HERITAGE HOUSE AT KELLER REHAB & NURSING

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for two (Residents #1 and#2) of four residents reviewed for elopement. <BR/>1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 09/25/23. <BR/>2. The facility failed to ensure Resident #2 was provided with adequate supervision to prevent him from eloping from the facility on 09/28/23. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 09/25/23 and ended on 09/30/23. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury. <BR/>Findings included:<BR/>1. Review of Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, non-Alzheimer's dementia, and cognitive communication deficit. Resident #1 had long and short-term memory impairment and a BIMS could not be completed due to his impaired cognition. <BR/>Review of Resident #1's care plan initiated on 08/04/23 revealed the resident wandered related to cognitive impairment and was at risk for elopement. Interventions included putting the resident on 1:1 (one-on-one supervision) while behaviors like seeking exit were noted. The care plan further reflected Resident #1 was able to self propel his wheelchair. <BR/>Review of Resident #1's elopement assessment dated [DATE] reflected the resident was at a high risk to elope and a care plan for elopement was indicated. <BR/>Review of the facility's Provider Investigation Report dated 09/25/23 reflected the following:<BR/>At 5:02am [on 09/25/23], when returning to the desk from down the 100 hall, [LVN A] heard the alarm sounding from the dining room door. She looked outside and around the door and didn't see anyone, so she immediately called for a code silver and staff completed a head count. At 5:06am, it was noted that [Resident #1] was not able to be located and a search ensued, including the interior and exterior of the facility, parking lots, bushes, etc. At 5:25am, the search was expanded by car to include the area directly surrounding the facility. [Resident #1] was noted at the gas station about half a block from the facility at approximately 5:30am, with 2 police officers, by [LVN A]. Resident was returned to the facility, and released to the nurse assigned to him, [LVN A] who completed a head to toe assessment and placed the resident on 1:1 staff supervision <BR/>Review of Resident #1's progress notes dated 09/25/23 completed by LVN B reflected the following:<BR/>At 5:00 [AM] code silver was initiated. Census was printed and a complete head count was done on all the resident [sic]. At 5:10 we noted that [Resident #1] was missing, CNA's along side with nurses searched the outside grounds. Resident was located at 5:36 am. Resident was returned to the inside of the facility at 5:40 am. A completed head to toe assessment was done, not noted skin abnormalities was seen Resident was placed on a one to one observation for acute monitoring <BR/>Review of a [NAME] map on 10/24/23 revealed the location where Resident #1 was located on 09/25/23 was 0.3 miles from the facility. <BR/>Attempts to interview LVN A and LVN B on 10/24/23 were unsuccessful. <BR/>Interview on 10/24/23 at 11:29 AM with the Receptionist revealed Resident #1 always sat at the front lobby and looked outside and let her know when visitors were coming to the door and greeted all who entered the facility. She stated Resident #1 was confused but had never made any attempts to elope nor expressed wanting to leave to her. <BR/>Interview on 10/24/23 at 12:29 PM with CNA C revealed Resident #1 had confusion but he was not exit seeking and self-propelled his wheelchair through the facility. <BR/>Interview on 10/24/23 at 2:42 PM with LVN D revealed Resident #1 was confused and sat in the front lobby greeting all the visitors that entered the facility. Resident #1 was very calm and was never known to be exit seeking. <BR/>Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed he was on his way to work the morning Resident #1 eloped from the facility, 09/25/23. When he arrived at the facility, he checked all the exit doors to ensure they were all operating and there were no concerns. The Maintenance Director further stated Resident #1 was confused but he had never known the resident to be exit seeking. <BR/>Interview on 10/24/23 at 10:56 AM with the ADON revealed Resident #1 used a wheelchair to get around and he was alert and oriented to himself only. She stated the resident did not wander or was exit seeking to her knowledge nor had he ever expressed wanting to leave the facility. <BR/>Interview on 10/24/23 at 9:00 AM with the Administrator and DON revealed they were immediately made aware of Resident #1's elopement and he was put on 1:1 supervision until he was transferred to a facility with a secure unit to prevent another incident. <BR/>2. Review of Resident #2's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included cerebrovascular accident (stroke) and non-Alzheimer's dementia. The MDS further reflected Resident #2 had a BIMS of 3 (cognition severely impaired). <BR/>Review of Resident #2's undated care plan revealed he had impaired cognition and was at risk for a further decline in cognitive and functional decline abilities. Interventions included to monitor/document/report to physician any changes in cognitive function.<BR/>Review of Resident #2's Elopement assessment dated [DATE] revealed he was low risk. <BR/>Review of the facility's Provider Investigation Report dated 09/29/23 reflected the following:<BR/>The resident was noted to be missing from his room at 4:05 PM [on 09/28/23] by his nurse [LVN E]. As she was going to the front to call a code silver, a visitor was informing the receptionist that there was a resident in the parking lot. The resident was returned to the facility at 4:07 PM and a head to toe assessment was completed with no injuries noted. During door alarm checks, it was noted that the 200 hall door lock was malfunctioning. A sentry was placed at the door until the maintenance supervisor repaired the door, then q 4 hour door checks were performed until the alarm company came to inspect all the doors. Door checks continue daily.<BR/>Interview on 10/24/23 at 3:04 PM with LVN E revealed she arrived to work the day of Resident #2's elopement, 09/28/23 at 2:00 PM, and during her initial rounds, she saw the resident in his room. Around 3:30 PM, she noticed Resident #2 was not in his room or the bathroom and asked nearby staff if they had seen the resident. At that time, they began to look for the resident and they had called a code silver as the same time an employee from a nearby business was in the front lobby saying Resident #2 was at their business and the resident was taken back to the facility. LVN said Resident #2 had not been at the facility long but during that short time, the resident had not been exit-seeking. The LVN further stated the resident was ambulatory without assistance. Resident #2 was put on 1:1 supervision until he was discharged from the facility. <BR/>Interview on 10/24/23 at 12:29 PM with CNA C revealed the day of Resident #2's elopement, 09/28/23, the resident had been seen at the nurse's station around 3:35 PM, and around 4:00 PM LVN E was looking for the resident and decided to call a code silver. At that same time, they got word that Resident #2 had been found outside next door at a nearby establishment and they had the resident. Facility staff went to the establishment and brought Resident #2 back to the facility. CNA C further stated that during the short time the resident was at the facility, he had never been exit seeking nor had he ever made the comment about wanting to leave. <BR/>Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed when he was made aware of Resident #2's elopement, he was called to check the exit doors and he found the exit door on 200 hall was not working. It appeared the exit door had come out of adjustment but once he fixed it, it began to work again. The Maintenance Director stated all the exit doors were checked weekly and all the doors had just been checked a few day prior, when Resident #1 eloped on 09/25/23 and they had all been in good and operating correctly. After Resident #2's incident, the mag lock on the 200 hall door was replaced and all facility exit doors were being checked and the codes were being changed every morning as well. <BR/>Interview on 10/24/23 at 10:56 AM with the ADON revealed on the day of Resident #2's elopement, 09/28/23, she was in her office on the 500 hall when she heard LVN E asked if anyone had seen Resident #2. At that time, they activated a code silver when they saw an employee of a nearby business in the front lobby saying they had one of their residents. Resident #2 was brought back to the facility and the nurse did a head-to-toe assessment and there were no injuries noted. After the resident was brought back to the facility, he was asked why he had left and the resident stated because this is a free country. Resident #2 was put on 1:1 supervision until he was discharged from the facility with family. The ADON further stated the resident had only been at the facility for a short time and he had never shown exit seeking behaviors. <BR/>Observation from the 200 exit door of the facility on 10/24/23 at 2:23 PM revealed the establishment where Resident #2 was found was about 100 yards from the facility premises. The establishment and facility shared a paved parking lot with some landscaped grass. <BR/>Interview on 10/24/23 at 5:27 PM with the Regional Nurse Consultant revealed Residents #1 and #2 were discharged from the facility to a secure unit. All staff were re-educated on code silver and live drills were done every shift for a week and a half, then daily, then transitioned weekly and now are being done monthly so all staff knew what to do in case a resident went missing. Exit door checks were being done daily by the Maintenance Director and the mag lock was changed on the hall 200 exit door. She further stated there was an elopement assessment done on all the residents after the incidents and there were two additional residents identified and measures were put in place to prevent any further incidents. <BR/>Observation on 10/24/23 from 9:34 AM to 9:50 AM revealed all 13 facility exit doors were checked with the Maintenance Director and all of the doors were functioning properly. Each door was equipped with a 15 second egress release followed by an alarm after it was opened. There were 3 dining room doors and there was an additional louder alarm added so they could be heard throughout the facility. <BR/>Review of the facility's policy titled Missing Resident Policy revised on 08/15/23 reflected the following:<BR/>This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk <BR/>This was determined to be a Past Non-Compliance Immediate Jeopardy on 10/24/23 at 5:15 PM. The Administrator, DON, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/24/23 at 5:26 PM. <BR/>The facility took the following actions to correct the non-compliance prior to the investigation:<BR/>Record review of the following in-services, dated 09/25/23 and 09/28/23, reflected the in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM:<BR/>- Missing resident guidelines;<BR/>- Missing resident protocol-Elopement binder;<BR/>- Code Silver;<BR/>- Exit seeking behavior; and<BR/>- Head count procedural guidelines.<BR/>Interviews on 10/24/23 from 9:34 AM to 3:59 PM with the Receptionist, HR Director, Restorative Aide, Maintenance Director, ADON, LVN A, LVN B, CNA C, LVN D, and LVN E who worked all three shifts revealed they were able to conduct a code silver drill for a missing resident, perform a head count check, what to do when they heard a door alarm and monitor any changes in condition that could indicate a resident was a high elopement risk. <BR/>Record review of the facility's Code Silver drills revealed they were conducted daily on each shift beginning on 09/25/23 and they were currently being done monthly with no end date. <BR/>Record review of exit door checks on 09/25/23, after Resident #1 eloped, revealed all exit doors were functioning properly. <BR/>Record review dated 09/28/23 revealed staff were doing 15 minute checks on the 200 hall door from 4:20 PM until the Maintenance Director arrived and it was fixed at 6:47 PM. <BR/>Record review of the fire and security invoice revealed that on 09/30/23 a delayed egress lock was replaced on the 200 hall. <BR/>Record review of the door alarm checks dated 09/29/23 to 10/23/23 revealed they were being checked daily by the Maintenance Director. <BR/>Record review revealed an elopement assessment was completed on all the residents on 09/29/23 to identify any additional high risk residents. Two additional residents were identified as being at high risk for elopement. One of the resident was transferred out to a more secure facility and the other resident was monitored until he was deemed safe to remain at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one of one (Resident #1) reviewed for intravenous fluids.<BR/>The facility failed to change Resident #1's PICC (this is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing before 02/20/25. <BR/>This failure could affect residents by placing them at risk for infection and IV complications.<BR/>Findings included:<BR/>Review of Resident #1's admission record dated 02/20/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were acquired absence of left leg above the knee, orthopedic after care following surgical amputation, pressure ulcers (bed sore), and infection following a procedure.<BR/>Review of Resident #1's physician's orders for February 2025 reflected:<BR/>-Change transparent dressing to the Midline (a type of IV line) site one time a day every 7 day(s) for PICC IV ACCESS. Measure upper arm circumference and exterior catheter length with each dressing change.<BR/>- Observe IV access site for erythema (redness), drainage, and edema (swelling) every shift for IV access Record any abnormal findings in the progress notes and notify the physician.<BR/>Review of Resident #1's care plan initiated 02/12/25 revealed Resident#1 had multiple pressure ulcers to sacrum & thigh and was at increased risk for infection, pain, and a decline in functional abilities. The goal was Resident #1's pressure ulcer would show signs of healing through next review date. Resident#1's pressure ulcer would be free from infection and the risk for infection would be minimized through the next review date. The intervention was to provide pain management prior to dressing changes and repositioning as needed, provide wound care per physician's order, Keep dressing clean, dry, and intact, replace the dressing as needed for soiling. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Low air loss mattress. Provide incontinent care as needed. The care plan did not reflect Resident #1 a PICC line.<BR/>Review of Resident #1's MAR/TAR for February 2025 reflected Change transparent dressing to the Midline site one time a day every 7 day(s) for PICC IV ACCESS Measure upper arm circumference and exterior catheter length with each dressing change. Start Date- 02/14/2025 0900, the MAR/TAR was marked that the dressing change was completed by LVN D on 02/14/25 at 09:00 AM.<BR/>During wound care observation and interview with LVN A on 02/20/25 at 1:30 PM, it was revealed that Resident #1 had an IV on her right upper arm with a single lumen (access port of the IV line) . LVN A stated it was a PICC line. The PICC line dressing was dated 02/10/25.<BR/>In an interview with LVN A on 02/20/25 at 1:48 PM, LVN A stated the PICC dressing was supposed to be changed every 7 days. He stated Resident #1's PICC dressing should have been changed 3 days ago [02/17/25]. He stated the nurse taking care of Resident #1 was responsible for changing the IV dressing unless the floor nurse had asked him to do so, he would have changed it. He stated if he had noticed the IV dressing beforehand, he would have informed the nurse (LVN C) taking care of Resident #1. He stated he was training on PICC line dressings. He stated he would inform the floor nurse, LVN C, right away. LVN A stated IV dressing changes was important to prevent infection.<BR/>In an interview with LVN C on 02/20/25 at 1:54 PM, she stated she did not check the date on Resident #1's IV dressing. She stated, To be honest I only focused on the assessment of the IV site for redness and swelling. She stated she had used the PICC line to infuse an antibiotic this morning. She stated the PICC line dressing was changed every 7 days or as needed. She stated the risk to the resident was infection. She stated she would change the dressing immediately. <BR/>In an interview with the DON on 02/20/25 at 4:47 PM, she stated they had a batch order for a PICC line, and the task had popped up on the EMR 3 days ago and one of the nurses might have marked the task as done . She stated nurses were responsible for completing the tasks and not just marking it as completed. She stated LVN C was responsible for accessing the PICC before and after use and she should have noticed the date. She stated the expectation was that PICC dressing change was completed every 7 days on the night shift. She stated all nursing was responsible for accessing the IV's. She stated the dressing change was necessary for infection control.<BR/>LVN D was not available for interview on 02/20/25 by 5:15 PM.<BR/>In an interview with the Administrator on 02/20/25 at 5:15 PM revealed that nurses were responsible for assessing the PICC line dressings and completing dressing changes as ordered, weekly. She said all dressing changes should be documented by the nurses. She stated if the IV dressing was not changed as ordered, then there was a potential for infection.<BR/>Review of the facility's PICC line Transparent Dressing Change policy, revised 07/06/2018, revealed, Policy to prevent external infection of the peripheral or central venous catheter .Upon initial insertion of PICC Line monitor the dressing in the first 24 hours for accumulation of blood fluid or moisture beneath the dressing . Transparent membrane dressings (no gauze over site) are changed every 7 days and PRN . Document the procedure in the Nurses Notes or initial Treatment Administration Record. Chart for any signs, symptoms of complications related to the vascular access device, arm circumference measurement and external exposed PICC line catheter measurement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 infections for 1 of 7 residents (Resident #1) reviewed for infection control. <BR/>CNA B failed to wear a gown for Enhanced Barrier Precautions while assisting LVN A with wound care for Resident #1.<BR/>These failures could place residents at risk of infectious disease. <BR/>The finding included:<BR/>Review of Resident #1's admission record dated 02/20/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were acquired absence of left leg above the knee, orthopedic after care following surgical amputation, pressure ulcers (bed sore), and infection following a procedure.<BR/>Review of Resident #1's admission MDS dated [DATE] was not completed and did not reflect a Brief Inventory of Mental Status (a standardized assessment to measure long and short-term memory), indwelling medical devices, wounds, wound vac (this is a medical device that helps to heal the wound from the inside using a suction motion) or infection.<BR/>Review of Resident #1's physician orders for February reflected:<BR/>-Cleanse pressure wound with cleanser, pat dry, apply collagen particles and calcium alginate to wound bed and cover with silicone foam dressing everyday shift for Right Posterior Thigh Wound.<BR/>-Cleanse pressure wound with cleanser, pat dry, apply collagen particles and calcium alginate to wound bed and cover with silicone foam dressing everyday shift for Sacrum (tail bone) Wound.<BR/>Review of Resident #1's care plan initiated 02/12/25 revealed Resident#1 had multiple pressure ulcers to sacrum & thigh and was at increased risk for infection, pain, and a decline in functional abilities. The goal was Resident #1's pressure ulcer would show signs of healing through next review date. Resident#1's pressure ulcer would be free from infection and the risk for infection would be minimized through the next review date. The intervention was to provide pain management prior to dressing changes and repositioning as needed, provide wound care per physician's order, Keep dressing clean, dry, and intact, replace the dressing as needed for soiling. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Low air loss mattress. Provide incontinent care as needed.<BR/>The care plan did not reflect EBP for Resident #1with wounds or wound vac.<BR/>Observation and interview on 02/20/25 at 1:30 PM, revealed a door signage that read STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as central lines, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring dressing. LVN A put on his gown and gloves to perform wound care for Resident #1. CNA B stated she was there to assist LVN A. CNA wore gloves. She did not wear a gown. Resident #1 was in the bed with family at bedside. Family stated Resident #1 moved from another facility due to worsening infection. Family stated resident had a wound vac on her amputated leg and that she admitted with wounds. CNA B helped to hold Resident #1 onto the left side by the amputated leg without a gown on. <BR/>In an interview with LVN A on 02/20/25 at 1:48 PM, he stated he did not remind CNA B to put on a gown because he thought only the person completing the actual wound care needed to wear a gown. LVN A stated following EBP was important to prevent infection.<BR/>In an interview with CNA B on 02/20/25 at 1:51 PM, she stated she forgot to put on her gown for EBP. She stated she had been in serviced for EBP which was used to prevent infection. She stated she was not thinking and forgot to wear a gown.<BR/>In an interview with DON on 02/20/25 at 4:47 PM, DON stated CNA B should have worn a gown for PPE during wound care assistance. She stated the expectation was to follow precautions of EBP when touching bed, resident, or any high contact activities. She said EBP was put in place for infection control, and everyone should wear PPE, as necessary.<BR/>In an interview the administrator on 02/20/25 at 5:15 PM revealed that all staff were expected to wear their PPE for EBP. She stated this was part of the infection control and all staff were responsible for following the infection control policy.<BR/>Review of the facility's in-service dated 12/10/24, titled skin assessment during shower: Head to toe, Weekly skin assessment, abnormal findings must be reported, wound care revealed, LVN A, LVN C and CNA B had completed training.<BR/>Review of policy Infection Prevention and Control Program, revised 11/06/24, revealed, .Enhanced Barrier Precautions<BR/>EBP are used in conjunction with standard precautions and expand the use of PPE to donning of<BR/>gown and gloves during high-contact resident care activities that provide opportunities for<BR/>transfer of MDROs to staff hands and clothing.<BR/>EBP are indicated for residents with any of the following:<BR/>a. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply.<BR/>b. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding<BR/>tube, tracheostomy/ventilator) regardless of MDRO colonization status<BR/>During high-contact resident care activities:<BR/>o Dressing<BR/>o Bathing/showering<BR/>o Transferring<BR/>o Providing hygiene<BR/>o Changing linens<BR/>o Changing briefs or assisting with toileting<BR/>o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator<BR/>o Wound care: any skin opening requiring a dressing<BR/>Gloves and gowns prior to the high-contact care activity<BR/>(Change PPE before caring for another resident)<BR/>(Face protection may also be needed if performing activity with risk of splash or spray) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team determined if it was clinically appropriate to self-administer medications for 1 of 5 residents (Resident #7) reviewed for medication administration. The facility's interdisciplinary team failed to ensure Resident #7 was clinically appropriate to self-administer antihistamine eyedrops that was at the resident's bedside. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings included:Record review of Resident #7's quarterly MDS dated [DATE] reflected Resident #7 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #7's BIMS score of 15 indicated his cognition was intact. Resident #7's diagnoses included amputation (removal of body limbs), high blood pressure (when the force of blood flowing through the blood vessels is consistently too high), renal insufficiency (characterized by reduced kidney function), diabetes (high blood sugar), lack of coordination, with adequate vision with no use of corrective lenses. Observation and interview on 09/23/25 at 11:30 AM, revealed Resident #7 had a bottle of Olopatadine Hydrochloride Ophthalmic Solution (antihistamine eye drops) at his bedside table. Resident #7 said his family member might have brought him the eye drops because his eyes had been itching, especially his right eye. Resident #7 stated he used the eye drops once in the morning and then again in the evening hours, and he did this daily.Record review of Resident #7's order summary reflected orders for eye drops had been started on 09/23/25 and 09/24/25 with no prior orders, and the orders reflected the following: - Ketotifen Fumarate Ophthalmic Solution 0.035 % Instill 1 drop in right eye two times a day for Itch Relief Active with order date 09/23/25 Start date 09/23/25.- Blink Tears Ophthalmic Solution 0.25 % Instill 1 drop in both eyes one time a day for dry eyes unsupervised self-administration. Active with order date 09/23/25 Start date 09/24/25.Interview with RN C on 09/23/25 at 12:36 PM, who was the charge nurse for Hall 100, revealed he was not aware Resident #7 had eye drops at his bedside to administer to himself. RN C stated he was not aware of any concerns with Resident #7's eye irritation. RN C stated someone from Resident #7's family may have brought him the eye drops, however there was supposed to be a prescription for the eye drops and they should be stored in our mediation cart. I will let the physician know so I can get an order so he can have it at his bedside. According to RN C, a physician's order was required to administer all medications whether it was for nursing staff to administer or residents to self-administer. RN C was observed removing the eyedrops from the bedside table. RN C stated all staff was responsible for removing medications from bedside and alerting the nursing staff, ADONs, or the DON. RN C stated allowing residents to have medications at the bedside without a physician's order placed residents at risk of over-using medication, forgetting how and when to use them. Interview on 09/25/25 at 2:00 PM, ADON B revealed residents should not have any medications in the room with them. ADON B stated residents would have to pass an assessment which would indicate they are capable of administering medications on their own. ADON B stated nursing staff was responsible for ensuring residents did not have any type of medications whether over the counter or prescribed in their rooms. ADON B stated Resident #7 should not have eye drops in his room because it could place him at risk of overdose, overusing the medication. Interview on 09/25/25 at 2:16 PM, the DON revealed residents are not supposed to have medication of any kind in their rooms. The DON stated she expected all staff to be more vigilant while making rounds in resident rooms. The DON stated in order for residents to have medication at their bedside, a safe survey, care plan updated, and an order for the medication. The DON stated it was the responsibility of the nursing staff to remove any pills, prescriptions, or over the counter medications from resident rooms. The DON stated residents having medications in their rooms put them at risk of overmedicating, staff not knowing what they are taking, or other residents getting the medications. Record review of facility's policy titled Medication storage dated 1/20/2021 revealed It is the policy of this facility to ensure that all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. A. All drugs and biologicals will be stored in locked compartments.B. Only authorized personnel will have access to the keys to locked compartmentsC. During a medication pass, mediations must be under direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts (Halls 300 nurse medication cart) reviewed for labeling of drugs and biologicals. The facility failed to ensure expired medications was removed from the Hall 300 medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings included:Observation on 09/24/2025 at 1:27 PM of the Hall 300 nurse medication cart with LVN A revealed one bottle of Nitroglycerin 0.4 mg (used to treat or prevent attacks of chest pain) with an expiry date of July 2025 and 12 tablets of Oxycodone 10 mg (Schedule II opioid pain medication) with a use by date of 09/04/25. Interview on 09/24/2025 at 1:45 PM, LVN A revealed she was responsible for checking the cart for expired medications. She stated she checked the cart once a month for expired medications, and she last checked her cart two weeks ago. She stated failing to remove the expired medication could result in the medications being administered which could cause reactions, and the residents would not get the required therapy. She stated she had done training on checking the carts for expired medications, but she could not recall when she had completed the training. She stated she had been trained regarding labeling of medications, storage of medications, and putting the open date on insulin; however, she did not remember when she had been trained.Interview on 09/24/2025 at 2:14 PM, the DON revealed it was all nurses' responsibility to check the carts and refrigerator to ensure expired medications were removed for destruction. She stated it was the responsibility of the ADON to monitor and ensure the nurses was labelling and discarding the expired medications, but she did not specify how often. She stated if the staff was not checking carts for expired medications, it would place residents at risk of having reactions like the medication being ineffective since they could not tell of the potency. She provided documentation on training courses which included dating insulin once it was opened. The training was dated 08/16/25 and LVN C was not in attendance.Interview on 09/25/2025 at 1:27 PM, ADON B revealed her expectation was for nurses to check their cart for medication labelling and to look for expired medications every week. She stated she last checked the carts and the refrigerators at the end of August. She stated the risk of having expired medications on the cart was that if they were administered, they would not be effective. She stated she had done in-service training on medication labelling and storage, in August. Record review of facility's Medication Storage dated 01/20/21 reflected: .iii. Expiration dating (beyond-use dating) .3.Certain medications or package types, such as intravenous solutions, multiple dose injectables vials. require an expiration date shorter than the manufactures expiration date once opened to ensure medication purity and potency.8.Medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for two (Residents #1 and#2) of four residents reviewed for elopement. <BR/>1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 09/25/23. <BR/>2. The facility failed to ensure Resident #2 was provided with adequate supervision to prevent him from eloping from the facility on 09/28/23. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 09/25/23 and ended on 09/30/23. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury. <BR/>Findings included:<BR/>1. Review of Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, non-Alzheimer's dementia, and cognitive communication deficit. Resident #1 had long and short-term memory impairment and a BIMS could not be completed due to his impaired cognition. <BR/>Review of Resident #1's care plan initiated on 08/04/23 revealed the resident wandered related to cognitive impairment and was at risk for elopement. Interventions included putting the resident on 1:1 (one-on-one supervision) while behaviors like seeking exit were noted. The care plan further reflected Resident #1 was able to self propel his wheelchair. <BR/>Review of Resident #1's elopement assessment dated [DATE] reflected the resident was at a high risk to elope and a care plan for elopement was indicated. <BR/>Review of the facility's Provider Investigation Report dated 09/25/23 reflected the following:<BR/>At 5:02am [on 09/25/23], when returning to the desk from down the 100 hall, [LVN A] heard the alarm sounding from the dining room door. She looked outside and around the door and didn't see anyone, so she immediately called for a code silver and staff completed a head count. At 5:06am, it was noted that [Resident #1] was not able to be located and a search ensued, including the interior and exterior of the facility, parking lots, bushes, etc. At 5:25am, the search was expanded by car to include the area directly surrounding the facility. [Resident #1] was noted at the gas station about half a block from the facility at approximately 5:30am, with 2 police officers, by [LVN A]. Resident was returned to the facility, and released to the nurse assigned to him, [LVN A] who completed a head to toe assessment and placed the resident on 1:1 staff supervision <BR/>Review of Resident #1's progress notes dated 09/25/23 completed by LVN B reflected the following:<BR/>At 5:00 [AM] code silver was initiated. Census was printed and a complete head count was done on all the resident [sic]. At 5:10 we noted that [Resident #1] was missing, CNA's along side with nurses searched the outside grounds. Resident was located at 5:36 am. Resident was returned to the inside of the facility at 5:40 am. A completed head to toe assessment was done, not noted skin abnormalities was seen Resident was placed on a one to one observation for acute monitoring <BR/>Review of a [NAME] map on 10/24/23 revealed the location where Resident #1 was located on 09/25/23 was 0.3 miles from the facility. <BR/>Attempts to interview LVN A and LVN B on 10/24/23 were unsuccessful. <BR/>Interview on 10/24/23 at 11:29 AM with the Receptionist revealed Resident #1 always sat at the front lobby and looked outside and let her know when visitors were coming to the door and greeted all who entered the facility. She stated Resident #1 was confused but had never made any attempts to elope nor expressed wanting to leave to her. <BR/>Interview on 10/24/23 at 12:29 PM with CNA C revealed Resident #1 had confusion but he was not exit seeking and self-propelled his wheelchair through the facility. <BR/>Interview on 10/24/23 at 2:42 PM with LVN D revealed Resident #1 was confused and sat in the front lobby greeting all the visitors that entered the facility. Resident #1 was very calm and was never known to be exit seeking. <BR/>Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed he was on his way to work the morning Resident #1 eloped from the facility, 09/25/23. When he arrived at the facility, he checked all the exit doors to ensure they were all operating and there were no concerns. The Maintenance Director further stated Resident #1 was confused but he had never known the resident to be exit seeking. <BR/>Interview on 10/24/23 at 10:56 AM with the ADON revealed Resident #1 used a wheelchair to get around and he was alert and oriented to himself only. She stated the resident did not wander or was exit seeking to her knowledge nor had he ever expressed wanting to leave the facility. <BR/>Interview on 10/24/23 at 9:00 AM with the Administrator and DON revealed they were immediately made aware of Resident #1's elopement and he was put on 1:1 supervision until he was transferred to a facility with a secure unit to prevent another incident. <BR/>2. Review of Resident #2's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included cerebrovascular accident (stroke) and non-Alzheimer's dementia. The MDS further reflected Resident #2 had a BIMS of 3 (cognition severely impaired). <BR/>Review of Resident #2's undated care plan revealed he had impaired cognition and was at risk for a further decline in cognitive and functional decline abilities. Interventions included to monitor/document/report to physician any changes in cognitive function.<BR/>Review of Resident #2's Elopement assessment dated [DATE] revealed he was low risk. <BR/>Review of the facility's Provider Investigation Report dated 09/29/23 reflected the following:<BR/>The resident was noted to be missing from his room at 4:05 PM [on 09/28/23] by his nurse [LVN E]. As she was going to the front to call a code silver, a visitor was informing the receptionist that there was a resident in the parking lot. The resident was returned to the facility at 4:07 PM and a head to toe assessment was completed with no injuries noted. During door alarm checks, it was noted that the 200 hall door lock was malfunctioning. A sentry was placed at the door until the maintenance supervisor repaired the door, then q 4 hour door checks were performed until the alarm company came to inspect all the doors. Door checks continue daily.<BR/>Interview on 10/24/23 at 3:04 PM with LVN E revealed she arrived to work the day of Resident #2's elopement, 09/28/23 at 2:00 PM, and during her initial rounds, she saw the resident in his room. Around 3:30 PM, she noticed Resident #2 was not in his room or the bathroom and asked nearby staff if they had seen the resident. At that time, they began to look for the resident and they had called a code silver as the same time an employee from a nearby business was in the front lobby saying Resident #2 was at their business and the resident was taken back to the facility. LVN said Resident #2 had not been at the facility long but during that short time, the resident had not been exit-seeking. The LVN further stated the resident was ambulatory without assistance. Resident #2 was put on 1:1 supervision until he was discharged from the facility. <BR/>Interview on 10/24/23 at 12:29 PM with CNA C revealed the day of Resident #2's elopement, 09/28/23, the resident had been seen at the nurse's station around 3:35 PM, and around 4:00 PM LVN E was looking for the resident and decided to call a code silver. At that same time, they got word that Resident #2 had been found outside next door at a nearby establishment and they had the resident. Facility staff went to the establishment and brought Resident #2 back to the facility. CNA C further stated that during the short time the resident was at the facility, he had never been exit seeking nor had he ever made the comment about wanting to leave. <BR/>Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed when he was made aware of Resident #2's elopement, he was called to check the exit doors and he found the exit door on 200 hall was not working. It appeared the exit door had come out of adjustment but once he fixed it, it began to work again. The Maintenance Director stated all the exit doors were checked weekly and all the doors had just been checked a few day prior, when Resident #1 eloped on 09/25/23 and they had all been in good and operating correctly. After Resident #2's incident, the mag lock on the 200 hall door was replaced and all facility exit doors were being checked and the codes were being changed every morning as well. <BR/>Interview on 10/24/23 at 10:56 AM with the ADON revealed on the day of Resident #2's elopement, 09/28/23, she was in her office on the 500 hall when she heard LVN E asked if anyone had seen Resident #2. At that time, they activated a code silver when they saw an employee of a nearby business in the front lobby saying they had one of their residents. Resident #2 was brought back to the facility and the nurse did a head-to-toe assessment and there were no injuries noted. After the resident was brought back to the facility, he was asked why he had left and the resident stated because this is a free country. Resident #2 was put on 1:1 supervision until he was discharged from the facility with family. The ADON further stated the resident had only been at the facility for a short time and he had never shown exit seeking behaviors. <BR/>Observation from the 200 exit door of the facility on 10/24/23 at 2:23 PM revealed the establishment where Resident #2 was found was about 100 yards from the facility premises. The establishment and facility shared a paved parking lot with some landscaped grass. <BR/>Interview on 10/24/23 at 5:27 PM with the Regional Nurse Consultant revealed Residents #1 and #2 were discharged from the facility to a secure unit. All staff were re-educated on code silver and live drills were done every shift for a week and a half, then daily, then transitioned weekly and now are being done monthly so all staff knew what to do in case a resident went missing. Exit door checks were being done daily by the Maintenance Director and the mag lock was changed on the hall 200 exit door. She further stated there was an elopement assessment done on all the residents after the incidents and there were two additional residents identified and measures were put in place to prevent any further incidents. <BR/>Observation on 10/24/23 from 9:34 AM to 9:50 AM revealed all 13 facility exit doors were checked with the Maintenance Director and all of the doors were functioning properly. Each door was equipped with a 15 second egress release followed by an alarm after it was opened. There were 3 dining room doors and there was an additional louder alarm added so they could be heard throughout the facility. <BR/>Review of the facility's policy titled Missing Resident Policy revised on 08/15/23 reflected the following:<BR/>This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk <BR/>This was determined to be a Past Non-Compliance Immediate Jeopardy on 10/24/23 at 5:15 PM. The Administrator, DON, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/24/23 at 5:26 PM. <BR/>The facility took the following actions to correct the non-compliance prior to the investigation:<BR/>Record review of the following in-services, dated 09/25/23 and 09/28/23, reflected the in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM:<BR/>- Missing resident guidelines;<BR/>- Missing resident protocol-Elopement binder;<BR/>- Code Silver;<BR/>- Exit seeking behavior; and<BR/>- Head count procedural guidelines.<BR/>Interviews on 10/24/23 from 9:34 AM to 3:59 PM with the Receptionist, HR Director, Restorative Aide, Maintenance Director, ADON, LVN A, LVN B, CNA C, LVN D, and LVN E who worked all three shifts revealed they were able to conduct a code silver drill for a missing resident, perform a head count check, what to do when they heard a door alarm and monitor any changes in condition that could indicate a resident was a high elopement risk. <BR/>Record review of the facility's Code Silver drills revealed they were conducted daily on each shift beginning on 09/25/23 and they were currently being done monthly with no end date. <BR/>Record review of exit door checks on 09/25/23, after Resident #1 eloped, revealed all exit doors were functioning properly. <BR/>Record review dated 09/28/23 revealed staff were doing 15 minute checks on the 200 hall door from 4:20 PM until the Maintenance Director arrived and it was fixed at 6:47 PM. <BR/>Record review of the fire and security invoice revealed that on 09/30/23 a delayed egress lock was replaced on the 200 hall. <BR/>Record review of the door alarm checks dated 09/29/23 to 10/23/23 revealed they were being checked daily by the Maintenance Director. <BR/>Record review revealed an elopement assessment was completed on all the residents on 09/29/23 to identify any additional high risk residents. Two additional residents were identified as being at high risk for elopement. One of the resident was transferred out to a more secure facility and the other resident was monitored until he was deemed safe to remain at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #1) reviewed. <BR/>The facility failed to ensure the Wound Care Nurse used proper body mechanics while providing incontinence care to Resident #1 on 07/11/24. <BR/>This failure could place residents at risk of injury, change in condition, and not receiving proper treatment and care in a timely manner.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 10/22/24, reflected the resident was an [AGE] year-old female, with an initial admission date of 05/10/21 and a readmission date of 08/04/24. Resident #1 had diagnoses of cerebral infarction (brain tissue death due to blood blockage), irritant contact dermatitis due to fecal, urinary, or dual incontinence (skin rash), chronic pain syndrome (persistent pain), muscle wasting atrophy (loss or thinning of muscle tissue), cognitive communication deficit (difficulty with communication), muscle weakness (lack of muscle strength), abnormal posture (chronic or rigid body position), edema (fluid buildup in body tissue), and acute pain due to trauma. <BR/>Record review of Resident #1's MDS assessment dated [DATE], reflected Resident #1's had a BIMS score of 15, which meant the resident had intact cognition. <BR/>Record review of Resident #1's care plan dated 08/07/24, reflected the following:<BR/>[Resident #1] has recurrent chronic rash and recurrent cellulitis. Provide gentle peri-care after each incontinence episode.<BR/>Communication (Impaired): Resident has a communication problem related to history of aphasia (language disorder).<BR/>Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed.<BR/>Observation of a video, dated 07/11/24, reflected the Wound Care Nurse and Caregiver A as they provided perineal and incontinent care to Resident #1. In the video the Wound Care Nurse was seen lifting Resident #1's right leg straight in the air as he instructed Caregiver A on how to apply the white cream to the resident's under thigh area. The Wound Care Nurse was then seen putting Resident #1's leg back down straight on the bed, and the two staff members secured Resident #1's brief. The video had sound and it did not appear Resident #1 mentioned or appeared to have any pain. <BR/>Record review of the Resident #1's hospital record dated 07/26/24, reflected Resident #1 admitted to the emergency department due to an altered mental status. The hospital record noted Resident #1' Family Member stated Resident #1 had complained of right hip pain for 1 and half weeks. It noted Resident #1 had tenderness around the right hip and pain with range of motion. The hospital document noted Resident #1 had an acute sub-capital right femoral neck fracture (neck of thighbone) without dislocation at the right hip joint. It also noted mild right hip joint osteoarthritis (joint breakdown). <BR/>Record review of Resident #1 Medical Record from the Attending Surgeon at the hospital dated 07/26/2024 noted, Resident #1 was able to verbally tell her about the right hip pain. The Attending Surgeon noted upon starting the surgery the fracture site was not mobile and appeared subacute to chronic (bone fracture that started to heal). <BR/>The Attending Surgeon noted the following:<BR/>Addendum<BR/>The fracture appeared subacute to chronic in nature, given the amount of fibrous tissue at the fracture site and small hematoma. It is my professional opinion that the EMS team that transported the patient to the hospital just prior to this admission was not at fault. <BR/>In an interview on 10/22/24 at 12:08 PM, Resident #1's Family Member stated the family thought Resident #1's fracture resulted from the leg lift seen in the video. Resident #1's Family Member stated Resident #1 went to the hospital for something unrelated and asked the hospital to check her leg, because Resident #1 had complained about pain in the area. Resident #1's Family Member stated Resident #1 was diagnosed with a fracture while at the hospital. Resident #1's Family Member stated the resident had not fallen or had any accidents recently. The Family Member stated the facility did not report any incidents to the family which could have resulted in an injury. <BR/>In an interview on 10/22/24 at 1:50 PM, Resident #1's Primary Care Physician stated he had no concerns with the care of Resident #1 while she was at the facility. The Primary Care Physician stated he stayed on top of Resident #1's care, especially since the resident's family member was very involved and liked to be updated frequently. He stated Resident #1 passed away recently, but it was not due to the care from the facility. He stated the resident had a lot of health issues. The Primary Care Physician stated he did not think lifting the resident's leg about 60-65 degrees could have caused the hip fracture. The Primary Care Physician stated he had not received any reports from the facility regarding Resident #1 and pain, or an increased amount of pain. He stated there was no change of condition reported to him regarding pain. He stated he did not receive a report of acute pain until Resident #1 was transported to the hospital on [DATE]. He stated the facility management was convinced the fracture occurred during transport to the hospital. The Primary Care Physician stated he assessed the resident a couple of days before she went to the hospital, and Resident #1 did not complain of pain. <BR/>In an interview on 10/24/24 at 11:41 AM, the Wound Care Nurse stated he knew Resident #1 well, and she did not complain at all. He stated he never received any complaints from the family. He stated Resident #1 was vocal and would tell you how she liked staff to provide care at times. The Wound Care Nurse stated Resident #1's legs were kind of forced inward, and it was easier at times to elevate her leg instead of turning her on her side when providing care. He stated he would generally turn the resident instead of lifting the leg, but it would depend on the limitations of whichever resident. The Wound Care Nurse stated in this instance he thought she asked him to lift her leg, because it felt better for her due to the wounds on her right leg. He stated he did not document her request. The Wound Care Nurse stated there was never a time when he lifted her leg and she complained of pain. The Wound Care Nurse stated there was no risk when he lifted Resident #1's leg, because the leg was not straight up, but just lifted, and he stated the resident was not in any pain. <BR/>In an interview on 10/24/24 at 2:44 PM, the DON stated Resident #1 had a strong side and a weak side of her body. She stated Resident #1 would tell you if she wanted her care a certain way or if she was in pain. The DON stated the Wound Care Nurse would not have done Resident #1's care differently unless it was requested. The DON stated there was no documentation or any changes to the resident's care plan because it was probably a one-time request or a request in the moment. She stated if Resident #1 requested it more than once then it would have been care planned. The DON stated generally it was safer to turn a resident on their side instead of lifting the resident's leg. The DON stated the risk was the quality of care given to the resident if the resident did not request the leg lift. <BR/>In an interview on 10/24/24 at 3:19 PM, the Administrator stated Resident #1's family would communicate with him and his staff often and never mentioned any concerns with the resident's leg being lifted. The Administrator stated the residents should be repositioned instead of lifting their legs in most instances. He stated he did not recall her being injured and she did not complain of pain, so he did not see the risk of the leg lift. The Administrator stated there was a care plan meeting after the resident returned from the hospital, in which Resident #1's family told the staff the resident's hip was fractured. He stated they believe the fracture occurred during the transport to the hospital, because he nor the DON received any report of any incidents with the resident prior to her transport to the hospital. The Administrator stated the staff should follow their policy and reposition the resident unless the resident requests otherwise. The Administrator stated he was not aware of the video or Resident #1's leg being lifted. The Administrator stated he did not see the risk, because the staff would be handled and re-trained. <BR/>Record review of the facility's Incontinence Care policy, last revised 02/14/20, reflected the following:<BR/> .Procedure<BR/>Position on side turned away from caregiver.<BR/>Position on back with knees flexed and feet flat on the bed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 infections for 1 of 7 residents (Resident #1) reviewed for infection control. <BR/>CNA B failed to wear a gown for Enhanced Barrier Precautions while assisting LVN A with wound care for Resident #1.<BR/>These failures could place residents at risk of infectious disease. <BR/>The finding included:<BR/>Review of Resident #1's admission record dated 02/20/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were acquired absence of left leg above the knee, orthopedic after care following surgical amputation, pressure ulcers (bed sore), and infection following a procedure.<BR/>Review of Resident #1's admission MDS dated [DATE] was not completed and did not reflect a Brief Inventory of Mental Status (a standardized assessment to measure long and short-term memory), indwelling medical devices, wounds, wound vac (this is a medical device that helps to heal the wound from the inside using a suction motion) or infection.<BR/>Review of Resident #1's physician orders for February reflected:<BR/>-Cleanse pressure wound with cleanser, pat dry, apply collagen particles and calcium alginate to wound bed and cover with silicone foam dressing everyday shift for Right Posterior Thigh Wound.<BR/>-Cleanse pressure wound with cleanser, pat dry, apply collagen particles and calcium alginate to wound bed and cover with silicone foam dressing everyday shift for Sacrum (tail bone) Wound.<BR/>Review of Resident #1's care plan initiated 02/12/25 revealed Resident#1 had multiple pressure ulcers to sacrum & thigh and was at increased risk for infection, pain, and a decline in functional abilities. The goal was Resident #1's pressure ulcer would show signs of healing through next review date. Resident#1's pressure ulcer would be free from infection and the risk for infection would be minimized through the next review date. The intervention was to provide pain management prior to dressing changes and repositioning as needed, provide wound care per physician's order, Keep dressing clean, dry, and intact, replace the dressing as needed for soiling. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Low air loss mattress. Provide incontinent care as needed.<BR/>The care plan did not reflect EBP for Resident #1with wounds or wound vac.<BR/>Observation and interview on 02/20/25 at 1:30 PM, revealed a door signage that read STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as central lines, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring dressing. LVN A put on his gown and gloves to perform wound care for Resident #1. CNA B stated she was there to assist LVN A. CNA wore gloves. She did not wear a gown. Resident #1 was in the bed with family at bedside. Family stated Resident #1 moved from another facility due to worsening infection. Family stated resident had a wound vac on her amputated leg and that she admitted with wounds. CNA B helped to hold Resident #1 onto the left side by the amputated leg without a gown on. <BR/>In an interview with LVN A on 02/20/25 at 1:48 PM, he stated he did not remind CNA B to put on a gown because he thought only the person completing the actual wound care needed to wear a gown. LVN A stated following EBP was important to prevent infection.<BR/>In an interview with CNA B on 02/20/25 at 1:51 PM, she stated she forgot to put on her gown for EBP. She stated she had been in serviced for EBP which was used to prevent infection. She stated she was not thinking and forgot to wear a gown.<BR/>In an interview with DON on 02/20/25 at 4:47 PM, DON stated CNA B should have worn a gown for PPE during wound care assistance. She stated the expectation was to follow precautions of EBP when touching bed, resident, or any high contact activities. She said EBP was put in place for infection control, and everyone should wear PPE, as necessary.<BR/>In an interview the administrator on 02/20/25 at 5:15 PM revealed that all staff were expected to wear their PPE for EBP. She stated this was part of the infection control and all staff were responsible for following the infection control policy.<BR/>Review of the facility's in-service dated 12/10/24, titled skin assessment during shower: Head to toe, Weekly skin assessment, abnormal findings must be reported, wound care revealed, LVN A, LVN C and CNA B had completed training.<BR/>Review of policy Infection Prevention and Control Program, revised 11/06/24, revealed, .Enhanced Barrier Precautions<BR/>EBP are used in conjunction with standard precautions and expand the use of PPE to donning of<BR/>gown and gloves during high-contact resident care activities that provide opportunities for<BR/>transfer of MDROs to staff hands and clothing.<BR/>EBP are indicated for residents with any of the following:<BR/>a. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply.<BR/>b. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding<BR/>tube, tracheostomy/ventilator) regardless of MDRO colonization status<BR/>During high-contact resident care activities:<BR/>o Dressing<BR/>o Bathing/showering<BR/>o Transferring<BR/>o Providing hygiene<BR/>o Changing linens<BR/>o Changing briefs or assisting with toileting<BR/>o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator<BR/>o Wound care: any skin opening requiring a dressing<BR/>Gloves and gowns prior to the high-contact care activity<BR/>(Change PPE before caring for another resident)<BR/>(Face protection may also be needed if performing activity with risk of splash or spray) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the PASARR program for 1 (Resident #1) of 4 residents reviewed for PASRR coordination.<BR/>The facility failed to meet deadlines for submitting a NFSS for specialized services and customized manual wheelchair for Resident #1. <BR/>This failure could place residents at risk of not receiving qualified specialized services. <BR/>Findings included:<BR/>Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included seizures, Alzheimer's disease, and Parkinson's disease.<BR/>Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. The assessment revealed she required assistance with all of her ADLs, and she required the use of a wheelchair for mobility. <BR/>Review of Resident #1's care plan, dated 03/06/24, revealed she had the potential for falls related to gait and balance problems. She was PASRR positive for Intellectual Disability placing the resident at risk of not having the ordered specialized services provided with interventions of specialized services determined to be necessary by the IDT will be initiated and request submitted to DADS [HHSC] within 20 business days after date of IDT. Services will be delivered within 3 days after approval. Dated 08/08/23<BR/>Interview on 03/18/24 at 3:38 PM with the PASRR Unit Program Specialist revealed on 02/01/24 the Administrator was notified via phone and email his facility had to submit a NFSS for Specialized Services for OT and PT by 02/05/24 and by 02/07/24 for Customized Manual Wheelchair, based on the IDT meeting in August 2023. As of 02/22/24, the facility was considered delinquent. <BR/>Interview on 03/19/24 at 11:00 AM with the MDS Coordinator revealed the request for Specialized Services was handled by the Rehabilitation Department, so she did not know about the issues. <BR/>Interview on 03/19/24 at 11:10 AM with the Director of Rehabilitation Services revealed began working in her position on 03/04/24, and she did not know what the previous director had done or not done. She stated the previous director left around 02/14/24. She called the Regional Director of Rehabilitation Services for assistance. The Regional Director was able to reveal the NFSS had been submitted on 03/01/24. Resident #1 had been on Skilled Nursing Services, following an admission to the hospital, until 03/16/24, so the NFSS was denied. On 03/19/24, the Regional Director re-submitted the request. The Regional Director and the Director of Rehabilitation Services understood the re-submission was considered a late submission. <BR/>Interview on 03/19/24 at 3:00 PM with the Administrator revealed he recalled speaking to someone from HHSC about Resident #1's MDS, but the caller did not explain the issue very well. He stated he was confused about what she was talking about. The Administrator stated the caller had been so rude and he ended the call. The Administrator asked the MDS Coordinator to check Resident #1 to insure everything had been submitted. The Administrator stated he had not been aware that Rehab Services handled anything with the MDS so he did not think to follow up with them. <BR/>Review of the facility's undated MDS Coordination policy revealed it did not address Specialized Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (Residents #36, #107, and #69) of eight residents reviewed for ADL care.<BR/>1. The facility failed to provide two female residents, Residents #36 and #107, with grooming to ensure their facial hair was shaved. <BR/>2. The facility failed to provide Resident #69 assistance with timely incontinence care.<BR/>These failures could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.<BR/>Findings included:<BR/>1. Record review of Resident #107's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, ulcer, and communication deficit.<BR/>Record review of Resident #107's Quarterly MDS Assessment, dated 06/02/24, reflected a BIMS score of 4 indicating severe cognitive impairment. Her Functional Status evaluation indicated she required assistance with her personal hygiene. <BR/>Record review of Resident #107's care plan, dated 07/03/24, reflected she had an ADL self-care deficit, with interventions including Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Her care plan did not reflect she refused ADL care. <BR/>Observation and interview on 08/27/24 at 2:30 PM revealed Resident #107 was noted to have white facial hair on her chin, consisting of 6 hairs approximately an inch long. Resident #107 stated she was not aware of the hair on her chin, but she did not like the idea of having any facial hair. Resident #107 stated she thought her last shower was on the previous day (08/26/24) but could not recall her last shave. <BR/>Observation and interview on 08/28/24 at 12:24 PM revealed Resident #107 remained unshaved and stated she had not asked the CNA to shave her. <BR/>Record review of Resident #36's undated admission Record reflected she was admitted to the facility on [DATE] with diagnoses which included right ankle injury, morbid obesity, sleep apnea, and high blood pressure. <BR/>Record review of Resident #36's admission MDS, dated [DATE], reflected a BIMS score of 12 indicating she was cognitively intact. Her Functional Status evaluation indicated she required partial assistance with her personal hygiene. <BR/>Record review of Resident #36's care plan, dated 07/17/24 reflected she had an ADL self-care deficit, with interventions including Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Her care plan did not reflect any refusal of personal hygiene. <BR/>Observation and interview on 08/27/24 at 2:34 PM revealed Resident #36 was noted to have white facial hair consisting of four hairs on her chin that were approximately 1/2 inch long. Resident #36 stated she did not like having facial hair of any kind, it was embarrassing. Her last bed bath was on 08/26/24 but the CNA did no mention the facial hair. <BR/>Observation on 08/28/24 at 12:24 PM revealed Resident #36 was still unshaven. <BR/>Interview on 08/28/24 at 2:25 PM CNA A stated she had bathed both Resident #36 and #107 on 08/26/24. She stated she did not notice their facial hair at the time because she was in a hurry because she was too busy with her patient load. <BR/>Interview on 08/29/24 at 3:02 PM the DON stated the facility had plenty of staff to care for the residents, and any CNA could call for help any time they needed. The DON stated they did not have a policy that addressed shaving residents. She stated it should be done as part of the bathing process. <BR/>2. Record review of Resident #69's face sheet, dated 08/27/24, indicated Resident #69 was a [AGE] year-old male, admitted to the facility on [DATE], 09/04/19 and readmitted on [DATE]. Resident #69's diagnosis included Cerebral Infarction (stroke, poor blood flow to the brain), Contracture of Muscle (shortening of muscles causes joints to become stiff), Urinary Tract Infection (infection that affects part of the urinary tract), Acute Kidney failure (sudden decrease in kidney function), Type 2 Diabetes Mellitus (high blood sugar), Major Depressive Disorder (pervasive low mood, low self-esteem), absence of right leg above knee. <BR/>Record review of Resident #69's admission MDS assessment, dated 07/18/2024, indicated Resident #69 had the ability to make himself understood and understood others. The assessment indicated Resident #69's BIMS score was not indicated, because he was rarely understood. Resident #69 was dependent on staff with toileting. Resident #69 required substantial/maximal assistance with shower/bathing and personal hygiene. <BR/>Record review of Resident #69's care plan, undated, indicated Resident #69 was incontinent of bowel and bladder due to disease process and Resident #69 has potential for development for pressure ulcer related to immobility impairment. Goal: Resident will remain free from skin breakdown due to incontinence and brief use. Resident # 69 will be free of preventable breakdown. Interventions included: Check frequently for wetness and soiling, every two hours and change as needed. Briefs or incontinent products as needed for protection. Apply barrier cream after each incontinent episode. Weekly skin checks to monitor for redness, circulatory problems, breakdown, report any new skin conditions to the physician.<BR/>Record review of Resident #69's task for toileting care revealed Resident #69 had received incontinent care last at 03:17 (3:17 AM) on 08/27/24. <BR/>Interview and observation on 08/27/24 at 2:57 PM of Resident #69 revealed him in bed, Resident #69 stated lunch was great, and he had no concerns with his care at this time. Observation revealed Resident # 69's cloth bed pad was discolored with dark colored rings that indicated the resident may have been incontinent several times throughout the day. When Resident #69 was asked if he was soiled, he responded no. Surveyor did not observe any strong urine smells, however observation of the pad revealed his bedding had been wet at some point throughout the day. When Resident #69 was asked if he had any burning or irritation in his groin area he responded no. When Resident #69 was asked when the last time was, he had been changed he stated, I don't know. <BR/>Observation and interview on 08/27/24 at 3:22 PM revealed CNA C exiting the room emptying contents in the dirty laundry barrel. During interview with Resident #69 revealed he had his bedding changed, clothing changed, and was wearing a new brief. Resident #69 stated staff came in and changed him and bedding, he was not having any issues or concerns in his groin area. <BR/>Interview on 08/28/24 at 2:44 PM with CNA C revealed she arrived late to work on 08/27/24, and CNA D had to remain on shift to cover for her until she arrived. CNA C stated she entered the facility around 3:00 PM to begin her shift. CNA C stated she worked the 200 hall, CNA C stated she found Resident #69 heavily soiled. CNA C stated Resident #69 drank lots of fluid and was a heavy wetter. CNA C stated she had to change Resident#69 and his bedding and because she observed different colored rings on his bed pad indicating he soiled himself through the brief onto his bed. CNA C stated it was unknown when the last time Resident #69 had been changed, and the aide on previous shift did not report any concerns for Resident #69. According to CNA C the previous aide was responsible to ensure residents were clean and dry prior to end of their shift and she should report any concerns if she noted otherwise. CNA C stated if Resident #69 was changed around 2:00 PM, when she entered at 3:00 PM, Resident #69 would not have soiled to his bedding. CNA C stated since she was late to arrive to her shift, she felt it was necessary to jump in and get him changed. CNA C stated she had not reported this to the nurse because she had to ensure all residents had been cleaned and changed. CNA C stated having residents waiting too long to receive incontinent care could result in skin breakdown, infection, and irritation to the skin. <BR/>Interview on 08/28/24 at 3:24 PM with CNA D revealed she worked hall 200 and cared for Resident #69 on 08/27/24. According to CNA D she usually completed incontinent care for Resident #69 twice during her shift, once in the morning and again prior to end of her shift. According to CNA D she was really busy on 08/27/24, towels were late which made her late for completing showers. CNA D stated she was aware she did not change the resident for a second time. CNA D stated she observed the surveyor going into Resident #69's room. CNA D stated she was upset when she returned to resident at the end of her shift to find him soiled down to his bed sheets. CNA D stated she then completed care, changed his bedding, and cleaned up Resident #69. CNA D revealed she could not recall the last time she was inserviced on activities of daily living care. CNA D stated not changing a resident in a timely manner could result in skin breakdown. CNA D stated she was responsible to ensure residents were changed in timely manner. CNA D stated she did not report her findings to her nurse or the oncoming aide. <BR/>Interview on 08/29/24 at 10:56 AM with LVN E revealed she was notified of the incident with Resident #69 had not received proper incontinent care. LVN E stated CNA D was very good and works very hard at her job duties. LVN E stated it was reported to her that Resident #69 was a heavy wetter. LVN E stated aides that worked the floor were responsible to ensure residents were changed, clean and dry in a timely manner. LVN E stated she expected aides to notify her if they needed help with providing care so she could get adequate help or provide help herself. LVN E stated she noticed the linen closet was short on bed sheets and towels however it was not an excuse to prevent residents from having adequate care when it came to being changed. According to LVN E not changing residents in a timely manner could result in redness in their private areas and skin breakdown or infection. <BR/>Interview on 08/29/24 at 1:20 PM with the DON revealed she was alerted to incident with staff not changing Resident #69 in a timely manner. The DON stated Resident #69 was a heavy wetter so she did not understand how CNA D could have gone all day without changing him. The DON stated there was plenty of staff in the building that could have assisted on the hall to ensure residents had adequate care. The DON stated her expectations included nursing staff to alert the nurses on the floor if they were running behind or off schedule. According to The DON not changing Resident #69 placed him at risk of skin breakdown, infection, emotional abuse, dignity concerns and re-igniting previous pressure sores. <BR/>Review of the facility's policy Resident Showers , updated on 2/11/22, reflected:<BR/>3. The CNA will assess the skin for any changes while performing bathing and inform the nurse of any changes.<BR/>11. Assist the resident with showering as needed.<BR/>The policy did not address personal hygiene, specifically shaving of female residents. <BR/>Review of the facility's Provision of Quality of Life policy, revised 01/10/22, reflected: based on comprehensive assessments, the facility will ensure that each resident will receive the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well being, consistent with resident's comprehensive assessment and plan of care In order to achieve a culture and environment that supports quality of life the facility leadership will validate that all staff, across all shifts and departments receives training that provides understanding on the principles of quality of life.<BR/>Review of the facility's Incontinence Care policy, revised 02/14/20, reflected an outlined procedure for cleaning the perineum and buttocks after an incontinence episode. The policy did not address timeliness of incontinent care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for two (Residents #1 and#2) of four residents reviewed for elopement. <BR/>1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 09/25/23. <BR/>2. The facility failed to ensure Resident #2 was provided with adequate supervision to prevent him from eloping from the facility on 09/28/23. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 09/25/23 and ended on 09/30/23. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure placed residents at risk of harm and/or serious injury. <BR/>Findings included:<BR/>1. Review of Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, non-Alzheimer's dementia, and cognitive communication deficit. Resident #1 had long and short-term memory impairment and a BIMS could not be completed due to his impaired cognition. <BR/>Review of Resident #1's care plan initiated on 08/04/23 revealed the resident wandered related to cognitive impairment and was at risk for elopement. Interventions included putting the resident on 1:1 (one-on-one supervision) while behaviors like seeking exit were noted. The care plan further reflected Resident #1 was able to self propel his wheelchair. <BR/>Review of Resident #1's elopement assessment dated [DATE] reflected the resident was at a high risk to elope and a care plan for elopement was indicated. <BR/>Review of the facility's Provider Investigation Report dated 09/25/23 reflected the following:<BR/>At 5:02am [on 09/25/23], when returning to the desk from down the 100 hall, [LVN A] heard the alarm sounding from the dining room door. She looked outside and around the door and didn't see anyone, so she immediately called for a code silver and staff completed a head count. At 5:06am, it was noted that [Resident #1] was not able to be located and a search ensued, including the interior and exterior of the facility, parking lots, bushes, etc. At 5:25am, the search was expanded by car to include the area directly surrounding the facility. [Resident #1] was noted at the gas station about half a block from the facility at approximately 5:30am, with 2 police officers, by [LVN A]. Resident was returned to the facility, and released to the nurse assigned to him, [LVN A] who completed a head to toe assessment and placed the resident on 1:1 staff supervision <BR/>Review of Resident #1's progress notes dated 09/25/23 completed by LVN B reflected the following:<BR/>At 5:00 [AM] code silver was initiated. Census was printed and a complete head count was done on all the resident [sic]. At 5:10 we noted that [Resident #1] was missing, CNA's along side with nurses searched the outside grounds. Resident was located at 5:36 am. Resident was returned to the inside of the facility at 5:40 am. A completed head to toe assessment was done, not noted skin abnormalities was seen Resident was placed on a one to one observation for acute monitoring <BR/>Review of a [NAME] map on 10/24/23 revealed the location where Resident #1 was located on 09/25/23 was 0.3 miles from the facility. <BR/>Attempts to interview LVN A and LVN B on 10/24/23 were unsuccessful. <BR/>Interview on 10/24/23 at 11:29 AM with the Receptionist revealed Resident #1 always sat at the front lobby and looked outside and let her know when visitors were coming to the door and greeted all who entered the facility. She stated Resident #1 was confused but had never made any attempts to elope nor expressed wanting to leave to her. <BR/>Interview on 10/24/23 at 12:29 PM with CNA C revealed Resident #1 had confusion but he was not exit seeking and self-propelled his wheelchair through the facility. <BR/>Interview on 10/24/23 at 2:42 PM with LVN D revealed Resident #1 was confused and sat in the front lobby greeting all the visitors that entered the facility. Resident #1 was very calm and was never known to be exit seeking. <BR/>Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed he was on his way to work the morning Resident #1 eloped from the facility, 09/25/23. When he arrived at the facility, he checked all the exit doors to ensure they were all operating and there were no concerns. The Maintenance Director further stated Resident #1 was confused but he had never known the resident to be exit seeking. <BR/>Interview on 10/24/23 at 10:56 AM with the ADON revealed Resident #1 used a wheelchair to get around and he was alert and oriented to himself only. She stated the resident did not wander or was exit seeking to her knowledge nor had he ever expressed wanting to leave the facility. <BR/>Interview on 10/24/23 at 9:00 AM with the Administrator and DON revealed they were immediately made aware of Resident #1's elopement and he was put on 1:1 supervision until he was transferred to a facility with a secure unit to prevent another incident. <BR/>2. Review of Resident #2's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included cerebrovascular accident (stroke) and non-Alzheimer's dementia. The MDS further reflected Resident #2 had a BIMS of 3 (cognition severely impaired). <BR/>Review of Resident #2's undated care plan revealed he had impaired cognition and was at risk for a further decline in cognitive and functional decline abilities. Interventions included to monitor/document/report to physician any changes in cognitive function.<BR/>Review of Resident #2's Elopement assessment dated [DATE] revealed he was low risk. <BR/>Review of the facility's Provider Investigation Report dated 09/29/23 reflected the following:<BR/>The resident was noted to be missing from his room at 4:05 PM [on 09/28/23] by his nurse [LVN E]. As she was going to the front to call a code silver, a visitor was informing the receptionist that there was a resident in the parking lot. The resident was returned to the facility at 4:07 PM and a head to toe assessment was completed with no injuries noted. During door alarm checks, it was noted that the 200 hall door lock was malfunctioning. A sentry was placed at the door until the maintenance supervisor repaired the door, then q 4 hour door checks were performed until the alarm company came to inspect all the doors. Door checks continue daily.<BR/>Interview on 10/24/23 at 3:04 PM with LVN E revealed she arrived to work the day of Resident #2's elopement, 09/28/23 at 2:00 PM, and during her initial rounds, she saw the resident in his room. Around 3:30 PM, she noticed Resident #2 was not in his room or the bathroom and asked nearby staff if they had seen the resident. At that time, they began to look for the resident and they had called a code silver as the same time an employee from a nearby business was in the front lobby saying Resident #2 was at their business and the resident was taken back to the facility. LVN said Resident #2 had not been at the facility long but during that short time, the resident had not been exit-seeking. The LVN further stated the resident was ambulatory without assistance. Resident #2 was put on 1:1 supervision until he was discharged from the facility. <BR/>Interview on 10/24/23 at 12:29 PM with CNA C revealed the day of Resident #2's elopement, 09/28/23, the resident had been seen at the nurse's station around 3:35 PM, and around 4:00 PM LVN E was looking for the resident and decided to call a code silver. At that same time, they got word that Resident #2 had been found outside next door at a nearby establishment and they had the resident. Facility staff went to the establishment and brought Resident #2 back to the facility. CNA C further stated that during the short time the resident was at the facility, he had never been exit seeking nor had he ever made the comment about wanting to leave. <BR/>Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed when he was made aware of Resident #2's elopement, he was called to check the exit doors and he found the exit door on 200 hall was not working. It appeared the exit door had come out of adjustment but once he fixed it, it began to work again. The Maintenance Director stated all the exit doors were checked weekly and all the doors had just been checked a few day prior, when Resident #1 eloped on 09/25/23 and they had all been in good and operating correctly. After Resident #2's incident, the mag lock on the 200 hall door was replaced and all facility exit doors were being checked and the codes were being changed every morning as well. <BR/>Interview on 10/24/23 at 10:56 AM with the ADON revealed on the day of Resident #2's elopement, 09/28/23, she was in her office on the 500 hall when she heard LVN E asked if anyone had seen Resident #2. At that time, they activated a code silver when they saw an employee of a nearby business in the front lobby saying they had one of their residents. Resident #2 was brought back to the facility and the nurse did a head-to-toe assessment and there were no injuries noted. After the resident was brought back to the facility, he was asked why he had left and the resident stated because this is a free country. Resident #2 was put on 1:1 supervision until he was discharged from the facility with family. The ADON further stated the resident had only been at the facility for a short time and he had never shown exit seeking behaviors. <BR/>Observation from the 200 exit door of the facility on 10/24/23 at 2:23 PM revealed the establishment where Resident #2 was found was about 100 yards from the facility premises. The establishment and facility shared a paved parking lot with some landscaped grass. <BR/>Interview on 10/24/23 at 5:27 PM with the Regional Nurse Consultant revealed Residents #1 and #2 were discharged from the facility to a secure unit. All staff were re-educated on code silver and live drills were done every shift for a week and a half, then daily, then transitioned weekly and now are being done monthly so all staff knew what to do in case a resident went missing. Exit door checks were being done daily by the Maintenance Director and the mag lock was changed on the hall 200 exit door. She further stated there was an elopement assessment done on all the residents after the incidents and there were two additional residents identified and measures were put in place to prevent any further incidents. <BR/>Observation on 10/24/23 from 9:34 AM to 9:50 AM revealed all 13 facility exit doors were checked with the Maintenance Director and all of the doors were functioning properly. Each door was equipped with a 15 second egress release followed by an alarm after it was opened. There were 3 dining room doors and there was an additional louder alarm added so they could be heard throughout the facility. <BR/>Review of the facility's policy titled Missing Resident Policy revised on 08/15/23 reflected the following:<BR/>This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk <BR/>This was determined to be a Past Non-Compliance Immediate Jeopardy on 10/24/23 at 5:15 PM. The Administrator, DON, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/24/23 at 5:26 PM. <BR/>The facility took the following actions to correct the non-compliance prior to the investigation:<BR/>Record review of the following in-services, dated 09/25/23 and 09/28/23, reflected the in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM:<BR/>- Missing resident guidelines;<BR/>- Missing resident protocol-Elopement binder;<BR/>- Code Silver;<BR/>- Exit seeking behavior; and<BR/>- Head count procedural guidelines.<BR/>Interviews on 10/24/23 from 9:34 AM to 3:59 PM with the Receptionist, HR Director, Restorative Aide, Maintenance Director, ADON, LVN A, LVN B, CNA C, LVN D, and LVN E who worked all three shifts revealed they were able to conduct a code silver drill for a missing resident, perform a head count check, what to do when they heard a door alarm and monitor any changes in condition that could indicate a resident was a high elopement risk. <BR/>Record review of the facility's Code Silver drills revealed they were conducted daily on each shift beginning on 09/25/23 and they were currently being done monthly with no end date. <BR/>Record review of exit door checks on 09/25/23, after Resident #1 eloped, revealed all exit doors were functioning properly. <BR/>Record review dated 09/28/23 revealed staff were doing 15 minute checks on the 200 hall door from 4:20 PM until the Maintenance Director arrived and it was fixed at 6:47 PM. <BR/>Record review of the fire and security invoice revealed that on 09/30/23 a delayed egress lock was replaced on the 200 hall. <BR/>Record review of the door alarm checks dated 09/29/23 to 10/23/23 revealed they were being checked daily by the Maintenance Director. <BR/>Record review revealed an elopement assessment was completed on all the residents on 09/29/23 to identify any additional high risk residents. Two additional residents were identified as being at high risk for elopement. One of the resident was transferred out to a more secure facility and the other resident was monitored until he was deemed safe to remain at the facility.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. <BR/>-The facility failed to ensure food items and clean dishes were kept away from airborne contaminants and an unsanitary environment. <BR/>-The facility failed to ensure that two ice machines were clean and sanitary. <BR/>These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.<BR/>Findings included:<BR/>An observation of the kitchen on 07/18/2023 at 09:20 AM revealed that all four vents just above where the clean pots and pans were stored had debris and fluttering lint. Observation also revealed that the kitchen had two ice machines, and both had a brown, slimy buildup on the inside lining of the lids where ice was touching. <BR/>Interview on 07/18/2023 at 10:05 AM with Dietary Aide F, revealed she had worked at the facility for 2 years. She stated all kitchen staff were trained and in-serviced on kitchen sanitation at least once a month. She stated it was the responsibility of all kitchen staff to maintain the cleanliness and sanitation of the kitchen. She stated general cleaning of the kitchen such as sweeping, mopping, washing dishes and wiping down the counters and equipment was done daily. She stated that deep cleaning was done at least once a month and basically included the same tasks but more thorough and included equipment like the oven and ice machines. She denied that it was the kitchen staff's responsibility to clean the vents. Dietary Aide F stated that maintenance was responsible for cleaning the vents. She was unsure how often the vents were cleaned or when the last time it was done. She stated the risk of having debris and lint being in the vents could be cross-contamination if anything fell inside of the pots and pans where food would be prepared, which could lead to food-borne illness for the residents. <BR/>Interview and observation on 07/19/2023 at 10:15 AM, the Area Dietary Manager stated she was standing in because the assigned dietary manager was on vacation. She stated the expectation was for all kitchen staff to maintain cleanliness and sanitation of the kitchen daily. The Area Dietary Manager stated there was a weekly and monthly cleaning schedule for staff to follow and sign off on as the tasks were completed. She stated that all kitchen staff were trained on kitchen sanitation; however, she could not state how often the trainings were done. She was not able to provide copies of previous trainings and in-services for kitchen sanitation. Observation revealed that all four vents still had debris and lint. The Area Dietary Manager acknowledged that the vents above the clean pots and pans were covered in debris and lint and that both ice machines had a brown, slimy substance on the inside lining of the lids. She stated maintenance was responsible for cleaning the vents, but she did not know how often this was done. She stated the kitchen staff were responsible for keeping the ice machines clean and that they should be checked at least weekly. The Area Dietary Manager stated having dirty vents above the pots and pans and unsanitary ice machines could cause cross-contamination and place the residents at risk for food-borne and water-borne illness. <BR/>Interview and observation on 07/20/2023 at 1:30 PM, the Maintenance Director revealed that it was his responsibility to take down all vent covers in the kitchen for the kitchen staff to clean. He stated this was done every 6 months. He stated there was not a log of when the vents were cleaned, he just knew that it was done every 6 months. The Maintenance Director stated there were not any filters in the vents that needed to be changed and that was why the vents were only taken down every 6 months. Observation with the Maintenance Director revealed that all four vents still had debris and lint in them. The Maintenance Director stated the vents needed to be cleaned and that he would take them down for a cleaning as soon as possible. He stated the kitchen staff were responsible for cleaning the ice machines. The Maintenance Director stated the ice machines should be dumped and cleaned weekly because the facility's water had high calcium, which could cause buildup in the ice machines. <BR/>Record review of the facility's Monthly Cleaning Schedule, dated for July 2023, revealed the task of cleaning the ice machines. There were staff initials next to the task, indicating that it had been completed for the month. <BR/>Record review of the facility's Monthly Sanitation Audit, dated 06/28/2023, revealed all areas of the kitchen were satisfactory, except the vents. A note indicated that a maintenance request had been submitted for the vents to be cleaned. <BR/>Record review of the facility's policy titled Equipment Cleaning Procedures, revised 01/2013, revealed the following:<BR/> Policy: It is the policy of this facility that all dietary equipment and the environment are cleaned and sanitized in a manner that meets local (if applicable), state, and federal regulations. <BR/>Cleaning Frequency:<BR/> .<BR/>Weekly: .Clean refrigerator and freezer weekly. <BR/>Monthly: Wash walls, ceilings, and vents monthly or as needed. <BR/>Maintaining Kitchen and Storage Area: .Lighting, ventilation, temperature, and humidity must be properly maintained and controlled to prevent condensation and the growth of molds <BR/>Record review of the facility's policy titled Food Safety and Sanitation Plan, revised 11/2017, revealed the following:<BR/>Policy: It is the policy of the facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur <BR/>Procedures:<BR/> .<BR/>-Ice-Appropriate ice and water handling practices prevent contamination and the potential for water-borne illness Keeping the ice machine clean and sanitary will help prevent contamination of the ice. Contamination risks associated with ice and water handling practices may include, but are not limited to:<BR/> .<BR/>-Unclean equipment, including the internal components of ice machines that are not drained, cleaned and sanitized as needed to manufacturer's specifications.<BR/>Record review of the Federal Drug Administration Food Code dated 2017 section titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 infections for 1 of 7 residents (Resident #1) reviewed for infection control. <BR/>CNA B failed to wear a gown for Enhanced Barrier Precautions while assisting LVN A with wound care for Resident #1.<BR/>These failures could place residents at risk of infectious disease. <BR/>The finding included:<BR/>Review of Resident #1's admission record dated 02/20/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were acquired absence of left leg above the knee, orthopedic after care following surgical amputation, pressure ulcers (bed sore), and infection following a procedure.<BR/>Review of Resident #1's admission MDS dated [DATE] was not completed and did not reflect a Brief Inventory of Mental Status (a standardized assessment to measure long and short-term memory), indwelling medical devices, wounds, wound vac (this is a medical device that helps to heal the wound from the inside using a suction motion) or infection.<BR/>Review of Resident #1's physician orders for February reflected:<BR/>-Cleanse pressure wound with cleanser, pat dry, apply collagen particles and calcium alginate to wound bed and cover with silicone foam dressing everyday shift for Right Posterior Thigh Wound.<BR/>-Cleanse pressure wound with cleanser, pat dry, apply collagen particles and calcium alginate to wound bed and cover with silicone foam dressing everyday shift for Sacrum (tail bone) Wound.<BR/>Review of Resident #1's care plan initiated 02/12/25 revealed Resident#1 had multiple pressure ulcers to sacrum & thigh and was at increased risk for infection, pain, and a decline in functional abilities. The goal was Resident #1's pressure ulcer would show signs of healing through next review date. Resident#1's pressure ulcer would be free from infection and the risk for infection would be minimized through the next review date. The intervention was to provide pain management prior to dressing changes and repositioning as needed, provide wound care per physician's order, Keep dressing clean, dry, and intact, replace the dressing as needed for soiling. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Low air loss mattress. Provide incontinent care as needed.<BR/>The care plan did not reflect EBP for Resident #1with wounds or wound vac.<BR/>Observation and interview on 02/20/25 at 1:30 PM, revealed a door signage that read STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as central lines, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring dressing. LVN A put on his gown and gloves to perform wound care for Resident #1. CNA B stated she was there to assist LVN A. CNA wore gloves. She did not wear a gown. Resident #1 was in the bed with family at bedside. Family stated Resident #1 moved from another facility due to worsening infection. Family stated resident had a wound vac on her amputated leg and that she admitted with wounds. CNA B helped to hold Resident #1 onto the left side by the amputated leg without a gown on. <BR/>In an interview with LVN A on 02/20/25 at 1:48 PM, he stated he did not remind CNA B to put on a gown because he thought only the person completing the actual wound care needed to wear a gown. LVN A stated following EBP was important to prevent infection.<BR/>In an interview with CNA B on 02/20/25 at 1:51 PM, she stated she forgot to put on her gown for EBP. She stated she had been in serviced for EBP which was used to prevent infection. She stated she was not thinking and forgot to wear a gown.<BR/>In an interview with DON on 02/20/25 at 4:47 PM, DON stated CNA B should have worn a gown for PPE during wound care assistance. She stated the expectation was to follow precautions of EBP when touching bed, resident, or any high contact activities. She said EBP was put in place for infection control, and everyone should wear PPE, as necessary.<BR/>In an interview the administrator on 02/20/25 at 5:15 PM revealed that all staff were expected to wear their PPE for EBP. She stated this was part of the infection control and all staff were responsible for following the infection control policy.<BR/>Review of the facility's in-service dated 12/10/24, titled skin assessment during shower: Head to toe, Weekly skin assessment, abnormal findings must be reported, wound care revealed, LVN A, LVN C and CNA B had completed training.<BR/>Review of policy Infection Prevention and Control Program, revised 11/06/24, revealed, .Enhanced Barrier Precautions<BR/>EBP are used in conjunction with standard precautions and expand the use of PPE to donning of<BR/>gown and gloves during high-contact resident care activities that provide opportunities for<BR/>transfer of MDROs to staff hands and clothing.<BR/>EBP are indicated for residents with any of the following:<BR/>a. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply.<BR/>b. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding<BR/>tube, tracheostomy/ventilator) regardless of MDRO colonization status<BR/>During high-contact resident care activities:<BR/>o Dressing<BR/>o Bathing/showering<BR/>o Transferring<BR/>o Providing hygiene<BR/>o Changing linens<BR/>o Changing briefs or assisting with toileting<BR/>o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator<BR/>o Wound care: any skin opening requiring a dressing<BR/>Gloves and gowns prior to the high-contact care activity<BR/>(Change PPE before caring for another resident)<BR/>(Face protection may also be needed if performing activity with risk of splash or spray) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure total privacy for residents in 4 of 28 rooms (Rooms 401 A bed, 401 B bed, 405 A bed, and 405 B bed) reviewed for privacy.<BR/>The facility failed to provide privacy curtains to ensure residents' privacy in Rooms 401 A bed, 401 B bed, 405 A bed, and 405 B bed. Each of these rooms only had one curtain.<BR/>This failure could place residents at risk of decreased self-worth by being exposed during resident care. <BR/>Findings included: <BR/>Observation of room [ROOM NUMBER] revealed that there was only one curtain in the room that went between both A and B beds. For residents in room [ROOM NUMBER] (A bed) and room [ROOM NUMBER] (B bed) each to be provided privacy, a second curtain would be required to be hung in the room. Also, observation of room [ROOM NUMBER] revealed that there was only one curtain in the room that went between both A and B beds. For residents in room [ROOM NUMBER] (A bed) and room [ROOM NUMBER] (B bed) each to be provided privacy, a second curtain would be required to be hung in the room. <BR/>Interview and observation on 07/19/23 at 12:30 PM with Resident #59 (405 A bed) revealed the resident, who resided in this room, was receiving a bed bath. Further observation revealed there was not a privacy curtain available to surround the bed to ensure privacy when the door was opened. The hospice CNA G was giving a bed bath to the Resident #59 in her room. Staff was observed entering and exiting the room and leaving the door open during the resident's bed bath. When interviewed, the hospice CNA G stated that she felt the dignity and the privacy of the resident was not taken seriously because there was not a curtain. She stated she had not told her supervisor because she did not think about it. She stated she would try to close the door during care, but every time staff entered the room, they left the door open.<BR/>Observations on 7/19/2023 at 12:45 PM of rooms 401 (A bed) and 401 (B bed) revealed that neither rooms had privacy curtains. <BR/>Interview on 07/19/23 at 1:15 PM with the Housekeeping Supervisor revealed that each room should have two curtains for privacy. The Surveyor and the Housekeeping Supervisor went to room [ROOM NUMBER] (A bed). The Surveyor pointed out that room [ROOM NUMBER] (A bed) only had one curtain and asked the Housekeeping Supervisor why there was no second curtain. The Housekeeping Supervisor replied that The Maintenance Supervisor would have taken the curtain down. She also stated that the curtains were for privacy for patient care. <BR/>Interview on 07/19/23 at 3:04 PM with the Maintenance Supervisor revealed he had not taken down curtains in a while. He said the rooms should have two curtains in them. He also stated that the privacy curtains were used for privacy for the residents.<BR/>Interview on 07/19/23 at 3:18 PM with the ADON, again confirmed two curtains should have been up in all rooms with two patients. However, only one curtain was up. The ADON stated staff should keep the door closed and keep Resident #59 covered. She was uncertain when they took the curtain down. The ADON stated she did not know if curtains were not up in any other rooms. She stated they had the curtains for privacy. If the curtain was not there, there was no privacy to the resident. The ADON stated they have completed in-services on dignity and privacy. <BR/>Interview on 07/20/23 at 8:37 AM with Resident #79 room [ROOM NUMBER] (A bed) revealed the night shift had installed the missing privacy curtain the previous night (7/19/2023). She stated that one time they took her toenail off during a procedure and did not shut the door. She stated, That bothered me. <BR/>Interview on 07/20/23 at 8:41 AM with Resident #72 room [ROOM NUMBER] (B bed) revealed that at no time previous to the night before (7/19/23) had a second curtain ever been hung in her room. <BR/>Interview on 07/20/23 at 10:54 AM with the DON determined that two curtains were supposed to be in rooms with two residents for privacy. She noticed rooms did not have two curtains up on 7/19/2023. She called the housekeeper and maintenance to put the curtains up. She did not know the time that she instructed them to hang the curtains. The nurses taking care of the residents were supposed to let housekeeping know if they were taken down for any reason like washing needs. <BR/>Record review of facility policy Resident Rights, dated February 2021, states the following: The resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their written policies and procedures for investigating and reporting allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, for 1 (Resident #35) of 18 residents reviewed for abuse. <BR/>The facility failed to follow their policy and report to the State Survey Agency when Resident #35 alleged he had been cursed at by CNA C. <BR/>The failure could place residents at risk of repeated injuries, abuse and/or neglect.<BR/>Findings included:<BR/>Review of Resident #35's MDS revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, and contracture of muscle. Resident #35 had a BIMS of 15 (cognition intact).<BR/>Observation and interview on 07/18/23 at 10:15 AM revealed Resident #35 was in his room in bed watching TV The resident stated CNA C did not like him and had called him an asshole three times about three to four weeks ago. The resident said he reported the incident to his family and stated he was not afraid of the CNA and felt safe at the facility. <BR/>Interview on 07/18/23 at 11:54 AM with Resident #35's family revealed the resident had called them a few weeks back (did not recall he date) and told them CNA C had called him an asshole three times. Resident #35's family said they reported the allegation to the Social Worker and they had a care plan meeting and they were told CNA C had been spoken to about the matter. The family further stated the facility had offered to move the resident to another hall but the resident did not want to leave the room he was in. <BR/>Interview on 07/18/23 at 1:53 PM with the Social Worker revealed Resident #35's family had gone to her a while back (did not recall the date) and stated Resident #35 had complained about CNA C giving him a cold shower and they also mentioned the aide had called the resident an asshole. The Social Worker said she reported the incident to the ADON and an investigation had been done. <BR/>Review of the grievance report dated 05/25/23 completed by the Social Worker revealed family stated Resident #35 said CNA C called him an asshole and would not turn on the heater in the shower room. Further review of the grievance report revealed they had spoken with CNA C and she had not been in the building on the day the resident made the allegation. The CNA also said there was always a staff member present when she gave Resident #35 a shower. <BR/>Interview on 07/19/23 at 2:57 PM with the ADON revealed CNA B reported Resident #35 said CNA C had called him an asshole earlier that day. The ADON did not recall the date of the incident but recalled CNA C had not worked the day the resident alleged the incident occurred. The ADON said she spoke to the DON about the incident but had not been able to speak to the resident that day because he was asleep. <BR/>Interview on 07/19/23 at 12:19 PM with CNA B revealed she was feeding Resident #35 when he asked her if CNA C had been fired because she (CNA C) had called him an asshole three times. CNA B did not recall the date of the incident but thought it was some time in May (2023). CNA B reported the incident to the ADON because the Administrator and DON were not at the facility. <BR/>Interview on 07/19/23 at 12:19 PM with the DON revealed sometime in May (2023) Resident #35's family had called the Social Worker to report the resident said CNA C had given him a cold shower and called him an asshole. The DON did not recall the date but that it had been a Monday. Resident #35 had also reported the incident to CNA B and they had investigated the incident and gotten statements of the incident. <BR/>Attempts to contact CNA C on 07/18/23 were unsuccessful. <BR/>Interview on 07/18/23 at 11:45 AM with the DON revealed the incident between Resident #35 and CNA C was not reported to the Survey Agency because CNA C was not working the day Resident #35 said the incident occurred but they had gone ahead and completed an investigation. <BR/>Interview with the Administrator, working at the time of the incident, was not possible because he was on leave at the time of the investigation. <BR/>Review of the facility's policy titled Abuse, Neglect and Exploitation implemented 10/24/22 reflected the following:<BR/>Policy:<BR/>It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property <BR/> .VII. Reporting/Response<BR/> .2. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: a. Immediately, but not later than 2 hours after the allegation after the allegation is made

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse and neglect, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #35) of 18 residents reviewed for abuse and neglect. <BR/>The facility failed to report to the State Agency when Resident #35 made an allegation of verbal abuse against CNA C.<BR/>This failure could place residents at risk of incidents of abuse, neglect, and exploitation not being reported timely . <BR/>Findings included:<BR/>Review of Resident #35's MDS assessment revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, and contracture of muscle. Resident #35 had a BIMS of 15 (cognition intact).<BR/>Observation and interview on 07/18/23 at 10:15 AM revealed Resident #35 was in his room in bed watching TV. The resident stated CNA C did not like him and had called him an asshole three times about three to four weeks ago. The resident said he reported the incident to his family and stated he was not afraid of the CNA and felt safe at the facility. <BR/>Interview on 07/18/23 at 11:54 AM with Resident #35's family revealed the resident had called them a few weeks back (did not recall he date) and told them CNA C had called him an asshole three times. Resident #35's family said they reported the allegation to the Social Worker and they had a care plan meeting and they were told CNA C had been spoken to about the matter. The family further stated the facility had offered to move the resident to another hall but the resident did not want to leave the room he was in. <BR/>Interview on 07/18/23 at 1:53 PM with the Social Worker revealed Resident #35's family had gone to her a while back (did not recall the date) and stated Resident #35 had complained about CNA C giving him a cold shower and they also mentioned the aide had called the resident an asshole. The Social Worker said she reported the incident to the ADON and an investigation had been done. <BR/>Review of the grievance report dated 05/25/23 completed by the Social Worker revealed family stated Resident #35 said CNA C called him an asshole and would not turn on the heater in the shower room. Further review of the grievance report revealed they had spoken with CNA C and she had not been in the building on the day the resident made the allegation. The CNA also said there was always a staff member present when she gave Resident #35 a shower. <BR/>Interview on 07/19/23 at 2:57 PM with the ADON revealed CNA B reported Resident #35 said CNA C had called him an asshole earlier that day. The ADON did not recall the date of the incident but recalled CNA C had not worked the day the resident alleged the incident occurred. The ADON said she spoke to the DON about the incident but had not been able to speak to the resident that day because he was asleep. <BR/>Interview on 07/19/23 at 12:19 PM with CNA B revealed she was feeding Resident #35 when he asked her if CNA C had been fired because she (CNA C) had called him an asshole three times. CNA B did not recall the date of the incident but thought it was some time in May (2023). CNA B reported the incident to the ADON because the Administrator and DON were not at the facility. <BR/>Interview on 07/19/23 at 12:19 PM with the DON revealed sometime in May (2023) Resident #35's family had called the Social Worker to report the resident said CNA C had given him a cold shower and called him an asshole. The DON did not recall the date but that it had been a Monday. Resident #35 had also reported the incident to CNA B and they had investigated the incident and gotten statements of the incident. <BR/>Attempts to contact CNA C on 07/18/23 were unsuccessful. <BR/>Interview on 07/18/23 at 11:45 AM with the DON revealed the incident between Resident #35 and CNA C was not reported to the Survey Agency because CNA C was not working the day Resident #35 said the incident occurred but they had gone ahead and completed an investigation. <BR/>Interview with the Administrator, working at the time of the incident, was not possible because he was on leave at the time of the investigation. <BR/>Review of the facility's policy titled Abuse, Neglect and Exploitation implemented 10/24/22 reflected the following:<BR/>Policy:<BR/>It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property <BR/> .VII. Reporting/Response<BR/> .2. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: a. Immediately, but not later than 2 hours after the allegation after the allegation is made

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (500 Hall) of 2 medication rooms (refrigerators) reviewed for medication storage. <BR/>The facility failed to dispose of two expired vials of the influenza vaccine. <BR/>This failure could place the residents at risk of not receiving the required therapy or receiving vaccines that were expired.<BR/>Findings included:<BR/>Observation of the medication room on 500 hall on 07/19/23 at 9:20 AM revealed two vials of influenza vaccines. Both vials had been opened and had an expiration date of 06/29/23.<BR/>Interview on 07/19/23 at 9:26 AM with LVN E revealed the night shift nurses are the ones that are supposed to check the carts and the refrigerators for expired medications, but it is all nurse's responsibility to check and remove expired medications from the refrigerator. She stated she has done training on when to discard the vaccines once they expire. She stated failure to remove the expired medication, if administered they will cause reactions and the resident will not get the required therapy.<BR/>Interview on 07/19/23 at 9:57 AM with the DON revealed, her expectation was the night shift nurses were to check the medication carts and the refrigerators every night for the expired medications. She stated the ADON was responsible of auditing the cart and refrigerators every week and at most monthly. She said she did not have an ADON because she left weeks ago, and she has not been able to replace her. The DON stated the vaccines were supposed to have been removed from the refrigerator in May after the end of flu (is an infection of the nose, throat, and lung season) season. The DON stated she had done training with staffs on checking the refrigerators and removing expired medications. She also stated if the staff were not checking for expired medications and vaccines the risk will be the resident will be receiving expired medications and will not receive the expected therapy. The last destruction of expired medication was done on 07/11/23 and it was documented.<BR/>Review of the facility's storage of medication policy, revised August 2020, reflected the <BR/>1.Expiration dates (beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing.<BR/>2.Drugs dispensed in the manufacturers' original container will be labelled with the manufacturer's expiration date.<BR/>8.All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (500 Hall) of 2 medication rooms (refrigerators) reviewed for medication storage. <BR/>The facility failed to dispose of two expired vials of the influenza vaccine. <BR/>This failure could place the residents at risk of not receiving the required therapy or receiving vaccines that were expired.<BR/>Findings included:<BR/>Observation of the medication room on 500 hall on 07/19/23 at 9:20 AM revealed two vials of influenza vaccines. Both vials had been opened and had an expiration date of 06/29/23.<BR/>Interview on 07/19/23 at 9:26 AM with LVN E revealed the night shift nurses are the ones that are supposed to check the carts and the refrigerators for expired medications, but it is all nurse's responsibility to check and remove expired medications from the refrigerator. She stated she has done training on when to discard the vaccines once they expire. She stated failure to remove the expired medication, if administered they will cause reactions and the resident will not get the required therapy.<BR/>Interview on 07/19/23 at 9:57 AM with the DON revealed, her expectation was the night shift nurses were to check the medication carts and the refrigerators every night for the expired medications. She stated the ADON was responsible of auditing the cart and refrigerators every week and at most monthly. She said she did not have an ADON because she left weeks ago, and she has not been able to replace her. The DON stated the vaccines were supposed to have been removed from the refrigerator in May after the end of flu (is an infection of the nose, throat, and lung season) season. The DON stated she had done training with staffs on checking the refrigerators and removing expired medications. She also stated if the staff were not checking for expired medications and vaccines the risk will be the resident will be receiving expired medications and will not receive the expected therapy. The last destruction of expired medication was done on 07/11/23 and it was documented.<BR/>Review of the facility's storage of medication policy, revised August 2020, reflected the <BR/>1.Expiration dates (beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing.<BR/>2.Drugs dispensed in the manufacturers' original container will be labelled with the manufacturer's expiration date.<BR/>8.All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (Resident #57) of three residents reviewed for respiratory care. <BR/>The facility failed to ensure Resident #57's had a physician's order for oxygen treatment. <BR/>This deficient practice could affect residents who received oxygen therapy from receiving inadequate oxygen support and a decline in health.<BR/>Findings included:<BR/>Record review of Resident #57's significant change MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease , non-Alzheimer's dementia, respiratory failure, hypertension (high blood pressure), atrial fibrillation (an irregular often rapid heart rate). The MDS further reflected the resident was on hospice services.<BR/>Record review of Resident #57's progress notes dated 06/11/24 reflected the resident was on oxygen via nasal cannula. <BR/>Observation and interview on 08/27/24 at 11:40 AM of Resident #57 revealed she in bed watching TV. The resident was on continuous oxygen via nasal cannula, and it was running at 2 liters per minute. Resident #57 was asked if her oxygen was working well for her and she stated it was. The resident did not appear to be in any distress. <BR/>Record review of Resident #57's clinical record revealed there was no physician's order for the oxygen. <BR/>Interview on 08/29/24 at 12:08 PM with LVN B revealed Resident #57 had been put on continuous oxygen a while back, possibly two months prior, because her oxygen saturations were not staying above 90% on room air. LVN B did not realize there was not a physician's order for the oxygen when she checked the clinical record. LVN B said the nurse that received the order should have put the order into the system but she did know who the nurse was that got the initial order. LVN B further stated it was important to have an oxygen order so staff would know what care was needed for the residents. <BR/>Interview on 08/29/24 at 1:46 PM with the DON revealed she was not aware Resident #57 was on continuous oxygen and thought it was only as needed. The DON said all residents with oxygen should have a physician's order so that all staff knew what care was needed for the residents. <BR/>Review of the facility's Oxygen Administration policy, dated September 2014, reflected the following:<BR/>Policy<BR/>To describe methods for delivering oxygen to improve tissue oxygenation.<BR/>Procedure<BR/>1. Verify Physician Order<BR/>2. Order should have when to call the physician parameters