Every finding on record at Ussery Roan Texas State Veterans Home

Based on observation, interview, and record review, the facility failed to provide or obtain pharmaceutical services to meet the needs of its residents for 3 out of 4 medication carts (Hall 400, Hall 500, and Hall 600 Medication Carts) reviewed. The facility failed to complete mandatory daily quality control (QC) checks on glucometers to ensure accurate diagnostic readings for 3 out of 4 medication carts (Hall 400, Hall 500, and Hall 600 Medication Carts) from December 1st, 2025 to July 27th, 2026 on night shift. This failure could place residents at risk for severe medication errors, inappropriate dosing, and serious injury or hospitalization.Findings included: During a record review on 07/28/2026 at 12:05 PM, it was noted that glucometer control logs for Hall 400 and Hall 500 medication carts were missing information. The missing information spanned a period from December 2025 through July 2026. Missing dates for Hall 400 glucometer logs included December 12th, 17th, 18th, 19th, 21st, 23rd, and 31st of 2025, January 3rd, 4th, 11th, 13th, 14th, 15th, 16th, 18th, 19th, 20th, 22nd, 24th, 28th, and 31st of 2026, February 1st, 2nd, 3rd, 10th, 12th, 17th, 18th, 19th, 20th, 25th, 27th, and 28th of 2026, March 2nd, and 31st of 2026, April 24th and 27th of 2026, May 4th, 8th, 9th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 24th, 25th, 26th, 27th, 29th, 30th, and 31st of 2026, June 1st, 9th, and 10th of 2026, and July 2nd, 3rd, 13th, 14th, and 22nd of 2026. Missing dates for Hall 500 glucometer logs included January 5th, 6th, 14th, 15th, and 21st of 2026, February 6th, 7th, and 8th of 2026, April 3rd, 4th, 5th, and 18th of 2026, May 3rd and 17th of 2026, June 5th, 14th, 21st, and 28th of 2026, and July 1st, 2nd, 11th, 12th, and 13th of 2026. During an interview on 07/28/2026 at 12:05 PM, LVN F stated that glucometers should be checked every night shift. She stated that the preceptor training the employee or new staff oversaw training them how to complete the QC checks. During a record review on 07/29/2026 at 8:55 AM, glucometer control logs were checked for the Hall 800 medication cart, which revealed that logs for March 2026 through July 2026 were present, though all available logs were completed. During a record review on 07/29/2026 at 9:00 AM, glucometer control logs were checked for the Hall 600 medication cart for dates including December 2025 through July 2026. It was noted that glucometer control logs for Hall 600 medication cart were missing information. The missing information spanned a period from December 2025 through July 2026. Missing dates included December 1st, 4th, and 24th of 2025, February 10th, 14th, 15th, 16th, 19th, and 28th of 2026, March 2nd, 5th, 6th, 10th, 15th, 16th, 19th, 23rd, 24th, 27th, 28th, 29th, 30th, and 31st of 2026, April 13th and 17th of 2026, May 13th of 2026, June 2nd and 15th of 2026, and July 3rd, 4th, 5th, 17th, and 18th of 2026. During an interview on 07/29/2026 at 9:00 AM, LVN E stated that glucometers should be checked every night shift. LVN E stated that a negative outcome for not checking the glucometers every night could be getting a resident's blood sugar reading that was not accurate. LVN E stated that a negative outcome to the residents could be giving the wrong dose of insulin, which could lead to a blood sugar that was too high or too low. LVN E further stated that the preceptor training new staff oversaw training them on QC checks, and that the Unit Manager oversaw to ensure they were completed. During an interview on 07/29/2026 at 9:05 AM, RN P revealed that glucometers should be checked every night shift. RN R stated that a negative outcome for not checking the glucometers every night could be getting a false reading. RN R stated that a negative outcome to the resident could be that the residents receive insulin they may or may not need, which could lead to low blood sugar, hospitalization, and serious injury. During an interview on 07/29/2026 at 9:10 AM, LVN F revealed that glucometers should be checked every night shift. LVN F stated that a negative outcome for not checking the glucometers every night was getting a blood sugar reading that was off, resulting in too much or too little insulin. LVN F stated that a negative outcome to the resident could be having hypoglycemia or going into DKA and being hospitalized . LVN F further stated that Unit Manager LVN N oversaw ensuring it was completed. During an interview on 07/29/2026 at 1:14 PM, the ADON revealed that glucometers should be checked every night shift by the nurse. The ADON stated that preceptors training new employees should be training staff how to do this and that it needs to be done. The ADON confirmed that a negative outcome for not completing these checks was false readings that could affect the resident's blood sugar results, which could result in giving too much or too little insulin, leading to hypoglycemia and hospitalization. During an interview on 07/29/2026 at 2:15 PM, Unit Manager (RN M) (for Halls 600 and 800), revealed that glucometers should be checked every night shift by the nurse. RN M stated that preceptors training new employees should be training staff in how to do this and that it needs to be done. RN M confirmed that a negative outcome for not completing these checks was false readings that could affect the resident's blood sugar readings, resulting in too much or too little insulin, which could lead to hypoglycemia. Requested additional logs for Hall 800. RN M stated she did not know where they were. During an interview on 07/29/2026 at 2:30 PM, Unit Manager LVN N revealed that glucometers should be checked every night shift by the nurse. LVN N stated that preceptors training new employees should be training staff in how to do this and that it needs to be done. LVN N confirmed that a negative outcome for not completing these checks was false readings that could affect blood sugar readings, resulting in too much or too little insulin. LVN N further stated that the RN house supervisor should be verifying that these checks were completed. Record review of the facility's policy titled Glucometer Use and Cleaning (dated March 2019) revealed the following directive: Follow the manufacturers' directions and recommendations for glucometer use and cleaning. Record review of the manufacturer's guidelines for the Assure Platinum glucometers, which the facility utilized on 4 out of 4 medication carts, revealed that quality control (QC) checks should be completed every 24 hours. The guidelines noted that while there was a bypass to not complete these checks, it was the strict recommendation to complete them every 24 hours.

Based on observations, interviews, and record review, the facility failed to ensure current daily Menus were posted for residents in 1 of 1 kitchen/dining area (locked unit). The facility failed to update the posted daily menus for 4 consecutive days for residents who resided on the locked unit. This failure could place residents at risk of not knowing the meals scheduled to be served and contributing to confusion and frustration when the posted menu did not match the food provided. Findings included: During an observation on 07/28/26 at 9:12 AM, the posted menu in the locked unit dining area reflected Saturday, July 25, 2026, indicating residents would be served ham for lunch. During an observation on 07/28/26 at 11:48 AM, the posted menu remained unchanged and continued to display the menu for Saturday, July 25, 2026. During an observation on 07/29/26 at 8:40 AM, the posted menu still reflected Saturday, July 25th, 2026, rather than the current day's menu. During an interview on 07/29/26 at 10:05 AM, CNA D observed the posted menu and stated it did not reflect the correct day's menu and should have displayed Wednesday's menu. CNA D stated that if menus were not updated daily, residents would not know what meals were being served. During an interview on 07/26/26 at 10:10 AM, LVN E, the charge nurse for the locked unit, she confirmed the posted menu remained on Saturday's menu instead of the current day's menu. She stated residents had become frustrated because they expected to receive ham, as reflected on the posted menu, and residents on the locked unit could become fixated on the menu and upset when the meal served did not match what was posted. LVN E stated it was the dietary department's responsibility to ensure menus were changed daily. During an interview on 07/29/26 at 10:13 AM, AA Q stated the menu should reflect the correct day and confirmed the kitchen was responsible for updating menus daily. She stated that if menus were not changed, residents would not know what meal choices were available that day. During a confidential interview with an anonymous resident stated the outdated menus were bothersome because they did not know what would be served for lunch. During an interview on 07/29/26 at 3:19 PM, the DM stated it was the dietary department's responsibility to update menus daily and acknowledged she was unaware the locked unit menus had not been changed since Saturday. The DM stated staff were typically consistent about updating menus but acknowledged a mistake had occurred. She stated residents could become upset if they expected a meal listed on the menu but were served something different. During an interview on 07/29/26 at 10:22 AM, the ADM stated dietary staff were responsible for posting updated menus each morning in accordance with facility policy and acknowledged the locked unit menu not being changed since Saturday was an issue. He stated that residents relied on the posted menu and expected to receive the meal listed. The ADM stated when the meal served differed from the posted menu, residents could become unhappy and stressed because they had anticipated receiving a diffferent meal. Record review of the Facility Menu, dated Spring/Summer 2026, Tuesday, Week 5 reflected lunch menu would be meatloaf with brown gravy, mashed potatoes, mixed vegetables, and wheat roll. Record review of Facility policy titled, Menu Planning, dated 2023, revealed the following information in part: 1. All current menus will be posted during the appropriate time period. 5. Menus will be posted in areas that are accessible to patients/residents and at a height where all individuals can easily view them.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure freezer, refrigerator, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses.Findings included:Observation of the prep area in the kitchen on 07/28/26 at 8:07 AM revealed the following:1. (1) clear plastic bin full of individual creamers, not dated.2. (3) bags of bread - not labeled or dated.3. (1) clear plastic bin, 1/2 full, contained white substance, not labeled or dated.Observation of the pantry on 07/14/26 at 8:09 AM revealed the following:1. (1) large bin with lid, full of individual snacks, not labeled or dated.2. (3) bags of chips, not dated.3. (2) bags of cereal, half empty, not labeled or dated.4. (2) bags of marshmallow, not dated.5. (5) boxes of cream of wheat, not dated.6. (9) containers of grits, not dated.7. (6) containers of oats, not dated.Observation of the freezer on 07/28/26 at 8:15 AM revealed the following:1. (4) meat patties, not labeled or dated.2. (2) bags of shrimp, not labeled or dated.3. (1) opened box of shrimp, not labeled or dated.4. (1) tray of frozen biscuits, not labeled or dated.5. (1) [NAME] cake covered with plastic wrap, not labeled or dated.6. (7) individual ice creams, not labeled or dated.7. (1) tray of cobbler, not labeled or dated.8. (1) box with undetermined items inside, not labeled or dated.Observation of the refrigerator on 07/28/26 at 8:19 AM revealed the following:1. (1) tray of uncovered eggs, not labeled or dated.2. (1) gallon of milk, 1/4 full, not dated.3. (3) cups of covered glasses with liquid that appeared to be either tea or juice, lids were not labeled or dated.4. (2) trays containing individual cartons of health shakes, not dated.In an interview on 07/28/26 at 8:25 AM, [NAME] A stated she had worked at the facility for four months and was trained to label and date food when they were delivered from the truck and any leftover food as well. She stated it was everyone's responsibility to label and date the food in the kitchen. [NAME] A stated if that did not happen, they could serve expired food which could make residents sick. In an interview on 07/28/26 at 8:26 AM, [NAME] B stated she had worked at the facility for four weeks and was trained to label and date all food in the kitchen. She stated that everyone who worked in the kitchen was responsible for labeling and dating food. [NAME] B stated that if it did not happen, residents could get food poisoning or consume spoiled food.In an interview on 07/28/26 at 8:28 AM, [NAME] C stated it was everyone's responsibility to label and date food, and she was trained to do that. She stated the kitchen could serve spoiled food to residents if food was not labeled and dated properly, which could make residents sick.In an interview on 07/28/26 at 8:31 AM, the DM stated she had worked at the facility for over a year as the DM and it was everyone's responsibility to label and date all food in the kitchen. The DM stated not labeling and dating food could put residents at risk of foodborne illnesses and the kitchen could cause an outbreak if the food being served from the kitchen was not served during the proper time. Record review of facility policy, titled General Food Preparation and Handling, dated 2023 revealed the following information in part:4. Food Service d. Leftovers must be dated, labeled, covered, cooled and stored in a refrigerator. Record review of facility policy titled, Food Storage, dated June 2019, revealed the following in part:1. Dry Storage Rooms.d. All containers must be labeled and dated.2. Refrigeratorsd. Date, label and tightly seal all refrigerated foods.3. Freezerse. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #52) of 25 residents reviewed for resident rights. Urine was observed in Resident #52's catheter bag during the noon meal in the dining room on 7/28/26 because no privacy bag was provided to cover his catheter bag. This failure could place residents at risk of feeling uncomfortable and disrespected, leading to isolation. Findings included: Record review of Resident #52's face sheet printed 6/11/26 revealed he was an [AGE] year-old male resident admitted [DATE] with diagnoses to include hemiplegia (a condition characterized by severe or complete paralysis on one side of the body, typically resulting from brain damage), obstructive and reflux uropathy (a blockage that stops urine from flowing normally through the body, while reflux uropathy was kidney damage caused by urine flowing backwards from the bladder), and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland that commonly affects men as they age, often causing bothersome urinary symptoms). Record review of Resident #52's annual MDS assessment completed 5/28/26 listed Resident #52 with a BIMS of 4 indicating he was severely cognitively impaired, he had a functionality of being dependent on staff for his toileting hygiene, and he required an indwelling catheter. Record review of Resident #52's care plan with admission date of 8/27/24 revealed the following: Focus - Resident has an indwelling catheter r/t obstructive uropathy. Date Initiated: 08/30/2024. Record review of Resident #52's Order Summary Report printed 7/28/26 with Active Orders As Of: 7/28/26 revealed the following order:- Foley catheter care with perineal (an anatomical adjective that means relating to the perineum-the diamond-shaped area of the soft tissue located at the bottom of the pelvis between the thighs) wipes and/or soap and water Q SHIFT and PRN- schedule . Active 10/14/2024. During an observation on 07/28/2026 at 11:46 AM Resident #52 was in the dining room sitting by the front entrance in a Geri-chair (a specialized padded medical recliner with wheels designed for elderly patients or individuals with limited mobility) with approximately 40 residents and 7 staff present in the dining room. Resident #52's catheter bag was hanging from under his Geri-Chair in view of the dining room. A small amount of amber urine was observed in the catheter bag. Eleven residents could be observed seated at three tables located in front of Resident #52 that could observe the uncovered catheter bag while eating their meal. This surveyor attempted to interview Resident #52, and he did not respond to introduction or any questions. Resident #52 just stared blankly. During an interview and observation on 07/28/2026 at 12:28 PM CNA G (a CNA working the hallway Resident #52 was located on this shift) was asked to go to the dining room and evaluated Resident #52's current condition. CNA G observed the catheter was hanging from the foot of Resident #52's Geri-Chair in view of the dining room and stated, they must have replaced it (Resident #52's catheter bag) yesterday because it was usually in a privacy bag. I bet they forgot to cover it. CNA G reported this was an issue because other people could see the urine in the bag and it could be a dignity issue for Resident #52. CNA G reported she would immediately get Resident #52 a privacy bag and make sure his catheter bag was covered. CNA G reported she was not the CNA that got Resident #52 up for the noon meal. During an observation and attempted interview on 07/30/2026 at 9:22 AM Resident #52 was observed in his bed sleeping and did not wake. His catheter bag could be observed hanging from the left side of his bed between the bed and wall with no privacy bag. The bag could not be observed from the hallway or in the room. During an interview on 07/30/2026 at 9:58 AM CNA H (the CNA working on the hall Resident #52 was on this shift) reported a resident's catheter should be stored in a privacy bag off the floor with a cover. CNA H reported if a resident's catheter bag was exposed it could affect the resident and it could affect other residents especially when they were eating. CNA H reported she was not sure when the last time she was trained on catheter care that she just knew what to do, and that it had been maybe 6 months since the last time they were trained by the facility on catheter care. During an interview on 07/30/2026 at 10:03 AM LVN F (the nurse working on the hall Resident #52 was on this shift) reported a resident's catheter bag should be stored in a privacy bag and if the catheter bag was not stored in a privacy bag and that resident was in the hallway or the dining room then you have the eww factor and other residents might not like that. LVN F could not remember when the last training on catheter care was provided by the facility. During an interview on 07/30/2026 at 10:11 AM the DON reported all catheters should be stored in a privacy bag and if they were not, it would be a dignity issue affecting the resident with the catheter and if another resident saw it they might not react well. The DON reported the facility's staff development coordinator who was responsible for all staff training. During an interview on 07/30/2026 at 10:33 AM the SDC reported she trained all staff and all catheters should have a leaf cover or be in a blue bag. The SDC reported that if the resident's catheter bag was not stored in a blue bag and the bag touched the floor then it was an infection control issue. The SDC reported if residents saw discolored urine such as red with blood, then it would probably bother them. Record review of the training titled Foley Catheter Drainage Bag Safety In-Service dated 3/13/26, revealed the following: Policy Statement: All Foley Catheter drainage bags must be placed inside a designated black catheter bag holder and must remain of the floor at all times.Noted this training had been provided to 44 staff and CNA G, CNA H and LVN F did not receive the training. Record review of facility provided policy titled, Resident Rights - Statement of Resident Rights undated, revealed the following: Purpose: The purpose of this policy is to affirm and protect the fundamental rights of all patients/resident receiving care in accordance with federal and state regulations. This policy ensures that all residents are treated with dignity and respect. Record review of the facility policy provided as part of the resident admission packet titled Resident Rights revised February 2020, revealed the following: Resident Rights - The resident has the right to a dignified existence,.

Based on observation, interview, and record review, the facility failed to allow residents privacy of communications sent to the facility by a postal service for 2 of 25 residents reviewed for resident rights (Resident #35 and Resident #108). The facility failed to allow Resident #35 and Resident #108 to receive unopened mail at the facility. This failure could place residents at risk of decreased quality of life, hinder autonomy, and increase symptoms of depression.Findings Included:Resident #35Record review of Resident #35's face sheet, dated 07/28/2026, revealed a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #35's diagnoses included chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), hypertension (high blood pressure), age-related physical debility (decline in physical abilities due to age), and cognitive communication deficit (mental processes for communication are disrupted). Face sheet provided a Decision-Making Resident Representative, [name of Resident #35's family member].Record review of Resident #35's Annual MDS Assessment, dated 06/25/2026, revealed a BIMS score of 15, indicating Resident #35 was cognitively intact.Record review of Resident #35's care plan, dated 7/5/2026, revealed no focus or intervention related to Resident #35's ability to receive mail in the facility.Resident #108Record review of Resident #108's face sheet, dated 07/30/2026, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #108's diagnoses included Type 2 diabetes (chronic condition due to insulin resistance and high blood sugar levels), Parkinsonism (group of movement symptoms found in several conditions), and post-traumatic stress disorder (mental health condition by witnessing or experiencing a traumatic event). Record review of Resident #108's Comprehensive MDS Assessment, dated 07/12/2026, revealed a BIMS score of 14, indicating Resident #108 was cognitively intact.Record review of Resident #108's care plan, dated 07/15/2026, revealed no focus or intervention related to Resident #108's ability to receive mail in the facility.In an interview on 07/28/2026 at 8:49 AM, Resident #108 stated he received a piece of mail opened from the VA regarding an appointment. Resident #108 stated that he knew it was open because it was taped shut. Resident #108 stated that his FM had the envelope that was opened.In an interview on 07/28/2026 at 10:12 AM, AA Q stated that some mail was found in a closet. AA R went into the closet after bingo. AA Q stated that the activities department just completed ANE training. AA Q stated that mail was opened because some of it wasn't appropriate for the resident. AA Q stated she saw some mail in a trashcan and identified it as mail AA R had opened and thrown away. AA Q stated that Resident #35 was not present when mail was opened. AA Q stated that the AD presented a piece of mail for Resident #35 that stated something inappropriate. AA Q stated she notified the VLB, ADM, and DON. AA Q stated the VLB stated the resident must be present when opening mail. AA Q stated AA R stopped opening the resident's mail. AA Q stated a negative outcome of not honoring residents' rights of receiving mail would be residents' stuff should be taken.In an interview on 07/28/2026 at 2:00 PM, Resident #35 stated he received cards that were opened. In an interview on 07/29/2026 at 9:16 AM, AA R stated they did online training and classes once a month for ANE. AA R stated there was some mail that was filtered out as it shouldn't be read to Resident #35. AA R stated the letters they went through were from the school and the classrooms in the area. AA R stated they did not talk to Resident #35 but talked to Resident #35's family member. AA R stated the AD was the person who gave the instructions to sort through the mail and give Resident #35 the cards. AA R stated the policy stated residents have the right to open their own mail. AA R stated Resident #35 was not asked if he wanted the cards opened in front of him or to have them filtered. AA R stated residents have the right to open their own mail. AA R stated based off of Resident #35's family member it was appropriate to filter them. AA R stated facility staff should take the direction of the family member. AA R stated a better way was to pull Resident #35 into the room and not read the bad ones. AA R stated a negative outcome of not honoring residents right to receive unopened mail would be depends on what the mail is. Resident #35's rights were violated overall. The way it played out made sense. Resident #35 did receive some mail unopened. AA R stated it was the residents' right to receive the mail unopened.In an interview on 07/29/2026 at 2:36 PM, the FM stated the facility had permission to do everything they did. The FM stated the facility read a bad card and the FM told the facility not to read it to him. The FM stated they did not remember the staff member they spoke with.In an interview on 07/29/2026 at 2:51 PM, the AD stated the VLB requested cards for veterans from the public for Resident #35's 100th birthday. The AD stated they started in May 2026 and AA R was assisting. The AD stated there was a meeting with the staff and stated the cards must be read to him. The AD stated it was the activities department's responsibility to finish reading them. The AD stated there was a box or two with cards in them. The AD stated that some of the cards were opened but cannot confirm they were all sealed. The AD stated that Resident #35 had a right to all the cards and believed he had the right to read or hear the cards or not. The AD stated Resident #35 has not read the card that was inappropriate, but it was sitting on AD's desk. The AD stated that it was determined for him that he would not read the card. The AD stated a negative outcome for violating resident rights where the resident could take it personally and feel bad.In an interview on 07/29/2026 at 3:35 PM, the ADM stated the letters were found after a long time. The ADM stated the boxes were taken to Resident #35 and read to him. The ADM stated it was two boxes and they had to open the boxes to see what the letters were. The ADM stated he was unaware if Resident #35 was asked about opening mail and reading it to him. The ADM stated he had not talked to the FM. The ADM stated Resident #35 should have made the decision to read the cards and it should be his choice to read some cards or not. The ADM stated one card was filtered out and Resident #35 should have been able to say one way or the other. The ADM stated Resident #35 was [AGE] years old but could still make his own decisions. The ADM stated a negative outcome for residents' receiving opened mail was that people knew stuff was sent to them and they knew information that the resident may not want them to know. In an interview on 07/30/2026 at 9:24 AM, Resident #108 stated his mail was opened and didn't notice until Resident #108 had seen it was taped. Resident #108 stated that was the only piece of mail he received since being admitted to the facility. Resident #108 stated that no one was supposed to open mail without permission. In an observation and interview on 07/30/2026 at 9:34 AM, FM stated she still had the opened envelope for Resident #108. FM provided an envelope that was opened on the left side with a smooth cut and frayed edges that appeared it was opened by a letter opener and taped. FM stated they didn't know why it was delivered opened. Observation indicated the opened envelope was post-marked dated 07/15/2026.In an interview on 07/30/2026 at 9:39 AM, the REC stated that she and the security guard handled mail. The REC stated that she sorted the mail and the security guard delivered it. The REC stated she was given instructions that service-connected people did not get their mail. The REC stated that she sorted the mail when it was received and then sent it to the family of the residents and kept what corporate paid for. The REC stated the mail arrived addressed in the resident's name or the name of the facility. The REC stated they were opened and then sent to the corporate office. The REC stated that residents have the right to receive mail unopened. The REC was provided with open mail for Resident #108 and stated she did not understand why it was opened. The REC stated a negative outcome could be some residents could not pay their own bills.Record review of an in-service titled, Resident Rights, Cleaning Surfaces, Medication Errors, New Admits/Readmits, instructed by the DON, dated 02/17/2026 and 02/18/2026, revealed the REC completed the training. Record review of [name of facility corporate] Resident Rights policy, dated October 2012, reflected, , Policy Explanation and Compliance Guidelines: 4.: Every resident shall have the right to unrestricted private communication, including receiving and sending unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any reasonable time. Record review of Nursing Facility Resident Rights, provided by Texas Long-Term Care Ombudsman, dated November 2021, reflected, Privacy and Confidentiality: Send and receive unopened mail and to receive help in reading or writing correspondence. Record review of document titled [name of facility] Resident Mail Rights, Privacy, and Staff Assistance, dated 07/14/2026, revealed a purpose statement of, All Veterans retain the right to receive personal correspondence unopened unless they voluntarily request assistance or have otherwise authorized assistance in accordance with their wishes and facility policy.Resident Rights: Every Veteran has the right to: receive mail unopened and privacy in written communications.Prohibited Conduct:, staff shall not: remove, retain, conceal, destroy, or discard personal correspondence contrary to the Veteran's wishes. AA R signed the document on 07/14/2026. Record review of policy titled, Resident Rights, dated February 2020, stated under heading, Resident Rights, 1., Resident rights: The resident has the right to a dignified existence, self-determination, and communication with an access to persons and services inside and outside of the facility. 7.- Information and Communication: The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility- i.: The resident has the right to send and receive unopened mail and to receive letters, packages and other materials delivered to the facility for the resident through a mean other than a postal service, including the right to: I- Privacy of such communication consistent with this section. 8. Privacy and Confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records- a.: Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups but this does not require the facility to provide a private room for each resident.

Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 25 residents (Resident #4) reviewed for accuracy of assessments.The facility failed to accurately code Resident #4's MDS assessment by incorrectly identifying the resident as receiving dialysis while being a resident in the facility. This failure could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings included:Record review of Resident #4's admission record, dated 07/28/2026, revealed a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis (autoimmune disease that affects joints), unspecified, depression (feeling of sadness and atrial fibrillation (irregular heart rhythm). Record review of Resident #4's quarterly MDS assessment, dated 06/11/2026, revealed he had a BIMS of 15 indicating he was cognitively intact. Further record review of the MDS assessment in Section 0 (Special Treatments, Procedure and Programs) J1 was marked to indicate the resident received dialysis while a resident of the facility within the 14 day look back period. Record review of Resident #4's comprehensive care plan, dated 07/25/2026, revealed no focus areas, goals, or interventions related to dialysis. During an observation and interview on 07/28/2026 at 3:01 PM, Resident #4 was observed sitting in his wheelchair and appeared clean and well groomed. Resident #4 stated he had never received dialysis while residing at the facility or prior to admission.During an interview on 07/29/2026 at 10:58 AM, the ADM stated the MDS Coordinator was responsible for completing the MDS assessments. The ADM stated the Resident Assessment Instrument (RAI) was used as the primary resource when completing the MDS Assessment. The ADM stated a potential negative outcome for documenting inaccurate information on the assessment could result in the residents not receiving care that accurately reflected the residents' needs. During an interview on 07/30/2026 at 8:03 AM, the MDS RN stated she was employed at the facility for approximately 10 months and the information entered into the MDS assessment was based on physician orders and the resident's current clinical status. She stated the RAI Manual served as the primary reference for completing MDS assessments. The MDS RN further stated the MDS Director conducted periodic audits of completed MDS assessments and provided feedback to ensure accuracy. The MDS RN further stated the MDS Director and DON were responsible for oversight of the MDS process ensuring compliance. The MDS RN stated a potential negative outcome of an inaccurate MDS assessment was that a resident care may not be accurately identified or addressed. She stated the MDS assessment for Resident #4 was incorrectly documented that the resident was receiving dialysis and stated the error was likely the result of a data entry mistake since Resident #4 was not receiving dialysis care. The MDS RN said she did not believe the inaccurate MDS assessment affected reimbursement because most residents at the facility were private pay, however, she stated the inaccurate assessment remained a state compliance concern. During an interview on 07/30/2026 at 10:20 AM, the DON stated it was the responsibility of the MDS RN to ensure each MDS assessment accurately reflected the resident's status. The DON stated the MDS Director was responsible for overseeing the MDS process and ensuring assessments were completed accurately but stated she was equally responsible as the DON. The DON further stated that a potential negative outcome of an inaccurate MDS assessment was that the resident's care needs may not be accurately identified or addressed. During an interview on 07/30/2026 at 10:25 AM, the Clinical VP stated it was the responsibility of the MDS RN to ensure each MDS assessment accurately reflected the resident's status. The Clinical VP stated the MDS Director was responsible for auditing assessments completed by the MDS RN to ensure their accuracy. The Clinical VP further stated the facility had systems in place to verify the accuracy of MDS assessments but was unsure how the inaccurate MDS assessment for Resident #4 was not identified. The Clinical VP stated a potential negative outcome of an inaccurate MDS assessment was that a resident might be unable to access services and resources for which the resident was eligible. During a telephone interview on 07/30/2026 at 11:11 AM, the MDS Director stated she was responsible for overseeing and auditing MDS assessments completed by the MDS RN. She stated the inaccurate MDS assessment for Resident #4 must have been a data entry error. The MDS Director stated the MDS assessment served as the foundation of the RAI process and that information entered into the MDS generated triggers used to develop the resident's care plan. She stated that if the MDS assessment contained inaccurate information, the care plan could be wrong, and the residents might not receive accurate care for their needs. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025, revealed the following: SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. O0110J1, Dialysis Code peritoneal or renal dialysis which occurs at the nursing home or at another facility, record treatments of hemofiltration, Slow Continuous Ultrafiltration (SCU, Continuous Arteriovenous Hemofiltration (CAVH), and Continuous Ambulatory Peritoneal Dialysis (CAPD) in this item. IVs, IV medication, and blood transfusions administered during dialysis are considered part of the dialysis procedure and are not to be coded under items K0520A (Parenteral/IV), O0110H (IV medications), or O0110I (transfusions). This item may be coded if the residents perform their own dialysis.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 1 resident (Resident #13) reviewed for significant weight loss.The facility failed to ensure that dietary interventions were accurately provided according to the resident's meal ticket preferences, failed to accurately reconcile meal consumption data with active medical records, and failed to report systemic supplement refusals to the Physician and Registered Dietitian (RD) for Resident #13.This failure could place residents at risk for severe malnutrition, skin breakdown, and physiological decline.Findings included:Record review of Resident #13's admission record, undated , revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (memory loss), cerebral infarction (the death of brain tissue caused by a blocked blood vessel), hypertension (high blood pressure), delusional disorders (a mental health condition defined by holding a strong false belief), benign prostatic hyperplasia (an enlargement of the prostate gland causing difficulty in urinating), atrial fibrillation (a heart condition that causes blood to stay in the heart and produce an abnormal heartbeat), anemia in chronic kidney disease (lack of the ability to make red blood cells due to damage within the kidney), presence of cardiac pacemaker (a small electronic device placed under the skin in the upper chest to manage abnormal heart rhythms), generalized muscle weakness, stage 4 kidney disease (severe damage of the kidneys), cognitive communication deficit (a breakdown in communication caused by problems thinking), hypothyroidism (a condition of the thyroid gland where the gland does not produce effect thyroid hormone), vitamin D deficiency (low vitamin D levels), and hearing loss.Record review of Resident #13's quarterly MDS assessment, completed on 05/25/26, revealed a BIMS score of 6 which indicated severely impaired cognition. Section GG (Functional Abilities) revealed Resident #13 was dependent on staff for toileting, bathing, and dressing and required setup or clean-up assistance with eating.Record review of Resident #13's care plan, completed on 05/07/26, revealed he had an ADL self-care performance deficit, required setup or clean-up assistance with eating, and weight loss interventions such as monitoring monthly weights and offering snacks if resident eats less than 50% of meals.During a dining observation on 07/28/2026 at 12:10 PM, Resident #13 was observed struggling to eat meatloaf and could not get the food onto his fork. The resident was observed eating bread without difficulty but appeared visibly frustrated during the meal.During a record review on 07/28/2026 at 2:11 PM, Resident #13's medical record was reviewed and revealed a significant, progressive pattern of weight loss: a 2.04% weight loss in 1 month from June 2nd, 2026 to July 3rd, 2026, a 6.40% weight loss in 3 months from April 6th, 2026 to July 3rd, 2026, and a 13.17% weight loss over a 6-month period from November 1st, 2026 to July 3rd, 2026.During a record review on 07/29/2026 at 11:25 AM, Resident #13's chart showed he was care planned for weight loss, including refusing to eat. The care plan mandated that staff offer alternative foods if the resident consumed less than 50% of meals. Activities of Daily Living (ADL) documentation revealed staff consistently recorded that the resident ate 51% or more of his meals. A review of the Registered Dietitian (RD) progress notes showed the RD saw the resident monthly, with the last visit dated 06/09/2026. To address the significant weight loss, the RD recommended interventions including supplemental health shakes twice daily (BID) with meals, Magic Cups with meals, and an appetite stimulant. The physician ordered health shakes twice daily (BID) at 8:00 AM and 1:00 PM with meals, Magic Cups with meals, and an appetite stimulant.During an observation and record review of the lunch meal on 07/29/2026 at 12:15 PM, Resident #13 was observed eating his meal and did not appear to be struggling. Staff served the resident a chocolate supplemental shake, which the resident told staff he did not want. Review of the resident's meal ticket revealed a printed preference for a strawberry shake. Staff did not offer a strawberry shake and failed to provide the ordered Magic Cup.During a telephone interview on 07/29/2026 at 1:28 PM, Resident #13's representative, stated he was aware of the resident's weight loss and had no concerns regarding his care. He stated that he and his family participated in Care Plan meetings to discuss the weight loss and that the facility was addressing the issue. He noted that when he sat with the resident during meals, he did not notice any issues with the resident struggling to eat or use utensils.During an observation of the breakfast meal on 07/30/2026 at 7:33 AM, staff failed to provide Resident #13 with either the supplemental health shake or the Magic Cup as printed on his breakfast meal ticket.During an interview on 07/30/2026 at 7:55 AM, House Supervisor RN L revealed that sometimes the resident was offered the shake and Magic Cup, and sometimes he was not because he refused them. RN L stated that she did not report these continuous refusals to anyone else. She stated that a negative outcome of this practice would be the resident failing to gain the weight needed to meet his nutritional demands.During an interview on 07/30/2026 at 8:02 AM, the DM revealed that Resident #13 should be given his supplemental shakes and Magic Cups regardless of whether he was refusing them, due to his severe weight loss history. The DM stated that a negative outcome of skipping these items was continued weight loss. She stated that the kitchen had both strawberry and chocolate shakes fully available in stock at that time.During an interview on 07/30/2026 at 8:40 AM, LVN E revealed that she had worked with Resident #13 and had seen on many occasions that the resident liked the supplemental shakes and drank them. LVN E stated that a negative outcome of the resident not receiving his shakes would be continued weight loss and poor nutrition.During an interview on 07/30/2026 at 8:42 AM, CMA O revealed that Resident #13 liked the health shakes when they were offered to him. CMA O stated that a negative outcome of the resident not getting the shakes was that he would lose more weight.During an interview on 07/30/2026 at 8:50 AM, Unit Manager LVN N (for Halls 400 and 500), stated that she was not aware that staff were failing to give Resident #13 his shakes, nor was she aware that he actually liked them. LVN N stated that floor staff documented on records that they were successfully giving the shakes, and she did not know the resident was refusing them until RN L reported it to her moments prior. She stated that if she had known Resident #13 was not receiving the supplements, she would have reported it to the Physician and Registered Dietitian so they could order alternative interventions for his weight loss.Record review of Resident #13's Medication Administration Record (MAR) revealed documentation, showing that the patient sometimes refused the supplements and sometimes received them. This directly contradicted the ADL meal consumption records and floor observations.Record of the facility's policies for medication administration and physician services (dated July 2025 and November 2025) revealed that the policies mandated that staff must report and document any adverse side effects or medication/supplement refusals.No further policies were provided regarding nutrition, weight loss, and physician orders as requested.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 1 resident (Resident #52) observed.The facility failed to ensure that proper personal protective equipment (PPE) was worn during indwelling urinary catheter care by Certified Nursing Assistant (CNA) providing care to Resident #52.This failure could place residents at risk for cross-contamination, colonization of MDROs, and severe urinary tract infections.Findings included:Record review of Resident #52's admission record, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hemiplegia (partial paralysis or inability to move one side of the body), hemiparesis (muscle weakness or partial inability to move one side of the body) following cerebral infarction (the death of brain tissue caused by a blocked blood vessel), dysphagia (difficulty speaking words), hypothyroidism (a condition of the thyroid gland where the gland does not produce effect thyroid hormone), irondeficiency anemia (a common blood disorder where the iron levels prevent the body from making enough red blood cells) hyperlipemia (too many fats in the blood), depression, and generalized muscle weakness.Record review of Resident #52's quarterly MDS assessment, completed on 06/03/26, revealed a BIMS score of 4 which indicated severely impaired cognition. Section GG (Functional Abilities) revealed Resident #52 was dependent on staff for toileting, bathing, dressing and eating.Record review of Resident #13's care plan, completed on 06/03/26, revealed he had an ADL self-care performance deficit requiring extensive staff assistance and required enhanced barrier precautions indicating that a gown and gloves were to be worn during high contact resident care.During an observation on 07/29/2026 at 1:43 PM, CNA G was observed providing incontinent and urinary catheter care on Resident #52. An Enhanced Barrier Precautions (EBP) sign was noted on the door with PPE stationed outside of the resident's room. CNA G did not apply a gown prior to or during the high-contact care as indicated by the door signage.During a record review on 07/29/2026 at 2:17 PM, the facility policy entitled Infection Prevention and Control (dated April 2025) was reviewed and revealed the following directive: Enhanced Barrier Precautions will be used based upon guidance from CDC, CMS or the state health department. (Refer to the policy titled, Enhanced Barrier Precautions). Enhanced Barrier Precautions policy requested.During an interview on 07/29/2026 at 2:30 PM, Unit Manager, LVN N (for Halls 400 and 500), revealed that when caring for residents with an indwelling urinary catheter, PPE should be worn. LVN N stated a negative outcome of not wearing PPE could cause an infection to the resident and/or other residents, if the urine was infected.During a record review on 07/29/2026 at 3:00 PM, a review of Resident #52's medical records revealed active physician orders for Enhanced Barrier Precautions due to the presence of a Foley catheter started 01/11/2026 and active to this date 07/29/2026.During an interview on 07/30/2026 at 8:22 AM, CNA K revealed that they had been working at the facility since April of 2026. CNA K stated that only gloves needed to be worn when providing indwelling urinary catheter care. CNA K further stated that not all residents on Foley care needed EBP per training received from SDC. CNA K stated a negative outcome of not wearing proper PPE would be that infection could be spread to other residents and staff caring for the resident.During an interview on 07/30/2026 at 8:24 AM, CNA J revealed that they had been working at the facility for about a year and a half. CNA J stated that not everyone who had an indwelling urinary catheter required EBP precautions, and stated that the SDC, was the person who provided her with that information. However, CNA J stated that for residents who did have an EBP sign on the door, staff should be wearing gloves and a gown. CNA J also noted that other staff CNAs trained new CNAs and stated a negative outcome of not wearing the correct PPE was cross-contamination and infection to self and other residents.During an interview on 07/30/2026 at 8:27 AM, CNA G revealed that everyone with an indwelling urinary catheter would be placed on EBP, which included a gown and gloves. CNA G stated a negative outcome of non-compliance was contamination and infection to self and other residents and noted that other CNAs train new staff on procedures.During a record review on 07/30/2026 at 8:29 AM, the facility policy entitled Enhanced Barrier Precautions (dated October 2022) revealed the following:Purpose: To reduce the transmission of resistant organisms during high contact resident care activities .Enhanced Barrier Precautions (EBP) may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: Wounds and indwelling medical devices, regardless of MDRO (multidrug resistant organism) colonization status.Examples of high-contact resident care activities requiring gown and gloves and use for EBP includes: Devices care or use of central line urinary catheter, feeding tube, tracheostomy/ventilator .EBP are intended to be in place for the duration of a resident's stay in the facility or until the resolution of the wound or discontinuation of the indwelling medical device that placed them a higher risk.During an interview on 07/30/2026 at 8:40 AM, LVN E revealed that if a resident has an indwelling urinary catheter, it is standard precautions for staff cleaning and emptying the bag to put on EBP, which included a gown and gloves. LVN E stated a negative outcome was introducing bacteria into the urine of the resident and possibly spreading infection.During an interview on 07/30/2026 at 8:45 AM, CNA I revealed that they had worked at the facility for two years. CNA I stated that when a resident has an indwelling urinary catheter, they should be placed on EBP, which included a gown and gloves. CNA I stated that the SDC oversaw training and ensuring new staff were aware the use of EBP. CNA I stated a negative outcome of not wearing PPE was infection to the residents, other residents, and staff.During an interview on 07/30/2026 at 10:33 AM, the SDC, revealed that she trained staff on proper techniques of hand hygiene, use of gloves, and wiping front to back. The SDC stated that not all residents needed EBP unless they have an active infection.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure [NAME] F and [NAME] G 's hands were washed and gloves were changed during preparation of food. 2. The facility failed to ensure [NAME] E wore beard covers while in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: In an interview and observation on 5/28/25 at 11:30 am, [NAME] F was observed in the kitchen prep area using the blender to chop meat for the mechanical soft diets. [NAME] F picked up meat patties with her gloved hands and tore meat apart with her gloved hands. [NAME] F put the meat into the blender, then touched the blender buttons, blender lid and kitchen utensils. [NAME] F picked up a container and moved it to the blender. [NAME] F picked up the blender container. [NAME] F removed the lid and used a spatula to scrape meat into the prepared pan. [NAME] F then picked up more meat patties with her gloved hands. [NAME] F tore the meat patties up with her gloved hands and put the meat into the blender. [NAME] F did not change gloves or wash hands during this activity. [NAME] F stated she used her hands because it was easier to break up the food with hands rather than stop and cut it up. She stated I should have used tongs to pick up the meat. I should have changed my gloves. The DM was present and stated the staff should use tongs for everything. She stated she should have also changed gloves between tasks. In an interview and observation on 5/28/25 at 11:36 am, [NAME] E was observed walking into the kitchen with no beard cover on his face. [NAME] E went to the back of the kitchen. [NAME] E stated he was supposed to wear a beard cover while in the kitchen. He stated the consequences of no beard cover would be food borne illnesses. In an observation on 5/28/25 at 11:50 am, [NAME] G was observed in the kitchen prep area with gloved hands. [NAME] G took temperatures of food then opened the steamer oven and took out a pan of zucchini. [NAME] G poured the pan of zucchini into a different serving pan and used his gloved hand to scoop out the remainder of zucchini into the serving pan. [NAME] G put the pan down and walked to the freezer, opened the freezer door, picked up a box of frozen meat patties, carried the box to the prep counter and opened the box. [NAME] G picked up a handful of meat patties from the box. [NAME] G walked to the fryer and put the meat patties into the fryer using his gloved hand. [NAME] G picked up a second handful of meat patties with his gloved hand and put them into the fryer. [NAME] G did not change his gloves or wash his hands. In an observation on 5/28/25 at 12:00 pm, [NAME] G went to the freezer, opened the freezer door, got hamburger patties, and put the patties on a plate with his gloved hands. [NAME] G opened the hamburger bun package and took out the hamburger buns, picked up the butter spatula and put butter on the buns. [NAME] G placed the buttered buns on the griddle with his gloved hand, then put his gloved hand inside the bread wrapper and pulled out bread. [NAME] G picked up the butter spatula and buttered the bread, then put the bread on the griddle. [NAME] G went to the walk-in cooler, opened the door and brought out a package of cheese. [NAME] G unwrapped the cheese and placed cheese slices on the bread on the griddle, picked up a spatula, turned meat patties, took out more cheese from the package, put the cheese slices on the meat, touched the meat, took out ham from a package and put the ham on the grill with his gloved hands. [NAME] G did not change his gloves or wash his hands during this time. In an observation on 5/28/25 at 12:05 pm, [NAME] G picked up a clean pan, walked to the griddle picked up a spatula, slid the spatula under a sandwich, used his gloved hand to slide the sandwich off the spatula, picked up another pan and used his gloved hands to pick up the sandwiches and put the grilled sandwiches into a serving pan. [NAME] G did not change his gloves or wash his hands. In an observation on 5/28/25 at 12:10 pm [NAME] G looked at pages in a menu book, touched pans and kitchen surfaces, adjusted the knobs on the stove, opened the doors of the steamer oven, opened the freezer door, brought out a box of frozen meat, opened the box of meat, then took out the frozen meat patties with his gloved hands and put the meat patties into the fryer. [NAME] G did not change his gloves or wash his hands. In an interview on 5/29/25 at 10:00 am [NAME] G stated he should have changed his gloves and washed his hands when changing tasks and touching food during the lunch meal on 5/28/25. He stated he was busy and just forgot. He stated the consequences for residents would be food borne illness. In an interview on 5/30/25 at 10:10 am, the DM stated she had trained the staff on the use of hair restraints and hand washing. She stated she expected all staff to have all hair and beard covers on at all times and she expected staff to wash hands and change gloves between tasks. She stated the consequences of not having a beard cover or changing gloves and washing hands between tasks would be food borne illnesses and could make residents sick. Record Review of the policy dated October 2018 titled Employee Sanitation documented: Hairnets, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food contact surfaces. Employees must wash hands and exposed portions of their arms before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapping single service and single use foods . when switching between working with raw food and working with ready to eat foods, during food preparation including working with exposed food, clean equipment, and utensils. Gloves are not a substitute for thorough and frequent hand washing. When using gloves, always wash hands before touching or putting on new gloves. Use single use gloves for one task. Change gloves between each food preparation task, after touching items, utensils or equipment not related to task, when leaving the food prep area for any reason, when damaged soiled or when interrupted, every hour for all tasks taking longer than one hour. Do not store gloves in pockets or apron. Record Review of the policy dated October 2018 titled Handwashing documented: Hands should be washed after the following occurrences: handling raw food, touching un-sanitized equipment, work surfaces, changing tasks.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 9 of 32 residents (Resident #22, #35, #11, #70, #51, #25, #58, #107, and Resident #9) reviewed for infection control. -CNA A failed to use proper hand hygiene techniques in between assisting Resident #22, #35, #11, #70, and Resident #51 with cutting up their food. -CNA B failed to use proper hand hygiene techniques when assisting Resident #107 to eat after assisting Resident #9 with the cutting up of his meal. -CNA C failed to use proper hand hygiene techniques when assisting Resident #25 to eat after assisting Resident #9 to sit up in his wheelchair. This failure could place residents at an increased risk for potentially exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation on 05/28/25 at 12:25 PM CNA A was cutting up Resident # 22 chicken fried steak, CNA A then went to Resident # 35 to assist her with cutting up her steak, No HH was performed between these 2 residents. CNA A went to Resident # 11 to cut up his steak and then went to Resident # 70, no HH was performed between these 2 residents. CNA A proceeded to touch her hair and then went to assist Resident # 51 to cut up his steak, no HH was performed before touching Resident #51's eating utensils after touching her hair. During an observation on 05/28/25 at 12:44 PM CNA C was assisting Resident # 25 with eating her lunch and then got up to assist another Resident # 58 with cutting up his steak and then returned to feeding Resident #25, no HH was performed before or after assisting Resident #25 or Resident #58. During an observation on 05/28/25 at 12:46 PM CNA B was assisting Resident # 107 with eating, CNA B went to help another staff member move Resident # 9 to sit up more in his Geri-chair, then went back to assist Resident #107 with eating. No HH was performed before or after performing these tasks with either resident. During an interview on 05/28/25 at 02:34 PM CNA B was asked why HH was not performed when assisting a resident to eat, she stated, I didn't think about it, there could have been anything on his w/c. CNA B stated the negative outcome would be infection control. During an interview on 05/28/25 at 03:11 PM CNA A was asked why HH was not performed when assisting residents with the cutting up of their meals, CNA A stated, I wasn't thinking, I just wanted to get it done. CNA A was asked what a negative outcome would be she stated, There isn't one. During an interview on 05/28/25 at 03:14 PM CNA C was asked why HH was not performed, CNA C stated, it flew my mind. CNA C stated a negative outcome was there could be an infection control issue. During an interview on 05/30/25 at 08:39 AM DON stated a negative outcome for not performing HH could lead to an increased risk of infection for the residents. Record review of facility provided policy titled, Handwashing, dated 2013, revealed the following: .After handling soiled equipment or utensils. During good preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. .After in engaging in other activities that contaminate the hands.

Based on observation, interview, and record review the facility failed to ensure each resident had a right to a dignified existence and to treat each resident with respect and dignity for 1 (Resident #63) of 24 residents reviewed for resident's rights. The facility failed to keep Resident #63's catheter bag covered with a privacy bag. This failure could lead to residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated. Findings include: Record review of Resident #63's face sheet dated 05/28/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses that included, but were not limited to, cerebral infarction(stroke), dysphagia (difficulty swallowing in mouth and throat), unsteadiness on feet, abnormalities of gait and mobility, muscle weakness, paranoid schizophrenia (serious mental health disease causing misinterpretation of reality), post-traumatic stress disorder, generalized anxiety disorder (a group of mental illnesses that cause constant fear and worry), cognitive communication deficit (impaired though processes), and unspecified dementia (cognitive loss). Record review of Resident #63's Significant Change MDS dated [DATE] revealed a BIMS score of 3 out of 15 which indicated his cognition to be severely impaired. Record review of Resident #63's care plan dated 04/10/25 revealed a focus area that Resident required an indwelling Foley catheter, date initiated was 12/26/2024 and interventions stated, catheter care per protocol. Record review of Resident #63's physicians orders dated 05/28/2025 revealed the following: foley catheter start date of 03/01/2025 which was active and had no end date. During an observation on 05/28/2025 at 10:47 AM, Resident #63 was sitting at a table in common area, located in the locked unit. Resident #63 was observed to be in a w/c with catheter bag clipped to the underside of the w/c. Catheter bag was in full view of dining area and the bag had liquid in it that was visible to be about 1/4 full. During an observation on 05/28/2025 at 11:42 AM, Resident #63 was observed to be sitting at a dining table, soup and a glass of tea were in front of him, no privacy bag observed on catheter bag. During an observation on 05/28/2025 at 3:18 PM, Resident #63 was observed to be asleep, sitting in w/c in common area by the television in the locked unit. Observation of Resident #63's catheter bag without a privacy bag. During an interview on 05/30/2025 at 9:03 AM, CNA L stated she worked on the locked unit and started at the facility 2 months ago. She stated that residents should always have a privacy bag covering their catheter bags. CNA L stated that it was everyone's responsibility for making sure privacy bags were on resident's catheter bags, but the nurses were supposed to bring privacy bags and she stated she felt they could do a better job at doing this. CNA L stated that it was the facilities policy to have privacy bags on catheter bags and a possible negative outcome for them not having one could be a dignity issue - no one was supposed to see resident's urine. During an interview on 05/30/2025 at 9:07 AM, the ADON (the nurse for Resident #63 this shift) stated that if a resident with a catheter does not have a privacy bag, it was definitely a dignity issue. The ADON stated that it was everyone's responsibility to make sure that privacy bags are on, but mainly the nurses. She stated it was their policy to have a privacy bag on all catheter bags and a negative outcome for not having them on would be a violation of resident's dignity and rights. During an interview on 05/30/2025 at 9:27 AM, the DON stated that it was everyone's responsibility to make sure that privacy bags were on catheter bags. She stated it was the policy of the facility to have privacy bags on all catheter bags and a possible negative outcome for this not happening could be dignity of the resident would be violated and visitors could see it. Record review of facility provided policy titled, Catheter Care, Male dated 06/2024 revealed in part: Purpose: It is the policy of the facility to ensure residents with indwelling catheters receive appropriate catheter care using proper technique while maintaining the resident's privacy and dignity. No pertinent information concerning the use of privacy bags. Record review of facility provided policy titled, Resident Rights dated 10/2022 revealed in part . 1. Resident Rights. The resident has the right to a dignified existence. 5. Respect and Dignity. The resident has a right to be treated with respect and dignity .

Based on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for 1 of 24 residents (Resident #117) reviewed for environment. -Resident #117 had his evening meal tray left in his room until the next AM. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings include: Record review of Resident #117's clinical record revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include myocardial infraction (heart attack), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (a chronic condition in which the heart dose not pump blood as well as it should), basal cell carcinoma of the skin (cancer that begins in the lower part of the epidermis (the outer layer of the skin), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #117's clinical record revealed his last MDS was an admission completed 04/24/25 listing him with a BIMS score of 05 indicating he was severely cognitively impaired, and he had a functionality of requiring supervision/touching assistance with most of his activities of daily living. Record review of Resident #117's clinical record revealed a care plan with the admitted [DATE], which revealed the following: Focus: o Resident is at risk for alteration in nutrition r/t dx: COPD. Is on Regular diet/mechanical soft texture/thin liquids. Date Initiated: 04/21/2025. Interventions: o Encourage resident to eat all food served on meal tray. Assist as needed. Date Initiated: 04/21/2025 During an observation and interview on 05/28/25 at 08:45 AM Resident #117 was observed in his room in his bed under his covers. Resident #117 was sleeping well and did not wake to knocking or introduction. On the bedside table was Resident #117's dinner tray with a ticket that documented Dinner 05/27/25. The plate was covered and when uncovered noted grilled chicken, broccoli, noodles, and a roll. Also noted was a cobbler desert still covered, and the tea drink. None of the meal had been eaten. During an observation on 05/28/25 at 09:54 AM Resident #117 was not present in his room but his dinner meal tray from 05/27/25 was still on the bedside table in the same condition. During an observation and interview on 05/28/25 at 10:21 AM Resident #117's dinner tray from 05/27/25 was still present in his room. This surveyor asked CNA H (the CNA responsible for Resident #117 this shift) to entered Resident #117's room. Resident #117 was present and awake but did not respond to our presence or when spoken to by this surveyor. CNA H confirmed that Resident #117's meal tray was his dinner tray from the previous evening, that it should not be present, and that it should have been picked up 1 hour after the evening meal was delivered. CNA H stated that the evening meal was at 5:00 PM and the hall trays were delivered between 5:45-6:00 PM. CNA H stated that the tray left in the residents' room could be an issue because he could eat it, become sick, or it could attract bugs, or another resident could eat it. CNA H stated that staff were to make rounds every two hours and that she had just missed the meal tray this shift. During an interview on 05/29/25 at 08:32 AM the DON stated that all meal trays delivered to resident rooms should be picked up within 30-40 minutes after delivery or at minimum 1 hour after they were delivered. The DON stated that all staff should make rounds, especially the CNA's, every 2 hours and check each resident's room. The DON stated that if a meal tray were left in a resident room for 15 hours, that resident could eat it thus making that resident sick, or any resident could eat it making them sick. During an interview on 05/30/25 at 08:38 AM SC I stated that a resident's tray should not be left in their room for more than one hour after the tray had been delivered and that a tray left overnight could result in that resident or another resident eating food that could make them sick or the food could attract bugs. During an interview on 05/30/25 at 08:40 AM RN J (the nurse for Resident #117 this shift) stated that a residents meal tray should not be left in the resident's room overnight, that it should be picked up within one hour after it was delivered. If the tray is left out over time it could result in an infection if it grew bacteria and a resident ate it. Record review of the facility provided policy titled, Serving and Cleaning Up Room Trays in Long-Term Care undated, revealed the following: Purpose: To ensure safe, sanitary, and respectful delivery and removal of meal trays served in resident rooms, in accordance with CMS, infection control . Policy Statement: All room trays will be delivered and picked up by trained staff in a manor that preserved food safety, upholds resident dignity, and prevents the spread of infection. 3. Cleaning Up Room Trays: - Return promptly after meal service (within 1 hour) to collect trays.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 24 residents reviewed for accuracy of assessments. Resident #1 had an active order for oxygen at 3 lpm via NC to maintain Oxygen sats above 90% dated 03/14/2025 and his MDS with a completion date of 05/08/2025 did not indicate he received oxygen while a resident. This failure could place residents at risk of not having their needs identified and therefore not receiving necessary care. Findings Included: Record review of Resident #1's admission record dated 05/28/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), malignant neoplasm of unspecified part of unspecified bronchus or lung (cancer in the lungs or airways in the lungs where the specific location or type is not specified), panlobular emphysema (rare form of emphysema which are sacs in the lung can't switch oxygen and carbon dioxide leaving a person breathless, panlobular is a type of emphysema characterized by the destruction of the entire acinus (a cluster of air sacs, or alveoli) in the lung), and pulmonary embolism (clot blocking blood flow to lungs). Record review of Resident #1's quarterly MDS completed on 05/03/2025 revealed a BIMS of 06 which indicated severely impaired cognition. Section O of the MDS revealed Resident #1 was not receiving oxygen On Admission or While a Resident. Record review of Resident #1's care plan with a completion date of 05/07/2025 revealed a focus area of The resident has oxygen therapy r/t Ineffective gas exchange. Resident will maintain O2 sats >90% through next review date. This focus area was initiated on 06/22/23 and revised on 02/2/2024. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @3L/Min via NC to maintain O2 sats>90%. This intervention was initiated on 02/20/2024 and revised on 03/17/2025. Interventions for this focus area stated, resident was encouraged to keep his O2 on at all times and be given medications as ordered by physician. Record review of Resident #1's active order report dated 05/28/2025 revealed the following order: Oxygen at 3L/min via NC to maintain 02 sat>90% every shift . This order had a start date of 03/14/2025 and no end date. Record review of Resident #1's MAR dated 05/01/2025-05/30/2025 revealed Resident #1 was receiving O2 @ 3 lpm via NC to maintain O2 sats > 90% every day, with a start date of 3/14/2025. According to the MAR, Resident #1's O2 sats were being checked morning and evening throughout the month of May. Record review of Resident #1's O2 Sats Summary revealed 32 entries for the 14 days prior to completion of Resident #1's most recent MDS. Of those 32 entries, Resident #1 was receiving O2 31 times and was on room air 1 time. During an interview on 05/30/2025 at 9:16 AM, the DON stated she was the interim DON but had been doing the job of MDS director for one year. She stated she followed the RAI as her policy for completing MDS Assessments and it was her responsibility to make sure MDS's are accurate. The DON stated that a possible negative outcome for a resident not having an accurate MDS assessment could be that the care that they need would not be available for the nurses on the floor. She also stated that an incorrect MDS could affect the facilities funding and it could then affect the care a resident receives. During an interview on 05/30/2025 at 9:29 AM, the ADM stated that the facility used the RAI to fill out residents MDS assessments. She stated a possible negative outcome for not having an accurate MDS could result in an inaccurate care plan and resident could miss services as well as affect funding. Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following: . Section O: Special Treatments, Procedures, and Programs . The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs. Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column. Coding instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and with the last 14 days.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences, for 1 (Resident #1) of 24 residents reviewed for respiratory care. Resident #1 had orders for oxygen at 3 liters per minute and was observed to have an empty oxygen tank for an hour while in the dining area. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings included: Record review of Resident #1's admission record dated 05/28/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), malignant neoplasm of unspecified part of unspecified bronchus or lung (cancer in the lungs or airways in the lungs where the specific location or type is not specified), panlobular emphysema (rare form of emphysema which are sacs in the lung can't switch oxygen and carbon dioxide leaving a person breathless, panlobular is a type of emphysema characterized by the destruction of the entire acinus (a cluster of air sacs, or alveoli) in the lung), and pulmonary embolism (clot blocking blood flow to lungs). Record review of Resident #1's quarterly MDS completed on 05/03/2025 revealed a BIMS of 06 which indicated severely impaired cognition. Record review of Resident #1's care plan with a completion date of 05/07/2025 revealed a focus area of The resident has oxygen therapy r/t Ineffective gas exchange. Resident will maintain O2 sats >90% through next review date. This focus area was initiated on 06/22/23 and revised on 02/2/2024. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @3L/Min via NC to maintain O2 sats>90%. This intervention was initiated on 02/20/2024 and revised on 03/17/2025. Interventions for this focus area stated, resident was encouraged to keep his O2 on at all times and be given medications as ordered by physician. Record review of Resident #1's active order report dated 05/28/2025 revealed the following order: Oxygen at 3L/min via NC to maintain 02 sat>90% every shift . This order had a start date of 03/14/2025 and no end date. Record review of Resident #1's MAR dated 05/01/2025-05/30/2025 revealed Resident #1 was receiving O2 @ 3 lpm via NC to maintain O2 sats > 90% every day, with a start date of 3/14/2025. According to the MAR, Resident #1's O2 sats were being checked morning and evening throughout the month of May. Record review of Resident #1's O2 Sats Summary revealed 32 entries for the 14 days prior to completion of Resident #1's most recent MDS. Of those 32 entries, Resident #1 was receiving O2, 31 times and was on room air 1 time. During an observation on 05/28/2025 at 10:32 AM, Resident #1 was sitting in his w/c at a table in the common area of the locked unit. Resident #1 had nasal cannula in nose with an oxygen tank on the back of his w/c that registered 3 lpm, tank was empty. During an interview on 05/28/2025 at 11:15 AM, Resident #1's family member stated that he receives continual oxygen. During an observation on 05/28/2025 at 11:32 AM, Resident #1 was sitting at dining room table with nasal cannula in nose, O2 tank was observed as being empty. During an observation on 05/28/2025 at 11:37 AM, nursing staff were observed to change out empty tank for Resident #1. During an interview on 05/30/2025 at 8:53 AM, CNA K stated she had worked in the facility for 3 months on the locked unit and that the nurses were responsible for changing out oxygen tanks for residents. She stated that a possible negative outcome for a resident to be without oxygen for an hour could be delusion or behaviors, worst case could be passing out or death. CNA K stated that when residents have dementia, many already have behaviors, so going without oxygen could make the behaviors and delusions a lot worse. During an interview on 05/30/2025 at 9:08 AM, the ADON (the nurse for Resident #1 this shift) stated that everyone was responsible for keeping eyes on oxygen tanks, but the nurses were responsible for changing them out. She stated a possible negative outcome for a resident running out of oxygen for an hour could be a big change of condition, they could go unconscious or unresponsive which could lead to death. The ADON also stated that behaviors could change, and an hour with no oxygen could result in bad issues happening for the resident. During an interview on 05/30/2025 at 9:24 AM, The DON stated that the nurses were responsible for changing out oxygen tanks. She stated all nursing staff were supposed to check on levels on tanks during their rounds. The DON stated a possible negative outcome for a resident to be off their oxygen for an hour could be mental status and cardiovascular changes that could affect their health. Record review of facility policy titled, Oxygen Administration and dated February 2015 revealed the following in part: Policy: Correct technique and standards of practice will be used with oxygen administration. Procedure: 1. Check the physician's order for the flow rate and the method of administration.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 6 residents (Residents #97) who was observed for medication administration. -RN D administered medication to Resident #97 via nebulizer and left Resident #97 unattended. This failure can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization . Findings included: During an observation on 05/29/25 at 08:45 AM Resident #97 was lying in his bed with a nebulizer treatment going and no staff was present in room with the resident. Record review of Resident #97's face sheet, dated 05/29/2025, revealed Resident #97 was a [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of heart failure (heart muscle doesn't pump blood as well as it should), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), pulmonary hypertension due to lung diseases and hypoxia (high blood pressure in your pulmonary arteries, which carry oxygen-poor blood from your heart to your lungs), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits (a transient episode of neurologic dysfunction due to the focal brain, spinal cord, or retinal ischemia without acute infarction or tissue injury). Record review of Resident #97's MDS assessment, dated 03/14/2025, revealed that Resident 97 had a BIMS score of 09 which indicates that Resident #1 was moderately cognitively impaired. Resident #97's required supervision assistance with bathing; all care areas are supervision or set-up assistance needed only. Record review of Resident #1's care plan, dated 03/25/2025 revealed the following: Focus o Risk for Ineffective Airway Clearance r/t Respiratory Failure Date Initiated: 09/06/2024 Revision on: 09/06/2024 Goal o Resident Will Maintain Airway Patency Date Initiated: 09/06/2024 Target Date: 03/19/2025 Interventions o Administer nebulizer treatment, per order Date Initiated: 09/06/2024 o Educate Resident / Representative on energy conservation techniques Date Initiated: 09/06/2024 o Encourage ambulation Date Initiated: 09/06/2024 o Encourage participation in coughing, deep breathing and forced expiratory techniques, as ordered Date Initiated: 09/06/2024 o Ensure proper position for optimal breathing Date Initiated: 09/06/2024 o Evaluate for cough Date Initiated: 09/06/2024 o Evaluate for shortness of breath Date Initiated: 09/06/2024 o Evaluate hydration status including: skin turgor, mucous membranes and tongue Date Initiated: 09/06/2024 o Evaluate lung sounds Date Initiated: 09/06/2024 o Evaluate pulse oximetry Date Initiated: 09/06/2024 o Evaluate respiratory rate and effort Date Initiated: 09/06/2024 o Provide oxygen as indicated by Resident condition and / or provider order Date Initiated: 09/06/2024 Record review of Resident #97's electronic medication record, dated, 05/29/2025, revealed Resident #97 received Ipratropium-Albuterol Inhalation solution 0.5-2.5 (3) MG/3ML (Ipratropium-albuterol) 1 vial inhale orally three times a day related to Chronic Obstructive Pulmonary Disease, Unspecified (J44.9)-Start Date-09/01/2024 Record showed that medication was provided to resident at 08:00am. During an interview on 05/29/25 at 08:56 AM Resident #97 was asked about his nebulizer treatment, and Resident #97 was unable to state if the nurses stay with him during his treatment or not. During an interview on 05/29/25 at 08:57 AM Roommate of Resident #97 stated that they just put it (nebulizer mask) on him (Resident #97) and leave. During an interview on 05/29/25 at 10:39 AM LVN D stated I put it on him and then went to go and do something else, but he is always supervised. LVN D stated the negative outcome would be that the resident would not finish the medication or get the whole medication. During an observation on 05/29/25 at 01:39 PM Resident #97 had his nebulizer treatment mask on and receiving a treatment, no nurse or staff present during medication administration. During an interview on 05/30/25 at 08:39 AM DON stated the negative outcome for not staying with a resident during a nebulizer medication administration could be the resident would not receive all of the medication or have an adverse reaction. Record review of facility provided policy titled, Nebulizer Therapy, dated May 2025, revealed no information related to this event. Record review of facility provided policy titled, Medication Administration, dated October 2012, revealed no information related to this event.

Based on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 (Resident #20) of 24 residents reviewed for medication storage. The facility failed to ensure Resident #20 did not have access to 650 mg acetaminophen capsules. This failure could place residents at risk of injury due to ingesting non-prescribed medications. Findings Included: Record review of Resident #20's admission record dated 05/28/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), unspecified glaucoma (eye condition that damages optic nerve and can lead to vision loss or blindness), major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and unspecified dementia severe with agitation (decline in cognitive function and increase in behavioral disturbances such as restlessness, irritability, or aggression). Record review of Resident #20's quarterly MDS completed on 03/31/25 revealed the following: Section C Cognitive Patterns revealed Resident #20 had a BIMS score of 8 which indicated moderate cognitive impairment. Section GG Functional Abilities revealed Resident #29 needed supervision or touching assistance across all ADLs except for eating and rolling left to right for which he needed only set up or clean up assistance. Record review of Resident #20's care plan completed on 04/14/25 revealed he had impaired cognitive function/dementia or impaired thought processes r/t Dementia. The care plan revealed no mention of Resident #20 being allowed to administer acetaminophen to himself as needed. Record review of Resident #20's active orders as of 05/28/25 revealed no order for self-administering medication and no order for acetaminophen. During an observation and interview on 05/28/25 at 11:03 AM Resident #20 was seated on the edge of his bed. He stated he had pounding headaches often and when he asked staff for an aspirin, they told him he would need doctor orders for any medication. He expressed his disgust with this and reached over to open the bottom drawer of his nightstand. Resident #20 pulled out a bottle of acetaminophen 650 mg capsules, shook it, and stated, I don't have time for that. This is my doctor. He stated he took one pill and it usually helped with his headaches but sometimes he had to take two pills. During an observation on 05/29/25 at 10:20 AM the bottle of acetaminophen was in the bottom drawer of Resident #20's nightstand. It appeared to be 3/4 full of capsules. During an interview on 05/30/25 at 08:57 AM RN J stated nurses and CMAs were the only people allowed to administer medications to residents. She stated if it was care planned, a resident was allowed to have over the counter medication at their bedside. She stated if a resident was not care planned to self-administer medication, They could be taking too much. During an interview on 05/30/25 at 09:25 AM MA M stated nurses and medication aides were the only people allowed to administer medications to residents. She stated some residents had orders to self-administer medications and it was in the residents' care plan. She stated a resident could be negatively affected by having medication in their possession without a care plan or an order to do so. During an interview on 05/30/25 at 09:35 AM DON stated a nurses or CMAs were responsible for administering medications to residents. She stated residents were allowed to keep medications in their rooms sometimes. DON stated, They would do a medication administration test with us, tell us what it (the medication) is and how often they take it and how to use it. She stated if a resident was allowed to have medication in their room it would be in their care plan. She stated if a resident had medication in their room and it was not care planned it could result in medication error or overuse. She stated she was not aware Resident #20 had acetaminophen in his room. She stated staff did regular sweeps to keep that kind of thing from happening but residents could purchase their own over the counter medications or family members could bring said medications to the residents. During an interview on 05/30/25 at 10:23 AM ADM stated Resident #20 was very angry when staff attempted to remove his bottle of acetaminophen. She stated she told staff to give him time to cool off. ADM stated, Then we will get with him and see if he can tell us how to use, how much to use, and then care plan him for having the medication. Record review of facility policy titled Medication Storage and dated June 20, 2023, revealed the following: . It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy, medication rooms, and/or medication carts according to the manufacturer's recommendations . For residents who self-administer and maintain possession of their medications refer to the policy for self-administration. a. All drugs and biologicals will be stored in locked compartments . b. Only authorized personnel will have access to the locked compartments. 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications such as medication aides are allowed access to medications. Record review of facility policy titled Self-Administration of Medications and dated March 2021 revealed the following: . A resident may only self-administer medications after the interdisciplinary team has determined which medications may be safely self-administered. 4. Lockable drawers are required to store medications in the resident's room. 6. The resident's care plan will reflect their desire and ability to self-administer medications.

Based on observations, interview and record review, the facility failed to ensure the residents environment remained free from accidents as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1 did not elope from the facility. The noncompliance was identiified as Past Non-Compliance. The Immediate Jeopardy began on 3/7/25 and ended on 4/3/25. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk a serious injury or serious harm and placed residents at risk of heat or cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. Findings included: Record review of Resident #1s Face Sheet, undated, documented a [AGE] year-old male was admitted to the facility on [DATE] with the following diagnoses: Sequelae of nontraumatic intracerebral hemorrhage (long-term effects of a hemorrhage stroke - bleeding into the tissues of the brain), hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), depression, type 2 diabetes (high blood glucose), convulsions (uncontrolled jerking, blank stares or loss of consciousness caused by abnormal electrical activity in the brain), reflux (stomach acid or bile irritates the food pipe lining), Benign Prostatic Hyperplasia without lower urinary tract symptoms (enlarged prostrate but not cancerous), presence of prosthetic heart valve (an artificial device implanted to replace a damaged or malfunctioning heart valve), contusion and laceration of cerebrum with loss of consciousness greater than 24 hours without return to preexisting conscious level, with patient surviving (bruises and tears in the brain tissue), traumatic subdural hemorrhage with loss of consciousness (blood collects between the layers of tissue that cover the brain), hemorrhagic disorder due to extrinsic circulating anticoagulants (caused by blood thinners interfering with normal clotting factors) Record review of Resident #1's Care Plan, updated 3/7/25, documented the resident is an elopement risk related to history of attempts to leave the facility unattended. Interventions: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Provide structured activities: Toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxed. Wander guard to wrist. Check functioning of secure alarm per order, may attempt to exit seek after having visitors. Record review of Resident #1's admission MDS resident assessment, dated 3/4/25, documented the resident scored 12 of 15 on a mini-mental exam for cognitive awareness and could answer questions correctly, independent with all ADLs but bathing, occasionally incontinent of bladder and bowel, 70 inches tall and 212 pounds. Record review of Resident #1's nurses notes documented the following: 3/7/25 at 6:45 p.m. - This nurse notified via AC that Veterans spouse had contacted her via cell phone stating, My husband called me, and I can hear wind on the phone, and he says he doesn't know where he is. I can tell he is walking somewhere outside. This nurse and RN supervisor immediately began searching for the Veteran. Veteran was located at 6:30 p.m. approximately 500 feet from the facility seated on the ground. Veteran asked what happened and why he left the facility, Veteran responded, I was looking for my truck, it got stolen. Veteran assisted back to facility. Body audit completed: no injuries identified. Blood Pressure 131/75, oxygen saturation 95% on room air, 18 respirations, pulse 86. Wander guard placed to right ankle. One on one initiated upon return to facility. MD/NP ordered veteran be sent to ER for further evaluation. Spouse notified; Administrator notified. 3/11/25 at 4:39 p.m. - Resident here with wife getting reacquainted with unit and staff, was pleasant in conversation, has wander guard to right ankle and is confirmed to be active. Educated resident and family on call light use and to notify staff for outings, as well as proper usage of sign out book - both able to verbalize understanding. Record review of Resident #1's Elopement evaluation, dated 3/7/25 at 9:58 p.m., documented the following: History of elopement while at home: no Wandering behavior, a pattern or goal-directed: no Wanders aimlessly or non-goal-directed: no Wandering behavior likely to affect the safety or well-being of self/others: no Wandering behavior likely to affect the privacy of others: no Recently admitted within past 30 days and has not accepted the situation: no Elopement Score: 1.0 (The resident was not an elopement risk) Record review of the Provider Investigation Report, dated 3/8/25 and filled out by the DON reflected Resident #1, who was independently ambulatory, interviewable and had the capacity to make informed decisions, approached LVN A and said he was looking for his friend. LVN A informed the veteran that she hadn't seen anyone, Resident #1 ambulated back down the hallway. Later, when LVN A was passing meal trays in the dining room, she saw Resident #1 ambulating down the main hallway. The AC received a call from Resident #1's wife who said her husband had called her and did not now where he was at, but he was outside and by a road. The AC immediately contacted the DON, who along with the RN supervisor, got in a car to search the outside of the facility while staff were searching everywhere inside the building. Resident #1 was found in the back of the facility sitting on the ground. Resident #1 was assessed head to toe, and he was assisted back to the community. Body audit was completed on Resident #1, no injuries identified. Placed on 1:1 monitoring pending transport to ER. Vital signs obtained, Blood Pressure 131/75, Oxygen 95% on room air, 18 respirations, pulse 86. Resident #1 does not complain or show signs of symptoms of any physical, mental, or emotional injuries or distress. Resident #1 does not have any ill effects on his psychosocial wellbeing and was sent to the hospital for evaluation and treatment for prior existing elevated INR that was being monitored and the facility was waiting for new orders. Resident #1 was admitted to ICU at the hospital and treated for subdural hematoma. MD/NP and spouse notified. All staff in-service was immediate for: Elopement Procedures and Managing Exit Seeking Behaviors, Resident Specific Care Plan Interventions and Identifying Trippers related to Exit Seeking Behaviors. Staff were also re-educated on the Elopement Risk Book and drills. The facility has created a new position and will hire a nighttime Concierge/Security to help support the community's front entrance. This position will support the community when the daytime concierge leaves for the day During an interview on 4/9/25 at 10:00 a.m., LVN A stated she was making her last rounds right before dinner, Resident #1 approached her and was looking for somebody with blonde hair and wearing boots. LVN A stated she told Resident #1 she had not seen anyone fitting that description and he ambulated away to his room. LVN A stated she was passing trays in the dining room between 5:00 p.m. and 6:00 p.m., when she saw Resident #1 in the main hallway and then she no longer saw him. LVN A stated in the middle of dinner, it was announced that Resident #1 was not in the building. LVN A stated it was not too long and Resident #1 was found. LVN A stated the RN supervisor and the DON assessed Resident #1 and he did not have any injuries. LVN A stated Resident #1 was sent to the hospital because his cognition was worse than it normally was. LVN A stated they had held Resident #1's Coumadin (blood thinner), because his INR was elevated and at the hospital, it was reported to staff the Resident #1 had a subdural hematoma. LVN A stated Resident #1 had not fallen but his INR was elevated, and he was more confused than usual, so they sent him out to the hospital. LVN A stated Resident #1 had since been discharged home. During an interview on 4/9/25 at 10:25 a.m., the DON stated Resident #1's spouse had called the AC, and she was frantic because Resident #1 called her and said he was outside. The DON stated they called a Code [NAME] due to a missing resident. The DON stated they announce overhead and then they started looking for the resident. The DON stated staff were stationed at the front and back doors. The DON stated the charge nurse would identify who stayed on the hall and who looked for the resident. The DON stated she called Resident #1's spouse and said she could not find him as she was outside and drove around the block but could not see him. The DON stated she received a call from the AC that Resident #1 was in the back of the facility sitting on the ground and that was where she found him. The DON stated Resident #1 told her he just sat down. The DON stated Resident #1 was assessed and was more confused than usual. The DON stated Resident #1 was being monitored due to an elevated INR and they were watching for any type of bleeding. The DON stated the RN Supervisor took Resident #1 to his room and assessed him again and there was not any injury. The DON stated during this situation, if passed a certain amount of time, the police would have been called if the resident could not be found. The DON discussed with the provider about the elevated risk because of his elevated INR and they did not know if he fell or just sat down, so they sent him out to the hospital for further evaluation. The DON stated a normal INR was supposed to be between 2 - 3, but Resident #1's was elevated at 3.9, so they held his coumadin dose. The DON stated they previously checked Resident #1's INR and it was 3.9, the INR was checked again at the hospital, and it was over 5. The DON stated she did not understand the rise in the INR because Resident #1 was not given any extra Coumadin because they had followed the provider orders and held the Coumadin dose. The DON stated Resident #1 had been taking Coumadin for a long time. The DON stated they drew INR twice a week and if the INR was abnormal, they draw an INR more often. The DON stated when Resident #1 returned to the facility, he did not have any order for Coumadin due to his high risk. The DON stated Resident #1 was talking in word salad (just jumbled words) before the hospital visit and when Resident #1 returned, he was back to his baseline. The DON stated Resident #1 had only been in the facility for a week as he came in for strengthening. The DON stated Resident #1 had a family member visit that day and he was confused and wanted to go home. The DON stated the interventions after the incident included placing a wander guard on the resident and checking on him every 15 minutes. The DON stated they felt Resident #1 walked out of the front door as the Concierge had left the facility. An observation on 4/9/25 at 11:10 a.m. of the area where the resident was found was at the back edge of the property. Along with the DON and CMS representative, revealed the back door was located between halls 400 and 500 which was always kept unlocked. The large patio had an open sidewalk on the right with no gate and at the end of the patio, there was a large open area, with no gate, leading out to the parking lot. The parking lot was crossed, and the far end of the property is an empty field with a housing development behind it and a road coming off of a main road which was used as a driveway to the back parking area. During an interview on 4/9/25 at 11:30 a.m., the AC stated Resident #1 was a new to the facility. The AC stated when Resident #1's family member called her because she received a call from Resident #1 who was outside somewhere. The AC stated Resident #1's family member said Resident #1 said he did not know where he was, so she notified the supervisor. The AC stated the DON called a Code [NAME] overhead and the DON and supervisor got in a car and went looking for Resident #1 while other staff were looking for him in the facility. The AC stated she called Resident #1's family member back to get his cell phone number so AC called him and asked him questions about what his surroundings looked like. The AC stated pretty soon, she heard the DON talking to him, so she knew Resident #1 was ok. During a telephone interview on 4/9/25 at 11:40 a.m., Resident #1's family member stated Resident #1 called her on his cell phone and said he was somewhere outside and told her he could not make it and he could not find his truck. Resident #1's family member stated she thought he was dehydrated as he had just got out of an intense therapy rehab center. Resident #1's family member stated Resident #1 had been at a rehab facility all last summer and was in intense therapy as his brain injury was very severe. Resident #1's family member stated Resident #1's memory was the problem now, but he was no longer on Coumadin because it was too dangerous for him to continue the medication due to his history of brain bleeds. Resident #1's family member stated Resident #1's INR was elevated and was 5.4 when he got to the ER, and he was dehydrated. Resident #1's Family member stated her husband was on the phone with the AC while staff were looking for him. Resident #1's family member stated he went to the hospital after that, was treated and came back to the nursing home for more rehabilitation and was discharged home with home health on 3/24/25. Resident #1's family member stated once they were aware he left the facility, they kept a better watch on him. Resident #1's family member stated right after the incident, a wander guard was placed on Resident #1 for his safety. During a follow-up interview on 4/9/24 at 11:55 a.m., the DON stated the back doors off of the great room had never been locked but they did have gates on the patio doors, but the owners of the building had them removed a few years ago because they thought it restricted residents too much. During an interview on 4/9/25 at 1:15 p.m., the Administrator stated they could also put a lock on the door that the residents could go outside on the patio and then once they were outside, they could push a button to come back in. The Administrator stated the Maintenance Man had put a chirping alarm on the door already but was looking to get more parts so the door could be locked. The CMS representative asked when the elopement happened - 3/7/25 and what is today's date - 4/9/25, so why did it take so long to act. The Administrator stated the security guard at night was working and they had been getting bids for alarms on the door. Record review of a bid sheet, dated 3/28/25, revealed a quote was submitted from a reputable company for locks for the facility at a cost of $61,240.00. The quote was sent to the corporate office for further review and evaluation. Record review of the facility's undated policy titled, Elopement in the Long-Term Care Setting: Prevention and Response Protocol., documented the following: Code Green: Active Elopement: In our facility, Code [NAME] signals an active elopement. It means a resident is missing and immediate action is required. Elopement Response Procedure: 1. Notify the Manger on Duty, 2. Review the Sign-Out book to confirm where resident has been signed out by family member. 3. Page the resident over the public address system to alert all staff members. 4. Search the Facility - all rooms, hallways, and outdoor areas. 5. Notify Key Personnel - Administrator, DON. 6. Notify family within 30 minutes of discovering the elopement. 7. Report to Law Enforcement if resident is not found. 8. Indoor search - conduct another search within the building to check all areas thoroughly. 9. Notify Regulatory Agencies if resident is still missing. 10. Expand the Search: teams of staff should be assigned to search designated areas outside of the building. Flyers with resident's photo should be distributed. 11. Evaluate the Resident: once located, conduct a physical and emotional evaluation to ensure their well-being. 12. Report and Review: Create a detailed report about the incident and schedule a staff meeting to review the procedures and improve response strategies if needed. Elopement Binders: Located at all nurses' stations and the reception front desk. They contain critical procedures for managing an elopement incident. Veterans with elopement risks listed in the binders. Preventing Elopement: Personalized care plans for each resident: Identify Behavior and environmental triggers and include cognitive considerations. Staff can better anticipate and manage potential elopement behaviors. Record review of facility provided training documents revealed that the facility took the following actions prior to the surveyor entrance and no further elopements occurred: 3/7/25 Upon notification, the resident was assisted to re-enter the facility and assessed per RN on 3/7/25 at 6:35 p.m. with no injury's notes. The MD and responsible party were notified with new orders for resident to be sent to the ER due to deviation from baseline mental status. One-on-one initiated pending ER transfer, wander guard placement prior to ER transfer. Resident returned from hospital on 3/13/25 and discharged home with wife on 3/24/25. The resident's care plan was updated on 3/7/25 to include personalized interventions and potential triggers for exit seeking behavior by the DON and/or Social Worker. 100% of all available staff were trained on elopement procedures on 3/7/25 and all other staff will be trained before their next scheduled shift on elopement procedures and managing exit seeking behaviors by the DON and/or designee. Social Worker was educated on 3/7/25 by DON on resident specific care plan interventions and identify triggers related to exit seeking behaviors. An Elopement Drill was conducted on each shift starting with evening shift on 3/7/25 and completing with night shift 3/8/25 by DON and/or designee. Elopement Risk book reviewed and updated by Social Worker/Designee on 3/8/25. This book contains identification information on residents at risk for wandering. Picture of resident as well as face sheet are included. Book is available to all staff with copy at receptionist desk and on each nursing unit. 100% of available staff were trained on the elopement book by DON/Designee on 3/7/25. All other staff were trained before their next scheduled shift on the elopement book. All doors with the wander guard system were checked to ensure proper function on 3/7/25 by facility maintenance staff. All door wander guards were functioning properly. Elopement risk was completed on all residents by DON/Designee by 3/7/25. Any resident identified with elopement risk had interventions in added. These include but are not limited to Wander Guard, Secure Unit, frequent checks, and the Care Plan updated. These updates reflect resident specific interventions. Residents with any risk had interventions implemented. 3/10/25 - Security Staff job opening posted on hiring platforms for nighttime rounding, monitoring interior and exterior of facility examining doors to ensure they are functioning, secured and untampered. 4/1/25 - All Security job openings were filled, and orientation completed. The start date of them working in their official capacity was 4/3/25 - all rounding sheets reviewed with no concerns, elopements, or significant findings. Elopement policy was reviewed with no updates required by the Regional Clinical Consultant.

Based on observation, interview and record review, the facility failed to provide treatment and care to residents in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of 11 residents (Resident #1) reviewed for quality of care. CNA L failed to ensure Resident #1 had catheter care on 08/20/2024 resulting in Resident #1's suprapubic catheter leak to go undetected, resulting in Resident #1 being left in a saturated brief and in a bed with urine satured bed linens. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 08/20/2024 and ended on 08/21/2024 The facility corrected the noncompliance before the investigation began. This deficient practice could result in residents not receiving the necessary care to maintain optimum health and place them at risk of skin breakdown. Findings included: Record review of Resident #1's clinical record revealed a 69 -year-old male admitted to the facility originally on 08/04/22 with diagnoses to include MULTIPLE SCLEROSIS, ANXIETY DISORDER, UNSPECIFIED, BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS, VOLVULUS, IMMOBILITY SYNDROME (PARAPLEGIC), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE, MUSCLE WEAKNESS (GENERALIZED), OTHER MALAISE, NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED, VITAMIN D DEFICIENCY, UNSPECIFIED, CHRONIC IDIOPATHIC CONSTIPATION. , HEMIPLEGIA, UNSPECIFIED AFFECTING RIGHT DOMINANT SIDE, CHRONIC PAIN SYNDROME, MODERATE PROTEINCALORIE MALNUTRITION, CONTRACTURE, RIGHT WRIST, DEPRESSION, UNSPECIFIED, and PARAPLEGIA, UNSPECIFIED. Record review of Resident #1's clinical record revealed a 14-day MDS completed on 08/04/24 with a BIMS score of 13 indicating he was cognitively intact and a functional status of requiring two-person assistance with all activities. Section H-Bladder and Bowel H0100 A. Indwelling Catheter-Resident #1 was marked yes. Record review of Resident #1's clinical record revealed a care plan with the following: Problem: I am incontinent of bowel and r/t Multiple Sclerosis with loss of peritoneal tone and muscle control. I will remain free from skin breakdown due to incontinence. breakdown, if I am not cleaned properly and regularly. Related To: MS. Check me during rounds and as required for incontinence. Provide peri care with each incontinent episode. Change clothing PRN after incontinent episode. Revised on 9/03/24 observe skin while providing peri care and report signs of breakdown to the Nurse. Record review of Resident #1's clinical record revealed Active Orders with start dates from 5/21/24, 6/29/24. There were orders for catheter care, monitoring, or maintenance. Suprapubic Catheter 24Fr 10cc, change monthly and PRN every 1 hours as needed. Record review of Resident #1's Progress Note on 09/13/24 at 9:22 am revealed his foley was leaking around the insertion site. The foley was changed using sterile technique. During an observation on 09/12/24 at 9:19 AM, Resident #1 was in bed sleeping. A urinary catheter was noted hanging from the side of Resident #1's bed in a privacy bag. Observations and Interviews revealed sampled resident were clean and dry. During an observation on 09/13/24 am, Resident #1 was lying in bed watching TV. CNA G checked resident #1s catheter to ensure it was not leaking. During an interview on 09/12/24 at 11:43 AM, the DON stated a resident with a catheter should have orders for the catheter. Yes, they should have an order for a catheter and the care. The DON said the alleged CNA L on 08/20/2024 did not check Resident #1 during her rounds that morning. Resident 1 was found with a saturated brief and bed linens. The DON said the CNA L was terminated. During an interview on 09/12/24 at 3:30 pm, ADM stated CNA L did not do her job on 8/20/24 and was suspended due to pending investigation and then was terminated on 8/30/2024. During an interview on 09/12/24 at 9:23 am, RN B she said she completed a full skin assessment Resident #1 on 8/20/2024 after the CNAs finished cleaning him up. RN B stated the skin assessment did not reveal any skin breakdown and that Resident #1's skin was clear. RN B stated that there were multiple areas of blanchable redness with no skin breakdown. During an interview on 9/13/24 at 9:51 am, CNA I stated that when she was passing meal trays on 8/21/24 around 11:30 am, she found Resident #1 soaking in urine in his bed. CNA I stated she reported the incident to the nurse. CNA I stated the nurse assessed the resident after they cleaned him up. Record review of the facility's Provider Investigation Report revealed the following. The Provider Investigation Report was completed and signed on 8/26/24. The facility's investigation revealed that CNA L failed to check on Resident #1 in the morning of 8/20/24, resulting in Resident #1 being left unattended for an extended period of time. When assessed by RN B, Resident #1 was noted to have a large urine stain under him on the bottom sheet. RN B assessed Resident #1's suprapubic catheter and found it to be leaking. A skin assessment performed by RN B noted multiple areas of blanchable redness, no open areas. The Provider Investigation Report further documented that CNA L was immediately suspended pending the outcome of the investigation. The Provider Investigation Report documented this interview with CNA L by Admin: 8/20/24 2:15pm {Admin} met with {CNA L} related to an alleged abuse/neglect allegation .{Adm} asked {CNA L} if she had checked on Resident #1 this morning. {CNA L} replied that she did not go into Resident #1's room as she got busy Record review of Resident #1's nursing progress notes dated 8/20/24 at 12:44pm by RN B revealed, This nurse assessed resident head to toe after report of not being changed . Record review of facility provided in-service titled Resident Rights-Abuse/Neglect, Rounding, Catheter Care conducted on 8/21/24 revealed the facility's abuse/neglect policies were reviewed. Record review of the facility provided policy titled, Resident Rights undated, revealed the following: Right of the Elderly. b. An elderly individual has the right to be treated with dignity and respect . 2. has the right to be free from abuse, neglect .

Based on observation, interview, and record review; the facility failed to ensure drugs were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication rooms. -The facility failed to store Hydrocodone-Acet 325mg properly by putting them with non-controlled discontinued medication in Medication room [ROOM NUMBER] and then later putting the medication in an ADON's office. This failure could result in a drug diversion placing residents at risk of not getting their medications as ordered. Findings included: In an observation on [DATE] at 5:00 AM, revealed Medication room [ROOM NUMBER] had a black plastic bin where non controlled discontinued medications were stored. The black bin had a slit and a hole on the lid and a combination lock on the bin. In an Interview on [DATE] at 5:00 AM, LVN A stated that the medications that were in the bin in the medication room were over the counter, non-controlled, discontinued medications. All controlled medications stayed in the mediation cart until the Pharmacy Nurse retrieved the medication. In an interview with on [DATE] at 5:30 AM, LVN B stated that all narcotics stayed on the locked medication cart until the pharmacy nurse retrieved the medication. LVN B stated that non-narcotic drugs that were discontinued went into the black bin in the medication room. In an interview with on [DATE] at 5:40 AM, LVN C stated that she did not see RN D, or the Hospice Nurse put the Hydrocodone in the black bin but was told that was what occurred. LVN C stated that the Pharmacy Nurse was responsible for removing any narcotics from the medication cart. In an interview with on [DATE] at 6:00 AM, ADON F stated that RN D took Hydrocodone 325 mg and disposed of it on [DATE] and put the medications in the black bin in Medication room [ROOM NUMBER]. ADON F stated that when RN D realized she made a mistake she called RN E the next morning and told her the mistake. RN E went to the bin and took the medication out of the bin and put it under ADON G's door until she could give it to the Pharmacy Nurse. The medication was in ADON G's office until the following day when ADON G took it to the Pharmacy Nurse. ADON F stated the negative outcome for medications not to be properly stored would be that a nurse could take them, and a resident could miss their medications. In an interview with the DON on [DATE] at 8:00 AM, The DON stated that it was a mistake by RN D putting the medication in the wrong bin. The DON stated the protocol for disposing of narcotics was to leave the medication in the medication cart until the Pharmacy Nurse and DON can pick them up and put them in the Pharmacy Nurse's office where she and the pharmacist would then dispose of the medication. The negative outcome for not following the protocol would be that the medication could get lost or stolen and residents would miss their medications. In an interview with RN D on [DATE] at 10:02 AM, RN D stated that the hospice nurse told her that when a resident expired the medications had to be disposed of immediately. RN D said after she and the hospice nurse put the hydrocodones in the bin in Medication room [ROOM NUMBER] she realized she made a mistake and called RN E and told her what she had done, and RN E said she would retrieve them and to not let anything like that happen again. RN D stated the negative outcome for putting medications in the wrong area would be that the medications could go missing and a resident would not have their medication. In an interview with RN E on [DATE] at 10:16 AM, RN E stated that she got the card of 30 hydrocodone out of the bin in Medication room [ROOM NUMBER] and put the card of hydrocodone under ADON G's door. RN E stated the negative outcome for not having the medication in a locked permanently fixed container would be that the medication could get stolen. RN E stated that the Pharmacy Nurse was responsible for getting the medications out of the medication cart and disposing of them. In an interview on [DATE] at 12:31 PM, the Hospice Nurse stated that she and RN D disposed of the medications in the bin in the medication room. In an interview on [DATE] at 12:41 PM, ADON G stated that RN E told her that she retrieved the medication out of the bin in Medication room [ROOM NUMBER]. ADON G stated that she told RN E to lock the medication up, and she didn't think that RN E would put them under her door. ADON G said she had been in health care for a long time, and she knew better than to have the narcotics put under her door. ADON G stated when she returned to work, she took the medications out of her office and gave them to the Pharmacy Nurse to lock them up in her office. ADON G stated that it was the Pharmacy Nurses responsibility to remove the narcotics from the cart and lock them up until the Pharmacy Nurse and Pharmacist disposed of the medications. ADON G stated that her office is kept locked when she is not in the office. ADON G stated the negative outcome for not having controlled drugs under secured conditions that the medications could get lost, disappear or someone could get their hands on them and if the drugs were stolen or lost a resident would need that medication and not have it. Record review of facility provided policy, titled Storage of Medications, revised [DATE], revealed the following: .Schedule II-V controlled medication are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. Record review of facility provided policy, title Discarding and Destroying Medications, no date, revealed the following: .All unused controlled substance should be maintained in a securely locked area with restricted access until disposed of.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure general sanitary conditions in the kitchen were maintained during preparation and serving of food. 2. The facility failed to ensure hairnets and beard covers were worn. 3. The facility failed to ensure the food items were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: In an interview and observation on 3/4/24 at 8:15 am Cook A was observed in the kitchen preparing food with no beard cover. Cook A stated, Yes, I should have a beard cover on. I just did not grab one. My bad. In an interview and observation on 3/4/24 at 8:17 am, the DM was observed in the kitchen prep area with no beard cover over his beard and moustache. The DM stated, It is not a beard. It is just a 2-day growth. Observation of the freezer on 3/4/24 at 8:20 am revealed the following: 1. (1) plastic bag of biscuits, no label or date, not in original box. 2. (1) brown bag of food, no label or date, not in original box, sitting on top of a box of frozen potatoes. Observation of the walk-in cooler on 3/4/23 at 8:21 am revealed the following: 1. An opened package of turkey ham lunchmeat, no date. Observation of the kitchen prep area on 3/4/24 at 8:22 am revealed the following: 1. The front and sides of the fryer had food splatters and food debris on the sides of the fryer. There was a pool of grease in the corner of a tray covering the fryer oil. 2. There were 7 cups of orange drink sitting under a cabinet on a tray in the kitchen prep area. The drinks had no lid or covering. The drink glasses were warm to the touch. The drinks were not sitting in any ice. Cook C stated the drinks were for lunch. In an interview and observation on 3/4/24 at 10:40 am, the DM was observed in the kitchen prep area with no beard cover. The DM was observed to have shaved off his beard but still had a moustache. The DM stated he had shaved off his beard, so he did not have to wear a beard cover. The DM stated he did not need a beard cover with just a moustache. The DM made no move to get a beard cover to cover his moustache. In an interview and observation on 3/4/24 at 10:50 am, Cook A was observed in the kitchen prep area cutting meat with gloved hands. Cook A touched the counter of the prep table and the cutting board. Cook A picked up a pan of meat and moved the two pans of the meat from one place to another with both hands. Cook A picked up the knife and cut more meat using his right hand to hold the knife and his left hand to hold the meat. When Cook A transferred the cut meat into the pan from the cutting board, he used his left gloved hand to move the meat to the pan. Cook A continued to pick up the meat with his gloved hand and continue to cut more meat. Cook A did not wash his hands or change his gloves. Cook A stated he should have washed his hands and changed his gloves. Cook A stated time was running out and he had to get the meat cut. In an interview and observation on 3/4/24 at 10:55 am, Cook B was observed in the kitchen prep area with gloved hands. Cook B was observed touching the baked potatoes while cutting slits in the baked potatoes that were on a sheet pan. Cook B touched the counter with both gloved hands. Cook B opened the door of the warmer and took out a second pan of baked potatoes covered with foil. Cook B put the second pan of potatoes on the counter and turned around to close the warmer door. Cook B moved the pan of potatoes on the counter back from the edge of the counter with both hands. Cook B removed the foil and picked up the potatoes on the sheet pan one by one, squeezing the potatoes open, before then placing the potatoes in the second pan. When the second pan was full Cook B took the palm of his hand and pushed the top potatoes into the pan, replaced the foil and opened the door to the warmer. Cook B picked up the pan of potatoes and put the potatoes into the oven and shut the door. Cook B did not wash his hands or change his gloves. Cook B stated he did not realize he had touched other surfaces and should have changes his gloves. In an interview and observation on 3/4/24 at 11:07 am, Cook C was observed in the kitchen prep area with the front half of her hair and the sides of her hair not being covered by the hair. Cook C stated she should have all her hair covered. She stated it slipped off. In an observation on 3/4/24 at 11:30 am, the DM was observed in the kitchen at the prep table with gloved hands touching the kitchen surfaces, the prep table, and a pan of mashed potatoes. The DM opened several small plastic packages of sour cream and squeezed the sour cream into the potatoes. The DM picked up a package of shredded cheese, pulled open the top of the cheese package and reached into the package of cheese with his gloved hand. The DM dropped the handful of cheese into the pan of potatoes. The DM put his hand into the cheese package and pulled out a second handful of cheese and dropped the cheese into the potatoes. The DM did not change his gloves or wash his hands. In an observation on 3/4/24 at 11:41 am, the DM was observed in the kitchen at the noon meal making grilled cheese sandwiches on the grill. The DM was observed touching various kitchen surfaces in the kitchen then using his hand to turn the sandwiches over on the grill. The DM picked up a utensil in one hand and turned the sandwiches over using one hand to assist in the turning of the sandwich. The DM put the utensil down and picked up a pan of melted butter and poured butter onto the grill. The DM picked up the utensil and continued to use his gloved hand to turn the sandwiches over. In an interview and observation on 3/4/24 at 12:03 am, Cook B was observed in the kitchen serving the noon meal. Cook B picked up a plate, then picked up a serving utensil and placed the meat on the plate. Cook B put the serving utensil down and picked up a baked potato with his gloved hands and placed the potato on the plate. Cook B plated the rest of the foods then set the plate on the tray. Cook B then picked up a plate and a serving utensil. Cook B put meat on the plate then picked up a baked potato with his gloved hand. This occurred with three plates of food. Cook B did not change his gloves or wash his hands. Cook B stated he did not realize he did that, and he should have used tongs for the potatoes. In an interview and observation on 3/4/24 at 12:05 am, Cook D was observed in the kitchen serving area with gloved hands. Cook D was observed touching the bars of the serving tray line, the hot food rolling carts and the food trays. Cook D touched a tray, picked up a container of cheese, placed the container on the tray then picked up a roll with her gloved hand and placed the roll on the tray. Cook D carried the tray to the food cart opened the cart door placed the food tray into the cart then closed the door. Cook D returned to the serving line, picked up a container of cheese and put the cheese on the tray. Cook D picked up a roll and placed it on the plate. Cook D picked up the tray and put the tray in the cart. Cook D returned to the line and picked up a container of cheese placed it on the tray and picked up a roll with her gloved hand. Cook D did not change her gloves or wash her hands. Cook D stated, I have gloves on. Cook D stated she should have used tongs to touch the bread. The residents could get cross contamination. Observations of the kitchen freezer and walk in cooler on 3/5/24 at 10:30 AM revealed the brown bag of frozen food, the biscuits in the freezer and the lunchmeat in the walk-in cooler were still unlabeled and undated. In an interview and observation on 3/5/24 at 10:42 am, Cook E was observed in the kitchen prep area with no hair net and no beard cover. Cook E stated he had just forgotten to put the hair net and beard cover on. Cook E stated he was aware he was to wear the hairnet and beard cover so he would not cause cross contamination. In an interview on 3/7/24 at 2:32 pm, the DM stated of the issues in the kitchen with unlabeled and undated food the employees must have just missed those items and all food items should be labeled and dated. The DM stated he expects all staff to be cleaning daily. The DM stated he does spot checks for cleaning on a regular basis. When asked who trains the staff on the kitchen issues and cleaning practices, the DM stated he does the training. The DM stated he has already given the staff an in-service on hairnets and beard covers and labeling and dating food. The DM stated food borne illnesses and unsanitary surfaces are a consequence of not cleaning the kitchen,and not changing gloves and could make residents sick. He stated residents could get sick from the hairnets and beard covers not being worn. Record Review of the policy dated October 2018 titled Employee Sanitation documented: Hairnets, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food contact surfaces. Employees must wash hands and exposed portions of their arms before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapping single service and single use foods . when switching between working with raw food and working with ready to eat foods, during food preparation including working with exposed food, clean equipment, and utensils. Gloves are not a substitute for thorough and frequent hand washing. When using gloves, always wash hands before touching or putting on new gloves. Use single use gloves for one task. Change gloves between each food preparation task, after touching items, utensils or equipment not related to task, when leaving the food prep area for any reason, when damaged soiled or when interrupted, every hour for all tasks taking longer than one hour. Do not store gloves in pockets or apron. Record Review of the policy dated October 2018 titled General Kitchen Sanitation documented: Keep food contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. Clean all non-foods contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt food particles and otherwise in a clean and sanitary manner. Record Review of the policy dated June 2019 titled Food Storage documented: All containers must be labeled and dated. Date label and seal all refrigerated food. Store frozen food in moisture proof wrap or containers that are labeled and dated. Record Review of the policy dated October 2018 titled Food Holding and Service documented: Take cold foods from the refrigerator only as needed. Keep foods covered to maintain temperature. Rapidly cool all foods requiring refrigeration after preparation by placing food in 2-inch-deep pans and chill for 2 hours. Record Review of the policy dated June 2019 titled Food Holding and Service documented: Take cold foods items from the refrigerator only as needed. Ice down Record Review of the policy dated October 2018 titled Handwashing documented: Hands should be washed after the following occurrences: handling raw food, touching un-sanitized equipment, work surfaces .

Based on interviews, observation, and record reviews, the facility failed to ensure the right to be free from abuse was provided for 1 of 8 residents (Resident #2) reviewed for abuse. LVN A was observed striking Resident #2 on his upper arm/shoulder after resident had grabbed LVN A's right breast. An Immediate Jeopardy (IJ) was identified on 6/13/23 at 5:00 PM and the IJ template was provided to the facility Administrator on 6/13/23 at 6/13/23 at 5:00 PM. While the immediate jeopardy was listed on 6/14/23 at 8:00 PM, the facility remained out of compliance at a scope no actual harm with potential for more than minimal harm: and a severity level of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. This failure could place resident at risk of abuse, mental anguish, injury, fear and hopelessness. Findings included: Record review of Resident #2's clinical record revealed an admitted [DATE], was [AGE] years of age with the following diagnoses: dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, combined systolic (congestive) and diastolic heart failure, type 2 Diabetes mellitus with Diabetic Nephropathy, Osteoarthritis, hypertension, Nonrheumatic aortic valve stenosis (non-rheumatic aortic valve stenosis is narrowing of the valve between the left lower chamber of heart and a major blood vessel called aorta), nonrheumatic mitral valve disorder (problem with the valve located between the left heart chambers (left atrium and left ventricle)), Dementia in other diseases with other behavioral disturbance, spinal muscular atrophy, Alzheimer's disease with late onset, muscle weakness, muscle wasting and atrophy, malaise, major depressive disorder, intermittent explosive disorder, allergic rhinitis, heart-valve replacement, presence of automatic implantable cardiac defibrillator, atherosclerotic heart disease of native coronary artery, gout, personality and behavioral disorders due to known physiological condition. -A quarterly MDS resident #2 assessment dated [DATE], documented Resident #2 had a BIMS score of 08 out of 15 indicated moderately cognitively impairment. Resident's functionality requires extensive assistance with 2 person assistance with all ADL's. - Resident's care plan indicates resident #2 has a behavior problem related to being inappropriate with female resident initiated 11/23/22. Interventions to include observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. Staff to redirect resident when having inappropriate behaviors. Record review of statement by LVN A and signed on 6/6/23 documented the following: Tuesday, June 6 @ 0635 This nurse was walking toward the 500 hall nurses stations looking for the O2 key. {Resident #2} was sitting at 500 hall nurses station window. As I approached the 500 hall nurses station window, {Resident #2} grabbed my right breast and squeezed it twice. I reacted by pushing his hand away and then slapping his left arm saying with a firm voice, 'Don't do that!' Record review of resident #2's clinical record to include progress notes and nurse's notes on the date of the incident 6/6/23 did not reveal that the resident was assessed for physical or psychosocial injuries/harm after the incident. Record review of witness statement completed and signed by RN D on 6/6/23 documented the following: 6/6/23 At approximately 0635,{LVN A} was walking in front of the 500 unit nursing station, { Resident #2} was sitting in his wheelchair. This RN D heard {LVN A} state loudly, 'you don't do that.' This RN D looked up and saw {LVN A} take his left wrist away from her body and then smacked him on his upper left arm. This RN D called out to her and told her we couldn't do that. She stated to this RN D, 'he grabbed my breast.' This RN D reminded her we can't react to the behavior and then escorted him from the area to the TV area and reminded him he can't touch staff, can't flirt with staff, etc. he stated, 'Yes, Ma'am.' During an Interview on 6/13/23 at 08:30 AM, administrator was asked if LVN A hit Resident #2. Administrator stated LVN A did push his shoulder and was immediately suspended while facility conducted an investigation. Administrator stated Resident #2 has behaviors and he yells out sexual invitations to female staff, as well as grab breasts and bottoms of female staff. During an interview with LVN B on 6/13/23 at 09:16 AM, LVN B stated she observed LVN A being grabbed by Resident #2 on the breast and she slapped him three times across chest and back. LVN B stated LVN A was suspended for a couple of hours but feels LVN A should have been suspended longer. LVN B stated I know Resident #2 is a handful, but you don't hit them. LVN B stated the incident happened at 06:30 AM and LVN A was back to work by noon the same day. LVN B stated RN D on the floor witnessed the event. During an interview with LVN A on 6/13/23 at 09:59 AM LVN A stated Resident #2 has been inappropriate with her physically. LVN A stated her slapping Resident #2 was not retaliatory. LVN A states the first time Resident #2 physically touched her on her butt and she had a firm tone with him. LVN A stated this second incident he grabbed her breast and she smacked him on his left arm. LVN A stated she did not mean to hit Resident #2. LVN A stated she only slapped him once. LVN A stated she was suspended while the facility did their investigation. LVN A states there were several witnesses to this incident. LVN A stated witnesses for the incident were LVN B, RN D, LVN C and MA. LVN A states she was suspended for 1/2 a day and returned to the facility to finish her shift by approximately 1:00 PM. LVN A stated she does not know the details of the administration investigation; however she was cleared to return work. During an interview on 6/14/23 at 10:28 AM, RN D stated she heard LVN A yell stop don't do that and saw her swat Resident #2 on the left arm. RN D stated, I heard 'Don't do that' and interjected when I saw LVN A's arm swing up and make contact with the resident's arm. When asked if LVN A struck Resident #2 more than once, RN D stated LVN A did not hit Resident #2 more than one time. RN D stated LVN A was suspended but does not know length of time. RN D stated that she began the internal investigation. RN D stated she does not believe LVN A returned to work that day but honestly did not know when LVN A returned to work. During an Interview with LVN C on 6/13/23 at 11:54 AM, LVN C stated I wasn't a witness, I just heard the commotion. LVN C stated I heard what RN D told LVN A. LVN C stated RN D told LVN A You cannot hit Resident #2 like that. LVN A responded to RN D by stating well he grabbed my breast. LVN C stated RN D responded back to LVN A It doesn't matter. LVN C stated LVN A stated I'm sorry. It was a reaction. LVN C stated LVN A was crying. LVN C left interview, however came back in approximately 2 minutes later crying and stated, I just don't understand how they 'suspended' the nurse for just 2 hours. LVN C stated It's not all of Resident #2's fault. LVN C stated How can you let a nurse go for 2 hours and let her come back to the same side that Resident #2 resides on? It's not all of Resident #2's fault. Resident #2 cannot communicate well. During an interview with MA on 6/13/23 at 11:56 AM, MA stated I was on duty. I was getting started. I was cleaning off the medication cart. I heard LVN A on 6/6/23 at approximately 6:35 AM yell 'stop'. MA stated she heard all the commotion but did not actually see what happened. MA stated, I did not see Resident #2 touch her. MA stated that she saw a few nurses run towards LVN A because she was crying inconsolably. MA stated that by the time she started asking questions with LVN A, RN D had come to LVN A and was telling LVN A she needed to speak with her and console her. MA states Resident #2 is 'pretty vulgar' and requires a lot of redirecting and teaching of what is appropriate and what is not appropriate. MA states she did not see LVN A hit Resident #2. MA states the only reaction she saw from LVN A was her crying uncontrollably. MA states it wasn't surprising from what Resident #2 did. During an Interview with Resident #2 on 6/13/23 at 1:11 PM, Resident #2 stated staff treat him real good. When asked who he would go to if he had any problems, Resident #2 stated, the first person I saw. Resident #2 state, I don't have any problems. Resident #2 stated, as far as I know I'm safe here. I haven't had any incidents with anybody that I am aware of. During an interview with Admin on 6/13/23 at 1:25 PM, Admin was asked what steps the facility implements to ensure this type of incident did not occur again. Admin stated, We in serviced staff on appropriate approaches and responses and when staff have those negative behaviors. Admin stated the facility had QAPI'd the incident. During an interview with DON on 6/13/23 at 1:48 PM DON stated QAPI meeting is not scheduled until 6/22/23. DON handed what would be in the QAPI meeting titled What is a Behavior and Helping MANAGE BEHAVIORS Appropriately undated. DON states I will get every resource in here to protect Resident #2, especially when his behaviors effect his quality of life. I want Resident #2 to have the best quality of life. During the interview, a record review of Resident #2's care plan was reviewed with DON, RN D changed Resident #2's care plan to include: The resident has a behavior problem TOUCHING STAFF INAPPROPROIATELY date initiated 6/6/23 revised 6/13/23. DON stated LVN A has been moved to the memory care unit or the 800 hall to give her and Resident #2 a break from each other. DON stated she failed to obtain LVN A's signature on sign in sheet for in service as they did a 1:1 education in her office dated 6/6/23. DON states that Admin and DON counselled LVN A while educating her as they felt LVN A had no intent of harming resident and LVN A needed assistance with dealing and developing coping skills. DON states You're my patient regardless of your past and I put a blanket of protection over all of them. That also goes to my nurses. Record review on 6/13/23 of the facility's internal investigation revealed the incident occurred on 6/5/23 with corrective action notice and written counseling held with LVN A for 'failure to demonstrate a respectful, and cooperative demeanor in all interactions with patients.' The corrective action notice was signed by LVN A, DON and Admin on 6/5/23. Record review on 6/13/23 of internal investigation reveals letter written by Admin dated 6/7/23, documented the following: This administrator met with Resident #2 today in his room to discuss his continued inappropriate behavior with staff. Upon approach Resident #2 was alert and oriented. Informed Resident #2 why and what I was there to discuss. Resident #2 stated again. Informed Resident #2 that any form of sexual behavior such as making sexual comments, touching or grabbing is unacceptable and that it will not be tolerated. Informed Resident #2 that his increase in this sexual behavior had been discussed with his daughter in the special care plan last week and consideration for other placement had been discussed if the behavior did not cease. Resident #2 stated I'll behave. Asked Resident #2 if he was aware of his behavior as being inappropriate. He reported that that he just likes to have fun. Allowed Resident #2 to repeat his understanding of the importance of this conversation and the immediate need for this behavior to cease. He verbally acknowledged he understood. Will continue to follow up with staff in regard to Resident #2 behavior. Interview with LVN A on 6/14/23 at 1:26 PM to clarify what date incident occurred. Corrective Action Notice (written counseling) was signed and dated 6/5/23. Witness statements from LVN A and RN D both indicate incident occurred on 6/6/23. LVN A pulled up her timesheet while on phone with surveyor and stated she worked a full day on 6/5/23 and this incident occurred on 6/6/23. Based on this information the Corrective Action Notice (Written counseling) was signed and dated incorrectly with incorrect date on 6/5/23 and should have been dated 6/6/23. Record review of internal investigation reveals a facility copy of Resident Abuse Policy dated 2020, documented the following: Policy Statement: It is the responsibility of our facility employees/associates, consultants, attendings physicians, family members, visitors, etc., to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriate of resident property to facility management. POLICY INTERPRETATION AND IMPLEMENTATION 1. Our facility will not condone resident abuse by anyone, including associates (associates herein refer to covered individuals), staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends or other individuals. The Facility will not employ persons who have been found guilty of abuse, neglect or mistreatment or have had a finding entered into a state registry or licensing authority concerning such behaviors. 4. When an alleged or suspected case of exploitation, mistreatment, neglect, injuries of an unknown source, or abuse is reported, the Facility Administrator, or his/her designee, will notify the following persons or agencies per the current state/federal reporting requirements of such incident, if appropriate: a) The State licensing/certification agency responsible for surveying/licensing the Facility. b) The Resident's Representative (Sponsor) of Record. c) Law Enforcement Officials d) The Resident's Attending Physician, and e) The Facility Medical Director 6.Definitions of abuse . a) Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This it includes verbal abuse, sexual abuse, mental/psychological, or physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflect injury or harm. Including corporal punishment, involuntary seclusion or any other actions within this definition. ABUSE INVESTIGATIONS POLICY STATEMENT All reports of resident abuse, neglect and injuries which have an unknown source (defined per state regulations) shall be promptly and thoroughly investigated by the Facility management. POLICY INTERPRETATION AND IMPLEMENTATION 6. Associates/Employees of this facility who have an allegation against them of resident abuse may be reassigned to non-resident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator/designee. On 6/13/23 at 5:00 PM, The Administrator was notified that an Immediate Jeopardy had been identified, IJ template provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted 6/14/23 at 3:45 PM. The Facility's Plan of Removal F600 - 6/13/2023 Facility failed to protect the veteran from physical abuse. Resident grabbed LVN breast. In response the LVN physically removed his hand, then slapped the resident on the shoulder/upper arm. 1. Administrator/ DON/Designee to give Abuse and Neglect education/in-service to all staff on 6/6/2023. 2. Administrator/DON/ Designee Abuse and Neglect education/in-service to be provided to staff again beginning on 6/13/2023 and ongoing until all current staff are obtained. To include who is the abuse coordinator, what constitutes abuse, and to always report when in doubt. 3. DON/ Designee Education and Training to all staff provided on difficult/inappropriate behaviors and redirection interventions beginning 6/13/2023 and ongoing on how to deal with redirection/difficult and inappropriate behaviors. 4. DON/ Administrator to perform weekly random Q&A validation audits during rounds to include who is the abuse coordinator, how to deal with difficult behaviors, examples of abuse and neglect. 5. Director of Resident Care Services and Education (regional) provided education to Facility Management team on Regulatory Reporting on 06/13/2023. Facility staff member slapped a resident which has the potential to cause physical or psychosocial harm. 1. Staff member was suspended pending investigation. Prior to return to work on 6/6 employee received a write up to include how to respond to respond when a resident exhibits an inappropriate behavior. Staff member was not put on schedule to work and provide care to this resident. 2. Dir of Resident Care & Services (regional) to follow-up with staff member to validate understanding of how to respond appropriately to inappropriate behaviors (6/14/2023) 3. Administrator/DON/Social Worker to immediately assess and document all investigations of abuse. 4. DON/ADON/Designee to educate/in-service Nursing staff to assess and document in the veterans/residents record a head to toe skin assessment and in a progress note document veterans/residents' psychosocial wellbeing. 5. Psych Services to be notified and ask to visit veteran/resident if currently being seen or SW to ask resident/RR if would agree to psych consult visit request if necessary. 6. Resident Care Plan updated 6/6 and 6/13/2023 and again 6/14/2023 to include interventions to assist staff in helping resident with his inappropriate behavior. Updated C.N.A. POC Kardex with helpful interventions for staff when interacting with resident. Facility had the responsibility to protect residents from abuse that could cause serious injury or harm. 1. If an abuse allegation is made the Administrator/DON/SW will address the allegation immediately by: a. Protecting the resident(s) immediately involved in the allegation and protecting other residents from the alleged perpetrator(s) b. Immediately reporting all allegations of A/N/E to the State per current regulatory requirements, c. Initiate a thorough investigation as to the allegation(s), including but not limited to assessing the resident(s) involved, obtaining statements of those allegedly involved, interviews with witnesses, suspending staff, re-enactments if needed. d. Follow the facility A/N/E policy. 2. If abuse involves an employee, an employee will be suspended based upon pending investigation. 3. Based upon results of investigation, the employee may be terminated. 4. If unfounded, facility will determine need for alternative staffing assignment. 5. DON/Administrator/Designee to provide 1:1 education/in-service how to respond/ Appropriate interventions and received a write up prior to returning to a floor assignment. 6. Will report and review Failure to protect to QAPI monthly for compliance for 6 months, plan to be modified as needed based upon audit results. Monitoring of the Plan of Removal included: During an interview on 6/14/23 at 4:29 PM with ADM would obtain copies of all education/in-services listed on Plan of Removal for surveyor. ADM stated facility had Q&A cards with questions about abuse, neglect and behavior interventions and each manager would ask random residents and staff weekly, log it and report this information to the ADM and DON. ADM clarified Corrective Action Notice date was incorrect. ADM stated the Corrective Action Notice (written counseling) date was in error and would be corrected. Copy of crossed-out date of 6/5/23 with corrected date of 6/6/23 and initials from admin was written on Corrective Action Notice. ADM stated once abuse had been reported, there would be a protocol for ADM, social worker and DON to know our part to take action. During interviews on 6/14/23 from 5:11 PM to 5:42 PM with staff members (listed below) regarding receiving in-service training on Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment. Out of 10 CNA's interviewed, 7 stated they had received and signed in-service training on 6/14/23. One CNA stated she was agency, did not sign the in-service training, but did receive the training. One CNA stated she was 'too busy' working and had not received it. One CNA, who was working, stated she had received verbal information about the incident but not about the in-service training. Four LVN's, all stated signed and received the in-service training. Two RN's, all stated signed and received the in-service training. Five office staff, all stated signed and received the in-service training. One Maintenance Director stated he had signed and received the in-service training. During an observation on 6/14/23 at 5:12 PM one RN was educating night supervisor RN regarding in-service training of Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment. Record review of the facility provided in-service sign in sheet revealed staff were trained on Validation of Education Managing Inappropriate Behaviors on 6/14/23, Abuse and Neglect Inservice Education dated 6/13/23, Regulatory Reports dated 6/14/23, Nursing Skin assessment, Nursing Notes to include psychosocial wellbeing dated 6/14/23, ANE (Resident #2. Incident) dated 6/6/23, How to Re-direct and Deal with Difficult Behaviors - Resident #2 dated 6/7/23, Q&A index Cards - Abuse, Neglect and Behavior Interventions An Immediate Jeopardy (IJ) was identified on 6/13/23 at 5:00 PM and the IJ template was provided to the facility Administrator at 6/13/23 at 5:00 PM. While the immediate jeopardy was lifted on 6/14/23 at 8:00 PM the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The Immediate Jeopardy was re-opened on 7/5/23 at 10:00 AM due to the facility failed to follow their Plan of Removal. Based on the Plan of Removal, if abuse involves an employee, an employee will be suspended based upon pending investigation. LVN A was allowed to continue to work with residents. Interview on 7/5/23 at 10:56 AM with Administrator and DON, administrator stated she and the DON felt that LVN A was capable of working with dementia residents and was very familiar with their behaviors and confused state of minds. Administrator and DON were notified that Immediate Jeopardy was re-opened until further investigation evidence was determined. Administrator stated that LVN A's personnel file had not been updated since 6/14/23, as their had not been any issues or concerns. Admin stated all personnel that worked in the vicinity of the incident had been interviewed and 2 witness statements (LVN A and RN D) were the only statements that had been in the investigation file. Interview on 7/5/23 at 11:20 AM DON stated LVN A had been suspended until investigation was thoroughly completed. Interview on 7/5/23 at 2:00 PM, DON stated the list of employees that completed in-service trainings on Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment were color coded and all staff had been trained. The one CNA that had reported to surveyor that she was too busy working had signed the in-service trainings, but no longer works at the facility. DON stated that LVN A has been removed from the schedule effective 7/6/23 through 7/15/23 as proactive measures since facility does not know what is going to happen with this investigation. DON stated schedule has not been posted and this was just for staffing coordinator and DON at this time. Interview on 7/5/23 at 2:15, LVN B stated that administrator or any upper management interviewed her about the incident. LVN B stated that her immediate supervisor (care coordinator previous ADON) was standing directly beside her and saw the entire incident occur. LVN B stated immediate supervisor told LVN B that she would take care of everything. LVN B stated she was told she did not have to document the incident. LVN B stated she was told to call the family and LVN B asked if she was supposed to tell the family that Resident #2 had been slapped she was told no. LVN B stated she yelled at LVN A You can't do that. LVN A stated RN D also yelled You can't do that upon seeing LVN A strike Resident #2. Interview on 7/5/23 at 2:32 PM, RN D stated no on was standing beside her. RN D believes LVN B was standing behind her at her medication cart and that there was someone at the computer but does not recall who this person was. RN D stated she was the only person that yelled You can't do that when she saw LVN A strike Resident #2. RN D stated she took LVN A to her office and had LVN A write up her statement and then sent her home. RN D stated later that day she told LVN B to complete a skin assessment on Resident #2, which was not completed. RN D stated she told LVN B to call Resident #2's family to notify them of the incident. RN D stated LVN B asked what she was supposed to tell the family and RN D stated to LVN B to follow the incident report questions. Interview on 7/5/23 at 3:22 PM, DON stated social worker completed safety rounds with all residents asking resident if they felt safe. DON stated psychiatrist saw Resident #2 on 6/6/23 and on 6/16/23. DON stated resident was placed in a behavioral facility for 2 weeks due to another incident. DON stated she was unaware of LVN B witnessing incident. DON stated she does not know where LVN B was at the time of the incident and that LVN B did not report to her or administrator that she was a witness to the incident. Interview on 7/5/23 at 3:43 PM, Administrator stated she did not interview LVN B and was unaware that LVN B was a witness to the incident. Administrator stated she had just started working on her investigation when she called corporate and was told this was not a reportable offense and did not need to be investigated. Administrator states the investigation file she has only has the two witnesses (LVN A and RN D) as witnessing the incident. Interview on 7/5/23 at 4:25 PM, Admin interviewed regarding plan of removal to protect all residents from abuse, neglect and exploitation. Plan of Removal reviewed for assurances that employee will be suspended until investigation is completely resolved of deficiencies, plan of care and board of nursing action. Record review of the facility provided in-service sign in sheets revealed all staff were trained on How to Re-direct and Deal with Difficult Behaviors - Resident #2, Abuse and Neglect, Nursing Skin Assessment Nursing Notes to include psychosocial wellbeing, Regulatory Reporting. Record review of the facility provided in-service sign in sheets revealed all residents were interviewed for safety rounds. Record review of the facility Provider Investigation Report dated 6/15/23 with no intake number. Record review of the facility schedule for LVN A for June 2023 and July 2023. LVN A worked 10 days after IJ was lifted and was removed from the facility on 7/5/23 at 11:15 AM. LVN A worked on the following dates: 6/14/23, 6/16/23, 6/19/23, 6/2023, 6/23/23, 6/24/23, 6/25/23, 7/1/23, 7/2/23 and 7/5/23. The Immediate Jeopardy (IJ) that was lifted on 6/14/23 at 8:00 PM was re-opened on 7/5/23 at 10:00 AM due to the facility failing to follow their plan of removal. While the immediate jeopardy was lifted on 7/5/23 at 5:30 PM, the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on interviews and record review, the facility failed to ensure the resident environment remains as free from accidents hazards as is possible, and each resident received adequate supervision and assistance to prevent accidents for 1 of 10 residents (Resident #1) reviewed for safety and supervision. TA A failed to properly secure wheelchair bound Resident #1 in the facility van resulting in the resident falling out of the wheelchair which resulted in a fracture. This failure could affect residents at the facility by placing them at risk for accidents that lead to injuries. Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE], with the following diagnoses: [CONDITION(S)] disorder (uncontrollable repetitive movements or unwanted sounds (tics), such as repeatedly blinking the eyes, shrugging shoulder, or blurting out offensive words), diabetes (too much sugar in the blood), diseases of the nervous system, history of falling, arthritis (joint inflammation), skin picking disorder, abnormal gait and mobility, [CONDITION(S)] (underactive [CONDITION(S)]), needs assistance with personal care. Record review of Resident #1's quarterly MDS resident assessment, dated 5/18/22, reflected the resident scored 14 of 15 on a mini-mental exam for cognitive awareness which indicated he was interviewable. Record review of a Provider Investigation Report, dated 7/21/22, concerning Resident #1's fall in the facility van documented the following: Facility driver transported wheelchair bound Resident #1 in facility van. Facility driver reported Resident #1 fell out of his wheelchair. Resident #1 appeared to have intermittent confusion, complained of nausea/vomiting, left lower leg pain and a raised area on his left forehead. Head to toe assessment completed and Resident #1 was transported to the emergency room by ambulance. Record review of Resident #1's nurses notes documented the following: -7/21/22 at 12:36 p.m. - was notified by Activity Director regarding patient having fallen in the transport van. Patient arrives to unit in electric wheelchair. Alert and oriented x 3 however does have intermittent episodes of confusion, blurred vision, and nausea. Large, raised area to left forehead with early-stage bruising noted. Voices of left lower extremity being in excruciating pain. Minimal movement to left lower extremity. Resident voices of left hip pain and right upper extremity. Notified nurse practitioner who gave order to send patient to emergency room to follow up with new injuries and onset of pain to left lower extremity. -7/22/22 at 3:40 p.m. - Patient arrived back at facility via transport. Patient returned to facility in standard wheelchair. Alert and oriented X 3. Voiced having discomfort to left knee which is result from fall injury. Received report from hospital nurse. Resident was admitted for [CONDITION(S)] (low oxygen levels) and right flank pain. Reports patient was to wear oxygen at all times; however, patient was refusing to wear at this time. Patient was sent with knee immobilizer however was refusing to wear. During an interview on 8/3/22 at 2:10 p.m., the Administrator stated Resident #1 fell out of his electric wheelchair and he was strapped in around his waist, but he was a large man who fidgeted with his wheelchair all the time. The Administrator stated when the TA stopped, Resident #1 went forward and fell out of his chair. The Administrator stated Resident #1 went to the hospital because he was having pain in his left leg, he had x-rays and he did not have a fracture. The Administrator stated that night Resident #1 kept saying his leg hurt, so he was sent back to the hospital and a fracture to his leg was found. During an interview on 8/3/22 at 1:50 p.m., TA B stated she had driven the van at other long term care facilities and in the past, they never took anyone in an electric wheelchair due to the weight of the chair. An observation on 8/3/22 at 2:15 p.m. with TA B in Resident #1's room revealed an electric wheelchair. The electric wheelchair had a seat belt located in the chair. An observation on 8/3/22 at 2:30 p.m., with TA B in the facility van revealed seat belt straps mounted almost to the top of the side of the van which would be used to go over a resident's shoulder and fastens to the floor of the van. Another strap from the floor goes over a resident's lap to hold the resident in the wheelchair. Hooks were located on the floor of the van to fasten to the wheels on the wheelchair to make sure the wheelchair was secure. During a telephone interview on 8/3/22 at 4:15 p.m., PTA C stated the therapy department was located close to the front of the building. PTA C stated when she got to the van, there was not a seatbelt across Resident #1 and the seat belt that was on his electric wheelchair was on the seat buckled and not being used. PTA C got to the van quick, and Resident #1 was lying on his right side with his right arm beneath him. During a telephone interview on 8/3/22 at 4:30 p.m., TA A stated Resident #1 had an appointment at 11:30 a.m. TA A stated Resident #1's electric wheelchair did not hook on the bottom of his wheelchair to secure it, so she had the bottom strapped good and tight. TA A stated she used the seat belt that went over Resident #1's belly and he did not have on the seat belt that was on his wheelchair. TA A stated she did not put the shoulder strap on Resident #1. TA A stated she had to stop because the light had turned yellow and that was when Resident #1 went forward out of the wheelchair. TA A stated she immediately called the Administrator, and she was told to drive carefully back to the facility and staff would be at the front door to assist her. TA A stated she was so scared and panicking but she got Resident #1 back to the facility and therapy was waiting for us at the front door. Record review of the Vehicle Transportation and Safety of Residents, documented the following: Please Check the following to ensure the safety of the residents. 9. After all residents are loaded, make sure that all residents have seat belts properly secured. 11. Securing wheelchairs and other equipment: a. Secure down all wheelchairs using the secure strap equipment. b. Always secure the strap to the frame of the wheelchair not the armrest or wheels. c. Place seat belt around all residents including those in wheelchairs. d. If the van comes with shoulder straps utilize those to assist in securing the resident/

Based on interviews and record review, it was determined the facility failed to ensure the resident environment remains as free from accidents hazards as is possible, and each resident received adequate supervision and assistance to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accident/hazards and supervision. CNA B and CNA C failed to transfer Resident #1 using two people and failed to use a gait belt for the transfer which resulted in Resident #1 receiving a laceration to her right lower calf that required stiches. This deficient practice has the potential to affect all residents in the building who required extensive assistance which could result in residents having falls, lacerations, fractures, and even death. The evidence is as follows: Record review of Resident #1's clinical record revealed she admitted to the facility on [DATE], was [AGE] years old with the following Diagnoses: [REDACTED]. -A quarterly MDS resident assessment, dated 6/21/2020, documented the resident scored 4 of 15 on a mini-mental exam, required extensive assistance by two staff for bed mobility, transfers, toileting, personal hygiene and bathing, required extensive assistance by one staff for dressing, frequently incontinent of bladder, occasionally incontinent of bowel, 69 inches tall and 164 pounds. -Care Plan: have ADL self-care performance deficit related to left sided weakness, gait/balance problems and cognitive impairment. During an interview on 8/20/20 at 8:20 a.m., the Administrator stated Resident #1 had to go out to the emergency room to have stitches in her leg. The Administrator stated she asked staff when Resident #1 was sent out to the emergency room if the injury was the facility's fault and she was told no it was not. The Administrator stated the girls always have their gait belts and use them every time and she was sure the CNAs used their gait belts to transfer Resident #1. During an interview on 8/20/20 at 8:50 a.m., the DON stated two CNAs were transferring Resident #1 from her bed to her wheelchair and the wheelchair got her on the inside of her right leg. The DON stated Resident #1 helps staff with transfers and was hard to keep in one place. The DON stated staff were supposed to use gait belts for transfers and they should have used them for Resident #1's transfer. The DON stated the two CNAs that were transferring Resident #1 always have a gait belt on them so she would think they would use have used them. During an interview on 8/20/2020 at 10:35 a.m., LVN A stated she was working the day Resident #1 was injured during a transfer. LVN A stated two CNAs were transferring Resident #1 as she can stand and pivot. LVN A stated one of the CNAs called for her to come to Resident #1's room because she received a skin tear. LVN A stated Resident #1 had more than a skin tear as it was bleeding a lot. LVN A stated she had to put a pressure dressing on the laceration and Resident #1was sent out to the hospital and got 9 stiches in her leg. LVN A stated the CNAs were not using a gait belt. LVN A stated as soon as she saw Resident #1's leg, she knew Resident #1 was going to be sent out to the hospital. During an interview on 8/20/20 at 1:00 p.m., CNA B stated they got Resident #1 dressed and sat her on the side of the bed. CNA B stated Resident #1 helped with the transfer and when Resident #1 sat down in the wheelchair, she saw a lot of blood on the floor. CNA B told CNA C to go get the nurse (LVN A). CNA B stated she did not know how Resident #1 injured herself or what happened. CNA B stated she did not have a gait belt on Resident #1. CNA B stated she knew she was supposed to use her gait belt for transfers but she didn't that time. During an interview on 8/2020 at 1:58 p.m., CNA C stated she was holding the locked wheelchair in place when CNA B transferred Resident #1 by herself. CNA C stated CNA B transferred Resident #1 to her wheelchair and that was when they both noticed blood on the floor. CNA C stated CNA B pulled up Resident #1's pant leg and that was when they saw the skin tear. CNA C stated she went and got the nurse (LVN A) to look at Resident #1's leg. CNA C stated CNA B was not using a gait belt when she transferred Resident #1 unassisted. Record review of a policy titled Gait Belt Issue and Return Acknowledgment, undated, documented the following: Policy: It is the policy of this company that resident transfers should be made with the use of a gait belt to help avoid incidents to the resident and team member. This community is committed to the safety of residents and team members. As one means to promote our safety policy, you are being issued a gait belt to be used for all transfers of residents. It is proven that transfers with gait belts reduce skin tears and other injuries to residents.

Based on observation, interview and record review, the facility failed to prevent neglect by providing goods and services necessary to avoid physical harm for for 1 of 12 residents (Resident #1) reviewed for neglect. Resident #1 received a laceration of unknown origin to the right calf, requiring 15 sutures. This deficient practice could place 116 residents residing in the facility at risk for neglect, resulting in serious injury. Findings include: Observation on 12/16/14 at 3:20pm of Resident #1's right inner calf revealed a horseshoe shaped laceration measuring 5 centimeters by 2.5 centimeters. The laceration was open and bloody and the skin around the laceration was red and swollen. During an interview on 12/15/14 at 8:55pm, RN E stated she was the RN supervisor at the facility for the 6pm-6am shift beginning the evening of 11/26/14 and ending at 6:00am on 11/27/14. When asked about Resident #1's injury, RN E stated she was notified of the injury by the LVN working in the memory care unit. RN E stated she went to the memory care unit to evaluate Resident #1. RN E stated, "I saw his leg and saw it needed medical attention. It was a big ole' laceration. It needed suturing." RN E stated CNA B told her that she did not check on Resident #1 every 2 hours as required. RN E stated that when the paramedics arrived, they questioned CNA B about the injury and stated that was a suspicious injury. RN E stated, "I felt like it (the laceration) could have been found sooner" and chose to move CNA B to another hallway for the remainder of the shift. During an interview on 12/15/14 at 9:45pm, CNA D stated she was on the 400 hallway on 11/27/14 but the supervisor "moved me to the secure unit to trade places with CNA B." CNA D stated, "I guess CNA B couldn't handle it by herself." CNA D stated, "all I know about Resident #1 is me and the nurse heard someone scream for help so we went to his room. We pulled back his sheets and saw him laying in a puddle of blood." During an interview on 12/15/14 at 10:00pm, CNA B stated she and another staff person "put Resident #1 to bed before 10:00pm." CNA B stated they transferred Resident #1 from the wheelchair to the bed and "I just handed everything to MA A. MA A did all the peri-care." CNA B stated that after putting Resident #1 to bed, "I waited 2 hours and did rounds. I did go to the room to see Resident #1's roommate but I didn't check Resident #1." CNA B stated that she did not visually check Resident #1 for the rest of the evening. CNA B stated, "maybe he got a cut from the wheelchair." During an interview on 12/16/14 at 9:40am, LVN C stated she became aware of the injury to Resident #1 around 2:00am on 11/27/14. LVN C stated she was at the nurse's station of the Memory Care Unit and heard a resident moan. LVN C stated she and CNA D went to Resident #1's room and noted that Resident #1's legs were not elevated on a pillow as they should have been. LVN C stated when she pulled back the bed covers to elevate Resident #1's legs, she observed that the bed sheets were soaked with blood-tinged fluids. Upon inspecting Resident #1, LVN C discovered the laceration which had exposed fat and muscle on Resident #1's right calf. LVN C stated she notifed RN E and began to clean the wound. LVN C stated "it looked like something punctured Resident #1's leg and tore it open." During an interview on 12/16/14 at 9:45am with MA A, MA A stated she came into work that evening to assist CNA B, who was working in the facility's memory care unit alone. MA A stated she and CNA B put Resident #1 to bed around 9:00pm and did not see any injuries on Resident #1's legs. MA A stated that when they transferred Resident #1 from his wheelchair to his bed, Resident #1 "drug his feet and we were just trying to make a safe transfer." MA A stated "I didn't check his skin like I should have" after putting him in bed. MA A stated she clocked out and left the facility at 9:40pm. During an interview on 12/16/14 at 2:55pm, ADON stated CNAs are expected to check on residents in the memory care unit every 2 hours during the night and unless it is careplanned that an incontinent resident should not be woken for peri-care, the resident should be checked and peri-care should be performed, if needed. ADON stated that Resident #1 should have been checked every 2 hours and that if he had been, ADON feels that the laceration would have been discovered earlier. During an interview on 12/16/14 at 3:35pm, when asked about Resident #1's injury, ADON stated, "it had to happen during the transfer" During an interview on 12/16/14 at 3:40pm with DON, DON stated she believes Resident #1's legs got caught under the wheelchair and the Podus boot Resident #1 had on his left foot hit his right leg and caused the laceration. DON stated, "a little bump could cause a massive injury." DON stated that after the incident, she removed the Podus boot from Resident #1's room and threw it away. During an interview on 12/16/14 at 4:45pm, DON stated that it is her expectation that CNAs do "accurate and complete checks on residents" when performing checks every 2 hours. Record review of Resident #1's clinical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's 5-day MDS completed 10/6/14 documented a BIMS of 0; range of motion impairment on lower extremeties, both sides and extensive, 2 person assist required for bed mobility and transfers. Record review of Resident #1's care plan dated 10/2/14 revealed Resident #1 requires 2 staff participation with transfers and staff are to observe skin for redness, open areas, scratches, cuts, bruises and report changes to the nurse. Record review of progress notes documented the following: 11/27/14 03:21 Risk Management Progress Note: Heard resident call out and went to check on resident with CNA. Entered residents room and he was moaning and saying it hurts. Pulled covers back to elevate his feet and residents legs and bed was covered in blood...Upon assessment large open area to right calf with blood draining from it. Cleansed with wound cleanser and applied pressure to attempt to stop the bleeding... 11/27/14 03:46 Nursing Progress Note: I the nurse supervisor in charge was notified of a laceration to resident calve. It is apparent that resident requires medical attention. CNA in charge of resident stated she did a round at 12am and did not see it. CNA was transferred to another unit due to severity of laceration and until further investigation could be obtained. DON notified. ADM notified. ADON notified. On call provider notified of severity with N/O to transfer to ER to evaluate and treat. Family notified. AMS was notified. AMS stated they would need to report to APD for investigation. I verbalized understanding. 11/27/14 09:00 Risk Management Progress Note: Follow up for laceration to right lower extremity...Resident returned to facility via ambulance at this time...Changed dressing to right lower calf at this time. Resident has 15 sutures to laceration on right calf. Laceration in a U shape measurements 6.5x0.1 bottom of the U. 4.0x0.1 going around and the top of the wound... Record review of the facility's Resident Abuse Policy dated November 1, 2012 documents: Policy Interpretation and Implementation 6g. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. According to information provided by ADM, the facility's census was 116.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prevent neglect for for 1 of 12 residents (Resident #1) reviewed for neglect. Resident #1 received a laceration of unknown origin to the right calf, requiring 15 sutures. This deficient practice could place 116 residents residing in the facility at risk for neglect, resulting in serious injury. Findings include: Record review of the facility's Resident Abuse Policy dated November 1, 2012 documents: Policy Interpretation and Implementation 6g. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Observation on 12/16/14 at 3:20pm of Resident #1's right inner calf revealed a horseshoe shaped laceration measuring 5 centimeters by 2.5 centimeters. The laceration was open and bloody and the skin around the laceration was red and swollen. During an interview on 12/15/14 at 8:55pm, RN E stated she was the RN supervisor at the facility for the 6pm-6am shift beginning the evening of 11/26/14 and ending at 6:00am on 11/27/14. When asked about Resident #1's injury, RN E stated she was notified of the injury by the LVN working in the memory care unit. RN E stated she went to the memory care unit to evaluate Resident #1. RN E stated, "I saw his leg and saw it needed medical attention. It was a big ole' laceration. It needed suturing." RN E stated CNA B told her that she did not check on Resident #1 every 2 hours as required. RN E stated that when the paramedics arrived, they questioned CNA B about the injury and stated that was a suspicious injury. RN E stated, "I felt like it (the laceration) could have been found sooner" and chose to move CNA B to another hallway for the remainder of the shift. During an interview on 12/15/14 at 9:45pm, CNA D stated she was on the 400 hallway on 11/27/14 but the supervisor "moved me to the secure unit to trade places with CNA B." CNA D stated, "I guess CNA B couldn't handle it by herself." CNA D stated, "all I know about Resident #1 is me and the nurse heard someone scream for help so we went to his room. We pulled back his sheets and saw him laying in a puddle of blood." During an interview on 12/15/14 at 10:00pm, CNA B stated she and another staff person "put Resident #1 to bed before 10:00pm." CNA B stated they transferred Resident #1 from the wheelchair to the bed and "I just handed everything to MA A. MA A did all the peri-care." CNA B stated that after putting Resident #1 to bed, "I waited 2 hours and did rounds. I did go to the room to see Resident #1's roommate but I didn't check Resident #1." CNA B stated that she did not visually check Resident #1 for the rest of the evening. CNA B stated, "maybe he got a cut from the wheelchair." During an interview on 12/16/14 at 9:40am, LVN C stated she became aware of the injury to Resident #1 around 2:00am on 11/27/14. LVN C stated she was at the nurse's station of the Memory Care Unit and heard a resident moan. LVN C stated she and CNA D went to Resident #1's room and noted that Resident #1's legs were not elevated on a pillow as they should have been. LVN C stated when she pulled back the bed covers to elevate Resident #1's legs, she observed that the bed sheets were soaked with blood-tinged fluids. Upon inspecting Resident #1, LVN C discovered the laceration which had exposed fat and muscle on Resident #1's right calf. LVN C stated she notifed RN E and began to clean the wound. LVN C stated "it looked like something punctured Resident #1's leg and tore it open." During an interview on 12/16/14 at 9:45am with MA A, MA A stated she came into work that evening to assist CNA B, who was working in the facility's memory care unit alone. MA A stated she and CNA B put Resident #1 to bed around 9:00pm and did not see any injuries on Resident #1's legs. MA A stated that when they transferred Resident #1 from his wheelchair to his bed, Resident #1 "drug his feet and we were just trying to make a safe transfer." MA A stated "I didn't check his skin like I should have" after putting him in bed. MA A stated she clocked out and left the facility at 9:40pm. During an interview on 12/16/14 at 2:55pm, ADON stated CNAs are expected to check on residents in the memory care unit every 2 hours during the night and unless it is careplanned that an incontinent resident should not be woken for peri-care, the resident should be checked and peri-care should be performed, if needed. ADON stated that Resident #1 should have been checked every 2 hours and that if he had been, ADON feels that the laceration would have been discovered earlier. During an interview on 12/16/14 at 3:35pm, when asked about Resident #1's injury, ADON stated, "it had to happen during the transfer" During an interview on 12/16/14 at 3:40pm with DON, DON stated she believes Resident #1's legs got caught under the wheelchair and the Podus boot Resident #1 had on his left foot hit his right leg and caused the laceration. DON stated, "a little bump could cause a massive injury." DON stated that after the incident, she removed the Podus boot from Resident #1's room and threw it away. During an interview on 12/16/14 at 4:45pm, DON stated that it is her expectation that CNAs do "accurate and complete checks on residents" when performing checks every 2 hours. Record review of Resident #1's clinical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's 5-day MDS completed 10/6/14 documented a BIMS of 0; range of motion impairment on lower extremeties, both sides and extensive, 2 person assist required for bed mobility and transfers. Record review of Resident #1's care plan dated 10/2/14 revealed Resident #1 requires 2 staff participation with transfers and staff are to observe skin for redness, open areas, scratches, cuts, bruises and report changes to the nurse. Record review of progress notes documented the following: 11/27/14 03:21 Risk Management Progress Note: Heard resident call out and went to check on resident with CNA. Entered residents room and he was moaning and saying it hurts. Pulled covers back to elevate his feet and residents legs and bed was covered in blood...Upon assessment large open area to right calf with blood draining from it. Cleansed with wound cleanser and applied pressure to attempt to stop the bleeding... 11/27/14 03:46 Nursing Progress Note: I the nurse supervisor in charge was notified of a laceration to resident calve. It is apparent that resident requires medical attention. CNA in charge of resident stated she did a round at 12am and did not see it. CNA was transferred to another unit due to severity of laceration and until further investigation could be obtained. DON notified. ADM notified. ADON notified. On call provider notified of severity with N/O to transfer to ER to evaluate and treat. Family notified. AMS was notified. AMS stated they would need to report to APD for investigation. I verbalized understanding. 11/27/14 09:00 Risk Management Progress Note: Follow up for laceration to right lower extremity...Resident returned to facility via ambulance at this time...Changed dressing to right lower calf at this time. Resident has 15 sutures to laceration on right calf. Laceration in a U shape measurements 6.5x0.1 bottom of the U. 4.0x0.1 going around and the top of the wound... According to information provided by ADM, the facility's census was 116.

Based on observations, interviews and record reviews, it was determined that for one of four sampled residents (Resident #1), who exhibited a behavior of exit-seeking, the facility failed to implement their written policy for neglect prevention when they failed to provide an appropriate level of supervision to prevent Resident #1, who exhibited a behavior of exit seeking, from exiting the facility without supervision. On 3/26/11, the facility was notified by the local police that cognitively impaired Resident #1 was found by the police at approximately 4:00 a.m., approximately three miles from the facility near an interstate highway. The local police returned Resident #1 to the facility at approximately 4:15 a.m. Resident #1 was placed at risk of serious injury or death. As of 4/13/11 at 2:30 a.m. (18 days after the incident), the facility had applied stick on door alarms to only 4 of 11 exit doors on the general population unit where Resident #1 resided. Therefore, Resident #1 remained at risk of exiting the facility without supervision. This led to the identification of an Immediate Jeopardy (IJ) on 04/13/11. While the IJ was removed on 04/14/11, the facility remained out of compliance at a severity of potential for more than minimal harm, and a scope of pattern due to not all employees had been in-serviced regarding the supervision of exit-seeking residents and the continued need of staff to monitor to ensure that direct-care staff were providing an appropriate level of supervision to prevent residents from exiting the facility. All eight residents, who exhibited a behavior of exit seeking, were placed at risk of harm due to failure of staff to provide an appropriate level of supervision to prevent incidents of exiting the facility without supervision. The evidence is as follows: 1. Review of the facility's policies revealed the following: - The Abuse Prevention Program policy, revised August 2006, documented: "Our resident shave the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. - Wandering Residents policy, revised April 2066, documented "Every effort will be made to prevent wandering episode while maintaining the least restrictive environment for residents who are at risk of elopement." 2. Review of the local police department's report of the incident documented that on 03/26/11 at approximately 3:48 a.m., the officer was dispatched to (a location approximately three miles from the facility) next to an interstate highway. It documented the officer had been notified that an elderly individual was in the area and that he was unable to provide a current address. It documented that upon arrival, the resident was found to have an assistive device (walker), and that he appeared to have some dementia, and that he was unable to provide his current address, and gave several different addresses and directions as to where he lived. It documented he said he was a veteran and that upon checking with the local Veteran's Administration Hospital, it was determined the individual resided at the nursing facility. It documented he was returned to the facility and the nightshift supervisor, RN "G", said Resident #1 had a history of [REDACTED]. It documented Resident #1 was found to have no WanderGuard bracelet on, and RN "G" said the device was probably in his room. 3. Review of Resident #1's clinical record revealed the following: - The form titled Admission Record documented Resident #1 admitted to the facility on [DATE] and that his current age was 81. - A quarterly MDS Resident Assessment, dated 03/10/11, documented his [DIAGNOSES REDACTED]. It documented he could be interviewed, but he had a deficit in his ability to recall facts and he was not oriented to date. It further noted he used an assistive device (walker) for independent mobility. (An on-line review of medical terms on 03/27/11 at MedicineNet.com, http://www.medterms.com, documented an aneurysm is a localized widening (dilatation) of an artery, vein, or the heart. At the area of an aneurysm, there is typically a bulge and the wall is weakened and may rupture. It documented meningoencephalitis was an inflammation of the brain and meninges. It documented meninges as the three membranes that cover the brain and spinal cord.) - The care plan, dated 03/09/11, documented in the summary of the care plan conference that Resident #1 had expressed a desire to go home. It documented a problem of potential wandering in unsafe areas and out of the community, and that the approaches would include the use of a WanderGuard, and that nurses were to check the WanderGuard every shift and ensure placement. An updated plan of care, dated 03/28/11 (2 days after the incident), documented that he had left the facility without telling staff, and the approaches included provide structured activities, walking inside and outside of the facility, watching movies, play bingo and other structured activities. It also documented he was to be checked every 30 minutes. - A nurse's notes, dated 03/26/11, documented at 4:15 a.m., the local police returned Resident #1 to the facility. It documented he resided on Hall 500. It documented he was assessed to have no injuries. It documented he told them he was going home, but he was reminded that this was his home. It documented a WanderGuard bracelet was placed on his right wrist. It documented he told staff he would remove the WanderGuard and leave again. - There was no nurses' note prior to the local police returning Resident #1 to the facility, to indicate the facility had been aware he was missing. - A nurse's note, dated 03/28/11, documented Resident #1 was moved from his room on Hall-500 to a room on Hall-800. 4. Review of the facility's list of residents who wore a WanderGuard, received 4/13/11, documented Resident #1 wore a WanderGuard. 5. Additional review of Resident #1's nurses' notes revealed he had a history of [REDACTED]. The evidence is as follows: - A nurse's note, dated 01/19/11 at 6:00 p.m., documented Resident #1's wife brought his WanderGuard bracelet to the nurses' station after he removed it and placed it in the trash. - A nurse's note, dated 01/19/11 at 12:15 a.m., documented Resident #1 went out the Hall-500 exit door, and his alarm (WanderGuard bracelet) was not present. It documented he told staff he used a toenail clipper to cut the WanderGuard bracelet off. It documented he told staff he was looking for his truck, and that he was redirected back into the facility and into his room and a new WanderGuard bracelet was applied. It documented he was told that he did not have a truck at the facility, and that he was reminded it was unsafe to be out in the cold. - A nurse's notes, dated 12/21/10 at 2:30 p.m., documented a nurse aide saw someone exiting the Hall-500 exit door, and discovered Resident #1 was outside. It documented he told them he was outside looking for his truck. 6. Information provided by the National Oceanic and Atmospheric Administration (NOAA) revealed that on the morning of 03/26/11 at 3:53 a.m., the temperature was 44.1 degrees Fahrenheit (F). 7. Observations of the facility on 04/13/11 starting at 2:30 a.m., revealed the following: - The facility had two wings: Hall-400 and Hall-500 were on one wing and Hall-600 and Hall-800 were on the opposite wing. - Three of four halls housed the general population residents: Hall-400, Hall-500 and Hall-800 were for the general population. - One hall housed the secured unit: Hall-600 was a designated secured unit. - Resident #1 now resided on Hall-800 in a room at approximately the mid point of the hall. 8. During an interview with LVN "B" on 04/13/11 at 2:45 a.m., she said since the incident of Resident #1 exiting the facility without staff supervision, they had added alarms on the exit doors. An observation at that time with LVN "B" revealed the following: - Hall-400 exit had two doors. The door to the right had a stick-on alarm. Upon opening the door, the alarm failed to activate. The door to the left-hand side had no alarm; thus, when the door was opened, there was no audible alarm sound. - In the sitting area for Hall-400 and Hall-500, the double door that exited on to the patio had no alarm device; thus, when each door was opened, no audible alarm activated. LVN "B" said the patio was not a secured area (i.e., no locked gates). - An exit door at the end of the sitting area and next to a room labeled room [ROOM NUMBER], had a single door which exited onto a patio. There was no alarm device on the door. Upon opening the door, no audible alarm activated. LVN "B" said the patio was not a secured area (i.e., no locked gates). 9. Further observations of the exit doors on 04/13/11 starting at 3:25 a.m. with the RSN, revealed the following: - Hall-400 exit, the door to the right side failed to activate the stick-on alarm four out of five attempts. The door on the left continued to have no alarm. - Dining room: The double door exiting onto the patio had no audible alarm device; thus, when each door was opened, no audible alarm activated. RSN said the patio area was not secured (i.e., no locked gates). - In the lobby, the electronic sliding main door was locked at that time. The side entry was a single door. No alarm device was attached to the door. Upon opening the door, there was no audible alarm. - In the main corridor, between the two wings, an open activity room had a single door exit that led onto a patio area. There was no alarm on the door. Upon opening the door, there was no audible alarm. RSN said the patio area was not secured (i.e., no locked gates). - In the main corridor, between the two wings, a hallway led to a double door which upon opening revealed a second hallway. RSN said the door to the right went to the dietary department. RSN said the door to the left went to a back patio and the back parking lot. The door to the left had no alarm device. Upon opening the door, no audible alarm activated. RSN said the patio area was not secured (i.e., no locked gates). - The Hall-800 exit door had two doors. The right-hand door had a stick-on alarm device. Two out of four attempts to activate the alarm by opening the door failed to cause an audible alarm. The left-hand door had no alarm device, and upon opening the door, there was no audible alarm. 10. During an interview with RN "G", on 04/13/11 at 2:55 p.m., she said she confirmed she was the house supervisor on duty the night shift of 03/25/11 and 03/26/11. She said She was on duty when the local police returned Resident #1 to the facility. She said she previously heard that on other shifts he had left the facility, and that she was aware he wore a WanderGuard and that he had a history of [REDACTED]. She said she had assessed him and found him to have no injuries. 11. An on-line review of Mapquest on 4/28/11, at http://classic.mapquest.com/, documented Resident #1 traveled approximately 3.21 miles from the facility. An observation on 04/13/11 at 2:25 a.m. revealed the five-lane road in front of the facility had a posted speed limit of 55 miles per hour (mph). 12. During an interview with LVN "F", on 04/13/11 at 2:35 p.m., she said she had worked the night shift on 03/25/11 to 03/26/11. She said she was the charge nurse for Hall-500 where Resident #1 resided at the time of the incident. She said Resident #1's room had been at the end of the hall nearest the exit door. She said Resident #1's wife had made them aware he had a history of [REDACTED]. She said on that particular night, she had made one round and that she last recalled seeing Resident #1 at 12:30 a.m. to 1:00 a.m. She said she was not aware he had ever worn a WanderGuard bracelet, but upon being returned by the police on the morning of 03/26/11, they placed a WanderGuard bracelet on his wrist. 13. During an interview with CNA "C", on 04/13/11 at 2:58 a.m., she said she worked the night shift on 03/25/11 and 03/26/11. She said that night she worked Hall-500 as the only nurse aide assigned to that hall. She said on the night of the incident, she had been told they were to visually check on Resident #1 every 30 minutes, because he had been wanting to leave with his wife. She said she checked on him approximately every hour and a half, not every 30 minutes as instructed. She said she was not aware he was missing until the local police department notified them he had eloped. She said she last recalled seeing Resident #1 around 2:45 a.m., and at that time, he had been in his room fully dressed and awake. She said when Resident #1 returned to the facility, he was wearing a sweater. 14. During an interview with Resident #1 on 04/13/11 at 11:10 a.m., he was observed to now reside on Hall-800. He said he once (unsure of dates) took a two-day trip to see his wife and brother. He said he traveled by night and slept by day. He said at night a highway patrolman brought him back to the facility, although, he did not want to return. As he discussed his travels and wanting to go home, he said he thought someone had taken him almost to his brother's house, but the "cops stopped the guy and brought him (Resident #1) back to the facility". He then added he wanted to go home to Henrietta, Texas (a town approximately 245 miles from the nursing facility). At that time, no WanderGuard bracelet was noted on either of Resident #1's wrists or ankles. 15. During an observation and interview with LVN "D" and ADON "E" on 04/13/11 at 11:33 a.m., while in Resident #1's room, it was confirmed Resident #1 was not wearing a WanderGuard bracelet. At that time, ADON "E" found the bracelet in a drawer in Resident #1's bedside table. The bracelet had frayed edges where the bracelet had been cut in order to release the bracelet from his ankle. At that time, Resident #1 told the staff he wanted "out of here". 16. An observation of the Hall-800 exit door on 04/13/11 at 11:36 a.m., revealed the double door continued to have only a door alarm on the right hand door, not the left hand door; thus, Resident #1 would be able to exit unsupervised through the unsecured exit door. 17. Review of the monitoring log for Resident #1, dated 04/13/11, documented staff were verifying his whereabouts every 30 minutes, which would provide time for Resident #1 to walk out the Hall-800 exit door without supervision of staff and off the facility grounds. 18. An observation on 04/13/11 at 12:00 p.m., revealed the RSN instructed staff to post a staff member at the Hall-400 and Hall-800 exit doors. 19. An observation on 04/13/11 at 12:35 p.m., confirmed a nurse aide (CNA "H") was seated in front of the Hall-800 exit doors. At that time, an interview with CNA "H" revealed he had been instructed to remain at the Hall-800 exit door until the door was fixed (i.e., alarms on both doors). 20. During an interview with the Administrator on 04/13/11 at 9:55 a.m., he said the facility had been designed to have a WanderGuard system, which was on each exit door. He said any resident, who wore a WanderGuard bracelet, would activate an alarm on the door the resident was attempting to exit. He said Resident #1 had no WanderGuard bracelet on at the time he exited the facility without supervision; thus, the WanderGuard alarm system did not activate. He said since the incident of /Resident #1 exiting without supervision, he had added another type of door alarm to each exit door, which activated an audible alarm any time anyone (i.e., resident, staff or visitor) opened an exit door. He said they purchased the available door alarms from a local vendor and the remaining alarms had been ordered, but had not arrived. 21. On 04/13/11 at 4:40 p.m., the Administrator, RSN, and Representative of the Texas Land Board, were notified that an Immediate Jeopardy (IJ) situation had been identified due to failure to provide an appropriate level of supervision for exit-seeking residents, which resulted in cognitively-impaired Resident #1, who had a history of [REDACTED]. 22. On 04/13/11 at 8:00 p.m., the facility's Action Plan was accepted. Review of the plan documented the following: - The facility had developed a notebook with photographs of all residents identified as potential wanderers, which were placed at each nurses' station - Staff were in-serviced regarding the notebook for identifying residents at risk of elopement. - As of 04/13/11, all residents' WanderGuard bracelets were checked to assure they were functioning properly. It documented WanderGuard bracelets were scheduled to be checked daily by the charge nurse or designee and documented in the resident's medical record. It further noted the DON or designee would monitor due to quality assurance weekly. - It documented on 03/26/11 that upon return of Resident #1, he was placed on 30-minute checks that continued until the writing of the action plan. It documented the cognitively-impaired resident was instructed as to the procedure of signing in and out, and that if the resident agreed to follow this protocol, assuring that he would let them know when he wanted to go home for visits. - It documented that on 04/13/11, the resident was accepted for admission to another nursing facility and discharged home with his family for an overnight stay. It documented that on 04/13/11, additional door alarms had been purchased and installed on all exit doors, and that charge nurses and/or designees would check all door alarms every two hours for 24 hours and then weekly thereafter by the maintenance department. - It documented that on 03/26/11, all staff were in-serviced regarding the policy and procedures for identifying and monitoring potential elopement-risk residents, and that on 04/13/11 that the facility had completed in-services. 23. Observations on 04/13/11 and 04/14/11 revealed the following steps taken by the facility in an effort to remove the Immediate Jeopardy: - On 04/13/11, all three nurses' station had a notebook with a list of residents identified as being at risk of elopement. Each notebook had a picture of each identified resident. - On 04/13/11, the facility discharged Resident #1. - On 04/14/11 by 6:20 p.m., all exit doors had functioning alarms that activated each time the exit doors were opened. 24. Interviews with staff from the day shift (6:00 a.m. to 2:00 p.m.), evening shift (2:00 p.m. to 10:00 p.m.) and night shift (10:00 p.m. to 6:00 a.m.) revealed the majority of the staff interviewed had received in-service training regarding which residents had a WanderGuard bracelet, what procedures they were to take if a door alarm activated, and which residents they were to be monitoring for potential risk of elopement. 25. On 04/14/11 at 4:50 p.m., the Administrator was notified the Immediate Jeopardy had been removed, but the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to not all employees had been in-serviced regarding supervision of exit-seeking residents, and the importance of responding to activated door alarms. In addition, monitoring to staff to ensure they were appropriately supervising residents with exit-seeking behavior and respond to activated door alarms was ongoing. 26. Review of a facility list titled Risk of Elopement, received 04/13/11, documented 14 residents on the general population were at risk of elopement. During an interview with the Administrator and RSN on 04/13/11 at 10:30 a.m., they said all 14 residents exhibited a behavior of wandering, but only the residents who wore a WanderGuard bracelet exhibited a behavior of exit seeking. Review of the list of residents with a WanderGuard bracelet documented 10 residents were at risk for exit seeking. Observations of the 10 residents and an interview with ADON "E" and RSN on 04/13/11 at 10:50 a.m. revealed three of the residents, who wore a WanderGuard bracelet, no longer were at risk of exit seeking due to a decline in their condition. During an interview with RN "G" on 04/13/11 at 2:55 p.m., she revealed Resident #2 also wore a WanderGuard bracelet, although, his name was not on the list of residents who wore a WanderGuard bracelet. RN "G" said Resident #2 was new resident, here since first part of April 2011. RN "G" said Resident #2 had exited the facility without staff supervision "several time", which resulted in a WanderGuard bracelet being utilized. An observation on 04/13/11 at 5:58 p.m. revealed Resident #2 exited his room, at the end of Hall-500, and activated the WanderGuard door alarm as he passed the open door. The bracelet was around his wrist. Therefore, it was determined eight residents, who wore a WanderGuard, were at risk of exiting the facility without staff supervision.

Based on observations, interviews and record reviews, it was determined that for one of four sampled residents (Resident #1), who exhibited a behavior of exit-seeking, the facility failed to provide an appropriate level of supervision to prevent Resident #1, who exhibited a behavior of exit seeking, from exiting the facility without supervision. On 3/26/11, the facility was notified by the local police that cognitively impaired Resident #1 was found by the police at approximately 4:00 a.m., approximately three miles from the facility near an interstate highway. The local police returned Resident #1 to the facility at approximately 4:15 a.m. Resident #1 was placed at risk of serious injury or death. As of 4/13/11 at 2:30 a.m. (18 days after the incident), the facility had applied stick on door alarms to only 4 of 11 exit doors on the general population unit where Resident #1 resided. Therefore, Resident #1 remained at risk of exiting the facility without supervision. This led to the identification of an Immediate Jeopardy (IJ) on 04/13/11. While the IJ was removed on 04/14/11, the facility remained out of compliance at a severity of potential for more than minimal harm, and a scope of pattern due to not all employees had been in-serviced regarding the supervision of exit-seeking residents and the continued need of staff to monitor to ensure that direct-care staff were providing an appropriate level of supervision to prevent residents from exiting the facility. All eight residents, who exhibited a behavior of exit seeking, were placed at risk of harm due to failure of staff to provide an appropriate level of supervision to prevent incidents of exiting the facility without supervision. The evidence is as follows: 1. Review of the local police department's report of the incident documented that on 03/26/11 at approximately 3:48 a.m., the officer was dispatched to (a location approximately three miles from the facility) next to an interstate highway. It documented the officer had been notified that an elderly individual was in the area and that he was unable to provide a current address. It documented that upon arrival, the resident was found to have an assistive device (walker), and that he appeared to have some dementia, and that he was unable to provide his current address, and gave several different addresses and directions as to where he lived. It documented he said he was a veteran and that upon checking with the local Veteran's Administration Hospital, it was determined the individual resided at the nursing facility. It documented he was returned to the facility and the nightshift supervisor, RN "G", said Resident #1 had a history of [REDACTED]. It documented Resident #1 was found to have no WanderGuard bracelet on, and RN "G" said the device was probably in his room. 2. Review of Resident #1's clinical record revealed the following: - The form titled Admission Record documented Resident #1 admitted to the facility on [DATE] and that his current age was 81. - A quarterly MDS Resident Assessment, dated 03/10/11, documented his [DIAGNOSES REDACTED]. It documented he could be interviewed, but he had a deficit in his ability to recall facts and he was not oriented to date. It further noted he used an assistive device (walker) for independent mobility. (An on-line review of medical terms on 03/27/11 at MedicineNet.com, http://www.medterms.com, documented an aneurysm is a localized widening (dilatation) of an artery, vein, or the heart. At the area of an aneurysm, there is typically a bulge and the wall is weakened and may rupture. It documented meningoencephalitis was an inflammation of the brain and meninges. It documented meninges as the three membranes that cover the brain and spinal cord.) - The care plan, dated 03/09/11, documented in the summary of the care plan conference that Resident #1 had expressed a desire to go home. It documented a problem of potential wandering in unsafe areas and out of the community, and that the approaches would include the use of a WanderGuard, and that nurses were to check the WanderGuard every shift and ensure placement. An updated plan of care, dated 03/28/11 (2 days after the incident), documented that he had left the facility without telling staff, and the approaches included provide structured activities, walking inside and outside of the facility, watching movies, play bingo and other structured activities. It also documented he was to be checked every 30 minutes. - A nurse's notes, dated 03/26/11, documented at 4:15 a.m., the local police returned Resident #1 to the facility. It documented he resided on Hall 500. It documented he was assessed to have no injuries. It documented he told them he was going home, but he was reminded that this was his home. It documented a WanderGuard bracelet was placed on his right wrist. It documented he told staff he would remove the WanderGuard and leave again. - There was no nurses' note prior to the local police returning Resident #1 to the facility, to indicate the facility had been aware he was missing. - A nurse's note, dated 03/28/11, documented Resident #1 was moved from his room on Hall-500 to a room on Hall-800. 3. Review of the facility's list of residents who wore a WanderGuard, received 4/13/11, documented Resident #1 wore a WanderGuard. 4. Additional review of Resident #1's nurses' notes revealed he had a history of [REDACTED]. The evidence is as follows: - A nurse's note, dated 01/19/11 at 6:00 p.m., documented Resident #1's wife brought his WanderGuard bracelet to the nurses' station after he removed it and placed it in the trash. - A nurse's note, dated 01/19/11 at 12:15 a.m., documented Resident #1 went out the Hall-500 exit door, and his alarm (WanderGuard bracelet) was not present. It documented he told staff he used a toenail clipper to cut the WanderGuard bracelet off. It documented he told staff he was looking for his truck, and that he was redirected back into the facility and into his room and a new WanderGuard bracelet was applied. It documented he was told that he did not have a truck at the facility, and that he was reminded it was unsafe to be out in the cold. - A nurse's notes, dated 12/21/10 at 2:30 p.m., documented a nurse aide saw someone exiting the Hall-500 exit door, and discovered Resident #1 was outside. It documented he told them he was outside looking for his truck. 5. Information provided by the National Oceanic and Atmospheric Administration (NOAA) revealed that on the morning of 03/26/11 at 3:53 a.m., the temperature was 44.1 degrees Fahrenheit (F). 6. Observations of the facility on 04/13/11 starting at 2:30 a.m., revealed the following: - The facility had two wings: Hall-400 and Hall-500 were on one wing and Hall-600 and Hall-800 were on the opposite wing. - Three of four halls housed the general population residents: Hall-400, Hall-500 and Hall-800 were for the general population. - One hall housed the secured unit: Hall-600 was a designated secured unit. - Resident #1 now resided on Hall-800 in a room at approximately the mid point of the hall. 7. During an interview with LVN "B" on 04/13/11 at 2:45 a.m., she said since the incident of Resident #1 exiting the facility without staff supervision, they had added alarms on the exit doors. An observation at that time with LVN "B" revealed the following: - Hall-400 exit had two doors. The door to the right had a stick-on alarm. Upon opening the door, the alarm failed to activate. The door to the left-hand side had no alarm; thus, when the door was opened, there was no audible alarm sound. - In the sitting area for Hall-400 and Hall-500, the double door that exited on to the patio had no alarm device; thus, when each door was opened, no audible alarm activated. LVN "B" said the patio was not a secured area (i.e., no locked gates). - An exit door at the end of the sitting area and next to a room labeled room 318, had a single door which exited onto a patio. There was no alarm device on the door. Upon opening the door, no audible alarm activated. LVN "B" said the patio was not a secured area (i.e., no locked gates). 8. Further observations of the exit doors on 04/13/11 starting at 3:25 a.m. with the RSN, revealed the following: - Hall-400 exit, the door to the right side failed to activate the stick-on alarm four out of five attempts. The door on the left continued to have no alarm. - Dining room: The double door exiting onto the patio had no audible alarm device; thus, when each door was opened, no audible alarm activated. RSN said the patio area was not secured (i.e., no locked gates). - In the lobby, the electronic sliding main door was locked at that time. The side entry was a single door. No alarm device was attached to the door. Upon opening the door, there was no audible alarm. - In the main corridor, between the two wings, an open activity room had a single door exit that led onto a patio area. There was no alarm on the door. Upon opening the door, there was no audible alarm. RSN said the patio area was not secured (i.e., no locked gates). - In the main corridor, between the two wings, a hallway led to a double door which upon opening revealed a second hallway. RSN said the door to the right went to the dietary department. RSN said the door to the left went to a back patio and the back parking lot. The door to the left had no alarm device. Upon opening the door, no audible alarm activated. RSN said the patio area was not secured (i.e., no locked gates). - The Hall-800 exit door had two doors. The right-hand door had a stick-on alarm device. Two out of four attempts to activate the alarm by opening the door failed to cause an audible alarm. The left-hand door had no alarm device, and upon opening the door, there was no audible alarm. 9. During an interview with RN "G", on 04/13/11 at 2:55 p.m., she said she confirmed she was the house supervisor on duty the night shift of 03/25/11 and 03/26/11. She said She was on duty when the local police returned Resident #1 to the facility. She said she previously heard that on other shifts he had left the facility, and that she was aware he wore a WanderGuard and that he had a history of [REDACTED]. She said she had assessed him and found him to have no injuries. 10. An on-line review of Mapquest on 4/28/11, at http://classic.mapquest.com/, documented Resident #1 traveled approximately 3.21 miles from the facility. An observation on 04/13/11 at 2:25 a.m. revealed the five-lane road in front of the facility had a posted speed limit of 55 miles per hour (mph). 11. During an interview with LVN "F", on 04/13/11 at 2:35 p.m., she said she had worked the night shift on 03/25/11 to 03/26/11. She said she was the charge nurse for Hall-500 where Resident #1 resided at the time of the incident. She said Resident #1's room had been at the end of the hall nearest the exit door. She said Resident #1's wife had made them aware he had a history of [REDACTED]. She said on that particular night, she had made one round and that she last recalled seeing Resident #1 at 12:30 a.m. to 1:00 a.m. She said she was not aware he had ever worn a WanderGuard bracelet, but upon being returned by the police on the morning of 03/26/11, they placed a WanderGuard bracelet on his wrist. 12. During an interview with CNA "C", on 04/13/11 at 2:58 a.m., she said she worked the night shift on 03/25/11 and 03/26/11. She said that night she worked Hall-500 as the only nurse aide assigned to that hall. She said on the night of the incident, she had been told they were to visually check on Resident #1 every 30 minutes, because he had been wanting to leave with his wife. She said she checked on him approximately every hour and a half, not every 30 minutes as instructed. She said she was not aware he was missing until the local police department notified them he had eloped. She said she last recalled seeing Resident #1 around 2:45 a.m., and at that time, he had been in his room fully dressed and awake. She said when Resident #1 returned to the facility, he was wearing a sweater. 13. During an interview with Resident #1 on 04/13/11 at 11:10 a.m., he was observed to now reside on Hall-800. He said he once (unsure of dates) took a two-day trip to see his wife and brother. He said he traveled by night and slept by day. He said at night a highway patrolman brought him back to the facility, although, he did not want to return. As he discussed his travels and wanting to go home, he said he thought someone had taken him almost to his brother's house, but the "cops stopped the guy and brought him (Resident #1) back to the facility". He then added he wanted to go home to Henrietta, Texas (a town approximately 245 miles from the nursing facility). At that time, no WanderGuard bracelet was noted on either of Resident #1's wrists or ankles. 14. During an observation and interview with LVN "D" and ADON "E" on 04/13/11 at 11:33 a.m., while in Resident #1's room, it was confirmed Resident #1 was not wearing a WanderGuard bracelet. At that time, ADON "E" found the bracelet in a drawer in Resident #1's bedside table. The bracelet had frayed edges where the bracelet had been cut in order to release the bracelet from his ankle. At that time, Resident #1 told the staff he wanted "out of here". 15. An observation of the Hall-800 exit door on 04/13/11 at 11:36 a.m., revealed the double door continued to have only a door alarm on the right hand door, not the left hand door; thus, Resident #1 would be able to exit unsupervised through the unsecured exit door. 16. Review of the monitoring log for Resident #1, dated 04/13/11, documented staff were verifying his whereabouts every 30 minutes, which would provide time for Resident #1 to walk out the Hall-800 exit door without supervision of staff and off the facility grounds. 17. An observation on 04/13/11 at 12:00 p.m., revealed the RSN instructed staff to post a staff member at the Hall-400 and Hall-800 exit doors. 18. An observation on 04/13/11 at 12:35 p.m., confirmed a nurse aide (CNA "H") was seated in front of the Hall-800 exit doors. At that time, an interview with CNA "H" revealed he had been instructed to remain at the Hall-800 exit door until the door was fixed (i.e., alarms on both doors). 19. During an interview with the Administrator on 04/13/11 at 9:55 a.m., he said the facility had been designed to have a WanderGuard system, which was on each exit door. He said any resident, who wore a WanderGuard bracelet, would activate an alarm on the door the resident was attempting to exit. He said Resident #1 had no WanderGuard bracelet on at the time he exited the facility without supervision; thus, the WanderGuard alarm system did not activate. He said since the incident of /Resident #1 exiting without supervision, he had added another type of door alarm to each exit door, which activated an audible alarm any time anyone (i.e., resident, staff or visitor) opened an exit door. He said they purchased the available door alarms from a local vendor and the remaining alarms had been ordered, but had not arrived. 20. On 04/13/11 at 4:40 p.m., the Administrator, RSN, and Representative of the Texas Land Board, were notified that an Immediate Jeopardy (IJ) situation had been identified due to failure to provide an appropriate level of supervision for exit-seeking residents, which resulted in cognitively-impaired Resident #1, who had a history of [REDACTED]. 21. On 04/13/11 at 8:00 p.m., the facility's Action Plan was accepted. Review of the plan documented the following: - The facility had developed a notebook with photographs of all residents identified as potential wanderers, which were placed at each nurses' station - Staff were in-serviced regarding the notebook for identifying residents at risk of elopement. - As of 04/13/11, all residents' WanderGuard bracelets were checked to assure they were functioning properly. It documented WanderGuard bracelets were scheduled to be checked daily by the charge nurse or designee and documented in the resident's medical record. It further noted the DON or designee would monitor due to quality assurance weekly. - It documented on 03/26/11 that upon return of Resident #1, he was placed on 30-minute checks that continued until the writing of the action plan. It documented the cognitively-impaired resident was instructed as to the procedure of signing in and out, and that if the resident agreed to follow this protocol, assuring that he would let them know when he wanted to go home for visits. - It documented that on 04/13/11, the resident was accepted for admission to another nursing facility and discharged home with his family for an overnight stay. It documented that on 04/13/11, additional door alarms had been purchased and installed on all exit doors, and that charge nurses and/or designees would check all door alarms every two hours for 24 hours and then weekly thereafter by the maintenance department. - It documented that on 03/26/11, all staff were in-serviced regarding the policy and procedures for identifying and monitoring potential elopement-risk residents, and that on 04/13/11 that the facility had completed in-services. 22. Observations on 04/13/11 and 04/14/11 revealed the following steps taken by the facility in an effort to remove the Immediate Jeopardy: - On 04/13/11, all three nurses' station had a notebook with a list of residents identified as being at risk of elopement. Each notebook had a picture of each identified resident. - On 04/13/11, the facility discharged Resident #1. - On 04/14/11 by 6:20 p.m., all exit doors had functioning alarms that activated each time the exit doors were opened. 23. Interviews with staff from the day shift (6:00 a.m. to 2:00 p.m.), evening shift (2:00 p.m. to 10:00 p.m.) and night shift (10:00 p.m. to 6:00 a.m.) revealed the majority of the staff interviewed had received in-service training regarding which residents had a WanderGuard bracelet, what procedures they were to take if a door alarm activated, and which residents they were to be monitoring for potential risk of elopement. 24. On 04/14/11 at 4:50 p.m., the Administrator was notified the Immediate Jeopardy had been removed, but the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to not all employees had been in-serviced regarding supervision of exit-seeking residents, and the importance of responding to activated door alarms. In addition, monitoring to staff to ensure they were appropriately supervising residents with exit-seeking behavior and respond to activated door alarms was ongoing. 25. Review of a facility list titled Risk of Elopement, received 04/13/11, documented 14 residents on the general population were at risk of elopement. During an interview with the Administrator and RSN on 04/13/11 at 10:30 a.m., they said all 14 residents exhibited a behavior of wandering, but only the residents who wore a WanderGuard bracelet exhibited a behavior of exit seeking. Review of the list of residents with a WanderGuard bracelet documented 10 residents were at risk for exit seeking. Observations of the 10 residents and an interview with ADON "E" and RSN on 04/13/11 at 10:50 a.m. revealed three of the residents, who wore a WanderGuard bracelet, no longer were at risk of exit seeking due to a decline in their condition. During an interview with RN "G" on 04/13/11 at 2:55 p.m., she revealed Resident #2 also wore a WanderGuard bracelet, although, his name was not on the list of residents who wore a WanderGuard bracelet. RN "G" said Resident #2 was new resident, here since first part of April 2011. RN "G" said Resident #2 had exited the facility without staff supervision "several time", which resulted in a WanderGuard bracelet being utilized. An observation on 04/13/11 at 5:58 p.m. revealed Resident #2 exited his room, at the end of Hall-500, and activated the WanderGuard door alarm as he passed the open door. The bracelet was around his wrist. Therefore, it was determined eight residents, who wore a WanderGuard, were at risk of exiting the facility without staff supervision.

Based on observations, interviews and record reviews, it was determined that for one of four sampled residents (Resident #1), who exhibited a behavior of exit-seeking, the facility failed to implement their neglect prevention policy for prohibiting incidents of neglect when they failed to provide an appropriate level of supervision to prevent Resident #1, who exhibited a behavior of exit seeking, from exiting the facility without supervision. On 3/26/11, the facility was notified by the local police that cognitively impaired Resident #1 was found by the police at approximately 4:00 a.m., approximately three miles from the facility near an interstate highway. The local police returned Resident #1 to the facility at approximately 4:15 a.m. Resident #1 was placed at risk of serious injury or death. As of 4/13/11 at 2:30 a.m. (18 days after the incident), the facility had applied stick on door alarms to only 4 of 11 exit doors on the general population unit where Resident #1 resided. Therefore, Resident #1 remained at risk of exiting the facility without supervision. This led to the identification of an Immediate Jeopardy (IJ) on 04/13/11. While the IJ was removed on 04/14/11, the facility remained out of compliance at a severity of potential for more than minimal harm, and a scope of pattern due to not all employees had been in-serviced regarding the supervision of exit-seeking residents and the continued need of staff to monitor to ensure that direct-care staff were providing an appropriate level of supervision to prevent residents from exiting the facility. All eight residents, who exhibited a behavior of exit seeking, were placed at risk of harm due to failure of staff to provide an appropriate level of supervision to prevent incidents of exiting the facility without supervision. The evidence is as follows: 1. Review of the local police department's report of the incident documented that on 03/26/11 at approximately 3:48 a.m., the officer was dispatched to (a location approximately three miles from the facility) next to an interstate highway. It documented the officer had been notified that an elderly individual was in the area and that he was unable to provide a current address. It documented that upon arrival, the resident was found to have an assistive device (walker), and that he appeared to have some dementia, and that he was unable to provide his current address, and gave several different addresses and directions as to where he lived. It documented he said he was a veteran and that upon checking with the local Veteran's Administration Hospital, it was determined the individual resided at the nursing facility. It documented he was returned to the facility and the nightshift supervisor, RN "G", said Resident #1 had a history of [REDACTED]. It documented Resident #1 was found to have no WanderGuard bracelet on, and RN "G" said the device was probably in his room. 2. Review of Resident #1's clinical record revealed the following: - The form titled Admission Record documented Resident #1 admitted to the facility on [DATE] and that his current age was 81. - A quarterly MDS Resident Assessment, dated 03/10/11, documented his [DIAGNOSES REDACTED]. It documented he could be interviewed, but he had a deficit in his ability to recall facts and he was not oriented to date. It further noted he used an assistive device (walker) for independent mobility. (An on-line review of medical terms on 03/27/11 at MedicineNet.com, http://www.medterms.com, documented an aneurysm is a localized widening (dilatation) of an artery, vein, or the heart. At the area of an aneurysm, there is typically a bulge and the wall is weakened and may rupture. It documented meningoencephalitis was an inflammation of the brain and meninges. It documented meninges as the three membranes that cover the brain and spinal cord.) - The care plan, dated 03/09/11, documented in the summary of the care plan conference that Resident #1 had expressed a desire to go home. It documented a problem of potential wandering in unsafe areas and out of the community, and that the approaches would include the use of a WanderGuard, and that nurses were to check the WanderGuard every shift and ensure placement. An updated plan of care, dated 03/28/11 (2 days after the incident), documented that he had left the facility without telling staff, and the approaches included provide structured activities, walking inside and outside of the facility, watching movies, play bingo and other structured activities. It also documented he was to be checked every 30 minutes. - A nurse's notes, dated 03/26/11, documented at 4:15 a.m., the local police returned Resident #1 to the facility. It documented he resided on Hall 500. It documented he was assessed to have no injuries. It documented he told them he was going home, but he was reminded that this was his home. It documented a WanderGuard bracelet was placed on his right wrist. It documented he told staff he would remove the WanderGuard and leave again. - There was no nurses' note prior to the local police returning Resident #1 to the faiclity, to indicate the facility had been aware he was missing. - A nurse's note, dated 03/28/11, documented Resident #1 was moved from his room on Hall-500 to a room on Hall-800. 3. Review of the facility's list of residents who wore a WanderGuard, received 4/13/11, documented Resident #1 wore a WanderGuard. 4. Additional review of Resident #1's nurses' notes revealed he had a history of [REDACTED]. The evidence is as follows: - A nurse's note, dated 01/19/11 at 6:00 p.m., documented Resident #1's wife brought his WanderGuard bracelet to the nurses' station after he removed it and placed it in the trash. - A nurse's note, dated 01/19/11 at 12:15 a.m., documented Resident #1 went out the Hall-500 exit door, and his alarm (WanderGuard bracelet) was not present. It documented he told staff he used a toenail clipper to cut the WanderGuard bracelet off. It documented he told staff he was looking for his truck, and that he was redirected back into the facility and into his room and a new WanderGuard bracelet was applied. It documented he was told that he did not have a truck at the facility, and that he was reminded it was unsafe to be out in the cold. - A nurse's notes, dated 12/21/10 at 2:30 p.m., documented a nurse aide saw someone exiting the Hall-500 exit door, and discovered Resident #1 was outside. It documented he told them he was outside looking for his truck. 5. Information provided by the National Oceanic and Atmospheric Administration (NOAA) revealed that on the morning of 03/26/11 at 3:53 a.m., the temperature was 44.1 degrees Fahrenheit (F). 6. Observations of the facility on 04/13/11 starting at 2:30 a.m., revealed the following: - The facility had two wings: Hall-400 and Hall-500 were on one wing and Hall-600 and Hall-800 were on the opposite wing. - Three of four halls housed the general population residents: Hall-400, Hall-500 and Hall-800 were for the general population. - One hall housed the secured unit: Hall-600 was a designated secured unit. - Resident #1 now resided on Hall-800 in a room at approximately the mid point of the hall. 7. During an interview with LVN "B" on 04/13/11 at 2:45 a.m., she said since the incident of Resident #1 exiting the facility without staff supervision, they had added alarms on the exit doors. An observation at that time with LVN "B" revealed the following: - Hall-400 exit had two doors. The door to the right had a stick-on alarm. Upon opening the door, the alarm failed to activate. The door to the left-hand side had no alarm; thus, when the door was opened, there was no audible alarm sound. - In the sitting area for Hall-400 and Hall-500, the double door that exited on to the patio had no alarm device; thus, when each door was opened, no audible alarm activated. LVN "B" said the patio was not a secured area (i.e., no locked gates). - An exit door at the end of the sitting area and next to a room labeled room [ROOM NUMBER], had a single door which exited onto a patio. There was no alarm device on the door. Upon opening the door, no audible alarm activated. LVN "B" said the patio was not a secured area (i.e., no locked gates). 8. Further observations of the exit doors on 04/13/11 starting at 3:25 a.m. with the RSN, revealed the following: - Hall-400 exit, the door to the right side failed to activate the stick-on alarm four out of five attempts. The door on the left continued to have no alarm. - Dining room: The double door exiting onto the patio had no audible alarm device; thus, when each door was opened, no audible alarm activated. RSN said the patio area was not secured (i.e., no locked gates). - In the lobby, the electronic sliding main door was locked at that time. The side entry was a single door. No alarm device was attached to the door. Upon opening the door, there was no audible alarm. - In the main corridor, between the two wings, an open activity room had a single door exit that led onto a patio area. There was no alarm on the door. Upon opening the door, there was no audible alarm. RSN said the patio area was not secured (i.e., no locked gates). - In the main corridor, between the two wings, a hallway led to a double door which upon opening revealed a second hallway. RSN said the door to the right went to the dietary department. RSN said the door to the left went to a back patio and the back parking lot. The door to the left had no alarm device. Upon opening the door, no audible alarm activated. RSN said the patio area was not secured (i.e., no locked gates). - The Hall-800 exit door had two doors. The right-hand door had a stick-on alarm device. Two out of four attempts to activate the alarm by opening the door failed to cause an audible alarm. The left-hand door had no alarm device, and upon opening the door, there was no audible alarm. 9. During an interview with RN "G", on 04/13/11 at 2:55 p.m., she said she confirmed she was the house supervisor on duty the night shift of 03/25/11 and 03/26/11. She said he was on duty when the local police returned Resident #1 to the facility. She said she previously heard that on other shifts he had left the facility, and that she was aware he wore a WanderGuard and that he had a history of [REDACTED]. She said she had assessed him and found him to have no injuries. 10. An on-line review of Mapquest on 4/28/11, at http://classic.mapquest.com/, documented Resident #1 traveled approximately 3.21 miles from the facility. An observation on 04/13/11 at 2:25 a.m. revealed the five-lane road in front of the facility had a posted speed limit of 55 miles per hour (mph). 11. During an interview with LVN "F", on 04/13/11 at 2:35 p.m., she said she had worked the night shift on 03/25/11 to 03/26/11. She said she was the charge nurse for Hall-500 where Resident #1 resided at the time of the incident. She said Resident #1's room had been at the end of the hall nearest the exit door. She said Resident #1's wife had made them aware he had a history of [REDACTED]. She said on that particular night, she had made one round and that she last recalled seeing Resident #1 at 12:30 a.m. to 1:00 a.m. She said she was not aware he had ever worn a WanderGuard bracelet, but upon being returned by the police on the morning of 03/26/11, they placed a WanderGuard bracelet on his wrist. 12. During an interview with CNA "C", on 04/13/11 at 2:58 a.m., she said she worked the night shift on 03/25/11 and 03/26/11. She said that night she worked Hall-500 as the only nurse aide assigned to that hall. She said on the night of the incident, she had been told they were to visually check on Resident #1 every 30 minutes, because he had been wanting to leave with his wife. She said she checked on him approximately every hour and a half, not every 30 minutes as instructed. She said she was not aware he was missing until the local police department notified them he had eloped. She said she last recalled seeing Resident #1 around 2:45 a.m., and at that time, he had been in his room fully dressed and awake. She said when Resident #1 returned to the facility, he was wearing a sweater. 13. During an interview with Resident #1 on 04/13/11 at 11:10 a.m., he was observed to now reside on Hall-800. He said he once (unsure of dates) took a two-day trip to see his wife and brother. He said he traveled by night and slept by day. He said at night a highway patrolman brought him back to the facility, although, he did not want to return. As he discussed his travels and wanting to go home, he said he thought someone had taken him almost to his brother's house, but the "cops stopped the guy and brought him (Resident #1) back to the facility". He then added he wanted to go home to Henrietta, Texas (a town approximately 245 miles from the nursing facility). At that time, no WanderGuard bracelet was noted on either of Resident #1's wrists or ankles. 14. During an observation and interview with LVN "D" and ADON "E" on 04/13/11 at 11:33 a.m., while in Resident #1's room, it was confirmed Resident #1 was not wearing a WanderGuard bracelet. At that time, ADON "E" found the bracelet in a drawer in Resident #1's bedside table. The bracelet had frayed edges where the bracelet had been cut in order to release the bracelet from his ankle. At that time, Resident #1 told the staff he wanted "out of here". 15. An observation of the Hall-800 exit door on 04/13/11 at 11:36 a.m., revealed the double door continued to have only a door alarm on the right hand door, not the left hand door; thus, Resident #1 would be able to exit unsupervised through the unsecured exit door. 16. Review of the monitoring log for Resident #1, dated 04/13/11, documented staff were verifying his whereabouts every 30 minutes, which would provide time for Resident #1 to walk out the Hall-800 exit door without supervision of staff and off the facility grounds. 17. An observation on 04/13/11 at 12:00 p.m., revealed the RSN instructed staff to post a staff member at the Hall-400 and Hall-800 exit doors. 18. An observation on 04/13/11 at 12:35 p.m., confirmed a nurse aide (CNA "H") was seated in front of the Hall-800 exit doors. At that time, an interview with CNA "H" revealed he had been instructed to remain at the Hall-800 exit door until the door was fixed (i.e., alarms on both doors). 19. During an interview with the Administrator on 04/13/11 at 9:55 a.m., he said the facility had been designed to have a WanderGuard system, which was on each exit door. He said any resident, who wore a WanderGuard bracelet, would activate an alarm on the door the resident was attempting to exit. He said Resident #1 had no WanderGuard bracelet on at the time he exited the facility without supervision; thus, the WanderGuard alarm system did not activate. He said since the incident of /Resident #1 exiting without supervision, he had added another type of door alarm to each exit door, which activated an audible alarm any time anyone (i.e., resident, staff or visitor) opened an exit door. He said they purchased the available door alarms from a local vendor and the remaining alarms had been ordered, but had not arrived. 20. Review of the facility's policies revealed the following: - The Abuse Prevention Program policy, revised August 2006, documented: "Our resident shave the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. - Wandering Residents policy, revised April 2066, documented "Every effort will be made to prevent wandering episode while maintaining the least restrictive environment for residents who are at risk of elopement." 21. On 04/13/11 at 4:40 p.m., the Administrator, RSN, and Representative of the Texas Land Board, were notified that an Immediate Jeopardy (IJ) situation had been identified due to failure to provide an appropriate level of supervision for exit-seeking residents, which resulted in cognitively-impaired Resident #1, who had a history of [REDACTED]. 22. On 04/13/11 at 8:00 p.m., the facility's Action Plan was accepted. Review of the plan documented the following: - The facility had developed a notebook with photographs of all residents identified as potential wanderers, which were placed at each nurses' station - Staff were in-serviced regarding the notebook for identifying residents at risk of elopement. - As of 04/13/11, all residents' WanderGuard bracelets were checked to assure they were functioning properly. It documented WanderGuard bracelets were scheduled to be checked daily by the charge nurse or designee and documented in the resident's medical record. It further noted the DON or designee would monitor due to quality assurance weekly. - It documented on 03/26/11 that upon return of Resident #1, he was placed on 30-minute checks that continued until the writing of the action plan. It documented the cognitively-impaired resident was instructed as to the procedure of signing in and out, and that if the resident agreed to follow this protocol, assuring that he would let them know when he wanted to go home for visits. - It documented that on 04/13/11, the resident was accepted for admission to another nursing facility and discharged home with his family for an overnight stay. It documented that on 04/13/11, additional door alarms had been purchased and installed on all exit doors, and that charge nurses and/or designees would check all door alarms every two hours for 24 hours and then weekly thereafter by the maintenance department. - It documented that on 03/26/11, all staff were in-serviced regarding the policy and procedures for identifying and monitoring potential elopement-risk residents, and that on 04/13/11 that the facility had completed in-services. 23. Observations on 04/13/11 and 04/14/11 revealed the following steps taken by the facility in an effort to remove the Immediate Jeopardy: - On 04/13/11, all three nurses' station had a notebook with a list of residents identified as being at risk of elopement. Each notebook had a picture of each identified resident. - On 04/13/11, the facility discharged Resident #1. - On 04/14/11 by 6:20 p.m., all exit doors had functioning alarms that activated each time the exit doors were opened. 24. Interviews with staff from the day shift (6:00 a.m. to 2:00 p.m.), evening shift (2:00 p.m. to 10:00 p.m.) and night shift (10:00 p.m. to 6:00 a.m.) revealed the majority of the staff interviewed had received in-service training regarding which residents had a WanderGuard bracelet, what procedures they were to take if a door alarm activated, and which residents they were to be monitoring for potential risk of elopement. 25. On 04/14/11 at 4:50 p.m., the Administrator was notified the Immediate Jeopardy had been removed, but the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to not all employees had been in-serviced regarding supervision of exit-seeking residents, and the importance of responding to activated door alarms. In addition, monitoring to staff to ensure they were appropriately supervising residents with exit-seeking behavior and respond to activated door alarms was ongoing. 26. Review of a facility list titled Risk of Elopement, received 04/13/11, documented 14 residents on the general population were at risk of elopement. During an interview with the Administrator and RSN on 04/13/11 at 10:30 a.m., they said all 14 residents exhibited a behavior of wandering, but only the residents who wore a WanderGuard bracelet exhibited a behavior of exit seeking. Review of the list of residents with a WanderGuard bracelet documented 10 residents were at risk for exit seeking. Observations of the 10 residents and an interview with ADON "E" and RSN on 04/13/11 at 10:50 a.m. revealed three of the residents, who wore a WanderGuard bracelet, no longer were at risk of exit seeking due to a decline in their condition. During an interview with RN "G" on 04/13/11 at 2:55 p.m., she revealed Resident #2 also wore a WanderGuard bracelet, although, his name was not on the list of residents who wore a WanderGuard bracelet. RN "G" said Resident #2 was new resident, here since first part of April 2011. RN "G" said Resident #2 had exited the facility without staff supervision "several time", which resulted in a WanderGuard bracelet being utilized. An observation on 04/13/11 at 5:58 p.m. revealed Resident #2 exited his room, at the end of Hall-500, and activated the WanderGuard door alarm as he passed the open door. The bracelet was around his wrist. Therefore, it was determined eight residents, who wore a WanderGuard, were at risk of exiting the facility without staff supervision.