Every finding on record at Vintage Health Care Center

Based on interviews and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 (Resident #3, # 4, #5, #6 and #7) of 8 residents reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 received their scheduled showers. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self-esteem.Findings included: Record review of Resident #3's face sheet, dated 05/28/26, reflected a [AGE] year-old female that was admitted to the facility on [DATE]. Resident #3 had diagnoses that included: urinary tract infection (a bacterial infection in any part of the urinary system (kidneys, bladder, or urethra), tremor (an involuntary, rhythmic muscle contraction and relaxation that causes shaking or trembling movements), Alzheimer's disease (a progressive, irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out simple tasks), sleep apnea (a common disorder where breathing repeatedly stops and starts during sleep), chronic pain, irritable bowel syndrome (a common, long-term functional gastrointestinal disorder, characterized by recurring abdominal pain, cramping, bloating, and changes in bowel habits like diarrhea, constipation, or both), pain in right shoulder, overactive bladder (a sudden, uncontrollable urge to urinate), abnormal uterine and vaginal bleeding (any bleeding that is heavier, lasts longer, occurs between periods, or happens after menopause). Record review of Resident #3's Quarterly MDS assessment, dated 04/08/26, reflected the resident had BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #3 needed setup or clean-up assistance with eating and was dependent on staff for toileting hygiene. The MDS assessment under Section GG-Functional Abilities there was no information provided for assistance with showering/bathing. Record review of Resident #3's care plan, initiated 10/13/25, reflected Resident #3 had an ADL self-care performance deficit. The interventions included: bathing: require staff x1 for assistance, bed Mobility: require staff x2 for assistance, discuss with resident/family care any concerns related to loss of independence, decline in function, dressing: require staff x1 for assistance, praise all efforts at self-care, PT/OT evaluation and treatment as per MD orders, the resident require a lift for all transfers, the resident used an electric wheelchair, toilet use: require staff x2 for assistance, transfer: the resident required 2 staff participation with transfers via the mechanical lift, encourage the resident to discuss feelings about self-care deficit, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance, monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, decline in function, bathing: check nail length and trim and clean on bath day and as necessary, dressing: assist the resident to choose simple comfortable clothing that maximizes the resident's ability to dress self. Record review of Resident #3's documented baths in PCC on 05/28/26, reflected the resident showers/baths were Tuesdays, Thursdays and Saturdays during 2:00PM-10:00PM shift. PCC documentation reflected no showers/baths for Resident #3 on 05/05/26 and 05/21/26 with no indication as to why it was not documented. Record review of Resident #4's face sheet, dated 05/28/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #4 had diagnoses that included: orthopedic aftercare (focus on pain management, wound care, and controlled physical rehabilitation) and osteoarthritis (degenerative joint disease where the protective cartilage cushioning the ends of bones wear down over time). Record review of Resident #4's MDS assessment dated [DATE], reflected that the resident had a BIMS score of 05, which indicated severe cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #4 was dependent on staff for personal hygiene, showering/bathing, oral hygiene, toileting, upper and lower body dressing, putting on/taking off footwear. Record review of Resident #4's care plan, date initiated 04/28/26, reflected Resident #4 had an ADL self-care performance deficit. The interventions were that the resident required staff x1 for assistance with bathing, required staff x2 for assistance with bed mobility, required staff x1 for assistance with dressing, required staff x1 for assistance with eating, required staff x2 for assistance with toilet use, discuss with resident/family care any concerns related to loss of independence and decline in function, praise all efforts at self-care, PT/OT evaluation and treatment as per MD orders, encourage the resident to discuss feelings about self-care deficit, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance, monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course and decline in function, check nail length and trim and clean on bath day and as necessary and assist the resident to choose simple comfortable clothing that maximizes the resident's ability to dress self. Record review of Resident #4's documented showers/baths in PCC on 05/28/26, reflected the resident showers/baths were Mondays, Wednesdays and Fridays on 6:00am-2:00pm shift. PCC reflected no documentation of showers/baths on 05/01/26, 05/04/26, 05/11/26 and 05/13/26 no indication as to why it was not documented. Record review of Resident #5's face sheet, dated 05/28/26, reflected an [AGE] year-old female that admitted to the facility on [DATE]. Resident #5 had diagnoses that included: urinary tract infection (infection in any part of the urinary system), difficulty walking, lack of coordination and chronic pain. Record review of Resident #5's MDS assessment dated [DATE], reflected the resident had a BIMS score of 13, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities reflected Resident #5 needed substantial assistancewith toileting hygiene. The MDS assessment did not provide any information for the question regarding assistance with showering/bathing. Record review of Resident #5's care plan, revised on 09/10/25, reflected the resident had an ADL self-care performance deficiency.The interventions were that the resident required staff x1 for assistance with bathing, dressing and toilet use, staff x2 for assistance with bed mobility, supervision with eating, discuss with resident/family care any concerns related to loss of independence, decline in function, praise all efforts at self-care, PT/OT evaluation and treatment as per MD orders, a lift for all transfers, use a wheelchair, encourage the resident to discuss feelings about self-care deficit, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance, monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, decline in function. Record review of Resident #5's documented showers/baths in PCC on 05/28/26, reflected the resident's showers/baths were on Tuesdays, Thursdays and Saturdays during 6:00am-2:00pm shift. PCC documentation reflected no showers/baths for Resident #5 on 05/05/26, 05/19/26 and 05/26/26 no indication as to why it was not documented. Record review of Resident #6 face sheet, dated 05/28/26, reflected a 60-yer-old male that was admitted to the facility on [DATE]. Resident #6 had diagnoses that included: cerebral infraction (blood flow to an area of the brain blocked or significantly reduced), chronic pain and tremors (an involuntary, rhythmic shaking movement in one or more parts of the body). Record review of Resident #6's MDS assessment dated [DATE], reflected the resident had a BIMS score of 14, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities reflected showering/bathing not applicable which indicated not attempted. Record review of Resident #6's care plan, revised on 05/27/26, reflected the resident was at risk for falls. The interventions were to anticipate and meet the resident's needs, ensure the resident's call light working and within reach and encourage the resident to use it for assistance as needed. Record review of Resident #6's documented baths in PCC, reflected the resident's shower/bath days were Tuesdays, Thursdays and Saturdays. PCC documentation reflected no showers/baths for Resident #6 on 05/05/26 no indication as to why it was not documented. Record review of Resident #7's face sheet, dated 05/28/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE].Resident #7 had diagnoses that included: hemiplegia (complete paralysis) and hemiparesis (partial weakness or weakness) following cerebral infarction affecting left non-dominant side (damage occurred in the right hemisphere of the brain), muscle wasting, lack of coordination, restless legs syndrome, chronic pain syndrome, paraplegia (he partial or complete loss of motor and sensory function in the lower half of the body, including both legs, typically caused by spinal cord injury or disease), benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous enlargement of the prostate gland which lead to weak urine stream, frequent urination, nocturia, and urgency) and contracture of left and right knee. Record review of Resident #7's MDS assessment dated [DATE], reflected that resident had a BIMS score of 12, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities reflected no information documented for showering/bathing. It further reflected Resident #7 needed setup or clean-up assistance with eating, dependent on staff with toileting hygiene, sitting to lying, lying to sitting on side of bed, chair/bed-to-chair transfer. Resident #7 was not ambulatory and used a manual wheelchair. Record review of Resident #7's documented baths in PCC on 05/28/26, reflected the resident's shower/bath days were Mondays, Wednesdays and Fridays during 2:00pm-10:00pm shift. PCC reflected no documented shower/bath for Resident #7 on 05/04/26 no indication as to why it was not documented. During an interview on 05/27/26 at 10:43 AM, Resident #3 stated she did not get a bath on 05/23/26. Resident #3 stated her shower/bath days were Tuesdays, Thursdays and Saturdays. Resident #3 stated she did not know why she did not receive her shower. She stated she knew the reason was not because the facility was short staffed. Resident #3 stated the staff would lie saying that she refused her shower, but she never refused her showers. During an interview on 05/28/26 at 11:20 AM, Resident #6 stated he only showered about two times the entire time he had been at the facility. Resident #6 stated he spoke with someone regarding the shower issue, and they were supposed to talk to the nurse or aide about ensuring he received his showers. He stated he did not remember who or when he spoke to someone about it. Resident #6 stated he required supervision for his showers. Resident #6 also stated staff was supposed to inform him of his time to shower and provide supervision but did not. During an interview on 05/28/26 at 11:59 AM, Resident #5 stated there have been many times that she did not receive her showers. She stated staff did not show up to shower her. Resident #5 stated staff have told her that they would do it later but have not done it by 2:00 PM. Resident #5 stated her shower days were Tuesdays, Thursdays and Saturdays. Resident #5 stated she had missed her Saturday showers numerous times. Resident #5 stated some weeks she received one shower, other times two showers but not her three showers. Resident #5 stated she did not refuse her showers and wanted her three showers a week. During an interview on 05/28/26 at 12:36 PM, Resident #7 stated he was supposed to receive his bed baths on Mondays, Wednesdays and Fridays on the 2:00pm-10:00pm shift. Resident #7 stated he did not always receive his three baths during the week. He stated it depended on what staff were on shift that determined if he would get his baths. Resident #7 stated he was unaware of exactly which staff it was that did not bathe him. Resident #6 stated he did not receive his bath on 05/20/26 or 05/22/26 but did not say anything to staff. During an interview on 05/28/26 at 2:22 PM, Resident #4's family stated the facility promised to shower Resident #4 on 04/28/26 but did not happen. Resident #4's family member stated the resident had not had a shower on 04/27/26-04/28/26. She stated Resident #4 received his first bath on 04/29/26 in which his family went to the facility and gave him a bed bath. Resident #4's family member stated on 05/02/26, both her and Resident #4's family gave him a bed bath. Resident #4's family member stated Resident #4 received his first bath from facility staff on 05/03/26. She stated the family was told that the resident's baths were Mondays, Wednesday and Fridays. She stated once they complained about the bath issue, the family was informed that Resident #4's baths were Tuesdays, Thursdays and Saturdays. During an interview on 05/28/26 at 5:20 PM, LVN A stated mostly CNAs provided residents with their showers. LVN A stated residents had complained about not being showered. LVN A stated one reason a resident would have not received a shower was due to being short staffed. LVN A stated another reason the resident may not have been showered was due to refusal and wanting to take it at another time. During an interview on 05/28/26 at 6:20 PM, the DON stated some residents refused and then said they did not get showered. The DON stated there was an option of PRN showers. The DON stated some residents would say they wanted their showers later. The DON stated she had not received any complaints from any residents about not being showered or bathed. The DON stated the expectations were for staff to give residents showers on their shower days. The DON stated if a resident refused, it should have been documented and reported to the nurse so the nurse could speak with the resident. The DON stated showers and baths were documented on skin sheets and signed off by the nurse. She also stated it was also documented in PCC. Record review of the facility's policy on Bath, Tub/Shower, no date, revealed the following in part: Bathing by tub or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation. A medicated tub bath can also be provided to treat skin conditions. The aging skin becomes dry, wrinkled, thinner, and blemished with various aging spots over time and is easily affected by environmental temperature and humidity, sun exposure, soaps, and clothing fabrics. The frequency and type of bathing depend on resident preference, skin condition, tolerance, and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

Based on interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for 4 (Resident #3, #5, #8 and #9) of 8 reviewed for personal property. The facility failed to allow Resident's #3, #5, #8 and #9 to exercise the right to retain and use personal possessions, including clothing. This failure could place residents at risk emotional distress, embarrassment, and lower self-esteem.Findings included: Record review of Resident #3's face sheet, dated 05/28/26, reflected a [AGE] year-old female that was admitted to the facility on [DATE]. Resident #3 had diagnoses that included: urinary tract infection (a bacterial infection in any part of the urinary system (kidneys, bladder, or urethra), tremor (an involuntary, rhythmic muscle contraction and relaxation that causes shaking or trembling movements), Alzheimer's disease (a progressive, irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out simple tasks), sleep apnea (a common disorder where breathing repeatedly stops and starts during sleep), chronic pain, irritable bowel syndrome (a common, long-term functional gastrointestinal disorder, characterized by recurring abdominal pain, cramping, bloating, and changes in bowel habits like diarrhea, constipation, or both), pain in right shoulder, overactive bladder (a sudden, uncontrollable urge to urinate), abnormal uterine and vaginal bleeding (any bleeding that is heavier, lasts longer, occurs between periods, or happens after menopause). Record review of Resident #3's Quarterly MDS assessment, dated 04/08/26, reflected the resident had BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #3 needed setup or clean-up assistance with eating and was dependent on staff for toileting hygiene. There was no information provided for assistance with showering/bathing. Record review of Resident #3's care plan, initiated 10/13/25, reflected Resident #3 had an ADL self-care performance deficit. The interventions included: bathing: requires staff x1 for assistance, bed Mobility: requires staff x2 for assistance, discuss with resident/family care any concerns related to loss of independence, decline in function, dressing: required staff x1 for assistance, praise all efforts at self-care, PT/OT evaluation and treatment as per MD orders, the resident required a lift for all transfers, the resident used an electric wheelchair, toilet use: required staff x2 for assistance, transfer: the resident required 2 staff participation with transfers via the Hoyer lift, encourage the resident to discuss feelings about self-care deficit, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance, monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function, bathing: check nail length and trim and clean on bath day and as necessary, dressing: assist the resident to choose simple comfortable clothing that maximizes the resident's ability to dress self. Record review of Resident #5's face sheet, dated 05/28/26, reflected an [AGE] year-old female that admitted to the facility on [DATE]. Resident #5's had diagnoses that included: urinary tract infection (infection in any part of the urinary system), difficulty walking, lack of coordination and chronic pain. Record review of Resident #5's MDS assessment dated [DATE], reflected the resident had a BIMS score of 13, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities reflected Resident #5 needed substantial assistancewith toileting hygiene. The MDS assessment did not provide any information for the question regarding assistance with showering/bathing. Record review of Resident #5's care plan, revised on 09/10/25, reflected the resident had an ADL self-care performance deficiency.The interventions were that the resident required staff x1 for assistance with bathing, dressing and toilet use, staff x2 for assistance with bed mobility, supervision with eating, discuss with resident/family care any concerns related to loss of independence, decline in function, Praise all efforts at self-care, PT/OT evaluation and treatment as per MD orders, a lift for all transfers, use a wheelchair, encourage the resident to discuss feelings about self-care deficit, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance, monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, decline in function. Record review of Resident #8's face sheet, dated 05/28/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #8 had diagnoses that included: acute respiratory failure with hypoxia (when the lungs cannot deliver enough oxygen to the blood), type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), chronic venous hypertension with ulcer of left and right lower extremity (a condition in which long-term elevated pressure in the veins of the lower extremities damages valves and vessel walls, leading to blood pooling, tissue damage, and often venous leg ulcers), sepsis due to methicillin resistant staphylococcus aureus (a life-threatening condition where antibiotic-resistant Staphylococcus aureus triggers a systemic inflammatory response, potentially leading to organ failure and death), congestive health failure, acute embolism and thrombosis of right internal jugular vein (he formation of a blood clot within the internal jugular vein, which is a major blood vessel in the neck responsible for draining blood from the brain), gastro-esophageal reflux disease without esophagitis (a common form of acid reflux where symptoms occur without visible esophageal damage), methicillin resistant staphylococcus aureus infection (a type of bacteria that causes skin infections and is resistant to many antibiotics, making it harder to treat), paralysis of vocal cords and larynx (when one or both vocal folds fail to move due to disrupted nerve signals to the larynx, leading to hoarseness, breathing difficulty, and swallowing problems), pleural effusion (abnormal accumulation of fluid in the pleural space around the lungs, which can impair breathing and requires treatment based on its cause), burns involving 50-59% of body surface with 20-29% third degree burns. Record review of Resident #8's MDS, dated [DATE], reflected a BIMS score of 14, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities Section GG-Functional Abilities reflected resident needed setup or clean-up assistance with eating, supervision with toileting hygiene and no other assistance with oral hygiene, showering/bathing, upper and lower body dressing, putting/taking off footwear or personal hygiene. Record review of Resident #9's face sheet, dated 05/28/26, reflected a [AGE] year-old female that was admitted to the facility on [DATE]. Resident #9 had diagnoses that included: multiple sclerosis (a chronic autoimmune disease that affects the central nervous system (brain, spinal cord, and optic nerves), paraplegia (partial or complete paralysis of the lower half of the body, including both legs), functional quadriplegia (the complete inability to move due to severe physical disability or frailty, completely independent of any physical injury or damage to the brain or spinal cord) weakness, difficulty walking, lack of coordination. Record review of Resident #9's Quarterly MDS assessment, dated 04/09/26, reflected the resident had a BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities reflected the resident was dependent on staff for toileting hygiene, sitting to standing, chair/bed-to-chair transfer, toilet transfer, substance assistance with sitting to lying, lying to sitting on side of bed and was independent with eating. The MDS assessment under Section GG-Functional Abilities Section GG-Functional Abilities also reflected oral hygiene, showering/bathing, upper and lower body dressing, personal hygiene, rolling left and right, tub/shower transfer and walking 10 feet were not applicable/not attempted. Record review of Resident #9's care plan, initiated 03/25/26, reflected the resident had an ADL self-care performance deficit. The interventions included: toilet use: require staff x2 for assistance, two person at all times during ADL care, dressing: the resident require (X2) staff participation to dress. Record review of Grievance Log, reflected Resident #8 filed a grievance on 05/18/26 for missing clothes. The grievance had no resolve date, but that laundry was notified and all items were returned. During an interview on 05/27/26 at 10:43AM, Resident #3 stated some of her clothes were stolen. Resident #3 stated she had also received other residents' clothes. Resident #3 stated her wheelchair was also broken by staff. Resident #3 stated her wheelchair could no longer turn on or move. Resident #3 stated her wheelchair was mishandled when staff were moving her belongings. Resident #3 also stated her TLC Roku television was broken. Resident #3 stated the facility had not replaced her television but put a Samsung tv that was not the same quality in her room. During an interview on 05/27/26 at 11:47 AM, LVN B stated some of the residents' clothes were missing. LVN B stated the residents had the names on the clothes, so she did not understand how laundry lost them. She stated some residents did not have clothes and staff had brought them in clothes. She stated laundry had an issue with losing residents' clothes and stated the names were not on them. LVN B stated she ensured she wrote residents' name on their personal items, so that was not the reason residents' personal items were lost. LVN B also stated residents' personal clothing that had been sent to laundry had gone missing. She stated residents' personal belongings should not be missing because she ensured to write the residents names and room number on them. During an interview on 05/27/26 at12:10 PM, CNA C stated she had a few residents on the memory care unit with clothes that were missing. CNA C stated the clothes went to laundry and did not return. She stated she could not remember if the names of the residents were on the clothes. During an interview on 05/27/26 at 12:42 PM, Housekeeping Supervisor stated the only way residents did not receive their personal items from laundry was if they did not have their name and room number on the clothing. She stated without the information, laundry did not know who it belonged to and put it in in the lost and found. During an interview on 05/27/26 at 3:01 PM, Resident #9 stated a lot of her clothes had gone missing. Resident #9 stated her favorite black shorts went missing approximately one month ago. Resident #9 stated two weeks ago, two pairs of gray shorts that she purchased from Amazon were missing. Resident #9 stated several of her underwear were missing. Resident #9 stated she had some washcloths that were missing. Resident #9 stated her name were on all her clothes that went missing. During an interview on 05/28/26 at 11:59 AM, Resident #5 stated she no longer sent her personal items to laundry because they have lost her items. Resident #5 stated laundry lost her hallmark quilt. Resident #5 stated laundry lost three sets of socks. She stated she had sent her personal items at the beginning of the week and at the end of the week it was not returned due to them losing it. Resident #5 stated as a result her family picked up her laundry and cleaned it. During an interview on 05/28/26 at 12:45 PM, Resident #8 stated several of his personal clothes had gone missing. He stated as of date, he had yet to receive his personal items that he sent to laundry during the week of 05/18/26 prior. Resident #8 stated he ensured to write his name on all his clothing and included a written note of all the items in the bag. Resident #8 stated he had a CNA to bring him to laundry to find his clothes when it was not returned to him. He stated he was about to find his clothes at that time. Review of the facility's policy, titled Resident Rights, no dated, reflected in part the following: Respect and dignity - The resident has a right to be treated with respect and dignity, including:1. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.2. The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.4. The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.5. The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.6. The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.7. The right to refuse to transfer to another room in the facility, if the purpose of the transfer is:a. to relocate a resident of a SNF from the distinct part of the institution that is a SNF to a part of the institution that is not a SNF, orb. to relocate a resident of a NF from the distinct part of the institution that is a NF to a distinct part of the institution that is a SNF.c. solely for the convenience of staff.d. A resident's exercise of the right to refuse transfer does not affect the resident's eligibility or entitlement to Medicare or Medicaid benefits.

Based on observation, interview and record review the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior for 3 (Resident #3, #7 and #9) of 8 resident's reviewed for environment. The facility failed to ensure there was clean bed linen at the time of residents' showers. The facility failed to change and provide clean bed linen for Resident #3 and Resident #7 on shower/bath days. The facility failed to provide clean bath towels for Resident #9 on shower days. This failure could affect any resident and place them at risk for not having clean linens which could lead to a decreased quality of life. Findings included: Record review of Resident #3's face sheet, dated 05/28/26, reflected a [AGE] year-old female that was admitted to the facility on [DATE]. Resident #3 had diagnoses that included: urinary tract infection (a bacterial infection in any part of the urinary system (kidneys, bladder, or urethra), tremor (an involuntary, rhythmic muscle contraction and relaxation that causes shaking or trembling movements), Alzheimer's disease (a progressive, irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to carry out simple tasks), sleep apnea (a common disorder where breathing repeatedly stops and starts during sleep), chronic pain, irritable bowel syndrome (a common, long-term functional gastrointestinal disorder, characterized by recurring abdominal pain, cramping, bloating, and changes in bowel habits like diarrhea, constipation, or both), pain in right shoulder, overactive bladder (a sudden, uncontrollable urge to urinate), abnormal uterine and vaginal bleeding (any bleeding that is heavier, lasts longer, occurs between periods, or happens after menopause). Record review of Resident #3's Quarterly MDS assessment, dated 04/08/26, reflected the resident had BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #3 needed setup or clean-up assistance with eating and was dependent on staff for toileting hygiene. There was no information provided for assistance with showering/bathing. Record review of Resident #3's care plan, initiated 10/13/25, reflected Resident #3 had an ADL self-care performance deficit. The interventions included: bathing: requires staff x1 for assistance, bed Mobility: requires staff x2 for assistance, discuss with resident/family/POA care any concerns related to loss of independence, decline in function, dressing: required staff x1 for assistance, praise all efforts at self-care, PT/OT evaluation and treatment as per MD orders, the resident required a lift for all transfers, the resident used an electric wheelchair, toilet use: required staff x2 for assistance, transfer: the resident required 2 staff participation with transfers via the mechanical lift, encourage the resident to discuss feelings about self-care deficit, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance, monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function, bathing: check nail length and trim and clean on bath day and as necessary, dressing: assist the resident to choose simple comfortable clothing that maximizes the resident's ability to dress self. Record review of Resident #7's face sheet, dated 05/28/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE].Resident #7 had diagnoses that included: hemiplegia (complete paralysis) and hemiparesis (partial weakness or weakness) following cerebral infarction affecting left non-dominant side (damage occurred in the right hemisphere of the brain), muscle wasting, lack of coordination, restless legs syndrome, chronic pain syndrome, paraplegia (he partial or complete loss of motor and sensory function in the lower half of the body, including both legs, typically caused by spinal cord injury or disease), benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous enlargement of the prostate gland which lead to weak urine stream, frequent urination, nocturia, and urgency) and contracture of left and right knee. Record review of Resident #7's MDS assessment, dated 03/26/26, reflected the resident had a BIMS score of 12, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities reflected no information documented for showering/bathing. It further reflected Resident #7 needed setup or clean-up assistance with eating, dependent on staff with toileting hygiene, sitting to lying, lying to sitting on side of bed, chair/bed-to-chair transfer. Resident #7 was not ambulatory and used a manual wheelchair. Record review of Resident #9's face sheet, dated 05/28/26, reflected a [AGE] year-old female that was admitted to the facility on [DATE]. Resident #9 had diagnoses that included: multiple sclerosis (a chronic autoimmune disease that affects the central nervous system (brain, spinal cord, and optic nerves), paraplegia (partial or complete paralysis of the lower half of the body, including both legs), functional quadriplegia (the complete inability to move due to severe physical disability or frailty, completely independent of any physical injury or damage to the brain or spinal cord) weakness, difficulty walking, lack of coordination. Record review of Resident #9's Quarterly MDS assessment, dated 04/09/26, reflected the resident had a BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities reflected the resident was dependent on staff for toileting hygiene, sitting to standing, chair/bed-to-chair transfer, toilet transfer, substance assistance with sitting to lying, lying to sitting on side of bed and was independent with eating. The MDS assessment under Section GG-Functional Abilities Section GG-Functional Abilities also reflected oral hygiene, showering/bathing, upper and lower body dressing, personal hygiene, rolling left and right, tub/shower transfer and walking 10 feet were not applicable/not attempted. Record review of Resident #9's care plan, initiated 03/25/26, reflected the resident had an ADL self-care performance deficit. The interventions included: toilet use: require staff x2 for assistance, two person at all times during ADL care, dressing: the resident required (X2) staff participation to dress. During an interview on 05/27/26 at 10:43 AM, Resident #3 stated her bed linens were not always changed on her shower days. She stated at times there were no clean bed linens available on her shower days. She also stated staff would leave dirty linen in her room. During an interview on 05/27/26 at 11:47 AM, LVN B stated she worked from 6:00AM-6:00PM. LVN B stated she worked the long-term hall (rooms 25-39) and the memory care unit. LVN B stated housekeeping had been slacking with the laundry. LVN B stated at times there were no clean linens from 6:00AM-11:00AM and would come out around 11:00AM-12:00PM. She stated there recently were days that there were no bed linens or bath towels on the halls. She stated at times linens were limited meaning they did not have enough for all residents. LVN B stated not having clean linens affected when residents would shower and caused their showers to be late or delayed. During an interview on 05/27/26 at 12:10 PM, CNA C stated she worked Monday-Friday from 6:00AM-2:00PM. CNA C stated she worked on the memory care unit. She stated sometimes tasks fell behind because there was no clean linen which made her showers/baths late. She stated they did not have clean linens for residents' bed and bath towels. CNA C stated residents' shower days were when bed linens were changed. CNA C stated often they did not receive clean linens by 11:00AM from housekeeping. CNA C stated CNAs were supposed to have residents' beds made by 10:00AM. She stated there had been times when the clean linen came it was at the end of her shift. She stated there had been times when residents did not receive their personal items back from laundry in a timely manner. CNA C stated it was 2-3 days before residents had their personal items returned from laundry. She stated it affected the residents with their baths if there was no clean linen. During an interview on 05/27/26 at 12:42 PM, Housekeeping Supervisor stated there had been issues with having clean linens available. The Housekeeping Supervisor stated the issue was that the CNAs were not returning the dirty linen in timely manner. She stated the nursing staff would drop dirty laundry at the end of their shifts making it hard for her staff to have it completed. The Housekeeping Supervisor also stated nursing staff had thrown away towels. She stated her laundry tech has had to go on the halls to find the barrels because they are not brought to laundry but nursing staff. The Housekeeping Supervisor stated she recently placed an order placed on 05/04/26 for more linens. The Housekeeping Supervisor stated there was no policy for laundry, but her expectations were to have the linen out by 8:00AM, 12:00PM and before leaving at 2:00PM. The Housekeeping Supervisor stated the residents not having cleaned linens could affect their level of comfort. During an observation on 05/27/26 at 12:55 PM, there were linens in the storage. In the storage, there was one pack of pillowcases, one case of wash clothes, 3 packs of wash clothes, one case of sheets, two cases of flat sheets with a quantity of 10 in each, and two packs of dry towels with a quantity of 12 in each pack. During an interview on 05/27/26 at 1:52 PM, CNA D stated she worked 6:00AM-2:00PM on both north and south hall. CNA D stated at times there were no clean linens. CNA D stated on 05/26/26 she did not have clean linen until she got it 9:30AM. She stated laundry was supposed to bring the linens on the halls. CNA D stated she felt part of the issue was that some nursing staff hid the towels and did not take the barrels with dirty linen as quickly. She stated part of problem was that the CNAs waited until the barrels overfilled to bring them to laundry. CNA D stated the barrels should be brought to laundry prior to it overfilling. She stated not having clean linen caused the residents to wait longer for showers. During an interview on 05/27/26 at 3:01 PM, Resident #9 stated at times there had been no clean linen, and she was unable to take her shower. Resident #9 stated she has had to purchase towels to take her showers. During an interview on 05/28/26 at 12:36 PM, Resident #7 stated his bed sheets were not changed on his bath days. Resident #7 stated he preferred his sheets changed every time he was given a bath. Resident #7 stated if he was lucky, staff would change his linens on his bed once a week. During an interview on 05/28/26 at 1:25 PM, CNA E stated prior to the week of 05/25/26, there had been issues with receiving clean linen. CNA E stated she showered her residents after breakfast between 9:00AM-10:00AM. She stated at times she did not have clean towels when it was time to start her showers. CNA E stated sometimes she had to shower after lunch due to waiting on clean towels. She also stated she ran out of clean linen quickly and had to wait hours to get more. CNA E stated when they had to wait on linens, she would have to stay late to complete her residents' showers. CNA E stated some of the bed linen would be clean but not all. She stated the fitted sheets may have been cleaned but there were no clean flat sheets. CNA E stated her thoughts were nursing staff did not take the barrels down immediately to be cleaned or wait until end of shift to bring them. During an interview on 05/28/26 at 2:21 PM, CNA F stated she worked Monday-Friday on 2:00PM-10:00PM shift. CNA F stated there were times she came in for her shift and there were no clean linens. CNA F stated on 05/14/26 there was no laundry person, and the Housekeeping Supervisor left work, so there was no clean linen available. CNA F stated not having clean linen affected the residents with their showers. CNA F stated she had some residents that were heavy wetters, so she had to remove their linens but there were no clean linens available. During an interview on 05/28/26 at 5:20 PM, LVN A stated there had been issues with laundry. LVN A stated the linens were not always available when needed. LVN A stated there had been no clean towels when it was time for residents to shower. LVN A stated it delayed the residents' showers. During an interview on 05/28/26 at 6:20 PM, the DON stated there was an issue with linens about a month ago. The DON stated residents had delayed showers or bed baths due to waiting on clean linen to return from laundry. She stated the risk was that the residents were not able to be showered without clean linen. Record review of the facility's policy titled, Resident Rights, no date, reflected in part the following: Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide--A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;Clean bed and bath linens that are in good condition;Private closet space in each resident room, as specified Adequate and comfortable lighting levels in all areas;Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 F; andFor the maintenance of comfortable sound levels.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #1 and Resident #2) of 8 residents reviewed for call lights. The facility failed to ensure Resident #1 and Resident #2 had call lights within reach while in their beds on 05/27/2026. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency. Findings included: Record review of Resident #1's face sheet, dated 05/28/26, reflected a [AGE] year-old female that was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included: legal blindness, lumbar spondylolysis (stress fracture or structural defect in the small bridge of bone connecting upper and lower joints of the lower back) and osteoarthritis (degenerative joint disease where the protective cartilage cushioning the ends of bones wear down over time). Record review of Resident #1's MDS assessment, dated 02/27/26, reflected the resident had a BIMS score of 12, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 was dependent on staff for personal hygiene, putting off footwear, lower body dressing, showering/bathing and toileting, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfer and shower transfer. It further reflected the resident needed supervision with eating and rolling left and right. Resident #1 also used a manual wheelchair to get around. Record review of Resident #1's care plan, revised on 10/11/24, reflected the resident was at risk of falling due to a history of falls, daily use of antianxiety, antipsychotic and antidepressant medications, diuretic medications, blindness, cognitive loss and dementia, weakness from current dialysis treatments and need for staff assistance with ADL tasks. The interventions were to keep call light within reach of resident and tell her the location of the call light due to blindness, cue and encourage resident to use the call light for assistance. The care plan also revealed Resident #1 was at risk for the development of pressure ulcers due to need for staff assistance with toileting, transfers and bed mobility. The interventions were to encourage resident to use call light for assistance with toileting tasks and answer call light promptly. Record review of Resident #2's face sheet, dated 05/28/26, reflected a [AGE] year-old female that was originally admitted to the facility on [DATE]. Resident #2 had diagnoses which included: osteoarthritis (degenerative joint disease where the protective cartilage cushioning the ends of bones wear down over time), seizures, unsteadiness on feet, muscle wasting, difficulty walking, lack of coordination and rheumatoid arthritis (chronic autoimmune disorder when immune systems malfunctions and attacks the lining of the joints). Record review of Resident #2's MDS assessment dated [DATE], reflected the resident had a BIMS score of 15, which indicated cognitively intact. The MDS assessment under Section GG-Functional Abilities, reflected Resident #2 needed supervision or touching assistance with eating, toileting, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfer and toilet transfer. Resident #1 also used a manual wheelchair to get around. Record review of Resident #2's care plan, revised on 05/05/22, reflected the resident had the potential for falls related to medications, poor safety awareness, unsteady balance and cognitive deficit. The interventions were to anticipate and meet the resident's needs, place items frequently used by the resident within easy reach when in the room, place the resident's call light within reach and encourage the resident to use it for assistance as needed. The care plan also revealed Resident #2 had an ADL self-care performance deficit related to: activity intolerance, confusion, dementia, fatigue, an impaired balance at risk for decline in ADL function. The interventions also consisted of Resident #2's care plan also revealed the resident had a fall related to deconditioning (decline in physical function of the body). The interventions were to anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, call do not fall sign in bathroom. During an observation and interview on 05/27/26 at 2:41 PM, Resident #1 was observed lying in bed and her call light was wrapped around bedrail with the call button facing the floor. Resident #1 attempted to reach for the call light but was unsuccessful. Resident #1 stated she could not reach for her call button at the time. Resident #1 stated she needed help with all ADLs. During an observation and interview on 05/27/26 at 2:50 PM, Resident #2 was observed lying in bed and her call light on the floor behind her oxygen tank. Resident #2 stated she could not reach her call light because it was not near her. Resident #2 also stated she needed assistance with most of her ADLs. During an interview on 05/27/26 at 2:55 PM, LVN A was informed of Resident #1's and Resident #2's call lights being out of reach. LVN A checked and observed that the call lights for Resident #1 and Resident #2 were not within reach. He stated the residents' call lights needed to be within reach to call for help. He also stated staff should be checking for call light placement when making rounds. LVN A stated the risk were that the residents could not call for help. During an interview on 05/28/26 at 1:25 PM, CNA E stated she worked 6:00AM-2:00PM with four days on and two days off. CNA E stated she was the CNA working with Resident #1 and Resident #2 on 05/27/26. CNA E stated she forgot to place Resident #1's call light within reach. CNA E stated she had gotten distracted due to Resident #1's family member being in the room. CNA E stated she did not put Resident #2 in bed but was ultimately responsible for ensuring the call light was within reach. CNA E stated the risk with the call light not being within reach was the resident not being able to call for help. A policy on call lights was requested on 05/27/26. The Administrator stated the facility did not have a call light policy. Respect and dignity - The resident has a right to be treated with respect and dignity, including:The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on observations, interviews, and record review, the facility failed to ensure the right for residents to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #4, #7, #9, and #10) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #4, #7, #9, and #10's room were in a position that was accessible to the resident on 04/22/2026.This failure could place the residents at risk of not obtaining assistance when needed and help in the event of an emergency.Findings include: Record review of Resident #4's Face Sheet, dated 04/22/26, reflected an [AGE] year-old female, admitted [DATE]. Resident #2 was diagnosed with fractures of the ribs, neck, and femur. Record review of Resident #4's MDS Assessment, dated 3/27/26, reflected the resident had a BIMS of 7, indicating severe cognitive impairment. The resident had an active diagnosis of fractures of the neck, and femur. The resident's ADL indicated she received maximum assistance with toileting and showering care. Record review of Resident #4's Comprehensive Care Plan, dated 10/01/25, reflected the resident was a fall risk and an intervention was to ensure call light was within reach.During an observation and interview on 04/22/26 at 11:30 a.m., Resident #4 was observed lying in bed and her call light was on the floor near the nightstand. Resident #4 stated she needed help with repositioning herself but did not know where her call light was. During an observation and interview on 04/22/26 at 11:33 a.m., CNA T observed Resident #4's call light lying on the floor and out of the resident's reach. She stated the resident needed the call light to be within her reach so she could call for help. During an interview on 04/22/26 at 12:06 a.m., LVN E was informed by the Investigator of Resident #4's call light being out of reach and her fall mat not placed alongside her bed. She stated the resident's call light needed to be within reach to contact someone for help and the resident should have a fall mat placed alongside her bed because she was a fall risk. She stated staff should be checking for this when making rounds. Record review of Resident #7's Face Sheet, dated 04/22/26, revealed a [AGE] year-old female who was admitted [DATE]. Diagnoses included Vascular Dementia (a decline in thinking, memory, and behavior caused by conditions that block or reduce blood flow to the brain, depriving brain cells of oxygen and nutrients) and repeated falls.Record review of Resident #7's active care plan, dated 03/05/26, revealed the resident was at risk for falls with intervention to 1) Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, 2) the resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach).Record review of Resident #7's Quarterly MDS assessment, dated 03/09/26, revealed the resident had repeated falls prior to admission in the last month. Record review of Resident #9's Face Sheet, dated 04/22/26, revealed a [AGE] year-old female admitted [DATE]. Diagnoses included legal blindness, as defined in the USA and Generalized Anxiety Disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life).Record review of Resident #9's care plan dated 04/08/26 revealed the resident was a risk for falls with intervention to 1) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, 2) the resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach).Record review of Resident #9's Quarterly MDS assessment, dated 04/02/26, revealed no fall diagnosis nor did the resident have an application for fall intervention.Record review of Resident #10's Face Sheet, dated 04/22/26, revealed a [AGE] year-old female, admitted [DATE]. Diagnosis included Lack of coordination (The inability of different parts of a system or body to work together effectively), difficulty walking, anxiety disorder.Record review of Resident #10's active care plan dated 03/10/26 revealed the resident is a risk for falls with intervention to 1) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, 2) the resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach).Record review of Resident #10's Quarterly MDS assessment, dated 03/04/26, revealed the resident has had no falls prior to admission to the facility.During an observation on 04/22/26 at 9:07 a.m., Resident #7 was observed lying in her bed. The resident call light was observed on the floor lying on the left side of her nightstand and out of her reach.During an observation on 04/22/26 at 9:07 a.m., Resident #9 was observed lying in her bed. The resident call light was observed on the floor lying behind the headboard and out of her reach.During an observation on 04/22/26 at 9:07 a.m., Resident #10's resident call light was observed on the floor next to her bed and out of her reach.During an interview on 04/22/26 at 1:00 p.m., LVN E stated the call light should be within reach of every resident and readily available for them to call for help. She stated that the risk of not having the call bell within reach was falls. LVN E stated the resident may not be able to call for hydration and help to the restroom when neededDuring an interview on 04/22/26 at 1:13 p.m., ADON K stated the call bell should be within reach whether the resident was in bed or in the wheelchair. He stated that all staff were responsible for making sure the call bell was within reach of all residents. He stated that since the residents were dependent on staff it could place them at risk of not receiving needed care.During an interview on 04/22/26 at 1:23 p.m., CNA U stated that the call bell should always be within reach for all residents and should be responded as soon as possible when the resident calls. She stated that the risk of not having the call bell within reach is possible falls and the residents need not being met in a timely manner. During an interview on 04/22/26 at 1:45 p.m., CNA V stated that the call bell should always be within reach, and that all staff should make sure it is within reach before leaving residents' room. She stated that the risk of not having the call bell within reach could result in falls, and inability to get to the in a timely manner. She also stated that if the residents are unable to reach the call bell, they could get upset and start yelling leading to behaviors that could also upset other residents. During an interview on 04/22/26 at 3:42 p.m., the DON stated the call bell should be withing reach of every resident per the facility policy. She stated that all staff was responsible for making sure that the call bells are within reach of every resident. She stated that the risk of not having the call bell within reach of the resident could result in a fall and possible injury. Review of the facility's policy on Call Light/Bell (08/03/21) revealed It is the policy of this facility to provide the resident a means of communication with nursing staff. 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor.

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 three of twelve (Resident #1, #2, and #6) reviewed for respiratory care. The facility failed to ensure Resident #1 had his nebulizer mask bagged when not in use on 04/22/26. The facility failed to ensure Resident #2's nasal cannula was bagged when not in use on 04/22/26.The facility failed to ensure Resident #2 had physician orders for use of the oxygen concentrator. The facility failed to ensure Resident #6's nasal canula was properly stored in a bag when not in use on 04/22/26 These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with congestive heart failure.Record review of Resident #1's Comprehensive MDS Assessment, dated 4/17/26, reflected Resident #1 had a BIMS score of 14 indicating intact cognition. The Comprehensive MDS Assessment indicated the resident had an active diagnosis of acute respiratory failure (lack of oxygen).Record review of Resident #1's Physician Order, dated 04/22/26, reflected no physician orders for the use of the nebulizer device. During an interview and observation on 04/22/26 at 8:59 a.m., Resident #1 was lying in bed, and his nebulizer mask was on top of the nightstand unbagged. He stated he had not used the nebulizer since last night.Record review of Resident #2's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with congestive heart failure and COPD (difficulty breathing).Record review of Resident #2's Comprehensive MDS Assessment, dated 4/13/26, reflected Resident #2 had a BIMS score of 15, indicating intact cognition. The Comprehensive MDS Assessment indicated Resident #2 had an active diagnosis of acute respiratory failure and COPD.Record review of Resident #2's Physician Order, dated 04/22/26, reflected no physician orders for the use of the oxygen device. During an interview and observation on 04/22/26 at 9:00 a.m., Resident #2 was lying in bed with the nasal cannula for the oxygen concentrator on the floor and unbagged. Resident #2 stated she had complications with the nasal cannula a few days ago because it had gotten fluid on it and it was hurting her nose Resident #2 stated she was trying to get the nasal cannula replaced but staff had not responded to her yet. Resident #2 stated she had not used it for a few days and really needed it to help with breathing.During an interview and observation on 04/22/26 at 9:05 a.m., LVN E went to Resident #1's and Resident #2's room and observed the breathing devices unbagged. LVN E stated they needed to be bagged to avoid the residents getting an infection.During an interview on 04/22/26 at 1:00 p.m., the DON and ADON J were informed by the Investigator of Resident #1 and Resident #2 breathing devices being unbagged. They stated it was everyone's responsibility to ensure the breathing devices were bagged when not in use. They stated not bagging the devices could result in the residents getting an infection. During an interview on 04/22/26 at 2:05 p.m., ADON J was informed by the Investigator of Resident #2 not having an active physician order for use of an oxygen concentrator until after LVN [NAME] was interviewed about the resident's nasal cannula being unbagged. She stated the resident should have had physician orders because it was a form of medication provided to the resident.During an interview on 04/22/26 at 2:10 p.m., the DON was informed by the Investigator of Resident #2 not having physician orders for oxygen use until 04/22/26. She stated the resident should have had physician orders for the use of oxygen because it was medication being administered to the resident. She stated the admitting charge nurse should check for orders.During an interview on 04/22/26 at 2:30 p.m., LVN E was informed by the Investigator of Resident #2 not having physician orders for the use of the Oxygen concentrator until 04/22/26. She stated she checked the resident's physician orders and realized the resident did not have orders. She stated she was able to contact the physician and get orders for the resident. She stated orders were needed for the resident because it was needed to treat the resident.Record review of Resident #6's Face Sheet, dated 04/22/26, revealed she was an [AGE] year-old female admitted [DATE]. Resident #6 diagnoses included Acute Kidney Failure (a sudden, temporary loss of kidney function, often occurring within hours or days) and Fracture of left Femur (a broken or cracked bone in the left thighbone).Record review of Resident #6's active physician order, dated 04/16/26, did not reveal an order for oxygen use or care.Record review of Resident #6's active care plan, dated 03/05/26, revealed a diagnosis of COPD with intervention to give oxygen therapy as ordered by the physician.Record review of Resident #6's Quarterly MDS assessment, dated 04/03/26, reflected a BIMS score of 00 (severe cognitive impairment). Resident #6's diagnosis included COPD. During an observation on 04/22/26 at 9:05 a.m., Resident #6's nasal cannula was lying on the floor unbagged.During an interview on 04/22/26 at 1:00 p.m., LVN E stated all oxygen nasal cannulas should be bagged when not in use. She stated all staff were responsible for making sure the nasal cannulas were bagged when not in use. She stated not bagging the nasal cannulas could result in respiratory infection and possible respiratory distress.During an interview on 04/22/26 at 1:13 p.m., ADON K stated oxygen nasal cannulas should be always bagged when not in use. He stated the resident could develop a respiratory infection if the nasal cannulas were exposed and collects germs. During an interview on 04/22/26 at 1:23 p.m., CNA U stated oxygen nasal cannulas should always be bagged when not in use and every staff member was responsible for making sure it was bagged or reported to the charge nurse to bag it. She stated that if not bagged the resident could develop an infection if the nasal cannula was contaminated and used on the resident, bugs could possibly crawl into the nasal cannula, which would not be good for the resident. During an interview on 04/22/26 at 1:45 p.m., CNA V stated the nasal cannulas should be bagged when not in use. She stated not bagging the nasal cannula could result in cross contamination, infection, and possibly the resident tripping over the tubing.During an interview on 04/22/26 at 3:42 p.m., the DON stated the nasal cannula should be bagged when not in use per the facility policy. She stated the risk of not having the nasal cannula bagged was bacteria getting on it that could cause an infection. Record review of the facility's policy titled, Oxygen Administration, dated 02/13/07, reflected Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40 % oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident=s bed or concentrator. All sources require humidification to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained as free of hazards as was possible for one of six residents (Resident #4) reviewed for accident hazards. The facility failed to ensure Resident #4 had fall mat placed alongside her bed for fall prevention. This failure could place residents at risk for potential injury. Findings included: Record review of Resident #4's Face Sheet, dated 04/22/26, reflected an [AGE] year-old female, admitted [DATE]. Resident #2 was diagnosed with fractures of the ribs, neck, and femur. Record review of Resident #4's MDS Assessment, dated 3/27/26, reflected the resident had a BIMS of 7, indicating severe cognitive impairment. The resident had an active diagnosis of fractures of the neck, and femur. The resident's ADL indicated she received maximum assistance with toileting and showering care. Record review of Resident #4's Comprehensive Care Plan, dated 10/01/25, reflected the resident was a fall risk and an intervention was to utilize the fall mat to provide cushion to landing area. During an observation on 04/22/26 at 11:30 a.m., Resident #4 was observed lying in bed and the resident's fall mat was leaning against a wall and not placed alongside the resident's bed.During an observation and interview on 04/22/26 at 11:33 a.m., CNA T observed Resident #4's fall mat leaning against the wall and not placed alongside the resident's bed. She stated the resident was a fall risk and should have her bed in a low position with the fall mat placed alongside her bed. She stated if the resident fell out of bed, the low bed and fall mat would limit her injuring herself. During an interview on 04/22/26 at 12:06 a.m., LVN E was informed by the Investigator of Resident #4's fall mat not placed alongside her bed. She stated the resident should have a fall mat placed alongside her bed because she was a fall risk. She stated the resident's bed was to be in a low position and fall mat in place to prevent the resident from having a severe injury if she fell out of bed. She stated staff should be checking for this when making rounds.During an interview on 04/22/26 at 1:00 p.m., the DON and ADON J was informed by the Investigator of Resident #4's fall mat not placed alongside her bed. They stated the resident was a fall risk and an intervention was to have a fall mat placed alongside her bed. They stated staff were responsible for checking to ensure the resident area was setup for fall prevention when she is in bed. Record review of the facility's policy titled, Resident Rights, dated 02/21, reflected Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be treated with respect and dignity for 2 of 4 residents (Resident #3 and #6) reviewed for dignity.Med Aide G was observed standing over Resident #1 feeding her while the resident was sitting in his wheelchair and not at eye level.The facility failed to ensure Resident #6's indwelling urinary catheter bag had a dignity/privacy bag/screen on 04/22/26.These failure could place residents at risk of not feeling not treated with dignity, privacy, and respect.Findings include:Record review of Resident #3's Face Sheet, dated 04/22/26, reflected a [AGE] year-old male admitted [DATE], diagnosis included difficulty swallowing.Record review of Resident #3's Quarterly MDS assessment, dated 04/19/26, reflected a BIMS score of 00 (severe cognitive impairment). The resident had an active diagnosis of difficulty swallowing. Record review of Resident #3's Comprehensive Care Plan, dated 04/17/26, reflected the resident had a nutritional problem; however, there was no intervention indicating the resident required assisted feeding. During an observation on 04/22/26 at 12:50 p.m., Medication Aide G was observed in the dining room feeding Resident #3 while he was sitting in his wheelchair. Medication Aide G was standing over him while feeding him and not sitting down at eye level of the resident.During an interview and observation on 04/22/26 at 12:51 p.m., LVN S and LVN E were observed watching Medication Aide G standing over Resident #3 while feeding him. They stated the medication aide was new and still in training. They stated the Med Aide should be sitting down at eye level feeding the resident. They stated it was a dignity issue and to ensure the residents did not choke. LVN S went over to Med Aide G and instructed her to sit down and feed the resident. During an interview on 04/22/26 at 1:00 p.m., the DON and ADON J were informed by the Investigator of Medication Aide G standing over Resident #3 while she was feeding him. They stated staff were to sit at eye level with the resident when feeding the resident. They stated it was for the residents' dignity and to ensure they did not choke.During an interview on 04/22/26 at 1:50 p.m., Medication Tech G stated she knew she should be sitting down when feeding Resident #3, but she was trying to monitor the entire dining area to ensure other residents did not choke. She stated they were to sit down at eye level to feed the resident but thought it was okay to stand.Record review of Resident #6's Face Sheet, dated 04/22/26, revealed she was an [AGE] year-old female admitted [DATE]. Diagnoses included Acute Kidney Failure (a sudden, temporary loss of kidney function, often occurring within hours or days), Fracture of left Femur (a broken or cracked bone in the left thighbone).Record review of Resident #6's active physician order, dated 04/16/26, revealed orders for Indwelling urinary catheter (a soft, flexible, hollow tube that is inserted into the bladder through the urethra to drain urine into a collection bag) 16 French (size of Foley catheter) with 5 ml bulb - change for occlusion, leaking, closed system was compromised Change foley catheter on the 15th of each month as Needed and Ensure foley bag is in privacy bag while in bed or wheelchair every shift.Record review of Resident #6's active care plan revealed no care plan problem goals, or intervention related to the resident's Indwelling urinary care. Record review of Resident #6's Quarterly MDS assessment, dated 04/03/26, reflected a BIMS score of 00 (severe cognitive impairment). Resident #6's diagnoses included Acute Kidney Failure (a sudden, temporary loss of kidney function, often occurring within hours or days), Fracture of left Femur (a broken or cracked bone in the left thighbone).During an observation on 04/22/26 at 9:05 a.m., Resident #6 was observed lying in bed, her catheter bag could be observed from the hallway hanging from her bed, and no privacy bag was covering it.During an interview and on 04/22/26 at 1:00 p.m,. LVN E stated the resident should have a privacy bag to always cover the catheter drainage bag as ordered by the physician. She stated it was the nursing staff's responsibility to ensure the resident had a privacy bag. She stated that the purpose of the privacy bag was to maintain the resident's dignity and privacy. She stated the risk of not having the drainage bag covered was a loss of dignity and self-respect for the residents. During an interview on 04/22/26 at 1:13 p.m., ADON K stated the resident should always have a privacy bag for her Foley catheter drainage bag, he stated they usually provide 2 privacy covers, one for when the resident was in bed and one for when they were out of bed. He stated that the purpose of the privacy covers were to maintain privacy of treatment and dignity. He stated that the risk of not having a privacy bag could result in a loss of dignity.During an interview on 04/22/26 at 1:23 p.m., h CNA U stated the foley catheter privacy bag should always be on. CNA U stated, I would be embarrassed if someone is looking at my urine. She stated that not having a privacy cover could result in a loss of dignity for the residents. During an interview on 04/22/26 at 1:45 p.m., the DON stated that the foley catheter drainage bag should be in place at all times, she stated it was the responsibility of all nursing staff to make sure that they are always in place. She stated that not having the privacy cover on will result in a loss of dignity and privacy violation. Record review of the facility's policy titled, Resident Rights, dated 07/13/2017, revealed, As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. A facility must 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, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Privacy and confidentiality - The resident has a right to personal privacy and confidentiality of his or her personal and medicalrecords.1. 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.2. The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is,spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and otherletters, packages and other materials delivered to the facility for the resident, including those delivered through a means otherthan a postal service.3. The resident has a right to secure and confidential personal and medical records.a. The resident has the right to refuse the release of personal and medical records except as provided at S483.70(i)(2)or other applicable federal or state laws.b. The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine aresident's medical, social, and administrative records in accordance with State law.

Based on interviews, and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #5) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #5 received her scheduled showers since admission on [DATE]. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings include: Record review of Resident #5's Face Sheet, dated 04/22/26, reflected a [AGE] year-old female admitted [DATE]. Resident #5 had a diagnosis of morbid obesity. Record review of Resident #5's MDS Assessment, dated 3/28/26, reflected the resident had a BIMS score of 13, which was an intact cognitive response. The MDS Assessment reflected the resident had active diagnosis of morbid obesity. The resident required maximum assistance for ADL care. Record review of Resident #5's Comprehensive Care Plan, dated 3/27/26, reflected the resident had an ADL self-care deficit and the resident was totally dependent on staff to provide ADL care. There was no mentioning of the resident refusing showers.Record review of Resident #5's Progress notes from 03/26/26 to 04/22/26 reflected no documentation of resident refusing showers.Record review of Residents' shower sheets for March 2026 to April 2026 revealed no shower sheets on file for Resident #5.During an interview on 04/22/26 at 12:21 p.m., Resident #5 stated she had been at the facility for a month and had only had one shower and one bed bath. She stated she had never refused a shower and would prefer a shower rather than a bed bath. Resident #5 stated staff always told her there was an issue with the Hoyer lift. She stated she could not recall when she received a shower and she stated she received a bed bath this past weekend. She stated she really wanted her hair washed. During an interview on 04/22/26 at 12:30 p.m., LVN B stated Resident #5 had just moved to the south hall last week. He stated he was not familiar with the resident. He was informed by the Investigator that the resident stated she had only received one shower and one bath since being at the facility. He stated the resident should have a shower sheet completed each time she received a shower and if she refused, the floor nurse should attempt to persuade the resident to shower.During an interview on 04/22/26 at 1:00 p.m., the DON and ADON J were informed by the Investigator of Resident #5 stating she had only received one shower and one bed bath since being admitted to the facility on [DATE]. They stated the resident was scheduled to receive her showers on Tuesday, Thursday, and Saturdays by the evening CNA. They stated the CNAs were to complete shower sheets for each resident and the sheets were to be signed off by the charge nurse. The DON stated if the resident refused a shower, the nurse was to attempt to persuade the resident to take a shower, and if they still refused, they were to contact the RP and attempt to encourage them to take a shower. They stated if the resident did not receive their shower it could cause skin breakdown.During an interview on 04/22/26 at 2:00 p.m., CNA S stated he provided the resident with a bed bath on 04/18/24. He stated he completed a shower sheet but did not give it to the charge nurse. He stated he had just placed it in a basket. He stated he and his co-worker had trouble using the Hoyer lift because the shower chair was too small, and the resident was not comfortable with the transfer. He stated this was the first time he provided a bed bath or shower to the resident and did not know why she had not received her showers. He stated the risk of the resident not getting her showers could result in an infection. Record review of the facility's policy on Bath, Tub/Shower, undated , revealed, Bathing by tub or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body order promote comfort, cleanliness, circulation, and relaxation. A medicated tub bath can also be provided to treat skin conditions. The aging skin becomes dry, wrinkled, thinner, and blemished with various aging spots over time and is easily affected by environmental temperature and humidity, sun exposure, soaps, and clothing fabrics. The frequency and type of bathing depends on resident preference, ski condition , tolerance, and energy level. Although the daily bath or shower is preferred nd necessary for some , the aging skin can be maintained by bathing every wo days or with partial bathing as needed.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services in accordance with currently accepted professional principles for three (Residents #44, #48, and #62) of twelve residents reviewed for pharmaceutical services. The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Hydrocodone to Resident #44 on 02/11/2026.The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Clonazepam to Resident #48 on 02/11/2026.The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Pregabalin to Resident #62 on 02/11/2026.This failure could place residents at risk of not receiving their medications as ordered by their physician. Findings include:Resident #44Record review of Resident #44's Face Sheet, dated 02/12/2026, reflected a [AGE] year-old male who admitted on [DATE]. He was diagnosed with unspecified pain. Record review of Resident #44's Comprehensive MDS Assessment, dated 11/25/2025, reflected moderately impaired cognition with a BIMS score of 08. Section N (Medications) indicated the resident received opioid medication. Record review of Resident #44's Comprehensive Care Plan, dated 11/19/2025, reflected the resident had the potential for uncontrolled pain. An intervention was to administer medication as ordered and evaluate the effectiveness.Record review of Resident #44's Physician's Order, dated 03/11/2025, reflected Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give 1 tablet by mouth every 4 hours for severe pain.Record review of Resident #44's Medication Administration Record revealed MA C documented administration of the 7:00 AM dose of Hydrocodone-Acetaminophen on 02/11/2026.Record review of the controlled medication logbook on MA C's medication cart, on 02/11/2026, did not reflect Resident #44's 7:00 AM dose of Hydrocodone-Acetaminophen was given on 02/11/2026.Resident #48Record review of Resident #48's Face Sheet, dated 02/12/2026, reflected a [AGE] year-old male who admitted on [DATE]. The resident was diagnosed with anxiety disorder. Record review of Resident #48's Comprehensive MDS Assessment, dated 01/05/2026, reflected the resident intact cognition with a BIMS score of 15. Section N (Medications) indicated the resident received anti-anxiety medication. Record review of Resident #48's Comprehensive Care Plan, dated 12/04/2025, reflected the resident received anti-anxiety medication. An intervention was to give the medication as ordered by the physician and monitor/document side effects and effectiveness. Record review of Resident #48's Physician Order, dated 03/06/2025, reflected Clonazepam) oral tablet 0.5 mg. Give 1 tablet by mouth two times a day for anxiety.Record review of Resident #48's Medication Administration Record revealed MA C documented administration of the morning dose of Clonazepam on 02/11/2026.Record review of the controlled medication logbook on MA C's medication cart, on 02/11/2026, did not reflect Resident #48's morning dose of Clonazepam was given on 02/11/2026.Resident #62Record review of Resident #62's Face Sheet, dated 02/12/2026, reflected a [AGE] year-old female who admitted on [DATE]. The resident was diagnosed with neuropathy (a condition that affects nerve signals and causes pain or numbness). Record review of Resident #62's Comprehensive MDS Assessment, dated 12/11/2025, reflected the resident had intact cognition with a BIMS score of 13. Section N (Medications) indicated the resident received an anti-convulsant medication (used to treat neuropathy). Record review of Resident #62's Comprehensive Care Plan, dated 12/08/2025, reflected the resident had the potential for uncontrolled pain. An intervention was to administer medication, monitor for side effects, and evaluate the effectiveness of the pain intervention. Record review of Resident #62's Physician Order, dated 04/10/2024, reflected Pregabalin oral capsule 100 mg. Give 1 capsule by mouth three times a day for neuropathy. Record review of Resident #62's Medication Administration Record revealed MA C documented administration of the 8:00 AM dose of Pregabalin on 02/11/2026.Record review of the controlled medication logbook on MA C's medication, on 02/11/2026, cart did not reflect Resident #62's 8:00 AM dose of Pregabalin was given on 02/11/2026.During an observation and interview on 02/11/2026 at 8:03 AM, ADON B observed the surveyor review MA C's medication cart for medication storage and labeling. ADON B stated MA C had gone to the dining room to help with breakfast. The controlled medications were in a separate locked box inside the medication cart. When comparing the medication count on the card of pills to the logbook, it showed the pill count was off by 1 when reviewing medication for Residents #44, #48, and #62. ADON A called MA C to the medication cart. MA C verified that she had given the medication but was called to the dining room before she could document the medication in the logbook. She opened the laptop on her medication cart to show she had documented giving the medications as ordered. MA C stated she was supposed to sign the book when she pulled medication from the locked box and gave it to the residents. She stated it was important to do it immediately to avoid a discrepancy. She stated it was also a way to verify what she actually gave and the time she gave it. ADON B stated it was important to document the dose when you pulled the medicine to ensure the medication count was accurate and reflected the correct time the resident received the medication. During an interview on 02/12/2026 at 10:17 AM, the DON stated it was important to document controlled medication in the logbook so everyone knew what was given. She stated even if the medication was documented on the residents' medication administration record, the best practice was to sign out the medication when you pulled it and gave it to the resident. She stated they had begun in-service training. Record review of the facility's policy Controlled Medications - Administration, undated, reflected Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulation.When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration Amount Administered Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure all food items in the facility kitchen were dated and discarded prior to their use-by date.The facility failed to ensure all canned items in the dry storage area were dated and discarded prior to their use-by date. These failures could place residents at risk for food contamination and food-borne illness.Finding included: During observation(s) on 02/10/2026 and 02/11/2026 between 9:15 AM and 9:50 AM in the facility's kitchen revealed: One Gallon size freezer bag containing several small plastic cups of ketchup, located in the refrigerator with a preparation date of 02/02/2026 and a use-by date of 02/09/2026. One Gallon size freezer bag containing several small plastic cups of orange colored sauce located in the refrigerator with a preparation date of 02/02/2026 and a use-by date of 02/09/2026. One Gallon size freezer bag containing several small plastic cups of shredded cheese, located in the refrigerator with a date of 02/03/2026 and a use-by date of 02/10/2026 Eight loaves of bread in the bread pantry with a best by date of 01/26/2026.Eight cans of peppers in the bread pantry dated 10/08/2024 with a best by date of December 2025. During an interview on 02/12/2026 at 1:00 PM the FSS stated she has been the FSS for about 5 months. The FSS stated she was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. The FSS stated she confirmed the surveyor observations. The FSS confirmed she was responsible for kitchen sanitation and proper storage of food products and that these ere oversights. She stated the risk of all these concerns observed in the kitchen could result in residents getting sick. The FSS stated the risk of the concerns not being addressed could result in food-borne illnesses. The labeling and dating were done by any of the staff who gets it in from the delivery, further it was their responsibility to label it and place it properly. During an interview on 02/12/2026 at 1:15 PM, the ADMIN stated he oversaw all departments, and ensured residents were taken care of. The ADMIN said the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. He said the risk to residents if policy were not followed was, they could get sick from food borne illnesses. The ADMIN stated he expected staff to ensure they were following policies and procedures of the facility kitchen policy, to protect residents and to deliver good care. The ADMIN stated the risk of these concerns not being addressed could result in food contamination and residents becoming ill. The Administrator stated if foods were not discarded properly, sanitized properly, or heated properly, there was the potential for foodborne illness.Record review of the facility's Dietary Services Policy & Procedure Manual, dated 2012, indicated 6 When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. Any product with a stamped expiration date will be discarded once that date passes. 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor, or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten food spoilage is observed prior to the best by date, the product will be discarded.Record review of the U.S. Food and Drug Administration (FDA ) Code (2022) revealed, Packaged Food shall be labeled as specified in law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 7 (Resident #10, Resident #12, Resident #49, Resident #56, Resident #63, Resident #64, and Resident #80) of 8 resident rooms observed and reviewed for grab/assist bars. The facility failed to have evidence of informed consent for Resident #12, Resident #49, Resident #56, Resident #63, Resident #64, and Resident #80, for grab/enabler bars (smaller bars used by the person in bed to reposition themselves) to be placed on the bed. The facility failed to have evidence of assessment for Resident #10, Resident #12, Resident #49, Resident #56, Resident #64, and Resident #80, for risk of entrapment and ability to safely use the grab/enabler bars. The facility failed to follow assessment recommendations for Resident#10 and Resident #62 which indicated the residents were not appropriate for grab/assist bars. These failures could affect residents who used grab/assist bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, and assessments not being completed for appropriateness. Findings include:Record Review of Resident #10's admission Record dated 02/11/2026 revealed a [AGE] year-old female who had originally admitted to the facility on [DATE] with most recent admission on [DATE]. Resident #10 was noted to have diagnoses including Difficulty in Walking, Unsteadiness on Feet, Other Lack of Coordination, Major Depressive Disorder (mental health disorder characterized by persistent, intense sadness or loss of interest), Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), Alzheimer's Disease (progressive, irreversible disorder that causes brain cells to degenerate, shrink, and die, resulting in memory loss, cognitive decline, and behavioral changes), and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (plaque buildup in the heart's natural arteries, reducing blood flow, without chest pain). Record review of Resident #10's Quarterly MDS, dated [DATE], revealed Resident #10 was usually able to make self understood and to understand others. Resident #10 was noted to utilize a wheelchair for mobility. Resident #10 was noted to be dependent for toileting hygiene and needed substantial/maximal assistance for putting on/taking off footwear. Resident #10 required partial/moderate assistance for oral hygiene and lower body dressing, and required supervision or touching assistance with upper body dressing, personal hygiene, and eating. Resident #10 was noted to be dependent with tub/shower transfers and needed substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/chair-to-bed transfer, and toilet transfer. Resident #10 was noted to require partial/moderate assistance with walking. Record review of Resident #10's BIMS revealed a score was not able to be obtained. Resident #10 was noted to continually have had have difficulty focusing attention, being easily distractible or having difficulty keeping track of what was said, having had disorganized or incoherent thinking, and an altered level of consciousness. Record review of Resident #10's Care Plan, last updated on 12/15/2025, revealed a focus area of The resident uses a bed rail to assist themselves with ADL's with interventions of Grab/Assist bar to be used, 1/4 rail to be used, The resident uses a rail on the right side of the bed, and Perform a Bed Rail Assessment at least every quarter. Record review of Resident #10's Bed Rail Consent, dated 07/24/2024, revealed verbal consent from the RP by telephone call. Record review of Resident #10 's Bed Rail Assessment - V 2, dated 05/08/2025, indicated: 1. Do any of the items below apply to this resident? Answered as 5. None OF The Above 2. Does the resident have a diagnosis of seizures or involuntary movements? Answered as 2. No 3. Will or does the resident utilize the bed rail or grab/assist bar to assist themselves with activities of daily living? Answered as 2. Nob. Based on the response(s) above, the resident is not a candidate for a bed rail or grab/assist bar at this time Observation on 02/10/2026 at 9:14 AM of resident beds revealed grab bars were attached to the bedframe and raised on the bed of Resident #10. The bed of Resident #10 was observed with a grab bar on the left-hand side of the bed; the resident was not in the room. Record review of Resident #12's admission Record dated 02/11/2026 revealed a [AGE] year-old male who had original admission date of 08/23/2024. Resident #12 was noted to have diagnoses including Chronic Venous Hypertension (Idiopathic) with Ulcer of Right Lower Extremity (condition caused by long term-high pressure in the veins, causing skin break downs), Major Depressive Disorder (mental health disorder characterized by persistent, intense sadness or loss of interest), Post-Traumatic Stress Disorder, Chronic Obstructive Pulmonary Disease (progressive, incurable lung disease that makes breathing difficult by damaging airways and air sacs), Type 2 Diabetes Mellitus (chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond to insulin properly, but has not yet caused organ damage), Cerebral Infarction (blocked blood flow to the brain leading to tissue death), and Bradycardia (abnormally slow resting heart rate). Record review of Resident #12's Quarterly MDS, dated 11/05.2025, revealed a BIMS score of 11 indicating moderate cognitive impairment. Resident #12 was noted to have functional abilities requiring partial/moderate assistance with shower/bathe self and lower body dressing and substantial/maximal assistance with putting on/taking off footwear. Record review of Resident #12's Care Plan, last updated on 07/15/2025, revealed no focus or intervention related to the use of bed rails or grab/assist bars. Record review of Resident #12's Assessment List and Miscellaneous Document List, both dated 02/11/2026, in the EHR revealed no assessment for bed rail or grab bar safety or bed rail consent form. Observation on 02/10/2026 at 9:14 AM of resident beds revealed grab bars were attached to the bedframe and raised on the bed of Resident #12. The bed of Resident #12 was observed with a grab bar on the right-hand side of the bed; the left-hand side of the bed was against the wall; the resident was asleep in the bed. Record review of Resident #49's admission Record dated 02/11/2026 revealed a [AGE] year-old female who had original admission date of 08/29/2025. Resident #49 was noted to have diagnoses including Alzheimer's Disease With Early Onset (progressive, irreversible disorder that causes brain cells to degenerate, shrink, and die, resulting in memory loss, cognitive decline, and behavioral changes developing in individuals before [AGE] years old), Major Depressive Disorder (mental health disorder characterized by persistent, intense sadness or loss of interest), Delusional Disorders (type of serious mental illness (psychosis) characterized by fixed, false beliefs (delusions) that persist even with evidence that contradicts them), Auditory Hallucinations (perception of sounds, most commonly voices, without any external stimulus), Dementia (diagnosis used when symptoms of cognitive decline- severe memory loss, impaired thinking, and reduced social abilities- are present but underlying cause has not been determined), Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), and Psychotic Disorder With Delusions (psychotic condition characterized by the presence of one or more fixed, false beliefs without severe functional impairment). Record review of Resident #49's Quarterly MDS, dated [DATE], revealed a BIMS score of 3 indicating severe cognitive impairment. Resident #49 was indicated to have functional abilities requiring partial/moderate assistance of oral hygiene, lower body dressing, putting on/taking off footwear, personal hygiene, and supervision or touching assistance for upper body dressing. Resident #49 was noted to be independent with mobility with the need for supervision or touching assistance for tub/shower transfers. Record review of Resident #49's Care plan, last updated on 10/08/2025, revealed no focus or intervention related to the use of bed rails or grab/assist bars. Record review of Resident #49's Assessment List and Miscellaneous Document List, both dated 02/11/2026, in the EHR revealed no assessment for bed rail or grab bar safety or bed rail consent form. Observation on 02/10/2026 at 9:14 AM of resident beds revealed grab bars were attached to the bedframe and raised on the bed of Resident #49. The bed of Resident #49 was observed with grab bars raised on both sides of the bed; the resident was not in the room. Record review of Resident #56's admission Record dated 02/11/2026 revealed a [AGE] year-old female who originally admitted on [DATE]. Resident #56 was noted to have diagnoses including Obsessive-Compulsive Disorder (chronic mental health condition characterized by uncontrollable, recurring thoughts or behaviors that an individual feels compelled to repeat), Generalized Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), Major Depressive Disorder (mental health disorder characterized by persistent, intense sadness or loss of interest), Unsteadiness On Feet, Alzheimer's Disease (progressive, irreversible disorder that causes brain cells to degenerate, shrink, and die, resulting in memory loss, cognitive decline, and behavioral changes), and Bipolar Disorder (chronic mental health condition causing extreme, debilitating shifts in mood, energy, and functioning). Record review of Resident #56's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating cognition was intact. Resident #56 had functional abilities requiring supervision or touching assistance were toileting, shower/bathing, and personal hygiene. Resident #56 was noted to require supervision or touching assistance with chair/bed-to-chair transfer, tub/shower transfer and toilet transfer. Record review of Resident #56's Care Plan, last updated on 09/10/2025, revealed a focus of Patient to have assist bar on bed for functional mobility and repositioning in bed with no intervention or indication of alternatives tried related to the use of bed rails or grab/assist bars. Record review of Resident #56's Assessment List and Miscellaneous Document List, both dated 02/11/2026,in the EHR revealed no assessment for bed rail or grab bar safety or bed rail consent form. Observation on 02/10/2026 at 9:14 AM of resident beds revealed grab bars were attached to the bedframe and raised on the bed Resident #56. The bed of Resident #56 was observed with grab bars raised on both sides of the bed; the resident was not in the room. Record review of Resident #63's admission Record dated 02/11/2026 revealed an [AGE] year-old female who had original admission date of 10/17/2022 and most recent admission date of 1/14/2026. Resident #63 was noted to have diagnoses including Acute Respiratory Failure with Hypoxia (critical condition where the lungs cannot adequately oxygenate the blood), Muscle Wasting and Atrophy, Unsteadiness on Feet, Difficulty in Walking, Generalized Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), Chronic Obstructive Pulmonary Disease (progressive, incurable, yet treatable lung disease that causes chronic airflow constriction leading to severe breathing difficulties), Alzheimer's Disease with Late Onset (progressive, irreversible disorder that causes brain cells to degenerate, shrink, and die, resulting in memory loss, cognitive decline, and behavioral changes developing in individuals aged 65 or older, with risks increasing significantly with age), Chronic Systolic (Congestive) Heart Failure (condition where the heart's left ventricle weakens, becomes enlarged, and cannot contract properly to pump enough blood), Unspecified Dementia (diagnosis used when symptoms of cognitive decline- severe memory loss, impaired thinking, and reduced social abilities- are present but underlying cause has not been determined), and Type 2 Diabetes Mellitus without Complications (chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond to insulin properly, but has not yet caused organ damage). Record review of Resident #63's quarterly MDS, dated [DATE], revealed resident was noted to have been able to make self understood and had the ability to understand others some of the time. Resident #63 had a BIMS (standardized assessment tool to evaluate cognitive function, specifically memory and orientation) score of 0 (zero) indicating severe impairment. Resident #63 was noted to need substantial/maximal assistance for toileting hygiene, lower body dressing, putting on/taking off footwear; partial/moderate assistance for oral hygiene, upper body dressing, and personal hygiene. Resident #63 was noted to need supervision or touching assistance for functional abilities of roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair, bed-to-chair transfer, and sit to stand, Resident was noted to need partial/moderate assistance for toilet transfer and walking. Record review of Resident #63's Care Plan, last updated on 01/23/2026, revealed a focus of The resident uses 1/4 assist rails to assist themselves with ADL's and interventions of Grab/Assist bar to be used, 1/4 rail to be used, The resident uses rails on the left and right side of the bed, and Perform a Bed Rail Assessment at least every quarter. Record review of Resident #63's Bed Rail Assessment - V 2, dated 05/08/2025, indicated: 1. Do any of the items below apply to this resident? Answered as 5. None OF The Above 2. Does the resident have a diagnosis of seizures or involuntary movements? Answered as 2. No 3. Will or does the resident utilize the bed rail or grab/assist bar to assist themselves with activities of daily living? Answered as 2. Nob. Based on the response(s) above, the resident is not a candidate for a bed rail or grab/assist bar at this time Observation on 02/10/2026 at 9:14 AM of resident beds revealed grab bars were attached to the bedframe and raised on the bed of Resident #63, Resident #64, and Resident #80. The bed of Resident #63 was observed with a grab bar on the right-hand side of the bed; the resident was asleep in the bed. Record review of Resident #64's admission Record dated 02/11/2026 revealed a [AGE] year-old female who originally admitted to the facility on [DATE]. Resident #64 was noted to have diagnoses including Type 2 Diabetes Mellitus (chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond to insulin properly, but has not yet caused organ damage), Pulmonary Embolism (condition where a blood clot travels to the lungs blocking blood flow), Acute Embolism And Thrombosis Of Unspecified Deep Veins (when blood clots form in deep veins and block flow), Unspecified Hearing Loss, Generalized Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), Cognitive Communication Deficit, Major Depressive Disorder (mental health disorder characterized by persistent, intense sadness or loss of interest), and Unspecified Dementia (diagnosis used when symptoms of cognitive decline- severe memory loss, impaired thinking, and reduced social abilities- are present but underlying cause has not been determined). Record review of Resident #64's Annual MDS, dated [DATE], revealed a BIMS score of 12 indicating moderate impairment. Resident #64 was assessed as having been independent with all functional abilities. Record review of Resident #64's Care Plan, last updated on 06/30/2025, revealed focus of Patient to have assist bar on bed to help with functional transfers and repositioning in bed and no intervention of previously attempted alternatives. Record review of Resident #64's Assessment List and Miscellaneous Document List, both dated 02/11/2026, in the EHR revealed no assessment for bed rail or grab bar safety or bed rail consent form. Observation on 02/10/2026 at 9:14 AM of resident beds revealed grab bars were attached to the bedframe and raised on the bed of Resident #64. The bed of Resident #64 was observed with a grab bar on the left-hand side of the bed; the resident was not in the room. Record review of Resident #80's admission Record dated 02/11/2026 revealed a [AGE] year-old male with initial admission date of 12/15/2023 and most recent re-admission date of 01/26/2026. Resident #80 was noted to have diagnoses including Unsteadiness On Feet, Cognitive Communication Deficit, Type 2 Diabetes Mellitus (chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond to insulin properly, but has not yet caused organ damage), Other Seizures, Cerebral Infarction (blocked blood flow to the brain leading to tissue death), and Bipolar Disorder (chronic mental health condition causing extreme, debilitating shifts in mood, energy, and functioning). Record review of Resident #80's BIMS, dated 01/29/2026, revealed a score of 15 indicating intact cognition. Record review of Resident #80's Care Plan, last updated on 01/27/2026, revealed no focus or intervention related to the use of bed rails or grab/assist bars. Record review for Resident #80 revealed no completed MDS. Record review of Resident #80's Assessment List and Miscellaneous Document List, both dated 02/11/2026, in the EHR revealed no assessment for bed rail or grab bar safety or bed rail consent form. Observation on 02/10/2026 at 9:14 AM of resident beds revealed grab bars were attached to the bedframe and raised on the bed of Resident #80. The bed of Resident #80 was observed with grab bars raised on both sides of the bed; the resident was not in the room. Interview on 02/12/2026 at 11:29 AM with GVN D revealed they were unsure about the facility requirements for grab bars or bed rails to be placed or remain on a resident bed; they would speak with the DON for clarification. GVN D stated that possibly a resident would need an assessment before going into new bed that had grab bars on it. GVN D agreed that grab bars or any change to a resident's bed should be included in their care plan as each resident would have individualized requirements that would be linked to their mobility function or therapy needs. GVN D also agreed that a resident or RP should provide consent for grab bars or bed rails to be placed on a resident bed as the items could be perceived as a type of restraint depending on type or size and be considered a danger. Interview on 02/12/2026 at 11:48 AM with LVN F revealed that a resident should have had an assessment, signed a consent form, and be care planned for any type of grab bar or bed rail. LVN F stated that grab bars or bed rails could be a danger to a patient if that patient were not assessed to be able to use the grab bar or bed rail in a safe manner. LVN F stated that consent from the resident or RP was needed so they knew the purpose of the grab are or bed rail and it was not for a restraint. LVN F stated that grab bars or bed rails could pose a risk to a resident who may potentially hurt themselves up to and including strangulation, skin tears, injuries, falls, or death. Interview on 02/12/2026 at 12:02 with CNA G revealed they were unsure of the requirements for grab bars or bed rails to be on a residents bed. CNA G stated the risks of grab bars or bed rails to a resident could be the bars or rails being seen as restraint or the resident could be injured. CNA G agreed that the resident or their RP should sign consent for the grab bars/bed rails, have an assessment to ensure they could safely utilize the grab bars or bed rails. Interview on 02/12/2026 at 12:21 PM with the DON revealed for grab bars or bed rails the facility required the resident to have an assessment to ensure they were able to use the grab bars or bed rails safely, a signed consent from the resident or RP, and for documentation in the resident's EHR notes. The DON agreed that the need for and ability to safely use the grab bars or bed rails would also be entered in the resident's care plan. The DON thought the version of the EHR the facility utilized the consent form was triggered by the completion of the assessment showing the resident was appropriate for grab bars or bed rails. The DON stated that the care plan and consents for acute needs or conditions was the responsibility of the DON or a RN, comprehensive care plan updates were the responsibility of the MDS nurse, and ultimately the DON was responsible for oversight of all care plan entries. The DON stated that assessments were the responsibility of the admitting nurse, the MDS nurse would conduct assessments periodically, and the ultimate responsibility was on the DON. The risks to a resident of grab bars or bed rails according to the DON were potentially being restrained or incurring an injury. Interview on 02/12/2026 at 12:55 PM with Adm revealed they expected residents to be referred to therapy for an assessment for appropriateness to utilize grab bars or bed rails and therapy should then be coordinated with nursing with the results of the assessment or evaluation. The Adm agreed that consent and care planning was needed for bed rails or grab bars to be placed or remain on a resident bed. The Adm stated that consents and care plans were the responsibility of the interdisciplinary team. Record review of the facility's provided Bed Rail policy, dated 11/08/2016, revealed a statement of This facility will utilize bed rails for those residents that use them for bed mobility. The policy further states The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements: Assess the resident for risk of entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Ensure that the bed's dimensions are appropriate for the resident's size and weight.a. Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.Assessment: Prior to use of a bed rail the resident will be assessed to ensure the proper rail is utilized for the resident's need. The facility will re-evaluate the use of the rail on a periodic basis Based on the resident assessment, the interdisciplinary team (IDT) will make the determination for the plan of care as it relates to bed rails.Consent - The resident and/or resident representative will provide consent for the use of rails prior to installation.

Based on observations and interviews, the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 doorway to the Clean Linen Storage on the secure unit reviewed for accidents and hazards. The facility failed to ensure residents who resided on the secure unit were safe from hazardous items when the door to the Clean Linen storage room was observed open on 2/10/2026. This failure could place residents in the secure unit at risk of harm from exposure to hazardous materials, injury from freestanding shelves and linens, or entrapment in a confined space.Findings included: Observation on 02/10/2026 at 1:15 PM in the facility's secure unit revealed the clean linen closet door that had a numerical combination locking handle was left open approximately 1 inch and the closet light left on. There was no staff visible in hall however two secure unit residents were seen walking in the hallway nearby. The door to the clean linen closet had a sign stating Please make sure the door is completely closed behind you. At 1:19 PM a secure unit staff member walked by the open clean linen door and exited secure unit without noticing. No staff member was observed at the nurse's station next to the clean linen closet. Observation of items in the clean linen closet included a shelving unit with 5 shelves to the right of the doorway holding clean sheets, gowns, and blankets; a 5 shelf unit along the back wall of the closet with towels, blankets, and pillow cases, and a wall mounted 5 shelf unit that contained incontinent supplies of adult diapers, 2 stacks of bed pads, a pack of premoistened premium adult washcloths, as well as a purple topped container of Sani-Cloth Germicidal Disposable Wipes, and opened case of large powder free stretch vinyl exam gloves. Interview and observation on 02/10/2026 at 1:29 PM with MA C revealed that any door with combination lock should remain closed when not in use; when an employee is exiting a room, they were responsible for making sure the door was closed and locked. MA C went and closed the clean linen closet door and checked twice it was secure. MA C stated this was so that a resident did not wander into the closet and get locked in. MA C stated that there was a potential for items unsafe for residents to be in the room and the residents could get hurt. MA C agreed that residents on the secure unit were particularly vulnerable as they all had a dementia diagnosis and may not be aware of the dangers as everything in the closet might be hazardous particularly the disinfectant wipes and washcloths from the chemicals in them as well as the sheets and blankets being a risk of tripping and falls. Interview on 02/10/2026 at 1:33 PM with CNA E revealed that any combination locking door should always to be closed for safety. CNA E stated that she did not recall formal training on doors with combination locking handles but keeping non-resident room or area doors closed and locked had been emphasized on the first 3 days working at the facility. CNA E stated that the open door could be dangerous because a resident or unauthorized person could go into the closet and become trapped or be exposed to dangerous items; the linens that were stored inside could be a trip hazard. CNA E stated that the wipes and washcloths could be extremely dangerous if ingested or put on the eyes. CNA E stated when a staff member saw an open storage door, they should check inside for anyone and if no one then close the door and check it was securely locked. Interview on 02/10/2026 at 2:01 PM with GVN D revealed that areas that had doors with combination locked doors should be left closed and always locked and not be left slightly open. GVN D stated that storage room doors, particularly in the secure unit, should not be left open as it presented a risk of someone getting hurt, a resident getting items not meant for them or that may be specific to another room. GVN D stated the hazards of items that were in the clean linen closet could include ingestion of toxins, items being placed in body areas that were inappropriate, sheets and blankets posed a risk of falls or tripping, choking, and items could be used as a suicidal ideation aid. Interview on 02/12/2026 at 12:55 PM with Adm revealed the purpose of storage areas with combination lock doors was to ensure the room and items within remained secured. The Adm stated the risk of these areas not being secured ranged from a resident having ability to enter and have access to hazardous items. The Adm stated that training covering doors with combination locks was conducted when the codes changed and when a new employee began work. A policy was requested from the Administrator and DON on 02/12/2026 at 9:32 AM and again on 02/12/2026 at 1:37 PM, but not provided, that addressed doors with combination locks or an environmental safety procedures policy.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #14) of sixteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #14's room was in a position that was accessible to the resident on 02/10/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: Record review of Resident #14's Face Sheet, dated 02/10/2026, reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. She was diagnosed with dementia and hearing loss.Record review of Resident #14's Comprehensive MDS Assessment (tool used to measure health status), dated 12/24/2025, reflected severely impaired cognition with a BIMS (tool used to measure cognitive status) score of 04. The Quarterly MDS Assessment indicated the resident required staff assistance with mobility and self-care needs. Record review of Resident #14's Comprehensive Care Plan, dated 12/04/2025, reflected the resident was at risk for falls. An intervention was to ensure the call light was within reach. During an observation and interview on 02/10/2026 at 9:14 AM, Resident #14 was sitting in her wheelchair near the foot of her bed. Her call light was observed on the floor between the wall and the head of the bed. When asked about her call light, she asked my car light? The Staffing Coordinator entered the room and stated the call light should have been within arm's reach. She picked up the call light from the floor and placed it on the bedside rail near the resident's wheelchair. She stated Resident #14 could not hear well. She spoke in a loud voice and reminded Resident #14 to push the button if she needed help. She stated the resident called staff to assist her with transferring to the toilet and it was important to ensure the call light was in reach. During an interview on 02/10/2026 at 9:28 AM, LVN B stated the call light should have been on the side of the bed so Resident #14 could reach it from her wheelchair. He stated maybe the resident had used it and dropped it. He stated the nurse, CNA, or any staff member in her room should ensure the call light was in reach before leaving. He stated it was important for Resident #14 to be able to call with any needs she had. During an interview on 02/10/2026 at 2:13 PM, ADON B stated everyone in the building monitored to ensure residents' call lights were in reach. She stated at the end of the day, everyone was an advocate. She stated if a resident had a need, the call light was the way to communicate it. During an interview on 02/12/2026 at 10:17 AM, the DON stated nurse and aides monitored the call lights during rounds to ensure residents' call lights were in reach. She stated all staff were expected to ensure the residents had their call light in reach before leaving the room. She stated it was important for the safety of the residents. She stated they had begun in-service training. During an interview on 02/12/2026 at 12:40 PM, the administrator stated the nursing staff monitored call lights during rounds. He stated the expectation was for every staff member to ensure the call light was in reach before leaving a resident's room. He stated it was important for call lights to be within the resident's reach and answered timely to ensure their needs were met.On 02/19/2026 at 1:34 PM, an email was sent to the Administrator requesting a policy related to the placement of call lights. A policy was not provided.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents had the right to personal privacy and confidentiality of his or her personal space for 1 of 4 residents (Resident #63) reviewed for privacy. The facility failed to ensure that the roommates of residents with AEM had signed consents in the active section of the EHR from the roommate or their RP acknowledging the AEM in the shared room since 01/28/2026. This failure could place residents at risk of having medical or personal information or conversations recorded or exposed to others, and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem.Findings included: Observation on 02/10/2026 at 9:20 AM of the shared room door for Resident #10 and Resident #63 revealed a sign stating This room is being electronically monitored. Observation on 02/11/2026 at 1:45 PM of the shared room door for Resident #10 and Resident #63 revealed a sign stating This room is being electronically monitored. Record Review of Resident #10's admission Record dated 02/11/2026 revealed a [AGE] year-old female who had originally admitted to the facility on [DATE] with most recent admission on [DATE]. Resident #10 was noted to have diagnosis including Difficulty in Walking, Unsteadiness on Feet, Other Lack of Coordination, Major Depressive Disorder (mental health disorder characterized by persistent, intense sadness or loss of interest), Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), Alzheimer's Disease (progressive, irreversible disorder that causes brain cells to degenerate, shrink, and die, resulting in memory loss, cognitive decline, and behavioral changes), and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (plaque buildup in the heart's natural arteries , reducing blood flow, without chest pain). Record Review of Resident #10's Care Plan, last updated on 12/15/2025, revealed focus area of Resident/Resident's responsible party has requested electronic monitoring with date of 12/15/2025. Intervention included Obtain consent from resident's (sp) roommate/Responsible party (if applicable) for electronic monitoring. Record review of Resident #63's admission Record dated 02/11/2026 revealed an [AGE] year-old female who had original admission date of 10/17/2022 and most recent admission date of 1/14/2026. Resident #63 was noted to have diagnosis including Acute Respiratory Failure with Hypoxia (critical condition where the lungs cannot adequately oxygenate the blood), Muscle Wasting and Atrophy, Unsteadiness on Feet, Difficulty in Walking, Generalized Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), Chronic Obstructive Pulmonary Disease (progressive, incurable, yet treatable lung disease that causes chronic airflow constriction leading to severe breathing difficulties), Alzheimer's Disease with Late Onset (progressive, irreversible disorder that causes brain cells to degenerate, shrink, and die, resulting in memory loss, cognitive decline, and behavioral changes developing in individuals aged 65 or older, with risks increasing significantly with age), Chronic Systolic (Congestive) Heart Failure (condition where the heart's left ventricle weakens, becomes enlarged, and cannot contract properly to pump enough blood), Unspecified Dementia (diagnosis used when symptoms of cognitive decline- severe memory loss, impaired thinking, and reduced social abilities- are present but underlying cause has not been determined), and Type 2 Diabetes Mellitus without Complications (chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond to insulin properly, but has not yet caused organ damage). Record Review of Resident #63's Care Plan, last updated 1/23/2026, revealed no indication of resident being in a room that currently had ongoing AEM. Record review of Resident #63's quarterly MDS, dated [DATE], revealed resident was noted to have been able to make self understood and had the ability to understand others some of the time. Resident #63 had a BIMS (standardized assessment tool to evaluate cognitive function, specifically memory and orientation) score of 0 (zero) indicating severe impairment. Resident #63 was noted to need substantial/maximal assistance for toileting hygiene, lower body dressing, putting on/taking off footwear; partial/moderate assistance for oral hygiene, upper body dressing, and personal hygiene. Resident #63 was noted to need supervision or touching assistance for functional abilities of roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair, bed-to-chair transfer, and sit to stand, Resident was noted to need partial/moderate assistance for toilet transfer and walking. Record review for Resident #63 revealed no consent from resident/RP to be moved into a room with ongoing AEM for roommate.Interview on 02/12/2026 at 11:29 AM with GVN D revealed that AEM in shared resident rooms required both parties to have signed consent forms. These forms showed the resident or RP had been informed of the monitoring by video and/or audio and that if the resident or families were not in agreement and preferred a room without AEM the resident could have been moved elsewhere. Interview on 02/12/2026 at 11:48 AM with LVN F revealed that in resident rooms with AEM, the roommate or their RP, needs to sign a form to consent to the monitoring. This was needed because the camera should only be pointed at intended monitored resident but could still end up recording the non-monitored roommate on camera too; if the camera has sound recording that could pick up private conversations the roommate may not want heard. LVN F stated that obtaining consents were the responsibility of all nursing staff, whoever was speaking with the resident or RP about a specific room for the resident should inform of the AEM and request the consent or the room will need to be changed to one without AEM. Interview on 02/12/2026 at 12:02 with CNA G revealed that when a resident was being prepared for a room change the staff member was to notify the resident or RP of the AEM in the room and be sure the curtain was pulled for privacy of the resident not being monitored. CNA G agreed that consent should be needed from a resident or RP being moved into a room with AEM, that way if the resident or family were not wanting to possibly be on camera or overheard the facility would offer a different room. CNA G also stated that the RP should be notified with any room change of a resident. Interview on 02/12/2026 at 12:21 PM with the DON revealed that for AEM to be approved by the facility, consent from the resident or RP, any roommate or their RP was required to be obtained. In addition, the facility would post a sign on the room door. The DON stated that AEM consent was obtained by the admitting nurse when monitoring was requested on admission to the facility from the family or resident, or by the DON or ADON when a room change was made after admission. The DON stated the signed consent form should be in miscellaneous or documents tab of the EHR. The DON stated that the risks of not having the signed consent was that there was no evidence the resident or RP was made aware they could possibly be filmed, and that there may be audio recording capabilities as well; this would be a privacy violation and that ultimately the DON was responsible to ensure all consents were obtained and in the EHR. Record review of the facility provided policy, dated 02/15/2005, revealed the statement A resident or the resident's guardian or legal representative is entitled to conduct authorized electronic monitoring (AEM) under Subchapter R, Chapter 242, Health and Safety Code. To request AEM, you, your guardian or your legal representative must:1) complete the Request for Authorized Electronic Monitoring form2) obtain the consent of other residents, if any, in your room, using the Consent to Authorized Electronic Monitoring form and3) give the form(s) to the facility administrator or designee.Who may consent to AEM?1) The other resident(s) in the room.2) The guardian of the other resident if the resident has been judicially declared to lack the required capacity.3) The legal representative of the other resident, if the resident does not have capacity to sign the form, but has not been judicially declared to lack the required capacity.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #38) of six residents reviewed for respiratory care.The facility failed to ensure Resident #38's nasal cannula was stored properly when not in use on 02/10/2026.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #38's Face Sheet, dated 02/10/2026, reflected a [AGE] year-old male who initially admitted on [DATE] and readmitted on [DATE]. A related diagnosis was shortness of breath on exertion. Record review of Resident #38's Comprehensive MDS Assessment, dated 11/11/2025, reflected intact cognition with a BIMS score of 15. Section O (Special Treatments, Procedures, and Programs) did not reflect the resident received oxygen therapy during the fourteen days prior to the MDS Assessment. Record review of Resident #38's Comprehensive Care Plan, dated 12/04/2025, reflected the resident had oxygen therapy related to ineffective gas exchange. An intervention was to administered oxygen via nasal cannula at 2-4 liters per minute. Record review of Resident #38's Physician Order, dated 09/12/2025, reflected oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath.During an observation on 02/10/2026 at 9:22 AM, Resident #38 was not in his room. A nasal cannula was connected to the oxygen concentrator. The nasal cannula was on his bed unbagged. During an observation and interview on 02/10/2026 at 9:28 AM, LVN B stated the nasal cannula should have been in a bag. He stated when Resident #38 left his room, he used the portable oxygen tank on his wheelchair. He stated staff reminded the resident to put the oxygen tubing in the bag or tell staff when he takes off oxygen so staff can place it in a bag. He stated Resident #38 had respiratory issues and it was important to keep the nasal cannula bagged for infection control. During an observation and interview on 02/11/2026 at 12:27 PM, Resident #38 was lying on his bed. He stated in the beginning he did not use oxygen, then he started using it just when he was in his room. He stated if he needed to use it when he left the room, he used the portable tank on his wheelchair. He stated he usually put the oxygen tubing in the bag himself so he did not have to wait for staff to come and do it. During an observation and interview on 02/10/2026 at 1:13 PM, ADON B stated the nasal cannula should have been in a bag. She stated the nurses and CNAs were responsible for monitoring to ensure the oxygen tubing was stored in a bag when the resident was not using it. She stated all staff were trained to report to nursing staff if they observed oxygen unbagged or on the floor. She stated it was important for infection control. During an observation and interview on 02/12/2026 at 10:17 AM, the DON stated the resident took off the nasal cannula in the room and switched to the oxygen on his wheelchair. She stated he had been educated to place the nasal cannula in the bag or call staff to put in the bag before leaving the room. She stated staff were responsible for rounding to ensure it was bagged appropriately for infection control. She stated they had begun in-service training for staff. During an observation and interview on 02/12/2026 at 12:40 PM, the Administrator stated the nasal cannula should be bagged to avoid cross contamination and infection. He stated the nursing staff and CNAs monitored during rounds to ensure those items were bagged when not in use. Record review of the facility's policy Oxygen Administration, revised February 13th, 2007, did not reflect storage of respiratory items when not in use. On 02/19/2026 at 1:34 PM, an email was sent to the Administrator requesting a policy for the storage of respiratory items when not in use. A policy was not provided.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #31) of twelve residents reviewed for medication storage. The facility failed to ensure Resident #31 did not have a topical analgesic ointment on her bedside table on 02/10/2026.This failure could place residents at risk of not receiving the full benefit of the medications or misuse of medications that could lead to adverse reactions or overdose.Findings include: Record review of Resident #31's Face Sheet, dated 02/10/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with osteoarthritis and blindness in one eye with low vision in the other eye. Record review of Resident #31's Comprehensive MDS Assessment, dated 11/17/2025, reflected intact cognition with a BIMS score of 15. She required assistance with mobility and self-care needs. Record review of Resident #31's Comprehensive Care Plan, dated 12/04/2025, reflected the resident had impaired visual function. Interventions included to encourage the resident to use her glasses and ensure appropriate visual aides were available to support her participation in activities. Record review of Resident #31's Physician Order reflected the resident did not have an order for topical analgesic ointment or to self-administer medication. An observation on 02/10/2026 at 9:14 AM revealed Resident #31 was not in her room. A container of topical analgesic ointment was on her bedside table.During an observation and interview on 02/10/2026 at 9:17 AM, the Staffing Coordinator was in Resident #31's room. She removed the topical analgesic ointment from Resident #31's bedside table and stated it should not be in the room. She stated a resident might get it and swallow it, put it in their eyes, or may use too much of it. During an interview on 02/10/2026 at 9:28 AM, LVN B stated he did not notice the ointment in the room. He stated it could be harmful if resident used it the wrong way. He stated there should not be any medication in residents' rooms. He stated that was a facility policy and everyone knew it. He stated another resident might get it and have side effects. He stated someone might use too much or not use it properly. He stated any medication should be locked in the nurse's or medication aide's cart. During an interview on 02/10/2026 2:13 PM, ADON A stated no one should have medication at the bedside. She stated staff try their best to look for issues and correct them. She stated she did not know if it belonged to the resident. She stated sometimes families brought in things the facility was unaware of. She stated when they see something like that, the facility addresses it. She stated it was for the safety of all the residents. During an interview on 02/12/2026 at 10:17 AM, the DON stated there should not be medication at any resident's bedside for safety. She stated some residents had dementia. She stated a resident might get the topical analgesic ointment and ingest it. She stated they had begun in-service training. During an interview on 02/12/2026 at 12:40 PM, the Administrator stated medications should not be at the bedside. He stated medications should be secured to ensure the right resident gets the right amount of medicine. Record review of the facility's policy Bedside Storage of Medications, dated 2003, reflected bedside medication storage is permitted for sublingual and emergency medications and for residents who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for fifteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) of twenty five resident reviewed for privacy and confidentiality. 1. The facility failed to ensure a list of residents who were using oxygen (Resident #1, #2, #3, #4, #5, and #6) was not left unattended on top of a nurse's cart on 11/04/2025. 2. The facility failed to ensure a list of residents who had a Foley (device used to help drain urine from bladder) (Resident #7) was not left unattended on top of a nurse's cart on 11/04/2025. 3. The facility failed to ensure a list of residents who were on dialysis (Residents #8, #9, and #10) was not left unattended on top of a nurse's cart on 11/04/2025. 4. The facility failed to ensure a list of resident (Resident #11) who had a g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach), was not left unattended on top of a nurse's cart on 11/04/2025. 5. The facility failed to ensure a list of residents who had a pacemaker (a small device implanted in the chest that helps regulate the heart's rhythm by sending electrical impulses to the heart) (Residents #12, #13, and #14) was not left on top of a nurse's cart on 11/04/2025 unattended on 11/04/2025. 6. The facility failed to ensure MA B did not leave Resident #15's medication blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for amlodipine on top of the medication cart unattended on 11/04/2025. These failures could place the residents at risk of their medical information being exposed to unauthorized individuals.Findings included: 1. Resident #1 Record review of Resident #1's Face Sheet, dated 11/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's Physician Order, dated 10/02/2025, reflected Oxygen LPM: 2-5 Via: Nasal Cannula (flexible tube used to deliver oxygen to the nose through two prongs). Resident #2 Record review of Resident #2's Face Sheet, dated 11/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #2's Physician Order, dated 10/02/2025, reflected Oxygen LPM: 2-5 Via: Nasal Cannula every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Resident #3 Record review of Resident #3's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath). Record review of Resident #3's Physician Order, dated 10/07/2025, reflected Oxygen LPM: 2-5 Via: Nasal Cannula every shift. Resident #4 Record review of Resident #4's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #4's Physician Order, dated 09/22/2025, reflected Oxygen LPM:2 Via: Nasal Cannula every shift. Resident #5 Record review of Resident #5's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #5's Physician Order, dated 08/15/2025, reflected Oxygen LPM: 2 - 4 Via: Nasal Cannula every shift. Resident #6 Record review of Resident #6's Face Sheet, dated 11/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure with hypoxia (insufficient amount of oxygen in the body). Record review of Resident #6's Physician Order, dated 11/21/2024, reflected O2 @ 2L via NC CONTINUOUS at night at bedtime. 2. Record review of Resident #7's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obstructive and reflux uropathy (a blockage in the urinary tract). Record review of Resident #7's Physician Order, dated 09/24/2025, reflected Urinary Catheter 16F (French: unit used to indicate the size of the catheter)/10cc to gravity drainage every shift related to OBSTRUCTIVE AND REFLUX UROPATHY. 3. Resident 8 Record review of Resident #8's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with end stage renal disease (a condition where the kidneys can no longer function adequately). Record review of Resident #8's Physician Order, dated 06/16/2025, reflected . Hemodialysis on Monday, Wednesday, Friday @ 1430. Resident 9 Record review of Resident #9's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic kidney disease (kidneys stop working). Record review of Resident #9's Physician Order, dated 06/16/2025, reflected Dialysis - Resident receives dialysis at . on Tuesday-Thursday-Saturdayroutinely. Resident 10 Record review of Resident #10's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic kidney disease. Record review of Resident #10's Physician Order, dated 10/02/2025, reflected Dialysis Every Mon-Wed-Fri @ 10:30 AM one time a day every Mon, Wed, Fri. 4. Resident 11 Record review of Resident #11's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #11's Physician Order, dated 10/06/2025, reflected every 12 hours Isosource 1.5 Cal continuous with 2h downtime. 5. Resident 12 Record review of Resident #12's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with presence of cardiac pacemaker. Record review of Resident #12's Comprehensive MDS Assessment, dated 08/17/2025, reflected the resident had severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident had a cardiac pacemaker. Record review of Resident #12's Comprehensive Care Plan, dated 08/21/2025, reflected the resident had a pacemaker and one of the interventions was to monitor vital signs as ordered. Record review of Resident #12's Physician Order, dated 07/12/2024, reflected Vital signs to include O2 sat q shift. Resident 13 Record review of Resident #13's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with presence of cardiac pacemaker. Record review of Resident #13's Comprehensive MDS Assessment, dated 09/24/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Staff Assessment for Mental Status of the resident showed that the resident had a memory problem. The Comprehensive MDS Assessment indicated the resident had a presence of cardiac pacemaker. Record review of Resident #13's Comprehensive Care Plan, dated 10/07/2025, reflected the resident had a pacemaker and one of the interventions was to monitor vital signs as ordered. Record review of Resident #13's Physician Order, dated 08/31/2025, reflected Assess resident's vital signs one time a day . and report abnormal to MD/NP. Resident 14 Record review of Resident #14's Face Sheet, dated 11/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with atrial fibrillation (an irregular, rapid heartbeat). Record review of Resident #14's Comprehensive MDS Assessment, dated 10/12/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had atrial fibrillation. Record review of Resident #14's Comprehensive Care Plan, dated 08/29/2025, reflected the resident had a pacemaker and one of the interventions was to monitor vital signs as ordered. Observation on 11/04/2025 at 8:49 AM revealed a piece of paper on top a nurse's cart that was parked in the hallway. On the piece of paper were the last names of residents who were using oxygen (Resident #1, #2, #3, #4, #5, and #6), with a Foley (Resident #7), was undergoing dialysis (Residents #8, #9, and #10), with a g-tube (Resident #11), and with pacemakers (Residents #12, #13, and #14). The cart was facing the hallway and the piece of paper, that was not flipped, was visible to individuals passing by the cart. In an interview on 11/04/2025 at 8:53 AM, LVN A said he did not put the paper on top of his cart. He said he was not the one who placed the paper on his cart and did not know who left it on his cart. During an observation and interview on 11/04/2025 at 8:54 AM, the ADON saw the paper that was on top of the nurse's cart. She took the paper and said the paper only have the last names of the residents and did not have their first names so it was not considered HIPAA. The ADON did not reply when asked if a resident being on oxygen therapy was a medical information. In an interview on 11/04/2025 at 10:36 AM, the DON said the information on the paper were definitely medical information and she already started an inservice about not leaving the residents medical information around. She said there was an emergency and maybe that was reason why it was left in the cart facing up. She said but even though there was an emergency, the paper should have been flipped before assisting with the emergency. She said she did not know who left the paper on the cart. She said the medical information were private information and should be kept confidential. In an interview on 11/04/2025 at 12:24 PM, LVN A stated the paper left on his cart could be considered medical information because it did mention the names of the residents who were using oxygen. He said he had an emergency and did not notice who let the paper on his cart. He said, even though there was an emergency, whoever left the paper on cart should have flipped it. He said it would not take five seconds to flip the paper and he was not sure that whoever left the paper even participated in the emergency. He said the paper should have flipped to keep the information private. He said a visitor could take it and go around the facility verifying the names of the residents on the list. He said an in-service was already going around about securing the medical information of the residents. 6. Resident #15 Record review of Resident #15's Face Sheet, dated 11/04/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #15's Physician Order, dated 10/05/2025, reflected Amlodipine Besylate Oral Tablet 2.5 MG (Amlodipine Besylate) Give 3 tablet by mouth one time a day for Hypertension. Take 3 Tablets (7.5 mg Total)/ Hold for SBP less than 110 DBP less than 60 or HR less than 60. Observation on 11/04/2025 at 10:45 AM revealed Resident #15's blister pack was on top of the medication cart parked outside the nurses' station. The blister pack had the resident's name, name of medication, the prescription number, the name of the medical doctor, and the instruction on how to take the medication, and the name of the resident's pharmacy. Observation and interview on 11/04/2025 at 11:46 AM, the ADON stated the blister should have been left facing up on top of the medication aide's cart because it was considered a HIPAA violation. She took the blister pack from the cart. In an interview on 11/04/2025 at 12:28 PM, MA B stated she was about to give the blister pack to the nurse when she was distracted and left the blister cart on her cart. She said she should have flipped it before leaving her cart or put it inside the cart. She said the blister pack had the resident's names and the name of the medication she was taking. She said it was considered as HIPAA because somebody, who were not authorized, could see the confidential information. In an interview on 11/04/2025 at 12:43 PM, the ADON stated the first incident with the paper on top of the cart was not considered HIPAA but the blister pack on top of the medication cart was considered HIPAA. She said the blister pack should have been flipped because it had the resident's name, the name of the medication, and the instruction on how to take it. When asked why an in-service was going around about securing medical information after a paper on the nurse's cart was observed the ADON did not reply. In an interview on 11/04/2025 at 1:12 PM, the DON said, just like the piece of paper, the blister pack should have been secured before the staff left the cart. She said she would make sure the in-service would be done by all the staff. The DON stated medical information about a resident should be protected and not be visible for everybody to see because those were confidential information. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said the staff should have made sure the paper containing a list of residents with oxygen, gtube, pacemakers, Foley, and undergoing dialysis, and the blister pack were flipped, and not exposed. She said if the confidential information were exposed, non-nursing staff, other resident, and visitors would be able to see it. She said all staff, including her, were expected to provide full confidentiality of all the residents' personal and medical information. In an interview on 11/04/2025 at 1:45 PM, the Administrator stated the staff must make sure that the medical information of the residents were safeguarded to prevent unlawful use of their information. He said the expectation was for the staff to be mindful about privacy and confidentiality. He said an in-service about privacy and confidentiality was already initiated by the DON. Record review of the facility's policy entitled, RESIDENT RIGHTS undated, reflected Privacy and confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records . 3. The resident has a right to secure and confidential personal and medical records.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four (Resident #1, #2, #3, and #4) of ten residents reviewed for medication storage. 1. The facility failed to ensure zinc oxide (medicated cream used to prevent skin irritation) was not left inside the Resident #1's room on 10/08/2025. 2. The facility failed to ensure zinc oxide was not left inside the Resident #4's room on 10/08/2025. 3. The facility failed to ensure a vial of solution used for breathing treatment was not left inside Resident #2's room on 10/08/2025. 4. The facility failed to ensure a tube of topical pain reliever was not inside Resident #3's room on 10/08/2025. These failures could place residents at risk of misuse of medications that could lead to overdosing or underdosing.Findings included: 1. Record review of Resident #1's Face Sheet, dated 10/08/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Record review of Resident #1's Comprehensive MDS Assessment, dated 09/15/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had dementia and was incontinent for bladder and bowel. Record review of Resident #1's Comprehensive Care Plan, dated 08/25/2025, reflected the resident had incontinence and one of the interventions was to apply barrier cream after each incontinent episode. Record review of Resident #1' Physician Order, dated 10/09/2024, reflected May apply barrier cream as needed every shift. During an observation and interview on 10/08/2025 at 8:44 AM revealed Resident #1 was in his bed, awake. It was observed that there was a cup of cream on top of the resident's drawer. The cup of cream was visible from the hallway. The resident said the cream was applied to his bottom. He said the staff would usually leave it on top of his drawer or sometimes on top of his side table. 2. Record review of Resident #4's Face Sheet, dated 10/08/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with obesity (excessive accumulation of body fats). Record review of Resident #4's Quarterly MDS Assessment, dated 08/08/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #4's Care Plan, dated 09/10/2025, reflected the resident reflected the resident was incontinent and one of the interventions was to apply barrier cream after every incontinent episode. Record review of Resident #4's Physician Order, dated 01/07/2024, reflected Barrier Cream of facility choice QID and PRN to prevent skin breakdown . four times a day for preventive care. During an observation and interview on 10/08/2025 at 8:56 AM revealed Resident #4 was in her bed awake. It was observed that a cup of cream was on top of her side table. the resident said the cream was used after incontinent care. She said she did not know who left the cream on her side table. During an observation and interview on 10/08/2025 at 9:07 AM, CNA B stated the cream inside the cups were zinc oxide used during incontinent care. She said it should not be left inside the rooms of the residents because they were medicated creams and confused residents might get hold of them and eat them. She said the resident might be allergic to the cream or might give them stomach issue. She went inside the Resident #1's room and took the cup of cream from the top of the drawer. She said Resident #4 was not assigned to her but she would also get the cup of zinc oxide from her room. She went inside Resident #4's room and took the cup of zinc oxide from the Resident #4's side table. She said she the cups of zinc oxide should be thrown away after incontinent care was done or should not be left inside the residents' rooms for use later. She said she did not know who left the cups of zinc oxide inside the residents' rooms and she did not notice it when she did her round. She said she would check the rooms of the residents and would also tell CNA C to check also the rooms assigned to her for any zinc oxides inside the room so the residents. In an interview on 10/08/2025 at 9:12 AM, CNA C stated CNA B already told her about the zinc oxide on Resident #4's side table. She said zinc oxide should not be left inside the rooms of the residents because the residents might though it was lotion and apply it to their face. She said it might cause irritation of the eyes. She said she would just finish cleaning a resident and then she would check the rooms assigned to her for any zinc oxide. She said she did not notice it when she did her round. 3. Record review of Resident #2's Face Sheet, dated 10/08/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #2's Quarterly MDS Assessment, dated 09/24/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #2's Comprehensive Care Plan, dated 10/08/2025, reflected the resident had chronic obstructive pulmonary disease and one of the interventions was give aerosol (substance released in fine mist) or bronchodilators (medication that caused widening of the air passages) as ordered. Record review of Resident #2's Physician's Order, dated 06/13/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 milliliter inhale orally every 6 hours as needed for SOB or Wheezing via nebulizer. During an observation and interview on 10/08/2025 at 8:47 AM revealed Resident #2 was in his bed, awake. It was observed that a nebulizer was on top of the resident's side table. The resident said it was his nebulizer and would use it on the need basis. He said the solution for breathing treatment must have been left the last time he was given his breathing treatment. 4. Record review of Resident #3's Face Sheet, dated 10/08/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with pain to left shoulder. Record review of Resident #3's Quarterly MDS Assessment, dated 07/14/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated the resident had pain to left shoulder. Record review of Resident #3's Care Plan, dated 09/18/2025, reflected the resident had potential for uncontrolled pain and one of the interventions was to monitor side effects of pain medications. Record review of Resident #3's Physician Order, dated 04/09/2025, reflected Voltaren External Gel 1% (Diclofenac Sodium) Apply to Left shoulder topically every 12 hours for pain. During an observation and interview on 10/08/2025 at 9:17 AM, LVN D stated there should be no medications inside the rooms of the residents unless they had an assessment that they could self-administer their medications. She said it might result to overmedication. She went inside Resident #2's room and saw the solution for breathing treatment on the Resident #2's side table and took it. She then went to Resident #3's room and saw the tube of pain reliver ointment on the Resident #2's table and took it. She said she did not notice the medications when she did her rounds. She said the medications should be inside the cart. She said she did not know who left the medications inside the rooms of the residents. In an interview on 10/08/2025 at 11:35 AM, ADON A stated medications should be inside the carts and not left inside the residents' rooms because confused residents could consume them or use the medications using a different route. He said the resident might have allergic reactions or stomach issues if the topical medications where ingested. He said the solution for breathing treatment might be mistaken for eye drops. He said the expectation was for the staff to be mindful not to leave any medication inside the residents' rooms and to always scan the rooms for any medication. He said they already started an in-service about medication storage as soon as they were notified that medications were observed inside the rooms of the residents. He said they also started a routine checking of the residents' rooms. He said they would also coordinate with the family to let the facility know if they were bringing any medication. In an interview on 10/08/2025 at 12:18 PM, the DON stated the solution for breathing treatment should not have been left inside Resident #2's room. She said the staff should only bring the solution that would be used and the rest of the solutions for breathing treatment should be inside the cart. She said zinc oxide was a form of medications that could be harmful when ingested like the resident getting sick. She said, sometimes, family would bring the medications but at least staff should take note of the medications specially if the medications were in plain view. She said the expectations were for the staff to always scan the residents' rooms for any medication and not to leave any medication inside the rooms of the residents. she said she would also coordinate with the family about the risk of medications inside the rooms of the residents. She said she already started an in-service about medication storage. In an interview on 10/08/2025 at 1:01 PM, the Administrator stated the expectation was for the staff to be mindful that they were not leaving any medications inside the rooms of the residents because it could be harmful for the residents. he said the DON already started an in-service and he would closely monitor the staffs' adherence to the policy. Record review of the facility's policy entitled, Medication Storage in the Facility P & P revised 03/2025 reflected Policy: Medications and biologicals are stored safely, securely . The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #2) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #2's breathing mask (medical device used to deliver medication in a form of mist) was stored properly when not in use on 10/08/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #2's Face Sheet, dated 10/08/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #2's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 09/24/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 15. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #2's Comprehensive Care Plan, dated 10/08/2025, reflected the resident had chronic obstructive pulmonary disease and one of the interventions was give aerosol (substance released in fine mist) or bronchodilators (medication that caused widening of the air passages) as ordered. Record review of Resident #2's Physician's Order, dated 06/13/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 milliliter inhale orally every 6 hours as needed for SOB or Wheezing via nebulizer. During an observation and interview on 10/08/2025 at 8:47 AM revealed Resident #2 was in his bed, awake. It was observed that a nebulizer was on top of the resident's shelf with a breathing mask connected to it. The breathing mask was not bagged. The resident said he would have the breathing treatment if he was having shortness of breath. He said nurses would give it to him and would come back to take it off. When asked when was the last time he had the breathing treatment, the resident said he could not remember. During an observation and interview on 10/08/2025 at 9:17 AM, LVN D stated if the resident was not using the breathing mask, it should be inside a clean plastic bag to ensure cleanliness for the next use. She said she did not notice that Resident #2's breathing mask was not bagged when she did her morning round. She said did not know when was the last time the resident used the breathing mask and said, if she was not mistaken, the order for his breathing treatment was if needed. She went inside the resident's room and disconnected the breathing mask and said she would get another breathing mask and would put it in a bag. She said she was one of the responsible in ensuring the breathing mask was bagged. In an interview on 10/08/2025 at 11:35 AM, ADON A stated the breathing mask should be stored properly to prevent cross contamination and respiratory infections. He said whoever administered the breathing treatment was responsible for cleaning it and storing it in a plastic bag. He said the expectation was for the staff to bag the breathing mask to when not in use. He said she would coordinate with the DON to do an in-service about bagging the breathing mask. In an interview on 10/08/2025 at 12:18 PM, the DON stated the breathing mask should be bagged when not in use to prevent any respiratory infection. She said the staff that administer the breathing treatment should have place it inside a bag after the breathing treatment. she said the expectation was for the breathing mask be bagged when not in use and for the staff to scan the rooms to see a breathing mask was not bagged so they could change it. She said it was her responsibility to check if the staff were compliant in bagging the breathing mask. She said she would start an in-service about bagging the breathing mask when not in use. In an interview on 10/08/2025 at 1:01 PM, the Administrator stated the expectation was for the staff to bag the breathing mask when not in use to prevent respiratory issues. He said he would coordinate with the DON to re-educate the staff about bagging the breathing mask when not in use. Policy specific to bagging the breathing mask requested verbally to the Administrator on 10/08/2025 at 1:01 PM but was not provided prior to exit. Record review of the facility's policy entitled Oxygen Administration Nursing Policy & Procedure Manual 2003, undated, reflected Goals . 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen . 3. The resident will be free from infection

Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 4 (Residents #1, #2, #3 and #5) of 9 residents reviewed for accidents and hazards. Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 4 (Residents #1, #2, #3 and #5) of 9 residents reviewed for accidents and hazards. 1. A. The facility failed to implement and modify interventions to ensure Resident #1 did not experience 7 falls after admitting to the facility on [DATE], and as a result of the last fall on 06/22/2025, sustain a head injury which resulted in the resident's death in the hospital on [DATE]. B. The facility failed to implement and modify interventions to ensure Resident #2 did not experience 5 falls after admitting to the facility on [DATE] with a right hip fracture resulting from a fall at home. C. The facility failed to implement and modify interventions to ensure Resident #3 did not experience 5 falls after admitting to the facility on [DATE]. 2. A. The facility failed to adequately assess, devise, and implement appropriate interventions to prevent Resident #5's elopement from the facility for approximately 5 minutes on 07/12/2025. The first non-compliance was identified, and an Immediate Jeopardy (IJ) situation was identified on 07/02/2025. The IJ was removed on 07/16/2025. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The second non-compliance was identified, and an Immediate Jeopardy (IJ) Template was presented to facility Administrator and DON on 07/15/2025 at 5:37 PM. The IJ was removed on 07/16/2025. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failures could place residents at risk of harm and injuries, hospitalization, and death. Findings include: 1. 1. Record review of Resident #1's Face Sheet, dated 06/26/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's disease (movement disorder of the nervous system that worsens over time), unspecified abnormalities of gait (walking pattern) and mobility, and a history of falls. Record review of Resident #1's admission MDS (tool used to assess health status) Assessment, dated 04/19/2025, reflected moderately impaired cognition with a BIMS (screening tool to assess cognitive status) score of 10. Section J (Health Conditions) reflected Resident #1 had 2 or more falls since admission with no injury. Record review of Resident #1's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/25/2025. Interventions included staff x 1 to assist resident with transfers, ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in his wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #1's Fall Risk Assessments, dated 06/12/2025, 06/20/2025, and 06/22/2025, reflected Resident #1 was in the high-risk category for falls. Record review of the facility's incident reports reflected Resident #1 fell on [DATE], 04/11/2025, 04/15/2025, 04/20/2025, 05/25/2025, 06/10/2025, 6/20/2025 which did not result in a serious injury. Resident #1 was sent to the hospital after he fell on [DATE]. Record review of Resident #1's progress notes, dated 06/13/2025, reflected RN C documented This client is somewhat confused. He does not abide by the nurses' instructions about his safety and constantly gets out of the recliner and makes movements that could severely hurt him. He slid out of the recliner at 2145. Once we put him in bed, 30 minutes later, we found him by the door in his chair, naked.We need a baby monitor so that the nurse can see him from the nurse's station. Record review of Resident #1's progress notes, dated 06/20/2025, reflected RN X documented This nurse was called by an Aide that resident was on the floor. Resident was lying next to his recliner and bed. Resident said he was trying to use the bathroom. Resident was lifted off the floor with a Hoyer lift. Resident sustained a skin tear on his right elbow. Site was cleaned and covered with border dressing. Resident assessed and his vital signs were normal. DON, family, and NP were notified. Record review of Resident #1's progress notes, dated 06/22/2025, reflected RN C documented nurse was called to resident room and observed resident on the floor next to the bed, resident is alert and able to response to verbal commands, disorientation also noted, head to toe assessment done at this time, laceration of about 1 cm x 0.5 cm noted right side of the head, extensive bruising from his right shoulder to right lower back, vital signs recorded at this time within normal range, scant amount of blood noted to laceration site, emergency services called, emergency personnels arrive and assessed patient, resident was transported to hospital for further evaluation. Record review of Resident #1's progress notes, dated 06/22/2025, reflected RN C also documented patient fell at 00:51 am, unwitnessed, sustained penetrating injury to his head in the right temporal area. Had an extensive bruise from left shoulder blade diagonally to right waist area. The patient needs close monitoring because he isn't aware of usage of call light. The client is confused, needs one on one or baby monitoring to prevent further falls. Record review of the incident report completed by RN C, dated 06/22/2025, reflected Resident #1 had an unwitnessed fall and was discovered on the floor next to his bed. The incident report reflected Resident #1 stated he tried to get up and fell out of bed. Record review of Resident #1's hospital records, dated 06/23/2025, reflected Resident #1 was admitted to the emergency department on 06/22/2025 at 1:38 AM with a large left subdural hematoma (brain bleed) with a mid-line shift to the right (displacement of the brain away from center line). Resident #1 was not a candidate for surgical repair of the bleed and was placed on palliative care until he passed away in the hospital on [DATE] at 3:30 AM. During a telephone interview on 06/26/2025 at 10:42 AM, CNA D stated Resident #1 tried get up by himself all the time. CNA D stated Resident #1 used a walker and would take himself to the restroom without using the call light and waiting for assistance. She stated when she rounded on her residents, just a few minutes before Resident #1 fell, he was asleep. CNA D stated she was at the nurse's station when she heard someone say help me and found Resident #1 on the floor. CNA D stated she called for RN C to assess the resident and told the resident not to move. She stated Resident #1 told her that he hurt and when CNA D asked where, he said he wasn't sure. She stated RN C assessed Resident#1 and the resident had a laceration on the right side of his head and 2 reddish color marks on his back. She stated Resident #1 was taken to the hospital. During an interview with RN C on 06/26/25 12:54 PM, he stated he was the resident's nurse at the time of the fall on 06/22/2025. He stated CNA D notified him Resident #1 fell and he went to the resident's room and assessed him. RN C stated the resident had a laceration on the right side of his head. He stated he notified the physician and received an order to send Resident #1 to the hospital for evaluation. RN C stated Resident #1 was supposed to use his call light before getting up but did not always do that. During an interview on 06/26/25 at 1:35 PM, the Administrator stated staff notified him Resident #1 was sent to the hospital after a fall. The Administrator stated he called CNA D and RN C to get their statements. He stated he talked to all staff who cared for Resident #1 starting 24 hours before the fall to see if anyone had seen anything out of the normal for Resident #1. He stated staff had not noticed anything different about him. During an interview on 06/26/2025 at 4:18 PM, ADON B stated RN C reported at about midnight he went to Resident #1's room. He stated RN C told him the resident was on the floor next to his bed and had a cut on his head. ADON B stated when RN C asked what happened, Resident #1 stated he thought it was morning and was getting up to get dressed. ADON B stated RN C called 911 because Resident #1 hit his head when he fell, and he was sent to the hospital. ADON B stated Resident #1 had previous falls and therapy had worked with him for balance/gait. He stated the resident used a walker. During an interview on 06/27/25 at 8:55 AM, the Rehab Director stated therapy services were discontinued for Resident #1 on 06/09/2025 and the resident was walker level. She stated the resident fell on the Friday before the incident. She stated Resident #1 needed lots of verbal reminders to walk with someone and not by himself. She stated the resident would use his walker to go to the restroom in his room without calling for assistance. She stated Resident #1 had a walker and wheelchair in his room. She stated the resident had cognition/safety impairment. She stated if Resident #1's knees were bothering him, he would use his wheelchair for longer distances. She stated she had not observed a change in Resident #1's condition prior to his fall. During an interview on 07/02/2025 at 10:26 AM, CNA H stated she worked on different halls and was not working on Resident #1's hall the day he transferred to the hospital. She stated Resident #1 used a walker to go to the bathroom by himself and changed his clothes without assistance. She stated he was not considered a high fall risk. She stated she rounded and checked on Resident #1 and his roommate every two hours. She stated Resident #1 liked to sit in his recliner and watch television. She stated after his wife brought the recliner to the facility; Resident #1 also slept in it. She stated the resident walked to the dining room for breakfast and ate lunch in his room because his wife was visiting with him. She stated the day of the fall she saw Resident #1 in the hall using his walker and another time he was pushing his wheelchair. She stated Resident #1 sat in his wheelchair when he got tired. She stated she did not see any change in mobility or cognition prior to the fall. 2. Record review of Resident #2's Face Sheet, dated 07/02/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnoses which included aftercare following joint replacement surgery, bipolar disorder (extreme mood swings that include emotional highs and lows), COPD (lung condition that makes it difficult to breathe), limitation of activities due to disability, and the need for assistance with personal care. Resident #2 had discharged from the facility. Record review of Resident #2's admission MDS Assessment, dated 05/22/2025, reflected moderately impaired cognition with a BIMS score of 10. Section I (Active Diagnoses) reflected the need for assistance with personal care, limitation of activities due to disability, and unsteadiness on feet. Resident #2 discharged from the facility on 07/02/2025. Record review of Resident #2's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/16/2025. Interventions included staff x 1 to assist resident with transfers, ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #2's Comprehensive Care Plan, dated 04/28/2025, reflected The resident has an ADL Self Care Performance. Interventions included Bed Mobility: requires staff x1 for assistance. The resident uses a wheelchair. Toilet use: requires staff x1 for assistance. Record review of Resident #2's Fall Risk Assessments, dated 05/24/2025, 06/03/2025, and 06/12/2025, and 06/17/2025 reflected the resident was in the high risk category for falls. Record review of the facility's incident reports reflected Resident #2 had a fall on 05/24/2025, 05/25/2025, 05/27/2025, 6/17/2025, and 06/29/2025. The falls did not result in serious injury. 3. Record review of Resident #3's Face Sheet, dated 07/02/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #3 had diagnoses which included unspecified dementia (decline in mental ability that interferes with daily life) with behavioral disturbances, bipolar disorder, and unsteadiness on feet. Record review of Resident #3's Quarterly MDS Assessment, dated 05/23/2025, reflected severely impaired cognition with a BIMS score of 0. Section C (Cognitive Patterns) reflected the resident demonstrated inattention and disorganized thinking. Section GG (Functional Abilities) reflected Resident #3 required partial/moderate assistance with mobility. Record review of Resident #3's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/05/2025. Interventions included anticipate and meet the resident's needs and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #3's Fall Risk Assessments, dated 05/11/25, 06/24/25, 06/28/25, 06/29/25, and 07/01/25, reflected Resident #3 was in the high-risk category for falls. Record review of the facility's incident reports reflected Resident #3 had a fall on 5/11/2025, 06/08/2025, 06/24/2025, 6/28/2025, 06/29/2025, and 07/01/2025. The falls did not result in serious injury. A follow-up record review of Resident #3's Comprehensive Care Plan reflected additional fall prevention interventions were initiated on 07/01/2025 which included Resident is to wear a soft helmet when out of bed to help prevent fall with major head injury and FREQUENT RESIDENT MONITORING: staff is to ensure that they can visualized residents where about as frequent as possible to help with redirection. An observation on 07/02/2025 at 11:35 AM revealed Resident #3 sitting in the tv room with other residents in the memory care unit. An attempt to interview Resident #3 was unsuccessful because of her cognitive status. Resident #3 was wearing a helmet. During an interview on 07/03/2025 at 11:44 AM, LVN F stated worked in different areas, but was working in the memory care unit today. She stated staff used a lot of redirections with residents in the memory unit. She stated residents wandered and it was important to ensure the space was free of clutter. She stated someone always has to have their eye on the residents. During the interview, LVN F went to assist Resident #3 when she stood up. She stated staff walked with Resident #3 to ensure her safety. During an interview on 07/03/2025 at 11:52 AM, CNA N stated it was important to monitor residents closely especially those who were a high fall risk. She stated Resident #3 liked to get up and walk, but someone had to be with her to be sure she did not fall. She stated Resident #3 was wearing the hat to prevent injury because she had previous falls. Review of the facility's policy Preventive Strategies to Reduce Fall Risk, dated 10/05/2016, reflected The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Review of the facility's policy Falls/Ambulation Difficulty, dated 2003, reflected Risk factors should be assessed upon admission and thereafter as necessary. Risk factors will be identified for all residents. This was determined to be an Immediate Jeopardy (IJ) on 07/02/2025 at 5:21 PM. The Administrator, Director of Nurse, Area Director of Operations and Regional Compliance Nurse were notified. The Director of Nurses, Area Director of Operations, and Regional Compliance Nurse were provided with the IJ template on 07/02/2025 at 5:21 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 07/03/2024 at 1:04 PM. Facility: [Facility Name]Date: 07/02/2025Problem: F689 Accidents and Hazards Plan of Removal Interventions: 1. Resident #1 no longer resides in facility as of 6/22/25. Resident #2 has discharged from the facility and no longer resides in the facility as of 7/2/25. Resident #3 assessed 7/2/25 for fall risk and individual care plan updated to reflect that she is now part of the Falling Stars Program. In addition, new order for a soft-shell helmet to help prevent injury. 2. All residents in the facility were assessed on 7/2/25 for risk of falls or repeat fall residents. Active care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. 3. We have initiated the NEW Falling Star Program. All residents that have had 5 falls in the last 6 months have Falling Stars Program initiated. This includes notation on the care plan and daily shift acknowledgement that the resident is high risk for falls. Resident #3 is a part of the Falling Star Program Total number of falls in 6 months: 115. 9 residents were identified as high risk for falls due to 5 falls or greater within the last 6 months. 4. The Compliance Nurse in-serviced the Administrator, DON, and ADON 1:1 on the following topics below: This was completed on 7/2/25. All residents whom are identified at high risk of falls will have an active care plan with resident specific interventions with the addition of the falling stars high risk fall program. Upon admission, and as needed, all residents will be assessed for risk of falls. The care plan will reflect findings, interventions based off of each resident's assessment post fall with individualized intervention to prevent serious injury, and monitoring weekly to ensure fall interventions are effective and in place. Upon admission the nurse/designee will be responsible for developing and implementing interventions within the care plan of risk of falls based upon their assessment. Inservice on care plan location and how to access the care plan in PCC (online electronic health record), including how to identify a resident high risk of falls in the Kardex (documentation system used to access and modify resident information). The following in-services were initiated by the DON, ADON, Regional Compliance Nurse : Any staff member not present or in-serviced on 7/2/25, will not be allowed to assume their duties until in-serviced.Licensed Nurses and Therapy Staff:All residents whom are identified at high risk of falls will have an active care plan with resident specific interventions with the addition of the falling stars high risk fall program. Upon admission, and as needed, all residents will be assessed for risk of falls. The care plan will reflect findings, interventions based off of each resident's assessment post fall with individualized intervention to prevent serious injury, and monitoring weekly to ensure fall interventions are effective and in place. Upon admission the nurse/designee will be responsible for developing and implementing interventions within the care plan of risk of falls based upon their assessment. Inservice on care plan location and how to access the care plan in PCC, including how to identify a resident high risk of falls in the Kardex. The following in-services were initiated by the DON, ADON, Regional Compliance Nurse : Any staff member not present or in-serviced on 7/2/25, will not be allowed to assume their duties until in-serviced.Non-Licensed Nursing Staff Inservice on care plan location and how to access the care plan in PCC, including how to identify a resident high risk of falls in the Kardex. All residents whom are at risk of falls will have an active care plan with interventions and monitoring.Monitoring: The DON/ADON/Designee will monitor all incidents and fall risk assessment post fall in daily stand-up meeting for 6 weeks and then PRN to ensure all resident specific interventions are in place with active care plan. The DON/ADON/Designee will monitor admission assessments, daily stand-up meeting for 6 weeks to ensure all resident care plans reflect their risk of falls and resident specific interventions based off current care needs and status. The DON/ADON/Designee will monitor falling star program weekly for 6 weeks and then PRN to ensure resident specific interventions are in place.An ADHOC QAPI was completed on 7/2/25 with medical director and interdisciplinary team to discuss the immediate jeopardy and plan of removal.The medical director was notified of this plan and monitoring on 7/2/25 when IJ was called at 5:21PM.The QAPI committee will review findings and makes changes as needed.*Active care planning addresses all acute needs of the resident**All monitoring will be located in the IJ Binder**All residents are at risk for falls, 9 residents identified at high risk for falls**No active restraints within the facility* Observations on 07/03/2025 at 09:20 AM revealed facility staff had placed a yellow star on the name plates of the doors of Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 to indicate they were a high fall risk. In a follow-up interview with the DON on 07/03/2025 at 12:32 PM, she stated the facility implemented the falling stars program on 07/02/2025 so everyone would know which residents were a high fall risk. The DON stated staff placed yellow stars on the name plates on high fall risk residents' doors the evening before. She stated the staff received in-service training on 07/02/2025 related to fall risk and prevention. She stated CNAs were in-serviced to ensure they knew how to access resident care information in Kardex. She stated if a resident fell, the resident's nurse should immediately put an intervention in place and include it in the resident's care plan. She stated staff were to increase monitoring and ensure all care planned interventions, such as a fall mat, bed in the lowest position, non-slip pad for wheelchair seat, or helmet were in place for the falling stars or residents at high risk for falls. The DON stated the facility had at risk meetings every week and evaluated residents' care plans and put appropriate interventions in place. She stated staff also discussed any concerns or changes during the interdisciplinary team meetings. The DON stated it was important to ensure residents were assessed as needed and interventions put in place to provide resident centered care and keep the residents safe. In interviews with direct care facility staff on 07/03/2025, between 10:30 AM and 4:10 PM, the DON, ADON A, ADON B, the Rehab Director, the MDS Coordinator, the Physical Therapist, COTA, Hospitality Aide RN C, CNA D, CNA E, LVN F, CNA G, CNA H, Medication Aide I, LVN J , CNA K, Medication Aide L, RN M, CNA N, CNA O, CNA P, RN Q, CNA R, CNA S, CNA T, CNA U, CNA V stated in-service training was provided 07/03/2025 focused on the importance of keeping residents safe in the facility. Staff were reminded to ensure every transfer was safe for the resident. In-service training included to ensure residents wore socks that prevented slipping or had on appropriate fitting shoes. Staff stated high fall risk residents had a yellow star on their name plate on the door and the information was also included in the Kardex. CNAs stated they were responsible for communicating with the nurse if they were going on break or needed to leave the hall briefly. Nursing staff were in-serviced about assessing residents with each fall, putting a new resident specific intervention in place, and ensuring the care plan was updated. Nurses stated they were responsible for communicating with CNAs and ensuring call lights were answered which included the nurse answering call lights when the CNAs were busy with another resident. Timely completion of Elopement Assessments (all assessments;) When a Significant Change in Status documentation and/or re-assessment is required, and Examples of Decline. In interviews with other staff members on 07/03/2025 between 10:30 AM and 4:10 PM, the Maintenance Director, Social Service, Dietary Staff, Dietary Cook, and Housekeeping stated it was important to observe residents around them to ensure residents were safe in their environment and to report any concerns to nursing staff. Staff stated the facility placed yellow stars on the name plates of doors to identify residents who were at high risk for falls. Record review of residents identified as high risk for falls on 07/03/2025 at 10:45 AM revealed compliance with resident specific care plans and inclusion in the facility's falling star program. Record review on 07/03/2025 of In-service, High Fall Risk: Yellow Star, conducted by RCN, reflected all high-risk residents would have a yellow star next to their name on the door and a yellow star on the Kardex. The In-Service included a list of falling star residents. The In-service roster included signatures of direct care staff. Record review on 07/03/2025 of In-service, Fall Risk, Intervention, Prevention, Monitoring, Care Plan Update, conducted by RCN, reflected on admission, and as needed, all residents would be assessed for risk of falls and the care plan would reflect findings, interventions, and monitoring. The In-service included identifying risk factors, reducing environmental hazards, and prevention of unsafe transfers and ambulation. The In-service included evaluating the residents' footwear, daily routine, medications, and social and psychological needs. It also included assessment of resident's gait by physical therapy and/or a nurse. This In-service was provided to all facility staff. The Director of Nurses, Area Director of Operations, and Regional Compliance Nurse were informed the Immediate Jeopardy was removed on 07/03/2025 at 1:04 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 2. Record review of Resident #5's Face Sheet, dated 07/15/2025 at 11:31 AM revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Chronic Viral Hepatitis C (viral infection that causes inflammation and damages the liver,) Alcohol Abuse, Dementia (general decline in mental ability,) and bipolar disorder (mental illness that causes a shift in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks.) Record Review of Resident #5's Quarterly Minimum Data Set (MDS) dated [DATE], revealed his cognition was severely impaired with a Brief Interview Mental Status (BIMS) score of 03. He was wheelchair bound. Section E- Behavior E. 0900 Wandering - Presence & Frequency (1) Behavior of this type occurred 1 to 3 days. Record review of Resident #5 Comprehensive Care Plan on 07/15/2025 at 1:24 PM revealed no interventions related to wandering and/or elopement prior to the elopement incident on 07/12/2025. Record review of Resident #5's Elopement Risk Assessment - V5 upon admission dated 07/08/2025 revealed he was at a low risk for elopement with a score of 09. The assessment stated Resident #5: -Self-propels himself in a wheelchair-Understands and verbalizes acceptance of need for nursing home care-Has modified independence related to cognitive skills for daily decision making-No previous attempts to leave his residence/facility-No restlessness or anxiety Record Review of Resident #5's ELOPEMENT RISK ASSESSMENT V5 dated 07/13/2025. Resident #5 was scored as a 19. Indicating at high risk. C. Adjustment to facility - Verbalized anger and frustration re: placement D. Cognitive Skills - Moderately impaired - decisions poor; cues/supervision required. E. History - Previous attempts to leave facility - No attempts to leave facility. Review of Resident #5's Pre-admission Clinical Documents revealed Treatment Notes from a neurology provider on 04/29/2025 revealed: Patient is alert to self only. [Resident #5's RP] reports at that time [Provider] recommended him to be in a care facility. [Resident #5's RP] reports the facility. did not accept him because he was a flight risk. Review of Resident #5's Event Nurses Note by RN C, titled Elopement, dated 07/12/2025 at 9:15 PM revealed Resident #5 was missing at 7:10 PM, and his wheelchair was located at the exit door. At 7:15 PM, Resident #5 was located walking in the parking lot. Attempts to interview RN C on 07/15/2025 at 2:00 PM and 3:07 PM were unsuccessful. In an interview with SW on 07/15/2025 at 1:57 PM, she stated that Resident #5 was very confused as to where he was and why. Resident #5 voiced to her that he wanted to leave on 07/09/2025. SW stated she observed Resident #5 wandering up and down the hallway of the facility and stated he wanted to go home. She stated she reported this to the DON at this time. She stated that Resident #5's wandering behavior was discussed multiple times in morning meeting which served as the facility's interdisciplinary meeting. She did receive an in-service training that covered topics including abuse, elopement protocols, and internal emergency codes. During an interview on 07/16/2025 at 2:45 PM CNA P stated was not present during the recent elopement but had been advised of the incident. CNA P stated does not develop or participate in the care planning of residents, that is a nursing thing. CNA P stated did receive in-service training today, which covered elopement prevention and response, identifying high-risk residents, and the correct reporting process. CNA P stated that now residents who are at high risk for elopement will be identified by using the POC Kardex. In an interview with DON on 07/15/2025 at 12:55 PM, she stated on 07/09/2025, Resident #5 voiced to her that he was confused as to why he was at the facility. She stated he was confused but did not verbalize any desire to leave the facility. She did not recall if his wandering behaviors were discussed in the facility's morning meeting. She did not recall if SW reported to her his wandering behaviors on 07/09/2025. She stated that upon admission, Resident #5 was assessed as a low risk for elopement which did not warrant elopement precautions to be in place at that time. She stated she did not see any information in the Pre-admission Clinical Documents that he was an elopement risk. She stated it was her responsibility to review any pre-admission clinical documents and it was her responsibility to determine if a resident was appropriate for admission clinically. She stated she should have seen the treatment notes that stated he was a flight risk prior to admitting the resident. Additionally, DON stated her expectations were for Resident #5 to have been accurately assessed for elopement upon admission. She stated that accurate assessment and documentation was important. She stated when important information was not reviewed, someone that was high risk for elopement can be admitted inappropriately. Additionally, inaccurate assessment of a resident's elopement risk can result in elopements because relevant interventions will not be in place. She stated policy to discuss elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. During an interview on 07/16/2025 at 3:15 PM CNA T stated has been there for about a year now. CNA T stated was not p

Based on interview and record review, the facility failed to ensure the comprehensive care plan described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four (Residents #1, #2, #3, and #5) of nine residents reviewed for Comprehensive Care Plans.Based on interview and record review, the facility failed to ensure the comprehensive care plan described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Residents #1. #2. #3 and #5) of nine residents reviewed for Comprehensive Care Plans.1.A. The facility failed to implement and modify interventions to ensure Resident #1 did not experience 7 falls after admitting to the facility on [DATE], and as a result of the last fall on 06/22/2025, sustain a head injury which resulted in the resident's death in the hospital on [DATE]. B. The facility failed to implement and modify interventions to ensure Resident #2 did not experience 5 falls after admitting to the facility on [DATE] with a right hip fracture resulting from a fall at home. C. The facility failed to implement and modify interventions to ensure Resident #3 did not experience 5 falls after admitting to the facility on [DATE]. The facility failed to create , implement and revise care plans to meet the medical , nursing, mental and psychosocial needs identified in the comprehensive assessment related to falls with appropriate and effective interventions . These failures placed residents at risk of serious injury and death. 2.The facility failed to devise and implement any Comprehensive Care Plan goals and/or interventions for Resident #5's documented wandering, exit seeking, and/or elopement behavior on 07/08/2025 to prevent an incident of elopement by Resident #1 on 07/12/2025. The care plan showed no elopement intervention until 07/13/2025. The first non-compliance was identified, and an Immediate Jeopardy (IJ) situation was identified on 07/02/2025. The IJ was removed on 07/16/2025. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The second non-compliance was identified, and an Immediate Jeopardy (IJ) Template was presented to facility Administrator and DON on 07/15/2025 at 5:37 PM. The IJ was removed on 07/16/2025. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. Findings Included: 1.1. Record review of Resident #1's Face Sheet, dated 06/26/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's disease (movement disorder of the nervous system that worsens over time), unspecified abnormalities of gait (walking pattern) and mobility, and a history of falls. Record review of Resident #1's admission MDS (tool used to assess health status) Assessment, dated 04/19/2025, reflected moderately impaired cognition with a BIMS (screening tool to assess cognitive status) score of 10. Section J (Health Conditions) reflected Resident #1 had 2 or more falls since admission with no injury. Record review of Resident #1's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/25/2025. Interventions included staff x 1 to assist resident with transfers, ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in his wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #1's Fall Risk Assessments, dated 06/12/2025, 06/20/2025, and 06/22/2025, reflected Resident #1 was in the high-risk category for falls. Record review of the facility's incident reports reflected Resident #1 fell on [DATE], 04/11/2025, 04/15/2025, 04/20/2025, 05/25/2025, 06/10/2025, 6/20/2025 which did not result in a serious injury. Resident #1 was sent to the hospital after he fell on [DATE]. Record review of Resident #1's progress notes, dated 06/13/2025, reflected RN C documented This client is somewhat confused. He does not abide by the nurses' instructions about his safety and constantly gets out of the recliner and makes movements that could severely hurt him. He slid out of the recliner at 2145. Once we put him in bed, 30 minutes later, we found him by the door in his chair, naked.We need a baby monitor so that the nurse can see him from the nurse's station. Record review of Resident #1's progress notes, dated 06/20/2025, reflected RN X documented This nurse was called by an Aide that resident was on the floor. Resident was lying next to his recliner and bed. Resident said he was trying to use the bathroom. Resident was lifted off the floor with a Hoyer lift. Resident sustained a skin tear on his right elbow. Site was cleaned and covered with border dressing. Resident assessed and his vital signs were normal. DON, family, and NP were notified. Record review of Resident #1's progress notes, dated 06/22/2025, reflected RN C documented nurse was called to resident room and observed resident on the floor next to the bed, resident is alert and able to response to verbal commands, disorientation also noted, head to toe assessment done at this time, laceration of about 1 cm x 0.5 cm noted right side of the head, extensive bruising from his right shoulder to right lower back, vital signs recorded at this time within normal range, scant amount of blood noted to laceration site, emergency services called, emergency personnels arrive and assessed patient, resident was transported to hospital for further evaluation. Record review of Resident #1's progress notes, dated 06/22/2025, reflected RN C also documented patient fell at 00:51 am, unwitnessed, sustained penetrating injury to his head in the right temporal area. Had an extensive bruise from left shoulder blade diagonally to right waist area. The patient needs close monitoring because he isn't aware of usage of call light. The client is confused, needs one on one or baby monitoring to prevent further falls. Record review of the incident report completed by RN C, dated 06/22/2025, reflected Resident #1 had an unwitnessed fall and was discovered on the floor next to his bed. The incident report reflected Resident #1 stated he tried to get up and fell out of bed. Record review of Resident #1's hospital records, dated 06/23/2025, reflected Resident #1 was admitted to the emergency department on 06/22/2025 at 1:38 AM with a large left subdural hematoma (brain bleed) with a mid-line shift to the right (displacement of the brain away from center line). Resident #1 was not a candidate for surgical repair of the bleed and was placed on palliative care until he passed away in the hospital on [DATE] at 3:30 AM. During a telephone interview on 06/26/2025 at 10:42 AM, CNA D stated Resident #1 tried get up by himself all the time. CNA D stated Resident #1 used a walker and would take himself to the restroom without using the call light and waiting for assistance. She stated when she rounded on her residents, just a few minutes before Resident #1 fell, he was asleep. CNA D stated she was at the nurse's station when she heard someone say help me and found Resident #1 on the floor. CNA D stated she called for RN C to assess the resident and told the resident not to move. She stated Resident #1 told her that he hurt and when CNA D asked where, he said he wasn't sure. She stated RN C assessed Resident#1 and the resident had a laceration on the right side of his head and 2 reddish color marks on his back. She stated Resident #1 was taken to the hospital. During an interview with RN C on 06/26/25 12:54 PM, he stated he was the resident's nurse at the time of the fall on 06/22/2025. He stated CNA D notified him Resident #1 fell and he went to the resident's room and assessed him. RN C stated the resident had a laceration on the right side of his head. He stated he notified the physician and received an order to send Resident #1 to the hospital for evaluation. RN C stated Resident #1 was supposed to use his call light before getting up but did not always do that. During an interview on 06/26/25 at 1:35 PM, the Administrator stated staff notified him Resident #1 was sent to the hospital after a fall. The Administrator stated he called CNA D and RN C to get their statements. He stated he talked to all staff who cared for Resident #1 starting 24 hours before the fall to see if anyone had seen anything out of the normal for Resident #1. He stated staff had not noticed anything different about him. During an interview on 06/26/2025 at 4:18 PM, ADON B stated RN C reported at about midnight he went to Resident #1's room. He stated RN C told him the resident was on the floor next to his bed and had a cut on his head. ADON B stated when RN C asked what happened, Resident #1 stated he thought it was morning and was getting up to get dressed. ADON B stated RN C called 911 because Resident #1 hit his head when he fell, and he was sent to the hospital. ADON B stated Resident #1 had previous falls and therapy had worked with him for balance/gait. He stated the resident used a walker. During an interview on 06/27/25 at 8:55 AM, the Rehab Director stated therapy services were discontinued for Resident #1 on 06/09/2025 and the resident was walker level. She stated the resident fell on the Friday before the incident. She stated Resident #1 needed lots of verbal reminders to walk with someone and not by himself. She stated the resident would use his walker to go to the restroom in his room without calling for assistance. She stated Resident #1 had a walker and wheelchair in his room. She stated the resident had cognition/safety impairment. She stated if Resident #1's knees were bothering him, he would use his wheelchair for longer distances. She stated she had not observed a change in Resident #1's condition prior to his fall. During an interview on 07/02/2025 at 10:26 AM, CNA H stated she worked on different halls and was not working on Resident #1's hall the day he transferred to the hospital. She stated Resident #1 used a walker to go to the bathroom by himself and changed his clothes without assistance. She stated he was not considered a high fall risk. She stated she rounded and checked on Resident #1 and his roommate every two hours. She stated Resident #1 liked to sit in his recliner and watch television. She stated after his wife brought the recliner to the facility; Resident #1 also slept in it. She stated the resident walked to the dining room for breakfast and ate lunch in his room because his wife was visiting with him. She stated the day of the fall she saw Resident #1 in the hall using his walker and another time he was pushing his wheelchair. She stated Resident #1 sat in his wheelchair when he got tired. She stated she did not see any change in mobility or cognition prior to the fall. 2. Record review of Resident #2's Face Sheet, dated 07/02/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnoses which included aftercare following joint replacement surgery, bipolar disorder (extreme mood swings that include emotional highs and lows), COPD (lung condition that makes it difficult to breathe), limitation of activities due to disability, and the need for assistance with personal care. Resident #2 had discharged from the facility. Record review of Resident #2's admission MDS Assessment, dated 05/22/2025, reflected moderately impaired cognition with a BIMS score of 10. Section I (Active Diagnoses) reflected the need for assistance with personal care, limitation of activities due to disability, and unsteadiness on feet. Resident #2 discharged from the facility on 07/02/2025. Record review of Resident #2's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/16/2025. Interventions included staff x 1 to assist resident with transfers, ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #2's Comprehensive Care Plan, dated 04/28/2025, reflected The resident has an ADL Self Care Performance. Interventions included Bed Mobility: requires staff x1 for assistance. The resident uses a wheelchair. Toilet use: requires staff x1 for assistance. Record review of Resident #2's Fall Risk Assessments, dated 05/24/2025, 06/03/2025, and 06/12/2025, and 06/17/2025 reflected the resident was in the high risk category for falls. Record review of the facility's incident reports reflected Resident #2 had a fall on 05/24/2025, 05/25/2025, 05/27/2025, 6/17/2025, and 06/29/2025. The falls did not result in serious injury. 3. Record review of Resident #3's Face Sheet, dated 07/02/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #3 had diagnoses which included unspecified dementia (decline in mental ability that interferes with daily life) with behavioral disturbances, bipolar disorder, and unsteadiness on feet. Record review of Resident #3's Quarterly MDS Assessment, dated 05/23/2025, reflected severely impaired cognition with a BIMS score of 0. Section C (Cognitive Patterns) reflected the resident demonstrated inattention and disorganized thinking. Section GG (Functional Abilities) reflected Resident #3 required partial/moderate assistance with mobility. Record review of Resident #3's Comprehensive Care Plan, dated 04/28/2025, reflected the focus resident at risk for falls was initiated on 05/05/2025. Interventions included anticipate and meet the resident's needs and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect each fall or a new intervention after each fall. Record review of Resident #3's Fall Risk Assessments, dated 05/11/25, 06/24/25, 06/28/25, 06/29/25, and 07/01/25, reflected Resident #3 was in the high-risk category for falls. Record review of the facility's incident reports reflected Resident #3 had a fall on 5/11/2025, 06/08/2025, 06/24/2025, 6/28/2025, 06/29/2025, and 07/01/2025. The falls did not result in serious injury. A follow-up record review of Resident #3's Comprehensive Care Plan reflected additional fall prevention interventions were initiated on 07/01/2025 which included Resident is to wear a soft helmet when out of bed to help prevent fall with major head injury and FREQUENT RESIDENT MONITORING: staff is to ensure that they can visualized residents where about as frequent as possible to help with redirection. An observation on 07/02/2025 at 11:35 AM revealed Resident #3 sitting in the tv room with other residents in the memory care unit. An attempt to interview Resident #3 was unsuccessful because of her cognitive status. Resident #3 was wearing a helmet. During an interview on 07/03/2025 at 11:44 AM, LVN F stated worked in different areas, but was working in the memory care unit today. She stated staff used a lot of redirections with residents in the memory unit. She stated residents wandered and it was important to ensure the space was free of clutter. She stated someone always has to have their eye on the residents. During the interview, LVN F went to assist Resident #3 when she stood up. She stated staff walked with Resident #3 to ensure her safety. During an interview on 07/03/2025 at 11:52 AM, CNA N stated it was important to monitor residents closely especially those who were a high fall risk. She stated Resident #3 liked to get up and walk, but someone had to be with her to be sure she did not fall. She stated Resident #3 was wearing the hat to prevent injury because she had previous falls. Review of the facility's policy Preventive Strategies to Reduce Fall Risk, dated 10/05/2016, reflected The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Review of the facility's policy Falls/Ambulation Difficulty, dated 2003, reflected Risk factors should be assessed upon admission and thereafter as necessary. Risk factors will be identified for all residents. This was determined to be an Immediate Jeopardy (IJ) on 07/02/2025 at 5:21 PM. The Administrator, Director of Nurse, Area Director of Operations and Regional Compliance Nurse were notified. The Director of Nurses, Area Director of Operations, and Regional Compliance Nurse were provided with the IJ template on 07/02/2025 at 5:21 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 07/03/2024 at 1:04 PM. Facility: [Facility Name]Date: 07/02/2025Problem: F689 Accidents and Hazards Plan of Removal Interventions: 1. Resident #1 no longer resides in facility as of 6/22/25. Resident #2 has discharged from the facility and no longer resides in the facility as of 7/2/25. Resident #3 assessed 7/2/25 for fall risk and individual care plan updated to reflect that she is now part of the Falling Stars Program. In addition, new order for a soft-shell helmet to help prevent injury. 2. All residents in the facility were assessed on 7/2/25 for risk of falls or repeat fall residents. Active care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse. 3. We have initiated the NEW Falling Star Program. All residents that have had 5 falls in the last 6 months have Falling Stars Program initiated. This includes notation on the care plan and daily shift acknowledgement that the resident is high risk for falls. Resident #3 is a part of the Falling Star Program Total number of falls in 6 months: 115. 9 residents were identified as high risk for falls due to 5 falls or greater within the last 6 months. 4. The Compliance Nurse in-serviced the Administrator, DON, and ADON 1:1 on the following topics below: This was completed on 7/2/25. All residents whom are identified at high risk of falls will have an active care plan with resident specific interventions with the addition of the falling stars high risk fall program. Upon admission, and as needed, all residents will be assessed for risk of falls. The care plan will reflect findings, interventions based off of each resident's assessment post fall with individualized intervention to prevent serious injury, and monitoring weekly to ensure fall interventions are effective and in place. Upon admission the nurse/designee will be responsible for developing and implementing interventions within the care plan of risk of falls based upon their assessment. Inservice on care plan location and how to access the care plan in PCC (online electronic health record), including how to identify a resident high risk of falls in the Kardex (documentation system used to access and modify resident information). The following in-services were initiated by the DON, ADON, Regional Compliance Nurse : Any staff member not present or in-serviced on 7/2/25, will not be allowed to assume their duties until in-serviced.Licensed Nurses and Therapy Staff:All residents whom are identified at high risk of falls will have an active care plan with resident specific interventions with the addition of the falling stars high risk fall program. Upon admission, and as needed, all residents will be assessed for risk of falls. The care plan will reflect findings, interventions based off of each resident's assessment post fall with individualized intervention to prevent serious injury, and monitoring weekly to ensure fall interventions are effective and in place. Upon admission the nurse/designee will be responsible for developing and implementing interventions within the care plan of risk of falls based upon their assessment. Inservice on care plan location and how to access the care plan in PCC, including how to identify a resident high risk of falls in the Kardex. The following in-services were initiated by the DON, ADON, Regional Compliance Nurse : Any staff member not present or in-serviced on 7/2/25, will not be allowed to assume their duties until in-serviced.Non-Licensed Nursing Staff Inservice on care plan location and how to access the care plan in PCC, including how to identify a resident high risk of falls in the Kardex. All residents whom are at risk of falls will have an active care plan with interventions and monitoring.Monitoring: The DON/ADON/Designee will monitor all incidents and fall risk assessment post fall in daily stand-up meeting for 6 weeks and then PRN to ensure all resident specific interventions are in place with active care plan. The DON/ADON/Designee will monitor admission assessments, daily stand-up meeting for 6 weeks to ensure all resident care plans reflect their risk of falls and resident specific interventions based off current care needs and status. The DON/ADON/Designee will monitor falling star program weekly for 6 weeks and then PRN to ensure resident specific interventions are in place.An ADHOC QAPI was completed on 7/2/25 with medical director and interdisciplinary team to discuss the immediate jeopardy and plan of removal.The medical director was notified of this plan and monitoring on 7/2/25 when IJ was called at 5:21PM.The QAPI committee will review findings and makes changes as needed.*Active care planning addresses all acute needs of the resident**All monitoring will be located in the IJ Binder**All residents are at risk for falls, 9 residents identified at high risk for falls**No active restraints within the facility* Observations on 07/03/2025 at 09:20 AM revealed facility staff had placed a yellow star on the name plates of the doors of Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 to indicate they were a high fall risk. In a follow-up interview with the DON on 07/03/2025 at 12:32 PM, she stated the facility implemented the falling stars program on 07/02/2025 so everyone would know which residents were a high fall risk. The DON stated staff placed yellow stars on the name plates on high fall risk residents' doors the evening before. She stated the staff received in-service training on 07/02/2025 related to fall risk and prevention. She stated CNAs were in-serviced to ensure they knew how to access resident care information in Kardex. She stated if a resident fell, the resident's nurse should immediately put an intervention in place and include it in the resident's care plan. She stated staff were to increase monitoring and ensure all care planned interventions, such as a fall mat, bed in the lowest position, non-slip pad for wheelchair seat, or helmet were in place for the falling stars or residents at high risk for falls. The DON stated the facility had at risk meetings every week and evaluated residents' care plans and put appropriate interventions in place. She stated staff also discussed any concerns or changes during the interdisciplinary team meetings. The DON stated it was important to ensure residents were assessed as needed and interventions put in place to provide resident centered care and keep the residents safe. In interviews with direct care facility staff on 07/03/2025, between 10:30 AM and 4:10 PM, the DON, ADON A, ADON B, the Rehab Director, the MDS Coordinator, the Physical Therapist, COTA, Hospitality Aide RN C, CNA D, CNA E, LVN F, CNA G, CNA H, Medication Aide I, LVN J , CNA K, Medication Aide L, RN M, CNA N, CNA O, CNA P, RN Q, CNA R, CNA S, CNA T, CNA U, CNA V stated in-service training was provided 07/03/2025 focused on the importance of keeping residents safe in the facility. Staff were reminded to ensure every transfer was safe for the resident. In-service training included to ensure residents wore socks that prevented slipping or had on appropriate fitting shoes. Staff stated high fall risk residents had a yellow star on their name plate on the door and the information was also included in the Kardex. CNAs stated they were responsible for communicating with the nurse if they were going on break or needed to leave the hall briefly. Nursing staff were in-serviced about assessing residents with each fall, putting a new resident specific intervention in place, and ensuring the care plan was updated. Nurses stated they were responsible for communicating with CNAs and ensuring call lights were answered which included the nurse answering call lights when the CNAs were busy with another resident. Timely completion of Elopement Assessments (all assessments;) When a Significant Change in Status documentation and/or re-assessment is required, and Examples of Decline. In interviews with other staff members on 07/03/2025 between 10:30 AM and 4:10 PM, the Maintenance Director, Social Service, Dietary Staff, Dietary Cook, and Housekeeping stated it was important to observe residents around them to ensure residents were safe in their environment and to report any concerns to nursing staff. Staff stated the facility placed yellow stars on the name plates of doors to identify residents who were at high risk for falls. Record review of residents identified as high risk for falls on 07/03/2025 at 10:45 AM revealed compliance with resident specific care plans and inclusion in the facility's falling star program. Record review on 07/03/2025 of In-service, High Fall Risk: Yellow Star, conducted by RCN, reflected all high-risk residents would have a yellow star next to their name on the door and a yellow star on the Kardex. The In-Service included a list of falling star residents. The In-service roster included signatures of direct care staff. Record review on 07/03/2025 of In-service, Fall Risk, Intervention, Prevention, Monitoring, Care Plan Update, conducted by RCN, reflected on admission, and as needed, all residents would be assessed for risk of falls and the care plan would reflect findings, interventions, and monitoring. The In-service included identifying risk factors, reducing environmental hazards, and prevention of unsafe transfers and ambulation. The In-service included evaluating the residents' footwear, daily routine, medications, and social and psychological needs. It also included assessment of resident's gait by physical therapy and/or a nurse. This In-service was provided to all facility staff. The Director of Nurses, Area Director of Operations, and Regional Compliance Nurse were informed the Immediate Jeopardy was removed on 07/03/2025 at 1:04 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 2.Record review of Resident #5's Face Sheet on 07/15/2025 at 11:31 AM revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Chronic Viral Hepatitis C (viral infection that causes inflammation and damages the liver,) Alcohol Abuse, Dementia (general decline in mental ability,) and bipolar disorder (mental illness that causes a shift in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks.) Record Review of Resident #5's Quarterly Minimum Data Set (MDS) dated [DATE], revealed his cognition was severely impaired with a Brief Interview Mental Status (BIMS) score of 03. He was wheelchair bound. Section E- Behavior E. 0900 Wandering - Presence & Frequency (1) Behavior of this type occurred 1 to 3 days. Record review of Resident #5's Comprehensive Care Plan dated 07/08/2025, revealed no interventions related to wandering and/or elopement prior to the elopement incident on 07/12/2025. Record Review of Resident #5's ELOPEMENT RISK ASSESSMENT V5 dated 07/08/2025. Resident #5 Scored out as a 9, shows him to be low risk for elopement. B. Physical Capability - Self propels wheelchair C. Adjustment to Facility - Understand ad verbalizes acceptance of need for nursing home careD. Cognitive Skills for Daily Decision Making - Modified independence - some difficulty in new situations only E. History - No attempts to leave own residence/facility Record Review of Resident #5's ELOPEMENT RISK ASSESSMENT V5 dated 07/13/2025. Resident #5 Scored out as a 19 shows him to be a high risk for elopement. C. Adjustment to facility - Verbalized anger and frustration re: placement D. Cognitive Skills - Moderately impaired - decisions poor; cues/supervision required. E. History - Previous attempts to leave facility - No attempts to leave facility Record Review of facility's Incident Report for July 2025, dated 07/16/2025, revealed no documentation of Resident #5's wandering, exit seeking, and/or elopement behavior/incident from 07/08/2025.Review of Resident #5's Pre-admission Clinical Documents revealed Treatment Notes from a neurology provider on 04/29/2025 revealed Patient is alert to self only. [Resident #5's RP] reports at that time [Provider] recommended him to be in a care facility. [Resident #5's RP] reports the facility. did not accept him because he was a flight risk. During an interview on 07/16/2025 at 2:15 PM ADON stated she believed Resident #5 was care planned for the Elopement. ADON said she knew Resident #5 had an Elopement Risk Assessment completed previously and thought it had already been care planned. ADON stated that the MDS nurse was responsible for preparing and updating care plans. The ADON indicated the purpose of care plans was to inform direct care staff about resident care needs and preferences. The ADON stated the Care Plan can be reviewed at any time. She added the care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI (Resident Assessment Instrument) manual. Additional updates to the care plan may be done as indicated. ADON stated it was the responsibility of the DON, MDS Coordinator to make sure care plans were updated. The ADON confirmed participation in an in-service training that covered topics including abuse, elopement protocols, and internal emergency codes.During a follow up interview on 07/16/2025 at 2:40 PM with SW she stated she has only been there about 3 months. Stated not entirely yet involved in the Care Planning of things still learning all the procedures. SW stated if resident was assessed it should have been in their care plan as an Elopement Risk. SW stated she was not working on the date the Elopement occurred. The SW stated the main focus and purpose of care plans was to inform direct care staff, about resident care needs and preferences. SW stated the care plan can be reviewed at any time. The SW stated the care plan can and should be updated as soon as a change in condition is noted. If not, the care plan should be updated and reviewed at least quarterly thereafter, then annually unless any significant changes occur. The SW stated she did receive an in-service training that covered topics including abuse, elopement protocols, and internal emergency codes.During an interview on 07/16/2025 at 3:35 PM DM stated has been DM for 5 years. DM stated is not involved specifically in care planning, unless there are dietary concerns, then both she and the dietician, become involved with the care plan. The care plan should serve as a guide, which should direct care needs, care choices and care preferences of the resident. DM stated it would have a negative affect if a resident had needs not properly cared planned, in terms of dietary issues from the types of food, how it is prepared and what they can and cannot eat. DM stated she did receive in-service training that covered topics including abuse, elopement protocols, and internal emergency codes.During an interview on 07/16/2025 at 3:53 PM AD stated have been an AD for 3 months. Stated not familiar with too much of the care planning of residents, she has her own type of care plan,

Based on observations, interview, and record review, the facility failed to ensure resident received adequate monitoring, supervision, and/or assistive devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents, hazards, and supervision. On 03/07/2025, the facility failed to identify potential hazards and follow internal systems in place to prevent Resident #1's elopement from the facility approximately two hours and twenty minutes after his admission. He was located approximately two hours later by local law enforcement approximately 1 mile east of the facility. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator on 04/17/2025 at 4:24 PM. The noncompliance began on 03/07/2025 and ended on 03/07/2025. The facility corrected the noncompliance before the investigation began . This failure could place residents at the facility at risk of injury and a decreased quality of life due to the lack of supervision and care that residents need to be safe. Findings Included: Review of Resident #1's Face Sheet, dated 04/17/2025 revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnosis included dementia. Review of Resident #1's Baseline Care Plan, completed after his elopement, dated 03/07/2025 revealed he was and/or had: -At Risk for falls -Impaired cognitive function related to dementia -Required antidepressant and antipsychotic medication -ADL self-care performance deficit -At risk for wandering and had history an elopement at the facility on 03/07/2025 Review of Resident #1's Admission MDS, completed after his elopement, dated 03/07/2025 revealed he admitted from a short-term general hospital. No other relevant information was stated. Attempts were made to interview Resident #1 on 04/17/2025 at 10:00 am and 2:00 pm were not successful. In an interview with facility's ADON on 04/17/2025 at 1:00 PM, he revealed he was assisting with Resident #1's admission on 03/07/2025. He stated that Resident #1 was admitted at approximately 12:00 PM that day and was alert to self and his location but had intermittent confusion. He stated he oriented Resident #1 to his room and then directed the resident to the dining area for lunch. He stated after lunch at approximately 2:20 PM, Resident #1 was seen at the north nurse's station talking to another resident. He stated Resident #1 did not appear to be in any distress at this time, did not voice to him that he wanted to leave, and did not seem confused as to where he was located. When Resident #1 was observed in his room, he was unpacking his belongings into the facility's closet and armoire. The ADON stated at approximately 3:00 PM, Resident #1 could not be located and a code orange [indicating a missing resident] was implemented. Around approximately 5:00 PM local law enforcement reported to the facility Resident #1 was located and was returned to the facility at approximately 5:30 PM. Upon Resident #1's return to the facility, he was thoroughly assessed and appeared the same from admission, was not in any distress , and upon interview he reported to him that a friend gave him a ride to somewhere but could not state any further specifics. The ADON stated he did not state how he exited the facility and was not harmed per assessment. The ADON stated the resident was placed on 1:1 supervision in the secured unit and was transferred to a sister facility by approximately 7:00 PM that evening. He stated it was important to keep residents in the facility for proper monitoring, care, and supervision. In interview with the facility's DON on 04/21/2025 at 1:28 PM, she stated she was not present for this incident, but she stated it was important to keep residents in the facility for proper monitoring, care, and supervision. In interview with the facility Administrator on 04/17/2025 at 1:13 PM, he stated he was not present at the time of the elopement but responded to the event afterwards. He stated it was important to keep residents in the facility for proper monitoring, care, and supervision. The Administrator further stated that he and his leadership team reviewed Resident #1's pre-admission clinical documents and nothing seemed concerning related to wandering and/or elopement. He stated that if he did see any concerning information related to the resident's wandering risk, he would not have admitted Resident #1 because the secured unit at the facility was female-only. He stated that the resident was not present at the facility long enough for his staff to complete all the admission assessments required. He stated his expectations were for the admission assessments to be completed within four hours of admission. He stated that Resident #1 eloped from the facility within two hours and twenty minutes of his admission. The administrator stated that the post-elopement interventions for Resident #1 included: -Physician and responsible party notification -Head-to-toe assessment completed and no injuries noted -Trauma-informed assessment completed and no trauma noted -Elopement risk assessments were immediately reviewed for all residents at the facility -Exit doors reviewed and inspected to be in working order -All resident care plans reviewed for high-risk for elopement residents -In-services to staff related to the incident were provided -A sign was placed at the skilled nursing entrance instructing families to ensure residents do not exit building -A hinged transparent cover on top of the green exit button was installed so someone with cognitive limitations would have a harder time locating it to prevent future elopements -Upon his return to the facility, Resident #1 was placed in the secured unit under 1:1 supervision prior to his transfer to a co-ed secured unit at a sister facility later that evening. In observation on 04/17/2025 at 1:00 PM with facility's ADON, facility exit doors were tested and inspected to be in working order, a sign located on the skilled nursing entrance that stated to ensure residents do not exit the building was observed, and a hinged, transparent cover was observed on top of the green exit button by the facility's entrance and exit doorway. Record review of facility's elopement drill, Internal Disaster Drill Form, dated 03/07/2025 at 3:00 PM provided by the facility's ADO revealed signatures from staff from all disciplines, departments, and shifts revealed Real Event, Missing Resident, police department was involved, and the duration of the drill was 2 hours. The narrative was listed as [Police Department] notified to assist in finding missing resident . Found approximately 5:00 PM. Record review of facility's In-service Trainings, Identifying at Risk Residents and Assessments, Elopement Policy and Procedure, One on one door monitoring, and Abuse and Neglect, dated 03/07/2025 provided by the facility's ADO revealed multiple signatures from staff from multiple disciplines, departments, and shifts covered. Education provided included: Identifying at Risk Residents and Assessments -Elopement risk assessment protocol -Assessments are for people that score above a 10 on elopement assessments -Staff are to be familiar with the resident's care needs and risk for wandering and elopement -Clinical staff are responsible to ensure assessments are completed and safety measures are in place and implemented Elopement Policy and Procedure -Every effort will be made to prevent elopement while maintaining the least restrictive environment for residents at risk or elopement -Clinical staff are required to assess residents for elopement risk and ensure safety measures are in place and implemented -Code Orange Procedures and delegation of roles, tasks -How to identify the cause of wandering -Intervention strategies that include: reducing discomfort, labeling residents room clearly, maintain a resident's routine, schedule ambulation and toileting, and reducing excess stimulation One on one door monitoring -Staff are required to monitor of and document on resident at all times until monitoring is discontinued Abuse and Neglect -Definition of abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion -Procedure for reporting any abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion to the abuse coordinator -Leadership is required to conduct a comprehensive investigation for all allegations abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion In interview with multiple staff over multiple disciplines, departments, and shifts included Administrator, ADO, CC, DON, ADON, SW, AD, [NAME] I, [NAME] J, [NAME] K, DA L, HSK M, HSK N, HSK O, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, and LVN B between 04/17/2025 and 04/21/2025 between 9:00 AM - 5:00 PM, they stated information related to their discipline that included how elopement risk assessment protocol relates to their job role, clinical staff were able to report that a resident is considered high risk when they score above a 10 on an elopement assessment, staff are required to be familiar with the resident's care needs and risk for wandering and elopement, clinical staff are responsible to ensure assessments are completed and safety measures are in place and implemented, that every effort will be made to prevent elopement while maintaining the least restrictive environment for residents at risk or elopement, clinical staff are required to assess residents for elopement risk and ensure safety measures are in place and implemented, reported information related to Code Orange and delegation of roles, how to identify the and causes/triggers of wandering, and intervention strategies that include: reducing discomfort, labeling residents room clearly, maintain a resident's routine, schedule ambulation and toileting, and reducing excess stimulation. Additionally, relevant staff reported they are required to monitor and document on resident at all times after an elopement or wandering behaviors are exhibited until monitoring is discontinued. Finally, staff were able to report the definition of abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion, the procedure for reporting any abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion to the abuse coordinator, and that leadership is required to conduct a comprehensive investigation for all allegations abuse, neglect, exploitation, misappropriation of property, mistreatment, and involuntary seclusion. Staff confirmed an elopement drill was conducted on 03/07/2025 and that Resident #1 was transferred to a secured unit the same day of the incident. In review of facility policy, Elopement Prevention, dated 01/2023 revealed Every effort will be made to prevent elopement while maintaining the least restrictive environment for residents at risk or elopement . 1. The Elopement Risk Assessment will be completed upon admission . the assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #99) of two residents reviewed for quality of care. 1. The facility failed to ensure physician orders for treatment, care, and monitoring of Resident #99's surgical site incision was obtained upon admission resulting a subsequent infection that required hospitalization and surgical intervention. 2. The facility failed to complete and document any skin/incision/wound assessments of Resident #99's surgical incision site resulting a subsequent infection that required hospitalization and surgical intervention. 3. The facility failed to develop a baseline care plan that addressed Resident #99's surgical care needs. An Immediate Jeopardy (IJ) situation was identified on 11/08/2024 at 12:35 PM. The IJ was removed on 11/27/2024 at 3:15 PM the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed Resident #99 at risk of not receiving timely medical intervention as needed and ordered by the physician, of not having their health condition monitored timely for changes in condition, which resulted in a delay in medical intervention and decline in health for Resident #99. As a result of these failures, Resident #99 was readmitted to the hospital on 11/08/2024 and required further treatment, surgeries, IV antibiotics, and medical devices. Findings include: Record review of Resident #99's Face Sheet, dated 11/07/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #99 had relevant diagnoses which included metabolic encephalopathy (alteration in consciousness caused by diffuse or global brain dysfunction from impaired cerebral metabolism,) subluxation of lumbar vertebra (misalignment of spine,) wedge compression fracture of thoracic vertebrae (one or more back bones collapse,) protein-calorie malnutrition, anxiety (persistent nervousness, anxiety, and/or restlessness) and major depressive disorder (persistent low mood.) Record review of Resident #99's MDS dated [DATE], reflected she was cognitively intact with a BIMS score of 15. She required a wheelchair for mobility and required substantial/maximal assistance with toileting and shower/baths which included transfers. Record review of Resident #99's Baseline Care Plan dated 09/26/2024 at 2:30 PM revealed no evidence of surgical site assessment, treatment, or care documentation. Record review of Resident #99's Comprehensive Care Plan was not available for review due to the resident's short-term stay at the facility. Record review of Resident #99's Physician Orders reflected her attending physician as Dr N, Admit to Skilled Services Under The Care of [Dr N] effective 09/20/2024. No orders stated monitoring of surgical site and/or treatment and care from Dr N were observed. Record review of Resident #99's Physician Orders from Dr L stated Clean surgical site on lower back with normal saline, pat dry and apply dry dressing one time a day for wound care start date 10/05/2024. An order to monitor surgical site stated, Monitor surgical site for infection one time a day for wound care start date 10/05/2024. Record review of Resident #99's Physician Orders on 11/27/2024 at 9:30 AM revealed no evidence of physician orders for monitoring of surgical site and/or treatment and care for Resident #99's surgical incision site for the month of September. Record review of Resident #99's Discharge Instructions, from [Hospital] prior to Resident #99's admission at [Facility,] dated 09/20/2024, reflected Resident #99 had back and pelvis surgery on 09/15/2024. Procedures/Surgeries . L4-L5 Laminectomy, L3 to Pelvis Posterior Instrumentation Fusion . Notify PCP of these signs and symptoms . increased redness, increased swelling, increased tenderness/pain . bleeding . pus-like discharge .Dispo: SNF on discharge. S/p L3-S2 instrumentation with pelvic fixation and L4-L5 laminectomy Record review of Resident #99's Progress Notes, dated 10/04/2024, completed by the facility's Treatment Nurse stated she reported Resident #99's incision site drainage to Dr L, Noticed resident surgical site was draining, wound DR was informed to see her next visit to the facility, but she stated she cannot see resident unless the surgeon request for her to see patient because patient is still under the care of the surgeon for 3 months. Order to clean surgical site with normal saline and apply dry dressing and order to monitor the surgical site are both in place. Record review of Provider Notes authored by Dr N's Nurse Practitioner, NP L with an encounter date 10/07/2024, reflected Patient lethargic today, she awakens to tactile stimuli and drifts off quickly. Nurse reports surgeon appointment tomorrow Record review of the document reflected no evidence of surgical site observation, assessment, and/or intervention. Record review of Resident #99's Weekly Skin Assessment - V 5 history reflected four assessments on 09/30/2024, two on 10/07/2024, and 10/08/2024 completed by facility's Treatment Nurse. No evidence of Resident #99's incision site was documented by any staff member nor the facility's Treatment Nurse. An additional record review of Resident #99's on 11/27/2024 of Weekly Skin Assessment - V 5 revealed no evidence of Resident #99's incision site documentation by any staff member nor the facility's Treatment Nurse. Record review of Resident #99's Progress Notes, with a look-back period between 10/04/2024 - 10/08/2024, reflected no documentation related to a completed assessment or notification to a provider of Resident #99's incision site drainage nor any other surgical concerns. An additional record review of Resident #99 on 11/27/2024 of Progress Notes, with a look-back period between 10/04/2024 - 10/08/2024, reflected no documentation related to a completed assessment or notification to a provider of Resident #99's incision site drainage nor any other surgical concerns. In interview with the facility's Wound Physician, Dr L, on 11/06/2024 at 7:16 AM, she stated she never saw or treated Resident #99 as a patient. She stated she never intended to see her at the facility as she did not see post operative neurological or orthopedic patients unless specifically requested by the surgeon. She stated she directed the Treatment Nurse to report her concerns to Resident #99's surgeon. She stated the appropriate monitoring and timely reporting of any surgical site concerns to Resident #99's surgeon was important for infection control purposes. Interview attempts with Resident #99's Surgeon, Dr B, on 11/07/2024 at 11:11 AM and 11/08/2024 at 11:32 AM were unsuccessful. In interview with CNA G on 11/08/2024 at 8:32 AM, she stated she recalled observing and immediately reporting to Treatment Nurse that Resident #99's dressing on her back was soiled with drainage, but she did not recall the specific date this occurred. In interview with the Treatment Nurse on 11/07/2024 at 2:08 PM, she stated CNA G reported Resident #99's surgical incision site on her back was draining on 10/04/2024. She stated she called the facility's wound care doctor, Dr L, for advice but stated Dr L was not Resident #99's provider at this time. She stated Dr L gave her a verbal order to change Resident #99's dressing, to monitor incision site for infection, and to notify her surgeon immediately for further instruction. The Treatment nurse stated she delegated Resident #99's nurse for that day, RN K, to notify the surgeon the incision site had drainage. In follow-up interview with facility's Treatment Nurse on 11/27/2024 at 11:50 AM, she stated she did not notify Resident #99's physician of a change in condition because she delegated that to RN K. She stated she did not document an incision site assessment because there was no physician order that came with [Resident #99's] incision when [Resident #99] was admitted . She stated she did not document any skin assessments of Resident #99's incision site because physician orders dictate her assessment documentation and treatment requirements. In interview with RN K on 11/07/2024 at 12:29 PM, he stated he did not recall any significant events of 10/04/2024 nor the facility's Treatment Nurse asking him to notify Resident #99's surgeon that day. He stated he was not sure if he was allowed to call Resident #99's surgeon directly. RN K referred to his cell phone and stated he was Resident #99 nurse on 10/04/2024, 10/06/2024, 10/07/2024 and 10/08/2024. He stated he did not notice any incision site changes on Resident #99 until just prior to the end of his shift on 10/07/2024. He stated he observed a little bit of pink drainage and the incision looked open on 10/07/2024. He stated he reported to Dr N that I think we need labs on this lady [Resident #99,] but he did not report to Dr N any concerns related to her incision site. He stated he did not report his observations to Resident #99's surgeon either. He stated it slipped his mind and he got busy and did not document it. He stated it was important to report any changes to a resident's surgical incision to a provider because it's an infection risk, a lot of things can happen . which can lead to sepsis. He stated he told the night shift nurse, LVN J, to watch out for this lady, but did not recall if he reported to her about Resident #99's incision site changes. In interview with LVN J on 11/07/2024 at 2:20 PM, she stated she did not recall any specifics as it's been a long time. She stated as far as she knew, when she took care of Resident #99 her incision site was intact during night shift. She stated it was important to report any changes in status of the resident to the doctor immediately for the safety of the resident. In interview with LVN Y on 11/07/2024 at 1:09 PM, she stated her first day of employment at the facility was 10/03/2024. She stated she worked with RN K under his supervision in orientation on 10/06/2024. She stated on 10/06/2024 she stated she observed Resident #99's incision dehisced (to come apart) and observed serosanguinous drainage (thin, watery, pink discharge containing serous fluid and blood) on Resident #99's back incision dressing. LVN Y stated she showed RN K the soiled dressing and reported her observation to him. She stated she did not notify any physicians. She stated she did not recall if any doctors were notified that day and she was on orientation and assumed [RN K] reported it to the doctor. In a follow up interview with RN K on 11/07/2024 at 2:50 PM, he stated he trained LVN Y on 10/06/2024. He stated he did not recall observing Resident #99's incision site that day but he should have. He stated LVN Y did show him Resident #99's soiled dressing with light drainage present, but he did not conduct any follow up assessments on Resident #99's incision site and could not specify why. He stated he should have because LVN Y was his trainee, and that it was his responsibility to assess Resident #99's incision site because something negative can occur. RN K stated he should have notified Resident #99's surgeon but stated he did not and could not specify why. In interview with Resident #99's attending doctor, Dr N, she stated she was not informed of any incision site physician orders, incision site changes, or concerns. She stated her expectations were, at a minimum, for the facility staff to notify her of any resident condition changes so follow up with the surgeon could be facilitated. She stated this was important for infection purposes, especially surgical cases. In interview with Dr N's Nurse Practitioner, NP L, on 11/08/2024 at 8:12 AM, she stated he was not informed of any incision site changes or concerns. She stated she saw Resident #99 at the facility on 10/07/2024 but was not informed of any incision site changes or concerns and did not assess the incision site. She stated if I had known, I would have taken a look at it [incision site] and assessed as it was important for infection purposes. She stated she expected the facility to ultimately report any incision site changes to the surgeon for further advisement. In interview with Resident #99's family member on 11/05/2024 at 11:33 AM and 11/07/2024 at 1:34 PM, he stated Resident #99 had to go back into the hospital for another surgery after her admission at [Facility.] He stated he believed the incision came apart on 10/06/2024. He further stated on 10/07/2024 I noticed her acting strange, like the infection had returned. On 10/08/2024, Resident #99 had a follow up appointment with her surgeon where it was found the infection had indeed returned and she was readmitted to the hospital where she had to have another surgery to clean out their [the facility's] mistake. He stated Resident #99 has experienced a lot of pain and suffering due to the facility's negligence. In a follow up interview with Resident #99's family member on 11/13/2024 at 9:11 AM, he stated Resident #99's current condition was she has pretty much [gone] out of her mind, she stays very confused, and she does not know where she is and is still having [cognitive] problems. He stated he was hopeful that her course of Intravenous (IV) antibiotics would help her get back to normal but it hasn't happened yet . Attempts to interview Resident #99 on 11/08/2024 at 2:00 PM and 11/13/2024 9:11 AM were unsuccessful due to her cognitive limitations. In interview with DON on 11/08/2024 at 9:14 AM, she stated it was her expectation for Resident #99's surgeon to be called immediately if there were any incision site changes. She stated this was not done and it was a failure on the facility's part. The DON stated no documentation was able to be provided to reflect that any provider of Resident #99 was notified about her incision site changes. She stated prompt notification to a provider about a decline in condition and/or incision site changes was important for infection control purposes. In interview with the Administrator on 11/08/2024 at 11:35 AM, he stated his expectations were for the nurse to have reported it [incision site changes] to the doctor. He stated it was important for facility nursing staff to notify the doctor of any changes a resident may have to prevent any decline. In interview with the facility's ADO on 11/08/2024 at 12:35 PM, she stated she did not expect the surgeon to be called by facility per their [facility] policy. She provided the State Surveyor with facility policy, Notifying the physician of Change in Status and stated facility nurses see incisions as wounds and she felt the facility notified the appropriate provider [Dr L.] She further stated it was then Dr L's responsibility to follow up with the surgeon and not the facility staff. Record review of the facility's staffing schedule, provided by the DON, via email on 11/07/2024 reflected: RN K worked day shift on 10/04/2024, 10/06/2024, 10/07/2024, and 10/08/2024. LVN J worked night shift 10/06/2024 and 10/07/2024. LVN Y worked day shift and was in orientation 10/05/2024 and 10/06/2024. On 10/06/2024, RN K oriented LVN Y on day shift. The following documents reviewed state Resident #99's status and condition immediately after her admission at [Facility] and after her 10/08/2024 surgical appointment that necessitated her subsequent re-admission to [Hospital] on 10/08/2024: Record review of Resident #99's Discharge Summary dated 10/30/2024, from Resident #99's hospital admission after her admission at [Facility] revealed Discharge diagnosis . lumbar incisional wound dehiscence with possible infection . Hospital course . recent L4/L5 laminectomy and L3 to pelvis posterior instrumentation done 09/15/2024 and discharged to SNF. She presented to outpatient neurosurgery clinic from SNF for evaluation of lower back wound with discharge. She was seen at outpatient clinic and sent to ER from neurosurgery clinic for evaluation of lumbar wound dehiscence and yellow-colored drainage . continue wound vac . intraoperative culture results and UTI culture results, both growing E. coli (bacteria) . ID recommend to continue 6 week of antibiotics, Rocephin 2 g daily through a PICC line, right upper extremity PICC line in place . Followed by plastic surgery . Procedures: 1. Excisional debridement of skin, subcutaneous tissue, muscle and bone, lumbar wound 120 square cm. 2. Drainage of deep lumbar abscess. 3. Application of a drug-eluting antibiotics beads deep in lumbar wound over lumbosacral area. 4. Application of VAC dressing, negative pressure dressing lumbar wound 80 square cm . Long-term wound VAC . Acute UTI . Anemia; uncertain etiology. May be related to postop blood loss versus infection . transfuse 1 PRBC 10/20 . Follow up with [ID Doctor] in 2-3 weeks after discharge. Patient will likely need oral suppressive antibiotic after finishing the IV as she does have infected hardware . wound vac in place on low back . Continue wound vac with MWF changes . Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Brief Operative Report, dated 10/22/2024, reflected Pre-operative diagnosis . Lumbar Spine Dehiscence . Name of Procedure: 1. Excisional debridement of skin, subcutaneous tissue, and bone of the lumbar spine 2. Placement of deep antibiotic beads 3. Placement of negative pressure wound vac . Findings: 1. Open lumbar spine wound 2. Necrotic tissue wound bed . Assessment/Plan . Plastic surgery was consulted for wound closure. Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Hospitalist Progress Note, dated 10/28/2024 revealed status post I&D by neurology on 10/09. Disposition . patient will need rehab secondary to multiple needs starting from deconditioning wound vac to IV antibiotics. Personally messaged plastic surgery . Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Wound Progress Note, dated 10/29/2024 revealed Wound Diagnosis: S/p excisional debridement of lumbar wound . location low back, midline . type open surgical or dehisce . drain wound vac/neg pressure . dressing drainage amount copious . serosanguineous . length/width/depth 8.8 x 3.5 x 5.9 cm . percent necrotic tissue 5%. Facility policy review: Record review of the facility policy, Notifying the Physician of Change in Status, dated 03/11/2013, reflected The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record . 3 . The nurse is responsible . for responding to a change in condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4 . The nurse will document all attempts to contact the physician in the resident's clinical record . Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. Review of facility policy, Skin Integrity Management, undated, provided by the facility's CCD via email on 11/08/2024 at 3:27 PM did not specifically address surgical/incisional site care. In interview with facility's CCD via email at 11/27/2024 at 10:35 AM revealed the facility did not have a policy specific to surgical care, incision site care, or quality of care. Review of facility policy, Base Line Care Plans, undated provided by facility CCD via email on 11/27/2024 at 11:51 AM revealed Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission . The baseline care plan will . Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- Initial goals based on admission orders, physician orders . The baseline care plan will reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives . This was determined to be an Immediate Jeopardy (IJ) on 11/08/2024 at 12:35 PM. The Administrator, Director of Nursing, Area Director of Operations, and Clinical Compliance Director were notified. The Administrator, DON, ADO, and the CCD as provided with the IJ template on 11/08/2024 at 12:35 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 11/27/2024 at 3:15 PM. [Facility] 11/8/2024 [rev. 11/27/2024] Plan of Removal F684 Quality of Care Interventions: 100% skin sweep of all residents completed on 11/8/24 by the DON, ADON, and Charge Nurses. All residents with wounds including surgical wounds were assessed on 11/8/24 by the DON for potential decline in wound status. No acute changes noted. The Administrator and DON were in-serviced 1:1 on the following by the Regional Compliance Nurse on 11/8/24. Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e., new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds have treatment orders, upon admission, as of 11/27/24. DON/designee to monitor weekly for compliance. -All skin assessments, upon admission and weekly reflect any surgical incision, as of 11/27/24. DON/designee to monitor initial skin assessments weekly for compliance. -DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions, starting 11/27/24. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect. The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds. The DON or Designee will ensure that the wound was assess and notification to the Attending MD as well as the Surgeon was completed timely. This will begin 11/8/24 and continue indefinitely. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds have treatment orders, upon admission, as of 11/27/24. DON/designee to monitor weekly for compliance. -All skin assessments, upon admission and weekly reflect any surgical incision, as of 11/27/24. DON/designee to monitor initial skin assessments weekly for compliance. -DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions, starting 11/27/24. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. The medical director was notified of the immediate jeopardy situation on 11/8/24 by the Administrator. An ADHOC QAPI meeting was completed on 11/8/24 to include the IDT team and Medical Director. The following in-services were initiated by the DON, ADON and regional nurse on 11/8/24. Any staff member not present or in-serviced on 11/8/24, will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation prior to taking an assignment. All agency staff will in serviced prior to their scheduled shift. All Charge Nurses: -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds have treatment orders, upon admission, as of 11/27/24. DON/designee to monitor weekly for compliance. -All skin assessments, upon admission and weekly reflect any surgical incision, as of 11/27/24. DON/designee to monitor initial skin assessments weekly for compliance. -The Charge nurse or designee will include surgical incision sites on the baseline care plan upon admission, as of 11/27/24. Charge nurse or designee will update the baseline care plan for changes in surgical incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions, starting 11/27/24. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect. Non-licensed nursing staff -Abuse and Neglect Policy- failure report a change a change in condition on a resident such as a new or worsening wound, could be considered neglect. -Notification of Change in Condition Policy- Reporting negative changes in condition involving wounds to the charge nurse immediately. Changes include a soiled dressing, foul odor, redness, or complaints of pain to the wound. If the charge nurse is not available, the DON or ADON will be notified. Monitoring of the POR Included the following: Record review of the facility's Skin Sweep Documentation on 11/08/2024 at 4:58 PM reflected no other post operative residents at the facility. Record review of 5 recent admissions at [Facility] on 11/27/2024 at approximately 3:00 PM revealed compliance with admission physician orders, baseline care plans, skin assessments, and clinical dashboard information. Record review on 11/08/2024 of facility's AD HOC QUAPI meeting minutes and sign in sheet, titled OFF CYCLE (AD HOC) QA MEETING DOCUMENT, content included facility failures related to physician notification, assessment, and abuse/and or neglect. Facility CCD, DON, Administrator, Medical Director, and ADO signatures were included. Record review on 11/08/2024 of In-service, Notification of Change in Condition, conducted by CCD, included facility definition, purpose, process for provider notification as it related to all surgical wounds/incisions changes or decline in condition are required to be reported to the surgeon and attending physician by utilizing the facility sanctioned communication documents. Facility Administrator and DON's signatures were included. Record review on 11/08/2024 of In-service, Notifying the Physician of Change in Status, conducted by the Administrator and the DON, included facility definition, purpose, process for provider notification as it related to all surgical wounds/incisions changes or decline in condition are required to be reported to the surgeon and attending physician by utilizing the facility sanctioned communication documents. Multiple staff RN and LVN signatures were included. Record review on 11/08/2024 of In-service, Abuse and Neglect, conducted by CCD, included facility definition of abuse/neglect, identification of abuse/neglect, and facility specific policy, protocol, and procedure for reporting abuse/neglect at the facility. Facility Administrator and DON's signatures were included. Record review on 11/08/2024 of In-service, Abuse and Neglect, conducted by DON, included facility definition of abuse/neglect, identification of abuse/neglect, and facility specific policy, protocol, and procedure for reporting abuse/neglect at the facility. Multiple staff signatures included department leadership, rehabilitation department, nurses, nursing aides, social services, dietary department, housekeeping, and the maintenance department. Record review on 11/27/2024 of In-service titled, SBAR, conducted by CCD, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Facility Administrator and DON's signatures were included. Record review on 11/27/2024 of In-service titled, SBAR for Surgical Incisions, conducted by DON, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Multiple facility nursing staff signatures were included. In interview with the facility Administrator and DON on 11/08/2024 at 6:10 PM and 6:02 PM respectively, they stated the clinical dashboard was reviewed for compliance as per the POR. In follow up interview with the Administrator and DON on 11/27/2024 at 1:50 PM, they stated the clinical dashboard was reviewed for compliance as per the POR. In interview with facility's CCD on 11/08/2024 at 1:00 PM she stated there were no post-operative surgical residents currently at the facility. In follow-up interview with facility's CCD on 11/27/2024 at 11:40 AM she stated there were no post-operative surgical residents currently at the facility. In follow up interview with facility's Administrator on 11/27/2024 at 2:30 PM he stated facility's DON, or a designee were responsible for daily monitoring of new surgical incision resident orders and will present this information to leader [TRUNCATED]

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for one of two (Resident #99) post operative surgical residents reviewed for notification of changes related to post operative care. The facility failed to notify Resident #99's attending physician or surgeon after changes to her surgical incision site were repeatedly observed resulting a subsequent infection that required hospitalization and surgical intervention. An Immediate Jeopardy (IJ) situation was identified on 11/08/2024 at 12:35 PM. The IJ was removed on 11/27/2024 at 3:15 PM the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a delay in medical intervention, decline in health, serious injury, harm, impairment or death. Findings include: Record review of Resident #99's face sheet, dated 11/07/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #99 had relevant diagnoses which included metabolic encephalopathy (alteration in consciousness caused by diffuse or global brain dysfunction from impaired cerebral metabolism,) subluxation of lumbar vertebra (misalignment of spine,) wedge compression fracture of thoracic vertebrae (one or more back bones collapse,) protein-calorie malnutrition, anxiety (persistent nervousness, anxiety, and/or restlessness) and major depressive disorder (persistent low mood.) Record review of Resident #99's MDS dated [DATE], reflected she was cognitively intact with a BIMS score of 15. She required a wheelchair for mobility and required substantial/maximal assistance with toileting and shower/baths which included transfers. Record review of Resident #99's Baseline Care Plan dated 09/26/2024 at 2:30 PM revealed no evidence of surgical site assessment, treatment, or care documentation. Record review of Resident #99's Comprehensive Care Plan was not available for review due to the resident's short-term stay at the facility. Record review of Resident #99's Physician Orders reflected her attending physician as Dr N, Admit to Skilled Services Under The Care of [Dr N] effective 09/20/2024. No orders stated monitoring of surgical site and/or treatment and care from Dr N were observed. Record review of Resident #99's Physician Orders from Dr L stated Clean surgical site on lower back with normal saline, pat dry and apply dry dressing one time a day for wound care start date 10/05/2024. An order to monitor surgical site stated, Monitor surgical site for infection one time a day for wound care start date 10/05/2024. Record review of Resident #99's Physician Orders on 11/27/2024 at 9:30 AM revealed no evidence of physician orders for monitoring of surgical site and/or treatment and care for Resident #99's surgical incision site for the month of September. Record review of Resident #99's Discharge Instructions, from [Hospital] prior to Resident #99's admission at [Facility,] dated 09/20/2024, reflected Resident #99 had back and pelvis surgery on 09/15/2024. Procedures/Surgeries . L4-L5 Laminectomy, L3 to Pelvis Posterior Instrumentation Fusion . Notify PCP of these signs and symptoms . increased redness, increased swelling, increased tenderness/pain . bleeding . pus-like discharge .Dispo: SNF on discharge. S/p L3-S2 instrumentation with pelvic fixation and L4-L5 laminectomy Record review of Resident #99's Progress Notes, dated 10/04/2024, completed by the facility's Treatment Nurse reflected, Noticed resident surgical site was draining, wound DR was informed to see her next visit to the facility, but she stated she cannot see resident unless the surgeon request for her to see patient because patient is still under the care of the surgeon for 3 months. Order to clean surgical site with normal saline and apply dry dressing and order to monitor the surgical site are both in place. Record review of Provider Notes authored by NP L with an encounter date 10/07/2024, reflected Patient lethargic today, she awakens to tactile stimuli and drifts off quickly. Nurse reports surgeon appointment tomorrow Record review of the document reflected no evidence of surgical site observation, assessment, and/or intervention. Record review of Resident #99's Weekly Skin Assessment - V 5 history reflected four assessments on 09/30/2024, two on 10/07/2024, and 10/08/2024 completed by facility's Treatment Nurse. No evidence of Resident #99's incision site was documented by any staff member nor the facility's Treatment Nurse. An additional record review of Resident #99's on 11/27/2024 of Weekly Skin Assessment - V 5 revealed no evidence of Resident #99's incision site documentation by any staff member nor the facility's Treatment Nurse. Record review of Resident #99's Progress Notes, with a look-back period between 10/04/2024 - 10/08/2024, reflected no documentation related to a completed assessment or notification to a provider of Resident #99's incision site drainage nor any other surgical concerns. An additional record review of Resident #99 on 11/27/2024 of Progress Notes, with a look-back period between 10/04/2024 - 10/08/2024, reflected no documentation related to a completed assessment or notification to a provider of Resident #99's incision site drainage nor any other surgical concerns. In interview with the facility's Wound Physician, Dr L, on 11/06/2024 at 7:16 AM, she stated she never saw or treated Resident #99 as a patient. She stated she never intended to see her at the facility as she did not see post operative neurological or orthopedic patients unless specifically requested by the surgeon. She stated she directed the Treatment Nurse to report her concerns to Resident #99's surgeon. She stated the appropriate monitoring and timely reporting of any surgical site concerns to Resident #99's surgeon was important for infection control purposes. Interview attempts with Resident #99's Surgeon, Dr B, on 11/07/2024 at 11:11 AM and 11/08/2024 at 11:32 AM were unsuccessful. In interview with CNA G on 11/08/2024 at 8:32 AM, she stated she recalled observing and immediately reporting to Treatment Nurse that Resident #99's dressing on her back was soiled with drainage, but she did not recall the specific date this occurred. In interview with the Treatment Nurse on 11/07/2024 at 2:08 PM, she stated CNA G reported Resident #99's surgical incision site on her back was draining on 10/04/2024. She stated she called the facility's wound care doctor, Dr L, for advice but stated Dr L was not Resident #99's provider at this time. She stated Dr L gave her a verbal order to change Resident #99's dressing, to monitor incision site for infection, and to notify her surgeon immediately for further instruction. The Treatment nurse stated she delegated Resident #99's nurse for that day, RN K, to notify the surgeon the incision site had drainage. In follow-up interview with facility's Treatment Nurse on 11/27/2024 at 11:50 AM, she stated she did not notify Resident #99's physician of a change in condition because she delegated that to RN K. She stated she did not document an incision site assessment because there was no physician order that came with [Resident #99's] incision when [Resident #99] was admitted . She stated she did not document any skin assessments of Resident #99's incision site because physician orders dictate her assessment documentation and treatment requirements. In interview with RN K on 11/07/2024 at 12:29 PM, he stated he did not recall any significant events of 10/04/2024 nor the facility's Treatment Nurse asking him to notify Resident #99's surgeon that day. He stated he was not sure if he was allowed to call Resident #99's surgeon directly. RN K referred to his cell phone and stated he was Resident #99 nurse on 10/04/2024, 10/06/2024, 10/07/2024 and 10/08/2024. He stated he did not notice any incision site changes on Resident #99 until just prior to the end of his shift on 10/07/2024. He stated he observed a little bit of pink drainage and the incision looked open on 10/07/2024. He stated he reported to Dr N that I think we need labs on this lady [Resident #99,] but he did not report to Dr N any concerns related to her incision site. He stated he did not report his observations to Resident #99's surgeon either. He stated it slipped his mind and he got busy and did not document it. He stated it was important to report any changes to a resident's surgical incision to a provider because it's an infection risk, a lot of things can happen . which can lead to sepsis. He stated he told the night shift nurse, LVN J, to watch out for this lady, but did not recall if he reported to her about Resident #99's incision site changes. In interview with LVN J on 11/07/2024 at 2:20 PM, she stated she did not recall any specifics as it's been a long time. She stated as far as she knew, when she took care of Resident #99 her incision site was intact during night shift. She stated it was important to report any changes in status of the resident to the doctor immediately for the safety of the resident. In interview with LVN Y on 11/07/2024 at 1:09 PM, she stated her first day of employment at the facility was 10/03/2024. She stated she worked with RN K under his supervision in orientation on 10/06/2024. She stated on 10/06/2024 she stated she observed Resident #99's incision dehisced (to come apart) and observed serosanguinous drainage (thin, watery, pink discharge containing serous fluid and blood) on Resident #99's back incision dressing. LVN Y stated she showed RN K the soiled dressing and reported her observation to him. She stated she did not notify any physicians. She stated she did not recall if any doctors were notified that day and she was on orientation and assumed [RN K] reported it to the doctor. In a follow up interview with RN K on 11/07/2024 at 2:50 PM, he stated he trained LVN Y on 10/06/2024. He stated he did not recall observing Resident #99's incision site that day but he should have. He stated LVN Y did show him Resident #99's soiled dressing with light drainage present, but he did not conduct any follow up assessments on Resident #99's incision site and could not specify why. He stated he should have because LVN Y was his trainee, and that it was his responsibility to assess Resident #99's incision site because something negative can occur. RN K stated he should have notified Resident #99's surgeon but stated he did not and could not specify why. In interview with Resident #99's attending doctor, Dr N, she stated she was not informed of any incision site physician orders, incision site changes, or concerns. She stated her expectations were, at a minimum, for the facility staff to notify her of any resident condition changes so follow up with the surgeon could be facilitated. She stated this was important for infection purposes, especially surgical cases. In interview with Dr N's Nurse Practitioner, NP L, on 11/08/2024 at 8:12 AM, she stated he was not informed of any incision site changes or concerns. She stated she saw Resident #99 at the facility on 10/07/2024 but was not informed of any incision site changes or concerns and did not assess the incision site. She stated if I had known, I would have taken a look at it [incision site] and assessed as it was important for infection purposes. She stated she expected the facility to ultimately report any incision site changes to the surgeon for further advisement. In interview with Resident #99's family member on 11/05/2024 at 11:33 AM and 11/07/2024 at 1:34 PM, he stated Resident #99 had to go back into the hospital for another surgery after her admission at [Facility.] He stated he believed the incision came apart on 10/06/2024. He further stated on 10/07/2024 I noticed her acting strange, like the infection had returned. On 10/08/2024, Resident #99 had a follow up appointment with her surgeon where it was found the infection had indeed returned and she was readmitted to the hospital where she had to have another surgery to clean out their [the facility's] mistake. He stated Resident #99 has experienced a lot of pain and suffering due to the facility's negligence. In a follow up interview with Resident #99's family member on 11/13/2024 at 9:11 AM, he stated Resident #99's current condition was she has pretty much [gone] out of her mind, she stays very confused, and she does not know where she is and is still having [cognitive] problems. He stated he was hopeful that her course of Intravenous (IV) antibiotics would help her get back to normal but it hasn't happened yet . Attempts to interview Resident #99 on 11/08/2024 at 2:00 PM and 11/13/2024 9:11 AM were unsuccessful due to her cognitive limitations. In interview with DON on 11/08/2024 at 9:14 AM, she stated it was her expectation for Resident #99's surgeon to be called immediately if there were any incision site changes. She stated this was not done and it was a failure on the facility's part. The DON stated no documentation was able to be provided to reflect that any provider of Resident #99 was notified about her incision site changes. She stated prompt notification to a provider about a decline in condition and/or incision site changes was important for infection control purposes. In interview with the Administrator on 11/08/2024 at 11:35 AM, he stated his expectations were for the nurse to have reported it [incision site changes] to the doctor. He stated it was important for facility nursing staff to notify the doctor of any changes a resident may have to prevent any decline. In interview with the facility's ADO on 11/08/2024 at 12:35 PM, she stated she did not expect the surgeon to be called by facility per their [facility] policy. She provided the State Surveyor with facility policy, Notifying the physician of Change in Status and stated facility nurses see incisions as wounds and she felt the facility notified the appropriate provider [Dr L.] She further stated it was then Dr L's responsibility to follow up with the surgeon and not the facility staff. Record review of the facility's staffing schedule, provided by the DON, via email on 11/07/2024 reflected: RN K worked day shift on 10/04/2024, 10/06/2024, 10/07/2024, and 10/08/2024. LVN J worked night shift 10/06/2024 and 10/07/2024. LVN Y worked day shift and was in orientation 10/05/2024 and 10/06/2024. On 10/06/2024, RN K oriented LVN Y on day shift. The following documents reviewed state Resident #99's status and condition immediately after her admission at [Facility] and after her 10/08/2024 surgical appointment that necessitated her subsequent re-admission to [Hospital] on 10/08/2024: Record review of Resident #99's Discharge Summary dated 10/30/2024, from Resident #99's hospital admission after her admission at [Facility] revealed Discharge diagnosis . lumbar incisional wound dehiscence with possible infection . Hospital course . recent L4/L5 laminectomy and L3 to pelvis posterior instrumentation done 09/15/2024 and discharged to SNF. She presented to outpatient neurosurgery clinic from SNF for evaluation of lower back wound with discharge. She was seen at outpatient clinic and sent to ER from neurosurgery clinic for evaluation of lumbar wound dehiscence and yellow-colored drainage . continue wound vac . intraoperative culture results and UTI culture results, both growing E. coli (bacteria) . ID recommend to continue 6 week of antibiotics, Rocephin 2 g daily through a PICC line, right upper extremity PICC line in place . Followed by plastic surgery . Procedures: 1. Excisional debridement of skin, subcutaneous tissue, muscle and bone, lumbar wound 120 square cm. 2. Drainage of deep lumbar abscess. 3. Application of a drug-eluting antibiotics beads deep in lumbar wound over lumbosacral area. 4. Application of VAC dressing, negative pressure dressing lumbar wound 80 square cm . Long-term wound VAC . Acute UTI . Anemia; uncertain etiology. May be related to postop blood loss versus infection . transfuse 1 PRBC 10/20 . Follow up with [ID Doctor] in 2-3 weeks after discharge. Patient will likely need oral suppressive antibiotic after finishing the IV as she does have infected hardware . wound vac in place on low back . Continue wound vac with MWF changes . Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Brief Operative Report, dated 10/22/2024, reflected Pre-operative diagnosis . Lumbar Spine Dehiscence . Name of Procedure: 1. Excisional debridement of skin, subcutaneous tissue, and bone of the lumbar spine 2. Placement of deep antibiotic beads 3. Placement of negative pressure wound vac . Findings: 1. Open lumbar spine wound 2. Necrotic tissue wound bed . Assessment/Plan . Plastic surgery was consulted for wound closure. Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Hospitalist Progress Note, dated 10/28/2024 revealed status post I&D by neurology on 10/09. Disposition . patient will need rehab secondary to multiple needs starting from deconditioning wound vac to IV antibiotics. Personally messaged plastic surgery . Record review from Resident #99's hospital admission after her admission at [Facility,] titled [Hospital] Wound Progress Note, dated 10/29/2024 revealed Wound Diagnosis: S/p excisional debridement of lumbar wound . location low back, midline . type open surgical or dehisce . drain wound vac/neg pressure . dressing drainage amount copious . serosanguineous . length/width/depth 8.8 x 3.5 x 5.9 cm . percent necrotic tissue 5%. Facility policy review: Record review of the facility policy, Notifying the Physician of Change in Status, dated 03/11/2013, reflected The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record . 3 . The nurse is responsible . for responding to a change in condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4 . The nurse will document all attempts to contact the physician in the resident's clinical record . Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. Review of facility policy, Skin Integrity Management, undated/provided by the facility's CCD via email on 11/08/2024 at 3:27 PM did not specifically address surgical/incisional site care. In interview with facility's CCD via email at 11/27/2024 at 10:35 AM revealed the facility did not have a policy specific to surgical care, incision site care, or quality of care. This was determined to be an Immediate Jeopardy (IJ) on 11/08/2024 at 12:35 PM. The Administrator, Director of Nursing, Area Director of Operations, and Clinical Compliance Director were notified. The Administrator, DON, ADO, and the CCD as provided with the IJ template on 11/08/2024 at 12:35 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 11/27/2024 at 3:15 PM. [Facility] 11/8/2024 [rev. 11/27/2024] Plan of Removal F580 Notify Change of Condition Interventions: 100% skin sweep of all residents completed on 11/8/24 by the DON, ADON, and Charge Nurses. All residents with wounds including surgical wounds were assessed on 11/8/24 by the DON for potential decline in wound status. No acute changes noted. The Administrator and DON were in-serviced 1:1 on the following by the Regional Compliance Nurse on 11/8/24. Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e., new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. This will start 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect. The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds. The DON or Designee will ensure that the wound was assess and notification to the Attending MD as well as the Surgeon was completed timely. This will begin 11/8/24 and continue indefinitely. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. This will start 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. The medical director was notified of the immediate jeopardy situation on 11/8/24 by the Administrator. An ADHOC QAPI meeting was completed on 11/8/24 to include the IDT team and Medical Director. The following in-services were initiated by the DON, ADON and regional nurse on 11/8/24. Any staff member not present or in-serviced on 11/8/24, will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation prior to taking an assignment. All agency staff will in serviced prior to their scheduled shift. All Charge Nurses: -Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e. new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified. -All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site, as of 11/27/24. DON/designee to monitor weekly for compliance. -All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. This will start 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee to ensure surgeon contact information is available in resident's EMR upon admission, starting 11/27/24. DON/designee to monitor weekly for compliance. -DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds, as of 11/27/24. DON/designee to monitor weekly for compliance. Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect. Non-licensed nursing staff -Abuse and Neglect Policy- failure report a change a change in condition on a resident such as a new or worsening wound, could be considered neglect. -Notification of Change in Condition Policy- Reporting negative changes in condition involving wounds to the charge nurse immediately. Changes include a soiled dressing, foul odor, redness, or complaints of pain to the wound. If the charge nurse is not available, the DON or ADON will be notified. Monitoring of the POR Included the following: Record review of the facility's Skin Sweep Documentation on 11/08/2024 at 4:58 PM reflected no other post operative residents at the facility. In interview with facility's CCD on 11/08/2024 at 1:00 PM she stated there were no post-operative surgical residents currently at the facility. In follow-up interview with facility's CCD on 11/27/2024 at 11:40 AM she stated there were no post-operative surgical residents currently at the facility. Record review on 11/08/2024 of facility's AD HOC QUAPI meeting minutes and sign in sheet, titled OFF CYCLE (AD HOC) QA MEETING DOCUMENT, content included facility failures related to physician notification, assessment, and abuse/and or neglect. Facility CCD, DON, Administrator, Medical Director, and ADO signatures were included. Record review on 11/08/2024 of In-service, Notification of Change in Condition, conducted by CCD, included facility definition, purpose, process for provider notification as it related to all surgical wounds/incisions changes or decline in condition are required to be reported to the surgeon and attending physician by utilizing the facility sanctioned communication documents. Facility Administrator and DON's signatures were included. Record review on 11/08/2024 of In-service, Notifying the Physician of Change in Status, conducted by the Administrator and the DON, included facility definition, purpose, process for provider notification as it related to all surgical wounds/incisions changes or decline in condition are required to be reported to the surgeon and attending physician by utilizing the facility sanctioned communication documents. Multiple staff RN and LVN signatures were included. Record review on 11/08/2024 of In-service, Abuse and Neglect, conducted by CCD, included facility definition of abuse/neglect, identification of abuse/neglect, and facility specific policy, protocol, and procedure for reporting abuse/neglect at the facility. Facility Administrator and DON's signatures were included. Record review on 11/08/2024 of In-service, Abuse and Neglect, conducted by DON, included facility definition of abuse/neglect, identification of abuse/neglect, and facility specific policy, protocol, and procedure for reporting abuse/neglect at the facility. Multiple staff signatures included department leadership, rehabilitation department, nurses, nursing aides, social services, dietary department, housekeeping, and the maintenance department. In interview with facility's CCD via email on 12/06/2024 at 12:32 PM, she clarified that the facility's Abuse and Neglect policy was not revised; but the facility in-serviced on the current policy. This includes a clarification that neglect could include failure to notify would be considered neglectful. Record review on 11/27/2024 of In-service titled, SBAR, conducted by CCD, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Facility Administrator and DON's signatures were included. Record review on 11/27/2024 of In-service titled, SBAR for Surgical Incisions, conducted by DON, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Multiple facility nursing staff signatures were included. In interview with the facility Administrator and DON on 11/08/2024 at 6:10 PM and 6:02 PM respectively, they stated the clinical dashboard was reviewed for compliance as per the POR. In follow up interview with the Administrator and DON on 11/27/2024 at 1:50 PM, they stated the clinical dashboard was reviewed for compliance which included action items added by the facility on 11/27/2024 per the POR. In interview with the facility Administrator on 11/08/2024 at 6:10 PM, he stated failure to report a change a change in condition to the resident's nurse could be considered neglect. Immediate notification to a provider for any resident change in condition was important. He sufficiently explained what would constitute a change in condition and the signs and symptoms his staff should be monitoring for infection. He further stated what and where his staff should be documenting any change in condition in the electronic medical record (EMR) and the other parties that should be notified in addition to the provider. He sufficiently defined abuse, neglect, and/or exploitation and the expectations of his staff to report any observed, reported, or suspected abuse, neglect, and/or exploitation to him immediately. In follow up interview with facility's Administrator on 11/27/2024 at 2:30 PM he stated facility's DON, or a designee were responsible for daily monitoring of new surgical incision resident orders and will present this information to leadership during the daily stand-up meeting to ensure treatment orders are in place and admission assessments included surgical incision sites. He stated the DON was responsible to ensure resident surgical contact information was updated in resident EMRs upon admission and was responsible for monitoring weekly for compliance. He stated he will ensure the DON will complete weekly audits to ensure that all surgical wounds were to monitored daily by nurses, any changes or decline were reported to attending physician and surgeon of incision site, to ensure all surgical wounds have treatment orders upon admission, all surgical wounds/incisions changes or decline in condition were reported to the surgeon and attending physician, and all skin assessments upon admission reflect any surgical incisions a resident may have. He stated the DON will complete an audit weekly to ensure charge nurses included surgical incision sites on baseline care plans upon admission and the DON included any updates in resident care plans when any change in condition or surgical incision site changes occur. He further stated all nurses were in-serviced by the DON and CCD and were expected to be knowledgeable on facility's SBAR document and his expectations were for facility nurses to utilize this document for any change in condition and/or changes to a resident's surgical incision site. In interview with the facility DON on 11/08/2024 at 6:02 PM, she stated failure to report a change a change in condition to the resident's nurse could be considered neglect. Immediate notification to a provider for any resident change in condition was important. She sufficiently explained

Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for each resident for (Resident #1, Resident #2, Resident #3) 3 of 6 residents reviewed for Comprehensive Care Plans. The facility failed to ensure Resident #1, Resident #2, and Resident #3 had comprehensive care plans to reflect their high elopement risk. Consequently, the facility failed to properly supervise Resident #1, a psychiatrically affected and assessed as high risk for elopement resident, from elopement on [DATE]. Resident #1 eloped via an unknown route and was located by Law Enforcement approximately 4.9 miles away from the facility. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM. This failure could place residents at risk for comprehensive care plans that do not meet the resident's customized supervison needs, which could lead to an elopement from the facility which could result in serious injury and/or death. Findings included: Review of Resident #1's Face Sheet dated [DATE] revealed he was a [AGE] year-old male readmitted to the facility on [DATE] from an acute care hospital for rehabilitation. Relevant diagnoses included schizoaffective disorder bipolar type (psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - either bipolar type (episodes of mania and sometimes depression), depression (mood disorder) unsteadiness on feet, unspecified lack of coordination, cognitive communication deficit, altered mental status, suicidal ideations, auditory hallucinations (hearing things that are not real,) and elevated white blood cell count (infection.) Record review of Resident #1's Elopement Risk Assessment, dated [DATE] revealed he was a high elopement risk. Resident #1's Elopement Risk Assessment reflected: .7. Elopement Screen .A score of 5 or greater = HIGH RISK for Wandering/Elopement Potential .5. Based on admission information and/or responsible party information has the resident ever eloped before or does the resident have a habit of wandering or pacing? A) Yes [score 5.] Review of Resident #1's MDS, dated [DATE], revealed he was cognitively intact with a BIMS score of 15. Resident #1 required supervision of one staff to physically assist him to walk in room, and supervision of setup help only to walk in corridor, locomotion on unit, locomotion off unit. He did not require any assistive devices for ambulation and was scored as steady at all times when moving from seated to standing position, walking, turning around and facing the opposite direction when walking, moving on and off toilet, and surface-to-surface transfers. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed he was at risk for falls, required assistance with ADLs, was on antidepressant, antianxiety, and hypnotic medications that required monitoring for effectiveness and/or negative outcomes. No evidence of elopement risk or precautions were indicated in Resident #1's care plan. Record Review of Resident #1's EHR on [DATE] revealed there was not an assessment or an evaluation to determine Residnet #1 ability to to independently and safety sign out of the facility on temporary leave by himself. Review of Resident #2's Face Sheet on [DATE] at 3:39 PM revealed she was a [AGE] year-old female admitted to the facility on [DATE] from an assisted living facility. Relevant diagnoses included dementia, visual loss, unsteadiness on feet, lack of coordination, disorientation, fatigue, and need for continuous supervision. Record review of Resident #2's most recent Elopement Risk Assessment, dated [DATE] revealed she was a high elopement risk due to C. Adjustment to Facility . Statement and/or threats to leave facility . 4. Confused expressions related to tasks to complete . D. Cognitive Skills for Daily Decision Making . 4. Moderately impaired - decisions poor, cues/supervision required. Review of Resident #2's Comprehensive Care Plan, dated [DATE], revealed she was at risk for falls, required assistance with ADLs, had impaired cognitive function, confusion, or memory problems, with an intervention that included to Report any new or worsening confusion to the nurse. No evidence of elopement risk or precautions were indicated in Resident #2s care plan. Review of Resident #3's Face Sheet on [DATE] at 3:45 PM revealed he was an [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included encephalopathy (damage or disease that affects the brain,) cerebral ischemia (impaired blood flow to the brain that results in injury,) dementia, difficulty walking, unsteadiness on feet, lack of coordination, hemiplegia and hemiparesis (muscle weakness on one side of the body) following cerebrovascular (related to blood flow to the brain) disease affecting right dominant side and need for assistance with personal care. Record review of Resident #3's most recent Elopement Risk Assessment, dated [DATE] revealed he was a high elopement risk due to B. Physical Capability . 1. Physical Capability 3. Self propels wheelchair . C. Adjustment to Facility . Statement and/or threats to leave facility . 4. Confused expressions related to tasks to complete . D. Cognitive Skills for Daily Decision Making . 4. Moderately impaired - decisions poor, cues/supervision required. Review of Resident #3's Comprehensive Care Plan, dated [DATE], revealed he was very impulsive and was a high fall risk, and required close monitoring to prevent serious injury related to falls. He required assistance with ADLs, was on an antipsychotic and anticoagulant medications that required monitoring for effectiveness and/or negative outcomes. Resident #3 had a history of behaviors that included agitation or anxiety and required special assistance and care when experiencing an episode. His care plan revealed no evidence of elopement risk or precautions prior to surveyor's entry into the facility. In an interview with the Administrator on [DATE] at 10:31 AM, he stated that Resident #1 had a BIMS score of 15 and was very high functioning. Administrator stated the facility was aware of Resident #1's elopement risk and they had provided him a room away from any exit doors, and in a high traffic area close to the nurse's station to enable enhanced monitoring. Administrator also stated that he personally had provided education to Resident #1 about the option of signing himself out of the facility if he wanted to temporarily leave the facility for whatever reason. He stated Resident #1 was admitted to the facility for rehabilitation, and MHMR and the facility's SW were working together to find him a group home upon discharge. He stated that his facility does not offer a secured unit nor a Wanderguard[TM] type device (WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers) but Resident #1 would not have been appropriate for that level of securement due to his cognitive function. He acknowledged that Resident #1's Care Plan should have included his elopement risk, but he did not feel it contributed to Resident #1's elopement. He stated the SW spoke with Resident #1 the morning of [DATE] around 9:00 AM to discuss discharge planning. The Administrator stated that around 1:20 PM, he was informed by staff they could not locate Resident #1. The facility was searched, and local law enforcement was contacted. The Administrator stated that during his investigation, Resident #4 stated she spoke with Resident #1 between 9:00 AM -10:30 AM that morning. The Administrator further stated that the charge nurse on duty, LVN S, reported seeing Resident #1 around 10:40 AM. He stated local Law Enforcement located the resident around 5:30 PM approximately 4.9 miles south near a lake eating cheese fries and drinking tea. He stated the Law Enforcement Officers reported to him that Resident #1 did not look in distress. Furthermore, he was going to be transported to a nearby psychiatric acute care facility per the Resident #1's request and would not be coming back to the facility. Administrator stated he reported this information to the physician. The Administrator further stated that Resident #1's family member was contacted to gather additional information about Resident #1's whereabouts. Resident #1's family member reported to the Administrator that she had access to his bank records and that Resident #1 made a withdrawal of cash from a bank approximately 1 mile away at 9:20 AM the morning of [DATE]. The Administrator stated he was not exactly sure how Resident #1 eloped, and the facility did not have cameras to review. The Administrator did not provide documention of the education for Resident #1 for temporary leave. Attempts to interview Resident #1 were made on [DATE] at 10:13 AM and [DATE] at 1:00 PM, but the phone line was disconnected. In an interview with the SW on [DATE] at 10:31 AM he stated he was aware of Resident #1's previous elopement attempt, wandering behavior, and episodes of impulsivity. He stated that while Resident #1 exhibited wandering behaviors as evidenced by pacing the halls, he did not have any exit seeking behaviors since his admission on the skilled unit. He stated Resident #1 had completed his rehabilitation at the facility and he had had found a group home that was willing to accept Resident #1. He stated that he went the morning of [DATE] around 8:30 AM to update Resident #1 to discuss the information. He recalled that the resident was not thrilled about going to a group home, and stated Resident #1 reported to him that he wanted to live independently. The SW further stated that Resident #1 told him that he wanted to go to the bank, grocery store, and go to an acute care psychiatric facility. The SW stated he told Resident #1 that the facility could arrange transport for him, and that Resident #1 going to an acute care psychiatric facility was a last resort. He stated he educated the resident on how a group home was a least restrictive option. The SW stated Resident #1 did not seem upset and did not give him the impression he was going to elope. He stated Resident #1 acknowledged that the facility would arrange transportation for him and was in agreeance with the current discharge plan. Furthermore, he stated that elopement risk assessments and interventions were a nursing component and he thought it would have fallen under the MDS nurse's scope of practice and responsibility. In an interview with Resident #4 on [DATE] at 9:00 AM, she stated that Resident #1 was really nice and that they had spoken previously on multiple occasions. She remembered seeing and speaking with Resident #1 after breakfast at approximately 9:00 AM on the day he eloped ([DATE].) She recalled that they spoke about what they had for breakfast, and that he stated to her that he did not like his breakfast that morning. She denied any knowledge of Resident #1 reporting to her any intent or plan to elope from the facility. Attempts to interview LVN S were made [DATE] at 11:25 AM and 2:30 PM. In interview with Resident #1's Guardian on [DATE] at 9:32 AM, he stated he was his guardian, but his guardianship expired on [DATE] and was not his guardian at the time of the elopement. He stated he remained in contact with Resident #1 and considered him a friend. He stated that he was contacted by Resident #1 the day of the elopement, not certain of the time, and told him he was on foot walking to [Acute Care Psychiatric Hospital.] He stated that Resident #1 told him that he met a gentlemen that looked homeless and gave him money, then proceeded walking south towards where [Acute Care Psychiatric Hospital] was located. He stated Resident #1 had a history of taking long walks and reported that information to Law Enforcement when they contacted him between ,d+[DATE]:00 PM the day of the elopement. In an interview with Resident #1's Family Member, on [DATE] at 9:45 AM she stated she was a co-signer on his bank account, and she kept a close eye to ensure his balance stayed where it needed to be. She stated she was not his responsible party and did not expect to be notified of his discharge, so she assumed that he was being discharged from the facility that day ([DATE]) and dismissed the withdrawal as initially concerning. She stated a few hours later she received a call from a nurse at the facility and later Law Enforcement stating that he was missing. She reported that Resident #1 made a withdrawal from [Bank] which was about 1 mile away from the facility around 9:00 AM that morning. She further stated she called the bank, as the bank staff were familiar with Resident #1 and reported to her that they recalled seeing him that morning, and that he made a withdrawal. In an interview with the MDS nurse on [DATE] at 5:42 PM, she stated it was her responsibility to complete resident MDS's and ensure resident care plans were updated to reflect their specific care needs and risks. She stated that Resident #1 did trigger for a high risk for elopement but stated in her opinion, Resident #1 was not an elopement risk and would not have included that in his care plan. Additionally, she did not provide a statement as to why Resident #2 and Resident #3 did not have their elopement risk care planned. She stated the facility policy dictated to put the risk with relevant interventions on the care plan but stated, it depends on the resident. She stated that the Elopement Assessment was just a tool' and triggers to give a possible risk but did not necessarily mean they were an elopement risk. She stated if someone was a true elopement risk, their care plan should reflect that as the nurses and the interdisciplinary care team looked at it during their morning meeting each day to ensure each resident's care needs were addressed. In an interview with the DON on [DATE] at 2:48 PM, she stated it was her first week employed at the facility and she was not involved in the elopement nor the investigation surrounding the elopement. She stated her expectation was for any elopement assessment scored as high risk should be entered into the care plan along with relevant interventions. She stated it was traditionally the MDS nurse's responsibility to ensure resident care plans were customized and comprehensive to address resident care needs. She further stated that was important so resident care needs could be reviewed every day in morning meeting, where they work from resident care plans. She stated if resident care plans were not updated for a high risk for elopement residents, an elopement could occur. In interview with the Administrator on [DATE] at 4:16 PM, he stated it was the MDS nurse's responsibility to ensure resident care plans were updated to reflect resident care needs. It was the former DON's responsibility to ensure the MDS nurse was completing that role. He stated if resident care plans were not updated for high risk for elopement residents, an elopement could occur. Review on [DATE] at 12:00 PM of the weather the day of the elopement revealed a high of 95 and a low of 71 degrees Fahrenheit. < https://www.accuweather.com/en/us/[NAME]/76201/august-weather/331112> Review of the facility policy, Elopement Prevention, revised [DATE] revealed Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission . The assessment tool should be completed and interventions implemented as indicated . 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM. The POR went as follows: Facility: [ Facility name] Date: [DATE] PLAN OF REMOVAL FOR Missing Resident Problem: F656 Care Plans Action Taken: Resident #1 eloped from facility on [DATE] approximately between 11:45 AM and 1:20 PM. The resident's care plan was not updated to reflect risk of elopement during length of stay. Facility failed to identify resident as elopement risk and implement care plan with monitoring and interventions. Regional Compliance, Administrator, DON, ADON A, and ADON B initiated care plan updates to reflect elopement scores as of [DATE]. Starting [DATE] and ongoing In-services: An in-service regarding the company care plan policy labeled Baseline care plan and comprehensive care plan was initiated as of [DATE] by Regional Compliance, DON, ADON A, and ADON B. All direct-care staff to be in-serviced prior to start of shift [DATE] and on-going. Policies to discuss baseline care plan initiation within 48 hours of admission, Comprehensive care plan updated with resident specific items to include elopement risk if applicable, changes of condition and quarterly review. Regional Compliance Nurse in-serviced Administrator and DON on care plan policies and procedures Baseline care plan and comprehensive care plan on [DATE]. Policies to discuss baseline care plan initiation within 48 hours of admission, Comprehensive care plan updated with resident specific items to include elopement risk if applicable, changes of condition and quarterly review. Regional Compliance in-serviced Administrator and DON on elopement care plan updates on [DATE]. Policy to discuss elopement risk care plan updates on admission, quarterly and as needed for change in condition. Monitoring: The Administrator and DON will monitor for compliance and ensure all staff have been in-serviced on [DATE] and ongoing. A printed roster of all staff who have been trained will be maintained by the DON and Administrator. Start Date on [DATE] and ongoing. The DON, ADON A, and ADON will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopements. Monitoring weekly x 6 weeks. Start Date [DATE]. Findings will reviewed in the monthly QAPI meeting by the IDT for 3 months. Involvement of Medical Director The Medical Director was notified of immediate jeopardy on [DATE]. Interviews were conducted with facility staff across multiple shifts on [DATE] between 12:45 PM and 4:00 PM. Staff interviewed were CNA C, CNA D, CNA E, CNA F, CMA G, CNA H, CNA I, LVN K, Medical Records, Admissions Director, Housekeeping L, Housekeeping M, Laundry, LVN S, LVN N, ADON A, and ADON B. Record review conducted on [DATE] at 4:00 PM revealed Resident #1, Resident #2, and Resident #3 care plan had updates to reflect elopement risk scores. Review of the facility's Care Planning - Elopement Response and Prevention in-service dated, [DATE], revealed 42 of staff from direct care staff positions signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to baseline and comprehensive care planning; In-service was facilitated by DON. Review of facility's Elopement Risk Assessment on Admit and Quarterly and Change of Condition, in-service dated [DATE], revealed 26 of staff from nursing and nurse aides signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to elopement response; In-service was facilitated by DON. Review of facility's Elopement, Care Plans, in-service dated [DATE] revealed Administrator and DON signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to baseline and comprehensive care planning; In-service was facilitated by Regional Compliance. Review of facility's Elopement Response and Prevention and Specific Response, in-service dated [DATE] revealed 121 of staff from all departments signed off on the in-service. The in-service covered general policies, protocols, and procedures as well as specific residents at the facility that were at risk for elopement and was facilitated by DON. Review of facility monitoring tool, Monitoring, with start date [DATE], revealed DON/ADON/Designee to ask 5 staff members weekly if they have noticed any residents attempting to elope or leave facility, what would their actions be? Was their response appropriate? Monitoring continues weekly times 6 weeks. Further review of monitoring tool revealed the sheet indicated monitoring for Maintenance Director to check all exit doors for proper alarming and functioning daily. The Care Plan monitoring tool revealed Don/ADON/Designee will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopement. Monitoring weekly x 6 weeks . Elopement risk assessment monitoring included DON/Administrator to monitor Elopement Risk Assessments in PCC (Point Click Care.) Were elopement risk assessments completed timely upon admission and quarterly? Monitoring continues weekly times 6 weeks. In interview with Administrator on [DATE] at 4:30 PM, he stated his management company was transitioning to a new company, and that they would be placing an experienced MDS nurse in the near future. He stated he was confident with a new MDS nurse coupled with new corporate support, this issue would be remedied . He stated he will be responsible for ensuring the monitoring for compliance will be completed by DON and he would ensure all staff have been in-serviced on [DATE] and ongoing. In interview with DON on [DATE] at 4:45 PM, she stated she would ensure that she and the ADONs at the facility will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopements. She stated she would monitor weekly and continue to monitor for 6 weeks. Interviews with facility staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Relevant staff were in-serviced regarding completing elopement evaluations and/or the identification of and/or monitoring for exit seeking behaviors. Additionally, relevant staff verbalized understanding of facility policies to discuss baseline care plan initiation within 48 hours of admission, comprehensive care plan updated with resident specific items to include elopement risk if applicable, and changes of condition and quarterly review. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM.

Based on interview, and record review the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement of (Resident #1) 1 of 6 residents reviewed for accidents, hazards, and supervision. The facility failed to adequately supervise Resident #1 who was assessed as high risk for elopement. This risk was not included on his comprehensive care plan. Consequently, on [DATE] Resident #1 eloped from an unknown route and was located by Law Enforcement approximately 4.9 miles away from the facility. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM. This failure could place residents requiring supervision at risk for serious injury and death. Findings included: Review of Resident #1's Face Sheet dated [DATE] revealed he was a [AGE] year-old male readmitted to the facility on [DATE] from an acute care hospital for rehabilitation. Relevant diagnoses included schizoaffective disorder bipolar type (psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder - either bipolar type (episodes of mania and sometimes depression), depression (mood disorder,) unsteadiness on feet, unspecified lack of coordination, cognitive communication deficit, altered mental status, suicidal ideations, auditory hallucinations (hearing things that are not real,) and elevated white blood cell count (infection.) Record review of Resident #1's Elopement Risk Assessment, dated [DATE] revealed he was a high elopement risk. Resident #1's Elopement Risk Assessment revealed: .7. Elopement Screen . A score of 5 or greater = HIGH RISK for Wandering/Elopement Potential . 5. Based on admission information and/or responsible party information has the resident ever eloped before or does the resident have a habit of wandering or pacing? A) Yes [score 5.] Review of Resident #1's MDS, dated [DATE], revealed he was cognitively intact with a BIMS score of 15. Resident #1 required supervision of one staff to physically assist him to walk in room, and supervision of setup help only to walk in corridor, locomotion on unit, locomotion off unit. He did not require any assistive devices for ambulation and was scored as steady at all times when moving from seated to standing position, walking, turning around and facing the opposite direction when walking, moving on and off toilet, and surface-to-surface transfers. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed he was at risk for falls, required assistance with ADLs, was on antidepressant, antianxiety, and hypnotic medications that required monitoring for effectiveness and/or negative outcomes. No evidence of elopement risk or precautions were indicated in Resident #1's care plan. Record review of Resident #1's EHR on [DATE] revealed there was not an assessment or an evaluation to determine Residnet #1 ability to to independently and safety sign out of the facility on temporary leave by himself. In an interview with the Administrator on [DATE] at 10:31 AM, he stated that Resident #1 had a BIMS score of 15 and was very high functioning. Administrator stated the facility was aware of Resident #1's elopement risk and they had provided him a room away from any exit doors, and in a high traffic area close to the nurse's station to enable enhanced monitoring. Administrator also stated that he personally had provided education to Resident #1 about the option of signing himself out of the facility if he wanted to temporarily leave the facility for whatever reason. He stated Resident #1 was admitted to the facility for rehabilitation, and MHMR and the facility's SW were working together to find him a group home upon discharge. He stated that his facility does not offer a secured unit nor a Wanderguard[TM] type device (WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers) but Resident #1 would not have been appropriate for that level of securement due to his cognitive function. He acknowledged that Resident #1's Care Plan should have included his elopement risk, but he did not feel it contributed to Resident #1's elopement. He stated the SW spoke with Resident #1 the morning of [DATE] around 9:00 AM to discuss discharge planning. The Administrator stated that around 1:20 PM, he was informed by staff they could not locate Resident #1. The facility was searched, and local law enforcement was contacted. The Administrator stated that during his investigation, Resident #4 stated she spoke with Resident #1 between 9:00 AM -10:30 AM that morning. The Administrator further stated that the charge nurse on duty, LVN S, reported seeing Resident #1 around 10:40 AM. He stated local Law Enforcement located the resident around 5:30 PM approximately 4.9 miles south near a lake eating cheese fries and drinking tea. He stated the Law Enforcement Officers reported to him that Resident #1 did not look in distress. Furthermore, he was going to be transported to a nearby psychiatric acute care facility per the Resident #1's request and would not be coming back to the facility. Administrator stated he reported this information to the physician. The Administrator further stated that Resident #1's family member was contacted to gather additional information about Resident #1's whereabouts. Resident #1's family member reported to the Administrator that she had access to his bank records and that Resident #1 made a withdrawal of cash from a bank approximately 1 mile away at 9:20 AM the morning of [DATE]. The Administrator stated he was not exactly sure how Resident #1 eloped, and the facility did not have cameras to review. The Administrator did not provide documention of the education for Resident #1 for temporary leave. Attempts to interview Resident #1 were made on [DATE] at 10:13 AM and [DATE] at 1:00 PM, but the phone line was disconnected. In an interview with the SW on [DATE] at 10:31 AM he stated he was aware of Resident #1's previous elopement attempt, wandering behavior, and episodes of impulsivity. He stated that while Resident #1 exhibited wandering behaviors as evidenced by pacing the halls, he did not have any exit seeking behaviors since his admission on the skilled unit. He stated Resident #1 had completed his rehabilitation at the facility and he had had found a group home that was willing to accept Resident #1. He stated that he went the morning of [DATE] around 8:30 AM to update Resident #1 to discuss the information. He recalled that the resident was not thrilled about going to a group home, and stated Resident #1 reported to him that he wanted to live independently. The SW further stated that Resident #1 told him that he wanted to go to the bank, grocery store, and go to an acute care psychiatric facility. The SW stated he told Resident #1 that the facility could arrange transport for him, and that Resident #1 going to an acute care psychiatric facility was a last resort. He stated he educated the resident on how a group home was a least restrictive option. The SW stated Resident #1 did not seem upset and did not give him the impression he was going to elope. He stated Resident #1 acknowledged that the facility would arrange transportation for him and was in agreeance with the current discharge plan. Furthermore, he stated that elopement risk assessments and interventions were a nursing component and he thought it would have fallen under the MDS nurse's scope of practice and responsibility. Attempts to interview LVN S were made [DATE] at 11:25 AM and 2:30 PM. In interview with Resident #1's Guardian on [DATE] at 9:32 AM, he stated he was his guardian, but his guardianship expired on [DATE] and was not his guardian at the time of the elopement. He stated he remained in contact with Resident #1 and considered him a friend. He stated that he was contacted by Resident #1 the day of the elopement, not certain of the time, and told him he was on foot walking to [Acute Care Psychiatric Hospital.] He stated that Resident #1 told him that he met a gentlemen that looked homeless and gave him money, then proceeded walking south towards where [Acute Care Psychiatric Hospital] was located. He stated Resident #1 had a history of taking long walks and reported that information to Law Enforcement when they contacted him between ,d+[DATE]:00 PM the day of the elopement. In an interview with Resident #1's Family Member, on [DATE] at 9:45 AM she stated she was a co-signer on his bank account, and she kept a close eye to ensure his balance stayed where it needed to be. She stated she was not his responsible party and did not expect to be notified of his discharge, so she assumed that he was being discharged from the facility that day ([DATE]) and dismissed the withdrawal as initially concerning. She stated a few hours later she received a call from a nurse at the facility and later Law Enforcement stating that he was missing. She reported that Resident #1 made a withdrawal from [Bank] which was about 1 mile away from the facility around 9:00 AM that morning. She further stated she called the bank, as the bank staff were familiar with Resident #1 and reported to her that they recalled seeing him that morning, and that he made a withdrawal. In interview with MDS nurse on [DATE] at 5:42 PM, she stated it was her responsibility to complete resident MDS's and ensure resident care plans were updated to reflect their specific care needs and risks. She stated that Resident #1 did trigger for a high risk for elopement but stated in her opinion, Resident #1 was not an elopement risk and would not have included that in his care plan. Additionally, she did not provide a statement as to why Resident #2 and Resident #3 did not have their elopement risk care planned. She stated that facility policy dictated to put the risk with relevant interventions on the care plan but stated, it depends on the resident. She stated that the Elopement Assessment was just a tool' and triggers to give a possible risk but does not necessarily mean they are an elopement risk. She stated if someone was a true elopement risk, their care plan should reflect that as the nurses and the interdisciplinary care team looked at it during their morning meeting each day to ensure each resident's care needs were addressed. In interview with DON on [DATE] at 2:48 PM, she stated it was her first week employed at the facility and was not involved in the elopement nor the investigation surrounding the elopement. She stated her expectation was for any elopement assessment scored as high risk should be entered into the care plan along with relevant interventions. She stated it was traditionally the MDS nurse's responsibility to ensure resident care plans were customized and comprehensive to address resident care needs. She further stated this was important so resident care needs can be reviewed every day in morning meeting, where they work from resident care plans. She stated if resident care plans were not updated for a high risk for elopement residents, an elopement could occur. In interview with Administrator on [DATE] at 4:16 PM, he stated it was the MDS nurse's responsibility to ensure resident care plans were updated to reflect resident care needs. It was the former DON's responsibility to ensure the MDS nurse was completing this role. He stated if resident care plans were not updated for high risk for elopement residents, an elopement could occur. Review on [DATE] at 12:00 PM of the weather the day of the elopement revealed a high of 95 and a low of 71 degrees Fahrenheit. < https://www.accuweather.com/en/us/[NAME]/76201/august-weather/331112> Review of facility policy, Elopement Prevention, rev. [DATE] revealed Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission . The assessment tool should be completed and interventions implemented as indicated . 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM. Facility: [Facility] Date: [DATE] PLAN OF REMOVAL FOR Missing Resident Problem: F689 Accident and Hazards Action Taken As of [DATE] Resident #1 eloped on the facility on [DATE] approximately between 11:45 AM and 1:20 PM. When located by [City] Police at approximately 5:30 PM, the resident transported and admitted to a behavioral hospital related to his schizophrenic diagnosis. The Facility failed to identify resident as elopement risk and implement care plan with monitoring and interventions. Elopement Risk Assessments were updated on [DATE] for all residents in the facility by the DON, ADON A, and ADON B, and the facility's Treatment Nurse. There were 7 residents identified for elopement risks. The Charge Nurse on shift will be responsible for completing elopement risk assessments on all resident admissions, quarterly assessments, and all residents with each change of condition related to increased risk elopement. Start Date [DATE] and ongoing. Elopement Risk Assessments for all new admissions, quarterly assessments, and all residents with change of condition related to increased elopement risk assessment will be reviewed and monitored by the Administrator and DON weekly. Starting [DATE] and ongoing. Regional Compliance, Administrator, DON, ADON A, and ADON B initiated care plan updates to reflect elopement risk scores for 7 residents, including Kardex alerts for residents at risk as of [DATE]. Starting [DATE] and ongoing. DON, ADON A, and ADON B will monitor by asking 5 staff per week if they noticed any resident attempting to elope or leave facility what would their actions be? Monitoring weekly x 6 weeks. Start Date [DATE]. All exit doors in the facility were checked by Regional Compliance and Administrator for proper alarm and functioning. No issues were identified. Completed [DATE]. Moving forward, the Maintenance Director, Maintenance X, and Maintenance Y will check all exit doors daily. Start Date [DATE] and ongoing. Administrator will review monitoring tool weekly for compliance. Start Date [DATE]. DON, ADON A, and ADON B will monitor all new and updated elopement risk assessments daily to identify any residents at risk for elopements. Monitoring weekly x 6 weeks. Start Date [DATE]. In-services: Regional Compliance Nurse in-serviced DON and Administrator on elopement policy and procedure on [DATE]. Policy to discuss elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Regional Compliance in-serviced DON and Administrator on the elopement risk assessments to be completed on admission, quarterly, and as needed for changes in condition on [DATE]. Policy to discuss elopement risk assessment of residents, assessment to be completed on all new admissions, quarterly, and change of condition related to elopement risk on all residents. An in-service regarding resident elopement facility protocols were initiated as of [DATE] by the Administrator and DON for all facility staff. All staff not present will be in-serviced prior to performing work duties. All staff will be in-serviced on [DATE] and on-going, prior to start of their shift. All Charge Nurses were in-serviced by DON that all residents must have elopement risk assessment completed upon admission, quarterly, and as needed for changes of condition. All nurses not present will be in-serviced prior to performing work duties. Start Date - [DATE]. All staff will be in-serviced prior to the start of their shift. Policy to discuss elopement risk assessment of residents, assessment to be completed on all new admissions, quarterly, and change of condition related to elopement risk on all residents. DON, ADON A, and ADON B will monitor all new and updated elopement risk assessments daily to identify any residents at risk for elopements. Monitoring weekly x 6 weeks. Start Date [DATE]. All direct care staff were in-serviced by DON, ADON A, and ADON B on current residents at risk for elopement, monitoring, and appropriate interventions. DON, ADON A, and ADON B will monitor by asking 5 staff per week if they noticed any resident attempting to elope or leave facility what would their actions be? Monitoring weekly x 6 weeks. Start Date [DATE]. Monitoring: The Administrator and DON will monitor for compliance and ensure all staff have been in-serviced on [DATE] and ongoing. A printed roster of all staff who have been trained will be maintained by the DON and Administrator. Start Date on [DATE] and ongoing by the following: Moving forward, the Maintenance Director, Maintenance X, and Maintenance Y will check all exit doors daily. Start Date [DATE] and ongoing. Administrator will review monitoring tool weekly for compliance. Start Date [DATE] DON, ADON A, and ADON B will monitor all new and updated elopement risk assessments daily to identify any residents at risk for elopements. Monitoring weekly x 6 weeks. Start Date [DATE]. DON, ADON A, and ADON B will monitor by asking 5 staff per week if they noticed any resident attempting to elope or leave facility what would their actions be? Monitoring weekly x 6 weeks. Start Date [DATE]. Findings will reviewed in the monthly QAPI meeting by the IDT for 3 months. Involvement of Medical Director The Medical Director was notified of immediate jeopardy on [DATE]. Interviews were conducted with facility staff across multiple shifts on [DATE] between 12:45 PM and 4:00 PM. Staff interviewed were CNA C, CNA D, CNA E, CNA F, CMA G, CNA H, CNA I, LVN K, Medical Records, Admissions Director, Housekeeping L, Housekeeping M, Laundry, LVN S, LVN N, ADON A, and ADON B. Record review conducted on [DATE] at 4:00 PM revealed Resident #1, Resident #2, and Resident #3 care plan had updates to reflect elopement risk scores. Review of the facility's Care Planning - Elopement Response and Prevention in-service dated, [DATE], revealed 42 of staff from direct care staff positions signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to baseline and comprehensive care planning; In-service was facilitated by DON. Review of facility's Elopement Risk Assessment on Admit and Quarterly and Change of Condition, in-service dated [DATE], revealed 26 of staff from nursing and nurse aides signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to elopement response; In-service was facilitated by DON. Review of facility's Elopement, Care Plans, in-service dated [DATE] revealed Administrator and DON signed off on the in-service. The in-service covered facility policy, protocol, and procedure related to baseline and comprehensive care planning; In-service was facilitated by Regional Compliance. Review of facility's Elopement Response and Prevention and Specific Response, in-service dated [DATE] revealed 121 of staff from all departments signed off on the in-service. The in-service covered general policies, protocols, and procedures as well as specific residents at the facility that were at risk for elopement and was facilitated by DON. Interviews with facility staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Relevant staff were in-serviced regarding completing elopement evaluations and/or the identification of and/or monitoring for exit seeking behaviors. Additionally, relevant staff verbalized understanding of facility policies to discuss baseline care plan initiation within 48 hours of admission, comprehensive care plan updated with resident specific items to include elopement risk if applicable, and changes of condition and quarterly review. Review of facility monitoring tool, Monitoring, with start date [DATE], revealed DON/ADON/Designee to ask 5 staff members weekly if they have noticed any residents attempting to elope or leave facility, what would their actions be? Was their response appropriate? Monitoring continues weekly times 6 weeks. Further review of monitoring tool revealed the sheet indicated monitoring for Maintenance Director to check all exit doors for proper alarming and functioning daily. The Care Plan monitoring tool revealed Don/ADON/Designee will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopement. Monitoring weekly x 6 weeks . Elopement risk assessment monitoring included DON/Administrator to monitor Elopement Risk Assessments in PCC [Point Click Care]. Were elopement risk assessments completed timely upon admission and quarterly? Monitoring continues weekly times 6 weeks. In interview with Administrator on [DATE] at 4:30 PM, he stated his management company was transitioning to a new company, and that they would be placing an experienced MDS nurse in the near future. He stated he was confident with a new MDS nurse coupled with new corporate support, this issue would be remedied . He stated he will be responsible for ensuring the monitoring for compliance will be completed by DON and he would ensure all staff have been in-serviced on [DATE] and ongoing. In interview with DON on [DATE] at 4:45 PM, she stated she would ensure that she and the ADONs at the facility will monitor all care plans daily for new admissions, quarterly and for any change in condition to ensure resident care plans reflect the risk for elopements. She stated she would monitor weekly and continue to monitor for 6 weeks. An IJ was identified on [DATE] at 4:14 PM. The IJ template was provided to the facility on [DATE] at 4:32 PM. While the IJ was removed on [DATE] at 12:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained at the time of exit [DATE] at 6:00 PM.

Based on observation, interview and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 1 of 6 residents reviewed for accidents hazards/supervision. (Resident#1). The facility failed to properly supervise Resident #1 who was cognitively impaired and who was residing in the memory unit, due to elopement behaviors. Resident #1 wandered out of side alarm fire door located near the dining room in the memory unit. She was located at the apartments behind the facility after law Enforcement was notified by someone at the apartments, because she was knocking on the door searching for her mother. It was determined these failures placed Resident #1 in an immediate Jeopardy (IJ) situation from 06/03/22 to 06/06/22. The facility took the following actions to correct the non-compliance on 06/06/22 1. implementing daily exit door audits to ensure and facility census. 2. Resident #1 was placed on close observations with interventions. 3. All staff were in-serviced by Maintenance worker on fire door alarm and monitoring and DON/ADON dementia 4. inspection of Fire door by vendors. The findings include: Record Review of Resident #1' face sheet revealed she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnosis included: Psoriatic Arthritis Mutilans ([CONDITION(S)] [CONDITION(S)] condition affecting the joints and skin), Dementia in other Disease Classified elsewhere without Behavioral Disturbance (Memory decline), Unspecified Dementia without behavioral disturbances, [CONDITION(S)] Disorder Mood), Recurrent severe without psychotic features. Record Review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 3, signifying a severe cognitive impairment. MDS, Section G revealed that resident needed 2 persons assist with ADLs of bed mobility and toileting, and only set up for and support for dressing, and Personal Hygiene including bathing. Resident #1 ambulates unsteady with a walker throughout the facility, due to a previously [CONDITION(S)] and unsteady gate. Record review of Resident#1's care plan, dated 06/23/22, revealed Resident #1 had potential for elopement and frequently exhibited exit seeking related to poor impulse, due to her disease process. The care plan reflected, Elopement Risk Interventions included attempting Non-Pharmacological interventions such as, offering Resident #1 diversional activities through positive interactions, food, television, books, and activities as well as talking in passing; Monitor behaving episodes and attempts to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes, as Resident #1's triggers for exit seeking are a deep desire to be with her parents, so de-escalation by validating her feelings and getting into her reality has been beneficial to her care needs and safety. Record review of Resident #1's physician's order revealed an order for Behavior observation and documentation to monitor Resident #1 for anxiety, agitation, possible side effects for [MEDICATION(S)], and the number of times exhibited during shift using intervention codes: 1 on 1, 2) activity 3) adjust room temperature, 4)backrub, 5) Change position, 6) give liquids, 7) Give food, 8) Redirect, 9) Remove resident from environment, 10) Return to room, 11) Toilet. Resident # 1 was prescribed [MEDICATION(S)] on 06/09/22 for anti-anxiety and chart all appropriate codes: 0-none, 1-sedation/drowsiness, 2-increased falls/dizziness, 3-[CONDITION(S)], 4-anxiety/agitation, 5-blurred vision, 6-sweating/rashes, 7-weakness, 8-headache, 9-[CONDITION(S)], 10-[CONDITION(S)]/hesitancy, 11-antichollnegic symptoms, 12- cardiac abnormalities, 13-hangove effect, and 14- other. In an interview with the Administrator on 06/22/2022 at 9:00 AM, revealed that on Friday 06/03/2022 at approximately 7:50 PM was the last time Resident #1 was seen in her room by CNA -A. Prior to this Resident #1 had pushed the alarm door open and attempted to exit out of the same before staff apprehended her for safety while providing consolation and reassurance in her room. The Administrator stated that at approximately 8:30 PM, DPD Law enforcement arrived at the facility inquiring if a resident was missing giving Resident #1's first name. Resident #1 was brought in by a second officer and CNA-A greeted resident and returned her to her room. Resident was not wet nor were her clothing soiled upon arriving back at the facility. He stated that law enforcement reported that Resident #1 was located after a 911 call was made reporting that the resident knocked on a resident's door asking for her mother. The specifics of engagement with the complainant were not provided by law enforcement as to the location and the person. At that time the DON, ADON, Administrator, MD, and family were notified of the incident. Staff were in serviced on supervision and interventions of exit seeking residents, monitoring resident one on one and maintaining a visual were instituted by all staff. LVN-H concluded that when Resident #1 opened the door the first time and she used the key to reset the alarm, that it was not armed, and resident returned to the door therefore exiting the building walking down the steps turning left, entering the open gate leading around to the apartment complex. In an interview with DON on 06/22/22 at 9:30 am revealed that on 06/03/2022 she was notified by the ADON that was on call, stating that Resident #1 had eloped from the facility and was returned by law enforcement at approximately 8:30 PM. She stated that she advised ADON to have the charge nurse, LVN-I, to In-service nursing staff to monitoring the alarm doors on each unit, maintain supervision and visuals of Resident #1 at all times, document exit seeking behaviors, aggression, and wandering. Assure that the light on every door demonstrates red, confirming that the door was armed. Implement interventions from the care plan and the psychiatrist to redirect and ease Resident #1's impulsivity and anxiety. In an observation of the memory unit on 06/22/22 at 10:00 AM revealed Resident #1 sitting in her chair in the dining room, she stated that she had not left the facility and had been here all day. She could not verbalize further nor recall the incident of eloping. In an interview with the ADON on 06/22/22 at 10:30 AM revealed that on 06/03/2022 she was notified by the LVN-H the nurse working with Resident #1, stating that she was passing medication on the north hall when CNA-A gestured for her for her to come with her and law enforcement. The ADON stated that Resident #1 was returned by law enforcement after eloping. The ADON stated that LVN-H and LVN-I, were approached by the DPD officer and given the details of locating Resident #1, which concluded that the nursing staff on the memory unit, CNA-A and LVN-H were not aware that Resident #1 had left the building. Once Resident #1 was returned, CNA-A greeted her and escorted her to her room and conduct assessments of her skin, neuro checks, scrapes, falls, skin tears, and dehydration, including vitals, blood pressure, oxygen, and pulse. The ADON stated that she then directed LVN-H and LVN-I to print off the facility census and conduct ongoing searches during each shift to account and confirm all residents were safe and on site to assure their safety and location, check all alarm doors and assure that they are armed and working properly, in-service and educate all staff to monitor the alarm doors on each unit, maintain supervision and visuals of Resident #1 at all times, document exit seeking behaviors, aggression, and wandering. The ADON stated that while awaiting the completion of the Census she proceeded to enter electronic orders prompts in the MAR and ADL's task to prompt staff to conduct the task throughout their shifts daily, and she called and spoke with each nurse on duty to in-service and educate for proper supervision and documentation including monitoring and auditing the fire alarm doors, implement interventions from care plan and psychiatrist to redirect exit behaviors, and ease Resident #1's impulsivity and anxiety. An interview with LVN-H on 06/22/22 at 10:30 AM, revealed that on 06/03/2022 she was passing medication on the north hall, when she observed the police and CNA-A walking down the hall south hall. LVN H stated that when CNA-A gestured for her to come quickly, she immediately complied and joined CNA-H and the DPD officer. The DPD officer stated that the resident was located outside the building in another law enforcement patrol vehicle, while he confirmed that the resident was missing from this facility. After LVN-I and DPD officer confirmed details of the 911 call made, LVN-H and CNA-A were able to confirm that Resident #1 was missing. Law enforcement and CNA-A met and greeted Resident #1 at the patrol car outside, and she was escorted her to her room while LVN-H and LVN-I completed a quick search of all doors and discovered that the south door on the memory unit side door was left open with the alarm sounding with a green light flashing, indicating the door was not armed. LVN H stated that she tried to open the door again and the alarm beeped three times, then opened. Charge nurse LVN-H assisted LVN-H to lock and arm the door. When trying to open the door again the alarm sounded. LVN H stated that the resident was returned to the facility by DPD and LVN H conducted a head-to-toe assessment that yielded no injuries, signs of pain, skin tears. LVN-H completed vitals on Resident #1, the vitals were 135/80 HR 92 02 97%. An interview with CNA-A on 06/22/2022 at 10:50 AM, revealed she was the direct care CNA for Resident #1. She stated she has received elopement training from the Charge nurse LVN-I, ADON, and DON. She stated the staff were expected to supervise Resident #1 at all times and intervene with validation, distractions, food, and document all behaviors. She was also instructed to assist with monitoring the doors and respond to alarms immediately when sounded. CNA-A stated that she was in Resident #1's room from 7:00 PM to 7:50 PM on 06/03/22 reassuring and assessing Resident #1 after she became angry hitting, kicking, and yelling on the north hall door and pushing alarm door. Once the resident was calm in her room, CNA-A left to check on other residents on her hall, and that was the last time she observed Resident #1 before the office arrived at the facility. Once the officer arrived at the facility, he spoke with LVN-I, the charge nurse, and she contacted CNA-A. Upon establishing that the resident in the DPD custody was Resident #1, she met the second patrol outside and greeted Resident #1 and escorted her to her room for assessments of vitals, bruises, tears, and confusion. She was not injured and she stated that the officer said that she had been gone approximately 30 minutes. An interview with LVN-I on 06/22/2022 at 11:50 AM, revealed she was the charge lead nurse on the South hall, and was approached by a DPD officer on 06/03/2022, inquiring if a Resident was missing by the name of Resident #1. LVN-I stated that she called for CNA-A for the, and she conducted a quick search to determine that the resident was missing. LVN-I stated that Resident #1 was currently in a second patrol car outside, and that 911 received a call that a person was knocking on their door in the apartments behind the facility asking for her mother. Law Enforcement responded to apartments, retrieved the resident, and checked at this facility first. CNA-A followed the officer to Resident # 1, greeted Resident #1 and returned to her room for assessments. LVN-I contacted ADON while LVN-H assessed resident then alarm doors. LVN-I was directed by ADON stated that she then directed LVN-H and LVN-I to print off facility census and conduct ongoing searches during each shift to account and confirm all residents were safe and on site to assure their safety and location, check all alarm doors and assure that they are armed and working properly, in-service and educate all staff to monitor the alarm doors on each unit, maintain supervision and visuals of Resident #1 at all times, document exit seeking behaviors, aggression, and wandering. LVN-I stated that when speaking with officer he stated that the resident was located in the apartments by a renter. An interview with SW on 06/22/22 at 12:15 PM revealed that she was informed that Resident #1 eloped from the fire door on Friday evening 06/03/22 during an IDT meeting. She stated that interventions were reviewed, family were notified, and she completed a trauma assessment, fall assessment, elopement assessment, all not exhibiting any changes with the resident. She was not aware of Resident #1's previous elopement history for another facility. She stated that there have not been any other incidents of residents eloping from the facility. An interview with SW on 06/22/22 at 12:15 PM revealed that she was informed that Resident #1 eloped from the fire door on Friday evening 06/03/22 during an IDT meeting. She stated that interventions were reviewed, family were notified, and she completed a trauma assessment, fall assessment, elopement assessment, all not exhibiting any changes with the resident. She was not aware of Resident #1's previous elopement history for another facility. She stated that there have not been any other incidents of residents eloping from the facility. An interview on 6/22/22 at 12:35 PM with MDS nurse reveal when a resident has eloped from the facility or off the wing or continues to exit seek from the facility was a concern, however it does not qualify for a change in condition, and it did not occur in two separate areas. She was not aware of any resident that left the building, and she didn't attend the IDT meeting on 06/06/22. She stated that the IDT meeting shares this information. She received an email later about the incident, with no concerns of changing her MDS. She stated that she completes quarterly MDS, and the Social worker completes the BIMS score. She was not aware that the previous facility had many incidents Resident #1 wandering. An interview on 06/22/22 12:50 PM with the Maintenance Director (MD) he revealed that he was aware of the incident involving Resident #1's elopement from the facility through the fire alarm door located on the memory unit during an IDT meeting on 06/03/22. The MD stated that he has been here a very short time, however the door was assessed and there were no concerns to whether the doors were working. MD stated that Maintenance staff conduct routine checks of the security and fire doors monthly and when staff communicate concerns of the doors not working. The MD stated that he did not know the history of the facility or if this has occurred previously. Record Review of the maintenance reports revealed that a work order with a qualified vendor's Invoice # 816 dated 05/10/22 and Invoice # 167 dated 05/11/22 revealed that the doors were assessed for functioning and one door required a replacement of the magnetic lock of the door entering the memory unit at the south station. Record Review of the maintenance reports revealed a fire alarm inspection completed on 06/16/16 confirming all fire alarm doors and additional facility related locked doors were operating and functioning appropriately. An interview with Maintenance Worker (MW) revealed that he has worked in the maintenance department at this facility for over [AGE] years and that it was rare for the magnet on the fire alarm doors to malfunction. He stated that the fire doors were checked on 06/06/2022 by maintenance and an official inspection was completed on a professional fire agency on 06/15/22 and will return for another check of the fire alarm doors on 06/24/22. He stated that he did conduct staff in-service on fire alarm doors. An observation on 06/06/22 at 3:15 PM revealed that the facility had a total of 5 fire alarm doors. Locations include Southeast, Southwest, West, Northwest, and Northeast. All doors were pushed and the alarm sounded indicating the doors were working properly. In an observation of the memory unit on 06/22/22 at 5:00 PM revealed Resident #1 getting up frequently stating that she had to meet her mother down at the bridge. CNA-A and LVN-M and LVN-H were observed engaging and implementing interventions of redirection, validation, guidance, support, and distractions. Resident #1 responded appropriately. In an interview on 06/23/22 at 10: 00 AM with CNA-B revealed that she normally works on the southeast hall, however today she has been assigned to supervise Resident #1 and maintain whereabouts, document any agitation, impulsivity, elopement seeking behaviors and report concerns to leadership. In an interview we LVN-K on 06/23/22 at 2:00 p.m. revealed that she was in-serviced by maintenance staff and leadership staff on the process of arming the fire doors, respond to the alarms immediately, use of distractions to redirect impulsive behaviors, supervision, census of residents during shifts, checking alarm lights and doors to assure that they are operating properly and notifying leadership and maintenance. She does work directly with Resident #1. In an interview we LVN-M on 06/23/22 at 2:30p.m revealed that she was in-serviced by leadership staff on Dementia Behaviors and interventions, process of setting alarms on fire doors and knowledge them being armed, prompts in system to conduct census of resident's as well as notifying maintenance staff if doors are not working properly. She has not worked with Resident #1. In an interview with LVN-N on 06/23/22 at 2:45 PM revealed that she was in-serviced on supervision, auditing alarm doors, setting alarms, completing census on shift to k now the whereabouts of the resident. LVN-N stated that she does not work with Resident In-service on a local procedure after the incident when a resident left the facility, she doesn't work with the resident however she was educated in the proper way to inspect fire door functioning while on duty elopement procedures, and dementia behaviors interventions. Review of resident provider investigation report revealed findings of Resident #1 eloping from the facility on 06/03/22 at approximately 7:50PM due to the fire alarm door on the memory unit not being reset properly, therefore not arming to prevent resident from exiting without an alarm. Resident #1 and another resident set the alarm off around 7:00pm 6/3/22, though staff had performed the necessary steps to reset the alarm and locking mechanism. Post-investigation Actions by Provider: Implementing daily exit door audits to ensure the magnetic locks are secured and function properly. Implementing daily gate audit to ensure the magnetic lock on the gate is secured and functions properly. In-servicing all nursing staff of the correct procedure to reset and secure the magnetic lock on the exit door in the memory care unit. In-servicing all staff on communicating with and validating dementia residents. When we receive the police report we will review it and will act on anything we may learn additionally, from the report. Review of in-service completed by MW on 06/06/22 read 1. The exit (or egress) door has a 15 second delay on door. The bar on the door must be pushed in for 15 seconds to disengage the magnetic lock (mag lock). Mag lock is green when it is unarmed. 2. When enough pressure has been applied to the door the mag lock audible alarm will sound, but it is not the ear-piercing sound the larger audible alarm makes when the door actually opens. 3. After the 15 seconds the door will open, and the larger audible alarm will go off. 4. 2 alarms - one on the mag lock itself and the other is the larger alarm on the side of the door frame. 5.The keypad operates the mag lock. The code is 1234. Entering the code will unlock the mag lock and will also silence the alarm. 6. Keypad resets the mag lock, you will hear it engage, and then the light turns red. 7. To reset the larger audible alarm the key is required. The key is on the nurse's key ring. 8. Turn the key clockwise (right) to turn off or silence the alarm. 9.Turn the key counterclockwise (left) to reset/arm the alarm, the light turns red for 15 seconds, then turns off and blinks red about every 30 seconds Record review of facility policy on Elopement revealed It is the policy of this center to assess residents for elopement potential and provide a safe and comfortable living environment. The center will be aware of the resident's usual habits and locations as reasonably practicable. A prompt investigation and search will be conducted if a patient/resident is considered missing Elopement includes when a resident leaves the premises or a safe area without the authorization and/or necessary supervision placing the resident at risk for harm or injury. Procedure: If identified as a risk for wandering, elopement, or other safety issues the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: Attempt to prevent the resident from leaving in a courteous manner. 3. In the occurrence that any staff member identifies that they cannot find a resident in a place that the resident is normally at, the staff member will notify their charge nurse/supervisor for assistance once verifying the resident was not signed out on pass. 4. Once it has been established that a patient/resident is missing, the following staff members are notified immediately: The Charge Nurse, Administrator, Director of Nursing, Social Service Designee, responsible party, the Primary Care Physician. 5. The DON or designee organizes and institutes an immediate and thorough search of the center and surrounding grounds. Including but not limited to a search of the area outside the nearest exit to the patient's/resident's room or the exit where he/she was last seen, and the entire unit where the patient/resident resides or was last seen, the remainder of the center (all rooms, closets - including storage facilities - bathrooms) and grounds, extending beyond the fence line. 6. The entire search process of the center and grounds, from the time the patient/resident is missing should be completed within thirty (30) minutes. 7. If the search fails to locate the missing patient/resident within 2 hours from the time the patient/resident is found to be missing (or sooner depending on the circumstances), the Administrator and/or designee contacts the appropriate community agencies (Local Law Enforcement) and the patient's/resident's legal representative. Staff will provide the Police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing, if known. 8. The search is continued. Two staff members search the surrounding streets by car for a two (2) mile radius around the center. 9. When the patient/resident is located, the Charge Nurse completes a head-to-toe assessment. The Social Service Designee assesses the patient/resident for emotional distress. The Charge Nurse reports any findings to the Director of Nursing. The Director of Nursing notifies the Administrator/designee and notifies the appropriate community agencies, attending physician and patient's resident's legal representative. Interview staff and obtain written statements. If resident was returned by outside personnel, obtain name, phone number and details with any information of where resident was found and under what circumstances the resident was found. Establish a monitoring system for resident until flight risk is resolved Determine what measures can be taken to prevent it from happening again (The resident is placed on one-to-one supervision until further arrangements are made to ensure the resident's safety.) Evaluate for need to relocate resident to another location/environment. 10. If a resident is not located during a search of the center, center grounds, and immediate vicinity and there are circumstances that place the resident's health, safety, and/or welfare at risk, the report must be made as soon as the center becomes aware the resident is missing and cannot be located. Examples include, but are not limited to: A resident requires medications that, if not taken as scheduled, place the resident at risk of serious illness or death or both. Extreme weather conditions expose the resident to potential freezing, heat prostration, or drowning from flooding. A resident is confused or otherwise incapable of assessing potential danger, or There is suspicion of foul play. 11. If the center has signaling (wander guard) and or door alarms, the supervisor/designee will: Determine if the electronic protection device used by the resident, if any, is present and )If so, the location of the device on the resident's body. Test any used electronic protection device both on the resident and attached to or associated with any doorways. Alert the Maintenance Director/designee in the occurrence that there is a malfunction with the device involved in the occurrence. In the occurrence that there is any doorway equipment malfunction supervision of that area will be provided unless there is only one resident at risk in which case the assigned staff member will provide one-on-one or other frequent observation to the resident as determined by the physician and or supervisor; and Re-evaluate the resident's risk for possible elopement regardless if the occurrence may constitute an elopement or not.

Based on observations, interviews, and record reviews the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection for 9 (MDS Nurse A, HSK Supervisor B, Assistant HSK Supervisor C, HSK D, Dietary Aide E, CNA G, the DON, ADON G, and RN M) of 20 facility staff reviewed for infection control. 1. The facility failed to maintain isolation precautions between the hot (COVID Positive) unit and the cold (COVID negative) unit when MDS Nurse A did not wear appropriate PPE in a COVID positive resident's room, HSK Supervisor B and Assistant HSK Supervisor C improperly wore PPE on the hot unit and then HSK Supervisor B and Assistant HSK Supervisor C re-entered the facility's cold unit. 2. The facility failed to ensure facility staff (HSK D, Dietary Aide E, and CNA G) wore their N95 respirators over their mouth and nose at all times when in resident care areas and failed to ensure HSK D did not alter his N95 mask. An Immediate Jeopardy (IJ) was identified on 01/13/22. While the IJ was removed on 01/15/22 , the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk of exposure of COVID-19 virus which could result in serious illness, hospitalization , and/or death. Findings included: 1. Review of the facility resident roster dated 01/12/22 reflected the facility had a census of 62. There were 28 COVID-19 positive residents on the hot unit and 2 COVID-19 positive residents admitted to the hospital. There were 34 residents on the cold unit. The facility did not have a warm unit. In an interview with ADON F on 01/12/22 at 9:30 AM, she stated the facility did not have a warm unit and the facility protocol was after entrance into the hot unit, staff should exit through a side door for the day and not re-enter the cold portion of the facility. ADON F also stated an N95 respirator was required at all times when in the facility. An observation on 01/12/22 at 10:00 AM revealed the facility hot unit was separated from the cold unit by two sets of double doors which were closed. There was a stop sign on the door and there was also a sign that droplet precautions were in place on the hot unit and a gown, gloves, face shield, and N95 respirator were to be used. An observation on the hot unit on 01/13/22 at 2:20 PM revealed MDS Nurse A entered Resident #2's room on the hot unit. She came within arm's reach of the resident who was not wearing a face mask. She was wearing an N95 respirator but was not wearing a face shield or gown. The MDS nurse explained to Resident #2 he had tested positive for COVID and had three more days left in his isolation period. After exiting the resident's room, the MDS nurse left the hot unit. An observation and interview on 01/13/22 at 2:30 PM revealed HSK Supervisor B and Assistant HSK Supervisor C entered the hot unit. They both were wearing N95 respirators. Assistant HSK Supervisor C donned a clean gown and gloves and entered room [ROOM NUMBER] and removed the personal belongings of a resident who had been sent to the hospital. After collecting the resident's belongings, Assistant HSK Supervisor C exited the room but did not doff her dirty gown or gloves. The HSK Supervisor B and Assistant Supervisor C walked down two halls on the hot unit side by side until they arrived at the hot unit double doors. Assistant HSK Supervisor C then placed a bag and picture frame on the floor and doffed her gown and gloves into a trash can. She picked up the bag and picture frame and took them outside through a side door. Assistant HSK Supervisor C and HSK Supervisor B then re-entered the facility's cold unit. HHSC Surveyor intervened and notified the DON that Assistant HSK Supervisor C and HSK Supervisor B had re-entered the cold unit. The DON stated she had been told staff could re-enter the hot unit if they waited 10 minutes and sprayed themselves down. The DON was notified Assistant HSK Supervisor C and HSK Supervisor B improperly used PPE and did not wait 10 minutes prior to re-entering the cold unit. The DON stated MDS Nurse A was waiting for her 10 minutes to pass and then would re-enter the cold unit. HHSC Surveyor intervened and told the DON that MDS nurse A had entered a resident's room on the hot unit, had come within arm's reach of the resident, and did not don a face shield or a gown. The DON stated she would send MDS Nurse A, HSK Supervisor B, and HSK Supervisor C home for the day. In an interview on 01/14/22 at 11:05 AM, HSK Supervisor B stated she entered the hot unit on 01/13/22 after she was notified the resident in room [ROOM NUMBER] would not be returning. She stated she did not enter the resident's room but after re-entering the building on 01/13/22, she instantly knew [she] shouldn't have re-entered the cold zone. She stated she walked through the building to her office and received a call from the DON instructing her to go home and she left. She stated she should not have entered the cold zone because she entered the hot zone and could transmit the virus because its airborne. In an interview on 01/14/22 at 11:15 AM, Assistant HSK Supervisor C stated she entered the hot zone on 01/13/22 because the receptionist told her the family was there to pick up personal items from the COVID unit. She stated there was a designated HSK for the hot unit to remove personal belongings, however the receptionist told her the family had been waiting long and she decided to go get the items herself. She stated she put on gloves and a gown prior to entering the room, got bags, and started putting the personal clothing in bags. Assistant HSK Supervisor C stated contact with resident's belongings on the hot unit could lead to COVID. She also stated she should have taken off her gown before exiting the room because she could become infected with COVID. She also stated she should not have re-entered the cold unit because the residents on the cold unit could become infected with COVID. In an interview on 01/14/22 at 11:50 AM, MDS Nurse A stated she entered the hot unit on 01/13/22 because a resident on the hot unit had wandered onto the cold unit and she was assisting him back to the hot unit by pushing his wheelchair. She stated she entered room [ROOM NUMBER] but was not going to provide any patient care and it was her understanding that [she] only needed to wear a gown or a face shield if [she was] providing patient care. She stated on 01/13/22 she received a call from the DON to tell her to go home. In an interview on 01/14/22 at 12:08 PM, the DON stated she misspoke when she said people could spray down and come 10 minutes later to the cold unit after being on the hot unit. The DON stated she expected staff not to re-enter the cold unit after being on the hot unit because they could spread COVID to a non-COVID patient. She also stated staff are expected to take off their dirty PPE at the room door and should not use it in the hallways. 2. An observation on 01/12/22 at 10:13 AM revealed HSK D wore a modified N95 respirator. The ties had been cut and re-tied to create loops which he wore behind his ears. The mask was loose fitting, and his nose was uncovered. ADON F walked past HSK D but did not correct his improper use of the N95 respirator. An observation on 01/13/22 at 12:49 PM revealed Dietary Aide E was in the dining room and he wore his N95 with both straps at his neck. His nose was not covered. Dietary Aide was cleaning the dining area tables with a rag he obtained from a red bucket. He also began drinking a soda and would pull his mask down under his mouth. Dietary Aide E was also coughing while his mask was under his mouth and nose. There were residents in their wheelchairs in the hall adjacent to the open dining area. In an interview on 01/13/22 at 12:54 PM, Dietary Aide E stated he did not know if he was wearing his N95 respirator properly and stated he did not receive any training on how to properly wear an N95 respirator. He also stated he had not notified the facility or his supervisor of his cough because it was just allergies. He stated the cough started that week due to the change in weather. In an interview on 01/13/22 at 1:01 PM, the Dietary Manager stated Dietary Aide E did not inform her he had a cough and would talk to him and review the policy and procedure with him. An observation in the hot unit on 01/13/22 at 1:28 PM revealed CNA G was wearing a KN95 face mask with loops behind her ears. She entered a resident's room on the hot unit. An interview on 01/13/22 1:42 PM, CNA G stated she was an agency staff and that was her first shift at the facility. She stated she was offered an N95 respirator when she arrived that morning at 5:45 AM, but she declined since she thought a KN95 face mask was okay. In an interview on 01/14/22 at 12:08 PM, the DON stated she expected staff to wear their N95 respirators properly covering their mouth and nose while in the facility and they should not modify the respirators. Review of the facility policy titled, Coronavirus Emergency Pandemic Policy Addendum dated 06/07/21, reflected the following: . The center's Coronavirus program includes early identification, transmission-based precautions, infection control and transfer of a person with active Coronavirus as needed. The program incorporates the following components . prompt recognition and transfer of residents with probable or confirmed Coronavirus. Administrative procedures and infection control methods to prevent and reduce the generation of infectious droplet nuclei in contaminated air (i.e. staff training on airborne, droplet and standard precautions and cough hygiene) Employees to follow the center's procedure for PPE and eye protection . a facemask for source control does not replace the need to wear an N95 or higher-level respirator (or other PPE) when indicated, including for the care of patients with probable or confirmed COVID-19 .If HC develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor . A probable or confirmed case of COVID is considered an outbreak in a resident or employee. DON/Infection Control Preventionist/designee in collaboration with the Medical director will give the directive to move the resident to the observation COVID-Hall that has been created . Confirmed Cases of COVID . If, the center's layout allows confirmed positive resident will be moved to the COVID Isolation Hall. Provide separate space to don (put on) and doff (take off) PPE when possible . When COVID-19 is identified in the center, employees wear all recommended PPE (i.e. isolation gown, gloves, eye protection, and an N95 or greater respirator if available.) . Quarantine Hall . Residents to wear cloth mask or cover nose and mouth with tissue when staff enter their room. Employees to give resident reminders as they enter the resident's room . Doffing will be conducted prior to exiting the room . The policy did not address the re-entry onto the cold unit by staff after being on the hot unit. On 01/13/22 at 5:55 PM the DON was notified an Immediate Jeopardy was identified and a Plan of Removal was requested. The IJ template was provided. The facility's Plan of Removal was accepted on 01/14/2022 3:54 PM and reflected the following: Plan for Removal [Facility Name] January 13, 2022 The Texas Department of Health and Human Services entered [Facility Name] on January 12, 2022, on a Complaint Investigation and Infection Control Survey. During their investigation an IJ (Immediate Jeopardy) was cited on 1/13/2022 regarding Infection Control citing- Facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection as evidenced by facility's failure to: o Ensure staff on the Hot Zone did not re-enter the Cold Zone after contact with residents or their belongings on the Hot Zone o Ensure that staff wore their N95 face masks properly covering their mouth and nose while in the cold zone/kitchen o Ensure staff on the Hot Zone wore N95 mask when working with residents Immediate interventions: Plan of Removal: Staff of all departments to include therapy department and agency staff will be in-serviced on the following- o It is the expectation that all staff will understand the significance of maintaining proper infection control procedures to include the practice of respecting the boundaries of the Hot Zone by acknowledging the need to NOT re-enter the cold or warm zones after contact with residents or their belongings on the hot zone. o Staff will demonstrate the proper way to wear their N95 face masks, always covering mouth and nose in all areas to include cold zone/kitchen and other areas of the facility that facility leadership, Infection Control Preventionist and Medical Director deem necessary in accordance with CDC guidelines. o Staff on the Hot Zone will demonstrate the proper way to wear their N95 face masks, always covering mouth and nose especially when working with residents. o All Staff will understand that it is not acceptable to alter the N95 mask in any way at any time. Any staff identified as wearing an altered N95 will be educated, and disciplinary actions may be imposed up to and possibly including termination. Agency staff may be placed on Do Not Return list. Director of Rehab will be notified of any therapy staff identified and will provide documentation to Administrator and/or Director of Nursing of actions taken. On 1/13/2022, the Director of Nursing and Regional Director of Clinical Operations began in-services with 2-10 shift of nursing staff and housekeeping staff on the necessity of always wearing N95 properly, covering nose and mouth, especially when providing direct patient care. At the time of the completion of in-servicing there were no therapy or dining staff on duty. Additional training was provided on the importance of respecting the boundaries of the Hot Zone by acknowledging that once contact is made with a resident or their belongings, the staff member may not exit the Hot Zone and enter/re-enter Cold Zone. This in service was started by the DON. Training will continue until it is completed with all staff of all departments including therapy department and agency staff. The staff will verify their understanding of these expectations by signing an acknowledgement of the training. On 1/13/2022, the facility Administrator and Director of Nursing held an ad hoc QAPI meeting with attendance to include Regional Director of Clinical Operations and Medical Director via phone. Impromptu agenda items were: Notification that an IJ (Immediate Jeopardy) was cited on 1/13/2022 regarding Infection Control citing- Facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection as evidenced by facility's failure to: o Ensure staff on the Hot Zone did not re-enter the Cold Zone after contact with residents or their belongings on the Hot Zone o Ensure that staff wear their N95 face masks properly covering their mouth and nose while in the cold zone/kitchen o Ensure staff on the Hot Zone wear N95 mask when working with residents Items determined by the QAPI team to address the issues were- o Education to all staff in all departments to include therapy department and agency staff of the need to- o Wear N95 at all times o An N95 is never to be altered o Staff must understand the boundaries between the Hot Zone and the Cold Zone and that once a staff member makes direct contact with a resident or their belongings in the Hot Zone that staff member cannot enter/re-enter the Cold Zone o Facility will monitor for ongoing compliance and any breaches in these expectations will require further education and possible disciplinary actions up to termination for all departments including therapy. Agency staff can be placed on Do Not Return list if deemed necessary. o QAPI Team discussed that such breaks in infection control processes could place residents at risk for transmission of Covid-19 and could possibly lead to serious illness, hospitalization , or death. On 1/13/2022, the Regional Director of Clinical Operations completed a direct one on one in-service with the housekeeping supervisor and housekeeper that re-entered the Cold Zone after making direct contact with a resident's belongings on the Hot Zone. Both explained the measures they took which they thought were adequate from an infection control perspective. The RDCO educated them on the reasons their good faith efforts were not adequate and explained that once contact is made with a resident or their belongings, the staff member may not exit the Hot Zone and enter/re-enter Cold Zone. RDCO will initiate in-services with therapy department on 1/14/2022 due to no members of therapy department being available after hours on 1/13/2022. On 1/13/2022, on the 2nd shift, the facility acknowledged that residents that could have been affected by staff failure to always wear N95 properly and by staff entering/re-entering the Cold Zone after making direct contact with a resident or their belongings in the Hot Zone. Facility will continue to monitor all residents for signs and symptoms of Covid-19 and address as needed. Training for all staff, newly hired staff and agency staff will include the instruction on the necessity of always wearing N95 properly, covering nose and mouth, especially when providing direct patient care. Additional training was provided on the importance of respecting the boundaries of the Hot Zone by acknowledging that once contact is made with a resident or their belongings, the staff member may not exit the Hot Zone and enter/re-enter Cold Zone. The staff will verify their understanding of these expectations by signing an acknowledgement of the training. Starting with the 2nd shift, all staff on duty were in-serviced on 1/13/2022, on the protocols of maintaining proper infection control measures to include wearing N95 properly in all areas of the facility deemed necessary by facility leadership, Infection Control Preventionist and Medical Director, by covering mouth and nose, not altering N95 in any manner, acknowledging that once entrance to the Hot Zone and direct contact is made with a resident or their belongings, entering/re-entering the Cold Zone is not permitted. This is to reduce the risk of breaks in isolation precautions which could cause transmission of Covid-19 and could possibly lead to serious illness, hospitalization , or death. The DON/ ADON/designee will conduct audits on all shifts and of staff in all departments to ensure that only N95 masks are worn in areas that require N95, that N95 masks are worn properly, covering mouth and nose, that N95 masks are not altered and acknowledge that once entrance to the Hot Zone and direct contact is made with a resident or their belongings, entering/re-entering the Cold Zone is not permitted. This is to reduce the risk of breaks in isolation precautions. Results of all audits will be reviewed by the Interdisciplinary Team to ensure proper adherence to Isolation Precautions and Infection Control measures is met. Any deviations or omissions will be addressed immediately with staff member. If a staff member does not properly adhere to the Isolation Precautions and Infection Control Measures of wearing N95 properly in all areas of the facility deemed necessary by facility leadership, Infection Control Preventionist and Medical Director, by covering mouth and nose, not altering N95 in any manner, acknowledging that once entrance to the Hot Zone and direct contact is made with a resident or their belongings, entering/re-entering the Cold Zone is not permitted, the facility will take actions to include education and possible disciplinary action up to termination. This will be reviewed monthly in QAPI until compliance is met. Monitoring of the Plan of Removal Included: An observation on 01/14/22 at 3:31 PM revealed CNA H was on the hot unit and she doffed her PPE at the room door prior to exiting. She was properly wearing an N95 respirator. In an interview and observation on 01/14/22 at 3:49 PM, LVN I stated she was working the hot unit and had received an in-service that day on how to doff and don PPE, hand washing, coming in through the front door to get screened, and wearing an N95 and not being allowed to alter the mask. She stated staff should not wear PPE in the hall because they could get it on their clothes and get everyone sick. She also stated staff on the hot unit were not able to go back to the cold unit because of cross contamination. She was properly wearing an N95 respirator. In an interview and observation on 01/14/22 at 4:07 PM, MA J stated she was trained on the proper PPE on hot unit, don't wear PPE in hall and to wear clean PPE between each patient, to prevent cross contamination. She stated staff were not to re-enter the cold unit after being on the hot unit. She was properly wearing an N95 respirator. In an interview and observation on 01/14/22, LVN K stated she received training on PPE. She stated she was to wear a gown, N95, and face shield when she entered a resident's room on the hot unit and should doff her gown and gloves prior to exiting the room. She stated she was also trained that after she entered the hot zone, she should exit the building for day should not enter the cold area to prevent cross contamination. She stated she was not allowed to alter N95 respirators. She was properly wearing an N95 respirator. In an interview on 01/15/22 at 10:00 AM with MDS Nurse A, she stated she received additional training on PPE in the hot unit and to wear the proper equipment to wear in the unit. She stated PPE for the hot unit included N95 at all times and a gown, gloves, and the face shield anytime I enter the room on the hot unit. MDS Nurse A stated dirty PPE should not be used in the hall because you would possibly be carrying the organism out. In interview on 01/15/22 at 10:20 AM, CNA K stated she worked double weekends. She stated she received training on N95 respirators, wearing them over mouth and nose, and not altering them. She stated after entering the hot unit staff had to leave for the day and could not re-enter the cold unit. In an interview on 01/15/22 at 10:40 AM, HSK L stated she worked weekends and was assigned to work the hot unit only. She stated she received training regarding PPE. She stated the PPE required on the hot unit included gowns, gloves, N95 mask, and face shield. She stated, We put on gown, gloves before stepping into the room, and take it off before I leave the room. She stated dirty PPE should not be worn in the hall to prevent the spread of the virus. She stated she was required to wear an N95 respirator always and was not allowed to alter the mask. She stated she was to leave the hot unit through a side door and could not re-enter the cold unit to prevent possible infecting other people in the non-infected area, spreading COVID. An observation on 01/15/22 from 9:45 AM to 11:00 AM revealed no staff exited the hot unit. While the IJ was removed on 01/15/22 at 4:42 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for one resident (Resident #8) of six residents reviewed for pain management, in that: 1. The facility failed to have Resident #8's [MEDICATION NAME] 10-325 mg (a narcotic [MEDICATION NAME] used to treat pain) available and to administer as ordered by the physician. 2. The facility failed to contact the Medical Director to obtain a triplicate for Resident #8's [MEDICATION NAME] when the resident's physician was unable to provide the triplicate so the [MEDICATION NAME] could be obtained. 3. Resident #8 missed four doses and was given a half a dose on two occasions in order to stretch the medication over a three day time period. 4. Resident #8 cried when she was told the medication was low. She had significant unrelieved pain for two days. This failure placed 77 residents with pain management at risk for unrelieved pain and a decreased quality of life. Findings included: Resident #8's face sheet, dated 02/26/17, reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's MDS Assessment, dated 12/12/16, reflected she was cognitively intact and was on scheduled and PRN pain medication regimen. The pain assessment reflected she was almost constantly in 7/10 pain (10 being the highest level of pain) which made it hard for her to sleep and limited her daily activities. Interview with LVN A on 01/24/17 at 7:00 PM revealed Resident #8 was alert, oriented, and interviewable. She stated Resident #8 was on routine pain management. Resident #8's physician's orders [REDACTED]. Resident #8's MAR, dated January 2017, reflected the following missed doses of [MEDICATION NAME]: 1. 01/21/17, at 9:00 PM. 2. 01/22/17, at 1:00 PM and 9:00 PM. 3. 01/23/17, at 9:00 AM. Resident #8's Controlled Substance Record, dated 01/14/17 through 01/22/17, reflected on 01/21/17 at 5:00 PM there were only two tablets of [MEDICATION NAME] left. On 01/22/17, one tablet was administered at 9:00 AM and the last tablet was administered at 5:00 PM. Resident #8's pain assessments, dated January 2017, reflected on 01/21/17 during the evening shift her pain scale was 5/10. On 01/22/17 during the day and evening shift her pain scale was also 5/10. Interview with Resident #8 on 01/25/17 at 2:20 PM revealed on Friday night, 01/20/17, staff told her there was only two tablets of her [MEDICATION NAME] left. Staff told her she could take one tablet one day and the other tablet the next day while they tried their best to get a refill. Resident #8 said she cried because she knew what was coming (regarding her pain). She said she waited as long as she could the next day before requesting her last tablet of [MEDICATION NAME] so she could try to get some sleep. She said one tablet was better than none but it was not what she was used to, which was two tablets every six hours. She said she was in 8.5/10 pain during those two days without her routine [MEDICATION NAME]. She said it was terrible, she was burning up inside but felt cool on the outside, and she was sick to her stomach because of the uncontrolled pain in her shoulders, neck, and back. She said she had [MEDICAL CONDITION] and chronic pain that worsened without her pain medication. Resident #8 said she did not get out of bed as much because she was hurting and she did not eat like usual, she said she maybe ate half a sandwich, and she did not sleep well on Saturday and Sunday, 01/21/17 through 01/22/17. She said when Monday, 01/23/17, came around the ADON took care of it and got her the refill. She said she understood it was a mistake and they just noticed she was running out too late. Resident #8's meal intake sheet, dated 01/25/17, reflected she refused dinner on 01/22/17. Interview with MA F on 01/26/17 at 1:30 PM revealed on Friday, 01/20/17 she noticed Resident #8's [MEDICATION NAME] was changed to routine but the count was not enough for the weekend so she notified LVN H. There was no nurses' notes on Friday, 01/20/17. Interview with LVN H on 01/26/17 at 3:00 PM revealed he was not aware of an issue with Resident #8's [MEDICATION NAME] until Monday 01/23/17. Resident #8's nurses' note, dated 01/21/17 at 8:00 PM, RN B wrote CMA (sic) notified this nurse that the resident will run out of the [MEDICATION NAME] from tomorrow, notified (Physician C) for triplicate. (Physician C) will not make triplicate until Monday. Called pharmacy if there any way to get [MEDICATION NAME] for tomorrow, pharmacy said no. ADON notified. Resident notified. Will continue to evaluate. There was no follow-up documentation. Interview with MA G on 01/25/17 at 5:24 PM revealed Resident #8's [MEDICATION NAME] order was changed from PRN to routine on 01/20/17. MA G said on Friday evening, 01/20/17, she notified LVN I that there was not enough tablets for the weekend and was told she would notify Physician C. She said later on, LVN I told her Physician C was not available. MA G said the next day, Saturday evening, 01/21/17, she notified RN B about not having enough [MEDICATION NAME] tablets for Resident #8 and was told RN B already tried to contact Physician C and there was nothing else she could do. She said she talked to Resident #8 about the issue and the resident decided to not take the 9:00 PM dose. She said the resident told her I can do without. MA G said she did not work on Sunday, 01/22/17, but when she returned on Monday, 01/23/17, she administered the ordered dose of [MEDICATION NAME] to Resident #8 at 5:00 PM. An unsuccessful attempt was made to contact LVN I on 01/26/17 at 12:00 PM. Interview with RN B on 01/26/17 at 12:30 PM revealed she was the charge nurse on Saturday, 01/21/17, and Sunday, 1/22/17. She said on Saturday, 01/21/17, the MA notified her Resident #8 only had two tablets remaining, so she called the pharmacy for a refill, but they told her there were no refills available. RN B said she called ADON D and was instructed to call Physician C and request a triplicate. She said she got a hold of Physician C but was told he was not available until Monday, 01/23/17. She said she told ADON D and was told to use PRN medication. RN B said Resident #8 was very sad when she told her the [MEDICATION NAME] was running out. She offered Resident #8 the option to take her last dose now or tomorrow and also offered Tylenol. She said the resident declined the Tylenol because it did not work for her and said she needed [MEDICATION NAME] so she would wait for it. RN B said when she assessed Resident #8's pain level it was 7/10. RN B said Resident #8 requested her last tablets on Sunday, 01/22/17, one at 9:00 AM and the last at 5:00 PM. Review of Physician C's response via text message on 01/21/17 at 7:58 PM reflected I won't be able to get them one until Monday. Can she stretch them until then? There was no more correspondence via text message after that. Interview with the ADON D on 01/25/17 at 2:45 PM revealed Resident #8's [MEDICATION NAME] was PRN and changed to routine on 01/20/17 because she took it so often. He said he was in the facility on Friday, 01/20/17 until about 5:00 PM and did not get any report of the [MEDICATION NAME] not being enough for the weekend. He said he did not receive any phone calls regarding this issue that night. ADON D said on Saturday evening, 01/21/17, RN B called him about not having enough tablets and needing a triplicate. She called Physician C but he told her we had to wait until Monday, 01/23/17, so he suggested to give one tablet instead of two and use the PRN Tylenol (which he thought was Tylenol #3 but later realized it was not). He said on Monday, 01/23/17, he got the triplicate and got the medication delivered STAT (as soon as possible). He said he did not contact the DON because he thought Resident #8 had Tylenol #3 ordered as needed but on Monday he realized it was regular strength Tylenol as needed and it was not administered. He said he should have gone further up the chain of command as the Medical Director could have signed a triplicate for Resident #8's [MEDICATION NAME]. Resident #8's triplicate, dated 01/23/17, reflected Physician C signed the order for [MEDICATION NAME] on 01/23/17 and it was faxed at 12:46 PM. Resident #8's pharmacy manifest, dated 01/23/17, reflected the [MEDICATION NAME] was delivered at 3:05 PM. Resident #8's Controlled Substance Record, dated 01/23/17, reflected the first dose from this delivery was administered on 01/23/17 at 5:00 PM, 24 hours since the last tablet was administered. Interview with the DON on 01/25/17 at 3:10 PM revealed she was not made aware of the issue regarding Resident #8's [MEDICATION NAME] until 1/25/17. She stated she should have been notified if the issue was not resolved. The DON said she expected staff to have gotten an order for [REDACTED].#8 was known to have pain and staff should have started the triplicate request when the order was changed because it was running out and should have at least three days worth of the medication on hand to get through the weekend. She said residents should not be running out of medication. The Facility's Pain Management Policy, revised March 2016, reflected Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain .Nursing home residents, are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life .If the resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED].>A list of residents on pain management, provided by the DON on 01/25/17 at 5:00 PM, reflected there were 77 residents with orders for PRN and/or routine pain medication.

Based on observation, interview and record review, it was determined the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for one (Residents #8) of six residents reviewed for pharmacy services. 1. The facility failed to have Resident #8's Norco 10-325 mg (a narcotic analgesic used to treat pain) available and to administer as ordered by the physician. 2. The facility failed to contact the Medical Director to obtain a triplicate for Resident #8's Norco when the resident's physician was unable to provide the triplicate so the Norco could be obtained. 3. Resident #8 missed four doses and was given a half a dose on two occasions in order to stretch the medication over a three day time period. 4. Resident #8 cried when she was told the medication was low. She had significant unrelieved pain for two days. This failure placed 77 residents with pain management at risk for unrelieved pain and a decreased quality of life. Findings included: Resident #8's face sheet, dated 02/26/17, reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's MDS Assessment, dated 12/12/16, reflected she was cognitively intact and was on scheduled and PRN pain medication regimen. The pain assessment reflected she was almost constantly in 7/10 pain (10 being the highest level of pain) which made it hard for her to sleep and limited her daily activities. Interview with LVN A on 01/24/17 at 7:00 PM revealed Resident #8 was alert, oriented, and interviewable. She stated Resident #8 was on routine pain management. Resident #8's physician's orders [REDACTED]. Resident #8's MAR, dated January 2017, reflected the following missed doses of Norco: 1. 01/21/17, at 9:00 PM. 2. 01/22/17, at 1:00 PM and 9:00 PM. 3. 01/23/17, at 9:00 AM. Resident #8's Controlled Substance Record, dated 01/14/17 through 01/22/17, reflected on 01/21/17 at 5:00 PM there were only two tablets of Norco left. On 01/22/17, one tablet was administered at 9:00 AM and the last tablet was administered at 5:00 PM. Resident #8's pain assessments, dated January 2017, reflected on 01/21/17 during the evening shift her pain scale was 5/10. On 01/22/17 during the day and evening shift her pain scale was also 5/10. Interview with Resident #8 on 01/25/17 at 2:20 PM revealed on Friday night, 01/20/17, staff told her there was only two tablets of her Norco left. Staff told her she could take one tablet one day and the other tablet the next day while they tried their best to get a refill. Resident #8 said she cried because she knew what was coming (regarding her pain). She said she waited as long as she could the next day before requesting her last tablet of Norco so she could try to get some sleep. She said one tablet was better than none but it was not what she was used to, which was two tablets every six hours. She said she was in 8.5/10 pain during those two days without her routine Norco. She said it was terrible, she was burning up inside but felt cool on the outside, and she was sick to her stomach because of the uncontrolled pain in her shoulders, neck, and back. She said she had Fibromyalgia and chronic pain that worsened without her pain medication. Resident #8 said she did not get out of bed as much because she was hurting and she did not eat like usual, she said she maybe ate half a sandwich, and she did not sleep well on Saturday and Sunday, 01/21/17 through 01/22/17. She said when Monday, 01/23/17, came around the ADON took care of it and got her the refill. She said she understood it was a mistake and they just noticed she was running out too late. Resident #8's meal intake sheet, dated 01/25/17, reflected she refused dinner on 01/22/17. Interview with MA F on 01/26/17 at 1:30 PM revealed on Friday, 01/20/17 she noticed Resident #8's Norco was changed to routine but the count was not enough for the weekend so she notified LVN H. There was no nurses' notes on Friday, 01/20/17. Interview with LVN H on 01/26/17 at 3:00 PM revealed he was not aware of an issue with Resident #8's Norco until Monday 01/23/17. Resident #8's nurses' note, dated 01/21/17 at 8:00 PM, RN B wrote CMA (sic) notified this nurse that the resident will run out of the norco from tomorrow, notified (Physician C) for triplicate. (Physician C) will not make triplicate until Monday. Called pharmacy if there any way to get norco for tomorrow, pharmacy said no. ADON notified. Resident notified. Will continue to evaluate. There was no follow-up documentation. Interview with MA G on 01/25/17 at 5:24 PM revealed Resident #8's Norco order was changed from PRN to routine on 01/20/17. MA G said on Friday evening, 01/20/17, she notified LVN I that there was not enough tablets for the weekend and was told she would notify Physician C. She said later on, LVN I told her Physician C was not available. MA G said the next day, Saturday evening, 01/21/17, she notified RN B about not having enough Norco tablets for Resident #8 and was told RN B already tried to contact Physician C and there was nothing else she could do. She said she talked to Resident #8 about the issue and the resident decided to not take the 9:00 PM dose. She said the resident told her I can do without. MA G said she did not work on Sunday, 01/22/17, but when she returned on Monday, 01/23/17, she administered the ordered dose of Norco to Resident #8 at 5:00 PM. An unsuccessful attempt was made to contact LVN I on 01/26/17 at 12:00 PM. Interview with RN B on 01/26/17 at 12:30 PM revealed she was the charge nurse on Saturday, 01/21/17, and Sunday, 1/22/17. She said on Saturday, 01/21/17, the MA notified her Resident #8 only had two tablets remaining, so she called the pharmacy for a refill, but they told her there were no refills available. RN B said she called ADON D and was instructed to call Physician C and request a triplicate. She said she got a hold of Physician C but was told he was not available until Monday, 01/23/17. She said she told ADON D and was told to use PRN medication. RN B said Resident #8 was very sad when she told her the Norco was running out. She offered Resident #8 the option to take her last dose now or tomorrow and also offered Tylenol. She said the resident declined the Tylenol because it did not work for her and said she needed Norco so she would wait for it. RN B said when she assessed Resident #8's pain level it was 7/10. RN B said Resident #8 requested her last tablets on Sunday, 01/22/17, one at 9:00 AM and the last at 5:00 PM. Review of Physician C's response via text message on 01/21/17 at 7:58 PM reflected I won't be able to get them one until Monday. Can she stretch them until then? There was no more correspondence via text message after that. Interview with the ADON D on 01/25/17 at 2:45 PM revealed Resident #8's Norco was PRN and changed to routine on 01/20/17 because she took it so often. He said he was in the facility on Friday, 01/20/17 until about 5:00 PM and did not get any report of the Norco not being enough for the weekend. He said he did not receive any phone calls regarding this issue that night. ADON D said on Saturday evening, 01/21/17, RN B called him about not having enough tablets and needing a triplicate. She called Physician C but he told her we had to wait until Monday, 01/23/17, so he suggested to give one tablet instead of two and use the PRN Tylenol (which he thought was Tylenol #3 but later realized it was not). He said on Monday, 01/23/17, he got the triplicate and got the medication delivered STAT (as soon as possible). He said he did not contact the DON because he thought Resident #8 had Tylenol #3 ordered as needed but on Monday he realized it was regular strength Tylenol as needed and it was not administered. He said he should have gone further up the chain of command as the Medical Director could have signed a triplicate for Resident #8's Norco. Resident #8's triplicate, dated 01/23/17, reflected Physician C signed the order for Norco on 01/23/17 and it was faxed at 12:46 PM. Resident #8's pharmacy manifest, dated 01/23/17, reflected the Norco was delivered at 3:05 PM. Resident #8's Controlled Substance Record, dated 01/23/17, reflected the first dose from this delivery was administered on 01/23/17 at 5:00 PM, 24 hours since the last tablet was administered. Interview with the DON on 01/25/17 at 3:10 PM revealed she was not made aware of the issue regarding Resident #8's Norco until 1/25/17. She stated she should have been notified if the issue was not resolved. The DON said she expected staff to have gotten an order for [REDACTED].#8 was known to have pain and staff should have started the triplicate request when the order was changed because it was running out and should have at least three days worth of the medication on hand to get through the weekend. She said residents should not be running out of medication. The Facility's Pain Management Policy, revised March 2016, reflected Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain .Nursing home residents, are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life .If the resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED].>A list of residents on pain management, provided by the DON on 01/25/17 at 5:00 PM, reflected there were 77 residents with orders for PRN and/or routine pain medication.

Based on interview and record review, it was determined the facility did not implement their facility's written abuse and neglect policies for one (Resident #1) of six residents reviewed for neglect. 1) When Resident #1 was in the bathroom without assistance and had an unwitnessed fall, facility nursing staff did not assess her for more than eight hours. 2) CNA C failed to report Resident #1's unwitnessed fall to the charge nurse. CNA C later still failed to report the resident had an unwitnessed fall and instead reported she had assisted the resident to the floor when the resident began to fall. 3) CNAs C, F and G failed to ensure the nurse assessed Resident #1 before transferring her to the wheelchair and then to bed following her fall. 4) CNAs F and G failed to report Resident #1's fall to the charge nurse. 5) LVN A failed to evaluate and assess Resident #1 when CNA D asked her about Resident #1's fall. 6) Resident #1 was not ever interviewed by the facility about her fall. These failures resulted in Resident #1 not receiving timely medical treatment for [REDACTED]. These failures could affect the facility's 73 resident who required assistance with transfers and placed them at risk for falling, lack of timely assessment and medical treatment, and pain resulting in serious injury, decreased mobility, loss of independence and/or death. Findings included: The Facility's Abuse Policy (undated) reflected: "...The facility has in place policies and procedures to aid in the prevention of abuse, neglect...Through the facility's Mission Statement each employee is expected to act in such a manner as to reflect the Mission Statement of this corporation...Each employee receives the "Employee Standards of Conduct," which outlines the standard for refraining from abuse or neglect of a resident...." Review of the Abuse/Neglect Prohibition Policy (undated) revealed: "...All employees are to report suspected abuse or neglect at any time it is identified, the person must report to their immediate supervisor, if not the charge nurse, who in turn will report to the charge nurse for that particular resident. The charge nurse receiving the allegation will immediately report to either the director of nursing or the administrator...." Review of the facility's current Incident/Accident System Policy (undated) revealed, "...A fall is defined as un-intentionally coming to rest on the floor, ground or lower level: A resident lowered to the floor by a staff member is considered a fall...." Review of the facility's current Incident/Accident System (undated) revealed, "Complete an incident/accident report (Available on the ERMA website) when staff is aware that an incident occurred...Review each incident report at morning or daily clinical meeting...All incidents are to be faxed to ERMA at least weekly...Complete a fall investigation after every fall." Review of the facility's current Notification of Changes Policy (undated) revealed, "...The facility will immediately inform the resident and consult with the resident's physician, if appropriate, when changes occur...." Review of Resident #1's Face Sheet, dated 03/25/13, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 10/15/13, revealed the resident required two-person physical assist for toileting transfers. Review of Resident #1's Care Plan, dated 08/10/13, revealed Resident #1 was at a high risk of injury from falling and decline in ADL functioning, and required staff assist. Review of Resident #1's Care Plan for falls was last updated 10/07/13. Review of Resident #1's Fall Risk Evaluation, dated 08/03/13, revealed a risk score of "20," which a score of 10 or more being considered at high risk for a fall. Review of Resident #1's Fall Risk Evaluation, dated 11/08/13, revealed her risk score was a "19," with a score of 10 or more being at risk for falls. Review of Resident #1's Fall Risk Evaluation, dated 01/08/14, revealed her risk score was a "26," which a score of 10 or more as being at high risk. Review of Resident #1's MDS assessment, dated 10/15/13, revealed Resident #1 scored a "15" out of 15 questions correctly on the BIMS test which revealed Resident #1's cognition was intact, without any signs of [MEDICAL CONDITION] (confusion). Resident #1 required extensive assistance with two person physical assistance during transfers, and two person physical assistance was provided during toilet use. Review of Resident #1's Care Plan, dated 08/10/13, revealed she was at high risk of injury from falling and decline in ADL functioning and required staff assist. The Care Plan for falls, revealed it was last updated 10/07/13, due to her unsteady gait. Review on Resident #1's Vital Signs and Weight Record, dated December 2013, revealed her weight was 205 lbs. Review of the facility's Provider Investigative Report, dated 01/01/14, revealed on 12/31/13 at 9:30 PM, CNA C assisted Resident #1 to the floor and with the help of CNA F and CNA G, assisted Resident #1 into her wheelchair and then onto her bed. "Because it was an assisted fall (CNA C) did not consider it a fall, therefore did not report to the nurse in order for (Resident #1) to be assessed." The next day on 01/01/14 at 7:00 AM (12 hours later), LVN B assessed Resident #1 and noticed her "Left knee was turned inward facing the inside of her Right Knee, the resident denied pain while still lying in bed." The Provider Investigative Report also revealed on 01/01/14 at 7:30 AM, Resident #1 was transferred to the hospital. "Staff reported (Resident #1) was not complaining of pain, and CNAs failed to report the fall/incident to the charge nurse. Resident #1 was transferred to the hospital, an investigation began on 01/01/14, and CNA C was suspended. The Provider Investigative Report findings revealed the incident was confirmed by the facility. The facility provided "staff education on reporting falls of any kind before getting residents off the floor, the nurses to be notified then the nurses are to perform a head to assessment of the resident." The Provider Investigative Report also revealed CNA C was brought back to work after counseling and education. Review of Resident #1's Nurse MAR, dated 12/31/13, revealed she was given three [MEDICATION NAME] pills on 12/31/13. (The medication did not have a dosage on the MAR.) Review of Resident #1's PRN Medication/Exception Documentation Sheet (undated), revealed [MEDICATION NAME] was given for right leg pain on 12/18/13, 12/26/13, and 12/31/13. Review of Resident #1's MAR indicated [REDACTED]. Review of Resident #1's Nurse's Notes revealed there was not any documentation on 12/31/13 from all three shifts regarding pain management provided to the resident. Review of Resident #1's Flow Sheet, dated 12/31/13, revealed she was repositioned four times during the nightshift. Review of Resident #1's Fall Risk Evaluation, dated 11/08/13, revealed Resident #1 was at a high risk for falling with a score of "18," based on scores of 10 or higher being at risk for falls. Review of Resident #1's Fall Risk Evaluation, dated 01/08/14, revealed Resident #1 was at a very high risk for falling with a score of "26," based on scores of 10 or higher being at risk for falls. Review of Resident #1's Hospital Face Sheet, dated 01/08/14, revealed this resident had surgery on 01/01/14 at 10:40 AM. Reason for visit: Left Distal Femur Fracture. Occurrence: 12/31/13. Review of Resident #1's hospital History and Physical, dated 01/01/14 revealed, "(Resident #1) was transferring from the wheelchair to commode, she fell and sustained a comminuted fracture of distal left femur for which the she was brought to the emergency room ...she currently complains of pain and moans and groans, but is able to answer questions appropriately...." [DIAGNOSES REDACTED]. Resident #1's X-ray, dated 01/01/14, reflected: "Reason for exam was done due to (Resident #1's) leg pain...There is a comminuted [MEDICAL CONDITION] femoral diaphysis with segmented fragment measuring approximately 7.5 cm in length, there is one half shafts width lateral and anterior displacement of the distal fragment...." In addition, the X-ray revealed, "...Healing [MEDICATION NAME] proximal fibular diaphysis, satisfactory appearance of left total hip arthroplasty hardware without evidence of hardware complication or failure...." Review of Resident #1's X-ray report, dated 01/03/14 revealed, "...An interval placement of a cast and unchanged comminuted [MEDICAL CONDITION] femoral diaphysis with anterior lateral displacement of the distal fracture fragment...." Review of Resident #1's Flow Sheet, dated 12/31/13, revealed she was repositioned four times during the nightshift. Review of Resident #1's Hospital Face Sheet, dated 01/08/14, revealed this resident had a cast put on her Left Leg on 01/01/14 at 10:40 AM. Reason for visit: Left Distal Femur Fracture. Occurrence: 12/31/13. In an interview on 01/15/14 at 12:27 PM, CNA C stated she had worked the 2:00 PM - 10:00 PM shift, and on 12/31/13, she saw Resident #1 in the bathroom on the toilet and when Resident #1 stood up she looked fine then the resident said her legs were going to give out. CNA C then stated that she told the resident to sit back down while she held onto Resident #1 with the gait belt around the resident. CNA C stated she was facing Resident #1, while her right hand held on to the gait belt around Resident #1 and her left hand under Resident #1's right arm. CNA C also stated when Resident #1 leaned forward, Resident #1 missed the toilet, then CNA C stated she "lowered the resident to the floor and (Resident #1) did not have a hard fall." CNA C then stated she asked two other aides (CNAs F and G) to help her put Resident #1 into her wheelchair and then the resident asked to be laid down so she and CNAs F and G laid Resident #1 onto the bed. CNA C also stated Resident #1 did not show having any signs of pain like facial grimacing, and when CNA C asked Resident #1 if she was in pain, the resident said she was fine. CNA C also stated Resident #1's leg looked perfectly fine. CNA C stated she only told CNAs F and G about Resident #1's fall, and did not notify the charge nurse about Resident #1's fall/incident. CNA C also stated, "It was not until the next morning the facility discovered that (Resident #1's) femur was broken." CNA C further stated "(Resident #1) used to be independent and weight bear, but two weeks prior to the resident falling on 12/31/13, the resident needed standby assistance to assist her out of the wheelchair." CNA C also stated the reason why she did not report Resident #1's fall to the charge nurse was because "It kind of just slipped my mind and the nightshift CNA (CNA D) was rushing me that night to finish up my checks and that I had summary documentation to complete." CNA C then stated that she did not remember being told she needed to notify the charge nurse for incidents. CNA C stated since Resident #1's fall on 12/31/13, she had worked other sections of the facility, but had not worked with Resident #1. In an interview on 01/15/14 at 2:06 PM, LVN B stated she worked the 6:00 AM - 2:00 PM shift and that she did not work on 12/31/13; however, on 01/01/14 while "I was making rounds I was asked to look at (Resident #1's) leg." CNA E asked her to look at Resident #1's leg, and asked, "Does it usually look like this?" LVN B stated Resident #1's leg was inverted, the knee was bent inward and the left leg did not look aligned. LVN B then asked the resident if she could move her leg, and the resident said she could not. LVN B stated Resident #1 was transferred to the hospital on [DATE], and LVN A, the 10:00 PM - 6:00 AM charge nurse, did not mention that Resident #1 had fallen or had pain issues during the 10:00 PM - 6:00 AM shift. LVN B stated she evaluated Resident #1 then the resident was transferred to the hospital before 8:00 AM on 01/01/14. LVN B stated Resident #1 was less mobile now, not able to sit up on the toilet, has a catheter, gets bed baths, and was a two person assist with a mechanical lift. LVN B also stated, "Before the fall on 12/31/13, the resident required one person assistance, the resident could bear weight, and turn and assist with transfers." LVN B also stated if a staff member witnessed or found a resident had fall, the staff member would alert the nurse immediately and not move the resident until the charge nurse had evaluated the resident. In an interview on 01/15/14 at 5:10 PM, LVN A stated she worked the 10:00 PM - 6:00 AM shift on 12/31/13, and was assigned to Resident #1. LVN A also stated that on 12/31/13, "I was not made aware of (Resident #1's) fall." Then on 01/01/14, LVN A stated she was asked by ADON J if Resident #1 had fallen, and she told ADON J not that she was aware of. However, LVN A stated, "During the 10:00 PM - 6:00 AM shift on 12/31/13, (Resident #1) asked to use the bedpan, but did not ask for pain medicine, and that around 4:00 AM on 01/31/14, (CNA D) assisted the resident with the use of a bedpan." LVN A stated, "Around 4:00 AM on 01/01/14, (CNA D) asked her did she know (Resident #1) had fallen." LVN A stated after talking with CNA D, she looked in Resident #1's chart and did not see anything about her falling. Then LVN A stated that she asked CNA D if Resident #1 complained of pain, and CNA D replied, 'No, (Resident #1) just said she had fallen last night during the 2:00 PM - 10:00 PM shift.' LVN A stated that she did not go to evaluate Resident #1 because she went by what CNA D had told her, that '(Resident #1) had fallen.' LVN A admitted to not talking to Resident #1 about her fall, and "if (Resident #1) wanted something she would ask for it and since she did not ask for pain medicine, she did not give pain medicine to (Resident #1)," on her 12/31/13 shift. LVN A also stated no one talked to her about Resident #1 falling, including CNA C. LVN A stated, "If a resident falls, the CNA should always tell the nurse first, for the nurse to evaluate and if the nurse says its okay to move the resident, then the resident can be moved." In an interview on 01/15/14 at 5:25 PM, ADON J stated she worked the 8:00 AM - 5:00 PM shift on 12/31/13, but did not hear about Resident #1 falling until 01/01/14. ADON J stated, "If a CNA was aware of a resident falling they should report it (fall/incident) to the charge nurse." ADON J stated she asked CNA C why she did not report Resident #1's fall to her charge nurse, and CNA C told her she did not consider it a fall because she was holding onto the resident. ADON J stated she told CNA C despite holding on to Resident #1 during her fall, it was still considered a fall. ADON J stated, "LVN B informed her that (Resident #1) had been transferred to the hospital on [DATE], because the resident's knee was bent inward in an un-natural angle." ADON J stated LVN B told her three CNAs had picked up Resident #1. ADON J stated she spoke to LVN A and was told by LVN A that Resident #1 had not complained of pain and was not given any pain pills the night of 12/31/13. ADON J stated, "The two other CNAs did not report (Resident #1's) fall because they had assumed (CNA C) had already reported the fall/incident to her charge nurse." ADON J stated she did not talk to Resident #1 about the fall on 12/31/13, because the resident could not remember much about it, just that she had fallen and broken her leg. In an interview on 01/15/14 at 5:35 PM, CNA D stated she worked the 10:00 PM - 6:00 AM shift, but she did not know about Resident #1's fall on 12/31/13, and did not find out about it until 01/03/14. CNA D said she helped Resident #1 use her bedpan on 01/01/14, and the resident "looked her regular self." CNA D stated she could not remember when she told LVN A about Resident #1's statement about falling and thought that it was after 2:00 AM, either halfway through or at the end of her 10:00 PM - 6:00 AM shift on 01/01/14. CNA D stated she put the bedpan under Resident #1 and took it from under her without any signs of pain and that the resident did not ask for any pain medicine. CNA D stated Resident #1 had told her that she had fallen and that three people had helped her off of the floor. CNA D stated she asked LVN A did she have any report of Resident #1 falling, and LVN A said there was no report regarding a fall, and also stated the resident was normally good at asking for pain medicine if she needed it. CNA D stated that CNA C had worked with her the night of 12/31/13, and did not mention that Resident #1 had fallen. CNA C had only said she was having a bad night, and that "(Resident #1) did not have any pain medications the night of 12/31/13." CNA D also stated prior to falling, the resident was able to standup and bear weight sometimes, and how resident transfers depended on the kind of day Resident #1 was having, but now the resident required two person assistance with a mechanical lift. In an interview on 01/15/14 at 2:40 PM, CNA H stated he was assigned to Resident #1, but did not work on 12/31/13. CNA H stated "(Resident #1) used a wheelchair and could transfer herself with one person assist with a gait belt, and since the fall the resident was now a two person assist with a mechanical lift." CNA H stated, "If (Resident #1) needs to be turned (repositioned) she must have assistance because of her leg." CNA H stated, "(Resident #1) was good about using her call light button for assistance and does not complain about pain unless her leg has been moved." CNA H stated, "If a resident was to fall, the first thing he would do is call another aide to get the nurse immediately while he stayed with the resident." CNA H also stated he "Would not touch the resident until the nurse had assessed the resident." In an interview on 01/15/14 at 3:20 PM, CNA I stated, "If a resident was to fall he would tell the charge nurse, then wait for the charge nurse to intervene, then document it." CNA I also stated he "Would not move a resident until the nurse had assessed the resident." On 01/15/14 at 4:10 PM, when the surveyor queried Resident #1 about the fall, she stated she had been in the bathroom and when she got up from the wheelchair she slipped from under her wheelchair, and that no one was in the bathroom when she fell on [DATE]. She stated she pulled the call light cord, while on the bathroom floor, then the nurses came in and picked her up and put her to bed. During the interview the resident also stated she did not press the call light after her fall because they had already given her pain medicine, then she stated she went to sleep. Resident #1 stated the next day (01/01/14), the facility got in touch with her physician, then she went to the hospital. Resident #1 also stated, "The hospital reset my leg then put my left leg into a cast." Resident #1 stated after her fall, her pain level was an "8" (using a scale of 0-10, with 10 being the worse). Resident #1 also stated since returning to the facility her pain level had been a zero, and that her pain level will go to a 5-6 or more when the staff moved her left leg. In an interview on 01/15/14 at 5:40 PM, the ADM stated either LVN B or ADON J had called him on either Saturday (01/04/14) or Sunday (01/05/14), about Resident #1 being found in an awkward position, and that this resident was sent to the emergency room . The ADM also stated ADON J or LVN B told him "(CNA C) took (Resident #1) to the bathroom and while transferring (Resident #1) to the commode that (CNA C) assisted the resident to the floor and that two other aides (CNAs F and G) had assisted (CNA C) with getting (Resident #1) up from the floor." The ADM stated since Resident #1 had returned from the hospital on [DATE], he had not spoken to the resident about her fall and could not say for sure if ADON J or LVN B had spoken to Resident #1. The ADM stated CNA C "should have called the nurse and made her aware of (Resident #1) falling," including the two other aides (CNAs F and G) who assisted CNA C with the resident who did not report the fall because they assumed CNA C had already reported it to her nurse. The ADM stated all three CNAs were counseled about their failure to report a fall, and if a resident is found on the floor, the CNAs are to report the incident to the Charge Nurse. The ADM stated he "does not have a plan in place to prevent this type of incident from happening again or to (Resident #1) because the resident is alert enough and staff assists her and she is not a resident who would get up by herself to begin with." On 01/15/14 at 6:00 PM, when the surveyor queried the DON about Resident #1's fall/incident on 12/31/13, she stated, "(Resident #1) had an assisted fall. Resident #1 was not an impulsive person and that the staff stands by the resident with a gait belt, and that the resident did not need an alarm because the resident does not try to get up." The DON stated the facility does not have a plan to prevent the incident (Resident #1's fall), from happening again. The DON further stated on 12/31/13, Resident #1 stood up to turn and pivot but her legs gave out and CNA C lowered the resident to the floor, which the DON stated was "still considered a fall." Review of the facility's Form CMS 672, Resident Census and Conditions of Residents, dated 01/15/14 and signed by the DON, revealed a census of 93 residents, and 73 residents were identified with the need of one or two staff assistance with transferring.

Based on interview and record review, the facility failed to implement the facility's policies and procedures, to prohibit neglect for one (Resident #1) of six residents reviewed for neglect. Failures included: 1) When Resident #1 was in the bathroom without assistance and had an unwitnessed fall, facility nursing staff did not assess her for more than eight hours. 2) CNA C failed to report Resident #1's unwitnessed fall to the charge nurse. CNA C later still failed to report the resident had an unwitnessed fall and instead reported she had assisted the resident to the floor when the resident began to fall. 3) CNAs C, F and G failed to ensure the nurse assessed Resident #1 before transferring her to the wheelchair and then to bed following her fall. 4) CNAs F and G failed to report Resident #1's fall to the charge nurse. 5) LVN A failed to evaluate and assess Resident #1 when CNA D asked her about Resident #1's fall. 6) Resident #1 was not ever interviewed by the facility about her fall. These failures resulted in Resident #1 not receiving timely medical treatment for [REDACTED]. These failures could affect the facility's 73 resident who required assistance with transfers and placed them at risk for falling, lack of timely assessment and medical treatment, and pain resulting in serious injury, decreased mobility, loss of independence and/or death. Findings included: Review of Resident #1's Face Sheet, dated 03/25/13, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 10/15/13, revealed the resident required two-person physical assist for toileting transfers. Review of Resident #1's Care Plan, dated 08/10/13, revealed Resident #1 was at a high risk of injury from falling and decline in ADL functioning, and required staff assist. Review of Resident #1's Care Plan for falls was last updated 10/07/13. Review of Resident #1's Fall Risk Evaluation, dated 08/03/13, revealed a risk score of "20," which a score of 10 or more being considered at high risk for a fall. Review of Resident #1's Fall Risk Evaluation, dated 11/08/13, revealed her risk score was a "19," with a score of 10 or more being at risk for falls. Review of Resident #1's Fall Risk Evaluation, dated 01/08/14, revealed her risk score was a "26," which a score of 10 or more as being at high risk. Review of Resident #1's MDS assessment, dated 10/15/13, revealed Resident #1 scored a "15" out of 15 questions correctly on the BIMS test which revealed Resident #1's cognition was intact, without any signs of [MEDICAL CONDITION] (confusion). Resident #1 required extensive assistance with two person physical assistance during transfers, and two person physical assistance was provided during toilet use. Review of Resident #1's Care Plan, dated 08/10/13, revealed she was at high risk of injury from falling and decline in ADL functioning and required staff assist. The Care Plan for falls, revealed it was last updated 10/07/13, due to her unsteady gait. Review on Resident #1's Vital Signs and Weight Record, dated December 2013, revealed her weight was 205 lbs. Review of the facility's Provider Investigative Report, dated 01/01/14, revealed on 12/31/13 at 9:30 PM, CNA C assisted Resident #1 to the floor and with the help of CNA F and CNA G, assisted Resident #1 into her wheelchair and then onto her bed. "Because it was an assisted fall (CNA C) did not consider it a fall, therefore did not report to the nurse in order for (Resident #1) to be assessed." The next day on 01/01/14 at 7:00 AM (12 hours later), LVN B assessed Resident #1 and noticed her "Left knee was turned inward facing the inside of her Right Knee, the resident denied pain while still lying in bed." The Provider Investigative Report also revealed on 01/01/14 at 7:30 AM, Resident #1 was transferred to the hospital. "Staff reported (Resident #1) was not complaining of pain, and CNAs failed to report the fall/incident to the charge nurse. Resident #1 was transferred to the hospital, an investigation began on 01/01/14, and CNA C was suspended. The Provider Investigative Report findings revealed the incident was confirmed by the facility. The facility provided "staff education on reporting falls of any kind before getting residents off the floor, the nurses to be notified then the nurses are to perform a head to assessment of the resident." The Provider Investigative Report also revealed CNA C was brought back to work after counseling and education. Review of Resident #1's Nurse MAR, dated 12/31/13, revealed she was given three [MEDICATION NAME] pills on 12/31/13. (The medication did not have a dosage on the MAR.) Review of Resident #1's PRN Medication/Exception Documentation Sheet (undated), revealed [MEDICATION NAME] was given for right leg pain on 12/18/13, 12/26/13, and 12/31/13. Review of Resident #1's MAR indicated [REDACTED]. Review of Resident #1's Nurse's Notes revealed there was not any documentation on 12/31/13 from all three shifts regarding pain management provided to the resident. Review of Resident #1's Flow Sheet, dated 12/31/13, revealed she was repositioned four times during the nightshift. Review of Resident #1's Fall Risk Evaluation, dated 11/08/13, revealed Resident #1 was at a high risk for falling with a score of "18," based on scores of 10 or higher being at risk for falls. Review of Resident #1's Fall Risk Evaluation, dated 01/08/14, revealed Resident #1 was at a very high risk for falling with a score of "26," based on scores of 10 or higher being at risk for falls. Review of Resident #1's Hospital Face Sheet, dated 01/08/14, revealed this resident had surgery on 01/01/14 at 10:40 AM. Reason for visit: Left Distal Femur Fracture. Occurrence: 12/31/13. Review of Resident #1's hospital History and Physical, dated 01/01/14 revealed, "(Resident #1) was transferring from the wheelchair to commode, she fell and sustained a comminuted fracture of distal left femur for which the she was brought to the emergency room ...she currently complains of pain and moans and groans, but is able to answer questions appropriately...." [DIAGNOSES REDACTED]. Resident #1's X-ray, dated 01/01/14, reflected: "Reason for exam was done due to (Resident #1's) leg pain...There is a comminuted [MEDICAL CONDITION] femoral diaphysis with segmented fragment measuring approximately 7.5 cm in length, there is one half shafts width lateral and anterior displacement of the distal fragment...." In addition, the X-ray revealed, "...Healing [MEDICATION NAME] proximal fibular diaphysis, satisfactory appearance of left total hip arthroplasty hardware without evidence of hardware complication or failure...." Review of Resident #1's X-ray report, dated 01/03/14 revealed, "...An interval placement of a cast and unchanged comminuted [MEDICAL CONDITION] femoral diaphysis with anterior lateral displacement of the distal fracture fragment...." Review of Resident #1's Flow Sheet, dated 12/31/13, revealed she was repositioned four times during the nightshift. Review of Resident #1's Hospital Face Sheet, dated 01/08/14, revealed this resident had a cast put on her Left Leg on 01/01/14 at 10:40 AM. Reason for visit: Left Distal Femur Fracture. Occurrence: 12/31/13. In an interview on 01/15/14 at 12:27 PM, CNA C stated she had worked the 2:00 PM - 10:00 PM shift, and on 12/31/13, she saw Resident #1 in the bathroom on the toilet and when Resident #1 stood up she looked fine then the resident said her legs were going to give out. CNA C then stated that she told the resident to sit back down while she held onto Resident #1 with the gait belt around the resident. CNA C stated she was facing Resident #1, while her right hand held on to the gait belt around Resident #1 and her left hand under Resident #1's right arm. CNA C also stated when Resident #1 leaned forward, Resident #1 missed the toilet, then CNA C stated she "lowered the resident to the floor and (Resident #1) did not have a hard fall." CNA C then stated she asked two other aides (CNAs F and G) to help her put Resident #1 into her wheelchair and then the resident asked to be laid down so she and CNAs F and G laid Resident #1 onto the bed. CNA C also stated Resident #1 did not show having any signs of pain like facial grimacing, and when CNA C asked Resident #1 if she was in pain, the resident said she was fine. CNA C also stated Resident #1's leg looked perfectly fine. CNA C stated she only told CNAs F and G about Resident #1's fall, and did not notify the charge nurse about Resident #1's fall/incident. CNA C also stated, "It was not until the next morning the facility discovered that (Resident #1's) femur was broken." CNA C further stated "(Resident #1) used to be independent and weight bear, but two weeks prior to the resident falling on 12/31/13, the resident needed standby assistance to assist her out of the wheelchair." CNA C also stated the reason why she did not report Resident #1's fall to the charge nurse was because "It kind of just slipped my mind and the nightshift CNA (CNA D) was rushing me that night to finish up my checks and that I had summary documentation to complete." CNA C then stated that she did not remember being told she needed to notify the charge nurse for incidents. CNA C stated since Resident #1's fall on 12/31/13, she had worked other sections of the facility, but had not worked with Resident #1. In an interview on 01/15/14 at 2:06 PM, LVN B stated she worked the 6:00 AM - 2:00 PM shift and that she did not work on 12/31/13; however, on 01/01/14 while "I was making rounds I was asked to look at (Resident #1's) leg." CNA E asked her to look at Resident #1's leg, and asked, "Does it usually look like this?" LVN B stated Resident #1's leg was inverted, the knee was bent inward and the left leg did not look aligned. LVN B then asked the resident if she could move her leg, and the resident said she could not. LVN B stated Resident #1 was transferred to the hospital on [DATE], and LVN A, the 10:00 PM - 6:00 AM charge nurse, did not mention that Resident #1 had fallen or had pain issues during the 10:00 PM - 6:00 AM shift. LVN B stated she evaluated Resident #1 then the resident was transferred to the hospital before 8:00 AM on 01/01/14. LVN B stated Resident #1 was less mobile now, not able to sit up on the toilet, has a catheter, gets bed baths, and was a two person assist with a mechanical lift. LVN B also stated, "Before the fall on 12/31/13, the resident required one person assistance, the resident could bear weight, and turn and assist with transfers." LVN B also stated if a staff member witnessed or found a resident had fall, the staff member would alert the nurse immediately and not move the resident until the charge nurse had evaluated the resident. In an interview on 01/15/14 at 5:10 PM, LVN A stated she worked the 10:00 PM - 6:00 AM shift on 12/31/13, and was assigned to Resident #1. LVN A also stated that on 12/31/13, "I was not made aware of (Resident #1's) fall." Then on 01/01/14, LVN A stated she was asked by ADON J if Resident #1 had fallen, and she told ADON J not that she was aware of. However, LVN A stated, "During the 10:00 PM - 6:00 AM shift on 12/31/13, (Resident #1) asked to use the bedpan, but did not ask for pain medicine, and that around 4:00 AM on 01/31/14, (CNA D) assisted the resident with the use of a bedpan." LVN A stated, "Around 4:00 AM on 01/01/14, (CNA D) asked her did she know (Resident #1) had fallen." LVN A stated after talking with CNA D, she looked in Resident #1's chart and did not see anything about her falling. Then LVN A stated that she asked CNA D if Resident #1 complained of pain, and CNA D replied, 'No, (Resident #1) just said she had fallen last night during the 2:00 PM - 10:00 PM shift.' LVN A stated that she did not go to evaluate Resident #1 because she went by what CNA D had told her, that '(Resident #1) had fallen.' LVN A admitted to not talking to Resident #1 about her fall, and "if (Resident #1) wanted something she would ask for it and since she did not ask for pain medicine, she did not give pain medicine to (Resident #1)," on her 12/31/13 shift. LVN A also stated no one talked to her about Resident #1 falling, including CNA C. LVN A stated, "If a resident falls, the CNA should always tell the nurse first, for the nurse to evaluate and if the nurse says its okay to move the resident, then the resident can be moved." In an interview on 01/15/14 at 5:25 PM, ADON J stated she worked the 8:00 AM - 5:00 PM shift on 12/31/13, but did not hear about Resident #1 falling until 01/01/14. ADON J stated, "If a CNA was aware of a resident falling they should report it (fall/incident) to the charge nurse." ADON J stated she asked CNA C why she did not report Resident #1's fall to her charge nurse, and CNA C told her she did not consider it a fall because she was holding onto the resident. ADON J stated she told CNA C despite holding on to Resident #1 during her fall, it was still considered a fall. ADON J stated, "LVN B informed her that (Resident #1) had been transferred to the hospital on [DATE], because the resident's knee was bent inward in an un-natural angle." ADON J stated LVN B told her three CNAs had picked up Resident #1. ADON J stated she spoke to LVN A and was told by LVN A that Resident #1 had not complained of pain and was not given any pain pills the night of 12/31/13. ADON J stated, "The two other CNAs did not report (Resident #1's) fall because they had assumed (CNA C) had already reported the fall/incident to her charge nurse." ADON J stated she did not talk to Resident #1 about the fall on 12/31/13, because the resident could not remember much about it, just that she had fallen and broken her leg. In an interview on 01/15/14 at 5:35 PM, CNA D stated she worked the 10:00 PM - 6:00 AM shift, but she did not know about Resident #1's fall on 12/31/13, and did not find out about it until 01/03/14. CNA D said she helped Resident #1 use her bedpan on 01/01/14, and the resident "looked her regular self." CNA D stated she could not remember when she told LVN A about Resident #1's statement about falling and thought that it was after 2:00 AM, either halfway through or at the end of her 10:00 PM - 6:00 AM shift on 01/01/14. CNA D stated she put the bedpan under Resident #1 and took it from under her without any signs of pain and that the resident did not ask for any pain medicine. CNA D stated Resident #1 had told her that she had fallen and that three people had helped her off of the floor. CNA D stated she asked LVN A did she have any report of Resident #1 falling, and LVN A said there was no report regarding a fall, and also stated the resident was normally good at asking for pain medicine if she needed it. CNA D stated that CNA C had worked with her the night of 12/31/13, and did not mention that Resident #1 had fallen. CNA C had only said she was having a bad night, and that "(Resident #1) did not have any pain medications the night of 12/31/13." CNA D also stated prior to falling, the resident was able to standup and bear weight sometimes, and how resident transfers depended on the kind of day Resident #1 was having, but now the resident required two person assistance with a mechanical lift. In an interview on 01/15/14 at 2:40 PM, CNA H stated he was assigned to Resident #1, but did not work on 12/31/13. CNA H stated "(Resident #1) used a wheelchair and could transfer herself with one person assist with a gait belt, and since the fall the resident was now a two person assist with a mechanical lift." CNA H stated, "If (Resident #1) needs to be turned (repositioned) she must have assistance because of her leg." CNA H stated, "(Resident #1) was good about using her call light button for assistance and does not complain about pain unless her leg has been moved." CNA H stated, "If a resident was to fall, the first thing he would do is call another aide to get the nurse immediately while he stayed with the resident." CNA H also stated he "Would not touch the resident until the nurse had assessed the resident." In an interview on 01/15/14 at 3:20 PM, CNA I stated, "If a resident was to fall he would tell the charge nurse, then wait for the charge nurse to intervene, then document it." CNA I also stated he "Would not move a resident until the nurse had assessed the resident." On 01/15/14 at 4:10 PM, when the surveyor queried Resident #1 about the fall, she stated she had been in the bathroom and when she got up from the wheelchair she slipped from under her wheelchair, and that no one was in the bathroom when she fell on [DATE]. She stated she pulled the call light cord, while on the bathroom floor, then the nurses came in and picked her up and put her to bed. During the interview the resident also stated she did not press the call light after her fall because they had already given her pain medicine, then she stated she went to sleep. Resident #1 stated the next day (01/01/14), the facility got in touch with her physician, then she went to the hospital. Resident #1 also stated, "The hospital reset my leg then put my left leg into a cast." Resident #1 stated after her fall, her pain level was an "8" (using a scale of 0-10, with 10 being the worse). Resident #1 also stated since returning to the facility her pain level had been a zero, and that her pain level will go to a 5-6 or more when the staff moved her left leg. In an interview on 01/15/14 at 5:40 PM, the ADM stated either LVN B or ADON J had called him on either Saturday (01/04/14) or Sunday (01/05/14), about Resident #1 being found in an awkward position, and that this resident was sent to the emergency room . The ADM also stated ADON J or LVN B told him "(CNA C) took (Resident #1) to the bathroom and while transferring (Resident #1) to the commode that (CNA C) assisted the resident to the floor and that two other aides (CNAs F and G) had assisted (CNA C) with getting (Resident #1) up from the floor." The ADM stated since Resident #1 had returned from the hospital on [DATE], he had not spoken to the resident about her fall and could not say for sure if ADON J or LVN B had spoken to Resident #1. The ADM stated CNA C "should have called the nurse and made her aware of (Resident #1) falling," including the two other aides (CNAs F and G) who assisted CNA C with the resident who did not report the fall because they assumed CNA C had already reported it to her nurse. The ADM stated all three CNAs were counseled about their failure to report a fall, and if a resident is found on the floor, the CNAs are to report the incident to the Charge Nurse. The ADM stated he "does not have a plan in place to prevent this type of incident from happening again or to (Resident #1) because the resident is alert enough and staff assists her and she is not a resident who would get up by herself to begin with." On 01/15/14 at 6:00 PM, when the surveyor queried the DON about Resident #1's fall/incident on 12/31/13, she stated, "(Resident #1) had an assisted fall. Resident #1 was not an impulsive person and that the staff stands by the resident with a gait belt, and that the resident did not need an alarm because the resident does not try to get up." The DON stated the facility does not have a plan to prevent the incident (Resident #1's fall), from happening again. The DON further stated on 12/31/13, Resident #1 stood up to turn and pivot but her legs gave out and CNA C lowered the resident to the floor, which the DON stated was "still considered a fall." The Facility's Abuse Policy (undated) reflected: "...The facility has in place policies and procedures to aid in the prevention of abuse, neglect...Through the facility's Mission Statement each employee is expected to act in such a manner as to reflect the Mission Statement of this corporation...Each employee receives the "Employee Standards of Conduct," which outlines the standard for refraining from abuse or neglect of a resident...." Review of the Abuse/Neglect Prohibition Policy (undated) revealed: "...All employees are to report suspected abuse or neglect at any time it is identified, the person must report to their immediate supervisor, if not the charge nurse, who in turn will report to the charge nurse for that particular resident. The charge nurse receiving the allegation will immediately report to either the director of nursing or the administrator...." Review of the facility's current Incident/Accident System Policy (undated) revealed, "...A fall is defined as un-intentionally coming to rest on the floor, ground or lower level: A resident lowered to the floor by a staff member is considered a fall...." Review of the facility's current Incident/Accident System (undated) revealed, "Complete an incident/accident report (Available on the ERMA website) when staff is aware that an incident occurred...Review each incident report at morning or daily clinical meeting...All incidents are to be faxed to ERMA at least weekly...Complete a fall investigation after every fall." Review of the facility's current Notification of Changes Policy (undated) revealed, "...The facility will immediately inform the resident and consult with the resident's physician, if appropriate, when changes occur...." Review of the facility's Form CMS 672, Resident Census and Conditions of Residents, dated 01/15/14 and signed by the DON, revealed a census of 93 residents, and 73 residents were identified with the need of one or two staff assistance with transferring.

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of six residents reviewed for falls. 1) When Resident #1 was in the bathroom without assistance and had an unwitnessed fall, facility nursing staff did not assess her for more than eight hours. 2) CNA C failed to report Resident #1's unwitnessed fall to the charge nurse. CNA C later still failed to report the resident had an unwitnessed fall and instead reported she had assisted the resident to the floor when the resident began to fall. 3) CNAs C, F and G failed to ensure the nurse assessed Resident #1 before transferring her to the wheelchair and then to bed following her fall. 4) CNAs F and G failed to report Resident #1's fall to the charge nurse. 5) LVN A failed to evaluate and assess Resident #1 when CNA D asked her about Resident #1's fall. 6) Resident #1 was not ever interviewed by the facility about her fall. These failures resulted in Resident #1 not receiving timely medical treatment for [REDACTED]. These failures could affect the facility's 73 resident who required assistance with transfers and placed them at risk for falling, lack of timely assessment and medical treatment, and pain resulting in serious injury, decreased mobility, loss of independence and/or death. Findings included: Review of Resident #1's Face Sheet, dated 03/25/13, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 10/15/13, revealed the resident required two-person physical assist for toileting transfers. Review of Resident #1's Care Plan, dated 08/10/13, revealed Resident #1 was at a high risk of injury from falling and decline in ADL functioning, and required staff assist. Review of Resident #1's Care Plan for falls was last updated 10/07/13. Review of Resident #1's Fall Risk Evaluation, dated 08/03/13, revealed a risk score of "20," which a score of 10 or more being considered at high risk for a fall. Review of Resident #1's Fall Risk Evaluation, dated 11/08/13, revealed her risk score was a "19," with a score of 10 or more being at risk for falls. Review of Resident #1's Fall Risk Evaluation, dated 01/08/14, revealed her risk score was a "26," which a score of 10 or more as being at high risk. Review of Resident #1's MDS assessment, dated 10/15/13, revealed Resident #1 scored a "15" out of 15 questions correctly on the BIMS test which revealed Resident #1's cognition was intact, without any signs of [MEDICAL CONDITION] (confusion). Resident #1 required extensive assistance with two person physical assistance during transfers, and two person physical assistance was provided during toilet use. Review of Resident #1's Care Plan, dated 08/10/13, revealed she was at high risk of injury from falling and decline in ADL functioning and required staff assist. The Care Plan for falls, revealed it was last updated 10/07/13, due to her unsteady gait. Review on Resident #1's Vital Signs and Weight Record, dated December 2013, revealed her weight was 205 lbs. Review of the facility's Provider Investigative Report, dated 01/01/14, revealed on 12/31/13 at 9:30 PM, CNA C assisted Resident #1 to the floor and with the help of CNA F and CNA G, assisted Resident #1 into her wheelchair and then onto her bed. "Because it was an assisted fall (CNA C) did not consider it a fall, therefore did not report to the nurse in order for (Resident #1) to be assessed." The next day on 01/01/14 at 7:00 AM (12 hours later), LVN B assessed Resident #1 and noticed her "Left knee was turned inward facing the inside of her Right Knee, the resident denied pain while still lying in bed." The Provider Investigative Report also revealed on 01/01/14 at 7:30 AM, Resident #1 was transferred to the hospital. "Staff reported (Resident #1) was not complaining of pain, and CNAs failed to report the fall/incident to the charge nurse. Resident #1 was transferred to the hospital, an investigation began on 01/01/14, and CNA C was suspended. The Provider Investigative Report findings revealed the incident was confirmed by the facility. The facility provided "staff education on reporting falls of any kind before getting residents off the floor, the nurses to be notified then the nurses are to perform a head to assessment of the resident." The Provider Investigative Report also revealed CNA C was brought back to work after counseling and education. Review of Resident #1's Nurse MAR, dated 12/31/13, revealed she was given three [MEDICATION NAME] pills on 12/31/13. (The medication did not have a dosage on the MAR.) Review of Resident #1's PRN Medication/Exception Documentation Sheet (undated), revealed [MEDICATION NAME] was given for right leg pain on 12/18/13, 12/26/13, and 12/31/13. Review of Resident #1's MAR indicated [REDACTED]. Review of Resident #1's Nurse's Notes revealed there was not any documentation on 12/31/13 from all three shifts regarding pain management provided to the resident. Review of Resident #1's Flow Sheet, dated 12/31/13, revealed she was repositioned four times during the nightshift. Review of Resident #1's Fall Risk Evaluation, dated 11/08/13, revealed Resident #1 was at a high risk for falling with a score of "18," based on scores of 10 or higher being at risk for falls. Review of Resident #1's Fall Risk Evaluation, dated 01/08/14, revealed Resident #1 was at a very high risk for falling with a score of "26," based on scores of 10 or higher being at risk for falls. Review of Resident #1's Hospital Face Sheet, dated 01/08/14, revealed this resident had surgery on 01/01/14 at 10:40 AM. Reason for visit: Left Distal Femur Fracture. Occurrence: 12/31/13. Review of Resident #1's hospital History and Physical, dated 01/01/14 revealed, "(Resident #1) was transferring from the wheelchair to commode, she fell and sustained a comminuted fracture of distal left femur for which the she was brought to the emergency room ...she currently complains of pain and moans and groans, but is able to answer questions appropriately...." [DIAGNOSES REDACTED]. Resident #1's X-ray, dated 01/01/14, reflected: "Reason for exam was done due to (Resident #1's) leg pain...There is a comminuted [MEDICAL CONDITION] femoral diaphysis with segmented fragment measuring approximately 7.5 cm in length, there is one half shafts width lateral and anterior displacement of the distal fragment...." In addition, the X-ray revealed, "...Healing [MEDICATION NAME] proximal fibular diaphysis, satisfactory appearance of left total hip arthroplasty hardware without evidence of hardware complication or failure...." Review of Resident #1's X-ray report, dated 01/03/14 revealed, "...An interval placement of a cast and unchanged comminuted [MEDICAL CONDITION] femoral diaphysis with anterior lateral displacement of the distal fracture fragment...." Review of Resident #1's Flow Sheet, dated 12/31/13, revealed she was repositioned four times during the nightshift. Review of Resident #1's Hospital Face Sheet, dated 01/08/14, revealed this resident had a cast put on her Left Leg on 01/01/14 at 10:40 AM. Reason for visit: Left Distal Femur Fracture. Occurrence: 12/31/13. In an interview on 01/15/14 at 12:27 PM, CNA C stated she had worked the 2:00 PM - 10:00 PM shift, and on 12/31/13, she saw Resident #1 in the bathroom on the toilet and when Resident #1 stood up she looked fine then the resident said her legs were going to give out. CNA C then stated that she told the resident to sit back down while she held onto Resident #1 with the gait belt around the resident. CNA C stated she was facing Resident #1, while her right hand held on to the gait belt around Resident #1 and her left hand under Resident #1's right arm. CNA C also stated when Resident #1 leaned forward, Resident #1 missed the toilet, then CNA C stated she "lowered the resident to the floor and (Resident #1) did not have a hard fall." CNA C then stated she asked two other aides (CNAs F and G) to help her put Resident #1 into her wheelchair and then the resident asked to be laid down so she and CNAs F and G laid Resident #1 onto the bed. CNA C also stated Resident #1 did not show having any signs of pain like facial grimacing, and when CNA C asked Resident #1 if she was in pain, the resident said she was fine. CNA C also stated Resident #1's leg looked perfectly fine. CNA C stated she only told CNAs F and G about Resident #1's fall, and did not notify the charge nurse about Resident #1's fall/incident. CNA C also stated, "It was not until the next morning the facility discovered that (Resident #1's) femur was broken." CNA C further stated "(Resident #1) used to be independent and weight bear, but two weeks prior to the resident falling on 12/31/13, the resident needed standby assistance to assist her out of the wheelchair." CNA C also stated the reason why she did not report Resident #1's fall to the charge nurse was because "It kind of just slipped my mind and the nightshift CNA (CNA D) was rushing me that night to finish up my checks and that I had summary documentation to complete." CNA C then stated that she did not remember being told she needed to notify the charge nurse for incidents. CNA C stated since Resident #1's fall on 12/31/13, she had worked other sections of the facility, but had not worked with Resident #1. In an interview on 01/15/14 at 2:06 PM, LVN B stated she worked the 6:00 AM - 2:00 PM shift and that she did not work on 12/31/13; however, on 01/01/14 while "I was making rounds I was asked to look at (Resident #1's) leg." CNA E asked her to look at Resident #1's leg, and asked, "Does it usually look like this?" LVN B stated Resident #1's leg was inverted, the knee was bent inward and the left leg did not look aligned. LVN B then asked the resident if she could move her leg, and the resident said she could not. LVN B stated Resident #1 was transferred to the hospital on [DATE], and LVN A, the 10:00 PM - 6:00 AM charge nurse, did not mention that Resident #1 had fallen or had pain issues during the 10:00 PM - 6:00 AM shift. LVN B stated she evaluated Resident #1 then the resident was transferred to the hospital before 8:00 AM on 01/01/14. LVN B stated Resident #1 was less mobile now, not able to sit up on the toilet, has a catheter, gets bed baths, and was a two person assist with a mechanical lift. LVN B also stated, "Before the fall on 12/31/13, the resident required one person assistance, the resident could bear weight, and turn and assist with transfers." LVN B also stated if a staff member witnessed or found a resident had fall, the staff member would alert the nurse immediately and not move the resident until the charge nurse had evaluated the resident. In an interview on 01/15/14 at 5:10 PM, LVN A stated she worked the 10:00 PM - 6:00 AM shift on 12/31/13, and was assigned to Resident #1. LVN A also stated that on 12/31/13, "I was not made aware of (Resident #1's) fall." Then on 01/01/14, LVN A stated she was asked by ADON J if Resident #1 had fallen, and she told ADON J not that she was aware of. However, LVN A stated, "During the 10:00 PM - 6:00 AM shift on 12/31/13, (Resident #1) asked to use the bedpan, but did not ask for pain medicine, and that around 4:00 AM on 01/31/14, (CNA D) assisted the resident with the use of a bedpan." LVN A stated, "Around 4:00 AM on 01/01/14, (CNA D) asked her did she know (Resident #1) had fallen." LVN A stated after talking with CNA D, she looked in Resident #1's chart and did not see anything about her falling. Then LVN A stated that she asked CNA D if Resident #1 complained of pain, and CNA D replied, 'No, (Resident #1) just said she had fallen last night during the 2:00 PM - 10:00 PM shift.' LVN A stated that she did not go to evaluate Resident #1 because she went by what CNA D had told her, that '(Resident #1) had fallen.' LVN A admitted to not talking to Resident #1 about her fall, and "if (Resident #1) wanted something she would ask for it and since she did not ask for pain medicine, she did not give pain medicine to (Resident #1)," on her 12/31/13 shift. LVN A also stated no one talked to her about Resident #1 falling, including CNA C. LVN A stated, "If a resident falls, the CNA should always tell the nurse first, for the nurse to evaluate and if the nurse says its okay to move the resident, then the resident can be moved." In an interview on 01/15/14 at 5:25 PM, ADON J stated she worked the 8:00 AM - 5:00 PM shift on 12/31/13, but did not hear about Resident #1 falling until 01/01/14. ADON J stated, "If a CNA was aware of a resident falling they should report it (fall/incident) to the charge nurse." ADON J stated she asked CNA C why she did not report Resident #1's fall to her charge nurse, and CNA C told her she did not consider it a fall because she was holding onto the resident. ADON J stated she told CNA C despite holding on to Resident #1 during her fall, it was still considered a fall. ADON J stated, "LVN B informed her that (Resident #1) had been transferred to the hospital on [DATE], because the resident's knee was bent inward in an un-natural angle." ADON J stated LVN B told her three CNAs had picked up Resident #1. ADON J stated she spoke to LVN A and was told by LVN A that Resident #1 had not complained of pain and was not given any pain pills the night of 12/31/13. ADON J stated, "The two other CNAs did not report (Resident #1's) fall because they had assumed (CNA C) had already reported the fall/incident to her charge nurse." ADON J stated she did not talk to Resident #1 about the fall on 12/31/13, because the resident could not remember much about it, just that she had fallen and broken her leg. In an interview on 01/15/14 at 5:35 PM, CNA D stated she worked the 10:00 PM - 6:00 AM shift, but she did not know about Resident #1's fall on 12/31/13, and did not find out about it until 01/03/14. CNA D said she helped Resident #1 use her bedpan on 01/01/14, and the resident "looked her regular self." CNA D stated she could not remember when she told LVN A about Resident #1's statement about falling and thought that it was after 2:00 AM, either halfway through or at the end of her 10:00 PM - 6:00 AM shift on 01/01/14. CNA D stated she put the bedpan under Resident #1 and took it from under her without any signs of pain and that the resident did not ask for any pain medicine. CNA D stated Resident #1 had told her that she had fallen and that three people had helped her off of the floor. CNA D stated she asked LVN A did she have any report of Resident #1 falling, and LVN A said there was no report regarding a fall, and also stated the resident was normally good at asking for pain medicine if she needed it. CNA D stated that CNA C had worked with her the night of 12/31/13, and did not mention that Resident #1 had fallen. CNA C had only said she was having a bad night, and that "(Resident #1) did not have any pain medications the night of 12/31/13." CNA D also stated prior to falling, the resident was able to standup and bear weight sometimes, and how resident transfers depended on the kind of day Resident #1 was having, but now the resident required two person assistance with a mechanical lift. In an interview on 01/15/14 at 2:40 PM, CNA H stated he was assigned to Resident #1, but did not work on 12/31/13. CNA H stated "(Resident #1) used a wheelchair and could transfer herself with one person assist with a gait belt, and since the fall the resident was now a two person assist with a mechanical lift." CNA H stated, "If (Resident #1) needs to be turned (repositioned) she must have assistance because of her leg." CNA H stated, "(Resident #1) was good about using her call light button for assistance and does not complain about pain unless her leg has been moved." CNA H stated, "If a resident was to fall, the first thing he would do is call another aide to get the nurse immediately while he stayed with the resident." CNA H also stated he "Would not touch the resident until the nurse had assessed the resident." In an interview on 01/15/14 at 3:20 PM, CNA I stated, "If a resident was to fall he would tell the charge nurse, then wait for the charge nurse to intervene, then document it." CNA I also stated he "Would not move a resident until the nurse had assessed the resident." On 01/15/14 at 4:10 PM, when the surveyor queried Resident #1 about the fall, she stated she had been in the bathroom and when she got up from the wheelchair she slipped from under her wheelchair, and that no one was in the bathroom when she fell on [DATE]. She stated she pulled the call light cord, while on the bathroom floor, then the nurses came in and picked her up and put her to bed. During the interview the resident also stated she did not press the call light after her fall because they had already given her pain medicine, then she stated she went to sleep. Resident #1 stated the next day (01/01/14), the facility got in touch with her physician, then she went to the hospital. Resident #1 also stated, "The hospital reset my leg then put my left leg into a cast." Resident #1 stated after her fall, her pain level was an "8" (using a scale of 0-10, with 10 being the worse). Resident #1 also stated since returning to the facility her pain level had been a zero, and that her pain level will go to a 5-6 or more when the staff moved her left leg. In an interview on 01/15/14 at 5:40 PM, the ADM stated either LVN B or ADON J had called him on either Saturday (01/04/14) or Sunday (01/05/14), about Resident #1 being found in an awkward position, and that this resident was sent to the emergency room . The ADM also stated ADON J or LVN B told him "(CNA C) took (Resident #1) to the bathroom and while transferring (Resident #1) to the commode that (CNA C) assisted the resident to the floor and that two other aides (CNAs F and G) had assisted (CNA C) with getting (Resident #1) up from the floor." The ADM stated since Resident #1 had returned from the hospital on [DATE], he had not spoken to the resident about her fall and could not say for sure if ADON J or LVN B had spoken to Resident #1. The ADM stated CNA C "should have called the nurse and made her aware of (Resident #1) falling," including the two other aides (CNAs F and G) who assisted CNA C with the resident who did not report the fall because they assumed CNA C had already reported it to her nurse. The ADM stated all three CNAs were counseled about their failure to report a fall, and if a resident is found on the floor, the CNAs are to report the incident to the Charge Nurse. The ADM stated he "does not have a plan in place to prevent this type of incident from happening again or to (Resident #1) because the resident is alert enough and staff assists her and she is not a resident who would get up by herself to begin with." On 01/15/14 at 6:00 PM, when the surveyor queried the DON about Resident #1's fall/incident on 12/31/13, she stated, "(Resident #1) had an assisted fall. Resident #1 was not an impulsive person and that the staff stands by the resident with a gait belt, and that the resident did not need an alarm because the resident does not try to get up." The DON stated the facility does not have a plan to prevent the incident (Resident #1's fall), from happening again. The DON further stated on 12/31/13, Resident #1 stood up to turn and pivot but her legs gave out and CNA C lowered the resident to the floor, which the DON stated was "still considered a fall." The Facility's Abuse Policy (undated) reflected: "...The facility has in place policies and procedures to aid in the prevention of abuse, neglect...Through the facility's Mission Statement each employee is expected to act in such a manner as to reflect the Mission Statement of this corporation...Each employee receives the "Employee Standards of Conduct," which outlines the standard for refraining from abuse or neglect of a resident...." Review of the Abuse/Neglect Prohibition Policy (undated) revealed: "...All employees are to report suspected abuse or neglect at any time it is identified, the person must report to their immediate supervisor, if not the charge nurse, who in turn will report to the charge nurse for that particular resident. The charge nurse receiving the allegation will immediately report to either the director of nursing or the administrator...." Review of the facility's current Incident/Accident System Policy (undated) revealed, "...A fall is defined as un-intentionally coming to rest on the floor, ground or lower level: A resident lowered to the floor by a staff member is considered a fall...." Review of the facility's current Incident/Accident System (undated) revealed, "Complete an incident/accident report (Available on the ERMA website) when staff is aware that an incident occurred...Review each incident report at morning or daily clinical meeting...All incidents are to be faxed to ERMA at least weekly...Complete a fall investigation after every fall." Review of the facility's current Notification of Changes Policy (undated) revealed, "...The facility will immediately inform the resident and consult with the resident's physician, if appropriate, when changes occur...." Review of the facility's Form CMS 672, Resident Census and Conditions of Residents, dated 01/15/14 and signed by the DON, revealed a census of 93 residents, and 73 residents were identified with the need of one or two staff assistance with transferring.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent a fall for one (Resident #1) of six residents reviewed for falls. 1) When Resident #1 was in the bathroom without assistance and had an unwitnessed fall, facility nursing staff did not assess her for more than eight hours. 2) CNA C failed to report Resident #1's unwitnessed fall to the charge nurse. CNA C later still failed to report the resident had an unwitnessed fall and instead reported she had assisted the resident to the floor when the resident began to fall. 3) CNAs C, F and G failed to ensure the nurse assessed Resident #1 before transferring her to the wheelchair and then to bed following her fall. 4) CNAs F and G failed to report Resident #1's fall to the charge nurse. 5) LVN A failed to evaluate and assess Resident #1 when CNA D asked her about Resident #1's fall. 6) Resident #1 was not ever interviewed by the facility about her fall. These failures resulted in Resident #1 not receiving timely medical treatment for [REDACTED]. These failures could affect the facility's 73 resident who required assistance with transfers and placed them at risk for falling, lack of timely assessment and medical treatment, and pain resulting in serious injury, decreased mobility, loss of independence and/or death. Findings included: Review of Resident #1's Face Sheet, dated 03/25/13, revealed an [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 10/15/13, revealed the resident required two-person physical assist for toileting transfers. Review of Resident #1's Care Plan, dated 08/10/13, revealed Resident #1 was at a high risk of injury from falling and decline in ADL functioning, and required staff assist. Review of Resident #1's Care Plan for falls was last updated 10/07/13. Review of Resident #1's Fall Risk Evaluation, dated 08/03/13, revealed a risk score of "20," which a score of 10 or more being considered at high risk for a fall. Review of Resident #1's Fall Risk Evaluation, dated 11/08/13, revealed her risk score was a "19," with a score of 10 or more being at risk for falls. Review of Resident #1's Fall Risk Evaluation, dated 01/08/14, revealed her risk score was a "26," which a score of 10 or more as being at high risk. Review of Resident #1's MDS assessment, dated 10/15/13, revealed Resident #1 scored a "15" out of 15 questions correctly on the BIMS test which revealed Resident #1's cognition was intact, without any signs of delirium (confusion). Resident #1 required extensive assistance with two person physical assistance during transfers, and two person physical assistance was provided during toilet use. Review of Resident #1's Care Plan, dated 08/10/13, revealed she was at high risk of injury from falling and decline in ADL functioning and required staff assist. The Care Plan for falls, revealed it was last updated 10/07/13, due to her unsteady gait. Review on Resident #1's Vital Signs and Weight Record, dated December 2013, revealed her weight was 205 lbs. Review of the facility's Provider Investigative Report, dated 01/01/14, revealed on 12/31/13 at 9:30 PM, CNA C assisted Resident #1 to the floor and with the help of CNA F and CNA G, assisted Resident #1 into her wheelchair and then onto her bed. "Because it was an assisted fall (CNA C) did not consider it a fall, therefore did not report to the nurse in order for (Resident #1) to be assessed." The next day on 01/01/14 at 7:00 AM (12 hours later), LVN B assessed Resident #1 and noticed her "Left knee was turned inward facing the inside of her Right Knee, the resident denied pain while still lying in bed." The Provider Investigative Report also revealed on 01/01/14 at 7:30 AM, Resident #1 was transferred to the hospital. "Staff reported (Resident #1) was not complaining of pain, and CNAs failed to report the fall/incident to the charge nurse. Resident #1 was transferred to the hospital, an investigation began on 01/01/14, and CNA C was suspended. The Provider Investigative Report findings revealed the incident was confirmed by the facility. The facility provided "staff education on reporting falls of any kind before getting residents off the floor, the nurses to be notified then the nurses are to perform a head to assessment of the resident." The Provider Investigative Report also revealed CNA C was brought back to work after counseling and education. Review of Resident #1's Nurse MAR, dated 12/31/13, revealed she was given three Tramadol pills on 12/31/13. (The medication did not have a dosage on the MAR.) Review of Resident #1's PRN Medication/Exception Documentation Sheet (undated), revealed Tramadol was given for right leg pain on 12/18/13, 12/26/13, and 12/31/13. Review of Resident #1's MAR dated December 2013 revealed, on 12/31/13, there were two pills given but there was not any documentation why it given to this resident on the PRN Medication/Exception Documentation Sheet. Review of Resident #1's Nurse's Notes revealed there was not any documentation on 12/31/13 from all three shifts regarding pain management provided to the resident. Review of Resident #1's Flow Sheet, dated 12/31/13, revealed she was repositioned four times during the nightshift. Review of Resident #1's Fall Risk Evaluation, dated 11/08/13, revealed Resident #1 was at a high risk for falling with a score of "18," based on scores of 10 or higher being at risk for falls. Review of Resident #1's Fall Risk Evaluation, dated 01/08/14, revealed Resident #1 was at a very high risk for falling with a score of "26," based on scores of 10 or higher being at risk for falls. Review of Resident #1's Hospital Face Sheet, dated 01/08/14, revealed this resident had surgery on 01/01/14 at 10:40 AM. Reason for visit: Left Distal Femur Fracture. Occurrence: 12/31/13. Review of Resident #1's hospital History and Physical, dated 01/01/14 revealed, "(Resident #1) was transferring from the wheelchair to commode, she fell and sustained a comminuted fracture of distal left femur for which the she was brought to the emergency room ...she currently complains of pain and moans and groans, but is able to answer questions appropriately...." [DIAGNOSES REDACTED]. Resident #1's X-ray, dated 01/01/14, reflected: "Reason for exam was done due to (Resident #1's) leg pain...There is a comminuted fracture of the distal femoral diaphysis with segmented fragment measuring approximately 7.5 cm in length, there is one half shafts width lateral and anterior displacement of the distal fragment...." In addition, the X-ray revealed, "...Healing transverse fracture of the left proximal fibular diaphysis, satisfactory appearance of left total hip arthroplasty hardware without evidence of hardware complication or failure...." Review of Resident #1's X-ray report, dated 01/03/14 revealed, "...An interval placement of a cast and unchanged comminuted fracture of the distal femoral diaphysis with anterior lateral displacement of the distal fracture fragment...." Review of Resident #1's Flow Sheet, dated 12/31/13, revealed she was repositioned four times during the nightshift. Review of Resident #1's Hospital Face Sheet, dated 01/08/14, revealed this resident had a cast put on her Left Leg on 01/01/14 at 10:40 AM. Reason for visit: Left Distal Femur Fracture. Occurrence: 12/31/13. In an interview on 01/15/14 at 12:27 PM, CNA C stated she had worked the 2:00 PM - 10:00 PM shift, and on 12/31/13, she saw Resident #1 in the bathroom on the toilet and when Resident #1 stood up she looked fine then the resident said her legs were going to give out. CNA C then stated that she told the resident to sit back down while she held onto Resident #1 with the gait belt around the resident. CNA C stated she was facing Resident #1, while her right hand held on to the gait belt around Resident #1 and her left hand under Resident #1's right arm. CNA C also stated when Resident #1 leaned forward, Resident #1 missed the toilet, then CNA C stated she "lowered the resident to the floor and (Resident #1) did not have a hard fall." CNA C then stated she asked two other aides (CNAs F and G) to help her put Resident #1 into her wheelchair and then the resident asked to be laid down so she and CNAs F and G laid Resident #1 onto the bed. CNA C also stated Resident #1 did not show having any signs of pain like facial grimacing, and when CNA C asked Resident #1 if she was in pain, the resident said she was fine. CNA C also stated Resident #1's leg looked perfectly fine. CNA C stated she only told CNAs F and G about Resident #1's fall, and did not notify the charge nurse about Resident #1's fall/incident. CNA C also stated, "It was not until the next morning the facility discovered that (Resident #1's) femur was broken." CNA C further stated "(Resident #1) used to be independent and weight bear, but two weeks prior to the resident falling on 12/31/13, the resident needed standby assistance to assist her out of the wheelchair." CNA C also stated the reason why she did not report Resident #1's fall to the charge nurse was because "It kind of just slipped my mind and the nightshift CNA (CNA D) was rushing me that night to finish up my checks and that I had summary documentation to complete." CNA C then stated that she did not remember being told she needed to notify the charge nurse for incidents. CNA C stated since Resident #1's fall on 12/31/13, she had worked other sections of the facility, but had not worked with Resident #1. In an interview on 01/15/14 at 2:06 PM, LVN B stated she worked the 6:00 AM - 2:00 PM shift and that she did not work on 12/31/13; however, on 01/01/14 while "I was making rounds I was asked to look at (Resident #1's) leg." CNA E asked her to look at Resident #1's leg, and asked, "Does it usually look like this?" LVN B stated Resident #1's leg was inverted, the knee was bent inward and the left leg did not look aligned. LVN B then asked the resident if she could move her leg, and the resident said she could not. LVN B stated Resident #1 was transferred to the hospital on [DATE], and LVN A, the 10:00 PM - 6:00 AM charge nurse, did not mention that Resident #1 had fallen or had pain issues during the 10:00 PM - 6:00 AM shift. LVN B stated she evaluated Resident #1 then the resident was transferred to the hospital before 8:00 AM on 01/01/14. LVN B stated Resident #1 was less mobile now, not able to sit up on the toilet, has a catheter, gets bed baths, and was a two person assist with a mechanical lift. LVN B also stated, "Before the fall on 12/31/13, the resident required one person assistance, the resident could bear weight, and turn and assist with transfers." LVN B also stated if a staff member witnessed or found a resident had fall, the staff member would alert the nurse immediately and not move the resident until the charge nurse had evaluated the resident. In an interview on 01/15/14 at 5:10 PM, LVN A stated she worked the 10:00 PM - 6:00 AM shift on 12/31/13, and was assigned to Resident #1. LVN A also stated that on 12/31/13, "I was not made aware of (Resident #1's) fall." Then on 01/01/14, LVN A stated she was asked by ADON J if Resident #1 had fallen, and she told ADON J not that she was aware of. However, LVN A stated, "During the 10:00 PM - 6:00 AM shift on 12/31/13, (Resident #1) asked to use the bedpan, but did not ask for pain medicine, and that around 4:00 AM on 01/31/14, (CNA D) assisted the resident with the use of a bedpan." LVN A stated, "Around 4:00 AM on 01/01/14, (CNA D) asked her did she know (Resident #1) had fallen." LVN A stated after talking with CNA D, she looked in Resident #1's chart and did not see anything about her falling. Then LVN A stated that she asked CNA D if Resident #1 complained of pain, and CNA D replied, 'No, (Resident #1) just said she had fallen last night during the 2:00 PM - 10:00 PM shift.' LVN A stated that she did not go to evaluate Resident #1 because she went by what CNA D had told her, that '(Resident #1) had fallen.' LVN A admitted to not talking to Resident #1 about her fall, and "if (Resident #1) wanted something she would ask for it and since she did not ask for pain medicine, she did not give pain medicine to (Resident #1)," on her 12/31/13 shift. LVN A also stated no one talked to her about Resident #1 falling, including CNA C. LVN A stated, "If a resident falls, the CNA should always tell the nurse first, for the nurse to evaluate and if the nurse says its okay to move the resident, then the resident can be moved." In an interview on 01/15/14 at 5:25 PM, ADON J stated she worked the 8:00 AM - 5:00 PM shift on 12/31/13, but did not hear about Resident #1 falling until 01/01/14. ADON J stated, "If a CNA was aware of a resident falling they should report it (fall/incident) to the charge nurse." ADON J stated she asked CNA C why she did not report Resident #1's fall to her charge nurse, and CNA C told her she did not consider it a fall because she was holding onto the resident. ADON J stated she told CNA C despite holding on to Resident #1 during her fall, it was still considered a fall. ADON J stated, "LVN B informed her that (Resident #1) had been transferred to the hospital on [DATE], because the resident's knee was bent inward in an un-natural angle." ADON J stated LVN B told her three CNAs had picked up Resident #1. ADON J stated she spoke to LVN A and was told by LVN A that Resident #1 had not complained of pain and was not given any pain pills the night of 12/31/13. ADON J stated, "The two other CNAs did not report (Resident #1's) fall because they had assumed (CNA C) had already reported the fall/incident to her charge nurse." ADON J stated she did not talk to Resident #1 about the fall on 12/31/13, because the resident could not remember much about it, just that she had fallen and broken her leg. In an interview on 01/15/14 at 5:35 PM, CNA D stated she worked the 10:00 PM - 6:00 AM shift, but she did not know about Resident #1's fall on 12/31/13, and did not find out about it until 01/03/14. CNA D said she helped Resident #1 use her bedpan on 01/01/14, and the resident "looked her regular self." CNA D stated she could not remember when she told LVN A about Resident #1's statement about falling and thought that it was after 2:00 AM, either halfway through or at the end of her 10:00 PM - 6:00 AM shift on 01/01/14. CNA D stated she put the bedpan under Resident #1 and took it from under her without any signs of pain and that the resident did not ask for any pain medicine. CNA D stated Resident #1 had told her that she had fallen and that three people had helped her off of the floor. CNA D stated she asked LVN A did she have any report of Resident #1 falling, and LVN A said there was no report regarding a fall, and also stated the resident was normally good at asking for pain medicine if she needed it. CNA D stated that CNA C had worked with her the night of 12/31/13, and did not mention that Resident #1 had fallen. CNA C had only said she was having a bad night, and that "(Resident #1) did not have any pain medications the night of 12/31/13." CNA D also stated prior to falling, the resident was able to standup and bear weight sometimes, and how resident transfers depended on the kind of day Resident #1 was having, but now the resident required two person assistance with a mechanical lift. In an interview on 01/15/14 at 2:40 PM, CNA H stated he was assigned to Resident #1, but did not work on 12/31/13. CNA H stated "(Resident #1) used a wheelchair and could transfer herself with one person assist with a gait belt, and since the fall the resident was now a two person assist with a mechanical lift." CNA H stated, "If (Resident #1) needs to be turned (repositioned) she must have assistance because of her leg." CNA H stated, "(Resident #1) was good about using her call light button for assistance and does not complain about pain unless her leg has been moved." CNA H stated, "If a resident was to fall, the first thing he would do is call another aide to get the nurse immediately while he stayed with the resident." CNA H also stated he "Would not touch the resident until the nurse had assessed the resident." In an interview on 01/15/14 at 3:20 PM, CNA I stated, "If a resident was to fall he would tell the charge nurse, then wait for the charge nurse to intervene, then document it." CNA I also stated he "Would not move a resident until the nurse had assessed the resident." On 01/15/14 at 4:10 PM, when the surveyor queried Resident #1 about the fall, she stated she had been in the bathroom and when she got up from the wheelchair she slipped from under her wheelchair, and that no one was in the bathroom when she fell on [DATE]. She stated she pulled the call light cord, while on the bathroom floor, then the nurses came in and picked her up and put her to bed. During the interview the resident also stated she did not press the call light after her fall because they had already given her pain medicine, then she stated she went to sleep. Resident #1 stated the next day (01/01/14), the facility got in touch with her physician, then she went to the hospital. Resident #1 also stated, "The hospital reset my leg then put my left leg into a cast." Resident #1 stated after her fall, her pain level was an "8" (using a scale of 0-10, with 10 being the worse). Resident #1 also stated since returning to the facility her pain level had been a zero, and that her pain level will go to a 5-6 or more when the staff moved her left leg. In an interview on 01/15/14 at 5:40 PM, the ADM stated either LVN B or ADON J had called him on either Saturday (01/04/14) or Sunday (01/05/14), about Resident #1 being found in an awkward position, and that this resident was sent to the emergency room . The ADM also stated ADON J or LVN B told him "(CNA C) took (Resident #1) to the bathroom and while transferring (Resident #1) to the commode that (CNA C) assisted the resident to the floor and that two other aides (CNAs F and G) had assisted (CNA C) with getting (Resident #1) up from the floor." The ADM stated since Resident #1 had returned from the hospital on [DATE], he had not spoken to the resident about her fall and could not say for sure if ADON J or LVN B had spoken to Resident #1. The ADM stated CNA C "should have called the nurse and made her aware of (Resident #1) falling," including the two other aides (CNAs F and G) who assisted CNA C with the resident who did not report the fall because they assumed CNA C had already reported it to her nurse. The ADM stated all three CNAs were counseled about their failure to report a fall, and if a resident is found on the floor, the CNAs are to report the incident to the Charge Nurse. The ADM stated he "does not have a plan in place to prevent this type of incident from happening again or to (Resident #1) because the resident is alert enough and staff assists her and she is not a resident who would get up by herself to begin with." On 01/15/14 at 6:00 PM, when the surveyor queried the DON about Resident #1's fall/incident on 12/31/13, she stated, "(Resident #1) had an assisted fall. Resident #1 was not an impulsive person and that the staff stands by the resident with a gait belt, and that the resident did not need an alarm because the resident does not try to get up." The DON stated the facility does not have a plan to prevent the incident (Resident #1's fall), from happening again. The DON further stated on 12/31/13, Resident #1 stood up to turn and pivot but her legs gave out and CNA C lowered the resident to the floor, which the DON stated was "still considered a fall." The Facility's Abuse Policy (undated) reflected: "...The facility has in place policies and procedures to aid in the prevention of abuse, neglect...Through the facility's Mission Statement each employee is expected to act in such a manner as to reflect the Mission Statement of this corporation...Each employee receives the "Employee Standards of Conduct," which outlines the standard for refraining from abuse or neglect of a resident...." Review of the Abuse/Neglect Prohibition Policy (undated) revealed: "...All employees are to report suspected abuse or neglect at any time it is identified, the person must report to their immediate supervisor, if not the charge nurse, who in turn will report to the charge nurse for that particular resident. The charge nurse receiving the allegation will immediately report to either the director of nursing or the administrator...." Review of the facility's current Incident/Accident System Policy (undated) revealed, "...A fall is defined as un-intentionally coming to rest on the floor, ground or lower level: A resident lowered to the floor by a staff member is considered a fall...." Review of the facility's current Incident/Accident System (undated) revealed, "Complete an incident/accident report (Available on the ERMA website) when staff is aware that an incident occurred...Review each incident report at morning or daily clinical meeting...All incidents are to be faxed to ERMA at least weekly...Complete a fall investigation after every fall." Review of the facility's current Notification of Changes Policy (undated) revealed, "...The facility will immediately inform the resident and consult with the resident's physician, if appropriate, when changes occur...." Review of the facility's Form CMS 672, Resident Census and Conditions of Residents, dated 01/15/14 and signed by the DON, revealed a census of 93 residents, and 73 residents were identified with the need of one or two staff assistance with transferring.

Based on observation, interview, and record review, it was determined the facility failed to provide residents with pressure ulcers the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for four (Residents #1, #7, #23, and #25) of seven residents reviewed with pressure ulcers. 1) Resident #1 had two pressure ulcers identified by the surveyor. RN A said the areas were excoriation, not pressure ulcers. The DON was not aware of the areas. After surveyor intervention, treatment orders were obtained. 2) Resident #7 had approximately 12 Stage II pressure ulcers, which were identified as yeast by RN A. The DON and the physician were not aware of the pressure ulcers. After surveyor intervention, new treatment orders were obtained. 3) Resident #23 had a Stage II pressure ulcer on her left buttocks, which was not identified until the DON conducted skin assessments on all residents after surveyor inquiry. 4) Resident #25 had a Stage II pressure ulcer on her right buttocks, which was not identified until the DON conducted skin assessments on all residents after surveyor inquiry. These failures affected Residents #1, #7, #23, and #25 and placed them at risk for infections, pain and discomfort, decreased quality of life, incorrect treatments, worsening pressure ulcers, and further skin breakdown. These failures could affect the other 11 residents, who were identified with pressure ulcers, by placing them at risk for infection, incorrect treatments, pain and discomfort, decreased quality of life, worsening pressure ulcers, and further skin breakdown. Findings included: 1) A review of the quarterly MDS assessment, dated 01/25/12, for Resident #1 revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The assessment reflected Resident #1 received her nutrition through a Gastrostomy Tube. Further review revealed Resident #1 was severely cognitively impaired, incontinent of bowel/bladder, and totally dependent on staff for all ADLs. Resident #1's MDS assessment reflected she was at risk for pressure ulcers, but she did not have any at that time. CNA C and the surveyor entered Resident #1's room on 02/29/12 at 9:25 a.m. Resident #1 was observed in bed. CNA C told the surveyor at that time the resident had a wound on her buttocks. The surveyor requested to see the wound. CNA C summoned RN A to assist in turning Resident #1 onto her left side. At this time, a brief stained with feces was covering two opened areas on the resident's right and left buttocks next to the resident's coccyx area. The surveyor requested wound treatment sheets from RN A. RN A reported there were no wound sheets available and no wound treatment was provided because the areas were excoriated and she did not consider the opened areas pressure ulcers. RN A said she was previously the facility treatment nurse, but the facility no longer had a treatment nurse. RN A said she was now a charge nurse and the charge nurses were now responsible for wound treatments. On 02/29/12 at 9:35 a.m., the DON and the surveyor observed the buttocks of Resident #1. The DON said Resident #1 had two Stage II pressure ulcers. The DON at that time, requested RN A to measure the wounds. RN A reported the following measurements: Site #1 on the left buttocks measured 0.5 cm by 0.3 cm and Site #2 on the right buttocks was a pin point size. On 03/02/12 the DON provided a skin sheet dated 03/01/12 at 8:30 p.m. for Resident #1. The pressure ulcer skin sheet reflected the right buttock had a Stage I pressure ulcer, which measured 4.3 cm by 3.8 cm with a Stage II pinpoint pressure ulcer within the Stage I area; and the left buttock had Stage I pressure ulcer, which measured 6.0 cm by 3.2 cm with a Stage II pressure ulcer measuring 0.7 cm by 0.5 cm within the Stage I area. On 03/02/12 at 10:00 a.m., the surveyor asked CNA C if she reported Resident #1 had a wound on her buttocks. CNA C said on Friday, 02/24/12, she noticed Resident #1 had a skin problem on her buttocks. CNA C said the skin had peeled leaving opened areas. CNA C stated she reported it to LVN D. CNA C said LVN D observed the resident's opened areas and applied Zinc Oxide to her buttocks. An interview was conducted with LVN D via telephone on 03/02/12 at 12:15 p.m. The surveyor asked LVN D if CNA C reported Resident #1's buttock wounds to her on 02/24/12. LVN D stated she remembered applying zinc oxide to the resident's buttocks, but she could not remember anything else. LVN D said when the CNAs provide incontinent care and tell her a resident has a skin problem, she always applied zinc oxide to keep the problem from getting worse. No further explanation was given. A review of the 24-Hour Report dated 02/24/12 revealed no documentation about Resident #1's opened areas on her buttocks. Resident #1's Physician's Telephone Order dated 02/29/12 reflected cleanse the opened areas to the resident's right and left buttocks and apply Zinc Oxide and leave open to air every shift and prn. Resident #1's Comprehensive Plan of Care did not address Resident #1's pressure ulcers until after surveyor intervention on 02/29/12. 2. On 03/01/12 at 2:30 p.m., the DON reported she conducted skin rounds and observed more residents with unidentified pressure ulcers. On 03/02/12 the DON provided a list of nine residents who were found with unidentified pressure ulcers during her skin rounds. 3. A review of the significant change MDS assessment, dated 02/27/12, for Resident #7 revealed she was admitted on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #7 required extensive two-person physical assistance with bed mobility, transfers and personal hygiene. The MDS assessment reflected Resident #7 had an indwelling catheter and was incontinent of bowel. Resident #7's MDS assessment also reflected she was at risk for pressure ulcers, but she did not have any pressure ulcers at that time. Resident #7's Braden's Scale dated 02/17/12 reflected she was at High Risk for pressure ulcers. A review of Resident #7's undated Comprehensive Plan of Care, revealed there was no care plan for pressure ulcers. Resident #7's Skin Condition Report dated 02/26/12 reflected the resident's skin was pink. The Report also reflected there was a scant amount of exudate (drainage), which was shiny. The Report also reflected there was an odor of yeast and this was a new area, but there were no measurements. The Report reflected the treatment was [MEDICATION NAME] and Zinc twice daily. On 02/29/12 at 9:20 a.m., the surveyor and RN A observed Resident #7's buttocks. The resident's skin was very red with opened, abraised areas. The RN applied Zinc Oxide and [MEDICATION NAME] Cream to her buttocks. The resident rolled onto her back and the RN applied the [MEDICATION NAME] Cream and Zinc Oxide to her perineal and groin area. Resident #7's Nurse's Notes dated 03/01/12 at 8:00 a.m. reflected, "Resident's yeast rash on bilat (bilateral) buttocks & (and) between legs worsening. Approx (approximately) 12 open (sic) areas of varying sizes noted to backs of thighs. Skin is bright red & shiny (with) strong yeast odor...." On 03/01/12 at 2:30 p.m., an interview was conducted with the DON regarding Resident #7's skin. The DON stated she found her buttocks "flaming red" with several opened areas on her buttocks and a yeast infection. The DON stated Resident #7 had multiple, approximately 12, Stage II pressure ulcers in the perineal area and groin. The DON said the physician had been notified and a new order for treatment twice a day had been ordered. The DON also stated the resident's first layer was skin was gone and the resident's buttocks were "torn up." Resident #7's Skin Condition Report dated 03/01/12 reflected the resident had approximately 12 opened areas of varying sizes caused by yeast. The Report reflected Resident #7's skin was red, and there was a small amount of shiny exudate. Resident #7's Skin Condition Report also reflected there was an odor of yeast and the area had deteriorated. The Report reflected the new treatment was Zinc and [MEDICATION NAME] every shift and as needed. The Report reflected the resident had pressure relieving mattress and other interventions included nutritional and positioning. Resident #7's Physician's Telephone Order dated 03/01/12 reflected [MEDICATION NAME] (antifungal) 100 mg every day for seven days and increased treatment of [REDACTED]. On 03/02/12 at 10:30 a.m., during a skin observation of Resident #7, the resident had two opened areas with the first layer of skin gone on her buttocks. When asked about the Stage II pressure ulcers on Resident #7's buttocks, RN A stated, "That's not a Stage II. The yeast infection caused the sloughing." RN A applied zinc oxide plus [MEDICATION NAME] cream to the multiple opened, bleeding areas on the resident's left and right buttocks. During an observation on 03/02/12 at 1:10 p.m. of Resident #7's buttocks and perineal area with the Medical Director, RN A, and the Clinical Wound Nurse Specialist, the Medical Director stated, "(Resident #7's) open areas are a Stage II (pressure ulcer)." The Clinical Wound Nurse Specialist stated, "Yes. That's a Stage II (pressure ulcer) (referring to the opened area on Resident #7's lower right buttock)." Resident #7 was on the list of residents with unidentified pressure ulcers provided by the DON. 4. An interview with the Medical Director on 03/02/12 at 1:25 p.m. revealed he felt there was a problem with communication regarding pressure ulcers. He stated he did not think the CNAs reported to the nurses observations of skin, which looked "abnormal." He stated skin assessments needed to be conducted on admission, weekly and quarterly. The Medical Director added he did not think the skin assessments were being completed every week. 5. Resident #23 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE], according to the undated Face Sheet. Her diagnoses, per the Face Sheet, included Backache, Symbolic Dysfunction, Joint Pain, [MEDICAL CONDITION], Loss of Coordination, Abnormal Gait, Hypertension, Coronary Bi-Pass, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. An observation on 03/02/12 at 9:30 a.m. revealed Resident #23 had a Stage II pressure ulcer on her medial left buttocks. Resident #23's Physician's Telephone Order dated 03/02/12 reflected cleanse wound with normal saline and then apply [MEDICATION NAME]. The facility's undated Form CMS-802 reflected Resident #23 was cognitively impaired, incontinent, had vision and/or hearing devices and assistive devices. The CMS-802 did not identify Resident #23 as having any pressure ulcers. Resident #23 was on the list of residents with unidentified pressure ulcers provided by the DON. 6. Resident #25 was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An observation on 03/02/12 at 10:45 a.m. revealed Resident #25 had a Stage II pressure ulcer on her right buttock. The facility's CMS-802 reflected Resident #25 had falls, was cognitively impaired, incontinent, had pain, had problems with range of motion, contractures and/or positioning, and problems with language/communication. The 802 did not identify Resident #25 as having pressure ulcers. 7. An interview with CNA J on 03/02/12 at 11:00 a.m. revealed she reported any problems with the residents' skin to LVN I. She stated if LVN I was not there, then she reported the problems to ADON K. CNA J stated if the wound looked worse, then she would again mention it to LVN I. She stated if something was not done about the wound, then she would tell ADON K. CNA J stated they did not document the skin problems they found. She stated they just told the nurses 8. An interview with LVN I on 03/02/12 at 11:21 a.m. revealed skin assessments were conducted weekly on every resident on either the 6:00 a.m. to 2:00 p.m. shift or the 2:00 p.m. to 10:00 p.m. shift, according to the resident's shower schedule. She stated the wounds were measured weekly by "whoever is here" the day it needed to be done. 9. An interview with CNA L on 03/02/12 at 11: 30 a.m. revealed she reported skin problems to the nurse and if nothing was done about them, then she reported the skin problems to ADON K. She stated she knew ADON K would do something about the skin problems. 10. The facility's policy "Pressure Ulcers/Skin Breakdown - Clinical Protocol" dated April 2007 reflected, "1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s)... 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or [MEDICAL CONDITION], overall medical instability, cancer [MEDICAL CONDITION] causing a catabolic state, and macerated or friable skin...." 11. The DON provided the surveyors with a list of six residents with pressure ulcers they knew about and a list of nine residents with pressure ulcers they did not know about dated 03/05/12.