Every finding on record at Vista Hills Health Care Center

Based on record review and interview the facility failed to in accordance with accepted professional standards and practices maintain medical records on each resident that are complete and accurately documented for 1 of 10 residents (Resident #1) reviewed for documented care areas. -The facility failed to accurately document shower acceptance and refusals for Resident #1 from 07/25/2026 to 08/24/2026. These failures could place residents at risk of having conditions and treatments undocumented and unreported.Record review of Resident #1's admission sheet dated 08/24/2026 revealed the resident was an [AGE] year-old female with an original admission date on 06/10/2026. Record review of Resident #1's admission MDS dated [DATE] revealed the resident had a BIMS score of 5 indicating the resident had severe cognitive impairment. Under section E for behaviors the resident was coded for not having rejection of care behaviors. Under Section GG - functional abilities/ under shower/bathing and tub/shower transfer, the resident did not attempt this task due to medical condition or safety concerns. Under Section M - skin conditions the resident was coded for at risk of skin ulcers but did not have any unhealed ulcers at the time of assessment. Record review of Resident #1's care plan dated 07/10/2026 revealed the resident had a focus area to address impaired cognitive function/impaired thought process related to dementia with intervention of keep resident's routine consistent. The resident was additionally coded for ADL self-care deficits and required 1 person assist with bathing. The resident had a focus care plan to address verbal/physical resistance and aggression with an intervention to monitor/document/report to medical doctor. Record review of Resident #1's physical and health dated 06/11/2026 revealed the resident had a diagnosis of major depressive disorder, recurrent, severe, with psychotic features (a serious mental health condition where repeated severe bouts of sadness include a loss of touch with reality), anxiety disorder (mental health conditions that cause ongoing, excessive fear, dread, and worry that interfere with daily life), and dementia with behavioral disturbance (a condition involving loss of memory, language, problem solving, and other thinking abilities with the presence of non-cognitive actions, such as agitation, aggression, or depression). Record review of Resident #1's POC dated 07/25/2026 to 08/24/2026 revealed under the bathing task that the resident had only received 1 shower on 08/20/2026. Under the PRN bathing with the same date range revealed the resident had refused only 1 shower on 07/28/2026. Record review of Resident #1's nursing progress notes revealed that the resident refused 2 showers on 07/28/2026, and 08/19/2026 and 1 refusal to have her hair washed during a shower on 08/04/2026 During an interview on 08/24/2026 at 12:27 p.m., Resident #1 stated she could not recall her shower schedule, any showers she missed, or showers she refused. During an interview on 08/20/2026 at 10:21 a.m., CNA A stated that if a resident refused care, staff members attempted to inform another CNA who might receive a positive response from the resident. CNA A stated that if the resident still refused, staff did not obligate them, but instead informed the nurse that the resident did not want to shower. CNA A stated that residents usually refused approximately twice a week, but they typically showered because a lack of bathing could cause infections and odors. During an interview on 08/20/2026 at 11:20 a.m., LVN B stated he completed his documentation every shift. He stated progress notes are completed right away when receiving notice from CNAS, reporting to the doctor, or family members. He stated this was done to ensure it was documented communicated and creating history that can be referenced within a time frame. He stated it was not good documentation practice to enter a progress note after the sometime because they could be inaccurate. He stated all nursing staff should adhere to the documentation standards. He stated the ADON and DON were responsible for reviewing documentation completed by nurses and CNAs on POC. He stated if these standards were not upheld there could be mix-ups in times, it could be inaccurate, miscommunication, confusion in what was done/provided to the resident. During an interview on 08/24/2026 at 11:23 a.m., CNA C stated that he provided bathing to residents every other day, with residents receiving a shower three times a week. He stated that when a refusal occurred, he notified the nurse, switched tasks with another CNA, and documented the occurrence on POC. He stated that the documentation needed to be completed as soon as possible and every single time whether it was a refusal or acceptance. He stated that documentation included ADLs, behaviors, continence, observations, and added that every instance required an entry. He stated that this process provided insight by ensuring care was observed and documented so that everyone remained informed. He stated that it helped create a track record for the nurses to review, and that nurses also documented the information as needed. He stated that this practice ensured the facility's credibility to proving the task was provided or encouraged following a refusal. During an interview on 08/24/2026 at 1:55 p.m., MDS Nurse stated that herself, ADONs, and nurses reviewed the documentation of the CNAs daily to ensure it was completed before the end of the shift. She stated that refusals were usually reported to the nurse and that every refusal needed to be documented by the CNA on the POC system, as well as by the nurse in progress notes. She stated that the purpose of documenting the event was to inform the family and elicit more assistance from them as needed. She stated that it assisted a monitoring system to track whether a resident was refusing or accepting showers. She stated that a lack of documentation affected the resident because the staff would not be aware of how many days the resident went without a shower. She stated that residents could experience skin breakdown, especially if they were incontinent, and could feel horrible and uncomfortable without a shower. She stated that staff members were responsible for documenting, and she stated that she did not recall the date of the last in-service training for documentation. During an interview on 08/24/2026 at 2:21 p.m., the ADON stated that when residents refused a shower, CNAs reported the refusal to the nurse. She stated that CNAs were supposed to document all accepted care in POC. She stated that the purpose of documenting all refusals and acceptances was to prove what was done for the resident. She stated that there should be at least 12 entries in the POC over the course of 30 days. She stated that the IDT - comprised of the DON, ADONs, Social Worker, Administrator, DOT, and Activities-reviewed the POC and progress note documentation daily. She stated that the shift nurse received a notification when a resident refused three consecutive days of showers. She was provided the POC report from 07/25/2026 to 08/24/2026 which only had 1 documented shower and stated that it did not look like the showers were being documented by the CNAs. She stated that she had not been notified by the MDS about the CNA documentation not being 100% compliant. She stated that she checked the system daily but was not notified of missing documentation by their own notification system, though she noted the system had worked to provide notifications in the past. She stated that undocumented showers affected a resident because the facility could not prove to the State that the resident was being provided or refused showers. She stated that CNAs and nurses were responsible for ensuring care was documented. She stated that she did not recall the last in-service training provided on completing documentation. She stated that she reviewed the CNA schedules and shower schedules to identify which CNAs were supposed to complete the documentation. During an interview on 08/24/2026 at 3:15 p.m., the DON stated that Resident #1 had dementia, was sometimes verbally and physically aggressive toward staff, and occasionally refused care. She stated that if a resident refused or accepted a shower, it needed to be documented that day for verification of care. She stated that the resident was away from the facility from August 5 to August 19, therefore those dates would not have any data for them. She stated that CNAs documented shower refusals and acceptances, and that floor nurses and the ADONs reviewed the records at the end of their shifts to ensure they were 100% complete. She stated that the facility utilized shower cards as well and provided them before exit. She stated that if care was not documented, she could not tell if the shower was completed or refused. She stated that ADONs and nurses should check the documentation at the end of each shift, and this was not noticed sooner because everyone did not notice the missing documentation on POC. During an interview on 08/24/2026 at 4:10 p.m., the Administrator stated that the shower schedule was every other day, separated by A/B bed assignments, and provided on an as-needed basis. She stated that refusals needed to be reported to the charge nurse, and when a plain refusal occurred, both the nurse and the CNA needed to document it in their designated portals. She stated that nurses documented on PCC and CNAs documented on the kiosk in the hallway to POC. She stated that there was an option for refusals and that there should be six completed or refused showers for the date range 07/25/2026 to 08/05/2026 for Resident #1. She stated that the nurses, ADONs, and DON were supposed to be monitoring POC entries to ensure compliance, especially if a resident was known to refuse care. She stated that if there was nothing entered, then it was not documented. She stated that there was no mention of POC completion rates during morning meetings at the end of July or beginning of August. She stated that she was notified daily of POC completion rates. No policy regarding documentation was provided before exiting on 08/24/2026. Record review of the facility's documents titled skin observation worksheet was provided by the DON as their shower card. Record review the documentation was signed off by an assigned CNA and Nurse for the following dates:07/02/2026, 07/04/2026, 07/07/2026, 07/09/2026, 07/11/2026, 07/14/2026, 07/16/2026, 07/18/2026, 07/21/2026, 07/23/2026, 07/25/2026, 07/28/2026, and 07/30/2026 Record review of the facility's in-service titled, Customer service and Personal Hygiene, rescheduling, reattempts, notification, documentation dated 08/05/2026 to 08/08/2026 revealed it was a facility wide in service provided to the nursing department.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents reviewed for care plans. (Resident #1). The facility failed to ensure Resident #1's care plan addressed wound care. This failure had the potential to affect residents by placing them at risk for unmet care needs. Findings included: Record review of Resident # 1's admission record dated 07/01/2026 revealed a [AGE] year-old female with an initial admission date of 04/09/2025 and a readmission date of 06/17/2026. Record review of Resident #1's History and Physical dated 06/21/2026 revealed diagnoses of hepatic encephalopathy (a condition where a damaged liver allows toxins to build up in the blood, which then affect the brain, causing confusion, memory problems, and changes in behavior). Record review of Resident #1's Comprehensive MDS dated [DATE] revealed a BIMS of 15 indicating intact cognitive function. Section J- Health Conditions revealed Resident #1 had one injury categorized as any of the following- skin tears, abrasions, lacerations, superficial bruises,hematomas and sprains; or any fall-related injury that causes the resident tocomplain of pain. Record review of Resident #1's care plan revised on 06/17/2026 did not address the hematoma she sustained after a fall on 06/16/2026. Record review of Resident #1's hospital discharge paperwork dated 06/17/2026 revealed Resident #1 was seen for a hematoma (localized collection of blood outside of a blood vessel, typically caused by a break or injury to vessel wall), and was discharged with orders for Tylenol 500mg Record review of Resident #1's physician progress note dated 06/17/2026 revealed Resident #1 was seen upon return from the ER for a fall resulting in a facial laceration. In an interview on 07/01/2026 at 2:14 p.m., LVN A stated that the purpose of the care plan was to address the care that the resident was receiving. He stated that any skin injuries were to be documented in the care plan to reflect the care that the resident will be provided and any follow ups needed. He stated that the care plan could be updated by the floor nurses, the charge nurse or wound care nurse. He stated that the ADONs oversee that the care plans are being updated accordingly as well as the MDS nurse. He stated that the risk of the care plan not being updated was that follow ups could be missed or there could be a delay in care. In an interview on 07/01/2026 at 2:40 p.m., the ADON stated that the purpose of the care plan being updated was to document any changes that the resident experiences, and to document the care that was to be provided to the resident. She stated that charge nurses, floor nurses, and wound care nurse could update the care plan. She stated that the ADONs received a report from the DON indicating which resident needed the care plan to be updated, and the ADONs were responsible to ensure the care plans were updated. She stated that the MDS nurse was also responsible, but she did not know how often she updated it. She stated that the risk could be staff overlooking care needed causing a delay in care. In an interview on 07/01/2026 at 2:53 p.m., the MDS nurse stated that after that after the fall that Resident #1 had she returned to the facility with a hematoma to the forehead. She stated that the care plan should have been updated to reflect the injury. She stated that the care plan needed to be updated so that the staff was informed about the injury. She stated that there was no risk to the resident by the care plan not being updated. She stated that the floor nurses, the DON and herself were responsible for ensuring that the care plans were updated. In an interview on 07/01/2026 at 4:05 p.m., the DON stated that the purpose of a care plan was to detail the care that the resident was receiving. She stated that the care plan was updated as needed and needed to include any injuries or skin changes that the resident sustained. She stated that mds nurse was responsible for reviewing the care plan; she stated bot knowing how often they review them. She stated that the corporate MDS consultant oversees the MDS nurse to ensure that the MDS nurse was updating the care plans. She stated that the risk of not updating the care plan was that the staff would not be aware of the changes or treatments being given. She stated that for Resident #1, the laceration/hematoma should have been included in the care plan when she returned from the emergency room. In an interview on 07/01/2026 at 4:30 p.m., the Administrator stated that the MDS nurse was responsible for updating the care plan and the DON and herself were responsible for overseeing that this was being done. She stated that the importance of updating the care plan was to reflect the current care and conditions the resident had. She stated that there could be a delay in care if the care plan was not updated to reflect any new injuries or treatment. She stated that for Resident #1 the injuries sustained after the fall had to be care planned to reflect the change in the residents condition. Record review of the facility's Nursing Policy & Procedure Manual, titled Comprehensive Care Plan, undated, read in part: The Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a residnet's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interviews, observation, and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to ensure they employed a full time or interim DON from 03/04/2026 through 03/17/2026, and 04/01/2026 to 04/19/2026. This failure could place all residents at risk of not receiving necessary care and services.Findings included:Record review of DON E's timesheet, with no date, revealed his last day working was 03/03/2026. Record review of Job Offer letter dated 03/19/2026, noted a job offer was extended to DON F for the role of the Nursing Facility's DON with start date 03/18/2026. Record review of a printed email from the Payroll Clerk dated 04/07/2026, noted DON F's termination date was 03/31/2026 due to Resignation, Health reasons. Record review of Job Offer letter dated 04/23/2026, noted a job offer was extended to DON D for the role of the Nursing Facility's DON with effective date 04/20/2026. During an observation and interview on 04/29/2026 at 08:35 AM, the Administrator stated DON D was at a sister Nursing Facility, training under another DON. DON D was not at the Nursing Facility during this State Surveyor's investigation on 04/29/26. In an interview on 04/29/2026 at 2:49 PM, the HR Coordinator stated DON E's last day of employment was 03/04/2026 and DON D was promoted to the role of DON on 04/20/2026. In an interview on 04/30/2026 at 10:48 AM, DON D stated she took the role as the Nursing Facility's DON on 04/20/2026. She stated the Nursing Facility had 2 ADONs who were assisting with overseeing residents and compensated for the lack of DON. She stated that there would be potential barriers or risks to residents if a Nursing Facility did not have a DON. DON D did not want to explain the potential barriers or risks. In an interview on 04/30/2026 at 1:10 PM the Administrator stated DON E's last day of employment was 03/03/2026, and there was no DON for two weeks, from 03/04/2026 to 03/17/2026, until DON F was hired in Mid-March 2026. She stated DON F then worked approximately 1-2 weeks; termination date noted was 03/31/2026. The Administrator stated DON F resigned due to health reasons. She stated that the Nursing Facility did not have a DON for those following two weeks, from 04/01/2026 to 04/19/2026. She stated that the Nursing Facility did advertise for the Job Opening for the Nursing Facility's DON online. She stated there were multiple Job Applicants, but many applicants were from the hospital, and she thought it would be in the Nursing Facility's best interest to have a DON with Nursing Facility experience. She stated there were possible barriers for residents if the Nursing Facility did not have a DON, including lack of supervision over the nursing staff which affects the residents. The Administrator added the potential risks to residents including residents' documentation, or residents could have a change of condition. In a follow up interview on 04/30/2026 at 2:04 PM, the Administrator stated the facility did not have a policy for the DON requirement, and the facility followed state regulations.Record review of the Texas State Regulations, it read in part: 483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis.

Based on observation, interview, and record review the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care was provided for 2 of 8 residents (Resident #1 and Resident #2) reviewed for privacy. -The facility failed on 04/29/2026 to provide glucose reading for Resident #1 and Resident #2 in a private setting.-The facility failed on 04/29/2026 to provide insulin injection for Resident #1 in a private setting. These deficient practices could affect residents by contributing to poor self-esteem, dignity issues, diminished quality of life, and leaking of protected health information.Findings included: Resident #1 Record review of Resident #1's admission sheet dated 04/29/2026 revealed a [AGE] year-old male with an initial admission date on 01/27/2025. Record review of Resident #1's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 13 with the significance being the resident was cognitively intact. Under section N the resident was coded for requiring insulin injections 6 out of 7 days a week. Record review of Resident #1's care plan dated 01/15/2026 revealed the resident had a focus area for Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar) with interventions to administer medication as ordered educate regarding medications and importance of compliance. Record review of Resident #1's physical and history dated 04/27/2026 revealed the resident was diagnosed with Type 2 diabetes with prescription orders of Insulin Aspart (100 unit/ml), BD AutoShield Duo Miscellaneous (30g x 5mm), Tresiba FlexTouch (100 unit/ml), metformin Hydrochloride (1000 mg) and Glucagon (1 mg). Record review of Resident #1's prescription orders beginning 02/18/2026 for Insulin Aspart FlexPen Subcutaneous (applied under the skin) Solution Pen-Injector 100 unit/ml with a frequency of 3 times a day at 7:30 AM, 11:00 AM, and 4:00 PM. Resident #1 was unavailable for interview on 04/30/2026 at 9:15 AM and 11:00 AM, due to participating in facility activities and meals. Resident #1 showed no signs of distress while participating in activities and meals. Resident #2 Record review of Resident #2's admission sheet dated 04/29/2026 revealed a [AGE] year-old male with an initial admission date on 04/08/2019 and a readmission date on 04/24/2024. Record review of Resident #2's Comprehensive MDS dated [DATE] revealed the resident had a BIMS of 15 with the significance being the resident was cognately intact. Under Section N the resident was coded for requiring insulin injections 7 out of 7 days a week. Record review of Resident #2's care plan dated 04/29/2026 revealed the resident had a focus area for Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar) with interventions to administer medication as ordered educate regarding medications and importance of compliance. Record review of Resident #2's physical and history dated 09/25/2025 revealed the resident had a diagnosis of Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar), Dementia (cognitive decline including memory loss, language difficulties and behavior changes) Bipolar disorder (a chronic psychiatric condition characterized by intense mood shifts between extreme highs and lows) and Schizophrenia (a chronic psychiatric condition characterized by hallucinations, delusions, disorganized speech and impaired social/occupational functioning). Record review of Resident #2's prescription orders beginning 01/05/2026 for Insulin Aspart FlexPen Subcutaneous (applied under the skin) Solution Pen-Injector 100 unit/ml with a frequency of 3 times a day at 7:30 AM, 11:00 AM, and 4:00 PM. In an interview on 04/29/2026 at 10:19 AM, Resident #2 denied having concerns with his care or treatment he received at the facility. He stated he had been at the facility for 7 years already and was happy with the services provided. He stated his guardian, Administrator, and LVN A were individuals he would report concerns of mistreatment, respect, and dignity to. In an observation on 04/29/2026, between 10:30 AM and 11:30 AM, at10:39 AM, LVN A was observed checking glucose levels for Resident #1. LVN A proceeded to administer insulin injection to Resident #1 in front of the nursing station; at no point was redirecting or prompting for privacy offered by LVN A. At 11:28 AM, RN B was observed being approached by Resident #2 at the nurse's station to request glucose reading. RN B was observed providing services to Resident #2 while at the nurse's station; at no point was redirecting or the resident was prompted for privacy offered by RN B. In an interview on 04/29/2026 at 10:44 AM, LVN A stated Resident #1 was provided glucose reading and insulin .She stated it was completed in front of the nurse's station. She stated she usually conducted glucose readings and insulin injections in residents' rooms. She stated Resident #1 had approached her and requested to have his glucose checked. She stated there were no observed or reported symptoms for hyperglycemia (elevated blood sugar) from Resident #1 that would have required immediate administration in front of the nurse's station. She stated at no point did she offer privacy to Resident #1. She stated there was no reason for why she did not offer privacy to Resident #1 and added she just didn't think to offer. She stated that providing care in the open was not allowed because it was an infection control and HIPAA issue. She clarified it was a resident's right to privacy. She stated if care was provided at the nurse's station that everyone can see what care a resident was receiving, disclose vitals, diagnosis, and medication. She stated all staff were responsible for providing care in a private setting. She stated that the ADON and DON D was responsible for ensuring staff were providing care to residents in a private setting. She stated the last in service she received for resident rights and infection control was a month ago. In an interview on 04/29/2026 at 1:33 PM, RN B stated Resident #2 had Type II diabetes and usually was fixated on his medications. She stated Resident #2 knows when he was feeling hyperglycemic and approached the nurses in the halls and at the stations to check his blood sugar. She stated his glucose reading was in the 200's when she checked it before lunch. She stated she had checked Resident #2's glucose in his room in the morning but before lunch she checked it by the medication cart that was in front of the nurse's station. She stated it was not okay to conduct glucose readings out in the open because resident's had a right to privacy. She stated the resident's diagnosis, vitals, and medication could be leaked if staff provided care at the nurses station. She stated it should have been completed in Resident #2's room or somewhere private. She stated that she as the nurse needed to educate and redirect residents about their privacy if they approached her to request care. She stated the last in services for privacy was in March 2025. She stated the last in service for residents' rights was in March 2025. She stated all staff members were responsible for ensuring that residents received private patient care. She identified the ADON and DON D were responsible for ensuring that the staff adhered to these standards. In an interview on 04/30/2026 at 9:03 AM, LVN C stated glucose readings and insulin injections should have been completed in the residents' rooms. He stated it should have been done in the residents' room for confidentiality and infection control reasons. He stated nurses were responsible for monitoring glucose levels and administering insulin. He stated that if a resident approached him at the nurses' station he would assist them back to their room to provide care and services in a private setting. He stated it affected residents because they could have felt a lack of dignity and privacy from receiving care in the open. He stated that HIPAA would have been breached because glucose readings are usually associated with a diagnosis of diabetes. He stated nursing staff were responsible for ensuring care was provided in a private setting. He stated the facility privacy protocol was to utilize the curtain rod in the room and close the door before beginning resident care. He stated the Administrator was responsible for ensuring that nursing staff were adhering to the protocols of privacy during resident care. He stated he did not remember the last in service for resident rights. In an interview on 04/30/2026 at 11:20 AM, DON D stated that resident's privacy protection included document disposal, information encryption, and administer orders in a private setting. She stated that care for residents needed to be completed in the resident's room. She stated it was a HIPPA violation because it shared a resident's diagnosis information to others who might be nearby. She stated nurses and leadership were responsible for protecting residents private information. She stated that staff should redirect residents at least once back to their room and uphold their preference if they were insistent on receiving care in front of the nurse's station. She stated it was not the facility's standard to allow staff to provide glucose reading and insulin injections in the open. She stated that any staff member who saw care being provided in the open could advise the nurse to redirect the resident to their room to receive care. She stated the ADON and herself were responsible for ensuring it was being completed. In an interview on 04/30/2026 at 1:58 PM the Administrator stated that glucose reading and insulin injections should be completed in the resident's room due to privacy concerns. She stated that the resident's diagnosis and treatments were exposed if care was completed at the nurse's station. She stated the nurses were responsible for ensuring that care was completed in the resident's room. She stated it if a resident approached a nurse requesting care it was the expectation for the staff to prompt and educate residents on privacy standards before providing care in the open. She stated if the resident was insistent on receiving glucose and insulin injection at the nurse's station then the care plan needed to be updated. She stated DON D and ADON were responsible for ensuring staff were adhering to these standards. She stated the last facility wide in service for resident's rights was in November 2025. Documentation was provided by the HR coordinator on 04/30/2026 at 11:33 AM. Record review of the facility's in-service titled, Resident Rights in Nursing Facilities revealed tenured staff completed this training within the first 3 weeks of November 2025 Record review of the facility's policy titled Resident Rights undated read in part, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. (Privacy and Confidentiality) The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment personal care.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Resident #33, Resident #43 and Resident #68) of 16 residents observed for oxygen management. The facility failed to clean the oxygen concentrator air filter for Resident # 33, and Resident # 43 while the oxygen was in use, concentrators was observed with air filters with dust, and lint collected on them on 02/09/2026.The facility failed to ensure Resident #68's dirty nasal cannula was replaced when it was observed on the floor on 02/09/26 and CNA F used a wipe to clean the nasal cannula.This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.Record review of Resident # 33's admission record dated 02/10/2026, revealed a [AGE] year old male with an admission date of 01/13/2026.Record review of Resident# 33's History and Physical dated 01/28/2026, revealed a medical history of acute bronchitis(short-term inflammation of the airways in the lungs).Record review of Resident # 33's admission MDS dated [DATE], revealed a BIMS score of 15 indicating intact cognition. Section O-special treatments, procedures, and programs revealed oxygen therapy was in use.Record review of Resident # 33's orders dated 01/13/2026, revealed oxygen at 2 liters per minute via nasal canula as needed for shortness of breath.Record review of Resident #33's care plan with initiation date on 01/14/2026 revealed resident had oxygen therapy as needed.An observation on 02/09/2026 at 10:36 a.m., revealed Resident #33's oxygen concentrator filter to be dusty and have lint.Resident # 43Record review of Resident # 43's admission record dated 02/10/2026 revealed a [AGE] year-old female with an admission date of 06/19/2025.Record review of Resident # 43's local hospital History and Physical dated 06/19/2026, revealed a past medical history of chronic obstructive pulmonary disease(a group of long-term diseases that make it difficult to breathe due to narrowed airways).Record review of Resident # 43's Annual MDS dated [DATE], revealed a BIMS of 15 indicating intact cognition. Section O- Special treatments, procedures and programs revealed resident was utilizing oxygen therapy.Record review of Resident #43's order summary report dated 02/10/2026, revealed Oxygen at 3 liters per minute via nasal cannula for shortness of breath order date 09/01/2025.Record review of Resident #43's care plan with a revision date of 01/13/2026, revealed resident had oxygen therapy. Interventions included oxygen at 3 liters per minute per nasal cannula.Record review of Resident #68's face-sheet dated 02/11/26 revealed a [AGE] year-old male with admission date 03/31/23.Record review of Resident #68's health and physical dated 09/26/23 revealed the following medical history: dysphagia (difficulty swallowing), Traumatic Brain Injury (brain injury caused by an outside source), Diabetes mellitus type II, Cognitive Communication deficit , Dementia, Seizure disorder, and tracheostomy status (surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), expressive aphasia ((partial loss of the ability to produce language,(spoken, manual, or written))Record review of Resident #68's quarterly MDS dated [DATE] revealed a BIMS of 15, indicating resident #68 was cognitively intact.Record review of Resident #68's care plan included is on Oxygen Therapy and to administer oxygen per physician's orders.An observation and interviews on 02/09/26 at 09:15 a.m., - Resident #68 was observed laying in his bed, his nasal cannula was observed on the floor. CNA F was observed to lifting the nasal cannula and cleaning it with a wipe. CNA F stated she cleaned the nasal cannula with a wipe because she did not have anything else to clean the cannula with. Resident #68 stated that was the first time he had seen staff clean the nasal cannula with a wipe.An observation on 02/09/2026 at 11:30 a.m., revealed Resident # 43's oxygen concentrator filter to have dust collected on it.During an interview on 02/11/26 at 10:55 a.m., CNA E stated CNAs were responsible for ensuring nasal cannulas were stored and sealed in bags. She stated that if nasal cannulas were observed on the floor, it was to be replaced, and the nurse was to be notified. She stated the risks of residents using a nasal cannula that was observed on the floor was infection or illness. She stated she was unsure who cleaned the oxygen concentrator filters, but if she was to observe one dirty, she would notify the nurse. She stated dirty oxygen concentrator filters were a risk for infection to residents and could cause them to be sick. She was unsure who monitored the oxygen concentrator filters.During an interview on 02/11/2026 at 11:17 a.m., CNA F stated she had not seen a dirty concentrator filter, and was not sure who was responsible for cleaning them. She stated if she noticed a dirty filter, she would report it to the nurse. She stated dirty filters could put residents at risk of respiratory problems. She stated she could not recall the last in-service regarding oxygen concentrator filters. She stated CNAs were responsible for storing nasal cannulas in a sealed bag. She stated if a nasal cannula was on the floor, it was considered contaminated and would put the resident at risk for illness. She stated it was not correct to wipe the nasal cannulas if they were dirty, she stated all staff were responsible to replace them.During an interview on 02/11/2026 at 12:09 p.m., LVN I stated the night shift nurses were responsible for cleaning the oxygen concentrator filters. He stated he was not sure who followed up and monitored the oxygen concentrator filters were clean. He stated having dirty filters on oxygen concentrators for residents included them being at risk for bacteria exposure and possible respiratory illness since the resident would be breathing in the oxygen being delivered from the concentrator. He stated nursing staff were responsible for ensuring nasal cannulas were stored in a sealed bag. He stated nursing was responsible for ensuring nasal cannulas that were not in use were stored in a sealed bag. He stated it was not acceptable for staff to attempt to clean a nasal cannula that touched the floor with a wipe, it was to be replaced due to infection control concerns. During an interview on 02/11/2026 at 4:28 p.m., the Administrator stated oxygen filters were checked weekly and on weekends. She stated staff assigned for ensuring oxygen concentrators were clean was central supply staff. She stated staff conducted weekly rounds to ensure that filters were clean and free of dust. She stated weekend nurses oversaw the maintenance of oxygen concentrator filters. She stated that residents with dirty oxygen filters were at risk of allergies. She stated she initiated an in-service regarding oxygen concentrator filters and nasal canula storage and disposal this week. On 02/11/26, the DON and Corporate Compliance Regional Nurse stated there was no policy addressing oxygen concetrator filters or the nasal cannulas.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 16 residents (Resident #12 and Resident #17 ) reviewed for pharmacy services. The facility failed to ensure skin ointment was not left at bedside and within reach of Resident #12 and Resident #17 and other residents on(02/09/2026) . The facility failed to maintain their treatment cart free from the Antimicrobial soap's red fluid spillage and red-dried drippings observed on the Antimicrobial soap on 02/11/26. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. Findings included:Record review of Resident #12's face sheet dated 2/9/2026, revealed a [AGE] year-old male initially admitted on [DATE] with a re-admission date of 12/26/2025. Record review of Resident #12's History and Physical dated 4/3/2025, revealed diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss and inability to think or function independently), aphasia following cerebral infarction (loss of ability to speak or understand language after a stroke), hemiplegia and hemiparesis affecting the left non-dominant side (paralysis and severe weakness on one side of the body), chronic kidney disease stage 4 (severe loss of kidney function), end stage renal disease on dialysis (kidneys no longer function requiring dialysis treatments to survive), chronic respiratory failure with hypoxia (long-term breathing condition where the body does not receive enough oxygen), dysphagia following cerebral infarction (difficulty swallowing after a stroke), and gastrostomy status (presence of a feeding tube placed directly into the stomach for nutrition and medications). The documentation indicated the resident had expressive aphasia and was unable to participate in examination or questioning. The record further indicated the resident was non-ambulatory and required supportive care. Record review of Resident #12's MDS annual assessment dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. Section B revealed the resident rarely or never made himself understood and rarely or never understood others. Section GG (Functional Abilities and Goals - Self-Care) revealed the resident was dependent on staff for upper body dressing and lower body dressing, requiring total assistance for dressing tasks. The documentation indicated the resident required extensive assistance for mobility and was non-ambulatory. Record review of Resident #12's care plan dated 1/1/2026 revealed the resident had bowel incontinence related to immobility and required staff assistance for toileting and peri care (cleaning the genital and anal area). The care plan indicated staff were to apply barrier cream after every incontinent episode. Interventions further stated Apply barrier cream after each incontinent episode, assigned to certified nursing assistants.In an observation on 02/09/2026 at 10:44 AM in Resident #12's bedroom, a cup containing a white substance and a tongue depressor inside the cup, was found on top of the resident's dresser. The cup was not labeled, and the contents were unknown.Record review of Resident # 17's admission record dated 02/11/2026, revealed a [AGE] year-old male admitted on [DATE].Record review of Resident #17's History and Physical dated 09/25/2025, revealed a past medical history of high blood pressure, and type II diabetes.Record review of Resident # 17's Quarterly MDS dated [DATE], revealed a BIMS score of 14 indicating intact cognition. Section H- Bladder and Bowel indicated resident was occasionally incontinent.Record review of Resident #17's care plan revised 01/28/2026 revealed resident had bowel incontinence, interventions included applying barrier cream after every incontinent episode.An observation on 02/09/2026 at 11:45p.m., of Resident #17's room revealed a clear plastic medicine cup not labeled with a white creamlike substance on the bedside table.In an interview with on 02/09/2026 at 1:50 p.m., Resident #17 stated the nurse had given him that ointment because he had a rash on his thigh area he stated that he at times applied it on himself and the staff applied it on him as well. He did not know the name of the ointment. During an interview on 02/09/2026 at 10:45 a.m., LVN C said that the ointment was not supposed to be there because it was not labeled and there was no way to know what its contents were. stated if the cream was to be applied to the resident after being left exposed could result in an adverse reaction such as a rash or worsening a wound if the cream was contaminated. During an interview on 02/09/2026 at 10:45 a.m., LVN D stated the leftover cream should have been disposed of immediately after staff had applied it to the resident to prevent infection control. Stated there were some residents in the facility with dementia who could get into the room and take it with them or ingest it which could make them sick. During an interview on 02/09/2026 at 10:45 a.m. CNA E said staff were supposed to throw away any leftovers of cream and dispose of it in the waste basket as biohazard. She said that crem left in the room was wrong because it was an infection control issue which could spread to other residents or if a resident with dementia ingested the cream it would make them sick. During an interview on 02/10/2026 at 2:14 p.m., ADON A stated that she had been informed about the medication left at bed side. She stated it was not acceptable because it was an infection control issue and there was a possibility that another resident could get the cream and ingest it which could result in that resident getting sick. During an interview on 02/11/2026 at 3:10 p.m. the DON stated all medication being administered was to not be left at bedside to include any topical medication. He stated that topical medication was to be disposed of after application. He stated if it was left at bedside, it would be a risk for cross contamination and could potentially cause harm to residents because the medication was not dated, or labeled and depending on the resident, it could be misused by the resident. He stated that it was the responsibility of whoever was administering the medication to ensure that it was properly disposed of and not left behind. He stated - an in-service was initiated regarding leaving medications at bedside. During an interview on 02/11/2026 at 3:32 p.m., the Administrator stated all medication being administered were to not be left at bedside to include any topical medication. She stated this was to be done to prevent the risk of the residents misusing the mediation and to prevent contamination. She stated that it was the responsibility of whoever was administering the medications to ensure medications were not left at bedside. She stated that an Inservice was initiated this week regarding leaving medications at bedside.Record review of the facility policy and procedure titled Medication Storage in the Facility read in part . Medications and biologicals are stored safely, securely and properly following manufacture's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .During an observation on 02/11/26 at 9:15 a.m, with Wound Care Nurse of the treatment cart, the Antimicrobial soap was on its' side, and observed with red fluid spillage from the bottle with the bottle cap being covered with red fluid.During an interview on 02/11/26 at 1:15 p.m. the Wound Care nurse stated the wound care nurse on shift was responsible for reviewing and cleaning the treatment cart. She stated this was done throughout the shift, including when starting the shift. She stated the ADONs review the treatment cart weekly. She stated it was not acceptable to have the antimicrobial soap with spillage in the cart, she stated she was to clean the cart and disinfect. She stated using soap with observed dried drippings and spillage was a risk for contamination and infection to residents.During an interview on 02/11/26 at 02:00 p.m. the ADON B stated the wound care nurses were responsible for their treatment carts including cleanliness. She stated the DON oversees and reviews the carts for clean carts, but was unsure how often. She stated it was not acceptanle to keep using soaps or bottles with observed spillage as it was no longer aseptic technique. She stated the risk of staff using a soap with observed spillage included infection to the resident.During an interview on 02/11/26 at 2:29 p.m., the DON stated the wound care nurse on shift was responsible for the cleanliness. He stated the ADONs and self, as the DON, would audited the carts for cleanliness. He stated it was done weekly, and the Regional Compliance Nurse also did random checks. He stated it was not acceptable for staff to have the antimicrobial soap in the cart if there was observed spillage, he stated it should have been thrown away. He stated possible risks for the residents included risk of infection.On 02/11/26 at 09:15 AM, the DON stated there was no policy for treatment carts.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage.-The facility failed to keep the deep fryer free of food particles, grease accumulation, and burnt oil, and the stove wall next to the fryer was not free of oil splatter and food particles.-The facility failed to keep the oven door free of grime and oil spatter.-The facility failed to keep the refrigerator clean.-The facility failed to dispose of moldy vegetables.-The facility failed to store frozen vegetables in a sealed bag inside the freezer to prevent food contamination and freezer burn.These failures had the potential to place all residents who received meals from the main kitchen at risk for foodborne illness due to unsanitary food preparation surfaces, improper food storage practices, and failure to discard contaminated produce.Findings included:During observations conducted on 02/09/2026 between 8:30 AM and 9:00 AM, the following were observed:-The deep fryer was observed with significant grease accumulation along its upper edges. The accumulated grease contained dry, adhered food particles consistent with prior cooking residue. The grease appeared darkened and old. The wall directly behind the deep fryer and the adjacent oven on the right side were observed with visible grease splatter, layered grime, and dry food particles adhered to the surfaces. The splatter appeared dried and longstanding, indicating the surfaces had not been effectively cleaned.-The oven exterior was observed with green and white discoloration consistent with corrosion, along with visible grease buildup. The presence of corrosion and grease residue indicated failure to maintain the equipment in a sanitary condition.-Inside the refrigerator located next to the pantry door, the back interior wall contained white, dried, smeared residue. The bottom interior surface of the refrigerator contained multiple dried smeared stains and scattered dry food particles. The buildup of residue and food debris indicated that the refrigerator had not been maintained in a clean and sanitary condition.-Inside the freezer, a one-gallon zip-top bag containing green beans was observed open and unsealed. The bag was not properly closed to protect the contents from exposure. Ice particles were observed inside the bag, indicating potential freezer burn and improper storage. Failure to seal the bag exposed the contents to potential contamination and compromised food integrity.-Underneath the kitchen sink, a sack of onions was observed stored. Inside the sack, three large onions were noted with visible dark circular mold growth. The moldy onions were stored among other onions intended for food preparation. The facility failed to remove and discard visibly contaminated produce.In an interview on 02/09/2026 at 8:45 a.m., DS G stated that food items stored in the freezer must remain sealed or properly closed to prevent contamination. When informed of the open bag of green beans observed in the freezer, DS G stated that leaving food exposed in that manner was not correct and could allow contamination. DS G stated that contaminated food could be served to residents and potentially make them sick. DS G further stated that refrigerators, ovens, and deep fryers were required to be cleaned routinely. When informed of the grease buildup in the fryer, the soiled oven door, and staining inside the refrigerator, DS G stated those conditions were unacceptable and could contaminate food surfaces, potentially causing resident illness.In an interview on 02/09/2026 at 12:40 AM with DS H, stated that all food stored in the freezer must be protected from exposure and that open packaging increased the risk of contamination. When informed of the open bag of green beans, DS H stated that the bag should have been sealed and secured and that serving contaminated vegetables could make residents sick. The DS H stated that dirty equipment, including the refrigerator, oven, and deep fryer, could contaminate food during storage or preparation and place residents at risk of illness.During an interview on 02/09/2026 at 10:29 a.m., the Dietary Director stated that food safety required all products to be stored and prepared in a manner that prevented contamination. When informed of the open bag of green beans in the freezer, the Dietary Director stated the product should have been sealed and that leaving it open created the potential for contamination and foodborne illness. The Dietary Director stated that grease buildup in the fryer, soilage on the oven door, and staining inside the refrigerator indicated sanitation procedures were not being followed and could result in cross-contamination of food served to residents. During an interview on 02/11/2026 at 4:12 p.m., the Administrator stated the facility was responsible for ensuring food was stored and prepared under sanitary conditions to protect residents from harm. When informed of the open bag of green beans, the Administrator stated leaving food unsealed was not acceptable because it could become contaminated and potentially cause illness. The Administrator stated that unsanitary kitchen equipment and food storage conditions could contaminate food and place all residents receiving meals prepared in the kitchen at risk of becoming sick.Record review of the facility's Dietary Services Policy and Procedure Manual dated 2012 titled Food Storage and Supplies stated in part: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin, and insects. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. Cleaning the Refrigerator. Refrigerators are maintained in a clean. sanitary condition free of offensive odors. Cleaning of the reach in refrigerator will be done on a daily or as needed basis. Wash walls and base with water and detergent. Give special attention to the floor of the box, corners, doors, openings, gaskets, hinges and latches. Clean all wire shelves carefully. Wipe down all heavily soiled exterior surfaces with a solution of warm water and an all purpose cleaner. Wipe dry with a clean cloth. Use a stainless steel cleaner to remove streaks. 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. There are two types of bacteria that can be found on food: pathogenic bacteria, which cause foodborne illness, and spoilage bacteria, which causes foods to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food not wholesome, but do not cause illness. Perishable foods have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply and this is what causes the food to deteriorate in quality and taste. If perishable food items are not stored at the proper temperature, spoilage bacteria can grow faster than anticipated and food becomes spoiled and should not be served. Food items such as loaves of bread or dairy products with a stamped best-by or use by date do not need to be labeled when opened as this will not affect the date by which they should be used. However, if possible food spoilage is observed prior to the best by date, the product will be discarded.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 residents (Residents #12) reviewed for dignity. -The facility failed to assist Resident #12 to dress with personal clothing instead of a hospital gown. -The facility failed on 02/09/2026 to ensure Resident #12's door was closed to provide privacy while resident's lower extremities were exposed. The deficient practice could affect residents by contributing to poor self-esteem, dignity issues and diminished quality of life. The findings included:Record review of Resident #12's face sheet dated 2/9/2026, revealed a [AGE] year-old male initially admitted on [DATE] with a re-admission date of 12/26/2025. Record review of Resident #12's History and Physical dated 4/3/2025, revealed diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss and inability to think or function independently), aphasia following cerebral infarction (loss of ability to speak or understand language after a stroke), hemiplegia and hemiparesis affecting the left non-dominant side (paralysis and severe weakness on one side of the body), chronic kidney disease stage 4 (severe loss of kidney function), end stage renal disease on dialysis (kidneys no longer function requiring dialysis treatments to survive), chronic respiratory failure with hypoxia (long-term breathing condition where the body does not receive enough oxygen), dysphagia following cerebral infarction (difficulty swallowing after a stroke), and gastrostomy status (presence of a feeding tube placed directly into the stomach for nutrition and medications). The document indicated the resident had expressive aphasia (a condition where a person knows what they want to say, but has trouble getting the words out) and was unable to participate in examination or questioning. Record review of Resident #12's MDS annual assessment dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. Section B revealed the resident rarely or never made himself understood and rarely or never understood others. Section GG (Functional Abilities and Goals - Self-Care) revealed the resident was dependent on staff for upper body dressing and lower body dressing, requiring total assistance for dressing tasks. The MDS indicated the resident required extensive assistance for mobility and was non-ambulatory. Record review of Resident #12's care plan dated 1/1/2026, revealed interventions addressing advanced dementia (progressive loss of memory and reasoning), hemiplegia, and impaired communication related to stroke. The care plan included interventions for enhanced barrier precautions (extra protective clothing when providing hands on care such as gloves and gows), PEG tube care (feeding tube placed into the stomach for nutrition), oxygen use related to respiratory failure (difficulty maintaining adequate oxygen levels), dialysis treatments for renal failure (machine-assisted blood filtration due to kidney failure), and total assistance with ADLs.An observation on 02/09/2026 at 10:44 a.m., Resident #12 was observed in his bedroom with door open lying in bed wearing a hospital gown. His lower body and brief were exposed. The resident was non-verbal and unable to communicate During an interview on 02/09/2026 at 10:45 a.m., LVN C stated he was unaware why Resident #12 was wearing a hospital gown or why his door was open while partially exposed. He stated residents are expected to wear personal clothing unless there are specific medical orders. LVN C stated that leaving the resident exposed with the door open could negatively impact the resident's dignity, cause embarrassment, and affect his wellbeing. During an interview on 02/09/2026 at 10:55 a.m., LVN D stated Resident #12 should not have been dressed in a hospital gown without a clinical reason and staff were responsible for ensuring residents were dressed appropriately in their personal clothing. He stated that allowing the resident to remain partially exposed with the door opened compromised the resident's dignity and privacy and was not consistent with facility expectations During an interview on 02/09/2026 at 11:02 a.m., CNA E stated it was inappropriate for the resident to be wearing a hospital gown and not his personal clothes, especially since he was non-verbal and unable to advocate for himself. She stated it was unacceptable for the resident's door to remain open while he was uncovered, as this could result in embarrassment and violated his privacy. A follow-up observation on 02/10/2026 at 9:36 a.m., Resident #12 was observed lying in bed wearing regular clothing. During an interview on 02/10/2026 at 2:14 p.m., ADON B stated residents had the right to wear their own clothing and to have their privacy protected. She stated leaving a resident exposed with the door open could constitute a violation of privacy and dignity. ADON B stated that staff should anticipate the needs of non-verbal residents by ensuring they were properly dressed, covered, and provided privacy at all times. ADON B stated that protecting resident rights and dignity was the responsibility of all staff. In an interview on 02/11/2026 at 2:14 p.m., the SW stated not having documentation about the residents' preferences and him being dressed on a hospital gown, there was a dignity issue because he could not advocate for himself. The SW stated Resident #12 could have potentially felt embarrassed if he was uncovered, and if people saw him from outside his room, and he was not able to voice his concerns. During an interview on 02/11/2026 at 3:10 p.m., the DON stated it was unacceptable for Resident #12 to be in bed wearing a hospital gown, partially uncovered, with the door open. He stated residents have the right to dignity and privacy at all times, regardless of their cognitive or communication status. The DON stated that leaving the resident exposed created a privacy concern and did not reflect expected standards of care. He stated staff should have monitored Resident #12 more closely and ensured he was appropriately covered and provided privacy. During an interview on 02/11/2026 at 4:00 p.m., the Administrator stated it was not acceptable for Resident #12 to be in a hospital gown, uncovered in bed, with the door open, as this compromised the residents' dignity and privacy. She stated that with the door open, staff, residents, and visitors could potentially view the resident, which constituted a violation of his privacy rights. The Administrator stated that all facility staff were responsible for protecting residents' dignity and privacy and stated that leadership was responsible for ensuring policies and practices were followed consistently. She stated safeguarding resident rights was a fundamental expectation of care within the facility of all staff. Record review of the facility's Policy and Procedures undated, titled Resident Rights read in part: Resident Rights, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. 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. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.-Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.- Respect and dignity-The resident has a right to be treated with respect and dignity, including 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.

Based on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 1 of 10 residents (Resident #68) reviewed for call lights. The facility failed to ensure Resident #68's call light was within reach on 02/09/2026. This failure placed residents at risk of having their needs unmet when they were unable to contact staff.Findings included:Record review of Resident #68's face-sheet dated 02/11/26 revealed a [AGE] year-old male with admission date 03/31/23.Record review of Resident #68's health and physical dated 09/26/23 revealed the following medical history: dysphagia (difficulty swallowing), Traumatic Brain Injury (brain injury caused by an outside source), Diabetes mellitus type II, Cognitive Communication deficit (), Dementia, Seizure disorder, and tracheostomy status (surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), expressive aphasia.Record review of Resident #68's quarterly MDS dated [DATE] revealed a BIMS of 15, indicating resident #68 was cognitively intact.Record review of Resident #68's care plan included resident had Communication problem related to expressive aphasia and interventions included leaving the call light within the resident's reach.In an observation on 02/09/26 at 09:01 a.m., with Resident #68 revealed resident was unable to reach call pad. Staff found it hanging on side of bed by the headboard and provided Resident #68 with the call pad.During an interview on 02/11/26 at 10:55 a.m., CNA E stated the purpose of call lights were for residents to communicate their requests or needs to staff. She stated the call lights were to be left within the residents' reach. CNA E stated all staff were responsible for ensuring call lights were within a resident's reach. She stated CNAs made rounds every 2 hours on residents and ensured their call light was within reach. She stated nurses were responsible for monitoring residents and confirming call lights were within residents' reach every shift. CNA E stated the risks for residents not having their call light within reach included the possibility of falling or becoming injured from attempting to grab the call light.In an interview on 02/11/26 at 11:11 AM with CNA F, she stated the purpose for call lights was for residents to notify or request assistance from staff. She stated that CNAs and all staff were responsible for ensuring the call light was within the residents' reach throughout their shift. She stated that any staff that entered the room was responsible for providing the call light within the resident's reach. She stated nurses were responsible for following up and monitoring their residents, including call lights. She stated the risks of residents not having their call light within reach included needs and care would be delayed.In an interview on 02/11/26 at 12:07 PM with LVN D, he stated call lights were to stay within a resident's reach, and it served the purpose for residents to communicate their needs to the nursing facility staff. He stated all staff were responsible for ensuring call lights were provided within a resident's reach. He stated all staff round on the residents, including nursing staff, which was frequent rounds throughout all shifts daily. LVN D stated the risks for residents having call lights out of reach included delayed care since residents would not be able to communicate their needs. In an interview on 02/11/26 at 2:21 PM with the DON, he stated the call bell was for residents to communicate their needs to staff. The DON stated all facility staff providing care were responsible for ensuring call lights were left within residents' reach before leaving them. He stated nursing staff round on residents throughout their shift, and supervisors from different departments were assigned different rooms to round on residents daily which included confirmation of call lights being in residents' reach. He stated the risk of residents not having their call light within reach included residents being unable to communicate their needs to staff.In an interview on 02/11/26 at 4:29 PM with the Administrator, she stated call lights were for residents to call staff for assistance when needed. She stated call lights were to remain within the reach of the resident. She stated that all staff providing resident care were responsible for ensuring call lights were within residents' reach. She stated the different Department Supervisors were assigned different resident rooms, which they rounded on and followed up on any concerns including confirming call lights were provided within a residents' reach. She stated the risk for residents now having the call light within reach included staff inability to meet the residents' needs.On 02/11/26 at 9 AM, the DON stated there was no Call Light policy.

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of residents' property for 1 out of 8 residents (Residents #15) reviewed for abuse and neglect. The facility failed to implement their abuse policy when they failed to report, unknown charges made to Resident #15's bank card in the amount of 700 dollars while the resident resided at the facility. This failure could place residents at risk for exploitation, misappropriation, abuse, and neglect by not immediately following the facility policies and procedures of recognizing, reporting, investigating, allegations of exploitation, misappropriation, abuse and neglect.Findings included:Record review of Resident # 15's admission record dated 02/11/2026 revealed a 70 y/o female admitted on [DATE]Record review of Resident #15's diagnosis information dated 02/11/2026 revealed a diagnosis of bipolar disorder(chronic mental health condition causing shift in moods, energy and activity levels).Record review of Resident #15's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition.Record review of Resident #15's care plan revised 09/28/2025 revealed Resident #15 had a mood problem related to bipolar disorder interventions included assisting resident to identify strengths, positive coping skills.Record review of Resident #15's resident grievance form dated 1/30/26, revealed that grievance was received on 01/30/26 generated by Resident #15. Per grievance form residents voiced concern was not having a card to purchase cigarettes and also regarded unclarity with the unknown amazon purchases. Pertinent findings included the facility along with Resident#15 contacted her bank together and that her card would be replaced for one last time as there had been a history card hackings. The online store was contacted as well and representative informed that money would be reimbursed. Corrective actions to be taken were to monitor resident and assuring her needs were being met and notifying the resident when her new bank card arrived. Incident was resolved on 1/30/2026.In an interview on 02/11/2026 at 10:22a.m., the Business Office manager stated the resident came to her office asking for assistance with checking her bank account, they both noticed that there had been charges made to her card with purchases from an online store She helped the resident call amazon, representative verified that the account had been compromised and opened a case. The representative stated that credit would be returned. She stated that she and resident contacted the bank branch via telephone as the bank is not local. She stated that the bank representative informed the resident that the card would be replaced. She stated that the facility did not manage the residents' funds and that Resident #15 would occasionally ask her to hold on to her bank card because she did not want to keep it in her room. She stated that she did inform Resident #15 that she did not hold on to bank cards, but she would make the exception. She stated that Resident #15 would ask her to store it for her and then come to ask her for it to buy cigarettes. She stated that as soon as she found out that there had been charges to the residents' card, she reported it to the Administrator. She stated that per the online store representative, the charges were made by an unidentifiable source and did not show a mailing address.In an interview on 02/11/2026 at 11:31 a.m., Resident #15 stated the facility would store her debit card in the business manager's office because she felt it was safer than keeping it on her, she stated the business office manger told her that she did not usually store resients bank cards, but she was able to leave it in there in a filing cabinet with a key. She stated she managed her own money. She stated she asked the business office manager to help her check her bank account and it was noted that several charges were made to the online store in the amount of -700 dollars. She stated she contacted and the representative informed her the card had been hacked, she stated not believing that because she did not use it frequently. She stated that she only used it for cigarettes and it was kept at the business office the rest of the time. She stated that the online store refunded her the money but not the overdraft fee and she was still paying that. She stated that she had contacted her bank and that they informed her that this would be the last card she would be getting due to there being many repeated instances like this in the past. She stated she spoke to the administrator and was told that she would contact the bank however she did not. She stated that she believed that the facility used her card and lied about the charges. she stated that she voiced this to the administrator but the administrator had told her to keep it quiet and to not make a big deal and that her staff would never do something like that.During an interview on 02/11/2026 at 2:38 p.m., The DON revealed if an allegation was made by a resident stating misappropriation of property or exploitation then it would be reported to the state survey agency, but if was just a complaint, then a grievance form would be done and the facility would work on correcting it. He stated that he and the administrator were responsible in reviewing allegations before reporting to the State Agency.During an interview on 02/11/2026 at 3:32 p.m., The Administrator revealed the Business office manager reported to her that she and Resident #15 identified charges made to her bank card. She stated when she spoke to Resident #15, the Resident had told her this had happened to her multiple times in the past. She stated that she asked Resident #15 if she believed if someone from the facility had used her card and Resident #15 stated she did not. The administrator stated she offered to call the police department to file a police report and the resident declined. She stated that she did not report the incident to the local State Survey Agency due to a history of the resident's bank accounts being compromised and the resident did not make the allegation against facility staff. She stated if the resident had made an allegation against facility staff, then it would have been reportable. She stated that since there was no allegation made, a grievance form was completed and followed up to help follow up on concerns. She stated it was her responsibility to report any allegations of abuse, neglect, and exploitation to the local State Survey Agency. She stated if allegations were not reported, residents could be at risk of ongoing abuse, neglect or exploitation.Review of facility policy titled Abuse/ Neglect revise on 5/9/2017 read in part .Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and or adult protective services . Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment, of residents, misappropriation resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report all allegations to HHSC

Based on interview and record review the facility failed to ensure alleged violations involving neglect or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 8residents (Resident #15) reviewed for reporting.The facility failed to report to the State Survey Agency when Resident #15 and Business Office Manager identified unknown charges in the amount of $700 charged to her debit card while she was a resident at the facility.this failure could place all residents at risk for misappropriation and neglect by not immediately reporting allegations of misappropriation to the proper authorities at the facility, other officials, and State Survey AgencyFindings include:Record review of Resident # 15's admission record dated 02/11/2026 revealed a 70 y/o female admitted on [DATE]Record review of Resident #15's diagnosis information dated 02/11/2026 revealed a diagnosis of bipolar disorder(chronic mental health condition causing shift in moods, energy and activity levels).Record review of Resident #15's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition.Record review of Resident #15's care plan revised 09/28/2025 revealed Resident #15 had a mood problem related to bipolar disorder interventions included assisting resident to identify strengths, positive coping skills.Record review of Resident #15's resident grievance form dated 1/30/26, revealed that grievance was received on 01/30/26 generated by Resident #15. Per grievance form residents voiced concern was not having a card to purchase cigarettes and also regarded unclarity with the unknown amazon purchases. Pertinent findings included the facility along with Resident#15 contacted her bank together and that her card would be replaced for one last time as there had been a history card hackings. The online store was contacted as well and representative informed that money would be reimbursed. Corrective actions to be taken were to monitor resident and assuring her needs were being met and notifying the resident when her new bank card arrived. Incident was resolved on 1/30/2026.In an interview on 02/11/2026 at 10:22a.m., the Business Office manager stated the resident came to her office asking for assistance with checking her bank account, they both noticed that there had been charges made to her card with purchases from an online store She helped the resident call amazon, representative verified that the account had been compromised and opened a case. The representative stated that credit would be returned. She stated that she and resident contacted the bank branch via telephone as the bank is not local. She stated that the bank representative informed the resident that the card would be replaced. She stated that the facility did not manage the residents' funds and that Resident #15 would occasionally ask her to hold on to her bank card because she did not want to keep it in her room. She stated that she did inform Resident #15 that she did not hold on to bank cards, but she would make the exception. She stated that Resident #15 would ask her to store it for her and then come to ask her for it to buy cigarettes. She stated that as soon as she found out that there had been charges to the residents' card, she reported it to the Administrator. She stated that per the online store representative, the charges were made by an unidentifiable source and did not show a mailing address.In an interview on 02/11/2026 at 11:31 a.m., Resident #15 stated the facility would store her debit card in the business manager's office because she felt it was safer than keeping it on her, she stated the business office manger told her that she did not usually store resients bank cards, but she was able to leave it in there in a filing cabinet with a key. She stated she managed her own money. She stated she asked the business office manager to help her check her bank account and it was noted that several charges were made to the online store in the amount of -700 dollars. She stated she contacted and the representative informed her the card had been hacked, she stated not believing that because she did not use it frequently. She stated that she only used it for cigarettes and it was kept at the business office the rest of the time. She stated that the online store refunded her the money but not the overdraft fee and she was still paying that. She stated that she had contacted her bank and that they informed her that this would be the last card she would be getting due to there being many repeated instances like this in the past. She stated she spoke to the administrator and was told that she would contact the bank however she did not. She stated that she believed that the facility used her card and lied about the charges. she stated that she voiced this to the administrator but the administrator had told her to keep it quiet and to not make a big deal and that her staff would never do something like that.During an interview on 02/11/2026 at 2:38 p.m., The DON revealed if an allegation was made by a resident stating misappropriation of property or exploitation then it would be reported to the state survey agency, but if was just a complaint, then a grievance form would be done and the facility would work on correcting it. He stated that he and the administrator were responsible in reviewing allegations before reporting to the State Agency.During an interview on 02/11/2026 at 3:32 p.m., The Administrator revealed the Business office manager reported to her that she and Resident #15 identified charges made to her bank card. She stated when she spoke to Resident #15, the Resident had told her this had happened to her multiple times in the past. She stated that she asked Resident #15 if she believed if someone from the facility had used her card and Resident #15 stated she did not. The administrator stated she offered to call the police department to file a police report and the resident declined. She stated that she did not report the incident to the local State Survey Agency due to a history of the resident's bank accounts being compromised and the resident did not make the allegation against facility staff. She stated if the resident had made an allegation against facility staff, then it would have been reportable. She stated that since there was no allegation made, a grievance form was completed and followed up to help follow up on concerns. She stated it was her responsibility to report any allegations of abuse, neglect, and exploitation to the local State Survey Agency. She stated if allegations were not reported, residents could be at risk of ongoing abuse, neglect or exploitation.Review of facility policy titled Abuse/ Neglect revise on 5/9/2017 read in part .Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and or adult protective services . Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment, of residents, misappropriation resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report all allegations to HHSC

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #10) reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #10 to address prescribed active Medications for pain, Tramadol 50 MG Take 1 tablet by mouth every 8 hours as needed pain, and Anxiety, Alprazolam 0.5 MG Take 1 tablet by mouth at bedtime.This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs.Record review of Resident #10's face sheet dated 02/11/26 revealed a [AGE] year-old female with admission date 04/09/2025.Record review of Resident #10's health and physical progress note dated 02/10/26 revealed a medical history of: Bell's Palsy (a condition that temporarily paralyzes facial muscles),generalized muscle weakness, hepatic encephalopathy (condition causing your liver to not filter the toxins in the body causing buildup and causing confusion) and Bipolar disorder.Record review of Resident #10's Comprehensive MDS dated [DATE], revealed a BIMS of 15 indicating resident was cognitively intact.Record review of Resident #10's care plan,the care plan did not include active medications, 1. Tramadol 50 MG 1 Tablet by mouth every 8 hours as needed for pain, and 2. Alprazolam 0.5 MG Take 1 tablet by mouth at bedtime.Record review of Resident #10's Order Summary Report dated 02/11/26 revealed the following medciations orders: Tramadol 50 MG 1 Tablet by mouth every 8 hours as needed for pain order start date 05/12/25, and Alprazolam 0.5 MG Take 1 tablet by mouth at bedtime Order start date 11/12/25.During an interview on 02/11/26 at 12:11 p.m., LVN D stated care plans served as a list of the resident's needs and what interventions were expected from the nursing facility staff. He stated pain medication was to be included in a resident's care plan so staff could be aware to monitor and manage that resident's pain. He stated residents taking anxiety medication was to also be included in the resident's care plan. He stated this was for staff being made aware of the resident's conditions and treat them accordingly. He stated the risks of these medications not being included in a resident's care plan included unmanaged pain, and untreated anxiety. He stated nursing staff were responsible for the nursing portion of the care plan which included medications. He stated the ADONs were responsible for monitoring and verifying changes as needed.During an interview on 02/11/26 at 12:19 p.m., LVN I stated the purpose of care plans was for staff to be aware of how to take care of the residents. She stated pain medication was to be included in the care plan, including name of the medication resident was taking, so staff could monitor pain, medication effectiveness, and side effects. She stated anxiety medications were to also be included in resident's care plans so staff could monitor medication effectiveness, or symptoms or medication side effects such as insomnia (), or drowsiness, for example. She stated nursing staff were responsible for acute changes in residents care, and the MDS nurses were responsible for monitoring the care plan on a quarterly basis. She stated the risks of these medications not being included in the care plan included staff not being able to monitor their residents effectively, relating to the medications, and possible injury from medication side effects.During an interview on 02/11/26 at 2:33 p.m., the DON stated care plans were personalized to residents' care and needs. He stated nurses initiated the baseline careplan and the MDS nurses reviewed it and made the Comprehensive care plan. He stated care plans were evaluated daily and MDS monitored quarterly. The DON stated medications for pain and anxiety were to be added to a resident's care plan so staff could monitor for side effects.During an interview on 02/11/26 at 4:22 p.m., the Administrator stated the care plan was to serve as the baseline for the resident's care and needs. She stated it was for the nursing facility to meet the resident's needs. She stated it was a communication tool for the nursing facility staff to be aware of the resident's needs. She stated nursing staff were responsible for the initial care plan, and MDS nurses composed the comprehensive and evaluated quarterly. She stated the risks of anxiety and pain medication not being included in the care plan were unmanaged pain and residents experiencing behaviors related to anxiety or the medication not being monitored.Record review of the facility's Nursing Policy & Procedure Manual, titled Comprehensive Care Plan, undated, read in part: The Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a residnet's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of eight residents ( Resident #58) reviewed for ADL care.The facility failed to ensure Resident #58's fingernails was clean and free from debris on 02/09/26. This failure could place residents who required assistance with ADL's at risk for unmet care needs.Findings included:Record review of Resident # 58's admission record dated 02/11/2026 revealed a [AGE] year old male admitted on [DATE] and readmitted on [DATE].Record review of Resident #58's History and Physical dated 01/13/2026, revealed a medical history of atrial fibrillation (heart condition where the top chambers of the heart quiver instead of beat causing irregular heartbeats).Record review of Resident # 58's five day MDS dated [DATE], revealed a BIMS score of 13 indicating intact cognition. Section GG indicated residents functional limitation in range of motion for upper extremity to include shoulder elbow wrist and hand was coded at a 2 meaning impairment to both sides.Record review of Resident # 58's care plan dated revealed Resident #58 had an ADL self-care deficit performance deficit intervention included, assisting with personal hygiene as required, hair, shaving, oral care as needed. During an observation and interview on 02/09/2026 at 11:37a.m., Resident #58's was observed with long nails with dark debri under nails on hands bilaterally. He stated his nails had not been cut and it would be nice if someone were to cut his nails. He stated staff had not offered to cut them.During an interview on 02/11/2026 at 11:03 a.m., CNA F stated that residents' fingernails were checked when residents were showered. She stated residents with long dirty fingernails could scratch themselves, potentially breaking the skin and leading to an infection. She stated it was the responsibility of the CNAs to ensure that fingernails were trimmed and clean. She stated that the facility provided ADL Inservice to include nail trimming. She could not recall the last Inservice.During an interview on 02/11/2026 at 11:40 a.m., LVN D stated residents' fingernails were checked upon rounds made by nurses, CNAs and department heads. He stated it was everyone's duty to observe and report long fingernails to the nurse. He stated that residents with long dirty fingernails were at risk of scratching and breaking the skin, leading to infection. He stated bacteria could be introduced by touching eyes, mouth, and nose. He stated that the facility did frequent in-services regarding ADLs. He could not recall the last in-service.During an interview on 02/11/2026 at 2:38 p.m., the DON stated residents' nails were checked on an as needed basis. He stated the CNAs and the nurses were responsible for ensuring residents' nails were clean and trimmed. He stated that the CNAs were to report when nails were long to the nurses so the nurses could assess and trim the nails. He stated that the facility conducted champion rounds, meaning every morning the department heads made rounds to each room and observed the overall grooming of the residents to include nail hygiene. He stated that residents with long dirty fingernails were at risk for infection because they could scratch themselves and break the skin. He stated that the last ADL Inservice was conducted last month.During an interview on 02/11/2026 at 3:32 p.m., the Administrator stated that residents' fingernails were trimmed on an as needed basis. She stated that some residents wanted to have their fingernails trimmed and some did not. She said residents were asked if they would like their nails trimmed, if they did not, the staff were to encourage them to wash their hands and they were to document every time the resident refused to have nails cut. She stated it was the responsibility of the nurses and CNAs to ensure fingernails were trimmed. She stated that champion rounds were done to identify residents with long fingernails. She stated that residents with long dirty fingernails were at risk of an infection. She stated she initiated an Inservice on 02/10/2026 regarding long fingernails.Review of facility policy and procedure titled Nail Care undated read in part . Nail care will be performed regularly and safely, the resident be free from abnormal nail conditions, and the resident will be free from infection .

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for repositioning.The facility failed to ensure adequate supervision and safe handling techniques were provided during routine repositioning to prevent injury for Resident #1 who sustained a spiral fracture of the distal right femur while being repositioned in bed by a CNA C.This failure could place residents at risk for injuries.The noncompliance was identified as PNC-IJ. The facility had corrected the noncompliance before the survey began.Findings included: Record review of Resident #1's admission record dated 10/15/2025 revealed an [AGE] year-old female with an initial admission date on 09/22/2023 and readmission date on 06/03/2025. Resident #1 was discharged from facility at family's request on 06/09/2025.Record review of Resident #1 physical and health dated 06/05/2025 revealed the resident had a diagnoses of advanced dementia (a degenerative neurological condition that affects an individual's emotional regulation, memory, an ability to complete ADLs), dysphagia (an impairment in speech production due to disease or damage), PEG tube in place (a feeding tube for individuals who are orally limited), and was recovering from post-surgery from a right distal femur fracture (lower end of the femur near the knee). As per documentation, patient is a very poor historian with altered mental status, unable to participate in exam or questioning. Record review of Resident #1 MDS assessment dated [DATE] revealed under section C - cognitive patterns the resident did not have a BIMS score as it was coded resident is rarely/never understood. Under section GG - ADL self-care/mobility the resident was coded at a 1 which signified the resident was dependent on staff to complete activities for care and ambulation. Under section H - Bladder and Bowel, the resident was coded at a 3 which signifies the resident is always incontinent.Record review of Resident #1 care plan dated 06/20/2025 (date of cancellation) stated the resident had a cognitive and communication impairment with interventions being consult with family, provide an ideal environment, and ongoing monitoring for change in condition. Per her care plan, the resident had a potential for pain with interventions recommending to evaluate the effectiveness of pain interventions, identify and record previous pain history, and record and treat the resident's existing conditions.Record review of Resident #1's SBAR dated 5/29/25 written by RN G at 10:29 pm revealed situation had blood pressure of 136/70, pulse was 75, respirations were 18 per minute, oxygen level was 96 at room air. It was noted that there was a functional status change of swelling, redness, and pain to right knee. The symptoms had started on 05/29/25 and STAT 2 vies right knee was ordered. It was suggested to continue monitoring and administer PRN pain medication every 4 hours for pain. Record review of Resident #1's Event note dated 5/29/25 written by RN G at 11:03 pm revealed the location of event was in [Resident #1's] room, she was cognitive impaired, her right knee appeared to be painful to touch, and she noted that CNA C notified her of right knee appearance. She noted that Resident #1 right knee appeared swollen, some redness, warmth and painful to touch. She documented her vitals to be blood pressure was at 136/70, temperature was 98.8 Fahrenheit, pulse was 75 beats per minute, respirations were 18 per minute. Initial treatment provided was administer as needed Tylenol 325mg 2 tablets every 4 hours for pain and STAT x-rays were ordered. Record review of Resident #1's MARS for month of May 2025 revealed she was administered Tylenol 325 mg 2 tablets for pain level of 2 and was signed off as effective at 11:38 pm. Record review of Resident #1's the x-ray provider Patient Report dated on 05/29/2025 revealed she had a spiral femur fracture and osteo-degeneration that was signed off by the Radiologist on 05/29/2025 at 11:51PM.Record review of Resident #1's EMS care report dated 05/30/2025 revealed Resident #1 had right knee deformity and pain an exert from Narrative stated caregiver (family) stated occurred yesterday trying to move patient around and heard a pop, possible fall/ no head strike or LOC reported. The record added Resident #1's vitals were stable with a blood pressure of 118/86, oxygen saturation at 96% with 2 liters per minute on home concentrator, heart rate 86, oriented to smiles, sounds, and interactions, and MAP at 97. Resident #1 arrived at the local hospital and transferred into care on 05/30/2025 at 07:22 AM.Record review of the hospital discharge for Resident #1 dated 05/30-31/2025 revealed Resident #1 with a history of Alzheimer's dementia (a degenerative neurological condition that affects an individual's emotional regulation, memory, an ability to complete ADLs), PEG-tube dependence (a feeding tube for individuals who are orally limited), hypertension (high blood pressure), hypothyroidism (a endocrine diseases in which the thyroid gland does not produce enough thyroid hormones), depression (a psychiatric disorder in which an individual was experiencing sadness that interfered with daily living), and prior bilateral knee and hip arthroplasties (surgical procedure where both knees and hips are replaced with artificial parts) was evaluated after reports of knee pain and swelling. X-rays showed a spiral, mildly displaced fracture (broken bones that had moved out of their normal position) of the distal (outermost; near the knee) right femoral diaphysis (central part of a long bone) near the prior arthroplasty (surgical reconstruction) site, with no acute fracture to the left leg. The initial hospital history and physical listed status-post fall as the cause of injury; however, Provider H note documented that Resident #1 had not suffered a fall, and that a CNA reported hearing a popping sound from the knee when care was provided. Initial evaluation at local hospital, Resident #1 was not noted to be in any form of distress and was on oxygen via nasal cannula. Resident #1 was transferred for further orthopedic (branch of medicine specializing in bones) evaluation and further orthopedic and cardiac (branch of medicine specializing in the heart/blood vessels) consultations were obtained. On 05/31/2025, she underwent right distal femur periprosthetic fracture (a fracture that occurs around the components of implants) repair with percutaneous (procedure conducted via needle through skin) knee-aided reduction and intramedullary nail fixation (a surgical procedure involving the insertion of a metal rod through bone for stability), which was completed without complications. Post-operatively, she remained stable with no cardiac events and continued oxygen therapy. The discharge plan included GI/DVT Prophylaxis (prevention of blood clots), fall precautions, frequent reorientation (changing an individual's focus), and routine monitoring of labs.In an over the phone interview on 10/15/2025 at 02:43 PM, CNA C stated she went to provide incontinent change for the resident on 05/29/2025 at approximately 09:00 PM. She stated she had used proper technique and placed one hand on the resident's back, one hand on the resident's buttocks, then placed the resident on an angle when she heard the pop. She stated Resident #1 did not acknowledge the noise nor complain about pain. She stated she went to retrieve RN G to conduct an assessment on the resident. She stated Resident #1 remained in bed for the entirety of care and had not fallen to the floor at any point. She stated she was unaware when the resident went to the hospital for care. She stated Resident #1 was a one-person assist at the time and she had performed care for Resident #1 independently before. She stated she was placed on suspension after the incident, she provided a statement to the facility, and was allowed to return after the investigation was completed. She stated that she received in-service trainings for resident care and abuse, neglect, and exploitation when she returned from suspension. She stated she did not remember what date she returned to work. She stated the last in-service for abuse, neglect, and exploitation was held last week (10/6/25 - 10/10/25). In an interview on 10/16/2025 at 04:47 PM over the phone with RN G, she stated that she worked the second shift (02:00 PM -10:00 PM) when the incident with Resident #1 occurred. Per RN G, CNA C was completing final rounds on 05/29/2025 at approximately 09:30 PM and requested RN G to look at the resident because she had heard a popping sound. She stated the resident was nonverbal and could not vocalize complaints. She stated she observed Resident #1 expressing dissatisfied facial expressions and inferred the resident was uncomfortable when pain assessment was completed. She stated the right knee appeared painful to touch, swollen, some redness, and warmth. She stated she notified ADON B and the Nurse Practitioner. She stated she received orders for a STAT x-ray. She stated the x-ray tech from the x-ray provider arrived at the end of her shift at approximately 10:00 PM when she was providing report to LVN E. She stated she paused her report to LVN E to assist the x-ray provider technician with x-rays. She stated she returned to finish report to LVN E, and notified him that the orders were STAT x-rays. She stated that STAT x-rays were used for emergency services and provided a rapid response. She stated she was notified that the resident was transferred to the local hospital due to significant findings in the x-ray on 05/30/2025. She stated that LVN E would be responsible for reviewing results and checking on the status during his shift. She stated that staff was trained to call the x-ray provider to find out the status of results if there was an extensive wait time from the time the technician had completed his task at the facility. She stated that if there were critical findings, the x-ray provider would call the facility. She stated that if critical findings are discovered, staff was trained to call the provider, notify The ADON, DON, and The Administrator. She stated Resident #1's femur fracture would have resulted in transfer to the local hospital with providers' orders. In an interview on 10/16/2025 at 11:35 AM over the phone with LVN E, he stated that he was the charge nurse for 3rd shift (10:00 PM - 06:00 AM) for the hall where Resident #1 resided on. He stated RN G provided report at 2nd to 3rd shift change and notified him that CNA C had provided incontinence care to Resident #1 and heard a pop noise from Resident #1's right femur area. He stated that he did not recall if the STAT x-rays were ready during his shift. He stated he checked on the resident after he received report and repeatedly checked on Resident #1 throughout his shift. He stated Resident #1 did not display any grimace or vocalization of discomfort when he conducted rounds; As per clinical documentation, the resident had communication impairments. He stated there were no progress notes entered for a reason because there was nothing to report. He stated the resident was verbal but disoriented and confused from time to time. He stated that when something was wrong or significant in the findings, the x-ray provider would call the facility to provide notice to the charge nurse. He stated the x-ray provider did not call the facility during his shift on 05/29/2025 at 10:00 PM to 05/30/2025 at 06:00 AM. He stated nurses could also log into the x-ray provider portal on the nursing station computers to obtain results. He stated that abnormal results would send notifications to the DON and ADONs. He stated he did not log in to the x-ray provider portal to review the STAT x-ray results because he was the only nurse in the night for 30 patients and was busy. He stated it is good clinical practice to follow-up with x-rays if you were aware that you had pending results. He stated he gave report to LVN D during the 3rd to 1st shift change. As per LVN E, he reported to LVN D that there were pending STAT x-ray results for Resident #1 and the results had not been checked by him while he worked 3rd shift. LVN E was heard projecting agitation in his tone while responding to surveyor. He became hostile during the interview and challenged the credentials of the surveyor for not being a nurse investigating a nursing facility. He became interruptive when being asked questions by surveyor. He was provided the option to terminate interview if he no longer wanted to participate in investigation. He stated he did want to terminate over the phone interview at 11:44 AM. In an interview on 10/16/2025 at 10:32 AM with LVN D, he stated he remembered the incident involving Resident #1. He stated he came in for his shift at approximately 06:00 AM on 05/30/2025 and received report from LVN E. He stated LVN E had notified him that there were pending x-ray results from the previous shift. He stated he went to conduct a round check for Resident #1 who was asleep on 05/30/2025 at approximately 06:15 AM. He stated he proceeded to contact the x-ray provider to obtain findings on x-rays. He stated the x-ray provider notified him that the results were online and could be accessed on the x-ray provider portal. He stated that all nurses had access to the x-ray provider portal located on software at the nursing station computers. He stated x-rays results usually took 3-4 hours to come in after the x-ray provider technician had captured the imaging. He stated that STAT x-rays were urgent and provided a more rapid response. He stated he contacted the x-ray provider to follow up on results because of clinical knowledge and experience. LVN D stated that a resident with a fracture was considered a significant finding, and results should be provided to the providers immediately. LVN D stated he contacted the Nurse Practitioner on 05/30/2025 at approximately 06:30 AM and was provided orders to send Resident #1 to the hospital. LVN D stated he contacted EMS on 05/30/2025 at approximately 06:32AM for Resident #1 to be transported to the hospital. He stated that a 7-hour delay was not considered a rapid response to the critical findings of the incident.In an interview with the Administrator on 10/16/2025 at 09:43 AM, stated the facility's internal investigation verified CNA C's account and that the fracture likely resulted from underlying bone fragility. CNA C was suspended during the review period and re-trained on safe repositioning and resident handling prior to reinstatement. The Administrator further stated all staff received in-service training on safe handling, abuse/neglect recognition, and incident reporting procedures following the event. In an interview on 10/16/2025 at 11:27 AM via phone was attempted with Resident #1's family, voicemail message left; Resident #1's family did not return phone call by 10/16/2025 at 06:33 PM. In an interview on 10/16/2025 at 04:46 PM over the phone with Provider H, he stated he was aware of Resident #1's case and recalled seeing her during the subsequent hospital evaluation on 05/30/2025 to 06/04/2025. Provider H noted the fracture mechanism was plausible from minimal movement during repositioning due to severe osteopenia and did not attribute it to abuse or rough handling. He stated that facility staff contacted the on-call service after a CNA C reported hearing a pop during peri-care. He stated RN G promptly notified the answering service, and a STAT x-ray was ordered. He stated that, in his view, staff acted appropriately and proactively. He expressed that he had no concerns regarding the care provided and pain was managed and effective.Record review of the facility's Nursing Policy and Procedure Manual: Abuse/Neglect policy dated 03/29/2018 revealed the facility defined neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Record review of the facility's Nursing Policy and Procedure Manual: Notifying the Physician of Change in Status policy undated revealed .the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information.The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering on 10/15/25.Record review- In-services conducted for: Turning and repositioning dated 5/30/25 was signed by all staff.Safe patient handling dated 5/30/25 was signed by all staff.Abuse and neglect dated 5/30/25 was signed by all staff.Interviews from 10/15/25- 10/16/25:ADON A, ADON B, CNA C, LVN D, LVN E, LVN F, RN G, CNA I, CNA J, CNA K, and CNA L confirmed receiving in-services on turning and reportioning, safe handling and abuse and neglect. Observations: 10/16/25 at 10:43 am- Resident #2 was repositioned by CNA I and CNA J. CNAs provided verbal prompts to give resident notification of what they were doing and going to be doing (raise the bed, lower head, touch the resident, etc.) CNAs engaged with resident and received positive head gestures from the resident when asked about comfort and preference. No distress was noted. 10/16/25 at 10:56 am- Resident #3 was repositioned by CNA K and CNA L. The resident was repositioned, and a pillow was placed behind his back. Another staff member assisted by turning the resident to his left side and placing a pillow between his legs. The staff informed the resident they would raise the bed and asked him to extend his legs. The CNA asked the resident if he was doing okay, to which he responded yes and requested the light be turned off. The call light was positioned within reach on his right side. No distress was noted.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 1 reviewed for quality of care. The facility failed to ensure staff acted in a timely manner to transfer Resident #1 to a hospital after radiologist confirmed a spiral femur fracture on 05/29/2025 at 11:51 PM and delayed response until 05/30/2025 at 06:32 AM. This failure resulted in the resident receiving delay in emergency care services for a fractured femur and placed the resident at risk of further harm and injury.Findings included: Record review of Resident #1's admission record dated 10/15/2025 revealed an [AGE] year-old female with an initial admission date on 09/22/2023 and readmission date on 06/03/2025. Resident #1 was discharged from facility at family's request on 06/09/2025. Record review of Resident #1 physical and health dated 06/05/2025 revealed the resident had a diagnoses of advanced dementia (a degenerative neurological condition that affects an individual's emotional regulation, memory, an ability to complete ADLs), dysphagia (an impairment in speech production due to disease or damage), PEG tube in place (a feeding tube for individuals who are orally limited), and was recovering from post-surgery from a right distal femur fracture (lower end of the femur near the knee). As per documentation, patient is a very poor historian with altered mental status, unable to participate in exam or questioning. Record review of Resident #1 MDS assessment dated [DATE] revealed under section C - cognitive patterns the resident did not have a BIMS score as it was coded resident is rarely/never understood. Under section GG - ADL self-care/mobility the resident was coded at a 1 which signified the resident was dependent on staff to complete activities for care and ambulation. Under section H - Bladder and Bowel, the resident was coded at a 3 which signifies the resident is always incontinent.Record review of Resident #1 care plan dated 06/20/2025 (date of cancellation) stated the resident had a cognitive and communication impairment with interventions being consult with family, provide an ideal environment, and ongoing monitoring for change in condition. Per her care plan, the resident had a potential for pain with interventions recommending to evaluate the effectiveness of pain interventions, identify and record previous pain history, and record and treat the resident's existing conditions.Record review of Resident #1's SBAR dated 5/29/25 written by RN G at 10:29 pm revealed situation had blood pressure of 136/70, pulse was 75, respirations were 18 per minute, oxygen level was 96 at room air. It was noted that there was a functional status change of swelling, redness, and pain to right knee. The symptoms had started on 05/29/25 and STAT 2 vies right knee was ordered. It was suggested to continue monitoring and administer PRN pain medication every 4 hours for pain. Record review of Resident #1's Event note dated 5/29/25 written by RN G at 11:03 pm revealed the location of event was in [Resident #1's] room, she was cognitive impaired, her right knee appeared to be painful to touch, and she noted that CNA C notified her of right knee appearance. She noted that Resident #1 right knee appeared swollen, some redness, warmth and painful to touch. She documented her vitals to be blood pressure was at 136/70, temperature was 98.8 Fahrenheit, pulse was 75 beats per minute, respirations were 18 per minute. Initial treatment provided was administer as needed Tylenol 325mg 2 tablets every 4 hours for pain and STAT x-rays were ordered. Record review of Resident #1's MARS for month of May 2025 revealed she was administered Tylenol 325 mg 2 tablets for pain level of 2 and was signed off as effective at 11:38 pm. Record review of Resident #1's the x-ray provider Patient Report dated on 05/29/2025 revealed she had a spiral femur fracture and osteo-degeneration that was signed off by the Radiologist on 05/29/2025 at 11:51PM.Record review of Resident #1's EMS care report dated 05/30/2025 revealed Resident #1 had right knee deformity and pain an exert from Narrative stated caregiver (family) stated occurred yesterday trying to move patient around and heard a pop, possible fall/ no head strike or LOC reported. The record added Resident #1's vitals were stable with a blood pressure of 118/86, oxygen saturation at 96% with 2 liters per minute on home concentrator, heart rate 86, oriented to smiles, sounds, and interactions, and MAP at 97. Resident #1 arrived at the local hospital and transferred into care on 05/30/2025 at 07:22 AM.Record review of the hospital discharge for Resident #1 dated 05/30-31/2025 revealed Resident #1 with a history of Alzheimer's dementia (a degenerative neurological condition that affects an individual's emotional regulation, memory, an ability to complete ADLs), PEG-tube dependence (a feeding tube for individuals who are orally limited), hypertension (high blood pressure), hypothyroidism (a endocrine diseases in which the thyroid gland does not produce enough thyroid hormones), depression (a psychiatric disorder in which an individual was experiencing sadness that interfered with daily living), and prior bilateral knee and hip arthroplasties (surgical procedure where both knees and hips are replaced with artificial parts) was evaluated after reports of knee pain and swelling. X-rays showed a spiral, mildly displaced fracture (broken bones that had moved out of their normal position) of the distal (outermost; near the knee) right femoral diaphysis (central part of a long bone) near the prior arthroplasty (surgical reconstruction) site, with no acute fracture to the left leg. The initial hospital history and physical listed status-post fall as the cause of injury; however, Provider H note documented that Resident #1 had not suffered a fall, and that a CNA reported hearing a popping sound from the knee when care was provided. Initial evaluation at local hospital, Resident #1 was not noted to be in any form of distress and was on oxygen via nasal cannula. Resident #1 was transferred for further orthopedic (branch of medicine specializing in bones) evaluation and further orthopedic and cardiac (branch of medicine specializing in the heart/blood vessels) consultations were obtained. On 05/31/2025, she underwent right distal femur periprosthetic fracture (a fracture that occurs around the components of implants) repair with percutaneous (procedure conducted via needle through skin) knee-aided reduction and intramedullary nail fixation (a surgical procedure involving the insertion of a metal rod through bone for stability), which was completed without complications. Post-operatively, she remained stable with no cardiac events and continued oxygen therapy. The discharge plan included GI/DVT Prophylaxis (prevention of blood clots), fall precautions, frequent reorientation (changing an individual's focus), and routine monitoring of labs.In an over the phone interview on 10/15/2025 at 02:43 PM, CNA C stated she went to provide incontinent change for the resident on 05/29/2025 at approximately 09:00 PM. She stated she had used proper technique and placed one hand on the resident's back, one hand on the resident's buttocks, then placed the resident on an angle when she heard the pop. She stated Resident #1 did not acknowledge the noise nor complain about pain. She stated she went to retrieve RN G to conduct an assessment on the resident. She stated Resident #1 remained in bed for the entirety of care and had not fallen to the floor at any point. She stated she was unaware when the resident went to the hospital for care. She stated Resident #1 was a one-person assist at the time and she had performed care for Resident #1 independently before. She stated she was placed on suspension after the incident, she provided a statement to the facility and was allowed to return after the investigation was completed. She stated that she received in-service trainings for resident care and abuse, neglect, and exploitation when she returned from suspension. She stated she did not remember what date she returned to work. She stated the last in-service for abuse, neglect, and exploitation was held last week (10/6/25 - 10/10/25). In an interview on 10/16/2025 at 04:47 PM over the phone with RN G, she stated that she worked the second shift (02:00 PM -10:00 PM) when the incident with Resident #1 occurred. Per RN G, CNA C was completing final rounds on 05/29/2025 at approximately 09:30 PM and requested RN G to look at the resident because she had heard a popping sound. She stated the resident was nonverbal and could not vocalize complaints. She stated she observed Resident #1 expressing dissatisfied facial expressions and inferred the resident was uncomfortable when pain assessment was completed. She stated the right knee appeared painful to touch, swollen, some redness, and warmth. She stated she notified ADON B and the Nurse Practitioner. She stated she received orders for a STAT x-ray. She stated the x-ray tech from the x-ray provider arrived at the end of her shift at approximately 10:00 PM when she was providing report to LVN E. She stated she paused her report to LVN E to assist the x-ray provider technician with x-rays. She stated she returned to finish report to LVN E, and notified him that the orders were STAT x-rays. She stated that STAT x-rays were used for emergency services and provided a rapid response. She stated she was notified that the resident was transferred to the local hospital due to significant findings in the x-ray on 05/30/2025. She stated that LVN E would be responsible for reviewing results and checking on the status during his shift. She stated that staff was trained to call the x-ray provider to find out the status of results if there was an extensive wait time from the time the technician had completed his task at the facility. She stated that if there were critical findings, the x-ray provider would call the facility. She stated that if critical findings are discovered, staff was trained to call the provider, notify The ADON, DON, and The Administrator. She stated Resident #1's femur fracture would have resulted in transfer to the local hospital with providers' orders. In an interview on 10/16/2025 at 11:35 AM over the phone with LVN E, he stated that he was the charge nurse for 3rd shift (10:00 PM - 06:00 AM) for the hall where Resident #1 resided on. He stated RN G provided report at 2nd to 3rd shift change and notified him that CNA C had provided incontinence care to Resident #1 and heard a pop noise from Resident #1's right femur area. He stated that he did not recall if the STAT x-rays were ready during his shift. He stated he checked on the resident after he received report and repeatedly checked on Resident #1 throughout his shift. He stated Resident #1 did not display any grimace or vocalization of discomfort when he conducted rounds; As per clinical documentation, the resident had communication impairments. He stated there were no progress notes entered for a reason because there was nothing to report. He stated the resident was verbal but disoriented and confused from time to time. He stated that when something was wrong or significant in the findings, the x-ray provider would call the facility to provide notice to the charge nurse. He stated the x-ray provider did not call the facility during his shift on 05/29/2025 at 10:00 PM to 05/30/2025 at 06:00 AM. He stated nurses could also log into the x-ray provider portal on the nursing station computers to obtain results. He stated that abnormal results would send notifications to the DON and ADONs. He stated he did not log in to the x-ray provider portal to review the STAT x-ray results because he was the only nurse in the night for 30 patients and was busy. He stated it is good clinical practice to follow-up with x-rays if you were aware that you had pending results. He stated he gave report to LVN D during the 3rd to 1st shift change. As per LVN E, he reported to LVN D that there were pending STAT x-ray results for Resident #1 and the results had not been checked by him while he worked 3rd shift. LVN E was heard projecting agitation in his tone while responding to surveyor. He became hostile during the interview and challenged the credentials of the surveyor for not being a nurse investigating a nursing facility. He became interruptive when being asked questions by surveyor. He was provided the option to terminate interview if he no longer wanted to participate in investigation. He stated he wanted to terminate over the phone interview at 11:44 AM. In an interview on 10/16/2025 at 10:32 AM with LVN D, he stated he remembered the incident involving Resident #1. He stated he came in for his shift at approximately 06:00 AM on 05/30/2025 and received report from LVN E. He stated LVN E had notified him that there were pending x-ray results from the previous shift. He stated he went to conduct a round check for Resident #1 who was asleep on 05/30/2025 at approximately 06:15 AM. He stated he proceeded to contact the x-ray provider to obtain findings on x-rays. He stated the x-ray provider notified him that the results were online and could be accessed on the x-ray provider portal. He stated that all nurses had access to the x-ray provider portal located on software at the nursing station computers. He stated x-rays results usually took 3-4 hours to come in after the x-ray provider technician had captured the imaging. He stated that STAT x-rays were urgent and provided a more rapid response. He stated he contacted the x-ray provider to follow up on results because of clinical knowledge and experience. LVN D stated that a resident with a fracture was considered a significant finding, and results should be provided to the providers immediately. LVN D stated he contacted the Nurse Practitioner on 05/30/2025 at approximately 06:30 AM and was provided orders to send Resident #1 to the hospital. LVN D stated he contacted EMS on 05/30/2025 at approximately 06:32AM for Resident #1 to be transported to the hospital. He stated that a 7-hour delay was not considered a rapid response to the critical findings of the incident.In an interview on 10/15/2025 at 02:31 PM with ADON A, she stated that nurses were allowed to order STAT x-rays from the x-ray provider with the order approval from the nurse practitioner or physicians. She stated that results were sent to the ADONs' and DON's email with the radiologist's findings. She stated she did not have the email from this incident. She stated that charge nurses were additionally notified by fax and phone call from the x-ray provider, ADONs, and DON if the findings from the x-rays were significant (e.g. confirmed fracture, dislocation, break). She stated that staff were trained to call the nurse practitioner or physicians to staff the findings and request transfer to higher level of care. She stated she was present when the resident was transferred by EMS ambulance on 05/30/2025 at 06:45 AM. She stated the Administrator was notified immediately when LVN D located the findings on the x-ray provider portal. She stated further investigation was initiated for resident neglect by CNA C. She stated the side of the facility where the incident occurred was under ADON B's responsibility and she would have more pertinent information. In an interview on 10/15/2025 at 03:02 PM with ADON B, she stated that x-rays completed by the x-ray provider were faxed to the facility and Resident #1 was transferred to a local hospital on [DATE] in the morning; she stated she did not remember the exact time. She stated the DON and ADONs would receive an email regarding the x-rays being developed from the x-ray provider. She stated the email from the x-ray provider was not in her inbox from the incident on 05/29/2025. She stated she had reviewed her email inbox for a notification from the x-ray provider on 05/29/2025 and 05/30/2025 about Resident #1 after being notified by ADON A. She stated that if the findings were critical, the x-ray provider radiologists would call the facility to notify charge nurse or providers of the findings. She stated a critical result, in terms of x-ray, would be a fracture. She stated results from the x-ray provider were not received until the morning when LVN D arrived for his shift; she was unable to elaborate how she obtained this information but knew that the results were not sent until the morning of 05/30/2025. She stated LVN D's discovery of x-rays was documented in the SBAR and in progress notes for Resident #1. She stated the time that the x-ray provider radiologist signed off on x-ray results was on 05/29/2025 at 11:51 PM and read this from the facility provided investigation binder. She stated the incident occurred on 05/29/2025 between 2nd and 3rd shift change, and RN G provided shift report to LVN E. She stated LVN E provided report to LVN D which resulted in LVN D discovering the x-ray results. She stated that when a resident had a critical finding in the x-ray, nursing staff is trained to contact the provider immediately. She stated from the time the radiologist had determined a spiral fracture (11:51 PM on 05/29/2025) to the time LVN D contacted the provider for hospital transfer order (06:45 AM on 05/30/2025), approximately 7 hours had elapsed. She stated this was not an immediate response to critical findings on the facility's behalf. In an interview with the Administrator on 10/16/2025 at 09:43 AM, she stated. She stated there was no policy for documenting when external test results were received from contracted partners.In an interview on 10/16/2025 at 11:27 AM via phone was attempted with Resident #1's family, voicemail message left; Resident #1's family did not return phone call by 10/16/2025 at 06:33 PM. In an interview on 10/16/2025 at 01:25 PM with LVN F, he stated the steps to responding to a resident injury was to assess the resident for pain and abnormalities, provide findings in assessment to the providers, and follow-up in completing provider's orders by contacting contracted partners (e.g. x-rays, labs, etc.). He stated he ordered x-rays and had to follow-up on findings before. He stated it was within his responsibilities as a nurse and it was good nursing practices to do so. He stated that all nurses have access to the x-ray provider portal and are trained to locate findings, to include STAT x-rays. He stated that he would check for x-ray orders every 30 minutes to an hour if he was aware that there were pending results. He stated that if the results were not available after hours of delay he would call the x-ray provider to find out the status of findings. He stated a femur fracture as being a critical finding and needed to be reported to the providers immediately. He stated that a resident with a femur fracture could be further injured, be in pain, and/or contract an infection. He stated that Resident #1 could have been at risk for a fat embolism (bone marrow causing a clot in the veins or lungs), could have contracted a bone infection or an infection in her blood. He stated there was no reason for nurses to not look for results during their shift. He stated that charge nurses were responsible for following up on pending results and identified ADONs and DON was responsible for ensuring charge nurses were completing their responsibilities. He stated it was not appropriate for staff to not review the x-ray provider portal throughout their shift. He stated delayed emergency care by 7 hours was a form of abuse, neglect, and malpractice. In an interview on 10/16/2025 at 02:14 PM with the Administrator, she stated that there was always two nurses always working the third shift (10:00 PM to 06:00 AM). She stated the facility was notified by the x-ray provider findings via phone call and portal results that all nurses had access to. She stated she did not know how often staff was trained to follow-up on pending STAT x-ray results. She stated that it was appropriate practice for nursing staff to follow-up to check on results at least once. She stated from the facility investigation binder for Resident #1, the x-ray provider radiologist signed off on the diagnosis on 05/29/2025 at 11:51 PM. She stated the nurse who would have been responsible to follow-up after 11:51 PM was LVN E. She stated from the facility's investigation binder for Resident #1 was that the resident was sent to the local hospital on [DATE] at 06:45 AM. She stated there was an additional potential for harm and infection for Resident #1 who had a fractured femur and delayed emergency medical response; she stated she could not elaborate further due to limited clinical knowledge. She stated the reason for the delay in emergency services occurred was because of lack of follow-up by LVN E. She stated this placed Resident #1 in harm. She stated the DON and ADONs were responsible for ensuring nursing staff were completing assigned responsibilities. She stated the DON and ADON should have followed up with LVN E. She stated being busy was not an acceptable reason for nurses not to follow up on STAT x-rays. In an interview on 10/16/2025 at 04:46 PM over the phone with Provider H, he stated he was aware of Resident #1's case and recalled seeing her during the subsequent hospital evaluation on 05/30/2025 to 06/04/2025. Provider H stated that facility staff contacted the on-call service after a CNA C reported hearing a pop during peri-care. He stated RN G promptly notified the answering service, and a STAT x-ray was ordered. He emphasized that because the setting was a nursing facility, there was typically a delay between the order, the mobile x-ray's arrival, and the radiologist's read. He explained that once the x-ray report was received, he instructed staff to transfer the resident to the local hospital due to findings consistent with a fracture. He stated that, in his view, staff acted appropriately and proactively. He expressed that he had no concerns regarding the care provided and pain was managed and effective, noting that the CNA and nurse followed proper procedure by reporting the incident and ensuring timely physician notification and diagnostic follow-up.Record review of Professional Service Agreement with the x-ray provider revealed the facility and the x-ray provider had been in contractual partnership since 12/16/2019. An exert under Now; Therefore in section 2 stated, Any notice or communication required or permitted to be given by one party to the other pursuant to this agreement shall be in writing, shall be effective upon receipt and shall be sent by United states mail, by telegram, telefax, or facsimile transmission.The facsimile transmission of any signed document shall be the same as a delivery of an original. At request of either party, parties will confirm facsimile transmitted signatures by signing the original document for delivery between the parties. In a secondary exert under Exhibit A Scope of Work in section 1 - C stated .[x-ray provider] shall be responsible for transporting the image to the radiologist and facsimile transmission of results . Record review of the facility's Nursing Policy and Procedure Manual: Abuse/Neglect policy dated 03/29/2018 revealed the facility defined neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Record review of the facility's Nursing Policy and Procedure Manual: Notifying the Physician of Change in Status policy undated revealed .the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information.

Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1 ) of 4 residents reviewed for physician notification. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 4 doses of the prescribed Entresto Oral Tablet on hand to administer to Resident #1 according to physician's orders. This failure could place residents at risk of delayed medical treatment. Findings Included: Review of the Admission Record dated 04/20/25 revealed an [AGE] year old female that was admitted on [DATE]. Review of the Annual History & Physical dated 03/29/23 for Resident #1 revealed diagnoses of congestive heart failure (the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and sick sinus syndrome(a type of heart rhythm disorder). Review of the optional state assessment MDS dated [DATE] for Resident #1, revealed no BIMS score. Review of the Care Plan initiated on 03/30/25 for Resident #1, revealed interventions indicating to administer medications as ordered. Review of the Physician Order Summary Report dated 04/20/2025 for Resident #1 revealed Order Range: 03/28/25 - 03/31/25. -Order Date: 03/28/25. Start Date: 03/29/25 Entresto Oral Tablet 24-25 mg (sacubitril-Valsartan) give 1 tablet by mouth two times a day for heart failure. Review of the schedule for March 2025 for Resident #1 revealed: Entresto Oral Tablet -Order Date: 03/29/25 for Entresto Oral Tablet 24-26 mg (Suacubitril- Valsartan) give one tablet by mouth two times a day for heart failure. MAR documented medication was not administered and coded at a 9, meaning to see nurses notes/other on 03/29/25 at 8:00 AM, and 4:00 PM; 03/30/25 at 8:00 AM, and 4:00 PM. Documented by Med Aide E Record Review revealed the facility did not have written documentation in Resident #1's electronic Nurses Progress Notes that documented attending the physician and/or NP were notified Entresto oral tablet 24-26 mg (sacubitril-Valsartan) give 1 tablet by mouth two times a day for heart failure was not available to administer according to physician's order on 03/29/25 at 8:00 AM, and 4:00 PM; 03/30/25 at 8:00 AM, and 4:00 PM. Interview on 4/20/2025 at 11:25 am with medical doctor revealed, Resident #1 was admitted to the facility from home and she was brought in by family. She stated that she was not notified of resident #1 not being administered scheduled 4 doses of Entresto medication. She stated that staff notify her of any clinical changes of conditions that residents have such as falls, unstable vital signs, and a change in baseline. Interview on 4/20/2025 at 1:00 pm with the DON revealed, Resident #1 was admitted to the facility on a Friday evening from home. She explained that when residents were admitted to the facility on the weekend after a certain time, the pharmacy did not deliver medications. In these cases, the facility asked family to bring in residents medications from home. She stated that the nurses were able to obtain the needed medications from the pyxis if medication was available. She stated that in the case of resident #1, residents' family was told to bring in her medications, which Entresto medication was not provided. She stated that Entresto medication was not available in the facilities pyxis. She stated that medication aides were to notify the nurse when medications were not administered, and nurses were to notify physician about medication not being administered and document the notification in progress note . She stated that medication aides and nurses were trained on this process upon hire. She stated that DON should be monitoring and staff could be reminding each other when giving and receiving report to one another. She stated that by not notifying the physician, this could cause a miscommunication in resident care. Interview on 4/20/2025 at 3:00pm with LVN A, revealed that she was the residents assigned nurse on the weekend of 3/29/25 and 3/30/25. She stated that medication aide was responsible for administering resident#1's medication on those days. She stated that the med aide did not report to her that Entresto medication were not being administered to resident #1. She stated that the medication aide was supposed to report any medication refusals to the nurse and nurse was supposed to report it to the physician and nurse was to document a progress note. Interview on 4/21/2025 at 10:00 am with medication Aide E, revealed that she did not remember resident#1., She stated that when residents refuse medications, or when medication was not administered, the nurse was to be notified and the nurse would be the one to follow up with the resident and with the physician. She stated that when medication was not administered, it was documented in the MAR by placing a number indicating that medication was not administered. She stated that it was important for nurse to be informed of medication refusals or when medication was not being administered because it could potentially cause miscommunication between caregivers. residents would not be getting medications as ordered. Interview on 04/21/2025 at 11:00am the with medical director, revealed that the facility policy stated that the staff must notify physicians when medications are not being administered to residents as per doctors orders. Interview on 4/21/2025 at 2:30 pm with the regional compliance nurse, revealed that nurses were supposed to notify doctors about residents not being administered medications per doctors' orders and nurses were supposed to document that they notified physician. She stated that nursing staff was trained on this upon hire. She stated that not notifying physician about medications not being available and not being administered then physician would not be able to instruct staff in alternative treatment. Record Review of facilities policy titled, Medication Administration, Refusal of Medications revised 03/11/2013 read in part . The nurse will notify the physician when the resident refuses medications. The physician may reorder the prescribed medication for a different time, route, dose , or discontinue the medication. The nurse will note any new orders and reflect those orders appropriately on the MAR.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 4 residents reviewed for pharmacy services in that: -The facility failed to administer Entresto Oral Tablet to Resident #1 as ordered. This failure placed residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medication as ordered. Findings included: Review of the Admission Record dated 04/20/25 revealed an [AGE] year old female that was admitted on [DATE]. Review of the Annual History & Physical dated 03/29/23 for Resident #1 revealed diagnoses of congestive heart failure (the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and sick sinus syndrome( a type of heart rhythm disorder). Review of the optional state assessment MDS dated [DATE] for Resident #1, revealed no BIMS score. Review of the Care Plan initiated on 03/30/25 for Resident #1, revealed interventions indicating to administer medications as ordered. Review of the Physician Order Summary Report dated 04/20/2025 for Resident #1 revealed Order Range: 03/28/25 - 03/31/25. -Order Date: 03/28/25. Start Date: 03/29/25 Entresto Oral Tablet 24-25 mg (sacubitril-Valsartan) give 1 tablet by mouth two times a day for heart failure. Review of the MAR schedule for March 2025 for Resident #1 revealed: Entresto Oral Tablet -Order Date: 03/29/25 for Entresto Oral Tablet 24-26 mg (Suacubitril- Valsartan) give one tablet by mouth two times a day for heart failure MAR documented medication was not administered and coded at a 9, meaning to see nurses notes/other on 03/29/25 at 8:00 AM, and 4:00 PM; 03/30/25 at 8:00 AM, and 4:00 PM. Documented by med aide E. Interview on 4/20/2025 at 1:00 pm with DON revealed, Resident #1 was admitted to the facility on a Friday evening from home. She explained that when residents were admitted to the facility on the weekend after a certain time, the pharmacy did not deliver medications. In these cases the facility asked the family to bring in residents medications from home. She stated that the nurses were able to obtain the needed medications from the pyxis if medication was available. She stated that in the case of resident #1, medications were ordered from facility pharmacy on 3/28/2025, but since it was a weekend, the pharmacy would not be able to deliver until Monday, therefore, residents' family was told to bring in her medications, which Entresto medication was not provided. She stated that Entresto medication was not available in the facilities pyxis . She stated that medication aides were to notify the nurse when medications were not administered, and nurses were to notify physician about medication not being administered and document the notification in progress note. She stated that all medications are to be administered as per doctors orders. Interview on 4/20/2025 at 3:00pm with LVN A, revealed that she was the residents assigned nurse on the weekend of 3/29/25 and 3/30/25. She stated that medication aide was responsible for administering resident#1's medication on those days. She stated that the med aide did not report to her that Entresto medication were not being administered to resident #1. She stated that the medication aide was supposed to report any medication refusals to the nurse and nurse was supposed to report it to the physician and nurse was to document a progress note. She stated that all medication is administered as per doctors' orders. Not administering medications as per doctors orders could result in resident not receiving intended care as ordered. Interview on 4/21/2025 at 10:00 am with medication Aide E, revealed that she did not remember resident#1, she stated that when residents refuse medications, or when medication was not administered, the nurse was to be notified and the nurse would be the one to follow up with the resident and with the physician. She stated that when medication was not administered, it was documented in the MAR by placing a number indicating that medication was not administered. She stated that it was important for nurse to be informed of medication refusals or when medication was not being administered because it could potentially cause miscommunication between caregivers and residents would not be getting medications as ordered. Interview on 04/21/2025 at 11:00am with the medical director, revealed that the facility policy stated that the staff must notify physicians when medications are not being administered to residents as per doctors' orders. He stated that all medications are to be administered to residents as per doctor orders. He stated that depending on what medication was not being administered, and the residents' medical condition, would determine the outcome of not receiving the medications as ordered. Record Review of facilities policy titled, Medication Administration Procedures revised 10/25/2017 read in part .If a dose of regularly scheduled medication is withheld or refused an explanatory note is to be entered in the nursing notes or in the PRN nurses notes sections of the medication administration record

Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for catheter care. The facility failed to ensure Residents #8s catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheters at risk of catheter pulling causing pain. Findings included: Record review of Resident #8's face sheet dated 1/14/25 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of retention of urine and neuromuscular dysfunction of bladder. Record review of Resident #8's significant change MDS assessment dated [DATE] revealed a BIMS score of 15, her cognition was intact and had and had indwelling catheter. Record review of Resident #8's physician order dated 10/16/24 revealed ensure catheter strap in place and holding, every shift change as needed. Record review of Resident #8's care plan dated 11/19/24 revealed a focus area for [Resident #8] has a Indwelling Catheter with goal of will remain free from catheter-related trauma through review date and interventions that included ensure tubing is anchored to the residents leg or linens so that tubing is not pulling on the urethra. In an observation and interview on 1/14/25 at 11:26 am, Resident # 8 was alert and oriented to place, time, and event. While in bed, it was observed that Resident # 8's urinary catheter was positioned below the bladder and hanging over the bed, with no leg strap secured. Resident # 8 stated that the catheter strap had not been in place for two days and that she had reported the issue, though she could not recall to whom or when. Resident # 8 stated that the lack of a secured strap caused discomfort when moving, as it allowed the catheter to shift. In an interview on 1/14/25 at 11:35 am, RN B stated that it was the responsibility of nursing aides and nurses to ensure urinary catheters were secured with leg straps and checked at least every two hours or as needed. RN B stated she had not received any communication indicating that Resident #8's catheter strap was not secured. RN B stated that she had spoken to Resident #8 that morning and asked how she was doing, but the resident had not mentioned the issue. RN B stated that during her check that morning, she only ensured the urinary catheter bag was off the floor and in a privacy bag, and she did not verify if the leg strap was in place. RN B stated that checking for the leg strap was part of her assessment, but she had forgotten to do so. RN B stated that the risk of not securing the leg strap included the catheter being tugged or pulled, potentially causing injury or trauma to the urethra. RN B stated she had received training on urinary catheter to include ensuring catheter strap was secured upon hire. In an interview on 1/14/25 at 11:49 am, CNA A stated that she had received training on urinary catheter care upon hire and at least twice a year. CNA A explained that it was the CNA's responsibility to ensure the leg strap was secured at all times, with checks performed at least every two hours or as needed. CNA A noted that Resident #8 was verbal and able to communicate her needs. CNA A clarified that she was not the CNA assigned to the resident but had assisted with perineal care. CNA A stated that the risk of an unsecured catheter included possible discomfort, as she had been told that catheter movement when not secured could cause residents some pain. In an interview on 1/14/25 at 3:00 pm, the DON stated that all staff, including CNAs, nurses, and nurse managers, were required to conduct rounds regularly. The DON stated nurse managers were expected to perform daily rounds, while CNAs and nurses were required to check on residents constantly and as needed throughout the day. The DON stated that nurses were expected to check catheter placement during their rounds, not just the privacy bags. The DON stated that nurses oversee the CNAs, while nurse managers oversee the nurses. The DON stated that failing to secure the catheter properly increases the risk of it being pulled out accidentally. In an interview on 1/14/25 at 4:01 pm, the Administrator referred the question to the DON. Record review of the facility's Cather Care policy dated 02/13/2007 read in part hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum.

Based on interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 5 of 13 residents in the confidential group interview. The facility failed to provide privacy by conducting care plan meetings in resident rooms. These failures could place residents at risk of decreased feelings of self-worth and decreased quality of life. Findings included: In a confidential interview during the Resident Group revealed Care Plan reviews were being done in the residents' rooms in the presence of their roommates and staff members and/or visitors were able to go into the room and hear everything that was being discussed. The residents said this made them feel embarrassed and was a violation of their privacy. In an interview on 11/19/24 at 4:53 PM, with LVN MDS Nurse revealed resident care plans were conducted in resident room's and she was not aware if residents had voiced any concerns about this practice. In an interview with the Administrator on 11/20/2024 at 10:13 AM, revealed she was not aware Care Plan reviews were being done in the resident rooms. She said the residents had not reported any concerns regarding staff discussing care plans in their room in front of other residents and/or visitors. She stated, The care plans should be discussed individually and in private with the residents. Record review of the Nursing Facility Residents' Rights dated November 2021 documented, Nursing Facility Resident Rights: Privacy and Confidentiality - You have the right to: Privacy, including privacy during visits, phone calls and while attending to personal needs. Have facility information about you maintained as confidential.

Based on interviews and record review, the facility failed to consider the views of the residents and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. The facility failed to demonstrate their responses and rational's for such response for 1 of 1 resident council. The facility failed to ensure concerns expressed in the resident council meetings for (the past 7 months) were reported to the administrator and designated department heads. This failure could lead to residents feeling unheard and unvalued in their place of residence. Findings included: In a confidential interview during the Resident Group revealed stated they felt the administrator did not make any efforts to address their concerns and grievances discussed in previous months at the resident council meetings. The residents stated they had requested copies of the Resident Council minutes from the previous meetings so that they could see what efforts had been made to resolve the grievances expressed by the residents but were denied a copy of the minutes by the administrator. It was reported the Administrator retaliates against the Resident Council President and [NAME] President for reporting concerns about her interference with Resident Council Elections, concerns with cold food temperatures and request to review Resident Council Minutes to see what the facility was doing to address those concerns voiced at the Resident Council Meetings. It was reported that they had reported these concerns to the local ombudsman. In an interview with the Activities Director on 11/19/2024 at 2:33 PM, she stated the residents had voiced concerns regarding food served cold during meals. She stated once the resident council meeting was over, she would complete the grievance form for all the concerns voiced during the meeting and give them to the administrator. The activities director said the administrator would review the Grievance Reports and Grievances Resolution at the morning meetings and the DON or administrator would provide in-services to address the concerns voiced at the Resident Council. She said Meal Test Tray checks were done by the Administrator on a quarterly basis to address concerns voiced regarding food. She said these concerns were also addressed at the Monthly QAPI Meeting where they reviewed the in-service training to verify if it was effective and to retrain staff as needed until the area of concern had been resolved. In an interview and record review with the Administrator on 11/19/2024 at 2:56 PM, revealed the Activities Director and her assistant were responsible for writing the Resident Council Meeting Minutes and for turning them in to the Administrator for review. The Administrator stated, I was not aware they were not writing down all of the concerns voiced by the residents during the Resident Council Meetings. After the Resident Council Meeting, I will follow up with the Resident Council President on any concerns voiced at the Resident Council Meeting. The Resident Council President sometimes becomes very defensive because I will be asking questions about what was reported at the meeting so I can address his concerns. That is why I always have a witness with me when I talk to him. The Administrator stated the Activities Director had not documented any concerns in the Resident Council Minutes regarding concerns voiced by the resident regarding serving cold during meals. In an interview on 11/20/24 at 9:44 AM, with the Administrator revealed their corporate staff would not permit the residents to review the Resident Council Minutes and were only allowed to provide the Resident Council President a list of residents who had attended the Resident Council Minutes. The Administrator stated the Activities Director wrote the minutes for the Resident Council Meetings and that is what she acted on. In an interview on 11/20/24 at 9:51 AM, with the Director of Food and Nutrition stated, I get concerns from the residents regarding cold food temperatures sporadically or occasionally. I did not write a Grievance Form for the concerns voiced regarding cold food temperatures. I do not remember when was the last time that we checked food temperatures on a test tray. The meal carts are not insulated and the staff needed to keep the door closed while they were passing trays to keep the food warm in the meal cart. Interview on 11/20/24 at 12:00 PM, with Administer reported they conduct monthly QAPI meetings. She said that as of now only the Dietary Manager, Maintenance Supervisor, Medical Director, Administrator and Director of Nursing. Topics discussed: Infection Control, Pharmacy Services, Incidents, PIPs, Immunizations and Staffing. Interview on 11/20/24 at 12:11 PM, with Director of Food and Nutrition reported they conduct monthly QAPI meetings. He said Administrator, Director of Nursing, Human Resource Coordinator, Medical Director, Maintenance Supervisor, and Admissions Marketer. Topics discussed: Weight Loss, Incident Reports, Safety, and Immunizations. Interview on 11/20/24 at 3:50 PM, Director of Nursing reported they conduct monthly QAPI meetings. Most of the department managers attend including the wound care nurses and one direct care staff. Medical Director attends all of the meeting. Topics discussed: Decline in ADLS, psychotropic drugs. Interview on 11/21/24 at 10:36 AM, Director of Rehab Services occasionally attend QAPI meetings. I do not remember when was the last time I attended a QAPI meeting. It has been a while since a attended a meeting. Interview on 11/21/24 at 10:43 AM, Maintenance Director Dietary new equipment, Cold Food, Falls, Admissions, Medications delivered on times, medical supplies ensure we have enough briefs; Who attends Medical Director, Dietary Supervisor, and DON. Review of Resident Council Minutes dated 05/31/24 through 10/01/24 did not document documents any concerns related to cold food temperatures. Record Review revealed QAA Committee members were Director of Nursing, Administrator,Medical Director, Maintenance Director, Director of Rehabilitation Services, and Director of Food and Nutrition. Record Review of the QAPI Sign in sheets revealed: -10/19/24 Continue to work with Care Planning concerns of clustering & individualizing the plan of care. -09/19/24 CS focus is to keep an accurate inventory count. MDS focus on documentation accuracy. -08/22/24 Medical Records continuing to compile the accuracy of rental inventory. MDS focus is to work on MDS assessments to submit on time. -07/28/24 Care Plans over due -06/11/24 Care Plans over-due -05/16/24 MDS focus is to do a follow-up on all care plans to update any areas identified on audit log e.g. clustering and individualize plans. Record review of the Grievance Policy Revised 11/19/2016 read: Residents and their families have the right to file a grievance without fear of reprisal. The designated grievance officer is the Administrator. Fundamental Information: Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection of residents. Procedure: Social service, under the guidance of the Administrator is responsible for the following: Maintain a system to keep records (file, log, copy of grievance registration forms, etc.) of all complaints reported which contains the date of report, circumstances, specifics of investigation, action taken, and follow up with the complainant. Conduct/designate routine interviews with residents and families related to specific areas of facility life and resident care. Document negative findings on the grievance form. The Administrator (grievance officer) is responsible for the following: Review grievances to validate the investigation of the facts and circumstances of the grievance. Written findings of fact, conclusion and recommendations and validated with person issuing the grievance timely. Establish a mechanism for all associates to communicate resident or family grievances to the designated staff so that all grievances will be documented and timely response developed and implemented. Coordinate orientation and in-service training to ensure that all facility associates are knowledgeable of the facilities grievance procedure and their role in providing responsive customer service to residents and families and grievance resolution. Validates designee follow up with resident family regarding resolution or explanation. A reasonable expected time frame for completing the review of the grievance. The right to obtain a written decision regarding his or her agreements. Provide a copy of the grievance policy to the resident upon request. Coordinate to validate residence or notice of rights and services, including the right to file the grievance prior to or upon admission and during the resident stay.

Based on observation, interview, and record review revealed the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 6 of 6 exit door alarms on resident hall s, 1 of 1 gate alarm in enclosed area by A Hall which resulted in an elopement of 1 of 7 (Resident #1) residents identified at risk of elopement. The facility failed to maintain battery operated door alarms on exit doors in resident halls A, B, C, D, E, and F according to manufacturer's specifications, to prevent accidents, for Resident #1 who had a history of wandering and was at risk for elopement. Resident exited facility on 05/15/22 at 11:25 PM, through exit on A Hall and then exited the gated area at side of facility that had a magnetic lock that was not latching, into front parking lot by a high traffic street. Resident sustained a large laceration to forehead that required 20 sutures and dense fracture of C1 and C2 (fractures of neck region of spinal column). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/20/2022. While the IJ was removed on 05/22/2022, the facility remained out of compliance at Actual Harm with a scope of isolated. This failure placed residents with wandering behavior at risk of elopement that could potentially result in accidents and possible death. Findings include: Record review of Admission Record dated 5/23/22 for Resident #1 documented admitted [DATE]. Record review of EMS report dated 05/15/2022 for Resident #1 documented in part: At 11:37 PM, [AGE] year-old female that had sustained a fall and strike her head. Witness stated that he was driving by when he noticed the patient sitting on the floor next to the street and he decided to stop. When the witness got close to the patient, he noticed that she was bleeding from her forehead and went to get help from the nursing home. Staff from the nursing home stated that she is a patient from the facility and don't know how she was able to get out. Record Review Hospital emergency room note dated 05/16/22 for Resident #1 documented in part: Arrived by ambulance. Patient's description of reason for visit: Patient was found outside nursing home by a pedestrian. Patient fell and hit right forehead. Nursing staff stated they do not know how she got out. Dressing to forehead with dry blood on face. Able to follow directions. High Risk for falls. Chief Complaint: Trauma. Mechanism of Injury: Fall. Type of impact surface: Concrete. Record review Hospital History and Physical dated 05/16/2022 for Resident # 1 documented in part: History of Present Illness: [AGE] year-old female escaped from her nursing home and fell . Additional Medical History: Alzheimer's Dementia, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Radiology data: Cervical Spine Type 2 dens fracture C1 (neck region of spinal column). Cervical collar applied. admitted to ICU (intensive care unit). Facial Bones: Right frontal Scalp laceration (laceration on right side of forehead) repaired with sutures and hematoma (injury that causes blood to collect and pool under the skin that looks like a bump). Interview on 05/18/2022 at 9:54 AM Hospital RN stated Resident #1 had been transferred to her care that morning from ICU. Hospital RN stated Resident #1 sustained C1 and C2 fractures and was wearing a brace to prevent movement to worsen fracture. Hospital RN stated Resident #1 also sustained injury to right side of forehead that required 20 sutures and had significant swelling to the affected area. Record review of Annual MDS dated [DATE] for Resident #1 documented in part: BIMS score of 4 (severely cognitive impaired). Active Diagnoses: [CONDITION(S)], Alzheimer's Disease, Dementia, Anxiety, [CONDITION(S)], [CONDITION(S)], Cognitive Communication Deficit, Difficulty in walking, Muscle weakness, Lack of coordination, Muscle wasting and atrophy, abnormality of gait and mobility. Walk in room, limited one- person physical assist; Walk in corridor, limited one-person physical assist; Locomotion on unit -supervision, one-person physical assist; Locomotion off unit - Extensive assistance, one-person physical assist; Walker. Record review of Resident #1 Care Plan dated 03/23/2022 documented in part: Resident has impaired visual function and is at risk for falls and injury. Self-Care Deficit related Cognitive Impairment, Impaired balance and coordination and Visual impairment. Ambulation-supervision and use Front Wheel Walker; Wandering/Exit Seeking: related to cognitive impairment and is at risk for injury. Check wander guard for proper functioning every shift and as needed. Record review of Annual History and Physical dated 01/19/2022 for Resident # 1 documented in part: [AGE] year-old female with diagnosis: Alzheimer Disease, Dementia, Cognitive Communication Deficit, Difficulty in walking, Muscle wasting and atrophy, [CONDITION(S)], Delusional disorder, [CONDITION(S)], Impaired Gait, [CONDITION(S)], and history of falling. Fall Precautions. Record review of Physician Order dated 04/15/2022 for Resident # documented in part: Check wander guard to left wrist and wheelchair for placement and function every shift. Record review of Quarterly Elopement assessment dated [DATE] for Resident #1 documented in part: Score: 1 - Behavioral Observations: Wanders between floors or units. Not at risk to elope at this time and placement on the Elopement Risk Protocol is not indicated. Record review of Other Elopement assessment dated [DATE] documented in part: Score - 6 Behavioral Observations: Wanders between floors or units. Hangs around facility exits. Verbalize a serious/strong intent to leave the facility in the absence of an appropriate discharge plan. Has the physical ability to leave the facility. Becomes agitated, confused and/or disoriented or displays poor judgement. Engages in theme behavior - packs belongings and wants to go home. At risk to elope and should be placed on the elopement risk protocol. Record review of Resident #1 Fall Risk assessment dated [DATE] revealed a score of 5, indicating low risk for falls, no behavior, and uses walker. Record review of Resident #1 Fall Risk assessment dated [DATE] revealed a score of 7, indicating a moderate risk for falls, behaviors not exhibited in the past 7 days, and uses walker. Interview on 05/17/2022 at 10:52 AM, Administrator reported that she received a telephone call at night on Sunday 05/15/2022, from the DON, to report Resident #1 had eloped and was found outside in the front of the facility with injuries. The DON and I went to the facility right away, to check all of the door alarms and magnetic locks on the gates to verify that the alarms were working properly. We did not find any problems with the exit door alarms or magnetic locks on the gates on that day. I placed a telephone to the alarm contractor to come and check all exit door alarms and magnetic locks as soon as possible. The alarm technician came to the facility 05/16/22 and reported that he had not found any problems with the exit door alarms and magnetic locks on the gates. Interview on 05/17/2022 at 1:46 PM, CNA A reported she worked on Sunday 05/15/2022, on the night shift and was assigned to Resident #1. CNA A reported she saw Resident #1 on her initial rounds at approximately 10:40 PM, on that day, and resident was asleep in bed. CNA A, stated, I woke the resident to check her vital signs and left room. CNA A stated, I was in another room on the same hall as Resident #1, providing incontinent care at approximately 11:30 PM and did not hear any alarms go off on the day of the incident. CNA A stated she had been trained to immediately respond to door alarms, and if with busy with a resident she would have to finish the task quickly and safely as possible, before responding to the door alarms. Interview on 05/17/2022 at 3:55 PM DON, confirmed she had received a telephone call from LVN C on Sunday 05/15/2022 at approximately 11:30 PM, to report Resident #1 got out and was found outside lying on the ground by a man who had called 911 because the resident was injured. DON stated, I instructed LVN B and C to immediately conduct a headcount and check all exit door alarms and gate alarms to verify they were all ringing when doors were opened and completely closing. DON stated she reported the incident to Administrator via text message and they both arrived at the facility around 12:30 AM, to try and determine how Resident #1 had walked out the exit door at the end of A Hall and walked out the gate door in the enclosed area by A Hall. DON reported all facility staff had been trained prior to the incident to immediately respond to door alarms/gate door alarms and check to see who had left the facility. DON reported that Resident #1 had a wander guard bracelet however the door on A hall does not have a wander guard alarm. Interview on 05/17/2022 at 11:30 PM, LVN B reported she had worked on 05/15/2022 on the night shift and was assigned to A, B and C Halls. LVN B stated, On that day at approximately 11:15 PM, Resident #1 walked to the nurse's station and asked for snack. I walked her back to her room and stood by the door until she went back to bed. A few minutes, later I went to the restroom, and heard the exit door alarm ring. I rushed to get out of the restroom and went out to check the resident rooms in A Hall and noted Resident #1 room was not in bed or in her room. As I was walking down the hallway, towards the exit, I noted the exit door in A Hall was cracked open and the alarm was not ringing. I pushed the door open, stepped outside into the gated area and pushed gate door open, and saw Resident #1 standing up with her walker with a man in the driveway by the facility sign that is in front of the facility by the sidewalk. When I approached Resident #1 the man was on the phone calling 911. Resident had an opened wound to right side of forehead and was bleeding. The man said that he was driving by the facility and had noticed Resident #1 was lying on the ground near the sidewalk and had pulled over to assist the resident. I did not get his name or telephone number. Resident was transported by EMS to the hospital emergency room . No one else at the facility responded to the door alarm on that day. LVN B reported that the gate door in the enclosed area by A Hall was unlocked when she had pushed the gate door opened. LVN B reported Resident #1 had a wand guard bracelet on the day of the incident, however the resident exited the facility through A hall exit door and unlocked gate in enclosed area that do not have a wander guard alarm. Interview on 05/18/2022 at 12:05 AM, LVN C confirmed she worked on Sunday 05/15/2022 on the night shift and was assigned to D, E, and F halls. LVN C stated she received a telephone call from LVN B asking for assistance because Resident #1 had got out of the facility, fell , and sustained injuries. LVN C stated, I am checking my phone calls on my cell phone and it shows that LVN B called me on 05/15/22 at 11:26 PM. LVN C reported she did not hear any exit door alarms go off on the night of the incident. LVN C stated, When went outside, and saw Resident #1 standing up her walker in front of the facility sign, located in the circular driveway at the front of the facility with a man and he was calling 911. Resident #1 was bleeding from her forehead and asked LVN B went to and get supplies to provide first aide to resident. LVN C reported when LVN B went inside to get supplies, EMS had arrived at the scene. LVN B had told me that unknown male that was driving by the facility had seen Resident #1 on the ground and pulled over to assist the resident. I called the DON at 11:29 PM to report the incident at which time she instructed us, to do a headcount and check all the alarm doors on the exit doors in resident hallways and check the locks on the gate by A Hall to verify the alarms were ringing and the exit doors completely closed. Resident #1 walked around the facility, but I never saw her attempting to leave the facility. Resident #1 was easily redirected. Interview on 05/18/2022 at 12:19 AM, CNA P reported she had worked on 05/15/2022 on the night shift and was assigned to D, E, and F Halls and did not hear any door alarm ring on that day. CNA P stated she had been trained to immediately respond to door alarms and check to see who left the facility. Interview on 05/18/2022 at 12:29 AM CNA D reported she had worked on Sunday 05/15/2022 on the night shift and was assigned to D, E, and F halls. CNA D stated he did not hear any doors alarm go off that night. CNA D stated she had been trained to immediately respond to an exit door alarm. Interview on 05/19/2022 at 3:18 PM CNA E reported she had worked on Sunday 05/15/2022 the night shift and was assigned to A, B, and C halls. CNA E stated she did not hear an alarm go off that night. CNA E stated she had been trained to immediately respond to an exit door alarm. Observation on 05/18/2022 at 12:04 PM with Administrator and Maintenance Director, revealed that the exit door in A Hall, triggered the door alarm when the door was pushed by Maintenance Director. It was observed that the exit door did not completely close leaving an approximate 2-inch gap between the door and door frame and alarm was continuous. Maintenance Director stated, I checked this door this morning and it was closely completely. The door is not closing because of the dirt that has accumulated on the under-door threshold and that is the reason for exit door not completely closing. Let me remove some of the dirt and re-check the door. The Maintenance Director forcefully pushed the push bar on the exit door, door completely opened, and it was observed that the exit door did not close leaving the 2-inch gap between the door and door frame. He forcefully had to pull the door to completely close. Observation, interview and record review on 05/18/22 at 1:17 PM, with Administrator and Maintenance Director, revealed there was an enclosed area at end of A Hall, that had a chain link fence with a door that had a keypad and magnetic lock. The gate door was opened by the Maintenance Director, surveyor stepped out of the gate on the side of the facility and door was closed. The surveyor pulled on the gate door and noted magnetic lock had not latched and the gate door was opened without entering a code in the keypad. The exit door was tested 3 more times and the Maintenance Director, and the surveyor was able to open the door without entering a code in the keypad. The Maintenance Director stated, I just came back from vacation today and was informed of the elopement incident by administrator and she asked that I check all of the exit door alarms on all resident halls and gate locks and keypad. You must forcefully close the gate door so the magnet latches. The Maintenance Director reported that the front door and exit door in the dining room area are the only two doors that have a wander guard alarm. The Maintenance Director reported that he checked the wander guard alarms once a week to verify they were working properly. Maintenance Director reported he documented his weekly QA checks in the facility's electronic work history reports. The Administrator reported that she reviewed the electronic work history reports weekly to verify that Maintenance Director was checking the exit door alarms on a weekly basis to ensure that the exit door alarms were working properly. Review of the facility's electronic work history report dated January 1, 2022 thru May 7, 2022 with Administrator and Maintenance Director documented that there were no issues identified with the exit alarms. Telephone interview on 05/20/2022 at 11:02 AM, LVN B reported that on the night of the incident, she heard the alarm go off when she was in the restroom, close to A Hall. LVN B stated, When I got to the exit door, the door alarm was no longer ringing. The door alarm should have continued to ring until I enter the code in the keypad to reset the alarm. LVN B stated, I did not report this to anyone. Prior to incident, a couple of months ago, I had noted that the door alarms would stop ringing prior to resetting the alarm. I did not report this to anyone at the facility. We had been trained to immediately respond to door alarms and to report any problems with the door alarms to the Administrator and DON. Telephone interview on 05/20/2022 at 11:45 AM, alarm contractor reported that came to the facility in on Monday 05/16/2022, to check all battery-operated exit door alarms and keypads. I found that the facility was not following the manufacturer's specification to conduct periodic test to verify the life of battery. It is recommended that the 9 Volt battery be changed twice a year. All the batteries in the exit door alarms in all the resident halls were dated July 2020, that is why the door alarms were not ringing. I also found that the magnetic lock and keypad had not been correctly installed on the gate door on the chain link fence by A Hall by the Maintenance Director and that was why the magnetic lock was not latching when the door was closed, and the door alarm was not ringing when the gate door was opened on 05/15/22. On that day, I demonstrated to the Administrator and Payroll Coordinator that the gate door on the chain link fence by A Hall would open by pushing on the door without entering a code in the keypad and the magnetic lock was not latching because ithad not been installed correctly. I reattached the magnetic lock and installed two new keypads on that day, one was installed on the exit door in A Hall and the other was installed on the gate door in the enclosed area by A Hall. Record review of Invoice from alarm contractor dated 05/16/22 documented in part: Service Call to Check All Doors. Replace All Batteries at Hallway Exit Door Alarms. Record review of Invoices from alarm contractor dated 05/20/22 documented in part: Service Call to Meet with State Inspectors. Reattach Maglock at A Hall Gate; Service Call to Replace 2 Outdoor Keypads at Gate at A Hall with 2 New Keypads Installed and Programmed. Telephone interview on 05/20/2022 at 1:11 PM, Payroll Coordinator stated, I remember a CNA, reported to me that the exit doors in resident hallways were not closing properly. I do not remember the date or the name of the person that reported this to me. I do remember that the CNA, said that she had reported this to the Maintenance Director but did not specify a time frame. Interview on 05/20/2022 at 1:28 PM Maintenance Director reported that he only calls the alarm contractor when there are any malfunctions to any of the exit door alarms and/or gate alarms. Maintenance Director reported that checks the door/gate alarms once a week by propping the door open to verify that they Record review Manufacture information dated October 2017 regarding specifications for checking battery door alarms documented in part: All units are recommended for indoor use only. Unit must be tested periodically to verify the life of battery. Manufacture recommends you change the 9 Volt battery twice a year. Interview on 05/20/2022 at 1:28 PM Maintenance Director reported that he only calls the alarm contractor when there are any malfunctions to any of the exit door alarms and/or gate alarms. Maintenance Director reported that checks the door/gate alarms once a week by propping the door open to verify that they sound off. Maintenance Director reported he did not have any specialize training on the alarm system and installation. An Immediate Jeopardy (IJ) was identified on 05/20/2022 at 4:24 PM, due to the above failures. The Administrator and DON was notified of the IJ the IJ template was provided on 05/20/2022 at 04:24 . The facility's Plan of removal was accepted on 05/21/2022 at 4:39 PM and indicated the following: Visual Wandering Resident checks: - The nurse aides will conduct every 20-minute checks on wandering residents due to their risk of leaving the building. - The nurse will conduct walking rounds at the beginning of the shift that include a visual check on the wandering resident's and when on the unit such as during med pass times, treatment times and answering lights. - The department Heads will complete visual checks during daily quality of life rounds to validate that resident at risk for wandering are safe. The Administrator or designee will validate that visual checks are completed daily by the nurse and department heads. Door/Gate checks - The Administrator or designee will complete an audit of facility exit doors, door closures, gates and that doors/ gates latch correctly one a week using QAPI Tool. The QAPI audit will be completed each week for 30 days, then monthly thereafter. - The QAPI Toll will be submitted to the QAA committee by the Administrator for review, evaluation, and recommendation every month. - Every day the Maintenance Director uses Tels to identify the security checks to be completed such as gates, exit door alarms, door closures, battery function, keypad and that doors/gates latch correctly. - The maintenance director will check the gates, exit door alarms, door closures, keypads and test that doors/ gates latch correctly. The daily checks will be documented in the Tels by the maintenance director. - The Administrator or designee will check the Tels report daily to validate the maintenance director has completed the monitoring and documentation of doors, alarms, keypads, door closures and latching of doors and gates. - On 05/20/2022 the Administrator validated the Tels entry for daily documentation of the door and alarm tests, door latch correctly and batteries. - The maintenance director will change alarm batteries monthly and document in Tels. The Administrator will validate that documentation of in Tels daily. Response to Malfunction of Exit Doors, Gates, Alarms, Keypads, Maglock, Door/ Gate closing. - All staff will immediately report to the Administrator when a door closure, door lock, keypad, or gate/door latching happens. 1. The Administrator will immediately call the Resident Technology to check doors, door closures, alarms, and repairs. 2. The Administrator will reassign an employee to monitor until the door is repaired. The purpose of assigning a staff member to a malfunction is to prevent a wandering resident from exiting the building. - Maintenance logs are kept at each nurse's station for staff to communicate malfunction of exit doors, closures, and alarms. The staff are aware that the purpose to the maintenance log is to communicate to the maintenance director facility repair needs. - The staff document the following examples on the maintenance log: broken equipment problems water temperatures, leaking toilets, damaged wheelchairs, leaking ceiling, broken tiles, exit doors not latching properly (after the administrator is contacted by phone). - The maintenance will pick up the maintenance log at each nurse's station daily, report maintenance requests and the completion of maintenance requests. The maintenance will document completion of maintenance requests on the log. Door Drill Alarms - The purpose of the door alarm drills is so the DON/ ADON/ Administrator can observe how staff respond to a resident attempting to leave the building unsupervised. The Don/ ADON/ or Administrator through observation of staff response if additional training, coaching, and instruction is necessary. - The DON/ ADON or Administrator uses a checklist with observation criteria to evaluate staff response to an alarming door such as 1) announcement to staff of a missing resident, 2) the length of time it takes for staff to respond to the door alarm, 3) if staff that responds to the door alarm leaves it on and goes out the door to look for the resident. - Door alarm drill observations will be completed once a month, on a day shift, afternoon shift, and night shift by the DON or designee. Door alarm drill will be completed as follows: on a week one of every month on the day shift door alarm drill will be conducted; on week two of every month the afternoon shift door alarm will be conducted; on week three of every month the night shift door alarm drill will be conducted. - The DON/ designee will document employee actions and response to the ringing door alarm. - The door alarm drills will be submitted to the QAA Committee by the DON for review, evaluation and for recommendations on additional training, increase in frequency of drills or need for consultation with a community resource such as Quality Monitor, fire department or LTC Education service. - QAPI audits and drills will be reviewed by the Quality Assurance Committee monthly to monitor consistent substantial compliance as determined by the committee. Observations, Interviews, and record review to confirm implementation of the Plan of Removal were conducted on 05/22/22 as follows: -Record review of in-service for all facility staff regarding Reporting Malfunction Facility Door, and Maintenance Log Use dated 5/20/22-5/22/22. - Record review of in service for missing resident policy, missing resident guidelines, and headcount guidelines dated 5/17/22 with posttest. - Record review of check list regarding Code Silver Drill, Headcount, Missing Resident Policy, Missing Person Guidelines dated 5/19/22 6-2, 5/16/22 2-10, 5/17/22 10-6, 5/16/22 2-10, 5/19/22 6-2, 5/16/22 2-10, 5/17/22 10-6, 5/17/22 10-6, 5/17/22 2-10. - Record review of in-service Maintenance Director regarding Testing of Doors, Alarms, and Batteries weekly dated 5/20/22. -Record review of Resident Technology Invoice for reattach maglock at hall gate dated 5/20/22. Initiated follow up to Plan of Removal through observation, interviews, and record reviews on 5/22/22 at 2:00 PM - 5/23/22 at 12:17 PM. Interviewed License staff and CNAs on different shifts, dietary staff, housekeeping staff, and department head and all confirmed receiving training regarding Missing Person policy and reporting malfunction of exit doors alarms/gate door magnetic lock not latching. All staff interviewed reported they had been trained to immediately respond to door alarms, go outside and check perimeter for who left the building, conduct headcount, report exit door/gate alarm malfunction to Maintenance Director and Administrator. The Administrator was notified the IJ was removed as of 05/22/2022 at 5:22 PM. However, the facility remained out of compliance at a severity level of Actual Harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation , interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 7 residents reviewed for wandering. The facility failed to provide adequate supervision for Resident #1 who had a history of wandering and at risk of elopment. Resident #1 exited the facility on 05/15/22 at 11:25 PM, through an exit on A Hall and then exited the gated area at the side of facility that had a magnetic lock and keypad, into the front parking lot by a high traffic street. Resident #1 sustained a large laceration to forehead that required 20 sutures and dense fracture of C1 and C2 (fractures of neck region of spinal column). Resident #1 fell down and sustained injuries. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/20/2022. While the IJ was removed on 05/22/2022, the facility remained out of compliance at Actual Harm with a scope of Isolated. This failure placed residents with wandering behavior at risk of elopement that could potentially result in accidents and possible death. Findings include: Record review of the Admission Record dated 5/23/22 for Resident #1 documented admitted was 09/11/2019 . Record review of an Annual History and Physical dated 01/19/2022 for Resident # 1 documented in part: [AGE] year-old female with diagnosis: [CONDITION(S)], Dementia, Cognitive Communication Deficit, Difficulty in walking, Muscle wasting and atrophy, [CONDITION(S)], Delusional disorder, [CONDITION(S)] Disorder, Impaired Gait, [CONDITION(S)], and history of falling. Fall Precautions. Record review of an Annual MDS dated [DATE] for Resident #1 documented in part: BIMS score of 4 (severely cognitive impaired). Active Diagnoses: [CONDITION(S)], Alzheimer's Disease, Dementia, Anxiety, [CONDITION(S)], [CONDITION(S)], Cognitive Communication Deficit, Difficulty in walking, Muscle weakness, Lack of coordination, Muscle wasting and atrophy, abnormality of gait and mobility. Walk in room, limited one- person physical assist; Walk in corridor, limited one-person physical assist; Locomotion on unit -supervision, one-person physical assist; Locomotion off unit - Extensive assistance, one-person physical assist; Walker. Record review of Resident #1 Care Plan dated 03/23/2022 documented in part: Resident has impaired visual function and is at risk for falls and injury. Self-Care Deficit related Cognitive Impairment, Impaired balance and coordination and Visual impairment. Ambulation-supervision and use Front Wheel Walker; Wandering/Exit Seeking: related to cognitive impairment and is at risk for injury. Check wander guard for proper functioning every shift and as needed. Record review of an EMS report dated 05/15/2022 for Resident #1 documented in part: At 11:37 PM, 92 -year-old female that had sustained a fall and strike her head. Witness stated that he was driving by when he noticed the patient sitting on the floor next to the street and he decided to stop. When the witness got close to the patient, he noticed that she was bleeding from her forehead and went to get help from the nursing home. Staff from the nursing home stated that she is a patient from the facility and don't know how she was able to get out. Record review of Hospital emergency room note dated 05/16/22 for Resident #1 documented in part: Arrived by ambulance. Patient's description of reason for visit: Patient was found outside nursing home by a pedestrian. Patient fell and hit right forehead. Nursing staff stated they do not know how she got out. Dressing to forehead with dry blood on face. Able to follow directions. High Risk for falls. Chief Complaint: Trauma. Mechanism of Injury: Fall. Type of impact surface: Concrete. Record review Hospital History and Physical dated 05/16/2022 for Resident # 1 documented in part: History of Present Illness: [AGE] year-old female escaped from her nursing home and fell . Additional Medical History: Alzheimer's Dementia, [CONDITION(S)] disorder, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Radiology data: Cervical Spine Type 2 dens fracture C1 (neck region of spinal column). Cervical collar applied. admitted to ICU (intensive care unit). Facial Bones: Right frontal Scalp laceration (laceration on right side of forehead) repaired with sutures and hematoma (injury that causes blood to collect and pool under the skin that looks like a bump). Interview on 05/18/2022 at 9:54 AM, Hospital RN stated Resident #1 had been transferred to her care that morning from ICU. Hospital RN stated Resident #1 sustained C1 and C2 fractures and was wearing a brace to prevent movement to worsen fracture. Hospital RN stated Resident #1 also sustained injury to right side of forehead that required 20 sutures and had significant swelling to the affected area. Record review of Physician Orders dated 04/15/2022 for Resident #1 documented in part: Check wander guard to left wrist and wheelchair for placement and function every shift. Record review of Quarterly Elopement assessment dated [DATE] for Resident #1 documented in part: Score: 1 - Behavioral Observations: Wanders between floors or units. Not at risk to elope at this time and placement on the Elopement Risk Protocol is not indicated. Record review of Other Elopement assessment dated [DATE] documented in part: Score - 6 Behavioral Observations: Wanders between floors or units. Hangs around facility exits. Verbalize a serious/strong intent to leave the facility in the absence of an appropriate discharge plan. Has the physical ability to leave the facility. Becomes agitated, confused and/or disoriented or displays poor judgement. Engages in theme behavior - packs belongings and wants to go home. At risk to elope and should be placed on the elopement risk protocol. Record review of Resident #1 Fall Risk assessment dated [DATE] revealed a score of 5, indicating low risk for falls, no behavior, and uses walker. Record review of Resident #1 Fall Risk assessment dated [DATE] revealed a score of 7, indicating a moderate risk for falls, behaviors not exhibited in the past 7 days, and uses walker. Interview on 05/17/2022 at 1:46 PM, CNA A reported she worked on Sunday 05/15/2022, on the night shift and was assigned to Resident #1. CNA A reported she saw Resident #1 on her initial rounds at approximately 10:40 PM, and the resident was asleep in bed. CNA A, stated, I woke the resident to check her vital signs and left room. CNA A stated, I was in [another room] providing incontinent care at approximately 11:30 PM and did not hear any alarms go off on the day of the incident. CNA A stated she had been trained to immediately respond to door alarms, and if busy with a resident she would have to finish the task quickly and safely as possible, before responding to the door alarms. Interview on 05/17/2022 at 3:55 PM, the DON confirmed she had received a telephone call from LVN C on Sunday 05/15/2022 at approximately 11:30 PM, to report Resident #1 got out and was found outside lying on the ground by a man who had called 911 because the resident was injured. DON stated, I instructed LVN B and C to immediately conduct a headcount and check all exit door alarms and gate alarms to verify they were all ringing when doors were opened and completely closing. DON stated she reported the incident to the Administrator via text message and they both arrived at the facility around 12:30 AM, to try and determine how Resident #1 had walked out the exit door at the end of A Hall and walked out the gate door in the enclosed area by A Hall. The DON reported all facility staff had been trained prior to the incident to immediately respond to door alarms/gate door alarms and check to see who had left the facility . DON reported that Resident #1 had a wander guard bracelet however the door on A hall does not have a wander guard alarm. Interview on 05/17/2022 at 11:30 PM, LVN B reported she had worked on 05/15/2022 on the night shift and was assigned to A, B and C Halls. LVN B stated, On that day at approximately 11:15 PM, Resident #1 walked to the nurse's station and asked for snack. I walked her back to her room and stood by the door until she went back to bed. A few minutes, later I went to the restroom, and heard the exit door alarm ring. I rushed to get out of the restroom and went out to check the resident rooms in A Hall and noted Resident #1 was not in bed or in her room. As I was walking down the hallway, towards the exit, I noted the exit door in A Hall was cracked open and the alarm was not ringing. I pushed the door open, stepped outside into the gated area and pushed gate door open, and saw Resident #1 standing up with her walker with a man in the driveway by the facility sign that is in front of the facility by the sidewalk. When I approached Resident #1 the man was on the phone calling 911. Resident had an opened wound to right side of forehead and was bleeding. The man said that he was driving by the facility and had noticed Resident #1 was lying on the ground near the sidewalk and had pulled over to assist the resident. I did not get his name or telephone number. Resident was transported by EMS to the hospital emergency room . No one else at the facility responded to the door alarm on that day. LVN B reported that the gate door in the enclosed area by A Hall was unlocked when she had pushed the gate door opened LVN B reported Resident #1 had a wand guard bracelet on the day of the incident, however the resident exited the facility through A hall exit door and unlocked gate in enclosed area that do not have a wander guard alarm. Interview on 05/18/2022 at 12:05 AM, LVN C confirmed she worked on Sunday 05/15/2022 on the night shift and was assigned to D, E, and F halls. LVN C stated she received a telephone call from LVN B asking for assistance because Resident #1 had got out of the facility, fell , and sustained injuries. LVN C stated, I am checking my phone calls on my cell phone and it shows that LVN B called me on 05/15/22 at 11:26 PM. LVN C reported she did not hear any exit door alarms go off on the night of the incident. LVN C stated, When went outside, and saw Resident #1 standing up her walker in front of the facility sign, located in the circular driveway at the front of the facility with a man and he was calling 911. Resident #1 was bleeding from her forehead and asked LVN B went to and get supplies to provide first aide to resident. LVN C reported when LVN B went inside to get supplies, EMS had arrived at the scene. LVN B had told me that unknown male that was driving by the facility had seen Resident #1 on the ground and pulled over to assist the resident. I called the DON at 11:29 PM to report the incident at which time she instructed us, to do a headcount and check all the alarm doors on the exit doors in resident hallways and check the locks on the gate by A Hall to verify the alarms were ringing and the exit doors completely closed. Resident #1 walked around the facility, but I never saw her attempting to leave the facility. Resident #1 was easily redirected . Interview on 05/18/2022 at 12:19 AM, CNA P reported she had worked on 05/15/2022 on the night shift and was assigned to D, E, and F Halls and did not hear any door alarm ring on that day. CNA P stated she had been trained to immediately respond to door alarms and check to see who left the facility. Interview on 05/17/2022 at 10:52 AM, the Administrator reported that she received a telephone call at night on Sunday 05/15/2022, from the DON, to report Resident #1 had eloped and was found outside in the front of the facility with injuries. The DON and I went to the facility right away, to check all of the door alarms and magnetic locks on the gates to verify that the alarms were working properly. We did not find any problems with the exit door alarms or magnetic locks on the gates on that day. I placed a telephone to the alarm contractor to come and check all exit door alarms and magnetic locks as soon as possible. The alarm technician came to the facility 05/16/22 and reported that he had not found any problems with the exit door alarms and magnetic locks on the gates. Observation, interview and record review on 05/18/22 at 1:17 PM, with Administrator and Maintenance Director, revealed there was an enclosed area at the end of A Hall, that had a chain link fence with a door that had a keypad and magnetic lock. The gate door was opened by the Maintenance Director, surveyor stepped out of the gate on the side of the facility and door was closed. The surveyor pulled on the gate door and noted the magnetic lock had not latched and the gate door was opened without entering a code in the keypad. The exit door was tested 3 more times and the Maintenance Director, and the surveyor was able to open the door without entering a code in the keypad. The Maintenance Director stated, I just came back from vacation today and was informed of the elopement incident by administrator and she asked that I check all of the exit door alarms on all resident halls and gate locks and keypad. You must forcefully close the gate door so the magnet latches. The Maintenance Director reported that the front door and exit door in the dining room area are the only two doors that have a wander guard alarm. The Maintenance Director reported that he checked the wander guard alarms once a week to verify they were working properly. Maintenance Director reported he documented his weekly QA checks in the facility's electronic work history reports. The Administrator reported that she reviewed the electronic work history reports weekly to verify that Maintenance Director was checking the exit door alarms on a weekly basis to ensure that the exit door alarms were working properly. Review of the facility's electronic work history report dated January 1, 2022 thru May 7, 2022 with Administrator and Maintenance Director documented that there were no issues identified with the exit alarms. Interview on 05/18/2022 at 12:29 AM, CNA D reported she had worked on Sunday 05/15/2022 on the night shift and was assigned to D, E, and F halls. CNA D stated he did not hear any doors alarm go off that night. CNA D stated she had been trained to immediately respond to an exit door alarm. Interview on 05/19/2022 at 3:18 PM, CNA E reported she had worked on Sunday 05/15/2022 the night shift and was assigned to A, B, and C halls. CNA E stated she did not hear an alarm go off that night. CNA E stated she had been trained to immediately respond to an exit door alarm . Observation and interview on 05/18/2022 at 12:04 PM, with the Administrator and Maintenance Director, revealed the exit door on A Hall, triggered the door alarm when the door was pushed by the Maintenance Director. It was observed that the exit door did not completely close leaving an approximate 2-inch gap between the door and door frame and alarm was continous. The Maintenance Director stated, I checked this door this morning and it was closing completely. The door is not closing because of the dirt that has accumulated on the under-door threshold, let me remove some of the dirt and re-check the door. The Maintenance Director forcefully pushed the push bar on the exit door, door completely opened, and it was observed that the exit door did not close leaving the 2-inch gap between the door and door frame. He forcefully had to pull the door to completely close. Telephone interview on 05/20/2022 at 11:02 AM, LVN B reported that on the night of the incident, she heard the alarm go off when she was in the restroom, close to A Hall. LVN B stated, When I got to the exit door, the door alarm was no longer ringing. The door alarm should have continued to ring until I enter the code in the keypad to reset the alarm. LVN B stated, I did not report this to anyone. Prior to incident, a couple of months ago, I had noted that the door alarms would stop ringing prior to resetting the alarm. I did not report this to anyone at the facility. We had been trained to immediately respond to door alarms and to report any problems with the door alarms to the Administrator and DON. Telephone interview on 05/20/2022 at 11:45 AM, the alarm contractor reported they came to the facility on Monday 05/16/2022, to check all battery-operated exit door alarms and keypads. I found that the facility was not following the manufacturer's specification to conduct periodic test to verify the life of battery. It is recommended that the 9 Volt battery be changed twice a year. All the batteries in the exit door alarms in all the resident halls were dated July 2020, that is why the door alarms were not ringing. I also found that the magnetic lock and keypad had not been correctly installed on the gate door on the chain link fence by A Hall by the Maintenance Director and that was why the magnetic lock was not latching when the door was closed, and the door alarm was not ringing when the gate door was opened on 05/15/22. On that day, I demonstrated to the Administrator and Payroll Coordinator that the gate door on the chain link fence by A Hall would open by pushing on the door without entering a code in the keypad and the magnetic lock was not latching because it had not been installed correctly. I reattached the magnetic lock and installed two new keypads on that day, one was installed on the exit door in A Hall and the other was installed on the gate door in the enclosed area by A Hall. Record review of Invoice from alarm contractor dated 05/16/22 documented in part: Service Call to Check All Doors. Replace All Batteries at Hallway Exit Door Alarms. Record review of Invoices from alarm contractor dated 05/20/22 documented in part: Service Call to Meet with State Inspectors. Reattach Maglock at A Hall Gate; Service Call to Replace 2 Outdoor Keypads at Gate at A Hall with 2 New Keypads Installed and Programmed. Telephone interview on 05/20/2022 at 1:11 PM, Payroll Coordinator stated, I remember a CNA, reported to me that the exit doors in resident hallways were not closing properly. I do not remember the date or the name of the person that reported this to me. I do remember that the CNA, said that she had reported this to the Maintenance Director but did not specify a time frame. Interview on 05/20/2022 at 1:28 PM, the Maintenance Director reported that he only calls the alarm contractor when there are any malfunctions to any of the exit door alarms and/or gate alarms. Maintenance Director reported that he checks the door/gate alarms once a week by propping the door open to verify that they sound off . The Maintenance Director reported he did not have any specialize training on the alarm system and installation. Record review of the Manufacture information dated October 2017 regarding specifications for checking battery door alarms documented in part: All units are recommended for indoor use only. Unit must be tested periodically to verify the life of battery. Manufacture recommends you change the 9 Volt battery twice a year. An Immediate Jeopardy (IJ) was identified on 05/20/2022 at 4:24 PM, due to the above failures. The Administrator and DON was notified of the IJ the IJ template was provided on 05/20/2022 at 04:24 . The facility's Plan of removal was accepted on 05/21/2022 at 4:39 PM and indicated the following: Visual Wandering Resident checks: - The nurse aides will conduct every 20-minute checks on wandering residents due to their risk of leaving the building. - The nurse will conduct walking rounds at the beginning of the shift that include a visual check on the wandering resident's and when on the unit such as during med pass times, treatment times and answering lights. - The department Heads will complete visual checks during daily quality of life rounds to validate that resident at risk for wandering are safe. The Administrator or designee will validate that visual checks are completed daily by the nurse and department heads. Door/Gate checks - The Administrator or designee will complete an audit of facility exit doors, door closures, gates and that doors/ gates latch correctly one a week using QAPI Tool. The QAPI audit will be completed each week for 30 days, then monthly thereafter. - The QAPI Toll will be submitted to the QAA committee by the Administrator for review, evaluation, and recommendation every month. - Every day the Maintenance Director uses Tels to identify the security checks to be completed such as gates, exit door alarms, door closures, battery function, keypad and that doors/gates latch correctly. - The maintenance director will check the gates, exit door alarms, door closures, keypads and test that doors/ gates latch correctly. The daily checks will be documented in the Tels by the maintenance director. - The Administrator or designee will check the Tels report daily to validate the maintenance director has completed the monitoring and documentation of doors, alarms, keypads, door closures and latching of doors and gates. - On 05/20/2022 the Administrator validated the Tels entry for daily documentation of the door and alarm tests, door latch correctly and batteries. - The maintenance director will change alarm batteries monthly and document in Tels. The Administrator will validate that documentation of in Tels daily. Response to Malfunction of Exit Doors, Gates, Alarms, Keypads, Maglock, Door/ Gate closing. - All staff will immediately report to the Administrator when a door closure, door lock, keypad, or gate/door latching happens. 1. The Administrator will immediately call the Resident Technology to check doors, door closures, alarms, and repairs. 2. The Administrator will reassign an employee to monitor until the door is repaired. The purpose of assigning a staff member to a malfunction is to prevent a wandering resident from exiting the building. - Maintenance logs are kept at each nurse's station for staff to communicate malfunction of exit doors, closures, and alarms. The staff are aware that the purpose to the maintenance log is to communicate to the maintenance director facility repair needs. - The staff document the following examples on the maintenance log: broken equipment problems water temperatures, leaking toilets, damaged wheelchairs, leaking ceiling, broken tiles, exit doors not latching properly (after the administrator is contacted by phone). - The maintenance will pick up the maintenance log at each nurse's station daily, report maintenance requests and the completion of maintenance requests. The maintenance will document completion of maintenance requests on the log. Door Drill Alarms - The purpose of the door alarm drills is so the DON/ ADON/ Administrator can observe how staff respond to a resident attempting to leave the building unsupervised. The Don/ ADON/ or Administrator through observation of staff response if additional training, coaching, and instruction is necessary. - The DON/ ADON or Administrator uses a checklist with observation criteria to evaluate staff response to an alarming door such as 1) announcement to staff of a missing resident, 2) the length of time it takes for staff to respond to the door alarm, 3) if staff that responds to the door alarm leaves it on and goes out the door to look for the resident. - Door alarm drill observations will be completed once a month, on a day shift, afternoon shift, and night shift by the DON or designee. Door alarm drill will be completed as follows: on a week one of every month on the day shift door alarm drill will be conducted; on week two of every month the afternoon shift door alarm will be conducted; on week three of every month the night shift door alarm drill will be conducted. - The DON/ designee will document employee actions and response to the ringing door alarm. - The door alarm drills will be submitted to the QAA Committee by the DON for review, evaluation and for recommendations on additional training, increase in frequency of drills or need for consultation with a community resource such as Quality Monitor, fire department or LTC Education service. - QAPI audits and drills will be reviewed by the Quality Assurance Committee monthly to monitor consistent substantial compliance as determined by the committee. Observations, Interviews, and record review to confirm implementation of the Plan of Removal were conducted on 05/22/22 as follows: -Record review of in-service for all facility staff regarding Reporting Malfunction Facility Door, and Maintenance Log Use dated 5/20/22-5/22/22. - Record review of in service for missing resident policy, missing resident guidelines, and headcount guidelines dated 5/17/22 with posttest. - Record review of check list regarding Code Silver Drill, Headcount, Missing Resident Policy, Missing Person Guidelines dated 5/19/22 6-2, 5/16/22 2-10, 5/17/22 10-6, 5/16/22 2-10, 5/19/22 6-2, 5/16/22 2-10, 5/17/22 10-6, 5/17/22 10-6, 5/17/22 2-10. - Record review of in-service Maintenance Director regarding Testing of Doors, Alarms, and Batteries weekly dated 5/20/22. -Record review of Resident Technology Invoice for reattach maglock at hall gate dated 5/20/22. Initiated follow up to Plan of Removal through observation, interviews, and record reviews on 5/22/22 at 2:00 PM - 5/23/22 at 12:17 PM. Interviewed License staff and CNAs on different shifts, dietary staff, housekeeping staff, and department head and all confirmed receiving training regarding Missing Person policy and reporting malfunction of exit doors alarms/gate door magnetic lock not latching. All staff interviewed reported they had been trained to immediately respond to door alarms, go outside and check perimeter for who left the building, conduct headcount, report exit door/gate alarm malfunction to Maintenance Director and Administrator. The Administrator was notified the IJ was removed as of 05/22/2022 at 5:22 PM. However, the facility remained out of compliance at a severity level of Actual Harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to provide 1 (Resident #1) of 5 residents, reviewed for elopement risk, adequate supervision to prevent elopement from the facility. On Friday, 6/02/17 at 4:00 PM, Resident #1, who had a history of [REDACTED]. A wander guard was placed on his ankle. On 6/04/17, the weekend staff, unaware Resident #1 left the building on Friday afternoon, last saw Resident #1 at 6:30 PM. He walked out the unsecured front door which had a wander guard system, without the facility being aware, and traveled approximately 1.7 miles uphill along heavily trafficked streets and crossed 2 busy 4 lane streets. Resident #1 was found by the police at 7:51 PM, confused and sweating heavily and was taken to the hospital at 8:22 PM by EMS (Emergency Medical Service). The facility staff noticed Resident #1 was missing around 9:00 PM when he was not available for his nightly medications and his meal tray was still in his room. When 9-1-1 was called, the dispatcher said a man matching the description given of Resident #1 was at a local hospital. Resident #1 was returned to the facility by ambulance at 11:07 PM. This was determined to be past non-compliance immediate jeopardy from 6/02/17 to 6/17/17 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could have affected 14 residents, identified by the facility of having elopement risk behaviors, by exposing them to risk of injury or death due to inappropriate monitoring. The findings included: Review of Face Sheet dated 6/06/17 documented Resident #1 was an [AGE] year old man admitted to the facility on [DATE] and readmitted on [DATE]. Review of the facility History and Physical (H&P) dated 5/24/17 documented [DIAGNOSES REDACTED]. The H&P stated Resident #1 had increased behaviors/wandering at night. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] documented in part: impaired vision, BIMS (Basic Interview Mental Status) score of 3 out of 15 (severely impaired cognitive ability for daily decision-making), wandering behaviors 1-3 days per week, required set-up help with supervision for transfer and walking and had active [DIAGNOSES REDACTED]. Review of Elopement/Wandering Assessment Tool dated 6/02/17 documented Resident #1's was at a moderate risk for elopement. He scored yes as he was physically able to leave the building, disoriented to place and current behavior of wandering/exit-seeking. Review of Nurse's Notes dated 6/02/17 documented Resident #1 was found by visitors who said resident was attempting to go to parking lot. Resident said he was going for a walk. He was redirected inside the building. A wander guard was placed on his left ankle. Review of Resident #1's Comprehensive Plan of Care dated 6/02/17 documented in part the following: a. Problem: Resident deemed at risk for wandering, is ambulatory and indications of dementia. Approach: Observe and document resident's location every 2 hours, Report any attempts to exit the facility, Place a wander guard colored Identification Bracelet on the resident for easy identification of resident. b. Problem: Wander Guard Bracelet and is at risk for injury from wandering in an un-safe environment. Approach: Monitor for placement every shift, monitoring for proper functioning every 24 hours. Review of Resident #1's Nurse's Notes dated 6/02/16 - 6/04/17 there was no documentation the resident was monitored, including his location, every 2 hours. Review of Incident/Accident Report dated 6/04/17 at 8:50 PM, by Licensed Vocational Nurse (LVN) A, documented the last time Resident #1 was seen was at 6:30 PM. At about 8:50 - 9:00 PM, the staff realized patient was no longer in the facility. Code Silver (missing resident alert) was announced, everyone started looking for resident in and out of the facility. The Summary of Investigation documented facility protocol was followed. Upon resident return, he was placed on 1 on 1. No injuries, medical and psych evaluations and wander guard in place. Review of the Provider Investigation Report dated 6/12/17, documented in part: On 6/04/17 at 8:00 PM Resident #1 was missing. His functional ability was no assistance, required no special supervision, was independently ambulatory, was interviewable but did not have the capacity to make informed decisions. He had a history of [REDACTED]. On 6/04/17, the evening nurse doing med pass found the resident was not in his room. The resident was found to be at a local hospital - no injuries reported. Resident returned to the facility the same evening. Review of the local police department Incident/Investigation Report dated 6/04/17 documented, in part: The officers arrived at a home at 7:51 PM on 6/04/17 after a report was received of a very elderly, confused man sitting on a rock wall. The officers approached Resident #1 who said he was lost. He was wearing several layers of clothing in 90 plus degree weather. The man stated he believed he was in a city in northern Mexico. The officers noted he was very wet due to perspiration and suspected he was dehydrated and summoned EMS. Review of the web site weather underground (www.wunderground.com), the documented temperature on 6/04/17 at the city airport ranged from 95 degrees Fahrenheit at 6 PM to 91.9 degrees Fahrenheit at 8 PM. Review of the local fire department Prehospital Care Report dated 6/04/17 documented patient was a [AGE] year old male. He was confused, his skin was diaphoretic, he complained of headache and chills. Patient stated he was wearing a jacket and was outside in the hot temperature climate all day. Patient was transported to the hospital for further evaluation. Review of the hospital emergency room record dated 6/04/17 documented Resident #1 arrived at 8:22 PM and was confused and complained of headache. Patient's clothing was wet. There were no injuries. The records documented at 10:14 PM the nursing director from (the facility) called and claimed the patient was one of theirs. At 10:30 PM, (the Business Development Specialist) came to claim patient and discharge instructions explained. Patient transported back to nursing home by ambulance at 10:50 PM. Observation on 8/16/17 at 1:57 PM, the most direct route from the facility to the house where Resident #1 was found measured 1.7 miles on the odometer. A mapping web site gave 2 indirect routes that were shorter (1.3) miles. Either route required Resident #1 to walk along 2 busy streets and cross 4 to 6 lanes of traffic twice, depending if he crossed at a light or in the middle of the street. All of the routes were majority uphill travel. Review of physician progress notes [REDACTED].#1 had wandered out of the building yesterday evening. Found by police walking in the street and taken to the hospital. Resident #1 has dementia and cannot tell me specifics of events. Resident #1 has moderate to advanced dementia. Assessment and Plan indicated 1) Resident #1 had eloped/wandered out of the building. This is very unusual behavior for patient. Today patient is at baseline mental status/behavior. Patient has wander guard on. Monitor mood and behavior. Does not need 1:1 supervision. 2) Dementia, moderate to advanced - needs 24 hour supervision. In a telephone interview on 8/21/17 at 9:34 AM, the Attending Physician for Resident #1 said Resident #1 was not able to make good decisions due to his dementia, schizophrenia, and Parkinson's. He would not be safe in the street. Review of the Psychiatric assessment dated [DATE] documented Resident #1 was restless and had no memory of leaving the facility. Staff reports patient is wandering more and goes to the front door frequently. Patient eloped from the facility this past Sunday, patient was confused and did not know who he was or where he was. Resident #1 had poor insight, poor judgement, severely impaired short term memory and moderately impaired long term memory. In an interview on 8/16/17 at 4:09 PM, LVN A said she gave Resident #1 his medications at 4 PM on 6/04/17, which included 5 units of Humalog (a fast-acting insulin. He needed to be fed within 5-10 minutes to prevent a possible drop in his blood sugar). He was going to dinner after that. LVN A said she last saw Resident #1 as he was walking towards the lobby around 6:30 PM. When she was going to give him his 8:00 PM medications around 7, Resident #1 was not in his room. She said she continued on her med pass and about 8:50 PM (2-1/2 hours after she last saw him), she asked the CNAs (Certified Nurse Aides) where he was and they started looking for him as his dinner tray was in his room untouched. They called the Code Silver and began searching. She said there were a lot of visitors that day and maybe he tagged along with them. The front lobby doors were unlocked and visitors could enter and exit without having to be let in or out by a staff member. LVN A said the alarm for the wander guard should have sounded but she did not remember hearing an alarm that Sunday evening. LVN A said Resident #1 is confused and she felt the resident could not safely cross the street. His gait was not steady. In a telephone interview on 8/17/17 at 5:47 PM., CNA (Certified Nurse Aide) C said she took care of Resident #1 on Saturday 6/03/17 and Sunday 6/04/17 from 6 AM to 10 PM. She said she was not told Resident #1 had been found outside of the building on Friday 6/02/17. CNA C said Resident #1 will walk around a lot in the evenings. She said she's not aware of him trying to get out of the building before. CNA C said she last saw Resident #1 about 5 or 5:30 PM on 6/04/17 as he was heading for the dining room. She said LVN A was looking for him later in the shift but wasn't sure the time. When LVN A asked her where Resident #1 was she went to his room and saw his uneaten dinner tray was still in his room but he was not anywhere around. She told this to LVN A. She began looking for him and could not find him so a silver alert was called and the staff began looking inside and outside for him. She said that the doors were not locked during daytime hours, only after dark. She said that when a resident with a wander guard leaves or gets close to the doors that they will beep. She said she did not hear an alarm on 6/04/17 that evening. In an interview on 8/16/17 at 11:31 AM, LVN B said Resident #1 paces in the evenings when he becomes confused. LVN B said he thinks Resident #1 probably slipped out with a visitor on 6/02/17. He did not have a wander guard bracelet at that time; it was placed afterwards. The LVN said all of the exit doors have alarms. LVN B said residents with wander guards were monitored every 2 hours. When asked where that was documented he said he was not sure and would check. In an interview on 8/16/17 at 2:31 PM., the Director of Nurses (DON) said she did not remember being notified Resident #1 was found outside of the building on 6/02/17. She said she was informed Resident #1 was missing on 6/04/17 about 9 PM by the nurse. She came to the building and the staff was searching inside and outside. She called 9-1-1 and when she gave them a description of Resident #1, the operator said he was picked up by the fire department and was at a local hospital. She said she did not know how he got out of the facility. The wander guard alarms will beep when a resident with a wander guard bracelet is close to the door. She said no one remembers hearing an alarm when Resident #1 eloped on 6/04/17, but when he returned from the hospital the alarm sounded and they had to put in the keypad code to let the ambulance drivers and resident in. The DON said she and the Administrator took every resident with a wander guard to the front door on the evening of 6/04/17 and all of the wander guards triggered the system by alarming and locking the door. In a telephone interview on 8/23/17 at 8:06 AM, LVN E said she has cared for Resident #1 for 4 years on the 2 PM - 10 PM shift on the weekends and he had never attempted to exit the building before 6/04/17. She said he did not even go into the lobby. LVN E said she did not work the weekend Resident #1 eloped but the next weekend she spoke with Resident #1. He said he was going for a walk and he said he walked out the front door. LVN E said the front doors were unlocked during the day, but would alarm and close when a resident with a wander guard got close enough to trigger the wander guard system. Visitors would hold open the doors for others to pass through. LVN E said prior to Resident #1's elopement, if the nurse suspected the wander guard bracelet was not working, the resident would be taken to a door with a wander guard system to see if it triggered the alarm. Wander guard bracelets were only visually checked for presence on the resident as there was no scanner to check to see if the bracelet functioned. After he eloped the facility purchased scanners to check the function of the wander guard bracelets. In an interview on 8/16/17 at 2:31 PM a Policy and Procedure for the wander guard system and resident elopement prevention were requested of the DON. The DON said the facility did not have those policies. The Administrator verified that in an interview on 8/17/17 at 2:23 PM. No other information was provided. It was determined this failure placed Resident #1 in an Immediate Jeopardy from 6/02/17 until 6/17/17, when staff education and missing resident drills were completed. On 8/17/17 at 2:23 PM, the Administrator was informed there was an immediate jeopardy. The facility took the following action to correct the non-compliance: 1) Resident #1 was placed on 1:1 supervision 6/04/17 until physician felt safe to come off . (6/05/17) 2) Vendor checked the wander guard system on 6/05/17 and found to be in working order. Door alarm cables changed out. Keypad codes changed. Staff had to key in code to allow visitors to leave the building. (Review of vendor Work Order # dated 6/05/17, # dated 6/22/17, # dated 6/21/17, # dated 6/19/17, # dated 6/16/17 and # dated 6/8/17) 2) Care conference with family (guardian) (6/07/17) to determine if needs could still be met. (Review of Nurse's Notes dated 6/07/17) 3) Reviewed all residents with wander guard placement for orders, documentation of checking of placement and function of the resident wander guard bracelets each shift, and documenting the expiration date of the bracelet device. (Review of Elopement/Wander Assessment Tools, Care Plans, Nurse's Notes and MARs for residents identified at risk for elopement from 6/5/17 - 6/7/17) (Observation of placement, function of bracelet and doors from 8/17/17 to 8/18/17) 4) CNA assignment sheets reviewed to reflect all residents at risk for elopement. (review of CNA Daily Assignment Sheets dated 6/06/17 and also those dated 8/21/17) 5) Elopement binder updated to reflect all residents at risk for elopement. (Reviewed on 8/17/17) 6) Resident census used for each hallway when a missing resident alert called to document the presence/location of each resident. Signed by charge nurse to verify all residents accounted for. (Reviewed missing resident drills from 6/07/17 - 6/08/17 ) and also observed usage during missing resident drills on 8/21/17) 7) Missing Resident tool to review actions taken during an elopement situation. Reviewed form from 6/7/17 and 6/08/17) 8) In-services on wandering residents and elopement P&P (policy and procedure) of all staff with post-test. (Reviewed in-service 6/07/17 through 6/14/17. Interviews conducted from 8/16/17 through 8/22/17 with licensed nurses, certified aides and ancillary staff confirmed education received.) There was no P&P entitled Elopement, there was one entitled Missing Resident. 9) Maintenance to ensure all doors are functioning properly. ( Maintenance door checks reviewed from May 2017 though 8/22/17. Interview on 8/20/16 with the Administrator and on 8/21/17 with Maintenance Director verified door alarm checks). 10) Door alarm drills on each shift 2 times a week for 2 weeks including weekends. (Reviewed records for door drills, missing resident 6/05/17, 6/09/17, 6/11/17, 6/15-17/17, 8/19-21/17) 11) QA meeting with the Safety Committee was held on 6/9/17. (Reviewed sign-in sheet) According to the list provided by Assistant Director of Nurses (ADON) F on 8/18/17, there were 14 residents identified as being elopement risks.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibited neglect for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to adequately supervise residents identified at risk of elopement. On Friday, 6/02/17 at 4:00 PM, Resident #1, who had a history of [REDACTED]. A wander guard was placed on his ankle. On 6/04/17, the weekend staff, unaware Resident #1 left the building on Friday afternoon, last saw Resident #1 at 6:30 PM. He walked out the unsecured front door which had a wander guard system, without the facility being aware, and traveled approximately 1.7 miles uphill along heavily trafficked streets and crossed 2 busy 4 lane streets. Resident #1 was found by the police at 7:51 PM, confused and sweating heavily and was taken to the hospital at 8:22 PM by EMS (Emergency Medical Service). The facility staff noticed Resident #1 was missing around 9:00 PM when he was not available for his nightly medications and his meal tray was still in his room. When 9-1-1 was called, the dispatcher said a man matching the description given of Resident #1 was at a local hospital. Resident #1 was returned to the facility by ambulance at 11:07 PM. This was determined to be past non-compliance immediate jeopardy from 6/02/17 to 6/17/17 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could have affected 14 residents, identified by the facility of having elopement risk behaviors, by exposing them to risk of injury or death due to inappropriate monitoring. The findings included: Review of the facility policy Abuse Policy revised 12/05/16 stated in part: The resident has the right to be free form abuse, neglect, misappropriation and exploitation. The facility must prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. Review of Face Sheet dated 6/06/17 documented Resident #1 was an [AGE] year old man admitted to the facility on [DATE] and readmitted on [DATE]. Review of the facility History and Physical (H&P) dated 5/24/17 documented [DIAGNOSES REDACTED]. The H&P stated Resident #1 had increased behaviors/wandering at night. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] documented in part: impaired vision, BIMS (Basic Interview Mental Status) score of 3 out of 15 (severely impaired cognitive ability for daily decision-making), wandering behaviors 1-3 days per week, required set-up help with supervision for transfer and walking and had active [DIAGNOSES REDACTED]. Review of Elopement/Wandering Assessment Tool dated 6/02/17 documented Resident #1's was at a moderate risk for elopement. He scored yes as he was physically able to leave the building, disoriented to place and current behavior of wandering/exit-seeking. Review of Nurse's Notes dated 6/02/17 documented Resident #1 was found by visitors who said resident was attempting to go to parking lot. Resident said he was going for a walk. He was redirected inside the building. A wander guard was placed on his left ankle. Review of Resident #1's Comprehensive Plan of Care dated 6/02/17 documented in part the following: a. Problem: Resident deemed at risk for wandering, is ambulatory and indications of dementia. Approach: Observe and document resident's location every 2 hours, Report any attempts to exit the facility, Place a wander guard colored Identification Bracelet on the resident for easy identification of resident. b. Problem: Wander Guard Bracelet and is at risk for injury from wandering in an un-safe environment. Approach: Monitor for placement every shift, monitoring for proper functioning every 24 hours. Review of Resident #1's Nurse's Notes dated 6/02/16 - 6/04/17 there was no documentation the resident was monitored, including his location, every 2 hours. Review of Incident/Accident Report dated 6/04/17 at 8:50 PM, by Licensed Vocational Nurse (LVN) A, documented the last time Resident #1 was seen was at 6:30 PM. At about 8:50 - 9:00 PM, the staff realized patient was no longer in the facility. Code Silver (missing resident alert) was announced, everyone started looking for resident in and out of the facility. The Summary of Investigation documented facility protocol was followed. Upon resident return, he was placed on 1 on 1. No injuries, medical and psych evaluations and wander guard in place. Review of the Provider Investigation Report dated 6/12/17, documented in part: On 6/04/17 at 8:00 PM Resident #1 was missing. His functional ability was no assistance, required no special supervision, was independently ambulatory, was interviewable but did not have the capacity to make informed decisions. He had a history of [REDACTED]. On 6/04/17, the evening nurse doing med pass found the resident was not in his room. The resident was found to be at a local hospital - no injuries reported. Resident returned to the facility the same evening. Review of the local police department Incident/Investigation Report dated 6/04/17 documented, in part: The officers arrived at a home at 7:51 PM on 6/04/17 after a report was received of a very elderly, confused man sitting on a rock wall. The officers approached Resident #1 who said he was lost. He was wearing several layers of clothing in 90 plus degree weather. The man stated he believed he was in a city in northern Mexico. The officers noted he was very wet due to perspiration and suspected he was dehydrated and summoned EMS. Review of the web site weather underground (www.wunderground.com), the documented temperature on 6/04/17 at the city airport ranged from 95 degrees Fahrenheit at 6 PM to 91.9 degrees Fahrenheit at 8 PM. Review of the local fire department Prehospital Care Report dated 6/04/17 documented patient was a [AGE] year old male. He was confused, his skin was diaphoretic, he complained of headache and chills. Patient stated he was wearing a jacket and was outside in the hot temperature climate all day. Patient was transported to the hospital for further evaluation. Review of the hospital emergency room record dated 6/04/17 documented Resident #1 arrived at 8:22 PM and was confused and complained of headache. Patient's clothing was wet. There were no injuries. The records documented at 10:14 PM the nursing director from (the facility) called and claimed the patient was one of theirs. At 10:30 PM, (the Business Development Specialist) came to claim patient and discharge instructions explained. Patient transported back to nursing home by ambulance at 10:50 PM. Observation on 8/16/17 at 1:57 PM, the most direct route from the facility to the house where Resident #1 was found measured 1.7 miles on the odometer. A mapping web site gave 2 indirect routes that were shorter (1.3) miles. Either route required Resident #1 to walk along 2 busy streets and cross 4 to 6 lanes of traffic twice, depending if he crossed at a light or in the middle of the street. All of the routes were majority uphill travel. Review of physician progress notes [REDACTED].#1 had wandered out of the building yesterday evening. Found by police walking in the street and taken to the hospital. Resident #1 has dementia and cannot tell me specifics of events. Resident #1 has moderate to advanced dementia. Assessment and Plan indicated 1) Resident #1 had eloped/wandered out of the building. This is very unusual behavior for patient. Today patient is at baseline mental status/behavior. Patient has wander guard on. Monitor mood and behavior. Does not need 1:1 supervision. 2) Dementia, moderate to advanced - needs 24 hour supervision. In a telephone interview on 8/21/17 at 9:34 AM, the Attending Physician for Resident #1 said Resident #1 was not able to make good decisions due to his dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. He would not be safe in the street. Review of the Psychiatric assessment dated [DATE] documented Resident #1 was restless and had no memory of leaving the facility. Staff reports patient is wandering more and goes to the front door frequently. Patient eloped from the facility this past Sunday, patient was confused and did not know who he was or where he was. Resident #1 had poor insight, poor judgement, severely impaired short term memory and moderately impaired long term memory. In an interview on 8/16/17 at 4:09 PM, LVN A said she gave Resident #1 his medications at 4 PM on 6/04/17, which included 5 units of Humalog (a fast-acting insulin. He needed to be fed within 5-10 minutes to prevent a possible drop in his blood sugar). He was going to dinner after that. LVN A said she last saw Resident #1 as he was walking towards the lobby around 6:30 PM. When she was going to give him his 8:00 PM medications around 7, Resident #1 was not in his room. She said she continued on her med pass and about 8:50 PM (2-1/2 hours after she last saw him), she asked the CNAs (Certified Nurse Aides) where he was and they started looking for him as his dinner tray was in his room untouched. They called the Code Silver and began searching. She said there were a lot of visitors that day and maybe he tagged along with them. The front lobby doors were unlocked and visitors could enter and exit without having to be let in or out by a staff member. LVN A said the alarm for the wander guard should have sounded but she did not remember hearing an alarm that Sunday evening. LVN A said Resident #1 is confused and she felt the resident could not safely cross the street. His gait was not steady. In a telephone interview on 8/17/17 at 5:47 PM., CNA (Certified Nurse Aide) C said she took care of Resident #1 on Saturday 6/03/17 and Sunday 6/04/17 from 6 AM to 10 PM. She said she was not told Resident #1 had been found outside of the building on Friday 6/02/17. CNA C said Resident #1 will walk around a lot in the evenings. She said she's not aware of him trying to get out of the building before. CNA C said she last saw Resident #1 about 5 or 5:30 PM on 6/04/17 as he was heading for the dining room. She said LVN A was looking for him later in the shift but wasn't sure the time. When LVN A asked her where Resident #1 was she went to his room and saw his uneaten dinner tray was still in his room but he was not anywhere around. She told this to LVN A. She began looking for him and could not find him so a silver alert was called and the staff began looking inside and outside for him. She said that the doors were not locked during daytime hours, only after dark. She said that when a resident with a wander guard leaves or gets close to the doors that they will beep. She said she did not hear an alarm on 6/04/17 that evening. In an interview on 8/16/17 at 11:31 AM, LVN B said Resident #1 paces in the evenings when he becomes confused. LVN B said he thinks Resident #1 probably slipped out with a visitor on 6/02/17. He did not have a wander guard bracelet at that time; it was placed afterwards. The LVN said all of the exit doors have alarms. LVN B said residents with wander guards were monitored every 2 hours. When asked where that was documented he said he was not sure and would check. In an interview on 8/16/17 at 2:31 PM., the Director of Nurses (DON) said she did not remember being notified Resident #1 was found outside of the building on 6/02/17. She said she was informed Resident #1 was missing on 6/04/17 about 9 PM by the nurse. She came to the building and the staff was searching inside and outside. She called 9-1-1 and when she gave them a description of Resident #1, the operator said he was picked up by the fire department and was at a local hospital. She said she did not know how he got out of the facility. The wander guard alarms will beep when a resident with a wander guard bracelet is close to the door. She said no one remembers hearing an alarm when Resident #1 eloped on 6/04/17, but when he returned from the hospital the alarm sounded and they had to put in the keypad code to let the ambulance drivers and resident in. The DON said she and the Administrator took every resident with a wander guard to the front door on the evening of 6/04/17 and all of the wander guards triggered the system by alarming and locking the door. In a telephone interview on 8/23/17 at 8:06 AM, LVN E said she has cared for Resident #1 for 4 years on the 2 PM - 10 PM shift on the weekends and he had never attempted to exit the building before 6/04/17. She said he did not even go into the lobby. LVN E said she did not work the weekend Resident #1 eloped but the next weekend she spoke with Resident #1. He said he was going for a walk and he said he walked out the front door. LVN E said the front doors were unlocked during the day, but would alarm and close when a resident with a wander guard got close enough to trigger the wander guard system. Visitors would hold open the doors for others to pass through. LVN E said prior to Resident #1's elopement, if the nurse suspected the wander guard bracelet was not working, the resident would be taken to a door with a wander guard system to see if it triggered the alarm. Wander guard bracelets were only visually checked for presence on the resident as there was no scanner to check to see if the bracelet functioned. After he eloped the facility purchased scanners to check the function of the wander guard bracelets. Policies and Procedures for the wander guard system and resident elopement prevention were requested of the DON on 8/16/17. The DON said the facility did not have those policies. The Administrator verified that on 8/17/17 at 2:23 PM. No other information was provided. It was determined this failure placed Resident #1 in an Immediate Jeopardy from 6/02/17 until 6/17/17, when staff education and missing resident drills were completed. On 8/17/17 at 2:23 PM, the Administrator was informed there was an immediate jeopardy. The facility took the following action to correct the non-compliance: 1) Resident #1 was placed on 1:1 supervision 6/04/17 until physician felt safe to come off . 2) Vendor checked the wander guard system on 6/05/17 and found to be in working order. Door alarm cables changed out. Keypad codes changed. Staff had to key in code to allow visitors to leave the building. (Review of vendor Work Order # dated 6/05/17, # dated 6/22/17, # dated 6/21/17, # dated/19/17, # dated 6/16/17 and # dated 6/8/17) 2) Care conference with family (guardian) (6/07/17) to determine if needs could still be met. (Review of Nurse's Notes dated 6/07/17) 3) Reviewed all residents with wander guard placement for orders, documentation of checking of placement and function of the resident wander guard bracelets each shift, and documenting the expiration date of the bracelet device. (Review of Elopement/Wander Assessment Tools, Care Plans, Nurse's Notes and MARs for residents identified at risk for elopement from 6/5/17 - 6/7/17) (Observation of placement, function of bracelet and doors from 8/17/17 to 8/18/17) 4) CNA assignment sheets reviewed to reflect all residents at risk for elopement. (review of CNA Daily Assignment Sheets dated 6/06/17 and also those dated 8/21/17) 5) Elopement binder updated to reflect all residents at risk for elopement. (Reviewed on 8/17/17) 6) Resident census used for each hallway when a missing resident alert called to document the presence/location of each resident. Signed by charge nurse to verify all residents accounted for. (Reviewed missing resident drills from 6/07/17 - 6/08/17 ) and also observed usage during missing resident drills on 8/21/17) 7) Missing Resident tool to review actions taken during an elopement situation. Reviewed form from 6/7/17 and 6/08/17) 8) In-services on wandering residents and elopement P&P (policy and procedure) of all staff with post-test. (Reviewed in-service 6/07/17 through 6/14/17. Interviews conducted from 8/16/17 through 8/22/17 confirmed education received.) There was no P&P entitled Elopement, there was one entitled Missing Resident. 9) Maintenance to ensure all doors are functioning properly. ( Maintenance door checks reviewed from May 2017 though 8/22/17. Interview on 8/20/16 with the Administrator and on 8/21/17 with Maintenance Director verified door alarm checks). 10) Door alarm drills on each shift 2 times a week for 2 weeks including weekends. (Reviewed records for door drills, missing resident 6/05/17, 6/09/17, 6/11/17, 6/15-17/17, 8/19-21/17) 11) QA meeting with the Safety Committee was held on 6/9/17. (Reviewed sign-in sheet) According to the list provided by Assistant Director of Nurses (ADON) F on 8/18/17, there were 14 residents identified as being elopement risks.

Based on observation, interview and record review the facility failed to prohibit and prevent neglect for 1 (Resident #1) of 5 residents reviewed for neglect The facility failed to adequately supervise residents identified at risk of elopement. On Friday, 6/02/17 at 4:00 PM, Resident #1, who had a history of [REDACTED]. A wander guard was placed on his ankle. On 6/04/17, the weekend staff, unaware Resident #1 left the building on Friday afternoon, last saw Resident #1 at 6:30 PM. He walked out the unsecured front door which had a wander guard system, without the facility being aware, and traveled approximately 1.7 miles uphill along heavily trafficked streets and crossed 2 busy 4 lane streets. Resident #1 was found by the police at 7:51 PM, confused and sweating heavily and was taken to the hospital at 8:22 PM by EMS (Emergency Medical Service). The facility staff noticed Resident #1 was missing around 9:00 PM when he was not available for his nightly medications and his meal tray was still in his room. When 9-1-1 was called, the dispatcher said a man matching the description given of Resident #1 was at a local hospital. Resident #1 was returned to the facility by ambulance at 11:07 PM. This was determined to be past non-compliance immediate jeopardy from 6/02/17 to 6/17/17 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could have affected 14 residents, identified by the facility of having elopement risk behaviors, by exposing them to risk of injury or death due to inappropriate monitoring. The findings included: Review of Face Sheet dated 6/06/17 documented Resident #1 was an [AGE] year old man admitted to the facility on [DATE] and readmitted on [DATE]. Review of the facility History and Physical (H&P) dated 5/24/17 documented [DIAGNOSES REDACTED]. The H&P stated Resident #1 had increased behaviors/wandering at night. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] documented in part: impaired vision, BIMS (Basic Interview Mental Status) score of 3 out of 15 (severely impaired cognitive ability for daily decision-making), wandering behaviors 1-3 days per week, required set-up help with supervision for transfer and walking and had active [DIAGNOSES REDACTED]. Review of Elopement/Wandering Assessment Tool dated 6/02/17 documented Resident #1's was at a moderate risk for elopement. He scored yes as he was physically able to leave the building, disoriented to place and current behavior of wandering/exit-seeking. Review of Nurse's Notes dated 6/02/17 documented Resident #1 was found by visitors who said resident was attempting to go to parking lot. Resident said he was going for a walk. He was redirected inside the building. A wander guard was placed on his left ankle. Review of Resident #1's Comprehensive Plan of Care dated 6/02/17 documented in part the following: a. Problem: Resident deemed at risk for wandering, is ambulatory and indications of dementia. Approach: Observe and document resident's location every 2 hours, Report any attempts to exit the facility, Place a wander guard colored Identification Bracelet on the resident for easy identification of resident. b. Problem: Wander Guard Bracelet and is at risk for injury from wandering in an un-safe environment. Approach: Monitor for placement every shift, monitoring for proper functioning every 24 hours. Review of Resident #1's Nurse's Notes dated 6/02/16 - 6/04/17 there was no documentation the resident was monitored, including his location, every 2 hours. Review of Incident/Accident Report dated 6/04/17 at 8:50 PM, by Licensed Vocational Nurse (LVN) A, documented the last time Resident #1 was seen was at 6:30 PM. At about 8:50 - 9:00 PM, the staff realized patient was no longer in the facility. Code Silver (missing resident alert) was announced, everyone started looking for resident in and out of the facility. The Summary of Investigation documented facility protocol was followed. Upon resident return, he was placed on 1 on 1. No injuries, medical and psych evaluations and wander guard in place. Review of the Provider Investigation Report dated 6/12/17, documented in part: On 6/04/17 at 8:00 PM Resident #1 was missing. His functional ability was no assistance, required no special supervision, was independently ambulatory, was interviewable but did not have the capacity to make informed decisions. He had a history of [REDACTED]. On 6/04/17, the evening nurse doing med pass found the resident was not in his room. The resident was found to be at a local hospital - no injuries reported. Resident returned to the facility the same evening. Review of the local police department Incident/Investigation Report dated 6/04/17 documented, in part: The officers arrived at a home at 7:51 PM on 6/04/17 after a report was received of a very elderly, confused man sitting on a rock wall. The officers approached Resident #1 who said he was lost. He was wearing several layers of clothing in 90 plus degree weather. The man stated he believed he was in a city in northern Mexico. The officers noted he was very wet due to perspiration and suspected he was dehydrated and summoned EMS. Review of the web site weather underground (www.wunderground.com), the documented temperature on 6/04/17 at the city airport ranged from 95 degrees Fahrenheit at 6 PM to 91.9 degrees Fahrenheit at 8 PM. Review of the local fire department Prehospital Care Report dated 6/04/17 documented patient was a [AGE] year old male. He was confused, his skin was diaphoretic, he complained of headache and chills. Patient stated he was wearing a jacket and was outside in the hot temperature climate all day. Patient was transported to the hospital for further evaluation. Review of the hospital emergency room record dated 6/04/17 documented Resident #1 arrived at 8:22 PM and was confused and complained of headache. Patient's clothing was wet. There were no injuries. The records documented at 10:14 PM the nursing director from (the facility) called and claimed the patient was one of theirs. At 10:30 PM, (the Business Development Specialist) came to claim patient and discharge instructions explained. Patient transported back to nursing home by ambulance at 10:50 PM. Observation on 8/16/17 at 1:57 PM, the most direct route from the facility to the house where Resident #1 was found measured 1.7 miles on the odometer. A mapping web site gave 2 indirect routes that were shorter (1.3) miles. Either route required Resident #1 to walk along 2 busy streets and cross 4 to 6 lanes of traffic twice, depending if he crossed at a light or in the middle of the street. All of the routes were majority uphill travel. Review of physician progress notes [REDACTED].#1 had wandered out of the building yesterday evening. Found by police walking in the street and taken to the hospital. Resident #1 has dementia and cannot tell me specifics of events. Resident #1 has moderate to advanced dementia. Assessment and Plan indicated 1) Resident #1 had eloped/wandered out of the building. This is very unusual behavior for patient. Today patient is at baseline mental status/behavior. Patient has wander guard on. Monitor mood and behavior. Does not need 1:1 supervision. 2) Dementia, moderate to advanced - needs 24 hour supervision. In a telephone interview on 8/21/17 at 9:34 AM, the Attending Physician for Resident #1 said Resident #1 was not able to make good decisions due to his dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. He would not be safe in the street. Review of the Psychiatric assessment dated [DATE] documented Resident #1 was restless and had no memory of leaving the facility. Staff reports patient is wandering more and goes to the front door frequently. Patient eloped from the facility this past Sunday, patient was confused and did not know who he was or where he was. Resident #1 had poor insight, poor judgement, severely impaired short term memory and moderately impaired long term memory. In an interview on 8/16/17 at 4:09 PM, LVN A said she gave Resident #1 his medications at 4 PM on 6/04/17, which included 5 units of Humalog (a fast-acting insulin. He needed to be fed within 5-10 minutes to prevent a possible drop in his blood sugar). He was going to dinner after that. LVN A said she last saw Resident #1 as he was walking towards the lobby around 6:30 PM. When she was going to give him his 8:00 PM medications around 7, Resident #1 was not in his room. She said she continued on her med pass and about 8:50 PM (2-1/2 hours after she last saw him), she asked the CNAs (Certified Nurse Aides) where he was and they started looking for him as his dinner tray was in his room untouched. They called the Code Silver and began searching. She said there were a lot of visitors that day and maybe he tagged along with them. The front lobby doors were unlocked and visitors could enter and exit without having to be let in or out by a staff member. LVN A said the alarm for the wander guard should have sounded but she did not remember hearing an alarm that Sunday evening. LVN A said Resident #1 is confused and she felt the resident could not safely cross the street. His gait was not steady. In a telephone interview on 8/17/17 at 5:47 PM., CNA (Certified Nurse Aide) C said she took care of Resident #1 on Saturday 6/03/17 and Sunday 6/04/17 from 6 AM to 10 PM. She said she was not told Resident #1 had been found outside of the building on Friday 6/02/17. CNA C said Resident #1 will walk around a lot in the evenings. She said she's not aware of him trying to get out of the building before. CNA C said she last saw Resident #1 about 5 or 5:30 PM on 6/04/17 as he was heading for the dining room. She said LVN A was looking for him later in the shift but wasn't sure the time. When LVN A asked her where Resident #1 was she went to his room and saw his uneaten dinner tray was still in his room but he was not anywhere around. She told this to LVN A. She began looking for him and could not find him so a silver alert was called and the staff began looking inside and outside for him. She said that the doors were not locked during daytime hours, only after dark. She said that when a resident with a wander guard leaves or gets close to the doors that they will beep. She said she did not hear an alarm on 6/04/17 that evening. In an interview on 8/16/17 at 11:31 AM, LVN B said Resident #1 paces in the evenings when he becomes confused. LVN B said he thinks Resident #1 probably slipped out with a visitor on 6/02/17. He did not have a wander guard bracelet at that time; it was placed afterwards. The LVN said all of the exit doors have alarms. LVN B said residents with wander guards were monitored every 2 hours. When asked where that was documented he said he was not sure and would check. In an interview on 8/16/17 at 2:31 PM, the Director of Nurses (DON) said she did not remember being notified Resident #1 was found outside of the building on 6/02/17. She said she was informed Resident #1 was missing on 6/04/17 about 9 PM by the nurse. She came to the building and the staff was searching inside and outside. She called 9-1-1 and when she gave them a description of Resident #1, the operator said he was picked up by the fire department and was at a local hospital. She said she did not know how he got out of the facility. The wander guard alarms will beep when a resident with a wander guard bracelet is close to the door. She said no one remembers hearing an alarm when Resident #1 eloped on 6/04/17, but when he returned from the hospital the alarm sounded and they had to put in the keypad code to let the ambulance drivers and resident in. The DON said she and the Administrator took every resident with a wander guard to the front door on the evening of 6/04/17 and all of the wander guards triggered the system by alarming and locking the door. In a telephone interview on 8/23/17 at 8:06 AM, LVN E said she has cared for Resident #1 for 4 years on the 2 PM - 10 PM shift on the weekends and he had never attempted to exit the building before 6/04/17. She said he did not even go into the lobby. LVN E said she did not work the weekend Resident #1 eloped but the next weekend she spoke with Resident #1. He said he was going for a walk and he said he walked out the front door. LVN E said the front doors were unlocked during the day, but would alarm and close when a resident with a wander guard got close enough to trigger the wander guard system. Visitors would hold open the doors for others to pass through. LVN E said prior to Resident #1's elopement, if the nurse suspected the wander guard bracelet was not working, the resident would be taken to a door with a wander guard system to see if it triggered the alarm. Wander guard bracelets were only visually checked for presence on the resident as there was no scanner to check to see if the bracelet functioned. After he eloped the facility purchased scanners to check the function of the wander guard bracelets. Policies and Procedures for the wander guard system and resident elopement prevention were requested of the DON on 8/16/17. The DON said the facility did not have those policies. The Administrator verified that on 8/17/17 at 2:23 PM. No other information was provided. Review of the facility policy Abuse Policy revised 12/05/16 stated in part: The resident has the right to be free form abuse, neglect, misappropriation and exploitation. The facility must prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. It was determined this failure placed Resident #1 in an Immediate Jeopardy from 6/02/17 until 6/17/17, when staff education and missing resident drills were completed. On 8/17/17 at 2:23 PM, the Administrator was informed there was an immediate jeopardy. The facility took the following action to correct the non-compliance: 1) Resident #1 was placed on 1:1 supervision 6/04/17 until physician felt safe to come off . 2) Vendor checked the wander guard system on 6/05/17 and found to be in working order. Door alarm cables changed out. Keypad codes changed. Staff had to key in code to allow visitors to leave the building. (Review of vendor Work Order # dated 6/05/17, # dated 6/22/17, # dated 6/21/17, # dated 6/19/17, # dated 6/16/17 and # dated 6/8/17) 2) Care conference with family (guardian) (6/07/17) to determine if needs could still be met. (Review of Nurse's Notes dated 6/07/17) 3) Reviewed all residents with wander guard placement for orders, documentation of checking of placement and function of the resident wander guard bracelets each shift, and documenting the expiration date of the bracelet device. (Review of Elopement/Wander Assessment Tools, Care Plans, Nurse's Notes and MARs for residents identified at risk for elopement from 6/5/17 - 6/7/17) (Observation of placement, function of bracelet and doors from 8/17/17 to 8/18/17) 4) CNA assignment sheets reviewed to reflect all residents at risk for elopement. (review of CNA Daily Assignment Sheets dated 6/06/17 and also those dated 8/21/17) 5) Elopement binder updated to reflect all residents at risk for elopement. (Reviewed on 8/17/17) 6) Resident census used for each hallway when a missing resident alert called to document the presence/location of each resident. Signed by charge nurse to verify all residents accounted for. (Reviewed missing resident drills from 6/07/17 - 6/08/17 and also observed usage during missing resident drills on 8/21/17) 7) Missing Resident tool to review actions taken during an elopement situation. Reviewed form from 6/7/17 and 6/08/17) 8) In-services on wandering residents and elopement P&P (policy and procedure) of all staff with post-test. (Reviewed in-service 6/07/17 through 6/14/17. Interviews conducted from 8/16/17 through 8/22/17 confirmed education received.) There was no P&P entitled Elopement, there was one entitled Missing Resident. 9) Maintenance to ensure all doors are functioning properly. ( Maintenance door checks reviewed from May 2017 though 8/22/17. Interview on 8/20/16 with the Administrator and on 8/21/17 with Maintenance Director verified door alarm checks). 10) Door alarm drills on each shift 2 times a week for 2 weeks including weekends. (Reviewed records for door drills, missing resident 6/05/17, 6/09/17, 6/11/17, 6/15-17/17, 8/19-21/17) 11) QA meeting with the Safety Committee was held on 6/9/17. (Reviewed sign-in sheet) According to the list provided by Assistant Director of Nurses (ADON) F on 8/18/17, there were 14 residents identified as being elopement risks.

Based on observation, interview, and record review, the facility failed ensure assistance devices and supervision were provided to prevent falls for one resident (Resident #2) of 4 residents reviewed for accidents and supervision. Resident #2 was assessed by the facility to be at high risk for falls. The facility failed to implement measures to decrease fall risk. Resident #2 fell on [DATE] resulting in a fractured clavicle and subdural hematoma. This failure could affect 37 residents on fall precautions, placing them at risk of falls and injuries. Findings Included: Review of the Face sheet dated 11/14/16 revealed Resident #2 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of Resident #2 Fall Risk Assessment revealed: On 10/28/16 score = 14 On 11/10/16 score = 14. The document revealed total score of 10 or above represents high risk. Review of the Interim Plan of Care dated on 10/28/16 (date of admission) revealed no mention of high risk for falls. Review of Resident #2 ' s Minimum Data Assessment ((MDS) dated [DATE] revealed: Section G- Functional status: Resident #2 required 2 staff member for bed mobility: how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Resident #2 required 2 staff members for transfer: how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. Functional Limitations in Range of Motion that interfered with daily functions or placed resident at risk of injury: upper extremity (shoulder, elbow, wrist, hand) - impairment to one side. Lower extremity (hip, knee, ankle, foot) - impairment on both sides. Review of Investigation Facility Investigation Report dated 11/15/16 revealed the following: at approximately 1630 (4:30 PM) she (Resident #2) noticed on top of her leg rest by staff. Immediately she was aided and assessed. EMS was called to take her to the hospital. Resident #2 ' s family member came to the facility to inform the Director of Nursing that Resident #2 had sustained a fracture to the left shoulder and subdural hematoma. Review of Care Plan revealed falls were not included in the care plan until 11/14/16. Review of Nurses Notes dated 11/10/16 at 4:35 pm by Assistant Director of Nursing (ADON) G revealed: I saw resident on the floor on her back. I go on my knees to assess resident. I noticed her forehead was red, I asked her if she hit her head, she said yes. Asked her if her neck was hurting she said yes. So I told her not to move her head. Review of Nurses Notes dated 11/10/16 at 4:40 PM, by ADON F revealed: Asked Resident #2 what was she trying to do and how she fell , resident stated that she was fixing her sock. Review of Hospital Progress Note dated 11/10/16 revealed: CT scan/ CT brain without contrast, Impression 4mm right frontal subdural hematoma. No shift of midline structures. Basilar cisterns are normal. Small amount of soft tissue swelling is noted adjacent to the right frontal bone. Right distal clavicle fracture- very displaced but closed and in her paretic right upper extremity that she does not use. In an interview on 11/28/16 at 3:45 PM, Resident #2 ' s daughter stated she had told LVN C Resident #2 needed a wheel chair alarm; she would slip out of her wheel chair. Resident #2 ' s daughter stated I told Licensed Vocational Nurse (LVN) C several times that my mom needed something to warn them she was about to fall, she would just say ok, or at one time she said ' we will get to it. She would try to get up, or start to slip down. We saw she never did get the alarm or talked to us about it, she ignored us completely. In an interview on 12/6/16 at LVN E stated when the Fall Risk Assessment scored higher than a 10 we start the precautions, get order for fall mats or alarms. LVN E stated when family members request wheel chair alarms we (nurses) are supposed to call the doctor and let them decide if they will give us an order. In an interview on 12/6/16 at LVN B stated if residents score higher than a 10 on that fall risk assessment we start the precautions, fall mat, the alarm do what we can to protect the resident. In an interview on 12/16/16 at 2:35 PM, LVN C stated if a resident scored higher that what the indicated number on the Fall Risk Assessment we would call the doctor and get the alarms. LVN C stated she did not remember Resident #2 ' s family members asking her for any wheel chair alarms. In an interview on 11/28/16 at 4:15 PM, the Director of Nursing (DON) stated she was notified after Resident #2 ' s fall on 11/10/16 that the family had notified LVN C there was a need for a wheel chair alarm. The DON stated LVN C did not say anything to her about the family ' s request and concerns. The DON stated if she would have said something then we would have done interventions to see if something could be done. LVN C did not explain the process well to Resident #2 ' s daughter. In an interview on 11/28/16 at 4:55 PM, the Nursing Home Administrator (NHA) stated if Resident #2 scored as a high risk on the Fall Risk Assessment then we would of done everything, the floor mat, the wheel chair alarm, everything. The NHA stated LVN C knew the family was saying Resident #2 needed something, they were asking for something and she did not get it she knew the resident needed something for her care and did not get it that is neglect. The NHA stated in her interview with LVN C before she fired her, LVN C admitted being aware Resident #2 ' s family requested a wheel chair alarm. The NHA stated LVN C disclosed the family had complaints and concerns about the lack of fall prevention methods and had communicated them to LVN C and she never informed the DON or the NHA. The NHA stated LVN C did not notify her family was requesting a wheel chair alarm prior to the fall. The NHA stated LVN C did not follow policy regarding the family ' s request. The DON stated if the family that knows her more is saying she can fall, the nurse was aware of that she should have said something to us. Review of the Incident /Accident Reporting and Supervision policy dated (5/2005) revealed the following: It is the policy of this facility to provide an environment that is free from hazards over which the facility has control and provides supervision and assistance devices to each resident to prevent avoidable accidents. Implement interventions, including adequate supervision, consistent with resident ' s needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. Review of the Incident/Accident Reporting and Supervision dated (11/07) revealed: It is the policy of this facility to provide an environment that is free from hazards over which the facility has control and provides supervision and assistive to each resident to prevent avoidable accidents. Implement interventions including adequate supervision consisted with resident ' s needs goals plan of care and current standards of practice in order to reduce the risk of an accident and or monitor the effectiveness of interventions and modifies the interventions as necessary in accordance with current standards of practice. In an interview on 12/16/16 at 6:00 PM, the DON stated there were 37 residents on fall precautions residing in the facility.

Based on observation, interview and record review the facility failed to ensure 1 (ID #1) of 8 residents reviewed for pressure sores received the necessary care and treatment to prevent new pressure sores from developing and to promote the healing of current pressure sores as evidenced by: A. Resident #1 had a pressure ulcer that deteriorated from a skin tear to a Stage IV within 30 days. The facility did not properly identify or treat this area. B. Resident #1 had open areas and eschar on both feet. The facility did not identify, assess, or provide the ordered pressure relieving devices. This deficient practice resulted in an immediate jeopardy identified on 2/27/15. While the immediate jeopardy was removed on 3/4/15, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. The failure could affect the 11 residents identified with pressure ulcers by placing them at risk of delayed treatment and interventions to prevent pressure ulcer development and deterioration. The findings are: Resident #1: Review of the Admission Record dated 2/23/2015 revealed Resident #1 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Annual Minimum Data Set ((MDS) dated [DATE] documented no pressure ulcers, no other ulcers, wounds or skin problems, dependent on staff for bed mobility. Review of Care plan initiated date 5/16/13 and last updated 1/23/14 documented Resident #1 has potential for pressure ulcer development. The Goal listed was the resident will be free of preventable breakdown through next review date. The interventions included weekly skin assessments and resident to wear Prevalon boots. Review of Quarterly MDS dated [DATE] documented no pressure ulcers, no other ulcers, wounds or skin problems. Review of most recent physician orders [REDACTED].#1 had orders for Prevalon boots (pressure-relieving protector boots), initiated on 12/20/11, and Skin Assessment every week on Tuesday evening shift, initiated on 8/30/12. Review of Nurses notes dated 1-16-15 reported an open skin area to the left buttock. The treatment nurse was notified and treated the skin tear. Review of Nurses notes dated 1/18/15 reported found open area to left foot 2nd digit. Cleaned with normal saline, patted area and applied triple antibiotic ointment. Review of Nurses notes dated 2-8-15 reports Nurse Practitioner (NP) notified of wound to buttock noted pus and slough areas. New order received to clean with normal saline, pat dry, [MEDICATION NAME] to discolored area, santyl to slough area, dermaseptin to pink area, collegen to whole wound, cover with foam dressing. Review of physician progress notes [REDACTED].#1 seen due to hip buttock decubitus ulcer getting worse. As per nurse this ulcer started 2 - 3 weeks ago as a skin tear. Send to Wound Care Center for evaluation. Review of the Skin Condition report for the site left upper buttock revealed the following measurements: 1/17/15 - Length = 1.5 cm, Width = 1.5 cm, Depth = 0.4 - Clean with NS pat dry cover with border dressing 1/28/15 - Length = 1.7 cm, Width = 1.6 cm - Same treatment 2/2/15 - Length = 5.6 cm, Width = 3.7 cm 2/16/15 - Length = 6.5 cm, Width = 5.4 cm, Depth = 0.6 - Stage IV wound to left hip, 50% slough, 10% granulation, eschar (thick, dry, black necrotic tissue ) surrounding the wound. 2/23/15 - Length = 7.0 cm, Width = 8.5, Depth - 0 Review of Wound Care Center (WCC) notes revealed Resident #1 was not seen for 5 days on 2/18/15. Resident #1's first visit to the WCC she was accompanied by her sister and had a pressure ulcer to the left hip which had a large amount of drainage was covered with slough and measured; length 7.4cm, width 4.3cm depth 0.9cm and undermining 9-5 o ' clock 2.1cm. Review of Wound Care Center wound culture and sensitivity dated 2/18/15 identified 3 infectious bacteria. Review of Wound Care Center notes dated 2/23/15 documented Resident #1 was accompanied by her sister-in-law and described a large amount of exudate and necrotic tissue to the left hip pressure ulcer. The note also documented wounds noted to both feet that were not reported by the facility. Attached pictures of the right heel, left 2nd toe, left great toe, right great toe, right 2nd toe and the left hip documented the black necrotic eschar tissue. Review of Nurse ' s Notes dated 2/23/15 at 6:30 PM documented Resident #1 went for her wound care appointment, noted that her heels were reddened. Notified her Responsible Party (RP) regarding wounds and blackened discoloration of her toes. Physician also notified. Observation on 2/25/15 at 10:47 AM revealed Resident #1 in the dining room sitting in her Broda chair with her eyes closed. Resident #1 had blue bunny boots on. She was not wearing Prevalon boots as ordered. In an interview on 2/25/15 at 2:00 PM the Treatment Nurse (TN) said the Wound Care Center called him on 2/24/15 and told him Resident #1's feet had multiple pressure ulcers and were black. He was unaware of them. The TN said the charge nurses were supposed to do the weekly full body skin assessments on the residents to inspect their skin and look for any new areas of pressure or discoloration. Once wounds have been identified he will assess wounds. The TN said he had not done any assessments on Resident #1's skin. TN said he only does full body skin assessments on admission or re-admission. In an interview on 2/25/15 at 4:10 PM Registered Nurse (RN) N said she was the evening nurse for Resident #1. RN N said if a resident has a wound she does not do a skin assessment. She said the TN should do the full body skin assessment when they do the treatment. RN N said she had not inspected Resident #1's skin since she got a wound 1/16/15. Observation on 2/26/15 at 7:15 AM of the TN performing wound care on Resident #1 revealed the TN placed 2 pairs of gloves on then removed the bandage covering the "upper buttock area." The wound had thick green drainage on the bandage and in the cavity with a very strong foul odor; the wound was covered with thick yellow slough. The TN removed 1 pair of gloves and irrigated the wound with normal saline (NS). The TN measured the wound; length = 6.5 cm, width = 5.8 cm, depth = 1.5 cm, undermining 12 O ' clock to 4 O ' clock 1.7 cm and 4 O ' clock to 6 O ' clock 1.2 cm. The TN removed his gloves and put on 2 new pairs of gloves and removed the bandages from Resident #1's left foot revealing the great toe and next 2 toes were black/purple in color the small toe was black/purple on the bottom and side, the ball of the foot spanning all the way across the foot was black/purple. The TN applied skin prep to the heel, ball of foot and toes, and applied cream to the scaly top of the foot, ankle and lower leg. He removed 1 pair of gloves and placed gauze between the toes, and ABD pad over the heel and wrapped it all with rolled gauze. The TN put on 2 pairs of gloves revealing the right foot, the heel, the outer half of the ball of foot, and all 5 toes were black/purple in color, the right great toe and second toe had open areas. In an interview on 2/27/15 at 3:20 PM Resident #1's physician said the facility called her to report a skin tear to her left hip on 1/16/15. Resident #1 ' s physician said she looked at the left hip on 2/16/15 and immediately wrote an order for [REDACTED].#1 ' s physician said she spoke to the Responsible Party (RP) to request permission to place a gastric tube (GT)(a tube surgically inserted into to the stomach) but the RP refused a GT. Resident #1 ' s physician said she had just seen Resident #1's toes a few minutes earlier and they were necrotic (the localized death of cells or tissues). Resident #1's physician said she had telephoned the RP. In an interview on 2/27/15 at 9:15 AM TN said he became a Licensed Vocational Nurse (LVN) seven (7) months ago. TN said he was working 2pm to 10pm as a floor nurse but the treatment nurse position opened up and the hours were better so he switched. TN said the facility did not provide any training on being a wound care nurse. TN said he had to learn as he went along on the job. In an interview on 2/27/15 at 10:20 AM DON said there were no competencies for the wound care nurse and no one observed him doing wound care, but he can come and ask the DON if he has any questions. The DON said she was new to long term care she started December 22, 2014. The DON said she did not know who was supposed to do the full body skin assessment and she did not know what Prevalon boots were. In interviews on 2/25/14 at 11:15 AM, 2/26/15 at 9:21 AM, 2/27/15 at 7:30 AM and 3/2/15 at 2:55 PM with DON and NHA the Wound Care Nurse job description was requested, this was not provided. Review of Skin Management Policy revision date 2/1/14 documented in part: "... A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or in combination with shear A weekly skin evaluation is completed by the licensed nurse. A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers ..." Review of Pressure Ulcer Prevention and Skin Management revision date 12/04 documented in part: "... A licensed nurse shall complete a weekly skin assessment on each resident Measures to prevent the spread of infection shall be implemented The LN shall re-evaluate the wound for progression in healing weekly and implement treatment changes as indicated ..." An immediate jeopardy was identified on 2/27/15 and the Nursing Facility Administrator was informed at 12:02 PM on 2/27/15. On 3/4/15 the facility submitted their 5th corrective action plan of removal: "Removal of Immediacy On February 27, 2015 Medical Director, RN P and ADON I immediately began a review and evaluation of Resident #1 treatment plan for pressure ulcers. The assessment and reevaluation included a full body assessment, identification of the wounds, measurement, stage, documentation and validation of the treatment, review of the pressure ulcer risk assessment, pain evaluation and care plan prevention interventions. Pressure ulcer sites are: left hip, right heel and open areas on the left lateral bunion, right foot great toe, right foot 2nd toe, left foot 2nd toe, left foot great toe. Resident #1 is on a [MEDICATION NAME] pump and Tylenol #3 one bid and for pain management and [MEDICATION NAME] Patch, order obtained on 2/27/15. Resident #1 is on Tylenol #3 1 tablet 30 min before dressing changes. 3/2/15 Therapy is evaluating patient ' s bed mobility and staff training on resident ' s bed mobility and repositioning. On 2/27/15 Medical Director re-approached Resident #1's family regarding deteriorating condition and interventions, family member made decision to admit to hospital on [DATE] for further treatment. RN P and ADON I have taken wound care courses and/or have certifications on skin management. ADON I has been placed in the treatment nurse position and will be working with the wound care clinic on residents who have pressure ulcers. The wound nurse has been removed from the treatment nurse position. Identification of other residents having the potential to be affected was accomplished by: All residents will be evaluated for alterations of skin integrity. This will be completed by 3/1/15. Patients with pressure ulcer will receive a review of pressure ulcer risk assessments to validated prevention intervention by RN P and ADON I. Prevention intervention will be changed as necessary. RN P and ADON I contacted the physician for changes in current treatments for residents with existing open areas if indicated or obtained treatment orders for new alterations in skin integrity. The family or responsible parties are being notified. The care plans will be reviewed, implemented or revised with prevention interventions by the treatment nurse as indicated. This will be completed by 3/1/15 Additional Actions include: All residents were reassessed for turning and positioning/repositioning needs and those requiring assistance have been identified and are being monitored Residents were reassessed for need of specialty mattress and additional specialty mattresses were obtained on reassessment Residents were reassessed for need of Off-Loading devices and have ensured devices have been implemented/steps taken for odd-loading Nutritional Evaluations as indicated Actions taken/systems put into place to reduce the risk of future occurrence include: All nurses will be in serviced on identifying open areas, treatments and skin intervention measures by the Regional Nurse Consultant. All nurses will have their in-service completed by 3/2/15. All PRN staff be removed from the schedule and will receive in-service prior to working. The facility will use a systematic approach for pressure ulcer prevention and promotion of pressure ulcer healing that includes efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions and modify the interventions as appropriate. 1. Assessment of Pressure Ulcer Risk a. Pressure ulcer risk assessments will be conducted upon admission/re-admission, after a change of condition, after any newly identified pressure ulcer and quarterly. The DON/ADON will monitor the completion of the pressure ulcer risk assessments and the implementation of interventions to stabilize, reduce, or remove underlying risk factors. b. Full body skin assessments will be conducted upon admission/re-admission and after a change in condition, and after any newly identified pressure ulcer. The DON/ADON will monitor the completion of the pressure risk assessments. c. Interventions will be based on specific factors identified in the risk assessment and skin assessment (e.g. Moisture management, impaired mobility, nutritional deficit, etc.) 2. Interventions for Prevention and to Promote Healing a. Physicians are notified of alterations of skin integrity, treatment orders are obtained and preventive measures are reviewed with physician for input. b. Interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure ulcer present c. Interventions will be documented in the care plan d. Interventions will be modified as needed e Interventions will be communicated to nursing assistants and licensed nurses for patient care 3. Monitoring a. Resident full body skin assessments will be conducted weekly for patients by a licensed or registered nurse b. Resident full body skin assessments will be conducted daily for patients with pressure ulcer by a licensed or registered nurse c. Resident full body skin inspections will be conducted by nursing assistants during bathing two times a week and any concerns reported to the resident ' s nurse immediately after the task d. DON and ADON is monitoring the turning and repositioning of patients and Weekend Supervisor monitors the weekends e. During off-shifts the Charge Nurses are responsible for monitoring turning and reposition. All Nurses and CNA's will be in-serviced on process of resident full body skin inspections. This will be done by Regional Nurse Consultant. All Nurses and CNA's will have their in-service completed by 3/2/15. All PRN staff will be removed from schedule until they receive in-service prior to working next schedule shift. Monitoring For all patients with new alterations in skin integrity, the nurse will contact the physician to identify the type of wound and treatment for [REDACTED]. The DON will monitor/validate the nurses have contacted the physician regarding new patients with skin alteration/integrity and have documented the conversation in the clinical records. The Medical Director has been notified of the Immediate Jeopardy." Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented. The immediate jeopardy was removed effective 3/4/15 at 3:23 PM. The facility remained out of compliance at a scope and severity at a pattern of actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. According to the 672 dated 2/25/15 11 residents had pressure sores.

Based on interview, observation, and record review, the facility failed to implement their written policies and procedures that prohibit mistreatment, and abuse of residents. The facility failed to ensure allegations of abuse/neglect were thoroughly investigated and reported to the State survey and certification agency, and to prevent further potential abuse for 3 of 28 Residents (Resident #14, #15, #16 and #22) reviewed for incidents of abuse/neglect. A. On 11/03/14 at 5:15 AM, Licensed Vocational Nurse (LVN) H found lucid Resident #22 with his boxer shorts partially down, standing by the head of cognitively impaired Resident #15 's bed. Resident #15 was turned towards Resident #22 , when LVN H turned the room lights on she noticed Resident #15's face had a white substance covering his chin area, mouth, and cheeks, LVN H reported incident to Nursing Facility Administrator and the Director of Nurses on 11/03/14 at 7:00 AM.The NFA began an investigation on 11/03/14, but she ended the investigation and did not report the allegation of resident-to-resident sexual abuse to the State Agency until 11/07/14 at 6:54 p.m., 4.5 days after the incident occurred. Resident #22 was moved to a new room, with a new roomate (#19) B. Certified Nurse Aide (CNA) A verbally abused Resident #16 during the night of 11/03/14. Assistant Director of Nurses (ADON) I was notified on 11/04/14 by Resident #14's husband. The NFA did not notify the State Agency until 11/06/14 at 5:43 PM. An Immediate Jeopardy (IJ) was identified on 11/07/14 and the NFA was informed at 2:54 PM. While the IJ was removed on 11/10/14, the facility remained out of compliance at a scope and severity of actual harm at pattern because the facility had not monitored their plan for effectiveness. This failure could affect all 110 residents residing in the facility by placing them at risk for abuse. Failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of 3 (Residents #14, #15 and #18) of 28 residents reviewed for abuse and neglect. A. The facility failed to report allegations of abuse and neglect to the state agency within the required time frames for 2 (Residents #14 and #18) of residents reviewed for abuse and neglect. a. On 11/03/14 at 5:15 AM, Licensed Vocational Nurse (LVN) H found lucid Resident #22 with his boxer shorts partially down, standing by the head of cognitively impaired Resident #15 's bed. Resident #15 was turned towards Resident #22 , when LVN H turned the room lights on she noticed Resident #15's face had a white substance covering his chin area, mouth, and cheeks, LVN H reported incident to Nursing Facility Administrator and the Director of Nurses on 11/03/14 at 7:00 AM.The NFA began an investigation on 11/03/14, but she ended the investigation and did not report the allegation of resident-to-resident sexual abuse to the State Agency. The NFA reported the incident to the State Agency on 11/07/14, 4 days after the incident occurred. b. Certified Nurse Aide (CNA) A verbally abuse Resident #18 during the night of 11/03/14. Assistant Director of Nurses (ADON) I was notified on 11/04/14 by Resident #14's husband. The Nursing Facility Administrator (NFA) did not notify the State Agency until 11/06/14 at 5:43 PM. An Immediate Jeopardy (IJ) was identified on 11/07/14 and the NFA was informed at 2:54 PM. While the IJ was removed on 11/10/14, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at widespread because the facility had not monitored their plan for effectiveness. This failure could affect all 110 residents residing in the facility by placing them at risk for abuse or neglect. The findings included: Review of the facility policy Incident/Accident Reporting and Supervision revised November 2007 stated in part the following: Policy: It is the policy of this facility to report and investigate all incidents and accidents that occur in the facility or on facility property in a timely manner. Appropriate authorities will be notified in a timely manner for all reportable incidents and accidents. Incident: an unusual or unexpected event that is not consistent with the routine operation of the facility or the routine care of the resident. Procedure: 1. Immediately assess the condition of the person(s) involved in the incident/accident. 2. Initiate emergency first aid and determine need for acute emergency care. 4. Immediately notify the Administrator, Director of Nursing or Department Head on duty. The Administrator and/or the Director of Nursing determine if the incident is reportable to the State Agencies. 5. Notify responsible parties via telephone and document the notification. 7. Make an entry of the incident/accident on the 24 hour report form. Review of the facility policy Abuse Prohibition Policy and Procedure revised July 2012 stated in part: Policy: The Facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and other State Agencies (if appropriate) will be notified in accordance with federal and state law. V. Investigation: The facility must have evidence that all violations, including allegations, are thoroughly investigated. The results of the investigation must be reported to the Administrator and to other officials in accordance with state law (including state survey agency and certification agency) within 5 working days of the incident. If the alleged violation is verified, appropriate corrective and disciplinary action will be taken. VII. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies. G. The Administrator or designated representative will immediately begin an investigation and follow the State Guidelines for reporting incidents and accidents. Investigation guidelines include: 1. Resident(s) and responsible party interviews, as applicable 2. Physical examination 3. Staff interviews and written statements, as applicable 4. Collaboration with state agencies 5. Methods to support the individual and detect and prevent further victimization. Record review of Resident #15's Admission Record Sheet, undated, revealed a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) dated 9/07/14 documented Resident #15 had a BIMS score of 3 out of 15 indicating severe cognitive impairment. Record Review of Resident #15's Care Plan revealed Resident #15 had an active care plan for which identified him for having " Cognitive function or impaired thought process related to Dementia " Record review of Resident #22's Admission Communication Record revealed a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #22's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 09/07/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) score as "14 " Indicating Resident #22's cognition was intact. Record Review of Incident/Accident Reports revealed an incident that took place on 11/03/14 at 5:15 a.m. involving Resident #15 and Resident #22. On incident report LVN H stated she walked into room E-6 to find Resident #15 lying in bed on his right side, facing the window, while Resident # 22 was standing, and facing Resident #15 with his boxers partially down. Observation during initial rounds with on 11/04/14 at 3:06 PM, Resident #22 was in his room and his roommate Resident #19 was present in the room. There was no staff present. Record Review on 11/05/14 of medical chart revealed no evidence of Resident # 22 being placed on 1:1 as per NFA had informed surveyor. In an interview with NFA on 11/07/14 at 9:20 a.m. NFA stated as a precutionary measure resident # 22 had been placed on 1:1 In a telephone interview on11/07/2014 at 12:00 p.m., LVN H stated she was making rounds early in the morning of 11/03/14 around 5:00 a.m. and that she was also passing the early morning medications and checking blood sugars for residents in the E-hall. LVN H said when she got to the room ,she knocked with her foot and the door opened and she immediately noticed Resident#15 in bed A lying down in his bed on his right side facing the window and Resident #22 who occupies bed B was standing close to resident #15's head , facing him, with his boxer shorts partially down. When Resident #22 saw her walk in the room he went to his side of the room and closed the curtains and got into his bed. LVN H stated she then looked at Resident #15 and asked him "what's going on?" And he didn't respond, she then asked Resident #22 the same question and he responded he was just turning on the light for Resident #15. LVN H said when she turned the light to the room on, she noticed Resident #15's face had a white crusty substance, which she noticed to also be on his chin area, cheeks and mouth area. LVN H said when she saw this on resident #15's face she became fearful for his safety and decided to have resident showered. LVN H called CNA F take resident #15 and shower him. LVN H stated she then asked Resident #22 what had happened and he responded that nothing had happened , that he was just turning on the light for Resident#15. LVN H said she felt uneasy, more so because of the way Resident #22 had reacted when she walked in the room. LVN H said after Resident #15 had been showered she placed Resident #15 by the nurse's station and asked him again "What happened" and he responded "nothing". Resident #15 asked LVN H "are you mad at me? " and she told him that she would be mad if he didn't tell her the truth as to what had happened in his room. Resident #15 went on to tell LVN H "The man wanted me to play sex games with him." LVH said she then asked Resident #15 "Well and did you" to which Resident #15 responded "Yes" Surveyor asked LVN H who had she reported incident to? And she stated she had made incident reports and when she informed her DON she was told not to worry that they would report everything to the police department and to the state. LVN H said she had informed NFA (Nursing Facility Administrator ) that she would be awake all day (LVN H works the 10p.m to 6 a.m. shift) to wait for their phone call in case they had questions for her, but they never called. In an interview on 11/05/14 at 11:15 a.m., Resident #15 was asked if anybody had ever being abusive towards him, or had made him feel uncomfortable, Resident #15 said " Yes " Surveyor than asked him if this happened recently and if it involved staff or another resident? Resident #15 took a while to respond and when he did he responded. " I don ' t know, I don ' t remember " and refused to talk again. In an interview on 11/07/14 at 11:34 a.m. with Restorative Nurse Assistant E (RNA) said she has worked in facility for 3 months, and has worked with both Resident #15 and Resident #22. RNA E said she did not witness incident that occurred on 11/03/14 involving Resident #15 and Resident #22, but was told by CNA F about the incident. RNA E stated she has worked with Resident #15 in the past and she has noticed Resident #15 ' s behavior has changed since the incident. RNA E said Resident #15 talks about the devil holding him down at night; RNA E said this is behavior that Resident # 15 had never displayed before. In a telephone Interview on 11/07/14 at 12:45p.m., CNA F stated she was called by LVN H on 11/03/14 at around 5:30a.m. to come and take Resident #15 to the shower and change and was told by LVN H not to leave resident #15 alone. She also stated when she first came to get resident #15 to shower she noticed he had a white fluid on his face, but mostly around his mouth, and that she had never before seen this on Resident # 15. CNA F said she noticed significant amount of blood stains on Resident #15 ' s bed. CNA F said she noticed resident #15 had cuts on the inside of his mouth, which she noticed when she cleaned his mouth with toothettes. CNA F was then asked if she had reported cuts and blood found to anyone. And CNA F responded she had informed LVN H. CNA F stated that once she brought Resident #15 and sat him by the nurse ' s station as per LVN H ' s request she overheard LVN H asking Resident #15 what had happened, and Resident #15 responded " He wanted me to play sex games with him " . LVN H then asked if he had in fact played the games with him and he responded " Yes " and said " Penis " and pointed to his mouth. CNA F said she didn ' t report the incident to anyone, since LVN H had told her, LVN H had said she would report it to the NFA and the DON. CNA F said she had noticed a change in Resident #15 ' s behavior and said he was now aggressive towards others and said this type of behavior wasn ' t present prior to incident. In a telephone interview on 11/07/14 at 3:30 p.m. with LVN H she was asked about the blood stains CNA F said she had found on Resident #15 ' s bed and had reported to her. LVN H said she had noticed stains on resident ' s bed but to her they looked like brownish stains that the laundry department couldn ' t get rid of. LVN H was also asked if she had assessed Resident # 15, and if she had seen the cuts in Resident # 15 ' s mouth. LVN H responded she hadn ' t seen any cuts, but stated she hadn ' t checked the inside of resident ' s mouth at the time of the assessment. In a telephone interview on 11/07/14 at 2:20 p.m., with Resident #15 ' s sister who stated she was informed of an incident that occurred on 11/03/14 involving her brother and his roommate (Resident #22) Resident # 15 ' s sister said she was informed her brother ' s roommate had been caught standing by his brother ' s bedside with his underwear halfway down. And that the roommate ' s Resident #22 ' s explanation was that he was trying to pull the privacy curtain because his roommate (Resident #15) had asked him to. Resident #15 ' s Sister stated she found this to be odd since her brother ' s roommate (Resident #22) had been found standing, and if he was only trying to pull the curtain there was no need for him to get up, since privacy curtains could be pulled when laying down. Sister denied knowing about blood stains, cuts or any other detail. Resident #15 " s Sister said she had been thinking about calling Nurse to find out if he (Resident #15) had a recent med change because of his recent behavior. Sister was asked as to what behavior, and she said her brother Resident #15 had recently asked her what kind of casket she was getting for him, she had asked Resident #15 why was he asking for type of casket and he (Resident #15) replied because he was going to die soon. Sister also said Resident #15 had mentioned his bed being full of cockroaches. Sister said he (Resident #15) had never had this behavior in the past and thought it could be due to a recent medication change. Sister said 2 days ago on 11/05/14 when she came and visited Resident # 15 he had told her " What ' s the point of taking him out of my room (Resident #22) If I could see him every day " However Resident #22 was discharged from facility on 11/04/14 In an interview on 11/07/14 at 9:20 a.m., the NFA, when asked for the investigation on the alleged sexual assault on Resident #15, She stated there was no investigation report because nothing happened. A patrolman from the local police department came and spoke with Resident #15 and Resident #22. The NFA said the policeman said nothing happened and did not fill out a report so the investigation was stopped. LVN B wrote in Resident #15 ' s Nurse ' s Notes that she did not like what she saw. The NFA said the nurse saw Resident #22 ' s briefs low on his buttocks. The NFA said Resident #22 has a big belly and his briefs hang low in the back exposing his " crack. " He sometimes does not button the fly on his briefs and is exposed. The NFA said the nurse assumed something had happened but NFA did not investigate. Because of this, sensitivity training was done. The NFA said, " Just because a man puts his hand on a woman ' s leg does not mean he wants something; he may just be trying to comfort her. " The NFA said both residents denied anything happened. Resident #15 did say they were involved in " sex games " but his family said he had dementia and could not say what that meant. Record Review of Incident reportdated 11/03/14 showed no investigation was conducted. On incident report dated 11/03/14 for Resident #22 under " Summary of Investigation " with the following entry: " Resident immediately went to side of room, got in bed, no further concerns voiced " under " Recommendations/New Interventions surveyor found the following entry: " Monitor resident, encouraged not to stand on his foot " Record Review of Incident Report dated 11/03/14 showed also that no investigation was conducted. On incident report dated 11/03/14 for Resident #15 under " Summary of Investigation " the following entry was documented " Assisted Resident (#15) with CNA to get him out of room as soon as possible and provide care as he needs. Up in front of nurses ' w/c (wheelchair) to keep in line of sight " under " Recommendations/New Interventions " the following entry was documented " Resident assessed to shower room, care provided, assisted to nurses ' station, remained in the line of site vision " Record Review showed no evidence of an investigation being done by facility Review of the "Texas Department of Aging and Disability Services Regulatory Services Incident Investigation Worksheet" for Incident # 3 revealed the Administrator reported the incident with Residents #22 and #15 to DADs on 11/7/14 at 6:54 p.m. (4.5 days after the incident) This was determined to be Immediate Jeopardy (IJ) on 11/07/14 at 2:54 PM and the Administrator and DON were notified. The Plan of Removal was accepted on 11/10/4 at 4:57 PM and it included the following: The facility investigated the allegation by interviewing Residents #15 and #22, staff who were present at the time, family members and alert and oriented residents. Witness statements were obtained. Resident #22 was discharged . Inservices were held on 11/07/14 through 11/09/14 on the facility abuse policy and procedure with a post test given. In-services on refraining from showering residents who have made an allegation of sexual abuse until a thorough assessment can be made were started. The Administrator reported the incident ot he State Agency. The facility will continue with in-services of staff not present prior to being allowed to work. The facility will monitor compliance to their abuse policy. Record review of Facility's In-Service Training Report, dated 11/10/14, revealed Administrator and DON had in-serviced facility staff on Abuse/Neglect to address the IJ in the area of failure to report and investigate. The in-service instructed staff that " All incidents must be reported, if you witnessed something you need to report to your immediate supervisor, if unable to tell immediate supervisor then go through the chain of command ... All identified issues is to be reported immediately within a 24 hour timeframe ...All identified issues must be thoroughly investigated with documentation to support findings ... The abuse coordinator is the Administrator..." While the IJ was removed on 11/10/14, the facility remained out of compliance at a level of potential for more than minimal harm and scope of "pattern" because staff were still being in-serviced and the facility was monitoring the effectiveness of their plan of removal. B. Record review of the Face Sheet dated 11/10/14 documented Resident #14 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Record review of the Face Sheet dated 11/10/14 documented Resident #16 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. In an interview on 11/6/14 at 3:40 PM, Resident #16 stated CNA A was "rude and mean to me it was my first night in this new room I was nervous." She stated on Monday night (11/3/14) she had frequent episodes of diarrhea. "The lady next door helped me call her, by the third time she came in to help me she (CNA A) said to me, "Don't eat too much so I don't have to keep coming back and clean your dirty diaper." Resident #16 stated the 4th time she called for help CNA A told her, "Don't you know how to sleep through the night? I was cold and asked her to help me put on my gray sweater. CNA A got it from the chair and threw it on my face and said to me in Spanish 'Como friegas' (English translation: 'You are a pain in the ass.')" Resident #16 stated, "I felt so bad, I wish I could change my own diaper, wipe myself and not bother anyone but I can't. I felt so embarrassed to ask for help already. I don't want to see that woman (CNA A) around me again; she makes me feel bad and nervous." In an interview on 11/6/14 at 12:10 PM, Resident #14's husband stated on 11/4/14 his wife told him "she was scared of a CNA that works at night." He stated that Resident #14 stated that during the night of 11/3/14 her roommate (Resident #16) needed help and she (Resident #14) pressed the call light for her. Resident #14's husband stated that his wife had heard a loud noise coming from Resident #16's bedside after CNA had answered the call bell. Resident #14's husband stated that noise had woken her and scared Resident #14. Resident #14's husband stated he was talking to his wife in her room when Resident #16 said CNA A had been the staff member that had been in their room that night and had thrown a jacket at her (Resident #16's) face. In an interview on 11/6/14 at 3:20 PM, Resident #14 stated she had pressed the call bell for her roommate who was asking for help the night on 11/3/14. She stated CNA A stated, "Why are you pressing the button? I am right here. I am always coming in here for her (Resident #16). Resident #14 stated she told CNA A "this is your job to take care of us, you should not complain." Resident #14 stated she fell back asleep and was waken up by a loud sound of metal hitting the wall or the floor. "I was scared I could not see what it was, I could see she (CNA A) was still there and I told her not to scare us, she said mind your own business." In an interview on 11/10/14 at 4:15 PM, ADON I stated on 11/4/14 she had been notified by Resident #14's husband that CNA A had "acted unprofessionally towards Resident #14 and Resident #16." She stated she had previously received another complaint regarding the same CNA from an alert resident and decided to suspend her. She stated she completed her incident reports and notified the Nursing Home Administrator who is the facility's abuse coordinator to complete the investigation. In the Abuse Coordinator Interview on 11/06/14 at 11:04 AM, the Nursing Facility Administrator (NFA), who identified herself as the Abuse Prohibition Coordinator, when asked if there were any current investigations, said, " All of them are closed. There was a report of a CNA being upset. We had a risk event call this morning and the CNA was suspended. The resident ' s name was (Resident #14). " The NFA said if there was an allegation of abuse, the CNA is suspended. A Risk Event call is held with the Vice President of Operations and the Vice President of Clinical Services. They talk about the occurrence and decide if it is reportable. The NFA said she had 24 hours to report. The census of 110 was obtained from the CMS 672 dated 11/05/14.

Based on interview, observation, and record review, the facility failed to implement their policies and procedures that prohibit mistreatment, and abuse of residents. The facility failed to ensure allegations of abuse/neglect were thoroughly investigated and reported to the State survey and certification agency, and to prevent further potential abuse for 4 of 28 Residents (Resident #14, #15, #16 and #22) reviewed for incidents of abuse/neglect. A. On 11/03/14 at 5:15 AM, Licensed Vocational Nurse (LVN) H found lucid Resident #22 with his boxer shorts partially down, standing by the head of cognitively impaired Resident #15 's bed. Resident #15 was turned towards Resident #22 , when LVN H turned the room lights on she noticed Resident #15's face had a white substance covering his chin area, mouth, and cheeks, LVN H reported incident to Nursing Facility Administrator and the Director of Nurses on 11/03/14 at 7:00 AM.The NFA began an investigation on 11/03/14, but she ended the investigation and did not report the allegation of resident-to-resident sexual abuse to the State Agency until 11/07/14 at 6:54 p.m., 4.5 days after the incident occurred. Resident #22 was moved to a new room, with a new roomate (#19) B. Certified Nurse Aide (CNA) A verbally abused Resident #16 during the night of 11/03/14. Assistant Director of Nurses (ADON) I was notified on 11/04/14 by Resident #14's husband. The NFA did not notify the State Agency until 11/06/14 at 5:43 PM. An Immediate Jeopardy (IJ) was identified on 11/07/14 and the NFA was informed at 2:54 PM. While the IJ was removed on 11/10/14, the facility remained out of compliance at a scope and severity of actual harm at pattern because the facility had not monitored their plan for effectiveness. This failure could affect all 110 residents residing in the facility by placing them at risk for abuse. The findings included: Record review of Resident #15's Admission Record Sheet, undated, revealed a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) dated 9/07/14 documented Resident #15 had a BIMS score of 3 out of 15 indicating severe cognitive impairment. Record Review of Resident #15's Care Plan revealed Resident #15 had an active care plan for which identified him for having " Cognitive function or impaired thought process related to Dementia " Record review of Resident #22's Admission Communication Record revealed a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #22's Minimum Data Set (MDS) 3.0-Quarterly Resident Assessment and Care Screening, dated 09/07/14, reflected in Section C: Cognitive Patterns, C0100 Brief Interview for Mental Status (BIMS) score as "14 " Indicating Resident #22's cognition was intact. Record Review of Incident/Accident Reports revealed an incident that took place on 11/03/14 at 5:15 a.m. involving Resident #15 and Resident #22. On incident report LVN H stated she walked into room E-6 to find Resident #15 lying in bed on his right side, facing the window, while Resident # 22 was standing, and facing Resident #15 with his boxers partially down. Observation during initial rounds with on 11/04/14 at 3:06 PM, Resident #22 was in his room and his new roommate Resident #19 was present in the room. There was no staff present. Record Review on 11/05/14 of medical chart revealed no evidence of Resident # 22 being placed on 1:1 as per NFA had informed surveyor. In an interview with NFA on 11/07/14 at 9:20 a.m. NFA stated as a precutionary measure resident # 22 had been placed on 1:1. In a telephone interview on11/07/2014 at 12:00 p.m., LVN H stated she was making rounds early in the morning of 11/03/14 around 5:00 a.m. and that she was also passing the early morning medications and checking blood sugars for residents in the E-hall. LVN H said when she got to the room E-6 she tried to knock with her foot because her hands were busy with the medications, glucometer and other supplies. She knocked with her foot and the door opened and she immediately noticed Resident#15 in bed A lying down in his bed on his right side facing the window and Resident #22 who occupies bed B was standing close to resident #15's head , facing him, with his boxer shorts partially down. When Resident #22 saw her walk in the room he went to his side of the room and closed the curtains and got into his bed. LVN H stated she then looked at Resident #15 and asked him "what's going on?" And he didn't respond, she then asked Resident #22 the same question and he responded he was just turning on the light for Resident #15. LVN H said when she turned the light to the room on, she noticed Resident #15's face had a white crusty substance, which she noticed to also be on his chin area, cheeks and mouth area. LVN H said when she saw this on resident #15's face she became fearful for his safety and decided to have resident showered. LVN H called CNA F take resident #15 and shower him. LVN H stated she then asked Resident #22 what had happened and he responded that nothing had happened , that he was just turning on the light for Resident#15. LVN H said she felt uneasy, more so because of the way Resident #22 had reacted when she walked in the room. LVN H said after Resident #15 had been showered she placed Resident #15 by the nurse's station and asked him again "What happened" and he responded "nothing". Resident #15 asked LVN H "are you mad at me? " and she told him that she would be mad if he didn't tell her the truth as to what had happened in his room. Resident #15 went on to tell LVN H "The man wanted me to play sex games with him." LVH said she then asked Resident #15 "Well and did you" to which Resident #15 responded "Yes" Surveyor asked LVN H who had she reported incident to? And she stated she had made incident reports and when she informed her DON she was told not to worry that they would report everything to the police department and to the state. LVN H said she had informed NFA (Nursing Facility Administrator ) that she would be awake all day (LVN H works the 10p.m to 6 a.m. shift) to wait for their phone call in case they had questions for her, but they never called. In an interview on 11/05/14 at 11:15 a.m., Resident #15 was asked if anybody had ever being abusive towards him, or had made him feel uncomfortable, Resident #15 said " Yes " Surveyor than asked him if this happened recently and if it involved staff or another resident? Resident #15 took a while to respond and when he did he responded. " I don ' t know, I don ' t remember " and refused to talk again. In an interview on 11/07/14 at 11:34 a.m. with Restorative Nurse Assistant E (RNA) said she has worked in facility for 3 months, and has worked with both Resident #15 and Resident #22. RNA E said she did not witness incident that occurred on 11/03/14 involving Resident #15 and Resident #22, but was told by CNA F about the incident. RNA E stated she has worked with Resident #15 in the past and she has noticed Resident #15 ' s behavior has changed since the incident. RNA E said Resident #15 talks about the devil holding him down at night; RNA E said this is behavior that Resident # 15 had never displayed before. In a telephone Interview on 11/07/14 at 12:45p.m., CNA F stated she was called by LVN H on 11/03/14 at around 5:30a.m. to come and take Resident #15 to the shower and change and was told by LVN H not to leave resident #15 alone. She also stated when she first came to get resident #15 to shower she noticed he had a white fluid on his face, but mostly around his mouth, and that she had never seen this on Resident # 15 before. CNA F said she noticed significant amount of blood stains on Resident #15 ' s bed. CNA F said she noticed resident #15 had cuts on the inside of his mouth, which she noticed when she cleaned his mouth with toothettes. CNA F was then asked if she had reported cuts and blood found to anyone. And CNA F responded she had informed LVN H. CNA F stated that once she brought Resident #15 and sat him by the nurse ' s station as per LVN H ' s request she overheard LVN H asking Resident #15 what had happened, and Resident #15 responded " He wanted me to play sex games with him " . LVN H then asked if he had in fact played the games with him and he responded " Yes " and said " Penis " and pointed to his mouth. CNA F said she didn ' t report the incident to anyone, since LVN H had told her she would report it to the NFA and the DON. CNA F said she had noticed a change in Resident #15 ' s behavior and said he was now aggressive towards others and said this type of behavior wasn ' t present prior to incident. In a telephone interview on 11/07/14 at 3:30 p.m. with LVN H she was asked about the blood stains CNA F said she had found on Resident #15 ' s bed and had reported to her. LVN H said she had noticed stains on resident ' s bed but to her they looked like brownish stains that the laundry department couldn ' t get rid of. LVN H was also asked if she had assessed Resident # 15, and if she had seen the cuts in Resident # 15 ' s mouth. LVN H responded she hadn ' t seen any cuts, but stated she hadn ' t checked the inside of resident ' s mouth at the time of the assessment. In a telephone interview on 11/07/14 at 2:20 p.m., with Resident #15 ' s sister who stated she was informed of an incident that occurred on 11/03/14 involving her brother and his roommate (Resident #22) Resident # 15 ' s sister said she was informed her brother ' s roommate had been caught standing by his brother ' s bedside with his underwear halfway down. And that the roommate ' s Resident #22 ' s explanation was that he was trying to pull the privacy curtain because his roommate (Resident #15) had asked him to. Resident #15 ' s Sister stated she found this to be odd since her brother ' s roommate (Resident #22) had been found standing, and if he was only trying to pull the curtain there was no need for him to get up, since privacy curtains could be pulled when laying down. Sister denied knowing about blood stains, cuts or any other detail. Resident #15 " s Sister said she had been thinking about calling Nurse to find out if he (Resident #15) had a recent med change because of his recent behavior. Sister was asked as to what behavior, and she said her brother Resident #15 had recently asked her what kind of casket she was getting for him, she had asked Resident #15 why was he asking for type of casket and he (Resident #15) replied because he was going to die soon. Sister also said Resident #15 had mentioned his bed being full of cockroaches. Sister said he (Resident #15) had never had this behavior in the past and thought it could be due to a recent medication change. Sister said 2 days ago on 11/05/14 when she came and visited Resident # 15 he had told her " What ' s the point of taking him out of my room (Resident #22) If I could see him every day " However Resident #22 was discharged from facility on 11/04/14 In an interview on 11/07/14 at 9:20 a.m., the NFA, when asked for the investigation on the alleged sexual assault on Resident #15, She stated there was no investigation report because nothing happened. A patrolman from the local police department came and spoke with Resident #15 and Resident #22. The NFA said the policeman said nothing happened and did not fill out a report so the investigation was stopped. LVN B wrote in Resident #15 ' s Nurse ' s Notes that she did not like what she saw. The NFA said the nurse saw Resident #22 ' s briefs low on his buttocks. The NFA said Resident #22 has a big belly and his briefs hang low in the back exposing his " crack. " He sometimes does not button the fly on his briefs and is exposed. The NFA said the nurse assumed something had happened but NFA did not investigate. Because of this, sensitivity training was done. The NFA said, " Just because a man puts his hand on a woman ' s leg does not mean he wants something; he may just be trying to comfort her. " The NFA said both residents denied anything happened. Resident #15 did say they were involved in " sex games " but his family said he had dementia and could not say what that meant. Record Review of Incident report dated 11/03/14 showed no investigation was conducted. On incident report dated 11/03/14 for Resident #22 under " Summary of Investigation " the following entry: was documented " Resident immediately went to side of room, got in bed, no further concerns voiced " under " Recommendations/New Interventions, the following entry was documented " Monitor resident, encouraged not to stand on his foot " Record Review of Incident Report dated 11/03/14 showed that no investigation was conducted. On incident report dated 11/03/14 for Resident #15 under " Summary of Investigation " the following entry: was documented "Assisted Resident (#15) with CNA to get him out of room as soon as possible and provide care as he needs. Up in front of nurses ' w/c (wheelchair) to keep in line of sight " under " Recommendations/New Interventions " the following entry documented " Resident assessed to shower room, care provided, assisted to nurses ' station, remained in the line of site vision " Record Review showed no documented evidence of an investigation being done by facility. Review of the "Texas Department of Aging and Disability Services Regulatory Services Incident Investigation Worksheet" for Incident # 3 revealed the Administrator reported the incident with Residents #22 and #15 to DADs on 11/7/14 at 6:54 p.m. (4.5 days after the incident) Record review of the Facility's Leadership Policies and Procedures Incident/Accident Reporting and Supervision revised November 2007 stated in part the following: Policy: It is the policy of this facility to report and investigate all incidents and accidents that occur in the facility or on facility property in a timely manner. Appropriate authorities will be notified in a timely manner for all reportable incidents and accidents. Incident: an unusual or unexpected event that is not consistent with the routine operation of the facility or the routine care of the resident. Procedure: 1. Immediately assess the condition of the person(s) involved in the incident/accident. 2. Initiate emergency first aid and determine need for acute emergency care. 4. Immediately notify the Administrator, Director of Nursing or Department Head on duty. The Administrator and/or the Director of Nursing determine if the incident is reportable to the State Agencies. 5. Notify responsible parties via telephone and document the notification. 7. Make an entry of the incident/accident on the 24 hour report form. Record review of the Face Sheet dated 11/10/14 documented Resident #14 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Record review of the Face Sheet dated 11/10/14 documented Resident #16 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. In an interview on 11/6/14 at 3:40 PM, Resident #16 stated CNA A was "rude and mean to me it was my first night in this new room I was nervous." She stated on Monday night (11/3/14) she had frequent episodes of diarrhea. "The lady next door helped me call her, by the third time she came in to help me she (CNA A) said to me, "Don't eat too much so I don't have to keep coming back and clean your dirty diaper." Resident #16 stated the 4th time she called for help CNA A told her, "Don't you know how to sleep through the night? I was cold and asked her to help me put on my grey sweater. CNA A got it from the chair and threw it on my face and said to me in Spanish 'Como friegas' (English translation: 'You are a pain in the ass.')" Resident #16 stated, "I felt so bad, I wish I could change my own diaper, wipe myself and not bother anyone but I can't. I felt so embarrassed to ask for help already. I don't want to see that woman (CNA A) around me again; she makes me feel bad and nervous." In an interview on 11/6/14 at 12:10 PM, Resident #14's husband stated on 11/4/14 his wife told him "she was scared of a CNA that works at night." He stated that Resident #14 stated that during the night of 11/3/14 her roommate (Resident #16) needed help and she (Resident #14) pressed the call light for her. Resident #14's husband stated that his wife had heard a loud noise coming from Resident #16's bedside after CNA had answered the call bell. Resident #14's husband stated that noise had woken her and scared Resident #14. Resident #14's husband stated he was talking to his wife in her room when Resident #16 said CNA A had been the staff member that had been in their room that night and had thrown a jacket at her (Resident #16's) face. In an interview on 11/6/14 at 3:20 PM, Resident #14 stated she had pressed the call bell for her roommate who was asking for help the night on 11/3/14. She stated CNA A stated, "Why are you pressing the button? I am right here. I am always coming in here for her (Resident #16). Resident #14 stated she told CNA A "this is your job to take care of us, you should not complain." Resident #14 stated she fell back asleep and was waken up by a loud sound of metal hitting the wall or the floor. "I was scared I could not see what it was, I could see she (CNA A) was still there and I told her not to scare us, she said mind your own business." In an interview on 11/10/14 at 4:15 PM, ADON I stated on 11/4/14 she had been notified by Resident #14's husband that CNA A had "acted unprofessionally towards Resident #14 and Resident #16." She stated she had previously received another complaint regarding the same CNA from an alert resident and decided to suspend her. She stated she completed her incident reports and notified the Nursing Home Administrator who is the facility's abuse coordinator to complete the investigation. Review of the "Texas Department of Aging and Disability Services Regulatory Services Incident Investigation Worksheet" for Incident # 0 revealed the Administrator reported the incident with Residents #14 and #16 to DADs on 11/6/14 at 5:43 p.m. In the Abuse Coordinator Interview on 11/06/14 at 11:04 AM, the Nursing Facility Adminsitrator (NFA), who identified herself as the Abuse Prohibition Coordinator, when asked if there were any current investigations, said, "All of them are closed. There was a report of a CNA being upset. We had a risk event call this morning and the CNA was suspended. The resident's name was (Resident #14)." The NFA said if there was an allegation of abuse, the CNA is suspended. A Risk Event call is held with the Vice President of Operations and the Vice President of Clinical Services. They talk about the occurrence and decide if it is reportable. The NFA said she had 24 hours to report. This was determined to be Immediate Jeopardy (IJ) on 11/07/14 at 2:54 PM and the Administrator and DON were notified. The Plan of Removal was accepted on 11/10/4 at 4:57 PM and it included the following: The facility investigated the allegation by interviewing Residents #15 and #22, staff who were present at the time, family members and alert and oriented residents. Witness statements were obtained. Resident #22 was discharged . Inservices were held on 11/07/14 through 11/09/14 on the facility abuse policy and procedure with a post test given. In-services on refraining from showering residents who have made an allegation of sexual abuse until a thorough assessment can be made were started. The Administrator reported the incident to the State Agency. The facility will continue with in-services of staff not present prior to being allowed to work. The facility will monitor compliance to their abuse policy. Record review of Facility's In-Service Training Report, dated 11/10/14, revealed Administrator and DON had in-serviced facility staff on Abuse/Neglect to address the IJ in the area of failure to report and investigate. The in-service instructed staff that " All incidents must be reported, if you witnessed something you need to report to your immediate supervisor, if unable to tell immediate supervisor then go through the chain of command ... All identified issues is to be reported immediately within a 24 hour timeframe ...All identified issues must be thoroughly investigated with documentation to support findings ... The abuse coordinator is the Administrator..." Interviews with facility staff on 11/10/14 revealed staff was able to identify the following: Different types of abuse The facility ' s Abuse Coordinator, Appropriate methods for ensuring resident safety and reporting abuse Through interviews and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 11/10/14 at 4:57 PM and the Nursing Facility Administrator was notified. The facility remained out of compliance at a scope and severity of actual harm at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. The census of 110 was obtained from the CMS 672 dated 11/05/14.

Based on interview and record review, the facility failed to prohibit verbal and mental abuse for 2 (Residents #14 and #16) of 28 residents reviewed for verbal, mental and physical abuse. The facility failed to protect Residents #14 and #16 from verbal and mental abuse by Certified Nursing Assistant (CNA) A. These failures could affect 55 residents in the north hallway by placing them at risk of being abused. The findings include: Record review of the Face Sheet dated 11/10/14 documented Resident #14 was an alert [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed she required 2 person assist for transfers, bed mobility and dressing. Resident #14 had a BIMS score of 13. Record review of the Face Sheet dated 11/10/14 documented Resident #16 was a [AGE] year old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed she had a BIMS score of 8. The MDS revealed she required two persons to assis her in transfering and toilet use. In an interview on 11/6/14 at 3:40 PM, Resident #16 stated CNA A was "rude and mean to me it was my first night in this new room I was nervous." She stated on Monday night (11/3/14) she had frequent episodes of diarrhea. "The lady next door helped me call her, by the third time she came in to help me she (CNA A) said to me, "Don't eat too much so I don't have to keep coming back and clean your dirty diaper." Resident #16 stated the 4th time she called for help CNA A told her, "Don't you know how to sleep through the night? I was cold and asked her to help me put on my gray sweater. CNA A got it from the chair and threw it on my face and said to me in Spanish 'Como friegas' (English translation: 'You are a pain in the ass.') Resident #16 stated, "I felt so bad. I wish I could change my own diaper, wipe myself and not bother anyone but I can't, I felt so embarrassed to ask for help already. I don't want to see that woman (CNA A) around me again she makes me feel bad and nervous." In an interview on 11/6/14 at 12:10 PM, Resident #14's husband stated on 11/4/14 his wife told him, "she was scared of a CNA that works at night." He stated that Resident #14 stated that during the night of 11/3/14 her roommate (Resident #16) needed help and she (Resident #14) pressed the call light for her. Resident #14's husband stated that his wife had heard a loud noise coming from Resident #16's bedside after CNA had answered the call bell. Resident #14's husband stated that noise had woken her and scared Resident #14. Resident #14's husband stated he was talking to his wife in her room when Resident #16 said CNA A had been the staff member that had been in their room that night and had thrown a jacket at her (Resident #16's) face. In an interview on 1/6/14 at 3:20 PM, Resident #14 stated she had pressed the call bell for her roommate who was asking for help the night on 11/3/14. She stated CNA A stated, "Why are you pressing the button? I am right here. I am always coming in here for her (Resident #16). Resident #14 stated she told CNA A "this is your job to take care of us, you should not complain." Resident #14 stated she fell back asleep and was waken up by a loud sound of metal hitting the wall or the floor. "I was scared I could not see what it was, I could see she (CNA A) was still there and I told her not to scare us, she said mind your own business." In an interview on 11/10/14 at 4:15 PM, Assistant Director of Nurses (ADON) I stated on 11/4/14 she had been notified by Resident #14's husband that CNA A had "acted unprofessionally towards Resident #14 and Resident #16." She stated she had previously received another complaint regarding the same CNA from an alert resident and decided to suspend her on 11/4/14. She stated she completed her incident reports and notified the Nursing Home Administrator who is the facility's abuse coordinator to complete the investigation. In an interveiw on 11/10/14 at 3:30 PM, CNA A stated in Spanish "La Senora ( Resident #16) timbro toda la noche. Si no timbro 15 veces no fue mucho. Tiembra el timbre porque no puede dormir" translation: " Resident #16 rang the call bell all night. She rang it 15 times and that's the low estimate. She calls at night because she can not sleep." CNA A denied all allegations. Review of the facility Abuse Prohibition Policy and Procedure dated 7/2012 revealed facility policy was residents have the right to be free from abuse, corporal punishment and involuntary seclusion. The residents will not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers. Review of CNA A's Nursing Assistant Evaluation dated 5/8/13 revealed she received a score of C - needs improvement in the following areas: keeps residents clean and comfortable, treats residents with dignity and establishes positive relationship with resident families. Review of Individual Employee Time Cards dated 11/7/14 revealed CNA A last day of work was 11/3/14. The universe of 55 residents residing on the north side of the building was provided by the Nursing Home Administrator in the resident list report on 11/4/14.

Based on observation, interview and record review the facility failed to ensure that the resident environment remain as free from accident hazards as is possible for 1 (Resident #1) of 6 residents reviewed for smoking. The facility failed to: (A) Prohibit oxygen in the smoking area which resulted in a fire, nasal burn and inhalation injury to Resident #1. (B) Post signage that no concentrated oxygen sources are permitted in smoking areas. (C) Perform an assessment of each resident ' s capabilities and deficits for 6 of 6 residents reviewed for smoking. (D) Implement Care Plan interventions to reduce hazards and risks for 6 of 6 residents reviewed for smoking. This failure could affect all 6 residents identified as smokers. Findings include: Resident 1 Review of Admission Record revealed Resident #1 was a [AGE] year old male, admitted on [DATE] and re-admitted [DATE]. Resident #1 had [DIAGNOSES REDACTED]. In an interview on 5/25/14 at 3:55 PM Resident #1 said on Saturday, 5/24/14, he went out to smoke with 3 or 4 other residents and the nursing supervisor. He said he was smoking and all of a sudden there was a " POP " and he had a fireball on his face from his oxygen cannula. He started slapping at his face and the cannula came off and the fire went out. Resident #1 said his nose was burned and his mustache and goatee were burned. He said he was sent to the hospital emergency room and kept blowing plastic out of his nose. Observation on 5/25/14 at 3:55 PM revealed Resident #1 ' s lower 1/4 of his nose, bottom at the nostrils and inside both nostrils had the skin burned off and was bright red in color, a clear ointment was on the red areas. In an interview on 5/30/14 at 8:32 AM Assistant Director of Nursing (ADON) #1 said she was not scheduled to take the smokers out for smoke time but the smokers were all screaming and yelling that they had to go out now, so she took them. She said as Resident #1 went out of the door she turned his oxygen canister off but with all of the chaos and yelling from the smokers she did not take his oxygen cannula off of his face as she should have. ADON #1 said she was lighting each resident ' s cigarette but Resident #1 did not wait for her and lit his cigarette off of another resident ' s cigarette. A resident started screaming and the ADON #1 said she turned around and Resident #1 ' s face was on fire, she grabbed the nasal cannula and threw it to the ground and put out the fire. ADON #1 said she yelled in the door for a nurse to come because she couldn ' t leave the smokers alone. In an interview on 5/25/14 at 4:10 PM LVN A said she was called to the patio and when she got there the fire was out and she took Resident #1 into the building. LVN A said Resident #1 ' s physician was in the facility and came to assess him. She said the physician gave the order to send him to the emergency room and that's what was done. Review of hospital record dated 5/24/14 documented Resident #1 was treated for [REDACTED]. In an interview on 5/30/14 at 9:45 AM Resident #3 said she was outside at the smoking area when she heard a " POP " and then saw fire on Resident #1 ' s face, nose, mustache, goatee, cheeks and neck in the back. Resident #3 said she could not explain how witnessing that made her feel, so many things went through her mind and heart that it was difficult to explain. Observation on 5/30/14 at 9:50 AM revealed Resident #1 ' s bottom of nose and up inside nostrils were bright red with areas of black. In an interview on 5/30/14 at 9:55 AM Resident #1 said his nose was still painful. In an interview on 5/30/14 at 11:30 AM Resident #2 said he was at the smoking area on Saturday 5/24/14. Resident #2 said he saw the ADON turn Resident #1 ' s oxygen off but he still had his nasal cannula on. Resident #2 said Resident #1 was smoking and all of a sudden there was a " POP " and Resident #1 was on fire. Resident #2 said it was frightening because they could have all been blown up. Record review on 5/25/14 of Resident #1 ' s assessments revealed no smoking assessment had been completed. Record review on 5/25/14 of Resident #1 ' s Care Plan revealed smoking was not addressed. In an interview on 5/25/14 at 6:30 PM RN Supervisor verified there was no smoking assessment or smoking care plan completed for Resident #1. Observations multiple times during the investigation revealed no signs were posted on the door leading to the smoking area or in the smoking area warning that no concentrated oxygen sources were permitted in smoking areas. Review of the Smoking Policy revision date 3/5/2014 documented in part: Evaluate patients that smoke utilizing the Smoking Evaluation Tool upon admission, when the resident starts to smoke, significant change Upon completion of the evaluation, the interdisciplinary team will make an assessment of the patient ' s ability to understand smoking guidelines and handle smoking paraphernalia Smoking is not permitted while oxygen is in use. Posted signage clearly states that no concentrated oxygen sources are permitted in smoking areas. The signage is posted outside smoking area entrances and inside smoking areas. In an interview on 5/30/14 ADON #2 said sometimes we make a paper sign that says "NO OXYGEN" but corporate people don't like paper signs and they take them down. Review of physician progress notes [REDACTED]. New diagnosis - second degree burn Skin burn - nostrils with granulation tissue. Resident ' s 2, 3, 4, 5 and 6 Record review on 5/30/14 of Resident ' s #2, 3, 4, 5 and 6 assessments revealed no smoking assessment had been completed prior to the incident. Record review on 5/30/14 of Resident ' s #2, 3, 4, 5 and 6 Care Plans revealed smoking was not addressed prior to the incident. In an interview on 5/30/14 at 4:30 PM ADON verified there was no smoking assessment or smoking care plan completed for Resident ' s #2, 3, 4, 5 and 6 prior to the incident. The universe of 6 smokers was obtained from a list provided by the RN Supervisor at entrance on 5/25/14.