Every finding on record at Wurzbach Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #87, Resident #67 and Resident #68) of 5 residents and 4 (CNA A, CNA B, CNA C and CNA D) of 5 facility staff observed for infection control.CNA A failed to use a different wipe or different area of the same wipe to clean Resident #87's left buttocks area.CNA B failed to perform hand hygiene after removing gloves following direct contact with Resident #87 while providing incontinence care.CNA C failed to clean Resident #67's buttocks areas while providing incontinence care.CNA D failed to perform hand hygiene and change gloves after cleaning Resident #68 and removing the soiled brief while providing catheter and perineal care. These failures have the potential to result in infections from cross contamination. The findings included: Record review of Resident #87's face sheet, dated 08/05/2026, revealed a [AGE] year-old female with admission date of 11/30/2018. Diagnoses included Alzheimer's disease unspecified (brain disorder affecting memory and thinking skills), age related physical debility (physical weakness associated with old age), cachexia (excessive unplanned loss of weight) and age related osteoporosis (condition that weakens bones).Record review of Resident #87's MDS dated [DATE] section B revealed resident has no speech and rarely/never understands others, therefore the BIMS interview was not conducted (cognitive status was not assessed). Section GG of the MDS revealed that Resident #87 is dependent on staff for all ADL's, including toileting hygiene. Section H revealed that the resident was always incontinent of bowel and bladder. Observation of perineal care on 08/05/2026 at 10:51am for Resident #87 performed by CNA A and CNA B revealed CNA A wiped Resident #87's left buttock three times in succession while using the same area of the same wipe. During the same observation, CNA B did not perform hand hygiene or put on new gloves after removing her soiled gloves while assisting with perineal care. CNA B then touched the wipes packaging.During an interview with CNA A and CNA B on 08/05/2026 at 10:59am, CNA A stated that wiping the buttocks area with the same area of the wipe could potentially cause an infection. CNA B stated that by handling the wipes without washing the hands it could cause infection to spread.During an interview with the charge RN on 08/05/2026 at 11:06am, she stated that the expectation would be for staff to use a wipe one time and then throw it away after use. When done with care, they are expected to wash or sanitize the hands.During an interview with DON on 08/05/2026 at 11:12am, she stated that she had already started conducting inservices for pericare and catheter care with the staff today in order to reinforce the expectations. During an interview with the facility administrator on 08/05/2026 at 11:12am, it was stated that the ADON's were observing staff conduct catheter and incontinence care once a month.Record review of Resident #67's face sheet, dated 08/05/2026, revealed a [AGE] year-old female with original admission date of 01/25/2023. Diagnoses included Alzheimer's disease unspecified (brain disorder affecting memory and thinking skills), acquired absence of right leg below knee, acquired absence of left leg below knee and presence of cardiac pacemaker (electronic device placed under the skin in the chest that monitors heartbeat).A record review of Resident #67's quarterly MDS dated [DATE] Section C revealed resident had a BIMS score of 15, meaning the thinking and memory skills are intact. Section GG of the MDS revealed that Resident #67 requires substantial/maximal assistance from staff for toileting hygiene. Section H revealed that the resident was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #67's comprehensive care plan dated 02/13/2023 revealed: The resident has bowel and bladder incontinence r/t decrease mobility Date Initiated: 02/13/2023, Revision on: 03/02/2025 with goals: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Date Initiated: 02/13/2023. Revision on: 12/15/2025 and Target Date: 08/27/2026 and intervention: Incontinent: Check for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Date Initiated: 02/13/2023. Revision on 02/13/2023. Observation of perineal care on 08/05/2026 at 4:22pm for Resident #67 performed by CNA C revealed that CNA C did not clean the residents' buttocks while providing perineal care. During an interview with CNA C on 08/05/2026 at 4:26pm, CNA C stated she missed wiping the residents' buttocks which could lead up to an infection. She said that the residue from previous urine and sweat could affect the skin.During an interview with ADON B on 08/05/2026 at 4:31pm, the ADON stated that even though there is nothing visibly there, it's still possibly a risk of infection or UTI if the skin is not cleaned completely when providing incontinent care.Record review of Resident #68's face sheet, dated 08/06/2026, revealed a [AGE] year-old male with initial admission date of 04/10/2024 and readmission [DATE]. Diagnoses included Alzheimer's disease unspecified (brain disorder affecting memory and thinking skills), spina bifida (birth defect where the spinal column does not completely close during pregnancy) and obstructive and reflux uropathy (blockage or backwards flow of urine that can cause kidney damage).A record review of Resident #68's MDS dated [DATE] section C revealed resident has a BIMS score of 06, meaning severe impairment of thinking and memory skills. Section GG of the MDS revealed that Resident #68 required substantial/maximal assistance with toileting hygiene. Section H revealed that the resident had an indwelling catheter and was always incontinent of bowel. A record review of Resident #68's order summary report dated 08/06/2026 revealed Foley cath care q shift and PRN every shift and Urinary catheter Diagnosis: urinary outlet obstruction both with a start date of 03/25/2025. Record review of Resident #68's comprehensive care plan dated 12/27/2024 revealed: Resident has neurogenic bladder (loss of bladder control due to brain, spinal cord or nerve damage) with history of urinary retention (inability to empty urine from the bladder) and obstructive/reflux uropathy (blockage or backwards flow of urine that can cause kidney damage), and bladder spasms (sudden cramping of the bladder wall muscles), managed with an indwelling Foley catheter and history of recurrent UTI's. Date Initiated: 01/30/2025. Revision on: 06/26/2026 with goal as follows: The resident will show no s/sx of Urinary infection through review date. Date initiated 01/30/2026. Target date: 08/25/2026 and intervention: Foley cath care q shift and PRN. with initiation date of 01/30/2026. During an observation of indwelling urinary catheter and perineal care on 08/06/2026 at 10:56am for Resident #68 performed by CNA D and CNA E, it was revealed that CNA D performed catheter care and perineal care, then removed the soiled brief and placed it in the trash. CNA D did not remove gloves, perform hand hygiene or put on new gloves before handling and applying a clean brief for Resident #68 and repositioning the resident in bed. During an interview with CNA D on 08/06/2026 at 11:08am, CNA D stated that she forgot to change her gloves and sanitize her hands before placing the clean brief on Resident #68. She stated that the resident could get an infection if gloves are not changed after handling dirty items. A record review of facility policy titled Perineal Care, revised February 2018 stated the following: For a female resident: (2). Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth/or use one wipe per stroke and 4 (e) Wash the rectal area thoroughly. wiping from the base of the labia toward and extending over the buttocks. It also stated, For a male resident: 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly or use hand sanitizer. 12. Put on clean gloves and apply protective ointment if needed and clean brief.Record review of facility policy titled Handwashing/Hand Hygiene, revised August 2019 stated the following: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:.b. Before and after direct contact with residents.e. Before and after handling an invasive device (e.g. urinary catheters, IV access sites), g. Before handling clean or soiled dressings, gauze pads, etc.;.j. After contact with a resident's intact skin; k. After handling used dressings, contaminated equipment, etc ; m. After removing gloves;

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to properly store a box of kernel corn and a box of chicken patties in the walk-in freezer. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During observations and interviews on 08/03/2026 1:40 PM. The walk-in freezer had a box with a bag of kernel corn that was inside that was open. There was another box observed with a bag of chicken patties on the inside that was open. The DM said the bags should be closed to protect the food. The DM said the cook and anybody who entered the walk-in freezer was responsible to ensure the food was stored properly. During an interview on 08/05/2026 at 2:51 PM the DM said the chicken and the kernel corn in the freezer should not have been stored opened. The DM said open food in the freezer could cause freezer burn would make the food inedible and cause cross contamination that could cause food borne illness to the residents. During an attempted interview on 08/05/2026 at 3:09 PM a message was left for RD for a return call. Record review of the facility's policy titled, Food Storage, dated 6/1/2019 stated: To ensure that all food served by the facility is of good quality and safe for consumption; all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines. Section 3- Freezers, part e. stated: Store foods in moisture proof wrap.

Based on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #73) of 7 residents reviewed for accuracy and completeness of clinical records. The facility failed to complete a PASRR form 1012 (Mental Illness/Dementia Resident Review) for Resident #73. This failure could place the resident at risk for inadequate care and could result in diminished quality of care. Record review of Resident #73's face sheet dated 8/5/2026 revealed a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses that included: dementia (an umbrella term for the decline in memory, language, and thinking skills), Bipolar Disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels), and cirrhosis of the liver (a condition that replaces healthy tissue in the liver with scarred tissue, caused by chronic alcohol abuse). Record review of Resident #73's Care Plan dated 6/29/2026 revealed the resident was care planned for throwing call bell on the floor, elopement risk, inappropriate sexual behaviors with aggression towards staff- attempting to bite and hit staff during care, communication problem due to dementia- rambling speech at times, and risk for falls. Record review of Resident #73's quarterly MDS dated [DATE] revealed the resident had a BIMS that was not obtainable due to severe cognitive deficits. Further review revealed the resident required maximum assistance with ADLs. Record review of Resident #73's electronic record for PASRR revealed an incomplete PASRR form 1012 (Mental Illness/Dementia Resident Review) in the electronic medical record. The form at the bottom where the person who completed the form should have been checked PL1 (PASRR Level 1) remains negative and no new PL1 needs to be completed. The nursing facility files the completed form in the resident's chart. Record review of Resident #73's medical record did not reveal any services rendered for a resident who was PASRR positive (a person screened for or living in a Medicaid- certified nursing facility has been identified as having, or suspected of having a serious mental illness, intellectual disability, or developmental disability). During an interview on 08/05/2026 at 4:20 AM the MDS Coordinator said she was responsible for filling out the PASRRs for the residents. The MDSC viewed Resident #73's PASRR and said it was incomplete. The MDSC said the resident was not PASRR positive because Resident #73 was diagnosed with dementia before the mental illness diagnosis, which would make him negative for PASRR. The MDSC said the form should have been checked in the correct box before she signed the page and uploaded it in the resident's electronic medical record. Record review of facility policy titled, Documentation in Medical Record dated 2025 stated: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide the resident's progress through complete, accurate, and timely documentation

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for residents for 4 of 5 residents (Resident #1, Resident #2, Resident #3, and Resident #5) reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not have body wash/shampoo/conditioner in his bathroom. The facility failed to ensure Resident #2 did not have perineal/skin cleanser and shave cream in his bedroom and bathroom. The facility failed to ensure Resident #3 did not have mouthwash in her room. The facility failed to ensure Resident #5 did not have shampoo/body wash, peri-wash, and lotion in her room and peri-wash in her bathroom. This deficient practice could result in residents having diminished health and/or quality of life. Findings included: 1. Record review of Resident #1's admission Record, dated 6/30/26, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Severe Dementia (group of thinking and social symptoms that interferes with daily functioning), Aphasia (disorder that affects a person's ability to communicate) , and Schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly) . Record review of Resident #1's quarterly MDS assessment, dated 6/9/26, revealed the resident's cognitive skills for daily decision making was severely impaired. During observation and interview on 6/30/26 at 11:07 am of Resident #1's room with Housekeeper I revealed store-bought body wash/shampoo/conditioner in the resident's bathroom labeled .WARNING: FOR EXTERNAL USE ONLY. Housekeeper I said this item was not supposed to be in the resident's room. During an interview on 7/1/26 at 11:56 am, Resident #1 nodded when asked if he knew what the body wash/shampoo/conditioner in his bathroom was used for and said, In mouth, I don't know. 2. Record review of Resident #2's admission Record, dated 6/30/26, revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: Vascular Dementia (Brain damage caused by multiple strokes) and Cognitive Communication Deficit (difficulty with thinking and language). Record review of Resident #2's quarterly MDS, dated [DATE], revealed the resident's BIMS score 00, suggesting the resident's cognition was severely impaired. During observation and interview on 6/30/26 at 12:06 pm of Resident #2's room with Housekeeper I revealed medical-surgical supply brand perineal/skin cleanser, labeled .CAUTION: For external use only. and medical-surgical supply brand shaving cream, labeled .WARNING: Contents under pressure.Keep out of reach of children. and store bought shaving cream on the resident's side table labeled .WARNING: Contents under pressure.Intentional misuse by deliberately concentrating and inhaling the contents can be harmful or fatal.KEEP OUT OF REACH OF CHILDREN. Housekeeper I said those items were not supposed to be in the resident's room. During an interview on 7/1/26 at 11:56 am, Resident #2 said he knew what the shaving cream was for and he knew how to use it. 3. Record review of Resident #3's admission Record, dated 6/30/26, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Severe Dementia (group of thinking and social symptoms that interferes with daily functioning), Alzheimer's Disease (disease affecting memory and other important mental functions) , and Cognitive Communication Deficit (difficulty with thinking and language). Record review of Resident #3's quarterly MDS, dated [DATE], revealed the resident's BIMS score 07, suggesting the resident's cognition was severely impaired. During an observation and interview on 6/30/26 at 11:48 am of Resident #3's room with Housekeeper I revealed medical-surgical supply brand mouthwash, labeled .CAUTION: Keep out of reach of children. In case of accidental ingestion, seek professional assistance or contact a poison control center immediately. Housekeeper I said this item was not supposed to be in the resident's room. During an interview on 7/1/26 at 11:49 am, Resident #3 said she had mouthwash that stayed in her room. Resident #3 further stated that she knew how to use it and did not have small children. 4. Record review of Resident #5's admission Record, dated 7/2/26, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Senile Degeneration of the Brain (Dementia - group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #5's comprehensive MDS, dated [DATE], revealed the resident's BIMS score 00, suggesting the resident's cognition was severely impaired. During observation and interview on 6/30/26 at 12:52 pm of Resident #5's room revealed medical-surgical supply brand shampoo/body wash, labeled .CAUTION: For external use only., medical-surgical supply brand perineal/skin cleanser, labeled .CAUTION: For external use only., and medical-surgical supply brand lotion, labeled .CAUTION: For external use only. on her side table and medical-surgical supply brand perineal/skin cleanser, labeled .CAUTION: For external use only. in her bathroom. Housekeeper I said these items were not supposed to be in the resident's room. During an interview on 7/2/26 at 8:39 am, Resident #5 said she knew how to use the hygiene items in her room. Resident #5 proceeded to motion showering and applying lotion to her body and said, I just don't know. During an interview on 6/30/26 at 12:09 pm, Housekeeper I said lotion, shampoo and conditioners the family brought were supposed to be locked up. Housekeeper I said that the nurses were responsible for ensuring these items were not in the residents' rooms just in case another resident went in the room and took it. Housekeeper I further stated that some residents may try to eat or drink it the personal hygiene items, such as mouthwash. Housekeeper I said that the residents got confused, they had good days and bad days. Housekeeper I further stated that if a resident was having a bad day, there was a possibility that they may drink personal hygiene items and get sick. During an interview on 7/1/26 at 8:42 am, CNA A said Resident #3 used mouthwash and it was usually put in a drawer or in the restroom. CNA A further stated that Resident #3 was not ambulatory, but her roommate was, and her roommate also had Dementia; adding that when she was confused, these items could be a danger to her. CNA A said that she knew that staff were not supposed to leave personal hygiene items in the residents' rooms, especially for residents with dementia because some of the residents that were ambulatory can grab things. CNA A said that the residents did not know what they were doing and the staff knew that. CNA A further stated that residents could drink personal hygiene items and get sick. CNA A said that usually the nurse will tell the staff not to leave personal hygiene items in the residents' rooms. CNA A said that she did not leave the personal hygiene items in the residents' rooms after she provided care on 6/30/26 and did not know who did. A telephone interview was attempted on 7/1/26 at 8:56 am and 7:01 pm with CNA E (regarding personal hygiene items in resident rooms), without success. A telephone interview was attempted on 7/1/26 at 8:59 am with CNA F (regarding personal hygiene items in resident rooms), without success. During interview and observation on 7/1/26 at 12:14 pm of Resident #1, Resident #2, Resident #3, and Resident #5's rooms with ADON G, ADON G confirmed the store-bought body wash/shampoo/conditioner, medical-surgical supply brand perineal/skin cleanser, medical-surgical supply brand shaving cream, and store bought shaving cream, medical-surgical supply brand mouthwash, medical-surgical supply brand shampoo/body wash, and medical-surgical supply brand lotion were in the residents' rooms. ADON G said the nurses used the perineal/skin wash and must have forgotten it in the resident rooms. ADON G further stated shaving cream should be locked up as well and that sometimes the CNA forgot. ADON G said the residents' mind sometimes come and go, and sometimes they forgot. ADON G further stated that there was a possibility that residents may ingest the hygiene items. ADON G said, for the most part, the majority of the residents on the Memory Care Unit were alert, but they got confused. During an interview on 7/1/26 at 2:05 pm, CNA B said the staff were not supposed to keep shampoo or perineal wash in the residents' room because residents could drink them. CNA B said that the residents on the Memory Care Unit got confused. CNA B said if she saw personal hygiene items in the resident rooms, she removed them and put them in the shower room. CNA B said the CNAs were responsible for ensuring that personal hygiene items were not left in the residents' rooms. CNA B further stated that the person that did round and any staff that went into the resident rooms and saw these items were also responsible for removing them. CNA B said residents could become sick if the personal hygiene items were ingested or they may be allergic to the ingredients. CNA B said all the items had chemicals in them and could be dangerous to the residents. During an interview on 7/1/26 at 3:11 pm, CNA C said the personal hygiene items were not supposed to be in the resident rooms because they had chemicals and some had alcohol. CNA C further stated the residents could ingest the personal hygiene items. CNA C said if a resident ingested personal hygiene items they may need to go to the hospital. CNA C said all staff were responsible for ensuring that personal hygiene items were not in the resident rooms. CNA C said somebody might have forgotten the personal hygiene items in Resident #3's room because those items were usually not in her room. CNA C said that he did not know that there were personal hygiene items in Resident #1, Resident #2, Resident #3, or Resident #5's rooms because he did not work with them on 6/30/26. During a telephone interview on 7/1/26 at 6:21 pm, MR said she was assigned to complete room rounds for Resident #2. MR said that she completed room rounds on 6/30/26 around 6:30 am, and there wasn't any shaving cream in Resident #2's room because Resident #2 was not allowed to have shaving cream in his room because he resided in memory care and the staff did not want the resident to ingest it and cause harm. MR said that Resident #2 may have brought shaving cream from home after a pass. During an interview on 7/2/26 at 9:17 am, ADON H said she had read the labels on the personal hygiene items. ADON H said that the medical-surgical supply brand perineal/skin cleanser was okay to be in the resident rooms and so was the medical-surgical supply brand lotion. ADON H said she was not aware that the store-bought personal hygiene items were in the rooms. ADON H further stated that some of the families brought personal hygiene items and left them in the residents' rooms. ADON H said that she was not aware of the store-bought shave cream in Resident 2's room was a new one because sometimes his family would bring items in, but they were usually snacks. ADON H said that she preferred that the medical-surgical supply brand shave cream was not in the room. ADON H further stated she was not sure what the facility's policy was regarding personal hygiene items but said shaving cream was aerosolized and was potentially flammable. ADON H said she was not sure if the medical-surgical supply brand shave cream was aerosolized, but if they were, they were not to be left in the residents' rooms. ADON H said that all staff were responsible for ensuring the shave cream was not in resident rooms. ADON H said that most of the personal hygiene items the facility bought were from medical-surgical supply brand which were not toxic. During an interview on 7/2/26 at 10:42 am, the DON said she did know that there was perineal/skin cleanser, lotion shave cream or mouthwash in the residents' rooms. The DON said that the facility assigned staff to complete room rounds, but anyone that saw these items should remove them because the items were toxic. The DON said the residents were allowed to have non-toxic items in their rooms. The DON further stated that if the items said keep out of reach of children it would be a safety concern in case it was used incorrectly. The DON said having the personal hygiene items in the residents' rooms was a safety concern because they could be ingested or used incorrectly. The DON said the facility had not had any residents ingest personal hygiene items in the past. Record review of the facility's policy titled Personal Property, revised August 2022, revealed: .Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents. Record review of the facility's policy titled Homelike Environment, revised February 2021, revealed: .Residents are provided with a safe, clean, comfortable and homelike environment . Record review of the facility's admission packet revealed: .15. ITEMS PROHIBITED IN RESIDENT ROOMS. State and Federal laws prohibit many items from resident [sic] rooms. The following list is meant to be a guide only and not an exhaustive list.The decision to prohibit items from resident rooms is based upon governing laws, regulations and the need to maintain a safe living environment.No aerosol cans of any products as they are combustible. Further review of the facility's admission packet revealed it did not reference items with KEEP AWAY FROM CHILDREN, POISONOUS, or EXTERNAL USE ONLY warning labels.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 1 of 4 residents (Resident #4) reviewed for medication storage. The facility failed to ensure Resident #4 did not have the medication Mupirocin in her room on the Memory Care Unit on 6/30/26. This failure could place residents at risk of medication misuse and drug diversion. Findings included: Record review of Resident #4's admission Record, dated 6/30/26, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Vascular Dementia (Brain damage caused by multiple strokes), and Cognitive Communication Deficit (difficulty with thinking and language). Record review of Resident #4's quarterly MDS, dated [DATE], revealed the resident's BIMS score 00, suggesting the resident's cognition was severely impaired. Observation and interview on 6/30/26 at 11:42 am, revealed a tube of Mupirocin (prescription antibiotic ointment) in Resident #4's dresser draw. ADON G said she did not know that medication was in Resident #4's drawer and it was not supposed to be in there. ADON G further stated the facility had staff that did room rounds, but did not know who was assigned to Resident #4's room. ADON G said there should not be any medications in the residents' rooms because residents could ingest the medications and could die. ADON G further stated that residents in Memory Care did not self-administer medications. ADON G said all staff were responsible for ensuring there were not any medications in the residents' rooms, especially the staff that were assigned to that resident's room. During an interview on 7/2/26 at 9:17 am, ADON H said her expectation was that no medications were left in resident rooms, especially in the Memory Care Unit. ADON H further stated that she did not know that Resident #4 had the tube of Mupirocin in her room. ADON H said that Resident #4 did not have an order for Mupirocin and she did. ADON H further stated she did not know how the medication got there. ADON H said that the tubes of medication were always labeled by the pharmacy. ADON H said she did not know if Resident #4's family brought the Mupirocin for the resident. ADON H said that although The residents' drawers were not part of the routine rounds, she checked the drawers once or twice a week, but she did not like to invade the residents' privacy. ADON H said it was all of the staff's responsibility to ensure that medications were not in resident rooms. ADON H said that on 6/29/26, during her inspection, she went through the resident's drawer and did not see the Mupirocin in Resident #4's drawer. ADON H further stated that if she had seen the Mupirocin in Resident #4's drawer, she would have taken it out. ADON H said that she did not know that she had any resident that would open and try to use the Mupirocin, but the possibility of misuse was always there causing a possible allergic reaction or illness from ingestion. ADON H said that Resident #4 had Dementia and was ambulatory. ADOON B further stated that the majority of the residents on the unit were ambulatory. ADON H said that even though most of the residents did wander into other resident rooms, all of the residents had Dementia, Alzheimer's or other cognitive impairment that impeded their safety awareness. During an interview on 7/2/26 at 9:55 am, Resident #4's family member said that Resident #4 may have picked up the medication at her house during a pass because the resident had free [NAME] of her house when she was there. During an interview on 7/2/26 at 10:42 am, the DON said she did not know there was an ointment in Resident #4's room. The DON said that the staff usually did not go in the residents' drawers, where they had their personal belongings stored unless there was a concern. The DON further stated that all staff that entered resident rooms were responsible for ensuring there were no items that were not supposed to be in the resident's room. The DON said having medications in resident rooms put them at risk of taking medication that was not theirs, and they could have a (negative) reaction to that medication. Record review of the facility's policy titled, 6. Delivery, Receipt and Storage of Medication undated, revealed: .6.3. Storage of Medication The facility should ensure that only authorized facility staff should have access to the medication storage areas. authorized facility staff should include nursing staff and those authorized to administer medications.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (Resident #25, #237, and #19) of 20 residents reviewed for infection control practices. 1. CNA D failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #25. 2. When CNA-I was providing peri care to Resident #237, CNA-I grabbed new and clean brief with old and dirty gloves after cleaning Resident #237's buttock area, put the new and clean brief under the resident, and closed it. 3. When LVN-G administered medications to Resident #19 through gastrostomy tube (feeding tube inserted thought the belly that bring nutrition or medication directly to the stomach), LVN-G did not wear a gown. However, Resident #19 had enhanced barrier precaution, and the sign attached on the door said, Staff must wear gloves and gown for the following high-contact resident care activities such as cares using feeding tube. This deficient practice could place residents at risk for cross contamination and infections. The findings included: 1. Record review of Resident #25's electronic face sheet dated 06/12/2025 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female. Her diagnoses included: Alzheimer's disease (a brain disorder that destroys memory and thinking skills), dementia (loss of cognitive functioning that interferes with ADLs), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities) and cardiomyopathy (a disease that affects the heart muscle, making it harder for the heart to pump blood effectively). Record review of Resident #25's quarterly MDS assessment dated [DATE] reflected she usually understood and usually understands. She scored a 01 out of 15 on her BIMS which indicated she was severely cognitively impaired. She was occasionally incontinent of bladder and always incontinent of bowel. She required moderate assistance with ADLs. Record review of Resident #25's comprehensive care plan initiated 05/15/2025 reflected Problem, resident has a UTI, Interventions, check for incontinence, wash, rinse and dry soiled areas. Observation on 06/11/2025 at 4:07 pm of CNA D (agency aide) perform incontinent care for Resident #25 revealed she finished wiping Resident #25's buttocks and threw away the dirty wipes. CNA D then proceeded to take the clean incontinent brief and place it on the resident without changing gloves or sanitizing hands. During an interview on 06/11/2025 at 4:15 pm, CNA D stated she should have sanitized her hands and changed gloves between dirty and clean. She stated the wrong practice could result in cross contamination and the resident getting an infection. She stated she was trained to sanitize her hands and change gloves between dirty and clean. During an interview on 06/11/2025 at 3:00 pm., the DON stated Resident #25 was treated for a UTI, and agency staff are supposed to come trained and know how to do proper incontinent care. She stated CNA D needed to sanitize her hands and change her gloves prior to putting on Resident #25's clean brief to prevent cross contamination. Record review of Credentials (undated) sent by the agency for CNA D reflected she had completed a Long Term Care Essentials Clinical Assessment Outline, Urinary Incontinence, and Infection Control. Record review of the facility policy and procedure titled Infection Control revised February 2018 reflected This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Perineal care, rinse, and dry area thoroughly, discard disposable items into designated containers, remove gloves and discard into designated container, wash, and dry hands thoroughly or use hand sanitizer, put on clean gloves and apply protective ointment if needed and clean brief. 2. Record review of Resident #237's face sheet, dated 06/13/2025, revealed the resident was a [AGE] year-old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of cerebral palsy (congenital disorder of movement, muscle tone, or posture), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hypertension (high blood pressure), urinary tract infection (infection to the urinary bladder), and obstructive and reflux uropathy (the flow of urine is blocked). Record review of Resident #237's quarterly MDS assessment, dated 04/21/2025, revealed the resident's BIMS was 99 indicated the resident was not able to interview, required dependent (helper does all of the effort) to chair to bed and toilet transfer, had indwelling urinary catheter, and always bowel incontinence. Record review of Resident #237's comprehensive care plan, dated 08/02/2024, revealed The resident has chronic indwelling catheter and bowel incontinence. For intervention - Catheter care and monitor/document for signs and symptoms of urinary tract infection and bowel incontinence care. Observation on 06/11/2025 at 1:33 p.m. revealed CNA-I put on gloves and gown and cleaned Resident #237's indwelling urinary catheter, then rolled the resident to left side, cleaned the resident's buttock area, removed old and dirty brief, then made the resident on supine position. Without changing gloves, CNA-I grabbed a new and clean brief with old and dirty gloves, put it under the resident, and closed it. CNA-I took off the old and dirty gloves and washed her hands with water before leaving Resident #237's room. Interview on 06/11/2025 at 1:44 p.m. with CNA-I stated she grabbed and put a new and clean brief with old and dirty gloves to Resident #237. CNA-I said she should have changed her gloves after sainting her hands then grabbed the new and clean brief. CNA-I stated it was her mistake, and the resident might have infection. Interview on 06/13/2025 at 12:30 p.m. with ADON-B stated CNA-I should have changed her gloves after sanitizing her hands then grabbed the new and clean brief. Facility DON and ADONs conducted skill checkoffs once a year to all CNAs to make sure CNAs provide correct catheter and peri care to residents. ADON-B said Resident #237 might have infection. Record review of the facility policy, titled Perineal Care, revised 02/2018, revealed . Wash and rinse the rectal area thoroughly. Rinse and dry area thoroughly. Discard disposed items into designated containers. Removed gloves and discard into designated container. Wash and dry your hands. Put on gloves and apply protective ointment if needed and clean brief. 3. Record review of Resident #19's face sheet, dated 06/13/2025, revealed the resident was a [AGE] year old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of multiple sclerosis (disease that causes breakdown of the protect covering of nerve and cause numbness, weakness, trouble walking, and other symptoms), dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing), diverticulitis of intestine (inflammation of irregular bulging pouches in the wall of the large intestine), and gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritate the food pipe lining). Record review of Resident #19's annual MDS assessment, dated 04/29/2025, revealed the resident's BIMS was 99 which indicated the resident was not able to interview, required dependent (helper does all of the effort) to all daily activities of living, such as transfer, dressing, and personal hygiene, and had on feeding tube. Record review of Resident #19's comprehensive care plan, dated 04/15/2024, revealed The resident requires tube feeding related to dysphagia and nothing by mouth diet, and the resident requires enhanced barrier precaution related to gastrostomy tube. For intervention - gown and gloves required when providing direct care and follow enhanced barrier precaution guidelines when providing close contact resident care. Record review of Resident #19's physician order, dated 03/20/2025, revealed the resident had the order of Enhanced Barrier Precaution every shift due to gastrostomy tube. Observation on 06/12/2025 at 9:07 a.m. revealed when LVN-G administered medications to Resident #19 through gastrostomy tube, LVN-G put on gloves after washing her hands with water but did not wear a gown. Further observation revealed there was a sign posted regarding enhanced barrier precaution attached on the resident room door, and the sign attached on the door said, Staff must wear gloves and gown for the following high-contact resident care activities such as cares using feeding tube. Interview on 06/12/2025 at 10:04 a.m. with LVN-G said she should have put on a gown because Resident #19 had enhanced barrier precaution due to her gastrostomy tube care. LVN-G said she was nervous and forgot wearing a gown. It was her mistake, and the resident might have infection. Interview on 06/13/2025 at 12:30 p.m. with ADON-B stated LVN-G should have put on a gown because Resident #19 had enhanced barrier precaution due to her gastrostomy tube care. The facility did not have policy regarding enhanced barrier precaution but followed enhanced barrier precaution's guidelines, which was Staff must wear gloves and gown for the following high-contact resident care activities such as cares using feeding tube. Resident #19 might have infection if nurses did not follow the guidelines.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. 1. The facility failed to ensure two trays of prepared and poured glasses of beverages in the refrigerator were dated. 2. The facility failed to ensure a try with six prepared bowls of cereal in the dry storage were dated. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During observation 06/10/2025 at 8:53 a.m. the initial tour of the kitchen revealed in the walk-in refrigerator two trays with beverages poured not dated, and in the dry storage a tray with 6 bowls of cereal not dated. An interview with DM on 06/10/2025 at 10:27 a.m. revealed all open items being stored in the walk-in refrigerator and in the dry storage are to be labeled with the date prepared and date to use by. DM stated staff preparing to store open or prepared items in the walk-in refrigerator or dry storage are responsible to date items. DM stated by not dating the items the residents were at risk for food born illness. An interview with [NAME] on 06/12/2025 at 10:34 a.m. revealed all open items being stored in the kitchen's walk-in refrigerator and in the dry storage were to be labeled with the date opened and the use by date. [NAME] stated all staff are responsible to label items. [NAME] stated if items were not labeled then it would be possible to use old or expired items causing food born illness. Record review of the facility's policy named Food Storage dated 2018 revealed Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. and Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #19) of 13 residents and 2 of 2 medication rooms (A-wing and C-wing medication room) reviewed for pharmacy services. 1. When LVN-G administered medication (Omeprazole delayed release 20 mg) to Resident #19 through gastrostomy tube (feeding tube inserted thought the belly that bring nutrition or medication directly to the stomach), LVN-G opened the medication, but the label of the medication said, Do not open or crush! 2. There was one box of suction catheter kit expired 06/07/2025 found inside A-wing medication room on 06/11/2025. 3. There was one box of suction catheter tray expired 07/28/2024 found inside C-wing medication room on 06/11/2025. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Record review of Resident #19's face sheet, dated 06/13/2025, revealed the resident was a [AGE] years old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of multiple sclerosis (disease that causes breakdown of the protect covering of nerve and cause numbness, weakness, trouble walking, and other symptoms), dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing), diverticulitis of intestine (inflammation of irregular bulging pouches in the wall of the large intestine), and gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritate the food pipe lining). Record review of Resident #19's annual MDS assessment, dated 04/29/2025, revealed the resident's BIMS was 99 which indicated the resident was not able to interview, required dependent (helper does all of the effort) to all daily activities of living, such as transfer, dressing, and personal hygiene, and had on feeding tube. Record review of Resident #19's comprehensive care plan, dated 04/15/2024, revealed The resident requires tube feeding related to dysphagia and nothing by mouth diet, and the resident has chronic GERD (gastro-esophageal reflux disease). For interventions, give medications as ordered and monitor/document side effects and effectiveness. Record review of Resident #19's physician order, dated 12/07/2024, revealed the resident had the order of Omeprazole delayed release 20 mg one capsule once a day via gastrostomy tube for GERD (gastro-esophageal reflux disease). Record review of Resident #19's medication administration record, from 06/01/2025 to 06/30/2025, revealed Omeprazole delayed release 20 mg one capsule once a day via gastrostomy tube for GERD (gastro-esophageal reflux disease) was scheduled at 9:00 a.m. Observation on 06/12/2025 at 9:07 a.m. revealed LVN-G took out Resident #19's one capsule of omeprazole 20 mg from the bottle of the medication, opened the capsule, mixed it with water, and LVN-G administered the medication (omeprazole 20 mg) via Resident #19's gastrostomy tube. Further observation on 06/12/2025 at 10:04 a.m. revealed the bottle of Resident #19's omeprazole 20 mg had label, and the label said, Do not crush or do not open! Should swallow whole. Interview on 06/12/2025 at 10:04 a.m. with LVN-G stated the bottle of Resident #19's omeprazole 20 mg had label, and the label said, Do not crush or do not open! Should swallow whole. LVN-G said she did not pay attention to read the label, and that was why LVN-G opened it. LVN-G stated she should have read the label and followed the direction and contacted Resident #19's primary care physician regarding changing omeprazole to liquid form. If nurses did not follow the direction for omeprazole, the resident might not have therapeutic effects. Interview on 06/13/2025 at 12:30 p.m. with ADON-B said LVN-G should not open Resident #19's omeprazole 20 mg because the label said, Do not crush or do not open! Should swallow whole. The facility nurses should have contacted Resident #19's primary care physician regarding changing omeprazole to liquid form. If nurses did not follow the direction for omeprazole, the resident might not have therapeutic effects. Record review of the facility policy, titled Medication Administration, undated, revealed during medication administration, the facility staff should observe the 6 rights, ensure that the resident is properly positioned, administer medications at the appropriate medication administration time, document scheduled medication administration per facility policy, observe resident privacy rights per applicable law, observe manufacturer medication administration guidelines, and confirm resident consumption of the medication. 2. Observation on 06/11/2025 at 3:38 p.m. revealed one box of suction catheter kit expired on 06/07/2025 found inside the A-wing medication room. Interview on 06/11/2025 at 3:47 p.m. with regional RN acknowledged one box of suction catheter kit expired on 06/07/2025 found inside the A-wing medication room. Regional RN said she did not know the reason the expired suction catheter kit was inside the A-wing medication room, and nurses should discard all expired medications and suction kit from the medication rooms as per the facility policy. The facility did not have any residents for suction. Potential harm was nurses might use the expired suction kit, and the kit might not have therapeutic effects. 3. Observation on 06/11/2025 at 4:02 p.m. revealed one box of suction catheter tray expired on 07/28/2024 found inside the C-wing medication room. Interview on 06/11/2025 at 4:03 p.m. with regional RN acknowledged one box of suction catheter tray expired on 07/28/2024 found inside the C-wing medication room. Regional RN said she did not know the reason the expired suction catheter tray was inside the C-wing medication room, and nurses should discard all expired medications and suction tray from the medication rooms as per the facility policy. The facility did not have any residents for suction. Potential harm was nurses might use the expired suction tray, and the tray might not have therapeutic effects. Record review of the facility policy, titled Delivery, Receipt, and Storage of Medications, undated, revealed Facility staff should take all measures required by facility policy, applicable law, and the State Operations Manual following administration of medications. Following resident medication administration, facility staff should appropriately document medication administration, dispose of unused medications per facility policy, discard used supplies per facility policy, and clean reusable equipment and supplies.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accidents and hazards for 3 residents (Resident #22, #49 and #39) of 24 residents reviewed for environmental hazards, in that: 1.Resident #22's wheelchair did not have a pad on the right arm rest which exposed a bare metal bar with holes where bolts would be attached. 2.Resident #49's wheelchair did not have a pad on the right arm rest which exposed a bare metal bar with holes where bolts would be attached. 3. Resident #39's headboard on his bed was detached and his foot board had veneering missing which exposed raw rough particle board. This failure could place residents at risk of skin tears due to wheelchairs and furniture in disrepair. The findings included: 1.Record review of Resident #22's electronic face sheet dated 06/11/2025 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female and her diagnoses included: dementia (loss of cognitive functioning that interferes with ADLs), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities), anxiety (a feeling of worry, nervousness, or unease), and dysphagia (swallowing disorder). Record review of Resident #22's quarterly MDS assessment, dated 04/11/2025 reflected she could usually understand and usually be understood. She scored a 00 out of 15 on her BIMS which indicated she was severely cognitively impaired. Under Section GG0120 Mobility Devices, wheelchair was checked. Record review of Resident #22's care plan for the Problem of The resident has an ADL self-care performance needs extensive assistance x 2 with ADLS. Under Intervention was Assist with mobility as needed. Wheel resident to meals activities as needed, if in w/c. The care plan was initiated 05/30/2019 and revised 01/10/2024. Observation on 06/10/2025 at 10:17 am revealed Resident #22 was sitting in a wheelchair and the right arm rest did not have pad on the metal bar. Observation at the same time of Resident #22's right arm revealed there was no obvious injuries to her arm. During an interview on 06/10/2025 at 10:20 am, LVN A stated she was not aware Resident #22's right arm rest pad was missing, and she would put in a work order. She stated the arm rest needed the pad or the resident might get skin tears. She stated staff members could put work orders into the computer. During an interview on 06/11/2025 at 3:00 pm., the DON stated resident equipment needed to be maintained to prevent harm. She stated Resident #22's wheelchair needed an arm pad to prevent the resident from harm such as a skin tear. She stated she was not aware the resident's wheelchair arm pad was missing and sometimes it happens when residents are placed at tables. She stated Resident #22's right arm rest pad needed to be replaced as soon as possible. During an Interview on 06/12/2025 at 11:35 a.m. with the Maintenance Director revealed the nurses would put a work order into the computer or tell him about the issue. He stated when a wheelchair needed service, he would repair the wheelchairs within 24-hours. The Maintenance Director confirmed Resident #22's wheelchair right arm rest was missing the pad, and he replaced it. During an Interview on 06/12/2025 at 08:00 am with the Administrator revealed the facility did not have a policy on wheelchair maintenance. He stated the Maintenance Director was good at making repairs when he received a work order. He stated he did rounds on the Memory Care Unit and was not aware Resident #22's right arm rest pad was missing and needed to be of high priority for repair related to resident safety. 2. Record review of Resident #49's electronic face sheet dated 06/11/2025 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female and her diagnoses included: Alzheimer's disease (a brain disorder that destroys memory and thinking skills), dementia (loss of cognitive functioning that interferes with ADLs), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities), anxiety (a feeling of worry, nervousness, or unease), and dysphagia (swallowing disorder). Record review of Resident #49's quarterly MDS assessment, dated 05/01/2025 reflected she could usually understand and usually be understood. She scored a 99 on her BIMS which indicated the resident was not able to complete the interview. Under Section GG0120 Mobility Devices, wheelchair was checked. Record review of Resident #49's care plan for the Problem of The resident has an ADL self-care performance, Interventions, resident requires assistance by staff. Observation on 06/10/2025 at 10:18 am revealed Resident #49 was sitting in a wheelchair and the right arm rest did not have pad on the metal bar. Observation at the same time of Resident #49's right arm revealed there was no obvious injuries to her arm. During an interview on 06/10/2025 at 10:20 am, LVN A stated she was not aware Resident #49's right arm rest pad was missing, and she would put in a work order. She stated the arm rest needed the pad or the resident might get skin tears. She stated staff members could put work orders into the computer. During an interview on 06/11/2025 at 3:00 pm., the DON stated resident equipment needed to be maintained to prevent harm. She stated Resident #49's wheelchair needed an arm pad to prevent the resident from harm such as a skin tear. She stated she was not aware the resident's wheelchair arm pad was missing and sometimes it happens when residents are placed at tables. She stated Resident #49's right arm rest pad needed to be replaced as soon as possible. During an Interview on 06/12/2025 at 11:35 a.m. with the Maintenance Director revealed the nurses would put a work order into the computer or tell him about the issue. He stated when a wheelchair needed service, he would repair the wheelchairs within 24-hours. The Maintenance Director confirmed Resident #49's wheelchair right arm rest was missing the pad, and he replaced it. During an Interview on 06/12/2025 at 08:00 am with the Administrator revealed the facility did not have a policy on wheelchair maintenance. He stated the Maintenance Director was good at making repairs when he received a work order. He stated he did rounds on the Memory Care Unit and was not aware Resident #49's right arm rest pad was missing and needed to be of high priority for repair related to resident safety. 3. Record review of Resident #39's electronic face sheet dated 06/12/2025 reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male and his diagnoses included: dementia (loss of cognitive functioning that interferes with ADLs), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities), anxiety (a feeling of worry, nervousness, or unease), and degeneration of nervous system due to alcohol (progressive loss of nerve cell function and affects movement, mental and other bodily functions). Record review of Resident #39's annual MDS assessment, dated 05/01/2025 reflected he could usually understand and usually be understood. He scored a 5 out of 15 on his BIMS which indicated he was severely cognitively impaired. Record review of Resident #49's care plan for the Problem of The resident has an ADL self-care performance, deficit r/t confusion, Interventions, resident requires assistance by staff. Observation on 06/10/2025 at 10:30 am revealed Resident #39 was sitting in his room on his bed. The headboard of the bed was detached and sitting between the top of the bed and the wall. The footboard had exposed particle board which rough and uneven where the veneer had come off. During an interview on 06/10/2025 at 10:35 am, LVN A stated she was not aware Resident #39's headboard was off the bed and his footboard needed repair or replacement. She stated he could get a skin tear from the footboard. Observation on 06/11/2025 at 08:30 am of Resident #39's bed revealed the headboard and footboard were still in disrepair. During an interview on 06/11/2025 at 08:45 am with Resident #39, he stated the headboard was off his bed for some time, he was afraid to move on the bed because the headboard knocked against the wall, kaboom, kaboom, kaboom, and he worried about the resident who was in the next room. He stated if his leg were to get onto the foot board, he might get a scrape. During an interview on 06/11/2025 at 3:00 pm., the DON stated resident equipment needed to be maintained to prevent harm. She stated Resident #39's bed needed to have a safe headboard and footboard to prevent harm. She stated she was not aware of the issue and told staff to report equipment issues to the Maintenance Director with a work order. During an Interview on 06/12/2025 at 08:00 am with the Administrator revealed the facility did not have a policy on wheelchair maintenance. He stated the Maintenance Director was good at making repairs when he received a work order. He stated he did rounds on the MCU and was not aware Resident #39's headboard and footboard needed to be repaired to ensure his safety. During an Interview on 06/12/2025 at 11:35 a.m. with the Maintenance Director revealed the nurses would put a work order into the computer or tell him about the issue. He stated he was not aware of Resident #39's headboard and footboard needed to be repaired. During an interview on 06/12/2025 at 11:51 a.m. with CNA C, who worked on the MCU, stated Residents #22 and #49 were without armrest pads for two or three days. He stated he did not report it this week and did not know why. He stated he reported the headboard being off from Resident #39's bed and the footboard condition months ago but he could not remember to whom. He stated residents had frail skin and could get skin tears from equipment in disrepair. During an interview on 06/13/2025 at 08:27 am, ADON B stated staff were trained to report broken equipment or furniture. She stated the repairs were probably overlooked. Record review of the facility Work Orders dated April 1, 2025, to May30, 2025 did not reflect the missing arm rest pads for Residents #22 and #49 or the detached headboard and footboard in need of repair for Resident #39.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 20 residents (Residents #46 and #238) reviewed for storage. 1. Resident #46's insulin Lantus Solos Flex Pen for diabetes had no open date, found inside B-wing nursing cart on 06/11/2025. 2. Resident #238's insulin Novolog Flex Pen for diabetes had no open date, found inside B-wing nursing cart on 06/11/2025. These failures could place residents at risk of having not therapeutic effects by using old insulins. The findings were: 1. Record review of Resident #46's face sheet, dated 06/13/2025, revealed Resident #46 was a [AGE] year-old male and admitted to the facility 12/04/2020 and re-admitted to the facility 05/31/2024 with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hypokalemia (low potassium level in the blood), and heart failure (the heart muscle does not pump blood as well as it should). Record review of Resident #46's annual MDS, dated [DATE], revealed the resident's BIMS score was 14 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. Record review of Resident #46's physician's order, dated 03/24/2025, revealed the resident had the order of Insulin Lantus Solostar Subcutaneous solution Pen - inject 100 UNIT/ML - Inject 10 unit subcutaneously at bedtime for type 2 diabetes mellitus- hold for blood sugar under 150 and inject 18 unit subcutaneously one time a day in the morning for type 2 diabetes mellitus- hold for blood sugar under 150. Record review of Resident #46's medication administration record, dated from 06/01/2025 to 06/30/2025, revealed the resident was receiving Insulin Lantus Solostar Subcutaneous solution Pen - inject 100 UNIT/ML - Inject 10 unit subcutaneously at bedtime and 18 unit subcutaneously one time a day in the morning for type 2 diabetes mellitus at 7:30 am and 8:00 pm. Observation on 06/11/2025 at 4:38 p.m. revealed Resident #46's insulin Lantus Solostar Subcutaneous solution Pen for diabetes with no open date was found inside the B-wing nursing cart. Interview on 06/11/2025 at 4:39 p.m. with regional RN stated Resident #46's insulin Lantus Solostar Subcutaneous solution Pen for diabetes with no open date was found inside the B-wing nursing cart, and the insulin pen should have been discarded 28 days after opening it. If the insulin pen did not have any open date, nurses did not know when they have to discard the insulin pen. Interview on 06/11/2025 at 5:00 p.m. LVN-H stated he was working as an agency nurse, and when he came to the facility for work on 06/11/2025, he saw Resident #46's insulin Lantus Solostar Subcutaneous solution Pen without open date. LVN-H said he did not use it today (06/11/2025) morning time because Resident #46's blood sugar was less than 150. Further interview, LVN-H said Resident #46's insulin pen for diabetes should have been discarded 28 days after opening it. However, LVN-H did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-H did not know when the facility nurses opened Resident #46's insulin pen. 2. Record review of Resident #238's face sheet, dated 06/13/2025, revealed Resident #238 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnoses of cerebral atherosclerosis (build-up of plaque in the blood vessels of the brain occurs), dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), heart failure (the heart muscle does not pump blood as well as it should), and hypertension (high blood pressures). Record review of Resident #238's admission MDS revealed it was in progress at this time (06/13/2025) because the resident was admitted to the facility on [DATE]. Record review of Resident #238's physician's order, dated 06/10/2025, revealed the resident had the order of Insulin Novolog solution 100 unit/ml inject as per sliding scale if 100-150 = 6 units, 151-200 = 8units, 201-250 = 10 units, 251-300 = 12 units, 301-350 = 16 units subcutaneously before meals for diabetes. Record review of Resident #238's medication administration record, dated from 06/01/2025 to 06/30/2025, revealed the resident was receiving Insulin Novolog solution 100 unit/ml inject as per sliding scale if 100-150 = 6 units, 151-200 = 8units, 201-250 = 10 units, 251-300 = 12 units, 301-350 = 16 units subcutaneously before meals for diabetes at 7:00 am, 1100 am, and 5:00 pm. Observation on 06/11/2025 at 4:39 p.m. revealed Resident #238's insulin Novolog Flex Pen for diabetes with no open date was found inside the B-wing nursing cart. Interview on 06/11/2025 at 4:40 p.m. with regional RN stated Resident #238's insulin Novolog Flex Pen for diabetes with no open date was found inside the B-wing nursing cart, and the insulin pen should have been discarded 28 days after opening it. If the insulin pen did not have any open date, nurses did not know when they have to discard the insulin pen. Interview on 06/11/2025 at 5:01 p.m. LVN-H stated he was working as an agency nurse, and when he came to the facility for work on 06/11/2025, he saw Resident #238's insulin Novolog Flex Pen without open date. Further interview, LVN-H said Resident #238's insulin pen for diabetes should have been discarded 28 days after opening it. However, LVN-H did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-H said the resident's family might bring it from home, but it was still facility nurse's responsibility to write open date on the pen. Interview on 06/13/2025 at 12:30 p.m. ADON-B said the facility nurses should have written open dates on insulins when they opened them to discard them 28 days after opened. Nurses would not know when they have to discard insulins if insulins did not have open dates, and it might cause improper use, and residents might not have therapeutic effects. ADON-B said that it was nurse's responsibility, and ADONs sometimes reviewed nursing carts, but they did not know what reason nurses did not write the open dates. Further interview with ADON-B said there was no policy regarding insulin, and the facility followed standard of care. Record review of the professional guidelines, titled Mount [NAME] (https://www.mountsinai.org/health-library/special-topic/insulin-and-syringes-storage-and-safety), dated 06/20/2025, revealed Discard insulin after 28 days from the date of opening.

Based on interview and record review, the facility failed to ensure annual QAPI training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure QAPI training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received QAPI training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual QAPI training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. A policy required annual training topics, including QAPI training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to ensure annual abuse, neglect and exploitation training and dementia training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure abuse, neglect and exploitation training and dementia training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received abuse, neglect and exploitation training or dementia training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual abuse, neglect and exploitation training or dementia training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. A policy required annual training topics, including abuse, neglect and exploitation training and dementia training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to ensure annual rights of the resident training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure resident rights training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received resident rights training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual resident rights training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. A policy required annual training topics, including resident rights training, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to ensure annual communications training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure communication training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received annual communication training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual communication training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. A policy required annual training topics, including communication trainings, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 27 (Cook K, Dietary Aide L, CNA M, CNA N, and LVN O) employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured [NAME] K, Dietary Aide L and CNA M received required trainings upon hire. The facility failed to implement and maintain a training program that ensured CNA N and LVN O received required trainings annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of personnel record for [NAME] K revealed hire date of 03/25/2025. Review of training log provided by human resources revealed [NAME] K did not complete required trainings upon hire. Record review of personnel record for Dietary Aide L revealed hire date of 04/07/2025. Review of training log provided by human resources revealed Dietary Aide L did not complete required trainings upon hire. Record review of personnel record for CNA M revealed hire date of 05/12/2025. Review of training log provided by human resources revealed CNA M did not complete required trainings upon hire. Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N completed the required annual trainings. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O completed the required annual trainings. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line training system to keep track of the annual trainings. HR stated by not ensuring staff complete annual trainings it could lead to mistreatment or neglect of the residents. Interview with Administrator 06/13/2025 at 1:55 PM revealed employees received emails from the online training system when new trainings are assigned. Administrator stated it staff were to complete trainings when they are assigned. Administrator stated the facility did not have a policy that identified required trainings subjects or the timeframes when to complete them. Administrator stated he assumed human resources was responsible to ensure staff completed trainings. Administrator stated staff needed their annual trainings to ensure residents received good care. A policy indicating new hire training topics, time frame to complete initial trainings, required annual training topics, time frame to complete annual trainings and who is responsible to ensure trainings were completed was requested but not provided prior to exit.

Based on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #16) of 20 residents reviewed for medical records. The facility failed to ensure facility nurses documented Resident #16's mechanically altered diet correctly on 06/08/2025's Weekly Swallowing/Nutritional Status. This failure placed resident at risk for missed treatment and care which could result in decline in health and well-being. Findings included: Record review of Resident #16's face sheet, dated 06/13/2025, revealed the resident was a [AGE] year old male and originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit (complication of pulmonary aspiration or the inhalation of food, liquid, or vomit inti the lungs), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing), heart failure (the heart muscle does not pump blood as well as it should), and edema (swelling caused by fluid trapped in your tissues). Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS was 0 out of 15 indicated the resident had severe cognitive impairment, and the resident required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as resident completes activities) to eating and dependent (helper does all of the effort) to sit to stand and chair to bed transfer. Further record review of the MDS revealed the resident was receiving Mechanically altered diet. Record review of Resident #16's comprehensive care plan, dated 04/12/2023, revealed The resident is able to feed self with setup, cuing direction. Does not like staff assistance and The resident has potential nutritional problem related to severe intellectual disabilities and history of dysphagia - Provide and serve diet as ordered of pureed diet and thin liquid for diet. Record review of Resident #16's physician order, dated 05/28/2025, revealed Pureed diet and thin liquid diet. Record review of Resident #16's Swallowing/Nutritional Status Weekly, dated 06/08/2025, revealed regarding to the question Has the resident required a mechanically altered diet in the past 7 days? (for example, pureed food, thickened liquids), the facility nurses answered No. Observation on 06/10/2025 at 12:45 p.m. revealed Resident #16 received pureed diet with thin liquids per the physician order at the main dining room. Interview on 06/13/2025 at 12:30 p.m. with ADON-B stated Resident #16's Weekly Swallowing/Nutritional Status on 06/08/2025 was inaccurate because Resident #16 was receiving pureed and thin liquid diet as ordered; therefore, the answered should have been Yes. ADON-B said she did not know what reason facility nurses documented inaccurately, but the resident's medical document should be accurate because inaccurate medical record might cause incorrect care to the resident, and the facility did not have policy regarding accurate clinical records.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Residents #27) of 3 reviewed for respiratory care. Resident #27's nebulizer mask was not covered in a plastic bag when it was not used on 06/10/2025. This failure could affect residents with oxygen therapy and could lead them to lack of care including possible infection by not following infection control. The findings included: Record review of Resident #27's face sheet, dated 06/13/2025, revealed the resident was a [AGE] year-old female and originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), type 2 diabetes mellitus (not control blood sugars in the body), and hypertension (high blood pressure). Record review of Resident #27's quarterly MDS assessment, dated 03/21/2025, revealed the resident's BIMS score was 9 out of 15 which indicated the resident had moderate cognition impairment and required dependent (helper does all of effort) to sit to stand, chair-to-bed, and toilet transfer. Record review of Resident #27's physician order, dated 05/31/2025, revealed the resident had the order of Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/3ml - 3 ml inhale orally every 6 hours for 3 days and as needed for cough/congestion. Record review of Resident #27's medication administration record, from 06/01/2025 to 06/30/2025, revealed the order of Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/3ml - 3 ml inhale orally every 6 hours for 3 days and as needed for cough/congestion was scheduled 12:00 am, 6:00 am, 12:00 pm, and 6:00 pm and given by 06/03/2025 as ordered. Observation on 06/10/2025 at 2:38 p.m. revealed Resident #27 was on the bed and sleeping in her room. Resident #27's nebulizer mask connected to a nebulizer was on the nightstand uncovered. Interview on 06/10/2025 at 2:42 p.m. with LVN-F stated Resident #27's nebulizer mask was on the nightstand without a plastic bag. Further interview with LVN-F said the resident's nebulizer mask should have been covered in a plastic bag when it was not used to prevent possible infection. Interview on 06/13/2025 at 12:30 p.m. ADON-B stated Resident #27's nebulizer mask should have been covered in a plastic bag when it was not used to prevent possible infections. Further interview with ADON-B said the facility did not have a policy related to specifically covering a nasal cannula and mask in a plastic bag when not used, the facility follows standards nursing care, and it was nurse's responsibility. Record review of professional guidelines, titled HomeCare (https://www.homecaremag.com/february-2020/dont-let-oxygen-concentrator-lead-infection), dated 04/18/2025, revealed Patients receiving supplemental oxygen via an oxygen concentrator in the home are common. Unfortunately, compliance issues related to infection prevention and control are also common. To prevent these compliance issues-and, more importantly, to prevent respiratory infections-provide education based on the manufacturer's instructions for use. When none are provided, follow these five-infection prevention and control strategies for a patient on oxygen at a liter flow of up to 5 liters per minute (L/min) in the home except those with an artificial airway, with cystic fibrosis, or who are severely immunosuppressed. These patients and those on higher liter flows of oxygen may require a higher standard of respiratory equipment management and additional disinfection activities.

Based on interviews and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated this was not possible or the resident preferences indicated otherwise for 1 of 5 Residents (Residents #16) whose records were reviewed for nutrition status maintenance. The facility failed measuring Resident #16's weight when the resident was re-admitted to the facility on [DATE], and the physician order said, Measuring weight upon admission/re-admission and every week for 4 weeks. These failures could affect residents at risk for losing weight and result in unplanned weight loss and a decline in the resident's overall health. The findings were: Record review of Resident #16's face sheet, dated 06/13/2025, revealed the resident was [AGE] years old male and originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnosis of pneumonitis due to inhalation of food and vomit (complication of pulmonary aspiration or the inhalation of food, liquid, or vomit inti the lungs), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), dysphagia (difficulty swallowing), heart failure (the heart muscle does not pump blood as well as it should), and edema (swelling caused by fluid trapped in your tissues). Record review of Resident #16's quarterly MDS, dated [DATE], revealed the resident's BIMS was 0 out of 15 which indicated the resident had severe cognitive impairment, and the resident required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as resident completes activities) to eating and dependent (helper does all of the effort) to sit to stand and chair to bed transfer. Record review of Resident #16's comprehensive care plan, dated 04/12/2023, revealed The resident is able to feed self with setup, cuing direction. Does not like staff assistance and The resident has potential nutritional problem related to severe intellectual disabilities and history of dysphagia - weight is expected to fluctuate due to being on a diuretic, and weight loss may be due to recent hospitalization and recent downgrade in diet. For interventions - monitor/document/report any sign and symptom of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss, and weight: upon admission/readmission and every week for 4 weeks. Record review of Resident #16's physician order, dated 05/28/2025, revealed Pureed diet and thin liquid diet and weight upon admission/readmission and every week for 4 weeks. Record review of Resident #16's weight log revealed the resident's weight on 06/05/2025 was 162.4 pounds, and weight on 06/12/2025 was 164.6 pounds. There was no weight on re-admission date, which was on 05/28/2025. Record review of Resident #16's nursing note for readmission assessment, dated 05/28/2025, revealed the facility nurse did not measure Resident #16's weight on 05/28/2025. The facility nurse measured the resident's weight on 06/05/2025 (162.4 pounds) and 06/12/2025 (164.6 pounds). Interview on 06/12/2025 at 3:46 p.m. ADON-B stated the nurse who conducted re-admission assessment on 05/28/2025 did not measure Resident #16's weight per the physician order, and the nurse was an agency nurse and not work anymore. ADON-B said she did not know what reason the nurse did not measure Resident #16's weight on 05/28/2025 (re-admission date), the nurse should have measured the resident's weight as the physician order, and if the facility did not know the resident's weight correctly, the resident might have unplanned weight loss and a decline in the resident's overall health. Record review of the facility policy, titled Weight System, dated 04/2022, revealed Residents are weighted at admission, readmission, and per physician orders.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 20 residents (Resident #18) reviewed for accommodation of needs. The facility failed to ensure Resident #18's call light was within reach while she was positioned on her bed in her room. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: Record review of Resident #18's face sheet, dated 06/3/2025, revealed the resident was a [AGE] year-old female with an original admission date of 08/06/2013 and re-admitted on [DATE] with diagnoses that included: atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls, limiting blood flow to the heart), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduced blood flow to the limbs), dysphagia (difficulty swallowing), hypertension (high blood pressure), and arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age). Record review of Resident #18's annual MDS assessment, dated 05/02/2025, indicated her BIMS score was 0 reflecting she had severe cognitive impairment. Further record review indicated the resident required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as resident completes activity) to all daily activities such as toilet hygiene, dressing, personal hygiene, sit to stand, toilet transfer, and chair-to-bed transfer. Record review of Resident #18's comprehensive care plan, dated 12/22/2014, reflected [Resident #18] has high risk of fall. For intervention - be sure the resident's call light is within reach and encourage the resident to use it. Observation on 06/10/2025 at 9:58 a.m. revealed Resident #18 was laying down on her bed in her room, and the call light was on the floor, which was located to the head of the resident's bed, and it was not within reach. Interview on 06/10/2025 at 9:59 a.m. was attempted with Resident #18, but the resident ignored the surveyor and kept sleeping on her bed. Interview on 06/10/2025 at 10:03 a.m. LVN-E stated Resident #18 was on her bed in her room, and the call light was on the floor located to the head of the resident's bed, and it was not within reach. LVN-E stated Resident #18 technically could use her call light because the resident did not have any impairment to arms and legs even though the resident forgot it all the time. The call light should have been within reach all the time. LVN-E did not know what reason the call light was on the floor, and the nurse stated the resident might not have proper care because she couldn't access her call light to ask for help. Interview on 06/13/2025 at 12:30 p.m. ADON-B stated the facility did not have a DON, so ADONs functioned as the DON. Resident #18 could use the call light to get help even though the resident forgot using it all the time. The call light should have been always within reach per the resident's care plan, and the facility did not have the policy specifically regarding call lights. If Resident #18 could not use the call light because it was not within reach, the resident's care might be delayed. Record review of the facility policy, titled Resident Rights, revised 12/2016, revealed Team members shall treat all residents with kindness, respect, and dignity F. communicate with and access to people an services, both inside and outside the facility.

Based on observation, interview, and record review the facility failed to ensure 1 of 24 (Resident #66) residents was treated with dignity during dining room observation. On 06/10/2025 at 12:45 pm, the Activity Director stood over Resident #66 when she fed her lunch. This failure could affect all residents in the facility and could result in low self-esteem. The findings included: Record review of Resident #66's electronic face sheet dated 06/10/2025 revealed an original admission date of 03/09/2024 and readmission date of 02/05/2025. Resident #66 was a [AGE] year-old female and her diagnoses included: Alzheimer's disease (a brain disorder that destroys memory and thinking skills), dementia (loss of cognitive functioning that interferes with ADLs), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities), anxiety (a feeling of worry, nervousness, or unease), and dysphagia (swallowing disorder). Record review of Resident #66's comprehensive care plan revised date 02/20/2025 reflected Problem, resident has an ADL self-care performance deficit r/t dementia. Interventions, EATING: Resident is now fed by staff. Record review of Resident #66's quarterly MDS assessment dated [DATE] reflected Resident #66 could rarely/never understand and could rarely/never be understood. She was not a candidate for a BIMS which indicated she was severely cognitively impaired. She was dependent on staff for her ADLs. During an observation on 06/10/2025 at 12:45 pm, Resident #66 was observed being fed by the Activity Director. The Activity Director stood over Resident #66 who was constantly trying to grab the food tray. During an interview on 06/10/2025 at 12:50 pm, the Activity Director stated she realized after a few bites of food were given to Resident #66, she needed to sit down to feed the resident. The Activity Director stated the importance of sitting at the level of the resident and to look at Resident #66 was more dignified than to stand and look down at her. She stated she was trained to sit while she fed a resident. During an interview on 06/11/2025 at 3:00 pm., the DON stated the Activity Director needed to sit while she fed Resident #66. She stated the Activity Director sitting was more dignified than standing over the resident. She stated staff that are trained to assist residents with eating are supposed to sit and be at eye level with the resident. During an interview on 06/13/2025 at 08:27 am, ADON B stated everyone who assisted with feeding should be sitting to the resident at eye-to-eye level. She stated it was disrespectful or undignified to stand over someone. Record review of the agency's policy titled Resident Rights, revised December 2016, reflected Team members shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 09/24/2024. The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began. 2. CNA A transferred Resident #2 from the bed to the resident's wheelchair without using a lift on 08/15/2024. It caused Resident #2's toenail to catch on the floor, injuring her nailbed and removing her whole toenail on her left great toe. The noncompliance was identified as PNC. The noncompliance began on 08/15/2024 and ended on 08/16/2024. The facility had corrected the noncompliance before the survey began This deficient practice could place residents at-risk of harm, serious injury, or death. The findings included: 1. Record review of Resident #1's admission record, 03/07/2025, reflected that Resident #1 was a [AGE] year-old male initially admitted on [DATE], with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Resident #1's quarterly MDS assessment, dated 09/20/2024, reflected that Resident #1 had a BIMS score of 2, indicating severely impaired cognition. The MDS assessment further reflected that wandering behavior was not exhibited by Resident #1. Record review of Resident #1's Wandering Assessment with a completion date of 09/06/2024 reflected him to be ambulatory without a history of wandering and a score of 9, indicating the resident was At Risk to Wander. Record review of Resident #1's wandering risk scale assessment dated [DATE] reflected that the resident had no history of wandering. Record review of Resident #1's nursing note, dated 9/24/2024 at 6:25 PM, reflected, Resident observed by this writer walking with walker toward Exit. Name called multiple time. Resident keep walking [sic]. CNA came out of room right beside exit door at same time resident attempted to push door open. This writer was headed that way. This writer asked CNA to ask resident if he was in pain - Resident did say yes. At [6:05 PM] Pain medication given per PRN order. Resident was redirected away from exit. Went walking down the hall. Record review of Facility Provider Investigation Report, undated, reflected that on 09/24/2024 around 6:45 PM, Resident #1 was found approximately .2 miles from the facility in a parking lot down the street by the Admissions Coordinator, who put the resident in his vehicle after completing a quick assessment for injuries and brought him back to the facility. The Provider Investigation Report further reflected that through investigation, it was determined that Resident #1 had likely exited through the front door after being let out by an unknown visitor to the facility. Interview on 03/04/2025 at 1:45 PM, Admissions Coordinator stated he was on his way home from working at the facility when he saw the resident on the corner of an intersection approximately .2 miles from the front door of the facility. Interview on 03/04/2025 at 2:15 PM, LVN C stated that Resident #1 was attempting to leave through a fire door on A Hall, and after providing him pain medication and dinner it seemed as though he had calmed down and was not wandering anymore. LVN C stated she did the assessment after the resident came back after the elopement event and had worked with him prior to the event. LVN C stated she did not see him ever attempt elopement before and that the resident did not wander any more than the average resident prior to the event. Interview on 03/04/2025 at 2:36 PM, the DON stated Resident #1 was not an elopement risk prior to this incident. The DON stated in-servicing had been completed after the incident on elopement. Interview on 03/04/2025 at 2:40 PM, the Regional Corporate Nurse stated that there had not been an elopement at the facility since the incident. Interview on 03/04/2025 at 3:00 PM, the ADM stated he was not working at the facility at the time of the incident, and that he began as Administrator of the facility in December of 2024. The Administrator was notified on 03/05/2024 at 5:25 PM, a past non-compliance IJ situation had been identified due to the above failure. The facility implemented the following interventions. Record review of Resident #1's Care Plan, undated, reflected that the facility enhanced Resident #1's to include transferred to memory care unit 9/24/2024 d/t elopement from facility with interventions to include monitoring wandering patterns and document wandering behavior and attempted diversional interventions in behavior log. Further record review of the facilities provider investigation report reflected that after the incident, the facility reported the incident to the state, implemented frequent monitoring, updated the resident's care plan, and moved the resident to the secured unit in the building with family/RP consent due to wandering behaviors and elopement. Record review of in-service training documentation, dated 09/25/2024, reflected that 100% of facility staff were in-serviced on elopement, wandering, and responding to alarming doors. All new hires are also in serviced as part of the new hire onboarding process. 10% of staff were interviewed on in-servicing on elopements. Record review of facility Incidents and Accidents report, dated encompassing 03/04/2024 through 03/04/2025 reflected that no other resident had eloped apart from the incident on 09/24/2024. Interview with DON on 03/04/2024 at 2:36 PM, stated everyone's wandering assessments were reviewed to ensure accuracy and stated they have a receptionist at the front door until 5:00 pm and at 5:00 pm the doors automatically lock and staff has to open it for anyone to get in or out and staff were educated on ensuring residents aren't following anyone out of the door. The DON stated that no other resident had eloped prior to or since the incident with Resident #1 on 09/24/2024. Observation on 03/04/2024 at 2:45 PM near the entrance to the facility revealed a sign informing guests not to open the door for anyone outside of their party. Interview on 03/05/2025 at 10:47 AM, RN D stated she is not familiar with the incident but was trained on elopement at the time of hire and has been in-serviced on wandering and elopement since the incident in September of 2024. RN D stated if she saw a resident exhibiting exit seeking behaviors, she would redirect the resident and inform her ADON and/or DON. Interview on 03/05/2024 at 11:24 AM, LVN E stated she had been in-serviced on elopements and wandering after the incident with Resident #1 in September of 2024. LVN E stated that if a resident's wandering behaviors or exit seeking behaviors change from their baseline to inform the ADON or DON and begin more frequent visual checks on the resident. Interview on 03/07/2025 at 10:44 AM, CNA F stated she had been trained on wandering and elopements, particularly after the incident with Resident #1 in September of 2024. CNA F stated that if she saw a resident attempting to leave the facility through any door she would redirect the resident and inform the charge nurse and/or ADON of the behavior of the resident. Facility policy titled, Wandering and Elopements, dated revised March 2022, reflected, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The Facility Wandering and Elopements Policy then detailed the procedures for identifying residents at risk for elopement, locating a missing resident, and procedure for post-elopement. The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began 2. Record review of Resident #2's face sheet, dated 03/07/2025, reflected the resident was an [AGE] year-old female and originally admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (destroy memory and thinking skills), type 2 diabetes mellitus (not control blood sugar levels), and heart failure. Record review of Resident #2's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was dependent (helper does ALL the effort) sit to lying, bed-to-chair transfer, and tub/shower transfer, and that the resident was not physically able to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, toilet transfer, or walk 10 feet. Record review of Resident #2's care plan, dated 03/07/2025, reflected Resident #2, requires substantial/dependent assistance by staff to move between surfaces. Assist x 2 with hoyer. with an initiated date of 08/12/2024. Record review of the Facility Provider Investigation Report, dated 08/20/2024, reflected that at approximately 11:00 AM on 08/15/2024, CNA A transferred Resident #2 without a hoyer lift, by himself, by holding the resident under her arms and moving her. During this transfer, Resident #2 sustained an injury to her left foot. Record review of Resident #2's progress note on 08/15/2024 at 11:29 AM reflected, Acetaminophen tablet 500MG given for pain, pain due to left big toe injury results pending further review of progress note reflects that on 08/15/2024 at 1:30 PM an assessment was completed and Resident #2's left big toenail was lifted and bleeding, and there was redness to her hips and ribs. Record review of Resident #2's incident report, dated 8/15/2024 at 1:30 PM reflected that the resident had bleeding to left great toe, which was injured during a transfer, and PRN pain medication was provided. Record review of the facility in-service training report, dated 08/16/2025, reflected the facility provided in-services to all nursing and maintenance staff regarding Transfer Status to include how to find each residents inidvidual transfer status and how to appropriately transfer residents. Interview on 03/05/2025 at 10:47 AM, RN D stated she was trained on transfer status and is familiar with different residents need for different transfer status, to include rechecking transfer status for change in condition. RN D stated staff are frequently observed for competencies on transferring residents appropriately. Interview on 03/05/2024 at 11:24 AM, LVN E stated she had been in-serviced on transfer status and ensuring residents are appropriately transferred based on their plan of care. Interview on 03/07/2025 at 10:44 AM, CNA F stated she had been trained on transfer status and how to find what type of transfer a resident needs. CNA F was able to show the surveyors how to find out a residents transfer status in the EHR of the resident and was able to describe the procedure of different types of transfers to include hoyer transfers. Record review of staff competencies reviewed on transfer status after the incident reflected no concerns with competencies. Record review of the CNA A's employee profile reflected the facility terminated CNA A's employment on 08/15/2024. Record review of Podiatry Visit Notes, dated 08/16/2024, reflected that the podiatrist saw Resident #2 the day after the incident occurred and removed her left big toenail, which was no longer connected to the toe. Observation of transfer on 03/05/2025 at 10:30 AM reflected no concerns for the hoyer transfer of Resident #7 observed. Hoyer transfer was observed with 2 staff members operating the hoyer lift and no injuries to the resident as a result. Record review of Resident #7's Care Plan reflected that Resident #7 needed to be assisted with transfers with 2 staff members using a hoyer lift. Interview on 03/05/2025 at 3:00 PM, the ADM stated he was not working at the facility at the time of the incident, and that he began as Administrator of the facility in December of 2024. Interview on 03/05/2025 at 5:00 PM, with the DON and RNC, the DON stated CNA A had not reported the injury to the nurse, and the family had informed the nurse of the injury when they noticed it within minutes of the injury occurring. The DON stated he believes CNA A did not realize there was an injury but did not know why he would have the resident sit on the edge of the bed to dress her. The DON stated Resident #2 saw podiatry the next morning with no concerns. The DON stated the expectation is that staff transfer residents as is appropriate and on the resident's plan of care. The DON stated the risk to residents could include injury for not being appropriately transferred . The noncompliance was identified as PNC. The noncompliance began on 08/15/2024 and ended on 08/16/2024. The facility had corrected the noncompliance before the survey began

48366 Based on observations, interviews, and record reviews the facility failed to ensure the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 2 of 9 residents (Resident #1 and Resident #6) reviewed for accident hazards and supervision, in that; 1. Resident #1 had one unauthorized, unchaperoned elopement event on [DATE]. 2. Resident #6 had one unauthorized, unchaperoned elopement event on [DATE]. The non compliance was identified as past noncompliance IJ(immediate Jepordy). The first non compliance began on [DATE] and ended on [DATE]. The second non compliance began on [DATE] and ended on [DATE]. The facility had corrected the non compliance before the survey began. This failure could place residents at risk for harm, injury, or death due to elopement. The findings included: 1. Record review of Resident #1's admission record, dated [DATE], reflected a male with an admitted [DATE], and diagnoses which included paranoid schizophrenia (a mental illness characterized by delusions and hallucinations), unspecified dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities), major depressive disorder, generalized anxiety disorder, and alcohol dependence. Record review of Resident #1's MDS, dated [DATE], reflected Resident #1 had a BIMS of ,d+[DATE], indicating severe cognitive impairment. Resident #1's MDS revealed that he had physical and verbal behaviorial symptoms towards others that could put himself and others at risk for physical injury. His MDS further revealed that wandering behavior had not been exhibited. Record review of Resident #1's comprehensive person-centered care plan, reflected Resident #1 had a focus, initiated [DATE], of The Resident is an elopement risk/wanderer. Resident paces & wanders aimlessly at times, at other times he talks of leaving with interventions of Document wandering behavior and attempted diversional interventions and Identify pattern of wandering Intervene as appropriate. Another focus, initiated [DATE], revealed The resident has a potential behavior problem r/t dementia and schizophrenia, noted to be impatient and distrustful of others, can become physically aggressive and attempt to strike at others, noted to attempt to strike staff with a fork and also make aggressive gestures to staff, refuses care and medications at times Record review of Resident #1's nursing progress notes reflected a note on [DATE] authored by LVN F at 4:31 PM that reflected resident push open door to secure unit and ran straight to back exit door causing alarm to go off this nurse and 2 other staff pulled him back from door before he could exit he was hitting and kicking staff as we were trying to get him off unit . we finally got him back to B wing call was placed to [NP] ordered Haldol 1mg IM STAT. medication ordered from pharmacy. Which included an intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from the situation and take to alternate location as needed and Refer to Senior Psych for evaluation and treatment. Record Review of Resident #1's discharge summary, dated [DATE], revealed that residend discharged on [DATE] and transfered to another facility. During an interview on [DATE] at 11:56 AM, the RN Regional Director revealed that the B wing courtyard did not need to have a lock on the gate because it was not a secured unit. During an interview on [DATE] at 4:08 PM, the MDS nurse revealed that Resident #1 exhibited wandering behavior where he would wander into the C wing, which is the secure unit. Resident #1 lives in the B wing. MDS nurse revealed that the back fence in the B wing courtyard would alarm if the door was opened. This was done to prevent elopement. During an interview on [DATE] at 4:50 PM, the MDS nurse thought Resident #1 would be considered exit seeking. During an interview on [DATE] at 7:14 AM, RN A reported that [Resident #1] was discovered eloped. RN A stated that the B wing courtyard's back gate was discovered unlocked and opened when Resident #1 was missing. RN A revealed that this back gate had a bad magnetic lock and did not work. RN A stated the gate has been locked in the past and he had no knowledge as to when the gate became inoperable. RN A stated the common consensus was resident #1 eloped through the unlocked gate at the rear of the common courtyard. RN A stated he received information about the elopement from various nurses that were present while elopement procedures were being followed. RN A revealed that Resident #1 had a previous incident of attempted elopement (no date revealed). RN A stated Resident #1 was assessed as a wander risk and would make Resident #1 a priority to assess for elopement behavior during his shifts of duty. RN A stated the facility's elopement procedure was activated and he began to call local emergency room s to alert for Resident #1's elopement. RN A stated he was concerned for Resident #1's safety citing the road where the facility is located is a wide 4 lane busy road and the facility is surrounded by apartments and businesses. During an interview on [DATE] at 10:47 AM, the Account Manager revealed that the B-wing courtyard back door had to be pushed a certain way for it to be locked correctly. The account manager further revealed that the apartment complex behind the facility have had homeless people present sometimes and could be a danger to the facility. The Account Manager revealed that Resident #1 would tell her that he was going to leave and was exit seeking. During an interview on [DATE] at 1:42 PM, LVN B revealed that the back gate in the B wing courtyard should be secured and equipped with a loud alarm. LVN B revealed that if the back gate was broken, then the public could come into the facility. About a year ago, there was a homeless person found in the dumpster, in the back of the building, and there had been instances where homeless people would try to come into the facility through the front door. They would be stopped to protect the residents. During an interview on [DATE] at 2:55 PM, the Maintenance Director revealed that he checked the back fence every day and it was working. He suggested to management, prior to this incident, that Resident #1 should be in memory care because he always studied the exits and tried to follow people out. However, he could not be in memory care due to being aggressive. The Maintenance Director further revealed the door was old and Resident #1 ended up being able to have enough strength to break the magnetic lock and eloped. Observation from [DATE] through [DATE] revealed that the exit doors were secured and B wing courtyard fence appeared to be new with a working magnetic lock. Record Review of a Memory Care Placement assessment, undated, revealed that if a resident exhibited aggressive behavior, then the recommendation would be to place resident in psych care and not in the memory care secured unit. Record review of the investigation summary of this incident revealed that On [DATE] review of cameras reveal at approximately 8:45pm, [Resident #1] exited the lobby into the B wing courtyard. [Resident #1] does not live in the secured unit. A portion of the fence gate was found broken and the magnetic lock had been damaged (this courtyard is not part of the secured unit and the magnetic lock is not required). Record Review of the Facility Assessment, updated 1. 2023, revealed the facility has 3 secured courtyards for resident and family use. Record Review of the facility's Emergency Procedure-Missing Resident policy, revised [DATE], revealed, Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety 2. Record review of Resident #6's admission record, dated [DATE], reflected a female with an admitted [DATE], and diagnoses which included Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior) and unspecified dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities). Record review of Resident #6's MDS, dated [DATE], reflected Resident #6 had a BIMS of ,d+[DATE], indicating severe cognitive impairment. Resident #6's MDS revealed that resident's wandering behavior could put the resident at significant risk for getting to a potentially dangerous place. Record review of Resident #6's comprehensive person-centered care plan, reflected Resident #6 had a focus, initiated [DATE], of The Resident is an elopement risk/wanderer r/t Resident wanders aimlessly, hx of wandering with interventions of Document wandering behavior and attempted diversional interventions and Distract resident from wandering by offering pleasant diversions. Record Review of discharge summary dated [DATE], revealed resident discharged [DATE] due to family taking Resident #1 home. During an interview on [DATE] at 11:56 AM, the RN Regional Director revealed that Resident #6 was found within an hour and a half about 1 mile or so away, at [NAME] and Woodlake. The RN Regional Director revealed that it was possible that Resident #6 followed behind the laundry personnel out of the building. During an interview on [DATE] at 2:04 PM, LVN F revealed that she makes sure that Resident #6 is within eye sight of her as Resident #6 will wander into the hallway that she eloped through, which is not the hallway that she lived in. LVN F revealed that Resident #6 would wander into the hallway that she did not reside in for no particular reason. LVN F would have to redirect Resident #6 to her room or in front of the nurse's station. LVN F reported that the hallway that Resident #6 eloped was not as supervised as the other hallway in C wing. LVN F further revealed that she knew Resident #6 would need to be highly monitored. LVN F revealed that LVN G, who was present when Resident #6 eloped was new and was probably not aware of Resident #6's behaviors and how to manage Resident #6. LVN F revealed that the importance of making sure Resident #6 did not elope was because the street in front of the facility was a danger. LVN F referred to this street as a highway because of how busy the street was and how fast the cars drove by. During an interview on [DATE] at 4:08 PM, the MDS nurse revealed that according to the cameras in the C wing, the nurse was busy at the nurse's station with family. There were also multiple residents at the nurse's station with one resident taking his shirt off. The MDS nurse reported that there are not enough nursing staff for the C wing secured unit. During an interview on [DATE] at 10:47 AM, the Account Manager reported that the trash was usually taken out of the hallway that Resident #6 eloped from. After Resident #6's elopement, housekeeping and laundry personnel are not supposed to exit out of this hallway. During an interview on [DATE] at 11:57 AM, the DON revealed that if Resident #6's behaviors are noted in her care plan that it would have prevented the elopement. During an interview on [DATE] at 12:37 PM, LVN G revealed Resident #6 would hang out by exit doors and Resident #6 would follow people out or pulled the doors after someone closed it. LVN G voiced that there was a lot of work in the secured unit. LVN G approximated the it was two much work for 1 nurse and 2 CNAs to look after 38 residents with 5 to 7 exit seekers and 5 to 7 aggressive residents. LVN G reported being concerned for Resident #6 after elopement because it could be possible that Resident #6 could get run over in the street in the front of the building. During a combined interview with the Administrator and the DON on [DATE] at 4:15 PM, it was revealed that more staff were hired to have increased monitoring of the residents to keep the residents safe. They were still evaluating and finding what can be improved for the facility. It was revealed that inrterventions for elopement are individualized for each resident in order to prevent further elopement incidents and staff had been trained on elopement/wandering procedures. Observation from [DATE] through [DATE] revealed that the exit doors of the secured units were secured and functioning. Observation also revealed that the entire back fence was secured and locks were functioning properly, including the B wing fence being fixed. Record Review of the Facility Assessment, updated 1. 2023, revealed the memory care unit is a secured environment that serves as a safe haven for residents with Alzheimer's or related dementia diagnosis Record Review of the facility's Wandering and Elopements policy, revised [DATE], revealed, 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record Review of the Inservice attendance sheet, dated [DATE], presented by administrative staff for all staff revealed a topic of Exit seeking Behavior with an Objective of Reporting and monitoring exit seeking behavior including one to one observation. The non compliance was identified as past noncompliance IJ(immediate Jepordy). The first non compliance began on [DATE] and ended on [DATE]. The second non compliance began on [DATE] and ended on [DATE]. The facility had corrected the non compliance before the survey began. The facility implemented interventions to prevent further elopement risks such as discharging the residents, repairing the fence/door, and educating staff.

Based on observation, interviews and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 1 residents reviewed for CPR, in that; The facility failed to ensure Resident #1 received life saving measures including CPR (Cardiopulmonary Resuscitation) when he was found unresponsive on [DATE]. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of not receiving life safe measures including CPR and could lead to death. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed an admitted [DATE] with diagnoses which included: severe-protein-calorie malnutrition, vascular dementia, and type 1 diabetes. Record review of Resident #1's physician orders revealed an order for Code status: DNR dated [DATE] placed into the electronic medical record by LVN A. The physician order was not signed by the NP or physician. Record review of Resident #1's baseline care plan dated [DATE] revealed Do Not Resuscitate Status with interventions which included: In the event of cardiac or respiratory arrest, do not perform cardio-pulmonary resuscitation (CPR) and Please ensure that I (Resident #1) have a completed signed Texas Out of Hospital Do Not Resuscitate form filed on my chart along with a signed facility physician order form. Record review of Resident #1's progress note dated [DATE] revealed: Resident #1 was found unresponsive. LVN B documented Resident #1 was not breathing, had no pulse and no vitals were able to be obtained. She also documented she listened to the heart and no heartbeat was heard, pupils were fixed and dilated, and Resident #1 had expired (died ). Record review of a facility document, titled Skilled Status Bulletin (admission demographics) (undated) for Resident #1 revealed there was no documentation of code status. Record review of Resident #1's electronic medical record revealed there was no signed out of hospital DNR form. Record review of the facilities self-report document (undated) revealed the Administrator self-reported to HHSC that on [DATE] he was made aware Resident #1 expired (died ) and CPR was not administered. The self-report indicated the facility records indicated Resident #1 was DNR status, but the family stated they wanted the resident full code. During an interview on [DATE] at 3:22 p.m. the Administrator stated the facility did not have a signed out of hospital DNR form for Resident #1. During an interview on [DATE] at 4:11 p.m. LVN A stated he was the admission nurse for Resident #1. LVN A stated he received a verbal report from staff at a local hospital prior to Resident #1's admission on [DATE]. He stated he completed an assessment of Resident #1 and reviewed orders with the NP that he placed in the electronic medical record. LVN A stated the nurse at the local hospital told him in the verbal report that Resident #1 was DNR. LVN A stated all paperwork including the DNR status was completed prior to admission. He stated he reviewed the paperwork but did not look for an out of hospital DNR. He stated the facility usually did not have access to DNR paperwork until the family brought it to the facility. He stated he assumed the family had already brought the paperwork in before Resident #1's admission. LVN A stated he went off the report from the local hospital and did not verify. He stated he did not know at the time who was responsible for verifying the code status. He stated he called the NP when Resident #1 was admitted . He stated he gave the NP Resident #1's diagnoses and code status based on what he knew and hospital records. LVN A stated he did not talk to the family. LVN A stated he now knew he should have verified by looking for the out of hospital DNR documentation. He stated he had received training on advanced directives and code status after the incident. He stated he was trained to look in the electronic medical record for the out of hospital DNR documentation or to look in the code book binder for the document. During an interview on [DATE] at 4:24 p.m., Resident #1's RP stated Resident #1 was on hospice and a DNR status in the hospital. She stated while he was in the hospital, Resident #1 woke up and stated he wanted to live. The RP stated while he was still in the hospital, she revoked hospice and revoked the DNR status. The RP stated Resident #1 was supposed to have been full code in the nursing facility. The RP stated after a staff member (unknown) called her and said he passed away, the RP asked if they had tried to resuscitate Resident #1. The RP stated the staff stated he was DNR. The RP stated she asked to see the DNR paperwork, and the facility had not been able to provide it. The RP stated she did not sign any documents for the facility. During an interview on [DATE] at 4:56 p.m., the Admissions Coordinator stated his job responsibilities included reviewing a hospital patient to see if they were an appropriate resident for the facility. He stated he reviewed hospital documentation and talked to the family. The Admissions Coordinator stated his understanding of Resident #1's code status was the family wanted to pursue skilled nursing services at the facility and he would be full code status. He stated the family had declined a DNR status. The Admissions Coordinator stated he did not communicate directly with the Admissions nurse at the facility or to staff taking care of the resident. He stated he uploaded admission documents in the computer, but code status was not an item listed on the admission paperwork. The Admissions Coordinator stated his job duties did not included obtaining out of hospital DNRs. The Admissions Coordinator stated the facility nurses should look for the out of hospital DNR documentation if they cared about their license. He stated sometimes the family would have a change of heart about the DNR status. He stated the staff should verify with family the correct DNR status. The Admissions Coordinator stated the SW usually verified with family the DNR status within 48 hours of admission, even if there was an out of hospital DNR on file. He stated without an out of hospital DNR signed the patient (resident) would automatically be a full code status. The Admissions Coordinator stated it was important for staff to verify out of hospital DNR documents were in place so that the facility was honoring the wishes of the family and the resident. During an interview on [DATE] at 5:18 p.m. the SW stated Resident #1 was admitted on Saturday ([DATE]). She stated he was not listed as a pending admission on Friday. The SW stated by the time she got to the facility on Monday ([DATE]) he had already passed away. The SW stated she reviewed some of Resident #1's documentation from the hospital. She stated there was conflicting information documented in the hospital records. She stated she had not had the opportunity to speak with the family. She stated she did not see an out of hospital DNR in the paperwork. She stated for that reason Resident #1 should have been full code status. She stated she would expect nursing staff to perform CPR and other life saving measures for any change of condition that required life saving measures. She stated an accurate code status was important to ensure the facility was honoring the persons wishes. The SW stated since the incident she had audited the residents' medical records for DNR accuracy. She stated she spoke with families and updated a few records. She stated she had also participated in in-service training provided by the facility. During an interview on [DATE] at 11:02 a.m., LVN B stated she worked night shift on [DATE]-[DATE]. She stated Resident #1 had been up watching TV for a portion of the night. She stated he did not have any noticeable change of condition. She stated she rounded and checked on him multiple times during the night. LVN B stated at approximately 5:00 a.m. Resident #1 was sleeping and did not appear to be in any distress. She stated at approximately 5:20 a.m. she returned to Resident #1's room and saw the resident lying there with his eyes open. She stated she called his name a couple of times, and he did not respond. LVN B stated she performed a sternal rub (elicits pain by firmly rubbing the chest) and got no response. She stated she checked Resident #1's pulse on his wrist and neck and listened with a stethoscope to his chest. She stated Resident #1 did not have a heartbeat or breath sounds. She stated at that point she knew Resident #1 had expired. She stated she did not attempt CPR because on the computer (electronic medical record) it indicated Resident #1 was a DNR status. LVN B stated a DNR status was documented on Resident #1 face sheet, profile, and physician orders. LVN B stated she had been trained to look for an out of hospital DNR, but it all happened so fast that she looked at the computer. LVN B stated she first became aware Resident #1 did not have a signed DNR when family came in and asked what Resident #1's code status was. She stated she told them he was a DNR, and the family said he was supposed to have been full code. LVN B stated at that point she started looking for the DNR documentation and did not see one. During an interview on [DATE] at 11:55 a.m., the DON stated on [DATE] at 5:15 a.m., LVN B called her and said Resident #1 had passed (expired). The DON stated she asked LVN B what Resident #1's code status was since he was a new admission. The DON stated LVN B stated Resident #1 was a DNR. The DON stated LVN B stated she saw the actual out of hospital DNR form in the computer. The DON stated LVN B also confirmed Resident #1 had a physician's order for a DNR status which was put in the electronic medical record by LVN A and was signed by the NP. The DON stated when she arrived at the facility on [DATE] after speaking with the family she reviewed Resident #1's medical record. She stated she could not find the out of hospital DNR document. The DON stated at that point the facility self-reported the incident to HHSC. The DON stated staff had been trained to take report from the hospital, go through paperwork and see what there and then go from there for code status. The DON stated during the week, the facility management checked code status but Resident #1 came in on the weekend. The DON stated Resident #1's hospital record said the family did not want CPR in the hospital. She stated to ensure an appropriate DNR status at the facility, they needed an out of hospital DNR signed by the resident or family and the physician. The DON stated the SW was responsible for an out of hospital DNR during the week. The DON stated LVN A, the admitting nurse was responsible for ensuring the resident had a signed out of hospital DNR for Resident #1. The DON stated LVN A stated he called the NP and got an order for DNR status. The DON stated she had questions. She did not know how LVN A got an order without a signed out of hospital DNR. The DON stated the care plan should reflect accurate code status. The DON stated to correct the situation the facility identified how they were going to verify DNR status and had put policies in place. She stated the Weekend Supervisor will now be responsible for checking/verifying code status and are required to facetime management with the document to verify. The DON stated she had 18 licensed nurses on staff. She stated 14 of them had completed in-service training on the policy, how to identify code status and abuse/neglect. She stated the remaining 4 staff would have to complete in-service training before they could work again. The DON stated the SW and Admissions Coordinator had also been educated on the process and had completed the training. She stated the facility completed a full sweep audit of all medical records for out of hospital documentation which was completed on [DATE]. The DON stated the facility also held a QAPI meeting with the Medical Director on [DATE]. During an interview on [DATE] at 12:18 p.m., the NP stated she did receive a call from a staff member about Resident #1's admission. She stated she did not remember the date or time of the call. The NP stated she reviewed with the staff why the resident came to the facility. She stated she did not give an order for code status. The NP stated residents come from the hospital as full code status unless they had a out of hospital DNR. The NP stated the physician group typically reviewed with the resident code status in person. The NP stated she had not signed any orders for Resident #1. During an interview on [DATE] at 12:34 p.m., the Administrator stated on Monday, [DATE] the facility had the processes in place to verify code status but those process did not occur for Resident #1. The Administrator stated on [DATE] at approximately 5:,d+[DATE]:30 a.m. he received a call from LVN B notifying him that Resident #1 had passed (expired) and there was a DNR (document). The Administrator stated when he arrived at the facility the SW informed him she could not locate the DNR (document). He stated he also looked and could not find one. He stated he took the following steps after learning there was no DNR document for Resident #1: the Administrator stated he discussed with the DON and called in a self-report to HHSC. He stated the facility immediately conducted a full audit of out of hospital DNR's in the code binders and verified the DNR's were in place. He stated they also reviewed the care plans for the residents. The Administrator stated he started in-servicing nursing on code status. He stated to ensure competency he gave the in-service again a day later and added a post test to ensure competency. The Administrator stated he notified Resident #1's physician and the Medical Director. The Administrator stated they held a QAPI meeting with the Medical Director in which corporate regional staff also attended. The Administrator stated multiple people in management were part of the corrective action to ensure nothing got missed. He stated the Admissions Coordinator, the SW, LVN A and LVN B had also received 1 on 1 training in addition to the in-service. RR of a facility document titled Incident Investigation and Follow up- Code Status dated [DATE] revealed: -Resident affected: All residents with a code status that do not reflect the resident or responsible parties wishes have the potential to be affected. -The failure is as follows: The facility allegedly failed to follow policy by having a resident's code status that did not reflect the resident or responsible parties wishes. -In-servicing/education provided in response: 1. Facility policy on code status. Inservice's began on [DATE] and were completed with current nursing staff on [DATE]. All employees currently on shift will pass a post-test of 5 questions pertaining to the policy to demonstrate competency/understanding and a required grade of 100%. If they fail, they will be immediately re-educated and required to retake the post-test to achieve 100%. All other nursing staff not currently on shift will be in-serviced before taking any assignment in the facility. The nurse educations will be in-serviced by the DON on the code status policy and then the DON/RN and both ADON and Treatment Nurse will educate the nursing staff on the code status policy. All new hires that are nurses will receive training on the same topics during new employee orientation and prior to providing resident care. -A QAPI meeting was held on [DATE] to review the allegations surrounding the alleged incident and the plan moving forward related to the Incident Investigation and Follow-up. -The Medical Director was notified of alleged incident on [DATE]. Monitoring: -All new admits will have admissions orders reviewed with a specific focus on code status to ensure appropriate wishes have been honored. If the new admits are undecided, they will be educated that until a decision has been made to be an OOH DNR and a fully executed OOH DNR is obtained, they understand they will remain as a full code. Preventing Reoccurrence: -The DON, ADON, MDS nurse, Treatment Nurse or Weekend RN Supervisor will review the 24-hour report promulgated by PCC daily to review new admissions to ensure the code status of new admits are entered into PCC correct, reflect the resident or RP's wishes and if a DNR have a proper executed OOH DNR uploaded to PCC (Point Click Care). Record review of an Ad Hoc QAPI Code Status document dated [DATE] revealed: Problem: Resident #1 who was a full code was found unresponsive without a palpable pulse and nursing staff failed to perform CPR. Interventions: -Resident Code Status book and facility electronic medical records were reviewed and updated as needed to ensure all code status were properly identified and honored. -Facility nursing staff were in-serviced regarding code status, resident rights, and where the Advanced Directive books were located. Nurses also in-serviced how to look at the order for a DNR, how to look under the document tab for the OOH DNR. -RN Supervisor or designee on weekend to check and implement all DNR status. -Code status will be reviewed and updated as needed every Monday -Pending physician signature, telephone order may be obtained for code status -Went over the facility policy regarding Advanced Directives and DNR policy with our Medical Director -Had an Ad Hoc QAPI meeting regarding Code Status with Medical Director, DON, Administrator, and members of Regional Support Team Implementation of Changes: Audit of all code status to ensure residents code status have the proper paperwork in place with DNR (written order, paperwork, on PCC in the resident's profile under code status, DNR in pace). Monitoring: -Monitor all new admissions advanced directives every Monday and as needed -Weekend admission advanced directives will be reviewed by RN supervisor or designee -Code status books will be reviewed and updated at nurse's station. This document was signed by the Administrator, DON, Medical Director, Regional Director of Operations, and additional regional staff on [DATE]. Record review of Code Status Binders on all 3 hallways revealed all out of hospital DNR documents had appropriate signatures of resident/family and physician. Record review of an in-service training, titled Resident Rights dated [DATE] with attached Resident Rights policy and Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy revealed 19 licensed staff had signed the training document included the Admission Coordinator, LVN A and LVN B. Record review of an in-service training, titled Code Status dated [DATE] revealed 22 licensed staff including the DON had received training which included a review of the Full Code status policy, DNR policy and Advanced Directives and Advance Care Planning Procedures policy. Record review of 1:1 in-service training record revealed LVN A, LVN B and the Admission Coordinator completed training on abuse/neglect prevention policy, resident rights and DNR/Full Code given by the DON on [DATE]. During interviews on [DATE] licensed staff including 2 RN's and 5 LVN's verified they had received in-service training in out of hospital DNR's, code status, and abuse/neglect. During an interview on [DATE] the Medical Director stated he had been notified of the incident involving Resident #1. He stated he attended a QA meeting held by the facility. He stated during the QA meeting along with the Administrator, DON and Regional Director. The Medical Director stated he recommended amending the policy and addressing full code status since the facility did not have a policy for full code. Record review of a facility policy titled, Full Code Status (undated) revealed: 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses full code, the nurse enters a full code order into PCC. Record review of a facility policy titled DNR Policy (undated) revealed: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has two valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgment purposes and is not an approval for the DNR. Record review of a facility policy titled Advanced Directives and Advance Care Planning Procedure (undated) revealed: Prior to Admission: 1. Assessment of the individual prior to admission to the nursing facility to determine if the individual has already completed c. out of hospital Do Not Resuscitate (OOH DNR). 2. If the above documents have already been completed, they will be copied and forwarded to b. Charge nurse for placement on resident's medical chart. Upon Admission: 1. The admission charge nurse will obtain an order for code status. In the absence of an OOH DNR, the nurse will obtain a telephone order for Full Code Status .If OOH DNR is present, charge nurse will obtain a telephone order for Do Not Resuscitate . On [DATE] at 4:07 p.m. the Administrator, DON, and corporate staff were informed of the IJ. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began.

Based on observations, interviews, and record reviews the facility failed to ensure the rights of residents 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 5 residents reviewed (Resident #17) for accommodation of orthotic support devices, in that: The facility failed to report to Resident #17's physician's the inability to fulfill Resident #17's order for a back brace, ordered by a neurologist [a medical doctor who specializes in diagnosing and treating diseases of the brain, spinal cord, and nerves]. Resident #17 had a compression fracture of vertebra and kyphosis. Resident #17had spinal surgery and an order for a back brace from November 2022 that she did not receive. Resident revealed she was in [NAME] pain. This failure could place residents at risk for denial of their rights to have reasonable accommodations. The findings included: A record review of Resident #17's admission record, dated 03/01/2023, revealed an admitted [DATE], with diagnoses which included wedge compression fracture of T11-T12 vertebra [thoracic area of the spine], age-related osteoporosis [a silent disease that weakens your bones and makes them break easily], spinal stenosis [can cause pressure on your spinal cord or the nerves that go from your spinal cord to your muscles], lumbar region with neurogenic claudication [spinal nerves get compressed in the lower spine, causing intermittent leg pain], and kyphosis [a spinal disorder in which an excessive curve of the spine results in an abnormal rounding of the upper back]. A record review of Resident #17's care plan dated 03/01/2023, revealed, The Resident has osteoporosis . the Resident has pain related to vertebrae compression fractures and muscle pain .interventions; . monitor/document report as needed signs and symptoms or complications related to osteoporosis: acute fracture, compression fractures, loss of height, kyphosis, pian, especially back pain. A record review of Resident #17's quarterly MDS, dated [DATE], revealed Resident #17 was an [AGE] year-old female with needs for assistance with activities of daily life complicated by back pain, spine curvature, and porous bones. Resident #17's assessment revealed a BIMS of 14 out of 15 which indicated no mental cognition impairment. Resident #17 could be understood and could understand others. A record review of Resident #17's medical records revealed a progress note, dated 10/7/2023, authored by Resident #17's neurosurgeon, Medical Doctor L, . this is an [AGE] year-old female with osteoporosis and T12, L2 compression fractures with ongoing axial low back pain issues status post kyphoplasty [after a surgery to fix broken vertebrae caused by compression fractures, which can cause pain and deformity] at T12 and L2, 3 weeks ago. Patient no longer has the back brace. We will refer her to orthotics clinic for a TLSO [NAME] extension brace [a unique tool for limiting motion of the spine and reducing pressure on its tissues]. Brace should be worn at all times. A record review of Resident #17's medical records revealed an Encounter Summary, dated 10/12/2022, encounter type, after this visit, October 7th 2022 .reason for referral . orthotics, diagnosis, compression fracture of T12 vertebrae . comments: needs new TLSO [NAME] extension brace for T12 compression fracture with worsening kyphosis status post kyphoplasty . electronically signed by [Medical Doctor L]. During an observation and interview on 02/28/2023 at 02:00 PM, Resident #17 presented in her wheelchair self-ambulating to the dining room. Resident #17 was asked the question, are your needs being met here at the facility?, Resident #17 replied her needs were not being met. Resident #17 stated she had a painful curved spine, had recent spine surgery, and had a need for a back brace, which the neurosurgeon [Medical Doctor L] ordered for her. Resident #17 stated she had a back brace prior to her admission to the facility but somehow it has gone missing. Resident #17 stated she had been to the neurosurgeon [Medical Doctor L] in November [2022] and was prescribed a new back brace but has not received the brace. Resident #17 stated she has complained and asked for a status on the back brace often and has been told the hold-up is insurance paperwork. Resident #17 stated she has no money to pay for the back brace and the facility has reported to her they are attempting to have the neurosurgeon doctor's office fill out paperwork to have Medicaid pay for the brace. Resident stated she has been waiting for the brace since November of 2022. She stated she had had chronic pain and wishes to have the back brace, so my spine will not get worse. Resident #1 stated she has been strong and has not asked for much pain medication and stated she manages her pain by finding a comfortable position while sitting and or laying and only moves when she needs to due to the pain. Resident #17 stated the situation made her feel, angry and neglected. During an interview on 02/28/2023 at 10:00 AM, LVN E stated Resident #17 needed a back brace. LVN E stated Resident #17 has seen the neurosurgeon [Medical Doctor L] and has been fitted for the [TLSO] back brace, however the brace will not be supplied by the shop until the neurosurgeon's office has had the doctor sign and return 2 documents. LVN E stated she, the ADON, and the DON, have been working with the doctor's office since December [2022] and have not been able to have the doctor's office return the 2 documents needed to pay for the brace. LVN E stated Resident #17's attending physician at the facility is Medical Doctor N and is seen by Medical Doctor N's Nurse Practitioner O. LVN E stated she had not given Medical Director N nor Nurse Practitioner O a report about Resident #17 needed a back brace and did not have one. LVN E stated they know [Medical Director N nor Nurse Practitioner O] because they can read the notes and the Resident [#17] can tell them. A record review of Resident #17's medical record revealed a progress note authored by LVN E, dated 01/31/2021, detailing the most recent attempted call to neurosurgeon Medical Doctor L. The note revealed, Call placed to [name] orthotics clinic to follow up on [Resident #17's] TLSO Brace. Spoke to [M orthotics clinic personnel] who stated they have now sent SWO and title 19 forms to [Medical Doctor L's] office three times, since my last call. Forms have not been returned and the orthotics has called and emailed [Medical Doctor L] regarding the forms several times. Last attempt was 01/27/2023. Writer called [Medical Doctor L's] office to follow-up on forms. Message left for Dr. that Resident [#17] does not have brace and cannot attend his desired follow-up with brace due to forms not being faxed back to orthotics clinic. Expecting return phone call from [Medical Doctor L]. will continue to follow up. During an interview on 02/28/2023 at 10:20 AM, ADON D stated she was aware of Resident #17's need of a back brace and stated she and her staff have been attempting to have the appropriate paperwork supplied to the orthotics shop for payment of Resident #17 back brace. ADON D stated the facility and Resident #17 were waiting for the doctor's office [Medical Doctor L] to fill out the paper-work for Resident #17. ADON D stated she had not given Medical Director N nor Nurse Practitioner O a report about Resident #17 needed a back brace and did not have one. ADON D stated she believed everyone knew about Resident #17 back brace situation. ADON D stated there were many progress notes in Resident #17's chart. During an interview on 03/01/2023 at 11:10 AM, the SW stated she was aware Resident #17 needed a back brace but was not able to receive the back brace for unknown reasons. The SW stated she was not asked to intervene and advocate for Resident #17 by anyone at the facility. The SW stated she understood it was being resolved by the nursing staff. The surveyor asked the SW what could she have done if someone had asked her to intervene and advocate for Resident #17? The SW stated, Maybe, I would have called the doctor or doctors. During an interview on 03/01/2023 at 04:48 PM the Medical Director stated he was the medical Director for the facility and Resident #17. Medical Director stated Medical Doctor N was a peer and attended to Resident #17. The Medical Director stated no one has reported to him Resident #17 needed a back brace. The Medical Director stated Resident #17 had a kyphosis diagnosis and understood she was being seen by a neurosurgeon but did not know about the neurosurgeon's order for a back brace and the lack of the brace for Resident #17. The Medical Director stated he could not state what effect the lack of the brace could have on Resident #17 and Resident #17 should be re-assessed by the neurosurgeon due to the prolonged time Resident #17 has been without the brace. When asked if the facility had given the Medical Director a report what could you have done? The Medical Director replied, well, there are many interventions .but I could have intervened by calling the neurosurgeon [Medical Doctor L] .a physician-to-physician call surveyor asked, an intervention. The Medical Doctor replied, Yes. During an interview on 03/01/2023 at 05:48 PM Nurse Practitioner O stated no one has reported to him, nor Medical Doctor N, Resident #17 needed a back brace. NP O stated Resident #17 had a kyphosis diagnosis and understood she was being seen by a neurosurgeon but did not know about the neurosurgeon's order for a back brace and the lack of the brace for Resident #17. Nurse Practitioner O could not state what effect the lack of the brace could have on Resident #17 and Resident #17 should be re-assessed due to the prolonged time Resident #17 has been without the brace. Nurse Practitioner O stated he would give Medical Doctor N a report. During an interview on 03/02/2023 at 10:05 AM the DON stated she was aware and very involved in the situation of Resident #17's back brace. The DON stated she and her staff have been trying to work with Medical Doctor L's office to secure the 2 documents needed to secure Resident #17 back brace and have had no success with Medical Doctor L's office. The DON stated, we have done all we could, they have not returned the documents needed. When asked if the Medical Director, Resident #17's attending Medical Doctor N, or Nurse Practitioner O have been given a report the DON stated, yes they know, when asked for documentation to support the medical doctors knew; the DON stated there was not any documentation other than the progress notes which detail all the requests for the brace and/or paper-work needed from the doctor's office [Medical Doctor L's office]. When the DON was asked who was responsible for the failure to secure Resident #17's back brace; the DON replied, the doctor's office [Medical Doctor L's office] who would not supply the signed forms needed by the orthotics clinic. When the DON was asked how this failure could affect Resident #17; the DON stated the surveyor could ask the doctor. An accommodation of needs policy regarding Resident #17's back brace orthotics equipment was requested from the DON; the DON replied she did not believe there would be a specific policy for the situation due to the facility was not responsible to pay for items such as back braces. A record review of the facility's personal property policy did not adequately address the facility's response to Resident #17's reasonable accommodation of need for a back brace.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for adequate supervision. CNA A failed to supervise Resident #1 while she was in bed resulting in Resident #1 falling off the bed resulting in fractures of the right tibia (the inner large bone between the ankle and knee) and fibula (the outer smaller bone between the ankle and knee) between the middle and distal thirds. Additional fractures were noted by the ER to the proximal phalanx (bone in the toe) of the fifth toe and to the next of the second and third metatarsals (bones of the foot). This failure could result in residents experiencing accidents, injuries and/or a diminished quality of life. The findings included: Record review of Resident #1's face sheet dated 06/02/22, and EMR (electronic medical record) revealed, the resident was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Alzheimer's disease (primary), dementia, age related [CONDITION(S)] (brittle and fragile bones), muscular degeneration, and muscle wasting with atrophy. Record review of Resident #1's Annual MDS , dated 4/20/22, revealed: o BIMS Score was 0 indicating severe impairment. o ADLs B/B incontinent of both. Transfer extensive 2 person. Bed Mobility (Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) extensive 2 person assistance . Dressing: total dependence with one person assistance. ROM upper extremity-impairment on one side; lower extremity-impairment on both sides. Record review of Resident #1's Care Plan, undated, revealed: the resident required extensive assistance for ADLs. For the ADL of dressing, the intervention read, DRESSING: The resident requires extensive/total assistance by staff to dress. Dress resident in their own clothes. Allow resident to participate with choice of clothes as able. Allow sufficient time for dressing and undressing. The care plan also addressed the resident's risk for falls and her diagnosis of [CONDITION(S)]. Record review of facility's initial investigation report started 5/31/22 revealed: The incident occurred on 5/30/22 at 7:00 AM. Description of Incident: 5/30/(22): CNA A delivering care (dressing) turned to get clothes from closet & resident slipped from bed. CNA A attempted to catch & protect torso but contracted feet hit floor. Accident, observed, did not report. 5/31(22) Ombudsman called to discuss neglect allegation. Reported a neglect allegation Written statement completed by Administrator of follow-up interview with CNA A, undated, revealed: CNA A raised Resident #1's bed, he turned to get clothes from the closet (and) heard her vocalize 'aye, aye' .she turned herself and started to fall from the bed. I reached for her (and) caught her by the torso & head, lowered her (to) the floor .her lower extremities hit the floor .called (CNA D) & (LVN F) for help . Record review of Resident #1's Nurse Note, dated 5/30/22, authored by LVN F, read: Assessment: Resident was receiving morning ADLs by can (A). When can (A) went to her closet to get her belongings resident slid out of the bed due to her contractures and being on a reduced pressure air mattress and not having the proper body mechanics to prevent from leaning towards gravity. Resident contacted the ground with both feet CNA was able to assist resident to floor without injuring upper body and preventing her from further injuries from landing on the floor. Nurse was then called to assess resident and noticed 4x abrasions to the left foot and above the ankle on the right leg had [CONDITION(S)] to the site. Resident was assisted back in bed by staff x2 for further assessment and scrap/abrasion was noted to the back of her left elbow. Resident is unable to verbalize what happen, but nurse noticed facial grimacing. MD called and gave order to send to (hospital) for further evaluation, family RP . was notified and stated she will meet her at hospital, and . ambulance notified and gave ETA (estimated time of arrival) of 30 minutes. DON and ADON notified. Will continue to monitor resident. Record review of resident #1's ER record, dated 5/30/22, revealed: Chief Complaint: Swelling and pain to the right lower calf. She was seen and evaluated by (MD C) and a pathologic fracture of the right tibia and fibula were noted between the middle and distal thirds. Additional fractures were noted to the proximal phalanx of the fifth toe and to the next of the second and third metatarsals. The left foot has a decubitus ulcer stage IV, down to the bone, treated with daily wound care with [MEDICATION(S)] with limited success. Her contractures make her decubitus potential extremely high and turning on in bed, no doubt carries a risk of a fracture again, but fall out of bed remains a mystery, unwitnessed . Record review of Resident #1's Fall Risk Score, dated 5/30/22, revealed a score of 10 (high risk for falls). [only fall risk assessment in the Resident's medical record. No mention as to what made the resident a risk for falls except that resident was bedbound and had contractures of both legs]. Record review of Resident #1's ADL sheet for the Month of May 2022 revealed, she was a one person assist for dressing and two persons for mechanical lift. On 5/30/22 there was no mechanical lift documented in the morning shift (6 AM -2 PM); no documentation for bed mobility that included dressing; coded as 97 meaning not applicable. Record review of Resident #1's incident report revealed no falls in the past 90 days 9 ( March, April, May 2022). Record review of Nursing Staffing sheet for 5/30/22 revealed: (morning shift 6AM-2PM) 1 RN, 3 LVN, CNA 9, Medication Aide 2; total nursing staffing of 15. During a confidential interview on 6/2/22 at 9:00 AM, it was stated, the (Resident #1) experienced an injury, a fibula fracture, that might have happened from a forceful turn .the resident is contracted and bed bound and could not have fallen by herself .the family wanted the resident evaluated at the ER because of the injury to the resident's leg and right elbow .the resident is alert, not oriented and not verbal . [Location of confidential interview not disclosed by the surveyor]. Observation on 6/2/22 at 9:30 AM, Resident #1 was in a hospital bed, contracted in the right arm and both legs. The resident did not reveal bruises on the face, arms or legs. The resident had an inch skin tear to the right elbow that had healed. The resident's left foot revealed a pressure ulcer or wound. The resident was alert and not oriented; and could not answer any direct questions. During an interview on 6/22/22 at 9:37 AM, Resident #1's RP (was present in the hospital room with Resident #1) and revealed, she was concern about how the resident could had fallen given the resident was bedbound and had contractures of both legs. The RP felt the CNA A dropped the resident during a mechanical lift. During an interview on 6/2/22 at 12:15 PM, the Ombudsman stated, the resident (Resident #1) is bedbound and not mobile and has contractures; I saw her last week .she could not have fallen by herself . The Ombudsman revealed she did not express the latter concerns to the Administrator. During an interview on 6/2/22 at 2:00 PM, CNA A, stated, on 5/30/22 Resident #1 was his first resident and explained he would dress her. He had previously worked with the resident providing ADL services. The special training CNA A received was mechanical lift for the transfer of the resident. CNA A stated that only one person was needed to dress Resident #1 and two staff for transfer. He said he raised the bed up (provided no explanation for raising the bed) and then turned to select a dress then he heard her say, 'Aye Aye', she was off the bed and before she was flat on the bed. CNA A said he saw her feet off the bed and he went and pushed her back so that she would not fall. He said the feet were both dragging on the floor and might have hit the floor, and she had a contracted leg and one dressing to the right foot. There were no witnesses present. CNA said he called his co-worker (CNA D) and told her to call the nurse (LVN F ).LVN F assessed the resident then we dressed the resident on the bed He said the family and the DON were called and the doctor was called. He said Resident #1 cannot move, but she can move her cradle feet. CNA A stated he did not transfer her and does not know how she was injured. CNA A stated he was competent on transfers and mechanical lifts and could not explain what happened. He said maybe the air mattress swallowed her and she turned and hit her legs and she fell on the floor only the feet. He said he held half her body, the feet hit the floor. Record review of CNA A's competency checklist, dated, 4/10/22, revealed, CNA A was checked for mechanical lift and gait belt with demonstration signed by LVN H. [No disciplinary action was taken against CNA A except providing him with more education.] [The competency checklist did not cover dressing of residents]. During a telephone interview on 6/2/22 at 3:47 PM, CNA D, revealed, there was no mechanical lift in the room and CNA A was alone with the resident. Resident #1 was on the floor. During an interview on 6/2/22 at 4:00 PM, LVN F stated, on 5/30/22 in the morning around 6:40 PM, CNA D called me to help CNA A because Resident #1 was injured .when I entered the resident room she was totally on the floor .I assessed her and asked (CNA A) what happened .he said he was getting her a dress and heard her groaning for help and he held her upper body and he assisted her to the floor because of her contractures .the resident was on an air mattress .she was contracted and cannot pull back from falling .she might have slid form the mattress .she got injured by hitting the floor .he was only able to save her head and torso from hitting the floor .he lost sight of her .he was educated to first get her belongings or get a second person in the room so as to maintain 360 degree visibility .I notified the MD and RP and then the DON. The MD told me to send her out based on the injuries observed, the injuries observed were: right leg above ankle had [CONDITION(S)] and her left foot had abrasions to it, the resident was non-verbal and had a scrape to an elbow .we immediately started an in-service on fall prevention . During an interview on 6/2/22 at 4:21 PM, the DON revealed, on 5/30/22, she was informed by LNV (F) through a call that resident (#1) had fallen from the bed and (CNA A) while he went to get her a dress and heard her falling and the resident's foot was dangling ; and he caught her torso and head and lowered to the floor and never left her alone. The resident was on the floor and he called another aide to get a nurse. DON stated, I cannot say why he lost sight of her .the usual procedure was to get the resident's clothing first .we started training on fall prevention .she could not move .we are about 80 %; on the training on fall prevention which started on 5/31/22 .the injury was known and it was a witnessed fall .and it was an accident .we have reported it to HHS because the Ombudsman expressed a concern . [The incident was reported on 6/1/22] During an interview on 6/2/22 at 4:40 PM, the Administrator revealed, he reported the incident to HHS because the Ombudsman had expressed a concern on 5/31/22 about Resident #1 falling The Administrator stated, it was an unfortunate accident .he (CNA A) turned to get a dress and took his eyes from her (Resident #1) and the accident occurred .gravity pulled her from the air mattress .resident might have re-positioned herself based on the CNA (A) statement .although she is contracted . During a telephone interview on 6/3/22 at 9:00AM, MD G revealed, Resident #1 was elderly and fragile and contracted. The MD stated, I cannot explain how she had a fall given she was bedbound, contracted, and basically non-mobile . Record review of facility's Falls and Fall Risk, Managing policy, dated revised April 2022) read, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications of falling . Record review of in-service sign in-sheet on Fall Prevention, dated 6/1/22, conducted by DON revealed ( % of the nursing staff completed the training at time of exit (6/2/22). Total nursing staff was 41.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 sampled residents (Resident #8 and #24) in that: A. Resident #8 was assessed on 9/16/10 to need to wear a protective apron during meals to protect against injury from hot liquids. On 10/3/10 Resident #8 was not wearing the protective apron and spilled coffee onto her lap, sustaining a second degree burn. B. Resident #24 had a change in condition on 9/28/10 requiring hospitalization , due to increasing sleepiness, dementia, and altered mental status. Resident #24 was readmitted to the facility on [DATE], however the facility failed to complete an updated Hot Liquid Assessment for Resident #24. On 11/5/10 Resident #24 was not wearing a protective apron and spilled coffee onto her lap. These failures represented an Immediate Jeopardy (IJ) situation. While the IJ was removed on 11/8/10 at 10:15 A.M., the facility remained out of compliance at a scope of Isolated and a severity level of No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy. This deficient practice could affect 20 residents identified as being at risk for hot liquid/food burns and could result in burns and injuries. The findings were: 1. Resident # 8 Review of the medical face sheet dated 4/27/10 revealed that Resident #8 was admitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a document titled "Safety Evaluation Tool for Hot Liquids/Foods" dated 9/16/10 revealed that Resident #8 was identified, with an "x" marked in each box, to have: (1) hand tremors and (2) hands shake or tremble. Further review of the document revealed instructions indicating that "if one or more boxes are checked, the resident should have an additional protective covering such as an apron applied during mealtimes to assist in preventing the potential for a burn." Review of a document titled "Incident/Accident Report" dated 10/3/10 revealed that at 9:00 A.M. Resident #8 "stated to staff that she spilled her coffee on her lap @ breakfast. States she took the lid off mug & it tipped over onto her lap." Further review revealed "L outer thigh 7 x 18 cm with 3 lg & 6 sm blisters, L top thigh 3 x 10 cm with 3 lg blisters, L mid abd 3 x 3 cm blister, L outer abd 3 x 7 cm blisters." Further review revealed that the Resident was treated with Silvadene (topical antibiotic used for second and third degree burns) and the areas were covered with gauze. There was no indication that the Resident had an apron on this date. Review of a Nurse's Note dated 10/3/10 at 9:00 A.M. entered by the Treatment Nurse, LVN P, revealed that "Resident spilled coffee on L thigh during breakfast area of redness noted L upper thigh resident complained of pain. Silvadene ordered. (RP and physician were notified) Will monitor per facility protocol." Review of a Nurse's Notes entered by the DON dated 10/4/10 at 3:00 P.M. revealed that "Silvadene was ordered when physician was notified. Resident re-assessed with [REDACTED]. At 1415 (2:15 P.M.) treatment nurse reassessed the resident's skin. The resident continued with a red area on top of L thigh. Then when staff changing resident for bed around 2045 (8:45 P.M.), LVN noted blisters, 2 on abdomen 1 on top of thigh and 1 on outer thigh. Skin assessed with [REDACTED]. Continues with Silvadene treatment." Review of a Physician's Progress Note entered by FNP J dated 10/6/10 revealed that "Pt with incident of Burn to (L) Thigh spilled coffee. Pt has burn blisters to (L) upper thigh. Clean with NS apply Silvadine BID and cover. Keflex 500 mg (antibiotic) PO QID x 1 week." Interview and observation of Resident #8 on 11/3/10 at 2:51 P.M. revealed that she was served coffee in a mug with a lid. She stated that she took the lid off and the coffee spilled onto her shirt and eventually spilled onto her leg and thigh. Resident #8 stated that the incident took place in the dining room during breakfast. She stated that a nurse assessed her and applied cream to the area on the same day of the incident. Resident #8 stated that she was provided with a protective apron about 1 to 2 weeks ago. She stated that she did not use a protective apron and was not offered one prior the incident. During the interview the resident was observed to be shaking especially at her right arm and hand. Interview on 11/4/10 at 11:47 A.M. with the DON and Unit Manager, LVN B, revealed that Resident #8 was diagnosed with [REDACTED]. LVN B read through the pharmacy reviews and stated that Resident #8 had been treated for [REDACTED]. LVN B stated that she assessed Resident #8 on 9/16/10 and determined that she met the criteria to use a protective apron at meals. LVN B stated that Resident #8 was not wearing the protective apron on 10/3/10 and commented, "It's my fault, I didn't do it." The DON stated that Resident #8 did not start wearing the hot apron until 10/3/10, after the Resident was burned and reassessed for the use of the protective apron. The DON and LVN B stated that the Resident's hands would shake especially her right hand more so when agitated. LVN B stated that she noted that her condition had worsened in the last month. During an interview with the DON on 11/5/10 at 9:00 A.M. she stated she had assessed Resident #8's burn on 10/4/10 in the morning. She stated that Resident #8 was observed to have had blistering in the abdominal and left groin areas. She stated that Resident #8 had spilt coffee on her on 10/3/10 and had not called for help. She further stated she had determined Resident #8 had polyester pants on the day of the burn and stated she felt that it had added to the severity of the burn. The DON stated she did not know why Resident #8 was not wearing a hot liquid apron on 10/3/10 and stated that 11/4/10 was the first time she'd seen the Hot Liquid Assessment for Resident #8 (dated 9/16/10). During an interview with FNP J on 11/5/10 at 11:55 A.M. she stated the facility had notified her of Resident #8's burn on 10/3/10. She further stated Resident #8's burn had started out as a First Degree burn with redness and a treatment of [REDACTED]. She then stated she was informed the next day that the burn had progressed to a second degree burn with blistering. FNP J further stated the burn later became infected and was healing slowly, due to Resident #8's [DIAGNOSES REDACTED]. 2. Resident #24 Observation of Resident #24 in the dining room at 8:00 a.m. on 11/5/10 revealed that she was sleeping at the table. Her breakfast plate was in front of her. Her left hand was on the table and next to a coffee mug turned on its side. There was coffee spilled onto her breakfast plate and on the table. Unit Manager M confirmed this and ordered a new breakfast tray for Resident #24. Resident #24 was not wearing a protective apron at this time. The surveyor took the temperatures of the coffee in the urn in the dining room at 9:50 A.M. on 11/5/10 and found it to be 145.2 degrees Fahrenheit (F). The surveyor also took the temperature of the coffee in the kitchen at this time and found it to be 151.9 degrees F. During an interview with the DON on 11/5/10 at 11:11 A.M. she stated in August 2010 all residents had been assessed for hot liquid aprons. She stated if a resident had a change of condition or decline they would be reassessed at that time. The DON stated the nurse that performed the Hot Liquid Assessment would be the person who updated the dining room protective device resident list. When asked if residents were reevaluated after readmission, she stated it would only be done if there had been a change in how they ate and the assessment form was not part of their readmission paperwork. When how long the assessment process would take after a resident was admitted , she stated she would hope the nurses would have it completed immediately and used good judgment. She stated she trusted that the facility nurses would monitor residents day by day to evaluate whether it was an on-going problem for the residents. In an interview with LVN P at 12:30 p.m. on 11/5/10 regarding Resident #24's spilled coffee, she stated "We checked her (Resident #24) and didn't see anything indicating a burn. (Unit Manager M) was supposed to do another safety evaluation for hot liquids". In an interview with Unit Manager M at 12:35 p.m. on 11/5/10, she reported that she had watched Resident #24 at lunch and that there were no problems with her falling asleep or being unsafe with liquids/foods. Unit Manager M also reported that Resident #24 had not been falling asleep or showing signs of upper extremity weakness prior to the morning's coffee spill. However, Unit Manager M confirmed that Resident #24 was sleeping at breakfast. Review of FNP progress note dated 9/28/10 revealed that staff requested for the FNP to see Resident #24 secondary to her increasing sleepiness, dementia, and altered mental status. "Patient is delirious, confused, with hallucinations and trying to pull things from the air". Resident #24 was sent to the hospital as a result of this evaluation. History and physical dated 9/28/10 revealed that Resident #24 was admitted to the hospital with [REDACTED]. Facility admission/readmission summary dated 10/3/10 revealed that Resident #24 had [DIAGNOSES REDACTED]. She was assessed as requiring some assistance/cueing with eating; having short and long-term memory problems; having moderately impaired decision-making skills; being confused, disoriented, and hallucinating; requiring upper extremity support to rise from her chair; and having joint difficulties. A safety evaluation tool for hot liquids/foods form was not completed for Resident #24 at the time of her readmission on 10/3/10. The last safety evaluation tool for hot liquids/foods form found in Resident #24's chart was dated 8/28/10 and did not indicate an apron was required. Review of Resident #24's daily skilled nurse's notes revealed documentation on 10/4/10 of "falls asleep frequently during meals. Encouraged to wake frequently" and "eats well when awake", documentation on 10/24/10 of "appetite good - set up help required" and "diet taken fair with encouragement not to wrap plate with clothing bib", documentation on 10/28/10 of "verbal cues needed at meal times", and documentation on 10/29/10 of "does not eat well at meal times. Takes much encouragement to get resident to eat." Review of Resident #24's MDS assessment (dated 11/1/10) revealed that she had short and long-term memory problems, had severely impaired cognitive skills for daily decision making, needed limited/one-person physical assistance with eating, had dementia and depression, required a mechanically altered diet, was at risk for developing pressure ulcers, received antipsychotic/antidepressant medications, and participated in speech, occupational, and physical therapy. Review of Resident #24's care plan (not dated) revealed address of fall risk due to decline in mobility, increased weakness, disease progression, decreased cognition, and poor safety awareness; address of short and long-term memory problems, impaired decision making, and impaired cognitition with unawareness of physical and safety needs; address of arthritis with disturbed sleep; address of Seroquel (antipsychotic) need related to [DIAGNOSES REDACTED]. Review of the Safety Evaluation Tool for Hot liquids/foods for Resident #24, dated 11/5/10 (after the resident had spilled coffee onto her lap) and provided to the surveyor by Unit Manager M at 1:10 p.m. on 11/5/10, revealed no items checked under physical review and indicated "does not require apron". This evaluation was signed by Unit Manager M, LVN P, and RN Q. The Administrator was notified of the Immediate Jeopardy on 11/5/10 at 3:20 P.M. Observation of Resident #24 in the dining room at 8:00 a.m. on 11/6/10 revealed that she was sitting at the table with her eyes closed. She appeared to be falling asleep before the breakfast meal was served. Review of a facility policy titled, "Hot/Liquids &/or Foods" dated 5/2010" revealed under 7. "Residents who are at risk hot liquid/food burns due to physical or cognitive issues should have a safety evaluation completed and appropriate safety interventions (ex: apron, lid on cup, etc.) initiated. Based on the facility-provided list of residents required to wear protective aprons at meals, dated 11/4/10, there were 20 residents identified as being at risk for hot liquid/food burns. The facility submitted their Plan of Removal for the IJ on 11/8/10 at 8:00 A.M. The plan included: (a) Facility Nurses completed Hot Liquid Assessments for all residents and updated tray cards to reflect evaluations. DON in-serviced all nursing staff regarding the process of correctly completing the Hot Liquid Assessments. (b) Residents' names were added to the list posted in the dining room if they were assessed to need a protective apron (surveyors observed the list at the back of the dining room, out of public view). The Charge Nurse will monitor for compliance. (c) Residents will be assessed on-going upon admissions/readmissions/and based on input from care givers who notice changes in the resident. Caregivers will report changes to the Charge Nurse. (d) All staff were in-serviced on the Hot Liquid Assessment tool, dining room protective devices, and proper communication for change in ADL abilities. (e) Resident #24 was assessed by an RN and there were no signs or symptoms of a burn. Resident #24's physician was notified and the use of a protective apron was implemented. (f) Facility monitored each meal service over the weekend, 11/6/10 and 11/7/10. The Administrator/DON will perform random observations weekly for 4 weeks and report results to QAA Committee monthly for 3 months and as needed thereafter. (g) Facility will continue to monitor temperature of hot liquids (acceptable temperature range for hot liquids: 140-180 degrees F) and will take temperature of coffee and log the temperature prior to coffee being sent out to dining room. The plan was accepted and the IJ was removed on 11/8/10 at 10:15 A.M. when the survey team confirmed by observation, interview and record review that the measures listed above were being implemented.