Every finding on record at Whitesboro Health and Rehabilitation Center

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food items were properly stored in the refrigerator. 2. The facility failed to ensure products were dated the day they were received. These failures could place residents at risk of food-borne illnesses. Findings Included: During an observation of the facility's refrigerator on 07/15/2026 at 09:00 a.m., one large resealable bag of shredded cheese was observed to be open and exposed to air. During an observation of the facility's dry food pantry on 07/15/2026 at 09:08a.m., 8 cans of tomato juice were observed to not have a shipping label or marked with a date received. During an interview on 07/16/2026 at 10:01 a.m., the DM stated the expectation for staff was to bag, tag and label received products, and always keep an eye out for open bags. She stated the kitchen staff had completed in-service training on the expectations. The DM stated residents were at risk of getting sick if food was contaminated. A record review of the policy, Dietary Services Policy and Procedure Manual 2012, no date, stated the following: Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. Products without a dated shipping label should be dated when they are received by the facility so there is a method to keep track of the age of the product.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #24) of 5 residents, reviewed for infection control. CNA A and CNA B failed to don PPE prior to performing the high contact resident care activity on Resident #24 who was on enhanced barrier precautions.This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included:Record review of Resident #24's Face Sheet dated 07/08/26, reflected he was a [AGE] year-old male, readmitted [DATE], with diagnoses including Pressure ulcer of right heel (localized skin and tissue damage caused by prolonged pressure, friction, or shearing, often over bony areas like the heels, hips, and tailbone), Gastrostomy status (a flexible device inserted through the abdomen directly into the stomach.) and Dysphagia (difficulty or discomfort in swallowing).Record review of Resident #24's Comprehensive MDS Assessment, dated 04/08/26, reflected a BIMS Score of 03, indicating severe cognitive impairment and feeding tube for nutrition/fluids.Record review of Resident #24's Physician's Orders, dated 07/08/26, reflected Enteral Feed Order every shift- Isosource 1.5 @55ml/hr to g-tube daily; Enteral Feed Order every shift for G tube care -Gastrostomy site care cleanse with normal saline and soap and apply sponge every shift Record review of Resident #24's Care Plan, dated 02/11/25, reflected Resident was on enhanced barrier precautions with intervention- Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activityAn observation on 07/16/2026 at 8 AM, revealed Resident #24's room had an Enhanced Barrier Precaution sign outside his room, and cart set up with PPE outside the room. CNA A and CNA B performed high contact resident activities of repositioning, incontinent care, bed bath and dressing without wearing PPE (gown).During an interview with CNA A and CNA B on 07/16/26 at 8:10 AM, they stated they were aware that Resident #24 was on enhanced barrier precaution and should have won gown and glove when they gave care to him. CNA A stated residents with wounds, G/tube, catheters and open body areas were put on EBP. She stated the risk of not using PPE included the potential for infection.During an interview on 07/16/26 at 8:15 AM, LVN A revealed he knew Resident #24 was on enhanced barrier precautions, and CNAs should have donned PPE before repositioning, giving bed bath and dressing him. LVN A stated he did not know that CNA A and CNA B did not wear the gown while performing high contact care on Resident #24. He stated the failure to use PPE could put the residents at risk of infection. He stated he had been in-serviced on enhanced barrier precautions.During an interview on 07/16/26 at 9 AM, RN A stated that hospice CNAs were expected to follow enhanced barrier precautions just like facility staff to prevent spread of infection. She stated that hospice CNAs were trained on infection control.During an interview on 07/16/2026 at 1:00 PM, the DON revealed her expectation was staff, including hospice CNAs, should use appropriate PPE while providing care to residents on enhanced barrier precautions. She stated the risk to the patient was infection. She stated staff had been in-serviced on infection control and Enhance Barrier Precautions.Record review of the facility's policy titled Enhanced Barrier Precautions dated April 2024: stated .Enhance barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi drug resistant organisms that employ targeted gowns and gloves use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than one patient. EBP are indicated for residents with any of the following: colonization with a CDC targeted MDROs when contact precautions do not otherwise apply. Wounds and/or indwelling medical devices even if the residents are not known to be infected or colonized with MDRO. Indwelling medical devices examples include central lines, urinary catheters, feeding tubes and tracheostomies.

Based on interview and record review, the facility failed to complete a discharge summary for 1 of 3 residents (Resident #61) reviewed for discharge process. The facility failed to ensure Resident #61 discharged from the facility with a discharge summary that included an accurate and current description of the clinical status of the resident, and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care.Findings Included: A record review of Resident #61's discharge MDS dated [DATE] revealed she admitted to the facility on [DATE] with a primary diagnosis of end stage heart failure (the heart can no longer pump enough blood to meet the body's needs) and had an unplanned discharge on [DATE]. A record review of Resident #61's progress notes dated 06/17/2026 revealed she was in the facility for respite care coordinated through her hospice provider. A review of Resident #61's progress notes dated 06/20/2026 revealed the resident was discharged home due to her family's wishes. A record review of Resident #61's electronic health records revealed a discharge summary had not been completed. During an interview on 07/16/2026 at 2:05 p.m., RN B stated the discharge summary covered labs, medications and home health, and the expectation was that it would be completed, even if a resident discharged earlier than anticipated. RN B stated that the discharge summary for Resident #61 should have been completed. She stated there was no risk for the resident because they usually discharged home with their previous provider, such as home health or their PCP. A record review of the facility's policy, titled Discharge Planning Process Policy, no date, stated the following: Nursing Facility must complete discharge planning when discharge is anticipated to a private residence, Assisted Living, another Nursing Facility or Skilled Nursing facility, or another type of residential location.

Based on observation, interviews, and record review, the facility failed to ensure the resident's environment is free from accident hazards reviewed for four of five reviewed for quality of care. The facility failed to ensure the hallways were free of assistive devices and equipment. This failure could place residents at risk of accidents, injuries, and pain. Findings included:An observation on 7/15/26 at 10:00AM revealed manual and motorized wheelchairs, a mechanical lift, and linen carts not in current use on the one hundred hall.An observation on 7/15/26 at 11:00AM revealed a mechanical lift and linen cart not in current use on the two hundred hall. An observation on 7/15/26 at 1:00PM revealed two manual wheelchairs, a motorized wheelchair, a mechanical lift, a sit-to-stand patient lift, and linen carts not in current use on the four hundred hall. An observation on 7/16/26 at 11:50AM revealed assistive devices including wheelchairs, mechanical lifts, and linen carts on hall number five hundred not in current use. In a telephone interview on 7/21/26 at 1:00PM with the Administrator, it was revealed all staff were responsible for ensuring the hallways are free and clear of hazards that could cause injury. The Administrator stated there is the potential to have accidents when things are in the hallways. Request on 7/17/26 at 1:12PM to review facility policies for ensuring the resident's environment is free from accident hazards and in-service on storing assistive devices to which the Administrator stated the facility does not currently have an in-service on storing of assistive devices. The Administrator did not provide any policies related to this topic.

Based on observation, interview, and record review the facility failed to establish and maintain respiratory care including oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen for two (Resident #17 and #47) of six residents reviewed for respiratory care. The facility failed to ensure that Resident #17's and #47's oxygen tubing/nasal cannula were bagged in a plastic bag. These failures could place residents receiving respiratory therapy at risk of health-associated infections.Findings included: 1. Record review of Resident #17's Face Sheet, dated 07/16/26, reflected she was an [AGE] year-old female readmitted on [DATE], with diagnoses including Cerebral ischemia attack ( when a shortage of blood flow deprives brain tissue of necessary oxygen and nutrients), Calculus of Kidney ( a hard, mineral deposit that forms when urine becomes highly concentrated with substances like calcium, oxalate, or uric acid) and Tachycardia (an abnormally fast resting heart rate, typically exceeding 100 beats per minute (bpm) in adults.) Record review of Resident #17's MDS Assessment, dated 01/30/26, reflected she had a BIMS score of 04 indicating severe cognitive impairment.Record review of Resident #17's Physician's Orders, dated 07/16/26, reflected an active order for Oxygen via N/C 2 liters in both nostrils every 24 hours as needed for SOB/wheezing O2 saturation 90% or below 2-4 liters via N/C PRN.Record review of Resident #17's Care Plan, dated 07/15/26, reflected (.Oxygen therapy with goal -Resident will have no signs/symptoms of poor absorption, oxygen at 3-4 lpm per nasal canula prn .).An observation on 07/15/26 at 9:23 AM, revealed Resident #17's oxygen tubing/ nasal canula was not in use and was hanging on her wheelchair armrest, unbagged at station 400 hallway. Resident #17 was not in her room. 2. Record review of Resident #47's Face Sheet, dated 07/16/2026, reflected a [AGE] year-old male, admitted on [DATE]. The resident was diagnosed with Alzheimer's disease (a progressive, irreversible brain disorder and the most common cause of dementia), muscle spasm and Depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and physical fatigue)Record review of Resident #47's Comprehensive MDS Assessment, dated 12/23/2025, reflected no BIMS score.Record review of Resident #47's Physician's Orders, dated 07/16/26, reflected an active PRN order for oxygen at 2-4 L/minute via nasal cannula night as needed at bedtime for SOB.An observation on 07/15/26 at 9:00 AM revealed Resident #47's was in bed and sleeping. His oxygen tubing/nasal cannula was not in use and was lying on his oxygen concentrator, unbagged. Resident was not interview able. During an interview with the ADON on 07/15/26 at 9:25 AM, she confirmed observing Resident #17's oxygen tubing/nasal cannula, not in use and unbagged. The ADON stated oxygen tubing/nasal cannulas should be bagged when not in use. She stated the risk of not bagging the items included the potential for infection.During an interview with the DON on 07/15/26 at 10 AM, she stated that Resident #47's wife could have left the oxygen N/C unbagged. DON stated oxygen tubing/nasal cannulas and nebulizer masks should all be bagged when not in use. She stated the risk of not bagging these items included the potential for infection. The DON stated it was the responsibility of every staff member to ensure respiratory equipment was appropriately bagged when not in use to prevent infection.During an interview with the Administrator on 07/16/26 at 3:20 PM, he stated they did not have a policy related to proper storage of respiratory equipment (such as oxygen tubing/nasal cannulas and nebulizer masks).

Based on observation, interview and record review, the facility failed to properly label and store all drugs and biological in accordance with currently accepted professional principles for one resident (Resident #3) of six residents reviewed for medication storage.The facility failed to ensure that Resident #3 swallowed his medications before staff left the Resident #3's room during medication administration on 07/15/26. This failure could place Resident #3 at risk of medication error, reduced therapeutic effectiveness, unsafe administration, and potential adverse outcomes due to improper storage of medication. Findings included:Review of Resident #3's Comprehensive MDS Assessment, dated 03/11/2026, reflected he was admitted on [DATE]. He was a [AGE] year-old male and had a BIMS score of 12 which indicated moderate cognition. The resident had diagnoses which included, Depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), Cerebral Infarction (occurs when blood flow to an area of the brain is blocked, depriving brain tissue of oxygen and glucose) and generalized muscle weakness.Review of Resident #3's Comprehensive Care Plan, initiated 05/08/2025, reflected no areas indicating he could have medication at bedside or self-medicate.Review of Resident #3's active physician orders dated: 07/16/2026 reflected no orders indicating he can have medication at bedside or self-medicate.During an observation and interview on 07/15/20226 at 9:20 AM, 6 white pills, 2 yellow pills, and 1 green pill were in a medication cup on Resident #3's bedside table, unattended. Resident #3 stated the nurse left them for him and that he would take them later.During an interview on 07/15/2026 at 9:40 AM, the ADON stated she administered Resident #3's morning medication. She stated she always ensured the residents swallowed their medication before leaving the room, but couldn't tell how medications were left in a cup for Resident #3. The ADON stated Resident #3 did not have physician orders to self-medicate or have medication at bedside. She stated the risk to the resident was over medicating or missing to take medications or another resident getting the medication. She stated she had been in-serviced on medication administration and medication storage.During an interview on 07/15/2026 at 10 AM, LVN A stated that nurses and medication aides were supposed to watch the resident take his medication before leaving the room, or bring it later to Resident #3 when he was ready to take his medication. LVN A stated the risk was Resident #3 missing the medication or another resident taking the medication. He stated he had been in-serviced on medication administration and medication storage.During an interview on 06/16/26 at 11:30 AM, the DON stated no medications were expected to be left at bedside, at any time. She stated that the medication aides and nurses were expected to stand and watch residents swallow their medications before exiting the room. The DON stated medication aides and nurses had been in-serviced on medication administration and storage.Despite requests for relevant polices, the facility had no policy on residents' self-medication administration or leaving medication at bedside.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of ten residents (Resident #1 and Resident #2) reviewed for abuse and neglect.The facility failed to ensure Resident #1 was free from abuse when Resident #2 hit him on 01/04/2026. This failure could place residents at risk of abuse and emotional stress.The findings include:Record review of Resident #1's Face Sheet, dated 01/30/2026, reflected the resident was a [AGE] year-old male who admitted on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (loss of memory and cognitive ability that interferes with daily life) and unspecified psychosis (the person has trouble differentiating between what is real and what is not). Resident #1 resided in the memory care unit. Record review of Resident #1's Quarterly MDS (tool used to assess health status) Assessment, dated 12/11/2025, reflected severely impaired cognition with a BIMS (screening tool to assess cognitive status) score of 05. Section E (Behavior) indicated the resident wandered daily. It did not reflect other behaviors. Section GG (Functional Abilities) reflected the resident required assistance with self-care and mobility needs. Record review of Resident #1's Comprehensive Care Plan, dated 11/24/2025, reflected The resident has impaired cognitive function/dementia or impaired thought processes. Interventions included The resident understands consistent, simple, directive sentences. Engage the resident in simple, structured activities that avoid overly demanding tasks. Use task segmentation to support short term memory deficits. Resident #1's Comprehensive Care Plan did not indicate behaviors toward staff or other residents. Record review of Resident #2's Face Sheet, dated 01/30/2026, reflected the resident was an [AGE] year-old male who originally admitted on [DATE] and re-admitted on [DATE]. Resident #2 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), schizophrenia (mental health disorder that affects how a person thinks, feels, and behaves), and bipolar disorder (extreme mood swings, including emotional highs and lows). Resident #2 resided in the memory care unit. Record review of Resident #2's Quarterly MDS, dated [DATE], reflected severely impaired cognition with a BIMS score of 00. Section E (Behavior) reflected Resident #2 did not have any behavioral symptoms. Section GG (Functional Abilities) indicate Resident #2 required assistance with self-care and mobility needs. Record review of Resident #2's Comprehensive Care Plan, dated 11/24/2025, reflected the resident has potential to demonstrate physical behaviors. Interventions included Medication review and labs as necessary and Minimize resident's disruptive behaviors by offering tasks which divert attention.Record Review of LVN E's Progress Note, dated 11/21/2025, reflected Resident #2 was agitated with the aide who was trying to get another resident out of bed. The resident was directed to his room to decrease stimulation. Record review of LVN E's Progress Note, dated 01/02/2026, reflected Resident #2 swung at a staff member and another resident. Resident #2 was directed to a different room and given food. Interventions included direct to the resident's room to decrease stimulation and provide music or sensory stimulation.Record review of LVN E's Progress Note, dated 01/04/2026, reflected CNA F informed him Resident #1 was sitting on the couch and Resident #2 hit him. No injury was noted. The residents were separated and Resident #2 had one-on-one staff monitoring. Record review of the DON's Progress Note, dated 01/05/2026, reflected the psych nurse practitioner adjusted Resident #2's medication and the resident remained on one-one-one supervision. Record review of the facility-provided monitoring logs reflected Resident #2 had one-on-one monitoring on 01/04/2026 and 01/05/2026. He had q15 minute monitoring from 01/06/2026 until he discharged on 01/08/2026.During an interview on 01/30/2026 at 9:39 AM, CNA A stated she had cared for Resident #2 since he admitted to the facility. She stated Resident #1 like to talked constantly and Resident #2 did not like it. She stated she never saw Resident #1 or Resident #2 hit anyone. CNA A stated Resident #2 did swing at her one time. She stated she was trying to get him to sit down in a chair. She stated the chair did not have arms and Resident #2 felt like he was falling if a chair did not have arms to grab. She stated the main thing with Resident #2 was how you approached him. She stated other staff had said he tried to hit them when they provided care. She said if he was upset, give him a few seconds before you re-approached, and he was fine. During an interview on 01/30/2026 at 9:50 AM, CNA B stated when she started working on the memory care unit, she was told to watch Resident #2 because he might try to hit her. She stated Resident #2 never tried to hit her, and she did not have to intervene to keep him from hitting another resident. She stated staff had in-service training on resident abuse and resident altercations. She stated if residents had an altercation, staff would separate, re-direct and get residents interested in something else, or take their hand and walk with them. She said Resident #1 liked to get up and wander, and she walked with him. She stated Resident #1 did not bother anyone. He knocked on residents' doors and tried to talk with them. During an interview on 01/30/2026 at 10:04 AM, Resident #1 was lying on his bed watching television. When asked if he felt safe at the facility, he replied Oh, yes. He replied, No when asked if he was afraid of anyone. When asked if another resident had ever hit him, he replied not that I can think of. Resident #1 stated he would not let anyone hit him. During an interview on 01/30/2026 at 10:44 AM, LVN C stated she worked the day shift on the memory care unit. She stated she was not working at the time of the incident involving Resident #1 and Resident #2. She stated Resident #2 had his moments but she never saw him hit anyone. She stated he would yell for other residents to get out of his room. She stated the CNAs had not reported to her that Resident #2 hit a resident. She stated the facility had recent in-service training on abuse, neglect, and resident altercations. She stated they also had online training. An interview attempt with CNA F on 01/30/2026 at 10:57 AM was unsuccessful.An interview attempt with LVN E on 01/30/2026 at 11:05 AM was unsuccessful.During an interview on 01/30/2026 at 12:38 PM, the Administrator stated Resident #2 needed to be re-directed in the late afternoon and evening because he was unsure of what to do with himself. He stated on the day of the incident, Resident #1 and Resident #2 were in the dining room. He stated Resident #1 was not overly loud as he talked. He stated Resident #2 walked over and tapped Resident #1 on his cowboy hat he wore. He stated Resident #1 did not express pain or show a reaction. The Administrator stated based on the report he received and his own interviews, Resident #1 and Resident #2 did not remember the incident. He stated the facility initiated discharge planning at that time and Resident #2 moved to another facility. He stated Resident #2 was easily re-directed. He stated offering him a book or a drink to distract him worked great. He stated Resident #2 had not hit another resident prior to the incident with Resident #1. During an interview on 01/30/2026 at 3:29 PM, the Regional Compliance Nurse stated Resident #1 was sitting on the couch when he was hit by Resident #2. She stated she was not at the facility at the time, but heard Resident #2 gave Resident #1 a tap and thought it was on his arm. She opened her laptop to view his chart and stated a skin assessment was completed for Resident #1 which showed no injury. Resident #1 had a trauma informed care assessment for psychosocial wellbeing. She stated Resident #1 denied pain or feeling upset about it. She stated the staff received in-service training related to de-escalation and recognizing early warning signs. She stated Resident #2 was evaluated and his medication was adjusted. She stated Resident #2 was monitored to ensure he did not feel another resident was in his personal space. She stated Resident #2 also had a private room. She stated their secured unit was very small and staff felt Resident #2 might do better in a larger secured unit where he had more space around him. During an interview on 01/30/2026 at 12:25 PM, the Social Worker stated she spoke to Resident #1 and Resident #2 after the incident. She stated Resident #2 was sitting on the couch in the dining room looking at a book. She stated she also spoke with Resident #1. Neither resident had any memory of the incident. During a telephone interview on 02/01/2026 at 9:43 PM, LVN E stated he worked nights in the memory care unit. He stated he remembered CNA F telling him Resident #2 was sitting on the couch and Resident #1 swung at him. He stated after CNA F separated the residents and notified him; he assessed Resident #1 and Resident #2. There was no injury to either resident. He stated they kept the residents separated and continued to monitor Resident #1. He stated another incident happened a while back, but he did not remember the details. He stated he put notes in the chart about what CNA F told him at the time. He stated Resident #2 had behaviors when the aides tried to change him, but he had not hit another resident. LVN E stated the facility had in-service training related to abuse, neglect, and resident altercations. He stated when a resident was upset, it was important to talk low and calm, and to re-direct. He stated any abuse should be reported to the Administrator, who was the Abuse Coordinator. During a telephone interview on 02/02/2026 at 11:27 AM, the DON stated she was called and told Resident #2 swatted at Resident #1. She stated they were unsure if Resident #1 was hit, and on the side of caution, reported the incident. She stated Resident #1 and Resident #2 were immediately separated, and Resident #2 was placed on 1:1 monitoring. She stated a skin assessment was completed for all residents on the unit to ensure there was no unknown injury. A secured care consult was scheduled and they discussed different interventions, activities, and things Resident #2 was interested in and like to do. She stated they usually scheduled a follow up meeting, but Resident #2 had moved to a sister facility and was doing well. She stated Resident #2 was territorial and liked his space. He did not like people in his room. She stated if he saw someone do something to upset a CNA or female resident, he would stand up and stare them down, but did not get physical. She stated looking back, Resident #1 had been talking and moving things in the dining/activity room, and it probably upset Resident #1. She stated in-service training was provided to staff after the altercation. She stated the most important intervention at the time was monitoring Resident #2. She stated Resident #1 did not remember the incident when asked about it and he had no injury. During a telephone interview on 02/02/2026 at 3:25 PM, CNA F stated she was in the dining room when Resident #2 hit Resident #1. She stated Resident #1 was watching television. She stated Resident #2 walked to the sofa where Resident #1 was sitting and hit him on the right side of his head. She stated Resident #1 was wearing his cowboy hat. She stated he did not express it caused any pain. She stated Resident #2 started kicking his foot at Resident #1, but his foot did not touch Resident #1. She stated the two residents had no previous altercation. She stated Resident #2 was placed on one-to-one monitoring after the incident and moved to another facility. She stated after the incident Resident #2 did not remember what happened and Resident #1 told staff he was not hit. She said the facility had in-service training about abuse and de-escalation and to report any abuse to the Administrator. Record review of the facility's policy Abuse/Neglect, undated, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Residents should not be subjected to abuse by anyone, including, but not limited to facility staff, other residents.The facility will provide and ensure the promotion and protect of resident rights. Physical abuse: Includes hitting, slapping, pinching, and kicking.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not break the window in her room, exit the window, and walk to the staff smoking area where she was found lying on a bench on 10/20/2025 at 8:10 PM, approximately 30 minutes after she was noted to be missing. The non-compliance was identified as PNC (Past Non-Compliance) on 10/22/2025 and the IJ template was provided to the facility on [DATE] at 3:21 PM. The noncompliance began on 10/20/2025 and ended 10/21/2025. The facility corrected the non-compliance before the survey began.This failure could place the residents at risk of serious harm, injury and death from wandering outside the facility in unfamiliar surroundings.Findings include:Record review of the facility reported incident, dated 10/20/2025, reflected Resident #1 broke her window and exited the building on 10/20/2025. Record review of Resident #1's Face Sheet, dated 10/22/2025, reflected the resident was an [AGE] year-old who admitted [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), bipolar disorder (extreme mood swings, including emotional highs and lows), and delusional disorders (false beliefs that are resistant to reasoning or contrary evidence). Record review of Resident #1's Comprehensive Care Plan, dated 10/21/2025, reflected The resident is at risk for wandering. Date initiated 07/13/2024. Interventions included to identify the pattern of wandering and intervene as appropriate; if the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, or using the call system; offer pleasant diversions, structured activities, food, conversation, television, or a book. Record review of Resident #1's Comprehensive Care Plan, dated 10/21/2025, reflected Actual elopement or elopement attempt. Resident left the facility unattended. Interventions included Supervise closely with increased staff monitoring x 72 hours or until further guidance. Begin with one-one-one monitoring. Dated Initiated: 10/20/2025.Determine the reason the resident is attempting to elope. Is the resident looking for something or someone Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 10/20/2025 . Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated: 10/20/2025.Distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books. Date Initiated 10/20/2025.Record review of Resident #1's clinical file on 10/22/2025 reflected no prior attempt to elope. Record review of Resident #1's Quarterly MDS (tool used to assess health status) Assessment, dated 09/25/2025, reflected severely impaired cognition with a BIMS (screening tool to assess cognitive status) score of 07 and indicated no behavioral symptoms. Resident #1 was ambulatory with a walker and independent with most activities of daily living. Record review of RN A's Event Nurses' Note, dated 10/20/2025, indicated Resident #1 exited through a window and was located 30 minutes after she was noted to be missing on the bench in the gated area of the garden. Resident #1 told staff she heard the [NAME] talking. Resident #1 was assessed, and vital signs were taken. She sustained no injury. Resident #1 was transported to the hospital for further evaluation. Record review of RN A's progress note, dated 10/20/2025, reflected Resident broke out window and crawled out. Was found on the bench in the fenced area of the garden lying on a bench with head covered with cowboy hat eyes closed. When approached and called by name opened eyes and answered all questions appropriately. Refused to sit up at that time. When asked what happened, Resident stated, 'Matt was talking to me the ARC Angel.' Taken by ambulance to hospital for evaluation at this time.An attempt to interview RN A by telephone on 10/22/2025 was unsuccessful. During an observation and interview on 10/22/2025 at 9:42 AM, the Administrator stated at 8:30 PM on 10/20/2025, he received a phone call notifying him Resident #1 had busted her bedroom window and got out of the building. He stated the charge nurse had looked in Resident #1's room a few minutes earlier and the resident was looking through her dresser drawers. The nurse went to give medication to another resident. When the nurse returned to Resident #1's room, she was not in her room, bathroom or closet. The nurse noticed the glass window was broken and alerted the staff to search for her. The Administrator stated a CNA located her outside in the smoking area lying on a bench. He stated Resident #1 told staff [NAME] said the building was on fire and she broke the window and got out. He stated Resident #1 was assessed and she had no cuts or injury. Resident #1 refused to go back inside the building with staff. He stated emergency medical services was called, came and assessed the resident, and took her to the hospital for evaluation. The Administrator stated no other resident had eloped since this incident. The administrator showed the surveyor the window Resident #1 had exited. The surveyor observed the layout and noted the distance from Resident #1's room to the smoking area was approximately 50 feet. Resident #1 exited her window and walked to the staff smoking area in the gated courtyard. There was an opening in the courtyard where Resident #1 could have exited to the staff parking lot. From the staff parking lot, the resident would have access to the main road. Resident #1 did not reside on secure unit at time of the incident. Resident #1 had not returned from the hospital. During an interview on 10/22/2025 at 10:06 AM, the Regional Compliance Nurse stated when RN A checked on Resident #1 at about 7:10 PM, she was rearranging stuff in her dresser. The nurse continued passing medication and when she returned to give Resident #1 medication, she was not in her room. The bedroom window was broken. She stated Resident #1 never left the property. She was found lying on the bench in the courtyard. She stated the nurse ensured the resident was safe and assessed her skin and pain. She stated Resident #1 refused to go back inside the facility. She stated Resident #1 believed the arch angel told her to get out because the building was on fire. She stated she was sent to the hospital for evaluation and the emergency room documentation indicated her diagnosis was hallucinations. Resident #1 did not have any injuries. She stated it appeared Resident #1 had used a dresser drawer and her trash can to break the window, because they were on the ground outside the bedroom window. She stated all the glass was knocked out. There were no glass shards sticking out. She stated the night of the incident the window was boarded up until the glass could be replaced the following day. The facility initiated hourly monitoring of all residents' windows to ensure no windows were broken. She stated by the end of the day, all residents' windows would be equipped with an alarm to ensure if glass broke, staff would be alerted. The Regional Compliance Nurse stated the facility would continue to have elopement drills three times weekly to ensure staff knew what to do when a resident was missing. She stated the door alarms were checked daily. She stated Resident #1 would remain on 1:1 monitoring and evaluated for any changes. She stated after the incident, an elopement risk assessment was competed for all other residents. She stated anyone at risk had interventions in place and included on the care plan. She stated residents that needed to be on the secure unit were already there. The Regional Compliance Nurse stated no other resident had eloped since Resident #1 exited the building. The Regional Compliance Nurse stated the hospital documentation revealed Resident #1 was admitted for a primary diagnoses of hallucinations and secondary diagnosis was hypertension (elevated blood pressure). She stated documentation revealed the resident had no physical injury. During an interview on 10/22/2025 at 11:30 AM, the Psych Nurse Practitioner was in the facility and stated she saw Resident #1 weekly. She stated she had seen her the previous week. She stated she had not seen any changes in Resident #1. She stated she was able to have logical conversations with Resident #1 and she had been very stable. She stated she could not believe the resident had gotten out of the building. She stated Resident #1 had not expressed wanting to leave the facility or reported voices telling her to leave the facility. She stated she would continue to see Resident #1. During an interview on 10/22/2025 at 1:10 PM, the DON stated the elopement risk assessment for Resident #1, dated 10/04/2025, indicated low risk with a score of 6. The risk assessment completed after the elopement indicated high risk with a score of 18. She stated Resident #1 had not exhibited any exit seeking behavior. She stated the resident was pleasant and enjoyed talking with people. She stated her family was at the facility frequently to visit and took the resident out of the facility to spend time with her. The DON stated no other resident had eloped since the incident. During a follow interview on 10/22/2025 at 1:25 PM, the Regional Compliance Nurse stated all residents had quarterly assessments for elopement risk. She stated Resident #1 was not having exit seeking behaviors and had had not attempted to get out of the building. She stated the resident's family member had a podcast focused on end time prophecy and he came in the evenings and discussed the book of Revelations with the resident. She stated staff felt that may have been a factor in Resident #1 getting out of the building, because when she was found she told staff the [NAME] told her to get out of the building because it was on fire. She stated staff discussed their concerns with the resident's family who were open to discussing other topics. An attempt to interview Resident #1's family member by telephone on 10/22/2025 at 1:50 PM was unsuccessful. During an interview on 10/22/2025 at 3:01 PM, CNA B stated she was assisting another resident and heard Resident #1 making a loud noise in her room. She stated she went to the room and Resident #1 was moving her clothes and a chair. She stated she did not think anything about it. She stated about 20 minutes later, the nurse told her the resident got out. She stated staff began searching everywhere inside the building. She stated she searched her hall and went to the exit door at the end of the hall. When she exited the building, she saw Resident #1 in the smoking area. She stated the following day when she returned to work, the facility had an elopement drill. She stated the facility called a code orange if a resident was missing. CNA B stated she had never seen Resident #1 try to get out of the building.During a follow up interview on 10/22/2025 at 4:06 PM, the Administrator stated risk assessments were completed for all residents and elopement drills were initiated. He stated administrative staff began logging hourly window checks and the facility had a work order for window alarms to be installed on all residents' windows. The Administrator stated it was important to have elopement prevention measure in place for the safety of the residents to prevent residents from getting out of the building and being harmed. He stated facility policies and elopement drills were in place to prevent elopement and ensure staff responded properly to help residents stay safe.During a follow up interview on 10/22/2025 at 4:14 PM, the DON stated Nurse A told her Resident #1 got out of her bedroom window and was found lying on the bench in the garden area. The DON stated patient safety was the number one priority. She stated it was important to provide in-services so staff knew what to do in an emergency such as elopement or potential elopement. She stated it was important to follow protocol to find the resident as soon as possible and ensure the resident was safe. The DON stated staff did what they were supposed to do and did it well. She stated it was something they did not do often and that was a different situation. The DON stated the resident was found within the 30 minutes of staff noticing she was missing. The DON stated Resident #1 told staff the [NAME] told her to get out of the building and when staff located her, she refused to go back into the building. She stated the nurse assessment revealed no physical injury. The DON stated the emergency medical services took Resident #1 to the hospital for evaluation. The DON printed Resident #1's hospital record which showed she was admitted for hallucinations and hypertension. The DON stated the resident would return on 1:1 monitoring.Interviews on 10/22/2025 between 1:42 PM and 5:40 PM were conducted with multiple staff members which included the Administrator, DON, Regional Compliance Nurse, ADON, Social Worker, RN A, CNA B, MDS Coordinator, Business Office Manager, Housekeeping Supervisor, LVN C, LVN D, CNA E, CNA F, CNA G, LVN I, Housekeeping Staff and CNA K. Interviews revealed staff members received elopement in-service training and participated in elopement drills. Staff were reminded to be alert to signs of exit seeking and to notify the charge nurse or DON to assess the resident as needed. Staff members were educated on their role when a code orange (elopement) was called in the facility. The elopement drills included the designation by the charge nurse of staff members to an assigned search area which included searching every room in the facility to ensure the resident was in the building and safe. If a resident was not located inside or outside the building, police, family, and the physician must be notified. No lack of knowledge or procedure was identified. The facility initiated the following interventions prior to the state surveyor entry on 10/21/2025:Record review of Resident #1's clinical file on 10/22/2025 at 10:15 AM reflected the following:-Resident #1's risk assessment on 10/04/2025 reflected the resident was not a high risk for elopement. The elopement risk assessment completed on 10/20/2025 indicated the resident was at high risk.-Resident #1's Comprehensive Care Plan was updated with interventions on 10/20/2025 after the resident exited the building.-Elopement risk assessments and care plans were updated on all residents in the building on 10/20/2025. -The Medical Doctor, Psychiatrist, Director of Nursing, Administrator, and Resident #1's family member were notified of the elopement on 10/20/2025. -Documentation of education of all staff on resident rights, abuse, neglect, and exploitation beginning with night shift staff on 10/20/2025. -Documentation of education of all staff on elopement prevention and response, exit seeking, and door protocols beginning with night shift on 10/20/2025.-Documentation of elopement drills initiated on 10/21/2025 and to continue three times weekly following the elopement.- Documentation of an hourly monitoring log initiated on 10/20/2025 to ensure all residents' windows were intact until window alarms installed- Documentation of a facility work order, dated 10/21/2025, for alarms to be installed on all residents' windows - Documentation of door alarm or lock function monitoring 5 times weekly for each exit door was initiated on 10/20/2025.Administrative staff were observed conducting window checks in the residents' rooms on 10/22/2025 at 10:00 AM, 11:00 AM, 12:00 PM, and 1:00 PM. The work order was completed and the residents' windows equipped with window alarms prior to the surveyor's exit. Record review of the facility's policy Elopement Prevention, undated, reflected Every effort will be made to prevent elopement episodes while maintaining the last restrictive environment for residents who are at risk for elopement. Record review of the facility's policy Elopement Response, undated, reflected Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented.

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 promoted maintenance or enhancement of his or her quality of life for 1 of 4 (Resident #1) residents reviewed for dignity.The facility failed to treat Resident #1 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his urinary catheter bag (collection bag for urine) on 09/10/2025.This failure could place residents at risk of not having their right to a dignified existence maintained.Findings included: Record review of Resident #1's Face Sheet, dated 09/10/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included benign prostatic hyperplasia (flow of urine from the bladder is blocked) and cerebral infarction (blood flow to a part of the brain is blocked). Record review of Resident #1's Quarterly MDS (tool used to assess functional capabilities and health needs) Assessment, dated 08/19/2025, reflected moderately impaired cognition with a BIMS (tool used to assess cognition) score of 08. Section H (bowel and bladder) indicated Resident #1 had an indwelling urinary catheter. Record review of Resident #1's Comprehensive Care Plan, dated 07/23/2025, reflected Resident #1 had an indwelling catheter. One intervention was position catheter bag and tubing below the level of the bladder and in a privacy bag.During an observation and interview on 9/10/2025 at 8:40 AM, Resident #1 was sitting in his wheelchair in the hallway near the nurse's station talking to CNA B. Resident #1's urinary catheter bag was hanging on his wheelchair and not in a privacy bag. Resident #1 stated it was usually covered. CNA B stated Resident #1 had probably lost the privacy bag. She stated it was supposed to be covered for the resident's dignity. CNA B stated she would get a privacy bag for the resident.During an interview on 09/10/2025 at 8:54 AM, LVN C stated Resident #1's urinary catheter bag should have been inside a privacy bag. She stated it was a dignity issue. During an interview on 09/10/2025 at 2:14 PM, the DON stated her expectation was for nursing staff to ensure urinary catheter bags were covered for the dignity of the residents. During an interview on 09/10/2025 at 3:20 PM, the ADON stated residents with a urinary catheter should have it in a privacy bag for the resident's dignity.The facility's policy Catheter Care, undated, did not address the use of a privacy bag.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 (Resident #3) residents reviewed for infection control.The facility failed to ensure CNA B changed gloves and washed his hands while providing incontinence care for Resident #3 on 09/10/2025.This failure could place residents at risk of cross-contamination and development of infections.The findings included:Record review of Resident #3's Face Sheet, dated 09/10/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #3 had diagnoses which included hypertension (high blood pressure) and chronic obstructive pulmonary disease (lung disease that causes shortness of breath). Record review of Resident #3's Quarterly MDS Assessment, dated 08/04/2025, reflected intact cognition with a BIMS score of 15. Section H (bladder and bowel) indicated Resident #3 was frequently incontinent of bowel and bladder. Record review of Resident #3's Comprehensive Care Plan, dated 06/26/2025, reflected Resident #3 has bladder incontinence. Interventions included to provide incontinence care as needed every two hours and monitor for signs and symptoms of a urinary tract infection. During an interview and observation on 09/10/2025 at 1:20 PM, CNA B provided incontinence care for Resident #3. Resident #3 agreed for the surveyor to observe CNA B provide care. CNA B washed his hands in the resident's restroom and placed incontinence care items on a towel draped over the bedside table. CNA B pulled down the front of the brief and cleaned the resident used a single wipe for each pass. CNA B removed his gloves and went to a cabinet in the resident's room, opened the door, and removed a clean brief. CNA B did not use hand sanitizer or wash his hands. CNA B returned to the bedside and put on clean gloves. Resident #3 rolled to her left side and CNA B cleaned the resident's bottom. He did not remove his gloves. CNA B placed the clean brief under Resident #3. He moved to the opposite side of the bed and Resident #3 rolled to her right side. CNA B pulled on the draw sheet to straighten it and straightened the brief under the resident. Resident #3 rolled to her back and CNA B secured the tabs on the brief. CNA B removed his gloves and washed his hands in the resident's restroom before exiting the room. CNA B stated he should have washed his hands or used hand sanitizer when he took off his gloves. CNA B stated he should not have touched the clean brief and draw sheet while wearing the gloves he used to clean Resident #3. CNA B stated it could spread infectious diseases. During an interview on 09/10/2025 at 2:02 PM, LVN C stated anytime a staff member removed gloves, they should wash their hands or use hand sanitizer. LVN C stated staff should not touch anything else with soiled gloves. She stated it was important for infection control. During an interview on 09/10/2025 at 2:14 PM, the DON stated the expectation of staff was to always wash their hands or use hand sanitizer between dirty and clean gloves. She stated this was important because of the potential for infection. She stated the facility would provide in-service training to ensure staff followed infection control measures when caring for residents. During an interview on 09/10/2025 at 3:20 PM, the ADON stated CNA B should have washed his hands or used hand sanitizer when changing gloves during incontinence care. He stated CNA B should not have touched clean items while wearing soiled gloves. The ADON stated it was important to prevent cross contamination and infection. Review of the facility's policy Fundamentals of Infection Control Precautions, undated, reflected, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . Before and after assisting a resident with personal care. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves.

Based on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 10 (Resident #2) residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #2's room was in a position accessible to the resident on 09/10/2025.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #2's Face Sheet, dated 09/10/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (decline in cognitive function that interferes with daily life) and unsteadiness on feet.Record review of Resident #2's Quarterly MDS Assessment, dated 08/20/2025, reflected severe cognitive impairment with a BIMS score of 03. Resident #2 required staff assistance for self-care needs. Record review of Resident #2's Comprehensive Care Plan, dated 09/01/2025, reflected the resident was at risk for falls. One of the interventions was to ensure the call light was within reach and encourage the resident to use it for assistance as needed. During an observation and interview on 09/10/2025 at 9:40 AM, Resident #2 was lying in bed awake. Resident #2's call light cord was on the floor approximately two feet to the right of the head of his bed. When he was asked if he used his call light, Resident #2 replied no. A further attempt to interview the resident was unsuccessful due to his cognitive status. CNA B came into the resident's room and stated the resident did not use the call light. He stated Resident #2 had poor vision and the call light was normally clipped near the resident's pillow. CNA B placed the call light within the resident's reach. He stated it was important for the call light to be within the resident's reach so he could use it to call for help. During an interview on 09/10/2025 at 10:23 AM, LVN C stated Resident #2 did not use the call light and staff had to anticipate his needs. She stated staff tried to keep the call light clipped on Resident #2's bed. She stated it was important to ensure the call light was within the resident's reach because it was a safety issue. LVN C stated it was also Resident #2's right to have access to his call light. During an interview on 09/10/2025 at 1:45 PM, the Administrator stated the facility did not have a policy specific to call light placement. He stated the expectation was for all residents to have access to their call lights. He stated the nursing staff monitored call light placement during rounds, and all staff should ensure the call light is within reach before leaving a resident's room. He stated the call light should have been clipped within Resident #2's reach. During an interview on 09/10/2025 at 2:14 PM, the DON stated Resident #2's call light should have been within his reach so if he wanted to use it he could. During an interview on 09/10/2025 at 3:20 PM, the ADON stated all residents should have their call light in reach. He stated it was for the residents' safety and to ensure they could notify staff if they needed assistance of any kind.The facility did not provide a policy related to the use of call lights.

Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #24, #23, and #1) of 12 residents reviewed for infection control. The facility failed to ensure LVN C cleaned the blood pressure cuff between residents when administering medication to Residents #24, #23, and #1 on 05/14/2025. These failures could place residents at risk of cross-contamination and development of infections. The findings included: During observation and interview on 05/14/2025 at 7:59 AM, LVN C was observed administering medication to residents. LVN C took a blood pressure cuff into Resident #24's room and checked her blood pressure prior to preparing the medication to administer. LVN C did not use a wipe to sanitize the blood pressure cuff when she returned to the medication cart. After administering the medication to Resident #24, LVN C took the blood pressure cuff into Resident #23's room and checked her blood pressure. She returned to the medication cart and did not use a wipe to sanitize the blood pressure cuff. LVN C prepared the medication and took it to Resident #23. LVN C took the blood pressure cuff into Resident #1's room to check his blood pressure. LVN C returned to the medication cart to prepare Resident #1's medication to administer. LVN C did not use a wipe to sanitize the blood pressure cuff. LVN C administered the medication to Resident #1 and returned to the medication cart. LVN C stated she did not clean the blood pressure cuff between residents. LVN C stated it was important to sanitize items used for more than one resident to control infection. During an interview on 05/14/2025 at 8:50 AM the Regional Nurse stated LVN C was probably nervous about being watched and forgot to clean the blood pressure cuff. She stated they would follow-up with LVN C. During an interview on 05/14/25 at 10:53 AM, the DON stated LVN C should have cleaned the blood pressure cuff between residents. She stated any equipment used for more than one resident must be wiped with a sanitizing wipe between residents. She stated this was important for infection control. The DON stated she had already provided 1:1 in-service to LVN C. Review of the facility's policy Infection Control Policy and Procedures Manual 2019, updated March 2024, reflected The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection .Ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed.

Based on observations, interviews, 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 promoted maintenance or enhancement of his or her quality of life for one (Resident #147) of five residents reviewed for dignity. The facility failed to treat Resident #147 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his foley bag (collection bag for urine) on 05/13/2025. This failure placed residents at risk of not having their right to a dignified existence maintained. Findings included: Record review of Resident #147's Face Sheet, dated 05/13/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #147 had diagnoses which included obstructive and reflux uropathy (urine flow is blocked) and central cord syndrome (affects motor function in arms and legs). Record review of Resident #147's Comprehensive MDS (tool used to assess functional capabilities and health needs) Assessment, dated 05/12/2025, reflected Resident #147 was cognitively intact with a BIMS (tool used to assess cognition) score of 15. Section H (bowel and bladder) reflected Resident #147 had an indwelling foley catheter. Record review of Resident #147's Comprehensive Care Plan, dated 05/13/2025, reflected Resident #147 had an indwelling catheter related to obstructive and reflux uropathy. One intervention was to provide a catheter bag with an attached cover. During an observation, an interview on 05/13/25 at 9:34 AM, Resident #147 was sitting in his wheelchair in the doorway of his room. His foley catheter bag was not in a privacy bag. Resident #147 stated he came to the facility on Friday and a staff member told him the previous day they would bring him a bag to cover it but did not. Resident #147 stated he wanted the foley bag hid because it was embarrassing. During an interview on 05/13/2025 at 9:38 AM, CNA B stated she just came on shift and was going to get Resident #147 a privacy bag. She stated she planned to get one as soon as she finished rounding on her residents. She stated it was important for the resident's dignity and other residents might not want to see the foley bag. During an interview on 05/13/2025 at 9:47 AM, RN A stated the Resident #147's foley bag should have been covered. She stated it could be embarrassing for the resident. She stated no one wanted to walk around with a foley bag and have everyone see what was in it. During an interview on 5/13/2025 at 11:30 AM, the DON stated she instructed staff to get Resident #147 a foley bag with an attached cover and remind the resident to call staff to empty the foley bag. The DON stated it was important to ensure foley bags were covered for the dignity of the resident. She stated the nurses and CNAs were responsible for monitoring to ensure foley bags were covered. She stated she would in-service staff. During an interview on 05/15/2025 at 1:40 PM, the administrator stated it was important to keep the foley catheter bag in a privacy bag for the resident's dignity. He stated it could be embarrassing for the resident. Review of the facility's policy Catheter Care did not reflect the use of a privacy bag.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #41 and Resident #24) of 10 residents reviewed for infection control. 1. The facility failed to ensure Resident #41's foley catheter (tube that drains urine) bag was not touching the floor when the resident was lying in bed on 05/13/2025. 2. The facility failed to ensure CNA D wiped from front to back when providing incontinent care to Resident #24 on 05/15/2025. These failures could place residents at risk of cross-contamination and development of infections. The findings included: Resident #41 Record review of Resident #41's Face Sheet, dated 05/13/2025, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #41 had diagnoses which included neuromuscular dysfunction of the bladder (bladder does not function properly) and hypertension (high blood pressure). Record review of Resident #41's Quarterly MDS Assessment, dated 03/16/2025, reflected severely impaired cognition with a BIMS score of 01. The MDS Assessment reflected Resident #41 had an indwelling foley catheter. Record review of Resident #41's Comprehensive Care Plan, dated 03/13/2025, reflected Resident #41 has indwelling foley catheter. Interventions included Position catheter bag and tubing below the level of bladder and in a privacy bag and check tubing for kinks and maintain drainage bag off the floor. During an observation on 05/13/2025 at 9:26 AM, Resident #41 was lying in bed asleep. Resident #41's foley bag (collects urine) was in a privacy bag and hung on the bedrail. The bottom of the privacy bag was touching the floor. During an interview on 05/13/2025 at 9:47 AM, RN A stated Resident #41's foley bag should not have been touching the floor. She stated it was not supposed to be on the floor because it could collect bacteria, become contaminated, and cause infection. During an interview on 05/13/25 at 11:30 AM, the DON stated it was important to prevent foley catheter bags from touching the ground to prevent contamination and infection. She stated the nurse and CNAs were responsible for monitoring the foley bags to ensure they were kept off of the floor. The DON stated she was in-servicing staff. Review of the facility's policy Catheter Care reflected Be sure the catheter tubing and drainage bag are kept off the floor. Resident #24 Record review of Resident #24's Face Sheet, dated 05/14/2025, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #24 had diagnoses which included dementia and the need for assistance with personal care. Record review of Resident #24's Quarterly MDS Assessment, dated 04/03/2025, reflected moderate impaired cognition with a BIMS score of 08. Section G (functional status) indicated Resident #24 required extensive assistance with toileting needs. Record review of Resident #24's Comprehensive Care Plan, dated 04/07/2025, reflected ADL Self Care Performance Deficit. One intervention was to assist resident with toileting needs. During an observation and interview on 05/15/2025 at 10:17 AM CNA D and CNA E provided incontinence care for Resident #24. CNA D and CNA E washed their hands in resident's restroom and put on gloves. CNA D pulled down the front of Resident #24's brief and used a single wipe with each pass to clean the resident, wiping in a downward motion. Resident #24 rolled to her left side and CNA E held the resident while CNA D cleaned the resident's bottom. CNA D did not wipe the resident from the front to the back, ensuring to wipe toward the bottom. After cleaning Resident #24's bottom, CNA D stated she should have wiped from front to back. CNA D did not clean the resident again. CNA D dropped the soiled brief into the trash bag. She used hand sanitizer when changing gloves. CNA D placed a clean brief under Resident #24 and applied barrier cream to the resident's bottom. CNA D used hand sanitizer when changing gloves. CNA D secured the tabs on each side of the brief and pulled up the resident's blanket. CNA D and CNA E removed their gloves and washed their hands in the resident's restroom. Upon exiting Resident #24's room, CNA D stated she should have wiped the resident from front to back to prevent infection. She stated it was important to not transfer anything. She stated not cleaning correctly could cause the resident to get a urinary tract infection. During an interview on 05/15/2025 at 11:42 AM, the DON and Regional Nurse stated it was important for staff to clean the residents properly when providing incontinence care to prevent the spread of infection. The DON stated staff would be in-serviced. Review of the facility's policy Infection Control Policy and Procedures Manual 2019, updated March 2024, reflected The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free from accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #41) of 8 residents reviewed for accident hazards. The facility failed to ensure Resident #41's fall mat was not folded up and leaned against a wall when Resident #41 was lying in bed on 05/13/2025. This failure could place residents at risk of harm and serious injuries. Findings included: Record review of Resident #41's Physician's Order, dated 04/08/2025, reflected low bed with floor mat at bedside. Record review of Resident #41's Face Sheet, dated 05/13/2025, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #41 had diagnoses which included unsteadiness on feet and a history of falls. Record review of Resident #41's Quarterly MDS Assessment, dated 03/16/2025, reflected severely impaired cognition with a BIMS score of 01. The Quarterly MDS Assessment indicated that the resident had dementia and seizure (abnormal brain activity affecting muscle control) disorder. Record review of Resident #41's Comprehensive Care Plan, dated 03/31/2025, reflected Resident #41 was at risk for falls r/t Confusion, Gait/balance problem. One intervention was Keep bed in lowest position with floor mat at bedside. During an observation on 05/13/2025 at 9:26 AM, Resident #41 was lying in bed asleep. Resident #41's fall mat was folded up and leaned against the wall near his bed. During an interview on 05/13/2025 at 9:47 AM, RN A stated Resident #41 had tried to get out of bed without assistance. She stated it was important to have Resident #41's fall mat next to his bed to prevent injury if he fell . She stated she was not sure if the fall mat was to be used at nighttime or any time the resident was in bed. During an interview on 05/13/2025 at 11:30 AM, the DON stated Resident #41's fall mat should have been placed next to the bed while the resident was lying in bed. She stated it should be put up when the resident was not in bed. She stated this intervention helped prevent an injury if the resident fell . During an interview on 05/15/2025 at 1:15 PM, CNA B stated Resident #41's bed had to be in the lowest position and the floor mat next to the bed when Resident #41 was in bed. She stated this was important to prevent injury if the resident fell . During an interview on 05/15/2025 at 1:40 PM, the Administrator stated it was important to have a fall mat in place in case Resident #41 tried to transfer or was non-compliant with waiting for staff to assist him. He stated if the resident rolled out of the bed, the fall mat could prevent injury. The facility did not provide a policy for fall mats prior to exit.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedure that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident #1) of four residents reviewed for pharmaceutical services. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 01/25/2025 and ended on 01/28/2025. The facility corrected the noncompliance before the investigation began. The facility failed to administer Resident #1's Lacosamide (anti- seizure medication) according to medication administration orders. Resident #1 did not receive her antiepileptic medication for two days (01/25/25 and 01/26/25). This failure could place residents at risk of not receiving medications as ordered by the physician, increasing the risk of inducing life-threatening seizures, injury and not receiving the therapeutic benefits of the medications. Findings included: Record review of Resident #1 face sheet dated 03/18/25, revealed Resident #1 was a [AGE] year-old female admitted to the facility for respite services on 01/21/25 and readmitted to the facility on [DATE]. Diagnosis included Metabolic Encephalopathy (chemical imbalance caused by illness in the blood affecting the brain); Epilepsy without status Epilepticus (seizure without a seizure lasting more than 5 minutes) and Severe Intellectual disability. Record review of Resident #1's MDS assessment, dated 01/24/25, revealed the resident's BIMS score of 03, which indicated severe cognitive impairment. Record review of Resident #1's medication administration record, dated from 01/21/25 to 01/31/25 revealed Resident #1 was receiving Lacosamide Oral Tablet 200 MG (Lacosamide) Give 1 tablet by mouth two times a day for Seizures. Review of Resident #1's physician order dated 01/21/25, on 03/19/25 revealed, Lacosamide (anti-convulsant that works by decreasing abnormal electrical activity in the brain) oral tablet 200 mg (Lacosamide) give one tablet by mouth two times a day for seizures. Review of MAR (Medication Administration Record) dated [DATE] on 03/19/25, revealed Resident #1's Lacosamide 200 mg tablet had been documented as having been administered twice a day from 01/21/25 to 01/27/25. Review of the Individual Resident Narcotic Record for resident # 1 initiated on 01/23/25 revealed that the facility did not administer the Lacosamide as ordered. There was an overage of Lacosamide remaining on the narcotic count after Resident #1 was sent to the hospital for her seizures. Resident # 1 missed four doses of her Lacosamide in total. On 03/19/25, review of the SBAR document dated 01/27/25 revealed, that LVN F had notified MD that Resident #1 had experienced three separate seizures lasting 45 seconds, 45 seconds and 1 minute 30 seconds respectively. Resident was sent to the hospital for evaluation. She returned the same day with no new orders. During an interview on 03/19/25 at 4:50 PM LVN A stated he worked weekends, rotating 12-hour shifts. He advised it was mid-week and not his normal shift on the date of the incident on 01/25/25. LVN A said when Resident #1 was admitted to the facility on [DATE], she did not have any medication available at the facility. He stated he called the pharmacy to request the medications. The medications were received on 01/22/25. The resident accidentally dislodged her IV catheter on 01/23/25 and was sent out to the hospital for replacement. She returned to the facility on [DATE] with no new medication orders. LVN A stated he looked for the Lacosamide on 01/25/25 for administration and he was unable to locate it. He stated he looked in the E kit and the Lacosamide was not there. He stated when he could not find the medication, he called the pharmacy to request it but did not call the DON to let her know. He said the meds were found in the cart on 01/27/25 but was not in the usual order, as they were normally organized alphabetically. LVN A stated he did not recall it being it being in alphabetical order so he could not find it. LVN A stated he did not administer Lacosamide 200 mg oral tablet on 01/25/25 and 01/26/25 because he thought the medication was unavailable. LVN A was given one on one in-service over medication administration by the DON on 01/27/25. LVN A stated it was both his and LVN B's responsibilities to administer medications to the residents. LVN A resigned on 01/27/25. During an interview on 03/18/25 at 5:30 PM, LVN B said she has been a charge nurse for about 4 months here and have been a nurse for [AGE] years. LVN B stated they did not have Lacosamide. Everything else came in but that one. She stated Resident #1 did not have any seizures for the whole shift. She stated the meds came in the next day or the day after and that the E kit did not have the Lacosamide. The meds were not administered on 01/25/25 and 01/26/25. LVN A said failure to administer medication could place the resident at risk and jeopardize their health and safety. LVN A called first on 01/25/25 to make sure it was coming he was told it would be there that night. She stated they usually get them by around 830 -900 PM at the latest, and they do not get deliveries over the weekend. LVN B said, we can't give any meds if we do not have the medication. LVN B stated we did not have Lacosamide 200 mg, everything else came in but that one. She said the e-kit medication is placed in the box by the resident's name and the lock box is where narcotics are stored, it is in alphabetical order. LVN B stated she did not recall Resident #1 having any seizures on the shifts that she worked. The medication did not come in until 01/27/25. LVN B stated she did not think that not receiving the medication would have had a negative effect on Resident #1's care and well-being due to her age. LVN B stated Resident #1 was discharged to the hospital for seizures on 01/27/25. LVN B received in-service with group over 5 Right of medication administration on 01/28/25. Further record review dated 01/28/25, medication administration record indicated the medication was administered to Resident #1. Review of the Narcotic count sheet revealed no Lacosamide was administered on 01/25/25 and 01/26/25. LVN A and LVN B documented the medication administration incorrectly and were suspended pending investigation. During a follow up interview on 03/20/25 at 2:55 PM LVN D stated they were in serviced on what to do when medications are not available. It comprised of Check to see if available in e-kit. If not in e-kit call MD to notify of medication unavailable. Request alternative available in-house medication and a HOLD order for current medication. Call pharmacy, request refill medication to be sent out. If replacement order, ask for that medications to be sent out. Correct orders in PCC either HOLD order or replacement. Chart your conversations and resolution. Ensure to put names of parties notified- RP, MD, and Pharmacy. Notify DON of above action. LVN D stated received in service training for location and using of e-kit. LVN D was able to correctly verbalize all current procedures related to medications. During a follow up interview on 03/20/25 at 3:00 PM LVN E advised it can have a negative impact on residents if they do not receive their anti-seizure meds, because it would put them at risk for break through seizures. She advised that if they do not receive their anti-seizure meds, they can have breakthrough seizures. LVN F stated they were in serviced on what to do when medications are not available. It comprised of Check to see if available in e-kit. If not in e-kit call MD to notify of medication unavailable. Request alternative available in-house medication and a HOLD order for current medication. Call pharmacy, request refill medication to be sent out. If replacement order, ask for that medications to be sent out. Correct orders in PCC either HOLD order or replacement. Chart your conversations and resolution. Ensure to put names of parties notified- RP, MD, and Pharmacy. Notify DON of above action. LVN E stated received in service training for location and using of e-kit. LVN E also correctly verbalized knowledge of medication procedures. During a follow up interview on 03/20/25 at 3:10 PM with LVN F advised that if they do not receive their anti-seizure meds, they can have breakthrough seizures. LVN F stated they were in serviced on what to do when medications are not available. It comprised of Check to see if available in e-kit. If not in e-kit call MD to notify of medication unavailable. Request alternative available in-house medication and a HOLD order for current medication. Call pharmacy, request refill medication to be sent out. If replacement order, ask for that medications to be sent out. Correct orders in PCC either HOLD order or replacement. Chart your conversations and resolution. Ensure to put names of parties notified- RP, MD, and Pharmacy. Notify DON of above action. LVN F stated received in service training for location and using of e-kit and was able to correctly identify medication procedures. Attempted phone call to Resident #1 Representative, on 03/19/25 at 3:02 PM went unanswered and no call backs were received by time of exit. During an interview on 03/19/2025 at 5:24 PM with Physician, he stated he was familiar with the incident for Resident # 1. He stated the facility notified him about the missed medications, and she had missed them. He stated the possible outcomes of missing medications for this resident specifically was inducing a seizure if her medication levels drop. He stated it would be concerning if a resident did not receive their doses of Lacosamide because it would put them at risk for break through seizures. He stated his expectations related to medication administration was discussed at the QAPI meeting and was care planned. He said that there had been no other additional missed medications of which he was aware. He stated an ADHOC QAPI meeting was completed on 01/27/25 to include the IDT team and Medical Director during which this incident was the main topic. Review of the facility policy titled Pharmacy Policy & Procedure Manual 2003, stated that The Accountability Audit of Controlled Drug Audit Sheets record will be filled in with the information that corresponds to the Rx supply. Staff will note how many doses were given and how many doses remain. 15. Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. Record review of the facility PIR on 03/18/24 revealed that the facility completed their investigation the incident. Th investigation included the audit of all medication, including anti-seizure medication for all residents. they also conducted audits of narcotic sheet documentation during which it was discovered that LVN A and LVN B did not administer Resident #1s Lacosamide as prescribed. The facility suspended LVN A and LVN B and completed their investigation. Resident #1 did return to the facility on [DATE], but discharge on the same day back to her previous residence per her family's request. The facility initiated the following interventions prior to surveyor entry on 03/18/25. 100% audit of all medications ordered in facility. 100% audit of all anti-epileptic medications for all residents The facility obtained all medications as ordered for Resident #2 Medication Error report completed 01/27/25. Notification of MD and RP 01/27/25 LVN A and LVN B were suspended pending investigation. Self-report called in to HHSC on In serviced all staff completed on 01/27/25 over: Admission and readmission medication reconciliation o Use of E-kit, when and how to use o medication administration, including seizure medication and those requiring triplicate o Physician orders o What to do if medication is unavailable o Abuse, Neglect, and Exploitation o Change in condition. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 01/25/2025 and ended on 01/28/2025. The facility corrected the noncompliance before the investigation began.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents are free from any significant medication error for 1 (Resident#1) of 4 residents reviewed for medication errors. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 01/25/2025 and ended on 01/28/2025. The facility corrected the noncompliance before the investigation began. The facility failed to administer Resident #1's Lacosamide (anti- seizure medication) according to medication administration orders. Resident #1 did not receive her antiepileptic medication for two days (01/25/25 and 01/26/25). This failure could place residents at risk of not receiving medications as ordered by the physician, increasing the risk of inducing life-threatening seizures, injury and not receiving the therapeutic benefits of the medications. Findings included: Record review of Resident #1 face sheet dated 03/18/25, revealed Resident #1 was a [AGE] year-old female admitted to the facility for respite services on 01/21/25 and readmitted to the facility on [DATE]. Diagnosis included Metabolic Encephalopathy (chemical imbalance caused by illness in the blood affecting the brain); Epilepsy without status Epilepticus (seizure without a seizure lasting more than 5 minutes) and Severe Intellectual disability. Record review of Resident #1's MDS assessment, dated 01/24/25, revealed the resident's BIMS score of 03, which indicated severe cognitive impairment. Record review of Resident #1's medication administration record, dated from 01/21/25 to 01/31/25 revealed Resident #1 was receiving Lacosamide Oral Tablet 200 MG (Lacosamide) Give 1 tablet by mouth two times a day for Seizures. Review of Resident #1's physician order dated 01/21/25, on 03/19/25 revealed, Lacosamide (anti-convulsant that works by decreasing abnormal electrical activity in the brain) oral tablet 200 mg (Lacosamide) give one tablet by mouth two times a day for seizures. Review of MAR (Medication Administration Record) dated [DATE] on 03/19/25, revealed Resident #1's Lacosamide 200 mg tablet had been documented as having been administered twice a day from 01/21/25 to 01/27/25. Review of the Individual Resident Narcotic Record for resident # 1 initiated on 01/23/25 revealed that the facility did not administer the Lacosamide as ordered. There was an overage of Lacosamide remaining on the narcotic count after Resident #1 was sent to the hospital for her seizures. Resident # 1 missed four doses of her Lacosamide in total. On 03/19/25, review of the SBAR document dated 01/27/25 revealed, that LVN F had notified MD that Resident #1 had experienced three separate seizures lasting 45 seconds, 45 seconds and 1 minute 30 seconds respectively. Resident was sent to the hospital for evaluation. She returned the same day with no new orders. During an interview on 03/19/25 at 4:50 PM LVN A stated he worked weekends, rotating 12-hour shifts. He advised it was mid-week and not his normal shift on the date of the incident on 01/25/25. LVN A said when Resident #1 was admitted to the facility on [DATE], she did not have any medication available at the facility. He stated he called the pharmacy to request the medications. The medications were received on 01/22/25. The resident accidentally dislodged her IV catheter on 01/23/25 and was sent out to the hospital for replacement. She returned to the facility on [DATE] with no new medication orders. LVN A stated he looked for the Lacosamide on 01/25/25 for administration and he was unable to locate it. He stated he looked in the E kit and the Lacosamide was not there. He stated when he could not find the medication, he called the pharmacy to request it but did not call the DON to let her know. He said the meds were found in the narcotic box on 01/27/25 so he could not find it originally. LVN A stated he did not administer Lacosamide 200 mg oral tablet on 01/25/25 and 01/26/25 because he thought the medication was unavailable. LVN A was given one on one in-service over medication administration by the DON on 01/27/25. LVN A stated it was both his and LVN B's responsibilities to administer medications to the residents. LVN A resigned on 01/27/25. During an interview on 03/18/25 at 5:30 PM, LVN B said she has been a charge nurse for about 4 months here and have been a nurse for [AGE] years. LVN B stated they did not have Lacosamide. Everything else came in but that one. She stated Resident #1 did not have any seizures for the whole shift. She stated the meds came in the next day or the day after and that the E kit did not have the Lacosamide. The meds were not administered on 01/25/25 and 01/26/25. LVN A said failure to administer medication could place the resident at risk and jeopardize their health and safety. LVN A called first on 01/25/25 to make sure it was coming he was told it would be there that night. She stated they usually get them by around 830 -900 PM at the latest, and they do not get deliveries over the weekend. LVN B said, we can't give any meds if we do not have the medication. LVN B stated we did not have Lacosamide 200 mg, everything else came in but that one. She said the e-kit medication is placed in the box by the resident's name and the lock box is where narcotics are stored, it is in alphabetical order. LVN B stated she did not recall Resident #1 having any seizures on the shifts that she worked. The medication did not come in until 01/27/25. LVN B stated she did not think that not receiving the medication would have had a negative effect on Resident #1's care and well-being due to her age. LVN B stated Resident #1 was discharged to the hospital for seizures on 01/27/25. LVN B received in-service with group over 5 Right of medication administration on 01/28/25. Further record review dated 01/28/25, medication administration record indicated the medication was administered to Resident #1. Review of the Narcotic count sheet revealed no Lacosamide was administered on 01/25/25 and 01/26/25. LVN A and LVN B documented the medication administration incorrectly and were suspended pending investigation. During a follow up interview on 03/20/25 at 2:55 PM LVN D stated they were in serviced on what to do when medications are not available. It comprised of Check to see if available in e-kit. If not in e-kit call MD to notify of medication unavailable. Request alternative available in-house medication and a HOLD order for current medication. Call pharmacy, request refill medication to be sent out. If replacement order, ask for that medications to be sent out. Correct orders in PCC either HOLD order or replacement. Chart your conversations and resolution. Ensure to put names of parties notified- RP, MD, and Pharmacy. Notify DON of above action. LVN D stated received in service training for location and using of e-kit. LVN D was able to correctly verbalize all current procedures related to medications including narcotic medication location. During a follow up interview on 03/20/25 at 3:00 PM LVN E advised it can have a negative impact on residents if they do not receive their anti-seizure meds, because it would put them at risk for break through seizures. She advised that if they do not receive their anti-seizure meds, they can have breakthrough seizures. LVN F stated they were in serviced on what to do when medications are not available. It comprised of Check to see if available in e-kit. If not in e-kit call MD to notify of medication unavailable. Request alternative available in-house medication and a HOLD order for current medication. Call pharmacy, request refill medication to be sent out. If replacement order, ask for that medications to be sent out. Correct orders in PCC either HOLD order or replacement. Chart your conversations and resolution. Ensure to put names of parties notified- RP, MD, and Pharmacy. Notify DON of above action. LVN E stated received in service training for location and using of e-kit. LVN E also correctly verbalized knowledge of medication procedures including narcotic medication location. During a follow up interview on 03/20/25 at 3:10 PM with LVN F advised that if they do not receive their anti-seizure meds, they can have breakthrough seizures. LVN F stated they were in serviced on what to do when medications are not available. It comprised of Check to see if available in e-kit. If not in e-kit call MD to notify of medication unavailable. Request alternative available in-house medication and a HOLD order for current medication. Call pharmacy, request refill medication to be sent out. If replacement order, ask for that medications to be sent out. Correct orders in PCC either HOLD order or replacement. Chart your conversations and resolution. Ensure to put names of parties notified- RP, MD, and Pharmacy. Notify DON of above action. LVN F stated received in s including narcotic medication location. Attempted phone call to Resident #1 Representative, on 03/19/25 at 3:02 PM went unanswered and no call backs were received by time of exit. During an interview on 03/19/2025 at 5:24 PM with Physician, he stated he was familiar with the incident for Resident # 1. He stated the facility notified him about the missed medications, and she had missed them. He stated the possible outcomes of missing medications for this resident specifically was inducing a seizure if her medication levels drop. He stated it would be concerning if a resident did not receive their doses of Lacosamide because it would put them at risk for break through seizures. He stated his expectations related to medication administration was discussed at the QAPI meeting and was care planned. He said that there had been no other additional missed medications of which he was aware. He stated an ADHOC QAPI meeting was completed on 01/27/25 to include the IDT team and Medical Director during which this incident was the main topic. Review of the facility policy titled Pharmacy Policy & Procedure Manual 2003, stated that The Accountability Audit of Controlled Drug Audit Sheets record will be filled in with the information that corresponds to the Rx supply. Staff will note how many doses were given and how many doses remain. 15. Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. Record review of the facility PIR on 03/18/24 revealed that the facility completed their investigation the incident. Th investigation included the audit of all medication, including anti-seizure medication for all residents. they also conducted audits of narcotic sheet documentation during which it was discovered that LVN A and LVN B did not administer Resident #1s Lacosamide as prescribed. The facility suspended LVN A and LVN B and completed their investigation. Resident #1 did return to the facility on [DATE], but discharge on the same day back to her previous residence per her family's request. The facility initiated the following interventions prior to surveyor entry on 03/18/25. 100% audit of all medications ordered in facility. 100% audit of all anti-epileptic medications for all residents The facility obtained all medications as ordered for Resident #2 Medication Error report completed 01/27/25. Notification of MD and RP 01/27/25 LVN A and LVN B were suspended pending investigation. Self-report called in to HHSC on In serviced all staff completed on 01/27/25 over: Admission and readmission medication reconciliation o Use of E-kit, when and how to use o medication administration, including seizure medication and those requiring triplicate o Physician orders o What to do if medication is unavailable o Abuse, Neglect, and Exploitation o Change in condition. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 01/25/2025 and ended on 01/28/2025. The facility corrected the noncompliance before the investigation began.

Based on observations, interviews, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. The facility failed to transport the resident in a safe manner by using the rollator walker as a wheelchair resulting in the resident falling forward and sustaining fractures to her left elbow, and right hip. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 02/15/2025 and ended on 02/21/2025. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk of injury and a decreased quality of life. Findings Included: Record review of Resident # 2's Face Sheet printed 03/18/25 reflected was an [AGE] year-old female admitted to the facility on [DATE]. It reflected a history of falls with injury; Rheumatoid Arthritis, history of prior fractures, advanced osteoarthritis, lack of coordination, muscle weakness, a BIMS score of 15 , ( brief screening tool that aids in detecting cognitive impairment) , however, the resident was noted to have difficulty focusing and disorganized thinking at baseline. Record review of Resident #2's Care Plan dated 03/18/25 revealed: The resident has an ADL Self Care Performance Deficit Date Initiated: 12/16/2024 - Interventions. The resident uses a walker Date Initiated: 12/16/2024. Toilet use: requires staff x1 for assistance Date Initiated: 12/16/2024. Walking: requires staff x1 for assistance Date Initiated: 12/16/2024 Record review of nursing notes dated 02/15/2025 at 1:30 PM Resident #2 complained of pain to her left shoulder, right elbow, and hip after falling from her rollator walker used for transporting her to the restroom by LVN C. She was medicated for pain but did not have relief from this, so she was sent to ER for evaluation. She returned same day with diagnosis of non-displaced hairline fracture to left proximal humorous and periprosthetic fracture around right internal prosthetic right hip joint. Further record review dated 02/15/25 at 5:14 PM, during the investigation of the incident, it was discovered that LVN C was transporting the resident using the rollator walker. The resident attempted to adjust herself in the seat of the walker while it was in motion and fell forward. As a result, the resident sustained a fracture to her left humorous and to her right femur. During an interview on 03/19/25 at 5:10 PM, LVN C, she stated she had been a nurse for about [AGE] years. She stated she was the weekend supervisor and sometimes on the weekends she would help the CNA. She stated sometimes the rollator and wheelchair were in resident #2's room. On 02/15/25, she stated she asked the resident which device she wanted to use to be transported, and the resident stated she wanted the rollator. LVN C stated she knew the resident should have been transported in the wheelchair and she had transferred Resident #2 using the rollator before. She said she helped the resident up and sat her in the rollator seat, moved forward then stopped for a second and the resident just rolled out and on the floor. LVN C stated she called and asked for assistance and then made the immediate decision to send her to the hospital for evaluation because resident #2 had some fractures in the past. LVN C stated if she had known Resident #2 was weaker, she would have sat her in the wheelchair. She said I have been in nursing homes for years; I usually have a second person with me but this time I did not. LVN C stated she had received one on one training after the incident and was also part of the group in service training on resident transfers, abuse, or neglect after the incident, and they also specified on not to use the Rollator, and ANE. Resident #1 was no longer at the facility and could not be contacted for interview. Record review of hospital records dated 02/15/25 revealed x-rays completed with diagnosis of fracture of Resident #1's right femur (thigh bone) and left humorous (upper arm bone). Record review of Care Plan dated 03/17/25, Resident #2 Interventions initiated prior to surveyor entry on 03/18/25: RP notified 02/15/25. MD notified 02/15/25. Record review of Investigation Safe surveys for observations of staff using rollator for transporting residents 02/15/25 LVN C, was suspended pending investigation. 02/15/25 02/21/25 One on one in service with LVN C over Transferring with a rollator walker specifying intended use and prohibiting using rollator as a wheelchair. Low bed ordered for resident. Pain management for fracture and bruising The facility completed in- services of all staff 23 total, on 02/17/25 on preventive strategies to reduce falls, falls/ ambulation difficulty, change in condition. Record review of Resident #2's In-services: dated 02/17/25, title Transferring with a rollator walker specifying intended use prohibiting using rollator as a wheelchair. Abuse and Neglect Monitoring - DON/designee to ask 6 nursing staff members per week how to locate how much assistance is needed for a resident task and what they would do if the proper number of staff is not present, resident. During facility rounds, are there any signs of staff performing their duties in a neglectful manner? Note any corrective actions. DON / Designee to monitor at least 5 of the following processes each week to ensure the proper number of staff is providing assistance: bathing, bed mobility, transferring, walking, incontinent care. Record review of Resident # 1's Care plan updated 02/15/25: The resident has an ADL Self Care Performance Deficit Date Initiated: 12/16/2024. Revision on: 03/17/2025 Toilet use: requires staff x1 for assistance Date Initiated: 12/16/2024. Created by: CN The resident uses a walker Date Initiated: 12/16/2024. Created by CN Record review of Resident # 1 Interventions: TRANSFER: the resident requires Mechanical lift and 2 staff for transfers. Date Initiated: 02/15/2025. Created by: RGCN The resident has a left humerus fracture and right femur fracture post Fall Date Initiated: 02/16/2025. Revision on: 03/17/2025 The resident has a left humerus fracture and right femur fracture post fall. Date Initiated: 02/16/2025. Revision on: 03/17/2025 GOAL: The resident will remain free of complications related to hip fracture, such as contracture formation, embolism, and immobility through review date Interventions: Rollator taken home by family Date Initiated: 02/17/2025 Created by:RGCN Report any pain to the charge nurse Date Initiated: 02/16/2025. Created by: RGCN Reposition as necessary to prevent skin breakdown. Prevent 90-degree flexion to prevent circulation problems. Date Initiated: 02/16/2025. Created by: RGCN The resident is risk for falls. Had an actual fall Date Initiated: 12/16/2024. Revision on: 03/17/2025 Goal The resident will be free of falls through the review date. Date Initiated: 12/16/2024. Intervention Ensure that the Resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Date Initiated: 12/16/2024. Created by: CN. Anticipate and meet the resident's needs. Date Initiated: 12/16/2024. Created by: CN. Review of NN dated 02/18/25 revealed the resident had a follow up appointment with orthopedic MD for 03/03/25 and remained on NWB status until then was upgraded to WB as tolerated. Sling to affected arm and PT. During an interview on 03/19/25 at 2:51 PM CNA A, stated she has been a CNA for [AGE] years at this facility. CNA A stated she has never transported a resident in a rollator walker. CNA A stated the correct method to transport residents, is If they can walk with a gait belt, or a wheelchair, if it is a rollator you must walk with them but since we have been in-serviced, we do not use it. CNA A stated she had heard about the incident nut was not involved. She stated it was on another wing. She verified that she had been in serviced over using rollator and that management staff were checking on them. During an interview on 03/19/25 at 3:07 PM CNA B stated she has been a CNA for [AGE] years, 6 months at this facility. She stated she had never transported a resident in a rollator walker. She stated walkers are made for walking that is what their purpose is. She stated the correct method to transport residents depending on their care plan, was to use a gait belt. Verbally let them know step by step, she said it helped them when you are communicating with them. She stated she had heard about the incident and was inservice over transporting residents, falls and walkers and wheelchairs. During an interview on 03/19/25 at 3:33 PM CNA C stated has been a CNA for [AGE] years, has been here at this facility for about 2 months. She stated she had never transported a resident in a rollator walker and that it is to be used as walker. She stated the correct method for using a walker was a walker make sure they use it properly, use a gait belt to transfer them. She was not familiar with the incident abd had received in-servicing on how to properly use a wheelchair, and do not use a Rollator. She stated that the person transporting the resident should ensure they are performing the task correctly. During an interview on 03/19/25 at 2:15 PM, OTA stated she has never transported a resident in a rollator walker. OTA stated the correct method to transport residents is by using a wheelchair or if resident is able to ambulate with walker and gait belt. OTA stated she heard was a CNA was pushing a resident in a in a rollator, and she fell hit her face on the floor. OTA stated we were in serviced it mainly dealt with the rollator is not a mode of transport and trained on the use of wheelchairs. Interview attempts with PT D on 03/19/25 at 2:36 PM, and 2:45 PM were unsuccessful left VM. During an interview on 03/19/25 at 2:55 PM, PTA E, stated works part time more like as a needed basis. Stated the following, she had never transported a resident in a rollator walker. She stated it was not the correct method to transport residents, it was by wheelchair, and should not t use the Rollator PTA E was not familiar with the incident and confirmed in-servicing was received after the incident over how to transport residents, and not to use the rollator. During an interview on 03/19/25 at 2:45 PM with PTA F, stated has been a here since 10/2024. PTA F stated he has never transported a resident in a rollator walker. PTA F verbalized correct method of transporting residents. He stated he was not familiar with the incident. On 03/19/25 at 3:45 PM, a request was submitted to the ADMIN requesting the following policies from the facility. Assisting residents with toileting, transfers or transportation of residents, and a safe handling policy. The ADMIN stated they had no specific safe patient handling policy. During an interview on 03/19/25 at 4:20 PM with LVN F, stated she has been an RN for approximately [AGE] years. LVN F had stated she never has transported a resident in a rollator walker. LVN F, stated the correct method to transport residents, was either by walker or wheelchair depending by their ambulation status. LVN F, stated she knew about the incident, she completed the fall assessment on Resident #2. She stated in servicing was done over no transportation on the seated walkers. Use wheelchairs. During an interview on 03/19/25 at 4:30 PM ADON, she stated had been nurse for 6 years, ADON for about 3 weeks, she stated she had been trained on resident transfers. She stated she was trained in this facility. The ADON, stated the resident should not have been transported in the walker and should have been transported to the restroom with the use of a wheelchair. The ADON stated after the incident the entire staff received in service on resident transfers, abuse, or neglect. Additionally, on to not use a rollator as a means of transport, use a wheelchair. During an interview on 03/19/25 at 5:30 PM, RCN stated she has been trained in the proper technique on resident transfers. RCN stated as part of her regularly assigned duties it is her job to instruct medical staff, including nurses on the proper techniques to transfer residents. RCN stated she should not have used the seated walker to transport the resident seated walker. But instead used a wheelchair, to transport the resident to the restroom. RCN stated she was the one responsible for and provided everyone on the nursing staff on proper transfer techniques including that a wheelchair is the proper method and not to use a rollator as a transport device because the resident could fall out of the rollator and be injured. During an interview on 03/20/25 at 9:00 AM, the ADMIN stated she has been trained by the Therapy department on resident transfers, RGCN, RELIAS training. ADMIN stated the LVN should not have transported the resident in the walker, but with a wheelchair if it was not a mobile resident. ADMIN stated after the incident all staff received in service on resident transfers, abuse, or neglect. During record review of staff training on 03/20/25 at 8:15 AM. Certifications were validated and verified via documentation provided from the facility, regarding the training on resident transfers. During record review of LVN C's employee file on 03/20/25 at 8:30 it indicated no previous infractions. Her file was reviewed and reflected that she received in service on transfer/transportation of residents during one-on-one training following the incident as well as in a group setting from 02/16/25 to 02/17/25. Observation of resident transfers on 03/20/25 from 1:00 PM to 3:00 PM for staff CNA A, CNA B, CNA C, PTA. COTA did not reflect any concerns for transfer technique. Review of the facility policy dated October 5, 2016, titled Fall Risk Mini Manual 2003. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and/or family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. Interventions initiated prior to surveyor entry on 03/18/25: Audit of all residents requiring use oof assistive devices including rollator walkers Notification of MD and RP on 02/15/25 One on one in service with LVN C Self-report to HHSC on In-services: * Transferring with a rollator walker specifying intended use prohibiting using rollator as a wheelchair. * Abuse and Neglect Monitoring of all above in-services by DON - from 02/16/25 to 03/14/25 A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 02/15/2025 and ended on 02/21/2025. The facility corrected the noncompliance before the investigation began.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerator and freezer items were dated, labeled, and sealed. 2. The facility failed to ensure Dietary Manager wore an effective hair restraint and performed hand hygiene during lunch meal preparation on 03/19/24. 3. The facility failed to ensure kitchen trash cans with food debris were covered. 4. The facility failed to ensure fryer was cleaned after use. 5. The facility failed to ensure 3-compartment sink water temperature logs were documented and monitored to ensure minimum water temperature log for wash and rinse sink. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observations of 1 of 2 freezers revealed the following on 03/19/24 during initial tour: - At 9:27 AM revealed an undated and vanilla ice cream in bowl with plastic covering the bowl. Interview with Dietary Manager revealed the food item was vanilla ice cream and was for one of the residents to have with for their lunch today. She stated she forgot to put a date or label on it when she put it in the freezer earlier this morning. - At 9:28 AM revealed an unsealed gallon size plastic zip bag dated 03/18/24 of tater tots. Interview with Dietary Manager revealed she would put it in 2 gallon bag so the tater tots bag can close properly. She stated it should have been sealed. - At 9:29 AM a plastic zip bag dated 2/1/24 of four celery and a plastic zip bag dated 2/1/24 of mixed vegetables not sealed in plastic bags. Observation on 03/19/24 at 9:30 AM of 1 of 2 refrigerators revealed a plastic bag dated 03/11/24 of bacon slices was not sealed. Interview on 03/19/24 at 9:33 AM with Dietary Manager revealed the items in the refrigerator and freezer should be labeled and dated when opened. She stated the refrigerator and freezer items should be sealed properly. Review of facility's dietary services Food Storage and Supplies dated 2012 reflected All facility storage areas will be maintained in an orderly manner that preserves the condition of food .4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened .9 .Perishable items that are refrigerated are dated once opened and used with 7 days, but nonperishable items that are refrigerated once opened . 2. Observations on 03/19/24 from 11:25 AM to 11:38 AM with Dietary Manager revealed her hair restraint was not covering about 0.5 inch hair above and near both of her ears along with exposing 1 inch of back of hair below the hair restraint while she pureed green beans and temped lunch food items with thermometer prior to food being served. Observation on 03/19/24 at 11:39 AM revealed the Dietary Manager mixed the pureed bread with a spoon after it came out of microwave. Dietary Manager took both of her gloves off, did not wash hands and put plastic over the pureed bread placing it own the food tray for Resident #6. She started plating food for residents' lunch. Interview on 03/19/24 at 11:45 AM with Dietary Manager revealed her gloves were not soiled when she took her gloves off. She stated she should have washed her hands hands after she took off her gloves for infection control purposes. She stated she was not aware her hair restraint was not covering her hair completely. She stated she was aware the hair restraint must cover all hair. She stated not washing her hands could place residents at risk for infections. She stated not wearing a proper hair restraint could place food at risk for being contaminated and getting hair in food. Review of facility's dietary services policy Hand Washing dated 2012 reflected We will ensure proper hand washing procedures are utilized. 3. Observation on 03/20/24 at 1:16 PM revealed cookie sheet covering the fryer and with cookie sheet removed. The fryer had dark brown grease with food particles floating on top with grease and food particles in top front of fryer. Interview on 03/20/24 at 1:17 PM with Dietary Manager revealed looking at the menu, it was last used on Monday night and should have been cleaned after use. She stated the grease is changed weekly. Review of facility's dietary services Equipment Sanitation dated 2012 reflected We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. 4. Observation on 03/20/24 at 1:18 PM revealed one kitchen trash can in the dish machine area, the lid off of the trash can; about 6 inches exposing food particles and leftovers; it was about 3/4 full. At 1:19 PM revealed one kitchen trash can in food preparation area about 1/2 full with food particles and debris. Interview on 03/20/24 at 1:20 PM with Dietary Manager revealed the kitchen trash can lids were not completely covering the kitchen trash cans because if they are covered then it makes it difficult to throw things away from without touching the lid. She stated they have to move the kitchen trash can lids off to dispose of trash which would contaminate their hands. Review of facility's dietary service policy Waste Control and Disposal dated 2012 reflected Waste Control and Disposal will be taken care of in a sanitary manner. Procedure: .2. Trash cans must be covered at all times, except during use. 5. Observation on 03/20/24 at 1:22 PM revealed the 3-compartment log for March 2024 posted on the wall had blanks for log for water temperatures for wash and rinse. Observation on 03/20/24 at 1:23 PM revealed a sign above the 3-compartment sink for wash sink (first sink on right) at 110 degrees F and rinse sink (2nd sink on right) 120 degrees F. Interview on 03/20/24 at 1:25 PM with Dietary Manager she stated she only had to do the sanitizing test strips for 3-compartment sink and did not need to check water temperatures for 3-compartment sink. She stated as long as sanitizer ppm were within appropriate levels. She stated the Maintenance Supervisor checked the water temperatures in the kitchen. She stated she used the 3-compartment sink after breakfast and lunch. Interview on 03/20/24 at 1:27 PM with Dietary Cook B revealed he used the 3-compartment sink in the evening after dinner and only checked the sanitizer sink. He did not check the water temperatures for the 3-compartment sink. Interview on 03/20/24 at 1:44 PM with Maintenance Supervisor revealed he did water temperatures in kitchen weekly but did not document them or put in water temp log. He stated he did have to run hot water for a fe to get the temperature up. He stated you have to run the dish machine about 6 times when it had not been in use to get it to 120 temperature. He stated the hot water heater was the same one connected to the resident hall which was not occupied by residents at this time due to the low census so it took longer to get water temperatures in kitchen up to proper temperature. Record Review of water temperature log for 3-compartment sink for January to March 2024 revealed no water temperatures for wash/rinse for 3-compartment sink. Record Review of Maintenance Supervisor's log revealed no kitchen log for water temperatures in the kitchen. Interview on 03/21/24 at 12:39 PM with Consultant Dietitian revealed the dietary staff changing gloves and not washing hands were an infection control issue and can cause cross contamination. She stated dietary staff not wearing effective hair restraints covering all hair could place food at risk of hair getting it in and cross contamination. She stated refrigerator and freezer items if removed from original container need to be labeled and dated when opened. She stated the refrigerator and freezer items should be sealed properly to prevent freezer burn and can impact the food integrity. Follow-up interview on 03/22/24 at 11:23 AM with Consultant Dietitian revealed she wanted to clarify the 3-compartment sink hot water temperatures should be monitored along with sanitizer levels. Review of the FDA US Food Code 2022 reflected the following: -under section 2-3 Personal Cleanliness 2-301.11 Clean Condition Food Employees shall keep their hands and exposed portions of their arms clean. -under section 3-602.11 Food Labels 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . -under section 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (medication cart) of 1 medication cart reviewed for pharmacy services in that: The facility failed to ensure the insulin pen for Resident #2 had an opened date. This failure could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: Record review of Resident #2's Comprehensive MDS, dated [DATE], revealed the resident was a 74 -year-old male admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus. He had a BIMS of 10 indicating his cognition was moderately impaired. Record review of Resident #2's physician's orders dated March 2024 revealed an order for insulin glargine solution 100 unit/ml. Inject 55 unit subcutaneously at bedtime for diabetes. Observation on 03/19/2024 at 9:20 AM revealed the medication cart had a clearly opened pen of insulin glargine solution 100 unit/ml for Resident #2. Observation revealed there was no opened date documented on the insulin pen. Interview on 03/19/2024 at 9:22 AM, LVN A stated the glargine solution 100 unit/ml that belonged to Resident #2 did not have an open date. LVN A stated she did not open the pen and she did not check if there was an open date on the pen. LVN A stated the purpose for putting an open date was for expiration purposes because the insulin was only good for 28 days. Interview on 03/21/24 at 9:13 AM, the DON stated the insulin flex pens, once opened, needed to be dated because each insulin pen had a 28- or 40-days shelf life and if not thrown out before that time the insulin could lose its effectiveness. Record review of the facility's policy titled Pharmacy Policy, revised 7/2012, revealed in part .Insulin Glargine: Refrigerate until initial use, expires 28 days after initial use regardless of product storage .

Based on observation, interview and record review, the facility failed to ensure that based on the resident's comprehensive assessment the resident received treatment and care in accordance with professional standards of practice, person centered care plan and the resident choice for one (#38) of five residents reviewed for quality of care. The facility failed to provide treatment to Resident #38 when CNAs identified a problem in the resident's perineal area. This failure resulted in Resident #38's yeast infection causing her severe discomfort and skin irritation before treatment was finally obtained, approximately a month after the issue was first identified. This failure resulted in Resident #38 not receiving the necessary care and treatment to prevent her from experiencing increased symptoms related to her diagnosis, including severe discomfort, and could result in other residents being at risk for the same outcome. Findings included: Review of Resident #38's undated face sheet reflected she was admitted to the facility 06/20/17. Review of Resident #38's 60-day MDS, dated [DATE], reflected she was cognitively impaired, frequently incontinent of bladder and required extensive assistance with activities of daily living. The active [DIAGNOSES REDACTED]. A review of Resident #38's Comprehensive Care Plan, dated 12/04/18, revealed she was cognitively impaired, required extensive assistance with all activities of daily living, and had altered skin integrity. A review of Resident #38's Nurse's Monthly Summary, dated 03/03/19, reflected Resident #38 had no skin issues. A review of the nurse aide's Point of Care Legend Report dated 03/06/19 for Resident #38 reflected from 02/01/19 through 02/28/19, a total of 84 shifts 5 nurse aides indicated resident had redness. Dates and shifts included: the night shifts on 02/04/19, 02/24/19, 02/25/19 and 02/28/19 and the evening shift on 02/23/19. In an interview on 03/06/19 at 2:10 PM CNA C stated that Resident #38's buttocks had been red at least a week, and that resident had been scratching her perineal area. CNA C stated she reported the redness and scratching to the nurse on the evening shift at least two or three times. In an interview on 03/06/19 at 2:45 PM with CNA D, she stated Resident #38's perineal area had been red about one week and she had reported it to LVN F . In an interview on 03/06/19 at 3:00 PM LVN E stated she was unaware that Resident #38 had any redness to her buttocks or perineal area. In an interview on 03/07/19 at 7:20 AM LVN F stated the CNA informed her on 03/04/19 that Resident #38's buttock was red. She stated she told the aid to apply barrier cream. She stated she observed Resident #38's buttock was pinkish-red but blanchable. In an interview on 03/05/19 at 11:40 AM CNA B stated Resident #38 often scratches at her buttocks and barrier cream was applied when the residents brief was changed. In an interview on 03/06/19 at 11:09 AM with Resident # 38 revealed her bottom itched she a lot. Observation on 03/06/19 at 9:31 AM revealed Resident #38's perineal area and buttocks were bright red and inflamed . The resident continuously attempted to scratch the area while the CNAs were performing peri-care. The buttocks were red with scattered white raised areas . In an interview on 03/06/19 at 11:50 AM LVN E stated she looked at Resident 38's buttock and she did not see redness, but the perineal area was red. She stated she contacted the physician and he instructed her to apply barrier cream. She stated the nurse aide had not informed her of the resident's buttocks or perineal area being red. Observation on 03/06/19 at 1:50 PM with Corporate RN, revealed the perineal area and inner thighs were red. The Corporate RN told the LVN E to call the physician to obtain an order for [REDACTED]. A review of Resident #38's Physician Orders, dated 03/06/19, revealed an order for [REDACTED].#38 was to receive [MEDICATION NAME] Tablet 100 milligrams daily for seven days . According the U.S. National Library of Health [MEDICATION NAME] is a medication used to treat fungal infections of the skin and is usually used two or three times a day. https://medlineplus.gov/druginfo/meds/a 5.html (accessed on 03/18/19) According to the U.S. National Library of Health [MEDICATION NAME] (generic name: fluconazole) is a medication used to treat fungal infections, including yeast infections of the vagina . Fluconazole is in a class of antifungals called triazoles. It works by slowing the growth of fungi that cause infection. https://medlineplus.gov/druginfo/meds/a 2.html (accessed on 03/18/19) In an interview 03/07/19 at 7:30 AM the Corporate RN stated if a resident was noted to have a skin issue the licensed nurse should assess the area, notify the doctor, and treat as ordered. In an interview on 03/07/19 at 8:40 AM the DON stated CNA's were to report skin issues to the licensed nurse who was to assess the area, notify the physician and family, and treat the area as ordered by the doctor. The Skin Management Policy undated, failed to provide guidance other than pressure related skin issues.

Based on observation, interview and record review, the facility failed to implement their policies and procedures that prohibit neglect for one (Resident #1) of five residents reviewed for neglect. The facility failed to provide adequate supervision to Resident #1 when they moved her off the secure unit and placed a wander guard bracelet on her. Resident #1 eloped out of the facility by entering the unsecured therapy room and exiting the facility through a exterior door. The resident fell out of her wheelchair at the end of the ramp and was bleeding from a laceration to her cheek and complaining of pain. Resident #1 sustained fractures to her C4 and C5 and a [MEDICAL CONDITION] wall of her maxillary sinus. An Immediate Jeopardy (IJ) existed from 11/02/17 to 11/08/17. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could affect the four residents, who resided in the general population unit and were identified by the facility as wanderers and/or an elopement risk, by placing them at risk for serious injury, harm or death. Findings included: Review of Resident #1's face sheet dated 11/06/17 reflected she was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected she was severely cognitively impaired. Resident #1 required extensive assistance with ADLs and had a wheelchair. Resident #1 had behaviors of wandering. Review of Resident #1's Care Plan, dated 10/27/17, revealed Resident #1 had cognitive impairment related to short term memory, long term memory and impaired ability to understand others. Resident #1 was high risk for falls related to hypertension and unsteady gait. Resident #1 was at risk for injury due to potential elopement as evidenced by wandering. Approaches included monitor every hour and prn to assure resident safety .redirect when wandering unsafely and wanderguard for elopement risk. Review of Resident #1's Physician telephone order dated 10/26/17 reflected a new order for wanderguard related to elopement risk. Review of Resident #1's Progress Note dated 10/26/17 at 1:20 PM written by social worker reflected Resident #1's family wanting to move resident to a facility with no secure unit. Resident #1 was moved to room [ROOM NUMBER]A (off the secure unit) and a wanderguard place on resident's left ankle. Review of Resident #1's Nurses' Note, dated 11/02/17 and completed by LVN C, revealed, 5:30 PM Aide went to take (Resident #1) to supper when walking past therapy gym aide noticed an open door went to see why door was open and resident was laying on ground at end of therapy gym wheelchair ramp. Aide called for help and supplies requesting 911 to be called this nurse called for DON. DON went to assess resident. This nurse called 911 at 5:33 PM EMTs arrived at 5:37 PM grandson notified at 5:35 PM primary care physician notified at 5:45 PM. Resident left facility at 5:55 to go to the local hospital ER. Review of Provider Investigation Report dated 11/08/17 signed by the Adm reflected on 11/02/17 at 5:30 PM CNA E went to look for Resident #1 to bring her to the dining room for supper. CNA E walked down 100 hallway and saw the Therapy gym door was open. When she entered the therapy room, she felt a breeze and saw the side door leading to the outside was open. At this time, CNA E saw Resident #1 lying on the ground on her left side with blood around her head and wounds to her left side of her face. CNA E called for help. LVN C arrived and called 911 at 5:33 PM. CNA F brought towels. DON arrived and began to assess Resident #1 noting a large laceration to her left cheek near her eye. Resident #1 was alert and oriented x2, unable to obtain blood pressure or oxygen saturation, respirations counted at 19, voiced she was hurting everywhere, appeared to be in pain but no acute distress. Resident #1 remained responsive to DON until EMS arrived at 5:37 PM. Resident #1 arrived to local hospital at 5:55 PM. The Provider Investigation Summary revealed on 11/02/17 around 4:45 PM Therapist G was working in therapy when Resident #1 wheeled herself into the therapy gym. Therapist G engaged in conversation with Resident #1 and gave her a magazine to look at. Approximately 10 or so minutes later Therapist G returned Resident #1 to the north nurses' station. LVN C noted at 5:10 PM seeing Resident #1 brought back by Therapist G to the north nurses' station. Therapist G returned to her office, gathered her belongings, shut the interior door to the therapy gym and exited through the side door to outside. Neither therapy door was locked. Review of Resident #1's ER hospital records, dated 11/02/17, reflected Resident #1 had fractures involving the posterior elements of C4 and of C5 primarily involving the spinous processes with extension into the left lamina at the C5 level and [MEDICAL CONDITION] wall in the left maxillary sinus with a blood level in the left maxillary sinus. In an interview on 11/14/17 at 2:15 PM CNA E stated she was in the dining room helping to feed residents and was passing out dinner trays when she noticed Resident #1's dinner tray. She went to go find Resident #1 who was usually near the nurses' station. She could not find her near the nurses' station or in her room on 200 hall so she went down 100 hall and could feel a breeze coming from the open therapy gym door. CNA E stated she went into the therapy gym and saw the outside side door was open. CNA E went to the open outside gym therapy door and saw Resident #1 was on lying on her left side partly on the ramp and off the ramp with her wheelchair resting beneath her buttocks. CNA E stated she moved the wheelchair out of the way so she could get to Resident #1 who was bleeding from her head and put pressure to stop the bleeding. CNA E went to get help and yelled for help down the hall, CNA F got towels and gloves, LVN C called 911 and DON assessed Resident #1. CNA E stated she had never known of Resident #1 going into the therapy room. CNA E stated Resident #1 told her and the DON she was hurting all over. CNA E stated the resident did wander usually around the nurses' station and could self-propel herself in the wheelchair. In an interview on 11/14/17 at 11:30 PM Therapist G stated she was finishing up paperwork and Resident #1 wheeled herself to the therapy gym. She stated she let Resident #1 stay for about 10 to 15 minutes and then wheeled Resident #1 back to the nurses' station. Therapist G stated she told the nurse who was on the 100 hall Resident #1 wheeled herself to the therapy room. Therapist G stated she returned to the therapy gym, went to the restroom, got her belongings and shut the door to the therapy room and did not see Resident #1 at all in the hallway before she shut the door. She stated no one was in the therapy gym so she left and did not lock the outside door in the therapy gym because it was only locked after all the therapists left for the day. Therapist G stated Therapist I was still in the building working with a resident in his or her room when she left. Therapist G stated there was no way to lock the therapy gym door. Therapist G stated after the incident the facility installed a key code lock on the therapy gym door and a double lock deadbolt on the outside door of the therapy gym. Therapist G stated the outside door of the therapy gym was permanently kept locked now and therapists did not have a key to the door. Therapist G stated the outside door was not an approved fire exit. In an interview on 11/14/17 at 2:37 PM LVN C stated about 5:10 PM when she was doing resident blood sugars she saw Therapist G wheeled Resident #1 down the hall and told her as they were passing by isn't it cute she knows where therapy gym is. LVN C stated she continued with the blood sugars, assumed Therapist G wheeled Resident #1 down to the dining room for meals and then later she was charting during dinner time when she heard CNA E calling for help/call 911. LVN C stated she went to call 911 while the DON went immediately to go assess Resident #1. LVN C stated she contacted the family and physician to inform Resident #1 was being sent out to hospital. LVN C stated she did not know the therapy gym outside door was unlocked but did know the therapy gym door was unlocked but shut when no one was in the therapy room. In an interview on 11/14/17 at 2:23 PM CNA F stated on 11/02/17 during dinner time when she was assisting residents with feeding she heard CNA E screaming for help so she came out of the resident's room and was told by CNA E to go get towels and gloves now bring them to therapy gym outside door. CNA F stated she immediately got the towels and gloves, saw Resident #1 was on the left side with her head turned away from the ground on the wheelchair ramp/ground. CNA F stated Resident #1 was bleeding from her head and CNA E was holding pressure on the bleed while DON was assessing Resident #1. CNA F stated Resident #1 did wander up and down the halls but did not go near the exit doors before. CNA F stated Resident #1 was complaining of hurting all over. In an interview on 11/14/17 at 5:55 PM the DON stated Resident #1 did have a wanderguard for wandering behaviors but had not shown any signs of exit seeking behaviors. The DON stated she was not aware the outside door in the therapy gym was unlocked during the day when the therapists were in the facility prior to the incident. The DON stated she assessed Resident #1 who was outside the therapy gym door partly on the ramp/ground on her left side. The DON stated LVN C called 911 and Resident #1 was sent to the hospital. The DON stated after the incident the Maintenance Director put in a keypad on the therapy gym door from the hallway and staff were present at all times during the day on the next day until the Maintenance Director got a double lock on the therapy outside door which was now kept locked at all times. The DON stated Resident #1's family was working on transferring Resident #1 to a facility with no secure unit so she was transferred off the secure unit to see how she would do and had a wanderguard put on her for precaution since she came off the secure unit. In an interview on 11/14/17 at 11:37 AM Therapist I stated she was in a female resident's room on Hall 100 when she heard a staff member yell help she came out of the room and other facility staff were assisting Resident #1 so she returned back to her resident. Therapist I stated prior to this incident there was no way to lock the therapy gym door and only locked the outside door to the therapy gym when the last therapist was leaving for the day. Therapist I stated when the last therapist left for the day he or she locked the outside door by turning the lock on the door knob. Therapist I stated the Adm got a double lock for the outside so it was permanently kept locked and not to be used by any staff anymore. Therapist I stated the therapy gym door was to be shut when no one was in the therapy gym. In an interview on 11/14/17 at 9:24 AM Therapist H stated the outside therapy gym door did not have a wanderguard system and was not an approved fire exit door. She stated the therapy gym outside door had a double lock and was permanently locked at all times. Review of CNA J's Witness Statement dated 11/02/17 revealed contributing factor included no lock/wander guard on therapy door. Review of the facility's Abuse and Neglect Prohibition Policy, undated, revealed, Neglect was the failure to provide goods or services including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. The facility must determine if an injury, harm to or death of a resident was due to facility failure to provide services, treatment or care to a resident. The facility took the following actions to correct the noncompliance prior to the start of the survey: The facility's Provider Investigation Report, dated 11/08/17, reflected the Maintenance Director installed an electronic keypad lock on interior therapy gym door and wanderguard tested on [DATE]. A double barrel key lock was installed on exterior the therapy gym door by Maintenance Director on 11/03/17 at 5:15 PM. Facility staff member would be present in therapy while office was open from 7:36 AM to 5:15 PM. Facility contracted fire safety company inspected all doors/wanderguard on 11/03/17. All locking hardware was working properly. The company also changed the exit ramp door and front door to be constantly locked. The facility installed timer and push button on front door to not allow outside entrance between 9:30 PM and 6:30 AM. An interior keypad was added at front door and tested all on 11/08/17. All staff were in-serviced on Elopement and Neglect. Elopement drills were completed on each shift and on weekend shift. Observations on 11/14/17 at 9:26 AM and 12:02 PM revealed the therapy gym door was secured with key pad and at 9:27 AM the outside therapy gym door was secured and locked. Observations on 11/14/17 at 11:52 AM to 12:00 PM revealed all facility doors were secured, locked and door alarms active. In an interview on 11/14/17 at 9:15 AM the Adm stated Resident #1 was discharged to another skilled nursing facility after hospital discharge. The Adm stated at the time of the incident neither the therapy gym door nor the therapy gym outside door was locked but now the facility had a key pad lock on the therapy gym door and the outside door was permanently locked with a double lock at all times. Review of all staff in-service training revealed in-service on 11/03/17 for therapists to have personnel present at all times throughout the day in therapy gym and back door to remain locked at all times no exceptions. Elopement and Neglect in-service which included the facility elopment and neglect policies occurred on 11/02/17 and 11/03/17 by the Administrator. A total of 52 facility staff participated in the in-service training, including staff that directly work with residents that are identified as a wanderer/elopement risk. Facility staff from all shifts were present and received the training. The Elopement in-service included to call a code green if resident missing contact Adm/DON, organize search for missing resident, after 30 minutes of resident missing for two facility staff to begin search in 2 separate vehicles for 2 square miles, contact law enforcement within 2 hours and beware of conditions that place resident's health and safety at risk. Review of the Facility Elopement Drill revealed drills were conducted on 11/03/17 on the first, second, and third shifts. Elopement drill conducted on 11/04/17 on the weekend shift. A total of 73 facility staff participated in the drills. Staff that are assigned to residents with wandering/elopement risk were included in the drill. Wanderguard daily testing also occurred. Individual Interviews were conducted with facility staff (LVN A, LVN B, LVN C) throughout the investigation on 11/14/17, revealed they had received neglect, elopement and missing resident training since incident on 11/02/17. Interviewed staff revealed they had participated in elopement drills. Interviewed staff were able to provide sufficient knowledge of the facility's elopement and missing resident policies. LVN A, LVN B, CNA D, CNA E and CNA F were able to identify behaviors to identify wanderers and the residents that were wanderers/elopement risks as identified by the facility. An Immediate jeopardy (IJ) was identified to have occurred from 11/02/17 through 11/08/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actioons that corrected the noncompliance prior to the beginning of the survey. On 11/14/17, the DON provided the resident roster with four residents identified as wanderers/elopement risks.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit neglect for one (Resident #1) of five residents reviewed for neglect. The facility failed to provide adequate supervision to Resident #1 when they moved her off the secure unit and placed a wander guard bracelet on her. Resident #1 eloped out of the facility by entering the unsecured therapy room and exiting the facility through a exterior door. The resident fell out of her wheelchair at the end of the ramp and was bleeding from a laceration to her cheek and complaining of pain. Resident #1 sustained fractures to her C4 and C5 and a [MEDICAL CONDITION] wall of her maxillary sinus. An Immediate Jeopardy (IJ) existed from 11/02/17 to 11/08/17. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could affect the four residents, who resided in the general population unit and were identified by the facility as wanderers and/or an elopement risk, by placing them at risk for serious injury, harm or death. Findings included: Review of the facility's Abuse and Neglect Prohibition Policy, undated, revealed, Neglect was the failure to provide goods or services including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. The facility must determine if an injury, harm to or death of a resident was due to facility failure to provide services, treatment or care to a resident. Review of Resident #1's face sheet dated 11/06/17 reflected she was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected she was severely cognitively impaired. Resident #1 required extensive assistance with ADLs and had a wheelchair. Resident #1 had behaviors of wandering. Review of Resident #1's Care Plan, dated 10/27/17, revealed Resident #1 had cognitive impairment related to short term memory, long term memory and impaired ability to understand others. Resident #1 was high risk for falls related to hypertension and unsteady gait. Resident #1 was at risk for injury due to potential elopement as evidenced by wandering. Approaches included monitor every hour and prn to assure resident safety .redirect when wandering unsafely and wanderguard for elopement risk. Review of Resident #1's Physician telephone order dated 10/26/17 reflected a new order for wanderguard related to elopement risk. Review of Resident #1's Progress Note dated 10/26/17 at 1:20 PM written by social worker reflected Resident #1's family wanting to move resident to a facility with no secure unit. Resident #1 was moved to room [ROOM NUMBER]A (off the secure unit) and a wanderguard place on resident's left ankle. Review of Resident #1's Nurses' Note, dated 11/02/17 and completed by LVN C, revealed, 5:30 PM Aide went to take (Resident #1) to supper when walking past therapy gym aide noticed an open door went to see why door was open and resident was laying on ground at end of therapy gym wheelchair ramp. Aide called for help and supplies requesting 911 to be called this nurse called for DON. DON went to assess resident. This nurse called 911 at 5:33 PM EMTs arrived at 5:37 PM grandson notified at 5:35 PM primary care physician notified at 5:45 PM. Resident left facility at 5:55 to go to the local hospital ER. Review of Provider Investigation Report dated 11/08/17 signed by the Adm reflected on 11/02/17 at 5:30 PM CNA E went to look for Resident #1 to bring her to the dining room for supper. CNA E walked down 100 hallway and saw the Therapy gym door was open. When she entered the therapy room, she felt a breeze and saw the side door leading to the outside was open. At this time, CNA E saw Resident #1 lying on the ground on her left side with blood around her head and wounds to her left side of her face. CNA E called for help. LVN C arrived and called 911 at 5:33 PM. CNA F brought towels. DON arrived and began to assess Resident #1 noting a large laceration to her left cheek near her eye. Resident #1 was alert and oriented x2, unable to obtain blood pressure or oxygen saturation, respirations counted at 19, voiced she was hurting everywhere, appeared to be in pain but no acute distress. Resident #1 remained responsive to DON until EMS arrived at 5:37 PM. Resident #1 arrived to local hospital at 5:55 PM. The Provider Investigation Summary revealed on 11/02/17 around 4:45 PM Therapist G was working in therapy when Resident #1 wheeled herself into the therapy gym. Therapist G engaged in conversation with Resident #1 and gave her a magazine to look at. Approximately 10 or so minutes later Therapist G returned Resident #1 to the north nurses' station. LVN C noted at 5:10 PM seeing Resident #1 brought back by Therapist G to the north nurses' station. Therapist G returned to her office, gathered her belongings, shut the interior door to the therapy gym and exited through the side door to outside. Neither therapy door was locked. Review of Resident #1's ER hospital records, dated 11/02/17, reflected Resident #1 had fractures involving the posterior elements of C4 and of C5 primarily involving the spinous processes with extension into the left lamina at the C5 level and [MEDICAL CONDITION] wall in the left maxillary sinus with a blood level in the left maxillary sinus. In an interview on 11/14/17 at 2:15 PM CNA E stated she was in the dining room helping to feed residents and was passing out dinner trays when she noticed Resident #1's dinner tray. She went to go find Resident #1 who was usually near the nurses' station. She could not find her near the nurses' station or in her room on 200 hall so she went down 100 hall and could feel a breeze coming from the open therapy gym door. CNA E stated she went into the therapy gym and saw the outside side door was open. CNA E went to the open outside gym therapy door and saw Resident #1 was on lying on her left side partly on the ramp and off the ramp with her wheelchair resting beneath her buttocks. CNA E stated she moved the wheelchair out of the way so she could get to Resident #1 who was bleeding from her head and put pressure to stop the bleeding. CNA E went to get help and yelled for help down the hall, CNA F got towels and gloves, LVN C called 911 and DON assessed Resident #1. CNA E stated she had never known of Resident #1 going into the therapy room. CNA E stated Resident #1 told her and the DON she was hurting all over. CNA E stated the resident did wander usually around the nurses' station and could self-propel herself in the wheelchair. In an interview on 11/14/17 at 11:30 PM Therapist G stated she was finishing up paperwork and Resident #1 wheeled herself to the therapy gym. She stated she let Resident #1 stay for about 10 to 15 minutes and then wheeled Resident #1 back to the nurses' station. Therapist G stated she told the nurse who was on the 100 hall Resident #1 wheeled herself to the therapy room. Therapist G stated she returned to the therapy gym, went to the restroom, got her belongings and shut the door to the therapy room and did not see Resident #1 at all in the hallway before she shut the door. She stated no one was in the therapy gym so she left and did not lock the outside door in the therapy gym because it was only locked after all the therapists left for the day. Therapist G stated Therapist I was still in the building working with a resident in his or her room when she left. Therapist G stated there was no way to lock the therapy gym door. Therapist G stated after the incident the facility installed a key code lock on the therapy gym door and a double lock deadbolt on the outside door of the therapy gym. Therapist G stated the outside door of the therapy gym was permanently kept locked now and therapists did not have a key to the door. Therapist G stated the outside door was not an approved fire exit. In an interview on 11/14/17 at 2:37 PM LVN C stated about 5:10 PM when she was doing resident blood sugars she saw Therapist G wheeled Resident #1 down the hall and told her as they were passing by isn't it cute she knows where therapy gym is. LVN C stated she continued with the blood sugars, assumed Therapist G wheeled Resident #1 down to the dining room for meals and then later she was charting during dinner time when she heard CNA E calling for help/call 911. LVN C stated she went to call 911 while the DON went immediately to go assess Resident #1. LVN C stated she contacted the family and physician to inform Resident #1 was being sent out to hospital. LVN C stated she did not know the therapy gym outside door was unlocked but did know the therapy gym door was unlocked but shut when no one was in the therapy room. In an interview on 11/14/17 at 2:23 PM CNA F stated on 11/02/17 during dinner time when she was assisting residents with feeding she heard CNA E screaming for help so she came out of the resident's room and was told by CNA E to go get towels and gloves now bring them to therapy gym outside door. CNA F stated she immediately got the towels and gloves, saw Resident #1 was on the left side with her head turned away from the ground on the wheelchair ramp/ground. CNA F stated Resident #1 was bleeding from her head and CNA E was holding pressure on the bleed while DON was assessing Resident #1. CNA F stated Resident #1 did wander up and down the halls but did not go near the exit doors before. CNA F stated Resident #1 was complaining of hurting all over. In an interview on 11/14/17 at 5:55 PM the DON stated Resident #1 did have a wanderguard for wandering behaviors but had not shown any signs of exit seeking behaviors. The DON stated she was not aware the outside door in the therapy gym was unlocked during the day when the therapists were in the facility prior to the incident. The DON stated she assessed Resident #1 who was outside the therapy gym door partly on the ramp/ground on her left side. The DON stated LVN C called 911 and Resident #1 was sent to the hospital. The DON stated after the incident the Maintenance Director put in a keypad on the therapy gym door from the hallway and staff were present at all times during the day on the next day until the Maintenance Director got a double lock on the therapy outside door which was now kept locked at all times. The DON stated Resident #1's family was working on transferring Resident #1 to a facility with no secure unit so she was transferred off the secure unit to see how she would do and had a wanderguard put on her for precaution since she came off the secure unit. In an interview on 11/14/17 at 11:37 AM Therapist I stated she was in a female resident's room on Hall 100 when she heard a staff member yell help she came out of the room and other facility staff were assisting Resident #1 so she returned back to her resident. Therapist I stated prior to this incident there was no way to lock the therapy gym door and only locked the outside door to the therapy gym when the last therapist was leaving for the day. Therapist I stated when the last therapist left for the day he or she locked the outside door by turning the lock on the door knob. Therapist I stated the Adm got a double lock for the outside so it was permanently kept locked and not to be used by any staff anymore. Therapist I stated the therapy gym door was to be shut when no one was in the therapy gym. In an interview on 11/14/17 at 9:24 AM Therapist H stated the outside therapy gym door did not have a wanderguard system and was not an approved fire exit door. She stated the therapy gym outside door had a double lock and was permanently locked at all times. Review of CNA J's Witness Statement dated 11/02/17 revealed contributing factor included no lock/wander guard on therapy door. The facility took the following actions to correct the noncompliance prior to the start of the survey: The facility's Provider Investigation Report, dated 11/08/17, reflected the Maintenance Director installed an electronic keypad lock on interior therapy gym door and wanderguard tested on [DATE]. A double barrel key lock was installed on exterior the therapy gym door by Maintenance Director on 11/03/17 at 5:15 PM. Facility staff member would be present in therapy while office was open from 7:36 AM to 5:15 PM. Facility contracted fire safety company inspected all doors/wanderguard on 11/03/17. All locking hardware was working properly. The company also changed the exit ramp door and front door to be constantly locked. The facility installed timer and push button on front door to not allow outside entrance between 9:30 PM and 6:30 AM. An interior keypad was added at front door and tested all on 11/08/17. All staff were in-serviced on Elopement and Neglect. Elopement drills were completed on each shift and on weekend shift. Observations on 11/14/17 at 9:26 AM and 12:02 PM revealed the therapy gym door was secured with key pad and at 9:27 AM the outside therapy gym door was secured and locked. Observations on 11/14/17 at 11:52 AM to 12:00 PM revealed all facility doors were secured, locked and door alarms active. In an interview on 11/14/17 at 9:15 AM the Adm stated Resident #1 was discharged to another skilled nursing facility after hospital discharge. The Adm stated at the time of the incident neither the therapy gym door nor the therapy gym outside door was locked but now the facility had a key pad lock on the therapy gym door and the outside door was permanently locked with a double lock at all times. Review of all staff in-service training revealed in-service on 11/03/17 for therapists to have personnel present at all times throughout the day in therapy gym and back door to remain locked at all times no exceptions. Elopement and Neglect in-service which included the facility elopment and neglect policies occurred on 11/02/17 and 11/03/17 by the Administrator. A total of 52 facility staff participated in the in-service training, including staff that directly work with residents that are identified as a wanderer/elopement risk. Facility staff from all shifts were present and received the training. The Elopement in-service included to call a code green if resident missing contact Adm/DON, organize search for missing resident, after 30 minutes of resident missing for two facility staff to begin search in 2 separate vehicles for 2 square miles, contact law enforcement within 2 hours and beware of conditions that place resident's health and safety at risk. Review of the Facility Elopement Drill revealed drills were conducted on 11/03/17 on the first, second, and third shifts. Elopement drill conducted on 11/04/17 on the weekend shift. A total of 73 facility staff participated in the drills. Staff that are assigned to residents with wandering/elopement risk were included in the drill. Wanderguard daily testing also occurred. Individual Interviews were conducted with facility staff (LVN A, LVN B, LVN C) throughout the investigation on 11/14/17, revealed they had received neglect, elopement and missing resident training since incident on 11/02/17. Interviewed staff revealed they had participated in elopement drills. Interviewed staff were able to provide sufficient knowledge of the facility's elopement and missing resident policies. LVN A, LVN B, CNA D, CNA E and CNA F were able to identify behaviors to identify wanderers and the residents that were wanderers/elopement risks as identified by the facility. An Immediate jeopardy (IJ) was identified to have occurred from 11/02/17 through 11/08/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actioons that corrected the noncompliance prior to the beginning of the survey. On 11/14/17, the DON provided the resident roster with four residents identified as wanderers/elopement risks.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for supervision. The facility failed to provide adequate supervision to Resident #1 when they moved her off the secure unit and placed a wander guard bracelet on her. Resident #1 eloped out of the facility by entering the unsecured therapy room and exiting the facility through a exterior door. The resident fell out of her wheelchair at the end of the ramp and was bleeding from a laceration to her cheek and complaining of pain. Resident #1 sustained fractures to her C4 and C5 and a fracture of the anterior wall of her maxillary sinus. An Immediate Jeopardy (IJ) existed from 11/02/17 to 11/08/17. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could affect the four residents, who resided in the general population unit and were identified by the facility as wanderers and/or an elopement risk, by placing them at risk for serious injury, harm or death. Findings included: Review of Resident #1's face sheet dated 11/06/17 reflected she was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected she was severely cognitively impaired. Resident #1 required extensive assistance with ADLs and had a wheelchair. Resident #1 had behaviors of wandering. Review of Resident #1's Care Plan, dated 10/27/17, revealed Resident #1 had cognitive impairment related to short term memory, long term memory and impaired ability to understand others. Resident #1 was high risk for falls related to hypertension and unsteady gait. Resident #1 was at risk for injury due to potential elopement as evidenced by wandering. Approaches included monitor every hour and prn to assure resident safety .redirect when wandering unsafely and wanderguard for elopement risk. Review of Resident #1's Physician telephone order dated 10/26/17 reflected a new order for wanderguard related to elopement risk. Review of Resident #1's Progress Note dated 10/26/17 at 1:20 PM written by social worker reflected Resident #1's family wanting to move resident to a facility with no secure unit. Resident #1 was moved to room 205A (off the secure unit) and a wanderguard place on resident's left ankle. Review of Resident #1's Nurses' Note, dated 11/02/17 and completed by LVN C, revealed, 5:30 PM Aide went to take (Resident #1) to supper when walking past therapy gym aide noticed an open door went to see why door was open and resident was laying on ground at end of therapy gym wheelchair ramp. Aide called for help and supplies requesting 911 to be called this nurse called for DON. DON went to assess resident. This nurse called 911 at 5:33 PM EMTs arrived at 5:37 PM grandson notified at 5:35 PM primary care physician notified at 5:45 PM. Resident left facility at 5:55 to go to the local hospital ER. Review of Provider Investigation Report dated 11/08/17 signed by the Adm reflected on 11/02/17 at 5:30 PM CNA E went to look for Resident #1 to bring her to the dining room for supper. CNA E walked down 100 hallway and saw the Therapy gym door was open. When she entered the therapy room, she felt a breeze and saw the side door leading to the outside was open. At this time, CNA E saw Resident #1 lying on the ground on her left side with blood around her head and wounds to her left side of her face. CNA E called for help. LVN C arrived and called 911 at 5:33 PM. CNA F brought towels. DON arrived and began to assess Resident #1 noting a large laceration to her left cheek near her eye. Resident #1 was alert and oriented x2, unable to obtain blood pressure or oxygen saturation, respirations counted at 19, voiced she was hurting everywhere, appeared to be in pain but no acute distress. Resident #1 remained responsive to DON until EMS arrived at 5:37 PM. Resident #1 arrived to local hospital at 5:55 PM. The Provider Investigation Summary revealed on 11/02/17 around 4:45 PM Therapist G was working in therapy when Resident #1 wheeled herself into the therapy gym. Therapist G engaged in conversation with Resident #1 and gave her a magazine to look at. Approximately 10 or so minutes later Therapist G returned Resident #1 to the north nurses' station. LVN C noted at 5:10 PM seeing Resident #1 brought back by Therapist G to the north nurses' station. Therapist G returned to her office, gathered her belongings, shut the interior door to the therapy gym and exited through the side door to outside. Neither therapy door was locked. Review of Resident #1's ER hospital records, dated 11/02/17, reflected Resident #1 had fractures involving the posterior elements of C4 and of C5 primarily involving the spinous processes with extension into the left lamina at the C5 level and fracture of the anterior wall in the left maxillary sinus with a blood level in the left maxillary sinus. In an interview on 11/14/17 at 2:15 PM CNA E stated she was in the dining room helping to feed residents and was passing out dinner trays when she noticed Resident #1's dinner tray. She went to go find Resident #1 who was usually near the nurses' station. She could not find her near the nurses' station or in her room on 200 hall so she went down 100 hall and could feel a breeze coming from the open therapy gym door. CNA E stated she went into the therapy gym and saw the outside side door was open. CNA E went to the open outside gym therapy door and saw Resident #1 was on lying on her left side partly on the ramp and off the ramp with her wheelchair resting beneath her buttocks. CNA E stated she moved the wheelchair out of the way so she could get to Resident #1 who was bleeding from her head and put pressure to stop the bleeding. CNA E went to get help and yelled for help down the hall, CNA F got towels and gloves, LVN C called 911 and DON assessed Resident #1. CNA E stated she had never known of Resident #1 going into the therapy room. CNA E stated Resident #1 told her and the DON she was hurting all over. CNA E stated the resident did wander usually around the nurses' station and could self-propel herself in the wheelchair. In an interview on 11/14/17 at 11:30 PM Therapist G stated she was finishing up paperwork and Resident #1 wheeled herself to the therapy gym. She stated she let Resident #1 stay for about 10 to 15 minutes and then wheeled Resident #1 back to the nurses' station. Therapist G stated she told the nurse who was on the 100 hall Resident #1 wheeled herself to the therapy room. Therapist G stated she returned to the therapy gym, went to the restroom, got her belongings and shut the door to the therapy room and did not see Resident #1 at all in the hallway before she shut the door. She stated no one was in the therapy gym so she left and did not lock the outside door in the therapy gym because it was only locked after all the therapists left for the day. Therapist G stated Therapist I was still in the building working with a resident in his or her room when she left. Therapist G stated there was no way to lock the therapy gym door. Therapist G stated after the incident the facility installed a key code lock on the therapy gym door and a double lock deadbolt on the outside door of the therapy gym. Therapist G stated the outside door of the therapy gym was permanently kept locked now and therapists did not have a key to the door. Therapist G stated the outside door was not an approved fire exit. In an interview on 11/14/17 at 2:37 PM LVN C stated about 5:10 PM when she was doing resident blood sugars she saw Therapist G wheeled Resident #1 down the hall and told her as they were passing by isn't it cute she knows where therapy gym is. LVN C stated she continued with the blood sugars, assumed Therapist G wheeled Resident #1 down to the dining room for meals and then later she was charting during dinner time when she heard CNA E calling for help/call 911. LVN C stated she went to call 911 while the DON went immediately to go assess Resident #1. LVN C stated she contacted the family and physician to inform Resident #1 was being sent out to hospital. LVN C stated she did not know the therapy gym outside door was unlocked but did know the therapy gym door was unlocked but shut when no one was in the therapy room. In an interview on 11/14/17 at 2:23 PM CNA F stated on 11/02/17 during dinner time when she was assisting residents with feeding she heard CNA E screaming for help so she came out of the resident's room and was told by CNA E to go get towels and gloves now bring them to therapy gym outside door. CNA F stated she immediately got the towels and gloves, saw Resident #1 was on the left side with her head turned away from the ground on the wheelchair ramp/ground. CNA F stated Resident #1 was bleeding from her head and CNA E was holding pressure on the bleed while DON was assessing Resident #1. CNA F stated Resident #1 did wander up and down the halls but did not go near the exit doors before. CNA F stated Resident #1 was complaining of hurting all over. In an interview on 11/14/17 at 5:55 PM the DON stated Resident #1 did have a wanderguard for wandering behaviors but had not shown any signs of exit seeking behaviors. The DON stated she was not aware the outside door in the therapy gym was unlocked during the day when the therapists were in the facility prior to the incident. The DON stated she assessed Resident #1 who was outside the therapy gym door partly on the ramp/ground on her left side. The DON stated LVN C called 911 and Resident #1 was sent to the hospital. The DON stated after the incident the Maintenance Director put in a keypad on the therapy gym door from the hallway and staff were present at all times during the day on the next day until the Maintenance Director got a double lock on the therapy outside door which was now kept locked at all times. The DON stated Resident #1's family was working on transferring Resident #1 to a facility with no secure unit so she was transferred off the secure unit to see how she would do and had a wanderguard put on her for precaution since she came off the secure unit. In an interview on 11/14/17 at 11:37 AM Therapist I stated she was in a female resident's room on Hall 100 when she heard a staff member yell help she came out of the room and other facility staff were assisting Resident #1 so she returned back to her resident. Therapist I stated prior to this incident there was no way to lock the therapy gym door and only locked the outside door to the therapy gym when the last therapist was leaving for the day. Therapist I stated when the last therapist left for the day he or she locked the outside door by turning the lock on the door knob. Therapist I stated the Adm got a double lock for the outside so it was permanently kept locked and not to be used by any staff anymore. Therapist I stated the therapy gym door was to be shut when no one was in the therapy gym. In an interview on 11/14/17 at 9:24 AM Therapist H stated the outside therapy gym door did not have a wanderguard system and was not an approved fire exit door. She stated the therapy gym outside door had a double lock and was permanently locked at all times. Review of CNA J's Witness Statement dated 11/02/17 revealed contributing factor included no lock/wander guard on therapy door. Review of the facility's Abuse and Neglect Prohibition Policy, undated, revealed, Neglect was the failure to provide goods or services including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. The facility must determine if an injury, harm to or death of a resident was due to facility failure to provide services, treatment or care to a resident. The facility took the following actions to correct the noncompliance prior to the start of the survey: The facility's Provider Investigation Report, dated 11/08/17, reflected the Maintenance Director installed an electronic keypad lock on interior therapy gym door and wanderguard tested on [DATE]. A double barrel key lock was installed on exterior the therapy gym door by Maintenance Director on 11/03/17 at 5:15 PM. Facility staff member would be present in therapy while office was open from 7:36 AM to 5:15 PM. Facility contracted fire safety company inspected all doors/wanderguard on 11/03/17. All locking hardware was working properly. The company also changed the exit ramp door and front door to be constantly locked. The facility installed timer and push button on front door to not allow outside entrance between 9:30 PM and 6:30 AM. An interior keypad was added at front door and tested all on 11/08/17. All staff were in-serviced on Elopement and Neglect. Elopement drills were completed on each shift and on weekend shift. Observations on 11/14/17 at 9:26 AM and 12:02 PM revealed the therapy gym door was secured with key pad and at 9:27 AM the outside therapy gym door was secured and locked. Observations on 11/14/17 at 11:52 AM to 12:00 PM revealed all facility doors were secured, locked and door alarms active. In an interview on 11/14/17 at 9:15 AM the Adm stated Resident #1 was discharged to another skilled nursing facility after hospital discharge. The Adm stated at the time of the incident neither the therapy gym door nor the therapy gym outside door was locked but now the facility had a key pad lock on the therapy gym door and the outside door was permanently locked with a double lock at all times. Review of all staff in-service training revealed in-service on 11/03/17 for therapists to have personnel present at all times throughout the day in therapy gym and back door to remain locked at all times no exceptions. Elopement and Neglect in-service which included the facility elopment and neglect policies occurred on 11/02/17 and 11/03/17 by the Administrator. A total of 52 facility staff participated in the in-service training, including staff that directly work with residents that are identified as a wanderer/elopement risk. Facility staff from all shifts were present and received the training. The Elopement in-service included to call a code green if resident missing contact Adm/DON, organize search for missing resident, after 30 minutes of resident missing for two facility staff to begin search in 2 separate vehicles for 2 square miles, contact law enforcement within 2 hours and beware of conditions that place resident's health and safety at risk. Review of the Facility Elopement Drill revealed drills were conducted on 11/03/17 on the first, second, and third shifts. Elopement drill conducted on 11/04/17 on the weekend shift. A total of 73 facility staff participated in the drills. Staff that are assigned to residents with wandering/elopement risk were included in the drill. Wanderguard daily testing also occurred. Individual Interviews were conducted with facility staff (LVN A, LVN B, LVN C) throughout the investigation on 11/14/17, revealed they had received neglect, elopement and missing resident training since incident on 11/02/17. Interviewed staff revealed they had participated in elopement drills. Interviewed staff were able to provide sufficient knowledge of the facility's elopement and missing resident policies. LVN A, LVN B, CNA D, CNA E and CNA F were able to identify behaviors to identify wanderers and the residents that were wanderers/elopement risks as identified by the facility. An Immediate jeopardy (IJ) was identified to have occurred from 11/02/17 through 11/08/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actioons that corrected the noncompliance prior to the beginning of the survey. On 11/14/17, the DON provided the resident roster with four residents identified as wanderers/elopement risks.