident was admitted and had elopement or wandering behaviors the facility would complete an elopement assessment on them and if a wander guard bracelet was necessary to keep them safe one would be placed. The DON said all staff knew to immediately report any new behaviors of a resident wandering or making elopement attempts. Interview on the phone on 05/15/25 at 9:20 AM with the Previous Administrator was unsuccessful as she did not answer. Interview on the phone on 05/15/25 at 9:21 AM with the Previous DON was unsuccessful as he did not answer. Interview on 05/15/25 at 10:10 AM with the Administrator revealed she was not yet employed by the facility on 04/19/24 when Resident #154 eloped from the facility. The Administrator said she was not informed about the elopement either when she arrived to the facility. The Administrator said since she was not at the facility on 04/19/24 she had no details about what happened. The Administrator said Resident #154 had tendencies to wander and exit seek and his family was upset about him having to wear a wander guard bracelet. The Administrator said Resident #154 was always at the doors of the facility trying to leave. The Administrator said Resident #154 was always setting off the door alarms and the wander guard system alarms. The Administrator said Resident #154 was easily redirectable away from the doors, however. The Administrator said Resident #154 should not have been able to elope from the facility back in April 2024. The Administrator said she expected all staff to frequently monitor all residents who were at risk of eloping/wandering and to ensure they each were inside and safely in the facility. The Administrator said if a resident had been identified as being at risk of eloping/wandering a wander guard bracelet was placed on them. The Administrator said each resident's nurse would be responsible for checking the wander guard bracelet's placement and functioning each shift. The Administrator said the Maintenance Director checked each door every week to make sure that the wander guard system was working as well. The Administrator said the staff were provided with training on elopements because the facility had other residents elope back in November 2024. The Administrator said if a resident was able to elope from the facility they were at risk because it was not safe outside the facility. The Administrator said she expected staff to report when a resident eloped from the facility. Interview and observation on 05/15/25 at 12:53 PM with the Maintenance Director revealed he was notified of Resident #154's elopement back in April 2024 but he could not recall any of the details. The Maintenance Director said if Resident #154 eloped from the back door of the facility near the dumpsters it would have been the door near the therapy gym at the end of the 400-hallway. Observation of the door at the end of the 400-hallway revealed it had a wander guard system alarm on it and the door was locked and required a code to turn the alarm off. Observation of the door being pushed open revealed an alarm went off and staff would have to enter the code in to the keypad to turn the alarm off. The door led out to a small parking lot that had the facility's dumpsters off to the left side and a gas station could be seen across the street. In front of the gas station was a busy highway as well. The Maintenance Director said he checks to make sure the wander guard system was working on each of the exterior doors once a week and documents that on his check off sheet. The facility implemented the following interventions: Review of an in-service roster, dated 11/01/24, and titled Staff in-services initiated the following: .elopement policy . reflected 108 staff's signatures. Review of the facility's policy, dated January 2024, and titled Elopement Response Protocol reflected: 1. Conduct a thorough search of the Facility and its grounds .8. A complete head to toe nursing assessment must be completed upon return of the Patient [sic]. The Administrator was informed of the PNC IJ on 05/15/25 at 12:42 PM.

Based on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for 1 of 5 residents (Resident #306) reviewed for laboratory services. The facility failed to send Resident #306's weekly labs to the infectious disease doctor while the resident resided at the facility from 11/27/24 to 12/20/24. This deficient practice placed the residents at high risk of not receiving treatment, and/or developing complications. Findings included: Review of Resident 306's MDS dated [DATE] reflected the resident was [AGE] year-old female admitted to the facility on [DATE] and discharged on 12/20/24. Her diagnoses included diabetes and anxiety disorder. Resident #306 had a BIMS of 6 indicating her cognition was severely impaired. The MDS also reflected the resident had a stage 4 pressure ulcer. Review of Resident #306's care plan effective on 11/28/24 reflected the resident had pressure ulcers to her right heel, unstageable to right hip, and stage 4 to the left lateral ankle. Interventions included to obtain labs per physician orders. Review of Resident #306's discharge hospital records dated 11/27/24 reflected the following: Labs to be followed: weekly CRP (a blood test that measures the level of CRP, a protein produced by the liver in response to inflammation)/BMP (measures eight different substances in your blood and it provides important information about your body's fluid balance, your metabolism and how well your kidneys are working)/CBC (group of blood tests that measure the number and size of the different cells in your blood) faxed to the office of [Doctor] Review of Resident #306's facility clinical record revealed labs were obtained on 12/02/24, 12/09/24, and on 12/16/24. Interview on 05/15/25 at 12:13 PM with Resident #306's family revealed the resident was discharged from the facility on 12/20/24. The family said the infectious disease doctor had ordered for the resident to have weekly labs drawn and faxed over to his office and the doctor's clinic said they had never received any of the lab requested. Interview on 05/15/25 at 11:47 AM with the Infectious Disease Doctor's clinic revealed they had called the facility on 12/02/24, 12/18/25 and on 12/31/24 to try and obtain Resident #306's labs copies. The clinic said that on 12/31/24 the facility finally sent one set of labs that were dated for 12/02/24. The Infectious Disease Clinic further stated the doctor would have wanted to keep up with the resident's infection treatment. Interview on 05/15/25 at 2:42 with ADON N revealed he will send or fax labs when he was asked but he could not specifically recall if he had sent Resident #306's labs to the infectious disease clinic. Interview on 05/15/25 at 2:55 PM with the DON revealed she thought she was sure she had asked ADON N to fax Resident #306's labs results to the infectious disease clinic. The DON further stated she did not know what else could have happened with the labs during that time. Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on 09/2012 reflected the following: Assessment and Recognition 1. The physician will identify and order diagnostic lab testing on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent a. Facility staff should document information about when, how, and to whom the information was provided and the response

Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #80) reviewed for regular ground diet needs. The facility failed to provide Resident #80 with his regular ground foods (mechanically altered diet that was prescribed for individuals who have difficulty chewing or swallowing food) as designated on his meal ticket on 05/14/25. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met. The findings included: Record review of Resident #80's face sheet dated 05/15/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #80's quarterly MDS Assessment, dated 04/15/25, reflected the resident had an active diagnosis of protein-calorie malnutrition, essential hypertension, depression and bipolar disorder. Resident #80's BIMS score of 03 indicating severe cognitive impairment. Record review of Resident #80's Care plan reflected Weight gain aeb 25lbs/90days. (13.2%) Regular Ground diet. 5/12/25: Weight Gain of 19.80lbs/180days (10.1%). Goal: The resident will not develop complications from weight gain such as skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Intervention: Resident encouraged to eat meals in the DR if tolerated. Interview on 05/13/25 at 03:24 PM, Resident #80 stated he was doing well. Resident #80 stated the only concern he had was that his meals had been a liquid/pureed texture instead of his food being cut/chopped. Resident #80 stated he did not like being served pureed foods. He stated when he gets the liquid texture he does not want to eat it. Observation on 05/14/25 at 12:20 PM, Resident #80 was provided with pureed consistency meal. Lunch meal consisted of pureed texture Salisbury steak, mashed potatoes and carrots. Resident #80's meal ticket indicated Regular Ground. Observed Central Supply feeding Resident #80's pureed lunch. Observation and interview on 05/14/25 at 12:28 PM, RD reviewed Resident #80's meal ticket, observed resident lunch and revealed Resident #80's was provided with the wrong food texture. RD stated resident should be on regular ground and not pureed. Resident #80 was provided with the correct meal texture. Interview on 05/14/25 at 12:38 PM with Director of Rehab revealed Resident #80 was on regular ground texture. Interview on 05/14/25 at 12:42 PM with Central Supply staff revealed each resident should receive what was on the meal ticket. She stated she glanced at the meal ticket to verify the name but did not ensure the food texture was correct. She stated since the nurse had checked it prior to giving her the lunch tray, she assumed the food was correct. Interview on 05/14/25 at 12:47 PM, Resident #80 stated it had been a while since he was provided with the correct food consistency. Resident #80 stated he had been provided with pureed food and he did not like that. Interview on 05/14/25 at 1:40 PM, Dietary Manager revealed his expectations were for all staff to follow meal tickets. He stated platting starts with the [NAME] and ends with the nurse verifying the residents receiving the correct meal. Dietary Manager stated today (05/14/25) the DON was checking meal tickets, and it was her responsibility to verify residents received the correct meal tray. He stated Resident #80's lunch meal should had been corrected before it was serviced to him. Dietary Manager stated there was no potential risk to the resident; however, it was a downgrade of texture. Interview on 05/14/25 at 1:48 PM, RD revealed her expectations were for all staff to follow exactly what was on the meal ticket. She stated they have a nurse who double checks the meal trays to ensure the trays are correct. RD stated today (05/14/25) the DON was checking the meal trays and meal tickets. She stated there was an error on Resident #80 lunch meal, he received pureed texture instead of regular ground. RD stated there was no potential risk of chocking since it was pureed; however, it was a downgrade of texture. Interview on 05/15/25 at 2:57 PM, the DON stated she was responsible for verifying meal tickets. She stated she observed Resident #80's tray and she observed ground meat. She stated when reviewed the meal tickets she ensures the food being plated matches the meal ticket. Record review of facility Therapeutic Diets policy, revised 10/2017, reflected the following: 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will be determined whether the resident is prescribed a therapeutic diet.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, 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, or not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures for 1 of 3 residents (Resident #154) reviewed for abuse and neglect. The facility failed to report to HHSC when Resident #154 was found to have eloped from the facility on 04/19/24. This failure to report could place the residents at risk for neglect. Findings included: Review of Resident #154's Face Sheet, dated 05/13/25, reflected he was an [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/20/24. Review of Resident #154's Quarterly MDS Assessment, dated 02/28/24, reflected he had a BIMS score of 04, indicating severe cognitive impairment. His MDS indicated he did not have any behaviors of wandering and that he utilized a wheelchair to ambulate. His active diagnoses included depression (feelings of severe despondency and dejection) and bipolar disorder (a mental health condition characterized by significant mood swings). Review of Resident #154's Care Plan, dated 05/14/25, reflected the following: Problems: [Resident #154] is at risk for wandering as evidenced by: Dementia/Alzheimer's .Interventions: Observe location each shift and prn .Report any attempts to exit the facility to IDT, family & MD as indicated and record in the clinical record .Place a wanderguard bracelet on [Resident #154] if attempt to leave out the facility [sic] .[Resident #154] requires a Wander Guard Bracelet [sic] and is at risk for injury from wandering in an un-safe enviornment [sic] .Interventions: Monitor for placement q shift, monitor for proper functioning q 24 hours . Review of Resident #154's Elopement Risk Assessment, dated 11/01/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK, A) Patient is cognitively impaired AND .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .Comments: Shows no signs of elopement. Review of Resident #154's Elopement Risk Assessment, dated 06/27/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan . Review of Resident #154's electronic health chart revealed there were not any other elopement risk assessments completed. Review of Resident #154's Clinical Notes Report reflected the following: - pt left the facility and was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. She is getting me some coffee'. [sic] pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix written on 04/19/24 at 9:24 PM by RN G - At this time resident remains in bed, no s/s of pain and or discomfort noted. Resident noted to be resting on and off, but resident remains in bed and no attempts to get out of bed or facility noted at this time. All safety measures met. Written on 04/20/24 at 12:33 AM by LVN H - Resident was brought to nurses station by reception informed [sic] that resident pushed door open trying to go outside call [sic] placed to [the NP]. Notified of resident attempt to go out of front door [sic]. N/O may apply Wander guard for safety. Call to [Resident #154's Family Member] at [phone number] notified of attempt to go out of front door will be [sic] placing a wander guard to lower extremity. foe [sic] safety reason. stated'thank You' [sic] written by LVN I on 07/26/24 at 11:39 AM. Review of an Accident/Incident Report, dated 04/19/24, reflected the following : Person in charge- account of occurrence: pt left the facility was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. she is getting me some coffee'. pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix. Completed by RN G. Review of the Texas Unified Licensure Information Portal revealed there was no incident report regarding Resident #154's elopement on 04/19/24 indicating the facility never reported it. Interview on the phone on 05/12/25 at 10:53 AM with Resident #154's Family Member revealed Resident #154 left the facility in November 2024. Resident #154's Family Member said Resident #154 used a wander guard bracelet while at the facility which she said was not necessary because the resident as far as she knew never tried leaving or left the facility. Interview on the phone on 05/13/25 at 2:06 PM with RN G revealed, she no longer worked at the facility and could not remember the incident from April 2024. Interview on the phone on 05/13/25 at 2:24 PM with CNA J was unsuccessful as she did not answer. CNA J was working on 04/19/24 and was assigned to Resident #154. Interview on 05/13/25 at 2:30 PM with RA K revealed she was not here when Resident #154 eloped from the facility on 04/19/24 but she heard he had left through the back door of the facility near where the dumpsters were at. RA K said Resident #154 had a wander guard placed on his leg after this incident happened. Interview on 05/14/25 at 11:45 AM with LVN H revealed she could not recall anything about Resident #154's elopement on 04/19/24. Interview on 05/14/25 at 3:15 PM with the DON revealed she was in training in April 2024 when Resident #154 eloped from the facility so she did not have any details about it. The DON said after reading the incident report, the elopement should have been reported to the state. Interview on the phone on 05/15/25 at 9:20 AM with the Previous Administrator was unsuccessful as she did not answer. Interview on the phone on 05/15/25 at 9:21 AM with the Previous DON was unsuccessful as he did not answer. Interview on 05/15/25 at 10:10 AM with the Administrator revealed she was not yet employed by the facility on 04/19/24 when Resident #154 eloped from the facility. The Administrator said she was not informed about the elopement either when she arrived to the facility. The Administrator said since she was not at the facility on 04/19/24 she had no details about what happened. The Administrator said she expected staff to report when a resident eloped from the facility. The Administrator said she was not sure if this incident was reportable or not because she would have to review the criteria and guidelines to see if it met the requirements to be reported. The Administrator said currently she was the Abuse Coordinator for the facility and would help to determine if something was reportable or not. The Administrator said at the time of the incident, the Previous Administrator or their designee would have been responsible for reporting the incident involving Resident #154's elopement on 04/19/24. The Administrator said all staff had been trained to know the facility's abuse/neglect policy. The Administrator said if the facility failed to report they would be cited for that. The Administrator said she rounds frequently with staff to ensure they were reporting necessary things to her. Review of an in-service roster, dated 11/01/24, and titled Staff in-services initiated the following: abuse prevention policy .Timely Reporting/Recognizing Abuse , Neglect [sic] and Misappropriation . reflected 108 staff's signatures. Review of the facility's policy, dated January 2024, and titled Elopement Response Protocol reflected: .9. Notify the state regulatory department according to the guidelines for reportable incidents. Review of the facility's policy, dated April 2019, and titled Abuse Protocol reflected: .7. The following definitions are provided to assist our Facility's [sic] staff members in recognizing incidents of Patient Abuse [sic]: i. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof .l. Neglect is the facility, it's employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .10. The Abuse Prevention Coordinator will: a Immediately (within 2 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incidents of Patient Abuse [sic] as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The Department of Aging and Disability Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance.

Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #66) reviewed for PASRR assessments. The facility did not refer Resident #66 to the appropriate state-designated mental health authority for review when he received a new diagnosis of schizoaffective disorder, bipolar type. This failure could place residents at risk of not being evaluated and receive needed PASRR services. Findings included: Record review of Resident #66's face sheet dated 05/15/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #66 was diagnosed with schizoaffective disorder, bipolar type on 04/14/25. Record review of Resident #66's MDS Assessment, dated 03/21/25, reflected the resident had an active diagnosis of depression disorder, anxiety disorder, psychotic disorder, non-Alzheimer's dementia and the resident had severe cognitive impairment with a BIMS score of 05. Record review of Resident #66's Care plan reflected [Resident #66] currently taking psychotropic medication(s) as evidenced by: Major Depressive Disorder, Anxiety/Panic Disorder, psychosis. Goals: [Resident #66] will not experience adverse side effects over the next 90 days. Interventions: Monitor and record any displayed behavior or mood problems. Record review of Resident #66's PASRR Level 1 Screening, dated 11/16/21, reflected he did not have a mental illness. PASRR Level 1 screening did not indicate Resident #66 had primary diagnosis of dementia. Record review of Resident #66's, 1012 Form (Mental Illness/Dementia Resident Review) dated 11/22/23 reflected: the individual has a primary diagnosis of dementia as define above. The physician signs and dates the form attesting to the dementia diagnosis. Complete Section D and E of the form. -Section D and Section E not completed. Interview on 05/15/25 at 2:21 PM, RCC stated Resident #66 had a negative PASRR Level 1. She stated Resident #66 had a primary diagnosis of Dementia. The RCC reviewed Resident #66's medical chart and stated Resident #66 did not have any documentation stating he had a diagnosis of Dementia other than the psych notes. RCC stated Resident #66 had a 1012 form completed on 11/22/23 and stated Resident #66's primary diagnosis was dementia. The RCC stated since the 1012 Form stated a primary diagnosis of dementia it would override any new diagnosis. Interview on 05/15/25 at 3:39 PM, the DON stated if a new diagnosis was given to a resident a new PASRR evaluation should be completed. The DON stated to ask RCC for any questions regarding Resident #66's PASRR. Follow up interview on 05/15/25 at 4:03 PM, the RCC stated Resident #66's, 1012 Form was not completed correctly. She stated since given a new diagnosis and new 1012 form or PASRR Level 1 should had been completed. She stated the potential risk would be resident being positive for PASRR and would be missing out on PASRR services. Record review of facility admission Criteria policy, undated, reflected the following: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.

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 resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #22) reviewed for care plan accuracy. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #22's care needs. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Record review of Resident #22's admission Record, dated 05/15/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #22's admission MDS Assessment, dated 04/16/25, reflected the resident had an active diagnosis of chronic obstructive pulmonary disease, heart failure, hypertension (high blood pressure), diabetes mellitus (inadequate control of blood levels of glucose), muscle weakness, and septicemia (infection where bacteria enter the bloodstream and spread throughout the body). Resident #22 had a BIMS score of 14, indicating cognitively intact. It also indicated she was being administered an antidepressant, antibiotic, diuretic, hypoglycemic and opioid medications. The MDS Assessment also indicated Resident #22 required substantial/maximal assistance with ADL care. Record review of Resident #22's Care plan, dated 05/01/25, reflected the following: Focus: Resident request Code Status of: Full Code. Goal: Status will be maintained over next review period. Interventions: Inform staff of code status. Monitor for decrease in change of condition-report to MD and responsible party. Focus: The resident is risk for falls r/t Gait/balance problems, Incontinence. Goal: The resident will not experience falls or injuries from falls through the review date. The resident will not sustain serious injury through the review date. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Follow facility fall protocol. Focus: The resident has Diabetes Mellitus and is currently receiving [Specify Meds]. No goal or interventions. Care Plan did not address Resident #22 use of antidepressant medication, use of opioids, use of insulin or ADL care. Record review of Resident #22's physician orders indicated the following medications being administered: Insulin Lispro 100 UNIT/ML Solution Inject as per sliding scale: if 250 - 300 = 1 Unit; 301 - 350 = 2 Units; 351 - 400 = 3 Units BS greater than 400 mg/dL, notify MD, subcutaneously at bedtime for DM. -Start Date- 04/12/2025. Gabarone Oral Tablet 400 MG (Gabapentin) Give 1 tablet by mouth three times a day for joint pain -Start Date- 04/12/2025. traZODone HCl Oral Tablet 150 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for insomnia - Start Date- 04/12/2025. Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression -Start Date- 04/12/2025. Anti-Depressant SE Monitoring: Observe closely for significant side effects of Anti-Depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. -Start Date- 04/15/2025 Torsemide Oral Tablet 100 MG (Torsemide) Give 1 tablet by mouth two times a day for diuretic -Start Date- 05/06/2025. Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Call MD if blood sugar greater than 400 -Start Date- 05/06/2025. Interview on 05/15/25 at 1:57 PM, ADON F revealed she was the ADON assigned to Resident #22. She stated ADONs and DON were responsible for completing care plans. She stated she was responsible for ensuring Resident #22's care plan was completed and accurate. ADON F stated Resident #22's use of an antidepressant, opioids, insulin, ADL care should be addressed on her care plan. ADON F reviewed Resident #22's care plan and stated it was started but not completed. She stated she was not sure why it was not completed. She stated anything that was triggered on the residents MDS Assessment should be care planned. ADON F stated care plans were needed for staff to know what the residents required. Interview on 05/15/25 at 3:00 PM, the DON revealed the IDR team was responsible for completing care plans. She stated the facility MDS Coordinator was on leave and the ADONs were responsible for completing care plans and Regional MDS Coordinator would review and request any additional items needed to be included. The DON stated Regional MDS Coordinator oversees the residents care plans. The DON stated the risk of care plans not being completed could lead staff not providing residents with the care that they supposed to get. Record review of facility Care Plans - Comprehensive policy, revised date 09/2010, reflected the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident medical, mental and psychological needs in developed for each resident. . 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. . 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).

Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding, for 1 of 1 resident (Resident #45) reviewed for enteral nutrition. The facility failed to follow physician orders for Resident #45's enteral feeding tube to be flushed with 50 ml of water every 1 hour and feeding with Jevity 1.2 at 55mls/hr. This failure could place residents who had gastrostomy tube at risk for fluid deficit and over feeding. Findings included: Record review of Resident #45's quarterly MDS assessment dated [DATE], reflected the resident was a [AGE] year-old female who was admitted to the facility initially on 09/24/2024 and readmitted on [DATE]. She had diagnoses that included dysphasia (swallowing difficulties). Resident #45's BIMS score was 11 revealing moderate cognition. The MDS further revealed Section K (Nutritional approaches) indicated the resident's nutritional approach was a feeding tube. Record review of Resident #45's care plan dated 03/18/25 reflected: Focus: Resident #45 requires tube feeding rule out Dysphagia. Goal: will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: Administer enteral feeding/water flushes as ordered by physician. Record review of Resident #45's physician orders, dated 05/05/25, reflected an order for Enteral Feed Order flush feeding tube with 50 cc of water every 1 hour and another Enteral Feed jevity 1.2 at 55ml/hr. via feeding to run continuously. Observation and interview on 05/13/2025 at 10:55 AM, revealed Resident #45 lying in bed. Resident #45 was connected to her feeding pump, the Jevity1.2 formula bag was dated 05/13/25 at a rate of 65 mL/hr and the water bag was dated 05/13/25 with a rate of 35ml/hr . Observation and interview on 05/14/25 at 10:43 AM with LVN A, who was the charge nurse for Resident #45, revealed Resident #45 was connected to her feeding pump.The Jevity 1.2 feeding rate was set at 65 mL /hr, and the water flush rate was set at 35 mL every 1 hour. She stated she was aware the physician order for the flush was supposed to be 35 mL/hr and jevity 1.2 at 65mls/hr. She stated when she came in the morning, she only checked to ensure the feeding was flowing. She stated she did not check the settings. She stated she knew she was supposed to check the settings, but she forgot. LVN A stated Resident #45 had a g-tube, and the night shift had hung a new formula and water bag. She stated she was not aware that the orders had been changed. She stated failure to follow the physician orders could lead to dehydration and overfeeding that could lead to vomiting and aspiration. LVN A stated she had done training on gastronomy tubes regarding medication and feeding administration. Interview on 05/14/25 at 02:30 PM with RN B, who was the charge nurse for Resident #45 on the second shift , revealed she was the one that had connected Resident #45 to her feeding pump on 05/13/25. She stated the feeding rate was set at 65 mL/hr, and the water flush rate was set at 35 mL every 1 hour. She stated she knew she was supposed to check the physician orders before hanging a new bottle of feeding and flushing water, but she did not check. She stated she was not aware that the orders had been changed. She stated failure to follow the physician orders could lead to dehydration and overweight. RN B stated she had done training on gastronomy tubes regarding medication and feeding administration. Interview on 05/14/25 at 02:51 PM with ADON N, revealed he was responsible of putting new orders given by dietician on the electronic records. He stated his expectation was for nurses to check orders before they hang the feeding bottle and the water flushes. He stated it was his responsibility to monitor nurses and ensure the pumps were set with the correct orders. He stated he had not been to Resident #45's room since the orders were changed. He stated the potential risk would be dehydration and weight gain. He stated he could not recall any in-service on g tube feeding administration. Interview with on 05/15/25 at 01:22pm with Regional Dietician she stated her expectation was nurses to carry out orders as given and follow instructions . She stated she changed the orders on 05/05/25 and she notified the ADON. She stated the risk of not following the orders would be dehydration and weight gain. Interview on 05/15/25 at 03:29 PM, the DON revealed she expected the nurses to follow physician and dietitian orders. The DON stated she also expected the nurses to set feeding pumps per the orders and check orders regularly for changes. The DON said the person responsible to ensure orders were followed, were nursing staff and ADON N. The DON said that ADON N was responsible to ensure orders were followed by nursing staff through audits and ensure the orders matches with the feeding and the flushes on the pump . She stated failure to follow the physician orders could lead to dehydration and weight gain. She stated she had done training with staff in April on g tube feeding and medication administration. Record review of the facility's training records for medication administration including tube feeding, dated April 13 2024, reflected RN B was not in attendance, but LVN A was in attendance. Record review of the facility's Enteral feeding safety precautions policy, dated MAY 2014 , reflected: .1.Check the enteral nutrition label against the order before administration. Check the following information . g. Rate of administration (ml/hour) .

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #98) reviewed for dialysis. The facility failed to ensure dialysis communication forms for Resident #98 were completed with the resident's dialysis treatment information on the following dates: 05/02/25, 05/05/25, and 05/09/25. This failure could place residents at risk of inadequate communication between the facility and dialysis center. Findings included: Record review of Resident #98's admission record, dated 05/14/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #98's admission MDS Assessment, dated 04/28/25, reflected she had a BIMS score of 10, indicating moderate cognitive impairment. Her active diagnoses included renal insufficiency, renal failure, or end-stage renal disease, heart failure, and respiratory failure. Her MDS indicated she received dialysis services. Record review of Resident #98's physician's orders, dated 05/14/25, reflected the following: - Dialysis- Post Tx Frequency in the evening every Mon, Wed, Fri Upon [sic] return, enter Dialysis Treatment Information received from Dialysis Center onto the Dialysis Communication Record. Complete the Post Dialysis Assessment Section. Check for any labs/ notes/ orders [sic] from the Dialysis Center with an active date of 04/29/25. - Dialysis- Pre Tx Frequency every day shift every Mon, Wed, Fri Complete Pre-Treatment section of Dialysis Communication Record. Print record and place in Dialysis Communication Folder prior to Transport. Ensure Food and/ or [sic] Meal goes with patient to each Dialysis treatment. with an active date of 04/29/25. Record review of Resident #98's care plan, initiated 04/23/25, reflected the following: Focus: The resident needs dialysis . Record review of Resident #98's Dialysis Communication Forms, dated 05/02/25 and 05/05/25, reflected only the Pre-Dialysis Information was filled in; the Dialysis Information was left blank. Record review of Resident #98's Dialysis Communication Form, dated 05/09/25, reflected the Pre-Dialysis Information was filled in, but the Dialysis Information had N/A written in each spot. Observation and interview on 05/13/25 at 11:26 AM with Resident #98 revealed she was lying in bed and was sleepy. Resident #98 said she never has any issues when she went to dialysis. Interview on 05/14/25 at 12:58 PM with LVN D revealed Resident #98 went to dialysis on Mondays, Wednesdays, and Fridays. LVN D said she worked the 6 AM to 2 PM shift so she sent Resident #98 to dialysis with a red binder. LVN D said the binder included her face sheet, orders, and dialysis communication form filled out for the pre-dialysis information. LVN D said Resident #98 did not come back on her shift from dialysis, so the 2 PM to 10 PM shift nurse on duty would be responsible for completing Resident #98's dialysis forms. Interview on 05/15/25 at 2:48 PM with LVN E revealed Resident #98 went to dialysis in the mornings on Mondays, Wednesdays, and Fridays and came back during her shift around 5:30 PM/6 PM. LVN E said Resident #98 left to go to dialysis with a red binder that included her dialysis communication forms. LVN E said the morning nurse for Resident #98 filled out the pre dialysis information on the form and the dialysis center was supposed to fill out the rest of the form and return it with the resident. LVN E said the dialysis center has not been returning the forms filled out for Resident #98 and when that happened she would call the dialysis center to get the information. LVN E said sometimes she was able to get in touch with someone at the dialysis center for the information and sometimes it was more difficult. LVN E said she was responsible for making sure the post dialysis information was included on the forms and filled out since she was the nurse on duty at the time the resident was brought back to the facility from dialysis. Interview on 05/15/25 at 3:01 PM with the DON revealed since Resident #98 came back to the facility from the dialysis center, the afternoon shift nurse would have been responsible for completing the dialysis communication form was filled out. The DON said the purpose of the form was to make sure the resident's vitals were okay and to communicate anything that required any follow-up. The DON said the ADON was responsible for making sure that the nurses were completing the dialysis communication forms for residents. The DON said she expected all staff to complete the dialysis communication form for residents and they had been trained to do that. The DON said if the dialysis communication form was not completed, the facility may not know how stable a resident was so they might send them to the hospital for something that the facility could have handled in house. Interview on 05/15/25 at 3:30 PM with ADON F revealed she was the ADON in charge of Resident #98's hall. ADON F said she checked the dialysis communication forms for completion about once a week. ADON F said she was not aware that Resident #98's dialysis communication forms were not completed. Record review of the facility's policy, dated August 2007, and untitled reflected the following: .7. The [Management Company's Name] will send a Dialysis Communication Record .to the dialysis center upon each dialysis visit. The [Management Company's Name] will complete the top section of the form, entitled 'Nursing Home Nurses' and provide to the Resident [sic] prior to exiting the center .8. The dialysis center should be encouraged to complete the middle section of the Dialysis Communication Record and return to the [Management Company's Name] .9. The [Management Company's Name] nurse will complete the Post Dialysis Assessment section of the Dialysis Communication Record and file the form in the dialysis binder.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (500 hall) and 2 of 2(Residents #25 and #59 ) reviewed for pharmacy services. The facility failed to ensure the 500 Hall nurses' medication cart contained accurate narcotic logs for Resident #25 and #59 on 05/14/25. These failures could place residents at risk for medication error, and drug diversion. Findings included: 1. Review of Resident# 25's Quarterly MDS Assessment, dated 12/29/24, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included Hip and Knee Replacement. The resident had moderately impaired cognition with a BIMS score of 10. Review of Resident #25's physician's orders dated 2/27/25 reflected an order for the resident to receive one tablet of Acetaminophen-Codeine Tablet 300-30MG (pain medication) by mouth as needed every six hours. 2. Review of Resident# 59's Quarterly MDS assessment, dated 04/07/25, reflected the resident was [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included pain. The resident had intact cognitive with a BIMS score of 15. Review of Resident #59's physician orders dated 04/13/24 reflected an order for the resident to received 1tablets of hydroco/apap tab 10-325mg by mouth every 6 hours for pain. Observation and record review on 05/14/25 at 8:52 AM of 500 Hall nurses' medication cart and the Narcotic Administration Record, with LVN C, revealed the following: Resident #25's Narcotic Administration Record for Acetaminophen-Codeine Tablet 300-30MG reflected a total of 51 pills remaining, while the blister pack count was 50 pills. It was last administered on 05/14/25 at 7:00AM. Resident #59's Narcotic Administration Record sheet for hydrocodone-acetaminophen 10-325 mg was last signed off on 05/14/25 for one-tablet dose given at 7:00 AM, for a total of 82 pills remaining, while the blister pack count was 83 pills. Interview with LVN C on 05/14/25 at 10:58 AM revealed she did not realize the narcotic count and narcotic log was not matching and she did not know she was missing 1 tablet.She checked on her MAR and she found out she had administered on 5/12/25 and she forgot to log of, and nobody had noted during shift change.LVN C stated she had administered medication to Resident#25 on 5/15/24 at 7:00AM and she did not compare the count and what was remaining,and she knew she was supposed to reconcile after administering . She stated failure to log after medication administration would cause drug diversion. She stated the Narcotic log should always match with the count.LVN C stated for Resident #59 hydrocodone-acetaminophen 10-325 mg by mouth every 6 hours for pain she stated she had signed off on 5/14/25 at 7:00AM and she got destructed and she forgot to administer to resident. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but she did not. She stated signing off when no medication was administered it could lead to medication error. She stated she had done an in-service on medication administration, but she could not recall when. Interview on 05/15/25 at 10.35AM with Resident #59 revealed he get his pain pill every morning with other medications. He stated on 5/14/25 for some reasons LVN C came back at around 10:00AM and told him she had forgotten to administer the pain pill. He stated he does not ask for the pain pill but when nurses are administering the morning medications would ask whether he need pain pill and they would administer. Interview on 05/15/25 at 10.35AM with Resident #25 revealed she get pain pill every morning before therapy and again at night before she sleeps. Interview on 05/15/25 at 03:21 PM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log to prevent discrepancies and to have proof the medications were administered. She stated the oncoming should count with outgoing staffs each shift and report any discrepancies. She stated the Narcotic administration record should match the count . She stated when she was notified she went back to the medication administration record, and she found out that LVN C had administered medication on 5/12/25 which was not logged off on the narcotic administration record . The DON stated nobody follows behind the nurses ,the nurses are supposed to check on each other ensuring the counts are correct. She stated Failure to document could lead to discrepancy and adverse effects like pain not being controlled .She stated her expectation was nurses to be completing one task before going to another task . She stated she had done training on medication administration. Review of the facility trainings reflected all as needed controlled substance must be documented on medication administration this is the only record of administration.The controlled substance reconciliation log if not a record of administration. Narcotics needs to be signed as you give them on 04/13/25 and LVN C was in attendance . Review of the facility's current Management of Controlled Medication - policy, dated January 2024, reflected: g. You must administer medication and sign the medication administration record and sign the medication administration record according to facility policy(either pop-sign-give)or (pop-give-sign),please ask and know your facility policy on this procedure prior to passing medications .

Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for one of three staff (LVN Q) which resulted in a 10% medication error rate after 30 opportunities with 3 errors for one of five residents (Residents #97) reviewed for medications. LVN Q crushed all medications and mixed them all together into one cup of pudding without an order to do so for Resident #97, creating an error rate of 10%, (3 errors out of 30 opportunities). This failure could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response. Findings included: Record review of Resident #97's comprehensive MDS assessment, dated 04/21/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE].The assessment reflected the resident cognition was severely impaired with a BIMS score of 5.The resident had diagnoses which included pneumonia(infection that inflames the air sacs in one or both lungs) and chronic kidney disease(a condition where the kidneys are damaged and cannot filter blood as effectively as they should). Record review of Resident #97's, May 2025, Physician Orders revealed the following order: -Bismuth/Metronidazole/Tetracycline Capsule 140-125-125 MG(Bismuth Sub citrate Potassium-Metronidazole-Tetracycline).Give 3 capsules by mouth three times a day. -Ascorbic Acid Tablet 500 MG. Give 1 tablet daily -Renal-Vite Oral Tablet 0.8 MG(B-Complex w/ C & Folic Acid).Give 1 tablet daily. Observation on 05/14/25 8:40 AM, revealed LVN Q crushed the following 2 medications for Resident #97 and opened three capsules put them together in one medication cup and mixed with pudding: -Bismuth /metronidazole/tetracycline capsule 140-125-125,3 capsule three times, -Renal vite 0.8 mgs b- complex v and folic acid 1 tablet daily -Vit C 500mgs 1 tablet daily She then administered all three medications embedded in pudding in one cup by mouth to Resident #97. Interview with LVN Q on 05/14/25 8:43 AM revealed she did not have a physician's order to crush and mix medications for Resident #97. She stated she was not aware she was supposed to have an order to crush and mix and she stated she need to inquire from her ADON. She stated she had been crushing and mixing since the resident had been there in the facility. She went to ask and came back and stated she was supposed to have an order to crush and mix together the medication. She stated the risk of mixing was drug interaction she stated she had done training on medication administration. Interview with ADON N on 05/14/25 12:59 PM revealed the facility staffs are supposed to have an order to crush and mix. ADON N stated the facility had a standing order for crushing medication but was not included on Resident #97 physician orders. to crush unless contraindicated. The DON stated he was not sure whether they should have orders to mix after crushing all the medications together. ADON N stated LVN Q was supposed to check orders before mixing into the cup and after crushing. He stated the risk of crushing and mixing was drug interaction. He stated facility had done in-service on medication administration. Interview with DON on 05/15/25 3:35 PM revealed her expectation was nurses should have physician orders to crush and mix medication. The DON stated the facility had standing orders to crush ,but she realized they were not on Resident #97 medication administration record. She stated her expectation was nurses should put all medications in different cups because of contraindications and interactions and incase the resident denies taking one it would be easier to separate. The DON stated she had completed training on medication administration with staff. Record review of the facility's current Administering Medication training dated 4/13/25 reflected the following: i. Do not crush meds without appropriate may crush meds order on medication administration record, this requires a physician order after speech therapy evaluation and a care plan for administration of crushed medication.

Based on interviews and record reviews the facility failed to immediately inform his or her authority, the resident representative(s) when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention and when a need to transfer or discharge the resident from the facility for 1 (Resident #1) of 6 residents reviewed for Change in condition. 1.LVN D failed to notify FM 1 after Resident #1 had an unwitnessed fall and complained of back pain on 04/06/25 at 2:50 am. 2.RN E failed to notify FM about Resident #1's transfer to the hospital after he fell with abnormal x-rays of his back on 04/06/25 around 3:26 pm. These failures could place residents with fall incidents or abnormal radiology reports at risk of a delay in prompt medical decisions, which could result in a decline in a resident's health and psycho-social well-being. Findings included: Record review of Resident #1's Admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, Record review of Resident #1's Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls. Record review of Resident #1's Face Sheet dated 04/08/25 revealed only one FM listed [FM 1] as the Responsible party and Resident #1 was the alternate contact. (FM 2 was not listed). Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 2:37 am revealed, Resident was found on the floor in his room next to his bed while CNA was making rounds. resident is unable to verbalize what happened. We were able to put resident back into the bed, when asked if he had injured himself, he pointed to his low back. neuro-checks were initiated and within normal limits, vital signs Temp 97.9-Blood Pressure-146/80-Respirations 16-Saturations 97% Room Air. Call To MD/NP received new orders for X-ray for lumbar spine and bilateral Lower Extremity. Family, DON/ADON informed. will continue to monitor condition. Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 4:02 am revealed, XR (x-ray) requested for Lumbar Spine and Bilateral Hips. Record review of Resident #1's Nurse Progress note by RN K dated 04/06/25 at 11:13 am revealed, Resident continues neuro checks due to recent fall. No pain or discomfort noted. Patient resting in bed. respirations even and unlabored. Medications given per orders. Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 3:36 pm revealed, x-ray of spin and bilateral hip results received provider hotline called, reviewed results with NP H, order to send to ER for evaluation. Responsible party made aware. Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 6:52 pm revealed, FM 2 was in the facility on day shift, made aware of resident's fall and pending x-ray by day shift staff, FM 2 exited the facility, FM 2 called the facility multiple times, left note with the receptionist for charge nurse to call him back to follow up on Resident #1's pending x-rays, this charge nurse called FM 2 back and FM 2 stated I came to visit Resident #1 a few hours ago, I was informed that Resident #1 fell and there were pending x-rays, are the results available yet? this charge nurse stated the x-ray results had been received and the NP was made aware of the results and the NP wanted to send the resident out for further evaluation, FM 2 said ok, he will come in and pick up a few things for Resident #1 such as his wallet and a few other items Resident #1 may want, FM later came into facility, this charge nurse informed FM that resident was transported to hospital for further evaluation pending x-ray results. Record review of Resident #1's Nurse progress note by RN E dated 04/06/25 at 9:35 pm revealed, Resident returned from [The Hospital] with no new orders, np made aware FM made aware @ (at) phone # (number). Record review of Resident #1's Change of condition completed by unknown staff dated 04/06/25 at 6:55 pm revealed, this change started 04/06/25 this afternoon. Resident's vitals were taken that were normal and he had an abnormal spine x-ray. The Resident Representative Notification was blank and there was not a signature on who completed this form. Record review of Resident #1's Radiology Report dated 04/06/25 revealed, PROCEDURE: SPINE 1V SPECIFY LEVEL Status: Final, Reason for Study: M54.50 LOW BACK PAIN, UNSPECIFIED, SPINE 1V SPECIFY LEVEL: FINDINGS: Moderate L1 and mild L2-L3 vertebral body compression demonstrated. The age of the compression is indeterminate. Vertebral bodies show degenerative osteophytic spurring and narrowing of disc spaces. The bones appear diffusely demineralized. L5-S1 anterior fusion hardware present. No comparison study is available. CONCLUSION: Abnormal spine. Consider more sensitive imaging evaluation with CT/MRI as clinically directed. Record review of Resident #1's Incident Report dated 04/06/25 at 2:15 am revealed, Resident was found on the floor next to his bed by CNA. No apparent injuries. Resident Unable to give Description, Vital signs taken, complete body assessment completed and neuro-checks initiated. MD/NP Called received order for XR ((X-rays) of bilateral lower extremities and lumbar spine. No injuries noted at the time of incident, bedridden, oriented to person, pain aid 4 (moaning/groaning, facial grimacing, distressed), confused, incontinent, gait imbalance, impaired memory. Responsible party, DON and DR/NP notified. Record review of Resident #1's Hospital Record dated 04/06/25 4:26 pm revealed, He admitted for abdominal pain and fall. At 4:43 PM Resident #1 is an [AGE] year-old male with a PMHx of HTN, a-fib, acute ischemic Left middle cerebral artery stroke, pancreatitis, and diabetes mellites who presents to the Emergency Department via Emergency Medical Service from a nursing home status post a fall yesterday evening. Per nurse relaying EMS, nursing home staff noticed the patient had an Altered Mental Status after falling out of bed yesterday evening. Per patient, he has bad back pain, left lower quadrant abdomen tenderness, and has vomited an unknown number of times recently. History of present illness and review of system limited secondary to chronic aphasia. CT scan of abdomen and pelvis with no abnormal findings. Radiology report from nursing home conducted at 1:00 pm today shows L1-L3 compression, unknown if acute or chronic. No acute changes on hips/pelvis x-ray. Pt (patient) has extensive cardiac history and history of stroke. The Lumbar findings were seen on prior imaging studies. Patient escorted from Emergency Department via stretcher accompanied by Ambulance service. Patient being taken back to the [The Facility]. Intravenous line removed by this RN. Discharge papers and face sheet given to transport team. No belongings left in room on pt departure. This RN attempted to call nursing home to let them know pt (patient) is coming back, no one responded. Interview on 04/09/25 at 1:48 pm, FM 1 stated he did not get a call about Resident #1 falling from the facility staff last Sunday 04/06/25. He stated FM 2 visited Resident #1 and was given the information about him falling and going to the hospital. He stated FM #2 called him around 4:30 pm telling him about Resident #1 falling and went to the hospital Sunday 04/06/25. He stated on 04/06/25 around 6:00 pm he went to the facility to get more information and they said they did not know where he was and finally the lady said Resident #1 was at the hospital. He stated they called him Sunday 04/06/25 at 10:30 pm saying Resident #1 had returned from the hospital and the nurse was not able to say what the hospital results were. He stated the nurse said he was okay and that it was abnormal but he was not sure what was abnormal. He stated he asked when did Resident #1 fall and was told by RN Weekend Supervisor F he fell last night. He stated some 15 1/2 hours later they told FM 2 not on the face sheet about his fall and hospital transfer. He stated RN Weekend Supervisor F said Resident #1's fall was reported to her and they needed to resolve his concern about not being notified of Resident #1's fall and hospital transfer. He stated the weekend supervisor said she would call the DON and Administrator about this issue. He stated to this day he's not been explained as to how his father fell and what was abnormal. Interview on 04/09/25 at 3:58 pm, CNA G stated on 04/06/25, she overheard Resident #1 had a fall on a previous shift and then he went to the hospital. She stated FM 1 was at this facility wanting to know about the fall and said no one had contacted him from this facility that he had gone to the hospital. She stated Resident #1 returned around 9:00 pm on 04/06/25. Interview on 04/10/25 at 9:55 am, the DON stated on 04/06/25 this past weekend, She stated Resident #1 fell and x-rays showed he had a lumbar spine that looked abnormal. She stated he was sent to the hospital and returned from the hospital and they confirmed the lumbar spine was a preexisting diagnosis. She stated RN E reached out to FM 2 and not FM 1 who was the responsible party . She stated she was not sure how she got confused, because she should have called FM 1 on the face sheet. She stated FM 1 spoke to the weekend supervisor about the matter. She stated she had not spoken to the staff about ensuring they spoke to the right family member but planned to do. She stated they planned to talk to the staff this upcoming Friday about incident reporting, notifications, and call outs. She stated RN Weekend supervisor F talked to RN E to try to figure out why she did not do the communication correctly. She stated after reviewing with RN E the notification on face sheet, RN E said she thought she had the right person. She stated she had not had a chance to speak to RN E because the State Surveyor came to the facility. She stated she had been tied up and was not aware FM 1 had not been updated about Resident # 1's hospital visit. Interview on 04/10/25 at 10:41 am, the Administrator stated she thought FM 1 had a concern on the weekend of 04/06/25 about FM 2 being notified instead of him . She stated FM 2 visited Resident #1 and was told by the nurse he fell and was waiting for the x-ray results. She stated Resident #1 went to the hospital and had no complaints about why Resident #1 was sent to hospital and result afterwards. She stated on 04/06/25 at 2:37 am, Resident #1 was found on floor, in his room and the resident was unable to say what happened. She stated according to the nurses notes, the nurse called the Dr/NP and family. She stated she had no complaints from FM 1 about not being aware of Resident #1 falling, abnormal x-ray and transfer to the hospital. She stated he was sent back the same day 04/06/25 and the facility had no issues with FM 1 about the details of Resident #1's hospital visit and fall that she was aware of. Interview on 04/10/25 at 11:45 am, ADON A stated FM 1 said a few days ago Resident #1 went to the hospital and he was not informed. She stated FM 1 should have been informed because he was listed as the Responsible party. She stated she reviewed Resident #1's chart and FM 2 was not on it but FM 2 was in Resident #1's room visiting on 04/06/25. She stated she addressed this issue with RN E making sure they informed the right people on the face sheet because the RP needed to be notified for change of condition. She stated not being sure if FM 1 was notified of Resident #1 falling. She stated if the nurse called and left a message she should have called again then let upcoming nurse know to keep calling and go to next person on face sheet. She stated in Resident #1's case there was not a second contact person but RN E assumed FM 2 was the RP. She stated they planned to have a training with all staff to ensure no one was contacting the wrong person. She stated she was not aware of FM 1 complained about not being notified of the hospital visit findings. She stated the staff were supposed to call the RP to let them know the resident returned and outcome of hospital stay. Interview on 04/11/25 at 10:59 am, Doctor J stated his NP H received the notice about Resident #1 fell and x-rays were ordered 04/06/25. She stated PA I was notified about the abnormal x-rays on 04/06/25 and sent the resident to the hospital. He stated Resident #1 fell out of bed and had bad back pain and had some vomiting. He stated he blood pressure and labs were fine and other vitals were fine and at the hospital he had a normal CT of his abdomen/pelvis. He stated Resident #1 had a diagnoses of diverticulitis and arthritis. He stated Resident #1's lumbar L1 and L2 were also negative and was sent back to this nursing facility the same day . Interview on 04/11/25 at 12:42 pm, LVN D stated she worked the 300 and 400 halls and on 04/06/25 around 1:30 or 2:30 am, Resident #1 fell . She stated the CNA told her he was on the floor and after he was assessed he was assisted back into his bed. She stated Resident #1 said he had pain and pointed to his lower back then she called NP H and she ordered x-rays for his lumbar and bilateral hips. She stated she called FM 1 but he did not answer and got a voice mail and she left a message to call [This Facility]. She stated FM 1 did not call back and she did not try to call FM 1 back, then she left at 6:15 am. She stated she documented he fell and she initiated neuro checks because he had an unwitnessed fall. She stated Resident #1 was on his back on the floor, between the 2 beds, he was lying flat on the floor with his knees up. She stated she found out later he was taken to the hospital for irregular x-rays. Interview on 04/11/24 at 1:24 pm, the Administrator stated they were trying to solve FM 1's complaints and they could not drop the ball again. She stated they had a meeting with FM 1 today 04/11/25 and FM 1 was giving them another opportunity to make things right for Resident #1. She stated not contacting the RP could potentially lead to the resident's needs not being met. She stated the DON was responsible for ensuring the change of condition process was done properly. She stated they were handling the issue with RN E and she was going to be written up and counseled, because she did not follow appropriate protocol. She stated FM 1 said when he came to the facility 04/06/25 to find out more information RN E was arguing with him that she had call him and he said no she did not call him. She stated RN E should have verified she spoke to the RP. She stated she was not aware LVN D did not call FM 1 after Resident #1 fell Interview on 04/11/25 at 10:09 am, RN E stated last Sunday 04/06/25 LVN K told her Resident #1 fell and neuro checks were needed. She stated FM 2 had visited earlier that day 04/06/25 and he found out about the fall and pending x-ray. She stated Resident #1 was in a little bit pain of pain of his lower back she told him he's going to the hospital for abnormal x-rays and he said okay. She stated she called NP H and got the order to send Resident #1 to the hospital for an evaluation. She stated Resident #1 was sent to the hospital around 3:00 pm or 4:00 pm because he had an abnormal lumbar x-ray. She stated FM 2 contacted her but she had not had the opportunity to call anyone yet, then she returned FM 2's call to follow-up with the x-ray result and told him what was going on and the resident was going to the hospital. She stated later that evening FM 1 said he was the RP and she responded she was unaware of that. She stated she normally looked at the face sheet to see who the RP was but did not in this case. She stated FM 1 wanted a follow-up on Resident #1's fall and x-ray results and she told him that she did not know the residents well on the 400 hall. She stated she was told FM 1 was the only RP Resident #1 had and to only contact him. She stated the DON told her to look at the resident's face sheets before talking to anyone about the residents. She stated the RP was upset and she apologized for not looking at the face sheet and not contacting him first. She stated around 10:00 pm Resident #1 returned back to the facility with no new orders. Record review of the Facility's Change in Condition policy undated revealed, CHANGE OF CONDITION Policy: To identify and evaluate a change in condition and notify the Physician and Responsible Party when indicated. A significant change in Resident's status is any sign or symptom that is Acute or sudden onset: - A marked change (i.e., more severe) in relation to usual signs and symptoms - New or worsening symptoms - Examples include but are not limited to the following: cardiovascular, respiratory, behavioral, fall with major injury, infection, dehydration, altered mental status, pressure injury and any other condition based on professional judgment. Procedure: When a change in condition occurs, the Licensed Nurse will: .3. Document date, time Physician, Responsible Party was notified of findings from the evaluation and any new orders obtained . 6. If the Physician chooses to send the Resident to the hospital for further evaluation and treatment, the charge nurse will initiate the transfer process. Evaluation findings will be documented on the communication tool used to transition the Resident to the next level of care.

Based on record review and interview, the facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision to prevent incidents for two (Resident #1 and Resident #2) of two residents reviewed for elopement. 1. The facility failed to provide Resident #1 and Resident #2 with adequate supervision to prevent each from leaving the building on 11/04/24 around 12:55 AM, when staff were not aware of the elopement until after 6:00 AM, at the start of the next shift. 2. The facility failed to provide Resident #1 with adequate supervision to prevent Resident #1 from removing the Wanderguard and eloping the facility. The noncompliance was identified as past noncompliance. The Immediate Jeopardy was identified on 11/19/24 and was removed on 11/19/24. The facility corrected the noncompliance before the investigation began on 11/19/24. The Immediate Jeopardy occurred in the past and the facility had already corrected the non-compliance. These failures placed residents at risk for harm and serious injury. Findings Included: Record review of Resident #1's facesheet reflected a [AGE] year-old female, with an admitted [DATE]. Resident #1 had a diagnosis of alcohol dependence with withdrawal (sleep change, rapid changes in mood, and fatigue), Psychoactive Substance Abuse (the abuse of drugs that affect how the brain works and causes change in mood, awareness, thoughts, feelings, and behavior), Muscle Spasm (sudden, involuntary contraction of a muscle), Cognitive Communication Deficit (difficulty with communication that is caused by impaired cognitive processes), Generalized Anxiety Disorder (constantly worries about everyday things), Diabetes (high blood sugar), Depression (serious mental health condition that can affect a person's thoughts, feelings, behavior, and sense of well-being), and Essential Hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS Assessment, dated 08/08/24, reflected Resident #1 had a BIMS score of 09, which indicated the resident had moderate cognitive impairment. Record review of Resident #1's Care Plan dated 11/19/24, did not address elopements or a Wanderguard. Resident #1's Elopement Risk assessment dated [DATE] reflected Resident #1 was not an elopement risk. Record review of Resident #1's Progress Notes dated 11/16/24, reflected the following: [Staff Member Name] came in making rounds to discover resident was not in room. [Staff Member Name] and manager searched each room on each hall in the building and outside parameter of facility and was unable locate resident. Code Pink was initiated. DON and Administrator made aware of situation, RP called, [City] PD called. Police showed up around 6:30 AM to begin searching in and around building following protocol for missing persons. Record review of Resident #2's facesheet reflected a [AGE] year-old male, with an initial admitted [DATE], and a re-admitted [DATE]. Resident #1 had a diagnosis of Diabetes (high blood sugar), Sepsis ( life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury), Acute Kidney Failure ( sudden decline in kidney function), Hypertensive Chronic Kidney Disease ( severe high blood pressure caused kidney damage), Essential Hypertension (high blood pressure), Bipolar Disorder (serious mental illness that causes extreme mood swings, along with changes in energy, thinking, behavior, and sleep), Hemiplegia (partial or full paralysis on one side of the body), Accidental Poisoning by Opioids, and Shortness of Breath. Record review of Resident #2's Initial MDS Assessment, dated 08/23/24, reflected Resident #1 had a BIMS score of 15, which indicated the resident had intact cognition. Record review of Resident #2's Care Plan dated 11/19/24, did not addres elopements. Record review of Resident #2's Progress Notes dated 11/01/24, reflected the following: patient unknowingly left the facility sometime in the early morning. In an interview with the Administrator and the DON, on 11/19/24 at 9:40 AM, the Administrator stated Resident #1 returned on 11/04/24, but could not tell them where Resident #2 was. The Administrator stated Resident #1 stated she and Resident #2 were hanging out in the hood, doing drugs, and she last saw Resident #2 in a shack. The Administrator stated Resident #1 and Resident #2 were in a relationship, and she felt Resident #2 was able to encourage Resident #1 to elope. She stated Resident #1's family member contacted the facility and told them Resident #1 went to visit a family member in another facility. Resident #1's family member brought Resident #1 back to the facility. She stated Resident #1 had no injuries. The Administrator stated Resident #1's BIMS score was 09, when she first admitted to the facility, but the facility reassessed her upon her return on 11/04/24 and her BIMS score was now a 15. The Administrator stated she assumed maybe since Resident #1 no longer had drugs in her system her BIMS score increased. The Administrator stated Resident #1 discharged to a group home a couple of days after she returned to the facility. The Administrator stated Resident #2 was never located, but she stated she received a tip that he might be at a local hospital. The Administrator stated she was able to confirm that Resident #2 was at a local hospital and provided the location and room number. The Administrator stated the hospital would not share any additional information on Resident #2 since he was no longer at the nursing facility. She stated she would see if she could confirm if he was admitted to the hospital. The Administrator stated Resident #1 and Resident #2 were not elopement risks prior to the elopement. The DON stated she started working at the facility after Resident #1 admitted , and she was not sure why she initially needed the Wanderguard. The DON stated the residents were usually checked on throughout the night, but like the Administrator stated some residents do not like to be checked on at night or were kind of independent. The DON stated Resident #1 and Resident #2 could do a lot on their own. The DON stated the two residents were often in the hallway together, so they had been seen by staff after 9:00 PM. The DON stated incoming staff from each shift were tasked with checking the Wanderguard residents. In an interview on 11/19/24 at 10:46 AM, PD Detective stated the police station received the call about the elopement on 11/01/24 around 6:030 AM or 7:00 AM that morning. PD Detective stated she received a call from the nursing facility around 11/04/24 that Resident #1 had been located by her sister and returned to the facility. She stated Resident #2 was never located but stated the nursing facility only reported Resident #1 as missing and did not report Resident #2 as missing. The PD Detective stated she spoke with Resident #1, and she was currently living in a group home. In a telephone interview on 11/19/24 at 11:11 AM, Resident #2 stated he left the facility, because he hated the facility. He stated the food was always late and cold when he received it. Resident #2 stated he went back home, was safe, and did not have any injuries from eloping from the facility. He stated he felt safe at the facility, but it did not feel like home. He stated he was pretty much able to take care of himself. Resident #2 stated he did not plan on returning to the facility but would eventually go to a different rehabilitation facility. Resident #2 stated he had been in the hospital for about two weeks. He stated he went to the hospital to get his kidneys checked and to get a diagnostic of his kidney function. In a follow up interview on 11/19/24 at 2:44 PM, The Administrator stated Resident #1 had already admitted to the facility by the time she started working at the facility. She stated Resident #1 did have some issues with ambulating when she first admitted , but shortly afterward she began to ambulate. She stated she believed that was the reason she was given a Wanderguard. She stated the Wanderguard residents are checked at the beginning of every shift. She stated both Resident #1 and Resident #2 were both very independent and were able to do a lot of tasks on their own. The Administrator stated both residents would be seen around the facility together and were known to be in a relationship. She stated it was normal to see them around the facility together. She stated generally, residents were checked on every 2 hours, but Resident #2 was very independent and did not want to be checked on throughout the night. She stated staff got used to the residents and what they like or how each resident was. An Immediate Jeopardy for past non-compliance was identified on 11/19/24. The Administrator was notified of the Immediate Jeopardy for past non-compliance on 11/19/24 at 3:45 PM and were provided with the Immediate Jeopardy Template. The facility was not asked to provide a Plan of Removal, since the Immediate Jeopardy occurred in the past and the facility had already corrected the non-compliance. Record review of the following: Record review of the facility's Wanderguard Check Log reflected the staff checked Resident #1's Wanderguard at the beginning of every shift on 10/31/24 and the Wanderguard was intact. Record review of the Wanderguard Check Log reflected Wanderguards had been checked for all Wanderguard residents at the beginning of each shift since 11/01/24. Record review of Safe Surveys completed on all residents on 11/01/24. No residents had concerns related to the allegations. Record review of in-services completed on 11/01/24 that covered Timely Reporting/Recognizing Abuse, Neglect, and Misappropriation, Changes in Condition, Documentation, Physician Notification and Family, Clinical Rounds for assistance, Supervision/Needs, Call Lights, Rounding, and Customer Service for all staff from all shifts. Record review of the facility's Quality Assurance Meeting Minutes, dated 11/01/24, reflected the following: Discussion items Review of missing residents/elopement timeline Review of policies for sufficiency Residents elopement Record review of the facility's QAPI Plan dated 11/01/24, reflected the following: Immediate Actions Taken 6:00 AM change of shift oncoming/outgoing nursing staff noted upon rounds that resident, [Resident #1 name] was not in her room. Code [NAME] (missing resident) was initiated with expansive room to room and facility search was immediately launched. With this search all other residents were accounted for except [Resident #1 name]. 6:30am-8:15am- all exit doors were validated to be functioning and working appropriately as well as the Wander Guard alarms. The Maintenance Director and Police reviewed the external camera tape, and it was noted that [Resident #1] exited the building walking alone (fully dressed in street clothes at 12:55 am); the review of the tape did not show [Resident #2] leaving out the facility front door but later discovery of the back gate camera noted he left with her at 12:55 am and walked across the street to [store name]. The last documented interaction with nurse for him was 2100 (9:00 PM). 8am- The Maintenance Director, under the direction of the Administrator, changed the Wander Guard code for the doors. Systematic Approach: 11/01/24- DON/Designees completed safe surveys on all interviewable residents to ensure that their needs are being met and that they felt safe- a pattern of concerns were noted with timeliness of call and staff knocking. Residents that were not interviewable were assessed by nursing for wellness and stability of their baseline. Education on rounding, answering call lights and knocking (customer service) was added to staff education. Nursing completed 100% of elopement assessments which revealed no new residents identified who are at risk for elopement. Wander Guard binder reviewed for accuracy. Reviewed all 9 residents with Wander Guards to ensure/validate placement, functionality- 100% compliance; the Maintenance Director checked all exit doors and alarms to ensure proper functioning-no malfunction found. Education: Staff in-services initiated the following abuse prevention policy, resident rights, missing; elopement policy; Timely reporting/Recognizing abuse, neglect and misappropriation: Changes in Condition; Documentation; Physician Notification and Family clinical round for assistance, supervision and needs; Answer the Call-Inservice on answer call lights, rounding and customer service. 1. Clinical staff will not be allowed to work their scheduled shift until they have completed all their education. 2. Training for all newly hired staff will be completed prior to being assigned to the floor beginning on 11/01/24 with monitoring through 12/01/24. This will continue for all new hires. 3. Training for all PRN staff who haven't worked since 10/31/24 will be completed prior working beginning 11/01/24 with monitoring through 12/01/24. This will continue ongoing for any staff not having been trained upon return to work. 4. Training for all current direct care staff began on 11/01/24 and will continue until 100% completion of a test covering abuse prevention and elopement protocols. 5. Elopement drills initiated on 11/01/24 will be completed on 3 shifts in the next 24 hours to be inclusive of a weekend shift on 11/02/24. 6. Administrator and DON educated by the Regional Director of Clinical Services on abuse prevention policy, resident rights, missing/elopement policy; Timely Reporting/Recognizing abuse, neglect, and misappropriation: Changes in condition; documentation; physician notification and family and clinical rounds for assistance, supervision and needs. Monitoring: 1. On-going education competency to ensure staff understanding of our abuse prevention policy, elopement policy and drill. This will be monitored by the DON and/or designees through observations and interviews and include: a. Verbal questions/answers to ensure understanding b. The Nurse will report on residents with elopement/wandering behavior problems or care issues daily and prn during the morning IDT 1. Rounding to ensure prevention methods are in place has been completed daily beginning 11/01/24. 2. DON or designee will conduct daily documentation review of all clinical notes to monitor any incidents that require supervision and intervention or additional training needs of facility staff. 3. DON will submit audit findings to the QA Committee for review, analysis and recommendations. 4. Rounding completed by DON and/or designees to ensure identification of residents who at risk for elopement daily beginning 11/01/24 and will continue daily for 4 weeks, then weekly for 3 months, then monthly thereafter. 5. DON or designee will conduct a weekly random audit for a period of 4 weeks ensuring nursing staff will continue to follow facility system for residents that at risk for elopement/wandering. 6. DON or designee will conduct daily documentation review of all clinical note to monitor any incidents that require supervision and intervention or additional training needs of facility staff. 7. DON will submit audit findings to QA Committee for review, analysis and recommendations. 8. Maintenance Director-Elopement Drills initiated on 11/01/24 will be completed on three shifts in the next 24 hours to be inclusive of a weekend shift on 11/02/24, quarterly and PRN. 9. Administrator Designees along with the local police will continue to search and investigate the whereabouts of the residents with all available means. In an interview at 11/20/24 at 2:01 PM, the ADON stated she was not present for the elopement, but immediately following the elopement, she and other staff were in-serviced on elopements, resident rights, customer service, rounding, call lights, abuse, neglect, and completed elopement drills. She stated no other residents had eloped since the incident with Resident #1 and Resident #2. In an interview on 11/21/24 at 12:57 PM, the Nutrition Aide stated she was trained on abuse and neglect, resident rights, customer service, and elopement. She stated the staff recently received in-services on resident rights, customer service, resident rights, and elopements. She stated she completed an elopement drill. In an interview on 11/21/24 at 1:25 PM, the CNA A stated she was not present during the elopement, but received in-services this month on abuse and neglect, resident rights, rounding and customer service, call light times, elopement, and participated in an elopement drill. She stated the norm was to check on all residents every two hours unless the resident needs something before the 2 hours. CNA A stated she usually checked on residents with Wanderguards more often. In an interview on 11/21/24 at 2:00 PM, LVN B stated she was not present during the elopement but was at work the morning afterward. She stated that same day, she received in-services on abuse and neglect, resident rights, customer service, call light times, rounding, and elopement. She stated she was present for an elopement drill. She stated all residents should be checked on every two hours or less, and Wanderguards were checked at the start of each shift. In an interview on 11/21/24 at 2:15 PM, RN C stated he was not at the facility during the elopement but worked the next day. He stated everyone in the facility was in-serviced on abuse and neglect, resident rights, rounding, customer services, elopement, and had an elopement drill. He stated all residents should be checked every two hours and Wanderguards are checked at the beginning of each shift. RN C stated he tried to check on his residents every hour on his hall. He stated he would sometimes sit in the hall closer to the residents. In a follow-up interview on 11/21/24 at 2:34 PM, the DON stated she felt everything went smoothly with the elopement. She stated protocols were followed once the staff realized the residents were missing. The DON stated some residents were more independent, and Resident #1 and Resident #2 were in a relationship. She stated staff tried to give them space for their friendship, and she felt Resident #1, and Resident #2 would have gotten out of the facility no matter what. The DON stated after the elopement, all staff were in-serviced on elopement and completed elopement drills. She stated Wanderguards were checked at the beginning of every shift. The DON stated Resident #1 had become very independent over her stay at the facility. The DON stated she felt there was no risk of it taking the staff hours to notice Resident #1 and Resident #2 were missing. She stated she thought the staff realized sooner than 6:00 AM but would try to find documentation to support that. She stated the facility staff contacted her and the Administrator as soon as staff realized the residents were missing. She stated the physicians, family members, and police were notified at that time. In a follow-up interview on 11/21/24 at 3:09 PM, the Administrator stated staff did check on Resident #1 that night, but her bed was fixed with pillows that made it appear she was in the bed. She stated Resident #2 was very independent. She stated staff would not check on her as often, because she was independent, and she was out in the hallways often. The Administrator stated rounding was usually every two hours, including for Wanderguard residents. She stated the staff of the morning shift did exactly what they were supposed to do they noticed the residents were missing. She stated she felt there were no risks of staff not immediately noticing staff were missing during the night shift. Record review of the facility's policy titled, Elopements, dated 2001 with a revision date of 12/2007, reflected the following: Staff shall investigate and report all cases of missing residents. 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.

Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADL activity the necessary services to maintain good personal hygiene for 2 (Residents #1, #2) of 9 residents reviewed for ADL care. The facility failed to ensure Resident #1 and #2 were provided timely incontinent care as needed. These failures could place residents at risk of not receiving personal care services, having decreased quality of life, and skin breakdown. Findings include: Record review of Resident's #1s Face Sheet dated 3-13-2024, showed a [AGE] year-old female, with a BIMS (Brief Interview of Mental Status) score of 11, which shows moderate cognitive impairment, who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), type 2 diabetes mellitus with diabetic Neuropathy, gastro-esophageal reflux, cramps and spasms, Weakness, Hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), and urinary tract infection. In an observation of Hall 200, on 3-13-2024, at 9:20 AM, most of the 200-hall smelled of urine. In an observation/interview of Resident #1, on 3-13-2024, at 6:30 AM, Resident #1 was in bed with a strong smell of urine in the room. Resident #1 revealed she had not been changed, with a wet brief, since 4 AM. Resident #1 stated that when CNA-C works her hall, CNA-C will provide incontinent care for her non-verbal roommate, but not her. At 9:40 AM, Resident #1 pressed her call light to get incontinent care. In an observation/interview on 3-13-2024, at 10:30 AM, Resident #1 still had not received incontinent care. Resident #1's room, still smelled of urine. Resident #1 stated that 10 minutes after she pressed the call light at 9:40 AM, a CNA came into her room, cut off the light, and left the room without providing incontinent care. In an observation of Resident #1s room, on 3-13-2024, at 11:45 AM, revealed Resident #1 received incontinent care. Record review of Resident #1s care plan, dated 7-24-2023, revealed resident is totally dependent on staff required a 2 person Hoyer lift to be moved out of bed and that incontinent care be provided every 2 hours. Record review of Resident #1's MDS Screening, revealed Resident #1 needed substantial/maximal assistance with toilet transfers, required partial/moderate assistance (helper does less than half the effort helper lifts, holds, or supports trunk or limbs, but provides less than half the effort), and rated as being frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Record review of Resident #2's Face Sheet dated 3-13-2024, showed a [AGE] year-old female, with a BIMS (Brief Interview for Mental Status) (it is a quick snapshot of how well you are functioning cognitively at the moment) score of 15 (which shows no cognitive impairment), who was admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Muscle wasting, rheumatoid arthritis, muscle weakness, type 2 diabetes mellites, Constipation, contracture of left hand, wheezing, intoxication delirium, vomiting without nausea, unspecified open-angle glaucoma, and indeterminate hypermetropia. In an observation/interview of Resident #2, on 3-13-2024, at 11:20 AM, it was revealed Resident #2 had not had her brief changed since 6:00 AM. There was a strong smell of urine in Resident #2s room. Resident #2 stated many times when she has pressed the call light, an aide comes in the room, turns the light off, leaves the room without providing incontinent care - until about 30 minutes later. Resident #2 stated that the 200-hall has a high percentage need of incontinent care, and the facility needs 2 aides to work that hall to provide timely incontinent care. However, the facility only has one aide for the hall and sometimes they are used in other halls - not just hall 200. Resident #2 said her right hand is paralyzed and cannot pull up her own brief. Resident #2 stated CNA-C, is not a good aide to deal with as she was needing help to fix her brief as it was pinching her after CNA-C provided incontinent care. Resident #2 stated she asked CNA-C to re-adjust the brief and CNA-C told Resident #2 to adjust it herself. Resident #2 stated she asked CNA-C to leave her room. After that incident, when CNA-C is working, CNA-C will not provide incontinent care, pick up resident #2s food tray, and won't provide Resident #2 with water. Resident #2 revealed this makes Resident #2 feel neglected. Resident #2 stated she has developed a rash due to incontinent care not being provided timely. Resident #2 stated she has had to wait up to 10 hours before receiving incontinent care at this facility. Resident #2 stated this makes her feel neglected. Resident #2 pressed the call light at 11:35 AM. Incontinent care was observed to be provided at 11:55 AM. Record review of Resident #2s care plan dated 6-15-2022, stated that Resident #2 needs assistance with ADL care to include incontinent care. Resident #2s care plan revealed the goal for Resident #2 is to maintain a sense of dignity by being clean, dry, odor free, and well-groomed. Resident #2s care plan stated for resident to be turned every 2 hours and use skin protocols with barrier cream. Record review of Resident #2's MDS (Minimum Data Set) ratings, revealed that Resident #2 was Dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene. In an interview with CNA-B, on 3-13-2024, at 12:31 PM, it was revealed that the facility is short staffed especially in the 200-hall. CNA-B stated the 200-hall needs 2 CNAs to keep up with the workload of providing care needed for residents. CNA-B revealed that she believes the urine that has been smelling in Resident #1s room, was probably from her roommate who is non-verbal. CNA-B stated Resident #1s roommate fights staff when staff try to provide incontinent care and it takes 2 people to provide incontinent care. CNA-B said she does not know if the night shift provides incontinent care to Resident #1s roommate because she can be so combative. CNA-B stated she does not believe the night shift are providing timely incontinent care. CNA-B stated she is the CNA who turned off Resident #1s call light at around 9:50 AM, and could not provide incontinent care at the time, because the Administrator pulled her out of the 200-hall to help with 100-hall to provide incontinent care. In an interview with CNA-C, on 3-14-2024, at 11:10 AM, it was revealed CNA-C will not provide incontinent care to a resident if the resident is rude or speaks mean or is abusive to her. CNA-C stated she will switch out with another CNA to provide care for the resident(s) who are rude, mean, or abusive toward her. In an interview with the Administrator, on 3-14-2024, at 2:45 PM, it was revealed that her call light response expectations were in a perfect world not to take over 10 minutes. The Administrator stated call light response becomes neglect by not being conducted. The Administrator stated, just make sure the residents are safe, if staff cannot meet their needs. The Administrator stated that it was the ADON and the DON's responsibility to ensure there was adequate staffing to meet the demands of call lights being used by residents. The Administrator stated if an aide cannot meet the needs, of a resident using a call light, just ensure staff are communicating with residents, at the time, and let them know you will be back later. The Administrator revealed it was everyone's responsibility to respond to call lights. The Administrator's expectations were for CNAs to make rounds for incontinent care every 2 hours. The Administrator stated that if a particular CNA isn't comfortable with providing care for certain residents, she wants to know about it. The Administrator stated if a CNA isn't comfortable with providing call light response to a resident, they will assign that particular room to another aide. Review of an article from International Continence Society, file:///C:/Users/TCodd01/Downloads/Skin_Damage_from_Incontinence%20(1).pdf, undated, revealed, .Urine or feces can damage skin if not immediately removed and the affected area thoroughly cleaned and dried. Irritating substances in feces can cause inflammation of the skin .skin damage from prolonged exposure to urine or feces can occur fast - within just a few days . Record Review of the facility's Call Light Policy, dated 6-14-2006, stated the purpose of the call light system is to provide prompt assistance to patients and ensure the system is working. 1. Answer all call lights promptly, whether or not you are assigned to the patient. 2. Answer all call lights in a prompt, calm, courteous manner. 3. Never make the patient feel you are too busy to give assistance; offer further assistance before you leave the room .

Based on interview and record, the facility failed to ensure each received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for accidents and supervision. CNA B failed to use a mechanical lift and obtain assistance from another staff when she transferred Resident #1, resulting in the resident sustaining an injury requiring 3 sutures to his leg during an improper transfer. This failure placed residents at risk for falls or injury during transfers. Findings included: Review of Resident #1's MDS assessment dated [DATE] reflected he dependent on staff for all Activities of Daily Living. Review of Resident #1's Face Sheet dated 07/21/23, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1's active diagnoses included cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), acute embolism and thrombosis (Thrombosis is a clot in a blood vessel. An embolism or thromboembolism is a clot that moves through your bloodstream.) of lower extremity (leg), local infection of the skin and subcutaneous tissue (the deepest layer of your skin). Review of Resident #1's Care Plan dated 06/29/23 reflected he was at risk for falls related to decreased mobility and functioning. Further review of Resident #1's Care Plan revealed that he required a mechanical lift for transfers as well the assistance of two persons for transfers. Interventions in place to remind him to call for assistance before moving from bed-to-chair and from chair-to-bed. Directive was to all staff. Review of Nursing Progress Note by LVN A for Resident #1 on 07/18/23, revealed Patient observed in bed after the assistance of the aide. The aide [C.N.A. B] states that she was transferring patient from the chair to the bed and patient became frighten and his leg get caught up on the tip of the chair side and cause a skin tear/laceration to the right shin area. Skin care provided with normal saline, pat dry and apply dry dressing and wrap with Kalex and secure with tape in place. [sic] (intentionally so written. When used after the quoted material, sic indicates that the words preceding it are an exact transcription from the original source, including any spelling mistakes, non-standard spelling, or grammatical errors.) Review of Nursing Progress Note by RN C for Resident #1 on 07/19/23, revealed, RP aware resident sent out to hospital due to laceration to right leg. escorted by facility van driver. Resident returned at 1400 (2:00 PM) escorted in via care flight, with new order for Cephalexin 500mg po 4x daily x 10 days. Resident received stitches to rt lower extremity WCTM throughout shift. [sic] (Will Continue To Monitor) . An attempt to interview Resident #1's physician on 08/08/23 at 1:43 PM was not successful, due to the physician being unavailable at the time of this investigation. An interview with Resident #1 on 08/08/32 at 2:11 PM, revealed the aide was trying to help him go from his wheelchair to his bed. He stated C.N.A. B did say that she needed to go get a different lift, however, he stated he was tired of being up and wanted to get in bed. He stated she told him that someone was coming to help her, but it was taking too long, so he told her he was ready now. He stated he did not feel it when his leg was injured. He stated he went to the hospital and had to get stitches. He stated the staff usually used the mechanical lifting device to move him in and out of bed, he stated he believed if the one C.N.A. B brought into the room had worked, they would have used it. Observation of Resident #1 on 08/08/23 at 2:16 PM, revealed the resident had a bandage on his leg, covering the laceration, which he pointed out to me. The date on the bandage was 08/07/23. An interview with C.N.A. B on 08/08/23 at 5:09 PM, revealed Resident #1 required two-person assist with a mechanical lifting device. She stated there was another aide, who was going to assist her with the resident's transfer, however, she had to go to the restroom. She stated she went to get the mechanical lifting device and saw that the battery was dead. She stated she let the resident know about the issue and that she was going to go get the other one from the other hall. She stated the resident got agitated because he was already fussing saying he was ready to get in bed. She stated he was demanding to be put in bed at immediately and the other aide had not returned, so she pushed his wheelchair as close to the bed as she could and then helped him into bed. She stated she assisted him to get in bed and he was losing balance, but she was able to keep him from falling. She stated at some point, he was injured. She stated he never hollered out or anything, so she did not realize he had been hurt, until she was putting his leg in bed and saw the blood. She stated his leg must have gotten caught by the footrest and that's how the laceration happened. She stated it scared her and she was upset with herself because he had gotten hurt. She stated she immediately reported it to the nurse. She stated she had been an aide for [AGE] years and she knew better, but she was just trying to accommodate the resident. She stated she was well-trained in using mechanical lifting devices. She stated she had received fall prevent trainings, which included training on using mechanical lifting devices, during her employment at the facility. An attempt was made on 08/08/23 at 5:21 PM to interview LVN A, whom the aide reported the incident to, however, the attempt was unsuccessful, due to the nurse not answering the call and a message could not be left, to request a call back. An interview with the DON on 08/08/23 at 5:33 PM, revealed Resident #1 required a mechanical lifting device with two-person assist for transfers per his Baseline Care Plan. He stated when staff login to the system to reference Plans of Care for each resident, they see the Baseline Care Plan. He stated that was why C.N.A. B was going to use a mechanical lifting device. He stated CNA B should not have tried to transfer the resident alone. He stated she should have tried to calm the resident and then went to find a working mechanical lifting device and also located an available nursing staff to assist her with the lift. The DON said Resident #1's wound started out as a skin tear, and it was cleaned, and his leg was wrapped because there was no excessive bleeding at the time of the initial assessment. The DON said the nurse who did the initial assessment did not think it was a laceration at the time and that's why he was not sent out until the next day. He stated they were just able to see the wound clearer the next morning. When the wound was checked the next morning, it looked worse than what the initial assessment indicated. He said this was because Resident #1's legs were contracted, and the wound was not clearly visualized the previous night. Upon reassessment, the day nurse realized the extent of the wound and Resident #1 was sent to the hospital for further evaluation and treatment. An interview with the Administrator on 0808/23 at 6:00 PM, revealed Resident #1 was able to get around better and could be transferred without the mechanical lifting device. She stated since the incident, he was mechanical lifting device only. She stated she did not know the specifics as to why and she wanted to look in the system. She stated C.N.A. B should have followed what was in the Base Line Care Plan, instead of appeasing the resident. She stated that was why they confirmed the allegation in their investigation and suspended her and also took disciplinary action against her, by doing a formal write-up. She provided evidence of the formal write-up. Record review of C.N.A. B's undated Mechanical Lift Competency Skills Checklist, on 08/08/23 at 11:00 AM revealed she successfully displayed proper skills in using the device. Review of the facility's policy titled, Continuing Care Network Patient Care Management System 12: Assessments, dated November 2017, reflected, 4. A Baseline, Person-centered Plan of Care for each patient that includes the instructions needed to provide effective and person-centered care of the patient that meet professional standards of care A Care Path must be used as a guide .the nursing staff must observe.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Resident #1 and Resident #2) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #1 received wound assessments, wound treatments, and on-going skin assessments in that: LVN A did not complete a full skin assessment for Resident #1 when the resident was admitted [DATE] and did not notify the physician or obtain treatment orders for a wound identified on the resident's sacrum on admission. The sacral wound was not assessed or treated until 32 days later when it was identified as an unstageable wound with necrotic (dead) tissue. Resident #1 did not receive a full skin assessment until 18 days after admission. The unit manager did not complete a skin assessment on 7/15/21 for Resident #1 after she identified the resident had not had a skin assessment since admission. LVN B did not complete a skin assessment for Resident #1 as she documented on 7/26/21 and 08/02/21. The treatment nurse did not notify the physician and obtain wound care orders when she identified Resident #1 had 5 pressure injuries on 7/30/21. Resident #1 was transferred to the hospital on 8/5/21 where she was admitted to the intensive care unit for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required surgical debridement of the sacral ulcer, IV antibiotics and aggressive volume resuscitation. 2. The facility failed to ensure Resident #2's pressure ulcers were identified, assessed and treatment provided to promote healing in that: RN E failed to document wounds and notify the physician for wound care orders for treatment when he identified DTIs on both of Resident #2's heels. The treatment nurse did not identify DTIs on each of Resident #2's heels and obtain treatment orders until surveyor intervention. An Immediate Jeopardy (IJ) was identified on 08/12/21 at 2:57 p.m. While the IJ was lowered on 08/13/21, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of life-threatening infection, which could manifest into other health complications, pain, worsening pressure ulcers and death. 1. Review of Resident #1's closed clinical records and undated face sheet revealed the resident was an [AGE] year old female admitted to the facility on [DATE]. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission MDS assessment, dated 07/08/21 revealed the resident was always incontinent of bowel/bladder, used a wheelchair for mobility, required extensive assistance of two persons for dressing, extensive assistance of one person for bed mobility, transfers and hygiene. The assessment reflected the resident was at risk of developing pressure ulcer but had no pressure ulcers at the time of the assessment. The resident's BIMS score was 9 indicating moderately impaired cognition. Review of Resident #1's care plan dated 07/01/21 revealed the problem of pressure ulcer prevention was addressed with a goal of not developing new pressure ulcers. Interventions included turning every two hours, utilizing a draw sheet, and using two persons for repositioning and transfers. Review of Resident #1's current Braden Scale (predicts risk for pressure ulcer development) dated 07/01/21 reflected a score of 14, indicating the resident was at a moderate risk for the development of pressure ulcers. Review of Resident #1's nursing admission assessment dated [DATE] revealed the resident admitted with an abrasion to the sacrum. The assessment did not reflect any description of the abrasion to include color, measurement, or other characteristics. Review of the resident's clinical records revealed there was no documented assessment of the abrasion noted on admission. Interview with LVN A on 08/11/21 at 2:35 p.m. revealed she admitted Resident #1 on 07/01/21 and completed the nursing admission assessment. She states the resident admitted with real red excoriated skin on the sacrum, but she was unable to recall the size. She stated she did not measure the area, notify the physician of the condition of the resident's skin, or obtain any wound care orders. LVN A further stated, she did not complete a full assessment of the resident's skin impairment because she told the TN about the resident's skin issues and the TN was responsible for wound assessments and obtaining wound care orders. Additionally, LVN A stated weekly skin assessments were input into the computer on admission and she was sure she put them in. She stated she may not have activated the order for weekly skin assessments which required an additional step that adds an entry on the nurse's TAR to perform weekly skin assessments. LVN A stated she was busy with three new admissions and may have forgotten. Interview with the TN on 08/11/21 at 2:00 p.m. she stated nurses were responsible for performing weekly skin assessments for residents and reporting any skin issues to her. She further stated Resident #1 had no order for weekly skin assessments input into the computer until 07/15/21. She stated the order should have been put in by the admitting nurse or else the weekly skin assessments for the resident would not populate and nurses would not know to perform a skin assessment. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Unit Manager on 08/12/21 at 5:55 p.m. revealed she put the order in the computer for Resident #1's weekly skin assessments on 07/15/21. She stated she just noticed a weekly skin assessment was not listed on the resident's TAR and felt it needed to be added, to ensure weekly skin assessments were done. She confirmed if the weekly assessments were not listed on the TAR the computer would not populate an assessment for the nurses to see. She stated she did not assess the resident's skin when she noticed weekly assessments were missing from the TAR and did not tell the nurse to perform an assessment. The Unit Manager was asked about why she did not perform a skin assessment for the resident or ensure nurses performed an immediate skin assessment when she realized they were not being performed. She stated she had no explanation about why she did not perform a skin assessment or ensure nurse performed an assessment for Resident #1 on 07/15/21. Review of Resident #1's weekly skin assessments revealed no skin assessments were performed until 07/19/21, 18 days after admission. Subsequent weekly skin assessments were performed on 07/26/21 and 08/02/21, all three-weekly head to toe skin assessments reflected the resident's skin was clear even though the WCP assessed the resident on 08/02/21 with five unstageable pressure ulcers. Interview with LVN B on 08/11/21 at 3:25 p.m. revealed she documented Resident #1's skin weekly skin assessment dated [DATE] as being clear. She stated she asked the CNAs daily about the condition of the resident's skin and if she was present during incontinent care and repositioning, she would do a skin check. She stated she did not perform a skin assessment for Resident #1 when she documented she had on 07/26/21. She stated she depended on the CNAs to tell her if a resident had any skin issues. She further stated she should have assessed the resident's entire body, and in the future, she would not rely on the CNAs. Interview with LVN B on 08/13/21 at 1:43 p.m. revealed she documented she performed a weekly skin assessment for Resident #1 on 08/02/21. She states she did not look at the resident's skin but depended on the CNAs to inform her of any skin issues. If the CNAs did not report any skin issues to her she documented the resident's skin was clear. She now knows she is to perform a complete head-to-toe assessment to include inspecting the resident's skin all over the body. Interview with CNA C on 08/12/21 at 1:52 p.m., she stated she provided care for Resident #1 and recalled a dark brown area on the resident's bottom, but was unable to recall what day. She stated the skin looked like an old healed area and was not open. She was not able to verbalize any size of the area. She further stated she informed the charge nurse, LVN B, and told the nurse she had been putting barrier cream on the area. The nurse did not say she should do anything different. Additionally, CNA C stated she had not completed shower skin sheets for the resident because she was rushing to get her work done. She stated she knew she should have completed the shower skin sheets. Interview with the TN on 08/11/21 at 10:35 a.m. revealed she was informed by someone of Resident #1's wound sometime at the end of July 2021, but she did not notify the resident's RP or physician. She stated she did not know why she did not notify the resident's family or physician, but at that time she was still performing ADON duties and TN duties. She stated prior to that the resident was not receiving any wound care. Interview with the TN on 08/12/21 at 5:00 p.m., she stated LVN A never told her Resident #1 admitted with any skin issues. She stated she performed the weekly skin assessment for Resident #1 on 07/19/21 and the resident's skin was clear. She stated she recalled on Friday 07/30/21, a CNA told her the resident had skin issues and that was the date the wounds were first discovered. She stated she assessed the resident with a black unstageable wound to the sacrum, and deep tissue injuries to the right and left heels. She documented her assessment on a note pad that was accidently placed in the shredder before she was able to document in Resident #1's clinical records. She stated she placed bilateral heel protectors on the resident and Performed treatments of skin prep to all the areas except the sacrum. She performed the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She further states she decided what treatments to use due to learning what type of treatments the WCP used during his visits. The TN further stated she contacted the WCP and the resident was placed on the list to be seen on Monday (08/02/21). The TN stated she did not receive any orders for wound care for Resident #1 or notify the resident's physician of the wounds discovered on 07/30/21. She stated she should have notified the physician and obtained wound care orders, but she did not know why she omitted notifying the physician. Additionally, the TN stated she had not been aware to perform skin assessments for newly admitted residents until the Regional Nurse informed her today (08/12/21) during training. Interview with the TN on 08/13/21 at 4:25 p.m. revealed when she was made aware of Resident #1's wounds on 07/30/21, and she believed she just forgot to notify the physician and RP. She stated she was busy performing ADON duties and TN duties at that time. She stated she was still doing both jobs up until yesterday (08/12/21) when the Regional Nurse told her from now on, she would only be required to perform TN duties. When asked if wound care had been performed for Resident #1 during the weekend of 07/31/21-08/01/21, she stated she did not know. Review of Resident #1's entire clinical records revealed there was no documented assessment of the wounds on 07/30/21. Review of Resident #1's TARS and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LVN D on 08/13/21 at 3:05 p.m. revealed he worked the weekend of 07/31/21-08/01/21. He stated he was the charge nurse assigned to provide care for Resident #1 and worked evening/night double shifts (2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m.) on 7/31/21 and evening shift (2:00 p.m. to 10:00 p.m.) on 08/01/21. He further stated he did not provide any wound care or treatments for Resident #1 during the weekend of 07/31/21-08/01/21. He stated there were no orders for wound care, he was not aware the resident had a wound and no treatment was listed on the TAR. Interview with RN E on 08/13/21 at 3:08 p.m. revealed he worked the weekend of 07/31/21 and 08/01/21 and was the charge nurse assigned to provide care for Resident #1 during the day shifts (6:00 a.m. to 2:00 p.m.) on both days. He further stated he did not provide any wound care or treatments for Resident #1 during the weekend of 07/31/21-08/01/21. He stated there were no orders for wound care, he was not aware the resident had a wound and no treatment was listed on the TAR. Review of Resident #1's initial WCP evaluation dated 08/02/21 reflected the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] (1) Left heel-unstageable DTI measuring 1.5 by 2 cm (LXW). (2) Right heel-unstageable DTI measuring 7 by 6.5 cm (LXW) presenting as a blood-filled blister. (3) Right hip-unstageable DTI measuring 7 by 3 cm (LXW). (4) Right lateral ankle-unstageable DTI measuring 2 by 1 cm (LXW). (5) Coccyx-unstageable necrotic wound to the coccyx measuring 8 by 4 cm (LXW) with thick adherent black necrotic tissue described as eschar (dry dark falling away dead tissue). Surgical debridement was performed to the coccyx during the evaluation to remove necrotic tissue. Review of WCP wound care orders dated 08/02/21 revealed skin prep daily was ordered for all wounds except the coccyx. The wound care orders for the coccyx were Calcium Alginate and Santyl daily. Interview with the WCP on 08/13/21 at 10:52 a.m. revealed he had assessed Resident #1 with multiple unstageable deep tissue injuries on 08/02/21. He stated the wounds did not appear to be newly developed and should have been receiving treatments prior to his visit on 08/02/21 if nursing staff had been aware of the wounds. Review of Resident #1's clinical notes dated 08/05/21 reflected the resident was noted with a blood glucose of 564, blood pressure was not obtainable, respirations were rapid and uneven. Orders were received to transfer the resident to the hospital for evaluation. Interview with LVN B on 08/11/21 at 11:06 a.m. revealed she was the charge nurse for Hall 200 where Resident #1 resided. She stated on 08/05/21, the resident was experiencing a change in condition to include low oxygen saturation levels, elevated blood glucose and a change in mental status prior to transfer to the hospital. She further stated the TN performed wound care and weekly skin assessments. She stated no one had ever told her anything about skin assessments. Review of Resident #1's hospital records revealed the resident admitted to the hospital ICU on 08/05/21 non-verbal, with [CONDITION(S)], fever and admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment included intravenous antibiotics and aggressive volume resuscitation. Review of hospital records dated 8/5/21 revealed Resident #1 was admitted with the following pressure ulcers: (1) left lateral foot/heel DTI, (2) left medial foot DTI, (3) right heel DTI, (4) right lateral ankle with black eschar, (5) left hip red blanchable, (6) left elbow DTI, (7) left hip DTI, (8) right elbow DTI and (9) coccyx unstageable with black eschar. No measurements documented during this assessment note. Review of a hospital wound consult dated 08/09/21 revealed Resident #1 admitted with upper and lower extremity contractures, a large sacral pressure ulcer and multiple lower extremity pressure ulcers. Wound exam dated 08/09/21 reflected: (1) Sacral area with full-thickness pressure ulcer measuring 7.5 by 9.0 (LXW) centimeters (cm) in the form of clusters likely a Stage IV. The wound bed appeared with very minimal pink-red viable tissue, mostly adherent slough, and necrotic tissue. The bone was palpable beneath the necrotic tissue. The wound included the sacrococcygeal and buttock. (2) Right hip with deep tissue injury, skin was still intact and 100% purple maroonish discoloration. The area measured 3.5 by 1 cm (LXW). (3) Right heel with full thickness pressure ulcer deep tissue injury measuring 5.5 by 6 by 0.1 cm. (LXWXD) mostly purple maroonish discoloration with some black necrotic tissue evolving. (4) Left medial foot and left heel revealed a deep tissue injury. The left media foot measured approximately 1.5 by 1.5 cm (LXW) and the left heel measured 1 by 1 cm (LXW) with purple maroonish discoloration beneath the level of the skin. The left media foot noted with areas of evolving necrotic tissue. (5) Right lateral ankle with deep tissue injury measuring approximately 2.5 by 2 cm. (LXW) (6) Right elbow and (7) Left elbow with deep tissue injuries that appeared to be resolving. No color or measurements in this note. (8) Left hip with some non-blanchable [CONDITION(S)] measuring 3.5 by 4.0 cm (LXW) appeared to be resolving. (9) Right great toe with deep tissue injury appeared stable measuring 1 by 0.5 cm (LXW) (10) Left lateral foot reveals clusters of deep tissue injuries with purple maroonish discoloration beneath the level of skin. No measurements in this note. Review of hospital wound care orders dated 08/09/21revealed treatment Dakin's half-strength and moist gauze covered with foam dressing two time daily for the sacrococcygeal ulcer and [MEDICATION(S)] paint to the lower extremity foot DTI and unstageable pressure ulcers. Continue with foam dressings to the right heel, left heel, right hip, and left hip. The wound consult notes for Resident #1 reflected the overall prognosis for wound healing was very poor specifically for the sacral pressure ulcer and right heel secondary to the resident's comorbidities, bedbound status, incontinence, lower and upper extremity contractures. Conservative wound care treatment plan was to keep the wounds as clean as possible and keep the resident comfortable. Review of Resident #1's hospital discharge summary dated 08/11/21 revealed surgical debridement was performed by general surgery of the sacrococcygeal ulcer and showed an abscess. Wound culture currently showed no growth, workup was ongoing, but family opted for palliative care and the resident was discharged home with hospice care on 08/11/21. Interview with the DON on 08/11/21 at 3:02 p.m. revealed the facility's protocol for all new admission was that the TN would assess the resident's skin in addition to the admission nurse's skin assessment. She stated there should be a complete skin assessment to include a description and measurements documented by the admitting nurse for any skin alterations noted. The admitting nurse was responsible for notifying the physician of skin alterations and initiating any orders received. Interview with the Regional Nurse on 08/12/21 at 1:10 p.m. she stated the TN was new to the position and had not been fully trained in all the company's policies/rules. The TN needed orientation, training, education, and it would be completed by next week to ensure the TN was fully educated on her position. She stated a 100% facility skin sweep was completed last evening, physicians were notified, wound care orders were received, and treatments initiated for residents discovered with unidentified wounds. Interview with the Regional Nurse on 08/13/21 at 9:41 a.m. revealed the facility's company policy was to have weekly SOC (Standard of Care) meetings to discuss facility systems to include skin, weights, and falls. She stated she was not in the facility daily and did not know if the SOC meetings were occurring. She further stated the DON was responsible for oversite of nurses to ensure wound treatments, wound/skin assessments were performed. The TN role changed from Unit Manager to TN 07/26/21. Interview with the DON on 08/13/21 at 11:28 a.m. about SOC meetings, revealed she and the TN reviewed skin sheets and the WCP weekly reports. She stated she had previously told the TN to perform skin assessments for all newly admitted residents after the admitting nurse performed a skin assessment. She stated she started her employment at the facility 06/01/21 and weekly SOC meetings to discuss the facility's systems including systems related to skin and pressure ulcers had not yet been initiated. Interview with Resident #1's primary physician on 08/13/21 at 1:25 p.m. revealed he did not recall if the resident admitted with wounds or being notified of the resident's wounds. He stated it was possible for bacteria to enter the body through any wound. 2. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed the resident was a [AGE] year old male admitted to the facility on [DATE]. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment reflected the resident was always incontinent of bowel/bladder, used a wheelchair for mobility and required extensive physical assistance of two people for bed mobility, extensive physical assistance of one person for transfers, eating, dressing and hygiene. The assessment reflected the resident was at risk of developing pressure ulcers but had no pressure ulcers/injury at the time of the assessment. The residents BIMS score was one indicating severe cognitive impairment. Review of Resident #2's current care plans dated 10/21/20 and review date of 05/12/21, revealed the resident's risk for pressure ulcer development was addressed. Interventions included preventing shearing, friction, keeping bed linens free of wrinkles and performing weekly skin assessments and recording findings. Review of Resident #2's current Braden Scale for predicting pressure ulcer risk dated 05/12/21, revealed a score of 15, indicating the resident was at a mild risk for the development of pressure ulcers. Observation/assessment of Resident #2's skin with the TN on 08/11/21 at 12:22 p.m. revealed the resident was resting in bed on an air mattress. Pressure relief booties were noted on the resident's bilateral feet. The resident was observed with dark black colored, deep tissue injuries to the bilateral heels. When the TN was asked what the discoloration was, she stated, it's nothing looks like an old healed area. The Regional Nurse was notified on 08/12/21 at 11:30 a.m., by the surveyor that Resident #2 was observed with the TN on 08/11/21 with deep tissue injuries to his bilateral heels and the TN had not identified the deep tissue injuries. The Regional Nurse stated she assessed Resident #2 earlier on 08/12/21 with the TN and told the TN the resident had bilateral heel deep tissue injuries. She further stated the TN was new to the role and was being trained today 08/12/21. Review of a wound assessment completed by the TN for Resident #2 on 08/12/21, after surveyor intervention revealed the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The left heel deep tissue injury measured 4 by 1.8 cm (LXW) and the right heel measured 2 by 2.5 cm (LXW) Wound care orders dated 08/12/21 reflected treatment with skin prep daily to both heels. Review of Resident #2's weekly skin assessments dated July and August 2021, revealed the resident's skin was clear to include the most recent assessment performed and documented by RN E on 08/05/21. Interview with RN E on 08/12/21 at 5:45 p.m. revealed he was the charge nurse assigned to provide care for Resident #2. He stated he performed weekly skin assessments for Resident #2, and last week he noticed the resident had deep tissue injuries on both heels. He stated he did not document the observation or initiate a wound assessment form. He further stated he did not notify the TN, physician or provide any treatment. He stated, he assumed the TN would take care of it. When asked about how the TN would know about the resident's impaired skin if he did not tell her, he stated, he should have reported it to the TN but provided no explanation about why he did not. Interview with the Regional Nurse on 08/13/21 at 3:45 p.m. revealed prior to 07/26/21, when the TN assumed the position as the TN, nurses were responsible for performing resident weekly skin assessments. Review of the facility's policy/procedure entitled Patient Care Management System 1 related to skin/pressure ulcers, dated November 2017, revealed, 1. A head to toe skin assessment must be completed and documented by the Admitting Nurse upon admission (including re-admission) of every Patient. In addition, nurse must notify the physician and Patient representative of any identified areas and must implement treatment and interventions. 5. A Weekly Head-to-Toe Skin assessment must be completed and documented on the day of admission (including re-admission), once weekly, and prior to discharge/transfer of a Patient. 6. A Wound Assessment must be completed and a narrative of each site must be documented weekly for any pressure injury and non-pressure skin condition, including but not limited to Arterial Ulcers, Diabetic [CONDITION(S)] Ulcers, [CONDITION(S)] Ulcers, Bruises, Skin Tears, and surgical Wounds. An Immediate Jeopardy (IJ) was identified on 08/12/21 at 2:57 p.m. The IJ template was provided to the Administrator on 08/12/21 at 2:57 p.m. The Administrator and Regional Nurse were notified on 08/12/21 at 2:57 p.m. that an Immediate Jeopardy was identified on 08/12/21. The Administrator was provided the Immediate Jeopardy template on 08/12/21 at 2:57 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on 08/13/21 at 11:40 a.m. and reflected the following: Systematic Approach: 1. The facility conducted 100% Skin Rounds completed on 08/11/2021 and 08/12/2021 to ensure that all Pressure/ Non-Pressure wounds are identified. 2. Residents with newly identified pressure/ non-pressure skin issues were identified, physicians were notified, and new orders were obtained. 3. The patient representative for each patient was notified of the assessment, identified wounds and plan of care on 8/12/2021. 4. Treatment orders obtained and wounds treated; on-going treatments are in the electronic medical record and are scheduled. 5. The staff members associated with the deficient practice were counseled on 8/12/2021. Education 6. Education will be provided by the Director of Nursing or trained designee on Patient Care Management Systems #1 Skin Management, to be completed by 8/13/2021, and includes: a. Admission Head to Toe Assessments - Will be completed by the admitting charge nurse or treatment nurse upon arrival to the facility. If any skin issues (Pressure or Non-Pressure) are noted by the Charge Nurse, the Treatment Nurse will verify findings and ensure documentation identifies the wound type, description, measurements, and other characteristics. b. Weekly Head to Toe Assessments will be completed by the Treatment or designated nurse and findings will be documented in the electronic medical record. If any skin issues (Pressure or Non-Pressure) are noted, the Treatment or designated nurse will ensure documentation identifies the wound type, description, measurements, and other characteristics. c. A Weekly Wound Evaluation will be completed in the electronic medical record by the Treatment nurse or designated nurse that details the type, description, measurements, and any other pertinent characteristics noted, including if the wound has no change or is improved or deteriorated. Notification to the physician/ extender and patient representative will be weekly and include any new, changed, or discontinued orders. d. The facility will utilize the Wound Care Physician Specialist for all pressure injuries and complex non-pressure wounds. e. Notifications to the physician and/or extender and patient representative to be completed by the Admitting Nurse and/or Treatment Nurse upon admission and re-admission and with any change in the wound condition and include review of any new, changed, or discontinued orders and recommendations. f. A Braden Risk Assessment will be completed upon admission and weekly x 4 and quarterly thereafter and completed with any significant change in a patient's wound or overall condition. g. A Pain assessment will be completed by the Treatment Nurse before and after treatments to address any pain issues that may arise. h. An interdisciplinary patient screen must be completed for any patient with a braden scale score of 12 or less and reviewed by the Director of Rehab. i. Pressure Ulcer Prevention methods including, timely incontinent care, turning and re-positioning every 2 or more hours, nutrition, hydration, and off-loading. j. The Certified Nurse Aides will monitor skin every shift and enter findings in the electronic medical record touchscreen. The CNA will alert the charge or treatment nurse of any newly identified skin issues, loose dressings, or missing dressings so that appropriate clinical interventions can occur. k. A pressure injury care plan will be completed, and interventions implemented based upon the Braden score and specific patient needs. The care plan will be updated with any changes as required. 7. Clinical staff will not be allowed to work their scheduled shift until they have completed all education related to PCMS#1 Skin Management. Monitoring: 8. On-going education competency to ensure understanding of PCMS#1 Skin Management will be monitored by the DON and Nurse Managers through rounding and include: a. Verbal question/ answers to ensure understanding b. Ensuring that turning, re-positioning, off-loading and other prevention methods are in place. c. Daily review of treatment documentation by the DON for 2 weeks; decreasing to weekly thereafter. d. Treatment Nurse will report any new, improved and/ or deteriorated wounds at Stand-Up. e. DON will observe the completion of wound treatment and dressing change observation weekly x 2 and then once monthly thereafter. f. The Executive Director will participate in Stand-Up and the verbal review by the Treatment nurse or designee and review the Weekly Wound Evaluation Log each week. 9. The Medical Director, Dr. Avian [NAME], has been notified of the Immediate Jeopardy status. 10. Rounding to ensure prevention methods are in place has been completed today 08/12/2021. Quality Assurance: 11. DON or designee will conduct a weekly random audit for a period of 4 weeks ensuring nursing staff and the treatment nurse continue to follow Policies & Procedures for Skin Management and Pressure Ulcer Prevention. 12. DON or designee will conduct documentation review to ensure all wounds have orders and a weekly head to toe is scheduled. 13. Monitored shifts include 6a-2p, 2p-10p 10p-6a, and the double weekends (6a-10p). 14. The DON will submit audit findings to the QA Committee for review, analysis, and recommendations. 15. Completion date 8/13/2021. The following interviews, and record reviews conducted to verify the implementation of the facility's Plan of Removal revealed the following: Interviews conducted with 6 LVNs and 2 RNs across multiple shifts on 8/13/21 from 1:32 p.m. to 3:22 p.m. revealed the nurses verbalized comprehension of the in- service training. They stated they had been in-serviced on the facility's policy/procedure to include completing a full skin assessment on new admissions and documenting any noted skin impairments to include a description, measurements, and color. The stated if a resident was noted with any skin impairment notification of the TN and the physician for treatment orders and they were to initiate the treatment. Weekly skin assessments were t[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure resident environment remained as free of accident hazards as possible for one (Resident #2) of 18 residents reviewed for accidents. On 05/28/19 the facility failed to ensure Resident #2's room was free from environmental hazards. Painter B left a large, tube shaped fluorescent light bulb inside Resident #2's room near the door. The light bulb was broken and Resident #2 sustained a laceration above his right eyebrow that required an overnight stay in the hospital and sutures. This failure could place residents at risk for injuries, hospitalization , and significant harm. Findings included: Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 05/16/19 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He had a Brief Interview Mental Status (BIMS) of 06, which indicated he was severely cognitively impaired. Resident #2 required supervision of one staff with his daily activities. The resident was not steady and was only able to stabilize with staff assistance. Review of the facility's Provider Investigation Report, signed and dated by the DON on 05/31/19, revealed on 05/28/19 Painter B left a fluorescent light bulb in Resident #2's room while changing out light bulbs in the facility. This resulted in Resident #2 receiving a laceration to his right eyebrow when the light bulb was broken. The investigation report concluded that Resident #2 was injured when he kicked or squeezed the light bulb left in his room by Painter B. The resident had a history of [REDACTED]. He was found in his room by LVN C bleeding above his right eye. He was assessed and his wound was cleansed and dressed. The post investigation provider action section of the report indicated all rooms in the facility were checked for hazardous materials or unsafe work environment, the painter was re-educated about safe work environment and was suspended pending investigation, and the facility staff was in-serviced on abuse and neglect. Staff and the painter were in-serviced on ensuring resident rooms were kept free of hazards and obstructions. Review of a facility incident report, dated 05/28/19 revealed the following: On 05/28/19 the nurse overheard a loud noise and upon investigation discovered Resident #2 in his room bleeding from the right side of his face. Resident #2 was assessed and found to have a laceration above the right eyebrow. He was sent to a local hospital for further evaluation. Review of Resident #2's care plan initiated 05/28/19 revealed he was at risk for falls related to gait/balance problems. Interventions included a rehab screening and education to keep environment free of clutter to prevent falls/injury. Resident #2's care plan initiated on 04/30/19 revealed he was at risk for falls related to an actual fall, with interventions including keeping the areas free of obstructions to reduce the risk of falls or injury. Review of a written statement by Painter B dated 05/28/19 revealed: I was changing out light bulbs in necessary rooms today and I accidentally left light bulbs in (Resident #2's ) room in the entrance on the right side of the room. In an interview on 06/11/19 at 1:11 PM Painter B revealed, on 05/28/19, he was changing out the light bulbs in Resident #2's room and he stepped out of the room for a moment to grab an item off his cart. Painter B stated he forgot the light bulb in the resident's room when he moved on to the next task on his list. He said they normally remove everything they brought into resident rooms when they leave but he was in a rush and just forgot to retrieve the light bulb. He said he found out what had occurred when his supervisor came to him and told him about it. He had only been working at the facility for a few weeks prior to the incident. He said that he was suspended for two days after the incident while an investigation was conducted. Painter B stated that he received an in-service and additional one on one training upon his return to the facility. In an interview on 06/11/19 at 1:55 PM LVN C revealed it was around 2:00 PM on 05/28/19 when she heard a loud boom. She stated she began searching the resident rooms, and she found Resident #2 in his room on the floor with what appeared to be smoke and glass from a broken light bulb around him . LVN C stated Resident #2 was bleeding from his forehead on the right side and was grimacing. LVN C stated Resident #2 was cognitively impaired, so he was not able to tell her with certainty what had occurred, but she thought that he had either kicked the light bulb or squeezed it and broke it. She stated she did not see any glass in the wound and applied pressure to the area. LVN C stated the wound nurse came to the resident's room, cleaned the area, and put a dressing on it. She stated Resident #2 was sent to the hospital for further evaluation. LVN C stated Resident #2 was given pain medication prior to leaving the facility and did not appear to be in any distress when he left the facility. She stated he returned to the facility the next day in stable condition. LVN C stated the facility conducted education training covering abuse, safety, items that should not be left in resident's rooms, and fall risks. Review of educational materials provided following the incident revealed that all departments in the facility had been provided the education. In an interview on 06/11/19 at 2:10 PM Wound Nurse D revealed on 05/28/19, the day of the incident involving Resident #2, she was on another hall when she was called to come and assess Resident #2. Wound Nurse D stated Resident #2 was bleeding from his forehead when she arrived at his room to assess him. She stated she cleaned the wound and realized the wound appeared to be more than she felt could be steri-stripped so she applied a pressure dressing to the area. She said there was no glass in the wound, but Resident #2 did have some fragments of glass in his hair. Wound Nurse D stated Resident #2 kept telling her he was fine and wanted to know what the issue was. She stated he was taken to the hospital by EMS and returned to the facility the next day. Wound Nurse D stated upon his return Resident #2 had three sutures to the forehead area right above his right eyebrow. An interview was attempted on 06/11/19 at 2:00 PM with Resident #2, and revealed he had no recollection of the incident. An interview with the SW on 06/12/19 at 11:35 AM revealed the facility held in-services with all of the staff regarding environmental safety and hazards in the work place. In an interview on 06/13/19 at 12:45 PM the facility administrator revealed that it was her expectation that all departments including maintenance follow the facility policy and keep the facility free of clutter and hazardous materials. She said that Painter B should not have left the light bulb in Resident #2's room. She said that Painter B had been suspended pending investigation and was able to return to work once he received the education on hazardous materials and safety in the workplace. In an interview on 06/13/19 at 1:45 PM the Maintenance Director stated on 05/28/19 Painter B was to make rounds and change light bulbs throughout the facility as needed. Painter B stated he forgot a bulb in Resident #2's room. The Maintenance Director stated while working in another resident's room he heard a loud pop. He stated he came out of the room he was working in and noticed a commotion. The Maintenance Director stated he followed the staff into Resident #2's room, and the nurses were tending to Resident #2. He stated he began to look around in the room to make sure the light bulb had not fallen out of the fixture, but the light in the fixture was intact. The Maintenance Director stated he and Painter B made rounds in all rooms of the facility and found no missing light bulbs. He said all existing bulbs were intact as well. He said the following day he made an additional round to ensure that there had been no changes. The Maintenance Director stated education was provided to Painter A for hazards, safety, and abuse. The Maintenance Director stated Painter B was in-serviced on ensuring all materials brought into residents' rooms were accounted for when they leave in order to ensure the safety of the residents, not leaving any materials unattended, and that the materials cart should be within eyesight at all times.

Based on observation, interview and record review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as was possible for one (Resident #1) of nine residents identified as being at risk for elopement. The facility failed to ensure the alarm on one of six emergency exits had been reset and alarmed when Resident #1 eloped from the facility through the emergency exit. The alarm did not sound when Resident #1 left the building. Once outside the facility, Resident #1's wheelchair turned over, and the resident fell to the ground sustaining a fractured shoulder/arm. Facility staff were in-serviced on how to reset the emergency exit door alarms following the incident with Resident #1 on 11/14/10. The Maintenance Supervisor continued to find the alarms at the emergency exit doors had not been reset and failed to alarm when tested . These failures could affect the nine residents identified at risk for elopement, including Resident #1, and placed them at risk for eloping and injuring themselves. t ground and sustained a fractured arm/shoulder. Once outside, Resident #1 turned her whair Findings included: Review of the monthly consolidated physician's orders [REDACTED]. Review of a Minimum Data Set (MDS) assessment dated [DATE] and coded as a quarterly assessment revealed Resident #1 had short-term and long-term memory problems, had moderately impaired cognitive skills for daily decision-making, was easily distracted and her mental function varied over the course of the day. The MDS assessment reflected Resident #1 was dependent on two staff for transfers. The MDS assessment reflected Resident #1 required supervision and set-up help only for locomotion on and off the unit. Resident #1's Comprehensive Care Plan dated 08/25/10 reflected, "Resident at risk for increasing confusion and decline in cognitive status related to dementia." A Comprehensive Care Plan dated 11/14/10 reflected Resident #1 was at risk for falls due to her cognitive impairment. Review of Resident #1's Elopement Risk Evaluations dated 05/01/10, 08/01/10, and 11/01/10 revealed she was a moderate risk for elopement and "Implement Elopement Risk Care Plan." An Elopement Risk Evaluation dated 11/14/10 reflected Resident #1 was an "imminent risk" for elopement. Review of the facility's Provider Investigation Report dated 11/19/10 and signed by the Administrator revealed on 11/14/10 at approximately 5:40 p.m., Resident #1 was observed outside the facility "on the grass." The report reflected Resident #1 was on her right side with her "wheelchair turned over." The report reflected the door alarm did not sound to alert staff Resident #1 had exited the facility. The report reflected Resident #1 complained of shoulder pain, ice was applied, and an X-ray was ordered, which revealed a fractured right shoulder. Provider Action Taken Post-Investigation included the door alarms were checked, the Maintenance Director would continue to check the alarms daily, and "Maintenance Director in-serviced all staff on use of alarms and how to reset after each time alarm sounds off." On 11/30/10 at 9:40 a.m., the Administrator revealed Resident #1's room was the last room on the hall and was immediately adjacent to the emergency exit for that hall. The Administrator said Resident #1 eloped from the facility on 11/14/10 at 5:40 p.m. by leaving through that door. The Administrator stated the "alarm wasn't triggered" when Resident #1 eloped. The Administrator further stated family members/visitors used the emergency exit door to access the parking lot even though there was a sign on the door indicating it was an emergency exit only, and the alarm would sound. The Administrator stated family members "know how to turn the alarm off." The Administrator did not know which family member left through the emergency exit door prior to Resident #1 eloping on 11/14/10 at 5:40 p.m., she did not know of any particular family members, who regularly used the emergency exits when they left the building. She revealed the alarm sounded approximately once per week due to a family member using the exit to depart the building. The Administrator stated she did not think the alarm was triggered by residents on a regular basis. She said Resident #1 was confused and not seeking to exit or elope from the facility. The Administrator told the surveyor the staff was in-serviced after the incident on 11/14/10 on how to disable and reset the emergency door alarms and how to respond when the alarms sounded. Resident #1 was discovered outside the building with an injury by the weekend supervisor, RN A, at 5:40 p.m., during "rounds." The Administrator stated RN A said she heard the alarm sound earlier in the day a "few times" on 11/14/10, but it did not sound when Resident #1 eloped at 5:40 p.m. On 11/30/10 at 9:40 a.m., the DON stated she heard the emergency door alarms sound approximately once per week. On 11/30/10 at 10:48 a.m., LVN B revealed she heard the emergency door alarms sound approximately twice per week, and it was usually visitors or church members exiting, who did not know an alarm would sound. On 11/30/10 at 10:49 a.m., LVN C said she heard the emergency door alarms sound approximately twice per week, and it was usually visitors or church members exiting, who did not know an alarm would sound. During the same interview, LVN C stated staff members needed to enter a code when the emergency exit alarms were activated and then enter another code to reset the alarm. She said she "was surprised" the alarm on the emergency exit door Resident #1 eloped from was not reset. She stated "even new staff members are reminded everyday" when the Maintenance Supervisor tested the alarms. LVN C stated staff members responded to the alarm when activated by checking the door. When the Maintenance Supervisor tested the alarm, he quizzed staff members about how to disable and reset the alarm. LVN C further stated it was only new family members or visitors, who triggered the alarms and not usually residents. She also stated she did not know of any family members, who repeatedly set off the emergency door alarms. On 11/30/10 at 10:58 a.m., the Maintenance Supervisor told the surveyor he had in-serviced all staff members after the incident on 11/14/10 when Resident #1 eloped. He stated during the in-service, he reviewed the steps to disable and reset the alarms on the emergency exit doors. The Maintenance Supervisor also stated he performed a drill once per day during which he checked all emergency exit doors to see if the alarms were activated and operating accurately. He added he performed these checks on different shifts and days regularly to see if staff members were familiar with the procedures in responding to, disabling and resetting the alarms. The Maintenance Supervisor said he documented these drills by keeping track of date, time and which alarms were activated at the time. He further stated he heard the emergency exit alarms go off approximately four to five times per month. The Maintenance Supervisor added staff members regularly accessed three emergency door exits that lead to parking lots. He stated one emergency door also provided easy access to a gas station where staff went to buy snacks and other items. He told the surveyor staff members disabled the emergency door alarms and either forgot to reset them or chose not to reset the alarms. He also stated staff members would "prop the doors open" while they were outside the building and would either forgot to reset or chose not to reset the alarms. The Maintenance Supervisor stated all emergency exit alarms were battery-operated and not affected by power outages or storms. Review of the Maintenance Supervisor's daily drills revealed he found the emergency exit alarms disabled on 13 occasions during the month of November 2010 and on four occasions during the month of October 2010. Review of the Maintenance Supervisor's daily drills further revealed he found the emergency exit alarms disabled on four occasions (11/17/10, 11/18/10, 11/20/10, and 11/29/10) after the incident on 11/14/10, when Resident #1 eloped. The Maintenance Supervisor's daily drill log also reflected he found four of six emergency exit alarms disabled on 11/12/10 and three of six alarms disabled on 11/10/10. On 11/30/10 at 1:26 p.m., RN A stated on 11/14/10 at approximately 5:30 p.m., she observed a "lady" outside the 100 hall exit door trying to get someone's attention. RN A stated she told the person to go around the building. At approximately 5:40 p.m. on 11/14/10, a staff member told her Resident #1 fell outside. RN A further stated she could not remember which staff member informed her of Resident #1's elopement. She observed the same unidentified female next to Resident #1 holding her hand. RN A stated she remembered hearing the emergency exit alarms go off earlier that day but stated the alarm on the emergency exit door through which Resident #1 eloped, was not activated. She added she thought the alarm had "malfunctioned." Resident #1's nurses' note dated 11/14/10 and timed 1740 (5:40 p.m.) reflected RN A reported the resident was observed lying outside. The note reflected Resident #1 was observed outside at the end of the 100 hall ramp on the grass with her wheelchair turned over near her right side. The note reflected Resident #1 complained of severe pain. Resident #1's clinical record revealed an X-ray report dated 11/14/10, which reflected the following detail: "Right humerus: Two views are presented demonstrating an oblique fracture through the distal metaphysis of the humerus. There is one half a shaft with lateral displacement of the distal fracture member. Impression: Acute right humerus fracture." On 11/30/10 at 2:28 p.m. the DON revealed the Nursing Staff would review every resident's chart to determine which residents were at risk for elopement. On 12/01/10 at 8:50 a.m. the Administrator revealed the staff reviewed and updated all the residents' charts to include current Elopement Risk Assessments and Elopement Risk Care Plans if needed. Record review revealed nine residents, which included Resident #1, in the facility were assessed as being a risk for elopement. Resident #2's face sheet reflected she was diagnosed with [REDACTED]. Resident #3's face sheet reflected she was diagnosed with [REDACTED]. Resident #4's Elopement Risk Evaluation dated 11/07/10 reflected he was assessed as a Moderate Risk for elopement, and he ambulates or propels himself. Resident #5's Elopement Risk Evaluations dated 04/29/10, 07/29/10, 10/29/10 and 11/10/10 reflected that she was assessed as a Moderate Risk for elopement, and she ambulates or propels herself. Resident #6's face sheet reflected that she was diagnosed with [REDACTED]. Resident #7's Elopement Risk Evaluations dated 02/01/10, 04/29/10, 07/29/10 and 10/29/10 reflected that he was assessed as a Moderate Risk for elopement and that he ambulates or propels himself. Resident #8's face sheet reflected she was diagnosed with [REDACTED]. Resident #9's face sheet reflected that she was diagnosed with [REDACTED]. Resident #9's Elopement Risk Care Plan dated 10/29/10 reflected she "has a potential risk for elopement." Resident #1's Fall Risk Assessments dated 01/20/10, 02/08/10, 05/02/10, 05/04/10, and 09/14/10 all assessed the resident with a score of "14." On 11/14/10, a new assessment was done and reflected a total score of "16." The assessment sheet reflected the higher the score, the greater risk. "Total score of 10 or above represents high risk." On 11/30/10 at 2:28 p.m., the DON said Resident #1 was still able to propel herself unassisted in her wheelchair post injury. During rounds with the Maintenance Director on 11/30/10 at 2:45 p.m. the alarms to the exit doors were activated. None of the alarms had been disabled or turned off by staff or visitors. On 11/30/10 at 2:48 p.m., the Administrator stated the Maintenance Supervisor would change the code to all exit alarms, and only the Administrator and the Maintenance Supervisor would have the code to disable the alarms. She further stated if an alarm was triggered, and the code was given to a staff member to disable the alarm, the code would be changed immediately. During an interview with the Administrator on 12/01/10 at 8:50 a.m., it was revealed staff had provided one-on-one supervision to Resident #1 the previous night. The Administrator stated Resident #1 was the only resident currently identified as a high risk for elopement.